Guidelines

SAN FRANCISCO – To reduce unnecessary transfusions, all it takes is a reminder in the electronic medical record system that they aren’t generally necessary if surgery patients have hemoglobins greater than 10 g/dL, according to investigators from Emory University in Atlanta.

A reminder in Emory’s EMR dropped transfusion rates in cardiothoracic patients without increasing negative outcomes. It also saved money and reduced the number of surgical site infections. Emory is now rolling it out systemwide (J. Am. Coll. Surg. 2014 June 25 [doi: 10.1016/j.jamcollsurg.2014.06.012]). Lead investigator Dr. Seyed Razavi explained the initiative in a video interview at the annual clinical congress of the American College of Surgeons.

[email protected]

SAN FRANCISCO – To reduce unnecessary transfusions, all it takes is a reminder in the electronic medical record system that they aren’t generally necessary if surgery patients have hemoglobins greater than 10 g/dL, according to investigators from Emory University in Atlanta.

A reminder in Emory’s EMR dropped transfusion rates in cardiothoracic patients without increasing negative outcomes. It also saved money and reduced the number of surgical site infections. Emory is now rolling it out systemwide (J. Am. Coll. Surg. 2014 June 25 [doi: 10.1016/j.jamcollsurg.2014.06.012]). Lead investigator Dr. Seyed Razavi explained the initiative in a video interview at the annual clinical congress of the American College of Surgeons.

[email protected]

SAN FRANCISCO – To reduce unnecessary transfusions, all it takes is a reminder in the electronic medical record system that they aren’t generally necessary if surgery patients have hemoglobins greater than 10 g/dL, according to investigators from Emory University in Atlanta.

A reminder in Emory’s EMR dropped transfusion rates in cardiothoracic patients without increasing negative outcomes. It also saved money and reduced the number of surgical site infections. Emory is now rolling it out systemwide (J. Am. Coll. Surg. 2014 June 25 [doi: 10.1016/j.jamcollsurg.2014.06.012]). Lead investigator Dr. Seyed Razavi explained the initiative in a video interview at the annual clinical congress of the American College of Surgeons.

[email protected]

Hands-on workshop helps hospitalists gain confidence in fundamentals, learn to teach physical exam skills better

Hands-on workshop helps hospitalists gain confidence in fundamentals, learn to teach physical exam skills better

Hands-on workshop helps hospitalists gain confidence in fundamentals, learn to teach physical exam skills better

Patients who have had kidney stones at least once should increase their fluid consumption to produce at least 2 L of urine per day to prevent the condition from recurring, according to new guidelines published by the American College of Physicians.

If increased fluid intake doesn’t prevent recurrent nephrolithiasis, the updated ACP guidelines recommend adding treatment with a thiazide diuretic, citrate, or allopurinol. “Increased fluid intake spread throughout the day can decrease stone recurrence by at least half with virtually no side effects,” said Dr. David A. Fleming, ACP president, in a statement. “However, people who already drink the recommended amount of liquids, or when increased fluid intake is contraindicated, should not increase their fluid intake.”

©Igor Dutina/Fotolia.com

The guidelines are based on a review of nephrolithiasis studies, in which the ACP’s director of clinical policy, Dr. Amir Qaseem, and his associates examined baseline stone composition, blood and urine chemistries, and final health outcomes, among other factors. Only English-language trials were used, and research was collected through searches of MEDLINE, the Cochrane Database of Systematic Reviews, Google Scholar, ClinicalTrials.gov, and Web of Science (Ann. Intern. Med. 2014;161:659-67).

Thiazide diuretics, citrates, or allopurinol significantly reduced recurrence of calcium-based stones (the most common type of kidney stone) in patients who had nephrolithiasis at least twice before, according to the analysis.

The ACP guidelines also caution against consuming non-fruit–flavored sodas and carbonated beverages, because they are acidified by phosphoric acid, and dietary animal protein and purines.

However, the guidelines encourage consumption of dietary oxalate – commonly found in chocolate, beets, nuts, rhubarb, spinach, strawberries, tea, and wheat bran – and support maintaining normal dietary calcium. There was no evidence to suggest a risk reduction advantage in drinking tap water rather than mineral water.

The recommendations do not apply to “patients with suspected hyperparathyroidism or other rare cases,” the guidelines authors noted.

Financial support for the guidelines came from the ACP operating budget. The authors had no other relevant financial disclosures.

[email protected]

Patients who have had kidney stones at least once should increase their fluid consumption to produce at least 2 L of urine per day to prevent the condition from recurring, according to new guidelines published by the American College of Physicians.

If increased fluid intake doesn’t prevent recurrent nephrolithiasis, the updated ACP guidelines recommend adding treatment with a thiazide diuretic, citrate, or allopurinol. “Increased fluid intake spread throughout the day can decrease stone recurrence by at least half with virtually no side effects,” said Dr. David A. Fleming, ACP president, in a statement. “However, people who already drink the recommended amount of liquids, or when increased fluid intake is contraindicated, should not increase their fluid intake.”

©Igor Dutina/Fotolia.com

The guidelines are based on a review of nephrolithiasis studies, in which the ACP’s director of clinical policy, Dr. Amir Qaseem, and his associates examined baseline stone composition, blood and urine chemistries, and final health outcomes, among other factors. Only English-language trials were used, and research was collected through searches of MEDLINE, the Cochrane Database of Systematic Reviews, Google Scholar, ClinicalTrials.gov, and Web of Science (Ann. Intern. Med. 2014;161:659-67).

Thiazide diuretics, citrates, or allopurinol significantly reduced recurrence of calcium-based stones (the most common type of kidney stone) in patients who had nephrolithiasis at least twice before, according to the analysis.

The ACP guidelines also caution against consuming non-fruit–flavored sodas and carbonated beverages, because they are acidified by phosphoric acid, and dietary animal protein and purines.

However, the guidelines encourage consumption of dietary oxalate – commonly found in chocolate, beets, nuts, rhubarb, spinach, strawberries, tea, and wheat bran – and support maintaining normal dietary calcium. There was no evidence to suggest a risk reduction advantage in drinking tap water rather than mineral water.

The recommendations do not apply to “patients with suspected hyperparathyroidism or other rare cases,” the guidelines authors noted.

Financial support for the guidelines came from the ACP operating budget. The authors had no other relevant financial disclosures.

[email protected]

Patients who have had kidney stones at least once should increase their fluid consumption to produce at least 2 L of urine per day to prevent the condition from recurring, according to new guidelines published by the American College of Physicians.

If increased fluid intake doesn’t prevent recurrent nephrolithiasis, the updated ACP guidelines recommend adding treatment with a thiazide diuretic, citrate, or allopurinol. “Increased fluid intake spread throughout the day can decrease stone recurrence by at least half with virtually no side effects,” said Dr. David A. Fleming, ACP president, in a statement. “However, people who already drink the recommended amount of liquids, or when increased fluid intake is contraindicated, should not increase their fluid intake.”

