Monthly Archives: July 2014

Increase in hospitalist workload associated with higher LOS and cost

Does increased hospitalist workload affect efficiency and quality of care?

Bottom Line

Increased hospitalist workload is associated with increased cost and length of stay (LOS). Quality metrics such as 30-day readmission rate, in-hospital mortality, and patient satisfaction were not affected by changes in workload.(LOE = 2b)

Reference

Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med 2014;174(5):786-793. Deveraux PJ, Mrkobrada M, Sessler DI et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med 2014;370:1504-1513.

Study Design: Cohort (retrospective)
Funding: Other
Setting: Inpatient (any location)
Allocation: Uncertain

Synopsis

Using data abstracted from the central data warehouse of an academic community health system, these authors examined the association between hospitalist workload and the efficiency and quality of care provided. A private hospitalist group that provided 24-hour care to patients at 2 hospitals within the system was selected for the study. Patients included were those who either had an attending of record or had admission and discharge bills submitted by a physician in this hospitalist group. Physician daily workload was measured using the total number of relative value units (RVUs) generated and the physician’s census as determined by the number of billable encounters submitted. Efficiency was measured by LOS and cost. Quality was measured by in-hospital mortality, rapid response team activation, 30-day readmission rate, and patient satisfaction. Models were adjusted for patient characteristics, including demographics; severity of illness; visit characteristics, including admission day of the week; and hospital-level characteristics, including hospital occupancy. Approximately 20,000 hospitalizations were included in the study. Hospitalists had a mean of 15.5 patient encounters and 28.6 RVUs per day. Results for LOS were stratified by hospital occupancy. For less than 75% occupancy, LOS increased linearly from 5.5 days to 7.5 days as workload increased. For greater than 85% occupancy, the change in LOS was J-shaped with a significant increase around an RVU of 30 or a census of 17. Cost also increased with higher workloads. For every unit increase in RVU, cost increased by $111; for every unit increase in census, cost increased by $205 (after adjustment for LOS). There were no significant associations with change in workload and patient satisfaction, in-hospital mortality, rapid response team activation, or 30-day readmission rate.

Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL

Neither anti-inflammatory nor antibiotic treatment significantly shortens duration of cough in acute bronchitis compared with placebo

The blog post below was excerpted from the British Medical Journal (http://ebm.bmj.com)
Commentary on: , Moragas , Bayona , . Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial. BMJ ;:f5762. Search Google Scholar

Context

Respiratory tract infections exert a significant burden on society through resultant school and employment absences and demand on primary care services. Most episodes are caused by respiratory viruses such as rhinovirus. Not only are there no effective antiviral drugs available to treat such infections, but our ability to manage their symptoms, especially cough, remains poor. Antibiotics are widely prescribed for acute bronchitis in primary care settings, even though their use demonstrates negligible effects on illness duration and correlates poorly with the presence of bacterial infection.1 2 Ineffective antibiotic use results in unnecessary cost and exposure for patients, and leads to greater bacterial resistance to antibiotics. Llor and colleagues hypothesise that airway inflammation in acute bronchitis may respond to non-steroidal anti-inflammatory drugs (NSAIDs). Although one study found no evidence that they reduce the duration of cough in the common cold,3 NSAIDs are often used for symptomatic benefits. A robust study to assess their effect on cough symptoms has not previously been reported. This study took the novel step of comparing the effect of NSAIDs against the broad-spectrum antibiotic co-amoxiclav and placebo.

Method

This was a single-blind, placebo-controlled, parallel group study conducted in nine primary care centres in Spain. The study assessed acute bronchitis, defined as a respiratory infection of less than 1 week in duration with cough, discoloured sputum and at least one other lower respiratory tract symptom, such as breathlessness, wheezing and chest pain and/or discomfort. Patients were aged 18–70 years. The key exclusion criteria included the presence of radiologically confirmed pneumonia; ‘severe illness’, according to the predefined clinical criteria; and a significant comorbidity (including asthma, chronic obstructive pulmonary disease and immunosuppression). Patients were randomised to thrice-daily treatment groups of either amoxicillin-clavulanic acid 500/125 mg, ibuprofen 600 mg or placebo for 10 days. Patients were blind to the intervention. The primary outcome was the number of days following randomisation that cough was still recorded by the patient on a daily diary card. The power calculation determined a clinically significant change in the cough duration as a difference of 2 days from placebo.

