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Older, Poorer Patients With Epilepsy Less Likely to Take their Medication
Approximately one-third of older adults with epilepsy do not adhere very well to their antiepileptic drug regimen, with older minority patients even less compliant. That’s the conclusion reached by researchers who analyzed Medicare claims from 2008 to 2010, using a 5% random sample of beneficiaries and augmenting it with minority patients. Piper et al looked at 36,912 cases of epilepsy and found 31.8% were nonadherent; that included 24.1% of whites and 34.3% of African Americans. They also found that Medicare beneficiaries who lived in high poverty areas were more likely to be noncompliant.
Piper K, Richman J, Faught E, at al. Adherence to antiepileptic drugs among diverse older Americans on Part D Medicare. Epilepsy Behav. 2017;66:68-73.
Approximately one-third of older adults with epilepsy do not adhere very well to their antiepileptic drug regimen, with older minority patients even less compliant. That’s the conclusion reached by researchers who analyzed Medicare claims from 2008 to 2010, using a 5% random sample of beneficiaries and augmenting it with minority patients. Piper et al looked at 36,912 cases of epilepsy and found 31.8% were nonadherent; that included 24.1% of whites and 34.3% of African Americans. They also found that Medicare beneficiaries who lived in high poverty areas were more likely to be noncompliant.
Piper K, Richman J, Faught E, at al. Adherence to antiepileptic drugs among diverse older Americans on Part D Medicare. Epilepsy Behav. 2017;66:68-73.
Approximately one-third of older adults with epilepsy do not adhere very well to their antiepileptic drug regimen, with older minority patients even less compliant. That’s the conclusion reached by researchers who analyzed Medicare claims from 2008 to 2010, using a 5% random sample of beneficiaries and augmenting it with minority patients. Piper et al looked at 36,912 cases of epilepsy and found 31.8% were nonadherent; that included 24.1% of whites and 34.3% of African Americans. They also found that Medicare beneficiaries who lived in high poverty areas were more likely to be noncompliant.
Piper K, Richman J, Faught E, at al. Adherence to antiepileptic drugs among diverse older Americans on Part D Medicare. Epilepsy Behav. 2017;66:68-73.
Inhalers used incorrectly at least one-third of time
Clinical question: What are the most common errors in inhaler use over the past 40 years?
Background: One of the reasons for poor asthma and COPD control is incorrect inhaler use. Problems with technique have been recognized since the launch of the metered-dose inhaler (MDI) in the 1960s. Multiple initiatives have been implemented, including the design of the dry powder inhaler (DPI); however, problems persist despite all corrective measures.
Study design: Meta-analysis.
Synopsis: The most frequent MDI errors were lack of initial full expiration (48%), inadequate coordination (45%), and no postinhalation breath hold (46%). DPI errors were lower, compared with MDI errors: incorrect preparation (29%), no initial full expiration before inhalation (46%), and no postinhalation breath hold (37%).
The overall prevalence of correct technique was the same as poor technique (31%). There was no difference in the rates of incorrect inhaler use between the first and second 20-year periods of investigation.
Bottom line: Incorrect inhaler use in patients with asthma and COPD persists over time despite multiple implemented strategies.
Citation: Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team. Systematic review of errors in inhaler use: has the patient technique improved over time? Chest. 2016;150(2):394-406.
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: What are the most common errors in inhaler use over the past 40 years?
Background: One of the reasons for poor asthma and COPD control is incorrect inhaler use. Problems with technique have been recognized since the launch of the metered-dose inhaler (MDI) in the 1960s. Multiple initiatives have been implemented, including the design of the dry powder inhaler (DPI); however, problems persist despite all corrective measures.
Study design: Meta-analysis.
Synopsis: The most frequent MDI errors were lack of initial full expiration (48%), inadequate coordination (45%), and no postinhalation breath hold (46%). DPI errors were lower, compared with MDI errors: incorrect preparation (29%), no initial full expiration before inhalation (46%), and no postinhalation breath hold (37%).
The overall prevalence of correct technique was the same as poor technique (31%). There was no difference in the rates of incorrect inhaler use between the first and second 20-year periods of investigation.
Bottom line: Incorrect inhaler use in patients with asthma and COPD persists over time despite multiple implemented strategies.
Citation: Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team. Systematic review of errors in inhaler use: has the patient technique improved over time? Chest. 2016;150(2):394-406.
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: What are the most common errors in inhaler use over the past 40 years?
