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Nonphysician Providers
The current state of our profession is that the US population is aging rapidly, requiring ever more healthcare, and there is a stagnant number of physicians to care for them. The question of who will care for our aging population has been raised over and over in the past decade but the question is worth repeating. As our country continues to deliver state‐of‐the‐art medical care, it is slow to embrace the notion that in order for it to continue, it will need to incorporate the professions of advanced practice nurses and physician assistants. Without these nonphysician providers our medical community will not be able to reach the patients we have sworn to treat.
The percent of the US population age >65 years is projected to increase from 12.4% in 2000 to 19.6% in 2030. The number of persons age >65 years is expected to increase from approximately 35 million in 2000 to an estimated 71 million in 2030, and the number of persons age >80 years is expected to increase from 9.3 million in 2000 to 19.5 million in 2030.1 Our aging America is also coupled with a growing physician shortage. In its report entitled Physician Workforce Policy Guidelines for the United States, 2000‐2020, the Council on Graduate Medical Education recommended increasing the number of medical school graduates by 3000 per year by the year 2015 to meet the increasing need.2 Given the current trend of decreasing physician reimbursement coupled with the average medical school debt of $139,517,3 it is doubtful that the extra 3000 physicians needed to graduate in 2015 will actually ever do so. Despite this possible additional physician workforce, there still stands to be enormous need for the nonphysician provider with our rapidly expanding senior population.
Our nation's hospitals are by no means spared from our aging population or physician shortage. In fact, they are likely to be the hardest hit. Hospitalists are already feeling the pressure of an overstressed workforce coupled with increasing patient volume.4 There is a growing body of evidence supporting the successful collaboration between hospitalists and nurse practitioners (NPs)/physician assistants (PAs) (collectively, nonphysician providers [NPPs]). No longer are NPPs only working in outpatient practices or in the operating room, but they are actively involved with inpatient medical units improving our Hospital Medicine (HM) specialty. According to Myers et al.,5 the hospitalist NP model improved program finances and increased physician and resident satisfaction. In order for Hospital Medicine to create increasing value for its parent hospital or to the community it serves, NPPs will need increased integration into our care model for improved overall efficiency. We focus herein on the advantages and potential benefits of NPPs relating to their varied roles within HM.
Scope of Practice
The scope of practice of NPPs is regulated by each individual state board of registration. However, differences from state to state are usually minor and general statements on the practice scope of PAs and NPs can be made.
PAs
PAs practice under the supervision of a physician. PAs are trained in programs affiliated with medical schools and according to the medical model of care that emphasizes diagnosis and treatment. Most PAs graduate with a masters of science degree. According to the American Association of Physician Assistants (AAPA), the scope of practice is guided by state law, facility policy, and delegatory decisions made by the supervising physician.6 Prior experience and training should be the framework for scope of practice decisions. All 50 states allow PAs to prescribe with some oversight and restriction of schedule 2 controlled substances or by using a state formulary. The AAPA embraces the concept of the physician as the captain of the healthcare team and sees the PA role as entirely complementary to the care provided by physicians.7 This means that PAs, under an individual supervision agreement, can prescribe medicines, order and interpret tests, diagnose, and treat patients just as a physician would.
Advanced Practice Nurses
Advanced practice nurses (APNs) are trained under the nursing model and generally have some years of nursing experience before they pursue an entry‐level masters of science degree to become an APN. APNs can be divided into two categories: Clinical nurse specialists, who generally focus on patient and institutional education and are considered experts in nursing practice, and NPs, who have a focus on diagnosis and treatment of medical conditions. A clinical nurse specialist does not have prescriptive training or authority. NP training can be general (adult or family) or specific (eg, acute care, geriatric, pediatric, psychiatric). The American Association of Colleges of Nursing (AACN) has recommended that the entry level of all new NPs should be a clinical doctorate of nursing practice. Although controversial, many colleges have embraced this recommendation and are opening clinical doctorate‐level programs.8 Although some states allow NPs to practice independently, most NPs have a practice agreement with a collaborating physician that delineates the degree of supervision. Generally, the NP's scope of practice is identical to PAs and includes the above‐mentioned activities as proscribed by state regulations and facility bylaws. As with PAs, their prior experience and training should be the most important determinant of their scope of practice in a new position.
Potential Benefits of NPPs
Continuity
If a nonacademic hospitalist program has high yearly turnover due to use of recent medical graduates who are planning to do fellowships, NPPs can provide much needed stability and facilitate orientation of new physicians to the hospital. NPPs who work in academic settings can also provide increased continuity for patients and hospital staff. Residents, fellows, and attendings have certain rotational cycles on each medical service. NPPs generally do not rotate and can be the anchor of a medical team for patients and ancillary staff. Utilizing NPPs as liaisons between the hospitalist team and other members of the care team (eg, nurses, case managers, therapists, and administration) provides continuity for these groups and a central person who can help to facilitate change.
Quality Measures
NPPs can play an important role in hospital compliance with internal hospital or insurance provider quality initiatives. Surveillance of patients and charts for compliance with core measures, infection control, and prevention of complications are within the scope of practice of NPPs and can be incorporated into job descriptions. NPs and PAs will have the added responsibility of not only leading these surveillance teams but also in the correction of outliers given their prescriptive abilities. This will become an increasingly important task as reimbursement for preventable complications is curtailed. Additionally, the development and implementation of clinical pathways can be a focus of the NPP role to standardize and enhance quality of care.
Multidisciplinary Team Approach
Multidisciplinary teams that consist of NPPs, physicians, nurses, and therapists have been shown to increase communication and collaboration between participants.9 Mary Naylor, a Professor of Nursing at the University of Pennsylvania, has authored multiple articles and studies which examine the benefit of a multidisciplinary team that includes APNs with hospitalized patients. She has found that involving APNs in patient care, discharges, and routine follow‐up after discharge led to longer time to readmissions and decreased healthcare costs.1012 Furthermore, a nonteaching group consisting of NPPs, fellows, and attendings at the Mayo Clinic found increased physician satisfaction, shorter length of stay (LOS), and increased efficiency for their patients.13 A study done at JFK Medical Center in Florida noted that a collaborative practice which included unit‐based NPs serving in the dual role of NP and clinical nurse specialist increased patient satisfaction and improved patient outcomes.14
Financial Advantages
Efficiency and quality care are the cornerstones of HM. The partnership of NPPs within the specialty is creating even better performance. Models incorporating NPPs in the Hospitalist team approach are continuing to drive efficiency. Cowan et al.15 demonstrated that a multidisciplinary team, including nurse practitioners, decreased LOS from 6.01 to 5.0 and a reduced cost by $1,591 per patient. It is this team approach that will lift our specialty to be the model of care for all future hospital practice.
Another factor in determining the fiscal advantage of NPPs is salary and medical liability comparison. According to the 2007 Society of Hospital Medicine (SHM) Survey, the average hospitalist salary is approaching $190,000, compared to an average NP earning $87,000 and PA earning $84,500.4 Furthermore, the average internal medicine malpractice payment for physicians ranges from $14,237 to $68,867.16 In comparison, the average malpractice insurance premium for NPPs varies from state to state but is approximately $800 to $2000 per year.17, 18 With increasing fiscal scrutiny from hospitals, HM groups (HMGs) will need to include NPPs to be fiscally stable.
Models of Care
There are many models for NPP roles in hospital medicine groups. Some groups use NPPs in the same role as physicians. They perform admissions, rounding, and discharges with varying degrees of oversight by physicians. Other groups use NPPs for a more limited role, such as exclusively performing histories and physicals in the emergency department or handling discharges on the wards. It is important to take into account the preferences and expectations of NPPs when designing job descriptions. While some NPPs may like the fast pace and quick turnover of admissions and discharges, others may prefer to follow patients throughout their hospital stay. The quality of handoffs is crucial if the former model is used, just as it is with physicians in this more truncated role. An NPP who works in a nonacademic model will likely have more autonomy and control over patient care decisions. An NPP role in the teaching service of an academic hospital is likely to be more collaborative and focus more on quality initiatives, patient teaching, and communication. It is crucial to design an NPP model that is sustainable with very strong support of management once the NPP is hired and orientated.
Registered Nurses And Hospital Medicine
Patient handoffs and communication are one of the most challenging aspects of an HMG. There is an increasing movement, throughout the country, to incorporate registered nurses (RNs) into daily workflow. The RN on the HM team can serve to augment the communication and workflow process. A highly motivated and organized registered nurse can help to improve overall provider's workflow efficiency. Communication to primary care physician and collecting ancillary medical information can allow the provider to treat more patients in a given shift and decrease the liability risk from lack of information. As HM organizations and hospitals become more financially bound, HMGs will need to become more efficient at time management and a dedicated RN can help smooth that process.
Potential Unintended Side Effects
Obviously, integration of NPPs can be a disaster for an HMG if not handled properly. Most hospitalists have heard of an integration of NPP into a group that was an unqualified failure. NPPs can feel unsupported, poorly oriented to the job, or thrown into a situation that is over their heads. Before an NPP is hired into an HMG, there needs to be a thorough examination of the rationale behind the decision and assessment of the hospital culture that will be the host of the new NPP. What does the HMG need for support? Are they looking for a short‐term fix for increased volume or a long‐term strategy to build a multidisciplinary team? Does the hospital culture see NPPs as poorly qualified to act as hospitalists or uniquely qualified to address shortcomings of the program? A clear job description should be the first step in determining what the NPP is expected to do. This can then be shared with the hospital leadership in advance to promote buy‐in. The second step is finding an NPP that fits the goals of the program. A new NPP, by virtue of the fact that they have less clinical hours in training than a physician hospitalist, will need more support and a longer orientation. NPPs who have experience in hospital medicine will have a much shorter orientation. A stepwise approach to orientation can be helpful in assessing skill level of new hires. These NPPs can be initially paired with an enthusiastic physician to provide support and assessment of existing skills. A gradual increase in independence can provide assurance that the NPP is qualified to provide care and gives many opportunities for reevaluation of the NPP. Clear expectations and constructive feedback should ultimately lead to a degree of comfort within the HMG, hospital, and the NPPs themselves.
Conclusions
It is clear that our healthcare system will need a very different approach to the economic problems it is facing. Standardization of care, integrated medical records, and expanded and universal resource utilization will drive the next generation of healthcare providers. The model of a private physician working alone under the direction of only his or her own medical knowledge is a thing of the past. Just as the HM specialty has grown from 300 in 1996 to more than 20,000 in 2008, so shall the integration of NPPs grow into our healthcare fabric.
- Centers for Disease Control and Prevention (CDC). Trends in aging—United States and worldwide. MMWR Morb Mortal Wkly Rep. 2003;52(6):101–104, 106.
- Council on Graduate Medical Education. Physician Workforce Policy Guidelines for the U.S. for 2000‐2020. Rockville, MD: U.S. Department of Health and Human Services;2005.
- American Medical Association. Medical Student Section. Advocacy and Policy. Medical Student Debt. Available at: http://www.ama‐assn.org/ama/pub/category/5349.html. Accessed June 2009.
- Society of Hospital Medicine (SHM). 2007‐2008 SHM Survey: State of the Hospital Medicine Movement. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Surveys2
The current state of our profession is that the US population is aging rapidly, requiring ever more healthcare, and there is a stagnant number of physicians to care for them. The question of who will care for our aging population has been raised over and over in the past decade but the question is worth repeating. As our country continues to deliver state‐of‐the‐art medical care, it is slow to embrace the notion that in order for it to continue, it will need to incorporate the professions of advanced practice nurses and physician assistants. Without these nonphysician providers our medical community will not be able to reach the patients we have sworn to treat.
The percent of the US population age >65 years is projected to increase from 12.4% in 2000 to 19.6% in 2030. The number of persons age >65 years is expected to increase from approximately 35 million in 2000 to an estimated 71 million in 2030, and the number of persons age >80 years is expected to increase from 9.3 million in 2000 to 19.5 million in 2030.1 Our aging America is also coupled with a growing physician shortage. In its report entitled Physician Workforce Policy Guidelines for the United States, 2000‐2020, the Council on Graduate Medical Education recommended increasing the number of medical school graduates by 3000 per year by the year 2015 to meet the increasing need.2 Given the current trend of decreasing physician reimbursement coupled with the average medical school debt of $139,517,3 it is doubtful that the extra 3000 physicians needed to graduate in 2015 will actually ever do so. Despite this possible additional physician workforce, there still stands to be enormous need for the nonphysician provider with our rapidly expanding senior population.
Our nation's hospitals are by no means spared from our aging population or physician shortage. In fact, they are likely to be the hardest hit. Hospitalists are already feeling the pressure of an overstressed workforce coupled with increasing patient volume.4 There is a growing body of evidence supporting the successful collaboration between hospitalists and nurse practitioners (NPs)/physician assistants (PAs) (collectively, nonphysician providers [NPPs]). No longer are NPPs only working in outpatient practices or in the operating room, but they are actively involved with inpatient medical units improving our Hospital Medicine (HM) specialty. According to Myers et al.,5 the hospitalist NP model improved program finances and increased physician and resident satisfaction. In order for Hospital Medicine to create increasing value for its parent hospital or to the community it serves, NPPs will need increased integration into our care model for improved overall efficiency. We focus herein on the advantages and potential benefits of NPPs relating to their varied roles within HM.
Scope of Practice
The scope of practice of NPPs is regulated by each individual state board of registration. However, differences from state to state are usually minor and general statements on the practice scope of PAs and NPs can be made.
PAs
PAs practice under the supervision of a physician. PAs are trained in programs affiliated with medical schools and according to the medical model of care that emphasizes diagnosis and treatment. Most PAs graduate with a masters of science degree. According to the American Association of Physician Assistants (AAPA), the scope of practice is guided by state law, facility policy, and delegatory decisions made by the supervising physician.6 Prior experience and training should be the framework for scope of practice decisions. All 50 states allow PAs to prescribe with some oversight and restriction of schedule 2 controlled substances or by using a state formulary. The AAPA embraces the concept of the physician as the captain of the healthcare team and sees the PA role as entirely complementary to the care provided by physicians.7 This means that PAs, under an individual supervision agreement, can prescribe medicines, order and interpret tests, diagnose, and treat patients just as a physician would.