©Igor Dutina/Fotolia.com

The guidelines are based on a review of nephrolithiasis studies, in which the ACP’s director of clinical policy, Dr. Amir Qaseem, and his associates examined baseline stone composition, blood and urine chemistries, and final health outcomes, among other factors. Only English-language trials were used, and research was collected through searches of MEDLINE, the Cochrane Database of Systematic Reviews, Google Scholar, ClinicalTrials.gov, and Web of Science (Ann. Intern. Med. 2014;161:659-67).

Thiazide diuretics, citrates, or allopurinol significantly reduced recurrence of calcium-based stones (the most common type of kidney stone) in patients who had nephrolithiasis at least twice before, according to the analysis.

The ACP guidelines also caution against consuming non-fruit–flavored sodas and carbonated beverages, because they are acidified by phosphoric acid, and dietary animal protein and purines.

However, the guidelines encourage consumption of dietary oxalate – commonly found in chocolate, beets, nuts, rhubarb, spinach, strawberries, tea, and wheat bran – and support maintaining normal dietary calcium. There was no evidence to suggest a risk reduction advantage in drinking tap water rather than mineral water.

The recommendations do not apply to “patients with suspected hyperparathyroidism or other rare cases,” the guidelines authors noted.

Financial support for the guidelines came from the ACP operating budget. The authors had no other relevant financial disclosures.

[email protected]

Lifestyle modifications, including eating a Mediterranean or DASH-style diet, should be encouraged to lower an individual’s risk of first-time stroke, according to new guidelines for the primary prevention of stroke from the American Heart Association and American Stroke Association.

Mediterranean and DASH (Dietary Approaches to Stop Hypertension) dietary plans are characterized by their emphasis on fruits, vegetables, whole grains, legumes, nuts, seeds, poultry, and fish, while limiting red meats, sweets, and any foods with saturated fats. This new guidelines – which have been endorsed by the American Academy of Neurology, American Association of Neurological Surgeons, Congress of Neurological Surgeons, and Preventive Cardiovascular Nurses Association – suggest that adopting either of these diets in addition to a few other healthy living habits can dramatically reduce an individual’s odds of suffering a stroke (Stroke 2014;45 [doi: 10.1161/STR.0000000000000046]).

©snyferok/thinkstockphoto.com

“We have a huge opportunity to improve how we prevent new strokes, because risk factors that can be changed or controlled – especially high blood pressure – account for 90% of strokes,” said Dr. James Meschia, chair of the writing committee and chairman of neurology at the Mayo Clinic in Jacksonville, Fla., in a statement. The last such guidelines were released 3 years ago (Stroke 2011;42:517-84)

The writing committee gathered data pertaining to the age, birth weight, race/ethnicity, and genetic factors, among several others. Studies examined included a U.S. Nationwide Inpatient Sample, which showed that stroke hospitalizations increased between 1998 and 2007 for individuals aged 25-34 years and 35-44 years; the Framingham Heart Study, which estimated that the odds of a middle-aged adult suffering a stroke are 1 in 6; an analysis of South Carolina Medicaid beneficiaries under age 50, which revealed that individuals born weighing less than 2,500 g were twice as likely to have a stroke as those born heavier; and an Atherosclerosis Risk in Communities (ARIC) study that showed Latino and African American populations being at higher risk for stroke due to hypertension, obesity, and diabetes.

Because blood pressure, hypertension, diabetes, and obesity are so commonly linked to stroke risk, the new American Heart Association/American Stroke Association (AHA/ASA) guidelines highly recommend a Mediterranean or DASH-style diet supplemented with nuts. Additionally, the guidelines advise health care professionals to advise patients to cut down on sodium intake, regularly monitor their blood pressure, talk to their physicians immediately if any medication does not do what it is intended to or creates negative side effects, and quit smoking, and, for women, consider an alternative to oral birth control pills.

Hypertension, “the most important, well-documented, modifiable stroke risk factor,” should be treated with antihypertensive medication to a target blood pressure of less than 140/90 mm Hg, the guidelines state.

Furthermore, the ASA/AHA guidelines continue to recommend regular physical exercise and acute monitoring of individuals’ cholesterol levels, such as LDL, HDL, and triglycerides, as failure to keep these numbers in check can easily lead to a serious stroke. The guidelines also state that although heavy alcohol consumption can increase the chance of stroke, “light to moderate” alcohol consumption can actually decrease the odds of suffering a stroke.

The AHA/ASA guidelines also examine factors such as migraines, which are associated with stroke in women under age 55, and hyperhomocysteinemia, which is also associated with an increased risk of stroke. Other factors like hypercoagulability and sleep apnea were not shown to have any identifiable relationship with an increased risk of stroke.

“As health professionals, we must ensure that progress in preventing stroke does not lead to complacency,” say the guidelines. “We must acknowledge that several recommendations remain vague because of suboptimal clinical trial evidence or, even more concerning, may be out of date and therefore irrelevant.”

Dr. Meschia and his associates warn that although medications are helpful, the best way to safeguard against a stroke is to change a person’s lifestyle into one of healthy eating and exercise habits. Unfortunately, say the authors, “it is easier to convince a patient to take a pill than to radically change his or her lifestyle, [but] we must expect the same standards of evidence for lifestyle interventions.”

Dr. Meschia disclosed that his research grant comes from the National Institute of Neurological Disorders and Stroke. He had no other relevant financial disclosures of interest. Several of the guidelines’ coauthors had disclosures of their own, which are listed in the statement.

[email protected]

Lifestyle modifications, including eating a Mediterranean or DASH-style diet, should be encouraged to lower an individual’s risk of first-time stroke, according to new guidelines for the primary prevention of stroke from the American Heart Association and American Stroke Association.

Mediterranean and DASH (Dietary Approaches to Stop Hypertension) dietary plans are characterized by their emphasis on fruits, vegetables, whole grains, legumes, nuts, seeds, poultry, and fish, while limiting red meats, sweets, and any foods with saturated fats. This new guidelines – which have been endorsed by the American Academy of Neurology, American Association of Neurological Surgeons, Congress of Neurological Surgeons, and Preventive Cardiovascular Nurses Association – suggest that adopting either of these diets in addition to a few other healthy living habits can dramatically reduce an individual’s odds of suffering a stroke (Stroke 2014;45 [doi: 10.1161/STR.0000000000000046]).

