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BACKGROUND: Acid-suppressive medications are increasingly prescribed for noncritically ill hospitalized patients, although the incidence of nosocomial gastrointestinal (GI) tract bleeding (GI bleeding) and magnitude of potential benefit from this practice are unknown. We aimed to define the incidence of nosocomial GI bleeding outside of the intensive care unit and examine the association between acid-suppressive medication use and this complication.

METHODS: We conducted a pharmacoepidemiologic cohort study of patients admitted to an academic medical center from 2004 through 2007, at least 18 years of age, and hospitalized for 3 or more days. Admissions with a primary diagnosis of GI bleeding were excluded. Acid-suppressive medication use was defined as any order for a proton pump inhibitor or histamine-2-receptor antagonist. The main outcome measure was nosocomial GI bleeding. A propensity matched generalized estimating equation was used to control for confounders.

RESULTS: The final cohort included 78,394 admissions (median age, 56 years; 41% men). Acid-suppressive medication was ordered in 59% of admissions, and nosocomial GI bleeding occurred in 224 admissions (0.29%). After matching on the propensity score, the adjusted odds ratio for nosocomial GI bleeding in the group exposed to acid-suppressive medication relative to the unexposed group was 0.63 (95% confidence interval, 0.42-0.93). The number needed to treat to prevent 1 episode of nosocomial GI bleeding was 770.

CONCLUSIONS: Nosocomial GI bleeding outside of the intensive care unit was rare. Despite a protective effect of acid-suppressive medication, the number needed to treat to prevent 1 case of nosocomial GI bleeding was relatively high, supporting the recommendation against routine use of prophylactic acid-suppressive medication in noncritically ill hospitalized patients.

CONTEXT: Medicare's per diem payment structure may create financial incentives to select patients who require less resource-intensive care and have longer hospice stays. For-profit and nonprofit hospices may respond differently to financial incentives.

OBJECTIVE: To compare patient diagnosis and location of care between for-profit and nonprofit hospices and examine whether number of visits per day and length of stay vary by diagnosis and profit status.

DESIGN, SETTING, AND PATIENTS: Cross-sectional study using data from the 2007 National Home and Hospice Care Survey. Nationally representative sample of 4705 patients discharged from hospice.

MAIN OUTCOME MEASURES: Diagnosis and location of care (home, nursing home, hospital, residential hospice, or other) by hospice profit status. Hospice length of stay and number of visits per day by various hospice personnel.

RESULTS: For-profit hospices (1087 discharges from 145 agencies), compared with nonprofit hospices (3618 discharges from 524 agencies), had a lower proportion of patients with cancer (34.1%; 95% CI, 29.9%-38.6%, vs 48.4%; 95% CI, 45.0%-51.8%) and a higher proportion of patients with dementia (17.2%; 95% CI, 14.1%-20.8%, vs 8.4%; 95% CI, 6.6%-10.6%) and other noncancer diagnoses (48.7%; 95% CI, 43.2%-54.1%, vs 43.2%; 95% CI, 40.0%-46.5%; adjusted P < .001). After adjustment for demographic, clinical, and agency characteristics, there was no significant difference in location of care by profit status. For-profit hospices compared with nonprofit hospices had a significantly longer length of stay (median, 20 days; interquartile range [IQR], 6-88, vs 16 days; IQR, 5-52 days; adjusted P = .01) and were more likely to have patients with stays longer than 365 days (6.9%; 95% CI, 5.0%-9.4%, vs 2.8%; 95% CI, 2.0%-4.0%) and less likely to have patients with stays of less than 7 days (28.1%; 95% CI, 23.9%-32.7%, vs 34.3%; 95% CI, 31.3%-37.3%; P = .005). Compared with cancer patients, those with dementia or other diagnoses had fewer visits per day from nurses (0.50 visits; IQR, 0.32-0.87, vs 0.37 visits; IQR, 0.20-0.78, and 0.41 visits; IQR, 0.26-0.79, respectively; adjusted P = .002) and social workers (0.15 visits; IQR, 0.07-0.31, vs 0.11 visits; IQR, 0.04-0.27, and 0.14 visits; IQR, 0.07-0.31, respectively; adjusted P < .001).

CONCLUSION: Compared with nonprofit hospice agencies, for-profit hospice agencies had a higher percentage of patients with diagnoses associated with lower-skilled needs and longer lengths of stay.

BACKGROUND: Increased peak postoperative B-type natriuretic peptide (BNP) is associated with increased major adverse cardiovascular events and all-cause mortality after coronary artery bypass graft (CABG) surgery. Whether increased postoperative BNP predicts worse postdischarge physical function (PF) is unknown. We hypothesized that peak postoperative BNP associates with PF assessed up to 2 yr after CABG surgery, even after adjusting for clinical risk factors. including preoperative PF.