Advanced Practice Nurses
Advanced practice nurses (APNs) are trained under the nursing model and generally have some years of nursing experience before they pursue an entry‐level masters of science degree to become an APN. APNs can be divided into two categories: Clinical nurse specialists, who generally focus on patient and institutional education and are considered experts in nursing practice, and NPs, who have a focus on diagnosis and treatment of medical conditions. A clinical nurse specialist does not have prescriptive training or authority. NP training can be general (adult or family) or specific (eg, acute care, geriatric, pediatric, psychiatric). The American Association of Colleges of Nursing (AACN) has recommended that the entry level of all new NPs should be a clinical doctorate of nursing practice. Although controversial, many colleges have embraced this recommendation and are opening clinical doctorate‐level programs.8 Although some states allow NPs to practice independently, most NPs have a practice agreement with a collaborating physician that delineates the degree of supervision. Generally, the NP's scope of practice is identical to PAs and includes the above‐mentioned activities as proscribed by state regulations and facility bylaws. As with PAs, their prior experience and training should be the most important determinant of their scope of practice in a new position.
Potential Benefits of NPPs
Continuity
If a nonacademic hospitalist program has high yearly turnover due to use of recent medical graduates who are planning to do fellowships, NPPs can provide much needed stability and facilitate orientation of new physicians to the hospital. NPPs who work in academic settings can also provide increased continuity for patients and hospital staff. Residents, fellows, and attendings have certain rotational cycles on each medical service. NPPs generally do not rotate and can be the anchor of a medical team for patients and ancillary staff. Utilizing NPPs as liaisons between the hospitalist team and other members of the care team (eg, nurses, case managers, therapists, and administration) provides continuity for these groups and a central person who can help to facilitate change.
Quality Measures
NPPs can play an important role in hospital compliance with internal hospital or insurance provider quality initiatives. Surveillance of patients and charts for compliance with core measures, infection control, and prevention of complications are within the scope of practice of NPPs and can be incorporated into job descriptions. NPs and PAs will have the added responsibility of not only leading these surveillance teams but also in the correction of outliers given their prescriptive abilities. This will become an increasingly important task as reimbursement for preventable complications is curtailed. Additionally, the development and implementation of clinical pathways can be a focus of the NPP role to standardize and enhance quality of care.
Multidisciplinary Team Approach
Multidisciplinary teams that consist of NPPs, physicians, nurses, and therapists have been shown to increase communication and collaboration between participants.9 Mary Naylor, a Professor of Nursing at the University of Pennsylvania, has authored multiple articles and studies which examine the benefit of a multidisciplinary team that includes APNs with hospitalized patients. She has found that involving APNs in patient care, discharges, and routine follow‐up after discharge led to longer time to readmissions and decreased healthcare costs.1012 Furthermore, a nonteaching group consisting of NPPs, fellows, and attendings at the Mayo Clinic found increased physician satisfaction, shorter length of stay (LOS), and increased efficiency for their patients.13 A study done at JFK Medical Center in Florida noted that a collaborative practice which included unit‐based NPs serving in the dual role of NP and clinical nurse specialist increased patient satisfaction and improved patient outcomes.14
Financial Advantages
Efficiency and quality care are the cornerstones of HM. The partnership of NPPs within the specialty is creating even better performance. Models incorporating NPPs in the Hospitalist team approach are continuing to drive efficiency. Cowan et al.15 demonstrated that a multidisciplinary team, including nurse practitioners, decreased LOS from 6.01 to 5.0 and a reduced cost by $1,591 per patient. It is this team approach that will lift our specialty to be the model of care for all future hospital practice.
Another factor in determining the fiscal advantage of NPPs is salary and medical liability comparison. According to the 2007 Society of Hospital Medicine (SHM) Survey, the average hospitalist salary is approaching $190,000, compared to an average NP earning $87,000 and PA earning $84,500.4 Furthermore, the average internal medicine malpractice payment for physicians ranges from $14,237 to $68,867.16 In comparison, the average malpractice insurance premium for NPPs varies from state to state but is approximately $800 to $2000 per year.17, 18 With increasing fiscal scrutiny from hospitals, HM groups (HMGs) will need to include NPPs to be fiscally stable.
Models of Care
There are many models for NPP roles in hospital medicine groups. Some groups use NPPs in the same role as physicians. They perform admissions, rounding, and discharges with varying degrees of oversight by physicians. Other groups use NPPs for a more limited role, such as exclusively performing histories and physicals in the emergency department or handling discharges on the wards. It is important to take into account the preferences and expectations of NPPs when designing job descriptions. While some NPPs may like the fast pace and quick turnover of admissions and discharges, others may prefer to follow patients throughout their hospital stay. The quality of handoffs is crucial if the former model is used, just as it is with physicians in this more truncated role. An NPP who works in a nonacademic model will likely have more autonomy and control over patient care decisions. An NPP role in the teaching service of an academic hospital is likely to be more collaborative and focus more on quality initiatives, patient teaching, and communication. It is crucial to design an NPP model that is sustainable with very strong support of management once the NPP is hired and orientated.
Registered Nurses And Hospital Medicine
Patient handoffs and communication are one of the most challenging aspects of an HMG. There is an increasing movement, throughout the country, to incorporate registered nurses (RNs) into daily workflow. The RN on the HM team can serve to augment the communication and workflow process. A highly motivated and organized registered nurse can help to improve overall provider's workflow efficiency. Communication to primary care physician and collecting ancillary medical information can allow the provider to treat more patients in a given shift and decrease the liability risk from lack of information. As HM organizations and hospitals become more financially bound, HMGs will need to become more efficient at time management and a dedicated RN can help smooth that process.
Potential Unintended Side Effects
Obviously, integration of NPPs can be a disaster for an HMG if not handled properly. Most hospitalists have heard of an integration of NPP into a group that was an unqualified failure. NPPs can feel unsupported, poorly oriented to the job, or thrown into a situation that is over their heads. Before an NPP is hired into an HMG, there needs to be a thorough examination of the rationale behind the decision and assessment of the hospital culture that will be the host of the new NPP. What does the HMG need for support? Are they looking for a short‐term fix for increased volume or a long‐term strategy to build a multidisciplinary team? Does the hospital culture see NPPs as poorly qualified to act as hospitalists or uniquely qualified to address shortcomings of the program? A clear job description should be the first step in determining what the NPP is expected to do. This can then be shared with the hospital leadership in advance to promote buy‐in. The second step is finding an NPP that fits the goals of the program. A new NPP, by virtue of the fact that they have less clinical hours in training than a physician hospitalist, will need more support and a longer orientation. NPPs who have experience in hospital medicine will have a much shorter orientation. A stepwise approach to orientation can be helpful in assessing skill level of new hires. These NPPs can be initially paired with an enthusiastic physician to provide support and assessment of existing skills. A gradual increase in independence can provide assurance that the NPP is qualified to provide care and gives many opportunities for reevaluation of the NPP. Clear expectations and constructive feedback should ultimately lead to a degree of comfort within the HMG, hospital, and the NPPs themselves.
Conclusions
It is clear that our healthcare system will need a very different approach to the economic problems it is facing. Standardization of care, integrated medical records, and expanded and universal resource utilization will drive the next generation of healthcare providers. The model of a private physician working alone under the direction of only his or her own medical knowledge is a thing of the past. Just as the HM specialty has grown from 300 in 1996 to more than 20,000 in 2008, so shall the integration of NPPs grow into our healthcare fabric.
The current state of our profession is that the US population is aging rapidly, requiring ever more healthcare, and there is a stagnant number of physicians to care for them. The question of who will care for our aging population has been raised over and over in the past decade but the question is worth repeating. As our country continues to deliver state‐of‐the‐art medical care, it is slow to embrace the notion that in order for it to continue, it will need to incorporate the professions of advanced practice nurses and physician assistants. Without these nonphysician providers our medical community will not be able to reach the patients we have sworn to treat.
The percent of the US population age >65 years is projected to increase from 12.4% in 2000 to 19.6% in 2030. The number of persons age >65 years is expected to increase from approximately 35 million in 2000 to an estimated 71 million in 2030, and the number of persons age >80 years is expected to increase from 9.3 million in 2000 to 19.5 million in 2030.1 Our aging America is also coupled with a growing physician shortage. In its report entitled Physician Workforce Policy Guidelines for the United States, 2000‐2020, the Council on Graduate Medical Education recommended increasing the number of medical school graduates by 3000 per year by the year 2015 to meet the increasing need.2 Given the current trend of decreasing physician reimbursement coupled with the average medical school debt of $139,517,3 it is doubtful that the extra 3000 physicians needed to graduate in 2015 will actually ever do so. Despite this possible additional physician workforce, there still stands to be enormous need for the nonphysician provider with our rapidly expanding senior population.
Our nation's hospitals are by no means spared from our aging population or physician shortage. In fact, they are likely to be the hardest hit. Hospitalists are already feeling the pressure of an overstressed workforce coupled with increasing patient volume.4 There is a growing body of evidence supporting the successful collaboration between hospitalists and nurse practitioners (NPs)/physician assistants (PAs) (collectively, nonphysician providers [NPPs]). No longer are NPPs only working in outpatient practices or in the operating room, but they are actively involved with inpatient medical units improving our Hospital Medicine (HM) specialty. According to Myers et al.,5 the hospitalist NP model improved program finances and increased physician and resident satisfaction. In order for Hospital Medicine to create increasing value for its parent hospital or to the community it serves, NPPs will need increased integration into our care model for improved overall efficiency. We focus herein on the advantages and potential benefits of NPPs relating to their varied roles within HM.
Scope of Practice
The scope of practice of NPPs is regulated by each individual state board of registration. However, differences from state to state are usually minor and general statements on the practice scope of PAs and NPs can be made.
PAs
PAs practice under the supervision of a physician. PAs are trained in programs affiliated with medical schools and according to the medical model of care that emphasizes diagnosis and treatment. Most PAs graduate with a masters of science degree. According to the American Association of Physician Assistants (AAPA), the scope of practice is guided by state law, facility policy, and delegatory decisions made by the supervising physician.6 Prior experience and training should be the framework for scope of practice decisions. All 50 states allow PAs to prescribe with some oversight and restriction of schedule 2 controlled substances or by using a state formulary. The AAPA embraces the concept of the physician as the captain of the healthcare team and sees the PA role as entirely complementary to the care provided by physicians.7 This means that PAs, under an individual supervision agreement, can prescribe medicines, order and interpret tests, diagnose, and treat patients just as a physician would.
Advanced Practice Nurses
Advanced practice nurses (APNs) are trained under the nursing model and generally have some years of nursing experience before they pursue an entry‐level masters of science degree to become an APN. APNs can be divided into two categories: Clinical nurse specialists, who generally focus on patient and institutional education and are considered experts in nursing practice, and NPs, who have a focus on diagnosis and treatment of medical conditions. A clinical nurse specialist does not have prescriptive training or authority. NP training can be general (adult or family) or specific (eg, acute care, geriatric, pediatric, psychiatric). The American Association of Colleges of Nursing (AACN) has recommended that the entry level of all new NPs should be a clinical doctorate of nursing practice. Although controversial, many colleges have embraced this recommendation and are opening clinical doctorate‐level programs.8 Although some states allow NPs to practice independently, most NPs have a practice agreement with a collaborating physician that delineates the degree of supervision. Generally, the NP's scope of practice is identical to PAs and includes the above‐mentioned activities as proscribed by state regulations and facility bylaws. As with PAs, their prior experience and training should be the most important determinant of their scope of practice in a new position.
Potential Benefits of NPPs
Continuity
If a nonacademic hospitalist program has high yearly turnover due to use of recent medical graduates who are planning to do fellowships, NPPs can provide much needed stability and facilitate orientation of new physicians to the hospital. NPPs who work in academic settings can also provide increased continuity for patients and hospital staff. Residents, fellows, and attendings have certain rotational cycles on each medical service. NPPs generally do not rotate and can be the anchor of a medical team for patients and ancillary staff. Utilizing NPPs as liaisons between the hospitalist team and other members of the care team (eg, nurses, case managers, therapists, and administration) provides continuity for these groups and a central person who can help to facilitate change.
Quality Measures
NPPs can play an important role in hospital compliance with internal hospital or insurance provider quality initiatives. Surveillance of patients and charts for compliance with core measures, infection control, and prevention of complications are within the scope of practice of NPPs and can be incorporated into job descriptions. NPs and PAs will have the added responsibility of not only leading these surveillance teams but also in the correction of outliers given their prescriptive abilities. This will become an increasingly important task as reimbursement for preventable complications is curtailed. Additionally, the development and implementation of clinical pathways can be a focus of the NPP role to standardize and enhance quality of care.
Multidisciplinary Team Approach
Multidisciplinary teams that consist of NPPs, physicians, nurses, and therapists have been shown to increase communication and collaboration between participants.9 Mary Naylor, a Professor of Nursing at the University of Pennsylvania, has authored multiple articles and studies which examine the benefit of a multidisciplinary team that includes APNs with hospitalized patients. She has found that involving APNs in patient care, discharges, and routine follow‐up after discharge led to longer time to readmissions and decreased healthcare costs.1012 Furthermore, a nonteaching group consisting of NPPs, fellows, and attendings at the Mayo Clinic found increased physician satisfaction, shorter length of stay (LOS), and increased efficiency for their patients.13 A study done at JFK Medical Center in Florida noted that a collaborative practice which included unit‐based NPs serving in the dual role of NP and clinical nurse specialist increased patient satisfaction and improved patient outcomes.14
Financial Advantages
Efficiency and quality care are the cornerstones of HM. The partnership of NPPs within the specialty is creating even better performance. Models incorporating NPPs in the Hospitalist team approach are continuing to drive efficiency. Cowan et al.15 demonstrated that a multidisciplinary team, including nurse practitioners, decreased LOS from 6.01 to 5.0 and a reduced cost by $1,591 per patient. It is this team approach that will lift our specialty to be the model of care for all future hospital practice.
Another factor in determining the fiscal advantage of NPPs is salary and medical liability comparison. According to the 2007 Society of Hospital Medicine (SHM) Survey, the average hospitalist salary is approaching $190,000, compared to an average NP earning $87,000 and PA earning $84,500.4 Furthermore, the average internal medicine malpractice payment for physicians ranges from $14,237 to $68,867.16 In comparison, the average malpractice insurance premium for NPPs varies from state to state but is approximately $800 to $2000 per year.17, 18 With increasing fiscal scrutiny from hospitals, HM groups (HMGs) will need to include NPPs to be fiscally stable.
Models of Care
There are many models for NPP roles in hospital medicine groups. Some groups use NPPs in the same role as physicians. They perform admissions, rounding, and discharges with varying degrees of oversight by physicians. Other groups use NPPs for a more limited role, such as exclusively performing histories and physicals in the emergency department or handling discharges on the wards. It is important to take into account the preferences and expectations of NPPs when designing job descriptions. While some NPPs may like the fast pace and quick turnover of admissions and discharges, others may prefer to follow patients throughout their hospital stay. The quality of handoffs is crucial if the former model is used, just as it is with physicians in this more truncated role. An NPP who works in a nonacademic model will likely have more autonomy and control over patient care decisions. An NPP role in the teaching service of an academic hospital is likely to be more collaborative and focus more on quality initiatives, patient teaching, and communication. It is crucial to design an NPP model that is sustainable with very strong support of management once the NPP is hired and orientated.
