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Update in Hospital Medical Literature 2008

Update in Hospital Medical Literature 2008. Mel L. Anderson, MD FACP Assistant Professor, UCDSOM Denver VA Medical Center September 23, 2008. Overview. Method of selection For each: Overview Results Bottom Line Summary of practice change Q & A. Objectives.

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Update in Hospital Medical Literature 2008

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  1. Update in Hospital Medical Literature 2008 Mel L. Anderson, MD FACP Assistant Professor, UCDSOM Denver VA Medical Center September 23, 2008

  2. Overview • Method of selection • For each: • Overview • Results • Bottom Line • Summary of practice change • Q & A

  3. Objectives • Take away a bottom line message from each study reviewed today • Reflect on whether your practice might be altered by this information • Seek an electronic means of maintaining currency with the medical literature

  4. Methods • Jan 08 – August 08 • N Engl J Med • JAMA • J Hospit Med, The Hospitalist • Lancet • Am J Med • Ann Intern Med + ACP J Club • Arch Intern Med • Circulation, J Am Coll Cardiol • BMJ, Chest, Mayo Clin Proceed • ACP Plus and BMJ Online update

  5. Methods • Thousand+ articles screened • Validity, importance, applicability • Practice change • 13 presented today

  6. Topics • Quality Improvement • ACS/CAD • Acute heart failure • VTE prevention, LOS • Staph aureusbacteremia • Palliative care

  7. Quality Imp. • Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross sectional study. Lancet 2008;371:387-94. PMID: 18242412

  8. Quality Imp. • Observational study of 68,183 medical and surgical inpatients across 358 hospitals in 32 countries • Prevalence of VTE risk • Prevalence of VTE prophylaxis • ACCP 2004 Guidelines

  9. Quality Imp. • About half of all patients were at risk for VTE • Among surgical patients, 58.5% received recommended prophylaxis • Among medical patients, 39.5% received recommended prophylaxis • We have a ways to go…

  10. Quality Imp. • Innovative approaches to increase DVT prophylaxis rate resulting in a decrease in hospital-acquired DVT at a tertiary-care teaching hospital. Journal of Hospital Medicine 2008;3:148-55. PMID: 18438791

  11. Quality Imp. • Descriptive review of “an active, multifaceted, layered combination of provider education, provider reminders with decision support, and audits with feedback” • Kings County Hospital SUNY 2002

  12. Quality Imp. • Rate of VTE prophylaxis increased from 63% in 2002 to 96% in 2005 • Hospital-acquired DVT rate decreased from 2.6/1000 discharges to 0.2/1000 discharges, p=0.007. • Wow.

  13. Quality Imp. • Hospital treatment of patients with ischemic stroke or transient ischemic attack using the Get With the Guidelines program. Arch Intern Med 2008;168:411-417. PMID: 18299497

  14. Quality Imp. • 1-year intervention study using the AHA/ASA “Get With The Guidelines-Stroke” program across 99 hospitals involving 18,410 pts • Adherence to 13 acute stroke care performance measures

  15. Quality Imp. • Significant improvement in 11/13 • Lytics: 23.5% 40.8% • Early antiplt: 88.2%  95.2% • Discharge antiplt: 91%  97.9% • AC for A fib: 81.4%  96.5% • Tob cess couns: 38.3%  54.5% • Statin if LDL>100: 58.7%  77%

  16. Quality Imp. • DM treatment: 48.5%  83.5% • Wt reduction: 32.5%  43.4% • All measures: 50.2%  58% • P<0.001 for all eleven • Missed: VTE proph, complications from lytics • www.americanheart.org

  17. ACS/CAD • Incidence of death and myocardial infarction associated with stopping clopidogrel after acute coronary syndrome. JAMA 2008;299:532-9. PMID: 18252883

  18. ACS/CAD • Retrospective cohort study of 3,137 veterans with ACS discharged on clopidogrel • Rates of mortality or acute myocardial infarction during the period after stopping clopidogrel

  19. ACS/CAD

  20. ACS/CAD

  21. ACS/CAD • Clustering of death and AMI in the first 90 days of stopping clopidogrel with a nearly two-fold increase in risk • This is a high risk period

  22. ACS/CAD • Early invasive vs conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction: a meta-analysis. JAMA 2008;300:71-80. PMID: 18594042

  23. ACS/CAD • Meta-analysis of 8 randomized trials enrolling 10,150 women and men • Death, MI, and re-hospitalization for ACS within 12 months • Odds ratios for combined endpoint

  24. ACS/CAD • All: OR 0.78 (0.61-0.98) NNT 21 • Men: OR 0.73 (0.55-0.98) NNT 20 • +Tn: OR 0.56 (0.46-0.67) NNT 10 • Women: OR 0.81 (0.65-1.01) NS • +Tn: OR 0.67 (0.50-0.88) NNT 15

