Clinical

Clinical question: What is the prevalence of pulmonary embolism (PE) in patients presenting to the ED with syncope?

Clinical question: What is the prevalence of pulmonary embolism (PE) in patients presenting to the ED with syncope?

Clinical question: What is the prevalence of pulmonary embolism (PE) in patients presenting to the ED with syncope?

Clinical question: Can a multifaceted intervention by a clinical pharmacist reduce the rate of ED visits and readmission over the subsequent 180 days?

Background: The period following an inpatient admission contains many potential risks for patients, among them the risk for adverse drug events. Approximately 45% of readmissions from adverse drug reactions are thought to be avoidable.

Study design: Multicentered, single-blinded, randomized, control trial, from September 2013 to April 2015.

Setting: Four acute inpatient hospitals in Denmark.

Synopsis: 1,467 adult patients being admitted for an acute hospitalization on a minimum of five medications were randomized to receive usual care, a basic intervention (medication review by a clinical pharmacist), or an extended intervention (medication review, three motivational interviews, and follow-up with the primary care physician, pharmacy and, if appropriate, nursing home by a clinical pharmacist). The primary endpoints were readmission within 30 days or 180 days, ED visits within 180 days, and a composite endpoint of readmission or ED visit within 180 days post discharge. For these endpoints, the basic intervention group had no statistically significant difference from the usual-care group. The extended intervention group had significantly lower rates of readmission within 30 days and 180 days, as well as the primary composite endpoint compared to the usual-care group (P less than .05 for all comparisons). For the extended intervention, the number needed to treat for the main composite endpoint was 12.

Bottom line: For patients admitted to the hospital, an extended intervention by a clinical pharmacist resulted in a significant reduction in readmissions.

Citation: Ravn-Nielsen LV et al. Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission. JAMA Intern Med. 2018;178(3):375-82.

Dr. Biddick is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: Can a multifaceted intervention by a clinical pharmacist reduce the rate of ED visits and readmission over the subsequent 180 days?

Background: The period following an inpatient admission contains many potential risks for patients, among them the risk for adverse drug events. Approximately 45% of readmissions from adverse drug reactions are thought to be avoidable.

Study design: Multicentered, single-blinded, randomized, control trial, from September 2013 to April 2015.

Setting: Four acute inpatient hospitals in Denmark.

Synopsis: 1,467 adult patients being admitted for an acute hospitalization on a minimum of five medications were randomized to receive usual care, a basic intervention (medication review by a clinical pharmacist), or an extended intervention (medication review, three motivational interviews, and follow-up with the primary care physician, pharmacy and, if appropriate, nursing home by a clinical pharmacist). The primary endpoints were readmission within 30 days or 180 days, ED visits within 180 days, and a composite endpoint of readmission or ED visit within 180 days post discharge. For these endpoints, the basic intervention group had no statistically significant difference from the usual-care group. The extended intervention group had significantly lower rates of readmission within 30 days and 180 days, as well as the primary composite endpoint compared to the usual-care group (P less than .05 for all comparisons). For the extended intervention, the number needed to treat for the main composite endpoint was 12.

Bottom line: For patients admitted to the hospital, an extended intervention by a clinical pharmacist resulted in a significant reduction in readmissions.

Citation: Ravn-Nielsen LV et al. Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission. JAMA Intern Med. 2018;178(3):375-82.

Dr. Biddick is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: Can a multifaceted intervention by a clinical pharmacist reduce the rate of ED visits and readmission over the subsequent 180 days?

Background: The period following an inpatient admission contains many potential risks for patients, among them the risk for adverse drug events. Approximately 45% of readmissions from adverse drug reactions are thought to be avoidable.

Study design: Multicentered, single-blinded, randomized, control trial, from September 2013 to April 2015.

Setting: Four acute inpatient hospitals in Denmark.

Synopsis: 1,467 adult patients being admitted for an acute hospitalization on a minimum of five medications were randomized to receive usual care, a basic intervention (medication review by a clinical pharmacist), or an extended intervention (medication review, three motivational interviews, and follow-up with the primary care physician, pharmacy and, if appropriate, nursing home by a clinical pharmacist). The primary endpoints were readmission within 30 days or 180 days, ED visits within 180 days, and a composite endpoint of readmission or ED visit within 180 days post discharge. For these endpoints, the basic intervention group had no statistically significant difference from the usual-care group. The extended intervention group had significantly lower rates of readmission within 30 days and 180 days, as well as the primary composite endpoint compared to the usual-care group (P less than .05 for all comparisons). For the extended intervention, the number needed to treat for the main composite endpoint was 12.

Bottom line: For patients admitted to the hospital, an extended intervention by a clinical pharmacist resulted in a significant reduction in readmissions.

Citation: Ravn-Nielsen LV et al. Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission. JAMA Intern Med. 2018;178(3):375-82.

Dr. Biddick is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Opioid use has not significantly declined over the past 10 years despite efforts to educate prescribers about the risks of opioid abuse, with over half of disabled Medicare beneficiaries using opioids each year, according to a recent retrospective cohort study published in the BMJ.

“We found very high prevalence of opioid use and opioid doses in disabled Medicare beneficiaries, most likely reflecting the high burden of illness in this population,” Molly M. Jeffery, PhD, from the Mayo Clinic, Rochester, Minn., and her associates wrote in their study.

The investigators evaluated pharmaceutical and medical claims data from 48 million individuals who were commercially insured or were Medicare Advantage recipients (both those eligible because they were older than 65 years and those under 65 years old who still were eligible because of disability). The researchers found that 52% of disabled Medicare patients, 26% of aged Medicare patients, and 14% of commercially insured patients used opioids annually within the study period.

In the commercially insured group, there was little fluctuation in patient opioid prevalence by quarter, with an average daily dose of 17 mg morphine equivalents (MME) during 2011-2016; 6% of patients used opioids quarterly at the beginning and end of the study. There was an increase of quarterly opioid prevalence in the aged Medicare group from 11% to 14% at the beginning and end of the study period. Average daily dose also increased during this period for the aged Medicare group from 18 MME in 2011 to 20 MME in 2016.

Researchers said commercial beneficiaries between 45 years and 54 years old had the highest prevalence of opioid use. The disabled Medicare group saw the greatest increase among groups in opioid prevalence and average daily dose, with a 26% prevalence in 2007 and 53 MME average daily dose, which increased to a prevalence of 39% and an average daily dose of 56 MME in 2016.

“Doctors and patients should consider whether long-term opioid use is improving the patient’s ability to function and, if not, should consider other treatments either as an addition or replacement to opioid use,” Dr. Jeffery and her colleagues wrote. “Evidence-based approaches are needed to improve both the safety of opioid use and patient outcomes including pain management and ability to function.”

The researchers noted limitations in the study, such as not including people with Medicaid, fee-for-service Medicare, or the uninsured. In addition, the data reviewed did not indicate the prevalence of chronic pain or pain duration in the patient population studied, they said.

The authors reported no relevant financial disclosures.
 

SOURCE: Jeffery MM et al. BMJ. 2018 Aug 1. doi: 10.1136/bmj.k2833.

Opioid use has not significantly declined over the past 10 years despite efforts to educate prescribers about the risks of opioid abuse, with over half of disabled Medicare beneficiaries using opioids each year, according to a recent retrospective cohort study published in the BMJ.

“We found very high prevalence of opioid use and opioid doses in disabled Medicare beneficiaries, most likely reflecting the high burden of illness in this population,” Molly M. Jeffery, PhD, from the Mayo Clinic, Rochester, Minn., and her associates wrote in their study.

The investigators evaluated pharmaceutical and medical claims data from 48 million individuals who were commercially insured or were Medicare Advantage recipients (both those eligible because they were older than 65 years and those under 65 years old who still were eligible because of disability). The researchers found that 52% of disabled Medicare patients, 26% of aged Medicare patients, and 14% of commercially insured patients used opioids annually within the study period.

In the commercially insured group, there was little fluctuation in patient opioid prevalence by quarter, with an average daily dose of 17 mg morphine equivalents (MME) during 2011-2016; 6% of patients used opioids quarterly at the beginning and end of the study. There was an increase of quarterly opioid prevalence in the aged Medicare group from 11% to 14% at the beginning and end of the study period. Average daily dose also increased during this period for the aged Medicare group from 18 MME in 2011 to 20 MME in 2016.

Researchers said commercial beneficiaries between 45 years and 54 years old had the highest prevalence of opioid use. The disabled Medicare group saw the greatest increase among groups in opioid prevalence and average daily dose, with a 26% prevalence in 2007 and 53 MME average daily dose, which increased to a prevalence of 39% and an average daily dose of 56 MME in 2016.

“Doctors and patients should consider whether long-term opioid use is improving the patient’s ability to function and, if not, should consider other treatments either as an addition or replacement to opioid use,” Dr. Jeffery and her colleagues wrote. “Evidence-based approaches are needed to improve both the safety of opioid use and patient outcomes including pain management and ability to function.”

The researchers noted limitations in the study, such as not including people with Medicaid, fee-for-service Medicare, or the uninsured. In addition, the data reviewed did not indicate the prevalence of chronic pain or pain duration in the patient population studied, they said.

The authors reported no relevant financial disclosures.
 

SOURCE: Jeffery MM et al. BMJ. 2018 Aug 1. doi: 10.1136/bmj.k2833.

Opioid use has not significantly declined over the past 10 years despite efforts to educate prescribers about the risks of opioid abuse, with over half of disabled Medicare beneficiaries using opioids each year, according to a recent retrospective cohort study published in the BMJ.

“We found very high prevalence of opioid use and opioid doses in disabled Medicare beneficiaries, most likely reflecting the high burden of illness in this population,” Molly M. Jeffery, PhD, from the Mayo Clinic, Rochester, Minn., and her associates wrote in their study.

The investigators evaluated pharmaceutical and medical claims data from 48 million individuals who were commercially insured or were Medicare Advantage recipients (both those eligible because they were older than 65 years and those under 65 years old who still were eligible because of disability). The researchers found that 52% of disabled Medicare patients, 26% of aged Medicare patients, and 14% of commercially insured patients used opioids annually within the study period.

In the commercially insured group, there was little fluctuation in patient opioid prevalence by quarter, with an average daily dose of 17 mg morphine equivalents (MME) during 2011-2016; 6% of patients used opioids quarterly at the beginning and end of the study. There was an increase of quarterly opioid prevalence in the aged Medicare group from 11% to 14% at the beginning and end of the study period. Average daily dose also increased during this period for the aged Medicare group from 18 MME in 2011 to 20 MME in 2016.