Registered Nurses And Hospital Medicine
Patient handoffs and communication are one of the most challenging aspects of an HMG. There is an increasing movement, throughout the country, to incorporate registered nurses (RNs) into daily workflow. The RN on the HM team can serve to augment the communication and workflow process. A highly motivated and organized registered nurse can help to improve overall provider's workflow efficiency. Communication to primary care physician and collecting ancillary medical information can allow the provider to treat more patients in a given shift and decrease the liability risk from lack of information. As HM organizations and hospitals become more financially bound, HMGs will need to become more efficient at time management and a dedicated RN can help smooth that process.
Potential Unintended Side Effects
Obviously, integration of NPPs can be a disaster for an HMG if not handled properly. Most hospitalists have heard of an integration of NPP into a group that was an unqualified failure. NPPs can feel unsupported, poorly oriented to the job, or thrown into a situation that is over their heads. Before an NPP is hired into an HMG, there needs to be a thorough examination of the rationale behind the decision and assessment of the hospital culture that will be the host of the new NPP. What does the HMG need for support? Are they looking for a short‐term fix for increased volume or a long‐term strategy to build a multidisciplinary team? Does the hospital culture see NPPs as poorly qualified to act as hospitalists or uniquely qualified to address shortcomings of the program? A clear job description should be the first step in determining what the NPP is expected to do. This can then be shared with the hospital leadership in advance to promote buy‐in. The second step is finding an NPP that fits the goals of the program. A new NPP, by virtue of the fact that they have less clinical hours in training than a physician hospitalist, will need more support and a longer orientation. NPPs who have experience in hospital medicine will have a much shorter orientation. A stepwise approach to orientation can be helpful in assessing skill level of new hires. These NPPs can be initially paired with an enthusiastic physician to provide support and assessment of existing skills. A gradual increase in independence can provide assurance that the NPP is qualified to provide care and gives many opportunities for reevaluation of the NPP. Clear expectations and constructive feedback should ultimately lead to a degree of comfort within the HMG, hospital, and the NPPs themselves.
Conclusions
It is clear that our healthcare system will need a very different approach to the economic problems it is facing. Standardization of care, integrated medical records, and expanded and universal resource utilization will drive the next generation of healthcare providers. The model of a private physician working alone under the direction of only his or her own medical knowledge is a thing of the past. Just as the HM specialty has grown from 300 in 1996 to more than 20,000 in 2008, so shall the integration of NPPs grow into our healthcare fabric.
- Centers for Disease Control and Prevention (CDC). Trends in aging—United States and worldwide. MMWR Morb Mortal Wkly Rep. 2003;52(6):101–104, 106.
- Council on Graduate Medical Education. Physician Workforce Policy Guidelines for the U.S. for 2000‐2020. Rockville, MD: U.S. Department of Health and Human Services;2005.
- American Medical Association. Medical Student Section. Advocacy and Policy. Medical Student Debt. Available at: http://www.ama‐assn.org/ama/pub/category/5349.html. Accessed June 2009.
- Society of Hospital Medicine (SHM). 2007‐2008 SHM Survey: State of the Hospital Medicine Movement. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Surveys2
- Centers for Disease Control and Prevention (CDC). Trends in aging—United States and worldwide. MMWR Morb Mortal Wkly Rep. 2003;52(6):101–104, 106.
- Council on Graduate Medical Education. Physician Workforce Policy Guidelines for the U.S. for 2000‐2020. Rockville, MD: U.S. Department of Health and Human Services;2005.
- American Medical Association. Medical Student Section. Advocacy and Policy. Medical Student Debt. Available at: http://www.ama‐assn.org/ama/pub/category/5349.html. Accessed June 2009.
- Society of Hospital Medicine (SHM). 2007‐2008 SHM Survey: State of the Hospital Medicine Movement. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Surveys2
In the Literature
Retrospective Study of Symptoms in Post-Discharge Patients
Epstein K, Juarez E, Loya K, et al. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. March/April 2007;2(2):58-68.
As hospital stays shorten and acuity rises, patients often are discharged with complex instructions and discharge plans including home health services, physical therapy, hospice service, antibiotic infusions, and follow-up appointments. The potential for new or progressive symptoms in the days following discharge is an important parameter in assessing whether our planning is safe and effective.
The researchers in this study investigated the post-discharge period using a retrospective analysis of new or worsening symptoms within two to five days of hospital discharge among 15,767 patients surveyed between May 1 and Oct. 31, 2003. Patients were all under the care of hospitalists employed by IPC, a large private hospitalist group based in North Hollywood, Calif. Total discharges from which this cohort was selected numbered 48,236.
Staff with medical backgrounds conducted a scripted survey by phone. Licensed nursing personnel contacted those patients whose answers to initial questions suggested they were at high risk for postdischarge complications. A five-point Likert scale was used so patients could rate their overall health status in addition to specific symptomatology ranging from abdominal pain to bleeding. Other questions targeted pick-up and administration of prescribed medications, insulin regimen adherence, and implementation of home health services.
Among all patients discharged, 32.7% were contacted within two days of discharge. The mean age was 60.1 years, and 57% were female. Ethnicity and socioeconomic status were not reported. Medicare and HMOs were the most common type of insurance. Of the 15,767 patients contacted, 11.9% reported symptoms that were new or worsening since discharge; of this subgroup, 64% had new symptoms whereas 36% had “worse” symptoms.
Women were more likely than men to report new or worsening symptoms, and patients who rated themselves as having a poor health status were more likely to have new or worsening symptoms. Younger patients were less likely to report new or worsening symptoms, particularly younger men. Those with new or worse symptoms were slightly more likely to have made a follow-up appointment but also more likely to have a problem with their medications. Interestingly, there was no correlation between self-rated health status and reported severity of illness based on the diagnosis related group (DRG) score. Patients discharged with a DRG of chest pain were less likely to report symptoms than all other patients.
The authors acknowledge the low response rate (32.7%) relative to the 48,236 discharges during the study period. Logistic challenges, resource limitations, and erroneous contact information precluded successful contact for the remainder of patients. The magnitude of this exclusion effect essentially precludes statistically valid extrapolation to the inception cohort (all discharges). For example, in a sensitivity analysis where all the excluded patients are assumed to have developed new or worsening symptoms, the actual rate overall would have been 71%. If none developed new or worsening symptoms, that rate would be 3.8%. The rate for the inception cohort may or may not approximate the 11.9% found among the studied patients. There is insufficient evidence to determine whether the studied cohort reflects the entire population of discharged patients.
To their credit, no such analysis or interpretation is claimed or intended by the authors, and the information derived from the included cohort nonetheless provides interesting and important descriptive data.
Ethnicity and cultural factors were not taken into consideration. One might postulate that language barriers could affect compliance and symptom reporting. Day-of-the-week and holiday status also were not reported with regard to discharge. It would be interesting and useful to know whether access to pharmacy and other resources varied in this regard and whether symptom reporting was affected by such timing.
In the final analysis, this study suggests hospitalists remain alert to possible problems that might develop during the vulnerable first few days following discharge. It reminds us to advise patients how to receive prompt and knowledgeable medical advice from someone familiar with their hospital care prior to their first scheduled follow-up.
Based on the reported rate of new or worsening symptoms, should a post-discharge clinic be part of hospitalists’ scope of practice, at least for selected patients? Can subsets of patients who would benefit most from such intervention be identified? These and many more questions are raised by this study. We look forward to further research into the best process for ensuring optimal outcomes in the immediate post-discharge period.
Rosiglitazone’s Effect on MI Risk in Diabetes Patients
Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 June 14;356(24):2457-2471.
Cardiovascular causes account for more than 65% of deaths in diabetic patients. Rosiglitazone—a thiazolidinedione-class drug—has been broadly used in diabetes, but its effect on cardiovascular morbidity and mortality has not been conclusively determined. The authors initiated this meta-analysis to determine the effect of rosiglitazone on the risk of myocardial infarction (MI) and death from cardiovascular causes in diabetics.
The meta-analysis included 42 trials from three data sources. Forty trials were obtained from the Food and Drug Administration (FDA) Web site and the GlaxoSmithKline clinical trials registry. The third data source comprised two recent large, well-known trials: the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) and the A Diabetes Outcome Prevention Trial (ADOPT).1-2 The authors’ inclusion criteria were a study with a duration of more than 24 weeks, the use of a randomized control group not receiving rosiglitazone (placebo or comparator drug), and the availability of outcome data for MI and death from cardiovascular causes.
The studies included 15,560 patients randomly assigned to regimens that included rosiglitazone and 12,283 patients to comparator groups that did not include rosiglitazone.
The authors reviewed the data summaries of the 42 trials and tabulated adverse events (not reported as outcomes) of MI and death from cardiovascular causes. Hazard ratios could not be calculated since time-to-event data were lacking. Summary data also precluded the ability to determine whether the same patient suffered both an MI and death from cardiovascular causes.
Results of the authors’ statistical analyses included odds ratios and 95% confidence intervals to assess the risk associated with the rosiglitazone group as well as the subgroups of metformin, sulfonylurea, insulin, and placebo versus rosiglitazone.
The authors tabulated 86 MIs and 39 unadjudicated deaths from cardiovascular causes in the rosiglitazone group, and 72 MIs plus 22 deaths from cardiovascular causes in the control group.
The main conclusion was that rosiglitazone was associated with a statistically significant increase in the risk of MI (odds ratio 1.43, 95% confidence interval 1.03 to 1.98, p=0.03), but was not associated with a statistically significant increase in the risk of death from cardiovascular causes (odds ratio 1.64, 95% confidence interval 0.98 to 2.74, p=0.06).
Additionally, there were no statistical differences between rosiglitazone versus placebo or the individual antidiabetics in the subanalyses.
The authors have recognized the following major limitations in this meta-analysis:
- The low rate of MI is 0.55% (86 of 15,560 cases) in the rosiglitazone group and 0.59% (72 of 12,283 cases) in the control group. The odds ratio of 1.43 was statistically significant in the rosiglitazone group, although the event rate was higher in the control group. The risk of cardiovascular death was not significant, though a trend toward a higher death rate is noted;
- The lack of source data did not allow the use of time event analysis including hazard ratios;
- The definition of MI was unavailable; and
- MI and cardiovascular events were recorded in the trials as adverse events, not outcomes. Therefore, deaths from the latter were unadjudicated.
The authors suggested that the potential mechanism for increased MI in the rosiglitazone group could be its known effects on increasing low-density lipoproteins (LDL), precipitating congestive heart failure and reducing hemoglobin levels.
Rosiglitazone is one of two peroxisome proliferation activated receptor y (PPAR-y) agonists licensed for use in the United States; the other is pioglitazone. The third drug was troglitazone; it was taken off the market in March of 2000 due to hepatotoxicity.
The PPAR-y agonists decrease plasma glycemia by increasing insulin sensitivity in the peripheral tissues. These drugs have complex physiologic effects in activating and suppressing multiple genes, with most target genes being unknown. The observed side effects with rosiglitazone are not necessarily a class effect. Pioglitazone showed a trend toward reducing triglycerides and cardiovascular events, including MI and CVA, in a prospective, randomized trial called Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROACTIVE).
This meta-analysis precipitated an interim analysis of the ongoing Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycemia in Diabetes (RECORD) trial.3 The RECORD trial is a randomized, open-label, multicenter, non-inferiority trial of 4,427 patients; 2,220 received add-on rosiglitazone, and 2,227 received a combination of metformin plus sulfonylurea (control group). The primary end point was hospitalization or death from cardiovascular causes. Interim findings were inconclusive for the rosiglitazone group. There was also no evidence of any increase in death from cardiovascular causes or all causes. However, rosiglitazone was found to be associated with an increased risk of congestive heart failure. The data were insufficient to determine whether the drug was associated with increased MI risk.
This important meta-analysis raises concerns about the association of rosiglitazone with cardiovascular events—but do not consider it definitive. For now, patients with comparable alternatives to rosiglitazone (indeed all patients on this medication) should be advised of the undetermined safety concerns. For those who consider rosiglitazone a compelling choice, abrupt discontinuation on the basis of this study may be premature.
Finally, we need to remain cognizant of the proven negative side effects of rosiglitazone—it increases fracture risks in women, precipitates congestive heart failure, increases LDL, and decreases hemoglobin levels. We should consider alternative anti-hyperglycemic agents in selected patients at risk until there are solid data from large randomized control trials with rosiglitazone that pre-empt its use altogether.
References
- Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized controlled trial. Lancet 2006 Sep 23; 368(9547):1096-1105.
- Kahn SE, Haffner SM, Heise MA, et al; ADOPT Study Group. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. N Engl J Med. 2006 Dec 7;355(23):2427-2443.
- Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone evaluated for cardiac outcomes and regulation of glycemia in diabetes (RECORD): study design and protocol. Diabetologia. 2005;48:1726-1735.
Statins and Sepsis in Dialysis Patients
Gupta R, Plantinga LC, Fink NE, et al. Statin use and hospitalization for sepsis in patients with chronic kidney disease. JAMA. 2007 Apr 4;297(13):1455-1464.
Epidemiological data has revealed an increase in the rate of sepsis in the U.S. during the past two decades.1 In individuals with chronic kidney disease who are on dialysis, sepsis is a significant cause of morbidity and mortality. Various studies have looked at risk factors associated with septicemia in patients with chronic kidney disease; however, no preventive treatments have been identified.
Recent research has shown the use of statins has been associated with a decreased rate of sepsis and improved sepsis outcomes. The authors of this study investigated whether statin use may help reduce the incidence of sepsis in patients with chronic kidney disease on dialysis.
This prospective cohort study enrolled 1,041 participants attending dialysis clinics from October 1995 to June 1998, with a follow-up through Jan. 1, 2005. Statin use at baseline was determined by review of medical records. The primary outcome was hospitalization for sepsis, indicated by hospital data from the U.S. Renal Data System (mean follow-up 3.4 years).
The association of statin use and sepsis was assessed using two analyses. A multivariate regression analysis was performed on the entire cohort, and adjustments were made for potential confounders. An analysis was performed on a sub-cohort comparing sepsis rates in statin users with a control group identified through the likelihood of having been prescribed a statin (propensity matching).
There were 303 hospitalizations for sepsis among the 1,041 patients enrolled, with 14% of participants receiving a statin at baseline. The crude incidence rate of sepsis was 41/1,000 patient-years among statin users compared with 110/1,000 patient-years in the control group (p<0.001). The fully adjusted incidence ratio for sepsis among statin users versus nonusers was 0.38, or 62% lower among statin users.
