Rebecca Allyn, MD

The combination of decreasing hospital lengths of stay and increasing age and comorbidity of the United States population is a principal driver of the increased use of postacute care in the US.^1-3 Postacute care refers to care in long-term acute care hospitals, inpatient rehabilitation facilities, skilled nursing facilities (SNFs), and care provided by home health agencies after an acute hospitalization. In 2016, 43% of Medicare beneficiaries received postacute care after hospital discharge at the cost of $60 billion annually; nearly half of these received care in an SNF.⁴ Increasing recognition of the significant cost and poor outcomes of postacute care led to payment reforms, such as bundled payments, that incentivized less expensive forms of postacute care and improvements in outcomes.^5-9 Early evaluations suggested that hospitals are sensitive to these reforms and responded by significantly decreasing SNF utilization.^10,11 It remains unclear whether this was safe and effective.

In this context, increased attention to how hospital clinicians and hospitalized patients decide whether to use postacute care (and what form to use) is appropriate since the effect of payment reforms could negatively impact vulnerable populations of older adults without adequate protection.¹² Suboptimal decision-making can drive both overuse and inappropriate underuse of this expensive medical resource. Initial evidence suggests that patients and clinicians are poorly equipped to make high-quality decisions about postacute care, with significant deficits in both the decision-making process and content.^13-16 While these gaps are important to address, they may only be part of the problem. The fields of cognitive psychology and behavioral economics have revealed new insights into decision-making, demonstrating that people deviate from rational decision-making in predictable ways, termed decision heuristics, or cognitive biases.¹⁷ This growing field of research suggests heuristics or biases play important roles in decision-making and determining behavior, particularly in situations where there may be little information provided and the patient is stressed, tired, and ill—precisely like deciding on postacute care.¹⁸ However, it is currently unknown whether cognitive biases are at play when making hospital discharge decisions.

We sought to identify the most salient heuristics or cognitive biases patients may utilize when making decisions about postacute care at the end of their hospitalization and ways clinicians may contribute to these biases. The overall goal was to derive insights for improving postacute care decision-making.

Study Design

We conducted a secondary analysis on interviews with hospital and SNF clinicians as well as patients and their caregivers who were either leaving the hospital for an SNF or newly arrived in an SNF from the hospital to understand if cognitive biases were present and how they manifested themselves in a real-world clinical context.¹⁹ These interviews were part of a larger qualitative study that sought to understand how clinicians, patients, and their caregivers made decisions about postacute care, particularly related to SNFs.^13,14 This study represents the analysis of all our interviews, specifically examining decision-making bias. Participating sites, clinical roles, and both patient and caregiver characteristics (Table 1) in our cohort have been previously described.^13,14

jhm015010022_t1.jpg

Analysis

We used a team-based approach to framework analysis, which has been used in other decision-making studies¹⁴, including those measuring cognitive bias.²⁰ A limitation in cognitive bias research is the lack of a standardized list or categorization of cognitive biases. We reviewed prior systematic^17,21 and narrative reviews^18,22, as well as prior studies describing examples of cognitive biases playing a role in decision-making about therapy²⁰ to construct a list of possible cognitive biases to evaluate and narrow these a priori to potential biases relevant to the decision about postacute care based on our prior work (Table 2).

burke01510821e_t2.jpg

We applied this framework to analyze transcripts through an iterative process of deductive coding and reviewing across four reviewers (ML, RA, AL, CL) and a hospitalist physician with expertise leading qualitative studies (REB).

Intercoder consensus was built through team discussion by resolving points of disagreement.²³ Consistency of coding was regularly checked by having more than one investigator code individual manuscripts and comparing coding, and discrepancies were resolved through team discussion. We triangulated the data (shared our preliminary results) using a larger study team, including an expert in behavioral economics (SRG), physicians at study sites (EC, RA), and an anthropologist with expertise in qualitative methods (CL). We did this to ensure credibility (to what extent the findings are credible or believable) and confirmability of findings (ensuring the findings are based on participant narratives rather than researcher biases).

We reviewed a total of 105 interviews with 25 hospital clinicians, 20 SNF clinicians, 21 patients and 14 caregivers in the hospital, and 15 patients and 10 caregivers in the SNF setting (Table 1). We found authority bias/halo effect; default/status quo bias, anchoring bias, and framing was commonly present in decision-making about postacute care in a SNF, whereas there were few if any examples of ambiguity aversion, availability heuristic, confirmation bias, optimism bias, or false consensus effect (Table 2).

Authority Bias/Halo Effect

While most patients deferred to their inpatient teams when it came to decision-making, this effect seemed to differ across VA and non-VA settings. Veterans expressed a higher degree of potential authority bias regarding the VA as an institution, whereas older adults in non-VA settings saw physicians as the authority figure making decisions in their best interests.

Veterans expressed confidence in the VA regarding both whether to go to a SNF and where to go:

“The VA wouldn’t license [an SNF] if they didn’t have a good reputation for care, cleanliness, things of that nature” (Veteran, VA CLC)

“I just knew the VA would have my best interests at heart” (Veteran, VA CLC)

Their caregivers expressed similar confidence:

“I’m not gonna decide [on whether the patient they care for goes to postacute care], like I told you, that’s totally up to the VA. I have trust and faith in them…so wherever they send him, that’s where he’s going” (Caregiver, VA hospital)

In some cases, this perspective was closer to the halo effect: a positive experience with the care provider or the care team led the decision-makers to believe that their recommendations about postacute care would be similarly positive.

“I think we were very trusting in the sense that whatever happened the last time around, he survived it…they took care of him…he got back home, and he started his life again, you know, so why would we question what they’re telling us to do? (Caregiver, VA hospital)

In contrast to Veterans, non-Veteran patients seemed to experience authority bias when it came to the inpatient team.

“Well, I’d like to know more about the PTs [Physical Therapists] there, but I assume since they were recommended, they will be good.” (Patient, University hospital)

This perspective was especially apparent when it came to physicians:

“The level of trust that they [patients] put in their doctor is gonna outweigh what anyone else would say.” (Clinical liaison, SNF)

“[In response to a question about influences on the decision to go to rehab] I don’t…that’s not my decision to make, that’s the doctor’s decision.” (Patient, University hospital)

“They said so…[the doctor] said I needed to go to rehab, so I guess I do because it’s the doctor’s decision.” (Patient, University hospital)

Default/Status quo Bias

In a related way, patients and caregivers with exposure to a SNF seemed to default to the same SNF with which they had previous experience. This bias seems to be primarily related to knowing what to expect.

“He thinks it’s [a particular SNF] the right place for him now…he was there before and he knew, again, it was the right place for him to be” (Caregiver, VA hospital)

“It’s the only one I’ve ever been in…but they have a lot of activities; you have a lot of freedom, staff was good” (Patient, VA hospital)

“I’ve been [to this SNF] before and I kind of know what the program involves…so it was kind of like going home, not, going home is the wrong way to put it…I mean coming here is like something I know, you know, I didn’t need anybody to explain it to me.” (Patient, VA hospital)

“Anybody that’s been to [SNF], that would be their choice to go back to, and I guess I must’ve liked it that first time because I asked to go back again.” (Patient, University hospital)

Anchoring Bias

While anchoring bias was less frequent, it came up in two domains: first, related to costs of care, and second, related to facility characteristics. Costs came up most frequently for Veterans who preferred to move their care to the VA for cost reasons, which appeared in these cases to overshadow other considerations:

“I kept emphasizing that the VA could do all the same things at a lot more reasonable price. The whole purpose of having the VA is for the Veteran, so that…we can get the healthcare that we need at a more reasonable [sic] or a reasonable price.” (Veteran, CLC)

“I think the CLC [VA SNF] is going to take care of her probably the same way any other facility of its type would, unless she were in a private facility, but you know, that costs a lot more money.” (Caregiver, VA hospital)

Patients occasionally had striking responses to particular characteristics of SNFs, regardless of whether this was a central feature or related to their rehabilitation:

“The social worker comes and talks to me about the nursing home where cats are running around, you know, to infect my leg or spin their little cat hairs into my lungs and make my asthma worse…I’m going to have to beg the nurses or the aides or the family or somebody to clean the cat…” (Veteran, VA hospital)

Framing

Framing was the strongest theme among clinician interviews in our sample. Clinicians most frequently described the SNF as a place where patients could recover function (a positive frame), explaining risks (eg, rehospitalization) associated with alternative postacute care options besides the SNF in great detail.

“Aside from explaining the benefits of going and…having that 24-hour care, having the therapies provided to them [the patients], talking about them getting stronger, phrasing it in such a way that patients sometimes are more agreeable, like not calling it a skilled nursing facility, calling it a rehab you know, for them to get physically stronger so they can be the most independent that they can once they do go home, and also explaining … we think that this would be the best plan to prevent them from coming back to the hospital, so those are some of the things that we’ll mention to patients to try and educate them and get them to be agreeable for placement.” (Social worker, University hospital)

Clinicians avoided negative associations with “nursing home” (even though all SNFs are nursing homes) and tended to use more positive frames such as “rehabilitation facility.”

“Use the word rehab….we definitely use the word rehab, to get more therapy, to go home; it’s not a, we really emphasize it’s not a nursing home, it’s not to go to stay forever.” (Physical therapist, safety-net hospital)

Clinicians used a frame of “safety” when discussing the SNF and used a frame of “risk” when discussing alternative postacute care options such as returning home. We did not find examples of clinicians discussing similar risks in going to a SNF even for risks, such as falling, which exist in both settings.

“I’ve talked to them primarily on an avenue of safety because I think people want and they value independence, they value making sure they can get home, but you know, a lot of the times they understand safety is, it can be a concern and outlining that our goal is to make sure that they’re safe and they stay home, and I tend to broach the subject saying that our therapists believe that they might not be safe at home in the moment, but they have potential goals to be safe later on if we continue therapy. I really highlight safety being the major driver of our discussion.” (Physician, VA hospital)

In some cases, framing was so overt that other risk-mitigating options (eg, home healthcare) are not discussed.

“I definitely tend to explain the ideal first. I’m not going to bring up home care when we really think somebody should go to rehab, however, once people say I don’t want to do that, I’m not going, then that’s when I’m like OK, well, let’s talk to the doctors, but we can see about other supports in the home.” (Social worker, VA hospital)

In a large sample of patients and their caregivers, as well as multidisciplinary clinicians at three different hospitals and three SNFs, we found authority bias/halo effect and framing biases were most common and seemed most impactful. Default/status quo bias and anchoring bias were also present in decision-making about a SNF. The combination of authority bias/halo effect and framing biases could synergistically interact to augment the likelihood of patients accepting a SNF for postacute care. Patients who had been to a SNF before seemed more likely to choose the SNF they had experienced previously even if they had no other postacute care experiences, and could be highly influenced by isolated characteristics of that facility (such as the physical environment or cost of care).