©snyferok/thinkstockphoto.com

“We have a huge opportunity to improve how we prevent new strokes, because risk factors that can be changed or controlled – especially high blood pressure – account for 90% of strokes,” said Dr. James Meschia, chair of the writing committee and chairman of neurology at the Mayo Clinic in Jacksonville, Fla., in a statement. The last such guidelines were released 3 years ago (Stroke 2011;42:517-84)

The writing committee gathered data pertaining to the age, birth weight, race/ethnicity, and genetic factors, among several others. Studies examined included a U.S. Nationwide Inpatient Sample, which showed that stroke hospitalizations increased between 1998 and 2007 for individuals aged 25-34 years and 35-44 years; the Framingham Heart Study, which estimated that the odds of a middle-aged adult suffering a stroke are 1 in 6; an analysis of South Carolina Medicaid beneficiaries under age 50, which revealed that individuals born weighing less than 2,500 g were twice as likely to have a stroke as those born heavier; and an Atherosclerosis Risk in Communities (ARIC) study that showed Latino and African American populations being at higher risk for stroke due to hypertension, obesity, and diabetes.

Because blood pressure, hypertension, diabetes, and obesity are so commonly linked to stroke risk, the new American Heart Association/American Stroke Association (AHA/ASA) guidelines highly recommend a Mediterranean or DASH-style diet supplemented with nuts. Additionally, the guidelines advise health care professionals to advise patients to cut down on sodium intake, regularly monitor their blood pressure, talk to their physicians immediately if any medication does not do what it is intended to or creates negative side effects, and quit smoking, and, for women, consider an alternative to oral birth control pills.

Hypertension, “the most important, well-documented, modifiable stroke risk factor,” should be treated with antihypertensive medication to a target blood pressure of less than 140/90 mm Hg, the guidelines state.

Furthermore, the ASA/AHA guidelines continue to recommend regular physical exercise and acute monitoring of individuals’ cholesterol levels, such as LDL, HDL, and triglycerides, as failure to keep these numbers in check can easily lead to a serious stroke. The guidelines also state that although heavy alcohol consumption can increase the chance of stroke, “light to moderate” alcohol consumption can actually decrease the odds of suffering a stroke.

The AHA/ASA guidelines also examine factors such as migraines, which are associated with stroke in women under age 55, and hyperhomocysteinemia, which is also associated with an increased risk of stroke. Other factors like hypercoagulability and sleep apnea were not shown to have any identifiable relationship with an increased risk of stroke.

“As health professionals, we must ensure that progress in preventing stroke does not lead to complacency,” say the guidelines. “We must acknowledge that several recommendations remain vague because of suboptimal clinical trial evidence or, even more concerning, may be out of date and therefore irrelevant.”

Dr. Meschia and his associates warn that although medications are helpful, the best way to safeguard against a stroke is to change a person’s lifestyle into one of healthy eating and exercise habits. Unfortunately, say the authors, “it is easier to convince a patient to take a pill than to radically change his or her lifestyle, [but] we must expect the same standards of evidence for lifestyle interventions.”

Dr. Meschia disclosed that his research grant comes from the National Institute of Neurological Disorders and Stroke. He had no other relevant financial disclosures of interest. Several of the guidelines’ coauthors had disclosures of their own, which are listed in the statement.

[email protected]

Lifestyle modifications, including eating a Mediterranean or DASH-style diet, should be encouraged to lower an individual’s risk of first-time stroke, according to new guidelines for the primary prevention of stroke from the American Heart Association and American Stroke Association.

Mediterranean and DASH (Dietary Approaches to Stop Hypertension) dietary plans are characterized by their emphasis on fruits, vegetables, whole grains, legumes, nuts, seeds, poultry, and fish, while limiting red meats, sweets, and any foods with saturated fats. This new guidelines – which have been endorsed by the American Academy of Neurology, American Association of Neurological Surgeons, Congress of Neurological Surgeons, and Preventive Cardiovascular Nurses Association – suggest that adopting either of these diets in addition to a few other healthy living habits can dramatically reduce an individual’s odds of suffering a stroke (Stroke 2014;45 [doi: 10.1161/STR.0000000000000046]).

©snyferok/thinkstockphoto.com

“We have a huge opportunity to improve how we prevent new strokes, because risk factors that can be changed or controlled – especially high blood pressure – account for 90% of strokes,” said Dr. James Meschia, chair of the writing committee and chairman of neurology at the Mayo Clinic in Jacksonville, Fla., in a statement. The last such guidelines were released 3 years ago (Stroke 2011;42:517-84)

The writing committee gathered data pertaining to the age, birth weight, race/ethnicity, and genetic factors, among several others. Studies examined included a U.S. Nationwide Inpatient Sample, which showed that stroke hospitalizations increased between 1998 and 2007 for individuals aged 25-34 years and 35-44 years; the Framingham Heart Study, which estimated that the odds of a middle-aged adult suffering a stroke are 1 in 6; an analysis of South Carolina Medicaid beneficiaries under age 50, which revealed that individuals born weighing less than 2,500 g were twice as likely to have a stroke as those born heavier; and an Atherosclerosis Risk in Communities (ARIC) study that showed Latino and African American populations being at higher risk for stroke due to hypertension, obesity, and diabetes.

Because blood pressure, hypertension, diabetes, and obesity are so commonly linked to stroke risk, the new American Heart Association/American Stroke Association (AHA/ASA) guidelines highly recommend a Mediterranean or DASH-style diet supplemented with nuts. Additionally, the guidelines advise health care professionals to advise patients to cut down on sodium intake, regularly monitor their blood pressure, talk to their physicians immediately if any medication does not do what it is intended to or creates negative side effects, and quit smoking, and, for women, consider an alternative to oral birth control pills.

Hypertension, “the most important, well-documented, modifiable stroke risk factor,” should be treated with antihypertensive medication to a target blood pressure of less than 140/90 mm Hg, the guidelines state.

Furthermore, the ASA/AHA guidelines continue to recommend regular physical exercise and acute monitoring of individuals’ cholesterol levels, such as LDL, HDL, and triglycerides, as failure to keep these numbers in check can easily lead to a serious stroke. The guidelines also state that although heavy alcohol consumption can increase the chance of stroke, “light to moderate” alcohol consumption can actually decrease the odds of suffering a stroke.

The AHA/ASA guidelines also examine factors such as migraines, which are associated with stroke in women under age 55, and hyperhomocysteinemia, which is also associated with an increased risk of stroke. Other factors like hypercoagulability and sleep apnea were not shown to have any identifiable relationship with an increased risk of stroke.

“As health professionals, we must ensure that progress in preventing stroke does not lead to complacency,” say the guidelines. “We must acknowledge that several recommendations remain vague because of suboptimal clinical trial evidence or, even more concerning, may be out of date and therefore irrelevant.”

Dr. Meschia and his associates warn that although medications are helpful, the best way to safeguard against a stroke is to change a person’s lifestyle into one of healthy eating and exercise habits. Unfortunately, say the authors, “it is easier to convince a patient to take a pill than to radically change his or her lifestyle, [but] we must expect the same standards of evidence for lifestyle interventions.”

Dr. Meschia disclosed that his research grant comes from the National Institute of Neurological Disorders and Stroke. He had no other relevant financial disclosures of interest. Several of the guidelines’ coauthors had disclosures of their own, which are listed in the statement.

