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Mortality, Readmission Rates Unchanged by Duty Hour Reforms
Clinical question: Did the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms change mortality rates or readmission rates at teaching hospitals?
Background: The 2011 ACGME duty hour reforms maintained the 80-hour weekly work limit for medical residents, decreased the number of continuous hours to 16 hours from 30 hours for interns, and decreased the number of continuous hours for residents to 24 hours, with an additional four hours allowed for transitions of care. These changes have raised concerns about increased handoffs and potential changes in patient safety.
Study design: Observational study of Medicare admissions before and after duty hour reforms.
Setting: Short-term, acute-care hospitals.
Synopsis: Investigators compared 4,325,854 inpatient Medicare admissions from the two years prior to duty hour reforms with 2,058,419 admissions the year after the reforms. For each time period, the 30-day mortality and 30-day readmission rates were assessed; outcomes from more intensive teaching hospitals were compared with the outcomes from less intensive teaching hospitals. Teaching intensity was assessed according to the resident-to-bed ratio, a measure that has been used in prior research.
No significant differences were found in the primary outcomes of 30-day all-location mortality or 30-day all-cause readmissions.
When looking at specific diagnoses, only stroke was found to have a higher risk of readmission in the post-reform period (OR 1.06, 95% CI 1.01-1.13).
Although 2011 duty hour reforms represented a large, national structural change in resident education, no significant positive or negative effect was found on these important patient safety measures, consistent with what has been found in prior reviews.
Bottom line: The 2011 ACGME duty hour reforms showed no significant changes in mortality or readmissions when comparing hospitals with intensive teaching roles to those with fewer trainees.
Clinical question: Did the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms change mortality rates or readmission rates at teaching hospitals?
Background: The 2011 ACGME duty hour reforms maintained the 80-hour weekly work limit for medical residents, decreased the number of continuous hours to 16 hours from 30 hours for interns, and decreased the number of continuous hours for residents to 24 hours, with an additional four hours allowed for transitions of care. These changes have raised concerns about increased handoffs and potential changes in patient safety.
Study design: Observational study of Medicare admissions before and after duty hour reforms.
Setting: Short-term, acute-care hospitals.
Synopsis: Investigators compared 4,325,854 inpatient Medicare admissions from the two years prior to duty hour reforms with 2,058,419 admissions the year after the reforms. For each time period, the 30-day mortality and 30-day readmission rates were assessed; outcomes from more intensive teaching hospitals were compared with the outcomes from less intensive teaching hospitals. Teaching intensity was assessed according to the resident-to-bed ratio, a measure that has been used in prior research.
No significant differences were found in the primary outcomes of 30-day all-location mortality or 30-day all-cause readmissions.
When looking at specific diagnoses, only stroke was found to have a higher risk of readmission in the post-reform period (OR 1.06, 95% CI 1.01-1.13).
Although 2011 duty hour reforms represented a large, national structural change in resident education, no significant positive or negative effect was found on these important patient safety measures, consistent with what has been found in prior reviews.
Bottom line: The 2011 ACGME duty hour reforms showed no significant changes in mortality or readmissions when comparing hospitals with intensive teaching roles to those with fewer trainees.
Clinical question: Did the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms change mortality rates or readmission rates at teaching hospitals?
Background: The 2011 ACGME duty hour reforms maintained the 80-hour weekly work limit for medical residents, decreased the number of continuous hours to 16 hours from 30 hours for interns, and decreased the number of continuous hours for residents to 24 hours, with an additional four hours allowed for transitions of care. These changes have raised concerns about increased handoffs and potential changes in patient safety.
Study design: Observational study of Medicare admissions before and after duty hour reforms.
Setting: Short-term, acute-care hospitals.
Synopsis: Investigators compared 4,325,854 inpatient Medicare admissions from the two years prior to duty hour reforms with 2,058,419 admissions the year after the reforms. For each time period, the 30-day mortality and 30-day readmission rates were assessed; outcomes from more intensive teaching hospitals were compared with the outcomes from less intensive teaching hospitals. Teaching intensity was assessed according to the resident-to-bed ratio, a measure that has been used in prior research.
No significant differences were found in the primary outcomes of 30-day all-location mortality or 30-day all-cause readmissions.
