Perioperative Medicine

ST. LOUIS – Vaginal cerclage, a novel surgical procedure for pelvic organ prolapse, is proving effective as a treatment option for severe and refractory prolapse in select patients.

Also known as introital cerclage, the procedure involves permanent suturing of the introitus, and is often performed in conjunction with vaginectomy. This obliterative approach is suitable only in those who are certain they no longer desire coital function, but on its own, vaginal cerclage also can serve as a bridge to nonobliterative repair, Dr. S. Robert Kovac and Dr. Carl W. Zimmerman said at an international pelvic reconstructive and vaginal surgery conference sponsored by the Society of Pelvic Reconstructive Surgeons.

Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery and director of the Emory Center for Reconstructive Pelvic Surgery at Emory University, Atlanta, used a video demonstration to show the surgical technique in an 82-year-old woman who had undergone two prior procedures for the treatment of prolapse, including a total abdominal hysterectomy followed by transvaginal repair with graft augmentation.

She presented with recurrent prolapse and complaints of vaginal bulge and discomfort, difficulty with voiding, and recurrent urinary tract infections.

A decision was made to perform vaginectomy augmented by the placement of a simple introital cerclage.

Dr. Kovac adequately infiltrated the introitus with 0.5% Marcaine with epinephrine, then used nonabsorbable braided sterile polyester suture beginning at the 12 o’clock position. The suture was placed away from the midurethra and closer to the bladder neck to decrease the risk of de novo stress urinary incontinence.

Suture placement continued in a circumferential manner toward the 6 o’clock position in several steps, ending at the 7 o’clock position to minimize discomfort. The suture ends were cut and tied down to obliterate the vagina and reduce the prolapse, and the ends were buried under the skin to decrease discomfort.

The same approach was used in a 77-year-old patient who had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy, as well as multiple prior prolapse repairs, including transvaginal repair with graft augmentation, a pubic bone sling, and transvaginal enterocele repair with graft augmentation and repeat enterocele repair with colpocleisis.

The patient presented with vaginal bulge, pressure, discharge, defecation dysfunction, and abdominal pain; she was diagnosed with stage IV vaginal vault prolapse. As in the first patient, vaginectomy was performed and augmented by vaginal cerclage. The patient’s vagina was obliterated, and her prolapse reduced with no change in urethral angle.

Both patients were doing well at 8 months’ follow-up, Dr. Kovac said.

Dr. Kovac, who argued that vaginal cerclage is superior to the “very outdated” LeFort colpocleisis procedure that’s used in patients with severe prolapse who still have their uterus, noted that the new technique also can be used as an intermediate procedure in certain patients awaiting nonobliterative prolapse repair.

For example, he described a patient with a significant prolapse who was unable to undergo surgery because of elevated creatinine. Vaginal cerclage allowed for temporary relief over the 8-9 days required for her creatinine levels to normalize.

“This approach provided improved comfort and quality of life, and reduced her hydronephrosis, which was causing the elevated creatinine, thus enabling her to undergo the full repair,” he said.

Similarly, Dr. Zimmerman, professor of obstetrics and gynecology at Vanderbilt University in Nashville, Tenn., described a patient who was preparing to undergo liver transplant and was found to have severe prolapse during a pelvic exam prior to surgery. Vaginal cerclage was used as a rescue procedure so that she could undergo the transplant surgery. The prolapse was reduced, the cerclage was placed, and the transplant was successful, he said.

Vaginal cerclage is a simple and “clever” procedure that can be accomplished in about 5 minutes, is reimbursed as a colpocleisis, and vastly improves patient comfort, Dr. Kovac said.

“It has great advantages, and we’re doing it routinely today on select patients who come in with recurrent prolapse after multiple attempts at correctional surgery – with excellent results.”

The availability of such a technique is important because, typically, the repair used for a failed colpocleisis is a repeat colpocleisis. Also, an increase in patients who seek treatment is anticipated, given that U.S. Census data indicate that the number of adults older than age 65 is expected to reach 90 million by 2050, and that 30%-50% of women experience prolapse in their lifetime, 11% undergo surgery for prolapse, and a third of prolapse and incontinence surgeries are for recurrent prolapse.

Improved techniques are needed, particularly in light of the high rate of repeat repairs, Dr. Kovac said.

Dr. Kovac disclosed that he is a consultant for Cook Medical Inc. and Ethicon Endo-Surgery Inc. Dr. Zimmerman is a speaker/proctor for Cook Medical, proctor for Boston Scientific Corp. and Covidien, and receives Royalties from Lumitex Inc. and Marina Medical Instruments Inc.

ST. LOUIS – Vaginal cerclage, a novel surgical procedure for pelvic organ prolapse, is proving effective as a treatment option for severe and refractory prolapse in select patients.

Also known as introital cerclage, the procedure involves permanent suturing of the introitus, and is often performed in conjunction with vaginectomy. This obliterative approach is suitable only in those who are certain they no longer desire coital function, but on its own, vaginal cerclage also can serve as a bridge to nonobliterative repair, Dr. S. Robert Kovac and Dr. Carl W. Zimmerman said at an international pelvic reconstructive and vaginal surgery conference sponsored by the Society of Pelvic Reconstructive Surgeons.

Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery and director of the Emory Center for Reconstructive Pelvic Surgery at Emory University, Atlanta, used a video demonstration to show the surgical technique in an 82-year-old woman who had undergone two prior procedures for the treatment of prolapse, including a total abdominal hysterectomy followed by transvaginal repair with graft augmentation.

She presented with recurrent prolapse and complaints of vaginal bulge and discomfort, difficulty with voiding, and recurrent urinary tract infections.

A decision was made to perform vaginectomy augmented by the placement of a simple introital cerclage.

Dr. Kovac adequately infiltrated the introitus with 0.5% Marcaine with epinephrine, then used nonabsorbable braided sterile polyester suture beginning at the 12 o’clock position. The suture was placed away from the midurethra and closer to the bladder neck to decrease the risk of de novo stress urinary incontinence.

Suture placement continued in a circumferential manner toward the 6 o’clock position in several steps, ending at the 7 o’clock position to minimize discomfort. The suture ends were cut and tied down to obliterate the vagina and reduce the prolapse, and the ends were buried under the skin to decrease discomfort.

The same approach was used in a 77-year-old patient who had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy, as well as multiple prior prolapse repairs, including transvaginal repair with graft augmentation, a pubic bone sling, and transvaginal enterocele repair with graft augmentation and repeat enterocele repair with colpocleisis.

The patient presented with vaginal bulge, pressure, discharge, defecation dysfunction, and abdominal pain; she was diagnosed with stage IV vaginal vault prolapse. As in the first patient, vaginectomy was performed and augmented by vaginal cerclage. The patient’s vagina was obliterated, and her prolapse reduced with no change in urethral angle.

Both patients were doing well at 8 months’ follow-up, Dr. Kovac said.

Dr. Kovac, who argued that vaginal cerclage is superior to the “very outdated” LeFort colpocleisis procedure that’s used in patients with severe prolapse who still have their uterus, noted that the new technique also can be used as an intermediate procedure in certain patients awaiting nonobliterative prolapse repair.

For example, he described a patient with a significant prolapse who was unable to undergo surgery because of elevated creatinine. Vaginal cerclage allowed for temporary relief over the 8-9 days required for her creatinine levels to normalize.

“This approach provided improved comfort and quality of life, and reduced her hydronephrosis, which was causing the elevated creatinine, thus enabling her to undergo the full repair,” he said.

Similarly, Dr. Zimmerman, professor of obstetrics and gynecology at Vanderbilt University in Nashville, Tenn., described a patient who was preparing to undergo liver transplant and was found to have severe prolapse during a pelvic exam prior to surgery. Vaginal cerclage was used as a rescue procedure so that she could undergo the transplant surgery. The prolapse was reduced, the cerclage was placed, and the transplant was successful, he said.

Vaginal cerclage is a simple and “clever” procedure that can be accomplished in about 5 minutes, is reimbursed as a colpocleisis, and vastly improves patient comfort, Dr. Kovac said.

“It has great advantages, and we’re doing it routinely today on select patients who come in with recurrent prolapse after multiple attempts at correctional surgery – with excellent results.”

The availability of such a technique is important because, typically, the repair used for a failed colpocleisis is a repeat colpocleisis. Also, an increase in patients who seek treatment is anticipated, given that U.S. Census data indicate that the number of adults older than age 65 is expected to reach 90 million by 2050, and that 30%-50% of women experience prolapse in their lifetime, 11% undergo surgery for prolapse, and a third of prolapse and incontinence surgeries are for recurrent prolapse.

Improved techniques are needed, particularly in light of the high rate of repeat repairs, Dr. Kovac said.

Dr. Kovac disclosed that he is a consultant for Cook Medical Inc. and Ethicon Endo-Surgery Inc. Dr. Zimmerman is a speaker/proctor for Cook Medical, proctor for Boston Scientific Corp. and Covidien, and receives Royalties from Lumitex Inc. and Marina Medical Instruments Inc.

ST. LOUIS – Vaginal cerclage, a novel surgical procedure for pelvic organ prolapse, is proving effective as a treatment option for severe and refractory prolapse in select patients.

Also known as introital cerclage, the procedure involves permanent suturing of the introitus, and is often performed in conjunction with vaginectomy. This obliterative approach is suitable only in those who are certain they no longer desire coital function, but on its own, vaginal cerclage also can serve as a bridge to nonobliterative repair, Dr. S. Robert Kovac and Dr. Carl W. Zimmerman said at an international pelvic reconstructive and vaginal surgery conference sponsored by the Society of Pelvic Reconstructive Surgeons.

Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery and director of the Emory Center for Reconstructive Pelvic Surgery at Emory University, Atlanta, used a video demonstration to show the surgical technique in an 82-year-old woman who had undergone two prior procedures for the treatment of prolapse, including a total abdominal hysterectomy followed by transvaginal repair with graft augmentation.

She presented with recurrent prolapse and complaints of vaginal bulge and discomfort, difficulty with voiding, and recurrent urinary tract infections.

A decision was made to perform vaginectomy augmented by the placement of a simple introital cerclage.

Dr. Kovac adequately infiltrated the introitus with 0.5% Marcaine with epinephrine, then used nonabsorbable braided sterile polyester suture beginning at the 12 o’clock position. The suture was placed away from the midurethra and closer to the bladder neck to decrease the risk of de novo stress urinary incontinence.

Suture placement continued in a circumferential manner toward the 6 o’clock position in several steps, ending at the 7 o’clock position to minimize discomfort. The suture ends were cut and tied down to obliterate the vagina and reduce the prolapse, and the ends were buried under the skin to decrease discomfort.

The same approach was used in a 77-year-old patient who had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy, as well as multiple prior prolapse repairs, including transvaginal repair with graft augmentation, a pubic bone sling, and transvaginal enterocele repair with graft augmentation and repeat enterocele repair with colpocleisis.

The patient presented with vaginal bulge, pressure, discharge, defecation dysfunction, and abdominal pain; she was diagnosed with stage IV vaginal vault prolapse. As in the first patient, vaginectomy was performed and augmented by vaginal cerclage. The patient’s vagina was obliterated, and her prolapse reduced with no change in urethral angle.

Both patients were doing well at 8 months’ follow-up, Dr. Kovac said.

Dr. Kovac, who argued that vaginal cerclage is superior to the “very outdated” LeFort colpocleisis procedure that’s used in patients with severe prolapse who still have their uterus, noted that the new technique also can be used as an intermediate procedure in certain patients awaiting nonobliterative prolapse repair.

For example, he described a patient with a significant prolapse who was unable to undergo surgery because of elevated creatinine. Vaginal cerclage allowed for temporary relief over the 8-9 days required for her creatinine levels to normalize.

“This approach provided improved comfort and quality of life, and reduced her hydronephrosis, which was causing the elevated creatinine, thus enabling her to undergo the full repair,” he said.

Similarly, Dr. Zimmerman, professor of obstetrics and gynecology at Vanderbilt University in Nashville, Tenn., described a patient who was preparing to undergo liver transplant and was found to have severe prolapse during a pelvic exam prior to surgery. Vaginal cerclage was used as a rescue procedure so that she could undergo the transplant surgery. The prolapse was reduced, the cerclage was placed, and the transplant was successful, he said.

Vaginal cerclage is a simple and “clever” procedure that can be accomplished in about 5 minutes, is reimbursed as a colpocleisis, and vastly improves patient comfort, Dr. Kovac said.

“It has great advantages, and we’re doing it routinely today on select patients who come in with recurrent prolapse after multiple attempts at correctional surgery – with excellent results.”

The availability of such a technique is important because, typically, the repair used for a failed colpocleisis is a repeat colpocleisis. Also, an increase in patients who seek treatment is anticipated, given that U.S. Census data indicate that the number of adults older than age 65 is expected to reach 90 million by 2050, and that 30%-50% of women experience prolapse in their lifetime, 11% undergo surgery for prolapse, and a third of prolapse and incontinence surgeries are for recurrent prolapse.