It is important to mention that cognitive biases do not necessarily have a negative impact: indeed, as Kahneman and Tversky point out, these are useful heuristics from “fast” thinking that are often effective.²⁴ For example, clinicians may be trying to act in the best interests of the patient when framing the decision in terms of regaining function and averting loss of safety and independence. However, the evidence base regarding the outcomes of an SNF versus other postacute options is not robust, and this decision-making is complex. While this decision was most commonly framed in terms of rehabilitation and returning home, the fact that only about half of patients have returned to the community by 100 days⁴ was not discussed in any interview. In fact, initial evidence suggests replacing the SNF with home healthcare in patients with hip and knee arthroplasty may reduce costs without worsening clinical outcomes.⁶ However, across a broader population, SNFs significantly reduce 30-day readmissions when directly compared with home healthcare, but other clinical outcomes are similar.²⁵ This evidence suggests that the “right” postacute care option for an individual patient is not clear, highlighting a key role biases may play in decision-making. Further, the nebulous concept of “safety” could introduce potential disparities related to social determinants of health.¹² The observed inclination to accept an SNF with which the individual had prior experience may be influenced by the acceptability of this choice because of personal factors or prior research, even if it also represents a bias by limiting the consideration of current alternatives.

Our findings complement those of others in the literature which have also identified profound gaps in discharge decision-making among patients and clinicians,^13-16,26-31 though to our knowledge the role of cognitive biases in these decisions has not been explored. This study also addresses gaps in the cognitive bias literature, including the need for real-world data rather than hypothetical vignettes,¹⁷ and evaluation of treatment and management decisions rather than diagnoses, which have been more commonly studied.²¹

These findings have implications for both individual clinicians and healthcare institutions. In the immediate term, these findings may serve as a call to discharging clinicians to modulate language and “debias” their conversations with patients about care after discharge.^18,22 Shared decision-making requires an informed choice by patients based on their goals and values; framing a decision in a way that puts the clinician’s goals or values (eg, safety) ahead of patient values (eg, independence and autonomy) or limits disclosure (eg, a “rehab” is a nursing home) in the hope of influencing choice may be more consistent with framing bias and less with shared decision-making.¹⁴ Although controversy exists about the best way to “debias” oneself,³² self-awareness of bias is increasingly recognized across healthcare venues as critical to improving care for vulnerable populations.³³ The use of data rather than vignettes may be a useful debiasing strategy, although the limitations of currently available data (eg, capturing nursing home quality) are increasingly recognized.³⁴ From a policy and health system perspective, cognitive biases should be integrated into the development of decision aids to facilitate informed, shared, and high-quality decision-making that incorporates patient values, and perhaps “nudges” from behavioral economics to assist patients in choosing the right postdischarge care for them. Such nudges use principles of framing to influence care without restricting choice.³⁵ As the science informing best practice regarding postacute care improves, identifying the “right” postdischarge care may become easier and recommendations more evidence-based.³⁶

Strengths of the study include a large, diverse sample of patients, caregivers, and clinicians in both the hospital and SNF setting. Also, we used a team-based analysis with an experienced team and a deep knowledge of the data, including triangulation with clinicians to verify results. However, all hospitals and SNFs were located in a single metropolitan area, and responses may vary by region or population density. All three hospitals have housestaff teaching programs, and at the time of the interviews all three community SNFs were “five-star” facilities on the Nursing Home Compare website; results may be different at community hospitals or other SNFs. Hospitalists were the only physician group sampled in the hospital as they provide the majority of inpatient care to older adults; geriatricians, in particular, may have had different perspectives. Since we intended to explore whether cognitive biases were present overall, we did not evaluate whether cognitive biases differed by role or subgroup (by clinician type, patient, or caregiver), but this may be a promising area to explore in future work. Many cognitive biases have been described, and there are likely additional biases we did not identify. To confirm the generalizability of these findings, they should be studied in a larger, more generalizable sample of respondents in future work.

Cognitive biases play an important role in patient decision-making about postacute care, particularly regarding SNF care. As postacute care undergoes a transformation spurred by payment reforms, it is more important than ever to ensure that patients understand their choices at hospital discharge and can make a high-quality decision consistent with their goals.

The combination of decreasing hospital lengths of stay and increasing age and comorbidity of the United States population is a principal driver of the increased use of postacute care in the US.^1-3 Postacute care refers to care in long-term acute care hospitals, inpatient rehabilitation facilities, skilled nursing facilities (SNFs), and care provided by home health agencies after an acute hospitalization. In 2016, 43% of Medicare beneficiaries received postacute care after hospital discharge at the cost of $60 billion annually; nearly half of these received care in an SNF.⁴ Increasing recognition of the significant cost and poor outcomes of postacute care led to payment reforms, such as bundled payments, that incentivized less expensive forms of postacute care and improvements in outcomes.^5-9 Early evaluations suggested that hospitals are sensitive to these reforms and responded by significantly decreasing SNF utilization.^10,11 It remains unclear whether this was safe and effective.

In this context, increased attention to how hospital clinicians and hospitalized patients decide whether to use postacute care (and what form to use) is appropriate since the effect of payment reforms could negatively impact vulnerable populations of older adults without adequate protection.¹² Suboptimal decision-making can drive both overuse and inappropriate underuse of this expensive medical resource. Initial evidence suggests that patients and clinicians are poorly equipped to make high-quality decisions about postacute care, with significant deficits in both the decision-making process and content.^13-16 While these gaps are important to address, they may only be part of the problem. The fields of cognitive psychology and behavioral economics have revealed new insights into decision-making, demonstrating that people deviate from rational decision-making in predictable ways, termed decision heuristics, or cognitive biases.¹⁷ This growing field of research suggests heuristics or biases play important roles in decision-making and determining behavior, particularly in situations where there may be little information provided and the patient is stressed, tired, and ill—precisely like deciding on postacute care.¹⁸ However, it is currently unknown whether cognitive biases are at play when making hospital discharge decisions.

We sought to identify the most salient heuristics or cognitive biases patients may utilize when making decisions about postacute care at the end of their hospitalization and ways clinicians may contribute to these biases. The overall goal was to derive insights for improving postacute care decision-making.

Study Design

We conducted a secondary analysis on interviews with hospital and SNF clinicians as well as patients and their caregivers who were either leaving the hospital for an SNF or newly arrived in an SNF from the hospital to understand if cognitive biases were present and how they manifested themselves in a real-world clinical context.¹⁹ These interviews were part of a larger qualitative study that sought to understand how clinicians, patients, and their caregivers made decisions about postacute care, particularly related to SNFs.^13,14 This study represents the analysis of all our interviews, specifically examining decision-making bias. Participating sites, clinical roles, and both patient and caregiver characteristics (Table 1) in our cohort have been previously described.^13,14

jhm015010022_t1.jpg

Analysis

We used a team-based approach to framework analysis, which has been used in other decision-making studies¹⁴, including those measuring cognitive bias.²⁰ A limitation in cognitive bias research is the lack of a standardized list or categorization of cognitive biases. We reviewed prior systematic^17,21 and narrative reviews^18,22, as well as prior studies describing examples of cognitive biases playing a role in decision-making about therapy²⁰ to construct a list of possible cognitive biases to evaluate and narrow these a priori to potential biases relevant to the decision about postacute care based on our prior work (Table 2).

burke01510821e_t2.jpg

We applied this framework to analyze transcripts through an iterative process of deductive coding and reviewing across four reviewers (ML, RA, AL, CL) and a hospitalist physician with expertise leading qualitative studies (REB).

Intercoder consensus was built through team discussion by resolving points of disagreement.²³ Consistency of coding was regularly checked by having more than one investigator code individual manuscripts and comparing coding, and discrepancies were resolved through team discussion. We triangulated the data (shared our preliminary results) using a larger study team, including an expert in behavioral economics (SRG), physicians at study sites (EC, RA), and an anthropologist with expertise in qualitative methods (CL). We did this to ensure credibility (to what extent the findings are credible or believable) and confirmability of findings (ensuring the findings are based on participant narratives rather than researcher biases).

We reviewed a total of 105 interviews with 25 hospital clinicians, 20 SNF clinicians, 21 patients and 14 caregivers in the hospital, and 15 patients and 10 caregivers in the SNF setting (Table 1). We found authority bias/halo effect; default/status quo bias, anchoring bias, and framing was commonly present in decision-making about postacute care in a SNF, whereas there were few if any examples of ambiguity aversion, availability heuristic, confirmation bias, optimism bias, or false consensus effect (Table 2).

Authority Bias/Halo Effect

While most patients deferred to their inpatient teams when it came to decision-making, this effect seemed to differ across VA and non-VA settings. Veterans expressed a higher degree of potential authority bias regarding the VA as an institution, whereas older adults in non-VA settings saw physicians as the authority figure making decisions in their best interests.

Veterans expressed confidence in the VA regarding both whether to go to a SNF and where to go:

“The VA wouldn’t license [an SNF] if they didn’t have a good reputation for care, cleanliness, things of that nature” (Veteran, VA CLC)

“I just knew the VA would have my best interests at heart” (Veteran, VA CLC)

Their caregivers expressed similar confidence:

“I’m not gonna decide [on whether the patient they care for goes to postacute care], like I told you, that’s totally up to the VA. I have trust and faith in them…so wherever they send him, that’s where he’s going” (Caregiver, VA hospital)

In some cases, this perspective was closer to the halo effect: a positive experience with the care provider or the care team led the decision-makers to believe that their recommendations about postacute care would be similarly positive.

“I think we were very trusting in the sense that whatever happened the last time around, he survived it…they took care of him…he got back home, and he started his life again, you know, so why would we question what they’re telling us to do? (Caregiver, VA hospital)

In contrast to Veterans, non-Veteran patients seemed to experience authority bias when it came to the inpatient team.

“Well, I’d like to know more about the PTs [Physical Therapists] there, but I assume since they were recommended, they will be good.” (Patient, University hospital)

This perspective was especially apparent when it came to physicians:

“The level of trust that they [patients] put in their doctor is gonna outweigh what anyone else would say.” (Clinical liaison, SNF)

“[In response to a question about influences on the decision to go to rehab] I don’t…that’s not my decision to make, that’s the doctor’s decision.” (Patient, University hospital)

“They said so…[the doctor] said I needed to go to rehab, so I guess I do because it’s the doctor’s decision.” (Patient, University hospital)

Default/Status quo Bias

In a related way, patients and caregivers with exposure to a SNF seemed to default to the same SNF with which they had previous experience. This bias seems to be primarily related to knowing what to expect.

