Literature Review

In This Edition

Literature At A Glance

A guide to this month’s studies

1. ICU pressures improve transfers to the floor
2. Morbidity, mortality rates high for respiratory syncytial virus infections
3. Antibiotic algorithm can guide therapy in healthcare-associated pneumonia
4. Three-month dual antiplatelet therapy for zotarolimus-eluting stents
5. De-escalating antibiotics in sepsis
6. New oral anticoagulants increase GI bleed risk
7. Single vs. dual antiplatelet therapy after stroke
8. Endoscopic vs. surgical cystogastrostomy for pancreatic pseudocyst drainage
9. Long-term cognitive impairment after critical illness
10. Holding chambers vs. nebulizers for acute asthma

ICU Pressures Improve Transfers to the Floor

Clinical question: Does ICU strain negatively affect the outcomes of patients transferred to the floor?

Background: With healthcare costs increasing and critical care staff shortages projected, ICUs will have to operate under increasing strain. This may influence decisions on discharging patients from ICUs and could affect patient outcomes.

Study design: Retrospective cohort study.

Setting: One hundred fifty-five ICUs in the United States.

Synopsis: Using the Project IMPACT database, 200,730 adult patients from 107 different hospitals were evaluated in times of ICU strain, determined by the current census, new admissions, and acuity level. Outcomes measured were initial ICU length of stay (LOS), readmission within 72 hours, in-hospital mortality rates, and post-ICU discharge LOS.

Increases of the strain variables from the fifth to the 95th percentiles resulted in a 6.3-hour reduction in ICU LOS, a 2.0-hour decrease in post-ICU discharge LOS, and a 1.0% increase in probability of ICU readmission within 72 hours. Mortality rates during the hospital stay and odds of being discharged home showed no significant change. This study was limited because the ICUs participating were not randomly chosen, outcomes of patients transferred to other hospitals were not measured, and no post-hospital data was collected, so no long-term outcomes could be measured.

Bottom line: ICU bed pressures prompt physicians to allocate ICU resources more efficiently without changing short-term patient outcomes.

Citation: Wagner J, Gabler NB, Ratcliffe SJ, Brown SE, Strom BL, Halpern SD. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159(7):447-455.

Adults Hospitalized for Respiratory Syncytial Virus Infections Have High Morbidity, Mortality Rates

Clinical question: What are the complications and outcomes of respiratory syncytial virus (RSV) infection in adults requiring hospitalization?

Background: RSV is a common cause of lower respiratory tract infection in infants and young children, leading to hospitalization and even death. RSV has been estimated to affect 3%-10% of adults annually, generally causing mild disease. However, the outcomes of adults with more severe disease are not fully known.

Study design: Retrospective cohort study.

Setting: Three acute care, public hospitals in Hong Kong.

Synopsis: All adult patients hospitalized with laboratory-confirmed RSV infection were included during the defined time period. The main outcome measure was all-cause death, with secondary outcome measures of development of acute respiratory failure requiring ventilator support and total duration of hospitalization among survivors. Additionally, the cohort of RSV patients was compared to patients admitted with seasonal influenza during this same time frame. Patients with pandemic 2009 H1N1 infection were not included.

Of patients with RSV, pneumonia was found in 42.3%, bacterial superinfection in 12.5%, and cardiovascular complications in 14.3%. Additionally, 11.1% developed respiratory failure requiring ventilator support. All-cause mortality at 30 days and 60 days was 9.1% and 11.9%, respectively, with pneumonia the most common cause of death. Use of systemic corticosteroids did not improve survival. When the RSV cohort was compared to the influenza cohort, the patients were similar in age, but the RSV patients were more likely to have underlying chronic lung disease and major systemic co-morbidities. The rate of survival and duration of hospitalization were not significantly different.

Bottom line: RSV infection is an underappreciated cause of lower tract respiratory infection in adults; severe infections that require hospitalization have rates of mortality similar to seasonal influenza. Further research on treatment or immunization is needed.

Citation: Lee N, Lui GC, Wong KT, et al. High morbidity and mortality in adults hospitalized for respiratory syncytial virus infections. Clin Infect Dis. 2013;57(8):1069-1077.

Antibiotic Algorithm Can Guide Therapy in Healthcare-Associated Pneumonia

Clinical question: Can an algorithm based on risk for multidrug-resistant (MDR) organisms and illness severity guide antibiotic selection in healthcare-associated pneumonia (HCAP)?

Background: The 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines identify patients with HCAP as those with recent contact with a healthcare environment, including nursing homes and hemodialysis; however, previous studies have shown that not all patients with healthcare contact have equal risk for MDR organisms.

Study design: Prospective cohort study.

Setting: Japan, multi-center.

Synopsis: Of the 445 enrolled patients, 124 were diagnosed with community-acquired pneumonia (CAP) and 321 with HCAP. Patients with HCAP were classified based on severity of illness or MDR pathogen risk factors (immune suppression, hospitalization within the last 90 days, poor functional status, and antibiotics within the past six months). Patients with low risk (0-1 factors) for MDR organisms were treated for CAP, and patients with high risk (≥2 factors) or moderate risk (≥1 factor) for severe illness were treated for HCAP.

HCAP patients had a higher 30-day mortality rate (13.7% vs. 5.6%, P=0.017), but mortality rate was less in the patients at low risk for MDR pathogens (8.6% vs. 18.2%, P=0.012). Of the HCAP patients, only 7.1% received inappropriate therapy (pathogen resistant to initial antibiotic regimen), and treatment failure was 19.3%.

Appropriateness of initial empiric therapy was determined not to be a mortality risk; however, this trial might be limited by its location, because Japan appears to have fewer MDR pathogens than the U.S.

Bottom line: A treatment algorithm based on risk for MDR organisms and severity of illness can be used to guide empiric antibiotic therapy in patients with HCAP, and, ideally, to reduce excessive use of broad-spectrum antibiotics.

Citation: Maruyama T, Fujisawa T, Okuno M, et al. A new strategy for healthcare-associated pneumonia: a 2-year prospective multicenter cohort study using risk factors for multidrug-resistant pathogens to select initial empiric therapy. Clin Infect Dis. 2013;57(10):1373-1383.

Three-Month Dual Antiplatelet Therapy for Zotarolimus-Eluting Stents

Clinical question: Is short-term, dual antiplatelet therapy noninferior to long-term therapy in zotarolimus-eluting stents?

Background: Current guidelines recommend long-term (>12 months) dual antiplatelet therapy after the placement of drug-eluting stents. The optimal therapy duration in second-generation drug-eluting stents has not been studied; moreover, some studies with multiple drug-eluting stents have suggested no added benefit from long-term therapy.

Study design: Randomized controlled trial.

Setting: Brazil, multi-center.

Synopsis: Researchers randomized 3,211 patients with stable coronary artery disease (CAD) or low-risk acute coronary syndrome (ACS) undergoing intervention with zotarolimus-eluting stents to short-term (three months) or long-term (12 months) dual antiplatelet therapy. Exclusion criteria included ST-elevation myocardial infarction (STEMI), previous drug-eluting stent, scheduled elective surgery within 12 months, or contraindication to aspirin or clopidogrel. Primary endpoints were a composite of death from any cause, MI, stroke, or major bleeding. Secondary endpoints were stent thrombosis, target lesion revascularization, adverse cardiac event, and any bleed.

At one-year follow-up, the short-term group had similar primary (6.0% vs. 5.8%) and secondary (8.3% vs. 7.4%) outcomes compared to the long-term. The short-term group’s noninferiority also was seen in several key subgroups.

This study included patients with stable CAD or low-risk ACS and cannot be generalized to higher-risk patients. Results for zotarolimus-eluting stents cannot be generalized to other second-generation drug-eluting stents.

Bottom line: Zotarolimus-eluting stents, followed by three months of dual antiplatelet therapy, were noninferior to 12 months of therapy in patients with stable CAD or low-risk ACS.

Citation: Feres F, Costa RA, Abizaid A, et al. Three vs. twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial. JAMA. 2013;310(23):2510-2522.

De-Escalating Antibiotics in Sepsis

Clinical question: Does tailoring antibiotics based on known pathogens impact mortality for patients with severe sepsis or shock?

Background: In patients with sepsis, the use of early empiric antibiotics reduces morbidity and mortality. De-escalation therapy refers to narrowing the broad-spectrum antibiotics once the pathogen and sensitivities are known; however, no randomized controlled studies have assessed the impact of this therapy on critically ill patients.

Study design: Prospective observational study.

Setting: Academic hospital ICU in Spain.

Synopsis: From January 2008 to May 2012, 628 adult patients were treated empirically with broad-spectrum antibiotics. De-escalation was applied to 219 patients (34.9%). Outcomes measured were ICU mortality, hospital mortality, and 90-day mortality in patients who received de-escalation therapy, patients whose antibiotics were not changed, and patients for whom antibiotics were escalated.

The in-hospital mortality rate was 27.4% in patients who were de-escalated, 32.6% in the unchanged group, and 42.9% in the escalation group. ICU and 90-day mortality were lower in the de-escalation group. De-escalation was more commonly used in medical than in surgical patients.

This study is limited because it is not a randomized controlled study and was single-centered, so it might only be applicable on the larger scale. Also, multi-drug resistant organisms were not evaluated.

Overall, it is safe to narrow empiric antibiotics in severe sepsis and shock when the pathogen and sensitivities are known.

Bottom line: De-escalation of antibiotics in severe sepsis and septic shock is associated with a lower mortality.

Citation: Garnacho-Montero J, Gutierrez-Pizarraya A, Escoresca-Ortega A, et al. De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock. Intensive Care Med. 2014;40(1):32-40.

New Oral Anticoagulants Increase GI Bleed Risk

Clinical question: Do thrombin and factor Xa inhibitors increase the risk of gastrointestinal (GI) bleeding when compared to vitamin K antagonists and heparins?

Background: New oral anticoagulants (thrombin and factor Xa inhibitors) are available and being used with increased frequency due to equal efficacy and ease of administration. Some studies indicate a higher risk of GI bleeding with these agents. Further evaluation is needed, because no reversal therapy is available.

Study design: Systematic review and meta-analysis.

Setting: Data from MEDLINE, Embase, and the Cochrane Library.

Synopsis: More than 150,000 patients from 43 randomized controlled trials were evaluated for risk of GI bleed when treated with new anticoagulants versus traditional therapy. Patients were treated for one of the following: embolism prevention from atrial fibrillation, venous thromboembolism (VTE) prophylaxis post orthopedic surgery, VTE prophylaxis of medical patients, acute VTE, and acute coronary syndrome (ACS). Use of aspirin or NSAIDs was discouraged but not documented. The odds ratio for GI bleeding with use of the new anticoagulants was 1.45, with a number needed to harm of 500. Evaluation of subgroups revealed increased GI bleed risk in patients treated for ACS and acute thrombosis versus prophylaxis. Post-surgical patients had the lowest risk.

This study was limited by the heterogeneity and differing primary outcomes (mostly efficacy rather than safety) of the included trials. Studies excluded high-risk patients, which the authors estimate to be 25%-40% of actual patients. More studies need to be done that include high-risk patients and focus on GI bleed as a primary outcome.

Bottom line: The new anticoagulants tend to have a higher incidence of GI bleed than traditional therapy, but this varies based on indication of therapy and needs further evaluation to clarify risk.

Citation: Holster IL, Valkhoff VE, Kuipers EJ, Tjwa ET. New oral anticoagulants increase risk for gastrointestinal bleeding: a systematic review and meta-analysis. Gastroenterology. 2013;145(1):105-112.

Single vs. Dual Antiplatelet Therapy after Stroke

Clinical question: Is dual antiplatelet therapy more beneficial or harmful than monotherapy after ischemic stroke?

Background: It is recommended that patients with ischemic stroke or transient ischemic attack (TIA) receive lifelong antiplatelet therapy; however, there have been insufficient studies evaluating the long-term safety of dual antiplatelet therapy.

Study design: Meta-analysis of randomized controlled trials (RCTs)

Setting: Data from PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

Synopsis: Data from seven RCTs, including 39,574 patients with recent TIA or ischemic stroke, were reviewed. Comparisons were made regarding occurrence of intracranial hemorrhage (ICH) and recurrent stroke between patients receiving dual antiplatelet therapy and those receiving aspirin or clopidogrel monotherapy. All patients were treated for at least one year.

There was no difference in recurrent stroke or ICH between patients on dual antiplatelet therapy versus aspirin monotherapy. Patients treated with dual antiplatelet therapy did have a 46% increased risk of ICH without any additional protective benefit for recurrent stroke or TIA when compared with patients on clopidogrel monotherapy.

This information should not be applied in the acute setting, given the high risk of stroke after TIA or ischemic stroke. One major limitation of this study was that the individual trials used different combinations of dual antiplatelet therapy.

Bottom line: The risk of recurrent stroke or TIA after dual antiplatelet therapy and after monotherapy with aspirin or clopidogrel is equal, but the risk of ICH compared to clopidogrel monotherapy is increased.

Citation: Lee M, Saver JL, Hong KS, Rao NM, Wu YL, Ovbiagele B. Risk-benefit profile of long-term dual- versus single-antiplatelet therapy among patients with ischemic stroke: a systematic review and meta-analysis. Ann Intern Med. 2013;159(7):463-470.

Endoscopic vs. Surgical Cystogastrostomy for Pancreatic Pseudocyst Drainage

Clinical question: How does endoscopic cystogastrostomy for pancreatic pseudocyst drainage compare to the standard surgical approach?

Background: Pancreatic pseudocysts are a common complication of pancreatitis and necessitate decompression when they are accompanied by pain, infection, or obstruction. Decompression of the pseudocyst can be accomplished using either endoscopic or surgical cystogastrostomy.

Study design: Open-label, single-center, randomized trial.

Setting: Single-center U.S. hospital.

Synopsis: A total of 40 patients were randomly equalized to both treatment arms; 20 patients underwent endoscopic and 20 patients underwent surgical cystogastrostomy. Zero patients in the endoscopic therapy had a pseudocyst recurrence, compared with one patient treated surgically. Length of stay (LOS) and cost were lower for the endoscopic group compared to the surgical group (two days vs. six days, P<0.001, $7,011 vs. $15,052, P=0.003).

This study is limited due to several factors. First, patients with pancreatic necrosis were excluded; had these patients been included, the complication rates and LOS would have been higher. Second, cost difference cannot be generalized across the U.S., because Medicare payments are based on provider types and regions.

Bottom line: Endoscopic cystogastrostomy for pancreatic pseudocyst is equal to the standard surgical therapy and results in decreased LOS and reduced costs.

Citation: Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013;145(3):583-590.

Long-Term Cognitive Impairment after Critical Illness

Clinical question: Are a longer duration of delirium and higher doses of sedatives associated with cognitive impairment in the hospital?

Background: Survivors of critical illness are at risk for prolonged cognitive dysfunction. Delirium (and factors associated with delirium, namely sedative and analgesic medications) has been implicated in cognitive dysfunction.

Study design: Prospective cohort study.

Setting: Multi-center, academic, and acute care hospitals.

Synopsis: The study examined 821 adults admitted to the ICU with respiratory failure, cardiogenic shock, or septic shock. Patients excluded were those with pre-existing cognitive impairment, those with psychotic disorders, and those for whom follow-up would not be possible. Two risk factors measured were duration of delirium and use of sedative/analgesics. Delirium was assessed at three and 12 months using the CAM-ICU algorithm in the ICU by trained psychology professionals who were unaware of the patients’ in-hospital course.

At three months, 40% of patients had global cognition scores that were 1.5 standard deviations (SD) below population mean (similar to traumatic brain injury), and 26% had scores two SD below population mean (similar to mild Alzheimer’s). At 12 months, 34% had scores similar to traumatic brain injury patients, and 24% had scores similar to mild Alzheimer’s. A longer duration of delirium was associated with worse global cognition at three and 12 months. Use of sedatives/analgesics was not associated with cognitive impairment.

Bottom line: Critically ill patients in the ICU who experience a longer duration of delirium are at risk of long-term cognitive impairments lasting 12 months.

Citation: Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306-1316.

Holding Chambers (Spacers) vs. Nebulizers for Acute Asthma

Clinical question: Are beta-2 agonists as effective when administered through a holding chamber (spacer) as they are when administered by a nebulizer?

Background: During an acute asthma attack, beta-2 agonists must be delivered to the peripheral airways. There has been considerable controversy regarding the use of a spacer compared with a nebulizer. Aside from admission rates and length of stay, factors taken into account include cost, maintenance of nebulizer machines, and infection control (potential of cross-infection via nebulizers).

Study design: Meta-analysis review of randomized controlled trials (RCTs).

Setting: Multi-centered, worldwide studies from community setting and EDs.

Synopsis: In 39 studies of patients with an acute asthma attack (selected from Cochrane Airways Group Specialized Register), the hospital admission rates did not differ on the basis of delivery method in 729 adults (risk ratio=0.94, confidence interval 0.61-1.43) or in 1,897 children (risk ratio=0.71, confidence interval 0.47-1.08). Secondary outcomes included the duration of time in the ED and the duration of hospital admission. Time spent in the ED varied for adults but was shorter for children with spacers (based on three studies). Duration of hospital admission also did not differ when modes of delivery were compared.

Bottom line: Providing beta-2 agonists using nebulizers during an acute asthma attack is not more effective than administration using a spacer.

Citation: Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013;9:CD000052.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. ICU pressures improve transfers to the floor
2. Morbidity, mortality rates high for respiratory syncytial virus infections
3. Antibiotic algorithm can guide therapy in healthcare-associated pneumonia
4. Three-month dual antiplatelet therapy for zotarolimus-eluting stents
5. De-escalating antibiotics in sepsis
6. New oral anticoagulants increase GI bleed risk
7. Single vs. dual antiplatelet therapy after stroke
8. Endoscopic vs. surgical cystogastrostomy for pancreatic pseudocyst drainage
9. Long-term cognitive impairment after critical illness
10. Holding chambers vs. nebulizers for acute asthma

ICU Pressures Improve Transfers to the Floor

Clinical question: Does ICU strain negatively affect the outcomes of patients transferred to the floor?

Background: With healthcare costs increasing and critical care staff shortages projected, ICUs will have to operate under increasing strain. This may influence decisions on discharging patients from ICUs and could affect patient outcomes.

Study design: Retrospective cohort study.

Setting: One hundred fifty-five ICUs in the United States.

Synopsis: Using the Project IMPACT database, 200,730 adult patients from 107 different hospitals were evaluated in times of ICU strain, determined by the current census, new admissions, and acuity level. Outcomes measured were initial ICU length of stay (LOS), readmission within 72 hours, in-hospital mortality rates, and post-ICU discharge LOS.

Increases of the strain variables from the fifth to the 95th percentiles resulted in a 6.3-hour reduction in ICU LOS, a 2.0-hour decrease in post-ICU discharge LOS, and a 1.0% increase in probability of ICU readmission within 72 hours. Mortality rates during the hospital stay and odds of being discharged home showed no significant change. This study was limited because the ICUs participating were not randomly chosen, outcomes of patients transferred to other hospitals were not measured, and no post-hospital data was collected, so no long-term outcomes could be measured.

Bottom line: ICU bed pressures prompt physicians to allocate ICU resources more efficiently without changing short-term patient outcomes.

Citation: Wagner J, Gabler NB, Ratcliffe SJ, Brown SE, Strom BL, Halpern SD. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159(7):447-455.

Adults Hospitalized for Respiratory Syncytial Virus Infections Have High Morbidity, Mortality Rates

Clinical question: What are the complications and outcomes of respiratory syncytial virus (RSV) infection in adults requiring hospitalization?

Background: RSV is a common cause of lower respiratory tract infection in infants and young children, leading to hospitalization and even death. RSV has been estimated to affect 3%-10% of adults annually, generally causing mild disease. However, the outcomes of adults with more severe disease are not fully known.

Study design: Retrospective cohort study.

Setting: Three acute care, public hospitals in Hong Kong.

Synopsis: All adult patients hospitalized with laboratory-confirmed RSV infection were included during the defined time period. The main outcome measure was all-cause death, with secondary outcome measures of development of acute respiratory failure requiring ventilator support and total duration of hospitalization among survivors. Additionally, the cohort of RSV patients was compared to patients admitted with seasonal influenza during this same time frame. Patients with pandemic 2009 H1N1 infection were not included.

Of patients with RSV, pneumonia was found in 42.3%, bacterial superinfection in 12.5%, and cardiovascular complications in 14.3%. Additionally, 11.1% developed respiratory failure requiring ventilator support. All-cause mortality at 30 days and 60 days was 9.1% and 11.9%, respectively, with pneumonia the most common cause of death. Use of systemic corticosteroids did not improve survival. When the RSV cohort was compared to the influenza cohort, the patients were similar in age, but the RSV patients were more likely to have underlying chronic lung disease and major systemic co-morbidities. The rate of survival and duration of hospitalization were not significantly different.

Bottom line: RSV infection is an underappreciated cause of lower tract respiratory infection in adults; severe infections that require hospitalization have rates of mortality similar to seasonal influenza. Further research on treatment or immunization is needed.

Citation: Lee N, Lui GC, Wong KT, et al. High morbidity and mortality in adults hospitalized for respiratory syncytial virus infections. Clin Infect Dis. 2013;57(8):1069-1077.

Antibiotic Algorithm Can Guide Therapy in Healthcare-Associated Pneumonia

Clinical question: Can an algorithm based on risk for multidrug-resistant (MDR) organisms and illness severity guide antibiotic selection in healthcare-associated pneumonia (HCAP)?

