Published in the July 2014 issue of Today’s Hospitalist
Azithromycin and pneumonia patients
NEW DATA show that older pneumonia patients whose therapy included azithromycin had significantly lower death rates than patients given other antibiotics, but a slightly increased risk of myocardial infarction.
The research, which appeared in the June 4 Journal of the American Medical Association, found that 90-day mortality rates were significantly lower for patients whose therapy included azithromycin (17.4%) compared to patients on other antibiotics (22.3%).
However, patients prescribed azithromycin had an increased risk of heart attack (5.1% vs. 4.4%) vs. pneumonia patients given other front-line antibiotics. Between the two patient groups, researchers found no increased risk of other cardiac events, arrhythmias or heart failure.
The authors looked at data on nearly 65,000 patients 65 or older treated for pneumonia in 2002-12 in Veterans Affairs hospitals. While previous studies have suggested that azithromycin in older patients may lead to increased cardiovascular events, researchers concluded that therapy including azithromycin produced a net benefit of about seven deaths averted for every one nonfatal MI.
What works to reduce heart failure readmissions?
A META-ANALYSIS of trials gauging the impact of different types of transitional care programs found that home visits and multidisciplinary heart failure clinics are most effective in lowering readmission rates and improving mortality among heart failure patients.
Results were published in the June 3 Annals of Internal Medicine. Over a three-to-six month period, high-intensity home visits reduced readmission rates for heart failure by 66% and lowered all-cause readmission rates.
However, multidisciplinary heart failure clinics lowered all-cause readmission rates only. The authors pointed out that few of the studies included in the analysis “and there were nearly 50 “reported 30-day readmission rates.
The authors also found that providing structured telephone support after discharge improved survival rates and produced fewer heart failure readmissions over six months. But telemonitoring and educational programs did not lower readmission rates or improve mortality. Currently, researchers pointed out, nearly one in four heart failure patients bounces back to the hospital within 30 days.
Depression linked to readmission rates
RESEARCHERS analyzing patients’ admission screens for depression have found a dose-response association between depression and 30-day readmission rates.
A study in the June issue of the Journal of Hospital Medicine looked at data for more than 1,400 hospitalized adults in one urban academic center. Among those patients, 16% screened positive for mild depression, while 24% screened positive for moderate or severe depression.
The 30-day readmission rate, which was 12.6 per 100 patients with no depression, jumped to 19.6 for those with mild depression and to 21.1 for those with moderate to severe depression. Patients with depression were also more likely to visit the ED within 30 days of discharge.
If future studies bear out the link between depression and readmission rates, the authors wrote, “policymakers should increase support for mental health screening and programming as an integral portion of general medical patient management.” They also recommended more studies on interventions for patients who screen positive for depression.
In arrests, faster epinephrine could boost survival
A RETROSPECTIVE STUDY published in May in the British Medical Journal concludes that faster administration of epinephrine in patients who arrest in the hospital with nonshockable rhythm is “strongly associated” with patient survival.
Researchers from Boston’s Beth Israel Deaconess Medical Center used a resuscitation registry of 25,000 patients who arrested in the hospital with either asystole or pulseless electrical activity. The study looked at how well patients survived to discharge. Authors also analyzed patients’ rates of 24-hour survival and return of spontaneous circulation.
Patients were excluded if they arrested in the ED, ICU or surgical unit. Those who were given epinephrine within one to three minutes had the greatest chances of survival when compared to patients who received epinephrine within nine minutes or more.
The authors recommended making “time to epinephrine” a quality metric to be used when arrested patients with nonshockable rhythm are being resuscitated. Currently, authors noted, standards of care for patients with nonshockable rhythm focus only on CPR.
Time for a new hospitalist subspecialty?
A LEADING HOSPITALIST RESEARCHER is pilot-testing a new type of hospitalist: a comprehensive care physician who would provide both inpatient and outpatient care to high-risk patients prone to repeat hospitalizations.
David Meltzer, MD, PhD, the head of hospital medicine at the University of Chicago, co-authored an article in the May issue of Health Affairs that describes the physician model being tested at the University. The pilot program is being funded by an innovation grant from the Centers for Medicare and Medicaid Services.
In the project, comprehensive care physicians are given a panel of about 200 patients. According to the article, that panel size is big enough for physicians to see patients daily in the hospital while also providing ambulatory care to patients in nearby clinics after discharge. Project results will be available in 2016.
In addition to improving care coordination for high-risk patients with multiple health conditions, the article states that the model may give participating physicians the psychological reward of caring for patients they know well.
CPOE tool blocks orders for duplicate labs
RESEARCHERS from the Cleveland Clinic report that a decision-support tool built into their CPOE system blocks physicians from ordering unnecessary duplicate labs, saving money for the hospital system.
Over two years, the use of the clinical decision-support tool blocked physician orders for nearly 12,000 duplicate lab tests. That effort produced a cost savings of more than $183,000.
Within those two years, the authors noted that there were no adverse events associated with the intervention. Results were published in the May issue of the American Journal of Clinical Pathology.
While the program won’t allow doctors to order unnecessary duplicate labs, it provides the results of the test that was previously ordered. In addition to increased costs, the authors wrote that unnecessary duplicate lab testing leads to unwarranted phlebotomy, reduced patient satisfaction and a higher rate of iatrogenic anemia.
Coverage of the initiative published by the American Association for Clinical Chemistry pointed out that the project began by blocking 10 tests that don’t need to be done more than once a day “a list that’s grown to include 1,200 tests.
Gender, specialty gap in political contributions
RESEARCH INTO physicians’ political donations finds that doctors have shifted some support toward Democratic candidates, with key contributing differences popping up in terms of gender, practice setting and specialty.
Researchers looked at contributions from physicians to federal and congressional candidates, party committees, and super PACs from 1991 to 2012. Over that time, the percentage of active doctors making political contributions jumped from 2.6% to 9.4%, while the value of their contributions soared from $20 million to $189 million. Results were posted online by JAMA Internal Medicine.
In the mid-1990s, nearly 75% of physician contributions went to the GOP, a percentage that fell to 50% by 2012. In 2011-12, 52% of contributions from male physicians went to Republicans vs. 23.6% of contributions from female physicians.
Among surgeons in 2011-12, 70.2% of contributions supported the GOP vs. 22.1% of contributions from pediatricians. The authors noted that the shift in political contributions could reflect the growing number of women physicians and the fewer number of solo or small practices.
New start-up crowd-sources diagnoses
A NEW START-UP is offering the Yelp approach to clinical diagnoses. Based in San Francisco, CrowdMed invites patients to submit difficult medical cases online.
According to the company’s Web site, submitting cases is free, although patients can offer a cash reward ($50 minimum). The site’s “medical detectives” “physicians, medical students and online researchers “then suggest possible diagnoses within 90 days as well as “bet” on the most likely diagnostic solutions. Patients are asked to pass those suggestions along to their physicians.
Medical detectives who either offer or bet on what prove to be the best diagnoses divide any cash reward offered. Medical detectives also earn points by making smart diagnoses and smart bets.
According to the site, patients have submitted more than 250 cases, 80% of whom reported receiving an accurate diagnosis. CrowdMed’s CEO founded the company in 2013 after his sister struggled for years to receive the correct diagnosis of a rare disease.
According to coverage in the San Jose Mercury News, CrowdMed has received $2.4 million in venture capital.
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