Published in the August 2011 issue of Today’s Hospitalist
Once-a-day pill approved for DVT prevention
THE FDA LAST MONTH approved rivaroxaban (Xarelto), an oral anticoagulant for DVT and PE prevention after hip and knee replacement surgery. Approved at a 10 mg dose, rivaroxaban is supposed to be taken for up to 12 days following knee replacement and up to 35 days for those with hip replacements.
According to an FDA press release, rivaroxaban has been shown in studies to reduce patients’ risk of developing VTE compared to enoxaparin. One study found that VTE was diagnosed in 9.7% of knee-replacement patients taking rivaroxaban compared to 18.8% of those taking enoxaparin. Rivaroxaban posted the same safety profile as enoxaparin in terms of major bleeding.
Last fall, the FDA approved another oral anticoagulant, dabigatran (Pradaxa), for preventing stroke and embolism in patients with atrial fibrillation. (Dabigatran was not approved for DVT prevention.) Analysts writing about rivaroxaban note that its once-a-day dosing may improve anticoagulation compliance compared to warfarin or to dabigatran, which must be taken twice a day
AHA warns of worsening drug shortages
AN AMERICAN HOSPITAL ASSOCIATION (AHA) survey of more than 800 hospitals found that all are experiencing some drug shortages, and that nearly half reported recent shortages involving more than 20 drugs.
Three-quarters of the hospitals reporting drug shortages said they’re rationing their supplies of those drugs. Survey results also indicated that hospitals were either delaying treatment for patients because of drug shortages or giving patients less effective “and, often, more expensive “drug alternatives.
Other survey results released earlier this year from a hospital purchasing alliance found increasing shortages for chemo, sedation and pain medications. That earlier survey also indicated that the number of drugs in short supply has increased three-fold since 2005.
Compounding the problem is the fact that hospitals only rarely receive any advance notice of an impending shortage, and they’re not told the reason for the shortage or how long it should last.
The AHA is endorsing a federal bill that would step up notification efforts when drug shortages occur.
Ambulances deliver faster scanning, interpretation times
PATIENTS WITH PRESUMED STROKES who come to the hospital via ambulance instead of private transport have brain scans completed and interpreted much more quickly. That in turn leads to faster treatment for patients with ischemic strokes.
A study published online by Stroke found that patients being transported by ambulance to hospitals were twice as likely to have timely brain scans as those taken privately to hospitals. Further, patients in ambulances where EMTs notified the hospital en route were three times more likely to have timely scans.
Guidelines now recommend brain scans for patients with stroke symptoms within 25 minutes of arriving at the hospital and interpretations of those results in the next 20 minutes. The study’s authors found that only 20% of patients in the study achieved scanning and interpretation in that timeframe. But patients brought in by ambulance where the hospital was notified had scans done within 48 minutes compared to 72 minutes for patients not transported via ambulance to a hospital.
Are hospitals PCI-happy?
A STUDY THAT LOOKED AT THE USE OF PCI in nearly 1,100 hospitals from 2009 to 2010 found that 71% of those procedures were for patients with acute indications including STEMI, non-STEMI and high-risk unstable angina.
However, among the 29% of PCIs performed for nonacute indications, only half were appropriate, according to researchers writing in the July 6
Journal of the American Medical Association. The authors found that among those PCIs deemed inappropriate, for instance, more than half of patients had no angina and more than 70% had low-risk ischemia on stress testing.
The rate of inappropriate PCIs also varied across hospitals, from a low of 6% to a high of 16% or more. According to the authors, the rate of inappropriate PCIs is likely driven by "clinician factors," although the researchers do note that patients overestimate PCI benefits and that "patient preferences may influence physicians’ decision."
The authors also said that quality improvement projects should target hospitals with higher rates of inappropriate procedures.
Low-risk PE patients may do as well with outpatient treatment AN INTERNATIONAL STUDY that randomized low-risk PE patients to either outpatient or inpatient treatment found that patients could be treated effectively as outpatients. Outpatients in the trial had similar rates of 90-day mortality, recurrent VTE, and major bleeding within 14 and 90 days as those who were admitted for inpatient care.
The noninferiority trial, which appeared in the July issue of The Lancet, looked at patients in EDs in Europe and the U.S. from 2007 to 2010. All patients included in the trial were in a pulmonary embolism severity index risk class of 1 or 2. Although guidelines recommend outpatient treatment for select, stable patients, the authors noted that most of these patients tend to be admitted.
The length of stay for patients admitted for treatment was between three and nine days. Patients were considered to be treated as outpatients if they were discharged up to 24 hours after they’d been randomized.
Do fall prevention programs work?
A REVIEW OF THE LITERATURE on hospital programs designed to prevent falls found little evidence that such programs significantly reduce the number of inpatient falls. Further, argued authors in the July Journal of the American Academy of Orthopedic Surgeons, many inpatient falls can be attributed to patients’ medical conditions or the use of medications and shouldn’t be classified as preventable.
Researchers noted that the use of interventions “such as patient education, vision assessment and walking aids “that help prevent falls in long-term care and at home do not have as much of an impact during shorter hospital stays. Authors also pointed out that many conditions such as delirium and Parkinson’s increase patients’ risk of falling.
While the authors concluded that hospitals should continue the fall prevention programs they have in place, they called for randomized trials to help determine which procotols work. The CMS no longer reimburses hospitals for the costs of treating inpatient falls, which the authors stated range as high as $20 billion per year.
Speed is the key to hypothermia success
RESULTS FROM THE MINNEAPOLIS HEART INSTITUTE indicated that among patients who received therapeutic hypothermia after cardiac arrest, 56% survived to discharge. A large majority of those patients (92%) also achieved normal or near normal neurologic function.
The study looked at hypothermia results in 140 patients from 2006 to 2009. Patients were eligible for the intervention if their spontaneous circulation returned in less than an hour. Survival was highest in patients whose spontaneous circulation returned in less than 30 minutes and for whom hypothermia was initiated less than 1.5 hours after the return of spontaneous circulation.
Three-quarters of the patients, the authors noted, were transferred to the hospital where therapeutic hypothermia was performed. Every one-hour delay in starting hypothermia, researchers said, reduced survival odds by 20%.
The authors found a strong association for mortality with nonventricular fibrillation arrest and cardiogenic shock, but patients with these characteristics who survived had very high rates of neurological recovery. The study appeared in the July 12 Circulation.
More than half of all medmal claims are dropped
A NEW ANALYSIS OF MALPRACTICE CLAIMS indicated that more than half of all claims filed (58.6%) are dropped before they reach settlement or adjudication.
The analysis, which was published in the July Health Affairs, also noted that 26.6% of claims are settled, while 14.8% end up in court. The major reason claims were dropped was not because those claims were frivolous, the author wrote, but because more information came out before any trial took place that weakened plaintiffs’ cases and caused them to abandon the claims.
In light of the number of medmal cases that are abandoned, the author recommended that hospitals and insurers adopt procedures to help plaintiff and defense attorneys exchange information more quickly and efficiently. That would allow claims that will eventually be dropped to be resolved more quickly, cutting down on both the number of claims and the costs for litigating medical malpractice.