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CHA2DS2-Vasc Score Modestly Predicts Stroke, Thromboembolism, Death
Clinical question: For patients with heart failure (HF), with and without concurrent Afib (AF), does the CHA2DS2-VASc score predict ischemic stroke, thromboembolism, and death?
Background: Factors in the CHA2DS2-VASc score predict increased risk of stroke, thromboembolism, and death, regardless of whether AF is present. It is unknown if this score can identify subgroups of patients with HF, with and without AF, at particularly high or low risk of these events.
Study design: Prospective, cohort study.
Setting: Three Danish registries, 2000-2012.
Synopsis: Among 42,987 patients 50 years and older with incident HF not on anticoagulation, the absolute risk of stroke among patients without AF was 1.5% per year or higher with a CHA2DS2-VASc score of two or higher. The absolute risk of stroke was 4% or higher at five years. Risks were higher in the 21.9% of patients with AF. The CHA2DS2-VASc score modestly predicted endpoints and had an approximately 90% negative predictive value for stroke, thromboembolism, and death at one-year follow-up, regardless of whether or not AF was present.
In this large study, HF patients in a non-diverse population were studied, and some patients may have had undiagnosed AF. Functional status and ejection fraction in patients with HF could not be categorized; however, reported five-year results may be generalizable to patients with chronic HF. Select patients with HF without AF, who have two or more factors of the score besides HF, might benefit from anticoagulation.
Bottom line: The CHA2DS2-VASc score modestly predicts stroke, thromboembolism, and death among patients with HF, but further studies are needed to determine its clinical usefulness.
Citation: Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GY. Assessment of the CHA2DS2-VASc Score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA. 2015;314(10):1030-1038.
Clinical question: For patients with heart failure (HF), with and without concurrent Afib (AF), does the CHA2DS2-VASc score predict ischemic stroke, thromboembolism, and death?
Background: Factors in the CHA2DS2-VASc score predict increased risk of stroke, thromboembolism, and death, regardless of whether AF is present. It is unknown if this score can identify subgroups of patients with HF, with and without AF, at particularly high or low risk of these events.
Study design: Prospective, cohort study.
Setting: Three Danish registries, 2000-2012.
Synopsis: Among 42,987 patients 50 years and older with incident HF not on anticoagulation, the absolute risk of stroke among patients without AF was 1.5% per year or higher with a CHA2DS2-VASc score of two or higher. The absolute risk of stroke was 4% or higher at five years. Risks were higher in the 21.9% of patients with AF. The CHA2DS2-VASc score modestly predicted endpoints and had an approximately 90% negative predictive value for stroke, thromboembolism, and death at one-year follow-up, regardless of whether or not AF was present.
In this large study, HF patients in a non-diverse population were studied, and some patients may have had undiagnosed AF. Functional status and ejection fraction in patients with HF could not be categorized; however, reported five-year results may be generalizable to patients with chronic HF. Select patients with HF without AF, who have two or more factors of the score besides HF, might benefit from anticoagulation.
Bottom line: The CHA2DS2-VASc score modestly predicts stroke, thromboembolism, and death among patients with HF, but further studies are needed to determine its clinical usefulness.
Citation: Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GY. Assessment of the CHA2DS2-VASc Score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA. 2015;314(10):1030-1038.
Clinical question: For patients with heart failure (HF), with and without concurrent Afib (AF), does the CHA2DS2-VASc score predict ischemic stroke, thromboembolism, and death?
Background: Factors in the CHA2DS2-VASc score predict increased risk of stroke, thromboembolism, and death, regardless of whether AF is present. It is unknown if this score can identify subgroups of patients with HF, with and without AF, at particularly high or low risk of these events.
Study design: Prospective, cohort study.
Setting: Three Danish registries, 2000-2012.
Synopsis: Among 42,987 patients 50 years and older with incident HF not on anticoagulation, the absolute risk of stroke among patients without AF was 1.5% per year or higher with a CHA2DS2-VASc score of two or higher. The absolute risk of stroke was 4% or higher at five years. Risks were higher in the 21.9% of patients with AF. The CHA2DS2-VASc score modestly predicted endpoints and had an approximately 90% negative predictive value for stroke, thromboembolism, and death at one-year follow-up, regardless of whether or not AF was present.
In this large study, HF patients in a non-diverse population were studied, and some patients may have had undiagnosed AF. Functional status and ejection fraction in patients with HF could not be categorized; however, reported five-year results may be generalizable to patients with chronic HF. Select patients with HF without AF, who have two or more factors of the score besides HF, might benefit from anticoagulation.
Bottom line: The CHA2DS2-VASc score modestly predicts stroke, thromboembolism, and death among patients with HF, but further studies are needed to determine its clinical usefulness.
Citation: Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GY. Assessment of the CHA2DS2-VASc Score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA. 2015;314(10):1030-1038.
Intraoperative Hypotension Predicts Postoperative Mortality
Clinical question: What blood pressure deviations during surgery are predictive of mortality?
Background: Despite the widely assumed importance of blood pressure (BP) management on postoperative outcomes, there are no accepted thresholds requiring intervention.
Study design: Retrospective cohort.
Setting: Six Veterans’ Affairs hospitals, 2001-2008.
Synopsis: Intraoperative BP data from 18,756 patients undergoing major noncardiac surgery were linked with procedure, patient-related risk factors, and 30-day mortality data from the VA Surgical Quality Improvement Program database. Overall 30-day mortality was 1.8%. Using three different methods for defining hyper- or hypotension (based on standard deviations from the mean in this population, absolute thresholds suggested by medical literature, or by changes from baseline BP), no measure of hypertension predicted mortality; however, after adjusting for 10 preoperative patient-related risk factors, extremely low BP for five minutes or more (whether defined as systolic BP <70 mmHg, mean arterial pressure <49 mmHg, or diastolic BP <30 mmHg) was associated with 30-day mortality, with statistically significant odds ratios in the 2.4-3.2 range.
Because this is an observational study, no causal relationship can be established from these data. Low BPs could be markers for sicker patients with increased mortality, despite researchers’ efforts to adjust for known preoperative risks.
Bottom line: Intraoperative hypotension lasting five minutes or more, but not intraoperative hypertension, predicts 30-day mortality.
Citation: Monk TG, Bronsert MR, Henderson WG, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology. 2015;123(2):307-319.
Clinical question: What blood pressure deviations during surgery are predictive of mortality?
Background: Despite the widely assumed importance of blood pressure (BP) management on postoperative outcomes, there are no accepted thresholds requiring intervention.
Study design: Retrospective cohort.
Setting: Six Veterans’ Affairs hospitals, 2001-2008.
Synopsis: Intraoperative BP data from 18,756 patients undergoing major noncardiac surgery were linked with procedure, patient-related risk factors, and 30-day mortality data from the VA Surgical Quality Improvement Program database. Overall 30-day mortality was 1.8%. Using three different methods for defining hyper- or hypotension (based on standard deviations from the mean in this population, absolute thresholds suggested by medical literature, or by changes from baseline BP), no measure of hypertension predicted mortality; however, after adjusting for 10 preoperative patient-related risk factors, extremely low BP for five minutes or more (whether defined as systolic BP <70 mmHg, mean arterial pressure <49 mmHg, or diastolic BP <30 mmHg) was associated with 30-day mortality, with statistically significant odds ratios in the 2.4-3.2 range.