[email protected]

A program that’s designed to help hospitals reduce readmissions after inpatient treatment for a heart attack or heart failure is being launched in 35 selected hospitals.

The Patient Navigator Program is sponsored by the American College of Cardiology and AstraZeneca, which provided $10 million in funding for the 2-year pilot program, but was not involved in selection of facilities or any other aspect.

It’s “a unique collaboration between the cardiovascular care team, patients, and families to manage the stress of hospitalization for complex conditions in a way that allows patients to return home, remain healthy, and avoid the need for readmission whenever possible,” said ACC President Patrick T. O’Gara, in a statement.

Hospitals have been under pressure to reduce readmissions since the fall of 2012. That’s when Medicare began penalizing facilities up to 1% of their inpatient admissions for excess readmissions within 30 days of patients with acute myocardial infarctions, heart failure, and pneumonia. The penalty increased to 2% in fiscal year 2014, and went up to 3% in the fiscal year that started Oct. 1. For this year, chronic obstructive pulmonary disease and hip/knee arthroplasty were added to the list of conditions being monitored for readmissions.

The penalties have already been assessed for fiscal year 2015.

Medicare’s Readmissions Reduction Program bases penalties on a prior 3-year period. Fiscal 2015 penalties were based on readmissions from 2010 to 2013.

The Medicare penalties were the driving force behind the creation of the program a few years ago, said Dr. Mary Norine Walsh, chair of the ACC’s Care Transition Oversight Program. But it also represented a chance “to pursue excellence,” said Dr. Walsh in an interview.

The 35 hospitals that are participating were selected by ACC senior staff and cardiologists like Dr. Walsh who are involved in the ACC’s quality improvement efforts. To be eligible, they had to be participants in the ACC’s National Cardiovascular Data Registry ACTION Registry–GWTG, which, according to the ACC, “is a risk-adjusted, outcomes-based quality improvement program that focuses exclusively on high-risk STEMI/NSTEMI myocardial infarction patients.” The registry helps hospitals apply ACC and American Heart Association clinical guideline recommendations and provides quality improvement tools.

They also had to be part of the ACC’s Hospital to Home Initiative, which helps hospitals and cardiovascular care providers improve transitions from hospital to homes.

All 35 hospitals are eligible to receive $80,000 a year for 2 years. Most likely, the facilities will use that money to hire an individual or individuals who can act as a navigator for heart failure and MI patients, said Dr. Walsh, who is the medical director of the heart failure and cardiac transplant program at St. Vincent Heart Center, Indianapolis, Ind.

While there are few randomized, controlled trials that examine what works to reduce readmission rates, there are several interventions that have been shown to help, she said. Patient eduction and getting patients in for follow-up care within 7 days are two key components that can make a difference, said Dr. Walsh. Multidisciplinary heart failure programs also have an impact.

The participating hospitals will share their processes and models, and at the end of the 2 years, the hope is that the facilities will continue to fund the program, said Dr. Walsh.

The ACC will also “be interested to find out what success looks like,” she said.

The Patient Navigator Program probably won’t help hospitals avoid penalties until fiscal year 2017 at the earliest, Dr. Walsh noted. However, the model will still be important, she said.

“We know that value-based purchasing is moving on, and the penalties will almost certainly extend to other diagnoses each sequential year, so hospitals are interested in preparing for the future,” said Dr. Walsh.

[email protected]

On Twitter @aliciaault

A program that’s designed to help hospitals reduce readmissions after inpatient treatment for a heart attack or heart failure is being launched in 35 selected hospitals.

The Patient Navigator Program is sponsored by the American College of Cardiology and AstraZeneca, which provided $10 million in funding for the 2-year pilot program, but was not involved in selection of facilities or any other aspect.

It’s “a unique collaboration between the cardiovascular care team, patients, and families to manage the stress of hospitalization for complex conditions in a way that allows patients to return home, remain healthy, and avoid the need for readmission whenever possible,” said ACC President Patrick T. O’Gara, in a statement.

Hospitals have been under pressure to reduce readmissions since the fall of 2012. That’s when Medicare began penalizing facilities up to 1% of their inpatient admissions for excess readmissions within 30 days of patients with acute myocardial infarctions, heart failure, and pneumonia. The penalty increased to 2% in fiscal year 2014, and went up to 3% in the fiscal year that started Oct. 1. For this year, chronic obstructive pulmonary disease and hip/knee arthroplasty were added to the list of conditions being monitored for readmissions.

The penalties have already been assessed for fiscal year 2015.

Medicare’s Readmissions Reduction Program bases penalties on a prior 3-year period. Fiscal 2015 penalties were based on readmissions from 2010 to 2013.

The Medicare penalties were the driving force behind the creation of the program a few years ago, said Dr. Mary Norine Walsh, chair of the ACC’s Care Transition Oversight Program. But it also represented a chance “to pursue excellence,” said Dr. Walsh in an interview.

The 35 hospitals that are participating were selected by ACC senior staff and cardiologists like Dr. Walsh who are involved in the ACC’s quality improvement efforts. To be eligible, they had to be participants in the ACC’s National Cardiovascular Data Registry ACTION Registry–GWTG, which, according to the ACC, “is a risk-adjusted, outcomes-based quality improvement program that focuses exclusively on high-risk STEMI/NSTEMI myocardial infarction patients.” The registry helps hospitals apply ACC and American Heart Association clinical guideline recommendations and provides quality improvement tools.

They also had to be part of the ACC’s Hospital to Home Initiative, which helps hospitals and cardiovascular care providers improve transitions from hospital to homes.

All 35 hospitals are eligible to receive $80,000 a year for 2 years. Most likely, the facilities will use that money to hire an individual or individuals who can act as a navigator for heart failure and MI patients, said Dr. Walsh, who is the medical director of the heart failure and cardiac transplant program at St. Vincent Heart Center, Indianapolis, Ind.

While there are few randomized, controlled trials that examine what works to reduce readmission rates, there are several interventions that have been shown to help, she said. Patient eduction and getting patients in for follow-up care within 7 days are two key components that can make a difference, said Dr. Walsh. Multidisciplinary heart failure programs also have an impact.

The participating hospitals will share their processes and models, and at the end of the 2 years, the hope is that the facilities will continue to fund the program, said Dr. Walsh.

The ACC will also “be interested to find out what success looks like,” she said.

The Patient Navigator Program probably won’t help hospitals avoid penalties until fiscal year 2017 at the earliest, Dr. Walsh noted. However, the model will still be important, she said.

“We know that value-based purchasing is moving on, and the penalties will almost certainly extend to other diagnoses each sequential year, so hospitals are interested in preparing for the future,” said Dr. Walsh.

[email protected]

On Twitter @aliciaault

A program that’s designed to help hospitals reduce readmissions after inpatient treatment for a heart attack or heart failure is being launched in 35 selected hospitals.

