Literature Review

Although open surgical resection is considered the gold standard for patients with epilepsy who do not respond to medical therapy, there are several viable alternatives, according to Englot and associates writing in Neurosurgical Review. Among the minimally invasive procedures to consider: stereotactic laser ablation and stereotactic radiosurgery, which the researchers say can offer relatively favorable seizure outcomes, especially in patients with mesial temporary lobe epilepsy. Other options include multiple subpial transections and corpus callosotomy in select patients. Among the palliative procedures to consider are vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation, which the authors say may significantly decrease seizure frequency and improve quality of life.

Englot DJ, Birk H, Chang EF. Seizure outcomes in nonresective epilepsy surgery: an update. Neurosurg Rev. 2016; May 21 [Epub ahead of print]

Although open surgical resection is considered the gold standard for patients with epilepsy who do not respond to medical therapy, there are several viable alternatives, according to Englot and associates writing in Neurosurgical Review. Among the minimally invasive procedures to consider: stereotactic laser ablation and stereotactic radiosurgery, which the researchers say can offer relatively favorable seizure outcomes, especially in patients with mesial temporary lobe epilepsy. Other options include multiple subpial transections and corpus callosotomy in select patients. Among the palliative procedures to consider are vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation, which the authors say may significantly decrease seizure frequency and improve quality of life.

Englot DJ, Birk H, Chang EF. Seizure outcomes in nonresective epilepsy surgery: an update. Neurosurg Rev. 2016; May 21 [Epub ahead of print]

Although open surgical resection is considered the gold standard for patients with epilepsy who do not respond to medical therapy, there are several viable alternatives, according to Englot and associates writing in Neurosurgical Review. Among the minimally invasive procedures to consider: stereotactic laser ablation and stereotactic radiosurgery, which the researchers say can offer relatively favorable seizure outcomes, especially in patients with mesial temporary lobe epilepsy. Other options include multiple subpial transections and corpus callosotomy in select patients. Among the palliative procedures to consider are vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation, which the authors say may significantly decrease seizure frequency and improve quality of life.

Englot DJ, Birk H, Chang EF. Seizure outcomes in nonresective epilepsy surgery: an update. Neurosurg Rev. 2016; May 21 [Epub ahead of print]

In order to determine how common sudden unexpected death from epilepsy (SUDEP) is in people with an extra isodicentric 15 chromosome (idic15), researchers studied approximately 709 families registered with the Dup15Q Alliance. Their case-control study found 19 deaths among patients with idic15, 17 of whom had epilepsy.  Nine of these deaths were caused by probable or definite SUDEP; 2 others had what investigators considered possible SUDEP. Researchers concluded that SUDEP is common among children and young adults with duplications of the idic15 chromosome and that the risk of death is most likely to occur in patients with the most severe neurologic dysfunction.

Friedman D, Thaler A, Thaler J et al. Mortality in isodicentric chromosome 15 syndrome: the role of SUDEP. Epilepsy Behav. 2016;61:1-5. 

In order to determine how common sudden unexpected death from epilepsy (SUDEP) is in people with an extra isodicentric 15 chromosome (idic15), researchers studied approximately 709 families registered with the Dup15Q Alliance. Their case-control study found 19 deaths among patients with idic15, 17 of whom had epilepsy.  Nine of these deaths were caused by probable or definite SUDEP; 2 others had what investigators considered possible SUDEP. Researchers concluded that SUDEP is common among children and young adults with duplications of the idic15 chromosome and that the risk of death is most likely to occur in patients with the most severe neurologic dysfunction.

Friedman D, Thaler A, Thaler J et al. Mortality in isodicentric chromosome 15 syndrome: the role of SUDEP. Epilepsy Behav. 2016;61:1-5. 

In order to determine how common sudden unexpected death from epilepsy (SUDEP) is in people with an extra isodicentric 15 chromosome (idic15), researchers studied approximately 709 families registered with the Dup15Q Alliance. Their case-control study found 19 deaths among patients with idic15, 17 of whom had epilepsy.  Nine of these deaths were caused by probable or definite SUDEP; 2 others had what investigators considered possible SUDEP. Researchers concluded that SUDEP is common among children and young adults with duplications of the idic15 chromosome and that the risk of death is most likely to occur in patients with the most severe neurologic dysfunction.