  25. ACS/CAD • Conclusion: All men and high-risk women benefit from an interventional strategy in non STE acute coronary syndrome • Conservative strategy in low risk women • Positive biomarkers much more benefit

  26. ACS/CAD • Use of cardiac catheterization for non ST-elevation acute coronary syndromes according to initial risk: Reasons why physicians choose not to refer their patients (Canadian ACS Registry II). Arch Intern Med 2008;168:291-296. PMID: 18268170

  27. ACS/CAD • Prospective multicenter observational study of 2136 patients with NSTE ACS • Divided by tertiles TIMI score • Interviewed “most responsible physician” re: why not referred

  28. ACS/CAD • Referral rate for cath 64.7% • “Low risk” most common reason given for not referring • Rate of referral for cath unchanged by TIMI risk score tertile (i.e. just as likely to get a cath whether low or high risk)

  29. ACS/CAD • Mortality rate lower in those undergoing cath (0.8% versus 3.7%, p<0.001) • High risk patients not getting cath frequently enough

  30. CHF • Influence of beta blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure (OPTIMIZE-HF). J Am CollCardiol 2008;52:190-9. PMID: 18617067

  31. CHF • OPTIMIZE-HF registry of 48,612 patients across 259 centers admitted with acute decompensated heart failure • Pre-specified sub-study of 5,791 patients with 60-90 day f/u • Risk of death / re-hospitalization

  32. CHF • Among 2,373 patients eligible for beta-blockers at discharge: • 56.9% continued therapy • 26.6% newly started • 12.8% eligible but not treated • 3.3% beta blockers withdrawn

  33. CHF • Continued on BB vs. eligible for BB but not started • Adj HR death 0.60 (0.37-0.99) • Newly started on BB vs. eligible for BB but not started • Adj HR death 0.41 (0.22-0.78)

  34. CHF • Withdrawn from BB vs. continued • Adj HR death 2.34 (1.20-4.55) • Have the courage to continue the beta blocker unless symptomatic bradycardia, hypotension, or cadiogenic shock is present

  35. VTE • Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med 2008; 358:2765-75. PMID: 18579811 • RECORD 1 (of 4)

  36. VTE • RCT oral direct thrombin inhibitor rivaroxaban 10 mg daily vs. enoxaparin 40mg daily x 35 days after hip arthroplasty • Combined endpoint: DVT, non-fatal PE, or death at 36 days • 4,541 patients

  37. VTE • Enoxaparin: 3.7% • Rivaroxaban: 1.1% • ARR 2.6%, NNT 39 • P<0.001 • “Major thromboembolism” – • Enoxaparin 2.0% • Rivaroxaban 0.2% • ARR 1.8%, NNT 56, p<0.001

  38. VTE • Bleeding no different • Unknown how rivaroxaban might compare to warfarin • Efficacy • Cost • Safety • For now, add to the tool kit and remember to treat for weeks

  39. VTE • Length of hospital stay and post-discharge mortality in patients with pulmonary embolism. Arch Intern Med 2008;168:706-712. PMID: 18413552

  40. VTE • Pennsylvania Health Care Cost Containment Council Database (PFC4) • 15,531 patient discharges with PE • Applied survival models to examine associations between • Pt/hospital factors and LOS • LOS and 30 day mortality

  41. VTE • Median LOS 6 days • 30 day mortality rate 3.3% • Severity of illness  greater LOS • LOS < 4 days vs. 5-6 days • Adj OR for death 1.55 (1.21-2.00) • LOS > 8 days vs. 5-6 days • Adj OR for death 2.39 (1.87-3.06)

  42. VTE • Why might shorter LOS patients fare worse? • Higher risk patients: about 50% of pts w/ LOS < 4 days were high risk • Anticoagulation suboptimal • Minimum 5 days heparin agent • Minimum 2 days overlap where both therapeutic INR and heparin are present

  43. VTE • Assess risk with a validated tool such as the Pulmonary Embolism Severity Index (PESI) to select patients at low risk / appropriate for early outpatient mgnt • Ensure correct subsequent anticoagulation bridging for all

  44. Staph aureus • Venous thrombosis in patients with short- and long-term central venous catheter-associated Staphylococcus aureus bacteremia. Crit Care Med 2008; 33:385-390. PMID:18091541

  45. Staph aureus • Prospective observational cohort of 65 consecutive line-associated Staph aureus bacteremia patients • Central line: IJ, brachial, or subclavian • All underwent US • How good are clinical signs of clot?

  46. Staph aureus • Clot present: 71% • Sensitivity of Phys exam <24% • Death/recurrent bacteremia • If thrombosis present: 32% • Without thrombosis: 14% • P=0.29 but numbers are low • All patients with line associated Staph aureus bacteremia need US

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