The Patient Navigator Program is sponsored by the American College of Cardiology and AstraZeneca, which provided $10 million in funding for the 2-year pilot program, but was not involved in selection of facilities or any other aspect.

It’s “a unique collaboration between the cardiovascular care team, patients, and families to manage the stress of hospitalization for complex conditions in a way that allows patients to return home, remain healthy, and avoid the need for readmission whenever possible,” said ACC President Patrick T. O’Gara, in a statement.

Hospitals have been under pressure to reduce readmissions since the fall of 2012. That’s when Medicare began penalizing facilities up to 1% of their inpatient admissions for excess readmissions within 30 days of patients with acute myocardial infarctions, heart failure, and pneumonia. The penalty increased to 2% in fiscal year 2014, and went up to 3% in the fiscal year that started Oct. 1. For this year, chronic obstructive pulmonary disease and hip/knee arthroplasty were added to the list of conditions being monitored for readmissions.

The penalties have already been assessed for fiscal year 2015.

Medicare’s Readmissions Reduction Program bases penalties on a prior 3-year period. Fiscal 2015 penalties were based on readmissions from 2010 to 2013.

The Medicare penalties were the driving force behind the creation of the program a few years ago, said Dr. Mary Norine Walsh, chair of the ACC’s Care Transition Oversight Program. But it also represented a chance “to pursue excellence,” said Dr. Walsh in an interview.

The 35 hospitals that are participating were selected by ACC senior staff and cardiologists like Dr. Walsh who are involved in the ACC’s quality improvement efforts. To be eligible, they had to be participants in the ACC’s National Cardiovascular Data Registry ACTION Registry–GWTG, which, according to the ACC, “is a risk-adjusted, outcomes-based quality improvement program that focuses exclusively on high-risk STEMI/NSTEMI myocardial infarction patients.” The registry helps hospitals apply ACC and American Heart Association clinical guideline recommendations and provides quality improvement tools.

They also had to be part of the ACC’s Hospital to Home Initiative, which helps hospitals and cardiovascular care providers improve transitions from hospital to homes.

All 35 hospitals are eligible to receive $80,000 a year for 2 years. Most likely, the facilities will use that money to hire an individual or individuals who can act as a navigator for heart failure and MI patients, said Dr. Walsh, who is the medical director of the heart failure and cardiac transplant program at St. Vincent Heart Center, Indianapolis, Ind.

While there are few randomized, controlled trials that examine what works to reduce readmission rates, there are several interventions that have been shown to help, she said. Patient eduction and getting patients in for follow-up care within 7 days are two key components that can make a difference, said Dr. Walsh. Multidisciplinary heart failure programs also have an impact.

The participating hospitals will share their processes and models, and at the end of the 2 years, the hope is that the facilities will continue to fund the program, said Dr. Walsh.

The ACC will also “be interested to find out what success looks like,” she said.

The Patient Navigator Program probably won’t help hospitals avoid penalties until fiscal year 2017 at the earliest, Dr. Walsh noted. However, the model will still be important, she said.

“We know that value-based purchasing is moving on, and the penalties will almost certainly extend to other diagnoses each sequential year, so hospitals are interested in preparing for the future,” said Dr. Walsh.

[email protected]

On Twitter @aliciaault

Hospitalist Monal Shah, MD, FACP, physician advisor for Parkland Health & Hospital System in Dallas, says that HM groups looking to anticipate potential cases of Ebola in their region should:

• Make sure doctors know contact information for infection-prevention staffers and their local health department;
• Double-check that physicians know how to quickly get in contact with infectious-disease (ID) specialists;
• Be aware of isolation procedures that will be necessary for this type of patient, including the use of standard, contact, and droplet precautions as well as others recommended by the Centers for Disease Control and Prevention; and
• Be diligent about asking patients about their recent travels when taking patient histories.

"For this particular disease, the travel is the big kicker," says Dr. Shah, a member of Team Hospitalist. "The other symptoms are just so nonspecific. It's vomiting, diarrhea, headaches, weakness...if we tried to admit everyone who had those types of symptoms, it wouldn't make sense."

Dr. Shah says that although he wasn't involved, emergency-preparedness discussions at his institution about dealing with potential Ebola patients started a couple of months ago as spread of the disease in Africa became global news. But although the disease has been making headlines, HM groups are unlikely to make major changes to their care delivery processes, as even just changing the primary lead from a hospitalist to an ID physician could have unintended consequences, he adds.

"Who would cover at night?" Dr. Shah asks. "Who would be the first call at night? Would our nurses know that flow?

"There are a lot of potential downstream things that would need to be changed."

Hospitalist Monal Shah, MD, FACP, physician advisor for Parkland Health & Hospital System in Dallas, says that HM groups looking to anticipate potential cases of Ebola in their region should:

• Make sure doctors know contact information for infection-prevention staffers and their local health department;
• Double-check that physicians know how to quickly get in contact with infectious-disease (ID) specialists;
• Be aware of isolation procedures that will be necessary for this type of patient, including the use of standard, contact, and droplet precautions as well as others recommended by the Centers for Disease Control and Prevention; and
• Be diligent about asking patients about their recent travels when taking patient histories.

"For this particular disease, the travel is the big kicker," says Dr. Shah, a member of Team Hospitalist. "The other symptoms are just so nonspecific. It's vomiting, diarrhea, headaches, weakness...if we tried to admit everyone who had those types of symptoms, it wouldn't make sense."

Dr. Shah says that although he wasn't involved, emergency-preparedness discussions at his institution about dealing with potential Ebola patients started a couple of months ago as spread of the disease in Africa became global news. But although the disease has been making headlines, HM groups are unlikely to make major changes to their care delivery processes, as even just changing the primary lead from a hospitalist to an ID physician could have unintended consequences, he adds.

"Who would cover at night?" Dr. Shah asks. "Who would be the first call at night? Would our nurses know that flow?

"There are a lot of potential downstream things that would need to be changed."

Hospitalist Monal Shah, MD, FACP, physician advisor for Parkland Health & Hospital System in Dallas, says that HM groups looking to anticipate potential cases of Ebola in their region should:

• Make sure doctors know contact information for infection-prevention staffers and their local health department;
• Double-check that physicians know how to quickly get in contact with infectious-disease (ID) specialists;
• Be aware of isolation procedures that will be necessary for this type of patient, including the use of standard, contact, and droplet precautions as well as others recommended by the Centers for Disease Control and Prevention; and
• Be diligent about asking patients about their recent travels when taking patient histories.

"For this particular disease, the travel is the big kicker," says Dr. Shah, a member of Team Hospitalist. "The other symptoms are just so nonspecific. It's vomiting, diarrhea, headaches, weakness...if we tried to admit everyone who had those types of symptoms, it wouldn't make sense."