Friedman D, Thaler A, Thaler J et al. Mortality in isodicentric chromosome 15 syndrome: the role of SUDEP. Epilepsy Behav. 2016;61:1-5. 

Contrary to conventional wisdom, the epilepsy surgery rate among adults in North America has remained stagnant according to a recent analysis of data from the Centers for Medicare and Medicaid Services Part B National Summary Data File and the American College of Surgeons National Surgical Quality Improvement Program. A review of 6200 surgeries performed from 2000 to 2013 revealed that temporal lobectomy, the most common operation, was done in 59% of patients, but surgical rates for temporal and extra-temporal surgery did not change significantly during the study period. The researchers concluded that the findings in this study contrasted with previously published reports that suggested a dramatic decline in temporal lobectomy rates at high volume epilepsy centers in recent years. However, investigators did find that surgical adverse effects were higher when statistics from low and high volume centers were combined.

Rolston JD, Englot DJ, Knowlton RC, Chang EF. Rate and complications of adult epilepsy surgery in North America: Analysis of multiple databases. Epilepsy Res. 2016;124:55-62. 

Contrary to conventional wisdom, the epilepsy surgery rate among adults in North America has remained stagnant according to a recent analysis of data from the Centers for Medicare and Medicaid Services Part B National Summary Data File and the American College of Surgeons National Surgical Quality Improvement Program. A review of 6200 surgeries performed from 2000 to 2013 revealed that temporal lobectomy, the most common operation, was done in 59% of patients, but surgical rates for temporal and extra-temporal surgery did not change significantly during the study period. The researchers concluded that the findings in this study contrasted with previously published reports that suggested a dramatic decline in temporal lobectomy rates at high volume epilepsy centers in recent years. However, investigators did find that surgical adverse effects were higher when statistics from low and high volume centers were combined.

Rolston JD, Englot DJ, Knowlton RC, Chang EF. Rate and complications of adult epilepsy surgery in North America: Analysis of multiple databases. Epilepsy Res. 2016;124:55-62. 

Contrary to conventional wisdom, the epilepsy surgery rate among adults in North America has remained stagnant according to a recent analysis of data from the Centers for Medicare and Medicaid Services Part B National Summary Data File and the American College of Surgeons National Surgical Quality Improvement Program. A review of 6200 surgeries performed from 2000 to 2013 revealed that temporal lobectomy, the most common operation, was done in 59% of patients, but surgical rates for temporal and extra-temporal surgery did not change significantly during the study period. The researchers concluded that the findings in this study contrasted with previously published reports that suggested a dramatic decline in temporal lobectomy rates at high volume epilepsy centers in recent years. However, investigators did find that surgical adverse effects were higher when statistics from low and high volume centers were combined.

Rolston JD, Englot DJ, Knowlton RC, Chang EF. Rate and complications of adult epilepsy surgery in North America: Analysis of multiple databases. Epilepsy Res. 2016;124:55-62. 

Clinical question: What are the effects of implementing standardized clinical pathways on length of stay, cost, readmissions, and patient quality of life?

Background: As payment models shift from volume- to value-based models, standardized clinical pathways are one option to simultaneously provide high-value care, improve quality, and control costs. Studies of individual clinical pathways suggest that they may be helpful in decreasing utilization, but the measured impact has varied significantly. It is unknown how much of the measured effect is due to the pathway and how much is due to the clinical factors of the disease or patient population studied. No prior studies have evaluated a suite of clinical pathways in pediatric populations.

Study design: Retrospective cohort study.

Setting: Single, 250-bed, tertiary care, freestanding children’s hospital.

Synopsis: Over four years, 15 clinical pathways were created for common pediatric medical, surgical, and psychiatric complaints (urinary tract infection, diabetes, both diabetic ketoacidosis [DKA] and non-DKA, fractures, spinal surgery, croup, neonatal jaundice, neonatal fever, depressive disorders, pyloric stenosis, pneumonia, tonsillectomy and adenoidectomy, disruptive behavior, and cellulitis/abscess).

