Primecuts – This Week in the Journals

By Ravi Shah, MD

Peer Reviewed 

With medicine advancing at such a rapid pace, it is crucial for physicians to keep up with the medical literature.  This can quickly become an overwhelming endeavor given the sheer quantity and breadth of literature released on a daily basis. Primecuts helps you stay current by taking a shallow dive into recently released articles that should be on your radar. Our goal is for you to slow down and take a few small sips from the medical literature firehose. 

Standardized Team-Based Care for Cardiogenic Shock: first to observe a mortality benefit

This single-center prospective observational study(1) sought to investigate if a standardized team-based approach to cardiogenic shock can improve mortality. A total of 204 consecutive patients were studied from Jan 2017 to June 2018, after the implementation of multidisciplinary team-based algorithm for the management of cardiogenic shock. There was no control group. The algorithm included activation of a “shock team,” mandatory invasive hemodynamic monitoring, and rapid transfer of patients on mechanical support to a cardiogenic shock center with a cardiac ICU. The principal finding was an overall 30-day survival rate over 75%, compared to a national average of less than 50% (2). Additionally, the authors used a linear regression model to develop a risk-stratification score to estimate the risk of 30-day mortality based on factors including cardiac power output >0.6 Watts, pulmonary arterial pulsatility index >1.0, lactate <3 at 24 h, age >71 y, diabetes mellitus, dialysis, and >36 h of vasopressor use at time of diagnosis.

This is the first study to observe a mortality benefit from a standardized team-based approach to the treatment of cardiogenic shock. The biggest strengths of the pilot program, and consequently the largest drivers of the mortality benefit, appear to have been rapid identification of shock, team-based decision making, ability to quickly transfer patients to the central hospital in the healthcare system, invasive hemodynamic monitoring, and early initiation of mechanical support. The overall survival rate was comparable with that of a protocol recently developed by the National Cardiogenic Shock Initiative (3). This now provides strong support in favor of a multidisciplinary team-based approach to the management of cardiogenic shock; however, several barriers exist for its widespread adoption. It requires care coordination between a wide array of medical and surgical specialties, emergent initiation of mechanical support within 60 minutes of initial medical contact, and the capability to rapidly transfer patients to established shock care centers.

Patient Readmission Rates For All Insurance Types After Implementation Of The Hospital Readmissions Reduction Program: readmission rates have dropped, but mortality may have increased

This retrospective observational study(4) investigated the effect that the Hospital Readmissions Reduction Program (HRRP) had on national readmissions, across all payer types. Investigators queried the publicly-available Nationwide Readmissions Database, which contains discharge data from 22 states, representing 51% of the US population and 49% of all hospitalizations. They compared how quarterly risk-standardized readmission rates for target conditions compared before (2010-12) and after (2012-14) HRRP implementation. Target conditions were AMI, heart failure, and pneumonia. The control group consisted of readmissions for nontarget conditions. The principle finding was that HRRP implementation is associated with a decreased rate of unplanned all-cause 30-day readmission across all payer types. The risk-adjusted readmission rate decreased from 21.3% to 19.4% for Medicare, from 20.9% to 20.4% for Medicaid, and from 13.5% to 12.5% for private payers. Both Medicare and Medicaid readmissions decreased faster in the aggregate and for individual target conditions compared to that for nontarget conditions. However, the rate of decrease in private payer readmissions from was not significantly different than the rate for nontarget conditions. Across all payer types, the unadjusted readmission rate for index conditions were 22.5% for heart failure, 16.1% for pneumonia, and 15.4% for AMI.

HRRP is associated with a decrease in 30-day readmissions not only for Medicare patients, but for patients across all payers. Composite readmission rates are much higher for Medicaid than Medicare patients; however, HRRP doesn’t appear to preferentially target Medicaid readmissions, which account for $830M in excess national health expenditures. The need to safely target Medicaid readmissions is reflected in the Data Driven Patient Care Strategy(5) recently announced by CMS, which will release Medicaid data to researchers. Finally, new data suggests that the largest decrease in readmissions for target conditions has been for heart failure; however, the observed decline may largely reflect treatment of these patients in emergency departments and observation units(6). Reductions in heart failure and pneumonia readmissions may also be associated with increases in post-discharge mortality, particularly for patients who are not readmitted(7).