When looking at specific diagnoses, only stroke was found to have a higher risk of readmission in the post-reform period (OR 1.06, 95% CI 1.01-1.13).
Although 2011 duty hour reforms represented a large, national structural change in resident education, no significant positive or negative effect was found on these important patient safety measures, consistent with what has been found in prior reviews.
Bottom line: The 2011 ACGME duty hour reforms showed no significant changes in mortality or readmissions when comparing hospitals with intensive teaching roles to those with fewer trainees.
Emergency Department Utilization May Be Lower for Attending-Only Physician Visits versus Supervised Visits
Clinical question: Does supervised learning in the ED lead to higher rates of resource utilization?
Background: Care at academic medical centers might be more expensive than nonteaching hospitals because of the increased testing and resource utilization that occurs among learners. Although there is a growing emphasis in training programs on cost-conscious care, little data has looked at resource use as an outcome.
Study design: Cross-sectional study of the National Hospital Ambulatory Medical Care Survey in 2010.
Setting: Probability sample of American EDs and ED visits.
Synopsis: Using the 2010 National Hospital Ambulatory Medical Care Survey ED sub-file, a probability sample of 29,182 ED visits was obtained—25,808 attending-only visits and 3,374 supervised visits.
Supervised visits were more likely to lead to hospital admissions (21% versus 14%), advanced imaging (28% vs. 21%), and a longer median ED stay, but not with more blood testing than attending-only ED visits. EDs were placed into three categories: “nonteaching”; “minor teaching,” where trainees are involved in fewer than 50% of visits; and “major teaching,” where trainees are involved in more than 50% of visits. Study results showed no increase in resource utilization in major teaching EDs, except for an increase in ED length of stay.
Although there was an attempt to adjust for biased selection and complexity, there is a risk that biased selection of “teaching cases” in minor teaching EDs could explain some of the higher resource use for these cases. This study does not imply causation; however, it suggests that further studies might be warranted to evaluate the relationship between learners and resource utilization.
Bottom line: Supervised visits were associated with increased hospital admissions, advanced imaging, and longer ED length of stay (LOS), but other than LOS, this relationship did not persist in major teaching EDs.
Clinical question: Does supervised learning in the ED lead to higher rates of resource utilization?
Background: Care at academic medical centers might be more expensive than nonteaching hospitals because of the increased testing and resource utilization that occurs among learners. Although there is a growing emphasis in training programs on cost-conscious care, little data has looked at resource use as an outcome.
Study design: Cross-sectional study of the National Hospital Ambulatory Medical Care Survey in 2010.
Setting: Probability sample of American EDs and ED visits.
Synopsis: Using the 2010 National Hospital Ambulatory Medical Care Survey ED sub-file, a probability sample of 29,182 ED visits was obtained—25,808 attending-only visits and 3,374 supervised visits.
Supervised visits were more likely to lead to hospital admissions (21% versus 14%), advanced imaging (28% vs. 21%), and a longer median ED stay, but not with more blood testing than attending-only ED visits. EDs were placed into three categories: “nonteaching”; “minor teaching,” where trainees are involved in fewer than 50% of visits; and “major teaching,” where trainees are involved in more than 50% of visits. Study results showed no increase in resource utilization in major teaching EDs, except for an increase in ED length of stay.
Although there was an attempt to adjust for biased selection and complexity, there is a risk that biased selection of “teaching cases” in minor teaching EDs could explain some of the higher resource use for these cases. This study does not imply causation; however, it suggests that further studies might be warranted to evaluate the relationship between learners and resource utilization.
Bottom line: Supervised visits were associated with increased hospital admissions, advanced imaging, and longer ED length of stay (LOS), but other than LOS, this relationship did not persist in major teaching EDs.
Clinical question: Does supervised learning in the ED lead to higher rates of resource utilization?
Background: Care at academic medical centers might be more expensive than nonteaching hospitals because of the increased testing and resource utilization that occurs among learners. Although there is a growing emphasis in training programs on cost-conscious care, little data has looked at resource use as an outcome.
Study design: Cross-sectional study of the National Hospital Ambulatory Medical Care Survey in 2010.
Setting: Probability sample of American EDs and ED visits.
