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In the Literature: The latest research you need to know

From: The Hospitalist, November 2011

Care-transitions intervention and rates of hospital readmission; Post-pneumonia CXR and rates of lung cancer identification; Hospitalist outcomes during and after hospitalization; Timing of smoking cessation and surgical outcomes

by Dimitriy Levin, MD, Kristin Furfari, MD, Laura Rosenthal, DNP, ACNP, Jennifer Simpson, MD, Nichole Zehnder, MD, Hospital Medicine Group, University of Colorado Denver

In This Edition

Literature At A Glance

A guide to this month’s studies

  1. Use of a Care-Transitions Intervention Reduces 30-Day Hospital Readmissions
  2. Routine Chest Radiographs after Pneumonia to Rule Out Lung Cancer Have Low Diagnostic Yield
  3. Hospitalist Care Shifts Costs to the Outpatient Environment
  4. Stopping Smoking at Any Time before Surgery Is Safe
  5. Hospitalization for Infection Increases Risk of Stroke
  6. Longer Duration of Perioperative Antibiotics May Be Beneficial after Cardiac Surgery
  7. Stroke Unit Care Combined with Early Supported Discharge Improves Outcomes
  8. Criteria May Help Identify Patients at Risk for Infective Endocarditis

Use of a Care-Transitions Intervention Reduces 30-Day Hospital Readmissions

Clinical question: Does use of a specific care-transitions intervention (CTI) reduce 30-day hospital readmissions in a nonintegrated healthcare system?

Background: Previous interventions addressing improved communication between members of the healthcare team, patients, and families at time of discharge show promise for reducing hospital readmissions. Although these interventions revealed positive results, no research has been completed within a system where healthcare is integrated across settings.

Study design: Quasi-experimental prospective cohort study.

Setting: Six Rhode Island acute-care hospitals, including two community hospitals, three teaching hospitals, and a tertiary-care center and teaching hospital. Facilities ranged from 129 beds to 719 beds.

Synopsis: The CTI is a patient-centered intervention occurring across 30 days. The intervention includes a home visit by a coach within three days of hospital discharge, a telephone call within seven to 10 days of discharge, and a final telephone call no later than 30 days after admission. During these contacts, coaches encourage patient and family participation in care, and active communication with their primary-care provider regarding their disease state. A convenience sample of fee-for-service Medicare beneficiaries was identified by admission diagnoses of acute myocardial infarction, congestive heart failure, or specific pulmonary conditions. Overall, 74% participants completed the entire intervention. The odds of a hospital readmission were significantly lower in the intervention population compared with those who did not receive the intervention (OR 0.61; 95% CI, 0.42-0.88).

Study design: Study design was limited by ability to provide coaching (only 8% of total population was approached), and therefore may not be representative of a typical integrated healthcare setting. In addition, the sample consisted of a convenience sample, which may limit generalizability.

Bottom line: The CTI appears to decrease the rate of 30-day hospital readmissions in Medicare patients with certain cardiac and pulmonary diagnoses.

Citation: Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. 2011;171:1232-1237.

Routine Chest Radiographs after Pneumonia to Rule Out Lung Cancer Have Low Diagnostic Yield

Clinical question: What is the incidence of new lung cancer detected on routine post-pneumonia chest radiographs?

Background: Routine chest radiographs have been recommended four to eight weeks after resolution of pneumonia to exclude underlying lung cancer. The diagnostic yield of this practice is uncertain.

Study design: Population-based cohort.

Setting: Seven emergency departments and six hospitals in Edmonton, Alberta, Canada.

Synopsis: Authors enrolled 3,398 patients with clinical and radiographic evidence of pneumonia. Of these, 59% were aged 50 and older, 52% were male, 17% were current smokers, 18% had COPD, and 49% were treated as inpatients. At 90-day follow-up, 1.1% of patients received a new diagnosis of lung cancer, with incidence steadily increasing to 2.2% at three-year follow-up. In multivariate analysis, age 50 and older, male sex, and current smoking were independent predictors of post-pneumonia new lung cancer diagnosis. Limiting follow-up chest radiographs to patients aged 50 and older would have detected 98% of new lung cancers and improved diagnostic yield to 2.8%.