Dr. Shah says that although he wasn't involved, emergency-preparedness discussions at his institution about dealing with potential Ebola patients started a couple of months ago as spread of the disease in Africa became global news. But although the disease has been making headlines, HM groups are unlikely to make major changes to their care delivery processes, as even just changing the primary lead from a hospitalist to an ID physician could have unintended consequences, he adds.

"Who would cover at night?" Dr. Shah asks. "Who would be the first call at night? Would our nurses know that flow?

"There are a lot of potential downstream things that would need to be changed."

Clinical question: Is the diagnosis of cardiovascular disease (CVD) associated with the risk of subsequent hip fracture?

Background: Osteoporosis and CVD are regarded as independent, age-related conditions. However, recent research suggests that the bone and vascular systems share common regulatory mechanisms. Stroke is a known risk factor for hip fractures, and bisphosphonates have been shown to prevent atherosclerosis and reduce total mortality rate.

Study design: Cohort study.

Setting: Swedish National Patient Registry.

Synopsis: The study identified 31,936 Swedish twins born from 1914 to 1944. This cohort was followed up to age 50, and time-dependent exposures using Cox-proportional hazard regression models were evaluated.

Times to hip fracture after CVD diagnosis were isolated. Crude absolute rate of hip fractures (per 1,000 person-years) was 12.6 after diagnosis of heart failure, 12.6 after a stroke, 6.6 after peripheral atherosclerosis, and 5.2 after ischemic heart disease (IHD), compared with 1.2 per 1,000 person-years without a CVD diagnosis. Multivariable-adjusted hazard ratio (HR) of hip fracture after heart failure was 4.40 (95% CI, 3.43-5.63); after a stroke was 5.09 (95% CI, 4.18-6.20); after peripheral atherosclerosis was 3.20 (CI, 2.28-4.50); and after an IHD event was 2.32 (CI, 1.91-2.84).

Identical twins even without heart failure and stroke also had an increased risk of hip fracture if their twin had been diagnosed with these diseases.

Bottom line: Cardiovascular disease is significantly associated with risk of subsequent hip fracture, and genetic factors probably play a role in the association.

Citation: Sennerby U, Melhus H, Gedeborg R, et al. Cardiovascular diseases and risk of hip fracture. JAMA. 2009;302(15):1666-1673.

Clinical question: Is the diagnosis of cardiovascular disease (CVD) associated with the risk of subsequent hip fracture?

Background: Osteoporosis and CVD are regarded as independent, age-related conditions. However, recent research suggests that the bone and vascular systems share common regulatory mechanisms. Stroke is a known risk factor for hip fractures, and bisphosphonates have been shown to prevent atherosclerosis and reduce total mortality rate.

Study design: Cohort study.

Setting: Swedish National Patient Registry.

Synopsis: The study identified 31,936 Swedish twins born from 1914 to 1944. This cohort was followed up to age 50, and time-dependent exposures using Cox-proportional hazard regression models were evaluated.

Times to hip fracture after CVD diagnosis were isolated. Crude absolute rate of hip fractures (per 1,000 person-years) was 12.6 after diagnosis of heart failure, 12.6 after a stroke, 6.6 after peripheral atherosclerosis, and 5.2 after ischemic heart disease (IHD), compared with 1.2 per 1,000 person-years without a CVD diagnosis. Multivariable-adjusted hazard ratio (HR) of hip fracture after heart failure was 4.40 (95% CI, 3.43-5.63); after a stroke was 5.09 (95% CI, 4.18-6.20); after peripheral atherosclerosis was 3.20 (CI, 2.28-4.50); and after an IHD event was 2.32 (CI, 1.91-2.84).

Identical twins even without heart failure and stroke also had an increased risk of hip fracture if their twin had been diagnosed with these diseases.

Bottom line: Cardiovascular disease is significantly associated with risk of subsequent hip fracture, and genetic factors probably play a role in the association.

Citation: Sennerby U, Melhus H, Gedeborg R, et al. Cardiovascular diseases and risk of hip fracture. JAMA. 2009;302(15):1666-1673.

Clinical question: Is the diagnosis of cardiovascular disease (CVD) associated with the risk of subsequent hip fracture?

Background: Osteoporosis and CVD are regarded as independent, age-related conditions. However, recent research suggests that the bone and vascular systems share common regulatory mechanisms. Stroke is a known risk factor for hip fractures, and bisphosphonates have been shown to prevent atherosclerosis and reduce total mortality rate.

Study design: Cohort study.

Setting: Swedish National Patient Registry.

Synopsis: The study identified 31,936 Swedish twins born from 1914 to 1944. This cohort was followed up to age 50, and time-dependent exposures using Cox-proportional hazard regression models were evaluated.

Times to hip fracture after CVD diagnosis were isolated. Crude absolute rate of hip fractures (per 1,000 person-years) was 12.6 after diagnosis of heart failure, 12.6 after a stroke, 6.6 after peripheral atherosclerosis, and 5.2 after ischemic heart disease (IHD), compared with 1.2 per 1,000 person-years without a CVD diagnosis. Multivariable-adjusted hazard ratio (HR) of hip fracture after heart failure was 4.40 (95% CI, 3.43-5.63); after a stroke was 5.09 (95% CI, 4.18-6.20); after peripheral atherosclerosis was 3.20 (CI, 2.28-4.50); and after an IHD event was 2.32 (CI, 1.91-2.84).

Identical twins even without heart failure and stroke also had an increased risk of hip fracture if their twin had been diagnosed with these diseases.

Bottom line: Cardiovascular disease is significantly associated with risk of subsequent hip fracture, and genetic factors probably play a role in the association.

Citation: Sennerby U, Melhus H, Gedeborg R, et al. Cardiovascular diseases and risk of hip fracture. JAMA. 2009;302(15):1666-1673.

Clinical question: Do over-the-counter (OTC) analgesics lead to acute hepatic decompensation among patients with cirrhosis?

Background: In theory, intake of acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen hepatic function and lead to complications among cirrhotic patients. The role of OTC analgesics in potentially triggering acute hepatic decompensation among cirrhotic patients has not been studied.

Study design: Prospective case-control study.

Setting: Two tertiary-care hospitals.

Synopsis: Cirrhotic patients hospitalized for acute liver decompensation were compared with compensated cirrhotic patients in the liver clinic (cirrhotic controls) and with randomly selected, noncirrhotic patients who were simultaneously hospitalized (noncirrhotic controls). Data collected through questionnaires included quantity and dose of OTC analgesics used and alcohol consumption in the past 30 days.

Thirty-five percent of the hospitalized cirrhotic patients, 52% of the cirrhotic controls, and 70% of the noncirrhotic controls used OTC analgesics. At doses lower than those recommended, acetaminophen is not associated with acute liver decompensation among cirrhotic patients, even with recent alcohol use. However, NSAIDs taken by the cirrhotic patients, when compared to control subjects, were in larger doses and used for a longer duration, suggesting NSAIDs may have contributed to the acute decompensation.

