Disclosures None National Health Expenditures 2009 25 trillion February 6 2014 February 6 2014 Uwe E Reinhardt httpeconomixblogsnytimescom20101224feesvolumeandspendingatmedicaremore94191 ID: 809603
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Slide1
Non-Evidence Based Medicine: Things We Do for No Reason
Slide2Slide3Disclosures- None
Slide4National Health Expenditures, 2009
$
2.5 trillion
February 6, 2014
Slide5February 6, 2014
Uwe
E. Reinhardt:
http://economix.blogs.nytimes.com/2010/12/24/fees-volume-and-spending-at-medicare/#more-94191
MedPac Data
Slide6Are there Unnecessary Costs?
Provider Inefficiency and Errors
Annual Waste: $75–$100 Billion
Lack of Care Coordination
Annual Waste: $25–$50 Billion
Unwarranted Use
Annual Waste: $250–$325 Billion
Thomson Reuters, October 2009
Slide7Why do we order unnecessary tests?
Doctors have a “limited understanding of diagnostic and nondrug therapeutic costs”
2008 systematic review
Patient expectations
Insufficient understanding of the operating characteristics of tests
Inability to retrieve previous results
Learned behaviors
Economic incentives (self-referral)
Defensive medicine
Allan GM,
Lexchin
J. Physician awareness of diagnostic and nondrug therapeutic costs: a systematic review.
Int J Technol
Assess Health Care. Spring 2008;24(2):158-165.
Slide8Case Presentation
A 65-year-old man with a history of coronary artery disease has had three days of vomiting and diarrhea.
He was standing in church when he began to feel lightheaded and then awoke on the ground-
DFOIC
.
The ED admits for a syncope work-up
Slide9The residents want to do a complete work-up and order carotid
dopplers
. Your best response is…
Did you order CK, CK/MB, and Trop I as well?
Don’t forget the EEG!
Great idea. We don’t want to miss any possible etiology.
We should probably cancel that order.
Excellent thought. What a great way to test for carotid hypersensitivity.
Slide10Syncope Epidemiology
Incidence: 3% annually in general population (6% in age > 75)
~1/3 of individuals will have syncope in lifetime
ER visits: 5% (500,000 visits/year)
Admission rate ~60%
Hospital Admissions: 3% (150,000
adm
/year)
Morbidity
Injuries occur in 35% of patients with syncope
Cost: Median Cost of Hospitalization ~$5500
>$2 billion annual costs in US
Slide112106 admission for 1920 patients
All ≥65yo syncope
pts
admitted at Yale
Retrospective Review of Records
(from d/c summary)
Mendu
ML,
McAvay
G,
Lampert
R,
Stoehr
J, Tinetti
ME. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Archives of internal medicine.
Jul 27 2009;169(14):1299-1305.
Slide122106 admission for 1920 patients
All ≥65yo syncope
pts
admitted at Yale
Not an algorithm
Assume tests were often ordered for a particular reason
High risk population- elderly and admitted
Mendu
ML,
McAvay
G,
Lampert
R,
Stoehr
J,
Tinetti
ME. Yield of diagnostic tests in evaluating
syncopal
episodes in older patients.
Archives of internal medicine.
Jul 27 2009;169(14):1299-1305.
Slide13Cost calculations
Standard
billing
charges converted to costs
multiplied charges by hospital’s cost/charge ratio (0.34)
approximately 460
000 hospitalizations per
year
yearly costs
associated with the most commonly obtained tests may be nearly $6 billion
Mendu
ML,
McAvay
G,
Lampert
R,
Stoehr
J,
Tinetti
ME. Yield of diagnostic tests in evaluating
syncopal
episodes in older patients.
Archives of internal medicine.
Jul 27 2009;169(14):1299-1305.
Slide14Diagnostic Yield and Utility of Neurovascular Ultrasonography in
the Evaluation of Patients With Syncope
Patients:
consecutive
patients who underwent
eval
for
a diagnosis of
syncope or
presyncope≥ 18 years old seen in 1997-1998Intervention:neurovascular ultrasonography in the
MGH Neurovascular Laboratory inpatients or outpatientsComparison: syncope without
neurovasc w/u
Schnipper JL, Ackerman RH, Krier JB,
Honour M. Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope. Mayo Clinic proceedings.
Mayo Clinic. Apr 2005;80(4):480-488.
Slide15Diagnostic Yield and Utility of Neurovascular Ultrasonography in
the Evaluation of Patients With Syncope
Excluded Patients:
documented ventricular tachycardia
circulatory shock
s
eizure
d
elirium
previous implantation of an intracardiac defibrillatortesting performed for a reason other
than syncope or presyncope
Schnipper JL, Ackerman RH, Krier
JB, Honour M. Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope. Mayo Clinic proceedings.
Mayo Clinic. Apr 2005;80(4):480-488.
