Recent Research

Hospitalizations predicted to increase by 2050, attire recommendations issued, and more.

Hospitalizations seen increasing 67% by 2050

The annual number of hospitalizations will increase 67% by 2050, and inpatient demand capacity will need to expand by 72%, according to a recent analysis.

Researchers obtained data on all-source hospitalizations and applied them to U.S. Census Bureau population estimates through 2050. To calculate age-specific hospitalization rates, they estimated age-specific hospitalization frequencies during 2011 using the Nationwide Inpatient Sample.

They converted the frequencies into rates by dividing each stratum-specific admission count by the population count of that age stratum in 2011 U.S. Census data. To find their main outcome, they calculated the ratio of change in hospitalization frequency to the change in population, comparing each future year to the 2011 baseline. They also calculated aggregate inpatient days.

The population is expected to increase by 41% between now and 2050, while inpatient admissions are expected to grow by 67%. This means inpatient admission frequency will grow 18% more than the population, due to the aging of the population. Meanwhile, the aggregate number of inpatient days will grow by 22% more than the population. Overall, inpatient capacity will need to expand by 72% by 2050 to keep up with population growth and aging, the researchers reported. Results were published in the March Journal of Hospital Medicine.

These projections assume that age-specific hospitalization rates and lengths of stay will stay the same, when in fact they could change due to factors like technology, epidemics, and increasing access to health care through the Affordable Care Act, the researchers noted. The ability of clinicians, academics and the government to influence hospital supply is limited, they added, since only 22% of registered U.S. hospitals are government-owned.

Almost 20% of eligible ACS inpatients don't get ACE inhibitors, ARBs at discharge

Nearly 20% of eligible patients hospitalized for an acute coronary syndrome (ACS) don't receive angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) at discharge, despite these being recommended by guidelines, a recent study found.

Researchers performed an observational analysis of 80,241 ACS patients who were discharged home between January 2005 and December 2009. Patients came from 311 hospitals that participated in the Get With the Guidelines-Coronary Artery Disease Program. Of these patients, 60,847 patients had an American College of Cardiology/American Heart Association (ACC/AHA) class I indication for ACE inhibitors or ARBs—i.e., they had left ventricular ejection fraction <40%, heart failure, hypertension, diabetes mellitus, or chronic kidney disease. Researchers sought to determine how many of these patients received ACE inhibitors or ARBs at discharge. Results were published in the March Circulation: Cardiovascular Quality and Outcomes.

Eighty-two percent (n=49,682) of the eligible patients received a prescription for ACE inhibitors or ARBs, with the rate increasing over the study period (76.7% to 84.6%; adjusted odds ratio [AOR], 1.17; 95% CI, 1.10 to 1.24; P<0.001). Patients who were younger, were male, had more cardiac risk factors, and underwent PCI were more likely to get a prescription. In-hospital coronary artery bypass grafting, atrial fibrillation, and renal insufficiency were independently associated with lower use of the recommended therapy (AOR, 0.55; 95% CI, 0.48 to 0.63 and AOR, 0.58; 95% CI, 0.52 to 0.64, respectively).

Of the study cohort, another 19,394 patients met the ACC/AHA class IIa indication for ACE inhibitors and ARBs at discharge (left ventricular ejection fraction ≤40%, hypertension, diabetes mellitus, or chronic kidney disease). Of these, 68% received a prescription (n=13,212). None of these patients had a history of hypertension or diabetes; they were more likely to be men and undergo PCI and, like the class I patients, less likely to have cardiac surgery, atrial fibrillation, or renal insufficiency. Prescriptions for these patients also increased over the study period (62.8% to 70.2%; P<0.001).

The uptick in prescriptions over the study period coincides with nationwide implementation of quality improvement programs, the authors wrote, but the results indicate more work is necessary.

Most scores moderately predictive for hemorrhage after thrombolysis

An analysis of scores to predict symptomatic intracranial hemorrhage risk after thrombolysis found all but one were moderately predictive, with one slightly better than the others.

