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Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago. She is editor of the Journal of Hospital Medicine POEMs.
Turn up the tunes in the ICU
Clinical question
Can patient-directed music therapy decrease anxiety and reduce sedative use in the intensive care unit?
Bottom line
Patient-directed music therapy in the intensive care unit (ICU) reduces anxiety in awake, ventilated patients while also decreasing the intensity and frequency of sedative use. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded);
Allocation
Concealed
Setting
Inpatient (ICU only)
Synopsis
These investigators studied the effects of patient-directed music therapy in reducing anxiety and sedative use in the ICU. Patients using ventilatory support for acute respiratory failure who were alert enough to consent and operate a music player were randomized, using concealed allocation, to 1 of 3 groups: (1) the use of headphones to listen to music (n = 126), (2) the use of noise-cancelling headphones to block out ICU noise (n = 122), and (3) usual care (n = 125). Only 5% of patients who were assessed for eligibility actually underwent randomization, as patients who were unable to consent because of confusion or deep sedation were excluded. A music therapist helped patients in group 1 select their preferred music. These patients were then directed and prompted to listen to music via headphones as often as desired. In group 2, patients were encouraged to wear noise-cancelling headphones whenever they wanted to block out ICU noise. Patients in all 3 groups had similar baseline characteristics, including anxiety scores at study entry and intensity and frequency of sedation 24 hours prior to enrollment. There was a wide range of Acute Physiology, Age and Chronic Health Evaluation III (APACHE III) scores, but the mean fell between 62 and 66 in all 3 groups. A research nurse administered a 100-mm anxiety visual analog scale to patients daily when feasible.
Patients in the music therapy group listened to music for an average of 80 minutes per day; those in the noise-cancelling group wore their headphones for 34 minutes per day. After adjusting for APACHE III scores and sedation frequency and intensity, the use of music therapy lowered anxiety scores by 19 mm compared with usual care (relative decrease of 36%; P = .003). The music group also had decreased sedation intensity (P = .05) and frequency (P = .01) over time when compared with usual care after adjustments were made for imbalances. For example, by day 5, patients in the music group received 3 doses per day of sedative medication, while those in the usual care group received 5 doses. The music therapy group also showed reduction in sedation frequency when compared with the noise-cancelling headphones group, but there were no significant differences detected in anxiety scoring or sedation intensity between these 2 groups. The study did not examine ICU length of stay or other clinical outcomes.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Can patient-directed music therapy decrease anxiety and reduce sedative use in the intensive care unit?
Bottom line
Patient-directed music therapy in the intensive care unit (ICU) reduces anxiety in awake, ventilated patients while also decreasing the intensity and frequency of sedative use. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded);
Allocation
Concealed
Setting
Inpatient (ICU only)
Synopsis
These investigators studied the effects of patient-directed music therapy in reducing anxiety and sedative use in the ICU. Patients using ventilatory support for acute respiratory failure who were alert enough to consent and operate a music player were randomized, using concealed allocation, to 1 of 3 groups: (1) the use of headphones to listen to music (n = 126), (2) the use of noise-cancelling headphones to block out ICU noise (n = 122), and (3) usual care (n = 125). Only 5% of patients who were assessed for eligibility actually underwent randomization, as patients who were unable to consent because of confusion or deep sedation were excluded. A music therapist helped patients in group 1 select their preferred music. These patients were then directed and prompted to listen to music via headphones as often as desired. In group 2, patients were encouraged to wear noise-cancelling headphones whenever they wanted to block out ICU noise. Patients in all 3 groups had similar baseline characteristics, including anxiety scores at study entry and intensity and frequency of sedation 24 hours prior to enrollment. There was a wide range of Acute Physiology, Age and Chronic Health Evaluation III (APACHE III) scores, but the mean fell between 62 and 66 in all 3 groups. A research nurse administered a 100-mm anxiety visual analog scale to patients daily when feasible.
Patients in the music therapy group listened to music for an average of 80 minutes per day; those in the noise-cancelling group wore their headphones for 34 minutes per day. After adjusting for APACHE III scores and sedation frequency and intensity, the use of music therapy lowered anxiety scores by 19 mm compared with usual care (relative decrease of 36%; P = .003). The music group also had decreased sedation intensity (P = .05) and frequency (P = .01) over time when compared with usual care after adjustments were made for imbalances. For example, by day 5, patients in the music group received 3 doses per day of sedative medication, while those in the usual care group received 5 doses. The music therapy group also showed reduction in sedation frequency when compared with the noise-cancelling headphones group, but there were no significant differences detected in anxiety scoring or sedation intensity between these 2 groups. The study did not examine ICU length of stay or other clinical outcomes.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Can patient-directed music therapy decrease anxiety and reduce sedative use in the intensive care unit?
Bottom line
Patient-directed music therapy in the intensive care unit (ICU) reduces anxiety in awake, ventilated patients while also decreasing the intensity and frequency of sedative use. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded);
Allocation
Concealed
Setting
Inpatient (ICU only)
Synopsis
These investigators studied the effects of patient-directed music therapy in reducing anxiety and sedative use in the ICU. Patients using ventilatory support for acute respiratory failure who were alert enough to consent and operate a music player were randomized, using concealed allocation, to 1 of 3 groups: (1) the use of headphones to listen to music (n = 126), (2) the use of noise-cancelling headphones to block out ICU noise (n = 122), and (3) usual care (n = 125). Only 5% of patients who were assessed for eligibility actually underwent randomization, as patients who were unable to consent because of confusion or deep sedation were excluded. A music therapist helped patients in group 1 select their preferred music. These patients were then directed and prompted to listen to music via headphones as often as desired. In group 2, patients were encouraged to wear noise-cancelling headphones whenever they wanted to block out ICU noise. Patients in all 3 groups had similar baseline characteristics, including anxiety scores at study entry and intensity and frequency of sedation 24 hours prior to enrollment. There was a wide range of Acute Physiology, Age and Chronic Health Evaluation III (APACHE III) scores, but the mean fell between 62 and 66 in all 3 groups. A research nurse administered a 100-mm anxiety visual analog scale to patients daily when feasible.
Patients in the music therapy group listened to music for an average of 80 minutes per day; those in the noise-cancelling group wore their headphones for 34 minutes per day. After adjusting for APACHE III scores and sedation frequency and intensity, the use of music therapy lowered anxiety scores by 19 mm compared with usual care (relative decrease of 36%; P = .003). The music group also had decreased sedation intensity (P = .05) and frequency (P = .01) over time when compared with usual care after adjustments were made for imbalances. For example, by day 5, patients in the music group received 3 doses per day of sedative medication, while those in the usual care group received 5 doses. The music therapy group also showed reduction in sedation frequency when compared with the noise-cancelling headphones group, but there were no significant differences detected in anxiety scoring or sedation intensity between these 2 groups. The study did not examine ICU length of stay or other clinical outcomes.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
No Mortality Benefit to Rapid Reduction of BP for Intracranial Bleeds (INTERACT2)
Clinical question
Does early intensive reduction of blood pressure improve outcomes in patients with hemorrhagic strokes?
Bottom line
As compared with more conservative management, early intensive lowering of blood pressure (BP) for patients with spontaneous intracranial bleeds does not significantly decrease mortality. However, this approach may result in better functional outcomes and quality of life. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded);
Allocation
(Uncertain)
Setting
Inpatient (ICU only)
Synopsis
Patients who presented with spontaneous intracranial hemorrhage within the previous 6 hours were randomly assigned, using concealed allocation, to receive intensive BP-lowering therapy (n = 1403) or standard BP management according to current guidelines (n = 1436). Patients with structural causes for the bleed, those who were in a deep coma, or those who required early hematoma evacuation were excluded. In the intensive treatment group, intravenous and oral BP medications were used to lower the systolic BP to less than 140 mmHg within 1 hour and maintain it at this level for 1 week. Those in the standard treatment group received BP-lowering agents only if their systolic BP was greater than 180 mmHg. The mean age of the patients in the 2 groups was 64 years and the median presenting Glasgow Coma Scale score was 14. As compared with the standard therapy group, the intensive treatment group started BP-lowering therapy earlier after onset of intracranial hemorrhage (4.0 hours vs 4.5 hours; P < .001) and was more likely to receive intravenous agents (90% vs 43%; P < .001). At 90 days, there was no difference in the primary outcome of death or major disability, defined as a score of 3 to 5 on the modified Rankin scale (0 to 6, where 0 indicates no symptoms and 6 indicates death). Overall, 12% of the patients in each group died. When looking at disability alone, the intensive treatment group had significantly lower modified Rankin scores than the standard therapy group (odds ratio = 0.87; 95% CI, 0.77-1.0; P = .04) and had higher health-related quality of life scores (0.60 vs 0.55; P = .002). As this trial was not masked, the possibility exists that patients in the 2 groups were managed differently beyond just the 2 BP-lowering strategies.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does early intensive reduction of blood pressure improve outcomes in patients with hemorrhagic strokes?
Bottom line
As compared with more conservative management, early intensive lowering of blood pressure (BP) for patients with spontaneous intracranial bleeds does not significantly decrease mortality. However, this approach may result in better functional outcomes and quality of life. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded);
Allocation
(Uncertain)
Setting
Inpatient (ICU only)
Synopsis
Patients who presented with spontaneous intracranial hemorrhage within the previous 6 hours were randomly assigned, using concealed allocation, to receive intensive BP-lowering therapy (n = 1403) or standard BP management according to current guidelines (n = 1436). Patients with structural causes for the bleed, those who were in a deep coma, or those who required early hematoma evacuation were excluded. In the intensive treatment group, intravenous and oral BP medications were used to lower the systolic BP to less than 140 mmHg within 1 hour and maintain it at this level for 1 week. Those in the standard treatment group received BP-lowering agents only if their systolic BP was greater than 180 mmHg. The mean age of the patients in the 2 groups was 64 years and the median presenting Glasgow Coma Scale score was 14. As compared with the standard therapy group, the intensive treatment group started BP-lowering therapy earlier after onset of intracranial hemorrhage (4.0 hours vs 4.5 hours; P < .001) and was more likely to receive intravenous agents (90% vs 43%; P < .001). At 90 days, there was no difference in the primary outcome of death or major disability, defined as a score of 3 to 5 on the modified Rankin scale (0 to 6, where 0 indicates no symptoms and 6 indicates death). Overall, 12% of the patients in each group died. When looking at disability alone, the intensive treatment group had significantly lower modified Rankin scores than the standard therapy group (odds ratio = 0.87; 95% CI, 0.77-1.0; P = .04) and had higher health-related quality of life scores (0.60 vs 0.55; P = .002). As this trial was not masked, the possibility exists that patients in the 2 groups were managed differently beyond just the 2 BP-lowering strategies.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does early intensive reduction of blood pressure improve outcomes in patients with hemorrhagic strokes?