Slide16Diagnostic Yield and Utility of Neurovascular
Ultrasonography in
the Evaluation of Patients With
Syncope
Outcomes:
S
troke neurologist/
neuroradiologist
served as the gold standard for whether test established a neurovascular cause of syncope
severe hemodynamic compromise of the basilarboth vertebral
both internal carotid arteries. Study outcomes included…
positive neurovascular ultrasound testdiagnostically useful test (revealed syncope cause)therapeutically useful
test (led to treatment change)
Schnipper JL, Ackerman RH, Krier JB, Honour
M. Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope. Mayo Clinic proceedings.
Mayo Clinic. Apr 2005;80(4):480-488.
Slide17Diagnostic Yield and Utility of Neurovascular
Ultrasonography in
the Evaluation of Patients With
Syncope
Results:
140
patients
3.3
% of all 4199
pts who presented with syncope during this period72%
inpts (primarily from the gen med services)
Schnipper
JL, Ackerman RH,
Krier
JB,
Honour
M. Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope.
Mayo Clinic proceedings.
Mayo
Clinic.
Apr 2005;80(4):480-488.
Slide18Diagnostic Yield and Utility of Neurovascular
Ultrasonography in
the Evaluation of Patients With
Syncope
Results:
Very select group of patients with high pre-test probability
Schnipper
JL, Ackerman RH,
Krier
JB,
Honour
M. Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope.
Mayo Clinic proceedings.
Mayo
Clinic.
Apr 2005;80(4):480-488.
Slide19Diagnostic Yield and Utility of Neurovascular
Ultrasonography in
the Evaluation of Patients With
Syncope
Results:
Very select group of patients with high
pre-test probability
Schnipper
JL, Ackerman RH,
Krier
JB,
Honour
M. Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope.
Mayo Clinic proceedings. Mayo
Clinic. Apr 2005;80(4):480-488.
Slide20Diagnostic Yield and Utility of Neurovascular
Ultrasonography in
the Evaluation of Patients With
Syncope
Results:
Very select group of patients with high pre-test probability
19/20 (95%) patients with + test results had focal
neuro
signs or carotid bruits
19/66 (29%) patients with focal
neuro
signs or bruits had + test results74/75 without focal
neuro symptoms or bruits had negative test results
Schnipper
JL, Ackerman RH,
Krier
JB,
Honour
M. Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope.
Mayo Clinic proceedings.
Mayo
Clinic.
Apr 2005;80(4):480-488.
Slide21Diagnostic Yield and Utility of Neurovascular
Ultrasonography in
the Evaluation of Patients With
Syncope
Take-home:
C
erebrovascular
causes of syncope are
uncommon
More likely to find cerebrovascular disease than the cause of syncopecerebrovascular disease may be associated with, but not causing, the syncopep
eople with cardiac causes of syncope often have cerebrovascular diseaseConsider neurovascular ultrasonography for patients…with a history or clinical evidence of cerebrovascular disease
with focal neurologic findings at the time of the syncopal
event based on a thorough history and neurologic examinationwith carotid bruits (this is another talk)Don’t order carotid US for patients without focal
neuro signs or bruits
Schnipper JL, Ackerman RH, Krier JB, Honour
M. Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope. Mayo Clinic proceedings.
Mayo
Clinic.
Apr 2005;80(4):480-488.
Slide22Synopsis of the National Institute for Health and Clinical
Excellence: Guideline
for Management of Transient
Loss
of
Consciousness- no carotid
doppler
mention
Cooper PN,
Westby M, Pitcher DW, Bullock I. Synopsis of the National Institute for Health and Clinical Excellence Guideline for management of transient loss of consciousness.
Annals of internal medicine. Oct 18 2011;155(8):543-549.
Slide23Case Presentation
A 63-year-old man is admitted with a STEMI involving the inferior region.
He has successful PTCI but his trop I peaks at 20
ng
/
mL.
You are contacted by the CCU nursing staff with his BMP and Mg results:
Potassium: 3.7mEq/L
Magnesium: 1.4mEq/L
The nurse says, “You didn’t activate the K+ and Mg+ replacement protocol. Are you going to buff the lytes?”
Slide24Are you going to buff the
lytes
? What is your best response…
Of course. Please replace so that K+ is ≥ 4mEq/L
and the
Mg+
≥
2mEq/L.
Let’s do a recheck BMP/Mg+ first.
Has he had any arrhythmias that I don’t know about?
I’m not sure that will help the patient.Isn’t there an intern you are supposed to call about this?
Slide25Background
E
xperts
and
professional societies recommend
K+ levels
between 4.0
-
5.0 mEq
/L or even 4.5 - 5.5Most prior studies conducted before routine
use of -blockers, reperfusion therapy, and early invasive managementSmall studies
Focus on arrhythmias and not mortality
Goyal A, Spertus JA, Gosch K, et al. Serum potassium levels and mortality in acute myocardial infarction.
JAMA : the journal of the American Medical Association. Jan 11 2012;307(2):157-164.
Slide26Current Guidelines
2004 ACCF/AHA STEMI guidelines
It is reasonable to correct electrolyte and
acid-base disturbances
(potassium greater than 4.0
mEq
/L
and magnesium
greater than 2.0 mg/
dL) to prevent recurrent episodes of VF once an initial episode of VF has been treated. (
Level of Evidence: C)2013 ACCF/AHA STEMI guidelinesPrevention of VT/VF is directed to
correction of electrolyte and acid/base abnormalities, optimization of myocardial perfusion, eradication of ongoing ischemia, and treatment of associated
complications such as HF or shock.