Researchers used prospectively collected data from 3,012 patients at 7 stroke centers who had had ischemic stroke and received intravenous thrombolysis. With this data, they evaluated 6 scores that estimate the risk of symptomatic intracranial hemorrhage (sICH): MSS (Multicenter Stroke Survey); HAT (Hemorrhage After Thrombolysis); SEDAN (blood sugar, early infarct signs, [hyper]dense cerebral artery sign, age, NIH Stroke Scale); GRASPS (glucose at presentation, race [Asian], age, sex [male], systolic blood pressure at presentation, and severity of stroke at presentation [NIH Stroke Scale]); SITS (Safe Implementation of Thrombolysis in Stroke); and the SPAN (stroke prognostication using age and NIH Stroke Scale)-100 positive index. Only patients with available variables for all scores were included in the study. For all scores, researchers calculated the area under the receiver-operating characteristic curve (AUC-ROC) and did logistic regression analysis. The results were published in the March Stroke.

Two hundred twenty-one patients, or 7.3%, had sICH per the National Institute of Neurological Disorders and Stroke criteria, 141 (4.7%) had it per the European Cooperative Acute Stroke Study II, and 86 (2.9%) had it per Safe Implementation of Thrombolysis in Stroke criteria. The scores' performances, assessed for predicting European Cooperative Acute Stroke Study II sICH, were: MSS, AUC-ROC 0.63 (95% CI, 0.58 to 0.68); HAT, AUC-ROC 0.65 (95% CI, 0.60 to 0.70); SEDAN, AUC-ROC 0.70 (95% CI, 0.66 to 0.73); GRASPS, AUC-ROC 0.67 (95% CI, 0.62 to 0.72); SITS, AUC-ROC 0.64 (95% CI, 0.59 to 0.69); and SPAN-100 positive index, AUC-ROC 0.56 (95% CI, 0.50 to 0.61).

In general, SPAN-100 had poor predictive power and the other scores had moderate predictive power. SEDAN had the highest nominal predictive performance in all comparisons. The modest differences between the scores reflect that most have similar components, with differences often lying in the weighting of the components, the researchers noted.

“At the moment, we must acknowledge the limitations of post-thrombolysis hemorrhage prediction scores, and we do not have the data to support withdrawal of thrombolysis treatment, which has a proven benefit, in patients with high risk of sICH,” the researchers wrote. For now, patients at high risk of sICH would likely benefit from intensive glucose and blood pressure monitoring and heightened alertness from staff after thrombolysis is administered, they wrote.

Transfusion in PCI patients associated with greater risk of heart attack, stroke, death

Among patients undergoing percutaneous coronary intervention (PCI), those who received a transfusion had a higher risk of heart attack, stroke or death in the hospital, an analysis found.

Researchers performed a retrospective cohort study of 2,258,711 patient visits that included PCI, using data from the CathPCI Registry. The visits at 1,431 hospitals covered the period of July 2009 to March 2013, and patients who had bleeding complications or who underwent coronary artery bypass graft (CABG) surgery were excluded. The main outcomes were the overall transfusion rate and transfusion rates per hospital. Researchers also measured the association between transfusion and myocardial infarction, stroke and death. Results were published in the Feb. 26 Journal of the American Medical Association.

The overall transfusion rate was 2.1%, and quarterly transfusion rates fell slightly during the nearly 4-year study period, from 2.11% to 2.04% (P<0.001; 95% CI, 1.97% to 2.12%). Receiving a transfusion was associated with a greater risk of myocardial infarction (MI) (4.5% vs. 1.8%; odds ratio [OR], 2.60; 95% CI, 2.57 to 2.63), stroke (2% vs. 0.2%; OR, 7.72; 95% CI, 7.47 to 7.98), and in-hospital death (12.5% vs. 1.2%; OR, 4.63; 95% CI, 4.57 to 4.69), regardless of bleeding complications. Older, female patients were more likely to receive transfusions, as were patients with hypertension, diabetes, advanced renal dysfunction, and prior MI or heart failure. There was a broad variation in transfusion patterns across hospitals, including variation in hemoglobin thresholds for transfusion.