Bottom line
As compared with more conservative management, early intensive lowering of blood pressure (BP) for patients with spontaneous intracranial bleeds does not significantly decrease mortality. However, this approach may result in better functional outcomes and quality of life. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded);
Allocation
(Uncertain)
Setting
Inpatient (ICU only)
Synopsis
Patients who presented with spontaneous intracranial hemorrhage within the previous 6 hours were randomly assigned, using concealed allocation, to receive intensive BP-lowering therapy (n = 1403) or standard BP management according to current guidelines (n = 1436). Patients with structural causes for the bleed, those who were in a deep coma, or those who required early hematoma evacuation were excluded. In the intensive treatment group, intravenous and oral BP medications were used to lower the systolic BP to less than 140 mmHg within 1 hour and maintain it at this level for 1 week. Those in the standard treatment group received BP-lowering agents only if their systolic BP was greater than 180 mmHg. The mean age of the patients in the 2 groups was 64 years and the median presenting Glasgow Coma Scale score was 14. As compared with the standard therapy group, the intensive treatment group started BP-lowering therapy earlier after onset of intracranial hemorrhage (4.0 hours vs 4.5 hours; P < .001) and was more likely to receive intravenous agents (90% vs 43%; P < .001). At 90 days, there was no difference in the primary outcome of death or major disability, defined as a score of 3 to 5 on the modified Rankin scale (0 to 6, where 0 indicates no symptoms and 6 indicates death). Overall, 12% of the patients in each group died. When looking at disability alone, the intensive treatment group had significantly lower modified Rankin scores than the standard therapy group (odds ratio = 0.87; 95% CI, 0.77-1.0; P = .04) and had higher health-related quality of life scores (0.60 vs 0.55; P = .002). As this trial was not masked, the possibility exists that patients in the 2 groups were managed differently beyond just the 2 BP-lowering strategies.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Improved Mortality Rates with Prone Positioning in Severe ARDS
Clinical question
Do patients with severe acute respiratory distress syndrome who require mechanical ventilation fare better with early prone positioning?
Bottom line
Prone positioning decreased 28-day and 90-day mortality rates in patients with severe acute respiratory distress syndrome (ARDS) who required mechanical ventilation. You would have to use prone positioning for 6 such patients to prevent one death. It is important to note that the intensive care units involved in this study were staffed with providers who were skilled at "proning patients." Although the technical difficulty of this process may be a limiting factor, it is one that can likely be overcome with time and experience, especially given the evident benefit. (LOE = 1b)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (ICU only)
Synopsis
These investigators enrolled patients with severe ARDS -- defined as a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (FiO2) of >150mm/Hg, with an FiO2 of at least 0.6, a positive end-expiratory pressure of at least 5 cm of water, and a tidal volume of 6 mL/kg of predicted body weight -- who were using mechanical ventilation for less than 36 hours. Patients were excluded from the study if they showed improvement in symptoms during an initial 12-hour to 24-hour stabilization period. Patients with contraindications to prone positioning such as those with elevated intracranial pressure or recent tracheal surgery were also excluded. Using concealed allocation, eligible patients were randomized to be part of a prone group (n = 237) or a supine group (n = 229). Patients in the prone group were placed in prone position while on mechanical ventilation for at least 16 consecutive hours per day up to day 28. Prone treatment was discontinued if patients had improved oxygenation while in a sustained supine position or if complications arose during prone positioning such as accidental extubation or cardiac arrest. Patients in the supine group were maintained in a semirecumbent position throughout the study. The 2 groups had similar average age and comorbidities. However, at baseline, the supine group used vasopressors more frequently, used neuromuscular blockers less frequently, and had a significantly higher mean Sepsis-related Organ Failure Assessment (SOFA) score as compared with the prone group. Patients in the prone group remained in the prone position for 73% of the time from the start of the first prone session to the end of the last session. Mortality was lower in the prone group than in the supine group at day 28 (16% vs 33%; P < .001; number needed to treat [NNT] = 6) and at day 90 (24% vs 41%; P < .001; NNT = 6). The decrease in mortality with prone positioning persisted after adjustment for SOFA scores and the use of neuromuscular blockers and vasopressors. Although the prone group had more successful extubations at day 90 (81% vs 65%; P < .001), there were no significant differences detected in duration of mechanical ventilation or number of tracheotomies placed.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Do patients with severe acute respiratory distress syndrome who require mechanical ventilation fare better with early prone positioning?
Bottom line
Prone positioning decreased 28-day and 90-day mortality rates in patients with severe acute respiratory distress syndrome (ARDS) who required mechanical ventilation. You would have to use prone positioning for 6 such patients to prevent one death. It is important to note that the intensive care units involved in this study were staffed with providers who were skilled at "proning patients." Although the technical difficulty of this process may be a limiting factor, it is one that can likely be overcome with time and experience, especially given the evident benefit. (LOE = 1b)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (ICU only)
Synopsis
These investigators enrolled patients with severe ARDS -- defined as a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (FiO2) of >150mm/Hg, with an FiO2 of at least 0.6, a positive end-expiratory pressure of at least 5 cm of water, and a tidal volume of 6 mL/kg of predicted body weight -- who were using mechanical ventilation for less than 36 hours. Patients were excluded from the study if they showed improvement in symptoms during an initial 12-hour to 24-hour stabilization period. Patients with contraindications to prone positioning such as those with elevated intracranial pressure or recent tracheal surgery were also excluded. Using concealed allocation, eligible patients were randomized to be part of a prone group (n = 237) or a supine group (n = 229). Patients in the prone group were placed in prone position while on mechanical ventilation for at least 16 consecutive hours per day up to day 28. Prone treatment was discontinued if patients had improved oxygenation while in a sustained supine position or if complications arose during prone positioning such as accidental extubation or cardiac arrest. Patients in the supine group were maintained in a semirecumbent position throughout the study. The 2 groups had similar average age and comorbidities. However, at baseline, the supine group used vasopressors more frequently, used neuromuscular blockers less frequently, and had a significantly higher mean Sepsis-related Organ Failure Assessment (SOFA) score as compared with the prone group. Patients in the prone group remained in the prone position for 73% of the time from the start of the first prone session to the end of the last session. Mortality was lower in the prone group than in the supine group at day 28 (16% vs 33%; P < .001; number needed to treat [NNT] = 6) and at day 90 (24% vs 41%; P < .001; NNT = 6). The decrease in mortality with prone positioning persisted after adjustment for SOFA scores and the use of neuromuscular blockers and vasopressors. Although the prone group had more successful extubations at day 90 (81% vs 65%; P < .001), there were no significant differences detected in duration of mechanical ventilation or number of tracheotomies placed.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Do patients with severe acute respiratory distress syndrome who require mechanical ventilation fare better with early prone positioning?
Bottom line
Prone positioning decreased 28-day and 90-day mortality rates in patients with severe acute respiratory distress syndrome (ARDS) who required mechanical ventilation. You would have to use prone positioning for 6 such patients to prevent one death. It is important to note that the intensive care units involved in this study were staffed with providers who were skilled at "proning patients." Although the technical difficulty of this process may be a limiting factor, it is one that can likely be overcome with time and experience, especially given the evident benefit. (LOE = 1b)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (ICU only)
Synopsis
These investigators enrolled patients with severe ARDS -- defined as a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (FiO2) of >150mm/Hg, with an FiO2 of at least 0.6, a positive end-expiratory pressure of at least 5 cm of water, and a tidal volume of 6 mL/kg of predicted body weight -- who were using mechanical ventilation for less than 36 hours. Patients were excluded from the study if they showed improvement in symptoms during an initial 12-hour to 24-hour stabilization period. Patients with contraindications to prone positioning such as those with elevated intracranial pressure or recent tracheal surgery were also excluded. Using concealed allocation, eligible patients were randomized to be part of a prone group (n = 237) or a supine group (n = 229). Patients in the prone group were placed in prone position while on mechanical ventilation for at least 16 consecutive hours per day up to day 28. Prone treatment was discontinued if patients had improved oxygenation while in a sustained supine position or if complications arose during prone positioning such as accidental extubation or cardiac arrest. Patients in the supine group were maintained in a semirecumbent position throughout the study. The 2 groups had similar average age and comorbidities. However, at baseline, the supine group used vasopressors more frequently, used neuromuscular blockers less frequently, and had a significantly higher mean Sepsis-related Organ Failure Assessment (SOFA) score as compared with the prone group. Patients in the prone group remained in the prone position for 73% of the time from the start of the first prone session to the end of the last session. Mortality was lower in the prone group than in the supine group at day 28 (16% vs 33%; P < .001; number needed to treat [NNT] = 6) and at day 90 (24% vs 41%; P < .001; NNT = 6). The decrease in mortality with prone positioning persisted after adjustment for SOFA scores and the use of neuromuscular blockers and vasopressors. Although the prone group had more successful extubations at day 90 (81% vs 65%; P < .001), there were no significant differences detected in duration of mechanical ventilation or number of tracheotomies placed.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Universal MRSA Decolonization in ICU Leads to Fewer Bloodstream Infections
Clinical question
Does universal decolonization for methicillin-resistant Staphylococcus aureus (MRSA) in patients in the intensive care unit decrease the rate of MRSA-positive clinical cultures?
Bottom line
As compared with no decolonization or a targeted decolonization, a universal decolonization strategy for MRSA using intranasal mupirocin and chlorhexidine bathing cloths for all patients admitted to the intensive care unit (ICU) is most effective at decreasing MRSA-positive clinical cultures and ICU-acquired bloodstream infections. Overall, you would need to treat 54 patients with universal decolonization to prevent one bloodstream infection. The cost effectiveness of this strategy as well as the concern of emerging resistance was not addressed in this study. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Uncertain
Setting
Inpatient (ICU only)
Synopsis
Prior research has shown that daily bathing with chlorhexidine lowers the rate of MRSA acquisition and decreases the overall number of hospital-acquired bloodstream infections in the ICU (Daily POEM 4/26/13). The current study's goal was to identify whether targeted or universal MRSA decolonization is the most effective at reducing MRSA infections in the ICU. Investigators randomized 43 hospitals to use 1 of 3 strategies within all their adult ICUs: (1) MRSA screening and contact isolation only; (2) screening, isolation, and decolonization of MRSA carriers; (3) decolonization of all patients without any screening procedures. Screening for MRSA was performed via swabs of bilateral nares upon ICU admission in the first 2 groups. Contact precautions were implemented for those with a positive MRSA screening result in groups 1 and 2 and for those with history of MRSA colonization or infection in all groups. Decolonization in groups 2 and 3 consisted of 5 days of twice-daily intranasal mupirocin, as well as daily bathing with chlorhexidine cloths during the entire ICU stay. Baseline characteristics of the patient populations in each group were similar. Patients in all adult ICUs of a participating hospital were assigned to the same study group. Although both universal and targeted decolonization resulted in a significant reduction in the primary outcome of MRSA-positive clinical cultures, the universal strategy was found to be most effective (hazard ratio [HR] = 0.63 for the universal strategy; HR = 0.75 for the targeted strategy; and HR = 0.92 for screening and isolation; P = .01). Additionally, universal decolonization led to the greatest reduction of overall bloodstream infections (HR = 0.56 for universal; HR = 0.78 for targeted; HR = 0.99 for screening and isolation; P < .001). Of note, the universal decolonization group contained 3 of the 4 hospitals that performed bone marrow and solid-organ transplantations, resulting in a higher baseline risk of infection than the other groups, but this difference was not statistically significant. Overall, only severe adverse events were noted in this study and all were classified as mild pruritus or rash due to chlorhexidine bathing. Investigators did not evaluate the cost-effectiveness of the different strategies nor did they examine the emergence of resistance with widespread use of chlorhexidine and mupirocin.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does universal decolonization for methicillin-resistant Staphylococcus aureus (MRSA) in patients in the intensive care unit decrease the rate of MRSA-positive clinical cultures?