“He thinks it’s [a particular SNF] the right place for him now…he was there before and he knew, again, it was the right place for him to be” (Caregiver, VA hospital)

“It’s the only one I’ve ever been in…but they have a lot of activities; you have a lot of freedom, staff was good” (Patient, VA hospital)

“I’ve been [to this SNF] before and I kind of know what the program involves…so it was kind of like going home, not, going home is the wrong way to put it…I mean coming here is like something I know, you know, I didn’t need anybody to explain it to me.” (Patient, VA hospital)

“Anybody that’s been to [SNF], that would be their choice to go back to, and I guess I must’ve liked it that first time because I asked to go back again.” (Patient, University hospital)

Anchoring Bias

While anchoring bias was less frequent, it came up in two domains: first, related to costs of care, and second, related to facility characteristics. Costs came up most frequently for Veterans who preferred to move their care to the VA for cost reasons, which appeared in these cases to overshadow other considerations:

“I kept emphasizing that the VA could do all the same things at a lot more reasonable price. The whole purpose of having the VA is for the Veteran, so that…we can get the healthcare that we need at a more reasonable [sic] or a reasonable price.” (Veteran, CLC)

“I think the CLC [VA SNF] is going to take care of her probably the same way any other facility of its type would, unless she were in a private facility, but you know, that costs a lot more money.” (Caregiver, VA hospital)

Patients occasionally had striking responses to particular characteristics of SNFs, regardless of whether this was a central feature or related to their rehabilitation:

“The social worker comes and talks to me about the nursing home where cats are running around, you know, to infect my leg or spin their little cat hairs into my lungs and make my asthma worse…I’m going to have to beg the nurses or the aides or the family or somebody to clean the cat…” (Veteran, VA hospital)

Framing

Framing was the strongest theme among clinician interviews in our sample. Clinicians most frequently described the SNF as a place where patients could recover function (a positive frame), explaining risks (eg, rehospitalization) associated with alternative postacute care options besides the SNF in great detail.

“Aside from explaining the benefits of going and…having that 24-hour care, having the therapies provided to them [the patients], talking about them getting stronger, phrasing it in such a way that patients sometimes are more agreeable, like not calling it a skilled nursing facility, calling it a rehab you know, for them to get physically stronger so they can be the most independent that they can once they do go home, and also explaining … we think that this would be the best plan to prevent them from coming back to the hospital, so those are some of the things that we’ll mention to patients to try and educate them and get them to be agreeable for placement.” (Social worker, University hospital)

Clinicians avoided negative associations with “nursing home” (even though all SNFs are nursing homes) and tended to use more positive frames such as “rehabilitation facility.”

“Use the word rehab….we definitely use the word rehab, to get more therapy, to go home; it’s not a, we really emphasize it’s not a nursing home, it’s not to go to stay forever.” (Physical therapist, safety-net hospital)

Clinicians used a frame of “safety” when discussing the SNF and used a frame of “risk” when discussing alternative postacute care options such as returning home. We did not find examples of clinicians discussing similar risks in going to a SNF even for risks, such as falling, which exist in both settings.

“I’ve talked to them primarily on an avenue of safety because I think people want and they value independence, they value making sure they can get home, but you know, a lot of the times they understand safety is, it can be a concern and outlining that our goal is to make sure that they’re safe and they stay home, and I tend to broach the subject saying that our therapists believe that they might not be safe at home in the moment, but they have potential goals to be safe later on if we continue therapy. I really highlight safety being the major driver of our discussion.” (Physician, VA hospital)

In some cases, framing was so overt that other risk-mitigating options (eg, home healthcare) are not discussed.

“I definitely tend to explain the ideal first. I’m not going to bring up home care when we really think somebody should go to rehab, however, once people say I don’t want to do that, I’m not going, then that’s when I’m like OK, well, let’s talk to the doctors, but we can see about other supports in the home.” (Social worker, VA hospital)

In a large sample of patients and their caregivers, as well as multidisciplinary clinicians at three different hospitals and three SNFs, we found authority bias/halo effect and framing biases were most common and seemed most impactful. Default/status quo bias and anchoring bias were also present in decision-making about a SNF. The combination of authority bias/halo effect and framing biases could synergistically interact to augment the likelihood of patients accepting a SNF for postacute care. Patients who had been to a SNF before seemed more likely to choose the SNF they had experienced previously even if they had no other postacute care experiences, and could be highly influenced by isolated characteristics of that facility (such as the physical environment or cost of care).

It is important to mention that cognitive biases do not necessarily have a negative impact: indeed, as Kahneman and Tversky point out, these are useful heuristics from “fast” thinking that are often effective.²⁴ For example, clinicians may be trying to act in the best interests of the patient when framing the decision in terms of regaining function and averting loss of safety and independence. However, the evidence base regarding the outcomes of an SNF versus other postacute options is not robust, and this decision-making is complex. While this decision was most commonly framed in terms of rehabilitation and returning home, the fact that only about half of patients have returned to the community by 100 days⁴ was not discussed in any interview. In fact, initial evidence suggests replacing the SNF with home healthcare in patients with hip and knee arthroplasty may reduce costs without worsening clinical outcomes.⁶ However, across a broader population, SNFs significantly reduce 30-day readmissions when directly compared with home healthcare, but other clinical outcomes are similar.²⁵ This evidence suggests that the “right” postacute care option for an individual patient is not clear, highlighting a key role biases may play in decision-making. Further, the nebulous concept of “safety” could introduce potential disparities related to social determinants of health.¹² The observed inclination to accept an SNF with which the individual had prior experience may be influenced by the acceptability of this choice because of personal factors or prior research, even if it also represents a bias by limiting the consideration of current alternatives.

Our findings complement those of others in the literature which have also identified profound gaps in discharge decision-making among patients and clinicians,^13-16,26-31 though to our knowledge the role of cognitive biases in these decisions has not been explored. This study also addresses gaps in the cognitive bias literature, including the need for real-world data rather than hypothetical vignettes,¹⁷ and evaluation of treatment and management decisions rather than diagnoses, which have been more commonly studied.²¹

These findings have implications for both individual clinicians and healthcare institutions. In the immediate term, these findings may serve as a call to discharging clinicians to modulate language and “debias” their conversations with patients about care after discharge.^18,22 Shared decision-making requires an informed choice by patients based on their goals and values; framing a decision in a way that puts the clinician’s goals or values (eg, safety) ahead of patient values (eg, independence and autonomy) or limits disclosure (eg, a “rehab” is a nursing home) in the hope of influencing choice may be more consistent with framing bias and less with shared decision-making.¹⁴ Although controversy exists about the best way to “debias” oneself,³² self-awareness of bias is increasingly recognized across healthcare venues as critical to improving care for vulnerable populations.³³ The use of data rather than vignettes may be a useful debiasing strategy, although the limitations of currently available data (eg, capturing nursing home quality) are increasingly recognized.³⁴ From a policy and health system perspective, cognitive biases should be integrated into the development of decision aids to facilitate informed, shared, and high-quality decision-making that incorporates patient values, and perhaps “nudges” from behavioral economics to assist patients in choosing the right postdischarge care for them. Such nudges use principles of framing to influence care without restricting choice.³⁵ As the science informing best practice regarding postacute care improves, identifying the “right” postdischarge care may become easier and recommendations more evidence-based.³⁶

Strengths of the study include a large, diverse sample of patients, caregivers, and clinicians in both the hospital and SNF setting. Also, we used a team-based analysis with an experienced team and a deep knowledge of the data, including triangulation with clinicians to verify results. However, all hospitals and SNFs were located in a single metropolitan area, and responses may vary by region or population density. All three hospitals have housestaff teaching programs, and at the time of the interviews all three community SNFs were “five-star” facilities on the Nursing Home Compare website; results may be different at community hospitals or other SNFs. Hospitalists were the only physician group sampled in the hospital as they provide the majority of inpatient care to older adults; geriatricians, in particular, may have had different perspectives. Since we intended to explore whether cognitive biases were present overall, we did not evaluate whether cognitive biases differed by role or subgroup (by clinician type, patient, or caregiver), but this may be a promising area to explore in future work. Many cognitive biases have been described, and there are likely additional biases we did not identify. To confirm the generalizability of these findings, they should be studied in a larger, more generalizable sample of respondents in future work.

Cognitive biases play an important role in patient decision-making about postacute care, particularly regarding SNF care. As postacute care undergoes a transformation spurred by payment reforms, it is more important than ever to ensure that patients understand their choices at hospital discharge and can make a high-quality decision consistent with their goals.

The combination of decreasing hospital lengths of stay and increasing age and comorbidity of the United States population is a principal driver of the increased use of postacute care in the US.^1-3 Postacute care refers to care in long-term acute care hospitals, inpatient rehabilitation facilities, skilled nursing facilities (SNFs), and care provided by home health agencies after an acute hospitalization. In 2016, 43% of Medicare beneficiaries received postacute care after hospital discharge at the cost of $60 billion annually; nearly half of these received care in an SNF.⁴ Increasing recognition of the significant cost and poor outcomes of postacute care led to payment reforms, such as bundled payments, that incentivized less expensive forms of postacute care and improvements in outcomes.^5-9 Early evaluations suggested that hospitals are sensitive to these reforms and responded by significantly decreasing SNF utilization.^10,11 It remains unclear whether this was safe and effective.

In this context, increased attention to how hospital clinicians and hospitalized patients decide whether to use postacute care (and what form to use) is appropriate since the effect of payment reforms could negatively impact vulnerable populations of older adults without adequate protection.¹² Suboptimal decision-making can drive both overuse and inappropriate underuse of this expensive medical resource. Initial evidence suggests that patients and clinicians are poorly equipped to make high-quality decisions about postacute care, with significant deficits in both the decision-making process and content.^13-16 While these gaps are important to address, they may only be part of the problem. The fields of cognitive psychology and behavioral economics have revealed new insights into decision-making, demonstrating that people deviate from rational decision-making in predictable ways, termed decision heuristics, or cognitive biases.¹⁷ This growing field of research suggests heuristics or biases play important roles in decision-making and determining behavior, particularly in situations where there may be little information provided and the patient is stressed, tired, and ill—precisely like deciding on postacute care.¹⁸ However, it is currently unknown whether cognitive biases are at play when making hospital discharge decisions.

We sought to identify the most salient heuristics or cognitive biases patients may utilize when making decisions about postacute care at the end of their hospitalization and ways clinicians may contribute to these biases. The overall goal was to derive insights for improving postacute care decision-making.