Bottom line: Routine post-pneumonia chest radiographs for lung cancer screening have low diagnostic yield that is only marginally improved by selecting high-risk populations.

Citation: Tang KL, Eurich DT, Minhas-Sandhu JK, Marrie TJ, Majumdar SR. Incidence, correlates, and chest radiographic yield of new lung cancer diagnosis in 3398 patients with pneumonia. Arch Intern Med. 2011;171:1193-1198.

Hospitalist Care Shifts Costs to the Outpatient Environment

Clinical question: How does hospitalist care affect medical utilization costs after hospital discharge?

Background: The number of patients cared for by hospitalists is growing rapidly. Some studies have shown hospitalists to decrease length of stay and inpatient costs. The impact of shorter hospitalization on outpatient medical utilization and costs is not known.

Study design: Population-based national cohort.

Setting: Hospitalized Medicare patients.

Synopsis: In this study of 58,125 Medicare admissions at 454 hospitals, hospitalist care was associated with a 0.64-day shorter adjusted length of stay and $282 lower hospital charges compared with patients cared for by their primary-care physicians (PCPs). This was offset by $332 higher Medicare spending in the 30 days following hospitalization. Patients cared for by hospitalists were less likely to be discharged home (OR 0.82, 95% CI, 0.78-0.86), and were more likely to require emergency department visits (OR 1.18, 95% CI, 1.12-1.24) and readmissions (OR 1.08, 95% CI, 1.02-1.14). The authors postulate that shorter length of stay associated with hospitalist care is achieved at the expense of shifting costs to the outpatient environment. The discharged patients are sicker and, as a result, require more skilled care and repeat hospital visits.

Bottom line: Hospitalist care may be associated with higher overall costs and more medical utilization.

Citation: Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

Stopping Smoking at Any Time before Surgery Is Safe

Clinical question: Is smoking cessation within eight weeks of surgery safe?

Background: Smoking cessation before surgery can decrease the risk of surgical complications. However, several studies found increased risk for perioperative complications when smoking was stopped within eight weeks of surgery. These findings created uncertainty about general safety of tobacco cessation counseling before surgery.

Study design: Systematic review and meta-analysis.

Setting: Smokers undergoing any type of surgery.

Synopsis: The authors identified nine studies involving 889 patients that compared smokers who quit within eight weeks of surgery with those who continued to smoke. There was considerable heterogeneity in the studies but no overall difference in perioperative complications between those who quit smoking and those who continued to smoke (OR 0.78, 95% CI, 0.57-1.07). The subset of studies examining pulmonary complications also found no difference (OR 1.18, 95% CI, 0.95-1.46).

Bottom line: Smoking cessation at any time before surgery appears to be safe.

Citation: Myers K, Hajek P, Hinds C, McRobbie H. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Arch Intern Med. 2011;171:983-989.

Hospitalization for Infection Increases Risk of Stroke

Clinical question: Can infection act as a precipitant for acute ischemic stroke?

Background: Little is known about precipitants of acute ischemic stroke. Severe infections have been shown to promote hypercoagulability and platelet activation, and to induce endothelial dysfunction. Authors postulated that infections severe enough to warrant hospitalization might transiently increase the risk for stroke.

Study design: Case-crossover analysis of data from a multicenter prospective cohort (Cardiovascular Health Study).

Setting: Medicare patients in four communities.

Synopsis: During a median follow-up of 12.2 years, 669 strokes occurred in 5,639 study participants. Hospitalization for infection within 14 days was associated with increased risk of stroke (OR 8.0, 95% CI, 1.6-77.3), and the risk remained elevated for hospitalizations within 90 days (OR 3.4, 95% CI, 1.8-6.5). The findings remained significant after adjusting for comorbidities, including age, sex, race, smoking, and diabetes. The number of patients hospitalized for infection before stroke was small—eight within 14 days, and 29 within 90 days.

Bottom line: Infection severe enough to require hospitalization may act as a trigger for acute ischemic stroke.

Citation: Elkind MS, Carty CL, O’Meara ES, et al. Hospitalization for infection and risk of acute ischemic stroke: the Cardiovascular Health Study. Stroke. 2011;42:1851-1856.