Because this is an observational study, no causal relationship can be established from these data. Low BPs could be markers for sicker patients with increased mortality, despite researchers’ efforts to adjust for known preoperative risks.
Bottom line: Intraoperative hypotension lasting five minutes or more, but not intraoperative hypertension, predicts 30-day mortality.
Citation: Monk TG, Bronsert MR, Henderson WG, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology. 2015;123(2):307-319.
Clinical question: What blood pressure deviations during surgery are predictive of mortality?
Background: Despite the widely assumed importance of blood pressure (BP) management on postoperative outcomes, there are no accepted thresholds requiring intervention.
Study design: Retrospective cohort.
Setting: Six Veterans’ Affairs hospitals, 2001-2008.
Synopsis: Intraoperative BP data from 18,756 patients undergoing major noncardiac surgery were linked with procedure, patient-related risk factors, and 30-day mortality data from the VA Surgical Quality Improvement Program database. Overall 30-day mortality was 1.8%. Using three different methods for defining hyper- or hypotension (based on standard deviations from the mean in this population, absolute thresholds suggested by medical literature, or by changes from baseline BP), no measure of hypertension predicted mortality; however, after adjusting for 10 preoperative patient-related risk factors, extremely low BP for five minutes or more (whether defined as systolic BP <70 mmHg, mean arterial pressure <49 mmHg, or diastolic BP <30 mmHg) was associated with 30-day mortality, with statistically significant odds ratios in the 2.4-3.2 range.
Because this is an observational study, no causal relationship can be established from these data. Low BPs could be markers for sicker patients with increased mortality, despite researchers’ efforts to adjust for known preoperative risks.
Bottom line: Intraoperative hypotension lasting five minutes or more, but not intraoperative hypertension, predicts 30-day mortality.
Citation: Monk TG, Bronsert MR, Henderson WG, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology. 2015;123(2):307-319.
Caprini Risk Assessment Tool Can Distinguish High Risk of VTE in Critically Ill Surgical Patients
Clinical question: Is the Caprini Risk Assessment Model for VTE risk valid in critically ill surgical patients?
Background: Critically ill surgical patients are at increased risk of developing VTE. Chemoprophylaxis decreases VTE risk, but benefits must be balanced against bleeding risk. Rapid and accurate risk stratification supports decisions about prophylaxis; however, data regarding appropriate risk stratification are limited.
Study design: Retrospective, cohort study.
Setting: Surgical ICU (SICU) at a single, U.S. academic medical center, 2007-2013.
Synopsis: Among 4,844 consecutive admissions, the in-hospital VTE rate was 7.5% (364). Using a previously validated, computer-generated, retrospective risk score based on the 2005 Caprini model, patients were most commonly at moderate risk for VTE upon ICU admission (32%). Fifteen percent (723) were extremely high risk. VTE incidence increased linearly with increasing Caprini scores. Data were abstracted from multiple electronic sources.
Younger age, recent sepsis or pneumonia, central venous access on ICU admission, personal VTE history, and operative procedure were significantly associated with inpatient VTE events. The proportion of patients who received chemoprophylaxis postoperatively was similar regardless of VTE risk. Patients at higher risk were more likely to receive chemoprophylaxis preoperatively.
Results from this retrospective, single-center study suggest that Caprini is a valid tool to predict inpatient VTE risk in this population. Inclusion of multiple risk factors may make calculation of this score prohibitive in other settings unless it can be computer generated.
Bottom line: Caprini risk scores accurately distinguish critically ill surgical patients at high risk of VTE from those at lower risk.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948. doi:10.1001/jamasurg.2015.1841.
Clinical question: Is the Caprini Risk Assessment Model for VTE risk valid in critically ill surgical patients?
Background: Critically ill surgical patients are at increased risk of developing VTE. Chemoprophylaxis decreases VTE risk, but benefits must be balanced against bleeding risk. Rapid and accurate risk stratification supports decisions about prophylaxis; however, data regarding appropriate risk stratification are limited.
Study design: Retrospective, cohort study.
Setting: Surgical ICU (SICU) at a single, U.S. academic medical center, 2007-2013.
Synopsis: Among 4,844 consecutive admissions, the in-hospital VTE rate was 7.5% (364). Using a previously validated, computer-generated, retrospective risk score based on the 2005 Caprini model, patients were most commonly at moderate risk for VTE upon ICU admission (32%). Fifteen percent (723) were extremely high risk. VTE incidence increased linearly with increasing Caprini scores. Data were abstracted from multiple electronic sources.
Younger age, recent sepsis or pneumonia, central venous access on ICU admission, personal VTE history, and operative procedure were significantly associated with inpatient VTE events. The proportion of patients who received chemoprophylaxis postoperatively was similar regardless of VTE risk. Patients at higher risk were more likely to receive chemoprophylaxis preoperatively.
Results from this retrospective, single-center study suggest that Caprini is a valid tool to predict inpatient VTE risk in this population. Inclusion of multiple risk factors may make calculation of this score prohibitive in other settings unless it can be computer generated.
Bottom line: Caprini risk scores accurately distinguish critically ill surgical patients at high risk of VTE from those at lower risk.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948. doi:10.1001/jamasurg.2015.1841.
Clinical question: Is the Caprini Risk Assessment Model for VTE risk valid in critically ill surgical patients?
Background: Critically ill surgical patients are at increased risk of developing VTE. Chemoprophylaxis decreases VTE risk, but benefits must be balanced against bleeding risk. Rapid and accurate risk stratification supports decisions about prophylaxis; however, data regarding appropriate risk stratification are limited.
Study design: Retrospective, cohort study.
Setting: Surgical ICU (SICU) at a single, U.S. academic medical center, 2007-2013.
Synopsis: Among 4,844 consecutive admissions, the in-hospital VTE rate was 7.5% (364). Using a previously validated, computer-generated, retrospective risk score based on the 2005 Caprini model, patients were most commonly at moderate risk for VTE upon ICU admission (32%). Fifteen percent (723) were extremely high risk. VTE incidence increased linearly with increasing Caprini scores. Data were abstracted from multiple electronic sources.
Younger age, recent sepsis or pneumonia, central venous access on ICU admission, personal VTE history, and operative procedure were significantly associated with inpatient VTE events. The proportion of patients who received chemoprophylaxis postoperatively was similar regardless of VTE risk. Patients at higher risk were more likely to receive chemoprophylaxis preoperatively.
Results from this retrospective, single-center study suggest that Caprini is a valid tool to predict inpatient VTE risk in this population. Inclusion of multiple risk factors may make calculation of this score prohibitive in other settings unless it can be computer generated.
Bottom line: Caprini risk scores accurately distinguish critically ill surgical patients at high risk of VTE from those at lower risk.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948. doi:10.1001/jamasurg.2015.1841.
Adherence to Restrictive Red Blood Cell Transfusion Guidelines Improved with Peer Feedback
Clinical question: Can a multifaceted approach involving clinician education, peer email feedback, and monthly audit data improve adherence to restrictive red blood cell (RBC) transfusion guidelines?
