Monthly Archives: November 2014

Fewer than 1 in 5 elders survive in-hospital CPR

Clinical Question

What are the outcomes of cardiopulmonary resuscitation in hospitalized elders?

Bottom Line

In general, hospitalized elders undergoing cardiopulmonary resuscitation (CPR) have an approximately 1 in 5 chance of surviving to hospital discharge. Among those who survive, nearly 80% will die in the following year. There is very little data about the functional outcomes of CPR and whether the elders are able to return to the community. (LOE = 2a)

Reference

van Gijn MS, Frijns D, van de Glind EM, van Munster BC, Hamaker ME. The chance of survival and the functional outcome after in-hospital cardiopulmonary resuscitation in older people: a systematic review. Age Ageing 2014;43(4):456-463.
Study Design Systematic review Funding Unknown/not stated
Setting Inpatient (ward only) Allocation Unknown

Synopsis

These authors searched several databases to find studies that described outcomes, including social status and functional outcome, of hospitalized elderly patients undergoing CPR. A single author screened all potential studies for possible inclusion and 2 authors independently determined their inclusion. Similarly, 2 authors independently assessed the quality of the included studies and a third member of the team resolved all disagreements. They ultimately included 29 studies with more than 400,000 hospitalized elders. The majority of studies were of fair quality. Ten studies reported that approximately 39% of elders had return of spontaneous circulation (range = 21% – 58%). The rate of survival to hospital discharge for patients aged between 70 years and 79 years was 19% (range = 8% – 36%); for those aged 80 to 89 years, 15% (range = 4% – 31%); and for elders older than 90 years,12% (range = 0 – 50%). Overall, more than half of patients who survived the CPR died before discharge. Only 5 small studies assessed what happened to those patients more than 6 months after hospital discharge: Between 7% and 20% were still alive after 1 year. These data are similar to the results from other systematic reviews that evaluated CPR outcomes in more diverse age groups and settings.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
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Increasing HDL level ineffective at decreasing cardiovascular events

Does treatment aimed at increasing high-density lipoprotein levels, in addition to treatment with statins, decrease cardiovascular events and deaths due to any cause?

Bottom Line

I guess being the “good” cholesterol is not the same as being the “useful” cholesterol. Drug therapy aimed at increasing high-density lipoprotein (HDL) cholesterol levels, when added to statin treatment, does not decrease patients’ likelihood of experiencing a cardiovascular event or dying earlier. (LOE = 1a)

Reference

Keene D, Price C, Shun-Shin MJ, Francis DP. Effect on cardiovascular risk of high density lipoprotein targeted drug treatments niacin, fibrates, and CETP inhibitors: meta-analysis of randomised controlled trials including 117 411 patients. BMJ 2014;349:g4379 doi: 10.1136/bmj.g4379.

Study Design: Meta-analysis (randomized controlled trials) Funding: Self-funded or unfunded
Setting: Various (meta-analysis) Allocation: Unknown

Synopsis

The researchers searched 3 databases, including the Cochrane Library, reference lists of previous meta-analyses and reviews, and conference proceedings to find large (> 1000 patients) randomized trials that compared drugs aimed at increasing HDL cholesterol levels with various interventions that do not increase HDL. Two authors independently completed the searches and 3 authors extracted the data. They found 11 studies of niacin, 20 of fibrates, and 8 studies of cholesteryl ester transfer protein (CETP) inhibitors such as anacetrapib and dalcetrapib (this class of drugs is not available in the United States, Canada, or the United Kingdom). All told, the studies enrolled more than 100,000 patients and found that attempting to increase the HDL level conferred no benefit on all-cause mortality, coronary heart disease mortality, or stroke likelihood. The problem, if you want to call it that, is the effect of statins — studies conducted in the current “statin era” do not show an added benefit of trying to bump HDL levels even though early studies of niacin by itself showed a pronounced effect in reducing nonfatal myocardial infarction.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Hospitalist discontinuity associated with higher cost

Does hospitalist discontinuity during an inpatient stay affect cost, readmissions, or patient satisfaction?

Bottom Line:

Hospitalist discontinuity may lead to an increase in total hospital costs. The authors of this study postulate that this could be due to additional testing or treatments or new clinical issues identified by hospitalist physicians when they take over care from their colleagues. (LOE = 2b-)

Reference

Turner J, Hansen L, Hinami K, et al. The impact of hospitalist discontinuity on hospital cost, readmissions, and patient satisfaction. J Gen Intern Med 2014;29(7):1004-1008.

Study Design: Cohort (retrospective) Funding: Other
Setting: Inpatient (any location) with outpatient follow-up Allocation: Uncertain

Synopsis

To assess for physician discontinuity during a hospitalization, these authors used 2 measures: (1) the Number of Physicians Index (NPI), which accounts for the total number of unique hospitalist physicians caring for a patient, and (2) the Usual Provider of Continuity Index (UPC), which calculates the largest number of patient encounters by a single hospitalist physician divided by the total number of encounters. A higher NPI and a lower UPC suggest greater discontinuity. All patients admitted to the hospitalist service during a 3.5-year period, except for those transferred from other services such as the intensive care unit, were included in the study. A physician was defined as caring for a patient if he or she wrote an admission note or progress note during the hospitalization. Nocturnists were not included in this calculation. Outcomes assessed in this study were total costs of hospitalization (excluding physician charges), 30-day readmissions, and patient satisfaction with physician communication using patients’ responses to three questions from the Hospital Consumer Assessment of Healthcare Providers and Systems survey. A positive outcome for patient satisfaction was defined as top box responses to all three questions. The baseline cohort consisted of approximately 18,000 hospitalizations with a mean NPI of 1.9 and a mean UPC of 0.75. Median hospital cost was $6300 per hospitalization and the 30-day readmission rate was 22%. Only 8.5% of patients answered all 3 of the patient satisfaction questions and of these, 63% had top box responses for all 3 questions. After adjusting for covariates, including demographic variables, case mix, Diagnosis Related Group (DRG) weight, and length of stay, a 1-unit increase in NPI was associated with a 0.9% higher median cost (P < .001). Alternative models categorizing DRG weight and length of stay into quartiles also showed higher costs with a 1-unit increase in NPI (8% cost increase; P < .001) and with a 0.1-unit decrease in UPC (12.6% cost increase; P < .001). For the readmissions outcome, although a 0.1-unit decrease in UPC was associated with a small decrease in 30-day readmissions (odds ratio = 0.97; 95% CI, 0.95-0.99), the other 3 models did not corroborate this finding. No statistically significant correlation was found between hospitalist discontinuity and patient satisfaction; however, the study may have been underpowered to detect this given the low number of respondents to the patient satisfaction survey.

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