Background: The 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines identify patients with HCAP as those with recent contact with a healthcare environment, including nursing homes and hemodialysis; however, previous studies have shown that not all patients with healthcare contact have equal risk for MDR organisms.

Study design: Prospective cohort study.

Setting: Japan, multi-center.

Synopsis: Of the 445 enrolled patients, 124 were diagnosed with community-acquired pneumonia (CAP) and 321 with HCAP. Patients with HCAP were classified based on severity of illness or MDR pathogen risk factors (immune suppression, hospitalization within the last 90 days, poor functional status, and antibiotics within the past six months). Patients with low risk (0-1 factors) for MDR organisms were treated for CAP, and patients with high risk (≥2 factors) or moderate risk (≥1 factor) for severe illness were treated for HCAP.

HCAP patients had a higher 30-day mortality rate (13.7% vs. 5.6%, P=0.017), but mortality rate was less in the patients at low risk for MDR pathogens (8.6% vs. 18.2%, P=0.012). Of the HCAP patients, only 7.1% received inappropriate therapy (pathogen resistant to initial antibiotic regimen), and treatment failure was 19.3%.

Appropriateness of initial empiric therapy was determined not to be a mortality risk; however, this trial might be limited by its location, because Japan appears to have fewer MDR pathogens than the U.S.

Bottom line: A treatment algorithm based on risk for MDR organisms and severity of illness can be used to guide empiric antibiotic therapy in patients with HCAP, and, ideally, to reduce excessive use of broad-spectrum antibiotics.

Citation: Maruyama T, Fujisawa T, Okuno M, et al. A new strategy for healthcare-associated pneumonia: a 2-year prospective multicenter cohort study using risk factors for multidrug-resistant pathogens to select initial empiric therapy. Clin Infect Dis. 2013;57(10):1373-1383.

Three-Month Dual Antiplatelet Therapy for Zotarolimus-Eluting Stents

Clinical question: Is short-term, dual antiplatelet therapy noninferior to long-term therapy in zotarolimus-eluting stents?

Background: Current guidelines recommend long-term (>12 months) dual antiplatelet therapy after the placement of drug-eluting stents. The optimal therapy duration in second-generation drug-eluting stents has not been studied; moreover, some studies with multiple drug-eluting stents have suggested no added benefit from long-term therapy.

Study design: Randomized controlled trial.

Setting: Brazil, multi-center.

Synopsis: Researchers randomized 3,211 patients with stable coronary artery disease (CAD) or low-risk acute coronary syndrome (ACS) undergoing intervention with zotarolimus-eluting stents to short-term (three months) or long-term (12 months) dual antiplatelet therapy. Exclusion criteria included ST-elevation myocardial infarction (STEMI), previous drug-eluting stent, scheduled elective surgery within 12 months, or contraindication to aspirin or clopidogrel. Primary endpoints were a composite of death from any cause, MI, stroke, or major bleeding. Secondary endpoints were stent thrombosis, target lesion revascularization, adverse cardiac event, and any bleed.

At one-year follow-up, the short-term group had similar primary (6.0% vs. 5.8%) and secondary (8.3% vs. 7.4%) outcomes compared to the long-term. The short-term group’s noninferiority also was seen in several key subgroups.

This study included patients with stable CAD or low-risk ACS and cannot be generalized to higher-risk patients. Results for zotarolimus-eluting stents cannot be generalized to other second-generation drug-eluting stents.

Bottom line: Zotarolimus-eluting stents, followed by three months of dual antiplatelet therapy, were noninferior to 12 months of therapy in patients with stable CAD or low-risk ACS.

Citation: Feres F, Costa RA, Abizaid A, et al. Three vs. twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial. JAMA. 2013;310(23):2510-2522.

De-Escalating Antibiotics in Sepsis

Clinical question: Does tailoring antibiotics based on known pathogens impact mortality for patients with severe sepsis or shock?

Background: In patients with sepsis, the use of early empiric antibiotics reduces morbidity and mortality. De-escalation therapy refers to narrowing the broad-spectrum antibiotics once the pathogen and sensitivities are known; however, no randomized controlled studies have assessed the impact of this therapy on critically ill patients.

Study design: Prospective observational study.

Setting: Academic hospital ICU in Spain.

Synopsis: From January 2008 to May 2012, 628 adult patients were treated empirically with broad-spectrum antibiotics. De-escalation was applied to 219 patients (34.9%). Outcomes measured were ICU mortality, hospital mortality, and 90-day mortality in patients who received de-escalation therapy, patients whose antibiotics were not changed, and patients for whom antibiotics were escalated.

The in-hospital mortality rate was 27.4% in patients who were de-escalated, 32.6% in the unchanged group, and 42.9% in the escalation group. ICU and 90-day mortality were lower in the de-escalation group. De-escalation was more commonly used in medical than in surgical patients.

This study is limited because it is not a randomized controlled study and was single-centered, so it might only be applicable on the larger scale. Also, multi-drug resistant organisms were not evaluated.

Overall, it is safe to narrow empiric antibiotics in severe sepsis and shock when the pathogen and sensitivities are known.

Bottom line: De-escalation of antibiotics in severe sepsis and septic shock is associated with a lower mortality.

Citation: Garnacho-Montero J, Gutierrez-Pizarraya A, Escoresca-Ortega A, et al. De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock. Intensive Care Med. 2014;40(1):32-40.

New Oral Anticoagulants Increase GI Bleed Risk

Clinical question: Do thrombin and factor Xa inhibitors increase the risk of gastrointestinal (GI) bleeding when compared to vitamin K antagonists and heparins?

Background: New oral anticoagulants (thrombin and factor Xa inhibitors) are available and being used with increased frequency due to equal efficacy and ease of administration. Some studies indicate a higher risk of GI bleeding with these agents. Further evaluation is needed, because no reversal therapy is available.

Study design: Systematic review and meta-analysis.

Setting: Data from MEDLINE, Embase, and the Cochrane Library.

Synopsis: More than 150,000 patients from 43 randomized controlled trials were evaluated for risk of GI bleed when treated with new anticoagulants versus traditional therapy. Patients were treated for one of the following: embolism prevention from atrial fibrillation, venous thromboembolism (VTE) prophylaxis post orthopedic surgery, VTE prophylaxis of medical patients, acute VTE, and acute coronary syndrome (ACS). Use of aspirin or NSAIDs was discouraged but not documented. The odds ratio for GI bleeding with use of the new anticoagulants was 1.45, with a number needed to harm of 500. Evaluation of subgroups revealed increased GI bleed risk in patients treated for ACS and acute thrombosis versus prophylaxis. Post-surgical patients had the lowest risk.

This study was limited by the heterogeneity and differing primary outcomes (mostly efficacy rather than safety) of the included trials. Studies excluded high-risk patients, which the authors estimate to be 25%-40% of actual patients. More studies need to be done that include high-risk patients and focus on GI bleed as a primary outcome.

Bottom line: The new anticoagulants tend to have a higher incidence of GI bleed than traditional therapy, but this varies based on indication of therapy and needs further evaluation to clarify risk.

Citation: Holster IL, Valkhoff VE, Kuipers EJ, Tjwa ET. New oral anticoagulants increase risk for gastrointestinal bleeding: a systematic review and meta-analysis. Gastroenterology. 2013;145(1):105-112.

Single vs. Dual Antiplatelet Therapy after Stroke

Clinical question: Is dual antiplatelet therapy more beneficial or harmful than monotherapy after ischemic stroke?

Background: It is recommended that patients with ischemic stroke or transient ischemic attack (TIA) receive lifelong antiplatelet therapy; however, there have been insufficient studies evaluating the long-term safety of dual antiplatelet therapy.

Study design: Meta-analysis of randomized controlled trials (RCTs)

Setting: Data from PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

Synopsis: Data from seven RCTs, including 39,574 patients with recent TIA or ischemic stroke, were reviewed. Comparisons were made regarding occurrence of intracranial hemorrhage (ICH) and recurrent stroke between patients receiving dual antiplatelet therapy and those receiving aspirin or clopidogrel monotherapy. All patients were treated for at least one year.

There was no difference in recurrent stroke or ICH between patients on dual antiplatelet therapy versus aspirin monotherapy. Patients treated with dual antiplatelet therapy did have a 46% increased risk of ICH without any additional protective benefit for recurrent stroke or TIA when compared with patients on clopidogrel monotherapy.

This information should not be applied in the acute setting, given the high risk of stroke after TIA or ischemic stroke. One major limitation of this study was that the individual trials used different combinations of dual antiplatelet therapy.

Bottom line: The risk of recurrent stroke or TIA after dual antiplatelet therapy and after monotherapy with aspirin or clopidogrel is equal, but the risk of ICH compared to clopidogrel monotherapy is increased.

Citation: Lee M, Saver JL, Hong KS, Rao NM, Wu YL, Ovbiagele B. Risk-benefit profile of long-term dual- versus single-antiplatelet therapy among patients with ischemic stroke: a systematic review and meta-analysis. Ann Intern Med. 2013;159(7):463-470.

Endoscopic vs. Surgical Cystogastrostomy for Pancreatic Pseudocyst Drainage

Clinical question: How does endoscopic cystogastrostomy for pancreatic pseudocyst drainage compare to the standard surgical approach?

Background: Pancreatic pseudocysts are a common complication of pancreatitis and necessitate decompression when they are accompanied by pain, infection, or obstruction. Decompression of the pseudocyst can be accomplished using either endoscopic or surgical cystogastrostomy.

Study design: Open-label, single-center, randomized trial.

Setting: Single-center U.S. hospital.

Synopsis: A total of 40 patients were randomly equalized to both treatment arms; 20 patients underwent endoscopic and 20 patients underwent surgical cystogastrostomy. Zero patients in the endoscopic therapy had a pseudocyst recurrence, compared with one patient treated surgically. Length of stay (LOS) and cost were lower for the endoscopic group compared to the surgical group (two days vs. six days, P<0.001, $7,011 vs. $15,052, P=0.003).

This study is limited due to several factors. First, patients with pancreatic necrosis were excluded; had these patients been included, the complication rates and LOS would have been higher. Second, cost difference cannot be generalized across the U.S., because Medicare payments are based on provider types and regions.

Bottom line: Endoscopic cystogastrostomy for pancreatic pseudocyst is equal to the standard surgical therapy and results in decreased LOS and reduced costs.

Citation: Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013;145(3):583-590.

Long-Term Cognitive Impairment after Critical Illness

Clinical question: Are a longer duration of delirium and higher doses of sedatives associated with cognitive impairment in the hospital?

Background: Survivors of critical illness are at risk for prolonged cognitive dysfunction. Delirium (and factors associated with delirium, namely sedative and analgesic medications) has been implicated in cognitive dysfunction.

Study design: Prospective cohort study.

Setting: Multi-center, academic, and acute care hospitals.

Synopsis: The study examined 821 adults admitted to the ICU with respiratory failure, cardiogenic shock, or septic shock. Patients excluded were those with pre-existing cognitive impairment, those with psychotic disorders, and those for whom follow-up would not be possible. Two risk factors measured were duration of delirium and use of sedative/analgesics. Delirium was assessed at three and 12 months using the CAM-ICU algorithm in the ICU by trained psychology professionals who were unaware of the patients’ in-hospital course.

At three months, 40% of patients had global cognition scores that were 1.5 standard deviations (SD) below population mean (similar to traumatic brain injury), and 26% had scores two SD below population mean (similar to mild Alzheimer’s). At 12 months, 34% had scores similar to traumatic brain injury patients, and 24% had scores similar to mild Alzheimer’s. A longer duration of delirium was associated with worse global cognition at three and 12 months. Use of sedatives/analgesics was not associated with cognitive impairment.

Bottom line: Critically ill patients in the ICU who experience a longer duration of delirium are at risk of long-term cognitive impairments lasting 12 months.

Citation: Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306-1316.

Holding Chambers (Spacers) vs. Nebulizers for Acute Asthma

Clinical question: Are beta-2 agonists as effective when administered through a holding chamber (spacer) as they are when administered by a nebulizer?

Background: During an acute asthma attack, beta-2 agonists must be delivered to the peripheral airways. There has been considerable controversy regarding the use of a spacer compared with a nebulizer. Aside from admission rates and length of stay, factors taken into account include cost, maintenance of nebulizer machines, and infection control (potential of cross-infection via nebulizers).

Study design: Meta-analysis review of randomized controlled trials (RCTs).

Setting: Multi-centered, worldwide studies from community setting and EDs.

Synopsis: In 39 studies of patients with an acute asthma attack (selected from Cochrane Airways Group Specialized Register), the hospital admission rates did not differ on the basis of delivery method in 729 adults (risk ratio=0.94, confidence interval 0.61-1.43) or in 1,897 children (risk ratio=0.71, confidence interval 0.47-1.08). Secondary outcomes included the duration of time in the ED and the duration of hospital admission. Time spent in the ED varied for adults but was shorter for children with spacers (based on three studies). Duration of hospital admission also did not differ when modes of delivery were compared.

Bottom line: Providing beta-2 agonists using nebulizers during an acute asthma attack is not more effective than administration using a spacer.

Citation: Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013;9:CD000052.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. ICU pressures improve transfers to the floor
2. Morbidity, mortality rates high for respiratory syncytial virus infections
3. Antibiotic algorithm can guide therapy in healthcare-associated pneumonia
4. Three-month dual antiplatelet therapy for zotarolimus-eluting stents
5. De-escalating antibiotics in sepsis
6. New oral anticoagulants increase GI bleed risk
7. Single vs. dual antiplatelet therapy after stroke
8. Endoscopic vs. surgical cystogastrostomy for pancreatic pseudocyst drainage
9. Long-term cognitive impairment after critical illness
10. Holding chambers vs. nebulizers for acute asthma

ICU Pressures Improve Transfers to the Floor

Clinical question: Does ICU strain negatively affect the outcomes of patients transferred to the floor?

Background: With healthcare costs increasing and critical care staff shortages projected, ICUs will have to operate under increasing strain. This may influence decisions on discharging patients from ICUs and could affect patient outcomes.

Study design: Retrospective cohort study.

Setting: One hundred fifty-five ICUs in the United States.

Synopsis: Using the Project IMPACT database, 200,730 adult patients from 107 different hospitals were evaluated in times of ICU strain, determined by the current census, new admissions, and acuity level. Outcomes measured were initial ICU length of stay (LOS), readmission within 72 hours, in-hospital mortality rates, and post-ICU discharge LOS.

Increases of the strain variables from the fifth to the 95th percentiles resulted in a 6.3-hour reduction in ICU LOS, a 2.0-hour decrease in post-ICU discharge LOS, and a 1.0% increase in probability of ICU readmission within 72 hours. Mortality rates during the hospital stay and odds of being discharged home showed no significant change. This study was limited because the ICUs participating were not randomly chosen, outcomes of patients transferred to other hospitals were not measured, and no post-hospital data was collected, so no long-term outcomes could be measured.

Bottom line: ICU bed pressures prompt physicians to allocate ICU resources more efficiently without changing short-term patient outcomes.

Citation: Wagner J, Gabler NB, Ratcliffe SJ, Brown SE, Strom BL, Halpern SD. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159(7):447-455.

Adults Hospitalized for Respiratory Syncytial Virus Infections Have High Morbidity, Mortality Rates

Clinical question: What are the complications and outcomes of respiratory syncytial virus (RSV) infection in adults requiring hospitalization?

Background: RSV is a common cause of lower respiratory tract infection in infants and young children, leading to hospitalization and even death. RSV has been estimated to affect 3%-10% of adults annually, generally causing mild disease. However, the outcomes of adults with more severe disease are not fully known.

Study design: Retrospective cohort study.

Setting: Three acute care, public hospitals in Hong Kong.

Synopsis: All adult patients hospitalized with laboratory-confirmed RSV infection were included during the defined time period. The main outcome measure was all-cause death, with secondary outcome measures of development of acute respiratory failure requiring ventilator support and total duration of hospitalization among survivors. Additionally, the cohort of RSV patients was compared to patients admitted with seasonal influenza during this same time frame. Patients with pandemic 2009 H1N1 infection were not included.

Of patients with RSV, pneumonia was found in 42.3%, bacterial superinfection in 12.5%, and cardiovascular complications in 14.3%. Additionally, 11.1% developed respiratory failure requiring ventilator support. All-cause mortality at 30 days and 60 days was 9.1% and 11.9%, respectively, with pneumonia the most common cause of death. Use of systemic corticosteroids did not improve survival. When the RSV cohort was compared to the influenza cohort, the patients were similar in age, but the RSV patients were more likely to have underlying chronic lung disease and major systemic co-morbidities. The rate of survival and duration of hospitalization were not significantly different.

Bottom line: RSV infection is an underappreciated cause of lower tract respiratory infection in adults; severe infections that require hospitalization have rates of mortality similar to seasonal influenza. Further research on treatment or immunization is needed.

Citation: Lee N, Lui GC, Wong KT, et al. High morbidity and mortality in adults hospitalized for respiratory syncytial virus infections. Clin Infect Dis. 2013;57(8):1069-1077.

Antibiotic Algorithm Can Guide Therapy in Healthcare-Associated Pneumonia

Clinical question: Can an algorithm based on risk for multidrug-resistant (MDR) organisms and illness severity guide antibiotic selection in healthcare-associated pneumonia (HCAP)?

Background: The 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines identify patients with HCAP as those with recent contact with a healthcare environment, including nursing homes and hemodialysis; however, previous studies have shown that not all patients with healthcare contact have equal risk for MDR organisms.

Study design: Prospective cohort study.

Setting: Japan, multi-center.

Synopsis: Of the 445 enrolled patients, 124 were diagnosed with community-acquired pneumonia (CAP) and 321 with HCAP. Patients with HCAP were classified based on severity of illness or MDR pathogen risk factors (immune suppression, hospitalization within the last 90 days, poor functional status, and antibiotics within the past six months). Patients with low risk (0-1 factors) for MDR organisms were treated for CAP, and patients with high risk (≥2 factors) or moderate risk (≥1 factor) for severe illness were treated for HCAP.

HCAP patients had a higher 30-day mortality rate (13.7% vs. 5.6%, P=0.017), but mortality rate was less in the patients at low risk for MDR pathogens (8.6% vs. 18.2%, P=0.012). Of the HCAP patients, only 7.1% received inappropriate therapy (pathogen resistant to initial antibiotic regimen), and treatment failure was 19.3%.

Appropriateness of initial empiric therapy was determined not to be a mortality risk; however, this trial might be limited by its location, because Japan appears to have fewer MDR pathogens than the U.S.

Bottom line: A treatment algorithm based on risk for MDR organisms and severity of illness can be used to guide empiric antibiotic therapy in patients with HCAP, and, ideally, to reduce excessive use of broad-spectrum antibiotics.

Citation: Maruyama T, Fujisawa T, Okuno M, et al. A new strategy for healthcare-associated pneumonia: a 2-year prospective multicenter cohort study using risk factors for multidrug-resistant pathogens to select initial empiric therapy. Clin Infect Dis. 2013;57(10):1373-1383.

Three-Month Dual Antiplatelet Therapy for Zotarolimus-Eluting Stents

Clinical question: Is short-term, dual antiplatelet therapy noninferior to long-term therapy in zotarolimus-eluting stents?

Background: Current guidelines recommend long-term (>12 months) dual antiplatelet therapy after the placement of drug-eluting stents. The optimal therapy duration in second-generation drug-eluting stents has not been studied; moreover, some studies with multiple drug-eluting stents have suggested no added benefit from long-term therapy.

Study design: Randomized controlled trial.

Setting: Brazil, multi-center.

Synopsis: Researchers randomized 3,211 patients with stable coronary artery disease (CAD) or low-risk acute coronary syndrome (ACS) undergoing intervention with zotarolimus-eluting stents to short-term (three months) or long-term (12 months) dual antiplatelet therapy. Exclusion criteria included ST-elevation myocardial infarction (STEMI), previous drug-eluting stent, scheduled elective surgery within 12 months, or contraindication to aspirin or clopidogrel. Primary endpoints were a composite of death from any cause, MI, stroke, or major bleeding. Secondary endpoints were stent thrombosis, target lesion revascularization, adverse cardiac event, and any bleed.

At one-year follow-up, the short-term group had similar primary (6.0% vs. 5.8%) and secondary (8.3% vs. 7.4%) outcomes compared to the long-term. The short-term group’s noninferiority also was seen in several key subgroups.

This study included patients with stable CAD or low-risk ACS and cannot be generalized to higher-risk patients. Results for zotarolimus-eluting stents cannot be generalized to other second-generation drug-eluting stents.

Bottom line: Zotarolimus-eluting stents, followed by three months of dual antiplatelet therapy, were noninferior to 12 months of therapy in patients with stable CAD or low-risk ACS.

Citation: Feres F, Costa RA, Abizaid A, et al. Three vs. twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial. JAMA. 2013;310(23):2510-2522.

De-Escalating Antibiotics in Sepsis

Clinical question: Does tailoring antibiotics based on known pathogens impact mortality for patients with severe sepsis or shock?

Background: In patients with sepsis, the use of early empiric antibiotics reduces morbidity and mortality. De-escalation therapy refers to narrowing the broad-spectrum antibiotics once the pathogen and sensitivities are known; however, no randomized controlled studies have assessed the impact of this therapy on critically ill patients.

Study design: Prospective observational study.

Setting: Academic hospital ICU in Spain.

