Journal watch: recent studies of note
From the May ACP Hospitalist, copyright © 2007 by the American College of Physicians.
Surgical patients at high risk for medication errors
Perioperative patients face the highest risk of harmful medication errors due to a lack of comprehensive oversight of medications, according to a new report from the nonprofit group U.S. Pharmacopeia (USP).
The report examined more than 11,000 medication errors reported by 500 hospitals between 1998 and 2005. Of the perioperative errors, 5% of errors resulted in harm, triple the overall rate of harm for medication errors. Pediatric patients were at the highest risk with 12% of errors resulting in harm. Overall, the most common errors were receiving the wrong drug, receiving the wrong amount of a drug, receiving the drug at the wrong time, receiving the drug incorrectly or not receiving the drug at all. Antibiotics and painkillers were the drugs most frequently involved.
The report focused on four parts of the perioperative setting—outpatient surgery, the preoperative holding area, the operating room and the post-anesthesia care unit.
USP's report included recommendations for reducing medication errors, including having surgical staff better coordinate handoffs to eliminate the loss of patient information, delegating a pharmacist to perioperative units and getting patients involved in the process.
EKG abnormalities indicate heart disease risk
Abnormalities in electrocardiograms of healthy women can predict an increased risk of cardiovascular events and mortality, according to a new study. The findings are based on data from the Women's Health Initiative (WHI), a randomized, controlled trial of 14,749 women.
Women in the WHI received EKGs at the start of the study, three years later, and six years later, if they were still participating in the study. Of the 9,744 women with normal EKGs, 118 women had a cardiovascular event. Of the 4,095 with minor abnormalities, 91 had an event, compared with 37 of the 910 with major abnormalities. The study was published in the March 7 Journal of the American Medical Association.
Researchers calculated that women with minor abnormalities had a 55% increased risk of an event, and those with major abnormalities had a 300% increase in risk. About 5% of the studied women developed abnormalities during the study and had a 260% higher risk of cardiovascular events. The researchers did not find any association between EKG abnormalities and hormone therapy use, which the WHI was designed to study.
Based on the findings, the EKG appears to be a useful tool for predicting future cardiovascular events in asymptomatic postmenopausal women, study authors concluded. The presence of EKG abnormalities should prompt physicians to consider further risk stratification or intensive therapeutic interventions for the prevention of cardiovascular events, they said.
Weekend heart attacks more likely to result in death
Heart attack patients admitted to the hospital on weekends are more likely to die and less likely to undergo invasive cardiac procedures, a new study in the March 15 New England Journal of Medicine found.
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In the most recent four-year interval, patients seen on weekends [with acute MI] were 7.5% more likely to die within 30 days than those admitted on weekdays. |
Researchers studied 231,164 patients admitted to New Jersey hospitals between 1987 and 2002 for first-time acute MI. They looked at trends over four-year periods, in part to account for advances in treatment over time. In the most recent four-year interval, patients seen on weekends were 7.5% more likely to die within 30 days than those admitted on weekdays. The difference became significant the day after admission, and remained so after one year.
Adjusted for age, medical problems and site of MI, the rate was still 5% higher if patients were admitted on a weekend, but the difference became non-significant after adjustment for invasive cardiac procedures. Death rates for most other four-year time spans yielded similar results. Weekend patients were less likely to undergo invasive cardiac procedures, especially in the first two days of hospitalization; for example, they were one-third less likely to get percutaneous coronary intervention (PCI) on admission. The number of days between admission and performance of catheterization, PCI or CABG was also higher for weekend patients than for weekday patients.
The study's main limitation was that unmeasured factors, such as medications administered or time from the onset of symptoms, may have contributed to mortality differences between weekend and weekday patients, the authors said. Strengths included a large sample and the absence of patient selection.
"Our study suggests that a hospital workweek of Monday through Friday is not optimal for the care of patients with acute myocardial infarction," the authors said, adding that better staffing or regionalization of care may prevent deaths.
Statins reduce sepsis in patients with kidney disease
Statins may reduce the risk of hospitalization for sepsis in patients with chronic kidney disease, according to a study in the April 4 Journal of the American Medical Association.
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The rate of sepsis-related hospitalization for patients on statins was 41 per 1,000 patient-years. |
Within a prospective, observational study of 1,041 dialysis patients (14% of whom took statins), researchers tracked 303 hospitalizations for sepsis. The rate of sepsis-related hospitalization for patients on statins was 41 per 1,000 patient-years, compared to 110 per 1,000 patient-years for patients not receiving statins. After adjustment for demographic characteristics, dialysis modality, comorbidities and laboratory values, statin users showed a 62% lower risk of hospitalization for sepsis.
Several mechanisms may explain the observed protective effects of statins, said study authors. The known immunomodulatory properties of the drugs may regulate the immune response to infections, minimizing the risk of clinical sepsis in patients with infections. Statins may also have direct antimicrobial effects, as previous studies of statins' effect on HIV, salmonella and yeast growth have shown, the authors noted.
Although limited by its observational design, this study is the first research to show that a medication administered long-term could have a strong and significant effect on sepsis rates among patients with chronic kidney disease. A randomized trial is warranted, given the high rates of sepsis and sepsis-related mortality in these patients, the authors concluded.
Many doctors don't consider patient costs for tests
Nearly half of physicians don't consider patients' out-of-pocket costs when deciding which diagnostic tests to recommend, though most do consider costs when prescribing drugs, a new study found.
Based on surveys returned by 6,628 practicing doctors, the study found that 40.2% consider insured patients' out-of-pocket costs for co-payments and deductibles when deciding which tests to recommend, and 51.2% consider these costs when choosing between inpatient and outpatient settings if a choice is available. But 78% take costs into account when prescribing generic versus brand-name drugs, according to the study published in the April 9 Archives of Internal Medicine.
Primary care doctors were more likely than specialists to consider patients' costs in prescribing drugs (85% vs. 75%), care settings (54% vs. 43%) and diagnostic tests (46% vs. 30%). Doctors who provide charity care, as well as those in solo or two-person practices, were more likely to consider patient costs when choosing tests or care settings, while those working in large groups or HMOs were more likely to consider costs when prescribing drugs.
Previous research has shown physicians' decisions affect how 90% of every health care dollar is spent, the authors noted. "Because physicians consider patient costs less frequently in making decisions about more expensive services, it's likely that increased patient cost sharing will be limited as an effective cost-control tool," said Hoangmai Pham, MD, MPH, the study's lead author.
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