Eight Things to Do Differently Tomorrow

The (Lack of) Evidence Behind Common Hospitalist Practices

Chad R. Stickrath, MDOctober 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 8/2012http://clinicalevidence.bmj.com.hsl-ezproxy.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) Identification of the infecting microbe2) Productive cough3) Early mobilization4) 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 3-Step Pathway(n =200)

Usual Care(n =201)

P Value

LOS 3.9 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) Identification of the infecting microbe2) Productive cough3) Early mobilization4) 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) Post-operative day 12) Post-operative day 33) Post-operative day 144) 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

• 239,614 had operation, 5419 (0.6%) post op VTE

The Risk for Post-Operative VTE Extends Well Beyond 2 Weeks

• Systematic Review• Randomized Trials– Comparing DVT ppx• 7-10 days vs. ≥ 20 days

How Long Should I Recommend Total Hip and Knee Arthroplasty Patients use Pharmacologic Prophylaxis?

• Included 8 RCTs

Shorter Duration vs. Longer Duration of VTE Prophylaxis

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) Post-operative day 12) Post-operative day 33) Post-operative day 144) 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 long-term antibiotics to prevent COPD exacerbations at discharge?1) Patient taking citalopram for depression2) Patient is “hard of hearing”3) Patient is taking methadone for back pain4) 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 yearfrom 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 …

• Wenzel et al. recommend Monday, Wednesday, Friday dosing instead of daily• Will need every 3 month follow-up to assess for side effects

Wenzel et al. Antibiotic prevention of acute exacerbations of COPD. NEJM 2012;367

• Consider recommending long term azithromycin to certain patients admitted with COPD exacerbations.

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 long-term antibiotics to prevent COPD exacerbations at discharge?1) Patient taking citalopram for depression2) Patient is “hard of hearing”3) Patient is taking methadone for back pain4) 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) Never2) 8 weeks after discharge3) 2 weeks after discharge4) 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) CIConfirmed recurrent bleed 8 4 -4 – 13 Death @ 30 days 1 7 4 – 20Death @ 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) Never2) 8 weeks after discharge3) 2 weeks after discharge4) 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) Normal ECG2) Normal RV size on CT pulmonary angiogram3) Normal Transthoracic Echocardiogram4) 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)

• 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

What is the Most Effective Method for Detecting RV Dysfunction in Hemodynamically

Stable Patients Admitted with PE?

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) Normal ECG2) Normal RV size on CT pulmonary angiogram3) Normal Transthoracic Echocardiogram4) 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) Lactobacillus PO while on antibiotics2) Metronidazole IV while on antibiotics3) Acidophilus PO for 7 days beyond antibiotic dc4) 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) Lactobacillus PO while on antibiotics2) Metronidazole IV while on antibiotics3) Acidophilus PO for 7 days beyond antibiotic dc4) 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) Chest X-ray2) Chest CT pulmonary angiogram3) Thallium stress test4) 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

• 271/286 patients responded

Patients Want Us to Discuss Risks and Benefits of Imaging Procedures but We Don’t

• 348/849 providers responded

Patients Want Us to Discuss Risks and Benefits of Imaging Procedures but We Don’t

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) Chest X-ray2) Chest CT pulmonary angiogram3) Thallium stress test4) Cardiac catherization

0.1 mSv15 mSv

40 mSv8 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 drug-eluting stents.

• Which intervention prescribed at discharge will NOT improve outcomes for him?1) Atorvastatin 80mg daily2) Smoking cessation therapies3) Post revascularization stress test in 6 months4) 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 drug-eluting stents.

• Which intervention prescribed at discharge will NOT improve outcomes for him?1) Atorvastatin 80mg daily2) Smoking cessation therapies3) Post revascularization stress test in 6 months4) Clopidogrel for at least one year

Summary – Do’s

• Do employ the “3 – Steps for Community-Acquired 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. 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.

2. Sweetland S, et al. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women prospective cohort study. BMJ 2009;339.

3. Sobieraj DM, et al. Prolonged versus standard duration venous thromboprophylaxis in major orthopedic surgery. Ann Intern Med 2012;156.

4. Albert RK, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med 2011;365.5. Sung JJY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding. Ann Intern Med

2010;152.6. Golpe R, et al. Electrocardiogram score predicts severity of pulmonary embolism in

hemodynamically stable patients. J Hosp Med 2011;6.7. Hempel S, et al. Probiotics for the prevention and treatment of antibiotic associated diarrhea.

JAMA 2012;307.8. Johson S, et al. Is primary prevention of Clostridium difficile infections possible with specific

probiotics? Int J Infect Disease 2012;In Press.9. 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;172.10. Harb SC et al. Exercise testing in asymptomatic patients after revascularization: are outcomes

altered? Arch Int Med 2012;172.

Post-Test1. Which of the following is true?

1. Infecting Microbe identification is important for decreasing LOS in CAP2. Post-operative DVT risk peaks on post-op day # 13. Daily antibiotics should be considered for all COPD patients with frequent

exacerbations4. Aspirin should be restarted in patients with peptic ulcer bleeding

immediately after endoscopic hemostasis has been achieved5. All of the above

2. Which of the following is true?1. For all patients presenting with PE, TTE is the cheapest way to assess RVD2. Probiotics effectively prevent antibiotic associated C diff3. Patients don’t want to hear about the risks of imaging procedures4. Patients should routinely undergo stress testing 12 months after being

revascularized