Synopsis: Using the 2010 National Hospital Ambulatory Medical Care Survey ED sub-file, a probability sample of 29,182 ED visits was obtained—25,808 attending-only visits and 3,374 supervised visits.
Supervised visits were more likely to lead to hospital admissions (21% versus 14%), advanced imaging (28% vs. 21%), and a longer median ED stay, but not with more blood testing than attending-only ED visits. EDs were placed into three categories: “nonteaching”; “minor teaching,” where trainees are involved in fewer than 50% of visits; and “major teaching,” where trainees are involved in more than 50% of visits. Study results showed no increase in resource utilization in major teaching EDs, except for an increase in ED length of stay.
Although there was an attempt to adjust for biased selection and complexity, there is a risk that biased selection of “teaching cases” in minor teaching EDs could explain some of the higher resource use for these cases. This study does not imply causation; however, it suggests that further studies might be warranted to evaluate the relationship between learners and resource utilization.
Bottom line: Supervised visits were associated with increased hospital admissions, advanced imaging, and longer ED length of stay (LOS), but other than LOS, this relationship did not persist in major teaching EDs.
Physician Spending Habits During Residency Training Can Persist for Years
Clinical question: For primary care physicians (PCPs), does residency training area affect the pattern of physician spending after training is complete?
Background: Regional and system-level variations in the intensity of medical services provided are common in the U.S. Residency training practice patterns could explain these variations. This study examines the relationship between spending patterns in the region of residency training and individual physician practice spending patterns after training.
Study design: Secondary, multilevel, multivariable analysis of 2011 Medicare claims data.
Setting: Random, nationally representative sample of family and internal medicine physicians completing residency between 1992 and 2010, with Medicare patient panels of 40 or more patients.
Synopsis: Investigators randomly selected 2,851 PCPs who completed residency training from 1992-2010, providing care to 491,948 Medicare beneficiaries. Practice locations and residency training were matched with the Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups.
Physicians practicing in high-spending regions who trained in high-spending regions spent $1,926 more per Medicare beneficiary than those trained in low-spending regions. In average-spending regions, physicians who trained in high-spending regions spent an average of $897 higher than those who trained in low-spending regions. No differences were found in low-spending regions.
This association varied significantly according to years in practice. For physicians in the first seven years of practice, patient expenditures in the highest-spending training HRR were 29% greater than those in the lowest-spending training HRR. After 16 years of practice, this variation disappeared.
Although this study does not establish causality, there may be opportunities to control spending with focused interventions in residency.
Bottom line: Spending patterns vary even within HRRs; however, this study’s findings suggest that physicians’ practice patterns are developed in residency training and that training in high-spending regions likely leads to increased expenditures. Focusing on cost-conscious care during residency training could be a significant option for curtailing healthcare costs in the future.
Clinical question: For primary care physicians (PCPs), does residency training area affect the pattern of physician spending after training is complete?
Background: Regional and system-level variations in the intensity of medical services provided are common in the U.S. Residency training practice patterns could explain these variations. This study examines the relationship between spending patterns in the region of residency training and individual physician practice spending patterns after training.
Study design: Secondary, multilevel, multivariable analysis of 2011 Medicare claims data.
Setting: Random, nationally representative sample of family and internal medicine physicians completing residency between 1992 and 2010, with Medicare patient panels of 40 or more patients.
Synopsis: Investigators randomly selected 2,851 PCPs who completed residency training from 1992-2010, providing care to 491,948 Medicare beneficiaries. Practice locations and residency training were matched with the Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups.
Physicians practicing in high-spending regions who trained in high-spending regions spent $1,926 more per Medicare beneficiary than those trained in low-spending regions. In average-spending regions, physicians who trained in high-spending regions spent an average of $897 higher than those who trained in low-spending regions. No differences were found in low-spending regions.
This association varied significantly according to years in practice. For physicians in the first seven years of practice, patient expenditures in the highest-spending training HRR were 29% greater than those in the lowest-spending training HRR. After 16 years of practice, this variation disappeared.
Although this study does not establish causality, there may be opportunities to control spending with focused interventions in residency.
Bottom line: Spending patterns vary even within HRRs; however, this study’s findings suggest that physicians’ practice patterns are developed in residency training and that training in high-spending regions likely leads to increased expenditures. Focusing on cost-conscious care during residency training could be a significant option for curtailing healthcare costs in the future.