Background: Randomized controlled trials and professional society guidelines support adoption of RBC transfusion strategies in stable, low-risk patients. Studies suggest that education and feedback from specialists may decrease inappropriate transfusion practices, but peer-to-peer feedback has not yet been explored.
Study design: Prospective, interventional study.
Setting: Tertiary care center SICU, single U.S. academic center.
Synopsis: All stable, low-risk SICU patients receiving RBC transfusions were included in this study. Intervention consisted of educational lectures to clinicians, dissemination of monthly aggregate audit transfusion data, and direct email feedback from a colleague to clinicians ordering transfusions outside of guidelines. Six-month intervention data were compared with six months of pre-intervention data.
During the intervention, total transfusions decreased by 36%, from 284 units to 181 units, and percentage of transfusions outside restrictive guidelines decreased to 2% from 25% (P<0.001). Six months after the end of the intervention period, transfusions outside restrictive guidelines increased back to 17%, suggesting a lack of permanent change in transfusion practices.
Bottom line: A multifaceted approach involving education, peer-to-peer feedback, and monthly audits improved adherence to restrictive RBC transfusion guidelines; however, changes were not sustained.
Citation: Yeh DD, Naraghi L, Larentzakis A, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79(1):65-70.
Clinical question: Can a multifaceted approach involving clinician education, peer email feedback, and monthly audit data improve adherence to restrictive red blood cell (RBC) transfusion guidelines?
Background: Randomized controlled trials and professional society guidelines support adoption of RBC transfusion strategies in stable, low-risk patients. Studies suggest that education and feedback from specialists may decrease inappropriate transfusion practices, but peer-to-peer feedback has not yet been explored.
Study design: Prospective, interventional study.
Setting: Tertiary care center SICU, single U.S. academic center.
Synopsis: All stable, low-risk SICU patients receiving RBC transfusions were included in this study. Intervention consisted of educational lectures to clinicians, dissemination of monthly aggregate audit transfusion data, and direct email feedback from a colleague to clinicians ordering transfusions outside of guidelines. Six-month intervention data were compared with six months of pre-intervention data.
During the intervention, total transfusions decreased by 36%, from 284 units to 181 units, and percentage of transfusions outside restrictive guidelines decreased to 2% from 25% (P<0.001). Six months after the end of the intervention period, transfusions outside restrictive guidelines increased back to 17%, suggesting a lack of permanent change in transfusion practices.
Bottom line: A multifaceted approach involving education, peer-to-peer feedback, and monthly audits improved adherence to restrictive RBC transfusion guidelines; however, changes were not sustained.
Citation: Yeh DD, Naraghi L, Larentzakis A, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79(1):65-70.
Clinical question: Can a multifaceted approach involving clinician education, peer email feedback, and monthly audit data improve adherence to restrictive red blood cell (RBC) transfusion guidelines?
Background: Randomized controlled trials and professional society guidelines support adoption of RBC transfusion strategies in stable, low-risk patients. Studies suggest that education and feedback from specialists may decrease inappropriate transfusion practices, but peer-to-peer feedback has not yet been explored.
Study design: Prospective, interventional study.
Setting: Tertiary care center SICU, single U.S. academic center.
Synopsis: All stable, low-risk SICU patients receiving RBC transfusions were included in this study. Intervention consisted of educational lectures to clinicians, dissemination of monthly aggregate audit transfusion data, and direct email feedback from a colleague to clinicians ordering transfusions outside of guidelines. Six-month intervention data were compared with six months of pre-intervention data.
During the intervention, total transfusions decreased by 36%, from 284 units to 181 units, and percentage of transfusions outside restrictive guidelines decreased to 2% from 25% (P<0.001). Six months after the end of the intervention period, transfusions outside restrictive guidelines increased back to 17%, suggesting a lack of permanent change in transfusion practices.
Bottom line: A multifaceted approach involving education, peer-to-peer feedback, and monthly audits improved adherence to restrictive RBC transfusion guidelines; however, changes were not sustained.
Citation: Yeh DD, Naraghi L, Larentzakis A, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79(1):65-70.
Corticosteroids Improve Outcomes in Community- Acquired Pneumonia
Clinical question: Are adjunctive corticosteroids beneficial for patients hospitalized with community-acquired pneumonia (CAP)?
Background: Numerous studies have tried to determine whether or not adjunctive corticosteroids for CAP treatment in hospitalized patients improve outcomes. Although recent trials have suggested that corticosteroids may improve morbidity and mortality, prior meta-analyses have failed to show a benefit, and steroids are not currently routinely recommended for this population.
Study design: Systematic review and meta-analysis of 13 RCTs, predominantly from Europe.
Synopsis: Analysis of 1,974 patients suggested a decrease in all-cause mortality (relative risk (RR) 0.67, 95% CI 0.45-1.01) with adjunctive corticosteroids. Subgroup analysis for severe CAP (six studies, n=388) suggested a greater mortality benefit (RR 0.39, 95% CI 0.2-0.77). There was a decrease in the risk of mechanical ventilation (five studies, n=1060, RR 0.45, CI, 0.26-0.79), ICU admission (three studies, n=950, RR 0.69, 95% CI, 0.46-1.03), and development of acute respiratory distress syndrome (four studies, n=945, RR 0.24, 95% CI 0.10-0.56).
Both hospital length of stay (LOS) and time to clinical stability (hemodynamically stable with no hypoxia) were significantly decreased (mean decrease LOS one day; time to clinical stability 1.22 days). Adverse effects were rare but included increased rates of hyperglycemia requiring treatment (RR 1.49, 95% CI 1.01-2.19). There was no increased frequency of gastrointestinal hemorrhage, neuropsychiatric complications, or rehospitalization.
Bottom line: Adjunctive corticosteroids for inpatient CAP treatment decrease morbidity and mortality, particularly in severe disease, and decrease LOS and time to clinical stability with few adverse reactions.
Citation: Siemieniuk RA, Meade MO, Alonso-Coello P, et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(7):519-528.
Clinical question: Are adjunctive corticosteroids beneficial for patients hospitalized with community-acquired pneumonia (CAP)?
Background: Numerous studies have tried to determine whether or not adjunctive corticosteroids for CAP treatment in hospitalized patients improve outcomes. Although recent trials have suggested that corticosteroids may improve morbidity and mortality, prior meta-analyses have failed to show a benefit, and steroids are not currently routinely recommended for this population.
Study design: Systematic review and meta-analysis of 13 RCTs, predominantly from Europe.
Synopsis: Analysis of 1,974 patients suggested a decrease in all-cause mortality (relative risk (RR) 0.67, 95% CI 0.45-1.01) with adjunctive corticosteroids. Subgroup analysis for severe CAP (six studies, n=388) suggested a greater mortality benefit (RR 0.39, 95% CI 0.2-0.77). There was a decrease in the risk of mechanical ventilation (five studies, n=1060, RR 0.45, CI, 0.26-0.79), ICU admission (three studies, n=950, RR 0.69, 95% CI, 0.46-1.03), and development of acute respiratory distress syndrome (four studies, n=945, RR 0.24, 95% CI 0.10-0.56).