The pathways were implemented when they were complete, with guidelines coming online throughout the study period. Implementation included an order set in the electronic medical record that included relevant literature references and decision support, online training, and integration into the clinical workflow for providers and nurses. Use of the pathways was monitored, and they were reviewed on at least a quarterly basis and revised, if necessary.

The authors examined pathway use for eligible patients, hospital costs, length of stay, 30-day readmissions, and parent-reported quality of life, both before and after pathway implementation. Patients meeting criteria for complex chronic conditions were excluded from the study.

Before implementation, 3,808 admissions fulfilled pathway criteria, and 2,902 fulfilled criteria after implementation. The pathway for depressive disorders was the most used pathway, with 411 admissions and 95% of eligible patients on the pathway. Both pyloric stenosis and neonatal jaundice had 100% pathway use.

The lowest rate of pathway use was for urinary tract infection (20%). Pathway implementation slowed the rate of rise of hospital costs. Prior to study implementation, the costs were increasing by $126 per month. Following implementation, costs decreased by $29 per month (95% CI, $100 decrease to $34 increase; P=.001). Post-implementation, the length of stay for pathway-eligible patients began a statistically significant downward trend at a rate that yielded a decrease in length of stay of 8.6 hours over a year (P=0.02). There were no differences in 30-day readmissions or parent-reported quality of life.

Bottom line: Systematic development and implementation of clinical pathways for a variety of conditions can contain costs and decrease length of stay while maintaining clinical outcomes and not increasing readmissions.

Citation: Lion KC, Wright DR, Spencer S, Zhou C, Del Beccaro M, Mangione-Smith R. Standardized clinical pathways for hospitalized children and outcomes. Pediatrics. 2016;137(4). pii:e20151202. doi:10.1542/peds.2015-1202.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question: What are the effects of implementing standardized clinical pathways on length of stay, cost, readmissions, and patient quality of life?

Background: As payment models shift from volume- to value-based models, standardized clinical pathways are one option to simultaneously provide high-value care, improve quality, and control costs. Studies of individual clinical pathways suggest that they may be helpful in decreasing utilization, but the measured impact has varied significantly. It is unknown how much of the measured effect is due to the pathway and how much is due to the clinical factors of the disease or patient population studied. No prior studies have evaluated a suite of clinical pathways in pediatric populations.

Study design: Retrospective cohort study.

Setting: Single, 250-bed, tertiary care, freestanding children’s hospital.

Synopsis: Over four years, 15 clinical pathways were created for common pediatric medical, surgical, and psychiatric complaints (urinary tract infection, diabetes, both diabetic ketoacidosis [DKA] and non-DKA, fractures, spinal surgery, croup, neonatal jaundice, neonatal fever, depressive disorders, pyloric stenosis, pneumonia, tonsillectomy and adenoidectomy, disruptive behavior, and cellulitis/abscess).

The pathways were implemented when they were complete, with guidelines coming online throughout the study period. Implementation included an order set in the electronic medical record that included relevant literature references and decision support, online training, and integration into the clinical workflow for providers and nurses. Use of the pathways was monitored, and they were reviewed on at least a quarterly basis and revised, if necessary.

The authors examined pathway use for eligible patients, hospital costs, length of stay, 30-day readmissions, and parent-reported quality of life, both before and after pathway implementation. Patients meeting criteria for complex chronic conditions were excluded from the study.

Before implementation, 3,808 admissions fulfilled pathway criteria, and 2,902 fulfilled criteria after implementation. The pathway for depressive disorders was the most used pathway, with 411 admissions and 95% of eligible patients on the pathway. Both pyloric stenosis and neonatal jaundice had 100% pathway use.

The lowest rate of pathway use was for urinary tract infection (20%). Pathway implementation slowed the rate of rise of hospital costs. Prior to study implementation, the costs were increasing by $126 per month. Following implementation, costs decreased by $29 per month (95% CI, $100 decrease to $34 increase; P=.001). Post-implementation, the length of stay for pathway-eligible patients began a statistically significant downward trend at a rate that yielded a decrease in length of stay of 8.6 hours over a year (P=0.02). There were no differences in 30-day readmissions or parent-reported quality of life.

Bottom line: Systematic development and implementation of clinical pathways for a variety of conditions can contain costs and decrease length of stay while maintaining clinical outcomes and not increasing readmissions.

