Postoperative function, hip fracture, and more

Summaries from ACP Hospitalist Weekly.

Six-minute walk distance before cardiac surgery predicts postoperative cognitive dysfunction

A lower six-minute walk distance (6MWD) before cardiac surgery was associated with higher risk of postoperative cognitive dysfunction, a study found.

The study included 181 Japanese patients with a mean age of 71.4 years who were undergoing cardiac surgery. Their 6MWD was measured at hospital admission. Postoperative cognitive dysfunction, defined as a decrease of two points or more in the Mini-Mental State Examination (MMSE) score, was found in 28% of the patients. Results were published online May 9 by Annals of Thoracic Surgery and appeared in the August issue.

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Image by Thinkstock

The group of patients who developed cognitive dysfunction had a significantly lower median preoperative 6MWD (400 m) than those who didn't (450 m). For each increase of 50 m in a patient's 6MWD, the odds ratio for postoperative cognitive dysfunction was 0.807. In addition to the 6MWD, intensive care unit length of stay, age, and MMSE score were found to be independent risk factors for postoperative cognitive dysfunction.

“To our knowledge, the present study is the first to indicate that the 6MWD is a useful screening tool for identifying patients at a high risk for [postoperative cognitive dysfunction]. It may be important to assess the functional exercise capacity in each patient to predict the risk of postoperative neurologic dysfunction,” the authors said. The decision to operate and perioperative management should be carefully considered in patients found to have a low 6MWD before surgery, the authors suggested, noting that exercise supervised by a physical therapist to increase functional exercise capacity is recommended in advance of cardiac surgery.

The study had a number of limitations that mean it should be interpreted cautiously, the authors said. It included only patients with MMSE scores of 24 or higher, so further research would be required in patients with mild cognitive impairment. Patients with severe comorbidities or postoperative complications were also excluded. The overall number of participants was small, and all were treated at a single medical center. “A validated scoring system should be created for a large number of participants,” the authors said.

Surgical, nonsurgical management of hip fracture compared in nursing home residents with advanced dementia

Surgical hip fracture repair was associated with lower mortality rates than nonsurgical management in nursing home residents with advanced dementia, but adverse outcomes remained common regardless of treatment, a study reported.

In the retrospective cohort study, researchers used nationwide Medicare claims data to compare survival rates among nursing home patients with advanced dementia and hip fracture who received surgical versus nonsurgical management. Documented pain, use of antipsychotics, use of physical restraints, pressure ulcers, and ambulatory status were also compared in nonsurgical and surgical patients who survived for six months. The study results were published online May 7 by JAMA Internal Medicine and appeared in the June issue.

A total of 3,083 patients were included in the study. Mean age was 84.2 years, and 79.2% were women. Surgical repair was performed in 2,615 patients (84.8%), while 468 (14.2%) were managed nonsurgically. Before the fracture, 879 patients (28.5%) had been ambulatory. At six-month follow-up, 31.5% of surgical patients and 53.8% of nonsurgical patients had died. The adjusted hazard ratio for death among surgery patients compared with nonsurgery patients was 0.88 (95% CI, 0.79 to 0.98).

Among the 2,007 patients who were alive at six-month follow-up, those who had been managed surgically had less documented pain and fewer pressure ulcers than those who had not (adjusted hazard ratios, 0.78 [95% CI, 0.61 to 0.99] and 0.64 [95% CI, 0.47 to 0.86], respectively). However, use of antipsychotic drugs and physical restraints did not appear to differ between groups, and few patients in either group remained ambulatory at six months (10.7% vs. 4.8%, respectively). Fewer than a quarter of patients (21.5%) received hospice care within six months of the fracture, and 1.1% of patients in both the surgical and nonsurgical groups got a “do not hospitalize” directive.

The authors noted that unmeasured differences between the groups may have affected their findings and that secondary outcomes were measured at one point in time, among other limitations. However, they concluded that their findings highlight the need for improved quality of care in nursing home residents with advanced dementia and hip fracture. “Proxies for these residents should consider the survival benefit of surgery together with the overall goals of care when making the difficult decision of whether to pursue surgery,” they wrote. They also recommended greater use of hospice and palliative care in this population, regardless of surgical repair.

