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From the November ACP Hospitalist, copyright © 2007 by the American College of Physicians
S. aureus infection, economic burden higher but related mortality lower in U.S. hospitals
Infection rates and the economic burden of Staphylococcus aureus have increased in U.S. hospitals, but related inpatient mortality rates have decreased, according to a study.
Researchers used the Nationwide Inpatient Sample, a federal database, to examine trends in S. aureus infection, economic burden and in-hospital mortality for all hospital stays and specific groups of stays (related to surgical procedures, invasive cardiovascular surgery, invasive orthopedic surgery and invasive neurosurgery) from 1998 to 2003. The study was published online on Sept. 21 and appears in the Nov. 1 Clinical Infectious Diseases.
From 1998 to 2003, S. aureus infection rates increased significantly for all inpatient stays (0.74% to 1.0%), surgical stays (0.90% to 1.3%) and invasive orthopedic surgical stays (1.2% to 1.8%). Infection rates for neurosurgical stays remained the same from 1998 to 2000 but increased from 1.4% in 2000 to 1.8% in 2003. Total economic burden of S. aureus infection also increased in all groups. In-hospital deaths related to S. aureus infection, however, decreased significantly for all stays (7.1% to 5.6%) and for surgical stays (7.1% to 5.5%) over the six-year period.
The authors speculated that the decrease in S. aureus-associated inpatient mortality rate may be due to improved infection control practices in U.S. hospitals or to improved treatment of methicillin-resistant strains, and that the observed increased infection prevalence may be due to improved detection and reporting. The authors noted that their study used ICD-9-CM codes that did not distinguish between methicillin-resistant and methicillin-susceptible S. aureus and that the former has been shown to more negatively affect mortality rates, cost and length of stay. They recommended that future studies should try to look at specific strains of S. aureus to determine the effects of each, and that hospitals should increase their efforts to reduce risk of nosocomial infections.
Hospitalist care reduces lengths of stay for some conditions
Care by teaching hospitalists can lead to shorter hospital stays for patients who require close monitoring and complicated discharge planning, according to a study.
Researchers at Montefiore Medical Center in New York compared patients cared for by teaching hospitalists with those cared for by nonhospitalists over a two-year period. The study's main objective was to determine which groups of patients would benefit most from hospitalist care. The results appeared in the Sept. 24 Archives of Internal Medicine.
The study sample was composed of 9,037 discharges, 2,913 from hospitalists and 6,124 from nonhospitalists. The mean length of stay was 5.01 days for the hospitalist group and 5.87 days for the nonhospitalist group. Reductions in length of stay were greatest in patients who required complex discharge planning and in those with conditions—congestive heart failure, asthma, stroke and pneumonia—that required close oversight.
The hospitalist and nonhospitalist groups did not differ significantly in rates of readmission, in-hospital mortality or 30-day mortality, although the authors acknowledged that few physicians were studied (five in the hospitalist group and 54 in the nonhospitalist group) and that small differences in readmission or mortality rates may not have been able to be detected. The authors attributed their findings to hospitalists' skill at working with other staff members to facilitate discharge planning, the continuous care they provide, and their ability to monitor patients with complicated conditions.
Closed ICUs may improve lung injury outcomes
"Closed" ICUs can result in improved mortality in patients with acute lung injury, according to a study.
Researchers at the University of Washington in Seattle used data from a cohort study to examine the relationship between ICU type—"closed" or "open"—and mortality rates in patients with acute lung injury. Closed ICUs were defined as those in which patients were cared for by an intensive care team or in which consultation with an intensivist was mandatory, while open ICUs were those in which any attending physician who had admission privileges could oversee care. The results appeared in the Oct. 1 American Journal of Respiratory and Critical Care Medicine.
Twenty-four ICUs (13 closed, 11 open) were eligible for the study, and complete data were available for 23. Of 1,075 patients with acute lung injury admitted to the ICUs from April 1999 to July 2000, 684 (64%) received care in closed units and 391 (36%) received care in open units. Patients in closed units had lower mortality than those in open units, and pulmonary consultation in open units had no significant effect on mortality. A difference in mortality between ICU types persisted after adjustment for several variables, including illness severity.
The authors acknowledged that their sample was small and that results of observational studies are often subject to bias. However, they concluded that their results confirm those of previous before-after studies and provide further support for the closed ICU model in critically ill patients.
Complications more likely with anastomotic leaks after bariatric surgery
Patients who develop anastomotic leaks after Roux-en-Y gastric bypass (RYGB) have longer hospital stays and worse outcomes than those who don't, according to a study.
Researchers at University of South Florida Health Sciences Center in Tampa examined data on 840 consecutive patients who had RYGB between 1998 and 2005. They wanted to determine whether those who developed anastomotic leaks after the surgery were also more likely to develop major complications. The results appeared in the October Archives of Surgery.
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Mortality rate (14% vs. 4%) and length of hospital stay (24.5 days vs. 4.5 days) were also statistically significantly higher in those who developed leaks [after RYGB]. |
Anastomotic leaks occurred in 36 patients (4.3%) after RYGB. In this group, 61% developed complications compared with 20% of patients who did not have leaks. Mortality rate (14% vs. 4%) and length of hospital stay (24.5 days vs. 4.5 days) were also statistically significantly higher in those who developed leaks. Sepsis, renal failure, small bowel obstruction, incisional hernia, thromboembolism and internal hernia were all more common in patients with leaks than in those without.
The authors cautioned that their study does not imply causality and that their results may not be clinically significant. However, they wrote, their data indicate that patients undergoing RYGB should be monitored closely for complications, in the ICU if possible, and treated aggressively as needed.
New evidence that annual flu shots benefit seniors
New long-term data indicate that seniors who get annual influenza vaccinations significantly reduce their risk of being hospitalized for pneumonia or influenza during flu season.
The observational study, published in the Oct. 4 New England Journal of Medicine, analyzed data on vaccinations administered from 1990-1991 through 1999-2000, including 713,872 person-seasons of observation. Vaccination was associated with a 27% reduction in the risk of hospitalization for pneumonia or influenza and a 48% reduction in the risk of death from any cause.
The consistency of the data over 10 flu seasons suggests that the protective effect of the vaccines is real and not due to confounding factors, such as a tendency for those who get vaccinations to be healthier or more compliant with medications, said an accompanying editorial. In addition, said the editorial, the protective effect varied according to how closely the vaccine matched the epidemic strain in a particular flu season.
The findings provide further support for continuing a strategy of vaccinating the elderly, said the editorial. The study also points to the need for developing safer and more effective vaccines, since about half of the hospitalizations and deaths in the study occurred among vaccinated adults. The editorial also called for improving the "appalling" low rate of vaccination among health care workers.
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