In the propensity-matched subcohort group, there were 54 hospitalizations during follow-up. The relative risk of sepsis was 0.24 (95% confidence interval, 0.11-0.49) for statin users compared with nonusers.
A strong and independent association exists between statin use and reduced incidence of sepsis in chronic kidney disease patients. This association remained statistically significant after controlling for potential confounding. Why the statins might have this effect is not definitively known.
This national study further demonstrates the potential protective effect of statins on the occurrence of sepsis, which has been observed in previous research in a non-renal population. The author mentions that this is the first study to show a strong and significant effect of a medication administered long term on lower rates of sepsis among patients with chronic kidney disease.
Because this is an observational study, it is limited due to lack of randomization. As such, this study cannot prove causality. Further limitations include the assessment of patient and treatment factors at baseline, which can lead to a misclassification of factors that change over time. It is important to point out the study was dependent on U.S. Renal Data System and Medicare data to determine outcome, and the use of their ICD-9 coding information may have resulted in decreased reporting of sepsis.
Still, the relevant results of this investigation warrant further examination of statins and the prevention of sepsis in a prospective randomized trial. TH
Reference
- Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int. 2000 Oct;58(4):1758-1764.
Retrospective Study of Symptoms in Post-Discharge Patients
Epstein K, Juarez E, Loya K, et al. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. March/April 2007;2(2):58-68.
As hospital stays shorten and acuity rises, patients often are discharged with complex instructions and discharge plans including home health services, physical therapy, hospice service, antibiotic infusions, and follow-up appointments. The potential for new or progressive symptoms in the days following discharge is an important parameter in assessing whether our planning is safe and effective.
The researchers in this study investigated the post-discharge period using a retrospective analysis of new or worsening symptoms within two to five days of hospital discharge among 15,767 patients surveyed between May 1 and Oct. 31, 2003. Patients were all under the care of hospitalists employed by IPC, a large private hospitalist group based in North Hollywood, Calif. Total discharges from which this cohort was selected numbered 48,236.
Staff with medical backgrounds conducted a scripted survey by phone. Licensed nursing personnel contacted those patients whose answers to initial questions suggested they were at high risk for postdischarge complications. A five-point Likert scale was used so patients could rate their overall health status in addition to specific symptomatology ranging from abdominal pain to bleeding. Other questions targeted pick-up and administration of prescribed medications, insulin regimen adherence, and implementation of home health services.
Among all patients discharged, 32.7% were contacted within two days of discharge. The mean age was 60.1 years, and 57% were female. Ethnicity and socioeconomic status were not reported. Medicare and HMOs were the most common type of insurance. Of the 15,767 patients contacted, 11.9% reported symptoms that were new or worsening since discharge; of this subgroup, 64% had new symptoms whereas 36% had “worse” symptoms.
Women were more likely than men to report new or worsening symptoms, and patients who rated themselves as having a poor health status were more likely to have new or worsening symptoms. Younger patients were less likely to report new or worsening symptoms, particularly younger men. Those with new or worse symptoms were slightly more likely to have made a follow-up appointment but also more likely to have a problem with their medications. Interestingly, there was no correlation between self-rated health status and reported severity of illness based on the diagnosis related group (DRG) score. Patients discharged with a DRG of chest pain were less likely to report symptoms than all other patients.
The authors acknowledge the low response rate (32.7%) relative to the 48,236 discharges during the study period. Logistic challenges, resource limitations, and erroneous contact information precluded successful contact for the remainder of patients. The magnitude of this exclusion effect essentially precludes statistically valid extrapolation to the inception cohort (all discharges). For example, in a sensitivity analysis where all the excluded patients are assumed to have developed new or worsening symptoms, the actual rate overall would have been 71%. If none developed new or worsening symptoms, that rate would be 3.8%. The rate for the inception cohort may or may not approximate the 11.9% found among the studied patients. There is insufficient evidence to determine whether the studied cohort reflects the entire population of discharged patients.
To their credit, no such analysis or interpretation is claimed or intended by the authors, and the information derived from the included cohort nonetheless provides interesting and important descriptive data.
Ethnicity and cultural factors were not taken into consideration. One might postulate that language barriers could affect compliance and symptom reporting. Day-of-the-week and holiday status also were not reported with regard to discharge. It would be interesting and useful to know whether access to pharmacy and other resources varied in this regard and whether symptom reporting was affected by such timing.
In the final analysis, this study suggests hospitalists remain alert to possible problems that might develop during the vulnerable first few days following discharge. It reminds us to advise patients how to receive prompt and knowledgeable medical advice from someone familiar with their hospital care prior to their first scheduled follow-up.
Based on the reported rate of new or worsening symptoms, should a post-discharge clinic be part of hospitalists’ scope of practice, at least for selected patients? Can subsets of patients who would benefit most from such intervention be identified? These and many more questions are raised by this study. We look forward to further research into the best process for ensuring optimal outcomes in the immediate post-discharge period.
Rosiglitazone’s Effect on MI Risk in Diabetes Patients
Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 June 14;356(24):2457-2471.
Cardiovascular causes account for more than 65% of deaths in diabetic patients. Rosiglitazone—a thiazolidinedione-class drug—has been broadly used in diabetes, but its effect on cardiovascular morbidity and mortality has not been conclusively determined. The authors initiated this meta-analysis to determine the effect of rosiglitazone on the risk of myocardial infarction (MI) and death from cardiovascular causes in diabetics.
The meta-analysis included 42 trials from three data sources. Forty trials were obtained from the Food and Drug Administration (FDA) Web site and the GlaxoSmithKline clinical trials registry. The third data source comprised two recent large, well-known trials: the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) and the A Diabetes Outcome Prevention Trial (ADOPT).1-2 The authors’ inclusion criteria were a study with a duration of more than 24 weeks, the use of a randomized control group not receiving rosiglitazone (placebo or comparator drug), and the availability of outcome data for MI and death from cardiovascular causes.
The studies included 15,560 patients randomly assigned to regimens that included rosiglitazone and 12,283 patients to comparator groups that did not include rosiglitazone.
The authors reviewed the data summaries of the 42 trials and tabulated adverse events (not reported as outcomes) of MI and death from cardiovascular causes. Hazard ratios could not be calculated since time-to-event data were lacking. Summary data also precluded the ability to determine whether the same patient suffered both an MI and death from cardiovascular causes.
Results of the authors’ statistical analyses included odds ratios and 95% confidence intervals to assess the risk associated with the rosiglitazone group as well as the subgroups of metformin, sulfonylurea, insulin, and placebo versus rosiglitazone.
The authors tabulated 86 MIs and 39 unadjudicated deaths from cardiovascular causes in the rosiglitazone group, and 72 MIs plus 22 deaths from cardiovascular causes in the control group.
The main conclusion was that rosiglitazone was associated with a statistically significant increase in the risk of MI (odds ratio 1.43, 95% confidence interval 1.03 to 1.98, p=0.03), but was not associated with a statistically significant increase in the risk of death from cardiovascular causes (odds ratio 1.64, 95% confidence interval 0.98 to 2.74, p=0.06).
Additionally, there were no statistical differences between rosiglitazone versus placebo or the individual antidiabetics in the subanalyses.
The authors have recognized the following major limitations in this meta-analysis:
- The low rate of MI is 0.55% (86 of 15,560 cases) in the rosiglitazone group and 0.59% (72 of 12,283 cases) in the control group. The odds ratio of 1.43 was statistically significant in the rosiglitazone group, although the event rate was higher in the control group. The risk of cardiovascular death was not significant, though a trend toward a higher death rate is noted;
- The lack of source data did not allow the use of time event analysis including hazard ratios;
- The definition of MI was unavailable; and
- MI and cardiovascular events were recorded in the trials as adverse events, not outcomes. Therefore, deaths from the latter were unadjudicated.
The authors suggested that the potential mechanism for increased MI in the rosiglitazone group could be its known effects on increasing low-density lipoproteins (LDL), precipitating congestive heart failure and reducing hemoglobin levels.
Rosiglitazone is one of two peroxisome proliferation activated receptor y (PPAR-y) agonists licensed for use in the United States; the other is pioglitazone. The third drug was troglitazone; it was taken off the market in March of 2000 due to hepatotoxicity.
The PPAR-y agonists decrease plasma glycemia by increasing insulin sensitivity in the peripheral tissues. These drugs have complex physiologic effects in activating and suppressing multiple genes, with most target genes being unknown. The observed side effects with rosiglitazone are not necessarily a class effect. Pioglitazone showed a trend toward reducing triglycerides and cardiovascular events, including MI and CVA, in a prospective, randomized trial called Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROACTIVE).
This meta-analysis precipitated an interim analysis of the ongoing Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycemia in Diabetes (RECORD) trial.3 The RECORD trial is a randomized, open-label, multicenter, non-inferiority trial of 4,427 patients; 2,220 received add-on rosiglitazone, and 2,227 received a combination of metformin plus sulfonylurea (control group). The primary end point was hospitalization or death from cardiovascular causes. Interim findings were inconclusive for the rosiglitazone group. There was also no evidence of any increase in death from cardiovascular causes or all causes. However, rosiglitazone was found to be associated with an increased risk of congestive heart failure. The data were insufficient to determine whether the drug was associated with increased MI risk.
This important meta-analysis raises concerns about the association of rosiglitazone with cardiovascular events—but do not consider it definitive. For now, patients with comparable alternatives to rosiglitazone (indeed all patients on this medication) should be advised of the undetermined safety concerns. For those who consider rosiglitazone a compelling choice, abrupt discontinuation on the basis of this study may be premature.
Finally, we need to remain cognizant of the proven negative side effects of rosiglitazone—it increases fracture risks in women, precipitates congestive heart failure, increases LDL, and decreases hemoglobin levels. We should consider alternative anti-hyperglycemic agents in selected patients at risk until there are solid data from large randomized control trials with rosiglitazone that pre-empt its use altogether.
References
- Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized controlled trial. Lancet 2006 Sep 23; 368(9547):1096-1105.
- Kahn SE, Haffner SM, Heise MA, et al; ADOPT Study Group. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. N Engl J Med. 2006 Dec 7;355(23):2427-2443.
- Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone evaluated for cardiac outcomes and regulation of glycemia in diabetes (RECORD): study design and protocol. Diabetologia. 2005;48:1726-1735.
Statins and Sepsis in Dialysis Patients
Gupta R, Plantinga LC, Fink NE, et al. Statin use and hospitalization for sepsis in patients with chronic kidney disease. JAMA. 2007 Apr 4;297(13):1455-1464.
Epidemiological data has revealed an increase in the rate of sepsis in the U.S. during the past two decades.1 In individuals with chronic kidney disease who are on dialysis, sepsis is a significant cause of morbidity and mortality. Various studies have looked at risk factors associated with septicemia in patients with chronic kidney disease; however, no preventive treatments have been identified.
Recent research has shown the use of statins has been associated with a decreased rate of sepsis and improved sepsis outcomes. The authors of this study investigated whether statin use may help reduce the incidence of sepsis in patients with chronic kidney disease on dialysis.
This prospective cohort study enrolled 1,041 participants attending dialysis clinics from October 1995 to June 1998, with a follow-up through Jan. 1, 2005. Statin use at baseline was determined by review of medical records. The primary outcome was hospitalization for sepsis, indicated by hospital data from the U.S. Renal Data System (mean follow-up 3.4 years).
The association of statin use and sepsis was assessed using two analyses. A multivariate regression analysis was performed on the entire cohort, and adjustments were made for potential confounders. An analysis was performed on a sub-cohort comparing sepsis rates in statin users with a control group identified through the likelihood of having been prescribed a statin (propensity matching).
There were 303 hospitalizations for sepsis among the 1,041 patients enrolled, with 14% of participants receiving a statin at baseline. The crude incidence rate of sepsis was 41/1,000 patient-years among statin users compared with 110/1,000 patient-years in the control group (p<0.001). The fully adjusted incidence ratio for sepsis among statin users versus nonusers was 0.38, or 62% lower among statin users.
In the propensity-matched subcohort group, there were 54 hospitalizations during follow-up. The relative risk of sepsis was 0.24 (95% confidence interval, 0.11-0.49) for statin users compared with nonusers.
A strong and independent association exists between statin use and reduced incidence of sepsis in chronic kidney disease patients. This association remained statistically significant after controlling for potential confounding. Why the statins might have this effect is not definitively known.
This national study further demonstrates the potential protective effect of statins on the occurrence of sepsis, which has been observed in previous research in a non-renal population. The author mentions that this is the first study to show a strong and significant effect of a medication administered long term on lower rates of sepsis among patients with chronic kidney disease.
Because this is an observational study, it is limited due to lack of randomization. As such, this study cannot prove causality. Further limitations include the assessment of patient and treatment factors at baseline, which can lead to a misclassification of factors that change over time. It is important to point out the study was dependent on U.S. Renal Data System and Medicare data to determine outcome, and the use of their ICD-9 coding information may have resulted in decreased reporting of sepsis.
Still, the relevant results of this investigation warrant further examination of statins and the prevention of sepsis in a prospective randomized trial. TH
Reference
- Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int. 2000 Oct;58(4):1758-1764.
Retrospective Study of Symptoms in Post-Discharge Patients
Epstein K, Juarez E, Loya K, et al. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. March/April 2007;2(2):58-68.
As hospital stays shorten and acuity rises, patients often are discharged with complex instructions and discharge plans including home health services, physical therapy, hospice service, antibiotic infusions, and follow-up appointments. The potential for new or progressive symptoms in the days following discharge is an important parameter in assessing whether our planning is safe and effective.
The researchers in this study investigated the post-discharge period using a retrospective analysis of new or worsening symptoms within two to five days of hospital discharge among 15,767 patients surveyed between May 1 and Oct. 31, 2003. Patients were all under the care of hospitalists employed by IPC, a large private hospitalist group based in North Hollywood, Calif. Total discharges from which this cohort was selected numbered 48,236.
Staff with medical backgrounds conducted a scripted survey by phone. Licensed nursing personnel contacted those patients whose answers to initial questions suggested they were at high risk for postdischarge complications. A five-point Likert scale was used so patients could rate their overall health status in addition to specific symptomatology ranging from abdominal pain to bleeding. Other questions targeted pick-up and administration of prescribed medications, insulin regimen adherence, and implementation of home health services.
Among all patients discharged, 32.7% were contacted within two days of discharge. The mean age was 60.1 years, and 57% were female. Ethnicity and socioeconomic status were not reported. Medicare and HMOs were the most common type of insurance. Of the 15,767 patients contacted, 11.9% reported symptoms that were new or worsening since discharge; of this subgroup, 64% had new symptoms whereas 36% had “worse” symptoms.