Background: One of the reasons for poor asthma and COPD control is incorrect inhaler use. Problems with technique have been recognized since the launch of the metered-dose inhaler (MDI) in the 1960s. Multiple initiatives have been implemented, including the design of the dry powder inhaler (DPI); however, problems persist despite all corrective measures.
Study design: Meta-analysis.
Synopsis: The most frequent MDI errors were lack of initial full expiration (48%), inadequate coordination (45%), and no postinhalation breath hold (46%). DPI errors were lower, compared with MDI errors: incorrect preparation (29%), no initial full expiration before inhalation (46%), and no postinhalation breath hold (37%).
The overall prevalence of correct technique was the same as poor technique (31%). There was no difference in the rates of incorrect inhaler use between the first and second 20-year periods of investigation.
Bottom line: Incorrect inhaler use in patients with asthma and COPD persists over time despite multiple implemented strategies.
Citation: Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team. Systematic review of errors in inhaler use: has the patient technique improved over time? Chest. 2016;150(2):394-406.
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Blood thinning with bioprosthetic valves
Clinical question: Does anticoagulation prevent thromboembolic events in patients undergoing bioprosthetic valve implantation?
Background: The main advantage of bioprosthetic valves, compared with mechanical valves, is the avoidance of long-term anticoagulation. Current guidelines recommend the use of vitamin K antagonist (VKA) during the first 3 months after surgery, which remains controversial. Two randomized controlled trials (RCTs) showed no benefit of using VKA in the first 3 months; however, other studies have reported conflicting results.
Study design: Meta-analysis and systematic review.
Setting: Multicenter.
Synopsis: This meta-analysis included two RCTs and 12 observational studies that compared the outcomes in group I (VKA) versus group II (antiplatelet therapy/no treatment). There was no difference in thromboembolic events between group I (1%) and group II (1.5%), but there were more bleeding events in group I (2.6%) versus group II (1.1%). In addition, no differences in all-cause of mortality rate and need for redo surgery were found between the two groups.
Bottom line: The use of VKA in the first 3 months after a bioprosthetic valve implantation does not decrease the rate of thromboembolic events or mortality, but it is associated with increased risk of major bleeding.
Citation: Masri A, Gillinov M, Johnston DM, et al. Anticoagulation versus antiplatelet or no therapy in patients undergoing bioprosthetic valve implantation: a systematic review and meta-analysis [published online ahead of print Aug. 3, 2016]. Heart. doi: 10.1136/heartjnl-2016-309630
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: Does anticoagulation prevent thromboembolic events in patients undergoing bioprosthetic valve implantation?
Background: The main advantage of bioprosthetic valves, compared with mechanical valves, is the avoidance of long-term anticoagulation. Current guidelines recommend the use of vitamin K antagonist (VKA) during the first 3 months after surgery, which remains controversial. Two randomized controlled trials (RCTs) showed no benefit of using VKA in the first 3 months; however, other studies have reported conflicting results.
Study design: Meta-analysis and systematic review.
Setting: Multicenter.
Synopsis: This meta-analysis included two RCTs and 12 observational studies that compared the outcomes in group I (VKA) versus group II (antiplatelet therapy/no treatment). There was no difference in thromboembolic events between group I (1%) and group II (1.5%), but there were more bleeding events in group I (2.6%) versus group II (1.1%). In addition, no differences in all-cause of mortality rate and need for redo surgery were found between the two groups.
Bottom line: The use of VKA in the first 3 months after a bioprosthetic valve implantation does not decrease the rate of thromboembolic events or mortality, but it is associated with increased risk of major bleeding.
Citation: Masri A, Gillinov M, Johnston DM, et al. Anticoagulation versus antiplatelet or no therapy in patients undergoing bioprosthetic valve implantation: a systematic review and meta-analysis [published online ahead of print Aug. 3, 2016]. Heart. doi: 10.1136/heartjnl-2016-309630
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: Does anticoagulation prevent thromboembolic events in patients undergoing bioprosthetic valve implantation?
Background: The main advantage of bioprosthetic valves, compared with mechanical valves, is the avoidance of long-term anticoagulation. Current guidelines recommend the use of vitamin K antagonist (VKA) during the first 3 months after surgery, which remains controversial. Two randomized controlled trials (RCTs) showed no benefit of using VKA in the first 3 months; however, other studies have reported conflicting results.