The ABATE Infection Trial: no benefit of aseptic bathing or decontamination in floor patients

The ABATE Infection Trial(7) sought to answer whether universal skin decolonization with chlorhexidine and targeted nasal decontamination with mupirocin in the non-critical-care inpatient setting reduces the rate of multidrug-resistant cultures, as it has already been shown to do in critical care units (8). The study was a cluster-randomized trial of 53 American hospitals in a single healthcare institution with a total sample size of approximately 340,000 patients, of which 180,000 were in the treatment arm. The treatment arm was compared against routine bathing care. There was no difference in the rate of unit-attributable MRSA-positive or VRE-positive clinical cultures. The hazard ratio was 0.79 (95% CI 0.73 – 0.87) in the decolonization group versus 0.87 (0.79 – 0.95) in the routine care group (p=0.17). However, a post-hoc analysis of patients with medical devices did show a reduction of 32% in all-cause bloodstream infections and 37% in MRSA or VRE clinical cultures.

ICUs have increasingly adopted protocols for daily chlorhexidine bathing and routine nasal decontamination because ample evidence suggests that they reduce device-associated bacteremia, all-cause bacteremia, and multidrug-resistant organisms by up to 50-60%(9). Because hospital-associated infections are the most frequent and serious complications suffered by non-critical-care patients, there is interest in infection prevention strategies. This is the first trial targeted to non-ICU patients, and suggests that the same benefit may not exist in the non-critical-care setting. One important confounder was the inability to measure quality of bathing and decontamination, though nurses did undergo on-site and computer-based training. Interestingly, both the treatment and control arms in this study saw statistically significant reductions in MDR infections from baseline; the reason for this is not known.

One Month of Rifapentine plus Isoniazid to Prevent HIV-Related Tuberculosis: non-inferior to a 9-month regimen

This open-label, phase 3 noninferiority, randomized controlled trial(10) investigated the efficacy and safety of a 1-month regimen for the prevention of TB in HIV-positive patients against a 9-month regimen, currently the standard of care. A total of 3,000 patients from 10 countries in 4 continents were studied from May 2012 to Nov 2014, with a median follow-up of 3.3 years. All patients were either from an area with a high prevalence of TB or had a personal history of latent TB. All medications were self-administered by patients. The principal finding was no difference in the incidence of first diagnosis of tuberculosis or death from tuberculosis or an unknown cause (0.65 per 100 person-years in the 1-month group, 0.67 per 100 person-years in the 9-month group, 95% CI −0.35 to 0.30). Completion of treatment was significantly higher in the 1-month group (97% vs 90%, p <0.001) and there was no difference in serious adverse effects (6% vs 7%, p=0.07).

Globally, TB remains the leading cause-of-death in HIV-positive individuals. Though high-quality data has long supported the role for preventive therapy in HIV-positive patients, only about 3% of those eligible receive any therapy, and even fewer complete it(11). This is primarily driven by poor adherence, concerns about promoting drug resistance, and drug–drug interactions with antiretroviral agents, and skepticism about the efficacy of preventive therapy. Now that there is additional data to support the efficacy of a preventive strategy(12, 13) and a practical regimen(10), there is renewed hope that more eligible patients will receive preventive therapy.

Mini-Cuts

1. With 3 new studies recently published, this meta-analysis concluded that renal sympathetic denervation (RSD) compared to sham reduced systolic and diastolic pressures, 24 h ambulatory, and daytime BP. The average decrease in BP varied between 1.6 to 6.5 mmHg; however, the effect was significantly larger in second-generation studied compared to first (14).

2. With new medications to treat Hepatitis C infection and the well-documented national shortage of transplantable organs, there is now the possibility in increase the donor pool by enabling the transplantation of hearts and lungs from HCV-infected donors to those without HCV. A recent study of 44 patients who received a heart or lung transplant from donors with HCV viremia found that treatment with an antiviral regimen for 4 weeks, initiated within a few hours after transplantation, prevented the establishment of HCV infection in the recipients (15).

3. Although studies have shown that primary care provided by residents is similar to that provided by attending physicians, most have had small sample sizes. This review of 76,000 VA patients across 10 sites nationally, compared patients assigned to resident vs attending clinics on outcomes including measures of diabetes care quality, use of a high-risk medication in patients older than 65 years, hypertension control, emergency department visits, and hospitalizations. Residents care for slightly more complex patients; however, outcome measures were overall similar between patients of resident physicians and patients of attending physicians (16).