Women were more likely than men to report new or worsening symptoms, and patients who rated themselves as having a poor health status were more likely to have new or worsening symptoms. Younger patients were less likely to report new or worsening symptoms, particularly younger men. Those with new or worse symptoms were slightly more likely to have made a follow-up appointment but also more likely to have a problem with their medications. Interestingly, there was no correlation between self-rated health status and reported severity of illness based on the diagnosis related group (DRG) score. Patients discharged with a DRG of chest pain were less likely to report symptoms than all other patients.
The authors acknowledge the low response rate (32.7%) relative to the 48,236 discharges during the study period. Logistic challenges, resource limitations, and erroneous contact information precluded successful contact for the remainder of patients. The magnitude of this exclusion effect essentially precludes statistically valid extrapolation to the inception cohort (all discharges). For example, in a sensitivity analysis where all the excluded patients are assumed to have developed new or worsening symptoms, the actual rate overall would have been 71%. If none developed new or worsening symptoms, that rate would be 3.8%. The rate for the inception cohort may or may not approximate the 11.9% found among the studied patients. There is insufficient evidence to determine whether the studied cohort reflects the entire population of discharged patients.
To their credit, no such analysis or interpretation is claimed or intended by the authors, and the information derived from the included cohort nonetheless provides interesting and important descriptive data.
Ethnicity and cultural factors were not taken into consideration. One might postulate that language barriers could affect compliance and symptom reporting. Day-of-the-week and holiday status also were not reported with regard to discharge. It would be interesting and useful to know whether access to pharmacy and other resources varied in this regard and whether symptom reporting was affected by such timing.
In the final analysis, this study suggests hospitalists remain alert to possible problems that might develop during the vulnerable first few days following discharge. It reminds us to advise patients how to receive prompt and knowledgeable medical advice from someone familiar with their hospital care prior to their first scheduled follow-up.
Based on the reported rate of new or worsening symptoms, should a post-discharge clinic be part of hospitalists’ scope of practice, at least for selected patients? Can subsets of patients who would benefit most from such intervention be identified? These and many more questions are raised by this study. We look forward to further research into the best process for ensuring optimal outcomes in the immediate post-discharge period.
Rosiglitazone’s Effect on MI Risk in Diabetes Patients
Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 June 14;356(24):2457-2471.
Cardiovascular causes account for more than 65% of deaths in diabetic patients. Rosiglitazone—a thiazolidinedione-class drug—has been broadly used in diabetes, but its effect on cardiovascular morbidity and mortality has not been conclusively determined. The authors initiated this meta-analysis to determine the effect of rosiglitazone on the risk of myocardial infarction (MI) and death from cardiovascular causes in diabetics.
The meta-analysis included 42 trials from three data sources. Forty trials were obtained from the Food and Drug Administration (FDA) Web site and the GlaxoSmithKline clinical trials registry. The third data source comprised two recent large, well-known trials: the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) and the A Diabetes Outcome Prevention Trial (ADOPT).1-2 The authors’ inclusion criteria were a study with a duration of more than 24 weeks, the use of a randomized control group not receiving rosiglitazone (placebo or comparator drug), and the availability of outcome data for MI and death from cardiovascular causes.
The studies included 15,560 patients randomly assigned to regimens that included rosiglitazone and 12,283 patients to comparator groups that did not include rosiglitazone.
The authors reviewed the data summaries of the 42 trials and tabulated adverse events (not reported as outcomes) of MI and death from cardiovascular causes. Hazard ratios could not be calculated since time-to-event data were lacking. Summary data also precluded the ability to determine whether the same patient suffered both an MI and death from cardiovascular causes.
Results of the authors’ statistical analyses included odds ratios and 95% confidence intervals to assess the risk associated with the rosiglitazone group as well as the subgroups of metformin, sulfonylurea, insulin, and placebo versus rosiglitazone.
The authors tabulated 86 MIs and 39 unadjudicated deaths from cardiovascular causes in the rosiglitazone group, and 72 MIs plus 22 deaths from cardiovascular causes in the control group.
The main conclusion was that rosiglitazone was associated with a statistically significant increase in the risk of MI (odds ratio 1.43, 95% confidence interval 1.03 to 1.98, p=0.03), but was not associated with a statistically significant increase in the risk of death from cardiovascular causes (odds ratio 1.64, 95% confidence interval 0.98 to 2.74, p=0.06).
Additionally, there were no statistical differences between rosiglitazone versus placebo or the individual antidiabetics in the subanalyses.
The authors have recognized the following major limitations in this meta-analysis:
- The low rate of MI is 0.55% (86 of 15,560 cases) in the rosiglitazone group and 0.59% (72 of 12,283 cases) in the control group. The odds ratio of 1.43 was statistically significant in the rosiglitazone group, although the event rate was higher in the control group. The risk of cardiovascular death was not significant, though a trend toward a higher death rate is noted;
- The lack of source data did not allow the use of time event analysis including hazard ratios;
- The definition of MI was unavailable; and
- MI and cardiovascular events were recorded in the trials as adverse events, not outcomes. Therefore, deaths from the latter were unadjudicated.
The authors suggested that the potential mechanism for increased MI in the rosiglitazone group could be its known effects on increasing low-density lipoproteins (LDL), precipitating congestive heart failure and reducing hemoglobin levels.
Rosiglitazone is one of two peroxisome proliferation activated receptor y (PPAR-y) agonists licensed for use in the United States; the other is pioglitazone. The third drug was troglitazone; it was taken off the market in March of 2000 due to hepatotoxicity.
The PPAR-y agonists decrease plasma glycemia by increasing insulin sensitivity in the peripheral tissues. These drugs have complex physiologic effects in activating and suppressing multiple genes, with most target genes being unknown. The observed side effects with rosiglitazone are not necessarily a class effect. Pioglitazone showed a trend toward reducing triglycerides and cardiovascular events, including MI and CVA, in a prospective, randomized trial called Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROACTIVE).
This meta-analysis precipitated an interim analysis of the ongoing Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycemia in Diabetes (RECORD) trial.3 The RECORD trial is a randomized, open-label, multicenter, non-inferiority trial of 4,427 patients; 2,220 received add-on rosiglitazone, and 2,227 received a combination of metformin plus sulfonylurea (control group). The primary end point was hospitalization or death from cardiovascular causes. Interim findings were inconclusive for the rosiglitazone group. There was also no evidence of any increase in death from cardiovascular causes or all causes. However, rosiglitazone was found to be associated with an increased risk of congestive heart failure. The data were insufficient to determine whether the drug was associated with increased MI risk.
This important meta-analysis raises concerns about the association of rosiglitazone with cardiovascular events—but do not consider it definitive. For now, patients with comparable alternatives to rosiglitazone (indeed all patients on this medication) should be advised of the undetermined safety concerns. For those who consider rosiglitazone a compelling choice, abrupt discontinuation on the basis of this study may be premature.
Finally, we need to remain cognizant of the proven negative side effects of rosiglitazone—it increases fracture risks in women, precipitates congestive heart failure, increases LDL, and decreases hemoglobin levels. We should consider alternative anti-hyperglycemic agents in selected patients at risk until there are solid data from large randomized control trials with rosiglitazone that pre-empt its use altogether.
References
- Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized controlled trial. Lancet 2006 Sep 23; 368(9547):1096-1105.
- Kahn SE, Haffner SM, Heise MA, et al; ADOPT Study Group. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. N Engl J Med. 2006 Dec 7;355(23):2427-2443.
- Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone evaluated for cardiac outcomes and regulation of glycemia in diabetes (RECORD): study design and protocol. Diabetologia. 2005;48:1726-1735.
Statins and Sepsis in Dialysis Patients
Gupta R, Plantinga LC, Fink NE, et al. Statin use and hospitalization for sepsis in patients with chronic kidney disease. JAMA. 2007 Apr 4;297(13):1455-1464.
Epidemiological data has revealed an increase in the rate of sepsis in the U.S. during the past two decades.1 In individuals with chronic kidney disease who are on dialysis, sepsis is a significant cause of morbidity and mortality. Various studies have looked at risk factors associated with septicemia in patients with chronic kidney disease; however, no preventive treatments have been identified.
Recent research has shown the use of statins has been associated with a decreased rate of sepsis and improved sepsis outcomes. The authors of this study investigated whether statin use may help reduce the incidence of sepsis in patients with chronic kidney disease on dialysis.
This prospective cohort study enrolled 1,041 participants attending dialysis clinics from October 1995 to June 1998, with a follow-up through Jan. 1, 2005. Statin use at baseline was determined by review of medical records. The primary outcome was hospitalization for sepsis, indicated by hospital data from the U.S. Renal Data System (mean follow-up 3.4 years).
The association of statin use and sepsis was assessed using two analyses. A multivariate regression analysis was performed on the entire cohort, and adjustments were made for potential confounders. An analysis was performed on a sub-cohort comparing sepsis rates in statin users with a control group identified through the likelihood of having been prescribed a statin (propensity matching).
There were 303 hospitalizations for sepsis among the 1,041 patients enrolled, with 14% of participants receiving a statin at baseline. The crude incidence rate of sepsis was 41/1,000 patient-years among statin users compared with 110/1,000 patient-years in the control group (p<0.001). The fully adjusted incidence ratio for sepsis among statin users versus nonusers was 0.38, or 62% lower among statin users.
In the propensity-matched subcohort group, there were 54 hospitalizations during follow-up. The relative risk of sepsis was 0.24 (95% confidence interval, 0.11-0.49) for statin users compared with nonusers.
A strong and independent association exists between statin use and reduced incidence of sepsis in chronic kidney disease patients. This association remained statistically significant after controlling for potential confounding. Why the statins might have this effect is not definitively known.
This national study further demonstrates the potential protective effect of statins on the occurrence of sepsis, which has been observed in previous research in a non-renal population. The author mentions that this is the first study to show a strong and significant effect of a medication administered long term on lower rates of sepsis among patients with chronic kidney disease.
Because this is an observational study, it is limited due to lack of randomization. As such, this study cannot prove causality. Further limitations include the assessment of patient and treatment factors at baseline, which can lead to a misclassification of factors that change over time. It is important to point out the study was dependent on U.S. Renal Data System and Medicare data to determine outcome, and the use of their ICD-9 coding information may have resulted in decreased reporting of sepsis.
Still, the relevant results of this investigation warrant further examination of statins and the prevention of sepsis in a prospective randomized trial. TH
Reference
- Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int. 2000 Oct;58(4):1758-1764.
In the Literature
Performance Measures and Outcomes for Heart Patients
Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70
As our population ages, more emphasis will be placed on issues surrounding efficient and evidence-based care. Heart failure, which accounted for 3.6 million hospitalizations in 2003 and has an overall prevalence of 5 million, will be at the forefront of public policy. As pay for performance (P4P) and standards of care become increasingly prevalent, the medical community will need to scrutinize the standards by which we are measured.
The American College of Cardiology and the American Heart Association (ACC/AHA) developed guidelines for the treatment and care of patients with heart failure. These measures include heart failure discharge instructions, evaluation of left ventricle (LV) function, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonist (ARB) for LV dysfunction, adult smoking cessation counseling, and anticoagulation at discharge for patients with atrial fibrillation. Adherence to these performance measures should be based on evidence.
The authors’ goal was to determine the validity of these guidelines. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry allowed for the documentation and follow-up of patients adhering to the heart failure guidelines as set forth by the ACC/AHA. The study assessed the relationship between these guidelines and clinical outcomes, including 60- to 90-day mortality and a composite end point of mortality or rehospitalization.
In this study the OPTIMIZE-HF registry was used as the source of prospective data collection. Ten percent of eligible patients were randomly selected from the registry between March 2003 and December 2004 from 91 hospitals. Eligibility for the OPTIMIZE-HF registry included patients 18 and older admitted for worsening heart failure or significant heart failure during their hospital stay. The performance measure of discharge instruction, smoking cessation, and anticoagulation were measured for all eligible patients. Patients with an ejection fraction of 40% or less, or moderate to severe systolic function, were included for the ACE inhibitor/ARB performance measure. One measure not included was treatment with beta-blockers at discharge. The authors included beta-blockers at discharge with metrics similar to those described for ACE/ARB criteria.
The conformity rates and process-outcome links were then determined for the performance measures and beta-blocker treatment as it related to 60- to 90-day mortality/rehospitalization.
The study focused on a random follow-up cohort of 5,791 patients from 91 hospitals. This was similar to the OPTIMIZE-HF cohort of 48,612 patients in 259 hospitals. Demographically, the average cohort’s age was 72, 51% male and 78% white, with 42% of patients diagnosed with ischemic heart disease and 43% with diabetes mellitus. These results were similar to the demographics of the overall OPTIMIZE-HF registry.
Of the eligible patients in the follow-up cohort, 66% (4,010) received complete discharge instructions. Eighty-nine percent of eligible patients (4,664) had their left ventricular function evaluated. For those patients with documented left ventricular systolic dysfunction (2,181), 83% were given an ACE inhibitor or ARB at discharge. Patients who had a diagnosis of atrial fibrillation were discharged with anticoagulation at a rate of 53%, and 72% of patients were counseled on smoking cessation. As compared with ACE inhibitors/ARB, similar results (84%) were seen for beta-blockers at discharge.
Only two of the five ACC/AHA performance measures were predictive of decreasing morbidity and mortality/rehospitalization in unadjusted analysis: patients discharged on ACE inhibitors/ARBs (odds ratio, 0.51; 95% CI 0.34–0.78; P- .002) and smoking cessation counseling. Beta-blockers, not a formal part of the ACC/AHA guidelines, were also a predictor of lower risk of both mortality and rehospitalization (odds ratio, 0.73; 95% CI, 0.55-0.96; P-0.02)
The OPTIMIZE-HF cohort analysis allowed for an opportunity to determine the degree of conformity for the ACC/AHA performance measures. The ACE inhibitors or ARB use at discharge was shown in the OPTIMIZE-HF cohort to have a relative reduction in one-year post discharge mortality by 17% (risk reduction, 0.83; 95% CI, 0.79-0.88) and a trend to lower 60- to 90-days post-discharge mortality and rehospitalization. Although smoking cessation had an early positive correlation, outcomes did not reach statistical significance. The measure of discharge instruction in the current study did not show a benefit on early mortality/rehospitalization in 60- to 90-days post discharge. It is unclear from this study if discharge instructions given to patients were either rushed or discussed in a comprehensive manner. This factor will need clarification and further research.
The measures of discharge instructions, smoking cessation, LV assessment, and anticoagulation for atrial fibrillation have not been examined as effective performance measures prior to this study. These measures were unable to show an independent decrease in 60- to 90-day mortality and rehospitalization.
