In the Literature

The Hospitalist. 2009 November;2009(11):

November 1, 2009|The Hospitalist

Robert Chang, MD;Nabil Alkhoury-Fallouh, MD;Anita Hart, MD;Hae-Won Kim, MD;Francis McBee-Orzulak, MD;Helena Pasieka, MD;Division Of General Medicine, University Of Michigan, Ann Arbor

In This Edition

Literature at a Glance

A guide to this month’s studies

CPOE and quality outcomes
Outcomes of standardized management of endocarditis
Effect of tPA three to 4.5 hours after stroke onset
Failure to notify patients of significant test results
PFO repair and stroke rate
Predictors of delay in defibrillation for in-hospital arrest
H. pylori eradication and risk of future gastric cancer
Bleeding risk with fondaparinux vs. enoxaparin in ACS
Perceptions of physician ability to predict medical futility

Clinical Short

PPI USE IN PATIENTS WITHOUT AN INDICATION CAN CAUSE ACID-RELATED SYMPTOMS

In a randomized, controlled trial of 120 healthy volunteers, the use of a PPI for eight weeks resulted in acid-related symptoms within the four weeks after withdrawal of the PPI. At 12 weeks, 21% of patients in the prior PPI group had symptoms, compared with 2% in the control group.

Citation: Reimer C, Søndergaard B, Hilsted L, Bytzer P. Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology. 2009;137(1):80–87.

CPOE Is Associated with Improvement in Quality Measures

Clinical question: Is computerized physician order entry (CPOE) associated with improved outcomes across a large, nationally representative sample of hospitals?

Background: Several single-institution studies suggest CPOE leads to better outcomes in quality measures for heart failure, acute myocardial infarction, and pneumonia as defined by the Hospital Quality Alliance (HQA) initiative, led by the Centers for Medicare and Medicaid Services (CMS). Little systematic information is known about the effects of CPOE on quality of care.

Study design: Cross-sectional study.

Setting: The Health Information Management System Society (HIMSS) analytics database of 3,364 hospitals throughout the U.S.

Synopsis: Of the hospitals that reported CPOE utilization to HIMSS, 264 (7.8%) fully implement CPOE throughout their institutions. These CPOE hospitals outperformed their peers on five of 11 quality measures related to ordering medications, and in one of nine non-medication-related measures. No difference was noted in the other measures, except CPOE hospitals were less effective at providing antibiotics within four hours of pneumonia diagnosis. Hospitals that utilized CPOE were generally academic, larger, and nonprofit. After adjusting for these differences, benefits were still preserved.

The authors indicate that the lack of systematic outperformance by CPOE hospitals in all 20 of the quality categories inherently suggests that other factors (e.g., concomitant QI efforts) are not affecting these results. Given the observational nature of this study, no causal relationship can be established between CPOE and the observed benefits. CPOE might represent the commitment of certain hospitals to quality measures, but further study is needed.

Bottom line: Enhanced compliance in several CMS-established quality measures is seen in hospitals that utilize CPOE throughout their institutions.

Citation: Yu FB, Menachemi N, Berner ES, Allison JJ, Weissman NW, Houston TK. Full implementation of computerized physician order entry and medication-related quality outcomes: a study of 3,364 hospitals. Am J Med Qual. 2009;24(4):278-286.

Clinical Shorts

ANTIBIOTICS WITHIN 30 MINUTES OF SURGERY MAY REDUCE SURGICAL SITE INFECTION RISK

A multicenter, collaborative, prospective study showed a trend toward lower risk of surgical site infection when antimicrobial prophylaxis were given within 30 minutes prior to incision.

Citation: Steinberg JP, Braun BI, Hellinger WC, et al. Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the Trial to Reduce Antimicrobial Prophylaxis Errors. Ann Surg. 2009;250(1):10-16.

WEIGHT EXTREMES PREDICT WORSE OUTCOMES FOR NONBARIATRIC SURGERY

Prospective study of 118,707 patients undergoing non-bariatric surgery showed the risk of death is highest in the underweight and morbidly obese extremes, and lowest in the overweight and moderately obese.

Citation: Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing non-bariatric general surgery. Ann Surg. 2009;250(1):166–172.

CHEST PAIN IS NOT PREDICTIVE FOR AN ACUTE CORONARY SYNDROME WITH A NORMAL EKG

Among patients presenting to the ED with a chief complaint of chest pain, there was no difference in the frequency of acute coronary syndrome between patients with chest pain at the time of acquisition of a normal electrocardiogram and those without chest pain during acquisition of a normal electrocardiogram.

Citation: Turnipseed SD, Trythall WS, Diercks DB, et al. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med. 2009;16(6):495-499.

“LEFT” RULE HIGHLIGHTS THREE VARIABLES THAT PREDICT DVT IN PREGNANCY

Observational study of 194 patients reported an increased risk of DVT in patients with left-side symptoms, swelling greater than 2 cm in the symptomatic leg, and the first trimester of pregnancy.

Citation: Chan WS, Lee A, Spencer FA, et al. Predicting deep venous thrombosis in pregnancy: out in “LEFt” field? Ann Intern Med. 2009;151(2):85-92.

AIR POLLUTION MAY CONTRIBUTE TO DVT FORMATION

In this case-control study of 663 participants with DVT and 859 age-matched controls without a DVT, the odds of DVT were 1.33 in those near a major road, compared with those who were not.

Citation: Baccarelli A, Martinelli I, Pegoraro V, et al. Living near major traffic roads and the risk of deep vein thrombosis. Circulation. 2009;119(24):3118-3124.