Researchers said commercial beneficiaries between 45 years and 54 years old had the highest prevalence of opioid use. The disabled Medicare group saw the greatest increase among groups in opioid prevalence and average daily dose, with a 26% prevalence in 2007 and 53 MME average daily dose, which increased to a prevalence of 39% and an average daily dose of 56 MME in 2016.

“Doctors and patients should consider whether long-term opioid use is improving the patient’s ability to function and, if not, should consider other treatments either as an addition or replacement to opioid use,” Dr. Jeffery and her colleagues wrote. “Evidence-based approaches are needed to improve both the safety of opioid use and patient outcomes including pain management and ability to function.”

The researchers noted limitations in the study, such as not including people with Medicaid, fee-for-service Medicare, or the uninsured. In addition, the data reviewed did not indicate the prevalence of chronic pain or pain duration in the patient population studied, they said.

The authors reported no relevant financial disclosures.
 

SOURCE: Jeffery MM et al. BMJ. 2018 Aug 1. doi: 10.1136/bmj.k2833.

ATLANTA – It’s possible to reduce chest x-rays for routine pediatric asthma exacerbations in the ED, but accomplishing this goal takes more than a new clinical practice guideline, according to a quality improvement team at the Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tenn.

M. Alexander Otto/MDedge News

The team eventually reduced the chest x-ray rate for pediatric asthma exacerbations from 30% to 15% without increasing 3-day all-cause readmissions, but it took some sleuthing in the ED and good relations with staff. “We were way out in left field when we started this. Working in silos is never ideal,” said senior project member David Johnson, MD, a pediatric hospitalist and assistant professor of pediatrics at Vanderbilt.

It’s been known for a while that chest x-rays are almost always a waste of time and money for asthma exacerbations, and national guidelines recommend against them. X-rays don’t improve outcomes and needlessly expose children to radiation.

In 2014, some of the providers at Vanderbilt, which has about 1,700 asthma encounters a year, realized that the institution’s 30% x-ray rate was a problem. The quality improvement team hoped a new guideline would address the issue, but that didn’t happen. “We roll out clinical practice guidelines” from on high, “and think people will magically change their behavior,” but they don’t, Dr. Johnson said at the annual Pediatric Hospital Medicine meeting.

The guideline was not being fully implemented. So the team asked the ED what was the standard procedure for a child presenting with asthma exacerbation. It turned out that the ED had a dyspnea order set that the team ”had no idea existed.” Chest x-rays were at the top of the list; next came blood gases, ventilation-perfusion scans, and leg Dopplers, he said.

The investigators tried to get rid of the whole order set but were unsuccessful. The ED department did, however, let the team eliminate chest x-rays in the default order set in July 2015. That helped, but more changes were needed.

The next conversation was to figure out why x-rays were being ordered in the first place. ED staff said they were worried about missing something, especially pneumonia. They also thought they were helping hospitalists by getting x-rays before sending kids to the ward even though, in reality, it didn’t matter whether x-rays were done a few hours later on the floor. ED providers also said that ill-appearing children often got better after a few hours but were kept back from discharge because x-ray results were still pending and that sometimes these results revealed problems at 3 a.m. that had nothing to do with why the patients were in the ED but still required a work-up.

This discussion opened a door. The ED staff didn’t want to order unnecessary x-rays, either. That led to talks about letting kids declare themselves a bit before x-rays were ordered. ED staff liked the idea, so the guidelines were updated in early 2016 to say that chest x-rays should only be ordered if there is persistent severe respiratory distress with hypoxia, there are focal findings that don’t improve after 12 hours of treatment, or there were concerns for pneumomediastinum or collapsed lung. The updated guidelines were posted in work areas and brought home by resident education. A reminder was added to the electronic medical record system that popped up when someone tried to order a chest x-ray for an child with asthma.

It worked. Chest x-ray rates in asthma fell to 15%, and have remained there since.

“We gave them permission to take their foot off the throttle and wait a little bit, and we don’t have more kids bouncing back from reduced x-rays.” The approach is “probably generalizable everywhere,” Dr. Johnson said.

It was essential that an ED fellow, Caroline Watnick, MD, led the effort and eventually bridged the gap between hospitalists and ED providers. In the end, “the change wasn’t something from the outside,” Dr. Johnson said.

There was no industry funding, and Dr. Johnson didn’t have any disclosures. The Pediatric Hospital Medicine meeting is sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]

ATLANTA – It’s possible to reduce chest x-rays for routine pediatric asthma exacerbations in the ED, but accomplishing this goal takes more than a new clinical practice guideline, according to a quality improvement team at the Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tenn.

M. Alexander Otto/MDedge News

The team eventually reduced the chest x-ray rate for pediatric asthma exacerbations from 30% to 15% without increasing 3-day all-cause readmissions, but it took some sleuthing in the ED and good relations with staff. “We were way out in left field when we started this. Working in silos is never ideal,” said senior project member David Johnson, MD, a pediatric hospitalist and assistant professor of pediatrics at Vanderbilt.

It’s been known for a while that chest x-rays are almost always a waste of time and money for asthma exacerbations, and national guidelines recommend against them. X-rays don’t improve outcomes and needlessly expose children to radiation.

In 2014, some of the providers at Vanderbilt, which has about 1,700 asthma encounters a year, realized that the institution’s 30% x-ray rate was a problem. The quality improvement team hoped a new guideline would address the issue, but that didn’t happen. “We roll out clinical practice guidelines” from on high, “and think people will magically change their behavior,” but they don’t, Dr. Johnson said at the annual Pediatric Hospital Medicine meeting.

The guideline was not being fully implemented. So the team asked the ED what was the standard procedure for a child presenting with asthma exacerbation. It turned out that the ED had a dyspnea order set that the team ”had no idea existed.” Chest x-rays were at the top of the list; next came blood gases, ventilation-perfusion scans, and leg Dopplers, he said.

The investigators tried to get rid of the whole order set but were unsuccessful. The ED department did, however, let the team eliminate chest x-rays in the default order set in July 2015. That helped, but more changes were needed.

The next conversation was to figure out why x-rays were being ordered in the first place. ED staff said they were worried about missing something, especially pneumonia. They also thought they were helping hospitalists by getting x-rays before sending kids to the ward even though, in reality, it didn’t matter whether x-rays were done a few hours later on the floor. ED providers also said that ill-appearing children often got better after a few hours but were kept back from discharge because x-ray results were still pending and that sometimes these results revealed problems at 3 a.m. that had nothing to do with why the patients were in the ED but still required a work-up.

This discussion opened a door. The ED staff didn’t want to order unnecessary x-rays, either. That led to talks about letting kids declare themselves a bit before x-rays were ordered. ED staff liked the idea, so the guidelines were updated in early 2016 to say that chest x-rays should only be ordered if there is persistent severe respiratory distress with hypoxia, there are focal findings that don’t improve after 12 hours of treatment, or there were concerns for pneumomediastinum or collapsed lung. The updated guidelines were posted in work areas and brought home by resident education. A reminder was added to the electronic medical record system that popped up when someone tried to order a chest x-ray for an child with asthma.

It worked. Chest x-ray rates in asthma fell to 15%, and have remained there since.

“We gave them permission to take their foot off the throttle and wait a little bit, and we don’t have more kids bouncing back from reduced x-rays.” The approach is “probably generalizable everywhere,” Dr. Johnson said.

It was essential that an ED fellow, Caroline Watnick, MD, led the effort and eventually bridged the gap between hospitalists and ED providers. In the end, “the change wasn’t something from the outside,” Dr. Johnson said.

There was no industry funding, and Dr. Johnson didn’t have any disclosures. The Pediatric Hospital Medicine meeting is sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]

ATLANTA – It’s possible to reduce chest x-rays for routine pediatric asthma exacerbations in the ED, but accomplishing this goal takes more than a new clinical practice guideline, according to a quality improvement team at the Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tenn.

M. Alexander Otto/MDedge News

The team eventually reduced the chest x-ray rate for pediatric asthma exacerbations from 30% to 15% without increasing 3-day all-cause readmissions, but it took some sleuthing in the ED and good relations with staff. “We were way out in left field when we started this. Working in silos is never ideal,” said senior project member David Johnson, MD, a pediatric hospitalist and assistant professor of pediatrics at Vanderbilt.

It’s been known for a while that chest x-rays are almost always a waste of time and money for asthma exacerbations, and national guidelines recommend against them. X-rays don’t improve outcomes and needlessly expose children to radiation.

In 2014, some of the providers at Vanderbilt, which has about 1,700 asthma encounters a year, realized that the institution’s 30% x-ray rate was a problem. The quality improvement team hoped a new guideline would address the issue, but that didn’t happen. “We roll out clinical practice guidelines” from on high, “and think people will magically change their behavior,” but they don’t, Dr. Johnson said at the annual Pediatric Hospital Medicine meeting.

The guideline was not being fully implemented. So the team asked the ED what was the standard procedure for a child presenting with asthma exacerbation. It turned out that the ED had a dyspnea order set that the team ”had no idea existed.” Chest x-rays were at the top of the list; next came blood gases, ventilation-perfusion scans, and leg Dopplers, he said.

The investigators tried to get rid of the whole order set but were unsuccessful. The ED department did, however, let the team eliminate chest x-rays in the default order set in July 2015. That helped, but more changes were needed.

The next conversation was to figure out why x-rays were being ordered in the first place. ED staff said they were worried about missing something, especially pneumonia. They also thought they were helping hospitalists by getting x-rays before sending kids to the ward even though, in reality, it didn’t matter whether x-rays were done a few hours later on the floor. ED providers also said that ill-appearing children often got better after a few hours but were kept back from discharge because x-ray results were still pending and that sometimes these results revealed problems at 3 a.m. that had nothing to do with why the patients were in the ED but still required a work-up.

This discussion opened a door. The ED staff didn’t want to order unnecessary x-rays, either. That led to talks about letting kids declare themselves a bit before x-rays were ordered. ED staff liked the idea, so the guidelines were updated in early 2016 to say that chest x-rays should only be ordered if there is persistent severe respiratory distress with hypoxia, there are focal findings that don’t improve after 12 hours of treatment, or there were concerns for pneumomediastinum or collapsed lung. The updated guidelines were posted in work areas and brought home by resident education. A reminder was added to the electronic medical record system that popped up when someone tried to order a chest x-ray for an child with asthma.

