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Hospitalist Reviews of New Research on Antibiotic-Resistant Bacteria, Pressure Ulcers, Severe Alcoholic Hepatitis, and More

From: The Hospitalist, February 2014

Also reviewed this month: surgical readmission rates, preventable hospitalizations, hospitalist-staffed post-discharge clinics

by Leigh Vaughan, MD, Kristin Wise, MD, Keri Holmes-Maybank, MD, Pamela Charity, MD, Hospital Medicine Program, Medical University of South Carolina, Charleston

In This Edition

Literature At A Glance

A guide to this month’s studies

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

Antibiotic Resistance Threats in the United States, 2013

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

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

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

Setting: United States.

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

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

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

The CDC recommends four core actions to fight antibiotic resistance:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Higher Continuity of Care Results in Lower Rate of Preventable Hospitalizations

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

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

Study design: Retrospective cohort study.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patients Overwhelmingly Prefer Inpatient Boarding to ED Boarding

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

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

Study design: Structured telephone survey.

Setting: Suburban, university-based, teaching hospital.

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

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

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

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

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


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