Clinical question: For primary care physicians (PCPs), does residency training area affect the pattern of physician spending after training is complete?
Background: Regional and system-level variations in the intensity of medical services provided are common in the U.S. Residency training practice patterns could explain these variations. This study examines the relationship between spending patterns in the region of residency training and individual physician practice spending patterns after training.
Study design: Secondary, multilevel, multivariable analysis of 2011 Medicare claims data.
Setting: Random, nationally representative sample of family and internal medicine physicians completing residency between 1992 and 2010, with Medicare patient panels of 40 or more patients.
Synopsis: Investigators randomly selected 2,851 PCPs who completed residency training from 1992-2010, providing care to 491,948 Medicare beneficiaries. Practice locations and residency training were matched with the Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups.
Physicians practicing in high-spending regions who trained in high-spending regions spent $1,926 more per Medicare beneficiary than those trained in low-spending regions. In average-spending regions, physicians who trained in high-spending regions spent an average of $897 higher than those who trained in low-spending regions. No differences were found in low-spending regions.
This association varied significantly according to years in practice. For physicians in the first seven years of practice, patient expenditures in the highest-spending training HRR were 29% greater than those in the lowest-spending training HRR. After 16 years of practice, this variation disappeared.
Although this study does not establish causality, there may be opportunities to control spending with focused interventions in residency.
Bottom line: Spending patterns vary even within HRRs; however, this study’s findings suggest that physicians’ practice patterns are developed in residency training and that training in high-spending regions likely leads to increased expenditures. Focusing on cost-conscious care during residency training could be a significant option for curtailing healthcare costs in the future.
Malpractice Reform Does Not Change Physician Practice Patterns
Clinical question: Do malpractice reform policies shift physician practice patterns toward lower utilization of healthcare resources?
Background: Physician-reported fears of lawsuits lead to defensive medicine practices, which contribute to high healthcare costs. It is unclear whether malpractice reform legislation reduces these costly physician practice patterns. The ED is a high-risk environment that may promote defensive medicine practices and is the focus of recent malpractice reform legislation in Texas, Georgia, and South Carolina.
Study design: Case-control.
Setting: EDs in Texas, Georgia, South Carolina, and adjacent states.
Synopsis: Using a 5% random sample of Medicare claims from 1997-2011, the investigators evaluated the impact of recent malpractice reform legislation on intensity of practice by ED physicians, as defined by rates of use of advanced imaging (computed tomography [CT] or magnetic resonance imaging [MRI]), hospital admission, and average charges. ED claims from the three reform states (Texas, Ga., and S.C.) were compared to neighboring (control) states.
Adjusted analysis of 3,868,110 ED visits from 1,166 eligible hospitals demonstrated no significant reductions in CT/MRI utilization, rates of hospital admission, or (in two of the three reform states) average per-visit ED charges attributable to policy reforms.
Bottom line: Broadly protective malpractice reform had minimal impact on emergency physicians’ intensity of practice, as measured by rates of advanced imaging use, hospital admission, and average charges. Such “pro-physician” legal reforms may be inadequate in isolation to significantly reduce costs.
Clinical question: Do malpractice reform policies shift physician practice patterns toward lower utilization of healthcare resources?
Background: Physician-reported fears of lawsuits lead to defensive medicine practices, which contribute to high healthcare costs. It is unclear whether malpractice reform legislation reduces these costly physician practice patterns. The ED is a high-risk environment that may promote defensive medicine practices and is the focus of recent malpractice reform legislation in Texas, Georgia, and South Carolina.
Study design: Case-control.
Setting: EDs in Texas, Georgia, South Carolina, and adjacent states.
Synopsis: Using a 5% random sample of Medicare claims from 1997-2011, the investigators evaluated the impact of recent malpractice reform legislation on intensity of practice by ED physicians, as defined by rates of use of advanced imaging (computed tomography [CT] or magnetic resonance imaging [MRI]), hospital admission, and average charges. ED claims from the three reform states (Texas, Ga., and S.C.) were compared to neighboring (control) states.
Adjusted analysis of 3,868,110 ED visits from 1,166 eligible hospitals demonstrated no significant reductions in CT/MRI utilization, rates of hospital admission, or (in two of the three reform states) average per-visit ED charges attributable to policy reforms.