An accompanying invited commentary said the study adds important new information about nursing home patients with advanced dementia who have a hip fracture but did not address factors that could help inform physicians' and families' choice of treatment, including risk for very early death and potential for postoperative complications. The commentary authors agreed with the study authors that there should be a larger role for hospice care and orders limiting hospitalization, calling the low rate of both the study's “most distressing finding,” since previous research has shown that hip fracture in advanced dementia is often a marker of the end of life.

“This situation calls for a discussion of goals of care and should prompt serious consideration of initiation of hospice care,” the commentary authors wrote. “Moreover, families and proxies need to understand the likely ultimate causes of death in patients with advanced dementia.”

Cardiologist care less likely for African-Americans in ICU with heart failure, study finds

African-American patients with heart failure may be less likely to receive care from a cardiologist in the ICU, according to a study.

Researchers used the Premier database to compare the likelihood of receiving primary ICU care from a cardiologist versus a noncardiologist among white and African-American patients with heart failure. A total of 104,835 adults admitted to the ICU with a diagnosis of heart failure at 497 hospitals from 2010 to 2014 were included. The study results were published by JACC: Heart Failure on April 30 and appeared in the May issue.

Overall, 80.3% of the study patients were white and 19.7% were African-American. Just over half of the patients were men. Odds of primary ICU cardiologist care were higher in white patients than in African-American patients (adjusted odds ratio, 1.42; 95% CI, 1.34 to 1.51). Primary ICU care from a cardiologist versus a noncardiologist was associated with better in-hospital survival (adjusted hazard ratio, 1.20; 95% CI, 1.11 to 1.28), and this association did not differ according to patient race.

The researchers noted that the data used for the study did not include details on physicians or information on patient medications or cause of death and that patient race was based on administrative data rather than self-report, among other limitations. However, they concluded that ICU care by a cardiologist for heart failure appeared to be less likely in African-American patients than in white patients and that admission by a cardiologist was associated with better rates of in-hospital survival regardless of patient race.

“Future research should identify strategies to reduce racial differences in receipt of care by a cardiologist and improve quality of care and outcomes for patients who receive care from noncardiologists,” the authors wrote.

An accompanying editorial noted that a significant percentage of African-American patients in the study had private insurance or Medicaid, indicating that lack of access or insurance was not to blame for a lack of cardiologist care and that inherent bias might have been at play. The editorialist pointed to an Institute of Medicine report published 15 years ago that examined potential sources of racial and ethnic disparities in health care and called for multiple interventions to help reduce them, including raising the awareness of clinicians and the public and expanding health insurance coverage. However, she noted that more data are needed to optimally reduce disparities in care: “One can ask, 15 years after the Institute of Medicine report, have we moved the needle much?”

Empirical colistin didn't improve survival in resistant, gram-negative infections

Empirical treatment with colistin did not improve mortality for patients with severe infections caused by carbapenem-resistant gram-negative bacteria (CRGNB), an analysis found.

Researchers conducted a secondary analysis of a randomized controlled trial that included 406 inpatients with a bloodstream infection, pneumonia, or urosepsis caused by CRGNB. The original trial randomized patients to IV colistin or colistin with meropenem and found no significant differences in outcomes. This analysis looked at whether patients who had received empirical antibiotics that covered CRGNB in the first 48 hours had lower mortality rates. Results were published by Clinical Infectious Diseases on April 27.

Slightly more than half of the patients (51.5%) received empirical covering antibiotics, with colistin being the in vitro covering antibiotic in almost all cases (95.7%). The most common pathogen identified was Acinetobacter baumannii (77% of patients). Patients who didn't receiving covering antibiotics were older, had more catheters, and were more likely to be unconscious, dependent, or on mechanical ventilation. The groups had similar 28-day mortality rates (42.6% with noncovering antibiotics vs. 45.9% with covering; P=0.504). Results were similar for the outcome of 14-day mortality, for the colistin monotherapy and the colistin-carbapenem subgroups, and when patients were propensity-matched.

The study authors reported that previous research has mostly failed to find a significant association between early covering empirical therapy and mortality after adjustment. “Thus, looking at our study and previous data, covering empirical antibiotic treatment is not necessarily associated with survival among patients with different types of infections caused by CRGNBs. These findings may reflect the doubtful efficacy of the available agents against CRGNBs,” they wrote. They noted that the study's results actually show an increase in mortality with empirical treatment, possibly the result of confounding. Other limitations include that only two patients were neutropenic at infection onset and that colistin susceptibility was not routinely tested, as is currently recommended.