Improved techniques are needed, particularly in light of the high rate of repeat repairs, Dr. Kovac said.

Dr. Kovac disclosed that he is a consultant for Cook Medical Inc. and Ethicon Endo-Surgery Inc. Dr. Zimmerman is a speaker/proctor for Cook Medical, proctor for Boston Scientific Corp. and Covidien, and receives Royalties from Lumitex Inc. and Marina Medical Instruments Inc.

The rates of sepsis and septic shock following general surgery are so excessive that identifying high-risk patients and screening them at 12-hour intervals for signs and symptoms may be warranted, according to a report.

An analysis of data on more than 360,000 general surgery patients showed that those at highest risk are older than 60 years of age, undergo emergency rather than elective surgery, and have a major comorbidity. The findings suggest that patients with any of these three risk factors “warrant a high index of suspicion…and that this patient population would most likely benefit from mandatory sepsis screening,” said Dr. Laura J. Moore and her associates at Methodist Hospital, Houston.

To date, programs to limit perioperative complications have focused on prevention plus early recognition and treatment of thromboembolism, surgery-related MI, and surgical site infections. These efforts have produced a significant decline in all three complications and in related mortality.

But the incidences of postoperative sepsis and septic shock have remained alarmingly high—far greater than those of thromboembolism and MI—and the associated mortality also remains excessively high (50%).

To characterize the severity and extent of postoperative sepsis and septic shock, Dr. Moore and her colleagues analyzed information that had been collected prospectively in the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) database. They examined data on 363,897 patients treated at 121 academic and community hospitals in 2005-2007.

A total of 8,350 patients (2.3%) developed sepsis, and 5,977 (1.6%) developed septic shock following general surgery. In comparison, pulmonary embolism developed in 0.3% and MI in 0.2%.

The development of sepsis raised the rate of 30-day mortality fourfold, whereas septic shock raised it 33-fold, the researchers said (Arch. Surg. 2010;145:695-700).

“Septic shock occurs 10 times more frequently than MI and has the same mortality rate; thus, it kills 10 times more people,” they said. “Therefore, our level of vigilance in identifying sepsis and septic shock needs to mimic, if not surpass, our vigilance for identifying MI and PE.”

Because closer monitoring of all surgical patients for signs and symptoms of sepsis is not realistic, it should be limited to those at highest risk. In this analysis, the percentage of patients older than age 60 was only 40% in the overall study group, compared with 52% in the group that developed sepsis and 70% in the group that developed septic shock.

The rate of sepsis was only 2% and that of septic shock was only 1% in patients undergoing elective procedures, compared with rates of approximately 5% for both sepsis and septic shock in patients undergoing emergency procedures.

Finally, approximately 90% of patients who developed sepsis and 97% of those who developed septic shock had at least one major comorbidity, compared with only 70% of those who did not develop sepsis. “The presence of any of the NSQIP–documented comorbidities increased the odds of developing sepsis or septic shock by sixfold” and raised the 30-day mortality by 22-fold, Dr. Moore said.

They found that clinicians at Methodist did not always accurately identify sepsis at the bedside in the most timely way. “A distinct window of early intervention exists in which the septic source must be eliminated and physiologic derangements corrected,” the investigators said.

The hospital implemented a program in which patients with any of these risk factors were screened every 12 hours for heart rate, white blood cell count, temperature, and respiratory rate. The program decreased sepsis-related mortality.

Disclosures: This study was supported by the Methodist Hospital Research Institute, Houston. No disclosures were reported.

The rates of sepsis and septic shock following general surgery are so excessive that identifying high-risk patients and screening them at 12-hour intervals for signs and symptoms may be warranted, according to a report.

An analysis of data on more than 360,000 general surgery patients showed that those at highest risk are older than 60 years of age, undergo emergency rather than elective surgery, and have a major comorbidity. The findings suggest that patients with any of these three risk factors “warrant a high index of suspicion…and that this patient population would most likely benefit from mandatory sepsis screening,” said Dr. Laura J. Moore and her associates at Methodist Hospital, Houston.

To date, programs to limit perioperative complications have focused on prevention plus early recognition and treatment of thromboembolism, surgery-related MI, and surgical site infections. These efforts have produced a significant decline in all three complications and in related mortality.

But the incidences of postoperative sepsis and septic shock have remained alarmingly high—far greater than those of thromboembolism and MI—and the associated mortality also remains excessively high (50%).

To characterize the severity and extent of postoperative sepsis and septic shock, Dr. Moore and her colleagues analyzed information that had been collected prospectively in the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) database. They examined data on 363,897 patients treated at 121 academic and community hospitals in 2005-2007.

A total of 8,350 patients (2.3%) developed sepsis, and 5,977 (1.6%) developed septic shock following general surgery. In comparison, pulmonary embolism developed in 0.3% and MI in 0.2%.

The development of sepsis raised the rate of 30-day mortality fourfold, whereas septic shock raised it 33-fold, the researchers said (Arch. Surg. 2010;145:695-700).

“Septic shock occurs 10 times more frequently than MI and has the same mortality rate; thus, it kills 10 times more people,” they said. “Therefore, our level of vigilance in identifying sepsis and septic shock needs to mimic, if not surpass, our vigilance for identifying MI and PE.”

Because closer monitoring of all surgical patients for signs and symptoms of sepsis is not realistic, it should be limited to those at highest risk. In this analysis, the percentage of patients older than age 60 was only 40% in the overall study group, compared with 52% in the group that developed sepsis and 70% in the group that developed septic shock.

The rate of sepsis was only 2% and that of septic shock was only 1% in patients undergoing elective procedures, compared with rates of approximately 5% for both sepsis and septic shock in patients undergoing emergency procedures.

Finally, approximately 90% of patients who developed sepsis and 97% of those who developed septic shock had at least one major comorbidity, compared with only 70% of those who did not develop sepsis. “The presence of any of the NSQIP–documented comorbidities increased the odds of developing sepsis or septic shock by sixfold” and raised the 30-day mortality by 22-fold, Dr. Moore said.

They found that clinicians at Methodist did not always accurately identify sepsis at the bedside in the most timely way. “A distinct window of early intervention exists in which the septic source must be eliminated and physiologic derangements corrected,” the investigators said.

The hospital implemented a program in which patients with any of these risk factors were screened every 12 hours for heart rate, white blood cell count, temperature, and respiratory rate. The program decreased sepsis-related mortality.

Disclosures: This study was supported by the Methodist Hospital Research Institute, Houston. No disclosures were reported.

The rates of sepsis and septic shock following general surgery are so excessive that identifying high-risk patients and screening them at 12-hour intervals for signs and symptoms may be warranted, according to a report.

An analysis of data on more than 360,000 general surgery patients showed that those at highest risk are older than 60 years of age, undergo emergency rather than elective surgery, and have a major comorbidity. The findings suggest that patients with any of these three risk factors “warrant a high index of suspicion…and that this patient population would most likely benefit from mandatory sepsis screening,” said Dr. Laura J. Moore and her associates at Methodist Hospital, Houston.

To date, programs to limit perioperative complications have focused on prevention plus early recognition and treatment of thromboembolism, surgery-related MI, and surgical site infections. These efforts have produced a significant decline in all three complications and in related mortality.

But the incidences of postoperative sepsis and septic shock have remained alarmingly high—far greater than those of thromboembolism and MI—and the associated mortality also remains excessively high (50%).

To characterize the severity and extent of postoperative sepsis and septic shock, Dr. Moore and her colleagues analyzed information that had been collected prospectively in the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) database. They examined data on 363,897 patients treated at 121 academic and community hospitals in 2005-2007.

A total of 8,350 patients (2.3%) developed sepsis, and 5,977 (1.6%) developed septic shock following general surgery. In comparison, pulmonary embolism developed in 0.3% and MI in 0.2%.

The development of sepsis raised the rate of 30-day mortality fourfold, whereas septic shock raised it 33-fold, the researchers said (Arch. Surg. 2010;145:695-700).

“Septic shock occurs 10 times more frequently than MI and has the same mortality rate; thus, it kills 10 times more people,” they said. “Therefore, our level of vigilance in identifying sepsis and septic shock needs to mimic, if not surpass, our vigilance for identifying MI and PE.”

Because closer monitoring of all surgical patients for signs and symptoms of sepsis is not realistic, it should be limited to those at highest risk. In this analysis, the percentage of patients older than age 60 was only 40% in the overall study group, compared with 52% in the group that developed sepsis and 70% in the group that developed septic shock.

The rate of sepsis was only 2% and that of septic shock was only 1% in patients undergoing elective procedures, compared with rates of approximately 5% for both sepsis and septic shock in patients undergoing emergency procedures.

Finally, approximately 90% of patients who developed sepsis and 97% of those who developed septic shock had at least one major comorbidity, compared with only 70% of those who did not develop sepsis. “The presence of any of the NSQIP–documented comorbidities increased the odds of developing sepsis or septic shock by sixfold” and raised the 30-day mortality by 22-fold, Dr. Moore said.

They found that clinicians at Methodist did not always accurately identify sepsis at the bedside in the most timely way. “A distinct window of early intervention exists in which the septic source must be eliminated and physiologic derangements corrected,” the investigators said.

The hospital implemented a program in which patients with any of these risk factors were screened every 12 hours for heart rate, white blood cell count, temperature, and respiratory rate. The program decreased sepsis-related mortality.

Disclosures: This study was supported by the Methodist Hospital Research Institute, Houston. No disclosures were reported.

MINNEAPOLIS — The use of oral antibiotics along with mechanical bowel preparation before colon resection significantly reduced the number of superficial surgical site infections, compared with the use of mechanical bowel preparation alone, according to the results of a retrospective study of 227 patients.

Superficial surgical site infections occurred in 3% of patients who were given oral antibiotics along with mechanical bowel preparation (MBP) vs. 11% of those who had MBP alone. There were also trends toward fewer deep surgical site infections, organ space surgical site infections, and anastomotic leaks, Dr. Khaled El-Badawi reported at the meeting.

The researchers performed a retrospective review of all elective segmental colon resections performed between 2007 and 2009. Patients were grouped by whether oral antibiotics had been used in conjunction with MBP. A total of 125 patients underwent MBP alone and 102 underwent MBP with oral antibiotics.

All patients were restricted to a clear liquid diet for at least 24 hours prior to surgery, and were also given 20 mg of bisacodyl and polyethylene glycol. Patients in the antibiotic group also received three doses of 1 g neomycin and 750 mg metronidazole on the day before surgery. Within 1 hour of surgical incision, all patients received 1 g ertapenem.

Dr. El-Badawi, who is a surgical resident at Grand Rapids Medical Education Partners in Michigan, noted that there was a significant difference between the two groups in terms of operative time: 154 minutes for the MBP-alone group vs. 125 minutes for the antibiotics and MBP group.

Disclosures: Dr. El-Badawi reported that he had no relevant financial relationships.

MINNEAPOLIS — The use of oral antibiotics along with mechanical bowel preparation before colon resection significantly reduced the number of superficial surgical site infections, compared with the use of mechanical bowel preparation alone, according to the results of a retrospective study of 227 patients.

Superficial surgical site infections occurred in 3% of patients who were given oral antibiotics along with mechanical bowel preparation (MBP) vs. 11% of those who had MBP alone. There were also trends toward fewer deep surgical site infections, organ space surgical site infections, and anastomotic leaks, Dr. Khaled El-Badawi reported at the meeting.

The researchers performed a retrospective review of all elective segmental colon resections performed between 2007 and 2009. Patients were grouped by whether oral antibiotics had been used in conjunction with MBP. A total of 125 patients underwent MBP alone and 102 underwent MBP with oral antibiotics.

All patients were restricted to a clear liquid diet for at least 24 hours prior to surgery, and were also given 20 mg of bisacodyl and polyethylene glycol. Patients in the antibiotic group also received three doses of 1 g neomycin and 750 mg metronidazole on the day before surgery. Within 1 hour of surgical incision, all patients received 1 g ertapenem.

Dr. El-Badawi, who is a surgical resident at Grand Rapids Medical Education Partners in Michigan, noted that there was a significant difference between the two groups in terms of operative time: 154 minutes for the MBP-alone group vs. 125 minutes for the antibiotics and MBP group.

Disclosures: Dr. El-Badawi reported that he had no relevant financial relationships.

MINNEAPOLIS — The use of oral antibiotics along with mechanical bowel preparation before colon resection significantly reduced the number of superficial surgical site infections, compared with the use of mechanical bowel preparation alone, according to the results of a retrospective study of 227 patients.

Superficial surgical site infections occurred in 3% of patients who were given oral antibiotics along with mechanical bowel preparation (MBP) vs. 11% of those who had MBP alone. There were also trends toward fewer deep surgical site infections, organ space surgical site infections, and anastomotic leaks, Dr. Khaled El-Badawi reported at the meeting.