Synopsis: From January 2008 to May 2012, 628 adult patients were treated empirically with broad-spectrum antibiotics. De-escalation was applied to 219 patients (34.9%). Outcomes measured were ICU mortality, hospital mortality, and 90-day mortality in patients who received de-escalation therapy, patients whose antibiotics were not changed, and patients for whom antibiotics were escalated.

The in-hospital mortality rate was 27.4% in patients who were de-escalated, 32.6% in the unchanged group, and 42.9% in the escalation group. ICU and 90-day mortality were lower in the de-escalation group. De-escalation was more commonly used in medical than in surgical patients.

This study is limited because it is not a randomized controlled study and was single-centered, so it might only be applicable on the larger scale. Also, multi-drug resistant organisms were not evaluated.

Overall, it is safe to narrow empiric antibiotics in severe sepsis and shock when the pathogen and sensitivities are known.

Bottom line: De-escalation of antibiotics in severe sepsis and septic shock is associated with a lower mortality.

Citation: Garnacho-Montero J, Gutierrez-Pizarraya A, Escoresca-Ortega A, et al. De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock. Intensive Care Med. 2014;40(1):32-40.

New Oral Anticoagulants Increase GI Bleed Risk

Clinical question: Do thrombin and factor Xa inhibitors increase the risk of gastrointestinal (GI) bleeding when compared to vitamin K antagonists and heparins?

Background: New oral anticoagulants (thrombin and factor Xa inhibitors) are available and being used with increased frequency due to equal efficacy and ease of administration. Some studies indicate a higher risk of GI bleeding with these agents. Further evaluation is needed, because no reversal therapy is available.

Study design: Systematic review and meta-analysis.

Setting: Data from MEDLINE, Embase, and the Cochrane Library.

Synopsis: More than 150,000 patients from 43 randomized controlled trials were evaluated for risk of GI bleed when treated with new anticoagulants versus traditional therapy. Patients were treated for one of the following: embolism prevention from atrial fibrillation, venous thromboembolism (VTE) prophylaxis post orthopedic surgery, VTE prophylaxis of medical patients, acute VTE, and acute coronary syndrome (ACS). Use of aspirin or NSAIDs was discouraged but not documented. The odds ratio for GI bleeding with use of the new anticoagulants was 1.45, with a number needed to harm of 500. Evaluation of subgroups revealed increased GI bleed risk in patients treated for ACS and acute thrombosis versus prophylaxis. Post-surgical patients had the lowest risk.

This study was limited by the heterogeneity and differing primary outcomes (mostly efficacy rather than safety) of the included trials. Studies excluded high-risk patients, which the authors estimate to be 25%-40% of actual patients. More studies need to be done that include high-risk patients and focus on GI bleed as a primary outcome.

Bottom line: The new anticoagulants tend to have a higher incidence of GI bleed than traditional therapy, but this varies based on indication of therapy and needs further evaluation to clarify risk.

Citation: Holster IL, Valkhoff VE, Kuipers EJ, Tjwa ET. New oral anticoagulants increase risk for gastrointestinal bleeding: a systematic review and meta-analysis. Gastroenterology. 2013;145(1):105-112.

Single vs. Dual Antiplatelet Therapy after Stroke

Clinical question: Is dual antiplatelet therapy more beneficial or harmful than monotherapy after ischemic stroke?

Background: It is recommended that patients with ischemic stroke or transient ischemic attack (TIA) receive lifelong antiplatelet therapy; however, there have been insufficient studies evaluating the long-term safety of dual antiplatelet therapy.

Study design: Meta-analysis of randomized controlled trials (RCTs)

Setting: Data from PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

Synopsis: Data from seven RCTs, including 39,574 patients with recent TIA or ischemic stroke, were reviewed. Comparisons were made regarding occurrence of intracranial hemorrhage (ICH) and recurrent stroke between patients receiving dual antiplatelet therapy and those receiving aspirin or clopidogrel monotherapy. All patients were treated for at least one year.

There was no difference in recurrent stroke or ICH between patients on dual antiplatelet therapy versus aspirin monotherapy. Patients treated with dual antiplatelet therapy did have a 46% increased risk of ICH without any additional protective benefit for recurrent stroke or TIA when compared with patients on clopidogrel monotherapy.

This information should not be applied in the acute setting, given the high risk of stroke after TIA or ischemic stroke. One major limitation of this study was that the individual trials used different combinations of dual antiplatelet therapy.

Bottom line: The risk of recurrent stroke or TIA after dual antiplatelet therapy and after monotherapy with aspirin or clopidogrel is equal, but the risk of ICH compared to clopidogrel monotherapy is increased.

Citation: Lee M, Saver JL, Hong KS, Rao NM, Wu YL, Ovbiagele B. Risk-benefit profile of long-term dual- versus single-antiplatelet therapy among patients with ischemic stroke: a systematic review and meta-analysis. Ann Intern Med. 2013;159(7):463-470.

Endoscopic vs. Surgical Cystogastrostomy for Pancreatic Pseudocyst Drainage

Clinical question: How does endoscopic cystogastrostomy for pancreatic pseudocyst drainage compare to the standard surgical approach?

Background: Pancreatic pseudocysts are a common complication of pancreatitis and necessitate decompression when they are accompanied by pain, infection, or obstruction. Decompression of the pseudocyst can be accomplished using either endoscopic or surgical cystogastrostomy.

Study design: Open-label, single-center, randomized trial.

Setting: Single-center U.S. hospital.

Synopsis: A total of 40 patients were randomly equalized to both treatment arms; 20 patients underwent endoscopic and 20 patients underwent surgical cystogastrostomy. Zero patients in the endoscopic therapy had a pseudocyst recurrence, compared with one patient treated surgically. Length of stay (LOS) and cost were lower for the endoscopic group compared to the surgical group (two days vs. six days, P<0.001, $7,011 vs. $15,052, P=0.003).

This study is limited due to several factors. First, patients with pancreatic necrosis were excluded; had these patients been included, the complication rates and LOS would have been higher. Second, cost difference cannot be generalized across the U.S., because Medicare payments are based on provider types and regions.

Bottom line: Endoscopic cystogastrostomy for pancreatic pseudocyst is equal to the standard surgical therapy and results in decreased LOS and reduced costs.

Citation: Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013;145(3):583-590.

Long-Term Cognitive Impairment after Critical Illness

Clinical question: Are a longer duration of delirium and higher doses of sedatives associated with cognitive impairment in the hospital?

Background: Survivors of critical illness are at risk for prolonged cognitive dysfunction. Delirium (and factors associated with delirium, namely sedative and analgesic medications) has been implicated in cognitive dysfunction.

Study design: Prospective cohort study.

Setting: Multi-center, academic, and acute care hospitals.

Synopsis: The study examined 821 adults admitted to the ICU with respiratory failure, cardiogenic shock, or septic shock. Patients excluded were those with pre-existing cognitive impairment, those with psychotic disorders, and those for whom follow-up would not be possible. Two risk factors measured were duration of delirium and use of sedative/analgesics. Delirium was assessed at three and 12 months using the CAM-ICU algorithm in the ICU by trained psychology professionals who were unaware of the patients’ in-hospital course.

At three months, 40% of patients had global cognition scores that were 1.5 standard deviations (SD) below population mean (similar to traumatic brain injury), and 26% had scores two SD below population mean (similar to mild Alzheimer’s). At 12 months, 34% had scores similar to traumatic brain injury patients, and 24% had scores similar to mild Alzheimer’s. A longer duration of delirium was associated with worse global cognition at three and 12 months. Use of sedatives/analgesics was not associated with cognitive impairment.

Bottom line: Critically ill patients in the ICU who experience a longer duration of delirium are at risk of long-term cognitive impairments lasting 12 months.

Citation: Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306-1316.

Holding Chambers (Spacers) vs. Nebulizers for Acute Asthma

Clinical question: Are beta-2 agonists as effective when administered through a holding chamber (spacer) as they are when administered by a nebulizer?

Background: During an acute asthma attack, beta-2 agonists must be delivered to the peripheral airways. There has been considerable controversy regarding the use of a spacer compared with a nebulizer. Aside from admission rates and length of stay, factors taken into account include cost, maintenance of nebulizer machines, and infection control (potential of cross-infection via nebulizers).

Study design: Meta-analysis review of randomized controlled trials (RCTs).

Setting: Multi-centered, worldwide studies from community setting and EDs.

Synopsis: In 39 studies of patients with an acute asthma attack (selected from Cochrane Airways Group Specialized Register), the hospital admission rates did not differ on the basis of delivery method in 729 adults (risk ratio=0.94, confidence interval 0.61-1.43) or in 1,897 children (risk ratio=0.71, confidence interval 0.47-1.08). Secondary outcomes included the duration of time in the ED and the duration of hospital admission. Time spent in the ED varied for adults but was shorter for children with spacers (based on three studies). Duration of hospital admission also did not differ when modes of delivery were compared.

Bottom line: Providing beta-2 agonists using nebulizers during an acute asthma attack is not more effective than administration using a spacer.

Citation: Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013;9:CD000052.

Dr. Howell

If only there were a place where young hospitalists, mid-career hospitalists, and veteran hospitalists in a new position could go to proverbially pick the brains of those who came before them in an informal setting that practically begs for crowd-sourced learning.

Wait, there is.

Sure, the roughly 3,000 hospitalists who descend upon SHM’s annual meeting at Mandalay Bay Resort and Casino will be there for HM14’s slate of educational offerings, keynote addresses, and clinical updates. But for guys like Darren Swenson, MD, a regional medical advisor for IPC The Hospitalist Co. in Las Vegas, it’s also a chance to catch up with long-lost colleagues and med-school buddies while making new friends and gleaning tips from a who’s who of industry leaders.

“Whether you’re early in your career, or eight, 10, 12 years into your career, healthcare is changing so rapidly now, getting access to leadership skills is essential,” he says.

HM14 course director Daniel Brotman, MD, FACP, SFHM, says it’s impossible to overstate the value of networking at the annual meeting.

“Many of these folks I see once a year, and I look forward to seeing them,” says Dr. Brotman, who practices at John Hopkins Hospital in Baltimore, Md. “For me, as a director of a hospitalist program, to network with other people who direct programs and are trying to navigate very similar challenges is great, because it gives me ideas for how I might do something different, and I can return the favor.”

There’s the flipside, too, where commiseration helps soothe the soul. But mostly, conversations with other physicians who struggle the same issues that you see can be the meeting’s most important takeaway.

“There’s so much commonality in what we’re dealing with on a day-to-day basis to run a hospitalist program successfully,” Dr. Brotman adds. “Ultimately, good ideas are good ideas.

“ Many of these folks I see once a year, and I look forward to seeing them. For me, as a director of a hospitalist program, to network with other people who direct programs and are trying to navigate very similar challenges is great, because it gives me ideas for how I might do something different, and I can return the favor. ”

–HM14 course director Daniel Brotman, MD, FACP, SFHM

“There is so much innovation going on in this field that’s it’s almost impossible not to attend this meeting and come away with so many new ideas.”

In particular, Dr. Brotman sees great opportunities for early-career hospitalists to meet, greet, and build relationships.

“One of the things that marks our specialty is recognizing that the future of hospital medicine is the young hospitalists who are attending these meetings and getting fired up about it,” he adds.

SHM President Eric Howell, MD, SFHM, chief of hospital medicine at Johns Hopkins Bayview Medical Center in Baltimore, sees another, less heralded benefit to networking: pride.

“You can really brag about your program’s success and your individual successes,” he says. “That can’t be underestimated in terms of value.”

Dr. Howell

Dr. Howell encourages junior faculty to attend in order to meet and interact with as many people as possible, through the poster contests or impromptu post-meeting beverages. Such discussion, whether it involves bragging or the aforementioned commiserating, tends to invigorate and energize staffers, he says.

“It’s therapeutic to be able to discuss these things,” Dr. Howell adds. “Networking is also peer-to-peer mentoring. You can tell them things you can’t tell your boss or the people you oversee. It allows you a fairly open conversation with a peer on how to advance your program and your career.”

Richard Quinn is a freelance writer in New Jersey.

Dr. Howell

If only there were a place where young hospitalists, mid-career hospitalists, and veteran hospitalists in a new position could go to proverbially pick the brains of those who came before them in an informal setting that practically begs for crowd-sourced learning.

Wait, there is.

Sure, the roughly 3,000 hospitalists who descend upon SHM’s annual meeting at Mandalay Bay Resort and Casino will be there for HM14’s slate of educational offerings, keynote addresses, and clinical updates. But for guys like Darren Swenson, MD, a regional medical advisor for IPC The Hospitalist Co. in Las Vegas, it’s also a chance to catch up with long-lost colleagues and med-school buddies while making new friends and gleaning tips from a who’s who of industry leaders.

“Whether you’re early in your career, or eight, 10, 12 years into your career, healthcare is changing so rapidly now, getting access to leadership skills is essential,” he says.

HM14 course director Daniel Brotman, MD, FACP, SFHM, says it’s impossible to overstate the value of networking at the annual meeting.

“Many of these folks I see once a year, and I look forward to seeing them,” says Dr. Brotman, who practices at John Hopkins Hospital in Baltimore, Md. “For me, as a director of a hospitalist program, to network with other people who direct programs and are trying to navigate very similar challenges is great, because it gives me ideas for how I might do something different, and I can return the favor.”

There’s the flipside, too, where commiseration helps soothe the soul. But mostly, conversations with other physicians who struggle the same issues that you see can be the meeting’s most important takeaway.

“There’s so much commonality in what we’re dealing with on a day-to-day basis to run a hospitalist program successfully,” Dr. Brotman adds. “Ultimately, good ideas are good ideas.

“ Many of these folks I see once a year, and I look forward to seeing them. For me, as a director of a hospitalist program, to network with other people who direct programs and are trying to navigate very similar challenges is great, because it gives me ideas for how I might do something different, and I can return the favor. ”

–HM14 course director Daniel Brotman, MD, FACP, SFHM

“There is so much innovation going on in this field that’s it’s almost impossible not to attend this meeting and come away with so many new ideas.”

In particular, Dr. Brotman sees great opportunities for early-career hospitalists to meet, greet, and build relationships.

“One of the things that marks our specialty is recognizing that the future of hospital medicine is the young hospitalists who are attending these meetings and getting fired up about it,” he adds.

SHM President Eric Howell, MD, SFHM, chief of hospital medicine at Johns Hopkins Bayview Medical Center in Baltimore, sees another, less heralded benefit to networking: pride.

“You can really brag about your program’s success and your individual successes,” he says. “That can’t be underestimated in terms of value.”

Dr. Howell

Dr. Howell encourages junior faculty to attend in order to meet and interact with as many people as possible, through the poster contests or impromptu post-meeting beverages. Such discussion, whether it involves bragging or the aforementioned commiserating, tends to invigorate and energize staffers, he says.

“It’s therapeutic to be able to discuss these things,” Dr. Howell adds. “Networking is also peer-to-peer mentoring. You can tell them things you can’t tell your boss or the people you oversee. It allows you a fairly open conversation with a peer on how to advance your program and your career.”

Richard Quinn is a freelance writer in New Jersey.

Dr. Howell

If only there were a place where young hospitalists, mid-career hospitalists, and veteran hospitalists in a new position could go to proverbially pick the brains of those who came before them in an informal setting that practically begs for crowd-sourced learning.

Wait, there is.

Sure, the roughly 3,000 hospitalists who descend upon SHM’s annual meeting at Mandalay Bay Resort and Casino will be there for HM14’s slate of educational offerings, keynote addresses, and clinical updates. But for guys like Darren Swenson, MD, a regional medical advisor for IPC The Hospitalist Co. in Las Vegas, it’s also a chance to catch up with long-lost colleagues and med-school buddies while making new friends and gleaning tips from a who’s who of industry leaders.

“Whether you’re early in your career, or eight, 10, 12 years into your career, healthcare is changing so rapidly now, getting access to leadership skills is essential,” he says.

HM14 course director Daniel Brotman, MD, FACP, SFHM, says it’s impossible to overstate the value of networking at the annual meeting.

“Many of these folks I see once a year, and I look forward to seeing them,” says Dr. Brotman, who practices at John Hopkins Hospital in Baltimore, Md. “For me, as a director of a hospitalist program, to network with other people who direct programs and are trying to navigate very similar challenges is great, because it gives me ideas for how I might do something different, and I can return the favor.”

There’s the flipside, too, where commiseration helps soothe the soul. But mostly, conversations with other physicians who struggle the same issues that you see can be the meeting’s most important takeaway.

“There’s so much commonality in what we’re dealing with on a day-to-day basis to run a hospitalist program successfully,” Dr. Brotman adds. “Ultimately, good ideas are good ideas.

“ Many of these folks I see once a year, and I look forward to seeing them. For me, as a director of a hospitalist program, to network with other people who direct programs and are trying to navigate very similar challenges is great, because it gives me ideas for how I might do something different, and I can return the favor. ”

–HM14 course director Daniel Brotman, MD, FACP, SFHM

“There is so much innovation going on in this field that’s it’s almost impossible not to attend this meeting and come away with so many new ideas.”

In particular, Dr. Brotman sees great opportunities for early-career hospitalists to meet, greet, and build relationships.

“One of the things that marks our specialty is recognizing that the future of hospital medicine is the young hospitalists who are attending these meetings and getting fired up about it,” he adds.

SHM President Eric Howell, MD, SFHM, chief of hospital medicine at Johns Hopkins Bayview Medical Center in Baltimore, sees another, less heralded benefit to networking: pride.

“You can really brag about your program’s success and your individual successes,” he says. “That can’t be underestimated in terms of value.”

Dr. Howell

Dr. Howell encourages junior faculty to attend in order to meet and interact with as many people as possible, through the poster contests or impromptu post-meeting beverages. Such discussion, whether it involves bragging or the aforementioned commiserating, tends to invigorate and energize staffers, he says.

“It’s therapeutic to be able to discuss these things,” Dr. Howell adds. “Networking is also peer-to-peer mentoring. You can tell them things you can’t tell your boss or the people you oversee. It allows you a fairly open conversation with a peer on how to advance your program and your career.”

Richard Quinn is a freelance writer in New Jersey.

HM14 offers something for every hospitalist, from procedures training to special interest forums to practice management pearls. The four-day annual meeting, coming up March 24-27 at the Mandalay Bay in Las Vegas, caters to young, old, and every doctor in between.

So how will you get the most value out of the conference?

“The highest-yield content is going to depend on what your background is and how to spend that time in a way that augments your knowledge, your perspective, or your exposure to like-minded colleagues in a very individual way,” says HM14 course director Daniel Brotman, MD, FACP, SFHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore. “One of the things that’s so cool about hospital medicine is its diversity.”

But don’t take Dr. Brotman’s well-educated word for it. Here’s a list of recommendations from Team Hospitalist, the only reader-involvement group of its kind in HM, on events they would not miss this year.

Team Hospitalist contributors: Danielle Scheurer, MD, MSCR, SFHM, hospitalist, chief quality officer, Medical University of South Carolina; Edward Ma, MD, hospitalist, Coatesville (Pa.) VA Medical Center; Nick Fitterman, MD, FACP, SFHM, vice chair of hospital medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, N.Y.; James O’Callaghan, MD, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital, University of Washington, and EvergreenHealth, Kirkland, Wash.; Klaus Suehler, MD, FHM, Mercy Hospital, Allina Health, Minneapolis, Minn.

1 “When Time is Brain (or Cord): Neurological Emergencies for the Hospitalist”

Tuesday, March 25

10:35-11:15 am

Dr. Suehler: As hospitalists, we often are the first ones to see patients with such neurological emergencies, and it is crucial to know when to get the neurologist or neurosurgeon involved. These are opportunities with a brief window of time to save or restore a patient’s neurological function.

2 “The ACA at 4: Impact on Costs, Quality, Lifestyle, and Payment”

Tuesday, March 25

10:35-11:50 am

Dr. Scheurer: This will be a packed session and will discuss all angles of the Affordable Care Act: how it will play out in hospitals around the country and, particularly, what it will mean to hospitalists. The complexity of the ACA is dizzying, so it will be time well spent to hear from several leaders in the field on how the major components of the ACA can and will impact us.

Dr. Ma: The ACA is nearly four years old, so I’m looking forward to a review on what precisely has been accomplished in medicine thus far and what can we anticipate down the road. The lawyers bantered about the constitutionality of the policy for the first two years. Politicians have been ranting about death panels, repeals, and amendments [for] the past four years. The public endured the latter part of 2013 reading about (or experiencing firsthand) the disastrous rollout of the healthcare.gov website. I want a clearer idea, beyond the fear and loathing, beyond the inane rhetoric, of the real impact that ACA has had and will have on the two most important components of healthcare: physicians and patients.

3 “Rate, Rhythm, Rivaroxaban, Ablation: Update in Atrial Fibrillation”

Tuesday, March 25

11:20 am-Noon

Dr. Suehler: This is a standard situation for hospitalists. We often admit patients with atrial fibrillation or get consulted when patients who are hospitalized for other reasons develop atrial fibrillation. It is very important for hospitalists to provide optimal care and counseling to patients with this arrhythmia, whether or not cardiologists get involved down the road.

4 “How ICD-10 Will Affect Hospitalists”

Tuesday, March 25

1:10-2:25 pm

Dr. Scheurer: Whether we like it or not, ICD-10 is right around the corner. This session will give an overview of what impact ICD-10 will have on our medical record documentation and coding, including how it can and will affect reimbursement. The more you know now, the better off you will be when your hospital implements it.