Citation: Lion KC, Wright DR, Spencer S, Zhou C, Del Beccaro M, Mangione-Smith R. Standardized clinical pathways for hospitalized children and outcomes. Pediatrics. 2016;137(4). pii:e20151202. doi:10.1542/peds.2015-1202.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question: What are the effects of implementing standardized clinical pathways on length of stay, cost, readmissions, and patient quality of life?

Background: As payment models shift from volume- to value-based models, standardized clinical pathways are one option to simultaneously provide high-value care, improve quality, and control costs. Studies of individual clinical pathways suggest that they may be helpful in decreasing utilization, but the measured impact has varied significantly. It is unknown how much of the measured effect is due to the pathway and how much is due to the clinical factors of the disease or patient population studied. No prior studies have evaluated a suite of clinical pathways in pediatric populations.

Study design: Retrospective cohort study.

Setting: Single, 250-bed, tertiary care, freestanding children’s hospital.

Synopsis: Over four years, 15 clinical pathways were created for common pediatric medical, surgical, and psychiatric complaints (urinary tract infection, diabetes, both diabetic ketoacidosis [DKA] and non-DKA, fractures, spinal surgery, croup, neonatal jaundice, neonatal fever, depressive disorders, pyloric stenosis, pneumonia, tonsillectomy and adenoidectomy, disruptive behavior, and cellulitis/abscess).

The pathways were implemented when they were complete, with guidelines coming online throughout the study period. Implementation included an order set in the electronic medical record that included relevant literature references and decision support, online training, and integration into the clinical workflow for providers and nurses. Use of the pathways was monitored, and they were reviewed on at least a quarterly basis and revised, if necessary.

The authors examined pathway use for eligible patients, hospital costs, length of stay, 30-day readmissions, and parent-reported quality of life, both before and after pathway implementation. Patients meeting criteria for complex chronic conditions were excluded from the study.

Before implementation, 3,808 admissions fulfilled pathway criteria, and 2,902 fulfilled criteria after implementation. The pathway for depressive disorders was the most used pathway, with 411 admissions and 95% of eligible patients on the pathway. Both pyloric stenosis and neonatal jaundice had 100% pathway use.

The lowest rate of pathway use was for urinary tract infection (20%). Pathway implementation slowed the rate of rise of hospital costs. Prior to study implementation, the costs were increasing by $126 per month. Following implementation, costs decreased by $29 per month (95% CI, $100 decrease to $34 increase; P=.001). Post-implementation, the length of stay for pathway-eligible patients began a statistically significant downward trend at a rate that yielded a decrease in length of stay of 8.6 hours over a year (P=0.02). There were no differences in 30-day readmissions or parent-reported quality of life.

Bottom line: Systematic development and implementation of clinical pathways for a variety of conditions can contain costs and decrease length of stay while maintaining clinical outcomes and not increasing readmissions.

Citation: Lion KC, Wright DR, Spencer S, Zhou C, Del Beccaro M, Mangione-Smith R. Standardized clinical pathways for hospitalized children and outcomes. Pediatrics. 2016;137(4). pii:e20151202. doi:10.1542/peds.2015-1202.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question: Are patients with obstructive sleep apnea (OSA) and preoperative hypercapnia more likely to experience postoperative complications than those without?

Background: Obesity hypoventilation syndrome (OHS) is known to increase medical morbidity in patients with OSA, but its impact on postoperative outcome is unknown.

Study design: Retrospective cohort study.

Setting: Single tertiary-care center.

Synopsis: The study examined 1,800 patients with body mass index (BMI) ≥30 who underwent polysomnography, elective non-cardiac surgery (NCS), and had a blood gas performed. Of those, 194 patients were identified as having OSA with hypercapnia, and 325 were identified as having only OSA. Investigators found that the presence of hypercapnia in patients with OSA, whether from OHS, COPD, or another cause, was associated with worse postoperative outcomes. They found a statistically significant increase in postoperative respiratory failure (21% versus 2%), heart failure (8% versus 0%), tracheostomy (2% versus 1%), and ICU transfer (21% versus 6%). Mortality data did not reach significance.