The researchers performed a retrospective review of all elective segmental colon resections performed between 2007 and 2009. Patients were grouped by whether oral antibiotics had been used in conjunction with MBP. A total of 125 patients underwent MBP alone and 102 underwent MBP with oral antibiotics.

All patients were restricted to a clear liquid diet for at least 24 hours prior to surgery, and were also given 20 mg of bisacodyl and polyethylene glycol. Patients in the antibiotic group also received three doses of 1 g neomycin and 750 mg metronidazole on the day before surgery. Within 1 hour of surgical incision, all patients received 1 g ertapenem.

Dr. El-Badawi, who is a surgical resident at Grand Rapids Medical Education Partners in Michigan, noted that there was a significant difference between the two groups in terms of operative time: 154 minutes for the MBP-alone group vs. 125 minutes for the antibiotics and MBP group.

Disclosures: Dr. El-Badawi reported that he had no relevant financial relationships.

Major Finding: Gel treatment of intraoperative air leaks during lung surgery led to a 42% rate of freedom from air leaks during hospitalization compared with a 31% rate in control patients, a difference that was not statistically significant.

Data Source: Multicenter, randomized controlled study with 121 patients undergoing lung surgery.

Disclosures: The study was sponsored by Covidien, the company that markets the tested gel. Dr. De Leyn said that he has been a consultant to Covidien.

TORONTO — A synthetic, absorbable gel designed to seal lung air leaks following lobectomy failed to produce a significant drop in all grades of air leaks during post-operative hospitalization in a randomized, multicenter study with 121 patients.

However, treatment with the gel significantly reduced the number of advanced, grade II and III air leaks compared with control patients in a post-hoc analysis that involved about two-thirds of the study's patients, Dr. Paul De Leyn said at the annual meeting.

This experience has guided Dr. De Leyn's use of the gel, PleuraSeal. “I use [the gel] in patients with a severe, grade II or III air leak,” said Dr. De Leyn, a professor of thoracic surgery at University Hospital, Leuven, Belgium.

PleuraSeal applies to tissue surfaces as two separate liquids, a polyethylene glycol ester solution, and a trilysine amine solution. When mixed, the liquids form an absorbable hydrogel that adheres to the pleura surface, and then gradually absorbs over 4-8 weeks.

The study enrolled patients who developed intraoperative air leaks following lobectomy or segmentectomy at any of seven academic, tertiary thoracic units in five European countries. Randomization assigned patients to standard care or standard care plus application of the gel.

The 62 patients randomized to the gel group averaged 62 years, 98% underwent a lobectomy, and all had surgery for lung cancer. The 59 patients in the control group averaged 63 years, 98% underwent a lobectomy, and 97% had surgery for lung cancer.

The study design stratified patients by their risk scores, based on a combination of preoperative and intraoperative features, such as the patients' forced expiratory volume, whether they received preoperative chemo- or radiotherapy, and their number of leak sites.

High-risk patients made up 18% of the gel group and 10% of the control group. The air-leak grade before treatment averaged 2.4 in the control patients and 2.8 in the gel patients. After, the grades averaged 2.0 in the control patients and 0.4 in the gel-treated patients.

During the intraoperative period, gel treatment controlled all air leaks in 71% of patients, compared with 24% of control patients whose air leaks resolved, a statistically significant difference.

However, during the balance of their hospitalization, patients free from air leaks reached 31% in the control group and 42% in the gel-treated group, a difference that was not statistically significant for the study's primary end point.

Among the patients who began with grade II or grade III air leaks, 15% of the control patients and 44% of the gel-treated patients remained air leak free during hospitalization, a significant difference. Among patients with grade I air leaks, 50% of controls and 38% of the gel-treated patients remained air leak free during hospitalization, a nonsignificant difference.

There were no differences in air leak duration, time needed for chest-tube drainage, amount of fluid removed via chest tubes, total duration of hospitalization, or complication rate.

No patient died while hospitalized, and none had an adverse event attributable to gel, including no effects on liver or kidney function, lung expansion or pneumothorax.

Major Finding: Gel treatment of intraoperative air leaks during lung surgery led to a 42% rate of freedom from air leaks during hospitalization compared with a 31% rate in control patients, a difference that was not statistically significant.

Data Source: Multicenter, randomized controlled study with 121 patients undergoing lung surgery.

Disclosures: The study was sponsored by Covidien, the company that markets the tested gel. Dr. De Leyn said that he has been a consultant to Covidien.

TORONTO — A synthetic, absorbable gel designed to seal lung air leaks following lobectomy failed to produce a significant drop in all grades of air leaks during post-operative hospitalization in a randomized, multicenter study with 121 patients.

However, treatment with the gel significantly reduced the number of advanced, grade II and III air leaks compared with control patients in a post-hoc analysis that involved about two-thirds of the study's patients, Dr. Paul De Leyn said at the annual meeting.

This experience has guided Dr. De Leyn's use of the gel, PleuraSeal. “I use [the gel] in patients with a severe, grade II or III air leak,” said Dr. De Leyn, a professor of thoracic surgery at University Hospital, Leuven, Belgium.

PleuraSeal applies to tissue surfaces as two separate liquids, a polyethylene glycol ester solution, and a trilysine amine solution. When mixed, the liquids form an absorbable hydrogel that adheres to the pleura surface, and then gradually absorbs over 4-8 weeks.

The study enrolled patients who developed intraoperative air leaks following lobectomy or segmentectomy at any of seven academic, tertiary thoracic units in five European countries. Randomization assigned patients to standard care or standard care plus application of the gel.

The 62 patients randomized to the gel group averaged 62 years, 98% underwent a lobectomy, and all had surgery for lung cancer. The 59 patients in the control group averaged 63 years, 98% underwent a lobectomy, and 97% had surgery for lung cancer.

The study design stratified patients by their risk scores, based on a combination of preoperative and intraoperative features, such as the patients' forced expiratory volume, whether they received preoperative chemo- or radiotherapy, and their number of leak sites.

High-risk patients made up 18% of the gel group and 10% of the control group. The air-leak grade before treatment averaged 2.4 in the control patients and 2.8 in the gel patients. After, the grades averaged 2.0 in the control patients and 0.4 in the gel-treated patients.

During the intraoperative period, gel treatment controlled all air leaks in 71% of patients, compared with 24% of control patients whose air leaks resolved, a statistically significant difference.

However, during the balance of their hospitalization, patients free from air leaks reached 31% in the control group and 42% in the gel-treated group, a difference that was not statistically significant for the study's primary end point.

Among the patients who began with grade II or grade III air leaks, 15% of the control patients and 44% of the gel-treated patients remained air leak free during hospitalization, a significant difference. Among patients with grade I air leaks, 50% of controls and 38% of the gel-treated patients remained air leak free during hospitalization, a nonsignificant difference.

There were no differences in air leak duration, time needed for chest-tube drainage, amount of fluid removed via chest tubes, total duration of hospitalization, or complication rate.

No patient died while hospitalized, and none had an adverse event attributable to gel, including no effects on liver or kidney function, lung expansion or pneumothorax.

Major Finding: Gel treatment of intraoperative air leaks during lung surgery led to a 42% rate of freedom from air leaks during hospitalization compared with a 31% rate in control patients, a difference that was not statistically significant.

Data Source: Multicenter, randomized controlled study with 121 patients undergoing lung surgery.

Disclosures: The study was sponsored by Covidien, the company that markets the tested gel. Dr. De Leyn said that he has been a consultant to Covidien.

TORONTO — A synthetic, absorbable gel designed to seal lung air leaks following lobectomy failed to produce a significant drop in all grades of air leaks during post-operative hospitalization in a randomized, multicenter study with 121 patients.

However, treatment with the gel significantly reduced the number of advanced, grade II and III air leaks compared with control patients in a post-hoc analysis that involved about two-thirds of the study's patients, Dr. Paul De Leyn said at the annual meeting.

This experience has guided Dr. De Leyn's use of the gel, PleuraSeal. “I use [the gel] in patients with a severe, grade II or III air leak,” said Dr. De Leyn, a professor of thoracic surgery at University Hospital, Leuven, Belgium.

PleuraSeal applies to tissue surfaces as two separate liquids, a polyethylene glycol ester solution, and a trilysine amine solution. When mixed, the liquids form an absorbable hydrogel that adheres to the pleura surface, and then gradually absorbs over 4-8 weeks.

The study enrolled patients who developed intraoperative air leaks following lobectomy or segmentectomy at any of seven academic, tertiary thoracic units in five European countries. Randomization assigned patients to standard care or standard care plus application of the gel.

The 62 patients randomized to the gel group averaged 62 years, 98% underwent a lobectomy, and all had surgery for lung cancer. The 59 patients in the control group averaged 63 years, 98% underwent a lobectomy, and 97% had surgery for lung cancer.

The study design stratified patients by their risk scores, based on a combination of preoperative and intraoperative features, such as the patients' forced expiratory volume, whether they received preoperative chemo- or radiotherapy, and their number of leak sites.

High-risk patients made up 18% of the gel group and 10% of the control group. The air-leak grade before treatment averaged 2.4 in the control patients and 2.8 in the gel patients. After, the grades averaged 2.0 in the control patients and 0.4 in the gel-treated patients.

During the intraoperative period, gel treatment controlled all air leaks in 71% of patients, compared with 24% of control patients whose air leaks resolved, a statistically significant difference.

However, during the balance of their hospitalization, patients free from air leaks reached 31% in the control group and 42% in the gel-treated group, a difference that was not statistically significant for the study's primary end point.

Among the patients who began with grade II or grade III air leaks, 15% of the control patients and 44% of the gel-treated patients remained air leak free during hospitalization, a significant difference. Among patients with grade I air leaks, 50% of controls and 38% of the gel-treated patients remained air leak free during hospitalization, a nonsignificant difference.

There were no differences in air leak duration, time needed for chest-tube drainage, amount of fluid removed via chest tubes, total duration of hospitalization, or complication rate.

No patient died while hospitalized, and none had an adverse event attributable to gel, including no effects on liver or kidney function, lung expansion or pneumothorax.

Major Finding: The postsurgical infection rate for patients who had surgery on the day they were admitted was 5.7% in CABG patients vs. 18.2% in those who waited 6-10 days. The corresponding rates were 8.4% vs. 21.6% in lung resection patients, and 10.2% vs. 20.6% in colon resection patients.

Data Source: Retrospective study of 163,000 elective-surgery patients from the Nationwide Inpatient Sample during 2003-2007.

Disclosures: Dr. Vogel reported no disclosures.

LAS VEGAS — The longer elective-surgery patients were hospitalized before their operation, the greater their risk of developing an infection postoperatively, according to a review of 163,000 patients.

Elective-admission patients hospitalized for just 1 day before their surgery had a significant 20%-50% increased risk of subsequent infection, compared with patients whose surgery took place the same day as their hospital admission, Dr. Todd R. Vogel reported.

Patients hospitalized for 6-10 days before surgery had a greater than twofold increased risk, said Dr. Vogel, a vascular surgeon at the Robert Wood Johnson Medical School, New Brunswick, N.J.

The data suggest it would be better to send patients home to await the day of their planned surgery than to keep them in the hospital until their slot on the schedule opens, he added.

Another possible explanation is that many of the delayed cases weren't really elective. “I think there were reasons for the delay that you can't pick out of your administrative database,” said Dr. E. Patchen Dellinger, professor and chief of the division of general surgery at the University of Washington, Seattle.

But Dr. Vogel pointed out that hospitals would want to “upcode” cases that were not elective because they would be paid more.

He and his associates used data collected during 2003-2007 in the Nationwide Inpatient Sample on elective admissions for three types of surgery: 87,318 for CABG, 46,728 for colon resection, and 28,960 for lung resection. Patients were aged 50-79 years. Nearly two-thirds were men, and 84% were white. The infectious complications analyzed included pneumonia, urinary tract infection, sepsis, and surgical site infections.

Patients undergoing CABG had the highest rate of delays between admission and surgery, with 53% having their surgery on the same day of admission, compared with 79% of colon resection patients and 94% of lung resection patients. Another 23% of the CABG patients had a 1-day delay, 21% had a 2-5 day delay, and 3% had their surgery 6-10 days after admission. In the colon resection group, 13% had a 1-day delay, 7% waited 2-5 days, and 2% waited 6-10 days. Among those having lung resection, 3% waited 1 day, 2% waited 2-5 days, and 1% waited 6-10 days.

The postsurgical infection rate for patients who had surgery on the day they were admitted was 5.7% in the CABG patients, 8.4% in the lung resection patients, and 10.2% in the colon resection patients. The rates increased for each incremental delay. Among patients whose surgery was performed 6-10 days after admission, postsurgical infection rates were 18.2% for CABG, 21.6% for lung resection, and 20.6% for colon resection.

Adjusted multivariate analysis showed that all delay durations led to significantly greater infection rates relative to no delay, for all three operations analyzed. (See box.)