O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Journal of the American College of Cardiology. Jan 29 2013;61(4):e78-140.Antman
EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction).
Circulation.
Aug 3 2004;110(5):588-636.
Slide27Current Guidelines
National Council on Potassium in Clinical Practices
Patients with Cardiac Arrhythmias
Maintenance of K+ ≥ 4.0
mmol
/L
Coadministration
of Mg+ should be considered
Macdonald et al.
it is sensible to maintain a serum potassium concentration above 4.5 mmol
/l during AMIIt would appear wise to avoid potassium levels above 5.5 mmol
/l
Cohn JN, Kowey PR, Whelton PK,
Prisant LM. New guidelines for potassium replacement in clinical practice: a contemporary review by the National Council on Potassium in Clinical Practice. Archives of internal medicine.
Sep 11 2000;160(16):2429-2436.Macdonald JE, Struthers AD. What is the optimal serum potassium level in cardiovascular patients? Journal of the American College of Cardiology. Jan 21 2004;43(2):155-161
.
Slide28Macdonald
JE, Struthers AD. What is the optimal serum potassium level in cardiovascular patients? Journal of the American College of Cardiology. Jan 21 2004;43(2):155-161.
Slide291985- VT study and admission K+
Patients:
60
pts
admitted to CCU within 12
hrs
of 1
st
AMIExclusion criteria-
current treatment withDigitalisβ-blockersCalcium antagonists
antiarrhythmic drugscardiogenic shock; alcoholism; AV block > grade 1
; BBB
Nordrehaug JE, Johannessen KA, von der Lippe
G. Serum potassium concentration as a risk factor of ventricular arrhythmias early in acute myocardial infarction. Circulation. Apr 1985;71(4):645-649.
Slide30Intervention
Meds that all
pts
received:
oral
diazepamOxygenMorphine
No
lyte
supplements
Lytes checked on admissionContinuous ECG
Nordrehaug JE, Johannessen KA, von der
Lippe G. Serum potassium concentration as a risk factor of ventricular arrhythmias early in acute myocardial infarction. Circulation.
Apr 1985;71(4):645-649.
Slide31Outcomes- arrhythmias
Ventricular
tachycardia
≥ three consecutive ventricular complexes
at a rate of greater than 120
beats/min
PVCs
Frequent: >5 isolated
unifocal beats/minBigeminy: alternate sinus and ventricular beats
Multifocal: multifocal beats in the same hour of recordingCouplets: two
consecutive ventricular beats, R-on-T according to R -R' R- T <0.85Overall frequency: total number of PVCs in the recording divided by
the number of analyzable hours and expressed as the number per hour
Nordrehaug JE, Johannessen KA, von der
Lippe G. Serum potassium concentration as a risk factor of ventricular arrhythmias early in acute myocardial infarction. Circulation. Apr 1985;71(4):645-649.
Slide32Potassium and VT
1
mEq
/L=1
mmol
/L
Nordrehaug
JE,
Johannessen
KA, von der
Lippe
G. Serum potassium concentration as a risk factor of ventricular arrhythmias early in acute myocardial infarction.
Circulation.
Apr 1985;71(4):645-649.
Slide33Potassium and VT
Conclusions
independent predictor variables
for VT
serum
potassium concentration
at admission
age
Nordrehaug
JE, Johannessen
KA, von der Lippe G. Serum potassium concentration as a risk factor of ventricular arrhythmias early in acute myocardial infarction.
Circulation. Apr 1985;71(4):645-649.
Slide34V Fib and Potassium
(1074
pts
on admission)
122
pts
≤ 3.5
21 (17.2%) had v fib
952
pts > 3.571 (7.5%) had v fib
5.4%
7.1%
12.5%
9.5%
13.3%
33.3%
Nordrehaug
JE, von der
Lippe
G.
Hypokalaemia
and ventricular fibrillation in acute myocardial infarction.
British heart journal.
Dec 1983;50(6):525-529
.
Slide35Deaths and Potassium
Nordrehaug
JE, von der
Lippe
G.
Hypokalaemia
and ventricular fibrillation in acute myocardial infarction.
British heart journal.
Dec 1983;50(6):525-529
.
Slide36Study Goals- JAMA 2012
characterize
the distribution
and trend
of serum potassium levels
during hospitalization in patients with
AMI
determine
the relationship between serum potassium
levels and in-hospital mortalityevaluate the relationship between potassium levels and ventricular arrhythmias or cardiac
arrest in patients with AMI
Goyal A, Spertus JA, Gosch
K, et al. Serum potassium levels and mortality in acute myocardial infarction. JAMA : the journal of the American Medical Association. Jan 11 2012;307(2):157-164.