The major limitation to the study is that hypercapnia is underrecognized in this patient population, and as a result, only patients who had a blood gas were included; many hypercapnic patients may have had elective NCS without receiving a blood gas and were thus excluded.

Bottom line: Consider performing a preoperative blood gas in patients with OSA undergoing elective NCS to help with postoperative complication risk assessment.

Citation: Kaw R, Bhateja P, Paz y Mar H, et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest. 2016;149(1):84-91 doi:10.1378/chest.14-3216.

Clinical question: Are patients with obstructive sleep apnea (OSA) and preoperative hypercapnia more likely to experience postoperative complications than those without?

Background: Obesity hypoventilation syndrome (OHS) is known to increase medical morbidity in patients with OSA, but its impact on postoperative outcome is unknown.

Study design: Retrospective cohort study.

Setting: Single tertiary-care center.

Synopsis: The study examined 1,800 patients with body mass index (BMI) ≥30 who underwent polysomnography, elective non-cardiac surgery (NCS), and had a blood gas performed. Of those, 194 patients were identified as having OSA with hypercapnia, and 325 were identified as having only OSA. Investigators found that the presence of hypercapnia in patients with OSA, whether from OHS, COPD, or another cause, was associated with worse postoperative outcomes. They found a statistically significant increase in postoperative respiratory failure (21% versus 2%), heart failure (8% versus 0%), tracheostomy (2% versus 1%), and ICU transfer (21% versus 6%). Mortality data did not reach significance.

The major limitation to the study is that hypercapnia is underrecognized in this patient population, and as a result, only patients who had a blood gas were included; many hypercapnic patients may have had elective NCS without receiving a blood gas and were thus excluded.

Bottom line: Consider performing a preoperative blood gas in patients with OSA undergoing elective NCS to help with postoperative complication risk assessment.

Citation: Kaw R, Bhateja P, Paz y Mar H, et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest. 2016;149(1):84-91 doi:10.1378/chest.14-3216.

Clinical question: Are patients with obstructive sleep apnea (OSA) and preoperative hypercapnia more likely to experience postoperative complications than those without?

Background: Obesity hypoventilation syndrome (OHS) is known to increase medical morbidity in patients with OSA, but its impact on postoperative outcome is unknown.

Study design: Retrospective cohort study.

Setting: Single tertiary-care center.

Synopsis: The study examined 1,800 patients with body mass index (BMI) ≥30 who underwent polysomnography, elective non-cardiac surgery (NCS), and had a blood gas performed. Of those, 194 patients were identified as having OSA with hypercapnia, and 325 were identified as having only OSA. Investigators found that the presence of hypercapnia in patients with OSA, whether from OHS, COPD, or another cause, was associated with worse postoperative outcomes. They found a statistically significant increase in postoperative respiratory failure (21% versus 2%), heart failure (8% versus 0%), tracheostomy (2% versus 1%), and ICU transfer (21% versus 6%). Mortality data did not reach significance.

The major limitation to the study is that hypercapnia is underrecognized in this patient population, and as a result, only patients who had a blood gas were included; many hypercapnic patients may have had elective NCS without receiving a blood gas and were thus excluded.

Bottom line: Consider performing a preoperative blood gas in patients with OSA undergoing elective NCS to help with postoperative complication risk assessment.

Citation: Kaw R, Bhateja P, Paz y Mar H, et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest. 2016;149(1):84-91 doi:10.1378/chest.14-3216.

Clinical question: How useful are rapid immunoassays (RIs) compared to other tests for heparin-induced thrombocytopenia (HIT)?

Background: HIT is a clinicopathologic diagnosis, which traditionally requires clinical criteria and laboratory confirmation through initial testing with enzyme-linked immunosorbent assay (ELISA) and “gold standard” testing with washed platelet functional assays when available. There are an increasing number of RIs available, which have lab turnaround times of less than one hour. Their clinical utility is not well understood.

Study design: Meta-analysis.

Setting: Twenty-three studies.