Analysis further documented that in-hospital delays before surgery were linked to higher hospital costs, Dr. Vogel said.

Vitals

Source Elsevier Global Medical News

Major Finding: The postsurgical infection rate for patients who had surgery on the day they were admitted was 5.7% in CABG patients vs. 18.2% in those who waited 6-10 days. The corresponding rates were 8.4% vs. 21.6% in lung resection patients, and 10.2% vs. 20.6% in colon resection patients.

Data Source: Retrospective study of 163,000 elective-surgery patients from the Nationwide Inpatient Sample during 2003-2007.

Disclosures: Dr. Vogel reported no disclosures.

LAS VEGAS — The longer elective-surgery patients were hospitalized before their operation, the greater their risk of developing an infection postoperatively, according to a review of 163,000 patients.

Elective-admission patients hospitalized for just 1 day before their surgery had a significant 20%-50% increased risk of subsequent infection, compared with patients whose surgery took place the same day as their hospital admission, Dr. Todd R. Vogel reported.

Patients hospitalized for 6-10 days before surgery had a greater than twofold increased risk, said Dr. Vogel, a vascular surgeon at the Robert Wood Johnson Medical School, New Brunswick, N.J.

The data suggest it would be better to send patients home to await the day of their planned surgery than to keep them in the hospital until their slot on the schedule opens, he added.

Another possible explanation is that many of the delayed cases weren't really elective. “I think there were reasons for the delay that you can't pick out of your administrative database,” said Dr. E. Patchen Dellinger, professor and chief of the division of general surgery at the University of Washington, Seattle.

But Dr. Vogel pointed out that hospitals would want to “upcode” cases that were not elective because they would be paid more.

He and his associates used data collected during 2003-2007 in the Nationwide Inpatient Sample on elective admissions for three types of surgery: 87,318 for CABG, 46,728 for colon resection, and 28,960 for lung resection. Patients were aged 50-79 years. Nearly two-thirds were men, and 84% were white. The infectious complications analyzed included pneumonia, urinary tract infection, sepsis, and surgical site infections.

Patients undergoing CABG had the highest rate of delays between admission and surgery, with 53% having their surgery on the same day of admission, compared with 79% of colon resection patients and 94% of lung resection patients. Another 23% of the CABG patients had a 1-day delay, 21% had a 2-5 day delay, and 3% had their surgery 6-10 days after admission. In the colon resection group, 13% had a 1-day delay, 7% waited 2-5 days, and 2% waited 6-10 days. Among those having lung resection, 3% waited 1 day, 2% waited 2-5 days, and 1% waited 6-10 days.

The postsurgical infection rate for patients who had surgery on the day they were admitted was 5.7% in the CABG patients, 8.4% in the lung resection patients, and 10.2% in the colon resection patients. The rates increased for each incremental delay. Among patients whose surgery was performed 6-10 days after admission, postsurgical infection rates were 18.2% for CABG, 21.6% for lung resection, and 20.6% for colon resection.

Adjusted multivariate analysis showed that all delay durations led to significantly greater infection rates relative to no delay, for all three operations analyzed. (See box.)

Analysis further documented that in-hospital delays before surgery were linked to higher hospital costs, Dr. Vogel said.

Vitals

Source Elsevier Global Medical News

Major Finding: The postsurgical infection rate for patients who had surgery on the day they were admitted was 5.7% in CABG patients vs. 18.2% in those who waited 6-10 days. The corresponding rates were 8.4% vs. 21.6% in lung resection patients, and 10.2% vs. 20.6% in colon resection patients.

Data Source: Retrospective study of 163,000 elective-surgery patients from the Nationwide Inpatient Sample during 2003-2007.

Disclosures: Dr. Vogel reported no disclosures.

LAS VEGAS — The longer elective-surgery patients were hospitalized before their operation, the greater their risk of developing an infection postoperatively, according to a review of 163,000 patients.

Elective-admission patients hospitalized for just 1 day before their surgery had a significant 20%-50% increased risk of subsequent infection, compared with patients whose surgery took place the same day as their hospital admission, Dr. Todd R. Vogel reported.

Patients hospitalized for 6-10 days before surgery had a greater than twofold increased risk, said Dr. Vogel, a vascular surgeon at the Robert Wood Johnson Medical School, New Brunswick, N.J.

The data suggest it would be better to send patients home to await the day of their planned surgery than to keep them in the hospital until their slot on the schedule opens, he added.

Another possible explanation is that many of the delayed cases weren't really elective. “I think there were reasons for the delay that you can't pick out of your administrative database,” said Dr. E. Patchen Dellinger, professor and chief of the division of general surgery at the University of Washington, Seattle.

But Dr. Vogel pointed out that hospitals would want to “upcode” cases that were not elective because they would be paid more.

He and his associates used data collected during 2003-2007 in the Nationwide Inpatient Sample on elective admissions for three types of surgery: 87,318 for CABG, 46,728 for colon resection, and 28,960 for lung resection. Patients were aged 50-79 years. Nearly two-thirds were men, and 84% were white. The infectious complications analyzed included pneumonia, urinary tract infection, sepsis, and surgical site infections.

Patients undergoing CABG had the highest rate of delays between admission and surgery, with 53% having their surgery on the same day of admission, compared with 79% of colon resection patients and 94% of lung resection patients. Another 23% of the CABG patients had a 1-day delay, 21% had a 2-5 day delay, and 3% had their surgery 6-10 days after admission. In the colon resection group, 13% had a 1-day delay, 7% waited 2-5 days, and 2% waited 6-10 days. Among those having lung resection, 3% waited 1 day, 2% waited 2-5 days, and 1% waited 6-10 days.

The postsurgical infection rate for patients who had surgery on the day they were admitted was 5.7% in the CABG patients, 8.4% in the lung resection patients, and 10.2% in the colon resection patients. The rates increased for each incremental delay. Among patients whose surgery was performed 6-10 days after admission, postsurgical infection rates were 18.2% for CABG, 21.6% for lung resection, and 20.6% for colon resection.

Adjusted multivariate analysis showed that all delay durations led to significantly greater infection rates relative to no delay, for all three operations analyzed. (See box.)

Analysis further documented that in-hospital delays before surgery were linked to higher hospital costs, Dr. Vogel said.

Vitals

Source Elsevier Global Medical News

Major Finding: Length of stay averaged 5.0 days with endocrine intervention vs. 5.8 days without, while costs per stay dropped from $9,301 to $8,009.

Data Source: Observational study of 1-year time periods with and without endocrine intervention for hospitalized surgical patients at an urban tertiary care hospital.

Disclosures: Dr. Chernoff stated that he had no disclosures.

BOSTON — Endocrine intervention resulted in a cost savings of more than $1 million among 820 hospitalized surgical patients with diabetes at an urban tertiary care hospital in Philadelphia.

Proactive consultation by an endocrinologist and a diabetes nurse-educator for surgical patients found to have abnormal glucose levels also reduced the average length of stay by nearly a day. “The bottom line is that endocrine intervention in surgical patients does pay, in terms of both cost savings to the hospital and quality of care for the patient,” Dr. Arthur Chernoff said at the meeting.

Adult patient data for admissions during July 2008–June 2009 (FY09) were compared with those of historical controls during July 2007–June 2008 (FY08). During the FY09 study period, endocrine intervention was triggered by a lab report of a blood glucose level above 199 mg/dL or below 50 mg/dL. Blood glucose management was individualized by the endocrinologist with the help of diabetes educators.

During the control period, the diabetic patients received care based on previously deployed protocols for the management of hyperglycemia in the ICU, hypoglycemia in all units, and insulin order sets.

In contrast to the control period, when an endocrinologist was typically called in only when there was a problem, “the key element of the intervention was to be proactive rather than reactive in the care of the diabetic patient,” said Dr. Chernoff, chair of the division of endocrinology and medical director of the Gutman Diabetes Institute at Albert Einstein Medical Center, Philadelphia.

There were 820 patients with and 2,534 without diabetes in the FY09 period and 681 with and 2,516 without diabetes in FY08. The diabetes patients were older than those without (59 vs. 49 years in FY09 and 61 vs. 50 years in FY08), but race and sex did not differ between the two groups, Dr. Chernoff reported in a poster.

Among the diabetic patients, length of stay was significantly lower during FY09, an average 5 days vs. 5.8 days in FY08. Time in the ICU also dropped, from 0.90 to 0.69 days. Among patients without diabetes, total length of stay did not differ significantly during the two time periods (4.1 in FY09 vs. 4.4 days in FY08), nor did time in the ICU (0.88 in FY09 vs. 0.87 in FY08).

Total expense for the hospital stay averaged $8,009 in FY09, a significant decrease from the average $9,301 in FY08. In contrast, hospital stay expense among those without diabetes improved only slightly, $7,440 in FY09 vs. $7,548 in FY08. Among all the hospitalized surgical patients, the total savings between the two time periods was 1,342 days and $1.15 million, of which half the days (656) and 92% of the cost ($1.06 million) were due to the improvements among those with diabetes, Dr. Chernoff noted.

Savings in length of stay and expense in the diabetic group were not due to a shifting of costs to other facilities or to increased mortality. The proportion discharged home from the hospital rose slightly, from 78% in FY08 to 79% in FY09, while deaths dropped from 1.8% to 1.6%.

In an interview, Dr. Chernoff said that the proactive nature of the intervention is the key to its success. “The idea is not waiting for trouble, but to be ahead of trouble and prevent all the rookie mistakes of those not familiar with diabetes. Some mistakes that we see over and over again can be avoided.”

“The key element of the intervention was to be proactive rather than reactive,” Dr. Arthur Chernoff said.

Source Miriam E. Tucker/Elsevier Global Medical News

Major Finding: Length of stay averaged 5.0 days with endocrine intervention vs. 5.8 days without, while costs per stay dropped from $9,301 to $8,009.

Data Source: Observational study of 1-year time periods with and without endocrine intervention for hospitalized surgical patients at an urban tertiary care hospital.

Disclosures: Dr. Chernoff stated that he had no disclosures.

BOSTON — Endocrine intervention resulted in a cost savings of more than $1 million among 820 hospitalized surgical patients with diabetes at an urban tertiary care hospital in Philadelphia.

Proactive consultation by an endocrinologist and a diabetes nurse-educator for surgical patients found to have abnormal glucose levels also reduced the average length of stay by nearly a day. “The bottom line is that endocrine intervention in surgical patients does pay, in terms of both cost savings to the hospital and quality of care for the patient,” Dr. Arthur Chernoff said at the meeting.

Adult patient data for admissions during July 2008–June 2009 (FY09) were compared with those of historical controls during July 2007–June 2008 (FY08). During the FY09 study period, endocrine intervention was triggered by a lab report of a blood glucose level above 199 mg/dL or below 50 mg/dL. Blood glucose management was individualized by the endocrinologist with the help of diabetes educators.

During the control period, the diabetic patients received care based on previously deployed protocols for the management of hyperglycemia in the ICU, hypoglycemia in all units, and insulin order sets.

In contrast to the control period, when an endocrinologist was typically called in only when there was a problem, “the key element of the intervention was to be proactive rather than reactive in the care of the diabetic patient,” said Dr. Chernoff, chair of the division of endocrinology and medical director of the Gutman Diabetes Institute at Albert Einstein Medical Center, Philadelphia.

There were 820 patients with and 2,534 without diabetes in the FY09 period and 681 with and 2,516 without diabetes in FY08. The diabetes patients were older than those without (59 vs. 49 years in FY09 and 61 vs. 50 years in FY08), but race and sex did not differ between the two groups, Dr. Chernoff reported in a poster.

Among the diabetic patients, length of stay was significantly lower during FY09, an average 5 days vs. 5.8 days in FY08. Time in the ICU also dropped, from 0.90 to 0.69 days. Among patients without diabetes, total length of stay did not differ significantly during the two time periods (4.1 in FY09 vs. 4.4 days in FY08), nor did time in the ICU (0.88 in FY09 vs. 0.87 in FY08).

Total expense for the hospital stay averaged $8,009 in FY09, a significant decrease from the average $9,301 in FY08. In contrast, hospital stay expense among those without diabetes improved only slightly, $7,440 in FY09 vs. $7,548 in FY08. Among all the hospitalized surgical patients, the total savings between the two time periods was 1,342 days and $1.15 million, of which half the days (656) and 92% of the cost ($1.06 million) were due to the improvements among those with diabetes, Dr. Chernoff noted.

Savings in length of stay and expense in the diabetic group were not due to a shifting of costs to other facilities or to increased mortality. The proportion discharged home from the hospital rose slightly, from 78% in FY08 to 79% in FY09, while deaths dropped from 1.8% to 1.6%.

In an interview, Dr. Chernoff said that the proactive nature of the intervention is the key to its success. “The idea is not waiting for trouble, but to be ahead of trouble and prevent all the rookie mistakes of those not familiar with diabetes. Some mistakes that we see over and over again can be avoided.”

“The key element of the intervention was to be proactive rather than reactive,” Dr. Arthur Chernoff said.