It worked. Chest x-ray rates in asthma fell to 15%, and have remained there since.

“We gave them permission to take their foot off the throttle and wait a little bit, and we don’t have more kids bouncing back from reduced x-rays.” The approach is “probably generalizable everywhere,” Dr. Johnson said.

It was essential that an ED fellow, Caroline Watnick, MD, led the effort and eventually bridged the gap between hospitalists and ED providers. In the end, “the change wasn’t something from the outside,” Dr. Johnson said.

There was no industry funding, and Dr. Johnson didn’t have any disclosures. The Pediatric Hospital Medicine meeting is sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]

Case

An 85-year-old man with long-standing chronic obstructive pulmonary disease (COPD) has a witnessed aspiration event while undergoing an outpatient procedure requiring conscious sedation. He is admitted to the hospital for observation overnight. The next morning, he feels well, but his oxygen saturation dips to 85% with ambulation. He reports this is not new for him, but he vehemently does not want supplemental oxygen.

Background

Patients with COPD and severe resting hypoxemia – arterial oxygen partial pressure less than or equal to 55 mm Hg or peripheral capillary oxygen saturation (SpO₂₎ less than or equal to 88% – commonly are prescribed supplemental oxygen. The evidence supporting this practice is limited to two small trials from the 1970s that showed a survival benefit of long-term oxygen therapy (LTOT) in this population,^1,2 but these trials may not be generalizable to patients today.

For patients with COPD and mild to moderate resting hypoxemia (SpO_2, 89%-93%) or patients with exercise-induced hypoxemia, LTOT has not been shown to improve survival, although it may improve symptoms of dyspnea, exercise tolerance, and other patient reported outcomes. Given the costs, risks, and burdens associated with LTOT, a high-quality clinical trial assessing the effects of LTOT on clinically meaningful outcomes, such as survival or hospitalization, in patients with COPD and moderate hypoxemia has been long overdue.
 

Overview of the data

The utility of long-term treatment with supplemental oxygen in patients with stable COPD and moderate resting or exercise-induced desaturation was examined by the Long-Term Oxygen Treatment Trial (LOTT) Research Group. Results were published in the New England Journal of Medicine in October 2016 in the article, “A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation.”³

The study was initially designed to test whether the use of supplemental oxygen would lead to longer time until death as compared with no supplemental oxygen in the subgroup of COPD patients with stable disease and moderate resting desaturation (defined as resting SpO₂ of 89%-93%). However, because of an enrollment of only 34 patients after 7 months, the trial was redesigned to include exercise-induced desaturation (defined as SpO₂ of greater than or equal to 80% for at least 5 minutes, and less than 90% for at least 10 seconds, on a 6-minute walk test) and the secondary outcome of all-cause hospitalization. Hospitalization for any cause was combined with mortality into a new composite primary outcome.

This study was a randomized, controlled trial which enrolled patients at a total of 14 regional clinical centers and their associated sites for a total of 42 centers in the United States. The experimental arm consisted of a long term supplemental oxygen group, and the control group did not receive long term supplemental oxygen. Patients were assigned to groups in a 1:1 ratio and the study was not blinded. Patients with moderate resting desaturation were prescribed 24 hour oxygen at 2 L/min, and patients with moderate exercise-induced desaturation were prescribed oxygen at 2 L/min during exercise and sleep only. The primary outcome was a composite outcome of time until death or time until first hospitalization for any cause. There were multiple secondary outcomes, including incidence of COPD exacerbation, incidence of severe resting desaturation and severe exercise-induced desaturation, quality of life, sleep quality, depression and anxiety, adherence to regimen, 6-minute walk distance, spirometric measurements, risk of cardiovascular disease, and neurocognitive function.

Data were gathered via yearly visits, biannual telephone interviews, and questionnaires mailed at 4 months and 16 months. Adherence was assessed by inquiring about oxygen use every 4 months. If patients in the supplemental oxygen group used stationary oxygen concentrators, logs of meter readings were kept as well. The necessary final sample size was calculated using a time to composite event survival model with the use of the log-rank test statistic.

A total of 738 patients were enrolled in the trial between January 2009 and September 2015 and were followed for 1-6 years. A total of 97% of participants had at least 1 year of follow-up. Out of the 738 randomized patients, 133 (18%) had only resting desaturations, 319 (43%) had only exercise-induced desaturations, and 286 (39%) had both resting and exercise-induced desaturations. Baseline characteristics including age, sex, race, smoking status, quality of life scores, resting SpO_2, and nadir SpO₂ during the 6-minute walk test were similar between the two groups. The only significant difference noted by the authors between the two groups was a lower BODE (body mass index, airflow obstruction, dyspnea, and exercise) index, which was lower in the group with no supplemental oxygen.

In the time-to-event analysis, there was no significant difference between the two groups in the time to death or first hospitalization (hazard ratio, 0.94; 95% confidence interval, 0.79-1.12; P = .52). There were no significant differences in the rates of all hospitalizations (rate ratio, 1.01; 95% CI, 0.91-1.13), COPD exacerbations (RR 1.08; 95% CI, 0.98-1.19), and COPD related hospitalizations (RR, 0.99; 95% CI, 0.83-1.17). There were also no differences between the experimental and control groups in quality of life, lung function, and 6-minute walk distance. There were no significant differences in the subgroups classified by desaturation profile, sex, race, nadir SpO₂ during the 6-minute walk test, and forced expiratory volume in 1 second.

The findings in this study show that, in the subgroup of chronic obstructive pulmonary disease patients with stable COPD and moderate resting or exercise-induced desaturation, supplemental oxygen did not affect the time to death or first hospitalization, time to death, time to first hospitalization, time to first COPD exacerbation, time to first hospitalization for a COPD exacerbation, rate of all hospitalizations, rate of all COPD exacerbations, or changes in metrics surrounding quality of life, anxiety/depression, or functional status. This supports earlier studies that demonstrated that long-term treatment with oxygen does not result in longer survival than does no long-term treatment with oxygen in patients with COPD and resting SpO₂ of more than 88%.

The results of this study are a departure from previous studies that had shown improved mortality in patients with COPD and severe desaturation who were treated with LTOT. The authors hypothesized that this may have been caused by physiological effects of oxygen saturation on pulmonary vasoconstriction, release of mediators, and ventilator drive, which occur at an O₂ saturation of 88% or less and may be more significant in patients with chronic hypoxemia. This trial also contrasted previous studies that had shown that oxygen therapy may reduce dyspnea in COPD patients with mild or no hypoxia because the LOTT trial showed no improvement in quality of life, anxiety, and depression measures in patients treated with long-term oxygen as compared with those treated with no oxygen.

Some limitations of the study included the absence of highly symptomatic patients or patients who the providers believed were too ill to participate, the effect of the unblinded nature of the study on outcomes that were patient reported, the lack of assessment of immediate effects of oxygen on exercise performance or symptoms, possible variability in amount of oxygen delivered, and the fact that patients may have overestimated their oxygen use.

In patients with stable COPD and moderate resting or exercise induced desaturation, long-term supplemental oxygen did not provide any benefit in regard to time until death or first hospitalization or any of the other measured outcomes.

Application of data to the case

Our patient has stable COPD and had only moderate exercise-induced desaturation. Long-term supplemental oxygen would not produce a benefit for him.

This study shows us that it would not increase his survival at this point; however, if he were to have worsening exercise-induced or new resting desaturation at some point in the future, supplemental oxygen would then be beneficial. At this point supplemental oxygen would not even affect his rate of hospitalization for COPD- or non-COPD–related reasons. Perhaps most importantly, adding oxygen therapy would not affect his overall quality of life, including his functional status and mood.
 

Bottom line

The addition of supplemental oxygen is not helpful for patients with COPD who have chronic stable moderate hypoxia.

Dr. Farber is a medical instructor in the Duke University Health System in Durham, N.C. Dr. Sata is a medical instructor in the Duke University Hospital. Dr. Wachter is an assistant professor of medicine at Duke University. Dr. Sharma is associate medical director for clinical education in hospital medicine at Duke Regional Hospital and an assistant professor of medicine at Duke University.

References

1. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: A clinical trial. Ann Intern Med. 1980 Sep;93(3):391-8.

2. Medical Research Council Working Party. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: Report of the Medical Research Council Working Party. Lancet 1981 Mar 28;1(8222):681-6.

3. Long-term oxygen treatment trial research group et al. A randomized trial of long-term oxygen for COPD with moderate desaturation. N Engl J Med. 2016 Oct 27;375(17):1617-27.

Additional reading

Stoller JK et al. Oxygen therapy for patients with COPD: Current evidence and the Long-term Oxygen Treatment Trial. Chest. 2010 July;138:179-87.

Qaseem A et al. Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91.

Ameer F et al. Ambulatory oxygen for people with chronic obstructive pulmonary disease who are not hypoxaemic at rest. Cochrane Database Syst Rev. 2014 Jun 24;(6):CD000238.

Vestbo J et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013 Feb 15;187(4):347-65.

Quiz: Does this patient need oxygen?

You are caring for a 72-year-old man with stable COPD who was admitted for cellulitis. He is improving clinically on appropriate antibiotics, and he has been stable on room air every time you examine him. The nurse pages you on the day of discharge – a Sunday – informing you that his oxygen saturation dropped to 88% while he was walking the halls this morning. She asks whether he needs to stay in the hospital so you can arrange home supplemental oxygen therapy. What should you do?

A. Keep him in the hospital until you can arrange home oxygen therapy.

B. Discharge him home Sunday but have the oxygen company go out to his house first thing on Monday.

C. Discharge him home without supplemental oxygen therapy.

D. Check an arterial blood gas to help decide if you should set up oxygen therapy.

The answer is C. He meets the description of stable COPD with mild to moderate exercise-induced desaturation. The LOTT trial supports our clinical decision that he would not benefit from supplemental oxygen therapy at this point.

Key Points

• Long-term oxygen therapy (LTOT) is beneficial in patients with COPD and severe resting hypoxemia (arterial oxygen partial pressure ≤ 55 mm Hg or SpO₂ ≤ 88%) and should be prescribed to improve survival in this population.
• Patients with COPD and mild to moderate resting hypoxemia or exercised-induced hypoxemia should not be routinely prescribed LTOT given the associated costs, risks, and burdens and the lack of evidence of benefit.