Study design: Meta-analysis and systematic review.
Setting: Multicenter.
Synopsis: This meta-analysis included two RCTs and 12 observational studies that compared the outcomes in group I (VKA) versus group II (antiplatelet therapy/no treatment). There was no difference in thromboembolic events between group I (1%) and group II (1.5%), but there were more bleeding events in group I (2.6%) versus group II (1.1%). In addition, no differences in all-cause of mortality rate and need for redo surgery were found between the two groups.
Bottom line: The use of VKA in the first 3 months after a bioprosthetic valve implantation does not decrease the rate of thromboembolic events or mortality, but it is associated with increased risk of major bleeding.
Citation: Masri A, Gillinov M, Johnston DM, et al. Anticoagulation versus antiplatelet or no therapy in patients undergoing bioprosthetic valve implantation: a systematic review and meta-analysis [published online ahead of print Aug. 3, 2016]. Heart. doi: 10.1136/heartjnl-2016-309630
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Instability of INRs
Clinical question: Does an initial stable international normalized ratio (INR) predict long-term stability?
Background: Warfarin decreases stroke risk among patients with atrial fibrillation; however, it interacts with food and drugs and requires monitoring to achieve a therapeutic INR. It is unclear if patients on warfarin with an initial stable INR value remain stable over time. Additionally, it is controversial whether patients on warfarin with previously stable INRs should benefit from switching to a non–vitamin K oral anticoagulant.
Study design: Retrospective study.
Setting: Outpatient clinics.
Synopsis: Data were collected from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation. Included in the study were patients taking warfarin at baseline with three or more INR values in the first 6 months and six or more INR values in the subsequent year. Stability was defined as 80% or more INRs in therapeutic range (2.0-3.0).
Only 26% of patients taking warfarin had a stable INR during the first 6 months, and only 34% continued to have a stable INR in the subsequent year.
Bottom line: Initial stable INR within the first 6 months among patients taking warfarin does not predict long-term INR stability in the subsequent year.
Citation: Pokorney SD, Simon DN, Thomas L, et al. Stability of international normalized ratios in patients taking long-term warfarin therapy. JAMA.2016;316(6):661-663
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: Does an initial stable international normalized ratio (INR) predict long-term stability?
Background: Warfarin decreases stroke risk among patients with atrial fibrillation; however, it interacts with food and drugs and requires monitoring to achieve a therapeutic INR. It is unclear if patients on warfarin with an initial stable INR value remain stable over time. Additionally, it is controversial whether patients on warfarin with previously stable INRs should benefit from switching to a non–vitamin K oral anticoagulant.
Study design: Retrospective study.
Setting: Outpatient clinics.
Synopsis: Data were collected from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation. Included in the study were patients taking warfarin at baseline with three or more INR values in the first 6 months and six or more INR values in the subsequent year. Stability was defined as 80% or more INRs in therapeutic range (2.0-3.0).
Only 26% of patients taking warfarin had a stable INR during the first 6 months, and only 34% continued to have a stable INR in the subsequent year.
Bottom line: Initial stable INR within the first 6 months among patients taking warfarin does not predict long-term INR stability in the subsequent year.
Citation: Pokorney SD, Simon DN, Thomas L, et al. Stability of international normalized ratios in patients taking long-term warfarin therapy. JAMA.2016;316(6):661-663
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: Does an initial stable international normalized ratio (INR) predict long-term stability?
Background: Warfarin decreases stroke risk among patients with atrial fibrillation; however, it interacts with food and drugs and requires monitoring to achieve a therapeutic INR. It is unclear if patients on warfarin with an initial stable INR value remain stable over time. Additionally, it is controversial whether patients on warfarin with previously stable INRs should benefit from switching to a non–vitamin K oral anticoagulant.
Study design: Retrospective study.
Setting: Outpatient clinics.
Synopsis: Data were collected from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation. Included in the study were patients taking warfarin at baseline with three or more INR values in the first 6 months and six or more INR values in the subsequent year. Stability was defined as 80% or more INRs in therapeutic range (2.0-3.0).
Only 26% of patients taking warfarin had a stable INR during the first 6 months, and only 34% continued to have a stable INR in the subsequent year.
Bottom line: Initial stable INR within the first 6 months among patients taking warfarin does not predict long-term INR stability in the subsequent year.