Bottom line: Broadly protective malpractice reform had minimal impact on emergency physicians’ intensity of practice, as measured by rates of advanced imaging use, hospital admission, and average charges. Such “pro-physician” legal reforms may be inadequate in isolation to significantly reduce costs.
Clinical question: Do malpractice reform policies shift physician practice patterns toward lower utilization of healthcare resources?
Background: Physician-reported fears of lawsuits lead to defensive medicine practices, which contribute to high healthcare costs. It is unclear whether malpractice reform legislation reduces these costly physician practice patterns. The ED is a high-risk environment that may promote defensive medicine practices and is the focus of recent malpractice reform legislation in Texas, Georgia, and South Carolina.
Study design: Case-control.
Setting: EDs in Texas, Georgia, South Carolina, and adjacent states.
Synopsis: Using a 5% random sample of Medicare claims from 1997-2011, the investigators evaluated the impact of recent malpractice reform legislation on intensity of practice by ED physicians, as defined by rates of use of advanced imaging (computed tomography [CT] or magnetic resonance imaging [MRI]), hospital admission, and average charges. ED claims from the three reform states (Texas, Ga., and S.C.) were compared to neighboring (control) states.
Adjusted analysis of 3,868,110 ED visits from 1,166 eligible hospitals demonstrated no significant reductions in CT/MRI utilization, rates of hospital admission, or (in two of the three reform states) average per-visit ED charges attributable to policy reforms.
Bottom line: Broadly protective malpractice reform had minimal impact on emergency physicians’ intensity of practice, as measured by rates of advanced imaging use, hospital admission, and average charges. Such “pro-physician” legal reforms may be inadequate in isolation to significantly reduce costs.
Updated Guidelines for Management of Non-ST-Elevation Acute Coronary Syndrome
Clinical question: What is the recommended approach for management of non-ST-elevation acute coronary syndrome (NSTE-ACS)?
Background: This is the first comprehensive update from the American Heart Association/American College of Cardiology (AHA/ACC) on NSTE-ACS since 2007 and follows a focused update published in 2012.
Synopsis: This guideline provides recommendations for acute and long-term care of patients with NSTE-ACS.
Cardiac-specific troponin assays (troponin I or T) are the mainstay for ACS diagnosis. When contemporary troponin assays are used for diagnosis, other biomarkers (CK-MB, myoglobin) are not useful.
Initial hospital care for all patients with NSTE-ACS should include early initiation of beta-blockers (within the first 24 hours), high-intensity statin therapy, P2Y12 inhibitor (clopidogrel or ticagrelor) plus aspirin, and parenteral anticoagulation.
An early invasive strategy (diagnostic angiography within 24 hours with intent to perform revascularization based on coronary anatomy) is preferred to an ischemia-guided strategy, particularly in high-risk NSTE-ACS patients (Global Registry of Acute Coronary Events [GRACE] score >140).
“Ischemia-guided” strategy replaces the term “conservative management strategy,” and its focus on aggressive medical therapy is an option in selected low-risk patient populations (e.g. thrombolysis in myocardial infarction [TIMI] risk score 0 or 1, GRACE score <109, low-risk troponin-negative females). Patients managed with an ischemia-guided strategy should undergo pre-discharge noninvasive stress testing for further risk stratification.
Regardless of angiography strategy (invasive vs. ischemia-guided), post-discharge dual antiplatelet therapy (clopidogrel or ticagrelor) is recommended for up to 12 months in all patients with NSTE-ACS. Prasugrel is an appropriate P2Y12 inhibitor option for patients following percutaneous coronary intervention with stent placement.
All patients with NSTE-ACS should be referred to an outpatient comprehensive cardiovascular rehabilitation program.
Clinical question: What is the recommended approach for management of non-ST-elevation acute coronary syndrome (NSTE-ACS)?
Background: This is the first comprehensive update from the American Heart Association/American College of Cardiology (AHA/ACC) on NSTE-ACS since 2007 and follows a focused update published in 2012.
Synopsis: This guideline provides recommendations for acute and long-term care of patients with NSTE-ACS.