Case

An 85-year-old man with long-standing chronic obstructive pulmonary disease (COPD) has a witnessed aspiration event while undergoing an outpatient procedure requiring conscious sedation. He is admitted to the hospital for observation overnight. The next morning, he feels well, but his oxygen saturation dips to 85% with ambulation. He reports this is not new for him, but he vehemently does not want supplemental oxygen.

Background

Patients with COPD and severe resting hypoxemia – arterial oxygen partial pressure less than or equal to 55 mm Hg or peripheral capillary oxygen saturation (SpO₂₎ less than or equal to 88% – commonly are prescribed supplemental oxygen. The evidence supporting this practice is limited to two small trials from the 1970s that showed a survival benefit of long-term oxygen therapy (LTOT) in this population,^1,2 but these trials may not be generalizable to patients today.

For patients with COPD and mild to moderate resting hypoxemia (SpO_2, 89%-93%) or patients with exercise-induced hypoxemia, LTOT has not been shown to improve survival, although it may improve symptoms of dyspnea, exercise tolerance, and other patient reported outcomes. Given the costs, risks, and burdens associated with LTOT, a high-quality clinical trial assessing the effects of LTOT on clinically meaningful outcomes, such as survival or hospitalization, in patients with COPD and moderate hypoxemia has been long overdue.
 

Overview of the data

The utility of long-term treatment with supplemental oxygen in patients with stable COPD and moderate resting or exercise-induced desaturation was examined by the Long-Term Oxygen Treatment Trial (LOTT) Research Group. Results were published in the New England Journal of Medicine in October 2016 in the article, “A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation.”³

The study was initially designed to test whether the use of supplemental oxygen would lead to longer time until death as compared with no supplemental oxygen in the subgroup of COPD patients with stable disease and moderate resting desaturation (defined as resting SpO₂ of 89%-93%). However, because of an enrollment of only 34 patients after 7 months, the trial was redesigned to include exercise-induced desaturation (defined as SpO₂ of greater than or equal to 80% for at least 5 minutes, and less than 90% for at least 10 seconds, on a 6-minute walk test) and the secondary outcome of all-cause hospitalization. Hospitalization for any cause was combined with mortality into a new composite primary outcome.

This study was a randomized, controlled trial which enrolled patients at a total of 14 regional clinical centers and their associated sites for a total of 42 centers in the United States. The experimental arm consisted of a long term supplemental oxygen group, and the control group did not receive long term supplemental oxygen. Patients were assigned to groups in a 1:1 ratio and the study was not blinded. Patients with moderate resting desaturation were prescribed 24 hour oxygen at 2 L/min, and patients with moderate exercise-induced desaturation were prescribed oxygen at 2 L/min during exercise and sleep only. The primary outcome was a composite outcome of time until death or time until first hospitalization for any cause. There were multiple secondary outcomes, including incidence of COPD exacerbation, incidence of severe resting desaturation and severe exercise-induced desaturation, quality of life, sleep quality, depression and anxiety, adherence to regimen, 6-minute walk distance, spirometric measurements, risk of cardiovascular disease, and neurocognitive function.

Data were gathered via yearly visits, biannual telephone interviews, and questionnaires mailed at 4 months and 16 months. Adherence was assessed by inquiring about oxygen use every 4 months. If patients in the supplemental oxygen group used stationary oxygen concentrators, logs of meter readings were kept as well. The necessary final sample size was calculated using a time to composite event survival model with the use of the log-rank test statistic.

A total of 738 patients were enrolled in the trial between January 2009 and September 2015 and were followed for 1-6 years. A total of 97% of participants had at least 1 year of follow-up. Out of the 738 randomized patients, 133 (18%) had only resting desaturations, 319 (43%) had only exercise-induced desaturations, and 286 (39%) had both resting and exercise-induced desaturations. Baseline characteristics including age, sex, race, smoking status, quality of life scores, resting SpO_2, and nadir SpO₂ during the 6-minute walk test were similar between the two groups. The only significant difference noted by the authors between the two groups was a lower BODE (body mass index, airflow obstruction, dyspnea, and exercise) index, which was lower in the group with no supplemental oxygen.

In the time-to-event analysis, there was no significant difference between the two groups in the time to death or first hospitalization (hazard ratio, 0.94; 95% confidence interval, 0.79-1.12; P = .52). There were no significant differences in the rates of all hospitalizations (rate ratio, 1.01; 95% CI, 0.91-1.13), COPD exacerbations (RR 1.08; 95% CI, 0.98-1.19), and COPD related hospitalizations (RR, 0.99; 95% CI, 0.83-1.17). There were also no differences between the experimental and control groups in quality of life, lung function, and 6-minute walk distance. There were no significant differences in the subgroups classified by desaturation profile, sex, race, nadir SpO₂ during the 6-minute walk test, and forced expiratory volume in 1 second.

The findings in this study show that, in the subgroup of chronic obstructive pulmonary disease patients with stable COPD and moderate resting or exercise-induced desaturation, supplemental oxygen did not affect the time to death or first hospitalization, time to death, time to first hospitalization, time to first COPD exacerbation, time to first hospitalization for a COPD exacerbation, rate of all hospitalizations, rate of all COPD exacerbations, or changes in metrics surrounding quality of life, anxiety/depression, or functional status. This supports earlier studies that demonstrated that long-term treatment with oxygen does not result in longer survival than does no long-term treatment with oxygen in patients with COPD and resting SpO₂ of more than 88%.

The results of this study are a departure from previous studies that had shown improved mortality in patients with COPD and severe desaturation who were treated with LTOT. The authors hypothesized that this may have been caused by physiological effects of oxygen saturation on pulmonary vasoconstriction, release of mediators, and ventilator drive, which occur at an O₂ saturation of 88% or less and may be more significant in patients with chronic hypoxemia. This trial also contrasted previous studies that had shown that oxygen therapy may reduce dyspnea in COPD patients with mild or no hypoxia because the LOTT trial showed no improvement in quality of life, anxiety, and depression measures in patients treated with long-term oxygen as compared with those treated with no oxygen.

Some limitations of the study included the absence of highly symptomatic patients or patients who the providers believed were too ill to participate, the effect of the unblinded nature of the study on outcomes that were patient reported, the lack of assessment of immediate effects of oxygen on exercise performance or symptoms, possible variability in amount of oxygen delivered, and the fact that patients may have overestimated their oxygen use.

In patients with stable COPD and moderate resting or exercise induced desaturation, long-term supplemental oxygen did not provide any benefit in regard to time until death or first hospitalization or any of the other measured outcomes.

Application of data to the case

Our patient has stable COPD and had only moderate exercise-induced desaturation. Long-term supplemental oxygen would not produce a benefit for him.

This study shows us that it would not increase his survival at this point; however, if he were to have worsening exercise-induced or new resting desaturation at some point in the future, supplemental oxygen would then be beneficial. At this point supplemental oxygen would not even affect his rate of hospitalization for COPD- or non-COPD–related reasons. Perhaps most importantly, adding oxygen therapy would not affect his overall quality of life, including his functional status and mood.
 

Bottom line

The addition of supplemental oxygen is not helpful for patients with COPD who have chronic stable moderate hypoxia.

Dr. Farber is a medical instructor in the Duke University Health System in Durham, N.C. Dr. Sata is a medical instructor in the Duke University Hospital. Dr. Wachter is an assistant professor of medicine at Duke University. Dr. Sharma is associate medical director for clinical education in hospital medicine at Duke Regional Hospital and an assistant professor of medicine at Duke University.

References

1. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: A clinical trial. Ann Intern Med. 1980 Sep;93(3):391-8.

2. Medical Research Council Working Party. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: Report of the Medical Research Council Working Party. Lancet 1981 Mar 28;1(8222):681-6.

3. Long-term oxygen treatment trial research group et al. A randomized trial of long-term oxygen for COPD with moderate desaturation. N Engl J Med. 2016 Oct 27;375(17):1617-27.

Additional reading

Stoller JK et al. Oxygen therapy for patients with COPD: Current evidence and the Long-term Oxygen Treatment Trial. Chest. 2010 July;138:179-87.

Qaseem A et al. Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91.

Ameer F et al. Ambulatory oxygen for people with chronic obstructive pulmonary disease who are not hypoxaemic at rest. Cochrane Database Syst Rev. 2014 Jun 24;(6):CD000238.

Vestbo J et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013 Feb 15;187(4):347-65.

Quiz: Does this patient need oxygen?

You are caring for a 72-year-old man with stable COPD who was admitted for cellulitis. He is improving clinically on appropriate antibiotics, and he has been stable on room air every time you examine him. The nurse pages you on the day of discharge – a Sunday – informing you that his oxygen saturation dropped to 88% while he was walking the halls this morning. She asks whether he needs to stay in the hospital so you can arrange home supplemental oxygen therapy. What should you do?

A. Keep him in the hospital until you can arrange home oxygen therapy.

B. Discharge him home Sunday but have the oxygen company go out to his house first thing on Monday.

C. Discharge him home without supplemental oxygen therapy.

D. Check an arterial blood gas to help decide if you should set up oxygen therapy.

The answer is C. He meets the description of stable COPD with mild to moderate exercise-induced desaturation. The LOTT trial supports our clinical decision that he would not benefit from supplemental oxygen therapy at this point.

Key Points

• Long-term oxygen therapy (LTOT) is beneficial in patients with COPD and severe resting hypoxemia (arterial oxygen partial pressure ≤ 55 mm Hg or SpO₂ ≤ 88%) and should be prescribed to improve survival in this population.
• Patients with COPD and mild to moderate resting hypoxemia or exercised-induced hypoxemia should not be routinely prescribed LTOT given the associated costs, risks, and burdens and the lack of evidence of benefit.

Case

An 85-year-old man with long-standing chronic obstructive pulmonary disease (COPD) has a witnessed aspiration event while undergoing an outpatient procedure requiring conscious sedation. He is admitted to the hospital for observation overnight. The next morning, he feels well, but his oxygen saturation dips to 85% with ambulation. He reports this is not new for him, but he vehemently does not want supplemental oxygen.

Background

Patients with COPD and severe resting hypoxemia – arterial oxygen partial pressure less than or equal to 55 mm Hg or peripheral capillary oxygen saturation (SpO₂₎ less than or equal to 88% – commonly are prescribed supplemental oxygen. The evidence supporting this practice is limited to two small trials from the 1970s that showed a survival benefit of long-term oxygen therapy (LTOT) in this population,^1,2 but these trials may not be generalizable to patients today.