Citation: Pokorney SD, Simon DN, Thomas L, et al. Stability of international normalized ratios in patients taking long-term warfarin therapy. JAMA.2016;316(6):661-663
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Inpatient antibiotic use has not declined
Clinical question: How has inpatient antibiotic use changed in the United States in recent years?
Study design: Retrospective analysis.
Setting: Adult and pediatric data from 300 acute-care hospitals, 2006-2012.
Synopsis: Weighted extrapolation of data from a database was used to estimate national antibiotic use. Overall, 55.1% of discharged patients received antibiotics. The rate of antibiotic use was 755/1,000 patient-days over the study period. The small increase in antibiotic use over the years (5.6 days of therapy/1,000 patient-days increase; 95% CI, –18.9 to 30.1; P = .65) was not statistically significant. There was a significant decrease in the use of aminoglycosides, first- and second-generation cephalosporins, fluoroquinolones, sulfonamide, metronidazole, and penicillins. The use of third- and fourth-generation cephalosporins, macrolides, glycopeptides, beta-lactam/beta-lactamase inhibitor, carbapenems, and tetracyclines has increased significantly.
Limitations of the study include underrepresentation of pediatric hospitals and certain geographic regions.
Bottom line: Antibiotic-use rates have not changed during 2006-2012. However, broad-spectrum antibiotic use has increased significantly.
Citation: Baggs J, Fridkin SK, Pollack LA, Srinivasan A, Jernigan JA. Estimating national trends in inpatient antibiotic use among US hospitals from 2006 to 2012. JAMA Intern Med. 2016;176(11):1639-1648.
Dr. Menon is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: How has inpatient antibiotic use changed in the United States in recent years?
Study design: Retrospective analysis.
Setting: Adult and pediatric data from 300 acute-care hospitals, 2006-2012.
Synopsis: Weighted extrapolation of data from a database was used to estimate national antibiotic use. Overall, 55.1% of discharged patients received antibiotics. The rate of antibiotic use was 755/1,000 patient-days over the study period. The small increase in antibiotic use over the years (5.6 days of therapy/1,000 patient-days increase; 95% CI, –18.9 to 30.1; P = .65) was not statistically significant. There was a significant decrease in the use of aminoglycosides, first- and second-generation cephalosporins, fluoroquinolones, sulfonamide, metronidazole, and penicillins. The use of third- and fourth-generation cephalosporins, macrolides, glycopeptides, beta-lactam/beta-lactamase inhibitor, carbapenems, and tetracyclines has increased significantly.
Limitations of the study include underrepresentation of pediatric hospitals and certain geographic regions.
Bottom line: Antibiotic-use rates have not changed during 2006-2012. However, broad-spectrum antibiotic use has increased significantly.
Citation: Baggs J, Fridkin SK, Pollack LA, Srinivasan A, Jernigan JA. Estimating national trends in inpatient antibiotic use among US hospitals from 2006 to 2012. JAMA Intern Med. 2016;176(11):1639-1648.
Dr. Menon is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: How has inpatient antibiotic use changed in the United States in recent years?
Study design: Retrospective analysis.
Setting: Adult and pediatric data from 300 acute-care hospitals, 2006-2012.
Synopsis: Weighted extrapolation of data from a database was used to estimate national antibiotic use. Overall, 55.1% of discharged patients received antibiotics. The rate of antibiotic use was 755/1,000 patient-days over the study period. The small increase in antibiotic use over the years (5.6 days of therapy/1,000 patient-days increase; 95% CI, –18.9 to 30.1; P = .65) was not statistically significant. There was a significant decrease in the use of aminoglycosides, first- and second-generation cephalosporins, fluoroquinolones, sulfonamide, metronidazole, and penicillins. The use of third- and fourth-generation cephalosporins, macrolides, glycopeptides, beta-lactam/beta-lactamase inhibitor, carbapenems, and tetracyclines has increased significantly.
Limitations of the study include underrepresentation of pediatric hospitals and certain geographic regions.
Bottom line: Antibiotic-use rates have not changed during 2006-2012. However, broad-spectrum antibiotic use has increased significantly.
Citation: Baggs J, Fridkin SK, Pollack LA, Srinivasan A, Jernigan JA. Estimating national trends in inpatient antibiotic use among US hospitals from 2006 to 2012. JAMA Intern Med. 2016;176(11):1639-1648.
Dr. Menon is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Evaluating the qSOF
Clinical question: How does the quick Sepsis-Related Organ Failure Assessment (qSOFA) compare with other sepsis scoring tools?