Source Miriam E. Tucker/Elsevier Global Medical News

Major Finding: Length of stay averaged 5.0 days with endocrine intervention vs. 5.8 days without, while costs per stay dropped from $9,301 to $8,009.

Data Source: Observational study of 1-year time periods with and without endocrine intervention for hospitalized surgical patients at an urban tertiary care hospital.

Disclosures: Dr. Chernoff stated that he had no disclosures.

BOSTON — Endocrine intervention resulted in a cost savings of more than $1 million among 820 hospitalized surgical patients with diabetes at an urban tertiary care hospital in Philadelphia.

Proactive consultation by an endocrinologist and a diabetes nurse-educator for surgical patients found to have abnormal glucose levels also reduced the average length of stay by nearly a day. “The bottom line is that endocrine intervention in surgical patients does pay, in terms of both cost savings to the hospital and quality of care for the patient,” Dr. Arthur Chernoff said at the meeting.

Adult patient data for admissions during July 2008–June 2009 (FY09) were compared with those of historical controls during July 2007–June 2008 (FY08). During the FY09 study period, endocrine intervention was triggered by a lab report of a blood glucose level above 199 mg/dL or below 50 mg/dL. Blood glucose management was individualized by the endocrinologist with the help of diabetes educators.

During the control period, the diabetic patients received care based on previously deployed protocols for the management of hyperglycemia in the ICU, hypoglycemia in all units, and insulin order sets.

In contrast to the control period, when an endocrinologist was typically called in only when there was a problem, “the key element of the intervention was to be proactive rather than reactive in the care of the diabetic patient,” said Dr. Chernoff, chair of the division of endocrinology and medical director of the Gutman Diabetes Institute at Albert Einstein Medical Center, Philadelphia.

There were 820 patients with and 2,534 without diabetes in the FY09 period and 681 with and 2,516 without diabetes in FY08. The diabetes patients were older than those without (59 vs. 49 years in FY09 and 61 vs. 50 years in FY08), but race and sex did not differ between the two groups, Dr. Chernoff reported in a poster.

Among the diabetic patients, length of stay was significantly lower during FY09, an average 5 days vs. 5.8 days in FY08. Time in the ICU also dropped, from 0.90 to 0.69 days. Among patients without diabetes, total length of stay did not differ significantly during the two time periods (4.1 in FY09 vs. 4.4 days in FY08), nor did time in the ICU (0.88 in FY09 vs. 0.87 in FY08).

Total expense for the hospital stay averaged $8,009 in FY09, a significant decrease from the average $9,301 in FY08. In contrast, hospital stay expense among those without diabetes improved only slightly, $7,440 in FY09 vs. $7,548 in FY08. Among all the hospitalized surgical patients, the total savings between the two time periods was 1,342 days and $1.15 million, of which half the days (656) and 92% of the cost ($1.06 million) were due to the improvements among those with diabetes, Dr. Chernoff noted.

Savings in length of stay and expense in the diabetic group were not due to a shifting of costs to other facilities or to increased mortality. The proportion discharged home from the hospital rose slightly, from 78% in FY08 to 79% in FY09, while deaths dropped from 1.8% to 1.6%.

In an interview, Dr. Chernoff said that the proactive nature of the intervention is the key to its success. “The idea is not waiting for trouble, but to be ahead of trouble and prevent all the rookie mistakes of those not familiar with diabetes. Some mistakes that we see over and over again can be avoided.”

“The key element of the intervention was to be proactive rather than reactive,” Dr. Arthur Chernoff said.

Source Miriam E. Tucker/Elsevier Global Medical News

Major Finding: After receiving a coronary artery bypass graft, patients who maintained a moderate blood glucose level of 126–179 mg/dL had a significant 40% lower mortality and a significant 30% lower rate of major complications, compared with patients whose mean blood glucose was 180 mg/dL or higher. Mortality and morbidity were not significantly lower in patients who maintained a blood glucose level of less than 126 mg/dL, compared with patients with levels that were 180 mg/dL or higher.

Data Source: Review of more than 4,600 post-CABG patients at a single U.S. center during 1995–2008.

Disclosures: Dr. Ailawadi said that he and his associates had no disclosures. Dr. Lazar disclosed that he has received research support from Eli Lilly & Co.

TORONTO — Moderate glucose control during the first days following coronary artery bypass graft surgery led to better outcomes than did liberal control, judging by a review of more than 4,000 patients at one U.S. center.

Patients who were maintained on tight glucose control, however, with an average blood glucose level of less than 126 mg/dL during the first 3 days after undergoing CABG, had no significant outcome advantage over those who were maintained on liberal control at a mean glucose level of more than 180 mg/dL.

On the basis of these findings as well as those of previous published studies, the ideal blood glucose target after CABG is 150 mg/dL, with a target range of 120–150 mg/dL, Dr. Gorav Ailawadi said.

Moderate glucose control, defined by Dr. Ailawadi as a mean blood glucose level during the first 3 days after surgery of 126–179 mg/dL, was linked to a significant reduction in both mortality and major complications, compared with liberal control, said Dr. Ailawadi, who is a cardiothoracic surgeon at the University of Virginia in Charlottesville.

“At our institution, our postoperative glucose control policy as of January 2010 has been a target range of 120–150 mg/dL hospitalwide,” not just in cardiac surgery patients, he said in an interview.

“The previous goal had been 80–110 mg/dL, but we felt there were enough data, including our own data, to support the change. We're not saying that you can be lax about glucose, but that you don't need to be as tight as 80–110 mg/dL. The goal is 120–150 mg/dL, and be sure it doesn't go above 180 mg/dL.”

Although it's unclear why tight control may not be as effective as moderate control, Dr. Ailawadi suggested that perhaps patients in the tight-control group have more hypoglycemic episodes.

In this series, the incidence of first postoperative glucose levels that measured 60 mg/dL or less ran 1.5% in the tight-control patients, 0.4% in the moderate-control group, and 0.1% in the liberal-control group, a significant difference for the tight-control patients compared with the other two groups.

Dr. Ailawadi said that the evidence in favor of moderate control confirms results from several recent randomized, controlled studies, including:

The Normoglycemia in Intensive Care Evaluation—Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study, which included 6,100 intensive care unit patients and found that a glucose target of less than 180 mg/dL led to significantly better survival than did a target of 81–108 mg/dL (N. Engl. J. Med. 2009;360:1283–97).

A study that randomized 400 on-pump cardiac surgery patients to tight postoperative glucose control with a target of 80–100 mg/dL or to conventional treatment with a blood glucose goal of less than 200 mg/dL and an achieved mean level of 157 mg/dL.

At 30 days' follow-up, the incidence of the primary end point—a composite of death, sternal infections, prolonged ventilation, cardiac arrhythmias, stroke, and renal failure—was identical in the two groups.

But the group on tight control had a trend toward more deaths that neared significance (P = .061) and a significantly higher rate of stroke (Ann. Intern. Med. 2007;146:233–43).

An unpublished study that randomized cardiac surgery patients to tight postoperative glucose control with a target mean level of 90–120 mg/dL, compared with a target mean of 120–180 mg/dL, and showed no significant difference in the rates of major adverse cardiovascular events between the two groups.

Dr. Harold L. Lazar, professor of cardiothoracic surgery at Boston University and lead investigator of that study, summarized the results during the discussion of Dr. Ailawadi's report.

Dr. Lazar also noted that the 2009 report from the Blood Glucose Guideline Task Force of the Society of Thoracic Surgeons set an “optimal glucose range” of 120–180 mg/dL for the peroid during and after adult cardiac surgery (Ann. Thorac. Surg. 2009;87:663–9).

A reason the task force selected this range was “to make it easier for people to be in compliance,” he said.

The study by Dr. Ailawadi and his associates included patients at the University of Virginia during 1995–2008 who underwent CABG and either had known type 2 diabetes preoperatively or developed perioperative hyperglycemia, defined as a blood glucose level of 126 mg/dL or higher at their first postoperative glucose measurement or a mean glucose of at least 126 mg/dL during the first 3 days after surgery. Their average age was 64 years, and about 70% were men.

During the first 3 postoperative days, average blood glucose levels were 118.9 mg/dL in the tight-control group, 152.5 mg/dL in the moderate-control group, and 214.6 mg/dL in the liberal-control group.

Unadjusted mortality rates during hospitalization were 2.9% in the tight-control group, 2.0% in the moderate-control group, and 3.4% in the liberal-control group.

The unadjusted rates of the combined complication end point were 19.4%, 11.1%, and 14.2% in the three groups, respectively.

Multivariate analysis that controlled for clinical and demographic differences revealed that moderate glucose control was linked to a significant 40% reduced mortality and a 30% reduced rate of complications compared with the liberal-control group.

The tight-control group had a 50% reduced mortality compared with the liberal-control group, but the difference was not significant.

Patients in the tight-control group had the same rate of complications as those in the liberal-control group, said Dr. Ailawadi.

'We're not saying that you can be lax about glucose, but that you don't need to be as tight as 80–110 mg/dL.”

Source DR. AILAWADI

My Take

Study Did Not Prove Moderate Better Than Tight Glucose Control

Neither the title of this paper nor the conclusions are in any way supported by the data. Nor is it possible that any difference between the tight- and moderate-control groups, if it did actually exist, could have been statistically detected in this study.

Due to the lack of sufficient numbers of patients in the tight-control group, the study was markedly underpowered to detect any difference between the tight- and moderate-control groups. The power of this study to detect an absolute 1% reduction in mortality between the two groups was only 3%. Furthermore, these were entirely retrospective data from an administrative database, not a clinical database. Clinical outcomes are assumed by interpolating coding information.

What this report has shown is that moderate control is better than no control at all, a finding supported by 15 years of published literature. Moderate control reduced mortality by 40% compared with no control. Interestingly, the point estimate for tight control in the multivariate mortality analysis shows a 50% reduction in mortality compared with no control, but with not enough patients to bring the point estimate to statistical significance. To imply that moderate control is superior to tight control when they weren't even directly compared is either wishful thinking or misleading marketing rhetoric that is not supported by the statistical data.

I have similar concerns about the morbidity conclusions. Of the five major complications included in the morbidity end point, three—stroke, prolonged ventilation, and reoperation—have never been shown to be associated with or caused by glycemia in cardiac surgery patients. Thus, glycemic control is unrelated to the complications studied.

Major Finding: After receiving a coronary artery bypass graft, patients who maintained a moderate blood glucose level of 126–179 mg/dL had a significant 40% lower mortality and a significant 30% lower rate of major complications, compared with patients whose mean blood glucose was 180 mg/dL or higher. Mortality and morbidity were not significantly lower in patients who maintained a blood glucose level of less than 126 mg/dL, compared with patients with levels that were 180 mg/dL or higher.

Data Source: Review of more than 4,600 post-CABG patients at a single U.S. center during 1995–2008.

Disclosures: Dr. Ailawadi said that he and his associates had no disclosures. Dr. Lazar disclosed that he has received research support from Eli Lilly & Co.

TORONTO — Moderate glucose control during the first days following coronary artery bypass graft surgery led to better outcomes than did liberal control, judging by a review of more than 4,000 patients at one U.S. center.

Patients who were maintained on tight glucose control, however, with an average blood glucose level of less than 126 mg/dL during the first 3 days after undergoing CABG, had no significant outcome advantage over those who were maintained on liberal control at a mean glucose level of more than 180 mg/dL.

On the basis of these findings as well as those of previous published studies, the ideal blood glucose target after CABG is 150 mg/dL, with a target range of 120–150 mg/dL, Dr. Gorav Ailawadi said.

Moderate glucose control, defined by Dr. Ailawadi as a mean blood glucose level during the first 3 days after surgery of 126–179 mg/dL, was linked to a significant reduction in both mortality and major complications, compared with liberal control, said Dr. Ailawadi, who is a cardiothoracic surgeon at the University of Virginia in Charlottesville.

“At our institution, our postoperative glucose control policy as of January 2010 has been a target range of 120–150 mg/dL hospitalwide,” not just in cardiac surgery patients, he said in an interview.

“The previous goal had been 80–110 mg/dL, but we felt there were enough data, including our own data, to support the change. We're not saying that you can be lax about glucose, but that you don't need to be as tight as 80–110 mg/dL. The goal is 120–150 mg/dL, and be sure it doesn't go above 180 mg/dL.”

Although it's unclear why tight control may not be as effective as moderate control, Dr. Ailawadi suggested that perhaps patients in the tight-control group have more hypoglycemic episodes.

In this series, the incidence of first postoperative glucose levels that measured 60 mg/dL or less ran 1.5% in the tight-control patients, 0.4% in the moderate-control group, and 0.1% in the liberal-control group, a significant difference for the tight-control patients compared with the other two groups.

