Journal watch: recent studies of note
Methylprednisolone improved outcomes in early severe ARDS
Patients with early severe cases of the acute respiratory distress syndrome (ARDS) had better outcomes after receiving low-dose methylprednisolone, a study found.
Researchers at five ICUs in Memphis, Tenn., wanted to determine whether reducing systemic inflammation with methylprednisolone improved outcomes in patients with early ARDS. In a randomized, controlled trial, they assigned 91 patients with ARDS, 66% of whom also had sepsis, to receive methylprednisolone infusion, 1 mg/kg of body weight per day, or placebo for up to 28 days. The study was published in the April issue of Chest.
By day 7, outcomes were better in the treated group. Almost 70% had a one-point reduction in lung injury score compared with approximately 36% in the placebo group, and approximately 54% versus 25% were breathing without assistance. Methylprednisolone treatment was also associated with less time receiving mechanical ventilation, shorter ICU stays, and lower infection and ICU mortality rates. The authors of this small study called for a larger randomized trial to confirm their findings.
Fenoldopam reduces acute kidney injury and death in critical illness
A review found that fenoldopam reduced acute renal failure (ARF) requiring renal replacement therapy and all-cause mortality in critically ill patients.
Researchers conducted a meta-analysis of 16 randomized, controlled trials that evaluated fenoldopam in critically ill patients in surgical or intensive care units. Control group treatments included placebo or best available treatment (usually low-dose dopamine). The review’s primary outcomes were ARF requiring one or more episodes of renal replacement therapy (RRT) and all-cause hospital mortality, with secondary outcomes of ICU length of stay (LOS), hospital LOS, peak serum creatinine level and hypotension.
The review found that the fenoldopam reduced risk for ARF, requirement for RRT and all-cause mortality. The intervention group also had shorter ICU stays, borderline shorter hospital LOS and lower peak serum creatinine levels, and the groups did not differ significantly for hypotensive episodes. The fenoldopam patients had 43% less ARF requiring RRT (number needed to treat [NNT] = 23) and 31% lower mortality (NNT = 17). The study is abstracted in the May/June ACP Journal Club.
The review, published earlier this year in the American Journal of Kidney Diseases (2007;49:56-68), suggests that fenoldopam provides patient-important benefits, although the small size of the included trials may limit the impact of the findings, said Journal Club reviewers Neill Adhikari, MD, and Jan Friedrich, MD, of the University of Toronto. Considering the trials’ sizes, methodological quality and the possibility of industry funding bias, the estimates of treatment may be overly optimistic. Fenoldopam is a promising therapy for ARF, the reviewers commented, but a larger, multicentered RCT is needed to further evaluate the therapy.
Stroke patients slow to reach hospital
More than half of stroke patients arrive at a hospital more than two hours after the onset of symptoms, found a new report from the CDC. Such delays in treatment make patients less likely to receive tissue plasminogen activator (tPA) therapy and increase the risk of stroke-related disability.
The study, conducted in 142 hospitals in 2005 and 2006, found that patients who call an ambulance are more likely to arrive at the emergency department within two hours of symptom onset. Patients who arrive by ambulance also experience fewer delays at the hospital—69.2% of them receive imaging within an hour compared with 56.3% of patients who arrive on their own.
Women are also less likely than men to receive prompt imaging (62.9% vs. 67.6% within one hour). The study found no racial disparities in the wait for imaging, but did find that blacks are less likely to arrive at the ED within two hours of symptom onset. The findings highlight the need for greater public education about stroke symptoms and the importance of stroke patients calling for ambulance transport, the CDC said.
In a related report, the CDC found that stroke prevalence varies widely among U.S. states—ranging from 1.5% in Connecticut to 4.3% in Mississippi. Almost a quarter of states, all located in the South or Midwest, had stroke prevalence of 3% or above. American Indian/Alaska Natives had the highest rate and Asians the lowest. Prevalence was also more than twice as high in individuals with less than 12 years of education than in college graduates. Both studies were published in the May 17 Morbidity and Mortality Weekly Report.
P4P doesn’t change hospital cardiac care, study finds
Pay-for-performance (P4P) has little impact on hospitals’ care for patients with acute myocardial infarction, according to a new study of the government’s largest-ever P4P pilot project.
Researchers compared adherence to American College of Cardiology/American Heart Association guidelines in 54 hospitals enrolled in CMS’ P4P pilot and 446 hospitals involved in a voluntary quality improvement program. Both groups showed improvement during the 2003-06 study period, and the P4P group improved at a slightly higher rate on two measures—prescribing aspirin at discharge and counseling patients on smoking cessation.
Overall, however, the study found that P4P was not associated with a significant improvement in quality of care or outcomes for heart attacks or in-hospital mortality over the control group. The researchers also did not find any negative impacts from P4P, with both hospital groups showing similar improvements in care measures that were not subject to financial incentives. The study was published in the June 6 Journal of the American Medical Association. The authors noted that additional research is needed to determine the optimal role of payment incentives in future quality-improvement initiatives.
Better treatment, lower risk factors caused drop in cardiac deaths
Decline in U.S. deaths from coronary heart disease from 1980-2000 can be attributed about equally to better medical treatments and a reduction of risk factors, a June 7 New England Journal of Medicine study found.
The study sought to uncover the reasons why the death rate for coronary heart disease was cut by almost half between 1980 and 2000. Using the IMPACT statistical model that incorporated risk factors like smoking, high blood pressure, diabetes and exercise habits, researchers found that medical treatments accounted for 47% of the drop, while reduced risk factors accounted for 44% of the decline.
The decreases caused by individual treatments were:
- 11%: secondary preventive therapies after myocardial infarction;
- 10%: initial treatments for acute myocardial infarction or unstable angina;
- 9%: treatments for heart failure;
- 5%: revascularization for chronic angina;
- 12%: other medical therapies.
The decreases caused by risk factor changes were:
- 24%: reductions in total cholesterol;
- 20%: reduction in systolic blood pressure;
- 12%: reduced smoking prevalence;
- 5%: increased physical activity.
The risk factor reductions were partially offset by an increase in deaths due to greater body-mass index (8% increase in deaths) and diabetes (10% increase in deaths). Together, diabetes and obesity caused an additional 60,000 cardiac deaths.
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