Published in the November 2012 issue of Today’s Hospitalist
New anticoagulants increase ACS bleeding risk
WHILE NEW ORAL ANTICOAGULANTS reduce ischemic events in patients with acute coronary syndrome, new research finds the drugs increase bleeding risk dramatically. That heightened risk may negate the benefits of fewer ischemic events.
The study, which was published online in September by the Archives of Internal Medicine, reviewed trials on three anticoagulants: dabigatran (Pradaxa), a direct thrombin inhibitor, and the factor Xa inhibitors rivaroxaban (Xarelto) and apixaban (Eliquis). The meta-analysis identified seven randomized trials comparing the therapies to placebo in more than 31,000 patients.
The odds ratio of major bleeding events with one of the new anticoagulants was 3.03, and all patients were also taking antiplatelets. The research did find that the therapies were associated with reduced rates of stent thrombosis and composite ischemic events, but those benefits didn’t translate to lower mortality.
The authors concluded that the “unrestricted use” of new anticoagulants in ACS patients wasn’t warranted. However, they noted that ACS patients with atrial fibrillation or other conditions might benefit from long-term anticoagulation with one of the agents.
Strokes on the rise among younger patients
REGIONAL REGISTRY DATA INDICATE that the number of strokes among older patients is declining “but that more first strokes are occurring among patients between the ages of 20 and 54.
Registry data from parts of Ohio and Kentucky find that the percentage of strokes suffered by younger patients rose from 12.9% of all strokes in 1993-94 to 18.6% in 2005. The analysis, which was published online in October by Neurology, found stroke-rate increases among both white and black patients.
The authors wrote that rising rates are due to increased incidence of hypertension, diabetes and coronary heart disease, as well as to smoking. They also pointed to the major public health implications of younger patients having strokes and facing a much greater burden of lifetime disability.
An editorial noted that the rise in stroke rates among younger patients may be due in part to the increased use of MRI over the study period, leading to more diagnoses.
WHILE BETA-BLOCKERS are considered standard therapy for many patients, new data found the drugs did not lower the risk of cardiovascular events in patients with only coronary artery disease risk factors, previous MI or known CAD without previous MI.
That was the conclusion of research in the Oct. 3 issue of the Journal of the American Medical Association. The observational study looked at data for nearly 45,000 patients who were followed for a median of 44 months.
Researchers found that in terms of cardiovascular death or nonfatal MI or stroke, patients taking beta-blockers had similar event rates as those not taking them. In addition, patients on beta-blockers who had only risk factors had a slightly higher event rate than patients not taking beta-blockers.
The authors pointed out that the use of beta-blockers remains standard care, but that the evidence supporting that use comes from older studies. They called for new trials to identify patient subgroups who benefit from beta-blockers and the optimal amount of time patients should take them.
Hypoglycemia and ICU mortality
BOTH MODERATE AND SEVERE HYPOGLYCEMIA increase death rates among ICU patients, according to an analysis in the Sept. 20 New England Journal of Medicine.
Researchers conducted a post-hoc analysis of 2009 NICE-SUGAR trial data, which found an association between hypoglycemia and higher mortality risk. In their current analysis, among the more than 6,000 patients enrolled in the trial, 45% were found to have moderate hypoglycemia, defined as blood glucose between 41 and 70 mg/dL, while 3.7% had severe hypoglycemia, defined as less than 41 mg/dL. Most of those with moderate or severe hypoglycemia were in the study arm with intensive glucose control.
Among patients without hypoglycemia, 23.5% died. But mortality rates were 28.5% for those with moderate hypoglycemia and 35.4% for those with severe hypoglycemia. The relationship between hypoglycemia and increased mortality risk was stronger in patients brought immediately to the ICU from surgery. The association was also stronger in patients who had moderate hypoglycemia for more than one day.
Authors recommended that clinicians adhere to American Diabetes Association guidelines, which advise maintaining a blood glucose level of between 144 and 180 mg/dL.
Better outcomes with hospitalist-run preop clinic
SWITCHING TO a hospitalist-run preoperative clinic at a Veterans Administration center reduced length of stay (LOS) for the sickest patients while also cutting down on the number of same-day surgical cancellations.
The authors of a retrospective review posted online in September by the Journal of Hospital Medicine looked at before-and-after data for more than 5,200 patients undergoing noncardiac surgery. Researchers wanted to gauge the impact of switching clinic supervision away from anesthesiologists to hospitalists.
They found that the switch led to lower LOS for the sickest patients, as well as a small absolute reduction in mortality rates. Patients also had fewer same-day cancellations, but more stress testing and perioperative beta-blockers.
While authors couldn’t pinpoint the precise factors that led to better outcomes, they surmise that hospitalists may have been able to identify more patients at high risk for perioperative complications. Hospitalists may also have done a better job getting preop consults and adjusting patients’ medications.
A look at hospital shootings
WHILE VIOLENCE IN HEALTH CARE SETTINGS is all too common, shootings are rare ” but EDs are particularly vulnerable. That’s according to a study published online by Annals of Emergency Medicine.
The research found that 154 hospital-related shootings have taken place in the U.S. between 2000 and 2011. Among those, 59% occurred inside the hospital, with 29% taking place in the ED and 19% in patient rooms. Most entailed “a determined shooter” with a specific target.
Common motives were suicide, revenge and euthanizing a sick relative. While 20% of victims were hospital employees, physicians made up 3% of victims, with nurses accounting for 5%.
Nearly one in four shootings that took place in the ED was the result of a perpetrator taking a gun away from a police or security officer. As a result, the authors conclude that metal detectors or checkpoints within a hospital will not act as a deterrent. They recommend better training for law enforcement and security officers in hospitals.
Get ready to report staff vaccination rates
HOSPITALS NEED TO BE MORE AGGRESSIVE immunizing staff and affiliated personnel against the flu, according to the CDC. And this flu season, hospitals have a new incentive to boost immunization rates: Starting Jan. 1, hospitals must start reporting their staff immunization rates.
Those rates will be posted on the Hospital Compare Web site beginning July 2013. According to a report in the Sept. 28 Morbidity and Mortality Weekly Report, 23.1% of hospital personnel in the 2011-12 flu season were not vaccinated. (In physician offices, 32.3% of personnel that year weren’t immunized, nor were 47.6% of personnel in long-term facilities.)
By occupation, physicians had the highest rate of vaccination coverage: 85.6% compared to 77.9% of nurses and 62.8% of other health care personnel. While 95.2% of hospital staff last year were vaccinated in facilities with mandatory immunization policies, that percentage fell to only 68.2% among hospitals that don’t require vaccination.
Hospitals will have to publicly report the vaccination rates of hospital employees, affiliated clinicians, trainees and volunteers.
It’s a good time to be a medical director
A NEW SURVEY on compensation for hospital medical directors finds that 35% of organizations in 2012 are offering performance bonuses to directors of service lines. That’s up from 27% of organizations surveyed in 2011.
Data from the Dallas-based consulting firm Integrated Healthcare Strategies indicate that 54% of medical directors are independent contractors, while the rest are employed. (For the most part, chief medical officers were excluded from the survey.) The most common directors in hospitals are for psychiatric and general, emergency and family medicine.
Among hospitals that don’t currently offer performance bonuses to their service directors, 25% are considering implementing one next year, the survey found. Survey data covered nearly 180 organizations and more than 3,000 medical directors.
Analysts also believe that the move away from fee-for-service reimbursement will spur more widespread use of such bonuses, particularly among specialty lines. The survey found that hospitals “particularly larger facilities ” are moving to hire more medical directors, and that many directors’ bonuses equal 10% of their salary.