Cardiac-specific troponin assays (troponin I or T) are the mainstay for ACS diagnosis. When contemporary troponin assays are used for diagnosis, other biomarkers (CK-MB, myoglobin) are not useful.
Initial hospital care for all patients with NSTE-ACS should include early initiation of beta-blockers (within the first 24 hours), high-intensity statin therapy, P2Y12 inhibitor (clopidogrel or ticagrelor) plus aspirin, and parenteral anticoagulation.
An early invasive strategy (diagnostic angiography within 24 hours with intent to perform revascularization based on coronary anatomy) is preferred to an ischemia-guided strategy, particularly in high-risk NSTE-ACS patients (Global Registry of Acute Coronary Events [GRACE] score >140).
“Ischemia-guided” strategy replaces the term “conservative management strategy,” and its focus on aggressive medical therapy is an option in selected low-risk patient populations (e.g. thrombolysis in myocardial infarction [TIMI] risk score 0 or 1, GRACE score <109, low-risk troponin-negative females). Patients managed with an ischemia-guided strategy should undergo pre-discharge noninvasive stress testing for further risk stratification.
Regardless of angiography strategy (invasive vs. ischemia-guided), post-discharge dual antiplatelet therapy (clopidogrel or ticagrelor) is recommended for up to 12 months in all patients with NSTE-ACS. Prasugrel is an appropriate P2Y12 inhibitor option for patients following percutaneous coronary intervention with stent placement.
All patients with NSTE-ACS should be referred to an outpatient comprehensive cardiovascular rehabilitation program.
Clinical question: What is the recommended approach for management of non-ST-elevation acute coronary syndrome (NSTE-ACS)?
Background: This is the first comprehensive update from the American Heart Association/American College of Cardiology (AHA/ACC) on NSTE-ACS since 2007 and follows a focused update published in 2012.
Synopsis: This guideline provides recommendations for acute and long-term care of patients with NSTE-ACS.
Cardiac-specific troponin assays (troponin I or T) are the mainstay for ACS diagnosis. When contemporary troponin assays are used for diagnosis, other biomarkers (CK-MB, myoglobin) are not useful.
Initial hospital care for all patients with NSTE-ACS should include early initiation of beta-blockers (within the first 24 hours), high-intensity statin therapy, P2Y12 inhibitor (clopidogrel or ticagrelor) plus aspirin, and parenteral anticoagulation.
An early invasive strategy (diagnostic angiography within 24 hours with intent to perform revascularization based on coronary anatomy) is preferred to an ischemia-guided strategy, particularly in high-risk NSTE-ACS patients (Global Registry of Acute Coronary Events [GRACE] score >140).
“Ischemia-guided” strategy replaces the term “conservative management strategy,” and its focus on aggressive medical therapy is an option in selected low-risk patient populations (e.g. thrombolysis in myocardial infarction [TIMI] risk score 0 or 1, GRACE score <109, low-risk troponin-negative females). Patients managed with an ischemia-guided strategy should undergo pre-discharge noninvasive stress testing for further risk stratification.
Regardless of angiography strategy (invasive vs. ischemia-guided), post-discharge dual antiplatelet therapy (clopidogrel or ticagrelor) is recommended for up to 12 months in all patients with NSTE-ACS. Prasugrel is an appropriate P2Y12 inhibitor option for patients following percutaneous coronary intervention with stent placement.
All patients with NSTE-ACS should be referred to an outpatient comprehensive cardiovascular rehabilitation program.
New Guidelines for Platelet Transfusions in Adults
Clinical question: What is the recommended approach to platelet transfusion in several common clinical scenarios?
Background: The AABB (formerly American Association of Blood Banks) developed these guidelines from a recent systematic review on platelet transfusion.
Synopsis: One strong recommendation was made based on moderate-quality evidence. Four weak or uncertain recommendations were made based on low- or very low-quality evidence.
For hospitalized patients with therapy-induced hypoproliferative thrombocytopenia, transfusion of up to a single unit of platelets is recommended for a platelet count of 10x109 cells/L or less to reduce the risk of spontaneous bleeding (strong recommendation, moderate-quality evidence).
For patients undergoing elective central venous catheter placement, platelet transfusion is recommended for a platelet count of less than 20x109 cells/L (weak recommendation, low-quality evidence).