Patients discharged with beta-blockers showed an association between lower mortality and rehospitalization. This association was found to be stronger than any of the formal ACC/AHA current performance measures.
The ACC/AHA guidelines are becoming standards of care for reporting to agencies such as Centers for Medicare and Medicaid Services or other P4P programs. To allow for improvement of quality, JCAHO and ACC/AHA designed the above criteria to act as a guide for the post discharge care of coronary heart failure patients. Because these criteria are the measures by which hospitals need to report, it will be necessary for data to show validity and a link between the clinical performance measures and improved outcomes.
Of the five measures stated, only ACE inhibitors/ARB at discharge was associated with a decrease in mortality/rehospitalization. Beta-blockers, currently not a performance measure, also showed this trend. Increased scrutiny needs to be part of the criteria for which hospitals and practitioners are being held accountable, and further research validating their effectiveness is warranted.
Risk Indexes for COPD
Niewoehner DE, Lockhnygina Y, Rice K, et al. Risk indexes for exacerbations and hospitalizations due to COPD. Chest. 2007 Jan;131(1):20-28.
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the U.S. and continues to increase its numbers annually.
The cornerstone of COPD diagnosis and key predictor of prognosis is a low level of lung function. Another important predictor of morbidity, mortality, and progression of disease is COPD exacerbations.
Unfortunately, the definition of an exacerbation is varied, ranging from an increase in symptoms to COPD-related hospitalizations and death.1 Therefore, prevention of COPD exacerbations is an important management goal. This study focuses on setting a risk model as a clinical management tool, similar to what exists for cardiovascular events or community acquired pneumonia. No previous study has attempted to identify risk factors for exacerbations using prospective data collection and a clearly stated definition of exacerbation.
The study was a parallel-group, randomized, double-blind, placebo-controlled trial in patients with moderate to severe COPD conducted at 26 Veterans Affairs medical centers in the United States. Subjects were 40 or older, with a cigarette smoking history of 10 packs a year or more, a clinical diagnosis of COPD, and a forced expiratory volume [FEV] of 60% or less predicted and 70% or less of the forced vital capacity [FVC].1 Patients were allocated to receive one capsule of tiotropium (18 mg) or placebo for six months.
Of the 1,829 patients selected, 914 were assigned to the tiotropium arm. Patients kept a daily diary, and the investigators collected data by monthly telephone interviews and by site visits at three and six months with spirometry evaluation. They evaluated the association between baseline characteristics, concomitant medications and the study drug and the time to first COPD exacerbation and the time to first hospitalization due to exacerbation. The authors defined an exacerbation as a complex of respiratory symptoms of more than one of the following: cough, sputum, wheezing, dyspnea, or chest tightness with a duration of at least three days requiring treatment with antibiotics and/or systemic corticosteroids and/or hospital admission.
The investigators found that a statistically significant greater risk for both COPD exacerbations and hospitalizations is associated with being of older age, being a noncurrent smoker, having poorer lung function, using home oxygen, visiting the clinic or emergency department more often, either scheduled or unscheduled, being hospitalized for COPD in the prior year, using either antibiotics or systemic steroids for COPD more often in the prior year, and using short-acting beta agonist, inhaled or oral corticosteroid at a baseline rate.
On the other hand, a statistically significant greater risk of only COPD exacerbation was seen in white patients, with presence of productive cough, longer duration of COPD, use of long-acting beta agonist or theophylline at baseline, and presence of any gastrointestinal or hepatobiliary disease. Lower body-mass index and the presence of cardiovascular comorbidity were associated with statistically significant greater risk for only hospitalization due to COPD.
The investigators also confirmed the previous suggestion that chronic cough is an independent predictor of exacerbation. Interestingly, they found that any cardiovascular comorbidity is a strong and independent predictor of hospitalizations due to COPD. It is unclear if cardiovascular disease truly predisposes subjects to COPD hospitalizations or merely represents a misdiagnosis because both diseases have similar symptoms.
Current smokers were identified as having lower risk of exacerbation and hospitalization, probably due to the “healthy smoker” theory—that deteriorating lung function causes the patient to quit smoking.
This study is the first to gather information about predictors of COPD exacerbations in a prospective fashion using a clear definition of exacerbation. The authors developed a model to assess the risk of COPD exacerbations and hospitalizations due to exacerbations in patients with moderate to severe COPD. Moreover, this model can easily be applied to individual patients and reproduced with simple spirometry and a series of questions.
Though this trial had a reasonable level of statistical significance, it is important to mention that the trial was conducted within a single health system (Veterans Affairs medical centers), there were few women in the study, and the eligibility criteria were very specific.
References
- Mannino DM, Watt G, Hole D, et al. The natural history of chronic obstructive pulmonary disease. Eur Respir J. 2006 Mar;27(3):627-643.
Glucose Management in Hospitalized Patients
Leahy JL. Insulin Management of diabetic patients on general medical and surgical floors. Endocr Pract. Jul/Aug 2006;12(Suppl3):86-89.
Although the rationale behind the science for tight control of blood sugar in subsets of hospitalized patient populations is without debate when it comes to the majority of general ward patients, the management of hyperglycemia becomes more of an art. Increasingly we recognize the effect of the relationship between improving glucose management and improving clinical outcomes.
Guidelines for inpatient targeted blood glucose levels exist, but hospitals are moving toward a more individualized approach to subcutaneous insulin protocols for their patients, thus moving beyond the passive sliding scale era.
Institution of an insulin protocol at one such hospital, the University of Vermont, highlights such an approach. The ongoing internal nonrandomized study exemplifies a two-tiered approach initially aimed at expanding the house physician comfort zone to change the culture of hyperglycemic management beyond simply avoiding hypoglycemia to one of an active and—per our current standards—aggressive individualized insulin protocol.
It seems the author envisions a gradual process allowing initial flexibility within the protocol, increasing the intensity of dosing as comfort zones expand. Throughout the process, the principles of determining a patient’s weight-based daily insulin needs are maintained, taking into consideration factors like comorbidities, severity of illness, amount of oral intake, steroid usage, and age. Then, the insulin regimen is physiologically (basal/bolus, basal, continuous) administered according to the route (i.e., total parenteral nutrition) and timing of their nutritional intake.
Adjustments being made to insulin regimens are based on fasting, pre-meal and bedtime glucose as well as the novel approach of bolus insulin after meals with short-acting insulin (i.e., lispro).
Unfortunately although the protocol does perhaps yield itself to being looked at more stringently—in terms of cost effectiveness, improved length of hospital stay, and improved clinical outcomes—the outcome studied here was primarily one of hospitalwide education in advancing the understanding and culture of aggressive individualized insulin protocols. These can often be even more statistically difficult to quantify. As self-reported, improvements were made.
One of the most important aspects of this paper is that it draws attention to the paucity of evidence for improved clinical and monetary outcomes supporting the aggressive hospital management of hyperglycemia in the non-acutely ill patient. Often, the guiding principle is to avoid hypoglycemia. Detailing the specific protocols of one such approach serves as an example for the motivated reader.
Early Switch from IV to Oral Antibiotic in Severe CAP
Oosterheert JJ, Bonten JM, Schneider MME, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia; multicentre randomised trial. BMJ. 2006 Dec 9; 333:1193.
Community acquired pneumonia (CAP) is a common and potentially fatal infection with high healthcare costs. When patients are first admitted to hospitals, antibiotics are usually given intravenously to provide optimal concentrations in the tissues.
The duration of intravenous treatment is an important determinant of length of hospital stay (LOS). The concept of early transition from intravenous to oral antibiotic in the treatment of CAP has been evaluated before, but only in mild to moderately severe disease—and rarely in randomized trials.
This multicenter random controlled trial from five teaching hospitals and two medical centers in the Netherlands enrolled 302 patients in non-intensive care units with severe CAP. The primary outcome was clinical cure and secondary outcome was LOS. The inclusion criteria were adults 18 or older with severe CAP; mean pneumonia severity index of IV-V, new progressive infiltrate on chest X-ray, plus at least two other criteria (cough, sputum production, rectal temperature >38o C or <36.1o C, auscultative findings consistent with pneumonia, leukocytes >109 WBC/L or >15% bands, positive cultures of blob or pleural fluids, CRP three times greater times upper limit of normal).
Exclusion criteria included the need for mechanical ventilation, cystic fibrosis, a history of colonization with gram-negative bacteria due to structural damage to the respiratory tract, malfunction of the digestive tract, life expectancy of less than one month because of underlying disease, infections other than pneumonia that needed antibiotic treatment, and severe immunosuppression (neutropenia [<0.5 109 neutrophils/liter] or a CD4 count< 200/mm3).
Treatment failure was defined as death, still in hospital at day 28 of the study, or clinical deterioration (increase in temperature after initial improvement or the need for mechanical ventilation, switch back to intravenous antibiotics, or readmission for pulmonary reinfection after discharge).
Clinical cure was defined as discharged in good health without signs and symptoms of pneumonia and no treatment failure during follow-up.
The control group comprised 150 subjects who were to receive a standard course of seven days’ intravenous treatment. Meanwhile, 152 subjects were randomized to the early switch group. Baseline characteristics were similar in both groups. More than 80% of patients were in pneumonia severity class IV or V. Most patients received empirical monotherapy with amoxicillin or amoxicillin plus clavulanic acid (n=174; 58%) or a cephalosporin (n=59; 20%), which is in line with Dutch prescribing policies.
The most frequently identified microorganism was S pneumoniae (n=76; 25%). Atypical pathogens were detected in 33 patients (11%). Before day three, 37 patients (12%) were excluded from analysis, leaving 132 patients for analysis in the intervention group and 133 in the control group.
Reasons for exclusion included when the initial diagnosis of CAP was replaced by another diagnosis (n=9), consent was withdrawn (n=11), the protocol was violated (n=4), the patient was admitted to an intensive-care unit for mechanical ventilation (n=6), and the patient died (n=7). After three days of intravenous treatment, 108 of 132 patients (81%) in the intervention group were switched to oral treatment, of whom 102 (94%) received amoxicillin plus clavulanic acid (500+125 mg every eight hours).
In the control group, five patients did not receive intravenous antibiotics for all seven days because of phlebitis associated with intravenous treatment; none of them needed treatment for line-related sepsis. Overall duration of antibiotic treatment was 10.1 days in the intervention group and 9.3 days in the control group (mean difference 0.8 days, 95% confidence interval -0.6 to 2.0).
The duration of intravenous treatment was significantly shorter in the intervention group (mean 3.6 [SD 1.5] versus 7.0 [2.0] days, mean difference 3.4, 2.8 to 3.9). Average time to meet the discharge criteria was 5.2 (2.9) days in the intervention group and 5.7 (3.1) days in the control group (0.5 days -0.3 to 1.2) Total length of hospital stay was 9.6 (5.0) and 11.5 (4.9) days for patients in the intervention group and control group (1.9 days 0.6 to 3.2).
The authors’ findings provide strong evidence that early transition from intravenous to oral antibiotic is also viable in patients with highly graded Pneumonia Severity Index (PSI) CAP, not only in mild to moderately severe disease. This leads to reduced LOS, cost, and possibly reduced risk of line infections and increased patient satisfaction for early discharge.
Note: This study was done with patients suffering straightforward, uncomplicated CAP. The investigators’ findings cannot be applied to patients with other comorbidities like diabetes, COPD, heart failure, or sickle cell, which might require more days on intravenous antibiotic. One might also wonder what impact would have been seen had 37 patients not dropped off, and if another class of oral antibiotic such as quinolones had been used.
Last, the study sample showed S pneumoniae identified in 25% of cases and atypical pathogens to be 11%. What then are the majority of pathogens identified 64% of the time? This would have been another key factor that might have had a great effect on the result.
Although a larger sampling and further risk stratification (to include patients with other comorbidities) are needed, this study makes a valid point for early transition to oral antibiotics in highly graded, uncomplicated CAP. TH
Performance Measures and Outcomes for Heart Patients
Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70
As our population ages, more emphasis will be placed on issues surrounding efficient and evidence-based care. Heart failure, which accounted for 3.6 million hospitalizations in 2003 and has an overall prevalence of 5 million, will be at the forefront of public policy. As pay for performance (P4P) and standards of care become increasingly prevalent, the medical community will need to scrutinize the standards by which we are measured.
The American College of Cardiology and the American Heart Association (ACC/AHA) developed guidelines for the treatment and care of patients with heart failure. These measures include heart failure discharge instructions, evaluation of left ventricle (LV) function, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonist (ARB) for LV dysfunction, adult smoking cessation counseling, and anticoagulation at discharge for patients with atrial fibrillation. Adherence to these performance measures should be based on evidence.
The authors’ goal was to determine the validity of these guidelines. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry allowed for the documentation and follow-up of patients adhering to the heart failure guidelines as set forth by the ACC/AHA. The study assessed the relationship between these guidelines and clinical outcomes, including 60- to 90-day mortality and a composite end point of mortality or rehospitalization.
In this study the OPTIMIZE-HF registry was used as the source of prospective data collection. Ten percent of eligible patients were randomly selected from the registry between March 2003 and December 2004 from 91 hospitals. Eligibility for the OPTIMIZE-HF registry included patients 18 and older admitted for worsening heart failure or significant heart failure during their hospital stay. The performance measure of discharge instruction, smoking cessation, and anticoagulation were measured for all eligible patients. Patients with an ejection fraction of 40% or less, or moderate to severe systolic function, were included for the ACE inhibitor/ARB performance measure. One measure not included was treatment with beta-blockers at discharge. The authors included beta-blockers at discharge with metrics similar to those described for ACE/ARB criteria.
The conformity rates and process-outcome links were then determined for the performance measures and beta-blocker treatment as it related to 60- to 90-day mortality/rehospitalization.
The study focused on a random follow-up cohort of 5,791 patients from 91 hospitals. This was similar to the OPTIMIZE-HF cohort of 48,612 patients in 259 hospitals. Demographically, the average cohort’s age was 72, 51% male and 78% white, with 42% of patients diagnosed with ischemic heart disease and 43% with diabetes mellitus. These results were similar to the demographics of the overall OPTIMIZE-HF registry.
Of the eligible patients in the follow-up cohort, 66% (4,010) received complete discharge instructions. Eighty-nine percent of eligible patients (4,664) had their left ventricular function evaluated. For those patients with documented left ventricular systolic dysfunction (2,181), 83% were given an ACE inhibitor or ARB at discharge. Patients who had a diagnosis of atrial fibrillation were discharged with anticoagulation at a rate of 53%, and 72% of patients were counseled on smoking cessation. As compared with ACE inhibitors/ARB, similar results (84%) were seen for beta-blockers at discharge.