Bottom line
As compared with no decolonization or a targeted decolonization, a universal decolonization strategy for MRSA using intranasal mupirocin and chlorhexidine bathing cloths for all patients admitted to the intensive care unit (ICU) is most effective at decreasing MRSA-positive clinical cultures and ICU-acquired bloodstream infections. Overall, you would need to treat 54 patients with universal decolonization to prevent one bloodstream infection. The cost effectiveness of this strategy as well as the concern of emerging resistance was not addressed in this study. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Uncertain
Setting
Inpatient (ICU only)
Synopsis
Prior research has shown that daily bathing with chlorhexidine lowers the rate of MRSA acquisition and decreases the overall number of hospital-acquired bloodstream infections in the ICU (Daily POEM 4/26/13). The current study's goal was to identify whether targeted or universal MRSA decolonization is the most effective at reducing MRSA infections in the ICU. Investigators randomized 43 hospitals to use 1 of 3 strategies within all their adult ICUs: (1) MRSA screening and contact isolation only; (2) screening, isolation, and decolonization of MRSA carriers; (3) decolonization of all patients without any screening procedures. Screening for MRSA was performed via swabs of bilateral nares upon ICU admission in the first 2 groups. Contact precautions were implemented for those with a positive MRSA screening result in groups 1 and 2 and for those with history of MRSA colonization or infection in all groups. Decolonization in groups 2 and 3 consisted of 5 days of twice-daily intranasal mupirocin, as well as daily bathing with chlorhexidine cloths during the entire ICU stay. Baseline characteristics of the patient populations in each group were similar. Patients in all adult ICUs of a participating hospital were assigned to the same study group. Although both universal and targeted decolonization resulted in a significant reduction in the primary outcome of MRSA-positive clinical cultures, the universal strategy was found to be most effective (hazard ratio [HR] = 0.63 for the universal strategy; HR = 0.75 for the targeted strategy; and HR = 0.92 for screening and isolation; P = .01). Additionally, universal decolonization led to the greatest reduction of overall bloodstream infections (HR = 0.56 for universal; HR = 0.78 for targeted; HR = 0.99 for screening and isolation; P < .001). Of note, the universal decolonization group contained 3 of the 4 hospitals that performed bone marrow and solid-organ transplantations, resulting in a higher baseline risk of infection than the other groups, but this difference was not statistically significant. Overall, only severe adverse events were noted in this study and all were classified as mild pruritus or rash due to chlorhexidine bathing. Investigators did not evaluate the cost-effectiveness of the different strategies nor did they examine the emergence of resistance with widespread use of chlorhexidine and mupirocin.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does universal decolonization for methicillin-resistant Staphylococcus aureus (MRSA) in patients in the intensive care unit decrease the rate of MRSA-positive clinical cultures?
Bottom line
As compared with no decolonization or a targeted decolonization, a universal decolonization strategy for MRSA using intranasal mupirocin and chlorhexidine bathing cloths for all patients admitted to the intensive care unit (ICU) is most effective at decreasing MRSA-positive clinical cultures and ICU-acquired bloodstream infections. Overall, you would need to treat 54 patients with universal decolonization to prevent one bloodstream infection. The cost effectiveness of this strategy as well as the concern of emerging resistance was not addressed in this study. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Uncertain
Setting
Inpatient (ICU only)
Synopsis
Prior research has shown that daily bathing with chlorhexidine lowers the rate of MRSA acquisition and decreases the overall number of hospital-acquired bloodstream infections in the ICU (Daily POEM 4/26/13). The current study's goal was to identify whether targeted or universal MRSA decolonization is the most effective at reducing MRSA infections in the ICU. Investigators randomized 43 hospitals to use 1 of 3 strategies within all their adult ICUs: (1) MRSA screening and contact isolation only; (2) screening, isolation, and decolonization of MRSA carriers; (3) decolonization of all patients without any screening procedures. Screening for MRSA was performed via swabs of bilateral nares upon ICU admission in the first 2 groups. Contact precautions were implemented for those with a positive MRSA screening result in groups 1 and 2 and for those with history of MRSA colonization or infection in all groups. Decolonization in groups 2 and 3 consisted of 5 days of twice-daily intranasal mupirocin, as well as daily bathing with chlorhexidine cloths during the entire ICU stay. Baseline characteristics of the patient populations in each group were similar. Patients in all adult ICUs of a participating hospital were assigned to the same study group. Although both universal and targeted decolonization resulted in a significant reduction in the primary outcome of MRSA-positive clinical cultures, the universal strategy was found to be most effective (hazard ratio [HR] = 0.63 for the universal strategy; HR = 0.75 for the targeted strategy; and HR = 0.92 for screening and isolation; P = .01). Additionally, universal decolonization led to the greatest reduction of overall bloodstream infections (HR = 0.56 for universal; HR = 0.78 for targeted; HR = 0.99 for screening and isolation; P < .001). Of note, the universal decolonization group contained 3 of the 4 hospitals that performed bone marrow and solid-organ transplantations, resulting in a higher baseline risk of infection than the other groups, but this difference was not statistically significant. Overall, only severe adverse events were noted in this study and all were classified as mild pruritus or rash due to chlorhexidine bathing. Investigators did not evaluate the cost-effectiveness of the different strategies nor did they examine the emergence of resistance with widespread use of chlorhexidine and mupirocin.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Early Fibrinolysis Effective in STEMI but Causes More Strokes (STREAM)
Clinical question
Is early fibrinolysis followed by angiography an effective strategy for patients with STEMI presenting to hospitals without the capability to perform percutaneous coronary intervention?
Bottom line
Current guidelines recommend primary percutaneous coronary intervention (PCI) with a door-to-balloon time of 90 minutes for patients presenting with ST-segment elevation myocardial infarction (STEMI). However, this can be difficult to achieve, especially in remote areas without prompt access to PCI. This study finds that early fibrinolysis plus adjunctive antiplatelet and anticoagulant therapy followed by coronary angiography within 24 hours is effective in preventing adverse outcomes in patients presenting with recent onset symptoms of STEMI in whom PCI within 1 hour is not feasible. However, fibrinolysis therapy leads to a higher rate of ischemic strokes and intracranial bleeding, suggesting that timely PCI is still the optimal therapy for these patients. (LOE = 1b)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Industry
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Using concealed allocation, these investigators randomized 1892 patients who presented within 3 hours after onset of symptoms of STEMI but could not undergo PCI within 1 hour to receive 1 of 2 interventions: immediate transfer to a PCI-capable facility, or initial fibrinolysis treatment with tenecteplase followed by angiography within 24 hours. The fibrinolysis group also received enoxaparin and clopidogrel as adjunctive therapy. The primary endpoint was the composite of all-cause mortality, shock, congestive heart failure, or reinfarction at 30 days. Baseline characteristics were similar in the 2 groups, except for a higher frequency of previous congestive heart failure in the PCI group. Partway through the trial, the dose of tenecteplase was halved in patients 75 years or older because of a higher frequency of intracranial bleeds in this group. The median time from symptom onset to start of reperfusion therapy (either initiation of fibrinolysis or arterial sheath insertion for PCI) was shorter in the fibrinolysis group (100 minutes vs 178 minutes; P < .0001). However, one third of the patients in the fibrinolysis group required rescue PCI because of failed reperfusion. Overall, there were no significant differences detected between the 2 groups in either the primary endpoint or in the individual components of the endpoint. The fibrinolysis group had a higher rate of total hemorrhagic and ischemic strokes (1.6% vs 0.5%; P = .03).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Is early fibrinolysis followed by angiography an effective strategy for patients with STEMI presenting to hospitals without the capability to perform percutaneous coronary intervention?
Bottom line
Current guidelines recommend primary percutaneous coronary intervention (PCI) with a door-to-balloon time of 90 minutes for patients presenting with ST-segment elevation myocardial infarction (STEMI). However, this can be difficult to achieve, especially in remote areas without prompt access to PCI. This study finds that early fibrinolysis plus adjunctive antiplatelet and anticoagulant therapy followed by coronary angiography within 24 hours is effective in preventing adverse outcomes in patients presenting with recent onset symptoms of STEMI in whom PCI within 1 hour is not feasible. However, fibrinolysis therapy leads to a higher rate of ischemic strokes and intracranial bleeding, suggesting that timely PCI is still the optimal therapy for these patients. (LOE = 1b)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Industry
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Using concealed allocation, these investigators randomized 1892 patients who presented within 3 hours after onset of symptoms of STEMI but could not undergo PCI within 1 hour to receive 1 of 2 interventions: immediate transfer to a PCI-capable facility, or initial fibrinolysis treatment with tenecteplase followed by angiography within 24 hours. The fibrinolysis group also received enoxaparin and clopidogrel as adjunctive therapy. The primary endpoint was the composite of all-cause mortality, shock, congestive heart failure, or reinfarction at 30 days. Baseline characteristics were similar in the 2 groups, except for a higher frequency of previous congestive heart failure in the PCI group. Partway through the trial, the dose of tenecteplase was halved in patients 75 years or older because of a higher frequency of intracranial bleeds in this group. The median time from symptom onset to start of reperfusion therapy (either initiation of fibrinolysis or arterial sheath insertion for PCI) was shorter in the fibrinolysis group (100 minutes vs 178 minutes; P < .0001). However, one third of the patients in the fibrinolysis group required rescue PCI because of failed reperfusion. Overall, there were no significant differences detected between the 2 groups in either the primary endpoint or in the individual components of the endpoint. The fibrinolysis group had a higher rate of total hemorrhagic and ischemic strokes (1.6% vs 0.5%; P = .03).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Is early fibrinolysis followed by angiography an effective strategy for patients with STEMI presenting to hospitals without the capability to perform percutaneous coronary intervention?
