Doctor of Medicine

Hospital Readmission Not a Good Quality Measure for Children.

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Preventable readmission rates for children are lower than all-cause readmission rates, according to a new study.

“The concern that many of us have is that there is much less to be gained from a major effort to reduce pediatric readmissions because so many are due to an unpredictable disease process,” James Gay, MD, from Monroe Carell Jr. Children’s Hospital at Vanderbilt University in Nashville, Tennessee, told Medscape Medical News.

“Pediatricians try very hard to keep their patients out of the hospital in the first place,” he explained, “so a large investment of time, energy, and funds to reduce pediatric admissions may not be very beneficial overall, and it might actually distract from efforts in other areas, such as concentrating on patient safety.”

Dr. Gay presented the results here at the American Academy of Pediatrics 2013 National Conference and Exhibition.

Pressure is on at hospitals to reduce 30-day readmissions, which are considered by some regulators to be a metric of patient safety and quality care. The Affordable Care Act requires a hospital readmission reduction program for facilities that treat Medicare patients and imposes penalties for institutions with high rates.

 

A large investment of time, energy, and funds to reduce pediatric admissions may not be very beneficial overall.

 

Hospital administrators are therefore keen to identify preventable readmissions. Some state Medicaid programs use the 3M Potentially Preventable Readmissions grouping software; however, data on its use in pediatric readmissions are lacking, said Dr. Gay.

His team assessed 1,749,747 hospitalizations in 58 Children’s Hospital Association member hospitals. They used the 3M software to calculate all-cause readmission rates with the company’s proprietary list of 314 All Patient Refined Diagnostic Related Groups.

The software flagged 80% or more of all-cause readmissions as potentially preventable for sickle cell crisis, bronchiolitis, ventricular shunt procedures, asthma, and appendectomy. In contrast, the software suggested that more than 40% of 30-day readmissions were not preventable, including those for seizures, gastroenteritis, central line infections, urinary tract infections, and failure to thrive.

For the 20 leading patient diagnostic groups for all-cause readmissions, the software algorithm removed chemotherapy, acute leukemia, and cystic fibrosis from the list of potentially preventable reasons.

Table. All-Cause vs Preventable Pediatric Readmissions

Day

All-Cause Readmissions (%)

Preventable Readmissions (%)

7

4.9

2.5

15

8.5

4.1

30

13.0

6.2

 

“There are many fewer pediatric than adult hospitalizations in the first place, and the numbers and rates of readmissions are lower in children,” Dr. Gay pointed out. According to Medicare estimates, “older adults have readmission rates of about 20% at 30 days. The overall pediatric rates are closer to 6% to 10%,” he added.

Conditions that drive hospital readmission in children, or lead to admission in the first place, are very different from those in adults, Dr. Gay said. For example, adults are more likely to be readmitted within 30 days because of a high prevalence of chronic conditions, like congestive heart failure and chronic obstructive pulmonary disease, whereas children have more acute illnesses, such as pneumonia, bronchiolitis, and asthma.

“Because of these issues, many hospital pediatricians believe that readmission rates are not a good quality measure for pediatrics,” Dr. Gay said.

Asked by Medscape Medical News to comment on this study, Mark Shen, MD, from Dell Children’s Medical Center in Austin, Texas, noted that “in this study, the single most common reason for readmission was chemotherapy. We expect these kids to come back — we’ve wiped out their immune system.”

Other children are discharged with the expectation they will return as well, he added. “Sometimes we know they’re coming back. We’re just giving them a break at home, such as children with sickle cell disease or ventricular shunts.”

This study is useful because it indicates that the rate of 30-day hospital readmission is lower for children than for adults. Further research could focus on key chronic conditions associated with more readmissions in children, which so far only have been identified in adults. “But we’re getting closer in pediatrics,” Dr. Shen added.

The study authors caution that the 3M software might not completely reflect the reasons for pediatric readmissions, and future studies are warranted to validate its use in this population. The broader issue is whether efforts to track and reduce adult hospital readmissions apply equally to pediatric patients, Dr. Gay said.

Home Test for Pharyngitis May Reduce Unneeded Strep Cultures.

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A patient-driven approach to streptococcal pharyngitis diagnosis using a new home test score might save on unnecessary physician visits, cultures, and treatment, according to a retrospective cohort study published online November 4 in the Annals of Internal Medicine. However, some experts are skeptical of the home score algorithm and of its potential cost-savings.

“Globally, group A streptococcal (GAS) pharyngitis affects hundreds of millions of persons each year,” write Andrew M. Fine, MD, MPH, from the Division of Emergency Medicine-Main 1, Boston Children’s Hospital in Massachusetts, and colleagues. “In the United States, more than 12 million persons make outpatient visits for pharyngitis; however, clinicians cannot differentiate GAS pharyngitis from other causes of acute pharyngitis (for example, viral) on the basis of a physical examination of the oropharynx.”

Most cases of sore throat are viral, rather than bacterial, and therefore are self-limiting and transient even without antibiotic treatment. To classify risk for GAS pharyngitis and guide management of adults with acute pharyngitis, the American College of Physicians and Centers for Disease Control and Prevention recommend use of clinical scores to identify low-risk patients. According to consensus guidelines, such patients should not be tested or treated for GAS pharyngitis.

The goal of this study was to help patients decide when to visit a clinician for evaluation of sore throat. The study sample consisted of 71,776 patients at least 15 years of age who were evaluated for pharyngitis from September 2006 to December 2008 at one of a national chain of retail health clinics.

Using information from patient-reported clinical variables, as well as local incidence of GAS pharyngitis, the investigators created a score and compared it with the Centor score and other traditional scores, using information from clinicians’ assessments. Clinical variables in the new score were fever, absence of cough, and age.

