In the Literature: HM-Related Research You Need to Know

The Hospitalist. 2010 October;2010(10):

October 1, 2010|The Hospitalist

In This Edition

Literature at a Glance

A guide to this month’s studies

Effect of early follow-up on readmission rates
Heart rate control and outcomes in atrial fibrillation
Pneumococcal vaccine to prevent stroke and MI
Long-term outcomes of endovascular repair of AAA
Insurance and outcomes in myocardial infarction
Risk of gastrointestinal bleeding and cardiovascular outcomes with concurrent PPI and clopidogrel use
CT in patients with suspected coronary artery disease

Reduced 30-Day Readmission Rate for Patients Discharged from Hospitals with Higher Rates of Early Follow-Up

Clinical question: Is early follow-up after discharge for heart failure associated with a reduction in readmission rates?

Background: Readmission for heart failure is very frequent and often unplanned. Early follow-up visits after discharge have been hypothesized to reduce readmissions but have been undefined.

Study design: Retrospective cohort study.

Setting: Patients with Medicare inpatient claims data linked to the OPTIMIZE-HF and GWTG-HF registries.

Synopsis: The study included 30,136 patients >65 years old with the principal discharge diagnosis of heart failure from 2003 to 2006. Hospitals were stratified into quartiles based upon the median arrival rate to “early” (within one week after discharge) follow-up appointments. Ranges of arrival rates to these appointments ranged from Quartile 1 (Q1) (<32.4% of patients) to Q4 (>44.5%). Readmission rates were highest in the lowest quartile of “early” follow-up (Q1: 23.3%; Q2: 20.5%; Q3: 20.5%; Q4: 20.5%, P<0.001). No mortality difference was seen.

The study also examined whether the physician following the patient after discharge impacted the readmission rate for these same quartiles, comparing cardiologists to generalists and comparing the same physician at discharge and follow-up (defined as “continuity”) versus different physicians. Follow-up with continuity or a cardiologist did not reduce readmissions.

Interestingly, nearly all markers of quality were best in Q1 and Q2 hospitals, which had the lowest arrival rates to appointments, which might reflect patient-centered rather than hospital-centered issues.

Bottom line: Hospitals with low “early” follow-up appointment rates after discharge have a higher readmission rate, although causality is not established.

Citation: Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303 (17):1716-1722.

Clinical Shorts

ICU patients admitted with chest pain have better outcomes with higher initial systolic blood pressure

Prospective cohort study of 119,151 admissions showed that patients with higher blood pressures (>163mm/Hg) had increasingly better prognoses, for unclear reasons. The authors caution that this finding should not guide therapy.

Citation: Stenestrand U, Wijkman M, Fredrikson M, Nystrom FH. Association between admission supine systolic blood pressure and 1-year mortality in patients admitted to the intensive care unit for acute chest pain. JAMA. 2010;303(12):1167-1172.

Patients receiving high-dose vitamin D fall MORE FREQUENTLY and have MORE fractures

Placebo-controlled, randomized study of 2,256 patients receiving an annual oral dose of vitamin D (500,000 IU) demonstrated a temporally correlated increased fall risk and fracture rate for three months after administration.

Citation: Sanders KM, Stuart AL, Williamson EJ, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA. 2010;303(18):1815-1822.

Strict Heart Rate Control Is Not Necessary in Management of Chronic Atrial Fibrillation

Clinical question: Is lenient heart rate control inferior to strict heart rate control in preventing cardiovascular events in patients with chronic atrial fibrillation?

Background: Guidelines generally call for the use of medications to achieve strict heart rate control in the management of chronic atrial fibrillation, but the optimal level of heart rate control necessary to avoid cardiovascular events remains uncertain.

Study design: Prospectively randomized, noninferiority trial.