For patients with COPD and mild to moderate resting hypoxemia (SpO_2, 89%-93%) or patients with exercise-induced hypoxemia, LTOT has not been shown to improve survival, although it may improve symptoms of dyspnea, exercise tolerance, and other patient reported outcomes. Given the costs, risks, and burdens associated with LTOT, a high-quality clinical trial assessing the effects of LTOT on clinically meaningful outcomes, such as survival or hospitalization, in patients with COPD and moderate hypoxemia has been long overdue.
 

Overview of the data

The utility of long-term treatment with supplemental oxygen in patients with stable COPD and moderate resting or exercise-induced desaturation was examined by the Long-Term Oxygen Treatment Trial (LOTT) Research Group. Results were published in the New England Journal of Medicine in October 2016 in the article, “A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation.”³

The study was initially designed to test whether the use of supplemental oxygen would lead to longer time until death as compared with no supplemental oxygen in the subgroup of COPD patients with stable disease and moderate resting desaturation (defined as resting SpO₂ of 89%-93%). However, because of an enrollment of only 34 patients after 7 months, the trial was redesigned to include exercise-induced desaturation (defined as SpO₂ of greater than or equal to 80% for at least 5 minutes, and less than 90% for at least 10 seconds, on a 6-minute walk test) and the secondary outcome of all-cause hospitalization. Hospitalization for any cause was combined with mortality into a new composite primary outcome.

This study was a randomized, controlled trial which enrolled patients at a total of 14 regional clinical centers and their associated sites for a total of 42 centers in the United States. The experimental arm consisted of a long term supplemental oxygen group, and the control group did not receive long term supplemental oxygen. Patients were assigned to groups in a 1:1 ratio and the study was not blinded. Patients with moderate resting desaturation were prescribed 24 hour oxygen at 2 L/min, and patients with moderate exercise-induced desaturation were prescribed oxygen at 2 L/min during exercise and sleep only. The primary outcome was a composite outcome of time until death or time until first hospitalization for any cause. There were multiple secondary outcomes, including incidence of COPD exacerbation, incidence of severe resting desaturation and severe exercise-induced desaturation, quality of life, sleep quality, depression and anxiety, adherence to regimen, 6-minute walk distance, spirometric measurements, risk of cardiovascular disease, and neurocognitive function.

Data were gathered via yearly visits, biannual telephone interviews, and questionnaires mailed at 4 months and 16 months. Adherence was assessed by inquiring about oxygen use every 4 months. If patients in the supplemental oxygen group used stationary oxygen concentrators, logs of meter readings were kept as well. The necessary final sample size was calculated using a time to composite event survival model with the use of the log-rank test statistic.

A total of 738 patients were enrolled in the trial between January 2009 and September 2015 and were followed for 1-6 years. A total of 97% of participants had at least 1 year of follow-up. Out of the 738 randomized patients, 133 (18%) had only resting desaturations, 319 (43%) had only exercise-induced desaturations, and 286 (39%) had both resting and exercise-induced desaturations. Baseline characteristics including age, sex, race, smoking status, quality of life scores, resting SpO_2, and nadir SpO₂ during the 6-minute walk test were similar between the two groups. The only significant difference noted by the authors between the two groups was a lower BODE (body mass index, airflow obstruction, dyspnea, and exercise) index, which was lower in the group with no supplemental oxygen.

In the time-to-event analysis, there was no significant difference between the two groups in the time to death or first hospitalization (hazard ratio, 0.94; 95% confidence interval, 0.79-1.12; P = .52). There were no significant differences in the rates of all hospitalizations (rate ratio, 1.01; 95% CI, 0.91-1.13), COPD exacerbations (RR 1.08; 95% CI, 0.98-1.19), and COPD related hospitalizations (RR, 0.99; 95% CI, 0.83-1.17). There were also no differences between the experimental and control groups in quality of life, lung function, and 6-minute walk distance. There were no significant differences in the subgroups classified by desaturation profile, sex, race, nadir SpO₂ during the 6-minute walk test, and forced expiratory volume in 1 second.

The findings in this study show that, in the subgroup of chronic obstructive pulmonary disease patients with stable COPD and moderate resting or exercise-induced desaturation, supplemental oxygen did not affect the time to death or first hospitalization, time to death, time to first hospitalization, time to first COPD exacerbation, time to first hospitalization for a COPD exacerbation, rate of all hospitalizations, rate of all COPD exacerbations, or changes in metrics surrounding quality of life, anxiety/depression, or functional status. This supports earlier studies that demonstrated that long-term treatment with oxygen does not result in longer survival than does no long-term treatment with oxygen in patients with COPD and resting SpO₂ of more than 88%.

The results of this study are a departure from previous studies that had shown improved mortality in patients with COPD and severe desaturation who were treated with LTOT. The authors hypothesized that this may have been caused by physiological effects of oxygen saturation on pulmonary vasoconstriction, release of mediators, and ventilator drive, which occur at an O₂ saturation of 88% or less and may be more significant in patients with chronic hypoxemia. This trial also contrasted previous studies that had shown that oxygen therapy may reduce dyspnea in COPD patients with mild or no hypoxia because the LOTT trial showed no improvement in quality of life, anxiety, and depression measures in patients treated with long-term oxygen as compared with those treated with no oxygen.

Some limitations of the study included the absence of highly symptomatic patients or patients who the providers believed were too ill to participate, the effect of the unblinded nature of the study on outcomes that were patient reported, the lack of assessment of immediate effects of oxygen on exercise performance or symptoms, possible variability in amount of oxygen delivered, and the fact that patients may have overestimated their oxygen use.

In patients with stable COPD and moderate resting or exercise induced desaturation, long-term supplemental oxygen did not provide any benefit in regard to time until death or first hospitalization or any of the other measured outcomes.

Application of data to the case

Our patient has stable COPD and had only moderate exercise-induced desaturation. Long-term supplemental oxygen would not produce a benefit for him.

This study shows us that it would not increase his survival at this point; however, if he were to have worsening exercise-induced or new resting desaturation at some point in the future, supplemental oxygen would then be beneficial. At this point supplemental oxygen would not even affect his rate of hospitalization for COPD- or non-COPD–related reasons. Perhaps most importantly, adding oxygen therapy would not affect his overall quality of life, including his functional status and mood.
 

Bottom line

The addition of supplemental oxygen is not helpful for patients with COPD who have chronic stable moderate hypoxia.

Dr. Farber is a medical instructor in the Duke University Health System in Durham, N.C. Dr. Sata is a medical instructor in the Duke University Hospital. Dr. Wachter is an assistant professor of medicine at Duke University. Dr. Sharma is associate medical director for clinical education in hospital medicine at Duke Regional Hospital and an assistant professor of medicine at Duke University.

References

1. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: A clinical trial. Ann Intern Med. 1980 Sep;93(3):391-8.

2. Medical Research Council Working Party. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: Report of the Medical Research Council Working Party. Lancet 1981 Mar 28;1(8222):681-6.

3. Long-term oxygen treatment trial research group et al. A randomized trial of long-term oxygen for COPD with moderate desaturation. N Engl J Med. 2016 Oct 27;375(17):1617-27.

Additional reading

Stoller JK et al. Oxygen therapy for patients with COPD: Current evidence and the Long-term Oxygen Treatment Trial. Chest. 2010 July;138:179-87.

Qaseem A et al. Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91.

Ameer F et al. Ambulatory oxygen for people with chronic obstructive pulmonary disease who are not hypoxaemic at rest. Cochrane Database Syst Rev. 2014 Jun 24;(6):CD000238.

Vestbo J et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013 Feb 15;187(4):347-65.

Quiz: Does this patient need oxygen?

You are caring for a 72-year-old man with stable COPD who was admitted for cellulitis. He is improving clinically on appropriate antibiotics, and he has been stable on room air every time you examine him. The nurse pages you on the day of discharge – a Sunday – informing you that his oxygen saturation dropped to 88% while he was walking the halls this morning. She asks whether he needs to stay in the hospital so you can arrange home supplemental oxygen therapy. What should you do?

A. Keep him in the hospital until you can arrange home oxygen therapy.

B. Discharge him home Sunday but have the oxygen company go out to his house first thing on Monday.

C. Discharge him home without supplemental oxygen therapy.

D. Check an arterial blood gas to help decide if you should set up oxygen therapy.

The answer is C. He meets the description of stable COPD with mild to moderate exercise-induced desaturation. The LOTT trial supports our clinical decision that he would not benefit from supplemental oxygen therapy at this point.

Key Points

• Long-term oxygen therapy (LTOT) is beneficial in patients with COPD and severe resting hypoxemia (arterial oxygen partial pressure ≤ 55 mm Hg or SpO₂ ≤ 88%) and should be prescribed to improve survival in this population.
• Patients with COPD and mild to moderate resting hypoxemia or exercised-induced hypoxemia should not be routinely prescribed LTOT given the associated costs, risks, and burdens and the lack of evidence of benefit.

Clinical question: Does balanced crystalloid fluid improve outcomes versus saline in noncritically ill patients who are hospitalized?

Background: Prior research has raised concerns about a connection between intravenous saline administration and adverse outcomes. However, this work has been limited to patients in the ICU and operative room settings.

Study design: Single-center, unblinded, multiple crossover (clustered randomization) trial.

Setting: A tertiary-care, academic medical center, from January 2016 to April 2017.

Dr. Biddick is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: Does balanced crystalloid fluid improve outcomes versus saline in noncritically ill patients who are hospitalized?

Background: Prior research has raised concerns about a connection between intravenous saline administration and adverse outcomes. However, this work has been limited to patients in the ICU and operative room settings.

Study design: Single-center, unblinded, multiple crossover (clustered randomization) trial.

Setting: A tertiary-care, academic medical center, from January 2016 to April 2017.

Dr. Biddick is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: Does balanced crystalloid fluid improve outcomes versus saline in noncritically ill patients who are hospitalized?

Background: Prior research has raised concerns about a connection between intravenous saline administration and adverse outcomes. However, this work has been limited to patients in the ICU and operative room settings.

Study design: Single-center, unblinded, multiple crossover (clustered randomization) trial.

Setting: A tertiary-care, academic medical center, from January 2016 to April 2017.