Bottom line
Current guidelines recommend primary percutaneous coronary intervention (PCI) with a door-to-balloon time of 90 minutes for patients presenting with ST-segment elevation myocardial infarction (STEMI). However, this can be difficult to achieve, especially in remote areas without prompt access to PCI. This study finds that early fibrinolysis plus adjunctive antiplatelet and anticoagulant therapy followed by coronary angiography within 24 hours is effective in preventing adverse outcomes in patients presenting with recent onset symptoms of STEMI in whom PCI within 1 hour is not feasible. However, fibrinolysis therapy leads to a higher rate of ischemic strokes and intracranial bleeding, suggesting that timely PCI is still the optimal therapy for these patients. (LOE = 1b)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Industry
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Using concealed allocation, these investigators randomized 1892 patients who presented within 3 hours after onset of symptoms of STEMI but could not undergo PCI within 1 hour to receive 1 of 2 interventions: immediate transfer to a PCI-capable facility, or initial fibrinolysis treatment with tenecteplase followed by angiography within 24 hours. The fibrinolysis group also received enoxaparin and clopidogrel as adjunctive therapy. The primary endpoint was the composite of all-cause mortality, shock, congestive heart failure, or reinfarction at 30 days. Baseline characteristics were similar in the 2 groups, except for a higher frequency of previous congestive heart failure in the PCI group. Partway through the trial, the dose of tenecteplase was halved in patients 75 years or older because of a higher frequency of intracranial bleeds in this group. The median time from symptom onset to start of reperfusion therapy (either initiation of fibrinolysis or arterial sheath insertion for PCI) was shorter in the fibrinolysis group (100 minutes vs 178 minutes; P < .0001). However, one third of the patients in the fibrinolysis group required rescue PCI because of failed reperfusion. Overall, there were no significant differences detected between the 2 groups in either the primary endpoint or in the individual components of the endpoint. The fibrinolysis group had a higher rate of total hemorrhagic and ischemic strokes (1.6% vs 0.5%; P = .03).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
No Difference in Long-Term Outcomes with Full vs Trophic Feeding for Acute Lung Injury Patients
Clinical question
Does initial trophic feeding, as compared with full feeding, affect long-term outcomes in critically ill patients with acute lung injury?
Bottom line
There were no significant long-term differences in physical function, survival, psychological symptoms, or cognitive function in patients with acute lung injury who received initial trophic feeding as compared with full enteral feeding. (LOE = 1b)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Low-energy permissive underfeeding, or "trophic feeding," is one proposed nutritional strategy for mechanically ventilated patients. The previously published EDEN trial showed no significant differences in short-term mortality or ventilation-free days in patients with acute lung injury who received initial trophic feeding versus full enteral feeding (Rice, et al. JAMA 2012;307(8):795-803). In this follow-up of the EDEN trial, investigators examined the long-term effects of this intervention. The patients included in the EDEN trial had acute lung injury primarily due to pneumonia or sepsis and had a mean age of 52 years. The patients were randomized to either full feeding (meeting 80% of the caloric goal) or trophic feeding (meeting 25% of the caloric goal) for up to 6 days. Of the 951 patients in the initial EDEN trial, 563 consented to this follow-up study. Research staff interviewed the surviving participants at 6 months (n = 514) and at 12 months (n = 487). Taken together, these patients had decreased physical and mental abilities as compared with population norms, impaired quality of life and return to work, and increased psychological symptoms. When comparing the full feeding cohort with the patients that received trophic feeding, there was no significant difference in the primary outcome of physical function at 6 or 12 months as assessed by the Short-form Health Outcomes Survey (SF-36). The SF-36 mental health measures favored the trophic feeding group at 12 months, but the differences in scores were small. Overall, there were no differences in specific psychological symptoms -- such as anxiety or depression, 12-month survival, cognitive function, or employment status -- between the 2 groups.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does initial trophic feeding, as compared with full feeding, affect long-term outcomes in critically ill patients with acute lung injury?
Bottom line
There were no significant long-term differences in physical function, survival, psychological symptoms, or cognitive function in patients with acute lung injury who received initial trophic feeding as compared with full enteral feeding. (LOE = 1b)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Low-energy permissive underfeeding, or "trophic feeding," is one proposed nutritional strategy for mechanically ventilated patients. The previously published EDEN trial showed no significant differences in short-term mortality or ventilation-free days in patients with acute lung injury who received initial trophic feeding versus full enteral feeding (Rice, et al. JAMA 2012;307(8):795-803). In this follow-up of the EDEN trial, investigators examined the long-term effects of this intervention. The patients included in the EDEN trial had acute lung injury primarily due to pneumonia or sepsis and had a mean age of 52 years. The patients were randomized to either full feeding (meeting 80% of the caloric goal) or trophic feeding (meeting 25% of the caloric goal) for up to 6 days. Of the 951 patients in the initial EDEN trial, 563 consented to this follow-up study. Research staff interviewed the surviving participants at 6 months (n = 514) and at 12 months (n = 487). Taken together, these patients had decreased physical and mental abilities as compared with population norms, impaired quality of life and return to work, and increased psychological symptoms. When comparing the full feeding cohort with the patients that received trophic feeding, there was no significant difference in the primary outcome of physical function at 6 or 12 months as assessed by the Short-form Health Outcomes Survey (SF-36). The SF-36 mental health measures favored the trophic feeding group at 12 months, but the differences in scores were small. Overall, there were no differences in specific psychological symptoms -- such as anxiety or depression, 12-month survival, cognitive function, or employment status -- between the 2 groups.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does initial trophic feeding, as compared with full feeding, affect long-term outcomes in critically ill patients with acute lung injury?
Bottom line
There were no significant long-term differences in physical function, survival, psychological symptoms, or cognitive function in patients with acute lung injury who received initial trophic feeding as compared with full enteral feeding. (LOE = 1b)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Low-energy permissive underfeeding, or "trophic feeding," is one proposed nutritional strategy for mechanically ventilated patients. The previously published EDEN trial showed no significant differences in short-term mortality or ventilation-free days in patients with acute lung injury who received initial trophic feeding versus full enteral feeding (Rice, et al. JAMA 2012;307(8):795-803). In this follow-up of the EDEN trial, investigators examined the long-term effects of this intervention. The patients included in the EDEN trial had acute lung injury primarily due to pneumonia or sepsis and had a mean age of 52 years. The patients were randomized to either full feeding (meeting 80% of the caloric goal) or trophic feeding (meeting 25% of the caloric goal) for up to 6 days. Of the 951 patients in the initial EDEN trial, 563 consented to this follow-up study. Research staff interviewed the surviving participants at 6 months (n = 514) and at 12 months (n = 487). Taken together, these patients had decreased physical and mental abilities as compared with population norms, impaired quality of life and return to work, and increased psychological symptoms. When comparing the full feeding cohort with the patients that received trophic feeding, there was no significant difference in the primary outcome of physical function at 6 or 12 months as assessed by the Short-form Health Outcomes Survey (SF-36). The SF-36 mental health measures favored the trophic feeding group at 12 months, but the differences in scores were small. Overall, there were no differences in specific psychological symptoms -- such as anxiety or depression, 12-month survival, cognitive function, or employment status -- between the 2 groups.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Top 10 Strategies to Improve Patient Safety
Clinical question
What are the most effective strategies in improving patient safety?
Bottom line
This group of experts, commissioned by the Agency for Healthcare Research and Quality (AHRQ), outlined the top 10 strategies for improved patient safety. These strategies, which are "strongly encouraged" for adoption in all health care systems, consist primarily of interventions that help prevent health care-associated infections and avoid medical errors. LOE = 5
Reference
Study design
Systematic review
Funding source
Government
Allocation
Uncertain
Setting
Various (guideline)
Synopsis
Previous publications by the Institute of Medicine and the AHRQ have highlighted the importance of patient safety practices. A group of researchers, supported by the AHRQ, evaluated the data on current strategies to improve patient safety. The group assessed the quality of existing systematic reviews on these topics and performed new literature searches when needed. The focus was on data that reported on implementation and adoption of these strategies, as well as on the context in which they have been used. Individual studies on safety interventions were examined for quality and risk of bias. The authors rated the strength of evidence of the effectiveness of each intervention, reported evidence on possible harmful consequences, assessed difficulty in implementation, and estimated costs. Of the 41 safety strategies that were evaluated, the following 10 were chosen as strategies that are "strongly encouraged" for adoption now: 1. Preoperative and anesthesia checklists to prevent perioperative events 2. Bundles that include checklists to prevent central line-associated bloodstream infections 3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders , or nurse-initiated removal protocols 4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia 5. Hand hygiene 6. The do-not-use list for hazardous abbreviations 7. Multicomponent interventions to reduce pressure ulcers 8. Barrier precautions to prevent health care-associated infections 9. Use of real-time ultrasonography for central line placement 10. Interventions to improve prophylaxis for venous thromboembolism.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
What are the most effective strategies in improving patient safety?
Bottom line
This group of experts, commissioned by the Agency for Healthcare Research and Quality (AHRQ), outlined the top 10 strategies for improved patient safety. These strategies, which are "strongly encouraged" for adoption in all health care systems, consist primarily of interventions that help prevent health care-associated infections and avoid medical errors. LOE = 5
Reference
Study design
Systematic review
Funding source
Government
Allocation
Uncertain
Setting
Various (guideline)
Synopsis
Previous publications by the Institute of Medicine and the AHRQ have highlighted the importance of patient safety practices. A group of researchers, supported by the AHRQ, evaluated the data on current strategies to improve patient safety. The group assessed the quality of existing systematic reviews on these topics and performed new literature searches when needed. The focus was on data that reported on implementation and adoption of these strategies, as well as on the context in which they have been used. Individual studies on safety interventions were examined for quality and risk of bias. The authors rated the strength of evidence of the effectiveness of each intervention, reported evidence on possible harmful consequences, assessed difficulty in implementation, and estimated costs. Of the 41 safety strategies that were evaluated, the following 10 were chosen as strategies that are "strongly encouraged" for adoption now: 1. Preoperative and anesthesia checklists to prevent perioperative events 2. Bundles that include checklists to prevent central line-associated bloodstream infections 3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders , or nurse-initiated removal protocols 4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia 5. Hand hygiene 6. The do-not-use list for hazardous abbreviations 7. Multicomponent interventions to reduce pressure ulcers 8. Barrier precautions to prevent health care-associated infections 9. Use of real-time ultrasonography for central line placement 10. Interventions to improve prophylaxis for venous thromboembolism.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
What are the most effective strategies in improving patient safety?