Study design: Single-center, retrospective analysis.
Setting: Hospital ED in China.
Synopsis: A total of 516 adult ED patients with clinically diagnosed infections were followed for 28 days. Calculated scores for qSOFA, SOFA, Mortality in ED Sepsis (MEDS), and Acute Physiology and Chronic Health Evaluation (APACHE) II were compared using ROC curves.
qSOFA was similar to the other scoring systems to predict ICU admission.
The area under the curve for qSOFA to predict 28-day mortality was lower than all other scoring systems but was statistically significant only when compared to MEDS. A qSOFA score of 2 had a positive likelihood ratio of 2.47 to predict mortality (95% CI, 2.3-5.4) and a positive likelihood ratio of 2.08 (95% CI, 1.7-4.1) to predict ICU admission.
Bottom line: qSOFA was similar to other scoring systems to predict 28-day mortality and ICU admission but slightly inferior than MEDS to predict mortality.
Citation: Wang JY, Chen YX, Guo SB, Mei X, Yang P. Predictive performance of quick sepsis-related organ failure assessment for mortality and ICU admission in patients with infection at the ED. Am J Em Med. 2016;34(9):1788-1793
Clinical question: How does the quick Sepsis-Related Organ Failure Assessment (qSOFA) compare with other sepsis scoring tools?
Study design: Single-center, retrospective analysis.
Setting: Hospital ED in China.
Synopsis: A total of 516 adult ED patients with clinically diagnosed infections were followed for 28 days. Calculated scores for qSOFA, SOFA, Mortality in ED Sepsis (MEDS), and Acute Physiology and Chronic Health Evaluation (APACHE) II were compared using ROC curves.
qSOFA was similar to the other scoring systems to predict ICU admission.
The area under the curve for qSOFA to predict 28-day mortality was lower than all other scoring systems but was statistically significant only when compared to MEDS. A qSOFA score of 2 had a positive likelihood ratio of 2.47 to predict mortality (95% CI, 2.3-5.4) and a positive likelihood ratio of 2.08 (95% CI, 1.7-4.1) to predict ICU admission.
Bottom line: qSOFA was similar to other scoring systems to predict 28-day mortality and ICU admission but slightly inferior than MEDS to predict mortality.
Citation: Wang JY, Chen YX, Guo SB, Mei X, Yang P. Predictive performance of quick sepsis-related organ failure assessment for mortality and ICU admission in patients with infection at the ED. Am J Em Med. 2016;34(9):1788-1793
Clinical question: How does the quick Sepsis-Related Organ Failure Assessment (qSOFA) compare with other sepsis scoring tools?
Study design: Single-center, retrospective analysis.
Setting: Hospital ED in China.
Synopsis: A total of 516 adult ED patients with clinically diagnosed infections were followed for 28 days. Calculated scores for qSOFA, SOFA, Mortality in ED Sepsis (MEDS), and Acute Physiology and Chronic Health Evaluation (APACHE) II were compared using ROC curves.
qSOFA was similar to the other scoring systems to predict ICU admission.
The area under the curve for qSOFA to predict 28-day mortality was lower than all other scoring systems but was statistically significant only when compared to MEDS. A qSOFA score of 2 had a positive likelihood ratio of 2.47 to predict mortality (95% CI, 2.3-5.4) and a positive likelihood ratio of 2.08 (95% CI, 1.7-4.1) to predict ICU admission.
Bottom line: qSOFA was similar to other scoring systems to predict 28-day mortality and ICU admission but slightly inferior than MEDS to predict mortality.
Citation: Wang JY, Chen YX, Guo SB, Mei X, Yang P. Predictive performance of quick sepsis-related organ failure assessment for mortality and ICU admission in patients with infection at the ED. Am J Em Med. 2016;34(9):1788-1793
Pulmonary embolism in COPD exacerbations
Clinical question: How frequent is pulmonary embolism (PE) in patients with unexplained acute chronic obstructive pulmonary disease (COPD) exacerbation?
Study design: Systematic review.
Setting: U.S. hospitals and EDs.
Synopsis: PE prevalence was 16.1% (95% CI, 8.3%-25.8%) in patients with unexplained COPD exacerbations. Thirty-two percent were subsegmental, 35% affected one of the main pulmonary arteries, and 32% were located in the lobar and interlobar arteries. Heterogeneity between the included studies was high. In-hospital and 1-year mortality were increased in patients with PE and COPD exacerbations in one study but not in another.
