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Conflicting evidence in heart failure treatment

January 2013

Published in the January 2013 issue of Today’s Hospitalist

Treating heart failure: which studies to believe?

TWO RECENT OBSERVATION STUDIES contradict findings from randomized, controlled trials in terms of the efficacy of heart failure treatments. In one study, Swedish researchers looked at registry data for nearly 42,000 patients with heart failure and preserved ejection fractions. They found that the use of ACE inhibitors or ARBs was associated with lower all-cause one-year mortality, although several randomized trials have found no mortality benefit from those agents.

In another study, researchers analyzing Medicare claims data found no survival benefit at three years from giving heart failure patients with reduced ejection fractions aldosterone antagonists at discharge.

According to the authors of that study, randomized trials had found the therapy to be “highly efficacious.” The authors did find that patients treated with aldosterone antagonists had fewer heart failure readmissions at three years, but not lower rates of cardiovascular readmissions. Patients treated with aldosterone antagonists also had higher 30-day readmission rates for hyperkalemia.

Both studies were published in the Nov. 28, 2012, Journal of the American Medical Association.

The high costs of ED crowding

IN WHAT MAY BE THE LARGEST STUDY to date to quantify poor outcomes associated with emergency department crowding, researchers say that patients coming to crowded EDs have a 5% greater risk of in-hospital mortality than those who visit the same hospitals when they’re less crowded. Patients visiting crowded EDs also rack up 1% more in higher costs.

In a retrospective analysis, researchers reviewed data on more than 995,000 ED visits to nearly 190 hospitals in California in 2007. The study used hours of ambulance diversion as a measure of ED crowding. Results were posted online in December by the Annals of Emergency Medicine.

In addition to finding higher mortality risk associated with patients visiting more crowded EDs, the study found that greater crowding was associated with a modest increase in LOS. Over the course of the period studied, the authors estimate that ED crowding contributed to 300 excess deaths, 6,200 preventable hospital days and $17 million in additional costs.

According to the authors, their findings suggest that ED crowding is “a marker of worse care” for ED patients who might need to be admitted to the hospital.

Mixed marks for shorter teaching rotations

RESEARCHERS AT A CHICAGO TEACHING HOSPITAL who randomized internal medicine attendings to either two- or four-week teaching rotations found that attendings significantly preferred shorter stints. Trainees, however, did not.

The year-long study, which was published in the Dec. 5, 2012, Journal of the American Medical Association, found that attendings working four-week rotations were twice as likely to report burnout and exhaustion as those working only two weeks. However, residents and medical students felt that having attendings on for only two weeks hurt their relationship with their teachers.

Attendings who worked two weeks instead of four also scored lower in their ability to evaluate trainees. Attendings in both groups had similar LOS for patients and the same number of unplanned patient visits “a measure that included ED visits, readmissions and transfers from other hospitals “within 30 days of discharge.

The authors noted that the trend in teaching hospitals is toward shorter rotations, including ones that are only one week. They also suggested that testing trainee skills might be a more effective way to measure attending performance than reporting the perceptions of residents and students.

When are you too old to practice?

WITH PHYSICIANS aging as quickly as patients, some hospitals are moving to require competency screening for older doctors to maintain their privileges.

Sources quoted in a Kaiser Health News article published in the Dec. 10 Washington Post note that between 5% and 10% of hospitals have started requiring physicians at age 70 or 75 to take physical and cognitive exams.

Some administrators believe that such testing is arbitrary and that doctors should be assessed individually, instead of having a specific age tied to mandatory screening. But other physicians quoted in the article noted a “code of silence” among colleagues of impaired older doctors. They also pointed to the fact that some older physicians “particularly surgeons ” do not keep up with technical innovations.

According to the article, 42% of the nation’s doctors are older than 55, while 21% are over 65. A geriatrician quoted in the article who runs a program assessing physician competency estimated that as many as 8,000 doctors with full-blown dementia are still practicing.