Study limitations include the nature of the study design, reliance on the patient’s recall of OTC analgesic use, and obtaining other possible causes of decompensation, such as herbal supplement intake or compliance with diuretics or dietary indiscretion.

Bottom line: Acetaminophen at doses lower than recommended is not associated with adverse complications in cirrhotic patients, but NSAIDs are possibly associated with acute decompensation.

Citation: Khalid SK, Lane J, Navarro V, Garcia-Tsao G. Use of over-the-counter analgesics is not associated with acute decompensation in patients with cirrhosis. Clin Gastroenterol Hepatol. 2009;7(9):994-999.

Clinical question: Do over-the-counter (OTC) analgesics lead to acute hepatic decompensation among patients with cirrhosis?

Background: In theory, intake of acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen hepatic function and lead to complications among cirrhotic patients. The role of OTC analgesics in potentially triggering acute hepatic decompensation among cirrhotic patients has not been studied.

Study design: Prospective case-control study.

Setting: Two tertiary-care hospitals.

Synopsis: Cirrhotic patients hospitalized for acute liver decompensation were compared with compensated cirrhotic patients in the liver clinic (cirrhotic controls) and with randomly selected, noncirrhotic patients who were simultaneously hospitalized (noncirrhotic controls). Data collected through questionnaires included quantity and dose of OTC analgesics used and alcohol consumption in the past 30 days.

Thirty-five percent of the hospitalized cirrhotic patients, 52% of the cirrhotic controls, and 70% of the noncirrhotic controls used OTC analgesics. At doses lower than those recommended, acetaminophen is not associated with acute liver decompensation among cirrhotic patients, even with recent alcohol use. However, NSAIDs taken by the cirrhotic patients, when compared to control subjects, were in larger doses and used for a longer duration, suggesting NSAIDs may have contributed to the acute decompensation.

Study limitations include the nature of the study design, reliance on the patient’s recall of OTC analgesic use, and obtaining other possible causes of decompensation, such as herbal supplement intake or compliance with diuretics or dietary indiscretion.

Bottom line: Acetaminophen at doses lower than recommended is not associated with adverse complications in cirrhotic patients, but NSAIDs are possibly associated with acute decompensation.

Citation: Khalid SK, Lane J, Navarro V, Garcia-Tsao G. Use of over-the-counter analgesics is not associated with acute decompensation in patients with cirrhosis. Clin Gastroenterol Hepatol. 2009;7(9):994-999.

Clinical question: Do over-the-counter (OTC) analgesics lead to acute hepatic decompensation among patients with cirrhosis?

Background: In theory, intake of acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen hepatic function and lead to complications among cirrhotic patients. The role of OTC analgesics in potentially triggering acute hepatic decompensation among cirrhotic patients has not been studied.

Study design: Prospective case-control study.

Setting: Two tertiary-care hospitals.

Synopsis: Cirrhotic patients hospitalized for acute liver decompensation were compared with compensated cirrhotic patients in the liver clinic (cirrhotic controls) and with randomly selected, noncirrhotic patients who were simultaneously hospitalized (noncirrhotic controls). Data collected through questionnaires included quantity and dose of OTC analgesics used and alcohol consumption in the past 30 days.

Thirty-five percent of the hospitalized cirrhotic patients, 52% of the cirrhotic controls, and 70% of the noncirrhotic controls used OTC analgesics. At doses lower than those recommended, acetaminophen is not associated with acute liver decompensation among cirrhotic patients, even with recent alcohol use. However, NSAIDs taken by the cirrhotic patients, when compared to control subjects, were in larger doses and used for a longer duration, suggesting NSAIDs may have contributed to the acute decompensation.

Study limitations include the nature of the study design, reliance on the patient’s recall of OTC analgesic use, and obtaining other possible causes of decompensation, such as herbal supplement intake or compliance with diuretics or dietary indiscretion.

Bottom line: Acetaminophen at doses lower than recommended is not associated with adverse complications in cirrhotic patients, but NSAIDs are possibly associated with acute decompensation.

Citation: Khalid SK, Lane J, Navarro V, Garcia-Tsao G. Use of over-the-counter analgesics is not associated with acute decompensation in patients with cirrhosis. Clin Gastroenterol Hepatol. 2009;7(9):994-999.

Clinical question: How do perioperative and long-term morbidity and mortality compare in endovascular and open repair of abdominal aortic aneurysm (AAA)?

Background: Open AAA repair has relatively high perioperative mortality. Endovascular repair was developed as a less-invasive option and has been shown to reduce inpatient perioperative mortality, length of hospital stay, and ICU requirement. However, data suggest it leads to more frequent reinterventions and the same mortality rate as open repair at two years.

Study design: Randomized clinical trial.

Setting: Veterans Affairs medical centers.

Synopsis: The study randomized 881 veterans who planned to have elective AAA repair and were eligible for both endovascular and open repair. This is a planned, two-year interim report in a nine-year study.

Perioperative mortality was 0.5% in the endovascular repair group, compared with 3.0% in the open repair group. However, this difference in mortality was not statistically significant at two years. The endovascular repair group experienced shorter procedure and mechanical ventilation time, decreased hospital and ICU stay, and lower rate of blood transfusions.

Overall, there was no difference between the groups for major morbidity, procedure failure, need for secondary therapeutic intervention, quality of life, or erectile dysfunction. More data on long-term comparison of these two interventions will be available at the conclusion of this study.

Bottom line: Endovascular repair of AAA has lower perioperative mortality than open repair but did not lead to improved morbidity or mortality at two years.

Citation: Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs. open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302 (14):1535-1542.

Clinical question: How do perioperative and long-term morbidity and mortality compare in endovascular and open repair of abdominal aortic aneurysm (AAA)?

Background: Open AAA repair has relatively high perioperative mortality. Endovascular repair was developed as a less-invasive option and has been shown to reduce inpatient perioperative mortality, length of hospital stay, and ICU requirement. However, data suggest it leads to more frequent reinterventions and the same mortality rate as open repair at two years.

Study design: Randomized clinical trial.

Setting: Veterans Affairs medical centers.

Synopsis: The study randomized 881 veterans who planned to have elective AAA repair and were eligible for both endovascular and open repair. This is a planned, two-year interim report in a nine-year study.

Perioperative mortality was 0.5% in the endovascular repair group, compared with 3.0% in the open repair group. However, this difference in mortality was not statistically significant at two years. The endovascular repair group experienced shorter procedure and mechanical ventilation time, decreased hospital and ICU stay, and lower rate of blood transfusions.

Overall, there was no difference between the groups for major morbidity, procedure failure, need for secondary therapeutic intervention, quality of life, or erectile dysfunction. More data on long-term comparison of these two interventions will be available at the conclusion of this study.

