First EDition: A-Fib Management Pathway in the ED, more

Atrial Fibrillation Management Pathway in the ED May Lower Hospital Admissions

TED BOSWORTH

FRONTLINE MEDICAL NEWS

An atrial fibrillation (AF) treatment pathway designed specifically to reduce the proportion of patients with this complaint who are admitted to the hospital from the ED was remarkably effective, according to a pilot study presented at the annual International AF Symposium.

“In this single-center observational study, a multidisciplinary AF pathway was associated with 5-fold reduction in admission rate and 2.5-fold reduction in length-of-stay [LOS] for those who were admitted,” reported Jeremy N. Ruskin, MD.

Relative to many other countries, admission rates for AF in the United States are “extremely high,” according to Dr Ruskin, director of the cardiac arrhythmia service at Massachusetts General Hospital, Boston. Citing 2013 figures from the Nationwide Emergency Department Sample (NEDS) database, rates ranged between 60% and 80% by geographic region, with an average of about 66%. In contrast, and as an example of lower rates elsewhere, fewer than 40% of AF patients with similar characteristics presenting at EDs in Ontario, Canada were admitted. Similarly low admission rates have been reported in Europe.

The AF pathway tested in the study at Massachusetts General was developed through collaboration between electrophysiologists and emergency physicians (EPs). It is suitable for patients presenting with a primary complaint of AF without concomitant diseases, such as sepsis or myocardial infarction. Patients were entered into this study after it was shown that AF was the chief complaint. The first step was to determine whether participants were best suited to a rhythm-control or rate-control strategy.

“The rhythm-control group was anticoagulated and then underwent expedited cardioversion with TEE [transesophageal echocardiogram] if necessary. The rate-control group was anticoagulated and then given appropriate pharmacologic therapy,” Dr Ruskin explained. Once patients were on treatment, an electrophysiologist and an EP evaluated the patients’ response. For both groups, stable patients were discharged and unstable patients were admitted.

In this nonrandomized observational study conducted over a 1-year period, 94 patients were managed with the AF pathway. Admissions and outcomes in this group were compared with 265 patients who received usual care.

Only 16% of those managed through the AF pathway were admitted versus 80% (P < .001) in the usual care group. Among those admitted, LOS was shorter in patients managed along the AF pathway relative to usual care (32 vs 85 hours; P = .002). Dr Ruskin reported that both the cardioversion rate and the proportion of patients discharged on novel oral anticoagulation drugs were higher in the AF pathway group.

The reductions in hospital admissions would be expected to translate into large reductions in costs, particularly as follow-up showed no difference in return visits to the hospital between those entered into the AF pathway relative to those who received routine care, according to Dr Ruskin. Emphasizing the cost burden of AF admissions, he noted that the estimated charges for the more than 300,000 AF admissions in US hospitals in 2013 exceeded $7 billion.

Currently, there are no uniform guidelines for managing AF in the ED, and there is wide variation in practice among centers, according to Dr Ruskin. He provided data from the NEDS database demonstrating highly significant variations in rates of admission by geographic region (eg, rates were >10% higher in the northeast vs the west) and hospital type (eg, rates were twice as high in metropolitan than nonmetropolitan hospitals).

In the NEDS database, various patient characteristics were associated with increased odds ratios (ORs) for admission. These included hypertension (OR, 2.3), valvular disease (OR, 3.6), and congestive heart failure (OR, 3.7). However, Dr Ruskin indicated that patients with these or other characteristics associated with increased likelihood of admission, such as older age, have better outcomes with hospitalization.

The data from this initial observational study were recently published, and a larger prospective study of this AF pathway is already underway at both Massachusetts General and at Brigham and Women’s Hospital, Boston. If the data confirm that AF admissions can be safely reduced through this pathway, Dr Ruskin anticipates that implementation will be adopted at other hospitals in the Harvard system.

Ptaszek LM, White B, Lubitz SA, et al. Effect of a multidisciplinary approach for the management of patients with atrial fibrillation in the emergency department on hospital admission rate and length of stay. Am J Cardiol. 2016;118(1):64-71. doi:10.1016/j.amjcard.2016.04.014.

Understanding SSTI Admission, Treatment Crucial to Reducing Disease Burden

DEEPAK CHITNIS

FRONTLINE MEDICAL NEWS

Decreasing the burden of treating skin and soft tissue infections (SSTIs) is critical to improving care and reducing the costs that SSTIs place on health care facilities, according to a study published in Hospital Practice.

“Despite expert panel recommendations and treatment guidelines, there is no widely accepted classification system for grading SSTIs to outcomes,” wrote the study’s lead author, Kristin E. Linder, PharmD, of Hartford (Connecticut) Hospital. “This leads to a considerable variation in treatment approach on initial presentation when deciding which patients should be admitted to receive intravenous antibiotic therapy or treated as outpatients.”

Dr Linder and her coinvestigators conducted a single-center retrospective cohort study with the primary objective of determining rates of admission and re-presentation, along with average LOS and cost of care for both inpatients and outpatients with SSTIs. Patients aged 18 years and older who received a primary diagnosis of an SSTI during May and June 2015 at Hartford Hospital were screened; 446 were deemed eligible, with 357 ultimately selected for inclusion.

“Patients were categorized into two groups based on disposition of care, inpatient or outpatient, on index presentation,” the authors explained. “Economic data were collected using reports from hospital finance databases and included reports of total billed costs.”

Of the 357 patients included for analysis, 106 (29.7%) were admitted as inpatients while the remaining 251 (70.3%) were treated as outpatients. However, there were no significant differences found in re-presentation rates, either overall (22.6% for inpatients and 28.3% for outpatients; P > .05) or for SSTI-related re-presentation (10.4% for inpatients and 15.1% for outpatients; P > .05). For those patients who were admitted, the mean LOS was 7.3 days.

Patients who presented with a Charlson Comorbidity Index (CCI) score of 0 were admitted at a rate of 14.1%, compared to 30.1% of those with a CCI score of 1, and 60.9% of those with a CCI score of 2 or higher. The biggest disparity, however, was in terms of cost of care; while outpatient care cost an average of $413 per patient, inpatient care cost an average of $13,313 per patient.

Wound and abscess cultures that were tested found methicillin-susceptible Staphylococcus aureus to be the most prevalent gram-positive organism (37.1%) found in inpatients, while for outpatients, methicillin-resistant S aureus (MRSA) was the most common (66.7%). According to the investigators, gram-negative bacteria were not isolated in every case, so “prevalent use of combination therapy in this setting may not be warranted.

“Understanding how and where patients with SSTI are treated and their re-presentation rate is important to understand to direct resources for this high-frequency disease,” the authors concluded. “This study demonstrated that approximately 70% of patients presenting to the ED with SSTI were treated as outpatients [and] while 30-day re-presentation was similar for inpatient and outpatients, readmission was more likely in those previously admitted.”