Background: Use of potentially inappropriate medications (PIM) in the elderly based on the Beers’ List is common in nursing homes, the emergency department (ED), and outpatient settings and is associated with adverse outcomes and hospitalization. Frequency of PIM use the inpatient setting has not been well studied.
Study Design: A retrospective cohort study.
Setting: 384 U.S. hospitals.
Synopsis: In this retrospective cohort study of 493,971 inpatients (older than 65) admitted with medical diagnoses to non-surgeons, PIM prescription was evaluated. Forty nine percent of all patients were prescribed at least one PIM, while 6% were prescribed three or more. In a multivariable model, physician specialty was associated with variation in high severity PIM (HSPIM) prescription. In comparison with internal medicine physicians, cardiologists (odds ratio [OR] 1.32) and pulmonologists (OR 1.10) were more likely to prescribe HSPIMs, while hospitalists (OR 0.90) and geriatricians (OR 0.60) were less likely. In addition, patient age older than 85 was associated with decreased HSPIM prescription (OR 0.59) compared with those younger than 85.
Compared with patients in the Midwest, patients in the South (OR 1.63) and West (OR 1.43) were more likely to prescribe HSPIMs, while those in the Northeast (OR 0.85) were less likely. Hospitals with geriatric services had less PIM use. The study couldn’t account for continuation of chronic medications and did not evaluate adverse outcomes from PIM prescribing.
Bottom line: PIM prescription to hospitalized geriatric patients is common and associated with provider and hospital characteristics.
Citation: Rothberg MB, Pekow PS, Liu F, et al. Potentially inappropriate medication use in hospitalized elders. J Hosp Med. 2008;3:91-102:91-102.
Background: The benefit of adjuvant corticosteroids in the treatment of bacterial meningitis in children in the developed world remains unclear; recent expert guidelines reflect this uncertainty.
Study Design: Retrospective cohort study.
Setting: Twenty-seven tertiary care hospitals in the United States.
Synopsis: Researchers examined 2,780 children with a primary diagnosis of bacterial meningitis discharged from 27 tertiary care centers in the U.S. from 2001-2006. Using a propensity analysis (to control for severity of illness), the study compared those who had received adjunctive corticosteroids with those who had not, with mortality and length of study (LOS) as primary outcomes.
The median age was nine months, 8.9% of children received corticosteroids, and the overall mortality rate was 4.2%. Adjuvent corticosteroids did not reduce mortality or LOS. The outcomes were unchanged in subgroup analyses.
Although limited by its retrospective design and lack of other outcome measures (e.g., hearing loss, neurological deficits), this study provides reasonable evidence that corticosteroid use in bacterial meningitis in children may not save lives or shorten LOS. Pediatric hospitalists may not want to routinely give steroids in this setting pending large randomized-controlled trials.
Bottom line: Adjunctive corticosteroids therapy in children with bacterial meningitis may not save lives or reduce LOS.
Citation: Mongelluzzo J, Mohamad Z, Ten Have TR, Shah SS. Corticosteroids and mortality in children with bacterial meningitis. JAMA. 2008;299(17):2048-2055.
Background: The current standard of care for the treatment of left main coronary artery disease is coronary-artery bypass grafting (CABG). With the advent of drug-eluting stents, there is growing interest in the use of percutaneous coronary intervention (PCI) to treat left main disease.
Study Design: Prospective observational study.
Setting: Twelve Korean cardiac centers.
Synopsis: From 2000 to 2006, patients with left main disease were treated with PCI or CABG at the discretion of the physician. Nearly 1,100 patients in each cohort were compared and evaluated for death and a composite outcome of death, myocardial infarction, or stroke. Propensity-matching was employed to control for confounders.