METHODS: This two-institution prospective cohort study included patients undergoing primary CABG surgery with cardiopulmonary bypass. Short Form-36 questionnaires were administered to subjects preoperatively and 6 months, 1 yr, and 2 yr postoperatively. Short Form-36 PF domain scores were calculated using the Short Form-36 norm-based scoring algorithm. Plasma BNP concentrations measured preoperatively and on postoperative days 1-5 were log(10) transformed before analysis. To determine whether peak postoperative BNP independently predicts PF scores 6 months through 2 yr after CABG surgery, multivariable longitudinal regression analysis of the postoperative PF scores was performed, adjusting for important clinical risk factors.

RESULTS: A total of 845 subjects (mean ± SD age, 65 ± 10 yr) were analyzed. Peak postoperative BNP was significantly associated with postoperative PF (effect estimate for log(10) peak BNP, -7.66 PF score points [95% CI, -9.68 to -5.64]; P = <0.0001). After multivariable adjustments, peak postoperative BNP remained independently associated with postoperative PF (effect estimate for log(10) peak BNP, -3.06 PF score points [95% CI, -5.15 to -0.97]; P = 0.004).

CONCLUSIONS: Increased peak postoperative BNP independently associates with worse longer-term PF after primary CABG surgery. Future studies are needed to determine whether medical management targeted toward reducing increased postoperative BNP can improve PF after CABG surgery.

PURPOSE: To understand the impact of breast cancer on older women's survival, we compared survival of older women diagnosed with breast cancer with matched controls. METHODS Using the linked 1992 to 2003 Surveillance, Epidemiology, and End Results (SEER) -Medicare data set, we identified women age 67 years or older who were newly diagnosed with ductal carcinoma in situ (DCIS) or breast cancer. We identified women not diagnosed with breast cancer from the 5% random sample of Medicare beneficiaries residing in SEER areas.We matched patient cases to controls by birth year and registry (99% or 66,039 [corrected] patient cases matched successfully). We assigned the start of follow-up for controls as the patient cases' date of diagnosis. Mortality data were available through 2006. We compared survival of women with breast cancer by stage with survival of controls using multivariable proportional hazards models adjusting for age at diagnosis, comorbidity, prior mammography use, and sociodemographics. We repeated these analyses stratifying by age.

RESULTS: Median follow-up time was 7.7 years. Differences between patient cases and controls in sociodemographics and comorbidities were small (< 4%). Women diagnosed with DCIS (adjusted hazard ratio [aHR], 0.7; 95% CI, 0.7 to 0.7) or stage I disease (aHR, 0.8; 95% CI, 0.8 to 0.8) had slightly lower mortality than controls.Women diagnosed with stage II disease or higher had greater mortality than controls (stage II disease:aHR, 1.2; 95% CI, 1.2 to 1.2). The association of a breast cancer diagnosis with mortality declined with age among women with advanced disease [corrected].

CONCLUSION: Compared with matched controls, a diagnosis of DCIS or stage I breast cancer in older women is associated with better [corrected] survival, whereas a diagnosis of stage II or higher breast cancer is associated with worse survival.

Delirium is an acute change in cognition and attention, which may include alterations in consciousness and disorganized thinking. Although delirium may affect any age group, it is most common in older patients, especially those with preexisting cognitive impairment. Patients with delirium after surgery recover more slowly than those without delirium and, as a result, have increased length of stay and hospital costs. The measured incidence of postoperative delirium varies with the type of surgery, the urgency of surgery, and the type and sensitivity of the delirium assessment. Although generally considered a short-term condition, delirium can persist for months and is associated with poor cognitive and functional outcomes beyond the immediate postoperative period. In this article, we provide a guide to assess delirium risk preoperatively and to prevent, diagnose, and treat this common and morbid condition. Care improvements such as identifying delirium risk preoperatively; training surgeons, anesthesiologists, and nurses to screen for delirium; implementing delirium prevention programs; and developing standardized delirium treatment protocols may reduce the risk of delirium and its associated morbidity.

BACKGROUND: African Americans are thought to be more distrustful of clinical research compared to elderly whites, but it is unknown whether specific types of distrust in clinical research, such as interpersonal or societal distrust, vary according to race. The primary objective was to identify racial differences in interpersonal or societal distrust in clinical research among African Americans and whites.

METHODS: Seven hundred seventy-six older African Americans and whites were surveyed about their interpersonal and societal distrust using a 7-item index of distrust in clinical research. We combined the 2 societal distrust items into a societal distrust subscale. We also assessed trust in primary care physicians, access to care, health/functional status, previous exposure to clinical research, awareness of the Tuskegee Syphilis Study, perceived discrimination in health care, and sociodemographic characteristics.

RESULTS: High societal distrust was more common among African Americans compared to whites (21% vs 7% in the top quartile of the societal distrust, p < .0001), but there were no racial differences in responses to the individual interpersonal distrust index items. In sequentially built multivariable analyses, the relationship between African American race and societal distrust (odds ratio, 2.2; 95% CI, 1.2-3.7) was not completely explained by other factors such as trust in one's physician, previous discrimination, or awareness of the Tuskegee Syphilis Study.