Study Design

We conducted a secondary analysis on interviews with hospital and SNF clinicians as well as patients and their caregivers who were either leaving the hospital for an SNF or newly arrived in an SNF from the hospital to understand if cognitive biases were present and how they manifested themselves in a real-world clinical context.¹⁹ These interviews were part of a larger qualitative study that sought to understand how clinicians, patients, and their caregivers made decisions about postacute care, particularly related to SNFs.^13,14 This study represents the analysis of all our interviews, specifically examining decision-making bias. Participating sites, clinical roles, and both patient and caregiver characteristics (Table 1) in our cohort have been previously described.^13,14

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Analysis

We used a team-based approach to framework analysis, which has been used in other decision-making studies¹⁴, including those measuring cognitive bias.²⁰ A limitation in cognitive bias research is the lack of a standardized list or categorization of cognitive biases. We reviewed prior systematic^17,21 and narrative reviews^18,22, as well as prior studies describing examples of cognitive biases playing a role in decision-making about therapy²⁰ to construct a list of possible cognitive biases to evaluate and narrow these a priori to potential biases relevant to the decision about postacute care based on our prior work (Table 2).

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We applied this framework to analyze transcripts through an iterative process of deductive coding and reviewing across four reviewers (ML, RA, AL, CL) and a hospitalist physician with expertise leading qualitative studies (REB).

Intercoder consensus was built through team discussion by resolving points of disagreement.²³ Consistency of coding was regularly checked by having more than one investigator code individual manuscripts and comparing coding, and discrepancies were resolved through team discussion. We triangulated the data (shared our preliminary results) using a larger study team, including an expert in behavioral economics (SRG), physicians at study sites (EC, RA), and an anthropologist with expertise in qualitative methods (CL). We did this to ensure credibility (to what extent the findings are credible or believable) and confirmability of findings (ensuring the findings are based on participant narratives rather than researcher biases).

We reviewed a total of 105 interviews with 25 hospital clinicians, 20 SNF clinicians, 21 patients and 14 caregivers in the hospital, and 15 patients and 10 caregivers in the SNF setting (Table 1). We found authority bias/halo effect; default/status quo bias, anchoring bias, and framing was commonly present in decision-making about postacute care in a SNF, whereas there were few if any examples of ambiguity aversion, availability heuristic, confirmation bias, optimism bias, or false consensus effect (Table 2).

Authority Bias/Halo Effect

While most patients deferred to their inpatient teams when it came to decision-making, this effect seemed to differ across VA and non-VA settings. Veterans expressed a higher degree of potential authority bias regarding the VA as an institution, whereas older adults in non-VA settings saw physicians as the authority figure making decisions in their best interests.

Veterans expressed confidence in the VA regarding both whether to go to a SNF and where to go:

“The VA wouldn’t license [an SNF] if they didn’t have a good reputation for care, cleanliness, things of that nature” (Veteran, VA CLC)

“I just knew the VA would have my best interests at heart” (Veteran, VA CLC)

Their caregivers expressed similar confidence:

“I’m not gonna decide [on whether the patient they care for goes to postacute care], like I told you, that’s totally up to the VA. I have trust and faith in them…so wherever they send him, that’s where he’s going” (Caregiver, VA hospital)

In some cases, this perspective was closer to the halo effect: a positive experience with the care provider or the care team led the decision-makers to believe that their recommendations about postacute care would be similarly positive.

“I think we were very trusting in the sense that whatever happened the last time around, he survived it…they took care of him…he got back home, and he started his life again, you know, so why would we question what they’re telling us to do? (Caregiver, VA hospital)

In contrast to Veterans, non-Veteran patients seemed to experience authority bias when it came to the inpatient team.

“Well, I’d like to know more about the PTs [Physical Therapists] there, but I assume since they were recommended, they will be good.” (Patient, University hospital)

This perspective was especially apparent when it came to physicians:

“The level of trust that they [patients] put in their doctor is gonna outweigh what anyone else would say.” (Clinical liaison, SNF)

“[In response to a question about influences on the decision to go to rehab] I don’t…that’s not my decision to make, that’s the doctor’s decision.” (Patient, University hospital)

“They said so…[the doctor] said I needed to go to rehab, so I guess I do because it’s the doctor’s decision.” (Patient, University hospital)

Default/Status quo Bias

In a related way, patients and caregivers with exposure to a SNF seemed to default to the same SNF with which they had previous experience. This bias seems to be primarily related to knowing what to expect.

“He thinks it’s [a particular SNF] the right place for him now…he was there before and he knew, again, it was the right place for him to be” (Caregiver, VA hospital)

“It’s the only one I’ve ever been in…but they have a lot of activities; you have a lot of freedom, staff was good” (Patient, VA hospital)

“I’ve been [to this SNF] before and I kind of know what the program involves…so it was kind of like going home, not, going home is the wrong way to put it…I mean coming here is like something I know, you know, I didn’t need anybody to explain it to me.” (Patient, VA hospital)

“Anybody that’s been to [SNF], that would be their choice to go back to, and I guess I must’ve liked it that first time because I asked to go back again.” (Patient, University hospital)

Anchoring Bias

While anchoring bias was less frequent, it came up in two domains: first, related to costs of care, and second, related to facility characteristics. Costs came up most frequently for Veterans who preferred to move their care to the VA for cost reasons, which appeared in these cases to overshadow other considerations:

“I kept emphasizing that the VA could do all the same things at a lot more reasonable price. The whole purpose of having the VA is for the Veteran, so that…we can get the healthcare that we need at a more reasonable [sic] or a reasonable price.” (Veteran, CLC)

“I think the CLC [VA SNF] is going to take care of her probably the same way any other facility of its type would, unless she were in a private facility, but you know, that costs a lot more money.” (Caregiver, VA hospital)

Patients occasionally had striking responses to particular characteristics of SNFs, regardless of whether this was a central feature or related to their rehabilitation:

“The social worker comes and talks to me about the nursing home where cats are running around, you know, to infect my leg or spin their little cat hairs into my lungs and make my asthma worse…I’m going to have to beg the nurses or the aides or the family or somebody to clean the cat…” (Veteran, VA hospital)

Framing

Framing was the strongest theme among clinician interviews in our sample. Clinicians most frequently described the SNF as a place where patients could recover function (a positive frame), explaining risks (eg, rehospitalization) associated with alternative postacute care options besides the SNF in great detail.

“Aside from explaining the benefits of going and…having that 24-hour care, having the therapies provided to them [the patients], talking about them getting stronger, phrasing it in such a way that patients sometimes are more agreeable, like not calling it a skilled nursing facility, calling it a rehab you know, for them to get physically stronger so they can be the most independent that they can once they do go home, and also explaining … we think that this would be the best plan to prevent them from coming back to the hospital, so those are some of the things that we’ll mention to patients to try and educate them and get them to be agreeable for placement.” (Social worker, University hospital)

Clinicians avoided negative associations with “nursing home” (even though all SNFs are nursing homes) and tended to use more positive frames such as “rehabilitation facility.”

“Use the word rehab….we definitely use the word rehab, to get more therapy, to go home; it’s not a, we really emphasize it’s not a nursing home, it’s not to go to stay forever.” (Physical therapist, safety-net hospital)

Clinicians used a frame of “safety” when discussing the SNF and used a frame of “risk” when discussing alternative postacute care options such as returning home. We did not find examples of clinicians discussing similar risks in going to a SNF even for risks, such as falling, which exist in both settings.

“I’ve talked to them primarily on an avenue of safety because I think people want and they value independence, they value making sure they can get home, but you know, a lot of the times they understand safety is, it can be a concern and outlining that our goal is to make sure that they’re safe and they stay home, and I tend to broach the subject saying that our therapists believe that they might not be safe at home in the moment, but they have potential goals to be safe later on if we continue therapy. I really highlight safety being the major driver of our discussion.” (Physician, VA hospital)

In some cases, framing was so overt that other risk-mitigating options (eg, home healthcare) are not discussed.

“I definitely tend to explain the ideal first. I’m not going to bring up home care when we really think somebody should go to rehab, however, once people say I don’t want to do that, I’m not going, then that’s when I’m like OK, well, let’s talk to the doctors, but we can see about other supports in the home.” (Social worker, VA hospital)

In a large sample of patients and their caregivers, as well as multidisciplinary clinicians at three different hospitals and three SNFs, we found authority bias/halo effect and framing biases were most common and seemed most impactful. Default/status quo bias and anchoring bias were also present in decision-making about a SNF. The combination of authority bias/halo effect and framing biases could synergistically interact to augment the likelihood of patients accepting a SNF for postacute care. Patients who had been to a SNF before seemed more likely to choose the SNF they had experienced previously even if they had no other postacute care experiences, and could be highly influenced by isolated characteristics of that facility (such as the physical environment or cost of care).

It is important to mention that cognitive biases do not necessarily have a negative impact: indeed, as Kahneman and Tversky point out, these are useful heuristics from “fast” thinking that are often effective.²⁴ For example, clinicians may be trying to act in the best interests of the patient when framing the decision in terms of regaining function and averting loss of safety and independence. However, the evidence base regarding the outcomes of an SNF versus other postacute options is not robust, and this decision-making is complex. While this decision was most commonly framed in terms of rehabilitation and returning home, the fact that only about half of patients have returned to the community by 100 days⁴ was not discussed in any interview. In fact, initial evidence suggests replacing the SNF with home healthcare in patients with hip and knee arthroplasty may reduce costs without worsening clinical outcomes.⁶ However, across a broader population, SNFs significantly reduce 30-day readmissions when directly compared with home healthcare, but other clinical outcomes are similar.²⁵ This evidence suggests that the “right” postacute care option for an individual patient is not clear, highlighting a key role biases may play in decision-making. Further, the nebulous concept of “safety” could introduce potential disparities related to social determinants of health.¹² The observed inclination to accept an SNF with which the individual had prior experience may be influenced by the acceptability of this choice because of personal factors or prior research, even if it also represents a bias by limiting the consideration of current alternatives.