Longer Duration of Perioperative Antibiotics May Be Beneficial after Cardiac Surgery

Clinical question: Is antibiotic prophylaxis for 24 or more hours better than shorter duration of treatment after cardiac surgery?

Background: Sternal surgical site infections are a serious complication of cardiac surgery. The optimal duration of perioperative antibiotic prophylaxis is not known, with recommendations ranging from a single dose to 72 hours. The Society of Thoracic Surgeons’ recommendation for 24 to 72 hours of prophylaxis is not based on a systematic review and meta-analysis.

Study design: Systematic review and meta-analysis.

Setting: Adult patients undergoing open-heart surgery who received perioperative antibiotic prophylaxis.

Synopsis: Authors identified 12 trials encompassing 7,893 patients. Compared with prophylaxis of ≥24 hours, prophylaxis of <24 hours was associated with a higher risk of sternal surgical site infections (RR 1.38, 95% CI, 1.13-1.69) and deep infections (RR 1.68, 95% CI, 1.12-2.53). There was no difference in mortality, other infections, or adverse events. Most studies had methodological limitations with a high risk for bias.

Bottom line: Perioperative antibiotic prophylaxis of ≥24 hours reduces sternal surgical infections.

Citation: Mertz D, Johnstone J, Loeb M. Does duration of perioperative antibiotic prophylaxis matter in cardiac surgery? A systematic review and meta-analysis. Ann Surg. 2011;254:48-54.

Stroke Unit Care Combined with Early Supported Discharge Improves Outcomes

Clinical question: Does early supported discharge (ESD) improve outcomes more than conventional follow-up in stroke patients?

Background: ESD is a mobile team that coordinates follow-up and rehabilitation. Previous studies have shown it to be beneficial in patients with mild to moderate disability at one year, but long-term effects of ESD are not known.

Study design: Randomized controlled trial.

Setting: Single center in Norway.

Synopsis: Stroke-unit patients were recruited and received standard care or ESD after discharge. All 320 patients received standard acute care. The proportion of patients with modified Rankin Score (mRS) of ≤2 was not significantly different in the two groups but identified a trend toward improvement in the intervention group (38% vs. 30%, P=0.106). More patients receiving conventional follow-up died or were institutionalized (P=0.032) but mortality rates at five years were similar (ESD 46% vs. 51%). Secondary outcomes (Scandinavian Stroke Scale, Barthel Index, Frenchay Activity Index, and Mini Mental Status Examination) were not statistically different. Predictors of good outcome in the ESD group included young age, low mRS, and living with others.

This study recruited patients from 1995 to 1997 and followed the patients for five years. Limitations to the applicability include advances in stroke rehabilitation in the last 10 years. The cost of a mobile multidisciplinary team consisting of a physiotherapist, occupational therapist, nurse, and part-time physician was not discussed and may limit the availability to many patients.

Bottom line: Early supported discharge may increase the proportion of patients living at home five years after stroke.

Citation: Fjaertoft H, Rohweder G, Indredavik B. Stroke unit care combined with early supported discharge improves 5-year outcome: a randomized controlled trial. Stroke. 2011;42:1707-1711.

Criteria May Help Identify Patients at Risk for Infective Endocarditis

Clinical question: Which patients with Staphylococcus aureus bacteremia benefit the most from transesophageal echocardiography?

Background: Infective endocarditis is a serious complication of S. aureus bacteremia (SAB), occurring in 5% to 17% of patients with documented SAB. It has been recommended to perform transesophageal echocardiography (TEE) in all patients with SAB. Large variation exists in rates of TEE, and identifying patients at low risk for endocarditis may help with more appropriate utilization of this test.

Study design: Retrospective cohort analysis.

Setting: Two university-based German tertiary hospitals (INSTINCT cohort) and one North American university-based hospital from October 1994 to December 2009 (SABG cohort).

Synopsis: A total of 736 cases of nosocomial SAB were analyzed. Age, source of infection, and 30-day and 90-day case fatality rates were similar between the two cohorts. Patients were followed during the index hospitalization and for three months after discharge.