Both hospital length of stay (LOS) and time to clinical stability (hemodynamically stable with no hypoxia) were significantly decreased (mean decrease LOS one day; time to clinical stability 1.22 days). Adverse effects were rare but included increased rates of hyperglycemia requiring treatment (RR 1.49, 95% CI 1.01-2.19). There was no increased frequency of gastrointestinal hemorrhage, neuropsychiatric complications, or rehospitalization.
Bottom line: Adjunctive corticosteroids for inpatient CAP treatment decrease morbidity and mortality, particularly in severe disease, and decrease LOS and time to clinical stability with few adverse reactions.
Citation: Siemieniuk RA, Meade MO, Alonso-Coello P, et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(7):519-528.
Clinical question: Are adjunctive corticosteroids beneficial for patients hospitalized with community-acquired pneumonia (CAP)?
Background: Numerous studies have tried to determine whether or not adjunctive corticosteroids for CAP treatment in hospitalized patients improve outcomes. Although recent trials have suggested that corticosteroids may improve morbidity and mortality, prior meta-analyses have failed to show a benefit, and steroids are not currently routinely recommended for this population.
Study design: Systematic review and meta-analysis of 13 RCTs, predominantly from Europe.
Synopsis: Analysis of 1,974 patients suggested a decrease in all-cause mortality (relative risk (RR) 0.67, 95% CI 0.45-1.01) with adjunctive corticosteroids. Subgroup analysis for severe CAP (six studies, n=388) suggested a greater mortality benefit (RR 0.39, 95% CI 0.2-0.77). There was a decrease in the risk of mechanical ventilation (five studies, n=1060, RR 0.45, CI, 0.26-0.79), ICU admission (three studies, n=950, RR 0.69, 95% CI, 0.46-1.03), and development of acute respiratory distress syndrome (four studies, n=945, RR 0.24, 95% CI 0.10-0.56).
Both hospital length of stay (LOS) and time to clinical stability (hemodynamically stable with no hypoxia) were significantly decreased (mean decrease LOS one day; time to clinical stability 1.22 days). Adverse effects were rare but included increased rates of hyperglycemia requiring treatment (RR 1.49, 95% CI 1.01-2.19). There was no increased frequency of gastrointestinal hemorrhage, neuropsychiatric complications, or rehospitalization.
Bottom line: Adjunctive corticosteroids for inpatient CAP treatment decrease morbidity and mortality, particularly in severe disease, and decrease LOS and time to clinical stability with few adverse reactions.
Citation: Siemieniuk RA, Meade MO, Alonso-Coello P, et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(7):519-528.
Standard Triple Therapy for H. Pylori Lowest Ranked among 14 Treatment Regimens
Clinical question: How do current Helicobacter pylori treatments compare in efficacy and tolerance?
Background: Efficacy of standard “triple therapy” for H. pylori (proton pump inhibitor plus clarithromycin and amoxicillin or metronidazole) is declining due to the development of antibiotic resistance. Different medication combinations and/or time courses are currently used, but comparative effectiveness of these treatments has not been evaluated comprehensively.
Study design: Systematic review and network meta-analysis.
Setting: Cochrane Library, PubMed, and Embase databases.
Synopsis: One hundred forty-three RCTs evaluating a total of 14 treatments for H. pylori were identified. Network meta-analysis was performed to rank order treatments for efficacy (eradication rate of H. pylori) and tolerance (adverse event occurrence rate). Seven days of “concomitant treatment” (proton pump inhibitor plus three antibiotics) ranked the highest in efficacy (eradication rate 0.94; 95% confidence interval [CI] 0.89-0.98), though this treatment group comprised a very small proportion of overall participants and studies and may be subject to bias. Seven days of standard “triple therapy” ranked the lowest in efficacy (eradication rate 0.73; 95% CI 0.71-0.75).
Of note, subgroup analysis showed variation in efficacy rankings by geographic location, suggesting that findings may not be universally applicable. Only two treatments showed significantly different adverse event occurrence rates compared to standard “triple therapy,” indicating overall similar tolerance for most treatments.
Bottom line: Several treatment regimens may be more effective than standard H. pylori “triple therapy” and equally well tolerated.
Citation: Li BZ, Threapleton DE, Wang JY, et al. Comparative effectiveness and tolerance of treatments for Helicobacter pylori: systematic review and network meta-analysis. BMJ. 2015;351:h4052.
Clinical question: How do current Helicobacter pylori treatments compare in efficacy and tolerance?
Background: Efficacy of standard “triple therapy” for H. pylori (proton pump inhibitor plus clarithromycin and amoxicillin or metronidazole) is declining due to the development of antibiotic resistance. Different medication combinations and/or time courses are currently used, but comparative effectiveness of these treatments has not been evaluated comprehensively.
Study design: Systematic review and network meta-analysis.
Setting: Cochrane Library, PubMed, and Embase databases.
Synopsis: One hundred forty-three RCTs evaluating a total of 14 treatments for H. pylori were identified. Network meta-analysis was performed to rank order treatments for efficacy (eradication rate of H. pylori) and tolerance (adverse event occurrence rate). Seven days of “concomitant treatment” (proton pump inhibitor plus three antibiotics) ranked the highest in efficacy (eradication rate 0.94; 95% confidence interval [CI] 0.89-0.98), though this treatment group comprised a very small proportion of overall participants and studies and may be subject to bias. Seven days of standard “triple therapy” ranked the lowest in efficacy (eradication rate 0.73; 95% CI 0.71-0.75).
Of note, subgroup analysis showed variation in efficacy rankings by geographic location, suggesting that findings may not be universally applicable. Only two treatments showed significantly different adverse event occurrence rates compared to standard “triple therapy,” indicating overall similar tolerance for most treatments.
Bottom line: Several treatment regimens may be more effective than standard H. pylori “triple therapy” and equally well tolerated.
Citation: Li BZ, Threapleton DE, Wang JY, et al. Comparative effectiveness and tolerance of treatments for Helicobacter pylori: systematic review and network meta-analysis. BMJ. 2015;351:h4052.
Clinical question: How do current Helicobacter pylori treatments compare in efficacy and tolerance?
Background: Efficacy of standard “triple therapy” for H. pylori (proton pump inhibitor plus clarithromycin and amoxicillin or metronidazole) is declining due to the development of antibiotic resistance. Different medication combinations and/or time courses are currently used, but comparative effectiveness of these treatments has not been evaluated comprehensively.
Study design: Systematic review and network meta-analysis.
Setting: Cochrane Library, PubMed, and Embase databases.
Synopsis: One hundred forty-three RCTs evaluating a total of 14 treatments for H. pylori were identified. Network meta-analysis was performed to rank order treatments for efficacy (eradication rate of H. pylori) and tolerance (adverse event occurrence rate). Seven days of “concomitant treatment” (proton pump inhibitor plus three antibiotics) ranked the highest in efficacy (eradication rate 0.94; 95% confidence interval [CI] 0.89-0.98), though this treatment group comprised a very small proportion of overall participants and studies and may be subject to bias. Seven days of standard “triple therapy” ranked the lowest in efficacy (eradication rate 0.73; 95% CI 0.71-0.75).