Our findings complement those of others in the literature which have also identified profound gaps in discharge decision-making among patients and clinicians,^13-16,26-31 though to our knowledge the role of cognitive biases in these decisions has not been explored. This study also addresses gaps in the cognitive bias literature, including the need for real-world data rather than hypothetical vignettes,¹⁷ and evaluation of treatment and management decisions rather than diagnoses, which have been more commonly studied.²¹

These findings have implications for both individual clinicians and healthcare institutions. In the immediate term, these findings may serve as a call to discharging clinicians to modulate language and “debias” their conversations with patients about care after discharge.^18,22 Shared decision-making requires an informed choice by patients based on their goals and values; framing a decision in a way that puts the clinician’s goals or values (eg, safety) ahead of patient values (eg, independence and autonomy) or limits disclosure (eg, a “rehab” is a nursing home) in the hope of influencing choice may be more consistent with framing bias and less with shared decision-making.¹⁴ Although controversy exists about the best way to “debias” oneself,³² self-awareness of bias is increasingly recognized across healthcare venues as critical to improving care for vulnerable populations.³³ The use of data rather than vignettes may be a useful debiasing strategy, although the limitations of currently available data (eg, capturing nursing home quality) are increasingly recognized.³⁴ From a policy and health system perspective, cognitive biases should be integrated into the development of decision aids to facilitate informed, shared, and high-quality decision-making that incorporates patient values, and perhaps “nudges” from behavioral economics to assist patients in choosing the right postdischarge care for them. Such nudges use principles of framing to influence care without restricting choice.³⁵ As the science informing best practice regarding postacute care improves, identifying the “right” postdischarge care may become easier and recommendations more evidence-based.³⁶

Strengths of the study include a large, diverse sample of patients, caregivers, and clinicians in both the hospital and SNF setting. Also, we used a team-based analysis with an experienced team and a deep knowledge of the data, including triangulation with clinicians to verify results. However, all hospitals and SNFs were located in a single metropolitan area, and responses may vary by region or population density. All three hospitals have housestaff teaching programs, and at the time of the interviews all three community SNFs were “five-star” facilities on the Nursing Home Compare website; results may be different at community hospitals or other SNFs. Hospitalists were the only physician group sampled in the hospital as they provide the majority of inpatient care to older adults; geriatricians, in particular, may have had different perspectives. Since we intended to explore whether cognitive biases were present overall, we did not evaluate whether cognitive biases differed by role or subgroup (by clinician type, patient, or caregiver), but this may be a promising area to explore in future work. Many cognitive biases have been described, and there are likely additional biases we did not identify. To confirm the generalizability of these findings, they should be studied in a larger, more generalizable sample of respondents in future work.

Cognitive biases play an important role in patient decision-making about postacute care, particularly regarding SNF care. As postacute care undergoes a transformation spurred by payment reforms, it is more important than ever to ensure that patients understand their choices at hospital discharge and can make a high-quality decision consistent with their goals.

In This Edition

• Perioperative smoking cessation reduces postoperative complications.
• Quality of life is not diminished in heart failure patients receiving defibrillator therapy.
• Simplification of the revised Geneva score may be useful in assessing for pulmonary embolism.
• Non-cardiac surgery after drug eluting stents not associated with major cardiac risk.
• Major cardiac risk is lowest 90 days after bare metal stent percutaneous coronary intervention.
• Extensive cancer screening in unexplained VTE detects more malignancies, but does not affect cancer related mortality.
• Preadmission use of statins decreases after hospitalization mortality in pneumonia.
• Drug-eluting stents are better than bare-metal stents for PCI in acute MI, but additional randomized study is needed.

Does a short duration of perioperative smoking cessation lead to a reduction in postoperative complications?

Background: Prior studies have demonstrated a reduction in postoperative complications when patients stop smoking in the perioperative period. However, they have not clearly shown what effect a fairly short duration of cessation, such as a period of only four weeks, has on the frequency of complications.

Study design: Randomized controlled trial.

Setting: Four university-affiliated hospitals in Sweden.

Synopsis: Using 117 patients who were daily smokers for less than one year between the ages of 18-79 who were scheduled for elective general or orthopedic surgery, this study showed that a smoking-cessation intervention initiated as little as four weeks prior to surgery resulted in fewer postoperative complications. The complication rate was reduced from 41% in the control group to 21% in the intervention group, which received cessation counseling and nicotine-replacement therapy. The relative risk reduction was 49% (95% confidence interval, 3-40) with a number needed to treat of five.

Because this was a randomized controlled trial with a large observed benefit, it appears to be reasonable to endorse perioperative smoking cessation as late as four weeks before an elective surgery. The study was limited in its ability to detect a difference in wound infections by the small sample size and the possibility patients might have unblinded themselves to outcome assessors, causing an overestimation of the effect of the intervention on the primary outcome of all complications.

Bottom line: Perioperative smoking cessation reduces postoperative complications even when started just four weeks prior to surgery.

Citation: Lindstrom D, Azodi OS, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications. Ann Surg. 2008;248(5):739-745.

Does implantable-defibrillator therapy cause deterioration in quality of life for patients with heart failure?

Background: Patients with depressed left-ventricular function are known to have improved survival after receiving implantable cardioverter defibrillators (ICDs). However, there is concern ICD therapy can prolong survival at the expense of a diminished quality of life.

Study design: Randomized placebo-controlled trial.

Setting: Multiple centers in the U.S., Canada, and New Zealand.

Synopsis: Using 2,479 patients from the Sudden Cardiac Death in Heart Failure trial who were 18 and older and had stable heart failure and depressed left-ventricular function, this study demonstrated no significant quality-of-life difference at 30 months when compared with patients who received ICD, amiodarone, and state-of-the-art medical therapy or an amiodarone placebo and state-of-the-art medical therapy. While functional status did not differ at any time between the three groups, psychological well-being was improved in the ICD group at three months (p=0.01) and 12 months (p=0.03) when compared with the placebo group, but at 30 months there was no difference between the groups.

While the trial was randomized and placebo-controlled, the investigators were unable to blind patients or outcome assessors. Nevertheless, the lack of deterioration of quality of life in ICD patients is reassuring.

Bottom line: Placement of ICDs in heart failure patients with a high risk of sudden cardiac death does not appear to decrease quality of life.

Citation: Mark DB, Anstrom KJ, Sun JL, et al. Quality of life with defibrillator therapy or amiodarone in heart failure. N Engl J Med. 2008;359:999-1008.

Can a simplified, revised Geneva score retain diagnostic accuracy and clinical utility?

Background: The revised Geneva score is a validated and objective clinical decision rule, but has multiple variables with different weights. This can make the tool cumbersome and difficult to remember, and could lead to inaccurate calculations and misjudgments in patient care.

Study design: Retrospective cohort study.

Setting: Four university-affiliated European hospitals.

Synopsis: Using data from two prior prospective trials involving patients with suspected pulmonary embolism (PE), this study showed re-analysis of these patients with a simplified, revised Geneva score, which gives only one point to each clinical factor, resulted in the same level of diagnostic accuracy. Specifically, data from 1,049 patients was used to construct a receiver-operating characteristic curve analysis comparing the standardized and simplified Geneva score, which showed areas under the curve of 0.75 (95% confidence interval 0.71-0.78) and 0.74 (0.70-0.77), respectively. Additionally, the safety of using this clinical tool to rule out PE was demonstrated when using both a three-level (low-intermediate probability) and a dichotomized scheme (PE unlikely) in combination with a negative D-dimer test.

The retrospective nature of the study was its major limitation. The authors suggest a prospective study to complete validation of the simplified, revised Geneva score.

Bottom line: With prospective analysis, it might be possible to further validate a simplified, revised Geneva score.

Citation: Klok FA, Mos ICM, Nijkeuter M, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008;168(19):2131-2136.

Is the rate of postoperative major adverse cardiac events (MACEs) inversely related to time after percutaneous coronary intervention (PCI) with a drug-eluting stent (DES)?

Background: The American College of Cardiology and the American Heart Association recently released an advisory that included a recommendation to delay elective noncardiac surgery (NCS) for one year after DES placement. However, no large study addresses the timing of NCS after PCI with DES.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 520 patients who had NCS after DES at the Mayo Clinic, 5.4% experienced MACEs, but the rate of MACEs was not significantly associated with the time after stent placement to surgery (p=0.337). However, observed rates of MACEs were lower after one year. Elderly patients and those going for emergent surgery are at the highest risk for MACE. Bleeding complications were not associated with antiplatelet use.

Although this study does not provide a clear cutoff time for when it is safe to proceed to NCS after DES, it is somewhat reassuring to see the relatively small number of MACEs and the lack of bleeding complications associated with antiplatelet use. However, careful coordination between hospitalists, cardiologists, anesthesiologists, and surgeons is still needed when coordinating NCS after DES, especially in the elderly or during emergent situations.

Bottom line: While time to noncardiac surgery after drug-eluting stent placement is not associated with major adverse cardiac events, observed rates of events are lower after one year.

Citation: Rabbitts JA, Nuttall GA, Brown MJ, et al. Cardiac risk of non-cardiac surgery after percutaneous coronary intervention with drug-eluting stents. Anesthesiology.2008;109: 596-604.

Is the risk of MACEs and bleeding events for patients undergoing NCS related to the time interval between PCI with bare-metal stent?

Background: In order to prevent thrombosis of bare-metal stents (BMS) placed during percutaneous coronary intervention (PCI), antiplatelet therapy is used. This poses a risk of bleeding, if surgery is needed during the antiplatelet therapy. The American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 899 patients who had NCS within one year of PCI with BMS at the Mayo Clinic between Jan. 1, 1990, and Jan. 1, 2005, this study found that when NCS was done 30 days or less after PCI with BMS, the MACEs rate was 10.5%, compared with 2.8% when NCS was done 91 or more days after PCI with BMS. After a multivariable analysis, it also was shown bleeding events were not associated with time between PCI with BMS and NCS.

While the American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS, waiting at least 90 days would permit completion of antiplatelet therapy and re-endothelialization of the stent.

Bottom line: The risk of MACEs with noncardiac surgery is lowest when performed at least 90 days after PCI with bare-metal stent.

Citation: Nuttall GA, Brown MJ, Stombaugh JW, et al. Time and cardiac risk of surgery after bare-metal stent, percutaneous coronary intervention. Anesthesiology. 2008;109: 588-595.

Should we screen extensively for cancer in patients with newly diagnosed venous thromboembolism (VTE)?

Background: It is well known VTE can be the first manifestation of previously undiagnosed cancer. Retrospective studies have suggested “limited” cancer screening, including a history and physical examination, along with basic blood work, adequately identifies malignancy in patients with unexplained VTE. However, more recent prospective studies have suggested more extensive screening, which includes imaging studies or tumor-marker measurement, can increase the rate of cancer detection.

Study design: Systematic review.

Setting: Literature search using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, and evidence-based medicine reviews.

Synopsis: Thirty-six studies of 9,516 patients with VTE reported the period prevalence of previously undiagnosed cancer from baseline to 12 months was 6.3% (95% confidence interval (CI) of 5.6% to 6.9%) in all patients with VTE, and was even higher in patients with unprovoked VTE, 10% (95% CI 8.6% to 11.3%). Of the 34 articles used for prevalence assessment, an extensive screening strategy using CT scans of the abdomen and pelvis increased the proportion of previously undiagnosed cancer detection from 49.4% (CI, 40.2% to 58.5%; limited screening) to 69.7% (CI, 61.1% to 77.8%) in patients with unprovoked VTE. Ultrasonography of the abdomen and pelvis and tumor-marker screening did not result in a clinically significant increase in the frequency of cancer detection.