Signs of cardiac failure, hypotension, and syncope were more frequently found in patients with COPD exacerbation and PE, compared with patients with COPD exacerbation without PE.
Bottom line: PE is a common occurrence in patients with unexplained COPD exacerbations; two-thirds of those emboli involved segmental circulation and therefore were clinically relevant.
Citation: Aleva FE, Voets LW, Simons SO, de Mast Q, van der Ven A, Heijdra YF. Prevalence and localization of pulmonary embolism in unexplained acute exacerbations of COPD: a systematic review and meta-analysis [published online ahead of print Aug. 11, 2016]. Chest. doi: 10.1016/j.chest.2016.07.034.
Clinical question: How frequent is pulmonary embolism (PE) in patients with unexplained acute chronic obstructive pulmonary disease (COPD) exacerbation?
Study design: Systematic review.
Setting: U.S. hospitals and EDs.
Synopsis: PE prevalence was 16.1% (95% CI, 8.3%-25.8%) in patients with unexplained COPD exacerbations. Thirty-two percent were subsegmental, 35% affected one of the main pulmonary arteries, and 32% were located in the lobar and interlobar arteries. Heterogeneity between the included studies was high. In-hospital and 1-year mortality were increased in patients with PE and COPD exacerbations in one study but not in another.
Signs of cardiac failure, hypotension, and syncope were more frequently found in patients with COPD exacerbation and PE, compared with patients with COPD exacerbation without PE.
Bottom line: PE is a common occurrence in patients with unexplained COPD exacerbations; two-thirds of those emboli involved segmental circulation and therefore were clinically relevant.
Citation: Aleva FE, Voets LW, Simons SO, de Mast Q, van der Ven A, Heijdra YF. Prevalence and localization of pulmonary embolism in unexplained acute exacerbations of COPD: a systematic review and meta-analysis [published online ahead of print Aug. 11, 2016]. Chest. doi: 10.1016/j.chest.2016.07.034.
Clinical question: How frequent is pulmonary embolism (PE) in patients with unexplained acute chronic obstructive pulmonary disease (COPD) exacerbation?
Study design: Systematic review.
Setting: U.S. hospitals and EDs.
Synopsis: PE prevalence was 16.1% (95% CI, 8.3%-25.8%) in patients with unexplained COPD exacerbations. Thirty-two percent were subsegmental, 35% affected one of the main pulmonary arteries, and 32% were located in the lobar and interlobar arteries. Heterogeneity between the included studies was high. In-hospital and 1-year mortality were increased in patients with PE and COPD exacerbations in one study but not in another.
Signs of cardiac failure, hypotension, and syncope were more frequently found in patients with COPD exacerbation and PE, compared with patients with COPD exacerbation without PE.
Bottom line: PE is a common occurrence in patients with unexplained COPD exacerbations; two-thirds of those emboli involved segmental circulation and therefore were clinically relevant.
Citation: Aleva FE, Voets LW, Simons SO, de Mast Q, van der Ven A, Heijdra YF. Prevalence and localization of pulmonary embolism in unexplained acute exacerbations of COPD: a systematic review and meta-analysis [published online ahead of print Aug. 11, 2016]. Chest. doi: 10.1016/j.chest.2016.07.034.
Nonischemic cardiomyopathy does not benefit from prophylactic ICDs
Clinical question: Do prophylactic implantable cardioverter defibrillators (ICDs) reduce long-term mortality in patients with symptomatic nonischemic systolic heart failure (NISHF)?
Study design: Multicenter, nonblinded, randomized controlled prospective trial.
Setting: Danish ICD centers.
Synopsis: A total of 1,116 patients with symptomatic NISHF (left ventricular ejection fraction of less than 35%) were randomized to either receive an ICD or usual clinical care. The primary outcome, death from any cause, occurred in 120 patients (21.6%) in the ICD group (4.4 events/100 person-years) and in 131 patients (23.4%) in the control group. The hazard ratio for death from any cause in the ICD group, as compared with the control group, was 0.87 (95% CI , 0.68-1.12; P = .28). The HR for death from any cause in the ICD group, as compared with the control group, was 0.87 (95% CI, 0.68-1.12; P = .28)
Bottom line: Prophylactic ICD implantation in patients with symptomatic NISHF does not reduce long-term mortality.
