Eight Things to Do Differently Tomorrow

1. Eight Things to Do Differently Tomorrow The (Lack of) Evidence Behind Common Hospitalist Practices Chad R. Stickrath, MD October 2nd, 2012

2. 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

3. The Benefits of 3000 Common Medical Treatments BMJ’s Clinical Evidence Website, accessed 9/2011 and 8/2012 http://clinicalevidence.bmj.com.hsl-ezproxy.ucdenver.edu/ceweb/about/knowledge.jsp

4. Topic Selection • Most Common Diagnoses • Clinical Evidence Reviews • HM Literature Updates • Colleagues • Source: http://choosingwisely.org/?page_id=13. Accessed 8/2012.

5. 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? • Identification of the infecting microbe • Productive cough • Early mobilization • Antibiotics within 30 minutes of presentation

6. 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

7. 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

8. We Can Safely Reduce LOS in CAP

9. 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

10. 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? • Identification of the infecting microbe • Productive cough • Early mobilization • Antibiotics within 30 minutes of presentation

11. 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? • Post-operative day 1 • Post-operative day 3 • Post-operative day 14 • Post-operative day 21

12. 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

13. 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

14. The Risk for Post-Operative VTE Extends Well Beyond 2 Weeks • 239,614 had operation, 5419 (0.6%) post op VTE

15. How Long Should I Recommend Total Hip and Knee Arthroplasty Patients use Pharmacologic Prophylaxis? • Systematic Review • Randomized Trials • Comparing DVT ppx • 7-10 days vs. ≥ 20 days

16. Shorter Duration vs. Longer Duration of VTE Prophylaxis • Included 8 RCTs

17. Tomorrow I Will … • Consider extending post op DVT prophylaxis to 35 days post-operatively for THA/TKA • 2012 ACCP Supplement:

18. 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? • Post-operative day 1 • Post-operative day 3 • Post-operative day 14 • Post-operative day 21

19. 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? • Patient taking citalopram for depression • Patient is “hard of hearing” • Patient is taking methadone for back pain • All of the above

20. 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 year from American Lung Association, http://www.lung.org, accessed 8/2012

21. Is There Anything We Can Do to Prevent COPD Exacerbations? • RCT of COPD patients • Daily Azithro vs. placebo • 1142 patients, 12 sites

22. 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%

23. Tomorrow I Will … • Consider recommending long term azithromycin to certain patients admitted with COPD exacerbations. • Wenzel et al. Antibiotic prevention of acute exacerbations of COPD. NEJM 2012;367 • Wenzel et al. recommend Monday, Wednesday, Friday dosing instead of daily • Will need every 3 month follow-up to assess for side effects

24. 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? • Patient taking citalopram for depression • Patient is “hard of hearing” • Patient is taking methadone for back pain • All of the above

25. 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? • Never • 8 weeks after discharge • 2 weeks after discharge • On discharge

26. 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)

27. 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.

28. Continuation of Aspirin in Peptic Ulcer Bleeding • 156 patients enrolled after endoscopic hemostasis of bleeding

29. 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

30. 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? • Never • 8 weeks after discharge • 2 weeks after discharge • On discharge

31. 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? • Normal ECG • Normal RV size on CT pulmonary angiogram • Normal Transthoracic Echocardiogram • All of the Above

32. 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)

33. What is the Most Effective Method for Detecting RV Dysfunction in Hemodynamically Stable Patients Admitted with PE? • 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

34. 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

35. 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

36. 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? • Normal ECG • Normal RV size on CT pulmonary angiogram • Normal Transthoracic Echocardiogram • All of the Above

37. 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? • Lactobacillus PO while on antibiotics • Metronidazole IV while on antibiotics • Acidophilus PO for 7 days beyond antibiotic dc • None of the above

38. 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)

39. 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

40. The Effectiveness of Probiotics for Preventing or Treating Antibiotic Associated Diarrhea • 82 randomized control trials included

41. 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

42. The Effectiveness of Probiotics for Preventing Antibiotic Associated Clostridium Difficile • 11 randomized control trials included • “seriously underpowered”

43. 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

44. 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? • Lactobacillus PO while on antibiotics • Metronidazole IV while on antibiotics • Acidophilus PO for 7 days beyond antibiotic dc • None of the above

45. 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? • Chest X-ray • Chest CT pulmonary angiogram • Thallium stress test • Cardiac catheterization

46. 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 CollRadiol 2010)

47. 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

48. Patients Want Us to Discuss Risks and Benefits of Imaging Procedures but We Don’t • 271/286 patients responded

49. Patients Want Us to Discuss Risks and Benefits of Imaging Procedures but We Don’t • 348/849 providers responded

50. 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)