Study limitations include that the data are observational and thus offer association and not causation and that transfusion patterns were examined across patients and hospitals but not clinicians.

“These data highlight the need for randomized trials of transfusion strategies to guide practice in patients undergoing PCI,” the researchers concluded. “Until these trials have been completed, operators should use strategies that reduce the risk of bleeding and [need for] transfusion.”

Guideline update issued on prevention of stroke in nonvalvular afib

The American Academy of Neurology recently issued a guideline update on preventing stroke in patients with nonvalvular atrial fibrillation (NVAF).

The guideline update reviewed the evidence published since 1998, when the Academy's last guideline on this topic was issued, and focused on how often various technologies identify previously undetected NVAF in patients with cryptogenic stroke, as well as which therapies including antithrombotic medications reduce stroke risk and severity and have the lowest risk of hemorrhage. The guideline panel based its practice recommendations on the strength of the evidence according to systematic review, principles of care, benefits and harms, costs, intervention availability, and patients' preferences.

The panel concluded that cardiac rhythm monitoring probably detects occult NVAF in patients who have recently had a cryptogenic stroke. In addition, it found that dabigatran, rivaroxaban and apixaban are probably at least as effective as warfarin for stroke prevention but confer a lower hemorrhage risk. Triflusal added to acenocoumarol appears to be more effective than acenocoumarol monotherapy in reducing risk for stroke, the panel noted. Clopidogrel plus aspirin, meanwhile, appears to be less effective than warfarin for stroke prevention with a lower intracranial bleeding risk; this combination also appears to reduce stroke risk more than aspirin alone but carries a higher risk for major hemorrhage. Aspirin and apixaban have similar bleeding risk, but the latter appears to be more effective in reducing risk for stroke, the panel said.

Based on its findings, the panel recommended that clinicians choose one of the following regimens to reduce risk for stroke or subsequent stroke in patients with NVAF who are thought to require oral anticoagulants (Level B recommendation):

  • warfarin, with a target international normalized ratio of 2.0 to 3.0;
  • dabigatran, 150 mg twice daily (in patients with a creatinine clearance >30 mL/min);
  • rivaroxaban, 15 mg/d (in patients with a creatinine clearance of 30 to 49 mL/min) or 20 mg/d;
  • apixaban, 5 mg twice daily (in patients with a serum creatinine >1.5 and <2.5 mg/dL and body weight <60 kg or age ≥80 years or both); or
  • triflusal, 500 mg, plus acenocoumarol, with a target international normalized ratio of 1.25 to 2.0 (for patients at moderate risk for stroke; this choice is mainly for those in developing countries).

The panel noted that clinicians might obtain outpatient cardiac rhythm studies in patients with cryptogenic stroke but no known NVAF in order to identify occult NVAF (Level C recommendation). In addition, the panel said, clinicians should prescribe dabigatran, rivaroxaban, or apixaban to patients with NVAF who require anticoagulant medication and have a high risk for intracranial bleeding (Level B recommendation).

Clinicians should offer oral anticoagulation routinely to NVAF patients older than 75 if they have no history of recent unprovoked bleeding or intracranial hemorrhage (Level B recommendation); oral anticoagulation can also be offered to NVAF patients with dementia or occasional falls, but patients or family members should be told that the risk-benefit ratio is not known in those whose dementia is moderate or severe or in those who fall very frequently, the panel said (Level B recommendation). The guideline was published Feb. 25 by Neurology.

Microsporidiosis detected as a transplant-associated disease

A recent public health investigation by the Centers for Disease Control and Prevention (CDC) found that febrile illness in 3 transplant recipients was caused by Encephalitozoon cuniculi in their common donor.