Dr. Ailawadi said that the evidence in favor of moderate control confirms results from several recent randomized, controlled studies, including:

The Normoglycemia in Intensive Care Evaluation—Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study, which included 6,100 intensive care unit patients and found that a glucose target of less than 180 mg/dL led to significantly better survival than did a target of 81–108 mg/dL (N. Engl. J. Med. 2009;360:1283–97).

A study that randomized 400 on-pump cardiac surgery patients to tight postoperative glucose control with a target of 80–100 mg/dL or to conventional treatment with a blood glucose goal of less than 200 mg/dL and an achieved mean level of 157 mg/dL.

At 30 days' follow-up, the incidence of the primary end point—a composite of death, sternal infections, prolonged ventilation, cardiac arrhythmias, stroke, and renal failure—was identical in the two groups.

But the group on tight control had a trend toward more deaths that neared significance (P = .061) and a significantly higher rate of stroke (Ann. Intern. Med. 2007;146:233–43).

An unpublished study that randomized cardiac surgery patients to tight postoperative glucose control with a target mean level of 90–120 mg/dL, compared with a target mean of 120–180 mg/dL, and showed no significant difference in the rates of major adverse cardiovascular events between the two groups.

Dr. Harold L. Lazar, professor of cardiothoracic surgery at Boston University and lead investigator of that study, summarized the results during the discussion of Dr. Ailawadi's report.

Dr. Lazar also noted that the 2009 report from the Blood Glucose Guideline Task Force of the Society of Thoracic Surgeons set an “optimal glucose range” of 120–180 mg/dL for the peroid during and after adult cardiac surgery (Ann. Thorac. Surg. 2009;87:663–9).

A reason the task force selected this range was “to make it easier for people to be in compliance,” he said.

The study by Dr. Ailawadi and his associates included patients at the University of Virginia during 1995–2008 who underwent CABG and either had known type 2 diabetes preoperatively or developed perioperative hyperglycemia, defined as a blood glucose level of 126 mg/dL or higher at their first postoperative glucose measurement or a mean glucose of at least 126 mg/dL during the first 3 days after surgery. Their average age was 64 years, and about 70% were men.

During the first 3 postoperative days, average blood glucose levels were 118.9 mg/dL in the tight-control group, 152.5 mg/dL in the moderate-control group, and 214.6 mg/dL in the liberal-control group.

Unadjusted mortality rates during hospitalization were 2.9% in the tight-control group, 2.0% in the moderate-control group, and 3.4% in the liberal-control group.

The unadjusted rates of the combined complication end point were 19.4%, 11.1%, and 14.2% in the three groups, respectively.

Multivariate analysis that controlled for clinical and demographic differences revealed that moderate glucose control was linked to a significant 40% reduced mortality and a 30% reduced rate of complications compared with the liberal-control group.

The tight-control group had a 50% reduced mortality compared with the liberal-control group, but the difference was not significant.

Patients in the tight-control group had the same rate of complications as those in the liberal-control group, said Dr. Ailawadi.

'We're not saying that you can be lax about glucose, but that you don't need to be as tight as 80–110 mg/dL.”

Source DR. AILAWADI

My Take

Study Did Not Prove Moderate Better Than Tight Glucose Control

Neither the title of this paper nor the conclusions are in any way supported by the data. Nor is it possible that any difference between the tight- and moderate-control groups, if it did actually exist, could have been statistically detected in this study.

Due to the lack of sufficient numbers of patients in the tight-control group, the study was markedly underpowered to detect any difference between the tight- and moderate-control groups. The power of this study to detect an absolute 1% reduction in mortality between the two groups was only 3%. Furthermore, these were entirely retrospective data from an administrative database, not a clinical database. Clinical outcomes are assumed by interpolating coding information.

What this report has shown is that moderate control is better than no control at all, a finding supported by 15 years of published literature. Moderate control reduced mortality by 40% compared with no control. Interestingly, the point estimate for tight control in the multivariate mortality analysis shows a 50% reduction in mortality compared with no control, but with not enough patients to bring the point estimate to statistical significance. To imply that moderate control is superior to tight control when they weren't even directly compared is either wishful thinking or misleading marketing rhetoric that is not supported by the statistical data.

I have similar concerns about the morbidity conclusions. Of the five major complications included in the morbidity end point, three—stroke, prolonged ventilation, and reoperation—have never been shown to be associated with or caused by glycemia in cardiac surgery patients. Thus, glycemic control is unrelated to the complications studied.

Major Finding: After receiving a coronary artery bypass graft, patients who maintained a moderate blood glucose level of 126–179 mg/dL had a significant 40% lower mortality and a significant 30% lower rate of major complications, compared with patients whose mean blood glucose was 180 mg/dL or higher. Mortality and morbidity were not significantly lower in patients who maintained a blood glucose level of less than 126 mg/dL, compared with patients with levels that were 180 mg/dL or higher.

Data Source: Review of more than 4,600 post-CABG patients at a single U.S. center during 1995–2008.

Disclosures: Dr. Ailawadi said that he and his associates had no disclosures. Dr. Lazar disclosed that he has received research support from Eli Lilly & Co.

TORONTO — Moderate glucose control during the first days following coronary artery bypass graft surgery led to better outcomes than did liberal control, judging by a review of more than 4,000 patients at one U.S. center.

Patients who were maintained on tight glucose control, however, with an average blood glucose level of less than 126 mg/dL during the first 3 days after undergoing CABG, had no significant outcome advantage over those who were maintained on liberal control at a mean glucose level of more than 180 mg/dL.

On the basis of these findings as well as those of previous published studies, the ideal blood glucose target after CABG is 150 mg/dL, with a target range of 120–150 mg/dL, Dr. Gorav Ailawadi said.

Moderate glucose control, defined by Dr. Ailawadi as a mean blood glucose level during the first 3 days after surgery of 126–179 mg/dL, was linked to a significant reduction in both mortality and major complications, compared with liberal control, said Dr. Ailawadi, who is a cardiothoracic surgeon at the University of Virginia in Charlottesville.

“At our institution, our postoperative glucose control policy as of January 2010 has been a target range of 120–150 mg/dL hospitalwide,” not just in cardiac surgery patients, he said in an interview.

“The previous goal had been 80–110 mg/dL, but we felt there were enough data, including our own data, to support the change. We're not saying that you can be lax about glucose, but that you don't need to be as tight as 80–110 mg/dL. The goal is 120–150 mg/dL, and be sure it doesn't go above 180 mg/dL.”

Although it's unclear why tight control may not be as effective as moderate control, Dr. Ailawadi suggested that perhaps patients in the tight-control group have more hypoglycemic episodes.

In this series, the incidence of first postoperative glucose levels that measured 60 mg/dL or less ran 1.5% in the tight-control patients, 0.4% in the moderate-control group, and 0.1% in the liberal-control group, a significant difference for the tight-control patients compared with the other two groups.

Dr. Ailawadi said that the evidence in favor of moderate control confirms results from several recent randomized, controlled studies, including:

The Normoglycemia in Intensive Care Evaluation—Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study, which included 6,100 intensive care unit patients and found that a glucose target of less than 180 mg/dL led to significantly better survival than did a target of 81–108 mg/dL (N. Engl. J. Med. 2009;360:1283–97).

A study that randomized 400 on-pump cardiac surgery patients to tight postoperative glucose control with a target of 80–100 mg/dL or to conventional treatment with a blood glucose goal of less than 200 mg/dL and an achieved mean level of 157 mg/dL.

At 30 days' follow-up, the incidence of the primary end point—a composite of death, sternal infections, prolonged ventilation, cardiac arrhythmias, stroke, and renal failure—was identical in the two groups.

But the group on tight control had a trend toward more deaths that neared significance (P = .061) and a significantly higher rate of stroke (Ann. Intern. Med. 2007;146:233–43).

An unpublished study that randomized cardiac surgery patients to tight postoperative glucose control with a target mean level of 90–120 mg/dL, compared with a target mean of 120–180 mg/dL, and showed no significant difference in the rates of major adverse cardiovascular events between the two groups.

Dr. Harold L. Lazar, professor of cardiothoracic surgery at Boston University and lead investigator of that study, summarized the results during the discussion of Dr. Ailawadi's report.

Dr. Lazar also noted that the 2009 report from the Blood Glucose Guideline Task Force of the Society of Thoracic Surgeons set an “optimal glucose range” of 120–180 mg/dL for the peroid during and after adult cardiac surgery (Ann. Thorac. Surg. 2009;87:663–9).

A reason the task force selected this range was “to make it easier for people to be in compliance,” he said.

The study by Dr. Ailawadi and his associates included patients at the University of Virginia during 1995–2008 who underwent CABG and either had known type 2 diabetes preoperatively or developed perioperative hyperglycemia, defined as a blood glucose level of 126 mg/dL or higher at their first postoperative glucose measurement or a mean glucose of at least 126 mg/dL during the first 3 days after surgery. Their average age was 64 years, and about 70% were men.

During the first 3 postoperative days, average blood glucose levels were 118.9 mg/dL in the tight-control group, 152.5 mg/dL in the moderate-control group, and 214.6 mg/dL in the liberal-control group.

Unadjusted mortality rates during hospitalization were 2.9% in the tight-control group, 2.0% in the moderate-control group, and 3.4% in the liberal-control group.

The unadjusted rates of the combined complication end point were 19.4%, 11.1%, and 14.2% in the three groups, respectively.

Multivariate analysis that controlled for clinical and demographic differences revealed that moderate glucose control was linked to a significant 40% reduced mortality and a 30% reduced rate of complications compared with the liberal-control group.

The tight-control group had a 50% reduced mortality compared with the liberal-control group, but the difference was not significant.

Patients in the tight-control group had the same rate of complications as those in the liberal-control group, said Dr. Ailawadi.

'We're not saying that you can be lax about glucose, but that you don't need to be as tight as 80–110 mg/dL.”

Source DR. AILAWADI

My Take

Study Did Not Prove Moderate Better Than Tight Glucose Control

Neither the title of this paper nor the conclusions are in any way supported by the data. Nor is it possible that any difference between the tight- and moderate-control groups, if it did actually exist, could have been statistically detected in this study.

Due to the lack of sufficient numbers of patients in the tight-control group, the study was markedly underpowered to detect any difference between the tight- and moderate-control groups. The power of this study to detect an absolute 1% reduction in mortality between the two groups was only 3%. Furthermore, these were entirely retrospective data from an administrative database, not a clinical database. Clinical outcomes are assumed by interpolating coding information.

What this report has shown is that moderate control is better than no control at all, a finding supported by 15 years of published literature. Moderate control reduced mortality by 40% compared with no control. Interestingly, the point estimate for tight control in the multivariate mortality analysis shows a 50% reduction in mortality compared with no control, but with not enough patients to bring the point estimate to statistical significance. To imply that moderate control is superior to tight control when they weren't even directly compared is either wishful thinking or misleading marketing rhetoric that is not supported by the statistical data.

I have similar concerns about the morbidity conclusions. Of the five major complications included in the morbidity end point, three—stroke, prolonged ventilation, and reoperation—have never been shown to be associated with or caused by glycemia in cardiac surgery patients. Thus, glycemic control is unrelated to the complications studied.

ATLANTA — Preoperative patient factors were moderately predictive of surgical site infection risk in a retrospective case-control study of 253 patients undergoing elective vascular surgery.

Previous scoring systems also have been predictive of risk for surgical site infections (SSIs), but these are based on a combination of pre-, peri-, and postoperative factors. Thus, the scores aren't helpful for gauging risk in individual patients prior to surgery.

Knowing risk before surgery could allow the pursuit of nonsurgical options as well as guide infection prevention processes in patients who are shown to be at high risk, Dr. Surbhi Leekha and her associates said in a poster at the Decennial International Conference on Healthcare-Associated Infections.

Further, the most commonly used risk stratification tool, the National Nosocomial Infections Surveillance System (NNIS) risk index (Am. J. Med. 1991;91:152S-7S), does not perform well for “clean” procedures such as cardiovascular surgery, said Dr. Leekha and her associates, of the Mayo Clinic, Rochester, Minn.

The study population included patients who had undergone elective vascular (abdominal aortic and peripheral arterial) surgery at the Mayo Clinic from 2003 through 2007. A total of 87 patients who developed SSIs requiring hospitalization were included, and were matched with 166 controls who had undergone the same type of procedure on the same day but did not develop an infection.

There were no significant differences between cases and controls in age, sex, diabetes, smoking, alcohol use, chronic kidney disease, liver disease, weight loss, immunosuppressive therapy, and presence of skin ulcers. In multivariate analysis, preoperative variables that were significantly associated with SSI risk included critical ischemia (odds ratio 2.91), previous SSI (OR 6.29 with previous surgery, OR 1.40 with no previous surgery), previous peripheral revascularization (OR 2.55), and chronic obstructive pulmonary disease (OR 2.22).

A preop score model was developed in which 1 point each was given for COPD, critical ischemia, and previous peripheral revascularization and 2 points for previous SSI. The concordance statistic (c-statistic) for the preop score model was 0.73, compared with 0.50 for the NNIS score, Dr. Leekha and her associates reported.