Of note, subgroup analysis showed variation in efficacy rankings by geographic location, suggesting that findings may not be universally applicable. Only two treatments showed significantly different adverse event occurrence rates compared to standard “triple therapy,” indicating overall similar tolerance for most treatments.
Bottom line: Several treatment regimens may be more effective than standard H. pylori “triple therapy” and equally well tolerated.
Citation: Li BZ, Threapleton DE, Wang JY, et al. Comparative effectiveness and tolerance of treatments for Helicobacter pylori: systematic review and network meta-analysis. BMJ. 2015;351:h4052.
Social Isolation, Polypharmacy Predict Medication Noncompliance Post-Discharge in Cardiac Patients
Clinical question: What are predictors of primary medication nonadherence after discharge?
Background: Primary nonadherence occurs when a patient receives a prescription at hospital discharge but does not fill it. Predictors of post-discharge primary nonadherence could serve as useful targets to guide adherence interventions.
Study design: RCT, secondary analysis.
Setting: Two tertiary care, U.S. academic hospitals.
Synopsis: Using the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study database, investigators conducted a secondary analysis of adults hospitalized for acute coronary syndrome or acute decompensated heart failure who received pharmacist-assisted medication reconciliation, discharge counseling, low-literacy adherence aids, and a follow-up phone call. The prevalence of primary nonadherence one to four days post-discharge was 9.4% among 341 patients. In subsequent multivariate analysis, significant factors for noncompliance were living alone (odds ratio 2.2, 95% CI 1.01-4.8, P=0.047) and more than 10 total discharge medications (odds ratio 2.3, 95% CI 1.05-4.98, P=0.036).
Limitations to this study include biases from patient-reported outcomes, lack of patient copayment data, and limited characterization of discharge medication type.
Bottom line: Among patients hospitalized for cardiac events, social isolation and polypharmacy predict primary medication nonadherence to discharge medications despite intensive pharmacist counseling.
Citation: Wooldridge K, Schnipper JL, Goggins K, Dittus RS, Kripalani S. Refractory primary medication nonadherence: prevalence and predictors after pharmacist counseling at hospital discharge [published online ahead of print August 21, 2015]. J Hosp Med. doi: 10.1002/jhm.2446.
Clinical question: What are predictors of primary medication nonadherence after discharge?
Background: Primary nonadherence occurs when a patient receives a prescription at hospital discharge but does not fill it. Predictors of post-discharge primary nonadherence could serve as useful targets to guide adherence interventions.
Study design: RCT, secondary analysis.
Setting: Two tertiary care, U.S. academic hospitals.
Synopsis: Using the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study database, investigators conducted a secondary analysis of adults hospitalized for acute coronary syndrome or acute decompensated heart failure who received pharmacist-assisted medication reconciliation, discharge counseling, low-literacy adherence aids, and a follow-up phone call. The prevalence of primary nonadherence one to four days post-discharge was 9.4% among 341 patients. In subsequent multivariate analysis, significant factors for noncompliance were living alone (odds ratio 2.2, 95% CI 1.01-4.8, P=0.047) and more than 10 total discharge medications (odds ratio 2.3, 95% CI 1.05-4.98, P=0.036).
Limitations to this study include biases from patient-reported outcomes, lack of patient copayment data, and limited characterization of discharge medication type.
Bottom line: Among patients hospitalized for cardiac events, social isolation and polypharmacy predict primary medication nonadherence to discharge medications despite intensive pharmacist counseling.
Citation: Wooldridge K, Schnipper JL, Goggins K, Dittus RS, Kripalani S. Refractory primary medication nonadherence: prevalence and predictors after pharmacist counseling at hospital discharge [published online ahead of print August 21, 2015]. J Hosp Med. doi: 10.1002/jhm.2446.
Clinical question: What are predictors of primary medication nonadherence after discharge?
Background: Primary nonadherence occurs when a patient receives a prescription at hospital discharge but does not fill it. Predictors of post-discharge primary nonadherence could serve as useful targets to guide adherence interventions.
Study design: RCT, secondary analysis.
Setting: Two tertiary care, U.S. academic hospitals.
Synopsis: Using the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study database, investigators conducted a secondary analysis of adults hospitalized for acute coronary syndrome or acute decompensated heart failure who received pharmacist-assisted medication reconciliation, discharge counseling, low-literacy adherence aids, and a follow-up phone call. The prevalence of primary nonadherence one to four days post-discharge was 9.4% among 341 patients. In subsequent multivariate analysis, significant factors for noncompliance were living alone (odds ratio 2.2, 95% CI 1.01-4.8, P=0.047) and more than 10 total discharge medications (odds ratio 2.3, 95% CI 1.05-4.98, P=0.036).
Limitations to this study include biases from patient-reported outcomes, lack of patient copayment data, and limited characterization of discharge medication type.
Bottom line: Among patients hospitalized for cardiac events, social isolation and polypharmacy predict primary medication nonadherence to discharge medications despite intensive pharmacist counseling.
Citation: Wooldridge K, Schnipper JL, Goggins K, Dittus RS, Kripalani S. Refractory primary medication nonadherence: prevalence and predictors after pharmacist counseling at hospital discharge [published online ahead of print August 21, 2015]. J Hosp Med. doi: 10.1002/jhm.2446.
Inpatient Navigators Reduce Length of Stay without Increasing Readmissions
Clinical question: Does a patient navigator (PN) who facilitates communication between patients and providers impact hospital length of stay (LOS) and readmissions?
Background: Increasing complexity of hospitalization challenges the safety of care transitions. There are few studies about the effectiveness of innovations targeting both communication and transitional care planning.
Study design: Retrospective, cohort study.
Setting: Single academic health center in Canada, 2010-2014.
Synopsis: PNs, dedicated team-based facilitators not responsible for clinical care, served as liaisons between patients and providers on general medicine teams. They rounded with medical teams, tracked action items, expedited tests and consults, and proactively served as direct primary contacts for patients/families during and after hospitalization. PNs had no specified prior training; they underwent on-the-job training with regular feedback.
Researchers matched 7,841 hospitalizations (5,628 with PN; 2,213 without) by case mix, age, and resource intensity. LOS and 30-day readmissions were primary outcomes. Hospitalizations with PNs were 21% shorter (1.3 days; 6.2 v 7.5 days, P<0.001) than those without PNs.
There were no differences in 30-day readmission rates (13.1 v 13.8%, P=0.48). In this single center study in Canada, the impact of PN salaries (the only program cost) relative to savings is unknown.
Bottom line: Inpatient navigators streamline communication and decrease LOS without increasing readmissions. Additional cost-benefit analyses are needed.
Citation: Kwan JL, Morgan MW, Stewart TE, Bell CM. Impact of an innovative patient navigator program on length of stay and 30-day readmission [published online ahead of print August 10, 2015]. J Hosp Med. doi: 10.1002/jhm.2442.
Clinical question: Does a patient navigator (PN) who facilitates communication between patients and providers impact hospital length of stay (LOS) and readmissions?
Background: Increasing complexity of hospitalization challenges the safety of care transitions. There are few studies about the effectiveness of innovations targeting both communication and transitional care planning.
Study design: Retrospective, cohort study.
Setting: Single academic health center in Canada, 2010-2014.