Slide37Patients
Retrospective cohort, database with 38,689 patients with AMI from 2000-2008
biomarker-confirmed AMI
had
at least 1 in-hospital serum
potassium
67 hospitals
88.5% urban
35.9% teaching
Represented all parts of USBroad range of sizes
Goyal A, Spertus
JA, Gosch K, et al. Serum potassium levels and mortality in acute myocardial infarction.
JAMA : the journal of the American Medical Association. Jan 11 2012;307(2):157-164.
Slide38Intervention:
Potassium levels defined
admission (baseline
) serum
K+
level
first K+ level obtained
during
hospitalizationmean post-admission serum
K+ levelAverage of all K+ levels measured after the admission level but before discharge
Goyal A,
Spertus JA, Gosch
K, et al. Serum potassium levels and mortality in acute myocardial infarction. JAMA : the journal of the American Medical Association. Jan 11 2012;307(2):157-164.
Slide39Outcome
relationship between mean
post-admission K
levels and
outcomes
relationship between admission K+ levels and outcomes
Goyal A,
Spertus
JA,
Gosch K, et al. Serum potassium levels and mortality in acute myocardial infarction.
JAMA : the journal of the American Medical Association. Jan 11 2012;307(2):157-164.
Slide40Results
K (
mEq
/L)
<3.0
3.0-3.4
3.5-3.9
4.0-4.4
4.5-4.9
5.0-5.4
≥5.5
Mortality
46.2%
OR 8.11
11.4%
OR
1.45
4.8%
OR 1 (ref)
5.0%
OR 1.25
10.0%
OR 1.96
24.8%
OR 3.27
61.4%
OR 6.44
Vfib
or arrest*
19.2%
OR 2.31
6.3%
OR 1.06
4.9%
OR
1 (ref)
4.1%
OR 1.03
4.1%
OR 1.15
6.8%
OR 1.62
14.7%
OR 2.65
*Adjusted odds ratio confidence intervals overlap 1.0
Goyal A,
Spertus
JA,
Gosch
K, et al. Serum potassium levels and mortality in acute myocardial infarction.
JAMA : the journal of the American Medical Association.
Jan 11 2012;307(2):157-164.
Slide41Rates of In-Hospital Mortality and of the Composite of Ventricular Fibrillation
or Cardiac
Arrest by Mean
Postadmission
Serum Potassium Level
Goyal A,
Spertus
JA,
Gosch
K, et al. Serum potassium levels and mortality in acute myocardial infarction.
JAMA : the journal of the American Medical Association.
Jan 11 2012;307(2):157-164.
Slide42Take-home
Maintaining
serum potassium
levels between
3.5 and 4.5
mEq/L may be more
advisable than the 4.0 to
5.0
mEq/L.
Based on an observational study, but better than any of the previous studies on which our current guidelines are based!Put together large trials that randomize patients with AMI to different potassium targets.
Slide43Case Presentation
A 71-year-old patient is transferred out of the MICU after treatment for a COPD exacerbation
The patient was treated with steroids, NIPPV, and bronchodilators
The resident continues the PPI that was started in the ICU for ulcer prophylaxis.
Slide44The resident asks if he should have continued the PPI for a
floor pt? Your best response
is…
Please stop it. There is no proven benefit.
There may be some benefit, but not enough to justify doing it for everyone.
We should consult GI.
Definitely, and we should use an IV PPI.
Do you work for a pharmaceutical company?
Slide45Acid-Suppressive Medication Use and the Risk for Nosocomial Gastrointestinal Tract
Bleeding
Outcome: nosocomial
GI
bleeding
Occurring outside
of the
ICU
any
overt GI bleeding (hematemesis, nasogastric aspirate containing “coffee grounds” material, melena, or hematochezia)
occurring more than 24 hours after hospital admissionSecondary outcome: clinically significant
nosocomial GI bleeding
Herzig
SJ, Vaughn BP, Howell MD, Ngo LH, Marcantonio ER. Archives of internal medicine.
Jun 13 2011;171(11):991-997.
Slide46Acid-Suppressive Medication Use and the Risk for Nosocomial Gastrointestinal Tract Bleeding
cohort
study
propensity matched
generalized estimating
equation was used to control
for confounders
patients
admitted to an academic
medical center from 2004 through 2007≥ 18 years of age, hospitalized ≥
3 daysnot admitted for GIBAcid-Suppressive Meds (ASM)
order for a proton pump inhibitor order for a histamine-2-receptor antagonist.
Herzig
SJ, Vaughn BP, Howell MD, Ngo LH, Marcantonio
ER. Archives of internal medicine. Jun 13 2011;171(11):991-997.
Slide4779,287 admissions in analytic cohort
ASM ordered in 45,882 (59%)
PPI 81%
H2-blocker 29%
Matched cohort
18,983 pts each arm
Herzig
SJ, Vaughn BP, Howell MD, Ngo LH,
Marcantonio
ER.
Archives of internal medicine.
Jun 13 2011;171(11):991-997
.
Slide48Acid-Suppressive Medication Use and the Risk for Nosocomial Gastrointestinal Tract Bleeding
primary outcome
occurred in 224
admissions (0.29%)
secondary
outcome of clinically
significant GI
bleeding occurred in 176 admissions (0.22
%).