For patients undergoing elective diagnostic lumbar puncture, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).
For patients undergoing major elective non-neuraxial surgery, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).
For patients undergoing cardiopulmonary bypass surgery, it is recommended that surgeons not perform routine transfusion of platelets in non-thrombocytopenic patients. For patients who have peri-operative bleeding with thrombocytopenia and/or evidence of platelet dysfunction, platelet transfusion is recommended (weak recommendation, very low-quality evidence).
There is insufficient evidence to recommend for or against platelet transfusion in patients with intracranial hemorrhage who are taking antiplatelet medications (uncertain recommendation, very low-quality evidence).
Clinical question: What is the recommended approach to platelet transfusion in several common clinical scenarios?
Background: The AABB (formerly American Association of Blood Banks) developed these guidelines from a recent systematic review on platelet transfusion.
Synopsis: One strong recommendation was made based on moderate-quality evidence. Four weak or uncertain recommendations were made based on low- or very low-quality evidence.
For hospitalized patients with therapy-induced hypoproliferative thrombocytopenia, transfusion of up to a single unit of platelets is recommended for a platelet count of 10x109 cells/L or less to reduce the risk of spontaneous bleeding (strong recommendation, moderate-quality evidence).
For patients undergoing elective central venous catheter placement, platelet transfusion is recommended for a platelet count of less than 20x109 cells/L (weak recommendation, low-quality evidence).
For patients undergoing elective diagnostic lumbar puncture, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).
For patients undergoing major elective non-neuraxial surgery, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).
For patients undergoing cardiopulmonary bypass surgery, it is recommended that surgeons not perform routine transfusion of platelets in non-thrombocytopenic patients. For patients who have peri-operative bleeding with thrombocytopenia and/or evidence of platelet dysfunction, platelet transfusion is recommended (weak recommendation, very low-quality evidence).
There is insufficient evidence to recommend for or against platelet transfusion in patients with intracranial hemorrhage who are taking antiplatelet medications (uncertain recommendation, very low-quality evidence).
Clinical question: What is the recommended approach to platelet transfusion in several common clinical scenarios?
Background: The AABB (formerly American Association of Blood Banks) developed these guidelines from a recent systematic review on platelet transfusion.
Synopsis: One strong recommendation was made based on moderate-quality evidence. Four weak or uncertain recommendations were made based on low- or very low-quality evidence.
For hospitalized patients with therapy-induced hypoproliferative thrombocytopenia, transfusion of up to a single unit of platelets is recommended for a platelet count of 10x109 cells/L or less to reduce the risk of spontaneous bleeding (strong recommendation, moderate-quality evidence).
For patients undergoing elective central venous catheter placement, platelet transfusion is recommended for a platelet count of less than 20x109 cells/L (weak recommendation, low-quality evidence).
For patients undergoing elective diagnostic lumbar puncture, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).
For patients undergoing major elective non-neuraxial surgery, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).
For patients undergoing cardiopulmonary bypass surgery, it is recommended that surgeons not perform routine transfusion of platelets in non-thrombocytopenic patients. For patients who have peri-operative bleeding with thrombocytopenia and/or evidence of platelet dysfunction, platelet transfusion is recommended (weak recommendation, very low-quality evidence).
There is insufficient evidence to recommend for or against platelet transfusion in patients with intracranial hemorrhage who are taking antiplatelet medications (uncertain recommendation, very low-quality evidence).
Shorter Treatment for Vertebral Osteomyelitis May Be as Effective as Longer Treatment
Clinical question: Is a six-week regimen of antibiotics as effective as a 12-week regimen in the treatment of vertebral osteomyelitis?
Background: The optimal duration of antibiotic treatment for vertebral osteomyelitis is unknown. Previous guidelines recommending six to 12 weeks of therapy have been based on expert opinion rather than clinical trial data.
Study design: Multi-center, open-label, randomized controlled trial.
Setting: Seventy-one medical care centers in France.
Synopsis: Three hundred fifty-six adult patients with culture-proven bacterial vertebral osteomyelitis were randomized to six- or 12- week antibiotic treatment regimens. The primary outcome was confirmed cure of infection at 12 months, as defined by absence of pain, fever, and CRP <10 mg/L. Outcomes were determined by a blinded panel of physicians.