Synopsis: PNs, dedicated team-based facilitators not responsible for clinical care, served as liaisons between patients and providers on general medicine teams. They rounded with medical teams, tracked action items, expedited tests and consults, and proactively served as direct primary contacts for patients/families during and after hospitalization. PNs had no specified prior training; they underwent on-the-job training with regular feedback.
Researchers matched 7,841 hospitalizations (5,628 with PN; 2,213 without) by case mix, age, and resource intensity. LOS and 30-day readmissions were primary outcomes. Hospitalizations with PNs were 21% shorter (1.3 days; 6.2 v 7.5 days, P<0.001) than those without PNs.
There were no differences in 30-day readmission rates (13.1 v 13.8%, P=0.48). In this single center study in Canada, the impact of PN salaries (the only program cost) relative to savings is unknown.
Bottom line: Inpatient navigators streamline communication and decrease LOS without increasing readmissions. Additional cost-benefit analyses are needed.
Citation: Kwan JL, Morgan MW, Stewart TE, Bell CM. Impact of an innovative patient navigator program on length of stay and 30-day readmission [published online ahead of print August 10, 2015]. J Hosp Med. doi: 10.1002/jhm.2442.
Clinical question: Does a patient navigator (PN) who facilitates communication between patients and providers impact hospital length of stay (LOS) and readmissions?
Background: Increasing complexity of hospitalization challenges the safety of care transitions. There are few studies about the effectiveness of innovations targeting both communication and transitional care planning.
Study design: Retrospective, cohort study.
Setting: Single academic health center in Canada, 2010-2014.
Synopsis: PNs, dedicated team-based facilitators not responsible for clinical care, served as liaisons between patients and providers on general medicine teams. They rounded with medical teams, tracked action items, expedited tests and consults, and proactively served as direct primary contacts for patients/families during and after hospitalization. PNs had no specified prior training; they underwent on-the-job training with regular feedback.
Researchers matched 7,841 hospitalizations (5,628 with PN; 2,213 without) by case mix, age, and resource intensity. LOS and 30-day readmissions were primary outcomes. Hospitalizations with PNs were 21% shorter (1.3 days; 6.2 v 7.5 days, P<0.001) than those without PNs.
There were no differences in 30-day readmission rates (13.1 v 13.8%, P=0.48). In this single center study in Canada, the impact of PN salaries (the only program cost) relative to savings is unknown.
Bottom line: Inpatient navigators streamline communication and decrease LOS without increasing readmissions. Additional cost-benefit analyses are needed.
Citation: Kwan JL, Morgan MW, Stewart TE, Bell CM. Impact of an innovative patient navigator program on length of stay and 30-day readmission [published online ahead of print August 10, 2015]. J Hosp Med. doi: 10.1002/jhm.2442.
Dexamethasone Potential Therapy for Asthma Exacerbations in Pediatric Inpatients
Clinical question: In children hospitalized in a non-ICU setting with asthma exacerbation, how effective is dexamethasone compared to prednisone/prednisolone?
Background: Asthma is the second most common reason for hospital admission in childhood.1 National guidelines recommend treatment with systemic corticosteroids in addition to beta-agonists.2 Traditionally, prednisone/prednisolone has been used for asthma exacerbations, but multiple recent studies in ED settings have shown equal efficacy with dexamethasone for mild to moderate exacerbations. Benefits of dexamethasone use include a longer half-life (so single dose or two-day courses can be used), good enteral absorption, general palatability, less emesis, and better adherence. To this point, no studies have compared dexamethasone with prednisone/prednisolone therapy in hospitalized children.
Study design: Multicenter, retrospective cohort study.
Setting: Freestanding, tertiary care children’s hospitals.
Synopsis: The authors used the PHIS (Pediatric Health Information System) database, which includes clinical and billing data from 42 children’s hospitals, to compare children who received dexamethasone to those who were treated with prednisone/prednisolone therapy for asthma exacerbations in the inpatient setting. Patients were included if they were aged four to 17 years, were hospitalized between January 2007 and December 2012 with ICD-9 code for a principal diagnosis of asthma, and received either dexamethasone or prednisone/prednisolone.
Exclusion criteria included:
- Management in the ICU at the time of admission;
- All patient refined diagnosis related groups (APR-DRG) severity level moderate or extreme;
- Complex chronic conditions;
- Secondary diagnosis other than asthma requiring steroids, or treatment with racemic epinephrine;
- Only the first admission was included out of multiple hospitalizations within a 30-day period; and/or
- Patient was treated with both dexamethasone and prednisone/prednisolone.
The primary outcome evaluated was length of stay (LOS); secondary outcomes included readmissions, cost, and transfer to ICU during hospitalization. The authors compared the overall groups, then performed 1:1 propensity score matching to address residual confounding; this statistical technique closely matches patient characteristics between cohorts.
Overall, there were 40,257 hospitalizations, with 1,166 children (2.9%) receiving dexamethasone and 39,091 (97.1%) receiving prednisone/prednisolone. The use of dexamethasone varied greatly between hospitals (35/42 hospitals used dexamethasone, with rates ranging from 0.047% to 77.4%).
In the post-match cohort, 1,284 patients were evaluated, 642 in each group. In this cohort, patients with dexamethasone had significantly shorter LOS (67.4% had LOS less than one day vs. 59.5% in the prednisone/prednisolone group; 6.7% of dexamethasone patients had LOS of more than three days vs. 12% of prednisone/prednisolone patients). Costs were lower for the dexamethasone group, both for the index admission and for episode admission (defined as index admission plus seven-day readmissions). There was no difference in readmissions between the groups, and no patients in this cohort were transferred to the ICU.
There are several limitations to this study. Dexamethasone use varied widely among participating hospitals. The data source did not permit access to dosing, duration, or compliance with therapy and could not compare albuterol use between groups. The findings may not be generalizable to all populations, because it excluded patients with high severity and medical complexity and only evaluated tertiary care children’s hospitals.
Bottom line: Dexamethasone is a potential alternative therapy for asthma exacerbations in the inpatient setting. Further studies are needed to evaluate effectiveness, including dosing, frequency, and duration.
Citation: Parikh K, Hall M, Mittal V, et al. Comparative effectiveness of dexamethasone versus prednisone in children hospitalized with asthma. J Pediatr. 2015;167(3):639-644.
References
- Yu H, Wier LM, Elixhauser A. Hospital stays for children, 2009. HCUP statistical brief #118. Agency for Healthcare Research and Quality. August 2011. Accessed November 1, 2015.
- National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma–Summary Report 2007. Accessed November 1, 2015.
Clinical question: In children hospitalized in a non-ICU setting with asthma exacerbation, how effective is dexamethasone compared to prednisone/prednisolone?
Background: Asthma is the second most common reason for hospital admission in childhood.1 National guidelines recommend treatment with systemic corticosteroids in addition to beta-agonists.2 Traditionally, prednisone/prednisolone has been used for asthma exacerbations, but multiple recent studies in ED settings have shown equal efficacy with dexamethasone for mild to moderate exacerbations. Benefits of dexamethasone use include a longer half-life (so single dose or two-day courses can be used), good enteral absorption, general palatability, less emesis, and better adherence. To this point, no studies have compared dexamethasone with prednisone/prednisolone therapy in hospitalized children.