Synopsis: The authors found 23 articles to include for review. These studies included 5,637 unique patients and included heterogeneous (medical, surgical, non-ICU) populations. These articles examined six different rapid immunoassays, which have been developed in recent years. All RIs examined had excellent negative predictive values (NPVs) ranging from 0.99 to 1.00, though positive predictive values (PPVs) had much wider variation (0.42–0.71). The greatest limitation in this meta-analysis is that 17 of the studies were marked as “high risk of bias” because they did not compare the RIs to the “gold standard” assay.

Bottom line: RIs for the diagnosis of HIT have very high NPVs and may be usefully incorporated into the diagnostic algorithm for HIT, but they cannot take the place of “gold standard” washed platelet functional assays.

Citation: Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accuracy of rapid immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis [published online ahead of print January 14, 2016]. Thromb Haemost. doi:10.1160/TH15-06-0523.

Clinical question: How useful are rapid immunoassays (RIs) compared to other tests for heparin-induced thrombocytopenia (HIT)?

Background: HIT is a clinicopathologic diagnosis, which traditionally requires clinical criteria and laboratory confirmation through initial testing with enzyme-linked immunosorbent assay (ELISA) and “gold standard” testing with washed platelet functional assays when available. There are an increasing number of RIs available, which have lab turnaround times of less than one hour. Their clinical utility is not well understood.

Study design: Meta-analysis.

Setting: Twenty-three studies.

Synopsis: The authors found 23 articles to include for review. These studies included 5,637 unique patients and included heterogeneous (medical, surgical, non-ICU) populations. These articles examined six different rapid immunoassays, which have been developed in recent years. All RIs examined had excellent negative predictive values (NPVs) ranging from 0.99 to 1.00, though positive predictive values (PPVs) had much wider variation (0.42–0.71). The greatest limitation in this meta-analysis is that 17 of the studies were marked as “high risk of bias” because they did not compare the RIs to the “gold standard” assay.

Bottom line: RIs for the diagnosis of HIT have very high NPVs and may be usefully incorporated into the diagnostic algorithm for HIT, but they cannot take the place of “gold standard” washed platelet functional assays.

Citation: Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accuracy of rapid immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis [published online ahead of print January 14, 2016]. Thromb Haemost. doi:10.1160/TH15-06-0523.

Clinical question: How useful are rapid immunoassays (RIs) compared to other tests for heparin-induced thrombocytopenia (HIT)?

Background: HIT is a clinicopathologic diagnosis, which traditionally requires clinical criteria and laboratory confirmation through initial testing with enzyme-linked immunosorbent assay (ELISA) and “gold standard” testing with washed platelet functional assays when available. There are an increasing number of RIs available, which have lab turnaround times of less than one hour. Their clinical utility is not well understood.

Study design: Meta-analysis.

Setting: Twenty-three studies.

Synopsis: The authors found 23 articles to include for review. These studies included 5,637 unique patients and included heterogeneous (medical, surgical, non-ICU) populations. These articles examined six different rapid immunoassays, which have been developed in recent years. All RIs examined had excellent negative predictive values (NPVs) ranging from 0.99 to 1.00, though positive predictive values (PPVs) had much wider variation (0.42–0.71). The greatest limitation in this meta-analysis is that 17 of the studies were marked as “high risk of bias” because they did not compare the RIs to the “gold standard” assay.

Bottom line: RIs for the diagnosis of HIT have very high NPVs and may be usefully incorporated into the diagnostic algorithm for HIT, but they cannot take the place of “gold standard” washed platelet functional assays.

Citation: Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accuracy of rapid immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis [published online ahead of print January 14, 2016]. Thromb Haemost. doi:10.1160/TH15-06-0523.

Clinical question: Is a delay in completion of hospital discharge summary associated with hospital readmissions?

Background: Inpatient discharge summaries serve as a communication tool to future care providers. Previous studies have shown mixed impact on the timeliness of discharge summaries on hospital readmissions.

Study design: Retrospective cohort study.

Setting: Adult medical patients at Johns Hopkins University Hospital, Baltimore.

Synopsis: Study authors examined the time between hospital discharge and discharge summary completion on 87,994 hospitalizations to assess whether a delay increased the odds of hospital readmission. In those hospitalizations, 14,248 patients (16.2%) were readmitted within 30 days of discharge. There was a statistically significant adjusted odds ratio of 1.09 (P=0.001) for readmission associated with discharge summaries completed more than three days after discharge.