Citation: Kober L, Thune JJ, Nielsen JC, et al. Defibrillator implantation in patients with nonischemic systolic heart failure. N Engl J Med. 2016;375:1221-1230.
Clinical question: Do prophylactic implantable cardioverter defibrillators (ICDs) reduce long-term mortality in patients with symptomatic nonischemic systolic heart failure (NISHF)?
Study design: Multicenter, nonblinded, randomized controlled prospective trial.
Setting: Danish ICD centers.
Synopsis: A total of 1,116 patients with symptomatic NISHF (left ventricular ejection fraction of less than 35%) were randomized to either receive an ICD or usual clinical care. The primary outcome, death from any cause, occurred in 120 patients (21.6%) in the ICD group (4.4 events/100 person-years) and in 131 patients (23.4%) in the control group. The hazard ratio for death from any cause in the ICD group, as compared with the control group, was 0.87 (95% CI , 0.68-1.12; P = .28). The HR for death from any cause in the ICD group, as compared with the control group, was 0.87 (95% CI, 0.68-1.12; P = .28)
Bottom line: Prophylactic ICD implantation in patients with symptomatic NISHF does not reduce long-term mortality.
Citation: Kober L, Thune JJ, Nielsen JC, et al. Defibrillator implantation in patients with nonischemic systolic heart failure. N Engl J Med. 2016;375:1221-1230.
Clinical question: Do prophylactic implantable cardioverter defibrillators (ICDs) reduce long-term mortality in patients with symptomatic nonischemic systolic heart failure (NISHF)?
Study design: Multicenter, nonblinded, randomized controlled prospective trial.
Setting: Danish ICD centers.
Synopsis: A total of 1,116 patients with symptomatic NISHF (left ventricular ejection fraction of less than 35%) were randomized to either receive an ICD or usual clinical care. The primary outcome, death from any cause, occurred in 120 patients (21.6%) in the ICD group (4.4 events/100 person-years) and in 131 patients (23.4%) in the control group. The hazard ratio for death from any cause in the ICD group, as compared with the control group, was 0.87 (95% CI , 0.68-1.12; P = .28). The HR for death from any cause in the ICD group, as compared with the control group, was 0.87 (95% CI, 0.68-1.12; P = .28)
Bottom line: Prophylactic ICD implantation in patients with symptomatic NISHF does not reduce long-term mortality.
Citation: Kober L, Thune JJ, Nielsen JC, et al. Defibrillator implantation in patients with nonischemic systolic heart failure. N Engl J Med. 2016;375:1221-1230.
Bundled payments reduce costs in joint patients
Clinical question: Does bundled payment for lower extremity joint replacement (LEJR) reduce cost without compromising the quality of care?
Study design: Observational study.
Setting: BPCI-participating hospitals.
Synopsis: At BPCI-participating hospitals, there were 29,441 LEJR episodes in the baseline period and 31,700 episodes in the intervention period; these were compared with a control group of 29,440 episodes in the baseline period and 31,696 episodes in the intervention period. The BPCI initiative was associated with a significant reduction in Medicare per-episode payments, which declined by an estimated $1,166 more (95% confidence interval, –$1634 to –$699; P less than .001) for the BPCI group than for the comparison group (between baseline and intervention periods).
There were no statistical differences in claims-based quality measures between the BPCI and comparison populations, which included 30- and 90-day unplanned readmissions, ED visits, and postdischarge mortality.
Bottom line: Bundled payments for joint replacements may have the potential to decrease cost while maintaining quality of care.
Citation: Dummit L, Kahvecioglu D, Marrufo G, et al. Association between hospital participation in a Medicare bundled payment initiative and payments and quality outcomes for lower extremity joint e replacement episodes. JAMA. 2016;316(12):1267-1278.
Dr. Briones is an assistant professor at the University of Miami Miller School of Medicine and medical director of the hospitalist service at the University of Miami Hospital.
Clinical question: Does bundled payment for lower extremity joint replacement (LEJR) reduce cost without compromising the quality of care?
Study design: Observational study.
Setting: BPCI-participating hospitals.
Synopsis: At BPCI-participating hospitals, there were 29,441 LEJR episodes in the baseline period and 31,700 episodes in the intervention period; these were compared with a control group of 29,440 episodes in the baseline period and 31,696 episodes in the intervention period. The BPCI initiative was associated with a significant reduction in Medicare per-episode payments, which declined by an estimated $1,166 more (95% confidence interval, –$1634 to –$699; P less than .001) for the BPCI group than for the comparison group (between baseline and intervention periods).