5 “Controversies in Perioperative Medicine”

Wednesday, March 26

11 am-Noon

Dr. Scheurer: We all know how much our surgeons depend on us to give them sound and evidence-based advice on how to manage surgical patients in the perioperative period. This session will review some controversial topics, from [the perspective of] two of the leaders in the field of perioperative medicine.

6 “Is It OK if I Sit Down?: Improving Patient Communication and Satisfaction at the Bedside”

Wednesday, March 26

11:45 am-12:25 pm

Dr. Fitterman: Any hospitalist or HM program leader struggling to raise patient satisfaction scores must attend this session. Recognizing that 30% of the value-based incentive pool for hospitals is directly linked to these scores, we all have “skin in the game.” Most hospitalists have part of their salary tied to patient satisfaction; however, many still lack the desired improvement in rankings despite multiple initiatives to address this issue. Four of the top five drivers of the patient experience are related to nursing, making our responsibility to impact this quite challenging. There is a correlation between the hospitals with the best satisfaction scores and lower patient mortality, so this is not just about the “chocolate on the pillow” but about filling gaps in care. I anticipate the discussion leaders will help us navigate this challenge with tips to bring back to our programs.

7 “Ending the Benevolent Dictatorship: Shared Decision-Making in the Hospital”

Wednesday, March 26

2:50-3:30 pm

Dr. Fitterman: This is a must attend for anyone interested in the “next blockbuster drug.” That is how patient activation and shared decision-making are being referred to (Health Affairs, February 2013). Where this has been implemented, patients have recognized better health outcomes, and there has been less decisional conflict (which likely equates to better satisfaction)—and all at lower costs. Sounds like a blockbuster drug, doesn’t it? The challenges I hope to see answered in this breakout session: First, most evidence wrapped around this topic is in the outpatient arena. Second, how do we overcome a lack of training in this field? Finally, how can we fit this into our busy workflows? Save me a seat.

8 “What Keeps Your CFO Awake at Night”

Wednesday, March 26

2:50-4:05 pm

Dr. Scheurer: The complexity of hospital finances can confuse even the brightest of hospitalists. This session will focus on the basics of what hospitalists should know and care about, as it relates to hospital finances. You won’t want to miss the concise opportunity to get informed.

9 “Different Generation/Different Concerns: Managing Boomers, Gen-Xers, and Gen Ys”

Thursday, March 27

8:45-9:40 am

Dr. Ma: This will likely be a contentious yet humorous session. The generational differences in attitude toward the practice of medicine can be very pronounced at times and certainly can lead to conflict in the workplace between the older and younger physicians. It’s important to recognize these differences without passing judgment and understand how they impact a practice.

10 “Effective, Efficient, and Prudent Syncope Evaluation”

Thursday, March 27

10:30-11:10 am

Dr. Suehler: Syncope is a frequent admission diagnosis for hospitalists. There is a wide spectrum of how hospitalists manage such patients (how long to monitor on telemetry, what additional tests to order). Hospitalists need to know how to provide a rational and cost-effective evaluation of patients with syncope and be able to identify patients who have a serious or life-threatening cause for their syncope.

11 “The Leadership Imperative: Building a Culture of Engagement and Ownership”

Thursday, March 27

10:55-11:50 am

Dr. O’Callaghan: Hospital practices, and the systems to which they belong, are complex organizations with their own culture. Producing long-term, sustainable change and improvement usually means changing this culture. Practices and their leaders need to develop hospitalists who think about improving the system of care, not just the patients in front of them. Successful practices are able to provide physicians with the freedom and responsibility to develop an ownership-mindset toward the practice. This lecture will help leaders develop the skills needed to support the development and maintenance of a culture of ownership.

12 “HFNC in Bronchiolitis: Best Thing Since Sliced Bread?”

Thursday, March 25

1:10-2:25 pm

Dr. O’Callaghan: Shawn Ralston, MD, is well known in pediatric hospital medicine for having both expertise and passion around the diagnosis of bronchiolitis. In the past year, she was lead author of a multi-site voluntary QI collaborative study that demonstrated that benchmarking decreased utilization of bronchodilators and chest physiotherapy in bronchiolitis (J Hosp Med. 2013;8:25-30). In addition, she was one of the authors of SHM’s Choosing Wisely Pediatric Hospital Medicine Recommendations (J Hosp Med. 2013;8(9):479-485). Dr. Ralston is a strong proponent of “doing more by doing less,” with regard to bronchiolitis, which is a self-limiting disease in pediatrics; however, along comes a potential new therapy—high flow nasal cannula therapy. I am very excited to see Dr. Ralston explore this new treatment. Will she have a debate with herself, and if so, which Ralston wins—doing-less Ralston or doing-more Ralston? I anticipate this session to be both highly informative and highly entertaining.

Richard Quinn is a freelance writer in New Jersey.

HM14 offers something for every hospitalist, from procedures training to special interest forums to practice management pearls. The four-day annual meeting, coming up March 24-27 at the Mandalay Bay in Las Vegas, caters to young, old, and every doctor in between.

So how will you get the most value out of the conference?

“The highest-yield content is going to depend on what your background is and how to spend that time in a way that augments your knowledge, your perspective, or your exposure to like-minded colleagues in a very individual way,” says HM14 course director Daniel Brotman, MD, FACP, SFHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore. “One of the things that’s so cool about hospital medicine is its diversity.”

But don’t take Dr. Brotman’s well-educated word for it. Here’s a list of recommendations from Team Hospitalist, the only reader-involvement group of its kind in HM, on events they would not miss this year.

Team Hospitalist contributors: Danielle Scheurer, MD, MSCR, SFHM, hospitalist, chief quality officer, Medical University of South Carolina; Edward Ma, MD, hospitalist, Coatesville (Pa.) VA Medical Center; Nick Fitterman, MD, FACP, SFHM, vice chair of hospital medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, N.Y.; James O’Callaghan, MD, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital, University of Washington, and EvergreenHealth, Kirkland, Wash.; Klaus Suehler, MD, FHM, Mercy Hospital, Allina Health, Minneapolis, Minn.

1 “When Time is Brain (or Cord): Neurological Emergencies for the Hospitalist”

Tuesday, March 25

10:35-11:15 am

Dr. Suehler: As hospitalists, we often are the first ones to see patients with such neurological emergencies, and it is crucial to know when to get the neurologist or neurosurgeon involved. These are opportunities with a brief window of time to save or restore a patient’s neurological function.

2 “The ACA at 4: Impact on Costs, Quality, Lifestyle, and Payment”

Tuesday, March 25

10:35-11:50 am

Dr. Scheurer: This will be a packed session and will discuss all angles of the Affordable Care Act: how it will play out in hospitals around the country and, particularly, what it will mean to hospitalists. The complexity of the ACA is dizzying, so it will be time well spent to hear from several leaders in the field on how the major components of the ACA can and will impact us.

Dr. Ma: The ACA is nearly four years old, so I’m looking forward to a review on what precisely has been accomplished in medicine thus far and what can we anticipate down the road. The lawyers bantered about the constitutionality of the policy for the first two years. Politicians have been ranting about death panels, repeals, and amendments [for] the past four years. The public endured the latter part of 2013 reading about (or experiencing firsthand) the disastrous rollout of the healthcare.gov website. I want a clearer idea, beyond the fear and loathing, beyond the inane rhetoric, of the real impact that ACA has had and will have on the two most important components of healthcare: physicians and patients.

3 “Rate, Rhythm, Rivaroxaban, Ablation: Update in Atrial Fibrillation”

Tuesday, March 25

11:20 am-Noon

Dr. Suehler: This is a standard situation for hospitalists. We often admit patients with atrial fibrillation or get consulted when patients who are hospitalized for other reasons develop atrial fibrillation. It is very important for hospitalists to provide optimal care and counseling to patients with this arrhythmia, whether or not cardiologists get involved down the road.

4 “How ICD-10 Will Affect Hospitalists”

Tuesday, March 25

1:10-2:25 pm

Dr. Scheurer: Whether we like it or not, ICD-10 is right around the corner. This session will give an overview of what impact ICD-10 will have on our medical record documentation and coding, including how it can and will affect reimbursement. The more you know now, the better off you will be when your hospital implements it.

5 “Controversies in Perioperative Medicine”

Wednesday, March 26

11 am-Noon

Dr. Scheurer: We all know how much our surgeons depend on us to give them sound and evidence-based advice on how to manage surgical patients in the perioperative period. This session will review some controversial topics, from [the perspective of] two of the leaders in the field of perioperative medicine.

6 “Is It OK if I Sit Down?: Improving Patient Communication and Satisfaction at the Bedside”

Wednesday, March 26

11:45 am-12:25 pm

Dr. Fitterman: Any hospitalist or HM program leader struggling to raise patient satisfaction scores must attend this session. Recognizing that 30% of the value-based incentive pool for hospitals is directly linked to these scores, we all have “skin in the game.” Most hospitalists have part of their salary tied to patient satisfaction; however, many still lack the desired improvement in rankings despite multiple initiatives to address this issue. Four of the top five drivers of the patient experience are related to nursing, making our responsibility to impact this quite challenging. There is a correlation between the hospitals with the best satisfaction scores and lower patient mortality, so this is not just about the “chocolate on the pillow” but about filling gaps in care. I anticipate the discussion leaders will help us navigate this challenge with tips to bring back to our programs.

7 “Ending the Benevolent Dictatorship: Shared Decision-Making in the Hospital”

Wednesday, March 26

2:50-3:30 pm

Dr. Fitterman: This is a must attend for anyone interested in the “next blockbuster drug.” That is how patient activation and shared decision-making are being referred to (Health Affairs, February 2013). Where this has been implemented, patients have recognized better health outcomes, and there has been less decisional conflict (which likely equates to better satisfaction)—and all at lower costs. Sounds like a blockbuster drug, doesn’t it? The challenges I hope to see answered in this breakout session: First, most evidence wrapped around this topic is in the outpatient arena. Second, how do we overcome a lack of training in this field? Finally, how can we fit this into our busy workflows? Save me a seat.

8 “What Keeps Your CFO Awake at Night”

Wednesday, March 26

2:50-4:05 pm

Dr. Scheurer: The complexity of hospital finances can confuse even the brightest of hospitalists. This session will focus on the basics of what hospitalists should know and care about, as it relates to hospital finances. You won’t want to miss the concise opportunity to get informed.

9 “Different Generation/Different Concerns: Managing Boomers, Gen-Xers, and Gen Ys”

Thursday, March 27

8:45-9:40 am

Dr. Ma: This will likely be a contentious yet humorous session. The generational differences in attitude toward the practice of medicine can be very pronounced at times and certainly can lead to conflict in the workplace between the older and younger physicians. It’s important to recognize these differences without passing judgment and understand how they impact a practice.

10 “Effective, Efficient, and Prudent Syncope Evaluation”

Thursday, March 27

10:30-11:10 am

Dr. Suehler: Syncope is a frequent admission diagnosis for hospitalists. There is a wide spectrum of how hospitalists manage such patients (how long to monitor on telemetry, what additional tests to order). Hospitalists need to know how to provide a rational and cost-effective evaluation of patients with syncope and be able to identify patients who have a serious or life-threatening cause for their syncope.

11 “The Leadership Imperative: Building a Culture of Engagement and Ownership”

Thursday, March 27

10:55-11:50 am

Dr. O’Callaghan: Hospital practices, and the systems to which they belong, are complex organizations with their own culture. Producing long-term, sustainable change and improvement usually means changing this culture. Practices and their leaders need to develop hospitalists who think about improving the system of care, not just the patients in front of them. Successful practices are able to provide physicians with the freedom and responsibility to develop an ownership-mindset toward the practice. This lecture will help leaders develop the skills needed to support the development and maintenance of a culture of ownership.

12 “HFNC in Bronchiolitis: Best Thing Since Sliced Bread?”

Thursday, March 25

1:10-2:25 pm

Dr. O’Callaghan: Shawn Ralston, MD, is well known in pediatric hospital medicine for having both expertise and passion around the diagnosis of bronchiolitis. In the past year, she was lead author of a multi-site voluntary QI collaborative study that demonstrated that benchmarking decreased utilization of bronchodilators and chest physiotherapy in bronchiolitis (J Hosp Med. 2013;8:25-30). In addition, she was one of the authors of SHM’s Choosing Wisely Pediatric Hospital Medicine Recommendations (J Hosp Med. 2013;8(9):479-485). Dr. Ralston is a strong proponent of “doing more by doing less,” with regard to bronchiolitis, which is a self-limiting disease in pediatrics; however, along comes a potential new therapy—high flow nasal cannula therapy. I am very excited to see Dr. Ralston explore this new treatment. Will she have a debate with herself, and if so, which Ralston wins—doing-less Ralston or doing-more Ralston? I anticipate this session to be both highly informative and highly entertaining.

Richard Quinn is a freelance writer in New Jersey.

HM14 offers something for every hospitalist, from procedures training to special interest forums to practice management pearls. The four-day annual meeting, coming up March 24-27 at the Mandalay Bay in Las Vegas, caters to young, old, and every doctor in between.

So how will you get the most value out of the conference?

“The highest-yield content is going to depend on what your background is and how to spend that time in a way that augments your knowledge, your perspective, or your exposure to like-minded colleagues in a very individual way,” says HM14 course director Daniel Brotman, MD, FACP, SFHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore. “One of the things that’s so cool about hospital medicine is its diversity.”

But don’t take Dr. Brotman’s well-educated word for it. Here’s a list of recommendations from Team Hospitalist, the only reader-involvement group of its kind in HM, on events they would not miss this year.

Team Hospitalist contributors: Danielle Scheurer, MD, MSCR, SFHM, hospitalist, chief quality officer, Medical University of South Carolina; Edward Ma, MD, hospitalist, Coatesville (Pa.) VA Medical Center; Nick Fitterman, MD, FACP, SFHM, vice chair of hospital medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, N.Y.; James O’Callaghan, MD, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital, University of Washington, and EvergreenHealth, Kirkland, Wash.; Klaus Suehler, MD, FHM, Mercy Hospital, Allina Health, Minneapolis, Minn.

1 “When Time is Brain (or Cord): Neurological Emergencies for the Hospitalist”

Tuesday, March 25

10:35-11:15 am

Dr. Suehler: As hospitalists, we often are the first ones to see patients with such neurological emergencies, and it is crucial to know when to get the neurologist or neurosurgeon involved. These are opportunities with a brief window of time to save or restore a patient’s neurological function.

2 “The ACA at 4: Impact on Costs, Quality, Lifestyle, and Payment”

Tuesday, March 25

10:35-11:50 am

Dr. Scheurer: This will be a packed session and will discuss all angles of the Affordable Care Act: how it will play out in hospitals around the country and, particularly, what it will mean to hospitalists. The complexity of the ACA is dizzying, so it will be time well spent to hear from several leaders in the field on how the major components of the ACA can and will impact us.

Dr. Ma: The ACA is nearly four years old, so I’m looking forward to a review on what precisely has been accomplished in medicine thus far and what can we anticipate down the road. The lawyers bantered about the constitutionality of the policy for the first two years. Politicians have been ranting about death panels, repeals, and amendments [for] the past four years. The public endured the latter part of 2013 reading about (or experiencing firsthand) the disastrous rollout of the healthcare.gov website. I want a clearer idea, beyond the fear and loathing, beyond the inane rhetoric, of the real impact that ACA has had and will have on the two most important components of healthcare: physicians and patients.

3 “Rate, Rhythm, Rivaroxaban, Ablation: Update in Atrial Fibrillation”

Tuesday, March 25

11:20 am-Noon

Dr. Suehler: This is a standard situation for hospitalists. We often admit patients with atrial fibrillation or get consulted when patients who are hospitalized for other reasons develop atrial fibrillation. It is very important for hospitalists to provide optimal care and counseling to patients with this arrhythmia, whether or not cardiologists get involved down the road.

4 “How ICD-10 Will Affect Hospitalists”

Tuesday, March 25

1:10-2:25 pm

Dr. Scheurer: Whether we like it or not, ICD-10 is right around the corner. This session will give an overview of what impact ICD-10 will have on our medical record documentation and coding, including how it can and will affect reimbursement. The more you know now, the better off you will be when your hospital implements it.

5 “Controversies in Perioperative Medicine”

Wednesday, March 26

11 am-Noon

Dr. Scheurer: We all know how much our surgeons depend on us to give them sound and evidence-based advice on how to manage surgical patients in the perioperative period. This session will review some controversial topics, from [the perspective of] two of the leaders in the field of perioperative medicine.

6 “Is It OK if I Sit Down?: Improving Patient Communication and Satisfaction at the Bedside”

Wednesday, March 26

11:45 am-12:25 pm

Dr. Fitterman: Any hospitalist or HM program leader struggling to raise patient satisfaction scores must attend this session. Recognizing that 30% of the value-based incentive pool for hospitals is directly linked to these scores, we all have “skin in the game.” Most hospitalists have part of their salary tied to patient satisfaction; however, many still lack the desired improvement in rankings despite multiple initiatives to address this issue. Four of the top five drivers of the patient experience are related to nursing, making our responsibility to impact this quite challenging. There is a correlation between the hospitals with the best satisfaction scores and lower patient mortality, so this is not just about the “chocolate on the pillow” but about filling gaps in care. I anticipate the discussion leaders will help us navigate this challenge with tips to bring back to our programs.

7 “Ending the Benevolent Dictatorship: Shared Decision-Making in the Hospital”

Wednesday, March 26

2:50-3:30 pm

Dr. Fitterman: This is a must attend for anyone interested in the “next blockbuster drug.” That is how patient activation and shared decision-making are being referred to (Health Affairs, February 2013). Where this has been implemented, patients have recognized better health outcomes, and there has been less decisional conflict (which likely equates to better satisfaction)—and all at lower costs. Sounds like a blockbuster drug, doesn’t it? The challenges I hope to see answered in this breakout session: First, most evidence wrapped around this topic is in the outpatient arena. Second, how do we overcome a lack of training in this field? Finally, how can we fit this into our busy workflows? Save me a seat.

8 “What Keeps Your CFO Awake at Night”

Wednesday, March 26

2:50-4:05 pm

Dr. Scheurer: The complexity of hospital finances can confuse even the brightest of hospitalists. This session will focus on the basics of what hospitalists should know and care about, as it relates to hospital finances. You won’t want to miss the concise opportunity to get informed.

9 “Different Generation/Different Concerns: Managing Boomers, Gen-Xers, and Gen Ys”

Thursday, March 27

8:45-9:40 am

Dr. Ma: This will likely be a contentious yet humorous session. The generational differences in attitude toward the practice of medicine can be very pronounced at times and certainly can lead to conflict in the workplace between the older and younger physicians. It’s important to recognize these differences without passing judgment and understand how they impact a practice.

10 “Effective, Efficient, and Prudent Syncope Evaluation”

Thursday, March 27

10:30-11:10 am

Dr. Suehler: Syncope is a frequent admission diagnosis for hospitalists. There is a wide spectrum of how hospitalists manage such patients (how long to monitor on telemetry, what additional tests to order). Hospitalists need to know how to provide a rational and cost-effective evaluation of patients with syncope and be able to identify patients who have a serious or life-threatening cause for their syncope.

11 “The Leadership Imperative: Building a Culture of Engagement and Ownership”

Thursday, March 27

10:55-11:50 am

Dr. O’Callaghan: Hospital practices, and the systems to which they belong, are complex organizations with their own culture. Producing long-term, sustainable change and improvement usually means changing this culture. Practices and their leaders need to develop hospitalists who think about improving the system of care, not just the patients in front of them. Successful practices are able to provide physicians with the freedom and responsibility to develop an ownership-mindset toward the practice. This lecture will help leaders develop the skills needed to support the development and maintenance of a culture of ownership.

12 “HFNC in Bronchiolitis: Best Thing Since Sliced Bread?”

Thursday, March 25

1:10-2:25 pm

Dr. O’Callaghan: Shawn Ralston, MD, is well known in pediatric hospital medicine for having both expertise and passion around the diagnosis of bronchiolitis. In the past year, she was lead author of a multi-site voluntary QI collaborative study that demonstrated that benchmarking decreased utilization of bronchodilators and chest physiotherapy in bronchiolitis (J Hosp Med. 2013;8:25-30). In addition, she was one of the authors of SHM’s Choosing Wisely Pediatric Hospital Medicine Recommendations (J Hosp Med. 2013;8(9):479-485). Dr. Ralston is a strong proponent of “doing more by doing less,” with regard to bronchiolitis, which is a self-limiting disease in pediatrics; however, along comes a potential new therapy—high flow nasal cannula therapy. I am very excited to see Dr. Ralston explore this new treatment. Will she have a debate with herself, and if so, which Ralston wins—doing-less Ralston or doing-more Ralston? I anticipate this session to be both highly informative and highly entertaining.

Richard Quinn is a freelance writer in New Jersey.

SHM’s annual meeting offers something new each year. For HM14, a timely new track dubbed “Bending the Cost Curve” will focus on hospitalists’ role in improving cost effectiveness for the healthcare system as a whole.

“The value equation has always been something that’s near and dear to us,” says HM14 course director Daniel Brotman, MD, SFHM. “What’s different now is that cost shifting to the outpatient setting is something that is now being recognized as a potential unintended consequence of rushing through hospitalizations. And as we’re moving into the accountable-care world, making sure that the cost shifting does not occur…is really important.

“That means that hospitalists need to own the care transition.”