The main advantage of the study is that the investigators reviewed a large number of hospitalizations. The major limitation is that deaths or admissions to other hospitals within 30 days of discharge were not measured.

Bottom line: Completing a discharge summary within three days of discharge may decrease the risk of 30-day readmission.

Citation: Hoyer EH, Odonkor CA, Bhatia SN, Leung C, Deutschendorf A, Brotman DJ. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland [published online ahead of print February 23, 2016]. J Hosp Med. doi:10.1002/jhm.2556

Short Take

Effectiveness of Rapid Response Teams

A meta-analysis of 30 eligible studies evaluating the impact of rapid response teams (RRTs) from 2000 to 2016 found that RRTs are effective at reducing both in-hospital cardiac arrest and hospital mortality.

Citation: Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis [published online ahead of print Febraury 1, 2016]. J Hosp Med. doi:10.1002/jhm.2554.

Clinical question: Is a delay in completion of hospital discharge summary associated with hospital readmissions?

Background: Inpatient discharge summaries serve as a communication tool to future care providers. Previous studies have shown mixed impact on the timeliness of discharge summaries on hospital readmissions.

Study design: Retrospective cohort study.

Setting: Adult medical patients at Johns Hopkins University Hospital, Baltimore.

Synopsis: Study authors examined the time between hospital discharge and discharge summary completion on 87,994 hospitalizations to assess whether a delay increased the odds of hospital readmission. In those hospitalizations, 14,248 patients (16.2%) were readmitted within 30 days of discharge. There was a statistically significant adjusted odds ratio of 1.09 (P=0.001) for readmission associated with discharge summaries completed more than three days after discharge.

The main advantage of the study is that the investigators reviewed a large number of hospitalizations. The major limitation is that deaths or admissions to other hospitals within 30 days of discharge were not measured.

Bottom line: Completing a discharge summary within three days of discharge may decrease the risk of 30-day readmission.

Citation: Hoyer EH, Odonkor CA, Bhatia SN, Leung C, Deutschendorf A, Brotman DJ. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland [published online ahead of print February 23, 2016]. J Hosp Med. doi:10.1002/jhm.2556

Short Take

Effectiveness of Rapid Response Teams

A meta-analysis of 30 eligible studies evaluating the impact of rapid response teams (RRTs) from 2000 to 2016 found that RRTs are effective at reducing both in-hospital cardiac arrest and hospital mortality.

Citation: Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis [published online ahead of print Febraury 1, 2016]. J Hosp Med. doi:10.1002/jhm.2554.

Clinical question: Is a delay in completion of hospital discharge summary associated with hospital readmissions?

Background: Inpatient discharge summaries serve as a communication tool to future care providers. Previous studies have shown mixed impact on the timeliness of discharge summaries on hospital readmissions.

Study design: Retrospective cohort study.

Setting: Adult medical patients at Johns Hopkins University Hospital, Baltimore.

Synopsis: Study authors examined the time between hospital discharge and discharge summary completion on 87,994 hospitalizations to assess whether a delay increased the odds of hospital readmission. In those hospitalizations, 14,248 patients (16.2%) were readmitted within 30 days of discharge. There was a statistically significant adjusted odds ratio of 1.09 (P=0.001) for readmission associated with discharge summaries completed more than three days after discharge.

The main advantage of the study is that the investigators reviewed a large number of hospitalizations. The major limitation is that deaths or admissions to other hospitals within 30 days of discharge were not measured.

Bottom line: Completing a discharge summary within three days of discharge may decrease the risk of 30-day readmission.

Citation: Hoyer EH, Odonkor CA, Bhatia SN, Leung C, Deutschendorf A, Brotman DJ. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland [published online ahead of print February 23, 2016]. J Hosp Med. doi:10.1002/jhm.2556

Short Take

Effectiveness of Rapid Response Teams

A meta-analysis of 30 eligible studies evaluating the impact of rapid response teams (RRTs) from 2000 to 2016 found that RRTs are effective at reducing both in-hospital cardiac arrest and hospital mortality.

Citation: Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis [published online ahead of print Febraury 1, 2016]. J Hosp Med. doi:10.1002/jhm.2554.