Four studies compared the rate of detection of early-stage, previously undiagnosed cancer between the limited and extensive screening strategies. Extensive screening led to an absolute decrease in cancer-related mortality of 1.9%, but this difference was not statistically significant.

In this systematic review, there is a great deal of heterogeneity in the studies. Most of the studies did not look at whether an increase in detection of new malignant conditions resulted in a change in the detection rate of early-stage cancer, or a decrease in cancer-related morbidity, cancer-related mortality, or overall mortality. Furthermore, the studies did not assess the consequences of extensive screening, such as patient anxiety and discomfort, testing complications, burden of additional tests for false-positive results, or cost-effectiveness. However, it is important for hospitalists to recognize undiagnosed cancer is common in unexplained VTE and warrants at least a limited-screening approach with more extensive screening.

Bottom line: Although the prevalence of undiagnosed cancer is common in VTE, extensive screening did not offer a cancer-related mortality benefit. CT of the abdomen and pelvis did, however, lead to a greater number of cancer diagnoses in patients with unexplained VTE.

Citation: Carrier M, Le Gal G, Wells PS, Fergusson D, Ramsay T, Rodger MA. Systematic review: the Trousseau syndrome revisited: should we screen extensively for cancer in patients with venous thromboembolism? Ann Intern Med. 2008;149: 323-333.

Does the use of preadmission statins decrease the risk of death, bacteremia, and pulmonary complications in patients admitted with pneumonia?

Background: Both experimental and clinical studies have suggested statins improve outcomes in severe infections, such as sepsis. This is thought to be due to the antithrombotic, anti-inflammatory, and immunomodulatory effects of statins. However, previous studies on the effect of statins on pneumonia have conflicting outcomes.

Study design: Population-based cohort study of 29,900 patients.

Setting: Danish Health Registry.

Synopsis: Researchers studied patients ages 15 years and older hospitalized with pneumonia for the first time between January 1997 and December 2004. While statin users had more co-morbidities than nonusers, the 30-day mortality was 10.3% in users, compared with 15.7% in nonusers, corresponding to an adjusted 30-day mortality rate ratio of 0.69 (95% CI of 0.58-0.82). The 90-day mortality ratio was 16.8% in users, compared with 22.4% in nonusers, corresponding to an adjusted 90-day mortality ratio of 0.75 (95% CI of 0.65-0.86). Former use of statins was not associated with a decreased risk of death. The adjusted risk for bacteremia and pulmonary complications was not significantly different between nonusers and users.

Because this was an observational study, a causal relationship cannot be determined. Hospitalists should be alerted to the possibility statins might, in the future, prove to be a standard treatment modality in pneumonia. A randomized, double-blind trial might help further determine the effect of the acute use of statins on pneumonia outcomes.

Bottom line: Preadmission statin use is associated with a decrease in 30- and 90-day mortality in pneumonia.

Citation: Thomsen RW, Riis A, Kornum JB, Christensen S, Johnsen SP, Sorensen HT. Preadmission use of statins and outcomes after hospitalization with pneumonia. Arch Intern Med. 2008;168(19):2081-2087.

Do outcomes differ when patients with acute myocardial infarction (MI) undergo PCI with drug-eluting stents (DES) compared with bare-metal stents?

Background: Randomized trials comparing drug-eluting stents with bare-metal stents in acute MI have been limited in size and duration. Concern exists regarding higher mortality among patients with ST-elevation MI treated with DES.

Study design: Observational, cohort study.

Setting: Patients were identified from a state-mandated database, in which all PCI performed in Massachusetts are reported.

Synopsis: Between April 2003 and September 2004, 7,217 eligible patients underwent stenting for acute MI. They were assigned to either the DES group or the bare-metal stent (BMS) group using propensity score matching. Patients in the DES group had lower mortality at two years, compared to a matched cohort of patients in the BMS group with MI (10.7% vs. 12.8%; absolute risk difference, -2.1%, CI, -3.8% to -0.4%). A statistically significant difference was noted among patients with or without ST-elevation MI.

The rates of target vessel revascularization at two years with MI were significantly lower among patients receiving DES than among those receiving BMS (9.6% vs. 14.5%; risk difference, -4.9%; CI, -6.1% to -3.1%).

The study is limited by its observational nature and residual confounding bias after matching. Importantly, this study was performed to determine if DESs were harmful, and the finding of reduced mortality was unanticipated.

Bottom line: Although patients with acute MI treated with drug-eluting stents had lower mortality and repeat revascularization rates compared with bare-metal stents, this outcome merits confirmation in randomized trials.

Citation: Mauri L, Silbaugh TS, Garg P, et al. Drug-eluting or bare-metal stents for acute myocardial infarction. N Engl J Med. 2008;359 (13):1330-1342.

In This Edition

• Perioperative smoking cessation reduces postoperative complications.
• Quality of life is not diminished in heart failure patients receiving defibrillator therapy.
• Simplification of the revised Geneva score may be useful in assessing for pulmonary embolism.
• Non-cardiac surgery after drug eluting stents not associated with major cardiac risk.
• Major cardiac risk is lowest 90 days after bare metal stent percutaneous coronary intervention.
• Extensive cancer screening in unexplained VTE detects more malignancies, but does not affect cancer related mortality.
• Preadmission use of statins decreases after hospitalization mortality in pneumonia.
• Drug-eluting stents are better than bare-metal stents for PCI in acute MI, but additional randomized study is needed.

Does a short duration of perioperative smoking cessation lead to a reduction in postoperative complications?

Background: Prior studies have demonstrated a reduction in postoperative complications when patients stop smoking in the perioperative period. However, they have not clearly shown what effect a fairly short duration of cessation, such as a period of only four weeks, has on the frequency of complications.

Study design: Randomized controlled trial.

Setting: Four university-affiliated hospitals in Sweden.

Synopsis: Using 117 patients who were daily smokers for less than one year between the ages of 18-79 who were scheduled for elective general or orthopedic surgery, this study showed that a smoking-cessation intervention initiated as little as four weeks prior to surgery resulted in fewer postoperative complications. The complication rate was reduced from 41% in the control group to 21% in the intervention group, which received cessation counseling and nicotine-replacement therapy. The relative risk reduction was 49% (95% confidence interval, 3-40) with a number needed to treat of five.

Because this was a randomized controlled trial with a large observed benefit, it appears to be reasonable to endorse perioperative smoking cessation as late as four weeks before an elective surgery. The study was limited in its ability to detect a difference in wound infections by the small sample size and the possibility patients might have unblinded themselves to outcome assessors, causing an overestimation of the effect of the intervention on the primary outcome of all complications.

Bottom line: Perioperative smoking cessation reduces postoperative complications even when started just four weeks prior to surgery.

Citation: Lindstrom D, Azodi OS, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications. Ann Surg. 2008;248(5):739-745.

Does implantable-defibrillator therapy cause deterioration in quality of life for patients with heart failure?

Background: Patients with depressed left-ventricular function are known to have improved survival after receiving implantable cardioverter defibrillators (ICDs). However, there is concern ICD therapy can prolong survival at the expense of a diminished quality of life.

Study design: Randomized placebo-controlled trial.

Setting: Multiple centers in the U.S., Canada, and New Zealand.

Synopsis: Using 2,479 patients from the Sudden Cardiac Death in Heart Failure trial who were 18 and older and had stable heart failure and depressed left-ventricular function, this study demonstrated no significant quality-of-life difference at 30 months when compared with patients who received ICD, amiodarone, and state-of-the-art medical therapy or an amiodarone placebo and state-of-the-art medical therapy. While functional status did not differ at any time between the three groups, psychological well-being was improved in the ICD group at three months (p=0.01) and 12 months (p=0.03) when compared with the placebo group, but at 30 months there was no difference between the groups.

While the trial was randomized and placebo-controlled, the investigators were unable to blind patients or outcome assessors. Nevertheless, the lack of deterioration of quality of life in ICD patients is reassuring.

Bottom line: Placement of ICDs in heart failure patients with a high risk of sudden cardiac death does not appear to decrease quality of life.

Citation: Mark DB, Anstrom KJ, Sun JL, et al. Quality of life with defibrillator therapy or amiodarone in heart failure. N Engl J Med. 2008;359:999-1008.

Can a simplified, revised Geneva score retain diagnostic accuracy and clinical utility?

Background: The revised Geneva score is a validated and objective clinical decision rule, but has multiple variables with different weights. This can make the tool cumbersome and difficult to remember, and could lead to inaccurate calculations and misjudgments in patient care.

Study design: Retrospective cohort study.

Setting: Four university-affiliated European hospitals.

Synopsis: Using data from two prior prospective trials involving patients with suspected pulmonary embolism (PE), this study showed re-analysis of these patients with a simplified, revised Geneva score, which gives only one point to each clinical factor, resulted in the same level of diagnostic accuracy. Specifically, data from 1,049 patients was used to construct a receiver-operating characteristic curve analysis comparing the standardized and simplified Geneva score, which showed areas under the curve of 0.75 (95% confidence interval 0.71-0.78) and 0.74 (0.70-0.77), respectively. Additionally, the safety of using this clinical tool to rule out PE was demonstrated when using both a three-level (low-intermediate probability) and a dichotomized scheme (PE unlikely) in combination with a negative D-dimer test.

The retrospective nature of the study was its major limitation. The authors suggest a prospective study to complete validation of the simplified, revised Geneva score.

Bottom line: With prospective analysis, it might be possible to further validate a simplified, revised Geneva score.

Citation: Klok FA, Mos ICM, Nijkeuter M, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008;168(19):2131-2136.

Is the rate of postoperative major adverse cardiac events (MACEs) inversely related to time after percutaneous coronary intervention (PCI) with a drug-eluting stent (DES)?

Background: The American College of Cardiology and the American Heart Association recently released an advisory that included a recommendation to delay elective noncardiac surgery (NCS) for one year after DES placement. However, no large study addresses the timing of NCS after PCI with DES.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 520 patients who had NCS after DES at the Mayo Clinic, 5.4% experienced MACEs, but the rate of MACEs was not significantly associated with the time after stent placement to surgery (p=0.337). However, observed rates of MACEs were lower after one year. Elderly patients and those going for emergent surgery are at the highest risk for MACE. Bleeding complications were not associated with antiplatelet use.