Dr. Biddick is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Non–private clinical encounters tied to diagnostic error and delays in delivery of care.

In a cross-sectional survey of 409 emergency physicians attending the American College of Emergency Physicians Scientific Assembly conference, a majority of respondents reported deviating from their standard history-taking and physical exam practices when practicing in a hallway location or when a patient had a companion present during the clinical encounter. Of those physicians who reported changing their practices during non–private clinical encounters, a significant proportion reported that these changes had led to a delay in patient care or diagnostic error.

Citation: Stoklosa H et al. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. Emerg Med J. 2018 Feb 13. doi: 10.1136/emermed-2017-207119.

Retrospective case series of fluoroquinolone-induced acute interstitial nephritis (AIN).

A 23-year retrospective review of biopsy-proven cases of acute interstitial nephritis secondary to fluoroquinolones revealed that only 17% of cases presented with the typical triad of fever, rash, and eosinophilia, but that discontinuation of the offending agent resulted in complete or partial recovery in a majority of patients, with a median time to recovery of 20.5 days.

Citation: Farid S et al. Clinical manifestations and outcomes of fluoroquinolone-related acute interstitial nephritis. Mayo Clin Proc. 2018 Jan;93(1):25-31.

Trimethoprim associated with increased risk of AKI and hyperkalemia.

In a cohort study of older patients with urinary tract infections, trimethoprim was associated with increased risk of acute kidney injury and hyperkalemia, but not increased risk of death, in comparison to other antibiotics for UTIs. These risks were amplified for patients simultaneously taking renin-angiotensin system blockers or spironolactone.

Citation: Crellin E et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ. 2018;360:k341.

Mortality of in-hospital cardiac arrest is decreasing, but disparities between on- and off-hours persist.

An analysis of 151,071 in-hospital cardiac arrests (IHCA) during 2000-2014 found that patient survival to hospital discharge increased from 13.6% to 22.0%, but return of spontaneous circulation, post-resuscitation survival, and overall survival to hospital discharge were all significantly lower for IHCA that occurred during nights or weekends, compared with weekday IHCA. The difference in on- and off-hours post-resuscitation survival rates did not significantly change over the 14-year study period.

Citation: Ofoma UR et al. Trends in survival after in-hospital cardiac arrest during nights and weekends. J Am Coll Cardiol. 2018;71(4):402-11.

Young women with acute myocardial infarction present differently than young men.

Interviews of 2,009 young women and 976 young men hospitalized for acute MI at U.S. hospitals revealed that, while both groups of patients reported chest pain as the predominant symptom, women were more likely to report a greater number of additional, non–chest pain symptoms.

Citation: Lichtman JH et al. Sex difference in the presentation and perception of symptoms among young patients with myocardial infarction. Circulation. 2018;137(8):781-90.

Non–private clinical encounters tied to diagnostic error and delays in delivery of care.

In a cross-sectional survey of 409 emergency physicians attending the American College of Emergency Physicians Scientific Assembly conference, a majority of respondents reported deviating from their standard history-taking and physical exam practices when practicing in a hallway location or when a patient had a companion present during the clinical encounter. Of those physicians who reported changing their practices during non–private clinical encounters, a significant proportion reported that these changes had led to a delay in patient care or diagnostic error.

Citation: Stoklosa H et al. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. Emerg Med J. 2018 Feb 13. doi: 10.1136/emermed-2017-207119.

Retrospective case series of fluoroquinolone-induced acute interstitial nephritis (AIN).

A 23-year retrospective review of biopsy-proven cases of acute interstitial nephritis secondary to fluoroquinolones revealed that only 17% of cases presented with the typical triad of fever, rash, and eosinophilia, but that discontinuation of the offending agent resulted in complete or partial recovery in a majority of patients, with a median time to recovery of 20.5 days.

Citation: Farid S et al. Clinical manifestations and outcomes of fluoroquinolone-related acute interstitial nephritis. Mayo Clin Proc. 2018 Jan;93(1):25-31.

Trimethoprim associated with increased risk of AKI and hyperkalemia.

In a cohort study of older patients with urinary tract infections, trimethoprim was associated with increased risk of acute kidney injury and hyperkalemia, but not increased risk of death, in comparison to other antibiotics for UTIs. These risks were amplified for patients simultaneously taking renin-angiotensin system blockers or spironolactone.

Citation: Crellin E et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ. 2018;360:k341.

Mortality of in-hospital cardiac arrest is decreasing, but disparities between on- and off-hours persist.

An analysis of 151,071 in-hospital cardiac arrests (IHCA) during 2000-2014 found that patient survival to hospital discharge increased from 13.6% to 22.0%, but return of spontaneous circulation, post-resuscitation survival, and overall survival to hospital discharge were all significantly lower for IHCA that occurred during nights or weekends, compared with weekday IHCA. The difference in on- and off-hours post-resuscitation survival rates did not significantly change over the 14-year study period.

Citation: Ofoma UR et al. Trends in survival after in-hospital cardiac arrest during nights and weekends. J Am Coll Cardiol. 2018;71(4):402-11.

Young women with acute myocardial infarction present differently than young men.

Interviews of 2,009 young women and 976 young men hospitalized for acute MI at U.S. hospitals revealed that, while both groups of patients reported chest pain as the predominant symptom, women were more likely to report a greater number of additional, non–chest pain symptoms.

Citation: Lichtman JH et al. Sex difference in the presentation and perception of symptoms among young patients with myocardial infarction. Circulation. 2018;137(8):781-90.

Non–private clinical encounters tied to diagnostic error and delays in delivery of care.

In a cross-sectional survey of 409 emergency physicians attending the American College of Emergency Physicians Scientific Assembly conference, a majority of respondents reported deviating from their standard history-taking and physical exam practices when practicing in a hallway location or when a patient had a companion present during the clinical encounter. Of those physicians who reported changing their practices during non–private clinical encounters, a significant proportion reported that these changes had led to a delay in patient care or diagnostic error.

Citation: Stoklosa H et al. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. Emerg Med J. 2018 Feb 13. doi: 10.1136/emermed-2017-207119.

Retrospective case series of fluoroquinolone-induced acute interstitial nephritis (AIN).

A 23-year retrospective review of biopsy-proven cases of acute interstitial nephritis secondary to fluoroquinolones revealed that only 17% of cases presented with the typical triad of fever, rash, and eosinophilia, but that discontinuation of the offending agent resulted in complete or partial recovery in a majority of patients, with a median time to recovery of 20.5 days.

Citation: Farid S et al. Clinical manifestations and outcomes of fluoroquinolone-related acute interstitial nephritis. Mayo Clin Proc. 2018 Jan;93(1):25-31.

Trimethoprim associated with increased risk of AKI and hyperkalemia.

In a cohort study of older patients with urinary tract infections, trimethoprim was associated with increased risk of acute kidney injury and hyperkalemia, but not increased risk of death, in comparison to other antibiotics for UTIs. These risks were amplified for patients simultaneously taking renin-angiotensin system blockers or spironolactone.

Citation: Crellin E et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ. 2018;360:k341.

Mortality of in-hospital cardiac arrest is decreasing, but disparities between on- and off-hours persist.

An analysis of 151,071 in-hospital cardiac arrests (IHCA) during 2000-2014 found that patient survival to hospital discharge increased from 13.6% to 22.0%, but return of spontaneous circulation, post-resuscitation survival, and overall survival to hospital discharge were all significantly lower for IHCA that occurred during nights or weekends, compared with weekday IHCA. The difference in on- and off-hours post-resuscitation survival rates did not significantly change over the 14-year study period.

Citation: Ofoma UR et al. Trends in survival after in-hospital cardiac arrest during nights and weekends. J Am Coll Cardiol. 2018;71(4):402-11.

Young women with acute myocardial infarction present differently than young men.

Interviews of 2,009 young women and 976 young men hospitalized for acute MI at U.S. hospitals revealed that, while both groups of patients reported chest pain as the predominant symptom, women were more likely to report a greater number of additional, non–chest pain symptoms.

Citation: Lichtman JH et al. Sex difference in the presentation and perception of symptoms among young patients with myocardial infarction. Circulation. 2018;137(8):781-90.

Background: There is an alarming trend toward overuse of computed tomographic pulmonary angiography (CTPA) for the rule-out of low clinical probability PE. The eight-item Pulmonary Embolism Rule-Out Criteria (PERC) rule was devised to be used in populations of patients with low clinical probability of PE to guide which patients would likely not benefit from CTPA imaging. Recent concerns have been raised that the use of the PERC rule could result in high false-negative rates.

Study design: Crossover cluster–randomized clinical noninferiority trial.

Setting: 14 EDs in France from August 2015 to September 2016.

Synopsis: 1,916 emergency department patients with low clinical probability of PE were cluster-randomized to usual care or to a PERC strategy where, if the PERC score was zero, PE was ruled out without additional testing. The primary outcome was diagnosis of a symptomatic PE within 3 months that had not been diagnosed initially. Primary outcome results met prespecified noninferiority criteria for the PERC group, compared with the usual-care group (0.1% in the PERC group, 0% in the control group). The PERC group had significantly lower median length of ED stay and lower likelihood of admission.

Limitations of this study include its younger average patient age (44 years) and its cluster, as opposed to per-patient, randomization design.

Bottom line: In patients for whom the clinical probability of PE is low, use of the PERC rule is noninferior to a conventional d-dimer and CTPA strategy for ruling out symptomatic PE.

Citation: Freund Y et al. Effect of the pulmonary embolism rule-out criteria on subsequent thromboembolic events among low-risk emergency department patients. JAMA. 2018;319(6):559-66.

Dr. Abdallah is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Background: There is an alarming trend toward overuse of computed tomographic pulmonary angiography (CTPA) for the rule-out of low clinical probability PE. The eight-item Pulmonary Embolism Rule-Out Criteria (PERC) rule was devised to be used in populations of patients with low clinical probability of PE to guide which patients would likely not benefit from CTPA imaging. Recent concerns have been raised that the use of the PERC rule could result in high false-negative rates.

Study design: Crossover cluster–randomized clinical noninferiority trial.

Setting: 14 EDs in France from August 2015 to September 2016.

Synopsis: 1,916 emergency department patients with low clinical probability of PE were cluster-randomized to usual care or to a PERC strategy where, if the PERC score was zero, PE was ruled out without additional testing. The primary outcome was diagnosis of a symptomatic PE within 3 months that had not been diagnosed initially. Primary outcome results met prespecified noninferiority criteria for the PERC group, compared with the usual-care group (0.1% in the PERC group, 0% in the control group). The PERC group had significantly lower median length of ED stay and lower likelihood of admission.