Study design: Multicenter, retrospective cohort study.
Setting: Freestanding, tertiary care children’s hospitals.
Synopsis: The authors used the PHIS (Pediatric Health Information System) database, which includes clinical and billing data from 42 children’s hospitals, to compare children who received dexamethasone to those who were treated with prednisone/prednisolone therapy for asthma exacerbations in the inpatient setting. Patients were included if they were aged four to 17 years, were hospitalized between January 2007 and December 2012 with ICD-9 code for a principal diagnosis of asthma, and received either dexamethasone or prednisone/prednisolone.
Exclusion criteria included:
- Management in the ICU at the time of admission;
- All patient refined diagnosis related groups (APR-DRG) severity level moderate or extreme;
- Complex chronic conditions;
- Secondary diagnosis other than asthma requiring steroids, or treatment with racemic epinephrine;
- Only the first admission was included out of multiple hospitalizations within a 30-day period; and/or
- Patient was treated with both dexamethasone and prednisone/prednisolone.
The primary outcome evaluated was length of stay (LOS); secondary outcomes included readmissions, cost, and transfer to ICU during hospitalization. The authors compared the overall groups, then performed 1:1 propensity score matching to address residual confounding; this statistical technique closely matches patient characteristics between cohorts.
Overall, there were 40,257 hospitalizations, with 1,166 children (2.9%) receiving dexamethasone and 39,091 (97.1%) receiving prednisone/prednisolone. The use of dexamethasone varied greatly between hospitals (35/42 hospitals used dexamethasone, with rates ranging from 0.047% to 77.4%).
In the post-match cohort, 1,284 patients were evaluated, 642 in each group. In this cohort, patients with dexamethasone had significantly shorter LOS (67.4% had LOS less than one day vs. 59.5% in the prednisone/prednisolone group; 6.7% of dexamethasone patients had LOS of more than three days vs. 12% of prednisone/prednisolone patients). Costs were lower for the dexamethasone group, both for the index admission and for episode admission (defined as index admission plus seven-day readmissions). There was no difference in readmissions between the groups, and no patients in this cohort were transferred to the ICU.
There are several limitations to this study. Dexamethasone use varied widely among participating hospitals. The data source did not permit access to dosing, duration, or compliance with therapy and could not compare albuterol use between groups. The findings may not be generalizable to all populations, because it excluded patients with high severity and medical complexity and only evaluated tertiary care children’s hospitals.
Bottom line: Dexamethasone is a potential alternative therapy for asthma exacerbations in the inpatient setting. Further studies are needed to evaluate effectiveness, including dosing, frequency, and duration.
Citation: Parikh K, Hall M, Mittal V, et al. Comparative effectiveness of dexamethasone versus prednisone in children hospitalized with asthma. J Pediatr. 2015;167(3):639-644.
References
- Yu H, Wier LM, Elixhauser A. Hospital stays for children, 2009. HCUP statistical brief #118. Agency for Healthcare Research and Quality. August 2011. Accessed November 1, 2015.
- National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma–Summary Report 2007. Accessed November 1, 2015.
Clinical question: In children hospitalized in a non-ICU setting with asthma exacerbation, how effective is dexamethasone compared to prednisone/prednisolone?
Background: Asthma is the second most common reason for hospital admission in childhood.1 National guidelines recommend treatment with systemic corticosteroids in addition to beta-agonists.2 Traditionally, prednisone/prednisolone has been used for asthma exacerbations, but multiple recent studies in ED settings have shown equal efficacy with dexamethasone for mild to moderate exacerbations. Benefits of dexamethasone use include a longer half-life (so single dose or two-day courses can be used), good enteral absorption, general palatability, less emesis, and better adherence. To this point, no studies have compared dexamethasone with prednisone/prednisolone therapy in hospitalized children.
Study design: Multicenter, retrospective cohort study.
Setting: Freestanding, tertiary care children’s hospitals.
Synopsis: The authors used the PHIS (Pediatric Health Information System) database, which includes clinical and billing data from 42 children’s hospitals, to compare children who received dexamethasone to those who were treated with prednisone/prednisolone therapy for asthma exacerbations in the inpatient setting. Patients were included if they were aged four to 17 years, were hospitalized between January 2007 and December 2012 with ICD-9 code for a principal diagnosis of asthma, and received either dexamethasone or prednisone/prednisolone.
Exclusion criteria included:
- Management in the ICU at the time of admission;
- All patient refined diagnosis related groups (APR-DRG) severity level moderate or extreme;
- Complex chronic conditions;
- Secondary diagnosis other than asthma requiring steroids, or treatment with racemic epinephrine;
- Only the first admission was included out of multiple hospitalizations within a 30-day period; and/or
- Patient was treated with both dexamethasone and prednisone/prednisolone.
The primary outcome evaluated was length of stay (LOS); secondary outcomes included readmissions, cost, and transfer to ICU during hospitalization. The authors compared the overall groups, then performed 1:1 propensity score matching to address residual confounding; this statistical technique closely matches patient characteristics between cohorts.
Overall, there were 40,257 hospitalizations, with 1,166 children (2.9%) receiving dexamethasone and 39,091 (97.1%) receiving prednisone/prednisolone. The use of dexamethasone varied greatly between hospitals (35/42 hospitals used dexamethasone, with rates ranging from 0.047% to 77.4%).
In the post-match cohort, 1,284 patients were evaluated, 642 in each group. In this cohort, patients with dexamethasone had significantly shorter LOS (67.4% had LOS less than one day vs. 59.5% in the prednisone/prednisolone group; 6.7% of dexamethasone patients had LOS of more than three days vs. 12% of prednisone/prednisolone patients). Costs were lower for the dexamethasone group, both for the index admission and for episode admission (defined as index admission plus seven-day readmissions). There was no difference in readmissions between the groups, and no patients in this cohort were transferred to the ICU.
There are several limitations to this study. Dexamethasone use varied widely among participating hospitals. The data source did not permit access to dosing, duration, or compliance with therapy and could not compare albuterol use between groups. The findings may not be generalizable to all populations, because it excluded patients with high severity and medical complexity and only evaluated tertiary care children’s hospitals.
Bottom line: Dexamethasone is a potential alternative therapy for asthma exacerbations in the inpatient setting. Further studies are needed to evaluate effectiveness, including dosing, frequency, and duration.
Citation: Parikh K, Hall M, Mittal V, et al. Comparative effectiveness of dexamethasone versus prednisone in children hospitalized with asthma. J Pediatr. 2015;167(3):639-644.
References
- Yu H, Wier LM, Elixhauser A. Hospital stays for children, 2009. HCUP statistical brief #118. Agency for Healthcare Research and Quality. August 2011. Accessed November 1, 2015.
- National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma–Summary Report 2007. Accessed November 1, 2015.
The Long-Term Impact of Childhood-Onset Epilepsy
Long-term seizure outcomes in adults with childhood-onset epilepsy are excellent, according to a study published in the November issue of Epilepsia. The study found that while patients with childhood onset had excellent remission rates in adulthood, long-term results depending on etiology did raise concerns, most notably in cerebrovascular disease. “The presence of imaging abnormalities suggestive of vascular disease may put these subjects at higher risk for clinically evident stroke and cognitive changes as they age,” said Matti Sillanpää, MD, and colleagues. Dr. Sillanpää is a Senior Research Scientist at the University of Turku in Finland.