Although this study does not provide a clear cutoff time for when it is safe to proceed to NCS after DES, it is somewhat reassuring to see the relatively small number of MACEs and the lack of bleeding complications associated with antiplatelet use. However, careful coordination between hospitalists, cardiologists, anesthesiologists, and surgeons is still needed when coordinating NCS after DES, especially in the elderly or during emergent situations.

Bottom line: While time to noncardiac surgery after drug-eluting stent placement is not associated with major adverse cardiac events, observed rates of events are lower after one year.

Citation: Rabbitts JA, Nuttall GA, Brown MJ, et al. Cardiac risk of non-cardiac surgery after percutaneous coronary intervention with drug-eluting stents. Anesthesiology.2008;109: 596-604.

Is the risk of MACEs and bleeding events for patients undergoing NCS related to the time interval between PCI with bare-metal stent?

Background: In order to prevent thrombosis of bare-metal stents (BMS) placed during percutaneous coronary intervention (PCI), antiplatelet therapy is used. This poses a risk of bleeding, if surgery is needed during the antiplatelet therapy. The American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 899 patients who had NCS within one year of PCI with BMS at the Mayo Clinic between Jan. 1, 1990, and Jan. 1, 2005, this study found that when NCS was done 30 days or less after PCI with BMS, the MACEs rate was 10.5%, compared with 2.8% when NCS was done 91 or more days after PCI with BMS. After a multivariable analysis, it also was shown bleeding events were not associated with time between PCI with BMS and NCS.

While the American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS, waiting at least 90 days would permit completion of antiplatelet therapy and re-endothelialization of the stent.

Bottom line: The risk of MACEs with noncardiac surgery is lowest when performed at least 90 days after PCI with bare-metal stent.

Citation: Nuttall GA, Brown MJ, Stombaugh JW, et al. Time and cardiac risk of surgery after bare-metal stent, percutaneous coronary intervention. Anesthesiology. 2008;109: 588-595.

Should we screen extensively for cancer in patients with newly diagnosed venous thromboembolism (VTE)?

Background: It is well known VTE can be the first manifestation of previously undiagnosed cancer. Retrospective studies have suggested “limited” cancer screening, including a history and physical examination, along with basic blood work, adequately identifies malignancy in patients with unexplained VTE. However, more recent prospective studies have suggested more extensive screening, which includes imaging studies or tumor-marker measurement, can increase the rate of cancer detection.

Study design: Systematic review.

Setting: Literature search using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, and evidence-based medicine reviews.

Synopsis: Thirty-six studies of 9,516 patients with VTE reported the period prevalence of previously undiagnosed cancer from baseline to 12 months was 6.3% (95% confidence interval (CI) of 5.6% to 6.9%) in all patients with VTE, and was even higher in patients with unprovoked VTE, 10% (95% CI 8.6% to 11.3%). Of the 34 articles used for prevalence assessment, an extensive screening strategy using CT scans of the abdomen and pelvis increased the proportion of previously undiagnosed cancer detection from 49.4% (CI, 40.2% to 58.5%; limited screening) to 69.7% (CI, 61.1% to 77.8%) in patients with unprovoked VTE. Ultrasonography of the abdomen and pelvis and tumor-marker screening did not result in a clinically significant increase in the frequency of cancer detection.

Four studies compared the rate of detection of early-stage, previously undiagnosed cancer between the limited and extensive screening strategies. Extensive screening led to an absolute decrease in cancer-related mortality of 1.9%, but this difference was not statistically significant.

In this systematic review, there is a great deal of heterogeneity in the studies. Most of the studies did not look at whether an increase in detection of new malignant conditions resulted in a change in the detection rate of early-stage cancer, or a decrease in cancer-related morbidity, cancer-related mortality, or overall mortality. Furthermore, the studies did not assess the consequences of extensive screening, such as patient anxiety and discomfort, testing complications, burden of additional tests for false-positive results, or cost-effectiveness. However, it is important for hospitalists to recognize undiagnosed cancer is common in unexplained VTE and warrants at least a limited-screening approach with more extensive screening.

Bottom line: Although the prevalence of undiagnosed cancer is common in VTE, extensive screening did not offer a cancer-related mortality benefit. CT of the abdomen and pelvis did, however, lead to a greater number of cancer diagnoses in patients with unexplained VTE.

Citation: Carrier M, Le Gal G, Wells PS, Fergusson D, Ramsay T, Rodger MA. Systematic review: the Trousseau syndrome revisited: should we screen extensively for cancer in patients with venous thromboembolism? Ann Intern Med. 2008;149: 323-333.

Does the use of preadmission statins decrease the risk of death, bacteremia, and pulmonary complications in patients admitted with pneumonia?

Background: Both experimental and clinical studies have suggested statins improve outcomes in severe infections, such as sepsis. This is thought to be due to the antithrombotic, anti-inflammatory, and immunomodulatory effects of statins. However, previous studies on the effect of statins on pneumonia have conflicting outcomes.

Study design: Population-based cohort study of 29,900 patients.

Setting: Danish Health Registry.

Synopsis: Researchers studied patients ages 15 years and older hospitalized with pneumonia for the first time between January 1997 and December 2004. While statin users had more co-morbidities than nonusers, the 30-day mortality was 10.3% in users, compared with 15.7% in nonusers, corresponding to an adjusted 30-day mortality rate ratio of 0.69 (95% CI of 0.58-0.82). The 90-day mortality ratio was 16.8% in users, compared with 22.4% in nonusers, corresponding to an adjusted 90-day mortality ratio of 0.75 (95% CI of 0.65-0.86). Former use of statins was not associated with a decreased risk of death. The adjusted risk for bacteremia and pulmonary complications was not significantly different between nonusers and users.

Because this was an observational study, a causal relationship cannot be determined. Hospitalists should be alerted to the possibility statins might, in the future, prove to be a standard treatment modality in pneumonia. A randomized, double-blind trial might help further determine the effect of the acute use of statins on pneumonia outcomes.

Bottom line: Preadmission statin use is associated with a decrease in 30- and 90-day mortality in pneumonia.

Citation: Thomsen RW, Riis A, Kornum JB, Christensen S, Johnsen SP, Sorensen HT. Preadmission use of statins and outcomes after hospitalization with pneumonia. Arch Intern Med. 2008;168(19):2081-2087.

Do outcomes differ when patients with acute myocardial infarction (MI) undergo PCI with drug-eluting stents (DES) compared with bare-metal stents?

Background: Randomized trials comparing drug-eluting stents with bare-metal stents in acute MI have been limited in size and duration. Concern exists regarding higher mortality among patients with ST-elevation MI treated with DES.

Study design: Observational, cohort study.

Setting: Patients were identified from a state-mandated database, in which all PCI performed in Massachusetts are reported.

Synopsis: Between April 2003 and September 2004, 7,217 eligible patients underwent stenting for acute MI. They were assigned to either the DES group or the bare-metal stent (BMS) group using propensity score matching. Patients in the DES group had lower mortality at two years, compared to a matched cohort of patients in the BMS group with MI (10.7% vs. 12.8%; absolute risk difference, -2.1%, CI, -3.8% to -0.4%). A statistically significant difference was noted among patients with or without ST-elevation MI.

The rates of target vessel revascularization at two years with MI were significantly lower among patients receiving DES than among those receiving BMS (9.6% vs. 14.5%; risk difference, -4.9%; CI, -6.1% to -3.1%).

The study is limited by its observational nature and residual confounding bias after matching. Importantly, this study was performed to determine if DESs were harmful, and the finding of reduced mortality was unanticipated.

Bottom line: Although patients with acute MI treated with drug-eluting stents had lower mortality and repeat revascularization rates compared with bare-metal stents, this outcome merits confirmation in randomized trials.

Citation: Mauri L, Silbaugh TS, Garg P, et al. Drug-eluting or bare-metal stents for acute myocardial infarction. N Engl J Med. 2008;359 (13):1330-1342.

In This Edition

• Perioperative smoking cessation reduces postoperative complications.
• Quality of life is not diminished in heart failure patients receiving defibrillator therapy.
• Simplification of the revised Geneva score may be useful in assessing for pulmonary embolism.
• Non-cardiac surgery after drug eluting stents not associated with major cardiac risk.
• Major cardiac risk is lowest 90 days after bare metal stent percutaneous coronary intervention.
• Extensive cancer screening in unexplained VTE detects more malignancies, but does not affect cancer related mortality.
• Preadmission use of statins decreases after hospitalization mortality in pneumonia.
• Drug-eluting stents are better than bare-metal stents for PCI in acute MI, but additional randomized study is needed.

Does a short duration of perioperative smoking cessation lead to a reduction in postoperative complications?

Background: Prior studies have demonstrated a reduction in postoperative complications when patients stop smoking in the perioperative period. However, they have not clearly shown what effect a fairly short duration of cessation, such as a period of only four weeks, has on the frequency of complications.

Study design: Randomized controlled trial.

Setting: Four university-affiliated hospitals in Sweden.

Synopsis: Using 117 patients who were daily smokers for less than one year between the ages of 18-79 who were scheduled for elective general or orthopedic surgery, this study showed that a smoking-cessation intervention initiated as little as four weeks prior to surgery resulted in fewer postoperative complications. The complication rate was reduced from 41% in the control group to 21% in the intervention group, which received cessation counseling and nicotine-replacement therapy. The relative risk reduction was 49% (95% confidence interval, 3-40) with a number needed to treat of five.

Because this was a randomized controlled trial with a large observed benefit, it appears to be reasonable to endorse perioperative smoking cessation as late as four weeks before an elective surgery. The study was limited in its ability to detect a difference in wound infections by the small sample size and the possibility patients might have unblinded themselves to outcome assessors, causing an overestimation of the effect of the intervention on the primary outcome of all complications.

Bottom line: Perioperative smoking cessation reduces postoperative complications even when started just four weeks prior to surgery.

Citation: Lindstrom D, Azodi OS, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications. Ann Surg. 2008;248(5):739-745.

Does implantable-defibrillator therapy cause deterioration in quality of life for patients with heart failure?

Background: Patients with depressed left-ventricular function are known to have improved survival after receiving implantable cardioverter defibrillators (ICDs). However, there is concern ICD therapy can prolong survival at the expense of a diminished quality of life.

Study design: Randomized placebo-controlled trial.

Setting: Multiple centers in the U.S., Canada, and New Zealand.

Synopsis: Using 2,479 patients from the Sudden Cardiac Death in Heart Failure trial who were 18 and older and had stable heart failure and depressed left-ventricular function, this study demonstrated no significant quality-of-life difference at 30 months when compared with patients who received ICD, amiodarone, and state-of-the-art medical therapy or an amiodarone placebo and state-of-the-art medical therapy. While functional status did not differ at any time between the three groups, psychological well-being was improved in the ICD group at three months (p=0.01) and 12 months (p=0.03) when compared with the placebo group, but at 30 months there was no difference between the groups.