Results showed 90.9% of the patients in the six-week group, and 90.8% of the patients in the 12-week group, met criteria for clinical cure. The lower bound of the 95% confidence interval for the difference in percentages of cure between groups was -6.2%, satisfying the predetermined noninferiority margin of 10%.
Antibiotic therapy in this trial was governed by French guidelines, which recommend oral fluoroquinolones and rifampin as first-line agents for vertebral osteomyelitis. Median duration of IV antibiotic therapy was less than 14 days. Relatively few patients had abscesses, and only eight of the 145 patients with Staphylococcus aureus (SA) infections had methicillin-resistant SA (MRSA).
Bottom line: A six-week regimen of antibiotics was shown to be noninferior to a 12-week regimen for treatment of vertebral osteomyelitis. Treatment for longer than six weeks may be indicated in the setting of drug-resistant organisms, extensive bone destruction, or abscesses.
Clinical question: Is a six-week regimen of antibiotics as effective as a 12-week regimen in the treatment of vertebral osteomyelitis?
Background: The optimal duration of antibiotic treatment for vertebral osteomyelitis is unknown. Previous guidelines recommending six to 12 weeks of therapy have been based on expert opinion rather than clinical trial data.
Study design: Multi-center, open-label, randomized controlled trial.
Setting: Seventy-one medical care centers in France.
Synopsis: Three hundred fifty-six adult patients with culture-proven bacterial vertebral osteomyelitis were randomized to six- or 12- week antibiotic treatment regimens. The primary outcome was confirmed cure of infection at 12 months, as defined by absence of pain, fever, and CRP <10 mg/L. Outcomes were determined by a blinded panel of physicians.
Results showed 90.9% of the patients in the six-week group, and 90.8% of the patients in the 12-week group, met criteria for clinical cure. The lower bound of the 95% confidence interval for the difference in percentages of cure between groups was -6.2%, satisfying the predetermined noninferiority margin of 10%.
Antibiotic therapy in this trial was governed by French guidelines, which recommend oral fluoroquinolones and rifampin as first-line agents for vertebral osteomyelitis. Median duration of IV antibiotic therapy was less than 14 days. Relatively few patients had abscesses, and only eight of the 145 patients with Staphylococcus aureus (SA) infections had methicillin-resistant SA (MRSA).
Bottom line: A six-week regimen of antibiotics was shown to be noninferior to a 12-week regimen for treatment of vertebral osteomyelitis. Treatment for longer than six weeks may be indicated in the setting of drug-resistant organisms, extensive bone destruction, or abscesses.
Clinical question: Is a six-week regimen of antibiotics as effective as a 12-week regimen in the treatment of vertebral osteomyelitis?
Background: The optimal duration of antibiotic treatment for vertebral osteomyelitis is unknown. Previous guidelines recommending six to 12 weeks of therapy have been based on expert opinion rather than clinical trial data.
Study design: Multi-center, open-label, randomized controlled trial.
Setting: Seventy-one medical care centers in France.
Synopsis: Three hundred fifty-six adult patients with culture-proven bacterial vertebral osteomyelitis were randomized to six- or 12- week antibiotic treatment regimens. The primary outcome was confirmed cure of infection at 12 months, as defined by absence of pain, fever, and CRP <10 mg/L. Outcomes were determined by a blinded panel of physicians.
Results showed 90.9% of the patients in the six-week group, and 90.8% of the patients in the 12-week group, met criteria for clinical cure. The lower bound of the 95% confidence interval for the difference in percentages of cure between groups was -6.2%, satisfying the predetermined noninferiority margin of 10%.
Antibiotic therapy in this trial was governed by French guidelines, which recommend oral fluoroquinolones and rifampin as first-line agents for vertebral osteomyelitis. Median duration of IV antibiotic therapy was less than 14 days. Relatively few patients had abscesses, and only eight of the 145 patients with Staphylococcus aureus (SA) infections had methicillin-resistant SA (MRSA).
Bottom line: A six-week regimen of antibiotics was shown to be noninferior to a 12-week regimen for treatment of vertebral osteomyelitis. Treatment for longer than six weeks may be indicated in the setting of drug-resistant organisms, extensive bone destruction, or abscesses.