Bottom line
This group of experts, commissioned by the Agency for Healthcare Research and Quality (AHRQ), outlined the top 10 strategies for improved patient safety. These strategies, which are "strongly encouraged" for adoption in all health care systems, consist primarily of interventions that help prevent health care-associated infections and avoid medical errors. LOE = 5
Reference
Study design
Systematic review
Funding source
Government
Allocation
Uncertain
Setting
Various (guideline)
Synopsis
Previous publications by the Institute of Medicine and the AHRQ have highlighted the importance of patient safety practices. A group of researchers, supported by the AHRQ, evaluated the data on current strategies to improve patient safety. The group assessed the quality of existing systematic reviews on these topics and performed new literature searches when needed. The focus was on data that reported on implementation and adoption of these strategies, as well as on the context in which they have been used. Individual studies on safety interventions were examined for quality and risk of bias. The authors rated the strength of evidence of the effectiveness of each intervention, reported evidence on possible harmful consequences, assessed difficulty in implementation, and estimated costs. Of the 41 safety strategies that were evaluated, the following 10 were chosen as strategies that are "strongly encouraged" for adoption now: 1. Preoperative and anesthesia checklists to prevent perioperative events 2. Bundles that include checklists to prevent central line-associated bloodstream infections 3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders , or nurse-initiated removal protocols 4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia 5. Hand hygiene 6. The do-not-use list for hazardous abbreviations 7. Multicomponent interventions to reduce pressure ulcers 8. Barrier precautions to prevent health care-associated infections 9. Use of real-time ultrasonography for central line placement 10. Interventions to improve prophylaxis for venous thromboembolism.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
No Reduction in Mortality or Readmission with Addition of Aliskiren for HF Patients (ASTRONAUT)
Clinical question
Does the addition of aliskiren, a direct renin inhibitor, to standard therapy decrease mortality and readmission in patients hospitalized for worsening heart failure?
Bottom line
The addition of aliskiren to standard therapy in patients hospitalized with heart failure (HF) does not reduce cardiovascular mortality or HF readmission rates. LOE = 1b
Reference
Study design
Randomized controlled trial (double-blinded)
Funding source
Industry
Allocation
Uncertain
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Despite current standard therapy, postdischarge mortality and rehospitalizations remain high for patients hospitalized for HF. To study the effect of direct renin inhibitors on these outcomes, investigators enrolled adults hospitalized for worsening HF with a left ventricular ejection fraction (LVEF) of 40% or less. Once these patients were clinically and hemodynamically stable, they were randomized to receive aliskiren 150 mg daily or placebo. Study patients were followed up at regular intervals and the aliskiren dose was increased to 300 mg daily as long as the initial dose was tolerated. Aliskiren, either 150 mg or 300 mg, was then continued up to a maximum follow-up time of 12 months. All patients also received standard HF therapy at the discretion of their treating physicians. The 2 groups had similar baseline characteristics. The patients' mean age was 65 years, mean LVEF was 28%, and the majority were New York Heart Association Class III-IV at randomization. For the primary end point of either cardiovascular death or HF rehospitalization at 6 months, there was no significant difference between the aliskiren and placebo groups. Events rates between the 2 groups were also similar at 12 months. The aliskiren group was more likely to experience hyperkalemia, hypotension, and renal impairment or renal failure. Additionally, a subgroup analysis showed that patients with diabetes fared worse with aliskiren, with a greater risk of all-cause mortality at 12 months, than those who took placebo.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does the addition of aliskiren, a direct renin inhibitor, to standard therapy decrease mortality and readmission in patients hospitalized for worsening heart failure?
Bottom line
The addition of aliskiren to standard therapy in patients hospitalized with heart failure (HF) does not reduce cardiovascular mortality or HF readmission rates. LOE = 1b
Reference
Study design
Randomized controlled trial (double-blinded)
Funding source
Industry
Allocation
Uncertain
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Despite current standard therapy, postdischarge mortality and rehospitalizations remain high for patients hospitalized for HF. To study the effect of direct renin inhibitors on these outcomes, investigators enrolled adults hospitalized for worsening HF with a left ventricular ejection fraction (LVEF) of 40% or less. Once these patients were clinically and hemodynamically stable, they were randomized to receive aliskiren 150 mg daily or placebo. Study patients were followed up at regular intervals and the aliskiren dose was increased to 300 mg daily as long as the initial dose was tolerated. Aliskiren, either 150 mg or 300 mg, was then continued up to a maximum follow-up time of 12 months. All patients also received standard HF therapy at the discretion of their treating physicians. The 2 groups had similar baseline characteristics. The patients' mean age was 65 years, mean LVEF was 28%, and the majority were New York Heart Association Class III-IV at randomization. For the primary end point of either cardiovascular death or HF rehospitalization at 6 months, there was no significant difference between the aliskiren and placebo groups. Events rates between the 2 groups were also similar at 12 months. The aliskiren group was more likely to experience hyperkalemia, hypotension, and renal impairment or renal failure. Additionally, a subgroup analysis showed that patients with diabetes fared worse with aliskiren, with a greater risk of all-cause mortality at 12 months, than those who took placebo.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does the addition of aliskiren, a direct renin inhibitor, to standard therapy decrease mortality and readmission in patients hospitalized for worsening heart failure?
Bottom line
The addition of aliskiren to standard therapy in patients hospitalized with heart failure (HF) does not reduce cardiovascular mortality or HF readmission rates. LOE = 1b
Reference
Study design
Randomized controlled trial (double-blinded)
Funding source
Industry
Allocation
Uncertain
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Despite current standard therapy, postdischarge mortality and rehospitalizations remain high for patients hospitalized for HF. To study the effect of direct renin inhibitors on these outcomes, investigators enrolled adults hospitalized for worsening HF with a left ventricular ejection fraction (LVEF) of 40% or less. Once these patients were clinically and hemodynamically stable, they were randomized to receive aliskiren 150 mg daily or placebo. Study patients were followed up at regular intervals and the aliskiren dose was increased to 300 mg daily as long as the initial dose was tolerated. Aliskiren, either 150 mg or 300 mg, was then continued up to a maximum follow-up time of 12 months. All patients also received standard HF therapy at the discretion of their treating physicians. The 2 groups had similar baseline characteristics. The patients' mean age was 65 years, mean LVEF was 28%, and the majority were New York Heart Association Class III-IV at randomization. For the primary end point of either cardiovascular death or HF rehospitalization at 6 months, there was no significant difference between the aliskiren and placebo groups. Events rates between the 2 groups were also similar at 12 months. The aliskiren group was more likely to experience hyperkalemia, hypotension, and renal impairment or renal failure. Additionally, a subgroup analysis showed that patients with diabetes fared worse with aliskiren, with a greater risk of all-cause mortality at 12 months, than those who took placebo.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
John Nelson: Fixing Complaints Between Primary-Care Physicians, Hospitalists Not Always Easy
In the course of my work with hospitalist practices around the country, I end up speaking with a lot of primary-care physicians (PCPs) who refer patients to hospitalists. I nearly always hear the same three frustrations or complaints from them:
- “I’m not reliably notified when my patient is admitted or discharged.”
- “The hospitalists too often make unnecessary or unhelpful changes in patients’ chronic medicines, because they either never get an accurate home medicine list to begin with, or too liberally adjust chronic therapy that should be left to me.”
- “I wish the hospitalists were more open to directly admitting some patients from my office, to save the patient the stress and expenses of an unnecessary stop in the ED.”
I’ve listed them in ascending order of what I think is difficulty to fix. The first of these can be difficult but not impossible to fix, while the last one—direct admissions—is really tricky to “fix” to the satisfaction of both hospitalists and most PCPs.
Direct Admissions and HM Reluctance
When explaining why they resist direct admissions, most hospitalists raise concerns that I too share. They typically begin with an anecdote, often from years ago, of a patient the PCP described as stable, but was in extremis when arriving to the floor bed and required emergent transfer to the ICU. In fact, I suspect this has happened at least once or twice to nearly every hospitalist. Much to the frustration of PCPs, hospital leaders, and some patients, this concern has led a number of HM groups to adopt a policy of never accepting direct admissions. They insist that all patients are seen first in the ED, which typically means that the ED physician, rather than the hospitalist, is the first doctor the patient encounters at the hospital.
Other reasons cited for reluctance or refusal to accept direct admissions include the longer time required to get test results like blood work or chest X-rays when ordered from the floor versus the ED. And because the patient’s precise time of arrival can’t be known, it is tricky for some groups to determine in advance which hospitalist will be seeing the patient, resulting in a complicated handoff.
Some PCPs, especially those who have practiced for decades, might be remembering the rationale and process for admitting patients years ago and inappropriately request direct admission for a patient who might not even need the hospital. But while it seems clear this happens occasionally, hospitalists could have a bias, leading them to feel like it is a much more common problem than it really is.
All of these are legitimate concerns, though in most settings I don’t think they justify setting a firm rule of “no direct admissions.”
Dearth of Meaningful Data to Guide Policy
There are seemingly an endless number of studies about things like the effects of resident work-hours and the value of handoff communication, so the literature must be full of studies about direct admissions. Surely some of the risks are offset by improvements in safety and fewer handoffs (by eliminating the ED doctor). But sadly, there aren’t any studies to go on. I couldn’t find a single one. (If you know of one or more studies that directly examine direct admissions from PCP offices, please let me know.)
The Agency for Healthcare Research and Quality (AHRQ) has a 2008 case study titled “Is It Safe to Be Direct?” (www.webmm.ahrq.gov/case.aspx?caseID=178) that describes and comments on a direct-admit case that didn’t go well, but it is an opinion piece without empiric data.1
The absence of research studies doesn’t stop a lot of people, including me, from expressing their opinions. Numerous articles and opinion pieces are available on the Internet. They generally summarize that despite having the same goal of safe and efficient patient care, PCPs and hospitalists often see direct admissions a little differently.
An Internet search of ”direct admission + hospitalist” turns up the practice website for a hospitalist group. I found several such sites that do accept direct admissions. Presumably, those hospitalist groups that refuse to accept direct admissions don’t advertise that on their website so don’t turn up in a search. This one is typical:
Hospitalists are also available to facilitate direct admissions to Beth Israel Deaconess Hospital-Needham, so that patients can avoid a trip through the emergency department. Please note that it is Beth Israel Deaconess Hospital-Needham policy that the patient needs to have been seen by the primary-care provider or specialist physician within the previous 24 hours to qualify for direct admission status.
Mass General Hospital for Children in Boston has posted a very detailed approach to direct admissions2 allowing them only from some PCP groups (presumably those in their system), and only when the patient has been seen in the office on the day of admission. And the hospitalist program at Johns Hopkins Hospital in Baltimore advertises its “VIP Direct-Admitting Service.”3
Recommendations
I’ve come to the following conclusions that I think most groups could follow, though I realize thoughtful people can see this differently.
- Most hospitalist groups should not have a policy of refusing all direct admissions. They should thoughtfully listen every time a doctor calls asking to refer a patient directly from an office setting. And, at least some of the time, they should say yes.
- You should more liberally accept direct admissions from PCPs you work with regularly. The better you know the PCP (i.e. have cared for many of that doctor’s patients), the more you can judge the risk the patient will arrive in a condition other than described.
- Requiring that the patient be in the office at the time of the decision to accept the direct admission, or within the preceding 12 or 24 hours, is a good idea.
- Work with your hospital to improve the speed of testing like blood work and X-rays done “on the floor” on new admissions so they’re resulted as quickly as in the ED. Consider notifying in advance the relevant department that you’ll likely be ordering a stat study as soon as the patient arrives. This is sort of like calling a restaurant to get in line for a table before you arrive.