Only two of the five ACC/AHA performance measures were predictive of decreasing morbidity and mortality/rehospitalization in unadjusted analysis: patients discharged on ACE inhibitors/ARBs (odds ratio, 0.51; 95% CI 0.34–0.78; P- .002) and smoking cessation counseling. Beta-blockers, not a formal part of the ACC/AHA guidelines, were also a predictor of lower risk of both mortality and rehospitalization (odds ratio, 0.73; 95% CI, 0.55-0.96; P-0.02)
The OPTIMIZE-HF cohort analysis allowed for an opportunity to determine the degree of conformity for the ACC/AHA performance measures. The ACE inhibitors or ARB use at discharge was shown in the OPTIMIZE-HF cohort to have a relative reduction in one-year post discharge mortality by 17% (risk reduction, 0.83; 95% CI, 0.79-0.88) and a trend to lower 60- to 90-days post-discharge mortality and rehospitalization. Although smoking cessation had an early positive correlation, outcomes did not reach statistical significance. The measure of discharge instruction in the current study did not show a benefit on early mortality/rehospitalization in 60- to 90-days post discharge. It is unclear from this study if discharge instructions given to patients were either rushed or discussed in a comprehensive manner. This factor will need clarification and further research.
The measures of discharge instructions, smoking cessation, LV assessment, and anticoagulation for atrial fibrillation have not been examined as effective performance measures prior to this study. These measures were unable to show an independent decrease in 60- to 90-day mortality and rehospitalization.
Patients discharged with beta-blockers showed an association between lower mortality and rehospitalization. This association was found to be stronger than any of the formal ACC/AHA current performance measures.
The ACC/AHA guidelines are becoming standards of care for reporting to agencies such as Centers for Medicare and Medicaid Services or other P4P programs. To allow for improvement of quality, JCAHO and ACC/AHA designed the above criteria to act as a guide for the post discharge care of coronary heart failure patients. Because these criteria are the measures by which hospitals need to report, it will be necessary for data to show validity and a link between the clinical performance measures and improved outcomes.
Of the five measures stated, only ACE inhibitors/ARB at discharge was associated with a decrease in mortality/rehospitalization. Beta-blockers, currently not a performance measure, also showed this trend. Increased scrutiny needs to be part of the criteria for which hospitals and practitioners are being held accountable, and further research validating their effectiveness is warranted.
Risk Indexes for COPD
Niewoehner DE, Lockhnygina Y, Rice K, et al. Risk indexes for exacerbations and hospitalizations due to COPD. Chest. 2007 Jan;131(1):20-28.
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the U.S. and continues to increase its numbers annually.
The cornerstone of COPD diagnosis and key predictor of prognosis is a low level of lung function. Another important predictor of morbidity, mortality, and progression of disease is COPD exacerbations.
Unfortunately, the definition of an exacerbation is varied, ranging from an increase in symptoms to COPD-related hospitalizations and death.1 Therefore, prevention of COPD exacerbations is an important management goal. This study focuses on setting a risk model as a clinical management tool, similar to what exists for cardiovascular events or community acquired pneumonia. No previous study has attempted to identify risk factors for exacerbations using prospective data collection and a clearly stated definition of exacerbation.
The study was a parallel-group, randomized, double-blind, placebo-controlled trial in patients with moderate to severe COPD conducted at 26 Veterans Affairs medical centers in the United States. Subjects were 40 or older, with a cigarette smoking history of 10 packs a year or more, a clinical diagnosis of COPD, and a forced expiratory volume [FEV] of 60% or less predicted and 70% or less of the forced vital capacity [FVC].1 Patients were allocated to receive one capsule of tiotropium (18 mg) or placebo for six months.
Of the 1,829 patients selected, 914 were assigned to the tiotropium arm. Patients kept a daily diary, and the investigators collected data by monthly telephone interviews and by site visits at three and six months with spirometry evaluation. They evaluated the association between baseline characteristics, concomitant medications and the study drug and the time to first COPD exacerbation and the time to first hospitalization due to exacerbation. The authors defined an exacerbation as a complex of respiratory symptoms of more than one of the following: cough, sputum, wheezing, dyspnea, or chest tightness with a duration of at least three days requiring treatment with antibiotics and/or systemic corticosteroids and/or hospital admission.
The investigators found that a statistically significant greater risk for both COPD exacerbations and hospitalizations is associated with being of older age, being a noncurrent smoker, having poorer lung function, using home oxygen, visiting the clinic or emergency department more often, either scheduled or unscheduled, being hospitalized for COPD in the prior year, using either antibiotics or systemic steroids for COPD more often in the prior year, and using short-acting beta agonist, inhaled or oral corticosteroid at a baseline rate.
On the other hand, a statistically significant greater risk of only COPD exacerbation was seen in white patients, with presence of productive cough, longer duration of COPD, use of long-acting beta agonist or theophylline at baseline, and presence of any gastrointestinal or hepatobiliary disease. Lower body-mass index and the presence of cardiovascular comorbidity were associated with statistically significant greater risk for only hospitalization due to COPD.
The investigators also confirmed the previous suggestion that chronic cough is an independent predictor of exacerbation. Interestingly, they found that any cardiovascular comorbidity is a strong and independent predictor of hospitalizations due to COPD. It is unclear if cardiovascular disease truly predisposes subjects to COPD hospitalizations or merely represents a misdiagnosis because both diseases have similar symptoms.
Current smokers were identified as having lower risk of exacerbation and hospitalization, probably due to the “healthy smoker” theory—that deteriorating lung function causes the patient to quit smoking.
This study is the first to gather information about predictors of COPD exacerbations in a prospective fashion using a clear definition of exacerbation. The authors developed a model to assess the risk of COPD exacerbations and hospitalizations due to exacerbations in patients with moderate to severe COPD. Moreover, this model can easily be applied to individual patients and reproduced with simple spirometry and a series of questions.
Though this trial had a reasonable level of statistical significance, it is important to mention that the trial was conducted within a single health system (Veterans Affairs medical centers), there were few women in the study, and the eligibility criteria were very specific.
References
- Mannino DM, Watt G, Hole D, et al. The natural history of chronic obstructive pulmonary disease. Eur Respir J. 2006 Mar;27(3):627-643.
Glucose Management in Hospitalized Patients
Leahy JL. Insulin Management of diabetic patients on general medical and surgical floors. Endocr Pract. Jul/Aug 2006;12(Suppl3):86-89.
Although the rationale behind the science for tight control of blood sugar in subsets of hospitalized patient populations is without debate when it comes to the majority of general ward patients, the management of hyperglycemia becomes more of an art. Increasingly we recognize the effect of the relationship between improving glucose management and improving clinical outcomes.
Guidelines for inpatient targeted blood glucose levels exist, but hospitals are moving toward a more individualized approach to subcutaneous insulin protocols for their patients, thus moving beyond the passive sliding scale era.
Institution of an insulin protocol at one such hospital, the University of Vermont, highlights such an approach. The ongoing internal nonrandomized study exemplifies a two-tiered approach initially aimed at expanding the house physician comfort zone to change the culture of hyperglycemic management beyond simply avoiding hypoglycemia to one of an active and—per our current standards—aggressive individualized insulin protocol.
It seems the author envisions a gradual process allowing initial flexibility within the protocol, increasing the intensity of dosing as comfort zones expand. Throughout the process, the principles of determining a patient’s weight-based daily insulin needs are maintained, taking into consideration factors like comorbidities, severity of illness, amount of oral intake, steroid usage, and age. Then, the insulin regimen is physiologically (basal/bolus, basal, continuous) administered according to the route (i.e., total parenteral nutrition) and timing of their nutritional intake.
Adjustments being made to insulin regimens are based on fasting, pre-meal and bedtime glucose as well as the novel approach of bolus insulin after meals with short-acting insulin (i.e., lispro).
Unfortunately although the protocol does perhaps yield itself to being looked at more stringently—in terms of cost effectiveness, improved length of hospital stay, and improved clinical outcomes—the outcome studied here was primarily one of hospitalwide education in advancing the understanding and culture of aggressive individualized insulin protocols. These can often be even more statistically difficult to quantify. As self-reported, improvements were made.
One of the most important aspects of this paper is that it draws attention to the paucity of evidence for improved clinical and monetary outcomes supporting the aggressive hospital management of hyperglycemia in the non-acutely ill patient. Often, the guiding principle is to avoid hypoglycemia. Detailing the specific protocols of one such approach serves as an example for the motivated reader.
Early Switch from IV to Oral Antibiotic in Severe CAP
Oosterheert JJ, Bonten JM, Schneider MME, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia; multicentre randomised trial. BMJ. 2006 Dec 9; 333:1193.
Community acquired pneumonia (CAP) is a common and potentially fatal infection with high healthcare costs. When patients are first admitted to hospitals, antibiotics are usually given intravenously to provide optimal concentrations in the tissues.
The duration of intravenous treatment is an important determinant of length of hospital stay (LOS). The concept of early transition from intravenous to oral antibiotic in the treatment of CAP has been evaluated before, but only in mild to moderately severe disease—and rarely in randomized trials.
This multicenter random controlled trial from five teaching hospitals and two medical centers in the Netherlands enrolled 302 patients in non-intensive care units with severe CAP. The primary outcome was clinical cure and secondary outcome was LOS. The inclusion criteria were adults 18 or older with severe CAP; mean pneumonia severity index of IV-V, new progressive infiltrate on chest X-ray, plus at least two other criteria (cough, sputum production, rectal temperature >38o C or <36.1o C, auscultative findings consistent with pneumonia, leukocytes >109 WBC/L or >15% bands, positive cultures of blob or pleural fluids, CRP three times greater times upper limit of normal).
Exclusion criteria included the need for mechanical ventilation, cystic fibrosis, a history of colonization with gram-negative bacteria due to structural damage to the respiratory tract, malfunction of the digestive tract, life expectancy of less than one month because of underlying disease, infections other than pneumonia that needed antibiotic treatment, and severe immunosuppression (neutropenia [<0.5 109 neutrophils/liter] or a CD4 count< 200/mm3).
Treatment failure was defined as death, still in hospital at day 28 of the study, or clinical deterioration (increase in temperature after initial improvement or the need for mechanical ventilation, switch back to intravenous antibiotics, or readmission for pulmonary reinfection after discharge).
Clinical cure was defined as discharged in good health without signs and symptoms of pneumonia and no treatment failure during follow-up.
The control group comprised 150 subjects who were to receive a standard course of seven days’ intravenous treatment. Meanwhile, 152 subjects were randomized to the early switch group. Baseline characteristics were similar in both groups. More than 80% of patients were in pneumonia severity class IV or V. Most patients received empirical monotherapy with amoxicillin or amoxicillin plus clavulanic acid (n=174; 58%) or a cephalosporin (n=59; 20%), which is in line with Dutch prescribing policies.
The most frequently identified microorganism was S pneumoniae (n=76; 25%). Atypical pathogens were detected in 33 patients (11%). Before day three, 37 patients (12%) were excluded from analysis, leaving 132 patients for analysis in the intervention group and 133 in the control group.
Reasons for exclusion included when the initial diagnosis of CAP was replaced by another diagnosis (n=9), consent was withdrawn (n=11), the protocol was violated (n=4), the patient was admitted to an intensive-care unit for mechanical ventilation (n=6), and the patient died (n=7). After three days of intravenous treatment, 108 of 132 patients (81%) in the intervention group were switched to oral treatment, of whom 102 (94%) received amoxicillin plus clavulanic acid (500+125 mg every eight hours).
In the control group, five patients did not receive intravenous antibiotics for all seven days because of phlebitis associated with intravenous treatment; none of them needed treatment for line-related sepsis. Overall duration of antibiotic treatment was 10.1 days in the intervention group and 9.3 days in the control group (mean difference 0.8 days, 95% confidence interval -0.6 to 2.0).
The duration of intravenous treatment was significantly shorter in the intervention group (mean 3.6 [SD 1.5] versus 7.0 [2.0] days, mean difference 3.4, 2.8 to 3.9). Average time to meet the discharge criteria was 5.2 (2.9) days in the intervention group and 5.7 (3.1) days in the control group (0.5 days -0.3 to 1.2) Total length of hospital stay was 9.6 (5.0) and 11.5 (4.9) days for patients in the intervention group and control group (1.9 days 0.6 to 3.2).
The authors’ findings provide strong evidence that early transition from intravenous to oral antibiotic is also viable in patients with highly graded Pneumonia Severity Index (PSI) CAP, not only in mild to moderately severe disease. This leads to reduced LOS, cost, and possibly reduced risk of line infections and increased patient satisfaction for early discharge.
Note: This study was done with patients suffering straightforward, uncomplicated CAP. The investigators’ findings cannot be applied to patients with other comorbidities like diabetes, COPD, heart failure, or sickle cell, which might require more days on intravenous antibiotic. One might also wonder what impact would have been seen had 37 patients not dropped off, and if another class of oral antibiotic such as quinolones had been used.
Last, the study sample showed S pneumoniae identified in 25% of cases and atypical pathogens to be 11%. What then are the majority of pathogens identified 64% of the time? This would have been another key factor that might have had a great effect on the result.
Although a larger sampling and further risk stratification (to include patients with other comorbidities) are needed, this study makes a valid point for early transition to oral antibiotics in highly graded, uncomplicated CAP. TH
Performance Measures and Outcomes for Heart Patients
Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70
As our population ages, more emphasis will be placed on issues surrounding efficient and evidence-based care. Heart failure, which accounted for 3.6 million hospitalizations in 2003 and has an overall prevalence of 5 million, will be at the forefront of public policy. As pay for performance (P4P) and standards of care become increasingly prevalent, the medical community will need to scrutinize the standards by which we are measured.
The American College of Cardiology and the American Heart Association (ACC/AHA) developed guidelines for the treatment and care of patients with heart failure. These measures include heart failure discharge instructions, evaluation of left ventricle (LV) function, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonist (ARB) for LV dysfunction, adult smoking cessation counseling, and anticoagulation at discharge for patients with atrial fibrillation. Adherence to these performance measures should be based on evidence.
The authors’ goal was to determine the validity of these guidelines. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry allowed for the documentation and follow-up of patients adhering to the heart failure guidelines as set forth by the ACC/AHA. The study assessed the relationship between these guidelines and clinical outcomes, including 60- to 90-day mortality and a composite end point of mortality or rehospitalization.
In this study the OPTIMIZE-HF registry was used as the source of prospective data collection. Ten percent of eligible patients were randomly selected from the registry between March 2003 and December 2004 from 91 hospitals. Eligibility for the OPTIMIZE-HF registry included patients 18 and older admitted for worsening heart failure or significant heart failure during their hospital stay. The performance measure of discharge instruction, smoking cessation, and anticoagulation were measured for all eligible patients. Patients with an ejection fraction of 40% or less, or moderate to severe systolic function, were included for the ACE inhibitor/ARB performance measure. One measure not included was treatment with beta-blockers at discharge. The authors included beta-blockers at discharge with metrics similar to those described for ACE/ARB criteria.
