Eight Things to Do
Differently Tomorrow
The (Lack of) Evidence Behind Common
Hospitalist Practices
Chad R. Stickrath, MD
October 2nd, 2012
Learning Objectives
• Discuss the level of evidence that exists for the
medical treatments reviewed today
• Consider making changes to our practice
based on this evidence
• No Disclosures
The Benefits of 3000 Common Medical
Treatments
BMJ’s Clinical Evidence Website, accessed
9/2011 and 8/2012
http://clinicalevidence.bmj.com.hslezproxy.ucdenver.edu/ceweb/about/knowledge.jsp
Topic Selection
• Most Common Diagnoses
• Clinical Evidence Reviews
• HM Literature Updates
• Colleagues
• Source: http://choosingwisely.org/?page_id=13. Accessed
8/2012.
Case #1
• A 67 year-old male with PMH including DM, HTN was
admitted overnight to the floor with dyspnea, cough,
fever, mild hypoxemia, and a RUL infiltrate.
• Which factor has been associated with decreased
length of stay in community-acquired pneumonia?
1)
2)
3)
4)
Identification of the infecting microbe
Productive cough
Early mobilization
Antibiotics within 30 minutes of presentation
Community Acquired Pneumonia is
Common and Costly
• 4,000,000 cases per year in the US (1/3
admitted)
• $40 billion per year in the US
– LOS most important component of cost
Are There Things We Can Do to Reduce Length
of Stay in Community-Acquired Pneumonia?
• Prospective, Randomized
• Patients presenting with CAP
• Randomized to 3-Step Pathway vs. Usual Care
– Step 1: Early mobilization
– Step2: Objective ∆ Abx IV -> PO
– Step 3: Predefined DC criteria
We Can Safely Reduce LOS in CAP
Outcome
LOS
3-Step
Pathway
(n =200)
3.9
Usual Care P Value
(n =201)
6.0
<.001
Length of IV
Antibiotics
2.0
4.0
<.001
Adverse Drug
Reactions
9
32
<.001
Readmission
18
15
0.59
Case-fatality rate
(30d)
4
2
0.45
Tomorrow I Will …
• Mobilize pneumonia patients early and often
• Switch patients from IV to Oral antibiotics when
they show:
– Clinical improvement
– Stable VS
– Absence of exacerbating comorbidities
• Discharge patients when:
– Baseline mental status, O2 requirements
– Meet criteria for PO antibiotics
• Bonus: consider implementing 3-Step Pathway at
your institution
Case #1
• A 67 year-old male with PMH including DM, HTN was
admitted overnight to the floor with dyspnea, cough,
fever, mild hypoxemia, and RUL infiltrate.
• Which factor has been associated with decreased
length of stay in community-acquired pneumonia?
1)
2)
3)
4)
Identification of the infecting microbe
Productive cough
Early mobilization
Antibiotics within 30 minutes of presentation
Case #2
• An 54 year-old female with HLD and HTN
underwent successful total hip arthroplasty for
severe osteoarthritis.
• When does the post-operative risk for developing
symptomatic DVT/PE peak?
1)
2)
3)
4)
Post-operative day 1
Post-operative day 3
Post-operative day 14
Post-operative day 21
Hospitalists Commonly Care for Total Hip and Knee
Arthroplasties and Make Recommendations about
VTE Prophylaxis
• > 600,000 Hip/Knee arthroplasties annually in
US (Kurtz, J Bone Joint Surg Am. 2007;89)
• Most frequent medical complication is VTE (Zhan, J
Bone Joint Surg Am. 2007;89)
• VTE prophylaxis is effective
How Long Should I Recommend Total Hip and Knee
Arthoplasty Patients use Pharmacologic Prophylaxis?
• Prospective cohort study
• Million Middle-aged Women
• Evaluated who had:
– Surgery
– VTE
The Risk for Post-Operative VTE Extends Well Beyond
2 Weeks
• 239,614 had operation, 5419 (0.6%) post op VTE
How Long Should I Recommend Total Hip and Knee
Arthroplasty Patients use Pharmacologic Prophylaxis?