OR switch from unadjusted to adjusted
Herzig
SJ, Vaughn BP, Howell MD, Ngo LH,
Marcantonio
ER.
Archives of internal medicine.
Jun 13 2011;171(11):991-997.
Slide49Number Needed to Treat
770
patients would
need to
be treated with acid-suppressive medication to
prevent 1 episode of nosocomial GI bleeding
834
to
prevent 1 episode of clinically significant nosocomial
GI bleeding.ASM use was associated with a 37% reduction in the odds of nosocomial GI bleeding.
Slide50Other important NNT
ASM and hospital-acquired
C
difficile
Infectionnumber needed to harm of 533
ASM and hospital-acquired pneumonia
needed to harm of 111
Herzig
SJ, Vaughn BP, Howell MD, Ngo LH,
Marcantonio
ER. Archives of internal medicine. Jun 13 2011;171(11):991-997.
Slide51Take Home
NNH for c
dif
and PNA < NNT for GIB
Recommend against prophylactic ASM use in patients outside of the ICU
Need to figure out a subset for whom ASM NNT is < NNH
Slide52Case Presentation
Is
the target hematocrit for a cardiac patient
30% (
hgb
10 g/dL
)?
Slide53Transfusion Requirements
After Cardiac Surgery
P: Consecutive adult cardiac sx patients (n=502)
R
andomly assigned
CABG or valve replacement using bypass
I: Liberal strategy of blood tx (maintain a hematocrit 30%) any time from the start of surgery until discharge from ICU
C: Restrictive strategy (hematocrit 24%)
O: Composite end point
30-day all-cause mortalitySevere morbidity occurring during the hospital staycardiogenic shock
acute respiratory distress syndromeacute renal injury requiring dialysis or hemofiltration
Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.
Jama. Oct 13;304(14):1559-1567.
Slide54Transfusion Requirements
After Cardiac Surgery
Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.
Jama. Oct 13;304(14):1559-1567.
Slide55Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.
Jama. Oct 13;304(14):1559-1567.
Slide56Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.
Jama. Oct 13;304(14):1559-1567.
Slide57Liberal or Restrictive Transfusion in High-Risk Patients after Hip Surgery
P: ≥ 50 years with hip-fx surgery
History of or risk factors for CV disease
Hemoglobin level < 10 g/dL after surgery
I: Liberal transfusion strategy
Hgb
threshold of 10 g/
dL
C: Restrictive transfusion strategy
Symptoms of anemia or at physician discretion for a hgb level of <8 g/dLO: Death or an inability to walk across a room without human assistance on 60-day follow-up
Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery.
N Engl J Med. Dec 29;365(26):2453-2462.
Slide58Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery.
N Engl J Med.
Dec 29;365(26):2453-2462.
Slide59Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery.
N Engl J Med.
Dec 29;365(26):2453-2462.
Slide60Outcomes
30 Days
60 Days
Liberal
Restrictive
Liberal
Restrictive
Death or inability to walk independently
46.1%
48.1%
35.2%
34.7%
Inability to walk independently40.9%43.8%
27.6%28.1%Death
5.2%4.3%7.6%
6.6%
No statistically significant differences
Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery.
N Engl J Med.
Dec 29;365(26):2453-2462.
Slide61Slide62TRIC Trial: Mixed ICU Trial
Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group.
N Engl J Med.
Feb 11 1999;340(6):409-417.
Slide63Transfusion Strategies for Acute Upper
Gastrointestinal Bleeding
Hypothesis: a restrictive threshold for red-cell transfusion (hgb of 7 g/dL) in patients with acute gastrointestinal bleeding is safer and more effective than a liberal hgb of 9 g/dL) transfusion strategy
Villanueva C et al. Transfusion strategies for acute upper gastrointestinal bleeding.
NEJM.
Jan 3 2013;368(1):11-21.
Slide64Study Design
June 2003 - December 2009
Consecutively enrolled patients
admitted in Barcelona
Adults > 18 years of age
Hematemesis or bloody NG aspirate
Melena
Both
Villanueva C et al. Transfusion strategies for acute upper gastrointestinal bleeding.
NEJM.
Jan 3 2013;368(1):11-21.
Slide65Study Design
Exclusions
Massive exsanguinating bleeding
an
acute coronary
syndrome,
symptomatic
peripheral
vasculopathy
Stroketransient ischemic attackTransfusion within the previous 90 days
a recent history of trauma or surgerylower
gastrointestinal bleeding;Rockall score of 0 with a hgb > 12 g/dL
Villanueva C et al. Transfusion strategies for acute upper gastrointestinal bleeding.
NEJM. Jan 3 2013;368(1):11-21.
Slide66Reference Slide
Rockall score: system for assessing the risk of further bleeding or death
scores range from 0 to 11
score of 2 or lower indicating low risk
scores of 3 to 11 indicating increasingly greater risk.
Villanueva C et al. Transfusion strategies for acute upper gastrointestinal bleeding.
NEJM.
Jan 3 2013;368(1):11-21.