Bottom line: Endovascular repair of AAA has lower perioperative mortality than open repair but did not lead to improved morbidity or mortality at two years.

Citation: Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs. open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302 (14):1535-1542.

Clinical question: How do perioperative and long-term morbidity and mortality compare in endovascular and open repair of abdominal aortic aneurysm (AAA)?

Background: Open AAA repair has relatively high perioperative mortality. Endovascular repair was developed as a less-invasive option and has been shown to reduce inpatient perioperative mortality, length of hospital stay, and ICU requirement. However, data suggest it leads to more frequent reinterventions and the same mortality rate as open repair at two years.

Study design: Randomized clinical trial.

Setting: Veterans Affairs medical centers.

Synopsis: The study randomized 881 veterans who planned to have elective AAA repair and were eligible for both endovascular and open repair. This is a planned, two-year interim report in a nine-year study.

Perioperative mortality was 0.5% in the endovascular repair group, compared with 3.0% in the open repair group. However, this difference in mortality was not statistically significant at two years. The endovascular repair group experienced shorter procedure and mechanical ventilation time, decreased hospital and ICU stay, and lower rate of blood transfusions.

Overall, there was no difference between the groups for major morbidity, procedure failure, need for secondary therapeutic intervention, quality of life, or erectile dysfunction. More data on long-term comparison of these two interventions will be available at the conclusion of this study.

Bottom line: Endovascular repair of AAA has lower perioperative mortality than open repair but did not lead to improved morbidity or mortality at two years.

Citation: Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs. open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302 (14):1535-1542.

Clinical question: Does perioperative beta-blocker discontinuation affect postoperative myocardial infarction (MI) in low-risk patients undergoing joint arthroplasty?

Background: Recent trials show no benefit of perioperative beta blockers in reducing the incidence of perioperative myocardial infarctions (POMI) in low-risk patients. This retrospective study examined the impact of continuing or discontinuing beta blockers and the occurrence of POMI in patients undergoing elective joint arthroplasties.

Study design: Retrospective chart review.

Setting: Large academic center in Ottawa, Canada.

Synopsis: Medical records for 5,178 patients undergoing elective hip or knee arthroplasty from January 2002 to June 2006 were included in the review. The primary outcome was POMI, defined as an increased troponin level. Patients were divided into three groups: beta blocker prescribed on post-operative day (POD) zero and continued for one week or until discharge; beta blocker prescribed on POD zero and discontinued at any time in the first week; and no beta blocker on POD 0.

Beta blockers were continued in 992 patients and discontinued in 252 patients. The rate of POMI and death increased in the beta-blocker discontinuation group (odds ratio 2.0 [1.1-3.9] and 2.0 [1.1-3.9], respectively). This association persisted after adjustment for cardiac risk using a validated risk score.

The study was limited by the fact that the control group did not include patients who were on a beta blocker at home, thus potentially increasing the number of events in this group. The discontinuation beta blocker group had an increased baseline risk for POMI. The reason for discontinuing the beta blocker was not known, and cessation of beta blocker could have been due to an acute event.

Bottom line: This study adds support to the American College of Cardiology and American Heart Association (ACC/AHA) guidelines, which recommend continuation of beta-blocker therapy in the perioperative period.

Citation: Van Klei WA, Bryson GL, Yang H, Forster AJ. Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology. 2009;111(4):717-724.

Clinical question: Does perioperative beta-blocker discontinuation affect postoperative myocardial infarction (MI) in low-risk patients undergoing joint arthroplasty?

Background: Recent trials show no benefit of perioperative beta blockers in reducing the incidence of perioperative myocardial infarctions (POMI) in low-risk patients. This retrospective study examined the impact of continuing or discontinuing beta blockers and the occurrence of POMI in patients undergoing elective joint arthroplasties.

Study design: Retrospective chart review.

Setting: Large academic center in Ottawa, Canada.

Synopsis: Medical records for 5,178 patients undergoing elective hip or knee arthroplasty from January 2002 to June 2006 were included in the review. The primary outcome was POMI, defined as an increased troponin level. Patients were divided into three groups: beta blocker prescribed on post-operative day (POD) zero and continued for one week or until discharge; beta blocker prescribed on POD zero and discontinued at any time in the first week; and no beta blocker on POD 0.

Beta blockers were continued in 992 patients and discontinued in 252 patients. The rate of POMI and death increased in the beta-blocker discontinuation group (odds ratio 2.0 [1.1-3.9] and 2.0 [1.1-3.9], respectively). This association persisted after adjustment for cardiac risk using a validated risk score.

The study was limited by the fact that the control group did not include patients who were on a beta blocker at home, thus potentially increasing the number of events in this group. The discontinuation beta blocker group had an increased baseline risk for POMI. The reason for discontinuing the beta blocker was not known, and cessation of beta blocker could have been due to an acute event.

Bottom line: This study adds support to the American College of Cardiology and American Heart Association (ACC/AHA) guidelines, which recommend continuation of beta-blocker therapy in the perioperative period.

Citation: Van Klei WA, Bryson GL, Yang H, Forster AJ. Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology. 2009;111(4):717-724.

Clinical question: Does perioperative beta-blocker discontinuation affect postoperative myocardial infarction (MI) in low-risk patients undergoing joint arthroplasty?

Background: Recent trials show no benefit of perioperative beta blockers in reducing the incidence of perioperative myocardial infarctions (POMI) in low-risk patients. This retrospective study examined the impact of continuing or discontinuing beta blockers and the occurrence of POMI in patients undergoing elective joint arthroplasties.

Study design: Retrospective chart review.

Setting: Large academic center in Ottawa, Canada.

Synopsis: Medical records for 5,178 patients undergoing elective hip or knee arthroplasty from January 2002 to June 2006 were included in the review. The primary outcome was POMI, defined as an increased troponin level. Patients were divided into three groups: beta blocker prescribed on post-operative day (POD) zero and continued for one week or until discharge; beta blocker prescribed on POD zero and discontinued at any time in the first week; and no beta blocker on POD 0.

Beta blockers were continued in 992 patients and discontinued in 252 patients. The rate of POMI and death increased in the beta-blocker discontinuation group (odds ratio 2.0 [1.1-3.9] and 2.0 [1.1-3.9], respectively). This association persisted after adjustment for cardiac risk using a validated risk score.

The study was limited by the fact that the control group did not include patients who were on a beta blocker at home, thus potentially increasing the number of events in this group. The discontinuation beta blocker group had an increased baseline risk for POMI. The reason for discontinuing the beta blocker was not known, and cessation of beta blocker could have been due to an acute event.

Bottom line: This study adds support to the American College of Cardiology and American Heart Association (ACC/AHA) guidelines, which recommend continuation of beta-blocker therapy in the perioperative period.

Citation: Van Klei WA, Bryson GL, Yang H, Forster AJ. Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology. 2009;111(4):717-724.