- The hospitalist should have the final say regarding whether a patient is appropriate for direct admission, or whether it is best to stop in the ED first. That is the case for all the practices I mentioned above. But don’t let this insulate you from the very real frustration suffered by PCPs and patients, should you unfairly refuse to allow it.
I don’t have any idea what might be an appropriate portion of direct admissions for a typical hospitalist practice; it’s probably no more than 1% or 2%. But I don’t think it should be zero.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
References
- Kulkarni N, Williams M. Is it safe to be direct? Agency for Healthcare Research and Quality website. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=178. Accessed Feb. 2, 2013.
- MassGeneral Hospital for Children. Direct admit policy. MassGeneral Hospital for Children website. Available at: http://www.massgeneral.org/children/professionals/direct_admit_policy.aspx. Accessed Feb. 2, 2013.
- Johns Hopkins Medicine. Hospitalists Introduce VIP Direct-Admitting Service. Johns Hopkins Medicine website. Available at: http://www.hopkinsmedicine.org/gim/news/2010_News_Items/6-17-10.html. Accessed Feb. 2, 2013.
In the course of my work with hospitalist practices around the country, I end up speaking with a lot of primary-care physicians (PCPs) who refer patients to hospitalists. I nearly always hear the same three frustrations or complaints from them:
- “I’m not reliably notified when my patient is admitted or discharged.”
- “The hospitalists too often make unnecessary or unhelpful changes in patients’ chronic medicines, because they either never get an accurate home medicine list to begin with, or too liberally adjust chronic therapy that should be left to me.”
- “I wish the hospitalists were more open to directly admitting some patients from my office, to save the patient the stress and expenses of an unnecessary stop in the ED.”
I’ve listed them in ascending order of what I think is difficulty to fix. The first of these can be difficult but not impossible to fix, while the last one—direct admissions—is really tricky to “fix” to the satisfaction of both hospitalists and most PCPs.
Direct Admissions and HM Reluctance
When explaining why they resist direct admissions, most hospitalists raise concerns that I too share. They typically begin with an anecdote, often from years ago, of a patient the PCP described as stable, but was in extremis when arriving to the floor bed and required emergent transfer to the ICU. In fact, I suspect this has happened at least once or twice to nearly every hospitalist. Much to the frustration of PCPs, hospital leaders, and some patients, this concern has led a number of HM groups to adopt a policy of never accepting direct admissions. They insist that all patients are seen first in the ED, which typically means that the ED physician, rather than the hospitalist, is the first doctor the patient encounters at the hospital.
Other reasons cited for reluctance or refusal to accept direct admissions include the longer time required to get test results like blood work or chest X-rays when ordered from the floor versus the ED. And because the patient’s precise time of arrival can’t be known, it is tricky for some groups to determine in advance which hospitalist will be seeing the patient, resulting in a complicated handoff.
Some PCPs, especially those who have practiced for decades, might be remembering the rationale and process for admitting patients years ago and inappropriately request direct admission for a patient who might not even need the hospital. But while it seems clear this happens occasionally, hospitalists could have a bias, leading them to feel like it is a much more common problem than it really is.
All of these are legitimate concerns, though in most settings I don’t think they justify setting a firm rule of “no direct admissions.”
Dearth of Meaningful Data to Guide Policy
There are seemingly an endless number of studies about things like the effects of resident work-hours and the value of handoff communication, so the literature must be full of studies about direct admissions. Surely some of the risks are offset by improvements in safety and fewer handoffs (by eliminating the ED doctor). But sadly, there aren’t any studies to go on. I couldn’t find a single one. (If you know of one or more studies that directly examine direct admissions from PCP offices, please let me know.)
The Agency for Healthcare Research and Quality (AHRQ) has a 2008 case study titled “Is It Safe to Be Direct?” (www.webmm.ahrq.gov/case.aspx?caseID=178) that describes and comments on a direct-admit case that didn’t go well, but it is an opinion piece without empiric data.1
The absence of research studies doesn’t stop a lot of people, including me, from expressing their opinions. Numerous articles and opinion pieces are available on the Internet. They generally summarize that despite having the same goal of safe and efficient patient care, PCPs and hospitalists often see direct admissions a little differently.
An Internet search of ”direct admission + hospitalist” turns up the practice website for a hospitalist group. I found several such sites that do accept direct admissions. Presumably, those hospitalist groups that refuse to accept direct admissions don’t advertise that on their website so don’t turn up in a search. This one is typical:
Hospitalists are also available to facilitate direct admissions to Beth Israel Deaconess Hospital-Needham, so that patients can avoid a trip through the emergency department. Please note that it is Beth Israel Deaconess Hospital-Needham policy that the patient needs to have been seen by the primary-care provider or specialist physician within the previous 24 hours to qualify for direct admission status.
Mass General Hospital for Children in Boston has posted a very detailed approach to direct admissions2 allowing them only from some PCP groups (presumably those in their system), and only when the patient has been seen in the office on the day of admission. And the hospitalist program at Johns Hopkins Hospital in Baltimore advertises its “VIP Direct-Admitting Service.”3
Recommendations
I’ve come to the following conclusions that I think most groups could follow, though I realize thoughtful people can see this differently.
- Most hospitalist groups should not have a policy of refusing all direct admissions. They should thoughtfully listen every time a doctor calls asking to refer a patient directly from an office setting. And, at least some of the time, they should say yes.
- You should more liberally accept direct admissions from PCPs you work with regularly. The better you know the PCP (i.e. have cared for many of that doctor’s patients), the more you can judge the risk the patient will arrive in a condition other than described.
- Requiring that the patient be in the office at the time of the decision to accept the direct admission, or within the preceding 12 or 24 hours, is a good idea.
- Work with your hospital to improve the speed of testing like blood work and X-rays done “on the floor” on new admissions so they’re resulted as quickly as in the ED. Consider notifying in advance the relevant department that you’ll likely be ordering a stat study as soon as the patient arrives. This is sort of like calling a restaurant to get in line for a table before you arrive.
- The hospitalist should have the final say regarding whether a patient is appropriate for direct admission, or whether it is best to stop in the ED first. That is the case for all the practices I mentioned above. But don’t let this insulate you from the very real frustration suffered by PCPs and patients, should you unfairly refuse to allow it.
I don’t have any idea what might be an appropriate portion of direct admissions for a typical hospitalist practice; it’s probably no more than 1% or 2%. But I don’t think it should be zero.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
References
- Kulkarni N, Williams M. Is it safe to be direct? Agency for Healthcare Research and Quality website. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=178. Accessed Feb. 2, 2013.
- MassGeneral Hospital for Children. Direct admit policy. MassGeneral Hospital for Children website. Available at: http://www.massgeneral.org/children/professionals/direct_admit_policy.aspx. Accessed Feb. 2, 2013.
- Johns Hopkins Medicine. Hospitalists Introduce VIP Direct-Admitting Service. Johns Hopkins Medicine website. Available at: http://www.hopkinsmedicine.org/gim/news/2010_News_Items/6-17-10.html. Accessed Feb. 2, 2013.
In the course of my work with hospitalist practices around the country, I end up speaking with a lot of primary-care physicians (PCPs) who refer patients to hospitalists. I nearly always hear the same three frustrations or complaints from them:
- “I’m not reliably notified when my patient is admitted or discharged.”
- “The hospitalists too often make unnecessary or unhelpful changes in patients’ chronic medicines, because they either never get an accurate home medicine list to begin with, or too liberally adjust chronic therapy that should be left to me.”
- “I wish the hospitalists were more open to directly admitting some patients from my office, to save the patient the stress and expenses of an unnecessary stop in the ED.”
I’ve listed them in ascending order of what I think is difficulty to fix. The first of these can be difficult but not impossible to fix, while the last one—direct admissions—is really tricky to “fix” to the satisfaction of both hospitalists and most PCPs.
Direct Admissions and HM Reluctance
When explaining why they resist direct admissions, most hospitalists raise concerns that I too share. They typically begin with an anecdote, often from years ago, of a patient the PCP described as stable, but was in extremis when arriving to the floor bed and required emergent transfer to the ICU. In fact, I suspect this has happened at least once or twice to nearly every hospitalist. Much to the frustration of PCPs, hospital leaders, and some patients, this concern has led a number of HM groups to adopt a policy of never accepting direct admissions. They insist that all patients are seen first in the ED, which typically means that the ED physician, rather than the hospitalist, is the first doctor the patient encounters at the hospital.
Other reasons cited for reluctance or refusal to accept direct admissions include the longer time required to get test results like blood work or chest X-rays when ordered from the floor versus the ED. And because the patient’s precise time of arrival can’t be known, it is tricky for some groups to determine in advance which hospitalist will be seeing the patient, resulting in a complicated handoff.
Some PCPs, especially those who have practiced for decades, might be remembering the rationale and process for admitting patients years ago and inappropriately request direct admission for a patient who might not even need the hospital. But while it seems clear this happens occasionally, hospitalists could have a bias, leading them to feel like it is a much more common problem than it really is.
All of these are legitimate concerns, though in most settings I don’t think they justify setting a firm rule of “no direct admissions.”
Dearth of Meaningful Data to Guide Policy
There are seemingly an endless number of studies about things like the effects of resident work-hours and the value of handoff communication, so the literature must be full of studies about direct admissions. Surely some of the risks are offset by improvements in safety and fewer handoffs (by eliminating the ED doctor). But sadly, there aren’t any studies to go on. I couldn’t find a single one. (If you know of one or more studies that directly examine direct admissions from PCP offices, please let me know.)
The Agency for Healthcare Research and Quality (AHRQ) has a 2008 case study titled “Is It Safe to Be Direct?” (www.webmm.ahrq.gov/case.aspx?caseID=178) that describes and comments on a direct-admit case that didn’t go well, but it is an opinion piece without empiric data.1
The absence of research studies doesn’t stop a lot of people, including me, from expressing their opinions. Numerous articles and opinion pieces are available on the Internet. They generally summarize that despite having the same goal of safe and efficient patient care, PCPs and hospitalists often see direct admissions a little differently.
An Internet search of ”direct admission + hospitalist” turns up the practice website for a hospitalist group. I found several such sites that do accept direct admissions. Presumably, those hospitalist groups that refuse to accept direct admissions don’t advertise that on their website so don’t turn up in a search. This one is typical:
Hospitalists are also available to facilitate direct admissions to Beth Israel Deaconess Hospital-Needham, so that patients can avoid a trip through the emergency department. Please note that it is Beth Israel Deaconess Hospital-Needham policy that the patient needs to have been seen by the primary-care provider or specialist physician within the previous 24 hours to qualify for direct admission status.
Mass General Hospital for Children in Boston has posted a very detailed approach to direct admissions2 allowing them only from some PCP groups (presumably those in their system), and only when the patient has been seen in the office on the day of admission. And the hospitalist program at Johns Hopkins Hospital in Baltimore advertises its “VIP Direct-Admitting Service.”3
Recommendations
I’ve come to the following conclusions that I think most groups could follow, though I realize thoughtful people can see this differently.