There were no statistical differences in claims-based quality measures between the BPCI and comparison populations, which included 30- and 90-day unplanned readmissions, ED visits, and postdischarge mortality.
Bottom line: Bundled payments for joint replacements may have the potential to decrease cost while maintaining quality of care.
Citation: Dummit L, Kahvecioglu D, Marrufo G, et al. Association between hospital participation in a Medicare bundled payment initiative and payments and quality outcomes for lower extremity joint e replacement episodes. JAMA. 2016;316(12):1267-1278.
Dr. Briones is an assistant professor at the University of Miami Miller School of Medicine and medical director of the hospitalist service at the University of Miami Hospital.
Clinical question: Does bundled payment for lower extremity joint replacement (LEJR) reduce cost without compromising the quality of care?
Background: Conventionally, Medicare makes separate payments to providers for the individual services rendered to patients. The Bundled Payments for Care Improvement (BPCI) program was developed to align incentives for providers across all specialties. LEJR is the most common Medicare inpatient procedure, costing more than $6 billion in 2014.
Study design: Observational study.
Setting: BPCI-participating hospitals.
Synopsis: At BPCI-participating hospitals, there were 29,441 LEJR episodes in the baseline period and 31,700 episodes in the intervention period; these were compared with a control group of 29,440 episodes in the baseline period and 31,696 episodes in the intervention period. The BPCI initiative was associated with a significant reduction in Medicare per-episode payments, which declined by an estimated $1,166 more (95% confidence interval, –$1634 to –$699; P less than .001) for the BPCI group than for the comparison group (between baseline and intervention periods).
There were no statistical differences in claims-based quality measures between the BPCI and comparison populations, which included 30- and 90-day unplanned readmissions, ED visits, and postdischarge mortality.
Bottom line: Bundled payments for joint replacements may have the potential to decrease cost while maintaining quality of care.
Citation: Dummit L, Kahvecioglu D, Marrufo G, et al. Association between hospital participation in a Medicare bundled payment initiative and payments and quality outcomes for lower extremity joint e replacement episodes. JAMA. 2016;316(12):1267-1278.
Dr. Briones is an assistant professor at the University of Miami Miller School of Medicine and medical director of the hospitalist service at the University of Miami Hospital.
Periventricular Nodular Heterotopia Poses Unique Surgical Challenges
Patients with epilepsy who also have periventricular nodular heterotopia (PVNH) are difficult to manage surgically because the relative influence of the nodular tissue and the overlying cortex on the generation of seizures is variable. A review of the relevant medical literature suggests that inter-ictal spiking from nodules often occurs in patients with PVNH, but it is rare for patients to experience seizures arising from the nodular tissue alone. It is more likely to find that the onset of seizures occurs simultaneously with overlying neocortex or mesial temporal structures.
Thompson SA, Kalamangalam GP, Tandon N. Intracranial evaluation and laser ablation for epilepsy with periventricular nodular heterotopia. Seizure. 2016;41:211-216.
Patients with epilepsy who also have periventricular nodular heterotopia (PVNH) are difficult to manage surgically because the relative influence of the nodular tissue and the overlying cortex on the generation of seizures is variable. A review of the relevant medical literature suggests that inter-ictal spiking from nodules often occurs in patients with PVNH, but it is rare for patients to experience seizures arising from the nodular tissue alone. It is more likely to find that the onset of seizures occurs simultaneously with overlying neocortex or mesial temporal structures.
Thompson SA, Kalamangalam GP, Tandon N. Intracranial evaluation and laser ablation for epilepsy with periventricular nodular heterotopia. Seizure. 2016;41:211-216.
Patients with epilepsy who also have periventricular nodular heterotopia (PVNH) are difficult to manage surgically because the relative influence of the nodular tissue and the overlying cortex on the generation of seizures is variable. A review of the relevant medical literature suggests that inter-ictal spiking from nodules often occurs in patients with PVNH, but it is rare for patients to experience seizures arising from the nodular tissue alone. It is more likely to find that the onset of seizures occurs simultaneously with overlying neocortex or mesial temporal structures.
Thompson SA, Kalamangalam GP, Tandon N. Intracranial evaluation and laser ablation for epilepsy with periventricular nodular heterotopia. Seizure. 2016;41:211-216.