Limitations of this study include its younger average patient age (44 years) and its cluster, as opposed to per-patient, randomization design.

Bottom line: In patients for whom the clinical probability of PE is low, use of the PERC rule is noninferior to a conventional d-dimer and CTPA strategy for ruling out symptomatic PE.

Citation: Freund Y et al. Effect of the pulmonary embolism rule-out criteria on subsequent thromboembolic events among low-risk emergency department patients. JAMA. 2018;319(6):559-66.

Dr. Abdallah is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Background: There is an alarming trend toward overuse of computed tomographic pulmonary angiography (CTPA) for the rule-out of low clinical probability PE. The eight-item Pulmonary Embolism Rule-Out Criteria (PERC) rule was devised to be used in populations of patients with low clinical probability of PE to guide which patients would likely not benefit from CTPA imaging. Recent concerns have been raised that the use of the PERC rule could result in high false-negative rates.

Study design: Crossover cluster–randomized clinical noninferiority trial.

Setting: 14 EDs in France from August 2015 to September 2016.

Synopsis: 1,916 emergency department patients with low clinical probability of PE were cluster-randomized to usual care or to a PERC strategy where, if the PERC score was zero, PE was ruled out without additional testing. The primary outcome was diagnosis of a symptomatic PE within 3 months that had not been diagnosed initially. Primary outcome results met prespecified noninferiority criteria for the PERC group, compared with the usual-care group (0.1% in the PERC group, 0% in the control group). The PERC group had significantly lower median length of ED stay and lower likelihood of admission.

Limitations of this study include its younger average patient age (44 years) and its cluster, as opposed to per-patient, randomization design.

Bottom line: In patients for whom the clinical probability of PE is low, use of the PERC rule is noninferior to a conventional d-dimer and CTPA strategy for ruling out symptomatic PE.

Citation: Freund Y et al. Effect of the pulmonary embolism rule-out criteria on subsequent thromboembolic events among low-risk emergency department patients. JAMA. 2018;319(6):559-66.

Dr. Abdallah is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

ATLANTA – An adjustment in the culture reporting schedule at Texas Children’s Hospital, Houston, helped reduce the average length of stay for neonatal fever from 48 to 43 hours, without increasing readmissions for serious bacterial infections, according to a review presented at the Pediatric Hospital Medicine meeting.

M. Alexander Otto/MDedge News

Investigators there were working to meet the goals of the Reducing Excessive Variability in Infant Sepsis Evaluation project (REVISE), a national collaboration aimed at improving care. One of the goals is to reduce the length of stay (LOS) for neonatal fever to fewer than 30 hours for low-risk infants and fewer than 42 hours among high-risk infants.

The traditional standard is to keep children in the hospital for 48 hours to rule out sepsis, but that thinking has begun to change amid evidence that blood cultures generally do not need that long to turn positive, among other findings, said investigator Huay-Ying Lo, MD, a pediatrician at Texas Children’s.

“At our institution,” which admits more than 200 NF cases annually, “we have order sets for neonatal fever, and we’re actually doing pretty well” meeting most of the REVISE goals, “so we decided to focus on reducing length of stay,” she said at the meeting.

Evidence of the safety and cost savings of earlier discharge was presented to providers, and weekly emails reminded them of the early discharge goal and updated them on the current average LOS for NF.

Dr. Lo and her team also brainstormed with providers to identify problems. “One of the barriers they consistently mentioned was the timing of cultures being reported out from the microbiology lab. A lot of time, people were just waiting for the report to say no growth for 36 hours or whatever it was going to be,” she said.

That led to talks with the microbiology department. Blood cultures were already automated, so there wasn’t much that needed to be done. Urine cultures were read manually three to four times a day after the initial incubation period. However, after an initial Gram stain, CSF cultures were read manually only one or two times a day – whenever somebody had time. The hours were random, and sometimes results were not reported until the evening, which meant the child had to spend another night in the hospital.

The lab director agreed that it was a problem, and standardized procedures to read cultures twice a day, at 7 a.m. and 2 p.m. “The times we agreed upon; 7 a.m. works really well for morning discharge, and at 2 p.m., the day team is still there and can get kids out that day,” Dr. Lo explained.

Along with staff education and LOS reporting, timely culture reports made a difference. Among infants 7-60 days old admitted with NF – excluding ill-appearing children and those with comorbidities that increased the risk of infections – the mean LOS fell from 48 hours among 144 infants treated before the intervention, to 43 hours among 157 treated afterward (P = .001), and “we didn’t have any more readmission for serious bacterial infections,” Dr. Lo said.

“We want to reduce it further. If we get to 42 hours, we’ll be pretty happy.” Updating discharge criteria, and letting providers know how their LOS’s compare with their peers’ might help. “I’m sure some people are more conservative and some a little more liberal,” she said.

There was no industry funding for the work, and the investigators had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]

ATLANTA – An adjustment in the culture reporting schedule at Texas Children’s Hospital, Houston, helped reduce the average length of stay for neonatal fever from 48 to 43 hours, without increasing readmissions for serious bacterial infections, according to a review presented at the Pediatric Hospital Medicine meeting.

M. Alexander Otto/MDedge News

Investigators there were working to meet the goals of the Reducing Excessive Variability in Infant Sepsis Evaluation project (REVISE), a national collaboration aimed at improving care. One of the goals is to reduce the length of stay (LOS) for neonatal fever to fewer than 30 hours for low-risk infants and fewer than 42 hours among high-risk infants.

The traditional standard is to keep children in the hospital for 48 hours to rule out sepsis, but that thinking has begun to change amid evidence that blood cultures generally do not need that long to turn positive, among other findings, said investigator Huay-Ying Lo, MD, a pediatrician at Texas Children’s.

“At our institution,” which admits more than 200 NF cases annually, “we have order sets for neonatal fever, and we’re actually doing pretty well” meeting most of the REVISE goals, “so we decided to focus on reducing length of stay,” she said at the meeting.

Evidence of the safety and cost savings of earlier discharge was presented to providers, and weekly emails reminded them of the early discharge goal and updated them on the current average LOS for NF.

Dr. Lo and her team also brainstormed with providers to identify problems. “One of the barriers they consistently mentioned was the timing of cultures being reported out from the microbiology lab. A lot of time, people were just waiting for the report to say no growth for 36 hours or whatever it was going to be,” she said.

That led to talks with the microbiology department. Blood cultures were already automated, so there wasn’t much that needed to be done. Urine cultures were read manually three to four times a day after the initial incubation period. However, after an initial Gram stain, CSF cultures were read manually only one or two times a day – whenever somebody had time. The hours were random, and sometimes results were not reported until the evening, which meant the child had to spend another night in the hospital.

The lab director agreed that it was a problem, and standardized procedures to read cultures twice a day, at 7 a.m. and 2 p.m. “The times we agreed upon; 7 a.m. works really well for morning discharge, and at 2 p.m., the day team is still there and can get kids out that day,” Dr. Lo explained.

Along with staff education and LOS reporting, timely culture reports made a difference. Among infants 7-60 days old admitted with NF – excluding ill-appearing children and those with comorbidities that increased the risk of infections – the mean LOS fell from 48 hours among 144 infants treated before the intervention, to 43 hours among 157 treated afterward (P = .001), and “we didn’t have any more readmission for serious bacterial infections,” Dr. Lo said.

“We want to reduce it further. If we get to 42 hours, we’ll be pretty happy.” Updating discharge criteria, and letting providers know how their LOS’s compare with their peers’ might help. “I’m sure some people are more conservative and some a little more liberal,” she said.

There was no industry funding for the work, and the investigators had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]

ATLANTA – An adjustment in the culture reporting schedule at Texas Children’s Hospital, Houston, helped reduce the average length of stay for neonatal fever from 48 to 43 hours, without increasing readmissions for serious bacterial infections, according to a review presented at the Pediatric Hospital Medicine meeting.

M. Alexander Otto/MDedge News

Investigators there were working to meet the goals of the Reducing Excessive Variability in Infant Sepsis Evaluation project (REVISE), a national collaboration aimed at improving care. One of the goals is to reduce the length of stay (LOS) for neonatal fever to fewer than 30 hours for low-risk infants and fewer than 42 hours among high-risk infants.

The traditional standard is to keep children in the hospital for 48 hours to rule out sepsis, but that thinking has begun to change amid evidence that blood cultures generally do not need that long to turn positive, among other findings, said investigator Huay-Ying Lo, MD, a pediatrician at Texas Children’s.

“At our institution,” which admits more than 200 NF cases annually, “we have order sets for neonatal fever, and we’re actually doing pretty well” meeting most of the REVISE goals, “so we decided to focus on reducing length of stay,” she said at the meeting.

Evidence of the safety and cost savings of earlier discharge was presented to providers, and weekly emails reminded them of the early discharge goal and updated them on the current average LOS for NF.

Dr. Lo and her team also brainstormed with providers to identify problems. “One of the barriers they consistently mentioned was the timing of cultures being reported out from the microbiology lab. A lot of time, people were just waiting for the report to say no growth for 36 hours or whatever it was going to be,” she said.

That led to talks with the microbiology department. Blood cultures were already automated, so there wasn’t much that needed to be done. Urine cultures were read manually three to four times a day after the initial incubation period. However, after an initial Gram stain, CSF cultures were read manually only one or two times a day – whenever somebody had time. The hours were random, and sometimes results were not reported until the evening, which meant the child had to spend another night in the hospital.

The lab director agreed that it was a problem, and standardized procedures to read cultures twice a day, at 7 a.m. and 2 p.m. “The times we agreed upon; 7 a.m. works really well for morning discharge, and at 2 p.m., the day team is still there and can get kids out that day,” Dr. Lo explained.

Along with staff education and LOS reporting, timely culture reports made a difference. Among infants 7-60 days old admitted with NF – excluding ill-appearing children and those with comorbidities that increased the risk of infections – the mean LOS fell from 48 hours among 144 infants treated before the intervention, to 43 hours among 157 treated afterward (P = .001), and “we didn’t have any more readmission for serious bacterial infections,” Dr. Lo said.