- Most hospitalist groups should not have a policy of refusing all direct admissions. They should thoughtfully listen every time a doctor calls asking to refer a patient directly from an office setting. And, at least some of the time, they should say yes.
- You should more liberally accept direct admissions from PCPs you work with regularly. The better you know the PCP (i.e. have cared for many of that doctor’s patients), the more you can judge the risk the patient will arrive in a condition other than described.
- Requiring that the patient be in the office at the time of the decision to accept the direct admission, or within the preceding 12 or 24 hours, is a good idea.
- Work with your hospital to improve the speed of testing like blood work and X-rays done “on the floor” on new admissions so they’re resulted as quickly as in the ED. Consider notifying in advance the relevant department that you’ll likely be ordering a stat study as soon as the patient arrives. This is sort of like calling a restaurant to get in line for a table before you arrive.
- The hospitalist should have the final say regarding whether a patient is appropriate for direct admission, or whether it is best to stop in the ED first. That is the case for all the practices I mentioned above. But don’t let this insulate you from the very real frustration suffered by PCPs and patients, should you unfairly refuse to allow it.
I don’t have any idea what might be an appropriate portion of direct admissions for a typical hospitalist practice; it’s probably no more than 1% or 2%. But I don’t think it should be zero.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
References
- Kulkarni N, Williams M. Is it safe to be direct? Agency for Healthcare Research and Quality website. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=178. Accessed Feb. 2, 2013.
- MassGeneral Hospital for Children. Direct admit policy. MassGeneral Hospital for Children website. Available at: http://www.massgeneral.org/children/professionals/direct_admit_policy.aspx. Accessed Feb. 2, 2013.
- Johns Hopkins Medicine. Hospitalists Introduce VIP Direct-Admitting Service. Johns Hopkins Medicine website. Available at: http://www.hopkinsmedicine.org/gim/news/2010_News_Items/6-17-10.html. Accessed Feb. 2, 2013.
Accurate Measures?
Everyone’s talking about quality. Encouraging high-value care is one of the stated objectives of the value-based purchasing program being rolled out by the Centers for Medicare & Medicaid Services (CMS). It’s also the subject of a new report to Congress from the Department of Health and Human Services (HHS), “National Strategy for Quality Improvement in Health Care” (www.healthcare.gov/center/reports/quality03212011a.html). For its part, SHM is placing added emphasis on a range of mentored quality-improvement (QI) initiatives for hospitalists.
Amid the flurry of activity, researchers are still attempting to address a central question that could determine the success or failure of many such efforts: How do you accurately measure what constitutes high-quality care?
Chris Murray, MD, DPhil, director of the Seattle-based Institute for Health Metrics and Evaluation, says the healthcare field traditionally has tried to assess quality in three main ways. One is to ask patients about their own experience: Were they satisfied with the level of care they received? Another is to assess what are known as process of care measures: Did the providers follow guidelines in providing patients with appropriate care? The third is to look at risk-adjusted outcomes: How did the patients ultimately fare?
Focused on Facts
CMS’s value-based purchasing program, at least initially, is focusing on the first two types of metrics. Process measures, Dr. Murray says, are popular in part because they’re relatively easy to gauge. For many of them, however, “the connection to improved health is a bit weak,” he says. Whether heart patients get a prescription for a beta-blocker drug, for example, doesn’t address the outcome. “The problem there is that we don’t know if they ever filled the prescription or if the patient takes the beta-blocker,” Dr. Murray says.
That uncertainty feeds into the larger question of how broadly to consider the accountability of providers when measuring quality. “Should we be thinking that quality means putting in place the supports required for a patient to actually achieve a good outcome, or just offering them?” Dr. Murray asks. The debate might be far from settled, but a growing number of tools and studies are at least helping researchers to connect the dots on how care is delivered, on what kind of practices might affect outcomes the most, and how a community’s underlying risks could influence both considerations.
A recent Annals of Internal Medicine study that scrutinized 30-day mortality rates for heart-attack patients found few quantitative differences between the top 5% and bottom 5% of hospitals, based on rates published on the CMS Hospital Compare website.1 Site visits and in-depth interviews with nearly 160 medical staff members, however, uncovered some telling distinctions.
The study found that following evidence-based protocols and processes, while important, likely is not sufficient to attain a high performance level in caring for heart-attack patients. Instead, “high-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI [acute myocardial infarction] care across the hospital.” In other words, everyone from management to the medical staff was fully invested in QI efforts. Notably, the staff “reported the presence of physician champions and empowered nursing staff, pharmacist involvement in patient care, and high qualification standards for all staff.”
For its 13th annual HealthGrades Quality in America study, the Denver-based ratings organization HealthGrades tried to look more quantitatively at the link between top hospitals and patient outcomes. Its study coauthors culled data from roughly 40 million Medicare discharges from 2007 through 2009 for most of the nation’s 5,000 hospitals, and assigned ratings based on 26 measures related to mortality and complication rates (www.healthgrades.com/business/news/press-releases/hospital-quality-2010.aspx).
If all hospitals were performing on par with what HealthGrades terms a five-star hospital, the study suggests the U.S. healthcare system could have saved the lives of more than 230,000 Medicare beneficiaries over the three-year period. More than half of the preventable deaths were associated with sepsis, pneumonia, respiratory failure, and heart failure.
Although the high number raises the question of whether some preventable deaths might exist only on paper, the study does raise other eye-popping calculations. Typical patients who went to a five-star hospital instead of a one-star hospital had a 72% lower risk of dying and reduced their risk by 53% compared with U.S. hospitals overall. The survival advantage persisted after hospitalization, too: Patients discharged from five-star-rated hospitals were 57% less likely to die within 30 days than all patients.
Ali Mokdad, PhD, professor of global health at the Institute for Health Metrics and Evaluation, says one big caveat to such rankings is the matter of adjusted risk. What kind of patient populations are these hospitals treating? Are people in the area inherently less healthy? Are significant barriers to healthcare blocking access to preventive medicine?
Dr. Murray says measuring quality with risk-adjusted outcomes has periodically fallen in and out of favor, due in part to concerns over how the risk is calculated and whether the assessments could be biased against providers that see more difficult patients. Nonetheless, he believes the metric is underused in the U.S. “I think the pendulum went way away from risk-adjusted outcomes to process measures too much, and we need to have a mixed combination,” he says.
With improvements to the methodology, he sees a wealth of potential in picking out risk predictors from large data sets. “The world is getting better at predicting rehospitalization, predicting death from attributes of the patient,” he says. “If you can do a better job at risk adjustment, you can do a better job on identifying quality.”
Risk Adjustment
One area in which the U.S. has lagged is in integrating the risk of death due to chronic conditions into broader measures of healthcare. At the recent Global Health Metrics & Evaluation Conference in Seattle, Dr. Mokdad pointed out the stringent oversight applied to commercial airliners. An avoidable crash and loss of life would quickly lead to a full-scale investigation. Why, he wondered, can’t the same scrutiny be brought to bear on preventable deaths due to chronic conditions such as diabetes and heart disease?
An ambitious new surveillance project, in fact, is trying to do exactly that. Known as the Monitoring Disparities in Chronic Conditions (MDCC) Study, the effort will use Washington state’s King County as a test case to hone the necessary data collection techniques. If it pans out, the study could become a national model for how to assess a population’s health status. “You know how a physician takes your pulse?” Dr. Mokdad says. “We’re doing that for the community.”
The research team, which includes Dr. Mokdad, Dr. Murray, and collaborators from Dartmouth and Harvard universities, will administer in-depth, culturally sensitive surveys to more than 3,000 county residents. A subset of 750 participants also will receive physical exams that measure markers of health and activity.
One goal is to work out how to efficiently integrate data from multiple sources so researchers can apply their risk adjustment strategies. For example, can they get enough information to ask how many heart attack patients are on beta-blockers one year after a hospital discharge? “There is also this big question of community background health risk,” Dr. Murray says. “Is this a community where people are just sicker, and how do you factor that in addition to taking into account the comorbidities that individuals have when they show up in the hospital?”
Researchers are close to obtaining enough information on such key factors as blood pressure, cholesterol, tobacco use, and obesity to actually rate communities according to risk, he says.2 “That’s never been done at the local level, and I think it’s where we need to go to truly put things on a level playing field when you’re assessing quality.” TH
Bryn Nelson is a freelance medical writer based in Seattle.
References
- Curry LA, Spatz E, Cherlin E, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? Ann Intern Med. 2001;154(6):384-390.
- Murray CJ, Kulkarni SC, Michaud C, et al. Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Med. 2006;3(9):e260.
Everyone’s talking about quality. Encouraging high-value care is one of the stated objectives of the value-based purchasing program being rolled out by the Centers for Medicare & Medicaid Services (CMS). It’s also the subject of a new report to Congress from the Department of Health and Human Services (HHS), “National Strategy for Quality Improvement in Health Care” (www.healthcare.gov/center/reports/quality03212011a.html). For its part, SHM is placing added emphasis on a range of mentored quality-improvement (QI) initiatives for hospitalists.
Amid the flurry of activity, researchers are still attempting to address a central question that could determine the success or failure of many such efforts: How do you accurately measure what constitutes high-quality care?
Chris Murray, MD, DPhil, director of the Seattle-based Institute for Health Metrics and Evaluation, says the healthcare field traditionally has tried to assess quality in three main ways. One is to ask patients about their own experience: Were they satisfied with the level of care they received? Another is to assess what are known as process of care measures: Did the providers follow guidelines in providing patients with appropriate care? The third is to look at risk-adjusted outcomes: How did the patients ultimately fare?
Focused on Facts
CMS’s value-based purchasing program, at least initially, is focusing on the first two types of metrics. Process measures, Dr. Murray says, are popular in part because they’re relatively easy to gauge. For many of them, however, “the connection to improved health is a bit weak,” he says. Whether heart patients get a prescription for a beta-blocker drug, for example, doesn’t address the outcome. “The problem there is that we don’t know if they ever filled the prescription or if the patient takes the beta-blocker,” Dr. Murray says.
That uncertainty feeds into the larger question of how broadly to consider the accountability of providers when measuring quality. “Should we be thinking that quality means putting in place the supports required for a patient to actually achieve a good outcome, or just offering them?” Dr. Murray asks. The debate might be far from settled, but a growing number of tools and studies are at least helping researchers to connect the dots on how care is delivered, on what kind of practices might affect outcomes the most, and how a community’s underlying risks could influence both considerations.
A recent Annals of Internal Medicine study that scrutinized 30-day mortality rates for heart-attack patients found few quantitative differences between the top 5% and bottom 5% of hospitals, based on rates published on the CMS Hospital Compare website.1 Site visits and in-depth interviews with nearly 160 medical staff members, however, uncovered some telling distinctions.
