Hot Topics in Hospital
Medicine
Noppon Pooh Setji MD
Sea Pines Resort, Hilton Head
July 2017
Case of syncope
Article Design
• Objective: To determine the prevalence of PE in patients admitted to the hospital for syncope
• Design: prospective cross sectional observational study
• Outcome: Pulmonary embolism diagnosed via CT scan, VQ scan or autopsy in patients admitted for their first episode of syncope
Inclusion Criteria
• Adult patients >18 yo admitted to 11
hospitals in Italy
• First episode of syncope
• Syncope defined as transient <1 minute
loss of consciousness with rapid resolution
• Obvious causes such as seizures, stroke
and head trauma ruled out
Exclusion Criteria
• Previous episodes of syncope
• Pregnancy
• Patients on anticoagulants
Reasons for Admission
• Trauma related to falls
• Severe co-existing conditions
• Failure to find explanation for syncope
• High probability for cardiac syncope on
basis the Evaluation in Guidelines for
Syncope Score
Study Methods
Study Methods
Testing for PE
• Pre-test probability determined using
Simplified Wells Score and D dimer testing
• CTA or VQ scan (for severe CKD or
contrast allergy) or autopsy in case of
death
Simplified Wells Score
Results
Results
• 25.4% of patients admitted for unexplained
syncope had PE
• 12.7% of patients who were thought to
have an explanation for syncope had a PE
• 25% of the patients diagnosed with PE
had no clinical signs of symptoms of PE
• Prevalence of PE was 17%
• Main pulmonary artery involved in 41%
Patients were different
Really?
Study Limitations?
• Very old patient population
• Very select group of patients
• European study – we’ve seen this before
(tight glycemic control, PE in copd flares)
• How do you explain all the small PE =
syncope?
Bottom Line
• Syncope evaluation image….
FAKE NEWS?
New Study on Pe and Syncope
• Same criteria as PESIT study
• Only Canadians this time!
• 1650 patients hospitalized with syncope
• 345 excluded (179 for anticoag and 166 prior syncope)
• PE eval in 146 or 11.2%
• PE found in 11, DVT in 10
• Total prevalance of 1.4%
Case of Anticoagulation
Article Design
• Objective: To Determine how rivaroxaban
compared with dabigatran for stroke,
bleeding and mortality risks in patient with
atrial fibrillation
• Design: Observational (new user, cohort)
• Outcome: Thromboembolic stroke,
Intracranial hemorrhage, major
extracranial bleeding and mortality
Inclusion Criteria
• Medicare patients age >65 (enrolled in
medicare part A, B, D)
• Patients with afib or flutter
• Filled their first prescription for rivaroxaban
or dabigatran from Nov 2011 to June 2014
Exclusion Criteria
• Age <65
• On medicare <6 months
• Prior treatment with NOAC or warfarin
• Residing in SNF or nursing home
• Enrolled in hospice
• Patients w hospitalization extending beyond the index date
• Patients on HD or with a kidney transplant
• Patients with alternative diagnosis requiring anticoagulation in past 6 months
Study Design
Patient with first RX for dabigatran or
rivaroxaban
52, 240 Dabigatran patients and 66, 651 Rivaroxaban
patients
Analyzed for outcomes over
study period
Outcomes
• 2537 total outcomes
• 306 strokes
• 176 ICH bleeds
• 1209 major extra cranial bleeds
• 846 deaths
Stroke Risk – no statistical difference
ICH
GI Bleed
Mortality- not statistically significant…
unless
Bottom Line
• In older medicare patients >65 who have
atrial fibrillation or atrial flutter:
• Rivaroxaban has higher rates of gi bleed,
extracranial major bleeding and ICH than
dabigatran without lower rates of stroke
• For patients older than 75 or with CHADS2
score >2: mortality was higher in patients
on rivaroxaban
Case for choosing your doctor
Study Design
• Analysis of 20% sample of Medicare inpatient and carrier files to find pts hospitalized from 2011 to 2014
• Non – elective hospitalizations and excluded AMA discharges
• Physician attribution was based on NPI for provider who accounted for the largest part of medicare part b spending during that hospital stay
• Generalist only
• Physician data came from doximity, ABMS, licensing boards and collaborating hospitals and med schools
Outcomes
• 30 day mortality and gender of provider
• 30 day readmission rates and gender of
provider
• Outcomes for 8 most common medical
conditions treated by generalists
• Outcomes based on disease severity
Mortality
Readmissions
Mortality Superiority By Condition
Readmissions Superiority by Condition
Bottom Line
My Own Study
• Top Hospitalist
• Yearly review M v F
Bottom Line:
Case for antibiotics for respiratory
infections
Peer Comparisons Never Cease
Study Design
• Objective: To assess behavioral interventions
on the rates of inappropriate antibiotic
prescribing in ambulatory visits for URIs
• Design: Cluster randomized trial of 47
practices in Northeast and Southern
California
• Outcome: Antibiotic Prescribing Rates for
visits with antibiotic inappropriate diagnosis
Exclusion Criteria
• If no clinician had at least 5 inappropriate
abx prescription annually within a group
• 2 practices met this critieria
Visits
• Inclusion Criteria
• Pt had to be >18 yo
• Visit occurred during
study period
• No prior visit for acute
respiratory infection
within prior 30 days
• Exclusion Critieria
• Acute pharyngitis
• Acute rhinosinusitis
• Medical comorbitidies
such as copd/chronic
lung disease
• Concurrent diagnosis
where antibiotics may
be indicated
Interventions
• Suggested Alternatives-EHR clinical decision support or ordersets ie Antibiotics are not indicated for this diagnosis, please consider the following….
• Accountable justification- EHR prompt to justify in free text why you wanted to use antibiotics while informing clinicians that the note would be visible to patients in the chart
• Peer Comparison – email intervention where clinicians were ranked from highest to lowest in each region using the data from EHR.
Study Design
• 49 practices assessed
• 2 excluded
• 47 practices randomized for study
• 70% of clinicians agreed to participate
(248)
• 125,333 visits for acute respiratory
infection during study period
• 31, 712 met criteria for evaluation
Outcomes
Bottom Line: To Curtail Inappropriate
Antibiotic Prescribing • Peer Pressure works!
• Accountable
Justification (with
public accountability)
also works
Case for Opioids after surgery
Study Design
• Review of claims data from jan 2012 to
june 2015 for opioid naive pts aged 18-64
who underwent surgery
• Looked at minor and major surgery
procedures
• Compared to 10% random sample who did
not undergo surgery in the study period
Outcome
• New persistent opioid use (filled rx
between 90-180 days after surgery)
Inclusion Criteria
Exclusion Criteria
Risk Factors
• Male
• Tobacco use
• Mental Health disorder –anxiety do, mood
do
• Alcohol abuse
• Substance abuse
• Chronic pain
Take Home Points
• Do not Send patients out with buckets of
opioids after surgery
• Do educate patients about the risk of
opioid use whenever they are being
prescribed
• Consider multi-modal pain regimens for
patients