Reviews of Research on Steroids and VTE Risk, Epidural Catheterization, and Beta-Blockers During Noncardiac Surgery
In This Edition
Literature At A Glance
A guide to this month’s studies
- Steroids may increase VTE risk
- Mortality rates rise at critical-care hospitals
- Physicians don’t discuss advance-care planning with elderly, families
- Ultrasound imaging for lumbar puncture, epidural catheterization
- Financial impact of surgical complications on hospitals
- Lab test fees and frequency of test ordering
- Inpatient elderly multidisciplinary teams reduce readmissions
- Use of beta-blockers in high-risk patients during noncardiac surgery
- Patient-centered decision-making and health-care outcomes
- Adverse surgical outcomes in patients with schizophrenia
Steroids May Increase VTE Risk
Clinical question: Is exogenous glucocorticoid administration associated with an increased risk of VTE?
Background: Endogenous hypercortisolism is linked to increased VTE rates, and pathophysiologic data exist to suggest glucocorticoids increase clotting, but few studies have measured the clinical link between glucocorticoid administration and VTE events.
Study design: Case-control study.
Setting: Denmark.
Synopsis: The authors analyzed Danish national registries, which include information on diagnoses and prescriptions. The study selection period was Jan. 1, 2005, to Dec. 31, 2011. During this period, 38,675 cases of VTE (both DVT and pulmonary embolism) were identified in the population of Denmark. These cases were matched with 387,650 controls. Three routes of glucocorticoid use were studied: systemic (oral and intravenous), inhaled, and intestinal-acting. Cases were classified as present (within 90 days of VTE event), recent (91 to 365 days), or former (over 365 days) users of glucocorticoids. Categories were also created for new versus continuous users.
Glucocorticoid use was associated with a significant increase in VTE occurrence. The strongest link was in new and recent users, and the effect diminished over time. Key limitations of the study included its reliance on registry data, as well as the fact that cases had more comorbid conditions than controls (e.g. recent infection, chronic illnesses).
Bottom line: Recipients of glucocorticoids had an increased risk of VTE; the effect was strongest in new and recent users.
Citation: Johannesdottir SA, Horvath-Puho E, Dekkers OM, et al. Use of glucocorticoids and risk of venous thromboembolism. JAMA Intern Med. 2013;173(9):743-752.
Mortality Rates Rise at Critical-Access Hospitals
Clinical question: How have trends in mortality changed in the past decade at critical-access hospitals when compared to other hospitals?
Background: Hospitals are designated as critical-access hospitals (CAH) by meeting certain requirements—namely, rural setting, small number of beds, and minimum distance from the nearest hospital. Because of the intrinsic challenges they face, CAHs are exempt from certain quality measures. Little data exist on patient outcomes at CAHs.
Study design: Retrospective observational study.
Setting: All nonfederal hospitals in the U.S. that provide acute care to Medicare beneficiaries.
Synopsis: Using Medicare data, risk-adjusted 30-day mortality rates were calculated at critical-access hospitals and non-critical-access hospitals from 2002 to 2010 for three conditions: acute myocardial infarction, congestive heart failure, and pneumonia. Mortality trends across these conditions were compared at baseline and over time. In 2002, CAHs had mortality rates comparable with non-CAHs. From 2002 to 2010, mortality rates increased by 0.1% per year at CAHs and decreased by 0.2% per year at non-CAHs, resulting in a mortality difference between these two hospital groups at the end of the study period. The authors postulate that differences in policy initiatives, enforcement of quality measures, and access to technology may play a role.
This study is limited in its ability to explain the findings. Notably, within the CAHs, the authors found that 48% did improve from 2002 to 2010; there were no significant differences in hospital characteristics between the CAHs that did and did not improve. The reasons for the overall widening gap between CAHs and non-CAHs, therefore, merit further investigation.
