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18 Decemeber 2012 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 215-351-2653 or e-mail Angela Collom at acollom@acponline.org

1. Shorter Hospital Stays do not Increase Readmission Rates or Patient Mortality

Reducing length of stay (LOS) for hospitalized patients does not increase 30-day readmission rates. LOS reduction has been an important goal for hospitals, but hospital readmission – a long-time quality metric – is a concern. Researchers reviewed records for more than 4 million patients hospitalized at 129 acute care Veterans Affairs (VA) hospitals in the United States over 14 years to determine trends in hospital LOS, 30-day readmission rates, and 90-day mortality for all medical diagnoses combined and five specific common diagnoses (heart failure, COPD, acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage). The researchers found that while LOS decreased by 27 percent in adjusted analysis over the 14-year time frame, the relative readmission rates did not go up, but decreased by 16 percent. At the same time, all-cause mortality at 30 and 90 days decreased by about 3 percent annually. However, hospitals that released patients earlier than expected given the severity of their illness had a higher readmission rate, with a 6 percent increase risk for each day lower than expected, suggesting some trade-off between LOS and readmission. The authors of an accompanying editorial write that hospital readmissions is a useful metric, but it is not necessarily the best indicator of quality of care. Many factors affect readmission rates and not all factors are within the hospital’s control. As the nation’s largest accountable care organization, the VA can serve as a good example of how hospitals can improve efficiency and quality.

2. UK Colonoscopy Guidelines May Better Identify High-risk Patients

Colonoscopy guidelines from the United Kingdom may better identify patients who need short-interval follow-up screening compared to guidelines from the United States. Researchers analyzed four prospective studies of 3,226 postpolypectomy patients to compare risk for advanced colorectal neoplasia at one-year colonoscopy. Patients were cross-classified by U.S. and U.K. surveillance guidelines. Both U.S. and U.K. colonoscopy guidelines stratify patients into risk groups based on size and number of adenomas. However there are a few key differences between the guidelines. The U.K. criteria do not take into consideration histologic features (the U.S. guidelines do) and they recommend a clearing colonoscopy at one year for high-risk patients, as classified by having five or more small adenomas or three or more adenomas, at least one of which is at least 1 cm. The U.S. guidelines recommend follow-up at three years for these patients. In their analysis, the researchers found advanced neoplasia one year after polypectomy in 11.2 percent of high-risk patients based on U.S. criteria and in 18.7 percent of patients based on U.K criteria. The authors conclude that following the U.K. guidelines would help detect advanced adenomas two years earlier than following the U.S. guidelines for 19 percent of patients who have these lesions at one year without substantially increasing colonoscopy rates.

3. Adalimumab May Improve Quality of Life for Patients Suffering from Serious Skin Disease

Adalimumab may reduce inflammation and pain and improve quality of life for patients with hidradenitis suppurativa (HS). HS is a chronic skin disease that occurs deep in the skin around oil glands and hair follicles causing red, tender bumps that often enlarge, break open and drain foul-smelling pus. HS is associated with pain and scarring, and often is resistant to treatment. Researchers conducted a phase 2, randomized, placebo-controlled trial to evaluate the efficacy and safety of adalimumab, an anti-tumor necrosis factor-a antibody, in 154 patients with moderate to severe HS. Patients were assigned adalimumab, 40 mg/wk; adalimumab, 40 mg every other week (EOW); or placebo for 16 weeks. From weeks 17 to 52, all patients received adalimumab, 40 mg EOW, but were switched to weekly dosing if the response was suboptimum at weeks 28 or 31. At week 16, a significantly greater proportion of patients in the weekly treatment group achieved improvements in pain, inflammation, and quality of life based on a clinical scoring system. Adalimumab appeared to be well-tolerated at weekly and EOW doses, but this small study does not provide definitive safety data.