Slide67Protocol
Started immediately after admission
RCT:
computer-generated random numbers
group assignments placed in sealed, consecutively numbered, opaque envelopes.
Stratified by presence of cirrhosis
Villanueva C et al. Transfusion strategies for acute upper gastrointestinal bleeding.
NEJM.
Jan 3 2013;368(1):11-21.
Slide68Protocol
Hgb checked on admission and at least every 8 hours
restrictive-strategy group:
threshold for transfusion was 7 g/dL
target range for the post-transfusion hgb of 7 to 9
liberal-strategy group:
threshold for transfusion was 9 g/dL
target range for the post-transfusion hgb of 9 to 11
In both groups, 1 unit of PRBCs was transfused initially
the hgb checked after the transfusion
an additional unit was tx if the hgb was below the threshold
protocol applied until the patient’
s discharge from the hospital or deathprotocol allowed for tx any time symptoms or signs related to anemia developed, massive bleeding occurred during follow-up, or surgical intervention was required.EGD took place within 6 hours for all patients
Slide69Protocol
Primary Outcome
rate of death from any cause within the first 45 days
Secondary Outcomes
rate of further bleeding
rate of in-hospital complications
Villanueva C et al. Transfusion strategies for acute upper gastrointestinal bleeding.
NEJM.
Jan 3 2013;368(1):11-21.
Slide70Slide71Slide72Slide73Slide74Subgroup Analysis
Villanueva C et al. Transfusion strategies for acute upper gastrointestinal bleeding.
NEJM.
Jan 3 2013;368(1):11-21.
Slide75Slide76Take Home
Restrictive tx strategy improves outcomes in UGI bleeders
risk of further bleeding
need for rescue therapy
rate of complications
rate of survival was increased
Don
’
t tx until hgb is < 7 g/dL
Slide77AABB Recommendations
formerly, the American Association of Blood Banks
Patients
with preexisting cardiovascular disease
Suggests adhering to a restrictive strategy
T
ransfusion for patients with symptoms
Transfusion
for patients
with a hemoglobin level of ≤ 8 g/dLGrade: weak recommendation; moderate-quality evidenceHospitalized,
hemodynamically stable patients with ACSCannot recommend for or against a liberal or restrictive transfusion thresholdGrade: uncertain recommendation; very low quality evidence
Carson JL, Grossman BJ, Kleinman S, et al. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB.
Ann Intern Med. Mar 26.
Slide78Case Presentation
A 63-year old man with metastatic renal cell and a DVT develops severe melena on the floor at an OSH
He is orthostatic and
tachycardic
when he arrives at the ED
You come down to admit him, and the ED doc asks whether you want the NG lavage performed
The most appropriate response is…
Slide79Should I NG lavage?
Only if you dig sadomasochism
@#$*!
Duh, how else will I know if he is still bleeding?
Will it get him an EGD more quickly?
Slide80What is less painful than NG
intubation?
A
bscess
incision and
drainage
Fracture reduction
U
rethral catheterizationA
ll other commonly performed proceduresThis talk????!!!!!
Singer AJ, Richman PB, Kowalska A, et al. Comparison of patient and practitioner assessments of pain from commonly performed emergency
department procedures. Ann Emerg Med 1999;33:652-8.
Slide81Upper GI bleeding
N
early
400,000
hospital admissions
in the US annuallyM
ortality rate: 3%-14% per admission
Gastrointest Endosc 2011;74:971-80
Slide82Why do NG lavage?
Risk of
high-risk lesions on
endoscopy
45
% with a bloody
aspirate
15
% with
only a clear or bilious aspirateBut, does it improve pt outcomes to know who is at higher risk?What we need: RCT of NG lavageWhat we have: Propensity-matched retrospective analysis.
Slide83Impact of nasogastric lavage on outcomes in acute GI bleeding
P:
632
VA Greater
Los Angeles Healthcare
System patients
admitted with GI
bleeding
I: NG lavage C: No lavage
O: Thirty-day mortality rateLOSTx requirementsS
urgeryTime to endoscopy
Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM. Impact of nasogastric lavage on outcomes in acute GI bleeding.
Gastrointest Endosc. Nov;74(5):971-980.
Slide84Confounders
Age
Comorbidities
Liver Disease
GI
bleeding history
Past Medication
use
NSAIDs
PPIs Clopidogrel Warfarin SSRIsH2 blockers
Bed AssignmentDay of WeekTime of Day
LabsComplete blood count INR Higher
Platelets High BUN/creatinine Low albuminFrequency of testing
Changes in test valuesVital Signs- BP/HRRectal results
Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. Nov;74(5):971-980.
Slide85More Confounders
Use of Metoclopramide or erythromycin
Temporal
pattern
of administration
Time of administration
Time
to bowel preparation
Performed EGD
Performed colonoscopyNumber of procedures
Temporal pattern of procedureEGD and colonoscopy done at the same timeTime
of procedure Type of endoscope used Endoscopic findingsSource of bleeding identified Therapeutic intervention
Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM. Impact of nasogastric lavage on outcomes in acute GI bleeding.
Gastrointest Endosc. Nov;74(5):971-980.
