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Hot Topics in Hospital Medicine Noppon Pooh Setji MD Sea Pines Resort, Hilton Head July 2017
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