Findings

A total of 416 patients were randomised into the three treatment arms. Fifty-six per cent were women, while the mean age was 45.1 years (with SD of 14.3). The overall mean duration of cough was 10 days (95% CI 9 to 11). The mean duration for the ibuprofen group was 9 days (95% CI 8 to 10), versus 11 days for co-amoxiclav (95% CI 10 to 12) and 11 for placebo (95% CI 8 to 14). A logrank test result was 0.25.

The overall absence of clear benefit was similar across adjusted models and various secondary outcomes, including overall symptom duration and a measure of ‘clinical success’. Adverse events were significantly more common in the antibiotic group (12%) compared with the ibuprofen arm (5%) and patients receiving placebo (3%; p=0.008).

Commentary

This study adds to the weight of evidence against using antibiotics for self-limiting acute bronchitis and also provides evidence that the use of NSAIDs will not reduce the duration of cough in this condition.

The most important limitation is the exclusion of patients with comorbidities, those aged over 70 and those in residential care—groups presenting commonly and in whom, perhaps, any benefit might be greatest. The usefulness of the complete absence of cough as the primary endpoint is questionable. The duration of symptoms is likely important to patients but a reduction in symptom intensity might also allow an earlier return to usual activity. Assessing symptoms is challenging, with overall burden representing a complex composite of severity and duration. Perhaps, also, the treatment was started too late; there was a 4-day average delay between the symptom onset and the start of therapy. Moreover, the authors note that NSAIDs may be prescribed to reduce other symptoms such as chest discomfort—the decision not to collect data examining this perhaps represents a missed opportunity.

The study was single-blind, therefore the investigators were aware of the treatment allocation. This reflected the expense of manufacturing identical preparations in investigator-led studies and does not appear to have led to bias, given the similar outcomes between treatment arms.

In conclusion, it is clear that antibiotics and NSAIDs should not be used routinely to treat cough in acute bronchitis in patients under the age of 70 without comorbidity. That is not to downplay the importance of such circumstances; there remains a real and urgent need to develop effective therapies to reduce the burden of acute bronchitis and other viral infections of the respiratory tract.

Footnotes

  • Competing interests None.

References

Macfarlane ,Holmes , Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community. Thorax ;:–.
Raherison , Peray , Poirier , Management of lower respiratory tract infections by French general practitioners: the AIR II study. Analyse infections respiratoires. Eur Respir J;:
Chang ,Non-steroidal a Cochrane review recently found no evidence that they reduce duration of cough in the common cold (3). Anti-inflammatory drugs for the common cold. Cochrane Database Syst Rev ;:CD006362.

What long term treatment best prevents asthma exacerbations?

Loymans RJ, Gemperli A, Cohen J, et al. “Comparative effectiveness of long term drug treatment strategies to prevent asthma exacerbations: network meta-analysis.” BMJ. 2014 May 13;348:g3009. doi: 10.1136/bmj.g3009

OBJECTIVE: To determine the comparative effectiveness and safety of current maintenance strategies in preventing exacerbations of asthma.

DESIGN: Systematic review and network meta-analysis using Bayesian statistics.

DATA SOURCES: Cochrane systematic reviews on chronic asthma, complemented by an updated search when appropriate.

ELIGIBILITY CRITERIA: Trials of adults with asthma randomised to maintenance treatments of at least 24 weeks duration and that reported on asthma exacerbations in full text. Low dose inhaled corticosteroid treatment was the comparator strategy. The primary effectiveness outcome was the rate of severe exacerbations. The secondary outcome was the composite of moderate or severe exacerbations. The rate of withdrawal was analysed as a safety outcome.

RESULTS: 64 trials with 59 622 patient years of follow-up comparing 15 strategies and placebo were included. For prevention of severe exacerbations, combined inhaled corticosteroids and long acting beta agonists as maintenance and reliever treatment and combined inhaled corticosteroids and long acting beta agonists in a fixed daily dose performed equally well and were ranked first for effectiveness. The rate ratios compared with low dose inhaled corticosteroids were 0.44 (95% credible interval 0.29 to 0.66) and 0.51 (0.35 to 0.77), respectively. Other combined strategies were not superior to inhaled corticosteroids and all single drug treatments were inferior to single low dose inhaled corticosteroids. Safety was best for conventional best (guideline based) practice and combined maintenance and reliever therapy.

CONCLUSIONS: Strategies with combined inhaled corticosteroids and long acting beta agonists are most effective and safe in preventing severe exacerbations of asthma, although some heterogeneity was observed in this network meta-analysis of full text reports.