“We want to reduce it further. If we get to 42 hours, we’ll be pretty happy.” Updating discharge criteria, and letting providers know how their LOS’s compare with their peers’ might help. “I’m sure some people are more conservative and some a little more liberal,” she said.

There was no industry funding for the work, and the investigators had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]

ATLANTA – An asthma medication ratio below 0.5 nearly doubles the risk of children ending up in the hospital with an acute asthma exacerbation, according to researchers from the Medical University of South Carolina (MUSC), Charleston.

M. Alexander Otto/MDedge News

The asthma medication ratio (AMR) – the number of prescriptions for controller medications divided by the number of prescriptions for both controller and rescue medications – has been around for a while, but it’s mostly been used as a quality metric. The new study shows that it’s also useful in the clinic to identify children who could benefit from extra attention.

A perfect ratio of 1 means that control is good without rescue inhalers. The ratio falls as the number of rescue inhalers goes up, signaling poorer control. Children with a ratio below 0.5 are considered high risk; they’d hit that mark if, for instance, they were prescribed one control medication such as fluticasone propionate (Flovent) and two albuterol rescue inhalers in a month.

If control is good, “you should only need a rescue inhaler very, very sporadically;” high-risk children probably need a higher dose of their controller, or help with compliance, explained lead investigator Annie L. Andrews, MD, associate professor of pediatrics at MUSC.

The university uses the EPIC records system, which incorporates prescription data from Surescripts, so the number of asthma medication fills is already available. The system just needs to be adjusted to calculate and report AMRs monthly, something Dr. Andrews and her team are working on. “The information is right there, but it’s an untapped resource,” she said. “We just need to crunch the numbers, and operationalize it. Why are we waiting until kids are in the hospital” to intervene?

Dr. Andrews presented a proof-of-concept study at the Pediatric Hospital Medicine meeting. Her team identified 214,452 asthma patients aged 2-17 years with at least one claim for an inhaled corticosteroid in the Truven MarketScan Medicaid database from 2013-14.

They calculated AMRs for each child every 3 months over a 15-month period. About 9% of children at any given time had AMRs below 0.5.

The first AMR was at or above 0.5 in 93,512 children; 18.1% had a subsequent asthma-related event, meaning an ED visit or hospitalization, during the course of the study. Among the 17,635 children with an initial AMR below 0.5, 25% had asthma-related events. The initial AMR couldn’t be calculated in 103,305 children, which likely meant they had less-active disease. Those children had the lowest proportion of asthma events, at 13.9%.

An AMR below 0.5 nearly doubled the risk of an asthma-related hospitalization or ED visit in the subsequent 3 months, with an odds ratios ranging from 1.7 to 1.9, compared with other children. The findings were statistically significant.

In short, serial AMRs helped predict exacerbations among Medicaid children. The team showed the same trend among commercially insured children in a recently published study. The only difference was that Medicaid children had a higher proportion of high-risk AMRs, and a higher number of asthma events (Am J Manag Care. 2018 Jun;24[6]:294-300). Together, the studies validate “the rolling 3-month AMR as an appropriate method for identifying children at high risk for imminent exacerbation,” the investigators concluded.

With automatic AMR reporting already in the works at MUSC, “we are now trying to figure out how to intervene. Do we just tell providers who their high-risk kids are and let them figure out how to contact families, or do we use this information to contact families directly? That’s kind of what I favor: ‘Hey, your kid just popped up as high risk, so let’s figure out what you need. Do you need a new prescription or a reminder to see your doctor?’ ” Dr. Andrews said.

Her team is developing a mobile app to communicate with families.

The mean age in the study was 7.9 years; 59% of the children were boys, and 41% were black.

The work was funded by the National Institutes of Health, among others. Dr. Andrews had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]

ATLANTA – An asthma medication ratio below 0.5 nearly doubles the risk of children ending up in the hospital with an acute asthma exacerbation, according to researchers from the Medical University of South Carolina (MUSC), Charleston.

M. Alexander Otto/MDedge News

The asthma medication ratio (AMR) – the number of prescriptions for controller medications divided by the number of prescriptions for both controller and rescue medications – has been around for a while, but it’s mostly been used as a quality metric. The new study shows that it’s also useful in the clinic to identify children who could benefit from extra attention.

A perfect ratio of 1 means that control is good without rescue inhalers. The ratio falls as the number of rescue inhalers goes up, signaling poorer control. Children with a ratio below 0.5 are considered high risk; they’d hit that mark if, for instance, they were prescribed one control medication such as fluticasone propionate (Flovent) and two albuterol rescue inhalers in a month.

If control is good, “you should only need a rescue inhaler very, very sporadically;” high-risk children probably need a higher dose of their controller, or help with compliance, explained lead investigator Annie L. Andrews, MD, associate professor of pediatrics at MUSC.

The university uses the EPIC records system, which incorporates prescription data from Surescripts, so the number of asthma medication fills is already available. The system just needs to be adjusted to calculate and report AMRs monthly, something Dr. Andrews and her team are working on. “The information is right there, but it’s an untapped resource,” she said. “We just need to crunch the numbers, and operationalize it. Why are we waiting until kids are in the hospital” to intervene?

Dr. Andrews presented a proof-of-concept study at the Pediatric Hospital Medicine meeting. Her team identified 214,452 asthma patients aged 2-17 years with at least one claim for an inhaled corticosteroid in the Truven MarketScan Medicaid database from 2013-14.

They calculated AMRs for each child every 3 months over a 15-month period. About 9% of children at any given time had AMRs below 0.5.

The first AMR was at or above 0.5 in 93,512 children; 18.1% had a subsequent asthma-related event, meaning an ED visit or hospitalization, during the course of the study. Among the 17,635 children with an initial AMR below 0.5, 25% had asthma-related events. The initial AMR couldn’t be calculated in 103,305 children, which likely meant they had less-active disease. Those children had the lowest proportion of asthma events, at 13.9%.

An AMR below 0.5 nearly doubled the risk of an asthma-related hospitalization or ED visit in the subsequent 3 months, with an odds ratios ranging from 1.7 to 1.9, compared with other children. The findings were statistically significant.

In short, serial AMRs helped predict exacerbations among Medicaid children. The team showed the same trend among commercially insured children in a recently published study. The only difference was that Medicaid children had a higher proportion of high-risk AMRs, and a higher number of asthma events (Am J Manag Care. 2018 Jun;24[6]:294-300). Together, the studies validate “the rolling 3-month AMR as an appropriate method for identifying children at high risk for imminent exacerbation,” the investigators concluded.

With automatic AMR reporting already in the works at MUSC, “we are now trying to figure out how to intervene. Do we just tell providers who their high-risk kids are and let them figure out how to contact families, or do we use this information to contact families directly? That’s kind of what I favor: ‘Hey, your kid just popped up as high risk, so let’s figure out what you need. Do you need a new prescription or a reminder to see your doctor?’ ” Dr. Andrews said.

Her team is developing a mobile app to communicate with families.

The mean age in the study was 7.9 years; 59% of the children were boys, and 41% were black.

The work was funded by the National Institutes of Health, among others. Dr. Andrews had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]

ATLANTA – An asthma medication ratio below 0.5 nearly doubles the risk of children ending up in the hospital with an acute asthma exacerbation, according to researchers from the Medical University of South Carolina (MUSC), Charleston.

M. Alexander Otto/MDedge News

The asthma medication ratio (AMR) – the number of prescriptions for controller medications divided by the number of prescriptions for both controller and rescue medications – has been around for a while, but it’s mostly been used as a quality metric. The new study shows that it’s also useful in the clinic to identify children who could benefit from extra attention.

A perfect ratio of 1 means that control is good without rescue inhalers. The ratio falls as the number of rescue inhalers goes up, signaling poorer control. Children with a ratio below 0.5 are considered high risk; they’d hit that mark if, for instance, they were prescribed one control medication such as fluticasone propionate (Flovent) and two albuterol rescue inhalers in a month.

If control is good, “you should only need a rescue inhaler very, very sporadically;” high-risk children probably need a higher dose of their controller, or help with compliance, explained lead investigator Annie L. Andrews, MD, associate professor of pediatrics at MUSC.

The university uses the EPIC records system, which incorporates prescription data from Surescripts, so the number of asthma medication fills is already available. The system just needs to be adjusted to calculate and report AMRs monthly, something Dr. Andrews and her team are working on. “The information is right there, but it’s an untapped resource,” she said. “We just need to crunch the numbers, and operationalize it. Why are we waiting until kids are in the hospital” to intervene?

Dr. Andrews presented a proof-of-concept study at the Pediatric Hospital Medicine meeting. Her team identified 214,452 asthma patients aged 2-17 years with at least one claim for an inhaled corticosteroid in the Truven MarketScan Medicaid database from 2013-14.

They calculated AMRs for each child every 3 months over a 15-month period. About 9% of children at any given time had AMRs below 0.5.

The first AMR was at or above 0.5 in 93,512 children; 18.1% had a subsequent asthma-related event, meaning an ED visit or hospitalization, during the course of the study. Among the 17,635 children with an initial AMR below 0.5, 25% had asthma-related events. The initial AMR couldn’t be calculated in 103,305 children, which likely meant they had less-active disease. Those children had the lowest proportion of asthma events, at 13.9%.

An AMR below 0.5 nearly doubled the risk of an asthma-related hospitalization or ED visit in the subsequent 3 months, with an odds ratios ranging from 1.7 to 1.9, compared with other children. The findings were statistically significant.

In short, serial AMRs helped predict exacerbations among Medicaid children. The team showed the same trend among commercially insured children in a recently published study. The only difference was that Medicaid children had a higher proportion of high-risk AMRs, and a higher number of asthma events (Am J Manag Care. 2018 Jun;24[6]:294-300). Together, the studies validate “the rolling 3-month AMR as an appropriate method for identifying children at high risk for imminent exacerbation,” the investigators concluded.

With automatic AMR reporting already in the works at MUSC, “we are now trying to figure out how to intervene. Do we just tell providers who their high-risk kids are and let them figure out how to contact families, or do we use this information to contact families directly? That’s kind of what I favor: ‘Hey, your kid just popped up as high risk, so let’s figure out what you need. Do you need a new prescription or a reminder to see your doctor?’ ” Dr. Andrews said.

Her team is developing a mobile app to communicate with families.

The mean age in the study was 7.9 years; 59% of the children were boys, and 41% were black.

The work was funded by the National Institutes of Health, among others. Dr. Andrews had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]