Bottom line: Moderate-quality evidence suggests that probiotic prophylaxis results in a large reduction in C. diff-associated diarrhea without an increase in clinically important adverse events.
Citation: Johnston BC, Ma SSY, Goldenberg JZ, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Ann Intern Med. 2012;157(12):878-888.
Rates of Hemorrhage from Warfarin Therapy Higher in Clinical Practice
Clinical question: What is the incidence of hemorrhage in a large population-based cohort of patients with atrial fibrillation who have started warfarin therapy?
Background: There is strong evidence that supports the use of warfarin to reduce the risk of stroke and systemic embolism in patients with atrial fibrillation. There are currently no large studies offering real-world, population-based estimates of hemorrhage rates among patients taking warfarin.
Study design: Retrospective cohort study.
Synopsis: This population-based, cohort study included 125,195 residents of Ontario age ≥66 years with atrial fibrillation who started taking warfarin sometime from 1997 to 2008. Hemorrhage was defined as bleeding requiring an emergency department visit or hospital admission. The overall risk of hemorrhage was 3.8% per person-year, but it was 11.8% in the first 30 days of therapy. For subjects age >75 years, the overall risk was 4.6% compared with 2.9% for those between 66 and 75 years.
Most hospital admissions involved gastrointestinal hemorrhages (63%). Almost 1 in 5 people (18%) with hospital admissions for hemorrhages died in the hospital or within seven days of discharge.
Bottom line: Rates of hemorrhage for older patients on warfarin therapy are significantly higher in clinical practice than the rates reported in clinical trials. The difference is likely due to the strict inclusion criteria, younger average age, and close monitoring of patients in clinical trials.
Citation: Gomes T, Mamdani MM, Holbrook AM, Paterson JM, Hellings C, Juurlink DN. Rates of hemorrhage during warfarin therapy for atrial fibrillation. CMAJ. 2013; Jan 21 [Epub ahead of print].
Less Experienced Doctors Incur Higher Treatment Costs
Clinical question: Which physician characteristics are associated with higher cost profiles?
Background: While both public and private insurers increasingly use physician cost profiles to identify physicians whose practice patterns account for more healthcare spending than other physicians, the individual physician characteristics associated with cost-profile performance are unknown.
Study design: Retrospective cohort study.
Setting: Four commercial health plans in Massachusetts.
Synopsis: Data collected from the insurance claims records of 1.13 million patients aged 18-65 years who were enrolled in one of four commercial health plans in Massachusetts in 2004 and 2005 were matched with the public records of 12,116 doctors who were stratified into five groups according to years of experience (<10, 10-19, 20-29, 30-39, and ≥40 years).
A strong association was found between physician experience and cost profiles, with the most experienced doctors—40 or more years of experience—providing the least costly care. Costs increased with each successively less experienced group (by 2.5%, 6.5%, 10%, and 13.2% more, respectively, to treat the same condition). No association was found between cost profiles and other physician characteristics, such as having had malpractice claims or disciplinary actions, board certification status, and practice size.
Differences appear to be driven by high-cost outlier patients. While median costs were similar between physicians with different levels of experience, the costs of treating patients at the 95 percentile of cost were much higher among physicians with less experience.
Bottom line: Doctors in this study with the least experience incurred 13.2% greater costs than their most senior counterparts.
Citation: Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood). 2012;31(11):2453-2463.