While the trial was randomized and placebo-controlled, the investigators were unable to blind patients or outcome assessors. Nevertheless, the lack of deterioration of quality of life in ICD patients is reassuring.

Bottom line: Placement of ICDs in heart failure patients with a high risk of sudden cardiac death does not appear to decrease quality of life.

Citation: Mark DB, Anstrom KJ, Sun JL, et al. Quality of life with defibrillator therapy or amiodarone in heart failure. N Engl J Med. 2008;359:999-1008.

Can a simplified, revised Geneva score retain diagnostic accuracy and clinical utility?

Background: The revised Geneva score is a validated and objective clinical decision rule, but has multiple variables with different weights. This can make the tool cumbersome and difficult to remember, and could lead to inaccurate calculations and misjudgments in patient care.

Study design: Retrospective cohort study.

Setting: Four university-affiliated European hospitals.

Synopsis: Using data from two prior prospective trials involving patients with suspected pulmonary embolism (PE), this study showed re-analysis of these patients with a simplified, revised Geneva score, which gives only one point to each clinical factor, resulted in the same level of diagnostic accuracy. Specifically, data from 1,049 patients was used to construct a receiver-operating characteristic curve analysis comparing the standardized and simplified Geneva score, which showed areas under the curve of 0.75 (95% confidence interval 0.71-0.78) and 0.74 (0.70-0.77), respectively. Additionally, the safety of using this clinical tool to rule out PE was demonstrated when using both a three-level (low-intermediate probability) and a dichotomized scheme (PE unlikely) in combination with a negative D-dimer test.

The retrospective nature of the study was its major limitation. The authors suggest a prospective study to complete validation of the simplified, revised Geneva score.

Bottom line: With prospective analysis, it might be possible to further validate a simplified, revised Geneva score.

Citation: Klok FA, Mos ICM, Nijkeuter M, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008;168(19):2131-2136.

Is the rate of postoperative major adverse cardiac events (MACEs) inversely related to time after percutaneous coronary intervention (PCI) with a drug-eluting stent (DES)?

Background: The American College of Cardiology and the American Heart Association recently released an advisory that included a recommendation to delay elective noncardiac surgery (NCS) for one year after DES placement. However, no large study addresses the timing of NCS after PCI with DES.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 520 patients who had NCS after DES at the Mayo Clinic, 5.4% experienced MACEs, but the rate of MACEs was not significantly associated with the time after stent placement to surgery (p=0.337). However, observed rates of MACEs were lower after one year. Elderly patients and those going for emergent surgery are at the highest risk for MACE. Bleeding complications were not associated with antiplatelet use.

Although this study does not provide a clear cutoff time for when it is safe to proceed to NCS after DES, it is somewhat reassuring to see the relatively small number of MACEs and the lack of bleeding complications associated with antiplatelet use. However, careful coordination between hospitalists, cardiologists, anesthesiologists, and surgeons is still needed when coordinating NCS after DES, especially in the elderly or during emergent situations.

Bottom line: While time to noncardiac surgery after drug-eluting stent placement is not associated with major adverse cardiac events, observed rates of events are lower after one year.

Citation: Rabbitts JA, Nuttall GA, Brown MJ, et al. Cardiac risk of non-cardiac surgery after percutaneous coronary intervention with drug-eluting stents. Anesthesiology.2008;109: 596-604.

Is the risk of MACEs and bleeding events for patients undergoing NCS related to the time interval between PCI with bare-metal stent?

Background: In order to prevent thrombosis of bare-metal stents (BMS) placed during percutaneous coronary intervention (PCI), antiplatelet therapy is used. This poses a risk of bleeding, if surgery is needed during the antiplatelet therapy. The American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 899 patients who had NCS within one year of PCI with BMS at the Mayo Clinic between Jan. 1, 1990, and Jan. 1, 2005, this study found that when NCS was done 30 days or less after PCI with BMS, the MACEs rate was 10.5%, compared with 2.8% when NCS was done 91 or more days after PCI with BMS. After a multivariable analysis, it also was shown bleeding events were not associated with time between PCI with BMS and NCS.

While the American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS, waiting at least 90 days would permit completion of antiplatelet therapy and re-endothelialization of the stent.

Bottom line: The risk of MACEs with noncardiac surgery is lowest when performed at least 90 days after PCI with bare-metal stent.

Citation: Nuttall GA, Brown MJ, Stombaugh JW, et al. Time and cardiac risk of surgery after bare-metal stent, percutaneous coronary intervention. Anesthesiology. 2008;109: 588-595.

Should we screen extensively for cancer in patients with newly diagnosed venous thromboembolism (VTE)?

Background: It is well known VTE can be the first manifestation of previously undiagnosed cancer. Retrospective studies have suggested “limited” cancer screening, including a history and physical examination, along with basic blood work, adequately identifies malignancy in patients with unexplained VTE. However, more recent prospective studies have suggested more extensive screening, which includes imaging studies or tumor-marker measurement, can increase the rate of cancer detection.

Study design: Systematic review.

Setting: Literature search using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, and evidence-based medicine reviews.

Synopsis: Thirty-six studies of 9,516 patients with VTE reported the period prevalence of previously undiagnosed cancer from baseline to 12 months was 6.3% (95% confidence interval (CI) of 5.6% to 6.9%) in all patients with VTE, and was even higher in patients with unprovoked VTE, 10% (95% CI 8.6% to 11.3%). Of the 34 articles used for prevalence assessment, an extensive screening strategy using CT scans of the abdomen and pelvis increased the proportion of previously undiagnosed cancer detection from 49.4% (CI, 40.2% to 58.5%; limited screening) to 69.7% (CI, 61.1% to 77.8%) in patients with unprovoked VTE. Ultrasonography of the abdomen and pelvis and tumor-marker screening did not result in a clinically significant increase in the frequency of cancer detection.

Four studies compared the rate of detection of early-stage, previously undiagnosed cancer between the limited and extensive screening strategies. Extensive screening led to an absolute decrease in cancer-related mortality of 1.9%, but this difference was not statistically significant.

In this systematic review, there is a great deal of heterogeneity in the studies. Most of the studies did not look at whether an increase in detection of new malignant conditions resulted in a change in the detection rate of early-stage cancer, or a decrease in cancer-related morbidity, cancer-related mortality, or overall mortality. Furthermore, the studies did not assess the consequences of extensive screening, such as patient anxiety and discomfort, testing complications, burden of additional tests for false-positive results, or cost-effectiveness. However, it is important for hospitalists to recognize undiagnosed cancer is common in unexplained VTE and warrants at least a limited-screening approach with more extensive screening.

Bottom line: Although the prevalence of undiagnosed cancer is common in VTE, extensive screening did not offer a cancer-related mortality benefit. CT of the abdomen and pelvis did, however, lead to a greater number of cancer diagnoses in patients with unexplained VTE.

Citation: Carrier M, Le Gal G, Wells PS, Fergusson D, Ramsay T, Rodger MA. Systematic review: the Trousseau syndrome revisited: should we screen extensively for cancer in patients with venous thromboembolism? Ann Intern Med. 2008;149: 323-333.

Does the use of preadmission statins decrease the risk of death, bacteremia, and pulmonary complications in patients admitted with pneumonia?

Background: Both experimental and clinical studies have suggested statins improve outcomes in severe infections, such as sepsis. This is thought to be due to the antithrombotic, anti-inflammatory, and immunomodulatory effects of statins. However, previous studies on the effect of statins on pneumonia have conflicting outcomes.

Study design: Population-based cohort study of 29,900 patients.

Setting: Danish Health Registry.

Synopsis: Researchers studied patients ages 15 years and older hospitalized with pneumonia for the first time between January 1997 and December 2004. While statin users had more co-morbidities than nonusers, the 30-day mortality was 10.3% in users, compared with 15.7% in nonusers, corresponding to an adjusted 30-day mortality rate ratio of 0.69 (95% CI of 0.58-0.82). The 90-day mortality ratio was 16.8% in users, compared with 22.4% in nonusers, corresponding to an adjusted 90-day mortality ratio of 0.75 (95% CI of 0.65-0.86). Former use of statins was not associated with a decreased risk of death. The adjusted risk for bacteremia and pulmonary complications was not significantly different between nonusers and users.

Because this was an observational study, a causal relationship cannot be determined. Hospitalists should be alerted to the possibility statins might, in the future, prove to be a standard treatment modality in pneumonia. A randomized, double-blind trial might help further determine the effect of the acute use of statins on pneumonia outcomes.

Bottom line: Preadmission statin use is associated with a decrease in 30- and 90-day mortality in pneumonia.

Citation: Thomsen RW, Riis A, Kornum JB, Christensen S, Johnsen SP, Sorensen HT. Preadmission use of statins and outcomes after hospitalization with pneumonia. Arch Intern Med. 2008;168(19):2081-2087.

Do outcomes differ when patients with acute myocardial infarction (MI) undergo PCI with drug-eluting stents (DES) compared with bare-metal stents?

Background: Randomized trials comparing drug-eluting stents with bare-metal stents in acute MI have been limited in size and duration. Concern exists regarding higher mortality among patients with ST-elevation MI treated with DES.

Study design: Observational, cohort study.

Setting: Patients were identified from a state-mandated database, in which all PCI performed in Massachusetts are reported.

Synopsis: Between April 2003 and September 2004, 7,217 eligible patients underwent stenting for acute MI. They were assigned to either the DES group or the bare-metal stent (BMS) group using propensity score matching. Patients in the DES group had lower mortality at two years, compared to a matched cohort of patients in the BMS group with MI (10.7% vs. 12.8%; absolute risk difference, -2.1%, CI, -3.8% to -0.4%). A statistically significant difference was noted among patients with or without ST-elevation MI.

The rates of target vessel revascularization at two years with MI were significantly lower among patients receiving DES than among those receiving BMS (9.6% vs. 14.5%; risk difference, -4.9%; CI, -6.1% to -3.1%).

The study is limited by its observational nature and residual confounding bias after matching. Importantly, this study was performed to determine if DESs were harmful, and the finding of reduced mortality was unanticipated.

Bottom line: Although patients with acute MI treated with drug-eluting stents had lower mortality and repeat revascularization rates compared with bare-metal stents, this outcome merits confirmation in randomized trials.

Citation: Mauri L, Silbaugh TS, Garg P, et al. Drug-eluting or bare-metal stents for acute myocardial infarction. N Engl J Med. 2008;359 (13):1330-1342.