The study found that following evidence-based protocols and processes, while important, likely is not sufficient to attain a high performance level in caring for heart-attack patients. Instead, “high-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI [acute myocardial infarction] care across the hospital.” In other words, everyone from management to the medical staff was fully invested in QI efforts. Notably, the staff “reported the presence of physician champions and empowered nursing staff, pharmacist involvement in patient care, and high qualification standards for all staff.”
For its 13th annual HealthGrades Quality in America study, the Denver-based ratings organization HealthGrades tried to look more quantitatively at the link between top hospitals and patient outcomes. Its study coauthors culled data from roughly 40 million Medicare discharges from 2007 through 2009 for most of the nation’s 5,000 hospitals, and assigned ratings based on 26 measures related to mortality and complication rates (www.healthgrades.com/business/news/press-releases/hospital-quality-2010.aspx).
If all hospitals were performing on par with what HealthGrades terms a five-star hospital, the study suggests the U.S. healthcare system could have saved the lives of more than 230,000 Medicare beneficiaries over the three-year period. More than half of the preventable deaths were associated with sepsis, pneumonia, respiratory failure, and heart failure.
Although the high number raises the question of whether some preventable deaths might exist only on paper, the study does raise other eye-popping calculations. Typical patients who went to a five-star hospital instead of a one-star hospital had a 72% lower risk of dying and reduced their risk by 53% compared with U.S. hospitals overall. The survival advantage persisted after hospitalization, too: Patients discharged from five-star-rated hospitals were 57% less likely to die within 30 days than all patients.
Ali Mokdad, PhD, professor of global health at the Institute for Health Metrics and Evaluation, says one big caveat to such rankings is the matter of adjusted risk. What kind of patient populations are these hospitals treating? Are people in the area inherently less healthy? Are significant barriers to healthcare blocking access to preventive medicine?
Dr. Murray says measuring quality with risk-adjusted outcomes has periodically fallen in and out of favor, due in part to concerns over how the risk is calculated and whether the assessments could be biased against providers that see more difficult patients. Nonetheless, he believes the metric is underused in the U.S. “I think the pendulum went way away from risk-adjusted outcomes to process measures too much, and we need to have a mixed combination,” he says.
With improvements to the methodology, he sees a wealth of potential in picking out risk predictors from large data sets. “The world is getting better at predicting rehospitalization, predicting death from attributes of the patient,” he says. “If you can do a better job at risk adjustment, you can do a better job on identifying quality.”
Risk Adjustment
One area in which the U.S. has lagged is in integrating the risk of death due to chronic conditions into broader measures of healthcare. At the recent Global Health Metrics & Evaluation Conference in Seattle, Dr. Mokdad pointed out the stringent oversight applied to commercial airliners. An avoidable crash and loss of life would quickly lead to a full-scale investigation. Why, he wondered, can’t the same scrutiny be brought to bear on preventable deaths due to chronic conditions such as diabetes and heart disease?
An ambitious new surveillance project, in fact, is trying to do exactly that. Known as the Monitoring Disparities in Chronic Conditions (MDCC) Study, the effort will use Washington state’s King County as a test case to hone the necessary data collection techniques. If it pans out, the study could become a national model for how to assess a population’s health status. “You know how a physician takes your pulse?” Dr. Mokdad says. “We’re doing that for the community.”
The research team, which includes Dr. Mokdad, Dr. Murray, and collaborators from Dartmouth and Harvard universities, will administer in-depth, culturally sensitive surveys to more than 3,000 county residents. A subset of 750 participants also will receive physical exams that measure markers of health and activity.
One goal is to work out how to efficiently integrate data from multiple sources so researchers can apply their risk adjustment strategies. For example, can they get enough information to ask how many heart attack patients are on beta-blockers one year after a hospital discharge? “There is also this big question of community background health risk,” Dr. Murray says. “Is this a community where people are just sicker, and how do you factor that in addition to taking into account the comorbidities that individuals have when they show up in the hospital?”
Researchers are close to obtaining enough information on such key factors as blood pressure, cholesterol, tobacco use, and obesity to actually rate communities according to risk, he says.2 “That’s never been done at the local level, and I think it’s where we need to go to truly put things on a level playing field when you’re assessing quality.” TH
Bryn Nelson is a freelance medical writer based in Seattle.
References
- Curry LA, Spatz E, Cherlin E, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? Ann Intern Med. 2001;154(6):384-390.
- Murray CJ, Kulkarni SC, Michaud C, et al. Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Med. 2006;3(9):e260.
Everyone’s talking about quality. Encouraging high-value care is one of the stated objectives of the value-based purchasing program being rolled out by the Centers for Medicare & Medicaid Services (CMS). It’s also the subject of a new report to Congress from the Department of Health and Human Services (HHS), “National Strategy for Quality Improvement in Health Care” (www.healthcare.gov/center/reports/quality03212011a.html). For its part, SHM is placing added emphasis on a range of mentored quality-improvement (QI) initiatives for hospitalists.
Amid the flurry of activity, researchers are still attempting to address a central question that could determine the success or failure of many such efforts: How do you accurately measure what constitutes high-quality care?
Chris Murray, MD, DPhil, director of the Seattle-based Institute for Health Metrics and Evaluation, says the healthcare field traditionally has tried to assess quality in three main ways. One is to ask patients about their own experience: Were they satisfied with the level of care they received? Another is to assess what are known as process of care measures: Did the providers follow guidelines in providing patients with appropriate care? The third is to look at risk-adjusted outcomes: How did the patients ultimately fare?
Focused on Facts
CMS’s value-based purchasing program, at least initially, is focusing on the first two types of metrics. Process measures, Dr. Murray says, are popular in part because they’re relatively easy to gauge. For many of them, however, “the connection to improved health is a bit weak,” he says. Whether heart patients get a prescription for a beta-blocker drug, for example, doesn’t address the outcome. “The problem there is that we don’t know if they ever filled the prescription or if the patient takes the beta-blocker,” Dr. Murray says.
That uncertainty feeds into the larger question of how broadly to consider the accountability of providers when measuring quality. “Should we be thinking that quality means putting in place the supports required for a patient to actually achieve a good outcome, or just offering them?” Dr. Murray asks. The debate might be far from settled, but a growing number of tools and studies are at least helping researchers to connect the dots on how care is delivered, on what kind of practices might affect outcomes the most, and how a community’s underlying risks could influence both considerations.
A recent Annals of Internal Medicine study that scrutinized 30-day mortality rates for heart-attack patients found few quantitative differences between the top 5% and bottom 5% of hospitals, based on rates published on the CMS Hospital Compare website.1 Site visits and in-depth interviews with nearly 160 medical staff members, however, uncovered some telling distinctions.
The study found that following evidence-based protocols and processes, while important, likely is not sufficient to attain a high performance level in caring for heart-attack patients. Instead, “high-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI [acute myocardial infarction] care across the hospital.” In other words, everyone from management to the medical staff was fully invested in QI efforts. Notably, the staff “reported the presence of physician champions and empowered nursing staff, pharmacist involvement in patient care, and high qualification standards for all staff.”
For its 13th annual HealthGrades Quality in America study, the Denver-based ratings organization HealthGrades tried to look more quantitatively at the link between top hospitals and patient outcomes. Its study coauthors culled data from roughly 40 million Medicare discharges from 2007 through 2009 for most of the nation’s 5,000 hospitals, and assigned ratings based on 26 measures related to mortality and complication rates (www.healthgrades.com/business/news/press-releases/hospital-quality-2010.aspx).
If all hospitals were performing on par with what HealthGrades terms a five-star hospital, the study suggests the U.S. healthcare system could have saved the lives of more than 230,000 Medicare beneficiaries over the three-year period. More than half of the preventable deaths were associated with sepsis, pneumonia, respiratory failure, and heart failure.
Although the high number raises the question of whether some preventable deaths might exist only on paper, the study does raise other eye-popping calculations. Typical patients who went to a five-star hospital instead of a one-star hospital had a 72% lower risk of dying and reduced their risk by 53% compared with U.S. hospitals overall. The survival advantage persisted after hospitalization, too: Patients discharged from five-star-rated hospitals were 57% less likely to die within 30 days than all patients.
Ali Mokdad, PhD, professor of global health at the Institute for Health Metrics and Evaluation, says one big caveat to such rankings is the matter of adjusted risk. What kind of patient populations are these hospitals treating? Are people in the area inherently less healthy? Are significant barriers to healthcare blocking access to preventive medicine?
Dr. Murray says measuring quality with risk-adjusted outcomes has periodically fallen in and out of favor, due in part to concerns over how the risk is calculated and whether the assessments could be biased against providers that see more difficult patients. Nonetheless, he believes the metric is underused in the U.S. “I think the pendulum went way away from risk-adjusted outcomes to process measures too much, and we need to have a mixed combination,” he says.
With improvements to the methodology, he sees a wealth of potential in picking out risk predictors from large data sets. “The world is getting better at predicting rehospitalization, predicting death from attributes of the patient,” he says. “If you can do a better job at risk adjustment, you can do a better job on identifying quality.”
Risk Adjustment
One area in which the U.S. has lagged is in integrating the risk of death due to chronic conditions into broader measures of healthcare. At the recent Global Health Metrics & Evaluation Conference in Seattle, Dr. Mokdad pointed out the stringent oversight applied to commercial airliners. An avoidable crash and loss of life would quickly lead to a full-scale investigation. Why, he wondered, can’t the same scrutiny be brought to bear on preventable deaths due to chronic conditions such as diabetes and heart disease?
An ambitious new surveillance project, in fact, is trying to do exactly that. Known as the Monitoring Disparities in Chronic Conditions (MDCC) Study, the effort will use Washington state’s King County as a test case to hone the necessary data collection techniques. If it pans out, the study could become a national model for how to assess a population’s health status. “You know how a physician takes your pulse?” Dr. Mokdad says. “We’re doing that for the community.”
The research team, which includes Dr. Mokdad, Dr. Murray, and collaborators from Dartmouth and Harvard universities, will administer in-depth, culturally sensitive surveys to more than 3,000 county residents. A subset of 750 participants also will receive physical exams that measure markers of health and activity.
One goal is to work out how to efficiently integrate data from multiple sources so researchers can apply their risk adjustment strategies. For example, can they get enough information to ask how many heart attack patients are on beta-blockers one year after a hospital discharge? “There is also this big question of community background health risk,” Dr. Murray says. “Is this a community where people are just sicker, and how do you factor that in addition to taking into account the comorbidities that individuals have when they show up in the hospital?”
Researchers are close to obtaining enough information on such key factors as blood pressure, cholesterol, tobacco use, and obesity to actually rate communities according to risk, he says.2 “That’s never been done at the local level, and I think it’s where we need to go to truly put things on a level playing field when you’re assessing quality.” TH
Bryn Nelson is a freelance medical writer based in Seattle.
References
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- Murray CJ, Kulkarni SC, Michaud C, et al. Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Med. 2006;3(9):e260.