A c-statistic of 1.0 indicates that the predictions are perfectly concordant with the actual outcomes, while 0.5 indicates that the predictions are no better than random chance. Thus, “based on these data, NNIS performs no better than a coin toss,” Dr. Leekha said in a follow-up interview.

The NNIS, the national standard for all types of surgeries, has been shown to perform poorly for cardiac surgery. Its performance for vascular surgery appears to be similar, possibly because the patients are similar in two of the three NNIS components—type of surgery (type 1/clean) and American Society of Anesthesiologists score of III or IV, she explained in the interview.

In their poster, Dr. Leekha and her associates recommended that patients predicted to be at high risk should be observed for wound problems and early intervention/wound care, but added that prospective validation of this tool is still required.

Disclosures: Dr. Leekha stated she had nothing to disclose.

ATLANTA — Preoperative patient factors were moderately predictive of surgical site infection risk in a retrospective case-control study of 253 patients undergoing elective vascular surgery.

Previous scoring systems also have been predictive of risk for surgical site infections (SSIs), but these are based on a combination of pre-, peri-, and postoperative factors. Thus, the scores aren't helpful for gauging risk in individual patients prior to surgery.

Knowing risk before surgery could allow the pursuit of nonsurgical options as well as guide infection prevention processes in patients who are shown to be at high risk, Dr. Surbhi Leekha and her associates said in a poster at the Decennial International Conference on Healthcare-Associated Infections.

Further, the most commonly used risk stratification tool, the National Nosocomial Infections Surveillance System (NNIS) risk index (Am. J. Med. 1991;91:152S-7S), does not perform well for “clean” procedures such as cardiovascular surgery, said Dr. Leekha and her associates, of the Mayo Clinic, Rochester, Minn.

The study population included patients who had undergone elective vascular (abdominal aortic and peripheral arterial) surgery at the Mayo Clinic from 2003 through 2007. A total of 87 patients who developed SSIs requiring hospitalization were included, and were matched with 166 controls who had undergone the same type of procedure on the same day but did not develop an infection.

There were no significant differences between cases and controls in age, sex, diabetes, smoking, alcohol use, chronic kidney disease, liver disease, weight loss, immunosuppressive therapy, and presence of skin ulcers. In multivariate analysis, preoperative variables that were significantly associated with SSI risk included critical ischemia (odds ratio 2.91), previous SSI (OR 6.29 with previous surgery, OR 1.40 with no previous surgery), previous peripheral revascularization (OR 2.55), and chronic obstructive pulmonary disease (OR 2.22).

A preop score model was developed in which 1 point each was given for COPD, critical ischemia, and previous peripheral revascularization and 2 points for previous SSI. The concordance statistic (c-statistic) for the preop score model was 0.73, compared with 0.50 for the NNIS score, Dr. Leekha and her associates reported.

A c-statistic of 1.0 indicates that the predictions are perfectly concordant with the actual outcomes, while 0.5 indicates that the predictions are no better than random chance. Thus, “based on these data, NNIS performs no better than a coin toss,” Dr. Leekha said in a follow-up interview.

The NNIS, the national standard for all types of surgeries, has been shown to perform poorly for cardiac surgery. Its performance for vascular surgery appears to be similar, possibly because the patients are similar in two of the three NNIS components—type of surgery (type 1/clean) and American Society of Anesthesiologists score of III or IV, she explained in the interview.

In their poster, Dr. Leekha and her associates recommended that patients predicted to be at high risk should be observed for wound problems and early intervention/wound care, but added that prospective validation of this tool is still required.

Disclosures: Dr. Leekha stated she had nothing to disclose.

ATLANTA — Preoperative patient factors were moderately predictive of surgical site infection risk in a retrospective case-control study of 253 patients undergoing elective vascular surgery.

Previous scoring systems also have been predictive of risk for surgical site infections (SSIs), but these are based on a combination of pre-, peri-, and postoperative factors. Thus, the scores aren't helpful for gauging risk in individual patients prior to surgery.

Knowing risk before surgery could allow the pursuit of nonsurgical options as well as guide infection prevention processes in patients who are shown to be at high risk, Dr. Surbhi Leekha and her associates said in a poster at the Decennial International Conference on Healthcare-Associated Infections.

Further, the most commonly used risk stratification tool, the National Nosocomial Infections Surveillance System (NNIS) risk index (Am. J. Med. 1991;91:152S-7S), does not perform well for “clean” procedures such as cardiovascular surgery, said Dr. Leekha and her associates, of the Mayo Clinic, Rochester, Minn.

The study population included patients who had undergone elective vascular (abdominal aortic and peripheral arterial) surgery at the Mayo Clinic from 2003 through 2007. A total of 87 patients who developed SSIs requiring hospitalization were included, and were matched with 166 controls who had undergone the same type of procedure on the same day but did not develop an infection.

There were no significant differences between cases and controls in age, sex, diabetes, smoking, alcohol use, chronic kidney disease, liver disease, weight loss, immunosuppressive therapy, and presence of skin ulcers. In multivariate analysis, preoperative variables that were significantly associated with SSI risk included critical ischemia (odds ratio 2.91), previous SSI (OR 6.29 with previous surgery, OR 1.40 with no previous surgery), previous peripheral revascularization (OR 2.55), and chronic obstructive pulmonary disease (OR 2.22).

A preop score model was developed in which 1 point each was given for COPD, critical ischemia, and previous peripheral revascularization and 2 points for previous SSI. The concordance statistic (c-statistic) for the preop score model was 0.73, compared with 0.50 for the NNIS score, Dr. Leekha and her associates reported.

A c-statistic of 1.0 indicates that the predictions are perfectly concordant with the actual outcomes, while 0.5 indicates that the predictions are no better than random chance. Thus, “based on these data, NNIS performs no better than a coin toss,” Dr. Leekha said in a follow-up interview.

The NNIS, the national standard for all types of surgeries, has been shown to perform poorly for cardiac surgery. Its performance for vascular surgery appears to be similar, possibly because the patients are similar in two of the three NNIS components—type of surgery (type 1/clean) and American Society of Anesthesiologists score of III or IV, she explained in the interview.

In their poster, Dr. Leekha and her associates recommended that patients predicted to be at high risk should be observed for wound problems and early intervention/wound care, but added that prospective validation of this tool is still required.

Disclosures: Dr. Leekha stated she had nothing to disclose.

Major Finding: The incidence of postoperative infections following elective colectomy or cholecystectomy in U.S. hospitals in 2006 exceeded the rates in 2001, despite widespread adoption of infection-control measures.

Data Source: Data from more than 180,000 surgical patients collected in the Nationwide Inpatient Sample from more than 1,000 hospitals in 38 states.

Disclosures: Dr. Davis reported no relevant disclosures.

LAS VEGAS — The pathogens causing postsurgical infections were not controlled by the steps that hospitals took in recent years to fight the infections, according to U.S. sample data on more than 183,000 hospitalized patients.

Most U.S. hospitals were participating in the Surgical Care Improvement Project (SCIP) by 2006 because that year the Centers for Medicare and Medicaid Services began imposing a reimbursement penalty on hospitals that failed to report their compliance with the SCIP, Dr. John M. Davis said at the annual meeting of the Surgical Infection Society. A portion of the SCIP was designed to cut postoperative infection rates through steps such as antibiotic prophylaxis and surgical site preparation.

Despite widespread compliance, postoperative infection rates in patients undergoing elective colectomy or cholecystectomy in 2006 significantly surpassed the rates at the same hospitals in 2001, said Dr. Davis, a professor of surgery at Jersey Shore University Hospital in Neptune, N.J.

Dr. Davis attributed the increased infection rates to ongoing changes in the pathogens that surgical patients encounter while hospitalized. He said he believed that the infection picture in 2006 would have been far worse if the SCIP infection-control program had not been in place.

“There is a huge reservoir of very drug-resistant organisms, and their prevalence increased over the time period that we looked at,” Dr. Davis said in an interview.

Increased levels of vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and gram-negative pathogens such as Enterobacter and Acinetobacter were seen during the study period, he said.

And many pathogens are now resistant to cefazolin, which has been a mainstay prophylactic antibiotic for patients undergoing surgery.

The increased risk for postsurgical infection with these pathogens could be blunted by further improvements in the infection-control steps taken in hospitals, such as better skin preparation techniques and treatment with higher doses of or different prophylactic antibiotics that better suit current pathogen risks and patient weight, Dr. Davis said.

“We may have to intensify how we manage skin prep and the dosing of antibiotics,” he said.

Another step would be to change the timing when prophylactic antibiotics are administered, Dr. Davis said.

He and his associates analyzed data collected in 2001–2006 by the Nationwide Inpatient Sample, a program of the Healthcare Cost and Utilization Project, from more than 1,000 hospitals in 38 states. The data included came from 90,596 patients undergoing elective colectomy, 72,920 patients undergoing elective laparoscopic cholecystectomy, and 19,706 patients undergoing elective open cholecystectomy.

The analysis showed that the incidence of postoperative infections in all three types of patients in 2006 significantly exceeded the rates in 2001. (See box.) Postoperative mortality rates did not change significantly between 2001 and 2006.

Vitals

Source Elsevier Global Medical News

My Take

Project Did Not Live Up to Promise

Many of the physicians who developed the Surgical Care Improvement Project, myself included, hoped that the preventive measures promoted by the program would lead to reduced postoperative infection rates and better patient outcomes. The findings reported by Dr. Davis indicate that the promise of the program has not been fulfilled.

In addition, the infection rates seen in the Nationwide Inpatient Sample data suggest substantial underreporting of postoperative infection rates by hospitals. Two recent randomized, controlled studies of prophylactic antibiotics in patients undergoing colon surgery showed postoperative infection rates of about 20%. But the Nationwide Inpatient Sample data reported by Dr. Davis showed rates of 3%–4%.

DONALD E. FRY, M.D., is a surgeon and executive vice president for clinical outcomes management at Michael Pines & Associates in Chicago. He had no disclosures relevant to this topic.

Major Finding: The incidence of postoperative infections following elective colectomy or cholecystectomy in U.S. hospitals in 2006 exceeded the rates in 2001, despite widespread adoption of infection-control measures.

Data Source: Data from more than 180,000 surgical patients collected in the Nationwide Inpatient Sample from more than 1,000 hospitals in 38 states.

Disclosures: Dr. Davis reported no relevant disclosures.

LAS VEGAS — The pathogens causing postsurgical infections were not controlled by the steps that hospitals took in recent years to fight the infections, according to U.S. sample data on more than 183,000 hospitalized patients.

Most U.S. hospitals were participating in the Surgical Care Improvement Project (SCIP) by 2006 because that year the Centers for Medicare and Medicaid Services began imposing a reimbursement penalty on hospitals that failed to report their compliance with the SCIP, Dr. John M. Davis said at the annual meeting of the Surgical Infection Society. A portion of the SCIP was designed to cut postoperative infection rates through steps such as antibiotic prophylaxis and surgical site preparation.

Despite widespread compliance, postoperative infection rates in patients undergoing elective colectomy or cholecystectomy in 2006 significantly surpassed the rates at the same hospitals in 2001, said Dr. Davis, a professor of surgery at Jersey Shore University Hospital in Neptune, N.J.

Dr. Davis attributed the increased infection rates to ongoing changes in the pathogens that surgical patients encounter while hospitalized. He said he believed that the infection picture in 2006 would have been far worse if the SCIP infection-control program had not been in place.

“There is a huge reservoir of very drug-resistant organisms, and their prevalence increased over the time period that we looked at,” Dr. Davis said in an interview.

Increased levels of vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and gram-negative pathogens such as Enterobacter and Acinetobacter were seen during the study period, he said.

And many pathogens are now resistant to cefazolin, which has been a mainstay prophylactic antibiotic for patients undergoing surgery.

The increased risk for postsurgical infection with these pathogens could be blunted by further improvements in the infection-control steps taken in hospitals, such as better skin preparation techniques and treatment with higher doses of or different prophylactic antibiotics that better suit current pathogen risks and patient weight, Dr. Davis said.

“We may have to intensify how we manage skin prep and the dosing of antibiotics,” he said.

Another step would be to change the timing when prophylactic antibiotics are administered, Dr. Davis said.

He and his associates analyzed data collected in 2001–2006 by the Nationwide Inpatient Sample, a program of the Healthcare Cost and Utilization Project, from more than 1,000 hospitals in 38 states. The data included came from 90,596 patients undergoing elective colectomy, 72,920 patients undergoing elective laparoscopic cholecystectomy, and 19,706 patients undergoing elective open cholecystectomy.

The analysis showed that the incidence of postoperative infections in all three types of patients in 2006 significantly exceeded the rates in 2001. (See box.) Postoperative mortality rates did not change significantly between 2001 and 2006.