The conformity rates and process-outcome links were then determined for the performance measures and beta-blocker treatment as it related to 60- to 90-day mortality/rehospitalization.
The study focused on a random follow-up cohort of 5,791 patients from 91 hospitals. This was similar to the OPTIMIZE-HF cohort of 48,612 patients in 259 hospitals. Demographically, the average cohort’s age was 72, 51% male and 78% white, with 42% of patients diagnosed with ischemic heart disease and 43% with diabetes mellitus. These results were similar to the demographics of the overall OPTIMIZE-HF registry.
Of the eligible patients in the follow-up cohort, 66% (4,010) received complete discharge instructions. Eighty-nine percent of eligible patients (4,664) had their left ventricular function evaluated. For those patients with documented left ventricular systolic dysfunction (2,181), 83% were given an ACE inhibitor or ARB at discharge. Patients who had a diagnosis of atrial fibrillation were discharged with anticoagulation at a rate of 53%, and 72% of patients were counseled on smoking cessation. As compared with ACE inhibitors/ARB, similar results (84%) were seen for beta-blockers at discharge.
Only two of the five ACC/AHA performance measures were predictive of decreasing morbidity and mortality/rehospitalization in unadjusted analysis: patients discharged on ACE inhibitors/ARBs (odds ratio, 0.51; 95% CI 0.34–0.78; P- .002) and smoking cessation counseling. Beta-blockers, not a formal part of the ACC/AHA guidelines, were also a predictor of lower risk of both mortality and rehospitalization (odds ratio, 0.73; 95% CI, 0.55-0.96; P-0.02)
The OPTIMIZE-HF cohort analysis allowed for an opportunity to determine the degree of conformity for the ACC/AHA performance measures. The ACE inhibitors or ARB use at discharge was shown in the OPTIMIZE-HF cohort to have a relative reduction in one-year post discharge mortality by 17% (risk reduction, 0.83; 95% CI, 0.79-0.88) and a trend to lower 60- to 90-days post-discharge mortality and rehospitalization. Although smoking cessation had an early positive correlation, outcomes did not reach statistical significance. The measure of discharge instruction in the current study did not show a benefit on early mortality/rehospitalization in 60- to 90-days post discharge. It is unclear from this study if discharge instructions given to patients were either rushed or discussed in a comprehensive manner. This factor will need clarification and further research.
The measures of discharge instructions, smoking cessation, LV assessment, and anticoagulation for atrial fibrillation have not been examined as effective performance measures prior to this study. These measures were unable to show an independent decrease in 60- to 90-day mortality and rehospitalization.
Patients discharged with beta-blockers showed an association between lower mortality and rehospitalization. This association was found to be stronger than any of the formal ACC/AHA current performance measures.
The ACC/AHA guidelines are becoming standards of care for reporting to agencies such as Centers for Medicare and Medicaid Services or other P4P programs. To allow for improvement of quality, JCAHO and ACC/AHA designed the above criteria to act as a guide for the post discharge care of coronary heart failure patients. Because these criteria are the measures by which hospitals need to report, it will be necessary for data to show validity and a link between the clinical performance measures and improved outcomes.
Of the five measures stated, only ACE inhibitors/ARB at discharge was associated with a decrease in mortality/rehospitalization. Beta-blockers, currently not a performance measure, also showed this trend. Increased scrutiny needs to be part of the criteria for which hospitals and practitioners are being held accountable, and further research validating their effectiveness is warranted.
Risk Indexes for COPD
Niewoehner DE, Lockhnygina Y, Rice K, et al. Risk indexes for exacerbations and hospitalizations due to COPD. Chest. 2007 Jan;131(1):20-28.
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the U.S. and continues to increase its numbers annually.
The cornerstone of COPD diagnosis and key predictor of prognosis is a low level of lung function. Another important predictor of morbidity, mortality, and progression of disease is COPD exacerbations.
Unfortunately, the definition of an exacerbation is varied, ranging from an increase in symptoms to COPD-related hospitalizations and death.1 Therefore, prevention of COPD exacerbations is an important management goal. This study focuses on setting a risk model as a clinical management tool, similar to what exists for cardiovascular events or community acquired pneumonia. No previous study has attempted to identify risk factors for exacerbations using prospective data collection and a clearly stated definition of exacerbation.
The study was a parallel-group, randomized, double-blind, placebo-controlled trial in patients with moderate to severe COPD conducted at 26 Veterans Affairs medical centers in the United States. Subjects were 40 or older, with a cigarette smoking history of 10 packs a year or more, a clinical diagnosis of COPD, and a forced expiratory volume [FEV] of 60% or less predicted and 70% or less of the forced vital capacity [FVC].1 Patients were allocated to receive one capsule of tiotropium (18 mg) or placebo for six months.
Of the 1,829 patients selected, 914 were assigned to the tiotropium arm. Patients kept a daily diary, and the investigators collected data by monthly telephone interviews and by site visits at three and six months with spirometry evaluation. They evaluated the association between baseline characteristics, concomitant medications and the study drug and the time to first COPD exacerbation and the time to first hospitalization due to exacerbation. The authors defined an exacerbation as a complex of respiratory symptoms of more than one of the following: cough, sputum, wheezing, dyspnea, or chest tightness with a duration of at least three days requiring treatment with antibiotics and/or systemic corticosteroids and/or hospital admission.
The investigators found that a statistically significant greater risk for both COPD exacerbations and hospitalizations is associated with being of older age, being a noncurrent smoker, having poorer lung function, using home oxygen, visiting the clinic or emergency department more often, either scheduled or unscheduled, being hospitalized for COPD in the prior year, using either antibiotics or systemic steroids for COPD more often in the prior year, and using short-acting beta agonist, inhaled or oral corticosteroid at a baseline rate.
On the other hand, a statistically significant greater risk of only COPD exacerbation was seen in white patients, with presence of productive cough, longer duration of COPD, use of long-acting beta agonist or theophylline at baseline, and presence of any gastrointestinal or hepatobiliary disease. Lower body-mass index and the presence of cardiovascular comorbidity were associated with statistically significant greater risk for only hospitalization due to COPD.
The investigators also confirmed the previous suggestion that chronic cough is an independent predictor of exacerbation. Interestingly, they found that any cardiovascular comorbidity is a strong and independent predictor of hospitalizations due to COPD. It is unclear if cardiovascular disease truly predisposes subjects to COPD hospitalizations or merely represents a misdiagnosis because both diseases have similar symptoms.
Current smokers were identified as having lower risk of exacerbation and hospitalization, probably due to the “healthy smoker” theory—that deteriorating lung function causes the patient to quit smoking.
This study is the first to gather information about predictors of COPD exacerbations in a prospective fashion using a clear definition of exacerbation. The authors developed a model to assess the risk of COPD exacerbations and hospitalizations due to exacerbations in patients with moderate to severe COPD. Moreover, this model can easily be applied to individual patients and reproduced with simple spirometry and a series of questions.
Though this trial had a reasonable level of statistical significance, it is important to mention that the trial was conducted within a single health system (Veterans Affairs medical centers), there were few women in the study, and the eligibility criteria were very specific.
References
- Mannino DM, Watt G, Hole D, et al. The natural history of chronic obstructive pulmonary disease. Eur Respir J. 2006 Mar;27(3):627-643.
Glucose Management in Hospitalized Patients
Leahy JL. Insulin Management of diabetic patients on general medical and surgical floors. Endocr Pract. Jul/Aug 2006;12(Suppl3):86-89.
Although the rationale behind the science for tight control of blood sugar in subsets of hospitalized patient populations is without debate when it comes to the majority of general ward patients, the management of hyperglycemia becomes more of an art. Increasingly we recognize the effect of the relationship between improving glucose management and improving clinical outcomes.
Guidelines for inpatient targeted blood glucose levels exist, but hospitals are moving toward a more individualized approach to subcutaneous insulin protocols for their patients, thus moving beyond the passive sliding scale era.
Institution of an insulin protocol at one such hospital, the University of Vermont, highlights such an approach. The ongoing internal nonrandomized study exemplifies a two-tiered approach initially aimed at expanding the house physician comfort zone to change the culture of hyperglycemic management beyond simply avoiding hypoglycemia to one of an active and—per our current standards—aggressive individualized insulin protocol.
It seems the author envisions a gradual process allowing initial flexibility within the protocol, increasing the intensity of dosing as comfort zones expand. Throughout the process, the principles of determining a patient’s weight-based daily insulin needs are maintained, taking into consideration factors like comorbidities, severity of illness, amount of oral intake, steroid usage, and age. Then, the insulin regimen is physiologically (basal/bolus, basal, continuous) administered according to the route (i.e., total parenteral nutrition) and timing of their nutritional intake.
Adjustments being made to insulin regimens are based on fasting, pre-meal and bedtime glucose as well as the novel approach of bolus insulin after meals with short-acting insulin (i.e., lispro).
Unfortunately although the protocol does perhaps yield itself to being looked at more stringently—in terms of cost effectiveness, improved length of hospital stay, and improved clinical outcomes—the outcome studied here was primarily one of hospitalwide education in advancing the understanding and culture of aggressive individualized insulin protocols. These can often be even more statistically difficult to quantify. As self-reported, improvements were made.
One of the most important aspects of this paper is that it draws attention to the paucity of evidence for improved clinical and monetary outcomes supporting the aggressive hospital management of hyperglycemia in the non-acutely ill patient. Often, the guiding principle is to avoid hypoglycemia. Detailing the specific protocols of one such approach serves as an example for the motivated reader.
Early Switch from IV to Oral Antibiotic in Severe CAP
Oosterheert JJ, Bonten JM, Schneider MME, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia; multicentre randomised trial. BMJ. 2006 Dec 9; 333:1193.
Community acquired pneumonia (CAP) is a common and potentially fatal infection with high healthcare costs. When patients are first admitted to hospitals, antibiotics are usually given intravenously to provide optimal concentrations in the tissues.
The duration of intravenous treatment is an important determinant of length of hospital stay (LOS). The concept of early transition from intravenous to oral antibiotic in the treatment of CAP has been evaluated before, but only in mild to moderately severe disease—and rarely in randomized trials.
This multicenter random controlled trial from five teaching hospitals and two medical centers in the Netherlands enrolled 302 patients in non-intensive care units with severe CAP. The primary outcome was clinical cure and secondary outcome was LOS. The inclusion criteria were adults 18 or older with severe CAP; mean pneumonia severity index of IV-V, new progressive infiltrate on chest X-ray, plus at least two other criteria (cough, sputum production, rectal temperature >38o C or <36.1o C, auscultative findings consistent with pneumonia, leukocytes >109 WBC/L or >15% bands, positive cultures of blob or pleural fluids, CRP three times greater times upper limit of normal).
Exclusion criteria included the need for mechanical ventilation, cystic fibrosis, a history of colonization with gram-negative bacteria due to structural damage to the respiratory tract, malfunction of the digestive tract, life expectancy of less than one month because of underlying disease, infections other than pneumonia that needed antibiotic treatment, and severe immunosuppression (neutropenia [<0.5 109 neutrophils/liter] or a CD4 count< 200/mm3).
Treatment failure was defined as death, still in hospital at day 28 of the study, or clinical deterioration (increase in temperature after initial improvement or the need for mechanical ventilation, switch back to intravenous antibiotics, or readmission for pulmonary reinfection after discharge).
Clinical cure was defined as discharged in good health without signs and symptoms of pneumonia and no treatment failure during follow-up.
The control group comprised 150 subjects who were to receive a standard course of seven days’ intravenous treatment. Meanwhile, 152 subjects were randomized to the early switch group. Baseline characteristics were similar in both groups. More than 80% of patients were in pneumonia severity class IV or V. Most patients received empirical monotherapy with amoxicillin or amoxicillin plus clavulanic acid (n=174; 58%) or a cephalosporin (n=59; 20%), which is in line with Dutch prescribing policies.
The most frequently identified microorganism was S pneumoniae (n=76; 25%). Atypical pathogens were detected in 33 patients (11%). Before day three, 37 patients (12%) were excluded from analysis, leaving 132 patients for analysis in the intervention group and 133 in the control group.
Reasons for exclusion included when the initial diagnosis of CAP was replaced by another diagnosis (n=9), consent was withdrawn (n=11), the protocol was violated (n=4), the patient was admitted to an intensive-care unit for mechanical ventilation (n=6), and the patient died (n=7). After three days of intravenous treatment, 108 of 132 patients (81%) in the intervention group were switched to oral treatment, of whom 102 (94%) received amoxicillin plus clavulanic acid (500+125 mg every eight hours).
In the control group, five patients did not receive intravenous antibiotics for all seven days because of phlebitis associated with intravenous treatment; none of them needed treatment for line-related sepsis. Overall duration of antibiotic treatment was 10.1 days in the intervention group and 9.3 days in the control group (mean difference 0.8 days, 95% confidence interval -0.6 to 2.0).
The duration of intravenous treatment was significantly shorter in the intervention group (mean 3.6 [SD 1.5] versus 7.0 [2.0] days, mean difference 3.4, 2.8 to 3.9). Average time to meet the discharge criteria was 5.2 (2.9) days in the intervention group and 5.7 (3.1) days in the control group (0.5 days -0.3 to 1.2) Total length of hospital stay was 9.6 (5.0) and 11.5 (4.9) days for patients in the intervention group and control group (1.9 days 0.6 to 3.2).
The authors’ findings provide strong evidence that early transition from intravenous to oral antibiotic is also viable in patients with highly graded Pneumonia Severity Index (PSI) CAP, not only in mild to moderately severe disease. This leads to reduced LOS, cost, and possibly reduced risk of line infections and increased patient satisfaction for early discharge.
Note: This study was done with patients suffering straightforward, uncomplicated CAP. The investigators’ findings cannot be applied to patients with other comorbidities like diabetes, COPD, heart failure, or sickle cell, which might require more days on intravenous antibiotic. One might also wonder what impact would have been seen had 37 patients not dropped off, and if another class of oral antibiotic such as quinolones had been used.
Last, the study sample showed S pneumoniae identified in 25% of cases and atypical pathogens to be 11%. What then are the majority of pathogens identified 64% of the time? This would have been another key factor that might have had a great effect on the result.
Although a larger sampling and further risk stratification (to include patients with other comorbidities) are needed, this study makes a valid point for early transition to oral antibiotics in highly graded, uncomplicated CAP. TH