• Systematic Review
• Randomized Trials
– Comparing DVT ppx
• 7-10 days vs. ≥ 20 days
Shorter Duration vs. Longer Duration of
VTE Prophylaxis
• Included 8 RCTs
Tomorrow I Will …
• Consider extending post op DVT prophylaxis to
35 days post-operatively for THA/TKA
– 2012 ACCP Supplement:
Case #2
• An 54 year-old female with HLD and HTN
underwent successful total hip arthroplasty for
severe osteoarthritis.
• When does the post-operative risk for developing
symptomatic DVT/PE peak?
1)
2)
3)
4)
Post-operative day 1
Post-operative day 3
Post-operative day 14
Post-operative day 21
Case #3
• An 87 year old male with severe COPD, HTN,
Depression, and chronic low back pain from war
injuries is admitted with his third COPD exacerbation in
the last 12 months.
• Which would be a contraindication to initiating longterm antibiotics to prevent COPD exacerbations at
discharge?
1)
2)
3)
4)
Patient taking citalopram for depression
Patient is “hard of hearing”
Patient is taking methadone for back pain
All of the above
Millions of Americans Have COPD and
Their Care Cost $$$$$$$$$$s
• COPD is:
– Common
• > 700,000 hospitalizations per year
• 13-24 million Americans have COPD
– Morbid
• 3rd leading cause of death
• Over half of COPD patients say
symptoms limit daily acts
– Expensive
• Costs US about $50 billion per year
from American Lung Association,
http://www.lung.org, accessed 8/2012
Is There Anything We Can Do to
Prevent COPD Exacerbations?
• RCT of COPD patients
• Daily Azithro vs. placebo
• 1142 patients, 12 sites
The Impact of Scheduled Antimicrobials
on COPD
• Time to first exacerbation:
– 266 (Azithro) vs. 174 days
(Placebo)
• Exacerbations/year:
– 1.48 vs. 1.83
• Improved QOL
• Adverse events:
– No Mortality Difference
– Hearing decrement
• 142 vs. 110
– Colonization
• Overall 12% vs. 31%
• Macrolide resistance 81% vs.
41%
Tomorrow I Will …
• Consider recommending long term azithromycin to
certain patients admitted with COPD exacerbations.
Wenzel et al. Antibiotic
prevention of acute
exacerbations of COPD.
NEJM 2012;367
•
•
Wenzel et al. recommend Monday, Wednesday, Friday dosing instead of daily
Will need every 3 month follow-up to assess for side effects
Case #3
• An 87 year old male with severe COPD, HTN,
Depression, and chronic low back pain from war
injuries is admitted with his third COPD exacerbation in
the last 12 months.
• Which would be a contraindication to initiating longterm antibiotics to prevent COPD exacerbations at
discharge?
1)
2)
3)
4)
Patient taking citalopram for depression
Patient is “hard of hearing”
Patient is taking methadone for back pain
All of the above
Case #4
• A 61 year old female with CAD, DM, and HTN is
admitted for hematemesis and melena. She is
discovered to have a bleeding peptic ulcer, which
is treated successfully during endoscopy.
• When should aspirin therapy be reinitiated?
1)
2)
3)
4)
Never
8 weeks after discharge
2 weeks after discharge
On discharge
Aspirin is Good, Except When It Isn’t
• More than 40 million Americans take daily
aspirin
• Aspirin:
– Prevents heart disease
– May prevent some cancers
– Provides analgesia
– Increases the risk for peptic ulcer bleeding 2-3
times (Sung, Ann Intern Med 2010;152)
When Should Patients Resume Daily
Aspirin after Peptic Ulcer Bleeding?
• Randomized, blinded, placebo-controlled trial
• Patients taking daily aspirin admitted with peptic ulcer
bleeding
• Aspirin was reinitiated with PPI after endoscopic
control of bleeding vs. delaying restart for 8 weeks.