“ The educational component particularly the practice management track—is increasingly important in this era of rapid change. I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual. ”

–Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course

The debut offerings don’t stop there. Three new pre-courses are on this year’s agenda: “Cardiology: What Hospitalists Need to Know as Front-Line Providers,” “Efficient High-Value Evidence-Based Medicine for the Practicing Hospitalist,” and “NP/PA Playbook for Hospital Medicine.”

“As a pre-course director, I think the educational aspect is what sets the tone for the whole meeting,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform. “People come looking to improve their clinical skills and their hospitalist groups.”

Pre-courses are critical to the meeting’s educational offerings. In that vein, HM14 is keeping pace with generational reform in care delivery and payment methodologies.

“The educational component—particularly the practice management track—is increasingly important in this era of rapid change,” Flores adds. “I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual.”

To that end, another new feature at HM14 is a panel discussion titled, “Obamacare Is Here: What Does It Mean for You and Your Hospital?” The participants are a who’s who of the specialty’s thought leaders: Centers for Medicare & Medicaid Services chief medical officer Patrick Conway, MD, MSc, FAAP, SFHM; executive director and CEO of the Medical University of South Carolina and former SHM president Patrick Cawley, MD, MHM, FACP; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD.

“The SHM annual meeting is pretty much the only place a hospitalist can go to learn about these changes,” Flores says, “and how to cope with them from a hospitalist’s perspective.”

Richard Quinn is a freelance writer in New Jersey.

SHM’s annual meeting offers something new each year. For HM14, a timely new track dubbed “Bending the Cost Curve” will focus on hospitalists’ role in improving cost effectiveness for the healthcare system as a whole.

“The value equation has always been something that’s near and dear to us,” says HM14 course director Daniel Brotman, MD, SFHM. “What’s different now is that cost shifting to the outpatient setting is something that is now being recognized as a potential unintended consequence of rushing through hospitalizations. And as we’re moving into the accountable-care world, making sure that the cost shifting does not occur…is really important.

“That means that hospitalists need to own the care transition.”

“ The educational component particularly the practice management track—is increasingly important in this era of rapid change. I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual. ”

–Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course

The debut offerings don’t stop there. Three new pre-courses are on this year’s agenda: “Cardiology: What Hospitalists Need to Know as Front-Line Providers,” “Efficient High-Value Evidence-Based Medicine for the Practicing Hospitalist,” and “NP/PA Playbook for Hospital Medicine.”

“As a pre-course director, I think the educational aspect is what sets the tone for the whole meeting,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform. “People come looking to improve their clinical skills and their hospitalist groups.”

Pre-courses are critical to the meeting’s educational offerings. In that vein, HM14 is keeping pace with generational reform in care delivery and payment methodologies.

“The educational component—particularly the practice management track—is increasingly important in this era of rapid change,” Flores adds. “I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual.”

To that end, another new feature at HM14 is a panel discussion titled, “Obamacare Is Here: What Does It Mean for You and Your Hospital?” The participants are a who’s who of the specialty’s thought leaders: Centers for Medicare & Medicaid Services chief medical officer Patrick Conway, MD, MSc, FAAP, SFHM; executive director and CEO of the Medical University of South Carolina and former SHM president Patrick Cawley, MD, MHM, FACP; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD.

“The SHM annual meeting is pretty much the only place a hospitalist can go to learn about these changes,” Flores says, “and how to cope with them from a hospitalist’s perspective.”

Richard Quinn is a freelance writer in New Jersey.

SHM’s annual meeting offers something new each year. For HM14, a timely new track dubbed “Bending the Cost Curve” will focus on hospitalists’ role in improving cost effectiveness for the healthcare system as a whole.

“The value equation has always been something that’s near and dear to us,” says HM14 course director Daniel Brotman, MD, SFHM. “What’s different now is that cost shifting to the outpatient setting is something that is now being recognized as a potential unintended consequence of rushing through hospitalizations. And as we’re moving into the accountable-care world, making sure that the cost shifting does not occur…is really important.

“That means that hospitalists need to own the care transition.”

“ The educational component particularly the practice management track—is increasingly important in this era of rapid change. I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual. ”

–Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course

The debut offerings don’t stop there. Three new pre-courses are on this year’s agenda: “Cardiology: What Hospitalists Need to Know as Front-Line Providers,” “Efficient High-Value Evidence-Based Medicine for the Practicing Hospitalist,” and “NP/PA Playbook for Hospital Medicine.”

“As a pre-course director, I think the educational aspect is what sets the tone for the whole meeting,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform. “People come looking to improve their clinical skills and their hospitalist groups.”

Pre-courses are critical to the meeting’s educational offerings. In that vein, HM14 is keeping pace with generational reform in care delivery and payment methodologies.

“The educational component—particularly the practice management track—is increasingly important in this era of rapid change,” Flores adds. “I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual.”

To that end, another new feature at HM14 is a panel discussion titled, “Obamacare Is Here: What Does It Mean for You and Your Hospital?” The participants are a who’s who of the specialty’s thought leaders: Centers for Medicare & Medicaid Services chief medical officer Patrick Conway, MD, MSc, FAAP, SFHM; executive director and CEO of the Medical University of South Carolina and former SHM president Patrick Cawley, MD, MHM, FACP; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD.

“The SHM annual meeting is pretty much the only place a hospitalist can go to learn about these changes,” Flores says, “and how to cope with them from a hospitalist’s perspective.”

Richard Quinn is a freelance writer in New Jersey.

Mix the insights of a policy wonk and the accent of Sean Connery, and you have Ian Morrison, PhD, one of the keynote speakers at SHM’s annual meeting this spring.

A native of Scotland, Dr. Morrison is a well-known author, consultant, and futurist who often lectures on where healthcare is headed in this country. Appropriately, his address is titled, “The Future of the Healthcare Marketplace: Playing the New Game.”

A second-time annual meeting speaker, who last addressed HM attendees in 2008, Dr. Morrison is a founding partner in Strategic Health Perspectives (SHP), a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s Department of Health Policy and Management. Dr. Morrison is also president emeritus of the Institute for the Future (IFTF).

Dr. Morrison spoke at length with The Hospitalist about his speech next month in Las Vegas.

Question: What do you want a room full of hospitalists to know about what they should be doing?

Answer: What I’ve been urging groups to think about is to take the longer view. I think we all get caught up in the disaster of the moment, and it’s amplified by the ideological divide over healthcare and the politicization and partisanship over it. But I think what we’ve got to do is think about the one-, three-, and five-year time horizon, about the pace of change and what we’re trying to do here. Don’t conflate the future into a blur of simultaneous change. Some of these things are going to take time.

Q: How do you rise above that fray that is “the blur of simultaneous events?”

A: If you take the longer view, there are some things that are happening, no matter what, that will not be undone by even the politics of Washington, D.C. That is the massive consolidation in the delivery system—the fact that doctors are increasingly employed by hospital systems in the main. Now, this has always been true of hospitalists, but it’s increasingly true of cardiologists and everybody else. And those trends I don’t think are going to abate. The other “megatrend” that I think is over a longer time horizon is the increasing focus on reimbursement reform to reward quality and value, particularly on a population health basis. That, I think, has so much momentum that it’s unlikely to be undone. I urge people to think about the Wright Brothers as a metaphor, rather than the Indianapolis 500; let’s just get this sucker off the ground before we declare that flying is a bad idea.

Q: How do you tailor that message to hospitalists?

A: In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. They are trying to limit readmissions to hospitals where there are certainly financial incentives, and increasing senior management’s attention on that question. So I think hospitalists are in the center of all of those kinds of discussions, at the ground level.

“In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. ”

–Dr. Morrison

Q: Being at the eye of a storm isn’t always the best place to be. How do hospitalists navigate this landscape, both to address patient care challenges and to deal with the shift that’s going to take place over the next five to 10 years, regardless of how fumbled anything is politically?

A: The specialty may transform itself into more of a hospital-based care management specialty. In other words, just simply discharging patients and saying “My job is over” doesn’t seem to me to be the future of this particular discipline. I think they are going to be the hospital-based voice for redesigning care processes across the continuum of care. And they may find themselves reaching out, maybe not physically, but electronically and digitally, to patients as they leave the hospital and migrate back into their homes and into their other settings, like skilled nursing facilities and home care and long-term care. They’re having a more involved role in care coordination after the patient is gone, not necessarily on a routine basis, looking and seeing how they’re doing, but designing care processes across that system of care and monitoring their effectiveness.

Q: How does the healthcare system view hospital medicine?

A: Well, certainly among hospital CEOs and leaders, and I’m not just talking about ones that have medical training, I think they see [HM] as a critical asset. Hospitalists are actually in the vanguard of this transformation effect; they’re not the victims of it.

Richard Quinn is a freelance author in New Jersey.

Mix the insights of a policy wonk and the accent of Sean Connery, and you have Ian Morrison, PhD, one of the keynote speakers at SHM’s annual meeting this spring.

A native of Scotland, Dr. Morrison is a well-known author, consultant, and futurist who often lectures on where healthcare is headed in this country. Appropriately, his address is titled, “The Future of the Healthcare Marketplace: Playing the New Game.”

A second-time annual meeting speaker, who last addressed HM attendees in 2008, Dr. Morrison is a founding partner in Strategic Health Perspectives (SHP), a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s Department of Health Policy and Management. Dr. Morrison is also president emeritus of the Institute for the Future (IFTF).

Dr. Morrison spoke at length with The Hospitalist about his speech next month in Las Vegas.

Question: What do you want a room full of hospitalists to know about what they should be doing?

Answer: What I’ve been urging groups to think about is to take the longer view. I think we all get caught up in the disaster of the moment, and it’s amplified by the ideological divide over healthcare and the politicization and partisanship over it. But I think what we’ve got to do is think about the one-, three-, and five-year time horizon, about the pace of change and what we’re trying to do here. Don’t conflate the future into a blur of simultaneous change. Some of these things are going to take time.

Q: How do you rise above that fray that is “the blur of simultaneous events?”

A: If you take the longer view, there are some things that are happening, no matter what, that will not be undone by even the politics of Washington, D.C. That is the massive consolidation in the delivery system—the fact that doctors are increasingly employed by hospital systems in the main. Now, this has always been true of hospitalists, but it’s increasingly true of cardiologists and everybody else. And those trends I don’t think are going to abate. The other “megatrend” that I think is over a longer time horizon is the increasing focus on reimbursement reform to reward quality and value, particularly on a population health basis. That, I think, has so much momentum that it’s unlikely to be undone. I urge people to think about the Wright Brothers as a metaphor, rather than the Indianapolis 500; let’s just get this sucker off the ground before we declare that flying is a bad idea.

Q: How do you tailor that message to hospitalists?

A: In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. They are trying to limit readmissions to hospitals where there are certainly financial incentives, and increasing senior management’s attention on that question. So I think hospitalists are in the center of all of those kinds of discussions, at the ground level.

“In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. ”

–Dr. Morrison

Q: Being at the eye of a storm isn’t always the best place to be. How do hospitalists navigate this landscape, both to address patient care challenges and to deal with the shift that’s going to take place over the next five to 10 years, regardless of how fumbled anything is politically?

A: The specialty may transform itself into more of a hospital-based care management specialty. In other words, just simply discharging patients and saying “My job is over” doesn’t seem to me to be the future of this particular discipline. I think they are going to be the hospital-based voice for redesigning care processes across the continuum of care. And they may find themselves reaching out, maybe not physically, but electronically and digitally, to patients as they leave the hospital and migrate back into their homes and into their other settings, like skilled nursing facilities and home care and long-term care. They’re having a more involved role in care coordination after the patient is gone, not necessarily on a routine basis, looking and seeing how they’re doing, but designing care processes across that system of care and monitoring their effectiveness.

Q: How does the healthcare system view hospital medicine?

A: Well, certainly among hospital CEOs and leaders, and I’m not just talking about ones that have medical training, I think they see [HM] as a critical asset. Hospitalists are actually in the vanguard of this transformation effect; they’re not the victims of it.

Richard Quinn is a freelance author in New Jersey.

Mix the insights of a policy wonk and the accent of Sean Connery, and you have Ian Morrison, PhD, one of the keynote speakers at SHM’s annual meeting this spring.

A native of Scotland, Dr. Morrison is a well-known author, consultant, and futurist who often lectures on where healthcare is headed in this country. Appropriately, his address is titled, “The Future of the Healthcare Marketplace: Playing the New Game.”

A second-time annual meeting speaker, who last addressed HM attendees in 2008, Dr. Morrison is a founding partner in Strategic Health Perspectives (SHP), a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s Department of Health Policy and Management. Dr. Morrison is also president emeritus of the Institute for the Future (IFTF).

Dr. Morrison spoke at length with The Hospitalist about his speech next month in Las Vegas.

Question: What do you want a room full of hospitalists to know about what they should be doing?

Answer: What I’ve been urging groups to think about is to take the longer view. I think we all get caught up in the disaster of the moment, and it’s amplified by the ideological divide over healthcare and the politicization and partisanship over it. But I think what we’ve got to do is think about the one-, three-, and five-year time horizon, about the pace of change and what we’re trying to do here. Don’t conflate the future into a blur of simultaneous change. Some of these things are going to take time.

Q: How do you rise above that fray that is “the blur of simultaneous events?”

A: If you take the longer view, there are some things that are happening, no matter what, that will not be undone by even the politics of Washington, D.C. That is the massive consolidation in the delivery system—the fact that doctors are increasingly employed by hospital systems in the main. Now, this has always been true of hospitalists, but it’s increasingly true of cardiologists and everybody else. And those trends I don’t think are going to abate. The other “megatrend” that I think is over a longer time horizon is the increasing focus on reimbursement reform to reward quality and value, particularly on a population health basis. That, I think, has so much momentum that it’s unlikely to be undone. I urge people to think about the Wright Brothers as a metaphor, rather than the Indianapolis 500; let’s just get this sucker off the ground before we declare that flying is a bad idea.

Q: How do you tailor that message to hospitalists?

A: In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. They are trying to limit readmissions to hospitals where there are certainly financial incentives, and increasing senior management’s attention on that question. So I think hospitalists are in the center of all of those kinds of discussions, at the ground level.

“In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. ”

–Dr. Morrison

Q: Being at the eye of a storm isn’t always the best place to be. How do hospitalists navigate this landscape, both to address patient care challenges and to deal with the shift that’s going to take place over the next five to 10 years, regardless of how fumbled anything is politically?

A: The specialty may transform itself into more of a hospital-based care management specialty. In other words, just simply discharging patients and saying “My job is over” doesn’t seem to me to be the future of this particular discipline. I think they are going to be the hospital-based voice for redesigning care processes across the continuum of care. And they may find themselves reaching out, maybe not physically, but electronically and digitally, to patients as they leave the hospital and migrate back into their homes and into their other settings, like skilled nursing facilities and home care and long-term care. They’re having a more involved role in care coordination after the patient is gone, not necessarily on a routine basis, looking and seeing how they’re doing, but designing care processes across that system of care and monitoring their effectiveness.

Q: How does the healthcare system view hospital medicine?

A: Well, certainly among hospital CEOs and leaders, and I’m not just talking about ones that have medical training, I think they see [HM] as a critical asset. Hospitalists are actually in the vanguard of this transformation effect; they’re not the victims of it.

Richard Quinn is a freelance author in New Jersey.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Antibiotic resistance threats in the United States
2. Turning for ulcer reduction: A multi-site, randomized, clinical trial in nursing homes
3. Prednisolone with or without pentoxfylline, and survival of patients with severe alcoholic hepatitis
4. Characteristics and impact of a hospitalist-staffed, post-discharge clinic
5. Higher continuity of care results in lower rate of preventable hospitalizations
6. Variation in surgical readmission rates depends on volume, mortality rates
7. Patients prefer inpatient boarding to ED boarding

Antibiotic Resistance Threats in the United States, 2013

Clinical question: What antibiotic-resistant bacteria are the greatest threats for the next 10 years?

Background: Two million people suffer antibiotic-resistant infections yearly, and 23,000 die each year as a result. Most of these infections occur in the community, but deaths usually occur in healthcare settings. Cost estimates vary but may be as high as $20 billion in excess direct healthcare costs.

Study design: The CDC used several different surveys and databanks, including the National Antimicrobial Resistance Monitoring System, to collect data. The threat level for antibiotic-resistant bacteria was determined using several factors: clinical impact, economic impact, incidence, 10-year projection of incidence, transmissibility, availability of effective antibiotics, and barriers to prevention.

Setting: United States.

Synopsis: The CDC has three classifications of antibiotic-resistant bacteria: urgent, serious, and concerning. Urgent threats are high-consequence, antibiotic-resistant threats because of significant risks identified across several criteria. These threats might not currently be widespread but have the potential to become so and require urgent public health attention to identify infections and to limit transmission. They include carbapenem-resistant Enterobacteriaceae, drug-resistant Neisseria gonorrhoeae, and Clostridium difficile (does not have true resistance, but is a consequence of antibiotic overuse).

Serious threats are significant antibiotic-resistant threats. These threats will worsen and might become urgent without ongoing public health monitoring and prevention activities. They include multidrug-resistant Acinetobacter, drug-resistant Campylobacter, fluconazole-resistant Candida (a fungus), extended-spectrum β-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enterococcus, multidrug-resistant Pseudomonas aeruginosa, drug-resistant non-typhoidal Salmonella, drug-resistant Salmonella Typhimurium, drug-resistant Shigella, methicillin-resistant Staphylococcus aureus, drug-resistant Streptococcus pneumonia, and drug-resistant tuberculosis.

Concerning threats are bacteria for which the threat of antibiotic resistance is low, and/ or there are multiple therapeutic options for resistant infections. These bacterial pathogens cause severe illness. Threats in this category require monitoring and, in some cases, rapid incident or outbreak response. These include vancomycin-resistant Staphylococcus aureus, erythromycin-resistant Group A Streptococcus, and clindamycin-resistant Group B Streptococcus. Research has shown patients with resistant infections have significantly longer hospital stays, delayed recuperation, long-term disability, and higher mortality. As resistance to current antibiotics occurs, providers are forced to use antibiotics that are more toxic, more expensive, and less effective.

The CDC recommends four core actions to fight antibiotic resistance:

• Preventing infections from occurring and preventing resistant bacteria from spreading (immunization, infection control, screening, treatment, and education);
• Tracking resistant bacteria;
• Improving the use of antibiotics (antibiotic stewardship); and
• Promoting the development of new antibiotics and new diagnostic tests for resistant bacteria.

Bottom line: Antibiotics are a limited resource. The more antibiotics are used today, the less likely they will continue to be effective in the future. The CDC lists 18 antibiotic-resistant organisms as urgent, serious, or concerning and recommends actions to combat the spread of current organisms and emergence of new antibiotic organisms.

Citation: Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. CDC website. September 16, 2013. Available at: www.cdc.gov/drugresistance/threat-report-2013. Accessed Nov. 30, 2013.

Turning for Ulcer Reduction: A Multi-Site Randomized Clinical Trial in Nursing Homes

Clinical question: Is there a difference between repositioning intervals of two, three, or four hours in pressure ulcer formation in nursing home residents on high-density foam mattresses?

Background: Pressure ulcer formation in nursing home residents is a common problem. Current standard of care requires repositioning every two hours in patients who are at risk for pressure ulcer formation. Few studies have been performed to assess a difference in repositioning interval. This study was conducted to see if there is a difference in pressure ulcer formation among residents on high-density foam mattresses at moderate to high risk (according to the Braden scale).

Study design: Multi-site, randomized, clinical trial.

Setting: Twenty U.S. and seven Canadian nursing homes using high-density foam mattresses.

Synopsis: A multi-site, randomized clinical trial was executed in 20 U.S. and seven Canadian nursing homes. More than 900 residents were randomized to two-, three-, or four-hour intervals for repositioning. All participants were at either moderate (13-14) or high (10-12) risk on the Braden scale for pressure ulcer formation. All facilities used high-density foam mattresses. All participants were monitored for pressure ulcer formation on the sacrum/coccyx, heel, or trochanter for three consecutive weeks.

There was no significant difference in pressure ulcer formation between the two-, three-, or four-hour interval repositioning groups. There was no significant difference in pressure ulcer formation between the moderate or high-risk groups. Only 2% of participants developed a pressure ulcer, all stage I or II.

It is not clear if the outcomes were purely related to the repositioning intervals, as this study group had a much lower rate of pressure ulcer formation compared to national averages and previous studies. The high-density foam mattress might have improved outcomes by evenly redistributing pressure so that less frequent repositioning was required. The level of documentation may have led to earlier recognition of early stage pressure ulcers as well. This study also was limited to nursing home residents at moderate to high risk of pressure ulcer development.

Bottom line: There is no significant difference in pressure ulcer formation between repositioning intervals of two, three, or four hours among moderate and high-risk nursing home residents using high-density foam mattresses.

Citation: Bergstrom N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Turning for ulcer reduction: a multisite randomized clinical trial in nursing homes. 2013;61(10):1705-1713.

Prednisolone, Pentoxifylline, and Survival of Patients with Severe Alcoholic Hepatitis

Clinical question: Does the addition of pentoxifylline to prednisolone improve six-month mortality compared to prednisolone alone in patients with severe alcoholic hepatitis?

Background: Prednisolone improves liver function and reduces inflammation in patients with alcoholic hepatitis. Pentoxifylline appears to have a protective effect against hepatorenal syndrome in patients with severe alcoholic hepatitis. The medications have different mechanisms of action; therefore, the researchers hypothesized that the combination of medication would improve outcomes.

Study design: Multi-center, randomized, double-blinded clinical trial.