Slide86Methods
NGL
(cases
) matched
in a 1:1 ratio to patients who did not undergo
NGL (control) B
ased on
individual propensity
scores
Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc.
Nov;74(5):971-980.
Slide87Slide88Slide89Outcomes
Does this mean that physicians who order NGL (ED or GI) are just more aggressive? Can’t control for that.
Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM. Impact of nasogastric lavage on outcomes in acute GI bleeding.
Gastrointest Endosc.
Nov;74(5):971-980.
Slide90Time to Endoscopy
Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM. Impact of nasogastric lavage on outcomes in acute GI bleeding.
Gastrointest Endosc.
Nov;74(5):971-980.
Slide91Conclusions of Study
Performance
of
NGL is unlikely to directly affect
mortality
blood transfusion
need
for surgery
Performance of NGL mayprompt more endoscopiesspeed up time to endoscopyshorten
the length of hospital stay in those patients undergoing endoscopy
Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc.
Nov;74(5):971-980.
Slide92Does This Patient Have a Severe
Upper Gastrointestinal Bleed?
Likelihood of UGI Bleed
Likelihood of
Severe UGI
Bleed
Srygley FD, Gerardo CJ, Tran T, Fisher DA. Does this patient have a severe upper gastrointestinal bleed?
Jama.
Mar 14;307(10):1072-1079.
Slide93International Consensus on Nonvariceal Upper Gastrointestinal Bleeding
Consider
placement of a nasogastric tube in selected patients because the findings may have prognostic
value (unchanged from 2003 recommendations)
Barkun AN, Bardou M. Kuipers EJ, et al. International consensus
recommendations on
the management of patients with novariceal upper
gastrointestinal
bleeding
. Ann Intern Med 2010;152:101-13.
Slide94Conclusions of Daniel J.
Pallin
and
John R.
Saltzman from HMS
We conclude that the practice of NG lavage in
the management
of patients with acute upper GI bleeding
is antiquated.
Pallin DJ, Saltzman JR. Is nasogastric tube lavage in patients with acute upper GI bleeding indicated or antiquated?
Gastrointest Endosc. Nov;74(5):981-984.
Slide95Case Presentation
Is
FENa
/
FEUrea
helpful in the evaluation of acute kidney injury?
Slide96Acute Kidney Injury Definition
An
absolute increase in serum
creatinine
≥ 0.3 mg/dL (26.4 μmol/L) in 48 hours
A
percentage increase in serum
creatinine
≥ 50% in 48 hoursUrine output < 0.5 mL/kg/hour for > 6 hours.
Slide97FENa Definition
ratio of the rate of sodium
filtration to
the overall
glomerular filtration rate
Pre-renal cause: < 1%
Intrinsic (ATN) cause: > 3%
Slide9817 patients
Espinel CH. The
FENa
test. Use in the differential diagnosis of acute renal failure.
Jama.
Aug 9 1976;236(6):579-581.
Slide99Gotfried J, Wiesen J, Raina R, Nally JV, Jr. Finding the cause of acute kidney injury: which index of fractional excretion is better?
Cleve Clin J Med.
Feb;79(2):121-126.
Falsely elevated in pre-renal states: Diuretics
Slide100Urea
C
ontinuously
produced in the liver
Small
, water-soluble molecule
Freely
passes across cell
membranesContinuously filtered and excreted by the kidneys.Half of the normal solute content of urine
< 35% suggests a prerenal > 50
% suggests an intrinsic one
Slide101FENa
FEUrea
U/Pcr
Carvounis CP, Nisar S, Guro-Razuman S. Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure.
Kidney Int.
Dec 2002;62(6):2223-2229.
P
rerenal
azotemia (
N
50
)
P
rerenal azotemia treated
with diuretics (N 27)
ATN
(
N
25
)
Slide102FEUrea for detecting pre-renal
injury
Sensitivity- 85%
Specificity- 92%
Negative LR- .16
Positive LR- 10.6
Caveats: Only 102 ICU pts and AGN and obstructive
nephropathy were excluded
Carvounis CP, Nisar S, Guro-Razuman S. Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure.
Kidney Int.
Dec 2002;62(6):2223-2229.
Slide103Pépin
(99 patients)
Pepin MN, Bouchard J,
Legault
L,
Ethier
J. Diagnostic performance of fractional excretion of urea and fractional excretion of sodium in the evaluations of patients with acute kidney injury with or without diuretic treatment.
Am J Kidney Dis.
Oct 2007;50(4):566-573.
Slide104Pépin
FEUrea without diuretics
Sensitivity- 48%
Specificity- 75
%
FEUrea with
diuretics
Sensitivity- 79%
Specificity-
33% FENa without diureticsSensitivity- 78%Specificity- 75%
FENa with diureticsSensitivity- 58%Specificity- 81%
Pepin MN, Bouchard J,
Legault L, Ethier J. Diagnostic performance of fractional excretion of urea and fractional excretion of sodium in the evaluations of patients with acute kidney injury with or without diuretic treatment.
Am J Kidney Dis. Oct 2007;50(4):566-573.