The authors called for restricting empirical use of colistin and avoiding carbapenems for CRGNB infections. “To improve the dismal prognosis of patients with severe infections caused by CRGNB we probably need antibiotics more effective than colistin that will cover all CRGNB for the empirical treatment phase and rapid tests that will identify the pathogen and carbapenem resistance to allow start of better directed therapy,” the authors concluded.

Frailty risk score for hospitals developed using ICD-10 codes

A frailty risk score was developed based entirely on information from ICD-10 diagnostic codes and validated in elderly British hospital patients, a study reported.

The study used data from 22,139 British patients ages 75 years and older who were admitted to a hospital and had high resource use and diagnoses associated with frailty. The researchers created a Hospital Frailty Risk Score based on the ICD-10 codes that were common among these patients. In a separate cohort of more than 1 million patients, they tested how well the score predicted adverse outcomes and matched other frailty-identification tools. Results were published by The Lancet on April 26 and appeared in the May 5 issue.

In the development cohort, patients with diagnoses indicating frailty had more nonelective hospital use (33.6 bed-days over two years vs. 23.0 in the group with the next highest number of bed-days). In the validation cohort, 20.0% of patients had high Hospital Frailty Risk Scores, and compared with the 42.4% of patients with the lowest risk scores, they had higher odds of 30-day mortality (odds ratio [OR], 1.71; 95% CI, 1.68 to 1.75), extended hospital stay (OR, 6.03; 95% CI, 5.92 to 6.10), and 30-day readmission (OR, 1.48; 95% CI, 1.46 to 1.50). The Hospital Frailty Risk Score showed fair overlap with dichotomized Fried and Rockwood scales and moderate agreement with the Rockwood Frailty Index.

The study authors concluded that their score provides a “low-cost, systematic way to screen for frailty and identify a group of patients who are at greater risk of adverse outcomes,” although they cautioned that the score has low discriminative ability at the individual level. They noted that some of the codes included in the score were associated with acute conditions such as aspiration pneumonia and delirium, but others were less obviously connected to frailty. The score might miss some important elements of frailty and might be affected by variation in coding, the authors noted.

An accompanying editorial comment noted that the patients who were identified as frail accounted for almost half of all hospitalization days in the study. “A metric that identifies for hospitals the extent to which they are serving patients with frailty should signal the need to change from a most responsible diagnosis model to practices that can reduce the hazards of hospital stays for patients who are frail, and perhaps even focus on the goals of patients and their families,” the comment said.

Dripping lidocaine from syringe onto skin before injection reduces pain, study finds

Squirting a small amount of lidocaine on the skin before a lidocaine injection reduced pain from bedside procedures, a study found.

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Image by Thinkstock

The randomized trial included 481 patients referred to the University of Chicago Medical Center's procedure service from February 2011 through March 2015 for procedures such as peripherally inserted central catheter (PICC) insertion, central venous catheter insertion, thoracentesis, paracentesis, and lumbar puncture. All patients received 1% subcutaneous lidocaine injection, and half of the patients received about 1 to 2 mL of lidocaine squirted onto the skin prior to the injection.

The primary endpoint was the procedure pain perception as measured by the 100-mm Visual Analog Scale (VAS). VAS scores were 26% lower in the intervention group than in the control group (12.2 mm vs. 16.6 mm; P=0.03). Subgroup analysis revealed that the improvement was only significant with PICC insertions, which comprised the majority of procedures in the study (12.2 mm vs. 18.8 mm; P=0.02). The analyses of other procedures may have been underpowered, the authors noted. Results were published online by CHEST on April 23.

The lidocaine dripped on the skin had no direct anesthetic effect, the study authors said. They offered the hypothesis “that it is the room temperature solution on the skin (cooler temperature than skin body temperature) that generates sensory nerve traffic within the spinal cord dorsal horn that can ‘gate’ or inhibit the noxious signal from the lidocaine injection.” A limitation of the study was that the effect did not meet the threshold of a clinically important difference in VAS score, although that would be difficult to achieve, given the low pain scores in the control group, the authors said.

Putting lidocaine on the skin in this manner is “simple, risk-free, time-efficient, and effective,” the study authors said. They noted that reductions in the pain associated with bedside procedures could provide a number of benefits, including improvements in safety and comfort during the procedures, overall patient satisfaction, and pain perception beyond the duration of the procedure.