Setting: One Belgian and 23 French hospitals, from December 2007 to October 2010.

Synopsis: This study randomized 270 patients to receive either prednisolone and pentoxifylline or prednisolone and placebo for 28 days. Acute alcoholic hepatitis was defined by a positive biopsy, onset of jaundice three months prior to the study, and a Maddrey’s discriminant function score of >32. All patients were assessed for response to treatment using the Lille model at seven days of treatment, occurrence of hepatorenal syndrome, and survival at six months.

Results showed no significant difference in treatment response, alcohol relapse, death, time to death, or occurrence of hepatorenal syndrome between the two treatment groups; however, there were fewer episodes of hepatorenal syndrome in the pentoxifylline group.

Patients considered responders by the Lille model and those with lower Model for End-Stage Liver Disease scores had improved mortality. Patients treated with pentoxifylline had lower rates of hepatorenal syndrome at one month but no difference by six months. Patients with a lower Lille score had significantly less incidence of hepatorenal syndrome. The study may be underpowered to accurately determine outcomes other than six-month survival.

Bottom line: Adding pentoxifylline to prednisolone does not improve six-month survival in severe alcoholic hepatitis compared to prednisolone alone.

Citation: Mathurin P, Louvet A, Duhamel A, et al. Prednisolone with vs without pentoxifylline and survival of patients with severe alcoholic hepatitis: a randomized clinical trial. 2013;310(10):1033-1041.

Characteristics and Impact of Hospitalist-Staffed, Post-Discharge Clinic

Clinical question: What effect does a hospitalist-staffed, post-discharge clinic have on time to first post-hospitalization visit?

Background: Hospital discharge is a well-recognized care transition that can leave patients vulnerable to morbidity and re-hospitalization. Limited primary care access can hamper complex post-hospital follow-up. Discharge clinic models staffed by hospitalists have been developed to mitigate access issues, but research is lacking to describe their characteristics and benefits.

Study design: Single-center, prospective, observational database review.

Setting: Large, academic primary care practice affiliated with an academic medical center.

Synopsis: Between 2009 and 2011, this hospitalist-staffed, post-discharge clinic saw 596 patients, while the affiliated, large primary care practice saw 10,839 patients. Patients utilizing the hospitalist discharge clinic were more likely to be black (39% vs. 29%, <0.001) and to receive primary care from resident clinics (40% vs. 21%, <0.001). The median duration from hospital discharge to the first clinic visit was shorter for the post-discharge clinic (8.45 ± 0.43 days, <0.001).

The number of radiology and laboratory tests performed at the first post-discharge clinic visit showed similar patterns between the hospitalist discharge clinic and the primary care practice. Study design and size did not permit comparisons of readmission rates or mortality from time of discharge and also precluded evaluation of interventions on discharge-related medication errors or response time to outstanding test results.

Bottom line: A hospitalist-staffed, post-discharge clinic was associated with shorter time to first post-discharge visit, especially for patients who are black and receive primary care from resident clinics.

Citation: Doctoroff L, Nijhawan A, McNally D, Vanka A, Yu R, Mukamal KJ. The characteristics and impact of a hospitalist-staffed post-discharge clinic. 2013;126(11):1016.e9-1016.e15.

Higher Continuity of Care Results in Lower Rate of Preventable Hospitalizations

Clinical question: Is continuity of care related to preventable hospitalizations among older adults?

Background: Preventable hospitalizations cost approximately $25 billion annually in the U.S. The relationship between continuity of care and the risk of preventable hospitalization is unknown.

Study design: Retrospective cohort study.

Setting: Random sample of fee-for-service Medicare beneficiaries, for ambulatory visits and hospital admissions.

Synopsis: This study examined 3.2 million Medicare beneficiaries using 2008-2010 claims data to measure continuity and the first preventable hospitalization. The Prevention Quality Indicators definitions and technical specifications from the Agency for Healthcare Research and Quality were used to identify preventable hospitalizations. Both the continuity of care score and usual provider continuity score were used to calculate continuity metrics. Baseline risk of preventable hospitalization included age, sex, race, Medicaid dual-eligible status, and residential zip code.

During a two-year period, 12.6% of patients had a preventable hospitalization. After adjusting for variables, a 0.1 increase in continuity of care was associated with about a 2% lower rate of preventable hospitalization. Interestingly, continuity of care was not related to mortality rates.

This study extends prior research associating continuity of care with reduced rate of hospitalization; however, the associations found cannot assert a causal relationship. This study used coding practices that vary throughout the country, included only older fee-for-service Medicare beneficiaries, and could not verify why some patients had higher continuity of care. The authors suggest that efforts to strengthen physician-patient relationships through high-quality primary care will deter some hospital admissions.

Bottom line: Higher continuity of ambulatory care is associated with lower preventable hospitalizations in Medicare beneficiaries.

Citation: Nyweide DJ, Anthony DL, Bynum JP, et al. Continuity of care and the risk of preventable hospitalization in older adults. 2013;173(20):1879-1885.

Surgical Readmission Rate Variation Dependent on Surgical Volume, Surgical Mortality Rates

Clinical question: What factors determine rates of readmission after major surgery?

Background: Reducing hospital readmission rates has become a national priority. The U.S. patterns for surgical readmissions are unknown, as are the specific structural and quality characteristics of hospitals associated with lower surgical readmission rates.

Study design: Retrospective study of national Medicare data was used to calculate 30-day readmission rates for six major surgical procedures.

Setting: U.S. Hospitals, 2009-2010.

Synopsis: Six major surgical procedures were tracked by Medicare data, with 479,471 discharges from 3,004 hospitals. Structural characteristics included hospital size, teaching status, region, ownership, and proportion of patients living below the federal poverty line. Three well-established measures of surgical quality were used: the HQA surgical score, procedure volume, and 30-day mortality.

Hospitals in the highest quartile for surgical volume had a significantly lower readmission rate. Additionally, hospitals with the lowest surgical mortality rates had significantly lower readmission rates. Interestingly, high adherence to reported surgical process measures was only marginally associated with reduced admission rates. Prior studies have also shown inconsistent relationship between HQA surgical score and mortality.

Limitations to this study include inability to account for factors not captured by billing codes and the focus on a Medicare population.

Bottom line: Surgical readmission rates are associated with measures of surgical quality, specifically procedural volume and mortality.

Citation: Tsai TC, Joynt KE, Orav EJ, Gawande AA, Jha AK. Variation in surgical-readmission rates and quality of hospital care. 2013;369(12):1134-1142.

Patients Overwhelmingly Prefer Inpatient Boarding to ED Boarding

Clinical question: When hallway boarding is required, do patients prefer inpatient units over the ED?

Background: ED crowding is associated with patient dissatisfaction, ambulance diversion, delays in care, medical errors, and higher mortality rates. Strategies to alleviate the problem of boarding admitted patients in the ED can include relocation to inpatient hallways while awaiting a regular hospital bed. Traditional objections to inpatient hallway boarding include concerns regarding patient satisfaction and safety.

Study design: Structured telephone survey.

Setting: Suburban, university-based, teaching hospital.

Synopsis: Patients who required boarding in the ED hallway after hospital admission were eligible for inpatient hallway boarding according to the institutional protocol, which screens for those with only mild to moderate comorbidities. Of 110 consecutive patients contacted who experienced both ED and inpatient hallway boarding, 105 consented to participate in a tested telephone survey instrument.

The overall preferred location was inpatient hallways for 85% (95% CI 75-90) of respondents. Comparing ED boarding to inpatient hallway boarding, respondents preferred inpatient boarding with regard to staff availability (84%), safety (83%), confidentiality (82%), and comfort (79%).

Study results were subject to non-response bias, because working telephone numbers were required for study inclusion, as well as recall bias, because the survey was conducted within several months after discharge. This study’s results are based on actual patient experiences, whereas prior literature relied on patients to hypothesize the preferred environment after experiencing only ED hallway boarding to predict satisfaction.

Bottom line: Boarding in inpatient hallways was associated with higher patient satisfaction compared with ED hallway boarding.

Citation: Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding [published online ahead of print September 21, 2013].

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Antibiotic resistance threats in the United States
2. Turning for ulcer reduction: A multi-site, randomized, clinical trial in nursing homes
3. Prednisolone with or without pentoxfylline, and survival of patients with severe alcoholic hepatitis
4. Characteristics and impact of a hospitalist-staffed, post-discharge clinic
5. Higher continuity of care results in lower rate of preventable hospitalizations
6. Variation in surgical readmission rates depends on volume, mortality rates
7. Patients prefer inpatient boarding to ED boarding

Antibiotic Resistance Threats in the United States, 2013

Clinical question: What antibiotic-resistant bacteria are the greatest threats for the next 10 years?

Background: Two million people suffer antibiotic-resistant infections yearly, and 23,000 die each year as a result. Most of these infections occur in the community, but deaths usually occur in healthcare settings. Cost estimates vary but may be as high as $20 billion in excess direct healthcare costs.

Study design: The CDC used several different surveys and databanks, including the National Antimicrobial Resistance Monitoring System, to collect data. The threat level for antibiotic-resistant bacteria was determined using several factors: clinical impact, economic impact, incidence, 10-year projection of incidence, transmissibility, availability of effective antibiotics, and barriers to prevention.

Setting: United States.

Synopsis: The CDC has three classifications of antibiotic-resistant bacteria: urgent, serious, and concerning. Urgent threats are high-consequence, antibiotic-resistant threats because of significant risks identified across several criteria. These threats might not currently be widespread but have the potential to become so and require urgent public health attention to identify infections and to limit transmission. They include carbapenem-resistant Enterobacteriaceae, drug-resistant Neisseria gonorrhoeae, and Clostridium difficile (does not have true resistance, but is a consequence of antibiotic overuse).

Serious threats are significant antibiotic-resistant threats. These threats will worsen and might become urgent without ongoing public health monitoring and prevention activities. They include multidrug-resistant Acinetobacter, drug-resistant Campylobacter, fluconazole-resistant Candida (a fungus), extended-spectrum β-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enterococcus, multidrug-resistant Pseudomonas aeruginosa, drug-resistant non-typhoidal Salmonella, drug-resistant Salmonella Typhimurium, drug-resistant Shigella, methicillin-resistant Staphylococcus aureus, drug-resistant Streptococcus pneumonia, and drug-resistant tuberculosis.

Concerning threats are bacteria for which the threat of antibiotic resistance is low, and/ or there are multiple therapeutic options for resistant infections. These bacterial pathogens cause severe illness. Threats in this category require monitoring and, in some cases, rapid incident or outbreak response. These include vancomycin-resistant Staphylococcus aureus, erythromycin-resistant Group A Streptococcus, and clindamycin-resistant Group B Streptococcus. Research has shown patients with resistant infections have significantly longer hospital stays, delayed recuperation, long-term disability, and higher mortality. As resistance to current antibiotics occurs, providers are forced to use antibiotics that are more toxic, more expensive, and less effective.

The CDC recommends four core actions to fight antibiotic resistance:

• Preventing infections from occurring and preventing resistant bacteria from spreading (immunization, infection control, screening, treatment, and education);
• Tracking resistant bacteria;
• Improving the use of antibiotics (antibiotic stewardship); and
• Promoting the development of new antibiotics and new diagnostic tests for resistant bacteria.

Bottom line: Antibiotics are a limited resource. The more antibiotics are used today, the less likely they will continue to be effective in the future. The CDC lists 18 antibiotic-resistant organisms as urgent, serious, or concerning and recommends actions to combat the spread of current organisms and emergence of new antibiotic organisms.

Citation: Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. CDC website. September 16, 2013. Available at: www.cdc.gov/drugresistance/threat-report-2013. Accessed Nov. 30, 2013.

Turning for Ulcer Reduction: A Multi-Site Randomized Clinical Trial in Nursing Homes

Clinical question: Is there a difference between repositioning intervals of two, three, or four hours in pressure ulcer formation in nursing home residents on high-density foam mattresses?

Background: Pressure ulcer formation in nursing home residents is a common problem. Current standard of care requires repositioning every two hours in patients who are at risk for pressure ulcer formation. Few studies have been performed to assess a difference in repositioning interval. This study was conducted to see if there is a difference in pressure ulcer formation among residents on high-density foam mattresses at moderate to high risk (according to the Braden scale).

Study design: Multi-site, randomized, clinical trial.

Setting: Twenty U.S. and seven Canadian nursing homes using high-density foam mattresses.

Synopsis: A multi-site, randomized clinical trial was executed in 20 U.S. and seven Canadian nursing homes. More than 900 residents were randomized to two-, three-, or four-hour intervals for repositioning. All participants were at either moderate (13-14) or high (10-12) risk on the Braden scale for pressure ulcer formation. All facilities used high-density foam mattresses. All participants were monitored for pressure ulcer formation on the sacrum/coccyx, heel, or trochanter for three consecutive weeks.

There was no significant difference in pressure ulcer formation between the two-, three-, or four-hour interval repositioning groups. There was no significant difference in pressure ulcer formation between the moderate or high-risk groups. Only 2% of participants developed a pressure ulcer, all stage I or II.

It is not clear if the outcomes were purely related to the repositioning intervals, as this study group had a much lower rate of pressure ulcer formation compared to national averages and previous studies. The high-density foam mattress might have improved outcomes by evenly redistributing pressure so that less frequent repositioning was required. The level of documentation may have led to earlier recognition of early stage pressure ulcers as well. This study also was limited to nursing home residents at moderate to high risk of pressure ulcer development.

Bottom line: There is no significant difference in pressure ulcer formation between repositioning intervals of two, three, or four hours among moderate and high-risk nursing home residents using high-density foam mattresses.

Citation: Bergstrom N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Turning for ulcer reduction: a multisite randomized clinical trial in nursing homes. 2013;61(10):1705-1713.

Prednisolone, Pentoxifylline, and Survival of Patients with Severe Alcoholic Hepatitis

Clinical question: Does the addition of pentoxifylline to prednisolone improve six-month mortality compared to prednisolone alone in patients with severe alcoholic hepatitis?

Background: Prednisolone improves liver function and reduces inflammation in patients with alcoholic hepatitis. Pentoxifylline appears to have a protective effect against hepatorenal syndrome in patients with severe alcoholic hepatitis. The medications have different mechanisms of action; therefore, the researchers hypothesized that the combination of medication would improve outcomes.

Study design: Multi-center, randomized, double-blinded clinical trial.

Setting: One Belgian and 23 French hospitals, from December 2007 to October 2010.

Synopsis: This study randomized 270 patients to receive either prednisolone and pentoxifylline or prednisolone and placebo for 28 days. Acute alcoholic hepatitis was defined by a positive biopsy, onset of jaundice three months prior to the study, and a Maddrey’s discriminant function score of >32. All patients were assessed for response to treatment using the Lille model at seven days of treatment, occurrence of hepatorenal syndrome, and survival at six months.

Results showed no significant difference in treatment response, alcohol relapse, death, time to death, or occurrence of hepatorenal syndrome between the two treatment groups; however, there were fewer episodes of hepatorenal syndrome in the pentoxifylline group.

Patients considered responders by the Lille model and those with lower Model for End-Stage Liver Disease scores had improved mortality. Patients treated with pentoxifylline had lower rates of hepatorenal syndrome at one month but no difference by six months. Patients with a lower Lille score had significantly less incidence of hepatorenal syndrome. The study may be underpowered to accurately determine outcomes other than six-month survival.

Bottom line: Adding pentoxifylline to prednisolone does not improve six-month survival in severe alcoholic hepatitis compared to prednisolone alone.

Citation: Mathurin P, Louvet A, Duhamel A, et al. Prednisolone with vs without pentoxifylline and survival of patients with severe alcoholic hepatitis: a randomized clinical trial. 2013;310(10):1033-1041.

Characteristics and Impact of Hospitalist-Staffed, Post-Discharge Clinic

Clinical question: What effect does a hospitalist-staffed, post-discharge clinic have on time to first post-hospitalization visit?

Background: Hospital discharge is a well-recognized care transition that can leave patients vulnerable to morbidity and re-hospitalization. Limited primary care access can hamper complex post-hospital follow-up. Discharge clinic models staffed by hospitalists have been developed to mitigate access issues, but research is lacking to describe their characteristics and benefits.

Study design: Single-center, prospective, observational database review.

Setting: Large, academic primary care practice affiliated with an academic medical center.

Synopsis: Between 2009 and 2011, this hospitalist-staffed, post-discharge clinic saw 596 patients, while the affiliated, large primary care practice saw 10,839 patients. Patients utilizing the hospitalist discharge clinic were more likely to be black (39% vs. 29%, <0.001) and to receive primary care from resident clinics (40% vs. 21%, <0.001). The median duration from hospital discharge to the first clinic visit was shorter for the post-discharge clinic (8.45 ± 0.43 days, <0.001).

The number of radiology and laboratory tests performed at the first post-discharge clinic visit showed similar patterns between the hospitalist discharge clinic and the primary care practice. Study design and size did not permit comparisons of readmission rates or mortality from time of discharge and also precluded evaluation of interventions on discharge-related medication errors or response time to outstanding test results.

Bottom line: A hospitalist-staffed, post-discharge clinic was associated with shorter time to first post-discharge visit, especially for patients who are black and receive primary care from resident clinics.

Citation: Doctoroff L, Nijhawan A, McNally D, Vanka A, Yu R, Mukamal KJ. The characteristics and impact of a hospitalist-staffed post-discharge clinic. 2013;126(11):1016.e9-1016.e15.

Higher Continuity of Care Results in Lower Rate of Preventable Hospitalizations

Clinical question: Is continuity of care related to preventable hospitalizations among older adults?

Background: Preventable hospitalizations cost approximately $25 billion annually in the U.S. The relationship between continuity of care and the risk of preventable hospitalization is unknown.

Study design: Retrospective cohort study.

Setting: Random sample of fee-for-service Medicare beneficiaries, for ambulatory visits and hospital admissions.

Synopsis: This study examined 3.2 million Medicare beneficiaries using 2008-2010 claims data to measure continuity and the first preventable hospitalization. The Prevention Quality Indicators definitions and technical specifications from the Agency for Healthcare Research and Quality were used to identify preventable hospitalizations. Both the continuity of care score and usual provider continuity score were used to calculate continuity metrics. Baseline risk of preventable hospitalization included age, sex, race, Medicaid dual-eligible status, and residential zip code.

During a two-year period, 12.6% of patients had a preventable hospitalization. After adjusting for variables, a 0.1 increase in continuity of care was associated with about a 2% lower rate of preventable hospitalization. Interestingly, continuity of care was not related to mortality rates.

This study extends prior research associating continuity of care with reduced rate of hospitalization; however, the associations found cannot assert a causal relationship. This study used coding practices that vary throughout the country, included only older fee-for-service Medicare beneficiaries, and could not verify why some patients had higher continuity of care. The authors suggest that efforts to strengthen physician-patient relationships through high-quality primary care will deter some hospital admissions.

Bottom line: Higher continuity of ambulatory care is associated with lower preventable hospitalizations in Medicare beneficiaries.

Citation: Nyweide DJ, Anthony DL, Bynum JP, et al. Continuity of care and the risk of preventable hospitalization in older adults. 2013;173(20):1879-1885.

Surgical Readmission Rate Variation Dependent on Surgical Volume, Surgical Mortality Rates

Clinical question: What factors determine rates of readmission after major surgery?

Background: Reducing hospital readmission rates has become a national priority. The U.S. patterns for surgical readmissions are unknown, as are the specific structural and quality characteristics of hospitals associated with lower surgical readmission rates.

Study design: Retrospective study of national Medicare data was used to calculate 30-day readmission rates for six major surgical procedures.

Setting: U.S. Hospitals, 2009-2010.

Synopsis: Six major surgical procedures were tracked by Medicare data, with 479,471 discharges from 3,004 hospitals. Structural characteristics included hospital size, teaching status, region, ownership, and proportion of patients living below the federal poverty line. Three well-established measures of surgical quality were used: the HQA surgical score, procedure volume, and 30-day mortality.

Hospitals in the highest quartile for surgical volume had a significantly lower readmission rate. Additionally, hospitals with the lowest surgical mortality rates had significantly lower readmission rates. Interestingly, high adherence to reported surgical process measures was only marginally associated with reduced admission rates. Prior studies have also shown inconsistent relationship between HQA surgical score and mortality.

Limitations to this study include inability to account for factors not captured by billing codes and the focus on a Medicare population.

Bottom line: Surgical readmission rates are associated with measures of surgical quality, specifically procedural volume and mortality.

Citation: Tsai TC, Joynt KE, Orav EJ, Gawande AA, Jha AK. Variation in surgical-readmission rates and quality of hospital care. 2013;369(12):1134-1142.

Patients Overwhelmingly Prefer Inpatient Boarding to ED Boarding

Clinical question: When hallway boarding is required, do patients prefer inpatient units over the ED?

Background: ED crowding is associated with patient dissatisfaction, ambulance diversion, delays in care, medical errors, and higher mortality rates. Strategies to alleviate the problem of boarding admitted patients in the ED can include relocation to inpatient hallways while awaiting a regular hospital bed. Traditional objections to inpatient hallway boarding include concerns regarding patient satisfaction and safety.

Study design: Structured telephone survey.

Setting: Suburban, university-based, teaching hospital.

Synopsis: Patients who required boarding in the ED hallway after hospital admission were eligible for inpatient hallway boarding according to the institutional protocol, which screens for those with only mild to moderate comorbidities. Of 110 consecutive patients contacted who experienced both ED and inpatient hallway boarding, 105 consented to participate in a tested telephone survey instrument.