Slide105Exclusions
rhabdomyolysis
obstructive nephropathy
adrenal insufficiency
acute glomerulonephritis
nephrotoxic
acute kidney
injury
chronic
kidney diseasePepin MN, Bouchard J,
Legault L, Ethier J. Diagnostic performance of fractional excretion of urea and fractional excretion of sodium in the evaluations of patients with acute kidney injury with or without diuretic treatment.
Am J Kidney Dis. Oct 2007;50(4):566-573.
Slide106Summary of Results
Gotfried J, Wiesen J, Raina R, Nally JV, Jr. Finding the cause of acute kidney injury: which index of fractional excretion is better?
Cleve Clin J Med.
Feb;79(2):121-126.
Slide107February 6, 2014
107
Likelihood Ratios
Derived from sensitivity and specificity
It is a multiplication factor
(Pre-test odds)(LR)= post-test odds
We convert odds to percentages or use the Bayes
’
Nomogram
Slide108Likelihood Ratios
+LR: sens/1-spec
Increases your post-test probability
> 1
-LR: 1-sens/spec
Lowers your post-test probability
< 1
Slide109When are Likelihood Ratios
Helpful?
LRs >10 or < 0.1
generate large, and often conclusive changes from pre- to post-test probability
LRs of 5-10 and 0.1-0.2
generate moderate shifts in pre- to post-test probability
LRs of 2-5 and 0.5-0.2
generate small (but sometimes important) changes in probability
LRs of 1-2 and 0.5-1
alter probability to a small (and rarely important) degree.
How helpful also depends on your pre-test probability
Slide110LR in best and worse cases
Gotfried J, Wiesen J, Raina R, Nally JV, Jr. Finding the cause of acute kidney injury: which index of fractional excretion is better?
Cleve Clin J Med.
Feb;79(2):121-126.
Best Case +LR
Best Case
-LR
Worse Case
+LR
Worst Case
-LR
FENa
1. Prerenal
24
.042.4.32
2. Prerenal on diuretic3.5.45
1.5
.88
3. Intrinsic
75
.25
2.5
.56
FEUrea
1. Prerenal
92
.08
1.9
.69
2. Prerenal on diuretic
11
.01
1.2
.64
3. Intrinsic
37.5
.25
1.3
.67
Slide111Cautions
single
index,
calculated at
a specific time, often is insufficient to
properly characterize the pathogenesis
of AKI
urine samples collected
after acute changes in volume or osmolarity
may compromise their diagnostic utility
Gotfried J, Wiesen J, Raina R, Nally JV, Jr. Finding the cause of acute kidney injury: which index of fractional excretion is better? Cleve Clin J Med. Feb;79(2):121-126.
Slide112Case Presentation
Should
we get daily chest x-rays in the ICU or on step-down units?
Slide113Comparison of routine and on-demand prescription of chest
radiographs in mechanically ventilated adults: a multicentre,
cluster-randomized, two-period crossover study
21 French ICUs
P: Medical (88%) and surgical (12%) ICU patients receiving mechanical ventilation at the time of morning rounds
I: On demand chest x-ray
C: Daily chest radiograph, irrespective of clinical status
O: Mean number of chest radiographs per patient-day of mechanical ventilation
Days of mechanical ventilation
LOS in the ICU
Mortality of patients during stay in the ICU
Hejblum G, Chalumeau-Lemoine L, Ioos V, et al. Comparison of routine and on-demand prescription of chest radiographs. Lancet. Nov 14 2009;374(9702):1687-1693.
Slide114Results- 32% reduction in cxr
Chest x-ray/ patient-day of MV (total number; mean [95% CI])*
Routine strategy (n=424)
On-demand strategy (n=425)
p value
Morning rounds
3779; 0.90 (0.86–0.93)
2224; 0.54 (0.47–0.60)
<0.0001
Unscheduled
780; 0.18 (0.15–0.22)
893; 0.20 (0.16–0.25)
0.24
Total
4607; 1.09 (1.05–1.14)
3148; 0.75 (0.67–0.83)
<0.0001
Routine strategy (n=424)
On-demand strategy (n=425)
p value
Days of MV
4172
4226
0.90
Length of stay
13.96 (11.61); 10 (5–19)
13.21 (11.01); 10 (5–19)
0.28
Mortality
131 (31%)
136 (32%)
0.79
Hejblum G, Chalumeau-Lemoine L, Ioos V, et al. Comparison of routine and on-demand prescription of chest radiographs.
Lancet.
Nov 14 2009;374(9702):1687-1693.
Slide115728 routine cxr led/contributed to 824 therapeutic or diagnostic interventions in 264 patients
729 on demand cxr led/contributed to 834 interventions in 265 patients (p=0.77).
Slide116Abandoning Daily Routine Chest Radiography
in the Intensive Care Unit: Meta-Analysis
Daily routine chest radiography can be eliminated without increasing adverse outcomes in adult patients in intensive care units.
Oba Y, Zaza T. Abandoning daily routine chest radiography in the intensive care unit: meta-analysis.
Radiology.
May;255(2):386-395.