The latest research you need to know

The Hospitalist. 2009 May;2009(05):

May 1, 2009 | The Hospitalist

Brian Uthlaut, MD ; Benjamin Sneed, MD ; Lindsay Friesen, MD ; Joshua Barclay, MD ; George Hoke, MD ; Section OF

EMR Equals Lower Mortality, Fewer Complications, Lower Costs

Clinical question: Is improved automation of hospital information associated with reduced rates of inpatient mortality, complications, cost, and length of stay (LOS)?

Background: Clinical information technologies, including electronic medical records (EMR), are touted as an antidote for the fragmented, unsafe, and expensive American healthcare system. Most studies on the effect of such technologies are limited to a single site, and few involve commercially available information systems.

Study design: Cross-sectional study.

Setting: Urban hospitals in Texas.

Synopsis: Researchers used the previously validated Clinical Information Technology Assessment Tool to survey physicians providing inpatient care in 72 Texas hospitals. This tool measures the degree to which clinical information processes are computerized. Automation is divided into four subdomains: test results, notes and records, order entry, and decision support. To achieve a high score, a process must be fully computerized, the physician must know how to activate it, and the physician must choose the computerized process over alternatives. The authors examined the association between a hospital’s degree of automation and mortality, costs, and LOS among patients with myocardial infarction, congestive heart failure, coronary artery bypass grafting, and pneumonia.

Overall, greater automation was associated with lower mortality, fewer complications, and lower costs. No clear impact on LOS was found. Higher scores in the notes and records subdomains were most associated with lower mortality. Higher decision-support scores were most associated with lower complication rates and costs.

This study is one of the first to demonstrate the benefits of clinical information technologies across a variety of institutions using different information systems.

Bottom line: Hospitals with EMR, order entry, and clinical decision support have lower mortality rates, fewer complications, and lower costs.

Citation: Amarasingham R, Plantinga L, Diener-West M, et al. Clinical information technologies and inpatient outcomes. Arch Intern Med. 2009;169(2):108-114.

Short Takes

HIGHER CLOPIDOGREL DOSE ISN’T BETTER

This randomized trial demonstrated no benefit from a 600-mg loading dose of clopidogrel versus 300 mg for patients with an acute coronary syndrome managed with an early invasive strategy.

Citation: Yong G, Rankin J, Ferguson L, et al. Randomized trial comparing 600-mg with 300-mg loading dose of clopidogrel in patients with non-ST elevation acute coronary syndrome undergoing percutaneous coronary intervention: results of the Platelet Responsiveness to Aspirin and Clopidogrel and Troponin Increment after Coronary intervention in Acute coronary Lesions (PRACTICAL) trial. Am Heart J. 2009;157(1):60.e1-9.

BNP-GUIDED HEART FAILURE MANAGEMENT NO BETTER THAN SYMPTOM-GUIDED TREATMENT

This randomized, controlled trial demonstrated that intensified treatment for congestive heart failure based on BNP levels did not improve 18-month survival free of hospitalization or improve quality of life compared with symptom-guided therapy.

Citation: Pfisterer M, Buser P, Rickli, H, et al. BNP-guided vs. symptom-guided heart failure therapy. JAMA. 2009;301(4)383-392.

RESIDENTS STILL SLEEPY DESPITE DUTY-HOUR RESTRICTIONS

Observational study of 20 medical ICU residents suggests severe objective and subjective sleepiness on the post-call day despite adherence to duty-hour restrictions.

Citation: Reddy R, Guntupalli K, Alapat P, Surani S, et al. Sleepiness in medical ICU residents. Chest. 2009;135(1):81-85.

NEPHROTOXICITY OF GENTAMICIN IS ASSOCIATED WITH DURATION OF TREATMENT, BUT NOT WITH POST-DISCHARGE MORTALITY

Observational cohort study shows that each day of gentamicin treatment for infective endocarditis results in 0.5% decrease in endogenous creatinine clearance; this nephrotoxic effect was not associated with post-discharge mortality.

Citation: Buchholtz K, Larsen CT, Hassager C, et al. Severity of gentamicin’s nephrotoxic effect on patients with infective endocarditis: a prospective observational cohort study of 373 patients. Clin Infec Dis. 2009;48:65-71.

VASOPRESSIN-EPINEPHRINE AND CORTICOSTEROID COMBO IS EFFECTIVE IN CARDIAC ARREST

Randomized, controlled trial of 100 in-hospital cardiac arrest patients demonstrated robust improvement in return of spontaneous circulation and survival to discharge with combined vasopressin-epinephrine supplemented by corticosteroids during and after resuscitation.

Citation: Mentzelopoulos S, Zakynthinos S, Tzoufi M, et al. Vasopressin, epinephrine, and corticosteroids for in-hospital cardiac arrest. Arch Intern Med. 2009;169(1):15-24.

ACUTE KIDNEY INJURY AFTER INITIATION OF NSAIDS IN ELDERLY IS RELATIVELY UNCOMMON, BUT AGENTS VARY IN RISK OF HARM

Retrospective, population-based study of elderly patients shows low occurrence (0.47%) of acute kidney injury requiring hospitalization after NSAID initiation, but reveals significant increase in risk with use of rofecoxib, indomethacin, and ibuprofen.

Citation: Winkelmayer W, Waikar S, Mogun H, et al. Non-selective and cyclooxygenase-2-selective NSAIDs and acute kidney injury. Am J Med. 2008;121:1092-1098.

VITAMIN E AND VITAMIN C DO NOT REDUCE CARDIOVASCULAR EVENTS

Prospective, randomized, double-blind, placebo-controlled clinical trial of vitamin 400 IU vitamin E and 500 mg vitamin C, involving 14,641 men, did not show a reduced risk of major cardiovascular events.

Citation: Sesso H, Buring J, Christen W, et al. Vitamins E and C in the prevention of cardiovascular disease in men: the physicians’ health study II randomized controlled trial. JAMA. 2008;300(18):2123-2133.

INVESTIGATION NEEDED TO CLEARLY DEFINE ROLE OF CTA IN DIAGNOSIS OF PAD

Systematic review/meta-analysis shows accuracy of computed tomography angiography (CTA) in assessing presence and extent of peripheral arterial disease (PAD), but its appropriate application in the setting of particular patient populations and alternative diagnostic modalities needs further investigation.

Citation: Met R, Bipat S, Legemate DA, et al. Diagnostic performance of computed tomography angiography in peripheral arterial disease: a systematic review and meta-analysis. JAMA. 2009;301:415-424.