The overall preferred location was inpatient hallways for 85% (95% CI 75-90) of respondents. Comparing ED boarding to inpatient hallway boarding, respondents preferred inpatient boarding with regard to staff availability (84%), safety (83%), confidentiality (82%), and comfort (79%).

Study results were subject to non-response bias, because working telephone numbers were required for study inclusion, as well as recall bias, because the survey was conducted within several months after discharge. This study’s results are based on actual patient experiences, whereas prior literature relied on patients to hypothesize the preferred environment after experiencing only ED hallway boarding to predict satisfaction.

Bottom line: Boarding in inpatient hallways was associated with higher patient satisfaction compared with ED hallway boarding.

Citation: Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding [published online ahead of print September 21, 2013].

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Antibiotic resistance threats in the United States
2. Turning for ulcer reduction: A multi-site, randomized, clinical trial in nursing homes
3. Prednisolone with or without pentoxfylline, and survival of patients with severe alcoholic hepatitis
4. Characteristics and impact of a hospitalist-staffed, post-discharge clinic
5. Higher continuity of care results in lower rate of preventable hospitalizations
6. Variation in surgical readmission rates depends on volume, mortality rates
7. Patients prefer inpatient boarding to ED boarding

Antibiotic Resistance Threats in the United States, 2013

Clinical question: What antibiotic-resistant bacteria are the greatest threats for the next 10 years?

Background: Two million people suffer antibiotic-resistant infections yearly, and 23,000 die each year as a result. Most of these infections occur in the community, but deaths usually occur in healthcare settings. Cost estimates vary but may be as high as $20 billion in excess direct healthcare costs.

Study design: The CDC used several different surveys and databanks, including the National Antimicrobial Resistance Monitoring System, to collect data. The threat level for antibiotic-resistant bacteria was determined using several factors: clinical impact, economic impact, incidence, 10-year projection of incidence, transmissibility, availability of effective antibiotics, and barriers to prevention.

Setting: United States.

Synopsis: The CDC has three classifications of antibiotic-resistant bacteria: urgent, serious, and concerning. Urgent threats are high-consequence, antibiotic-resistant threats because of significant risks identified across several criteria. These threats might not currently be widespread but have the potential to become so and require urgent public health attention to identify infections and to limit transmission. They include carbapenem-resistant Enterobacteriaceae, drug-resistant Neisseria gonorrhoeae, and Clostridium difficile (does not have true resistance, but is a consequence of antibiotic overuse).

Serious threats are significant antibiotic-resistant threats. These threats will worsen and might become urgent without ongoing public health monitoring and prevention activities. They include multidrug-resistant Acinetobacter, drug-resistant Campylobacter, fluconazole-resistant Candida (a fungus), extended-spectrum β-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enterococcus, multidrug-resistant Pseudomonas aeruginosa, drug-resistant non-typhoidal Salmonella, drug-resistant Salmonella Typhimurium, drug-resistant Shigella, methicillin-resistant Staphylococcus aureus, drug-resistant Streptococcus pneumonia, and drug-resistant tuberculosis.

Concerning threats are bacteria for which the threat of antibiotic resistance is low, and/ or there are multiple therapeutic options for resistant infections. These bacterial pathogens cause severe illness. Threats in this category require monitoring and, in some cases, rapid incident or outbreak response. These include vancomycin-resistant Staphylococcus aureus, erythromycin-resistant Group A Streptococcus, and clindamycin-resistant Group B Streptococcus. Research has shown patients with resistant infections have significantly longer hospital stays, delayed recuperation, long-term disability, and higher mortality. As resistance to current antibiotics occurs, providers are forced to use antibiotics that are more toxic, more expensive, and less effective.

The CDC recommends four core actions to fight antibiotic resistance:

• Preventing infections from occurring and preventing resistant bacteria from spreading (immunization, infection control, screening, treatment, and education);
• Tracking resistant bacteria;
• Improving the use of antibiotics (antibiotic stewardship); and
• Promoting the development of new antibiotics and new diagnostic tests for resistant bacteria.

Bottom line: Antibiotics are a limited resource. The more antibiotics are used today, the less likely they will continue to be effective in the future. The CDC lists 18 antibiotic-resistant organisms as urgent, serious, or concerning and recommends actions to combat the spread of current organisms and emergence of new antibiotic organisms.

Citation: Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. CDC website. September 16, 2013. Available at: www.cdc.gov/drugresistance/threat-report-2013. Accessed Nov. 30, 2013.

Turning for Ulcer Reduction: A Multi-Site Randomized Clinical Trial in Nursing Homes

Clinical question: Is there a difference between repositioning intervals of two, three, or four hours in pressure ulcer formation in nursing home residents on high-density foam mattresses?

Background: Pressure ulcer formation in nursing home residents is a common problem. Current standard of care requires repositioning every two hours in patients who are at risk for pressure ulcer formation. Few studies have been performed to assess a difference in repositioning interval. This study was conducted to see if there is a difference in pressure ulcer formation among residents on high-density foam mattresses at moderate to high risk (according to the Braden scale).

Study design: Multi-site, randomized, clinical trial.

Setting: Twenty U.S. and seven Canadian nursing homes using high-density foam mattresses.

Synopsis: A multi-site, randomized clinical trial was executed in 20 U.S. and seven Canadian nursing homes. More than 900 residents were randomized to two-, three-, or four-hour intervals for repositioning. All participants were at either moderate (13-14) or high (10-12) risk on the Braden scale for pressure ulcer formation. All facilities used high-density foam mattresses. All participants were monitored for pressure ulcer formation on the sacrum/coccyx, heel, or trochanter for three consecutive weeks.

There was no significant difference in pressure ulcer formation between the two-, three-, or four-hour interval repositioning groups. There was no significant difference in pressure ulcer formation between the moderate or high-risk groups. Only 2% of participants developed a pressure ulcer, all stage I or II.

It is not clear if the outcomes were purely related to the repositioning intervals, as this study group had a much lower rate of pressure ulcer formation compared to national averages and previous studies. The high-density foam mattress might have improved outcomes by evenly redistributing pressure so that less frequent repositioning was required. The level of documentation may have led to earlier recognition of early stage pressure ulcers as well. This study also was limited to nursing home residents at moderate to high risk of pressure ulcer development.

Bottom line: There is no significant difference in pressure ulcer formation between repositioning intervals of two, three, or four hours among moderate and high-risk nursing home residents using high-density foam mattresses.

Citation: Bergstrom N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Turning for ulcer reduction: a multisite randomized clinical trial in nursing homes. 2013;61(10):1705-1713.

Prednisolone, Pentoxifylline, and Survival of Patients with Severe Alcoholic Hepatitis

Clinical question: Does the addition of pentoxifylline to prednisolone improve six-month mortality compared to prednisolone alone in patients with severe alcoholic hepatitis?

Background: Prednisolone improves liver function and reduces inflammation in patients with alcoholic hepatitis. Pentoxifylline appears to have a protective effect against hepatorenal syndrome in patients with severe alcoholic hepatitis. The medications have different mechanisms of action; therefore, the researchers hypothesized that the combination of medication would improve outcomes.

Study design: Multi-center, randomized, double-blinded clinical trial.

Setting: One Belgian and 23 French hospitals, from December 2007 to October 2010.

Synopsis: This study randomized 270 patients to receive either prednisolone and pentoxifylline or prednisolone and placebo for 28 days. Acute alcoholic hepatitis was defined by a positive biopsy, onset of jaundice three months prior to the study, and a Maddrey’s discriminant function score of >32. All patients were assessed for response to treatment using the Lille model at seven days of treatment, occurrence of hepatorenal syndrome, and survival at six months.

Results showed no significant difference in treatment response, alcohol relapse, death, time to death, or occurrence of hepatorenal syndrome between the two treatment groups; however, there were fewer episodes of hepatorenal syndrome in the pentoxifylline group.

Patients considered responders by the Lille model and those with lower Model for End-Stage Liver Disease scores had improved mortality. Patients treated with pentoxifylline had lower rates of hepatorenal syndrome at one month but no difference by six months. Patients with a lower Lille score had significantly less incidence of hepatorenal syndrome. The study may be underpowered to accurately determine outcomes other than six-month survival.

Bottom line: Adding pentoxifylline to prednisolone does not improve six-month survival in severe alcoholic hepatitis compared to prednisolone alone.

Citation: Mathurin P, Louvet A, Duhamel A, et al. Prednisolone with vs without pentoxifylline and survival of patients with severe alcoholic hepatitis: a randomized clinical trial. 2013;310(10):1033-1041.

Characteristics and Impact of Hospitalist-Staffed, Post-Discharge Clinic

Clinical question: What effect does a hospitalist-staffed, post-discharge clinic have on time to first post-hospitalization visit?

Background: Hospital discharge is a well-recognized care transition that can leave patients vulnerable to morbidity and re-hospitalization. Limited primary care access can hamper complex post-hospital follow-up. Discharge clinic models staffed by hospitalists have been developed to mitigate access issues, but research is lacking to describe their characteristics and benefits.

Study design: Single-center, prospective, observational database review.

Setting: Large, academic primary care practice affiliated with an academic medical center.

Synopsis: Between 2009 and 2011, this hospitalist-staffed, post-discharge clinic saw 596 patients, while the affiliated, large primary care practice saw 10,839 patients. Patients utilizing the hospitalist discharge clinic were more likely to be black (39% vs. 29%, <0.001) and to receive primary care from resident clinics (40% vs. 21%, <0.001). The median duration from hospital discharge to the first clinic visit was shorter for the post-discharge clinic (8.45 ± 0.43 days, <0.001).

The number of radiology and laboratory tests performed at the first post-discharge clinic visit showed similar patterns between the hospitalist discharge clinic and the primary care practice. Study design and size did not permit comparisons of readmission rates or mortality from time of discharge and also precluded evaluation of interventions on discharge-related medication errors or response time to outstanding test results.

Bottom line: A hospitalist-staffed, post-discharge clinic was associated with shorter time to first post-discharge visit, especially for patients who are black and receive primary care from resident clinics.

Citation: Doctoroff L, Nijhawan A, McNally D, Vanka A, Yu R, Mukamal KJ. The characteristics and impact of a hospitalist-staffed post-discharge clinic. 2013;126(11):1016.e9-1016.e15.

Higher Continuity of Care Results in Lower Rate of Preventable Hospitalizations

Clinical question: Is continuity of care related to preventable hospitalizations among older adults?

Background: Preventable hospitalizations cost approximately $25 billion annually in the U.S. The relationship between continuity of care and the risk of preventable hospitalization is unknown.

Study design: Retrospective cohort study.

Setting: Random sample of fee-for-service Medicare beneficiaries, for ambulatory visits and hospital admissions.

Synopsis: This study examined 3.2 million Medicare beneficiaries using 2008-2010 claims data to measure continuity and the first preventable hospitalization. The Prevention Quality Indicators definitions and technical specifications from the Agency for Healthcare Research and Quality were used to identify preventable hospitalizations. Both the continuity of care score and usual provider continuity score were used to calculate continuity metrics. Baseline risk of preventable hospitalization included age, sex, race, Medicaid dual-eligible status, and residential zip code.

During a two-year period, 12.6% of patients had a preventable hospitalization. After adjusting for variables, a 0.1 increase in continuity of care was associated with about a 2% lower rate of preventable hospitalization. Interestingly, continuity of care was not related to mortality rates.

This study extends prior research associating continuity of care with reduced rate of hospitalization; however, the associations found cannot assert a causal relationship. This study used coding practices that vary throughout the country, included only older fee-for-service Medicare beneficiaries, and could not verify why some patients had higher continuity of care. The authors suggest that efforts to strengthen physician-patient relationships through high-quality primary care will deter some hospital admissions.

Bottom line: Higher continuity of ambulatory care is associated with lower preventable hospitalizations in Medicare beneficiaries.

Citation: Nyweide DJ, Anthony DL, Bynum JP, et al. Continuity of care and the risk of preventable hospitalization in older adults. 2013;173(20):1879-1885.

Surgical Readmission Rate Variation Dependent on Surgical Volume, Surgical Mortality Rates

Clinical question: What factors determine rates of readmission after major surgery?

Background: Reducing hospital readmission rates has become a national priority. The U.S. patterns for surgical readmissions are unknown, as are the specific structural and quality characteristics of hospitals associated with lower surgical readmission rates.

Study design: Retrospective study of national Medicare data was used to calculate 30-day readmission rates for six major surgical procedures.

Setting: U.S. Hospitals, 2009-2010.

Synopsis: Six major surgical procedures were tracked by Medicare data, with 479,471 discharges from 3,004 hospitals. Structural characteristics included hospital size, teaching status, region, ownership, and proportion of patients living below the federal poverty line. Three well-established measures of surgical quality were used: the HQA surgical score, procedure volume, and 30-day mortality.

Hospitals in the highest quartile for surgical volume had a significantly lower readmission rate. Additionally, hospitals with the lowest surgical mortality rates had significantly lower readmission rates. Interestingly, high adherence to reported surgical process measures was only marginally associated with reduced admission rates. Prior studies have also shown inconsistent relationship between HQA surgical score and mortality.

Limitations to this study include inability to account for factors not captured by billing codes and the focus on a Medicare population.

Bottom line: Surgical readmission rates are associated with measures of surgical quality, specifically procedural volume and mortality.

Citation: Tsai TC, Joynt KE, Orav EJ, Gawande AA, Jha AK. Variation in surgical-readmission rates and quality of hospital care. 2013;369(12):1134-1142.

Patients Overwhelmingly Prefer Inpatient Boarding to ED Boarding

Clinical question: When hallway boarding is required, do patients prefer inpatient units over the ED?

Background: ED crowding is associated with patient dissatisfaction, ambulance diversion, delays in care, medical errors, and higher mortality rates. Strategies to alleviate the problem of boarding admitted patients in the ED can include relocation to inpatient hallways while awaiting a regular hospital bed. Traditional objections to inpatient hallway boarding include concerns regarding patient satisfaction and safety.

Study design: Structured telephone survey.

Setting: Suburban, university-based, teaching hospital.

Synopsis: Patients who required boarding in the ED hallway after hospital admission were eligible for inpatient hallway boarding according to the institutional protocol, which screens for those with only mild to moderate comorbidities. Of 110 consecutive patients contacted who experienced both ED and inpatient hallway boarding, 105 consented to participate in a tested telephone survey instrument.

The overall preferred location was inpatient hallways for 85% (95% CI 75-90) of respondents. Comparing ED boarding to inpatient hallway boarding, respondents preferred inpatient boarding with regard to staff availability (84%), safety (83%), confidentiality (82%), and comfort (79%).

Study results were subject to non-response bias, because working telephone numbers were required for study inclusion, as well as recall bias, because the survey was conducted within several months after discharge. This study’s results are based on actual patient experiences, whereas prior literature relied on patients to hypothesize the preferred environment after experiencing only ED hallway boarding to predict satisfaction.

Bottom line: Boarding in inpatient hallways was associated with higher patient satisfaction compared with ED hallway boarding.

Citation: Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding [published online ahead of print September 21, 2013].

Alcohol consumption may reduce the risk of developing multiple sclerosis (MS) and attenuate the effect of smoking, according to research published online ahead of print January 6 in JAMA Neurology. Scientists examined data from the Epidemiological Investigation of MS (EIMS), which included 745 cases and 1,761 controls, and from the Genes and Environment in MS (GEMS) study, which recruited 5,874 cases and 5,246 controls. In EIMS, women who reported high alcohol consumption (>112 g/week) had an odds ratio (OR) of 0.6 of developing MS, compared with nondrinking women. Men with high alcohol consumption (>168 g/week) in EIMS had an OR of 0.5, compared with nondrinking men. The OR for the comparison in GEMS was 0.7 for women and 0.7 for men. In both studies, the detrimental effect of smoking was more pronounced among nondrinkers.

A lentiviral vector-based gene therapy may be safe and improve motor behavior in patients with Parkinson’s disease, according to a study published online ahead of print January 10 in Lancet. In a phase I–II open-label trial, 15 patients received bilateral injections of gene therapy into the putamen and were followed up for 12 months. Participants received a low dose (1.9 × 107 transducing units [TU]), medium dose (4.0 × 107 TU), or a high dose (1 × 108 TU) of gene therapy. Patients reported 51 mild adverse events, three moderate adverse events, and no serious adverse events. The investigators noted a significant improvement in mean Unified Parkinson’s Disease Rating Scale part III motor scores off medication in all patients at six months, compared with baseline.

The FDA has approved a three-times-per-week formulation of Copaxone 40 mg/mL. The new formulation will enable a less-frequent dosing regimen to be administered subcutaneously to patients with relapsing forms of multiple sclerosis (MS). The approval is based on data from the Phase III Glatiramer Acetate Low-Frequency Administration study of more than 1,400 patients. In the trial, investigators found that a 40-mg/mL dose of Copaxone administered subcutaneously three times per week significantly reduced relapse rates at 12 months and demonstrated a favorable safety and tolerability profile in patients with relapsing-remitting MS. In addition to the newly approved dose, daily Copaxone 20 mg/mL will continue to be available. The daily subcutaneous injection was approved in 1996. Both formulations are manufactured by Teva Pharmaceutical Industries, which is headquartered in Jerusalem.

When administered with amitriptyline, cognitive behavioral therapy (CBT) may result in greater reductions in days with headache and in migraine-related disability among young persons with chronic migraine, compared with headache education, according to research published December 25, 2013, in JAMA. In a randomized clinical trial, 135 children (ages 10 to 17) with chronic migraine and a Pediatric Migraine Disability Assessment Score (PedMIDAS) greater than 20 points were assigned to CBT plus amitriptyline or headache education plus amitriptyline. At the 20-week end point, days with headache were reduced by 11.5 for the CBT plus amitriptyline group, compared with 6.8 for the headache education plus amitriptyline group. The PedMIDAS decreased by 52.7 points for the CBT group and by 38.6 points for the headache education group.

Low levels of vitamin D early in the course of multiple sclerosis (MS) are a strong risk factor for long-term disease activity and progression in patients who were primarily treated with interferon beta-1b, according to a study published online January 20 in JAMA Neurology. Researchers compared early and delayed interferon beta-1b treatment in 468 patients with clinically isolated syndrome, measuring serum levels of 25-hydroxyvitamin D (25[OH]D) at baseline and at six, 12, and 24 months. “A 50-nmol/L (20-ng/mL) increment in average serum 25(OH)D levels within the first 12 months predicted a 57% lower rate of new active lesions, 57% lower relapse rate, 25% lower yearly increase in T2 lesion volume, and 0.41% lower yearly loss in brain volume from months 12 to 60,” stated the study authors.

Excessive alcohol consumption in men was associated with faster cognitive decline, compared with light to moderate alcohol consumption, researchers reported online ahead of print January 15 in Neurology. The findings are based on data from 5,054 men and 2,099 women (mean age, 56) who had their alcohol consumption analyzed three times in the 10 years preceding the first cognitive assessment. In men, the investigators observed no differences in cognitive decline among alcohol abstainers, those who quit using alcohol, and light or moderate alcohol drinkers (<20 g/day). Alcohol consumption ≥36 g/day was associated with faster decline in all cognitive domains, compared with consumption between 0.1 and 19.9 g/day. In women, 10-year abstainers had a faster decline in the global cognitive score and executive function, compared with those drinking between 0.1 and 9.9 g/day of alcohol.

Vitamin D supplements may reduce pain in patients with fibromyalgia syndrome, according to a study in the February issue of Pain. The randomized controlled trial enrolled 30 women with fibromyalgia syndrome with serum calcifediol levels <32 ng/mL (80 nmol/L), in whom the goal was to achieve serum calcifediol levels between 32 and 48 ng/mL for 20 weeks with an oral cholecalciferol supplement. Re-evaluation was performed in both groups after an additional 24 weeks without cholecalciferol supplementation. The researchers observed a marked reduction in pain during the treatment period in those who received the supplement, and optimization of calcifediol levels had a positive effect on the perception of pain. “This economical therapy with a low side effect profile may well be considered in patients with fibromyalgia syndrome,” the researchers concluded.

A simple on-field blood test may help diagnose sports concussion. Relative and absolute increases in the astroglial protein, serum S100B, can accurately distinguish sports-related concussion from sports-related exertion, according to a study published online January 8 in PLOS One. Serum S100B was measured in 46 collegiate and semiprofessional contact sport athletes at preseason baseline, within three hours of injury, and at days 2, 3, and 7 post–sports-related concussion. Twenty-two athletes had a sports-related concussion, and 17 had S100B testing within three hours postinjury. The mean three-hour post–sports-related concussion S100B level was significantly higher than at preseason baseline, while the mean postexertion S100B level was not significantly different than that from the preseason baseline. S100B levels at postinjury days 2, 3, and 7 were significantly lower than at the three-hour level and were not different than at baseline.

Herpes zoster is an independent risk factor for vascular disease, particularly for stroke, transient ischemic attack, and myocardial infarction, in patients affected before age 40, researchers reported online ahead of print January 2 in Neurology. The findings are based on a retrospective cohort of 106,601 cases of herpes zoster and 213,202 controls from a general practice database in the United Kingdom. The investigators found that risk factors for vascular disease were significantly increased in patients with herpes zoster compared with controls. In addition, adjusted hazard ratios for TIA and myocardial infarction, but not stroke, were increased in all patients with herpes zoster. Stroke, TIA, and myocardial infarction were increased in cases in which herpes zoster occurred when the participants were younger than 40.