Continuation of Aspirin in Peptic
Ulcer Bleeding
• 156 patients enrolled after endoscopic
hemostasis of bleeding
Outcomes
Aspirin (N = 78) Placebo (N = 78)
CI
Confirmed recurrent bleed
8
4
-4 – 13
Death @ 30 days
1
7
4 – 20
Death @ 56 days
1
10
4 – 20
Tomorrow I Will …
• Continue low-dose aspirin with PPI therapy in
patients after endoscopic control of peptic
ulcer bleeding has been achieved
– Patients with a preexisting indication for aspirin use
Case #4
• A 61 year old female with CAD, DM, and HTN is
admitted for hematemesis and melena. She is
discovered to have a bleeding peptic ulcer, which
is treated successfully during endoscopy.
• When should aspirin therapy be reinitiated?
1)
2)
3)
4)
Never
8 weeks after discharge
2 weeks after discharge
On discharge
Case #5
• A 79 year-old male with PMH including DM, HTN,
is admitted with acute dyspnea and pleuritic
chest pain following a cross-country plane flight.
• Which tests could be effective in ruling out right
ventricular dysfunction in this patient?
1)
2)
3)
4)
Normal ECG
Normal RV size on CT pulmonary angiogram
Normal Transthoracic Echocardiogram
All of the Above
Pulmonary Embolism Prognosis Depends
on Hemodynamics and RV Function
• 300,000 people/year die from acute PE in US
(Tapson, NEJM 2008;358)
• Overall, mortality @ 3 months: 15-18%
– For hemodynamically unstable patients: up to 55%
– For hemodynamically stable patients with RV
dysfunction: 2- fold increase in mortality
(Goldhaber, Lancet 2012;379)
What is the Most Effective Method for
Detecting RV Dysfunction in Hemodynamically
Stable Patients Admitted with PE?
• Prospective, descriptive study to assess the prevalence of
RVD and PH in hemodynamically stable PE patients
• Consecutive patients admitted to ED underwent
– H&P, ECG, ABG, TTE, and CTPE
– ECG scoring method (Daniels, Chest 2001;120) compared
to TTE and CTPE evaluation of RVD
ECG Score to Predict Severity of PE
• 103 patients included
• RVD diagnosed
– 25 cases by TTE
– 33 cases by CTPE
• If ECG score = 0 used to exclude
RVD
– Sensitivity 94.1%, Specificity
27.1%
• If ECG score ≥ 9 used to confirm
RVD
– Sensitivity 58.8%, Specificity
92.0%
• Median ECG score 2.5
Tomorrow I Will …
• Employ the ECG score to help risk stratify
normotensive patients with acute PEs
– Avoid TTEs in patients with ECG score of 0
– Consider ordering TTEs with ECG score ≥ 9
Case #5
• A 79 year-old male with PMH including DM, HTN,
is admitted with acute dyspnea and pleuritic
chest pain following a cross-country plane flight.
• Which tests could be effective in ruling out right
ventricular dysfunction in this patient?
1)
2)
3)
4)
Normal ECG
Normal RV size on CT pulmonary angiogram
Normal Transthoracic Echocardiogram
All of the Above
Case #6
• A 73 year-old male with lung cancer is admitted
with a post-obstructive pneumonia complicated
by MSSA bacteremia and mitral valve
endocarditis. He is started on long-term IV
antibiotics.
• Which therapy will best help to prevent
complications?
1)
2)
3)
4)
Lactobacillus PO while on antibiotics
Metronidazole IV while on antibiotics
Acidophilus PO for 7 days beyond antibiotic dc
None of the above
Diarrhea is Common and Costly with
Antibiotics
• Up to 30% of patients on antibiotics develop
diarrhea
• C. diff projected to cost $3.2 billion/year in US
(McFarland, Anaerobe 2009;15)
Is There Anything We Can Do to Prevent
Antibiotic Associated Diarrhea?
• Systematic review and meta-analysis of
probiotic use for antibiotic-associated
diarrhea
• Randomized control trials
The Effectiveness of Probiotics for Preventing
or Treating Antibiotic Associated Diarrhea
• 82 randomized control trials included
Is There Anything We Can Do to Prevent
Antibiotic Associated Clostridium Difficile?