The CDC was notified in February 2012 of 3 patients who had developed febrile illness after receiving organs from the same donor. All patients received initial evaluation at their transplant hospitals and remained ill after concomitant infections were treated. Possible identification of Brucella infection led to directed therapy for brucellosis, but when the patients' condition did not improve, kidney biopsy samples from 1 patient were sent to the CDC, which confirmed microsporidiosis with E. cuniculi. The ensuing public health investigation was conducted to confirm the diagnosis in all 3 transplant recipients, assess recipient and donor risk factors and provide therapy recommendations. The results of the investigation were published in the Feb. 18 Annals of Internal Medicine.

One of the 3 patients received a left kidney, 1 received 2 lungs, and 1 received a right kidney from the same donor. All 3 developed fever 7 to 10 days after transplantation. The researchers used culture, immunofluorescent antibody, polymerase chain reaction, immunohistochemistry and electron microscopy to test specimens for microsporidia. They also reviewed the donor's medical records and used a questionnaire to interview the donor's family about potential microsporidial infection.

Urine culture, serologic and polymerase chain reaction were all positive for E. cuniculi in all 3 patients, and E. cuniculi was also identified in biopsy or autopsy specimens in all 3 cases. The donor had positive serologic results for E. cuniculi, but no autopsy specimens were available for culture or polymerase chain reaction, and the questionnaire completed by family revealed no risk factors for microsporidial infection.

The left kidney recipient had persistent fever, anuria and hemodynamic stability despite receiving broad-spectrum antibiotics and died 21 weeks after transplantation. The bilateral lung recipient showed improvement in encephalopathy and kidney function after beginning treatment with albendazole, 400 mg twice daily, but developed posttransplant lymphoproliferative disorder and died 20 months after transplantation. The right kidney recipient, who remains healthy, gradually improved after beginning albendazole therapy, 400 mg twice daily; he continued to take albendazole for 1 year after transplantation.

“Microsporidiosis should be considered in the differential diagnosis when an infectious cause is suspected, evaluation for common pathogens is unrevealing, and response to standard therapies is poor,” the authors wrote. “Furthermore, transplant-transmitted disease should be considered in recipients when the illness is common to other patients receiving organs from the same donor.”

Attire recommendations issued

The Society for Healthcare Epidemiology of America recently issued recommendations on attire for health care personnel who work in non-operating-room settings.

The writing group recommended that health care facilities consider a “bare below the elbows” approach, defined as short sleeves, no wristwatches, no jewelry and no neckties during clinical practice. In institutions that mandate white coats for clinicians, the writing group recommended that each clinician have at least 2, as well as access to convenient, economical on-site laundry facilities. In addition, the group recommended that coat hooks be provided so that clinicians can remove their coats or other long-sleeved outer garments and hang them up before coming in contact with patients.

Ideally, apparel that comes into contact with the patient or the patient environment should be washed daily, the writing group said, and white coats worn while caring for patients should be washed at least once per week and when visibly dirty. The writing group noted that clinicians who don't care for many patients or who are infrequently involved in direct patient care may need to wash their white coats less often than other clinicians.

The writing group also recommended that clinicians wear closed-toe shoes with low heels and nonskid soles. ID badges should be clearly visible, and they and similar items, such as lanyards and cell phones, should be disinfected, replaced or eliminated after direct contact with the patient or the patient environment. The writing group noted that the current evidence did not support limitations on use of items such as neckties; however, the recommendations state that neckties should be secured by a white coat or some other mechanism if worn.

The writing group noted that the evidence surrounding optimal health care attire is lacking and called for additional well-designed studies in this area. The authors issued a caveat that all of these recommendations should be voluntary and that facilities adopting them should make a concerted effort to communicate them to both clinicians and patients and to provide appropriate education. The full expert guidance statement was published in the February Infection Control and Hospital Epidemiology.