A study appearing January 22 online in Neurology found that a higher omega-3 index was correlated with larger total normal brain volume and hippocampal volume in postmenopausal women measured eight years later. Researchers assessed RBC eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and MRI brain volumes in 1,111 postmenopausal women from the Women’s Health Initiative Memory Study. In fully adjusted models, a 1-SD greater RBC EPA + DHA (omega-3 index) level was correlated with 2.1 cm3 larger brain volume. “DHA was marginally correlated with total brain volume while EPA was less so,” reported the investigators. In fully adjusted models, a 1-SD greater omega-3 index was correlated with greater hippocampal volume. “While normal aging results in overall brain atrophy, lower omega-3 index may signal increased risk of hippocampal atrophy,” wrote the investigators.

Exposure to DDT may increase the risk of developing Alzheimer’s disease, particularly in people older than 60, according to a study published online ahead of print January 27 in JAMA Neurology. Researchers examined the level of DDE, the chemical compound produced when DDT breaks down in the body, in the blood of 86 patients with Alzheimer’s disease and 79 controls. Blood levels of DDE were almost four times higher in 74 of the patients with Alzheimer’s disease than in the controls. Patients with APOE4, which greatly increases the risk of developing Alzheimer’s disease, and high blood levels of DDE exhibited more severe cognitive impairment than patients without the gene. In addition, DDT and DDE apparently increased the amount of a protein associated with plaques believed to be a hallmark of Alzheimer’s disease.

Mortality is higher among patients with multiple sclerosis (MS) than among Americans without the disease, according to research published online ahead of print December 26, 2013, in Multiple Sclerosis and Related Disorders. Investigators extracted records from a US commercial health insurance database—the OptumInsight Research database—for 30,402 patients with MS and 89,818 healthy comparators. Patient data were recorded from 1996 to 2009. Annual mortality rates were 899/100,000 among patients with MS and 446/100,000 among comparators. Standardized mortality ratio was 1.70 for patients with MS and 0.80 for the general US population. Kaplan–Meier analysis yielded a median survival from birth that was six years lower among patients with MS than among comparators. The six-year decrement in lifespan is consistent with a decrement found in recent research conducted in Canada, said the investigators.

Chronic obstructive pulmonary disease (COPD) may increase the risk of mild cognitive impairment (MCI), researchers reported in the November 2013 issue of Mayo Clinic Proceedings. The investigators evaluated 1,927 patients (ages 70 to 89) enrolled in the population-based Mayo Clinic Study of Aging. Participants received a nurse assessment, neurologic evaluation, and neuropsychologic testing. A consensus panel diagnosed MCI according to standardized criteria. COPD was identified by the review of medical records. A total of 288 patients had COPD. Prevalence of MCI was 27% among patients with COPD and 15% among patients without COPD. The odds ratio for MCI was 1.60 in patients who had had COPD for five years or fewer and 2.10 in patients who had had COPD for more than five years.

—Erik Greb and Colby Stong

Alcohol consumption may reduce the risk of developing multiple sclerosis (MS) and attenuate the effect of smoking, according to research published online ahead of print January 6 in JAMA Neurology. Scientists examined data from the Epidemiological Investigation of MS (EIMS), which included 745 cases and 1,761 controls, and from the Genes and Environment in MS (GEMS) study, which recruited 5,874 cases and 5,246 controls. In EIMS, women who reported high alcohol consumption (>112 g/week) had an odds ratio (OR) of 0.6 of developing MS, compared with nondrinking women. Men with high alcohol consumption (>168 g/week) in EIMS had an OR of 0.5, compared with nondrinking men. The OR for the comparison in GEMS was 0.7 for women and 0.7 for men. In both studies, the detrimental effect of smoking was more pronounced among nondrinkers.

A lentiviral vector-based gene therapy may be safe and improve motor behavior in patients with Parkinson’s disease, according to a study published online ahead of print January 10 in Lancet. In a phase I–II open-label trial, 15 patients received bilateral injections of gene therapy into the putamen and were followed up for 12 months. Participants received a low dose (1.9 × 107 transducing units [TU]), medium dose (4.0 × 107 TU), or a high dose (1 × 108 TU) of gene therapy. Patients reported 51 mild adverse events, three moderate adverse events, and no serious adverse events. The investigators noted a significant improvement in mean Unified Parkinson’s Disease Rating Scale part III motor scores off medication in all patients at six months, compared with baseline.

The FDA has approved a three-times-per-week formulation of Copaxone 40 mg/mL. The new formulation will enable a less-frequent dosing regimen to be administered subcutaneously to patients with relapsing forms of multiple sclerosis (MS). The approval is based on data from the Phase III Glatiramer Acetate Low-Frequency Administration study of more than 1,400 patients. In the trial, investigators found that a 40-mg/mL dose of Copaxone administered subcutaneously three times per week significantly reduced relapse rates at 12 months and demonstrated a favorable safety and tolerability profile in patients with relapsing-remitting MS. In addition to the newly approved dose, daily Copaxone 20 mg/mL will continue to be available. The daily subcutaneous injection was approved in 1996. Both formulations are manufactured by Teva Pharmaceutical Industries, which is headquartered in Jerusalem.

When administered with amitriptyline, cognitive behavioral therapy (CBT) may result in greater reductions in days with headache and in migraine-related disability among young persons with chronic migraine, compared with headache education, according to research published December 25, 2013, in JAMA. In a randomized clinical trial, 135 children (ages 10 to 17) with chronic migraine and a Pediatric Migraine Disability Assessment Score (PedMIDAS) greater than 20 points were assigned to CBT plus amitriptyline or headache education plus amitriptyline. At the 20-week end point, days with headache were reduced by 11.5 for the CBT plus amitriptyline group, compared with 6.8 for the headache education plus amitriptyline group. The PedMIDAS decreased by 52.7 points for the CBT group and by 38.6 points for the headache education group.

Low levels of vitamin D early in the course of multiple sclerosis (MS) are a strong risk factor for long-term disease activity and progression in patients who were primarily treated with interferon beta-1b, according to a study published online January 20 in JAMA Neurology. Researchers compared early and delayed interferon beta-1b treatment in 468 patients with clinically isolated syndrome, measuring serum levels of 25-hydroxyvitamin D (25[OH]D) at baseline and at six, 12, and 24 months. “A 50-nmol/L (20-ng/mL) increment in average serum 25(OH)D levels within the first 12 months predicted a 57% lower rate of new active lesions, 57% lower relapse rate, 25% lower yearly increase in T2 lesion volume, and 0.41% lower yearly loss in brain volume from months 12 to 60,” stated the study authors.

Excessive alcohol consumption in men was associated with faster cognitive decline, compared with light to moderate alcohol consumption, researchers reported online ahead of print January 15 in Neurology. The findings are based on data from 5,054 men and 2,099 women (mean age, 56) who had their alcohol consumption analyzed three times in the 10 years preceding the first cognitive assessment. In men, the investigators observed no differences in cognitive decline among alcohol abstainers, those who quit using alcohol, and light or moderate alcohol drinkers (<20 g/day). Alcohol consumption ≥36 g/day was associated with faster decline in all cognitive domains, compared with consumption between 0.1 and 19.9 g/day. In women, 10-year abstainers had a faster decline in the global cognitive score and executive function, compared with those drinking between 0.1 and 9.9 g/day of alcohol.

Vitamin D supplements may reduce pain in patients with fibromyalgia syndrome, according to a study in the February issue of Pain. The randomized controlled trial enrolled 30 women with fibromyalgia syndrome with serum calcifediol levels <32 ng/mL (80 nmol/L), in whom the goal was to achieve serum calcifediol levels between 32 and 48 ng/mL for 20 weeks with an oral cholecalciferol supplement. Re-evaluation was performed in both groups after an additional 24 weeks without cholecalciferol supplementation. The researchers observed a marked reduction in pain during the treatment period in those who received the supplement, and optimization of calcifediol levels had a positive effect on the perception of pain. “This economical therapy with a low side effect profile may well be considered in patients with fibromyalgia syndrome,” the researchers concluded.

A simple on-field blood test may help diagnose sports concussion. Relative and absolute increases in the astroglial protein, serum S100B, can accurately distinguish sports-related concussion from sports-related exertion, according to a study published online January 8 in PLOS One. Serum S100B was measured in 46 collegiate and semiprofessional contact sport athletes at preseason baseline, within three hours of injury, and at days 2, 3, and 7 post–sports-related concussion. Twenty-two athletes had a sports-related concussion, and 17 had S100B testing within three hours postinjury. The mean three-hour post–sports-related concussion S100B level was significantly higher than at preseason baseline, while the mean postexertion S100B level was not significantly different than that from the preseason baseline. S100B levels at postinjury days 2, 3, and 7 were significantly lower than at the three-hour level and were not different than at baseline.

Herpes zoster is an independent risk factor for vascular disease, particularly for stroke, transient ischemic attack, and myocardial infarction, in patients affected before age 40, researchers reported online ahead of print January 2 in Neurology. The findings are based on a retrospective cohort of 106,601 cases of herpes zoster and 213,202 controls from a general practice database in the United Kingdom. The investigators found that risk factors for vascular disease were significantly increased in patients with herpes zoster compared with controls. In addition, adjusted hazard ratios for TIA and myocardial infarction, but not stroke, were increased in all patients with herpes zoster. Stroke, TIA, and myocardial infarction were increased in cases in which herpes zoster occurred when the participants were younger than 40.

A study appearing January 22 online in Neurology found that a higher omega-3 index was correlated with larger total normal brain volume and hippocampal volume in postmenopausal women measured eight years later. Researchers assessed RBC eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and MRI brain volumes in 1,111 postmenopausal women from the Women’s Health Initiative Memory Study. In fully adjusted models, a 1-SD greater RBC EPA + DHA (omega-3 index) level was correlated with 2.1 cm3 larger brain volume. “DHA was marginally correlated with total brain volume while EPA was less so,” reported the investigators. In fully adjusted models, a 1-SD greater omega-3 index was correlated with greater hippocampal volume. “While normal aging results in overall brain atrophy, lower omega-3 index may signal increased risk of hippocampal atrophy,” wrote the investigators.

Exposure to DDT may increase the risk of developing Alzheimer’s disease, particularly in people older than 60, according to a study published online ahead of print January 27 in JAMA Neurology. Researchers examined the level of DDE, the chemical compound produced when DDT breaks down in the body, in the blood of 86 patients with Alzheimer’s disease and 79 controls. Blood levels of DDE were almost four times higher in 74 of the patients with Alzheimer’s disease than in the controls. Patients with APOE4, which greatly increases the risk of developing Alzheimer’s disease, and high blood levels of DDE exhibited more severe cognitive impairment than patients without the gene. In addition, DDT and DDE apparently increased the amount of a protein associated with plaques believed to be a hallmark of Alzheimer’s disease.

Mortality is higher among patients with multiple sclerosis (MS) than among Americans without the disease, according to research published online ahead of print December 26, 2013, in Multiple Sclerosis and Related Disorders. Investigators extracted records from a US commercial health insurance database—the OptumInsight Research database—for 30,402 patients with MS and 89,818 healthy comparators. Patient data were recorded from 1996 to 2009. Annual mortality rates were 899/100,000 among patients with MS and 446/100,000 among comparators. Standardized mortality ratio was 1.70 for patients with MS and 0.80 for the general US population. Kaplan–Meier analysis yielded a median survival from birth that was six years lower among patients with MS than among comparators. The six-year decrement in lifespan is consistent with a decrement found in recent research conducted in Canada, said the investigators.

Chronic obstructive pulmonary disease (COPD) may increase the risk of mild cognitive impairment (MCI), researchers reported in the November 2013 issue of Mayo Clinic Proceedings. The investigators evaluated 1,927 patients (ages 70 to 89) enrolled in the population-based Mayo Clinic Study of Aging. Participants received a nurse assessment, neurologic evaluation, and neuropsychologic testing. A consensus panel diagnosed MCI according to standardized criteria. COPD was identified by the review of medical records. A total of 288 patients had COPD. Prevalence of MCI was 27% among patients with COPD and 15% among patients without COPD. The odds ratio for MCI was 1.60 in patients who had had COPD for five years or fewer and 2.10 in patients who had had COPD for more than five years.

—Erik Greb and Colby Stong

Alcohol consumption may reduce the risk of developing multiple sclerosis (MS) and attenuate the effect of smoking, according to research published online ahead of print January 6 in JAMA Neurology. Scientists examined data from the Epidemiological Investigation of MS (EIMS), which included 745 cases and 1,761 controls, and from the Genes and Environment in MS (GEMS) study, which recruited 5,874 cases and 5,246 controls. In EIMS, women who reported high alcohol consumption (>112 g/week) had an odds ratio (OR) of 0.6 of developing MS, compared with nondrinking women. Men with high alcohol consumption (>168 g/week) in EIMS had an OR of 0.5, compared with nondrinking men. The OR for the comparison in GEMS was 0.7 for women and 0.7 for men. In both studies, the detrimental effect of smoking was more pronounced among nondrinkers.

A lentiviral vector-based gene therapy may be safe and improve motor behavior in patients with Parkinson’s disease, according to a study published online ahead of print January 10 in Lancet. In a phase I–II open-label trial, 15 patients received bilateral injections of gene therapy into the putamen and were followed up for 12 months. Participants received a low dose (1.9 × 107 transducing units [TU]), medium dose (4.0 × 107 TU), or a high dose (1 × 108 TU) of gene therapy. Patients reported 51 mild adverse events, three moderate adverse events, and no serious adverse events. The investigators noted a significant improvement in mean Unified Parkinson’s Disease Rating Scale part III motor scores off medication in all patients at six months, compared with baseline.

The FDA has approved a three-times-per-week formulation of Copaxone 40 mg/mL. The new formulation will enable a less-frequent dosing regimen to be administered subcutaneously to patients with relapsing forms of multiple sclerosis (MS). The approval is based on data from the Phase III Glatiramer Acetate Low-Frequency Administration study of more than 1,400 patients. In the trial, investigators found that a 40-mg/mL dose of Copaxone administered subcutaneously three times per week significantly reduced relapse rates at 12 months and demonstrated a favorable safety and tolerability profile in patients with relapsing-remitting MS. In addition to the newly approved dose, daily Copaxone 20 mg/mL will continue to be available. The daily subcutaneous injection was approved in 1996. Both formulations are manufactured by Teva Pharmaceutical Industries, which is headquartered in Jerusalem.

When administered with amitriptyline, cognitive behavioral therapy (CBT) may result in greater reductions in days with headache and in migraine-related disability among young persons with chronic migraine, compared with headache education, according to research published December 25, 2013, in JAMA. In a randomized clinical trial, 135 children (ages 10 to 17) with chronic migraine and a Pediatric Migraine Disability Assessment Score (PedMIDAS) greater than 20 points were assigned to CBT plus amitriptyline or headache education plus amitriptyline. At the 20-week end point, days with headache were reduced by 11.5 for the CBT plus amitriptyline group, compared with 6.8 for the headache education plus amitriptyline group. The PedMIDAS decreased by 52.7 points for the CBT group and by 38.6 points for the headache education group.

Low levels of vitamin D early in the course of multiple sclerosis (MS) are a strong risk factor for long-term disease activity and progression in patients who were primarily treated with interferon beta-1b, according to a study published online January 20 in JAMA Neurology. Researchers compared early and delayed interferon beta-1b treatment in 468 patients with clinically isolated syndrome, measuring serum levels of 25-hydroxyvitamin D (25[OH]D) at baseline and at six, 12, and 24 months. “A 50-nmol/L (20-ng/mL) increment in average serum 25(OH)D levels within the first 12 months predicted a 57% lower rate of new active lesions, 57% lower relapse rate, 25% lower yearly increase in T2 lesion volume, and 0.41% lower yearly loss in brain volume from months 12 to 60,” stated the study authors.

Excessive alcohol consumption in men was associated with faster cognitive decline, compared with light to moderate alcohol consumption, researchers reported online ahead of print January 15 in Neurology. The findings are based on data from 5,054 men and 2,099 women (mean age, 56) who had their alcohol consumption analyzed three times in the 10 years preceding the first cognitive assessment. In men, the investigators observed no differences in cognitive decline among alcohol abstainers, those who quit using alcohol, and light or moderate alcohol drinkers (<20 g/day). Alcohol consumption ≥36 g/day was associated with faster decline in all cognitive domains, compared with consumption between 0.1 and 19.9 g/day. In women, 10-year abstainers had a faster decline in the global cognitive score and executive function, compared with those drinking between 0.1 and 9.9 g/day of alcohol.

Vitamin D supplements may reduce pain in patients with fibromyalgia syndrome, according to a study in the February issue of Pain. The randomized controlled trial enrolled 30 women with fibromyalgia syndrome with serum calcifediol levels <32 ng/mL (80 nmol/L), in whom the goal was to achieve serum calcifediol levels between 32 and 48 ng/mL for 20 weeks with an oral cholecalciferol supplement. Re-evaluation was performed in both groups after an additional 24 weeks without cholecalciferol supplementation. The researchers observed a marked reduction in pain during the treatment period in those who received the supplement, and optimization of calcifediol levels had a positive effect on the perception of pain. “This economical therapy with a low side effect profile may well be considered in patients with fibromyalgia syndrome,” the researchers concluded.

A simple on-field blood test may help diagnose sports concussion. Relative and absolute increases in the astroglial protein, serum S100B, can accurately distinguish sports-related concussion from sports-related exertion, according to a study published online January 8 in PLOS One. Serum S100B was measured in 46 collegiate and semiprofessional contact sport athletes at preseason baseline, within three hours of injury, and at days 2, 3, and 7 post–sports-related concussion. Twenty-two athletes had a sports-related concussion, and 17 had S100B testing within three hours postinjury. The mean three-hour post–sports-related concussion S100B level was significantly higher than at preseason baseline, while the mean postexertion S100B level was not significantly different than that from the preseason baseline. S100B levels at postinjury days 2, 3, and 7 were significantly lower than at the three-hour level and were not different than at baseline.

Herpes zoster is an independent risk factor for vascular disease, particularly for stroke, transient ischemic attack, and myocardial infarction, in patients affected before age 40, researchers reported online ahead of print January 2 in Neurology. The findings are based on a retrospective cohort of 106,601 cases of herpes zoster and 213,202 controls from a general practice database in the United Kingdom. The investigators found that risk factors for vascular disease were significantly increased in patients with herpes zoster compared with controls. In addition, adjusted hazard ratios for TIA and myocardial infarction, but not stroke, were increased in all patients with herpes zoster. Stroke, TIA, and myocardial infarction were increased in cases in which herpes zoster occurred when the participants were younger than 40.

A study appearing January 22 online in Neurology found that a higher omega-3 index was correlated with larger total normal brain volume and hippocampal volume in postmenopausal women measured eight years later. Researchers assessed RBC eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and MRI brain volumes in 1,111 postmenopausal women from the Women’s Health Initiative Memory Study. In fully adjusted models, a 1-SD greater RBC EPA + DHA (omega-3 index) level was correlated with 2.1 cm3 larger brain volume. “DHA was marginally correlated with total brain volume while EPA was less so,” reported the investigators. In fully adjusted models, a 1-SD greater omega-3 index was correlated with greater hippocampal volume. “While normal aging results in overall brain atrophy, lower omega-3 index may signal increased risk of hippocampal atrophy,” wrote the investigators.

Exposure to DDT may increase the risk of developing Alzheimer’s disease, particularly in people older than 60, according to a study published online ahead of print January 27 in JAMA Neurology. Researchers examined the level of DDE, the chemical compound produced when DDT breaks down in the body, in the blood of 86 patients with Alzheimer’s disease and 79 controls. Blood levels of DDE were almost four times higher in 74 of the patients with Alzheimer’s disease than in the controls. Patients with APOE4, which greatly increases the risk of developing Alzheimer’s disease, and high blood levels of DDE exhibited more severe cognitive impairment than patients without the gene. In addition, DDT and DDE apparently increased the amount of a protein associated with plaques believed to be a hallmark of Alzheimer’s disease.

Mortality is higher among patients with multiple sclerosis (MS) than among Americans without the disease, according to research published online ahead of print December 26, 2013, in Multiple Sclerosis and Related Disorders. Investigators extracted records from a US commercial health insurance database—the OptumInsight Research database—for 30,402 patients with MS and 89,818 healthy comparators. Patient data were recorded from 1996 to 2009. Annual mortality rates were 899/100,000 among patients with MS and 446/100,000 among comparators. Standardized mortality ratio was 1.70 for patients with MS and 0.80 for the general US population. Kaplan–Meier analysis yielded a median survival from birth that was six years lower among patients with MS than among comparators. The six-year decrement in lifespan is consistent with a decrement found in recent research conducted in Canada, said the investigators.

Chronic obstructive pulmonary disease (COPD) may increase the risk of mild cognitive impairment (MCI), researchers reported in the November 2013 issue of Mayo Clinic Proceedings. The investigators evaluated 1,927 patients (ages 70 to 89) enrolled in the population-based Mayo Clinic Study of Aging. Participants received a nurse assessment, neurologic evaluation, and neuropsychologic testing. A consensus panel diagnosed MCI according to standardized criteria. COPD was identified by the review of medical records. A total of 288 patients had COPD. Prevalence of MCI was 27% among patients with COPD and 15% among patients without COPD. The odds ratio for MCI was 1.60 in patients who had had COPD for five years or fewer and 2.10 in patients who had had COPD for more than five years.

—Erik Greb and Colby Stong