• Systematic review and meta-analysis of the
evidence for probiotic use for clostridium
difficile infection
• Parallel randomized control trials
The Effectiveness of Probiotics for Preventing
Antibiotic Associated Clostridium Difficile
• 11 randomized control trials included
• “seriously underpowered”
Tomorrow I Will …
• Prescribe probiotics for patients taking antibiotics
to prevent clostridium difficile infections and to
prevent and treat antibiotic associated diarrhea
– Best probiotic not clear, duration of antibiotic course
and of probiotic course for benefit not defined
Case #6
• A 73 year-old male with lung cancer is admitted
with a post-obstructive pneumonia complicated
by MSSA bacteremia and mitral valve
endocarditis. He is started on long-term IV
antibiotics.
• Which therapy will best help to prevent
complications?
1)
2)
3)
4)
Lactobacillus PO while on antibiotics
Metronidazole IV while on antibiotics
Acidophilus PO for 7 days beyond antibiotic dc
None of the above
Case #7
• A 57 year-old female with RAD, HTN, and HLD
presents with acute onset substernal chest pain.
• Which test that could potentially be ordered
during her workup carries the highest level of
effective radiation exposure?
1)
2)
3)
4)
Chest X-ray
Chest CT pulmonary angiogram
Thallium stress test
Cardiac catheterization
We Order a Staggering Number of Imaging
Procedures, But it is Not Without Risk
• 5 billion imaging exams performed per year
(Picano, Cardiovascular Ultrasound 2007;5)
• 29,000 excess cancers/year from CT scans
(Berrington de Gonzales, Arch Int Med 2009;169)
• Incidentalomas are very common (Berland, J Am Coll Radiol
2010)
How Frequently/Effectively Do We Discuss the
Risks of Imaging Procedures with Patients?
• Survey of patients and providers assessing
risk-benefit discussion of imaging
– Patients awaiting outpatient CT scans at VA
– CU Providers: GIM, Pulm, Cards, EM, Rads
Patients Want Us to Discuss Risks and Benefits
of Imaging Procedures but We Don’t
• 271/286 patients responded
Patients Want Us to Discuss Risks and Benefits
of Imaging Procedures but We Don’t
• 348/849 providers responded
Tomorrow I Will …
• Discuss the benefits and risks of diagnostic
tests with my patients
– http://xrayrisk.com/
• Bonus:
– Consider ordering tests with the lowest radiation
risks possible to obtain information (e.g. Stress
Echo, instead of Nuclear Stress)
Case #7
• A 57 year-old female with RAD, HTN, and HLD
presents with acute onset substernal chest pain.
• Which test that could potentially be ordered
during her workup carries the highest level of
effective radiation exposure?
1)
2)
3)
4)
Chest X-ray 0.1 mSv
Chest CT pulmonary angiogram 15 mSv
Thallium stress test 40 mSv
Cardiac catherization 8 mSv
Case #8
• An 81 yo male with HTN, DM, and smoking is admitted
with acute coronary syndrome. He undergoes
percutaneous coronary intervention to his 90%
occluded LAD and 78% occluded circumflex with drugeluting stents.
• Which intervention prescribed at discharge will NOT
improve outcomes for him?
1)
2)
3)
4)
Atorvastatin 80mg daily
Smoking cessation therapies
Post revascularization stress test in 6 months
Clopidogrel for at least one year
Coronary Revascularization is Life-Saving,
But the Benefits are Not Always Durable
• 550,000 procedures in Medicare population in
2009 (Riley, Circ Cardiovasc Qual Outcomes 2011;4)
• 20-40% of patients will become symptomatic
or be revascularized within 5 years of initial
revascularization (Abbate, European Heart Journal 2007;28)
Is There Benefit in Looking for Potential
Ischemic Lesions in Patients Who Have Been
Previously Revascularized?
• Observational retrospective cohort study
• Asymptomatic patients with a history of coronary
revascularization undergoing stress echo
• To evaluate the outcomes of asymptomatic
revascularized patients undergoing stress testing.