Dr. Ravi Shah is a 2nd year resident at NYU Langone Health

Peer reviewed by Kevin Hauck, MD, associate editor, Clinical Correlations

Image courtesy of Wikimedia Commons

References

1. B.N. Tehrani, A.G. Truesdell, M.W. Sherwood, et al. Standardized team-based care for cardiogenic shock. J Am Coll Cardiol, 73 (2019), pp. 1659-1669 https://www.x-mol.com/paper/5626063
2. F.A. Masoudi, A. Ponirakis, J.A. de Lemos, et al. Trends in US cardiovascular care. 2016 Report from 4 ACC national cardiovascular data registries. J Am Coll Cardiol, 69 (2017), pp. 1427-1450
3. M.B. Basir, T.L. Schreiber, C.L. Grines, et al. Effect of early initiation of mechanical circulatory support on survival in cardiogenic shock. Am J Cardiol, 119 (2017), pp. 845-851
4. Ferro EG, Secemsky EA, Wadhera RK, et al. Patient Readmission Rates For All Insurance Types After Implementation Of The Hospital Readmissions Reduction Program. Health Aff. 2019; 38(4): 585–593.  https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05412
5. CMS.gov. Baltimore (MD): Centers for Medicare and Medicaid Services. Press release, CMS Administrator Verma unveils new strategy to fuel data-driven patient care, transparency; 2018 Apr 26.
6. Ody C, Msall L, Dafny LS, Grabowski DC, Cutler DM. Decreases in readmissions credited to Medicare’s program to reduce hospital readmissions have been overstated. Health Aff. 2019;38(1): 36–43. delivery system [Internet]. Washington (DC): MedPAC; 2018. Chapter 1, Mandated report: the effects of the Hospital Readmissions Reduction Program; [cited 2019 Jan 28]. Available from: http://www.medpac .gov/docs/default-source/reports/ jun18_ch1_medpacreport_sec.pdf

7. Wadhera RK, Joynt Maddox KE, Wasfy JH, Haneuse S, Shen C, Yeh RW. Association of the Hospital Re- admissions Reduction Program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA. 2018;320(24): 2542–52
8. Huang SS, Septimus E, Kleinman K, et al: Chlorhexidine versus routine bathing to prevent multidrug-resistant organisms and all-cause bloodstream infections in general medical and surgical units (ABATE Infection trial): a cluster-randomised trial. Lancet 2019; 393: pp. 1205-1215. https://www.populationmedicine.org/node/104232
9. Centers for Disease Control and Prevention: 2014 national and state healthcare-associated infections progress report. https://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf
10. Lowe CF, Lloyd-Smith E, Sidhu B, et al: Reduction in hospital-associated methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus with daily chlorhexidine gluconate bathing for medical inpatients. Am J Infect Control 2017; 45: pp. 255-259
11. Swindells S et al. One month of rifapentine plus isoniazid to prevent HIV-related tuberculosis. N Engl J Med 2019 Mar 14; 380:1001.
12. Global tuberculosis report 2018. Geneva: World Health Organization, 2018. https://www.nejm.org/doi/full/10.1056/NEJMoa1806808
13. Badje A, Moh R, Gabillard D, et al. Effect of isoniazid preventive therapy on risk of death in west African, HIV-infected adults with high CD4 cell counts: long-term follow-up of the Temprano ANRS 12136 trial. Lancet Glob Health 2017;5(11):e1080-e1089.
14. Hakim J, Musiime V, Szubert AJ, et al. Enhanced prophylaxis plus antiretroviral therapy for advanced HIV infection in Africa. N Engl J Med 2017;377:233-245.
15. Sham-Controlled Randomized Trials of Catheter-Based Renal Denervation in Patients With Hypertension (DOI: 10.1016/j.jacc.2018.12.082)
16. Heart and Lung Transplants from HCV-Infected Donors to Uninfected Recipients (DOI: 10.1056/NEJMoa1812406)
17. Quality of Outpatient Care With Internal Medicine Residents vs Attending Physicians in Veterans Affairs Primary Care Clinics (DOI: 10.1001/jamainternmed.2018.8624)

 

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