Clinical question: Does assigning a single medical team to a nursing unit (regionalizing) improve communication and prevent adverse events?

Background: Many factors impact communication in healthcare delivery. Failures in communication are a known source of adverse events in hospital care. Previous studies of the impact of regionalized care (assigning medical physician teams to nursing units) on communication and outcomes have had mixed results.

Study design: Pre-post intervention cohort analysis.

Setting: Brigham and Women’s Hospital, Boston.

Synopsis: Three medical teams were assigned to 15-bed nursing units with structured multidisciplinary meeting times for one year. Assessments of concordance of care plan and adverse event detection (with a focus on adverse drug events and poor glycemic control) were performed before and after this assignment. Regionalization of care in the study site improved recognition of care team members (0.56 versus 0.86; P<0.001), discussion of care plan (0.73 versus 0.88; P<0.001), and agreement on estimated discharge date (0.56 versus 0.68; P<0.003). However, it did not significantly improve nurse and physician concordance of the plan or reduce the odds of preventable adverse events.

This study may not have captured an impact on more subtle adverse events or other aspects of interprofessional relationships that enhance patient care.

Bottom line: Regionalization effectively promotes communication but may not lead to patient safety improvements.

Citation: Mueller SK, Schnipper JL, Giannelli K, Roy CL, Boxer R. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services [published online ahead of print February 24, 2016]. J Hosp Med. doi:10.1002/jhm.2566.

Clinical question: Does assigning a single medical team to a nursing unit (regionalizing) improve communication and prevent adverse events?

Background: Many factors impact communication in healthcare delivery. Failures in communication are a known source of adverse events in hospital care. Previous studies of the impact of regionalized care (assigning medical physician teams to nursing units) on communication and outcomes have had mixed results.

Study design: Pre-post intervention cohort analysis.

Setting: Brigham and Women’s Hospital, Boston.

Synopsis: Three medical teams were assigned to 15-bed nursing units with structured multidisciplinary meeting times for one year. Assessments of concordance of care plan and adverse event detection (with a focus on adverse drug events and poor glycemic control) were performed before and after this assignment. Regionalization of care in the study site improved recognition of care team members (0.56 versus 0.86; P<0.001), discussion of care plan (0.73 versus 0.88; P<0.001), and agreement on estimated discharge date (0.56 versus 0.68; P<0.003). However, it did not significantly improve nurse and physician concordance of the plan or reduce the odds of preventable adverse events.

This study may not have captured an impact on more subtle adverse events or other aspects of interprofessional relationships that enhance patient care.

Bottom line: Regionalization effectively promotes communication but may not lead to patient safety improvements.

Citation: Mueller SK, Schnipper JL, Giannelli K, Roy CL, Boxer R. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services [published online ahead of print February 24, 2016]. J Hosp Med. doi:10.1002/jhm.2566.

Clinical question: Does assigning a single medical team to a nursing unit (regionalizing) improve communication and prevent adverse events?

Background: Many factors impact communication in healthcare delivery. Failures in communication are a known source of adverse events in hospital care. Previous studies of the impact of regionalized care (assigning medical physician teams to nursing units) on communication and outcomes have had mixed results.

Study design: Pre-post intervention cohort analysis.

Setting: Brigham and Women’s Hospital, Boston.

Synopsis: Three medical teams were assigned to 15-bed nursing units with structured multidisciplinary meeting times for one year. Assessments of concordance of care plan and adverse event detection (with a focus on adverse drug events and poor glycemic control) were performed before and after this assignment. Regionalization of care in the study site improved recognition of care team members (0.56 versus 0.86; P<0.001), discussion of care plan (0.73 versus 0.88; P<0.001), and agreement on estimated discharge date (0.56 versus 0.68; P<0.003). However, it did not significantly improve nurse and physician concordance of the plan or reduce the odds of preventable adverse events.

This study may not have captured an impact on more subtle adverse events or other aspects of interprofessional relationships that enhance patient care.

Bottom line: Regionalization effectively promotes communication but may not lead to patient safety improvements.

Citation: Mueller SK, Schnipper JL, Giannelli K, Roy CL, Boxer R. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services [published online ahead of print February 24, 2016]. J Hosp Med. doi:10.1002/jhm.2566.

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.