Patients with infective endocarditis were more likely to have prolonged bacteremia; a permanent intracardiac device, such as a pacemaker or a heart valve; be recipients of hemodialysis; and have osteomyelitis. Of the 83 patients who did not fulfill any of the prediction criteria, no cases of infective endocarditis were found.

Bottom line: A set of simple criteria may help identify patients with nosocomial SAB who are at risk for infective endocarditis. The subset of patients who do not meet any of these criteria may not need diagnostic evaluation with TEE.

Citation: Kaasch, AJ, Fowler VG Jr., Rieg S, et al. Use of a simple criteria set for guiding echocardiography in nosocomial Staphylococcus aureus bacteremia. Clin Infect Dis. 2011;53:1-9.

CLINICAL SHORTS

PULMONARY NODULE NEEDLE BIOPSIES FREQUENTLY RESULT IN SERIOUS COMPLICATIONS

In a discharge database analysis, pneumothorax complicated 15% of all biopsies, with 44% requiring chest tube placement. Pulmonary hemorrhage occurred 1% of the time with 18% needing blood transfusions.

Citation: Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med. 2011;155:137-144.

CUMULATIVE ANTIBIOTIC EXPOSURES ASSOCIATED WITH RISK OF CLOSTRIDIUM DIFFICILE INFECTION

Retrospective cohort study of 7,792 patients during 10,154 hospitalizations found that cumulative dose, number, and duration of antibiotics were independently associated with the development of Clostridium difficile infection.

Citation: Stevens V, Dumyati G, Fine LS, Fisher SG, van Wijngaarden E. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis. 2011;53:42-48.

NESIRITIDE IN ACUTE HEART FAILURE HAS NO SIGNIFICANT EFFECT ON DYSPNEA, MORTALITY, OR RENAL FAILURE

A trial of 714 patients with acute heart failure randomized to receive nesiritide or placebo found no difference in death, rehospitalization, renal failure, or dyspnea. The nesiritide group experienced significantly more hypotension.

Citation: O’Connor CM, Starling RC, Hernandez AF, et al. Effect of nesiritide in patients with acute decompensated heart failure. N Eng J Med. 2011;365:32-43.

PROTON PUMP INHIBITOR THERAPY IS MODESTLY ASSOCIATED WITH INCREASED RISK OF HIP AND VERTEBRAL FRACTURES

A meta-analysis of 10 controlled observational studies found that use of proton pump inhibitors is associated with a modest increase in the risk of hip (OR 1.25; 95% CI, 1.14-1.37) and vertebral fractures (OR 1.50; 95% CI, 1.32-1.72). These results should be interpreted with caution as it is unclear if this represents causation or unmeasured confounding.

Citation: Ngamruengphong S, Leontiadis GI, Radhi S, Dentino A, Nugent K. Proton pump inhibitors and risk of fracture: a systematic review and meta-analysis of observational studies. Am J Gastroenterol. 2011;106:1209-1218.

STROKE PATIENTS HAVE HIGHER RATES OF REHOSPITALIZATION

One- and five-year mortality in Medicare stroke patients is six times and two times higher, respectively, than in non-stroke patients. Readmission rates for stroke patients are 2.5 and 1.3 times higher, respectively.

Citation: Lakashminarayan K, Schissel C, Anderson DC, et al. Five-year rehospitalization outcomes in a cohort of patients with acute ischemic stroke: Medicare linkage study. Stroke. 2011;42:1556-1562.

PROTON PUMP INHIBITORS REDUCE THE RISK OF GASTROINTESTINAL BLEEDING IN THE GENERAL POPULATION AND IN PATIENTS ON ANTITHROMBOTIC OR ANTI-INFLAMMATORY THERAPY

A population-based, nested case-control study found that proton pump inhibitor use is associated with a 20% lower risk of upper gastrointestinal bleeding in the general population. The risk reduction increases to 50% to 80% in users of gastrotoxic agents.

Citation: Lin KJ, Hernandez-Diaz S, Garcia Rodriguez LA. Acid suppressants reduce risk of gastrointestinal bleeding in patients on antithrombotic or anti-inflammatory therapy. Gastroenterology. 2011;141:71-79


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