CONCLUSIONS: Racial differences according to the type of distrust in clinical research may warrant assessing specific types of distrust separately among racially diverse populations in future studies.

OBJECTIVES: To further validate an index predicting mortality in community-dwelling older adults.

DESIGN: A comparison of the performance of the index in predicting mortality among new respondents to the National Health Interview Survey (NHIS, 2001-2004) with that of respondents from the original development and validation cohorts (1997-2000) and a test of its performance over extended follow-up (up to 9 years) using the original cohorts. Follow-up mortality data were available through 2006.

SETTING: NHIS.

PARTICIPANTS: Twenty-two thousand fifty-seven new respondents to the NHIS (2001-2004) and 24,139 respondents from the original development and validation cohorts (1997-2000).

MEASUREMENTS: A risk score was calculated for each respondent based on the presence or absence of 11 factors (function, illnesses, behaviors, demographics) that make up the index. Using the Kaplan-Meier method, 5-year mortality estimates were computed for the new and original cohort respondents and 9-year mortality estimates for the original cohorts.

RESULTS: New respondents were similar to original cohort respondents but were slightly more likely to be aged 85 and older, report diabetes mellitus, and have a body mass index of 25.0 kg/m² or greater. The model performed as well in the new cohort as it had in the original cohort. New respondents with risk scores of 0 to 1 had a 2% risk of 5-year mortality, whereas respondents who scored 18 or higher had a 69% risk of 5-year mortality (range 3-71% risk of 5-year mortality in the development cohort). The index also demonstrated excellent calibration and discrimination in predicting 9-year mortality (range 7% risk for scores of 0-1 to 92% risk for scores of ≥ 18, original validation cohort extended).

CONCLUSION: These results further justify use of this index to estimate life expectancy in clinical decision-making.

This issue provides a clinical overview of delirium focusing on prevention, diagnosis, treatment, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits. Only ACP members and individual subscribers can access the electronic features of In the Clinic. Non-subscribers who wish to access this issue of In the Clinic can elect "Pay for View." Subscribers can receive 1.5 category 1 CME credits by completing the CME quiz that accompanies this issue of In the Clinic. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians' Information and Education Resource) and MKSAP (Medical Knowledge and Self Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing division and with assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult www.acponline.org, http://pier.acponline.org, and other resources referenced within each issue of In the Clinic.

The objective of this study was to identify racial differences in willingness to participate in a population with previous exposure to clinical research. A survey instrument was administered to community-dwelling whites and African Americans who were voluntarily receiving a lay research and health education newsletter from a local Boston geriatric clinical research institution. The survey instrument assessed willingness to participate in 3 hypothetical clinical trials (diet trial for obesity, medication trial for hypertension [HTN], chemotherapy trial for cancer). Surveys were received from 473 whites and 279 African Americans (53% response rate) with mean age 74 (SD +/- 9). In multivariate models, race was not significantly related to willingness to participate in the multivariate models for any of the 3 trials. Previous trial participation was related to a higher odds of willingness to participate in the diet trial only (OR 1.8, 95% CI 1.2, 2.6). Lower levels of trust in one's primary care physician were associated with a lower odds of willingness to participate in clinical trials for the diet and HTN trials (OR 0.5, 95% CI 0.3, 0.8 and OR 0.6, 95% CI 0.3, 0.9, respectively). These findings suggest that, within populations previously exposed to clinical research, African Americans are no less willing to participate in clinical trials compared to whites.

OBJECTIVES: To determine whether donepezil hydrochloride can reduce the prevalence and severity of delirium in older adults undergoing hip fracture repair.

DESIGN: Pilot double-masked randomized placebo-controlled trial.

SETTING: Large academic medical center.

PARTICIPANTS: Sixteen individuals aged 70 and older with hip fracture.

INTERVENTION: Donepezil 5 mg or placebo was randomly allocated and initiated within 24 hours of surgery, preoperatively or postoperatively. Daily treatment was continued for 30 days or until side effects or the clinical situation required termination.

MEASUREMENTS: All outcomes were ascertained masked to treatment status. Information on drug tolerability and safety was obtained from the participant, nurse, and medical record. Delirium presence and severity were measured during daily hospital interviews and at 2, 4, and 6 weeks after surgery after a standardized assessment using the Confusion Assessment Method (CAM) and the Memorial Delirium Assessment Scale (MDAS).

RESULTS: Participants in the donepezil and placebo arms had similar baseline characteristics. Participants in the donepezil arm experienced significantly more side effects. In longitudinal models, there were no significant differences between the donepezil and placebo arms with regard to delirium presence over time (odds ratio = 0.9, 95% confidence interval (CI) = 0.4-2.3) or delirium severity over time (effect size = -0.2 on 30-point MDAS scale, 95%CI = -1.5-1.2).

CONCLUSION: Participants randomized to donepezil had no significant improvement in delirium presence or severity but experienced more side effects. Overall, sufficient evidence was not found from this pilot study to warrant a definitive Phase III trial.