A population-based cohort of 245 patients with childhood-onset epilepsy was assessed for outcome at 45 years. In addition, 51 of 78 surviving subjects with uncomplicated epilepsy (ie, no neurologic impairment at onset) and 52 of 99 originally matched controls participated in a detailed evaluation that included EEG, imaging, and laboratory studies at 50 years.
Of the 179 surviving subjects, 61% were in terminal 10-year remission and 43% were in remission off medications. At 45 years, 95% of the idiopathic group, 72% of the cryptogenic group, and 47% of the remote symptomatic group were in terminal remission. Abnormal neurologic signs were significantly more common in subjects with uncomplicated epilepsy than in controls. Mortality during the period from 1992 to 2012 was higher in subjects (9%) than in controls (1%). The rate of MRI abnormalities was higher in subjects than in controls (risk ratio, 2.0), specifically including findings indicative of cerebrovascular disease.
In the 50-year follow-up study, the 47 remaining willing patients who had no neurologic impairment at onset were compared with a group of 50 controls. The previously epileptic group was shown to be more susceptible to neurologic disorders than the controls (73% vs 55%, respectively).
This finding is consistent with the MRI results of the subjects when examined at middle age, which showed a significantly higher rate of neurologic abnormalities on examinations than controls did. These changes, while often present in the general population, had an earlier onset in the epileptic population. These findings suggest that underlying etiology, seizures, and treatment may be responsible for these changes.
This study’s significance lies in the long and continuing duration of the follow-up. The extended study time allowed researchers to compare development between patients with epilepsy and the general population. As the epilepsy and control groups reach an age characteristic of cerebrovascular risk, further analysis is needed to determine if the concerns about MRI results translate to disease, said Dr. Sillanpää.
—Adaeze Stephanie Onyechi
Suggested Reading
Sillanpää, M, Anttinen A, Rinne JO, et al. Childhood‐onset epilepsy five decades later: a prospective population‐based cohort study. Epilepsia. 2015;56(11):1774-1783.
Long-term seizure outcomes in adults with childhood-onset epilepsy are excellent, according to a study published in the November issue of Epilepsia. The study found that while patients with childhood onset had excellent remission rates in adulthood, long-term results depending on etiology did raise concerns, most notably in cerebrovascular disease. “The presence of imaging abnormalities suggestive of vascular disease may put these subjects at higher risk for clinically evident stroke and cognitive changes as they age,” said Matti Sillanpää, MD, and colleagues. Dr. Sillanpää is a Senior Research Scientist at the University of Turku in Finland.
A population-based cohort of 245 patients with childhood-onset epilepsy was assessed for outcome at 45 years. In addition, 51 of 78 surviving subjects with uncomplicated epilepsy (ie, no neurologic impairment at onset) and 52 of 99 originally matched controls participated in a detailed evaluation that included EEG, imaging, and laboratory studies at 50 years.
Of the 179 surviving subjects, 61% were in terminal 10-year remission and 43% were in remission off medications. At 45 years, 95% of the idiopathic group, 72% of the cryptogenic group, and 47% of the remote symptomatic group were in terminal remission. Abnormal neurologic signs were significantly more common in subjects with uncomplicated epilepsy than in controls. Mortality during the period from 1992 to 2012 was higher in subjects (9%) than in controls (1%). The rate of MRI abnormalities was higher in subjects than in controls (risk ratio, 2.0), specifically including findings indicative of cerebrovascular disease.
In the 50-year follow-up study, the 47 remaining willing patients who had no neurologic impairment at onset were compared with a group of 50 controls. The previously epileptic group was shown to be more susceptible to neurologic disorders than the controls (73% vs 55%, respectively).
This finding is consistent with the MRI results of the subjects when examined at middle age, which showed a significantly higher rate of neurologic abnormalities on examinations than controls did. These changes, while often present in the general population, had an earlier onset in the epileptic population. These findings suggest that underlying etiology, seizures, and treatment may be responsible for these changes.
This study’s significance lies in the long and continuing duration of the follow-up. The extended study time allowed researchers to compare development between patients with epilepsy and the general population. As the epilepsy and control groups reach an age characteristic of cerebrovascular risk, further analysis is needed to determine if the concerns about MRI results translate to disease, said Dr. Sillanpää.
—Adaeze Stephanie Onyechi
Long-term seizure outcomes in adults with childhood-onset epilepsy are excellent, according to a study published in the November issue of Epilepsia. The study found that while patients with childhood onset had excellent remission rates in adulthood, long-term results depending on etiology did raise concerns, most notably in cerebrovascular disease. “The presence of imaging abnormalities suggestive of vascular disease may put these subjects at higher risk for clinically evident stroke and cognitive changes as they age,” said Matti Sillanpää, MD, and colleagues. Dr. Sillanpää is a Senior Research Scientist at the University of Turku in Finland.
A population-based cohort of 245 patients with childhood-onset epilepsy was assessed for outcome at 45 years. In addition, 51 of 78 surviving subjects with uncomplicated epilepsy (ie, no neurologic impairment at onset) and 52 of 99 originally matched controls participated in a detailed evaluation that included EEG, imaging, and laboratory studies at 50 years.
Of the 179 surviving subjects, 61% were in terminal 10-year remission and 43% were in remission off medications. At 45 years, 95% of the idiopathic group, 72% of the cryptogenic group, and 47% of the remote symptomatic group were in terminal remission. Abnormal neurologic signs were significantly more common in subjects with uncomplicated epilepsy than in controls. Mortality during the period from 1992 to 2012 was higher in subjects (9%) than in controls (1%). The rate of MRI abnormalities was higher in subjects than in controls (risk ratio, 2.0), specifically including findings indicative of cerebrovascular disease.
In the 50-year follow-up study, the 47 remaining willing patients who had no neurologic impairment at onset were compared with a group of 50 controls. The previously epileptic group was shown to be more susceptible to neurologic disorders than the controls (73% vs 55%, respectively).
This finding is consistent with the MRI results of the subjects when examined at middle age, which showed a significantly higher rate of neurologic abnormalities on examinations than controls did. These changes, while often present in the general population, had an earlier onset in the epileptic population. These findings suggest that underlying etiology, seizures, and treatment may be responsible for these changes.
This study’s significance lies in the long and continuing duration of the follow-up. The extended study time allowed researchers to compare development between patients with epilepsy and the general population. As the epilepsy and control groups reach an age characteristic of cerebrovascular risk, further analysis is needed to determine if the concerns about MRI results translate to disease, said Dr. Sillanpää.
—Adaeze Stephanie Onyechi
Suggested Reading
Sillanpää, M, Anttinen A, Rinne JO, et al. Childhood‐onset epilepsy five decades later: a prospective population‐based cohort study. Epilepsia. 2015;56(11):1774-1783.
Suggested Reading
Sillanpää, M, Anttinen A, Rinne JO, et al. Childhood‐onset epilepsy five decades later: a prospective population‐based cohort study. Epilepsia. 2015;56(11):1774-1783.