Vitals

Source Elsevier Global Medical News

My Take

Project Did Not Live Up to Promise

Many of the physicians who developed the Surgical Care Improvement Project, myself included, hoped that the preventive measures promoted by the program would lead to reduced postoperative infection rates and better patient outcomes. The findings reported by Dr. Davis indicate that the promise of the program has not been fulfilled.

In addition, the infection rates seen in the Nationwide Inpatient Sample data suggest substantial underreporting of postoperative infection rates by hospitals. Two recent randomized, controlled studies of prophylactic antibiotics in patients undergoing colon surgery showed postoperative infection rates of about 20%. But the Nationwide Inpatient Sample data reported by Dr. Davis showed rates of 3%–4%.

DONALD E. FRY, M.D., is a surgeon and executive vice president for clinical outcomes management at Michael Pines & Associates in Chicago. He had no disclosures relevant to this topic.

Major Finding: The incidence of postoperative infections following elective colectomy or cholecystectomy in U.S. hospitals in 2006 exceeded the rates in 2001, despite widespread adoption of infection-control measures.

Data Source: Data from more than 180,000 surgical patients collected in the Nationwide Inpatient Sample from more than 1,000 hospitals in 38 states.

Disclosures: Dr. Davis reported no relevant disclosures.

LAS VEGAS — The pathogens causing postsurgical infections were not controlled by the steps that hospitals took in recent years to fight the infections, according to U.S. sample data on more than 183,000 hospitalized patients.

Most U.S. hospitals were participating in the Surgical Care Improvement Project (SCIP) by 2006 because that year the Centers for Medicare and Medicaid Services began imposing a reimbursement penalty on hospitals that failed to report their compliance with the SCIP, Dr. John M. Davis said at the annual meeting of the Surgical Infection Society. A portion of the SCIP was designed to cut postoperative infection rates through steps such as antibiotic prophylaxis and surgical site preparation.

Despite widespread compliance, postoperative infection rates in patients undergoing elective colectomy or cholecystectomy in 2006 significantly surpassed the rates at the same hospitals in 2001, said Dr. Davis, a professor of surgery at Jersey Shore University Hospital in Neptune, N.J.

Dr. Davis attributed the increased infection rates to ongoing changes in the pathogens that surgical patients encounter while hospitalized. He said he believed that the infection picture in 2006 would have been far worse if the SCIP infection-control program had not been in place.

“There is a huge reservoir of very drug-resistant organisms, and their prevalence increased over the time period that we looked at,” Dr. Davis said in an interview.

Increased levels of vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and gram-negative pathogens such as Enterobacter and Acinetobacter were seen during the study period, he said.

And many pathogens are now resistant to cefazolin, which has been a mainstay prophylactic antibiotic for patients undergoing surgery.

The increased risk for postsurgical infection with these pathogens could be blunted by further improvements in the infection-control steps taken in hospitals, such as better skin preparation techniques and treatment with higher doses of or different prophylactic antibiotics that better suit current pathogen risks and patient weight, Dr. Davis said.

“We may have to intensify how we manage skin prep and the dosing of antibiotics,” he said.

Another step would be to change the timing when prophylactic antibiotics are administered, Dr. Davis said.

He and his associates analyzed data collected in 2001–2006 by the Nationwide Inpatient Sample, a program of the Healthcare Cost and Utilization Project, from more than 1,000 hospitals in 38 states. The data included came from 90,596 patients undergoing elective colectomy, 72,920 patients undergoing elective laparoscopic cholecystectomy, and 19,706 patients undergoing elective open cholecystectomy.

The analysis showed that the incidence of postoperative infections in all three types of patients in 2006 significantly exceeded the rates in 2001. (See box.) Postoperative mortality rates did not change significantly between 2001 and 2006.

Vitals

Source Elsevier Global Medical News

My Take

Project Did Not Live Up to Promise

Many of the physicians who developed the Surgical Care Improvement Project, myself included, hoped that the preventive measures promoted by the program would lead to reduced postoperative infection rates and better patient outcomes. The findings reported by Dr. Davis indicate that the promise of the program has not been fulfilled.

In addition, the infection rates seen in the Nationwide Inpatient Sample data suggest substantial underreporting of postoperative infection rates by hospitals. Two recent randomized, controlled studies of prophylactic antibiotics in patients undergoing colon surgery showed postoperative infection rates of about 20%. But the Nationwide Inpatient Sample data reported by Dr. Davis showed rates of 3%–4%.

DONALD E. FRY, M.D., is a surgeon and executive vice president for clinical outcomes management at Michael Pines & Associates in Chicago. He had no disclosures relevant to this topic.

SAN DIEGO — Partial venous thromboembolic event prophylaxis in at-risk medical and surgical inpatients is associated with a mean 2-day greater hospital length of stay and $22,000 more per patient in total hospital charges than for recipients of best-practice appropriate prophylaxis, according to a large national study.

Thus, partial VTE prophylaxis—that is, any VTE prophylaxis not in accord with American College of Chest Physicians guidelines in terms of dose or duration—not only entails adverse clinical consequences, it also carries a significant economic price, Dr. Alpesh Amin observed at the annual meeting of the American College of Chest Physicians.

He presented a retrospective case-control study of economic and clinical outcomes in 21,001 medical and surgical inpatients around the nation who received VTE prophylaxis. The data were obtained from the Thomson Reuters MarketScan Hospital Drug Database.

The VTE prophylaxis was in step with ACCP guidelines in a mere 24.5% of patients, and such low rates have also been seen in numerous other studies. The in-hospital VTE rate in the appropriate-prophylaxis group was 1.9%, compared with 1.4% in the three-quarters of patients who got partial prophylaxis, according to Dr. Amin, professor and chairman of the department of medicine and executive director of the hospitalist program at the University of California, Irvine.

Mean hospital length of stay was 9.3 days in the appropriate-prophylaxis group, compared with 11.2 days with partial prophylaxis. Mean hospital charges were $47,981 with appropriate prophylaxis and $69,997 with partial prophylaxis. After adjustment for patient variables and hospital characteristics, including bed count, teaching status, and geographic region, the adjusted mean difference in total charges in a multivariate analysis was $21,260.

Total unadjusted hospital costs averaged $17,386 per patient in the appropriate VTE prophylaxis group, compared with $23,823 in the partial prophylaxis group. After adjustment, the mean difference in hospital costs was $6,370 less in favor of the appropriate-prophylaxis group.

Venous thromboembolic events cost the U.S. health care system an estimated $1.5 billion annually. The assumption is that most of the cost savings documented in this study in the appropriate-prophylaxis group stemmed from VTEs avoided, although that wasn't formally studied. A randomized clinical trial would be required to rule out the possibility that the outcome differences were due to confounders that were not controlled for, the physician noted.

Disclosures: The study was funded by Sanofi-Aventis. Dr. Amin reported no relevant financial interests.

My Take

What It Takes To Curb VTE

This is an important reminder that just doing “anything” for VTE prophylaxis is not the same as doing the “right” thing with respect to evidence-based medicine.

The current focus on VTE prophylaxis rates often misses the point that we need to improve our use of appropriate VTE prophylaxis. This means that we need to give the right method to the right patient at the right dose for the right duration of time. And for many patients, the intensity of VTE prophylaxis isn't commensurate with the VTE risk of the patient.

This study highlights how costly it is when physicians don't get VTE prophylaxis “right.”

FRANKLIN A. MICHOTA, M.D., is the director of academic affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

SAN DIEGO — Partial venous thromboembolic event prophylaxis in at-risk medical and surgical inpatients is associated with a mean 2-day greater hospital length of stay and $22,000 more per patient in total hospital charges than for recipients of best-practice appropriate prophylaxis, according to a large national study.

Thus, partial VTE prophylaxis—that is, any VTE prophylaxis not in accord with American College of Chest Physicians guidelines in terms of dose or duration—not only entails adverse clinical consequences, it also carries a significant economic price, Dr. Alpesh Amin observed at the annual meeting of the American College of Chest Physicians.

He presented a retrospective case-control study of economic and clinical outcomes in 21,001 medical and surgical inpatients around the nation who received VTE prophylaxis. The data were obtained from the Thomson Reuters MarketScan Hospital Drug Database.

The VTE prophylaxis was in step with ACCP guidelines in a mere 24.5% of patients, and such low rates have also been seen in numerous other studies. The in-hospital VTE rate in the appropriate-prophylaxis group was 1.9%, compared with 1.4% in the three-quarters of patients who got partial prophylaxis, according to Dr. Amin, professor and chairman of the department of medicine and executive director of the hospitalist program at the University of California, Irvine.

Mean hospital length of stay was 9.3 days in the appropriate-prophylaxis group, compared with 11.2 days with partial prophylaxis. Mean hospital charges were $47,981 with appropriate prophylaxis and $69,997 with partial prophylaxis. After adjustment for patient variables and hospital characteristics, including bed count, teaching status, and geographic region, the adjusted mean difference in total charges in a multivariate analysis was $21,260.

Total unadjusted hospital costs averaged $17,386 per patient in the appropriate VTE prophylaxis group, compared with $23,823 in the partial prophylaxis group. After adjustment, the mean difference in hospital costs was $6,370 less in favor of the appropriate-prophylaxis group.

Venous thromboembolic events cost the U.S. health care system an estimated $1.5 billion annually. The assumption is that most of the cost savings documented in this study in the appropriate-prophylaxis group stemmed from VTEs avoided, although that wasn't formally studied. A randomized clinical trial would be required to rule out the possibility that the outcome differences were due to confounders that were not controlled for, the physician noted.

Disclosures: The study was funded by Sanofi-Aventis. Dr. Amin reported no relevant financial interests.

My Take

What It Takes To Curb VTE

This is an important reminder that just doing “anything” for VTE prophylaxis is not the same as doing the “right” thing with respect to evidence-based medicine.

The current focus on VTE prophylaxis rates often misses the point that we need to improve our use of appropriate VTE prophylaxis. This means that we need to give the right method to the right patient at the right dose for the right duration of time. And for many patients, the intensity of VTE prophylaxis isn't commensurate with the VTE risk of the patient.

This study highlights how costly it is when physicians don't get VTE prophylaxis “right.”

FRANKLIN A. MICHOTA, M.D., is the director of academic affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

SAN DIEGO — Partial venous thromboembolic event prophylaxis in at-risk medical and surgical inpatients is associated with a mean 2-day greater hospital length of stay and $22,000 more per patient in total hospital charges than for recipients of best-practice appropriate prophylaxis, according to a large national study.

Thus, partial VTE prophylaxis—that is, any VTE prophylaxis not in accord with American College of Chest Physicians guidelines in terms of dose or duration—not only entails adverse clinical consequences, it also carries a significant economic price, Dr. Alpesh Amin observed at the annual meeting of the American College of Chest Physicians.

He presented a retrospective case-control study of economic and clinical outcomes in 21,001 medical and surgical inpatients around the nation who received VTE prophylaxis. The data were obtained from the Thomson Reuters MarketScan Hospital Drug Database.

The VTE prophylaxis was in step with ACCP guidelines in a mere 24.5% of patients, and such low rates have also been seen in numerous other studies. The in-hospital VTE rate in the appropriate-prophylaxis group was 1.9%, compared with 1.4% in the three-quarters of patients who got partial prophylaxis, according to Dr. Amin, professor and chairman of the department of medicine and executive director of the hospitalist program at the University of California, Irvine.

Mean hospital length of stay was 9.3 days in the appropriate-prophylaxis group, compared with 11.2 days with partial prophylaxis. Mean hospital charges were $47,981 with appropriate prophylaxis and $69,997 with partial prophylaxis. After adjustment for patient variables and hospital characteristics, including bed count, teaching status, and geographic region, the adjusted mean difference in total charges in a multivariate analysis was $21,260.

Total unadjusted hospital costs averaged $17,386 per patient in the appropriate VTE prophylaxis group, compared with $23,823 in the partial prophylaxis group. After adjustment, the mean difference in hospital costs was $6,370 less in favor of the appropriate-prophylaxis group.

Venous thromboembolic events cost the U.S. health care system an estimated $1.5 billion annually. The assumption is that most of the cost savings documented in this study in the appropriate-prophylaxis group stemmed from VTEs avoided, although that wasn't formally studied. A randomized clinical trial would be required to rule out the possibility that the outcome differences were due to confounders that were not controlled for, the physician noted.

Disclosures: The study was funded by Sanofi-Aventis. Dr. Amin reported no relevant financial interests.

My Take

What It Takes To Curb VTE

This is an important reminder that just doing “anything” for VTE prophylaxis is not the same as doing the “right” thing with respect to evidence-based medicine.

The current focus on VTE prophylaxis rates often misses the point that we need to improve our use of appropriate VTE prophylaxis. This means that we need to give the right method to the right patient at the right dose for the right duration of time. And for many patients, the intensity of VTE prophylaxis isn't commensurate with the VTE risk of the patient.

This study highlights how costly it is when physicians don't get VTE prophylaxis “right.”

FRANKLIN A. MICHOTA, M.D., is the director of academic affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.