Stress Tests in Asymptomatic Patients After
Revascularization Does Not Improve Outcomes
• 2105 asymptomatic patients with previous revascularizations identified at
referral for stress echo.
– 1143 PCI, 962 CABG
• 262 (13%) had evidence of ischemia
• Abnormal test results
associated with higher
mortality (4% vs. 8%, p =
0.03)
– Main predictor was
exercise capacity
• Repeat revascularization
was not associated with
more favorable
outcomes (p = 0.67)
Tomorrow I Will …
• Not order stress tests in asymptomatic
patients who have previously undergone
coronary revascularization
Case #8
• An 81 yo male with HTN, DM, and smoking is admitted
with acute coronary syndrome. He undergoes
percutaneous coronary intervention to his 90%
occluded LAD and 78% occluded circumflex with drugeluting stents.
• Which intervention prescribed at discharge will NOT
improve outcomes for him?
1)
2)
3)
4)
Atorvastatin 80mg daily
Smoking cessation therapies
Post revascularization stress test in 6 months
Clopidogrel for at least one year
Summary – Do’s
• Do employ the “3 –
Steps for CommunityAcquired PNA
• Do recommend post
THA/TKA DVT ppx for
35 days
• Do prescribe long term
antibiotics to the right
COPD patients
Summary – Do’s
• Do prescribe probiotics for
patients that will be on
intermediate or long-term
antibiotics
• Do discuss the risks and
benefits of imaging
procedures with your
patients
Summary – Don’ts
• Don’t stop aspirin in patients
with peptic ulcer bleeding
that has been endoscopically
treated
• Don’t order echocardiograms
for everyone with PE
• Don’t order stress tests for
asymptomatic patients who
have previously been
revascularized
Acknowledgements
• Jeff Glasheen
• VA Hospitalist Colleagues
–
–
–
–
–
Mel Anderson
Bob Burke
Kate Jennings
Eric Young
Cliff Zwillich
• Melanie Stickrath
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Carratal J, et al. Effect of a 3-Step pathway to reduce duration of intravenous antibiotic therapy
and length of stay in community-acquired pneumonia. Arch Intern Med 2012;172.
Sweetland S, et al. Duration and magnitude of the postoperative risk of venous
thromboembolism in middle aged women prospective cohort study. BMJ 2009;339.
Sobieraj DM, et al. Prolonged versus standard duration venous thromboprophylaxis in major
orthopedic surgery. Ann Intern Med 2012;156.
Albert RK, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med 2011;365.
Sung JJY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding. Ann Intern Med
2010;152.
Golpe R, et al. Electrocardiogram score predicts severity of pulmonary embolism in
hemodynamically stable patients. J Hosp Med 2011;6.
Hempel S, et al. Probiotics for the prevention and treatment of antibiotic associated diarrhea.
JAMA 2012;307.
Johson S, et al. Is primary prevention of Clostridium difficile infections possible with specific
probiotics? Int J Infect Disease 2012;In Press.
Stickrath C, et al. Patients and health care provider discussions about the risks of of medical
imaging: not ready for primetime. Arch Int Med 2012;172.
Harb SC et al. Exercise testing in asymptomatic patients after revascularization: are outcomes
altered? Arch Int Med 2012;172.
Post-Test
1.
Which of the following is true?
1.
2.
3.
4.
5.
2.
Infecting Microbe identification is important for decreasing LOS in
CAP
Post-operative DVT risk peaks on post-op day # 1
Daily antibiotics should be considered for all COPD patients with
frequent exacerbations
Aspirin should be restarted in patients with peptic ulcer bleeding
immediately after endoscopic hemostasis has been achieved
All of the above
Which of the following is true?
1.
2.
3.
4.
For all patients presenting with PE, TTE is the cheapest way to assess
RVD
Probiotics effectively prevent antibiotic associated C diff
Patients don’t want to hear about the risks of imaging procedures
Patients should routinely undergo stress testing 12 months after
being revascularized