The investigators estimated outcomes if patients who were at least 15 years of age with sore throat did not visit a clinician when the new score indicated less than 10% likelihood of GAS pharyngitis, compared with being managed by clinicians following guidelines using the Centor score. The researchers suggest that following this strategy would avoid 230,000 clinician visits in the United States each year, and that 8500 patients with GAS pharyngitis who would have received antibiotics under clinician management would not receive antibiotics.

A limitation of this approach is current lack of availability of real-time information about the local incidence of GAS pharyngitis, which is needed to calculate the new score. Study limitations include retrospective design and reliance on self-report of symptoms.

“A patient-driven approach to pharyngitis diagnosis that uses this new score could save hundreds of thousands of visits annually by identifying patients at home who are unlikely to require testing or treatment,” the authors write.

Experts Question Limitations and Cost-Savings of the New Score

In an accompanying editorial, Edward L. Kaplan, MD, MMC, from the Department of Pediatrics, University of Minnesota Medical School in Minneapolis, warns of limitations of the new home score. These include overly broad age range, as GAS pharyngitis is rare in persons older than 50 years, and the assumption that GAS pharyngitis has even prevalence across communities.

Dr. Kaplan recommends stratification by age categories and notes that uncomplicated GAS pharyngitis has not been reportable to health departments for several decades in most states, making incidence difficult to determine. Other limitations include failure to account for potential effects of the decisions made by the multiple clinicians from more than 70 clinics attended by patients in this sample, and lack of differentiation of true GAS infection from upper respiratory tract “carriers” among adults.

“Until we have a proven cost-effective vaccine to protect against Streptococcus pyogenes, we cannot expect the magnitude of this medical and public health issue to decrease,” Dr. Kaplan writes. “Even if a cost-effective vaccine is developed, how it may affect true infections and the carrier state in children may be entirely different in adults. Fine and colleagues have proposed an interim approach, but there are surely others.”

In a second editorial, Robert M. Centor, MD, from the University of Alabama at Birmingham in Huntsville, questions the potential cost-savings if the new score were widely used. Alternative strategies to improve treatment and reduce costs include clinical assessment that eliminates testing for patients at low risk, as well as the use of generic antibiotics for those with GAS pharyngitis. He also warns that all guidelines and recommendations for GAS pharyngitis apply only to patients who have had symptoms for fewer than 3 days.

“If symptoms persist or worsen, then the patient no longer has acute pharyngitis; therefore, we should use a different diagnostic and therapeutic approach,” he writes.

Other questions posed by Dr. Centor include whether patients would actually download and use such a test before deciding whether to seek medical care for sore throat and why many physicians, clinics, and emergency departments do not follow published guidelines recommending against antibiotic use for patients with low probability of GAS pharyngitis.

“Although the goals [of this study] are admirable, the approach does not seem practical or cost-saving,” Dr. Centor concludes. “We have more practical strategies for decreasing costs for patients with sore throat.

High Glucose Linked to Poorer Memory, Even in People Without Diabetes.

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Higher levels of both short-term and long-term blood glucose markers are significantly associated with poorer memory and with decreased volume and microstructure of the hippocampus in persons without diabetes or impaired glucose tolerance (IGT), according to a new study.

The results imply that lowering blood glucose levels, possibly even to relatively low levels, might help preserve cognition, study author Agnes Flöel, MD, Department of Neurology and Center for Stroke Research Berlin, Charite-University Medicine, Berlin, Germany, toldMedscape Medical News.

Strategies that help lower blood glucose levels include a healthy Mediterranean-type diet and regular physical activity, she added.

The study is published online October 23 in Neurology.

Direct Relationship

The cross-sectional study included 141 healthy persons (mean age, 63.1 years) who were recruited through advertising. Persons with diabetes, IGT, or neurologic disorders and those taking antidepressants were excluded.

Researchers obtained blood measurements, including glycosylated hemoglobin (HbA1c), which reflects peripheral glucose levels of the preceding 8 to 12 weeks; fasting glucose; and insulin. They also carried out apolipoprotein E (APOE) genotyping.

Participants underwent cognitive testing using the German version of the Rey Auditory Verbal Learning Test. Researchers calculated hippocampal volume from MRI scans and assessed hippocampal microstructure by mean diffusivity (MD) estimated by using diffusion tensor imaging.

According to Dr. Flöel, this was the first time that this MD method provided data on the association between hippocampal microstructure and glucose metabolism.

The investigators found that lower performance on 3 memory tasks (delayed recall, learning ability, and consolidation) was associated with higher levels of both the long-term marker of glucose control (HbA1c) and the short-term glucose marker (all P ≤ .01).

For insulin, there was a “general trend going in the same direction” but correlations were less clear, and without the same direct relationship, said Dr. Flöel.

Potential Mechanisms

Memory performance was correlated with hippocampal volume (P = .001) and lower MD (P = .01), lower age, and, in part, lower blood pressure and female sex. Researchers did not find a statistically significant association between memory performance and APOE genotype, body mass index, Beck Depression Inventory score, physical activity, or smoking.

Lower levels of HbA1c were associated with larger hippocampal volume (nonsignificant trend; P = .06). The associations between lower fasting glucose levels and higher hippocampal volume did reach significance (P = .01). There was no significant relationship between hippocampal volume and insulin.

As for hippocampal microstructure, the researchers noted that lower levels of all 3 markers of glucose metabolism significantly correlated with lower MD within the hippocampus.

There was no significant association between glucose markers and volume or MD in brain areas other than the hippocampus (eg, gray matter and thalamus).

The hippocampus is particularly vulnerable to disturbances in metabolic supply, including glucose, said Dr. Flöel.

“Elevated blood sugar levels may damage the outer membrane of the cells, or decrease neurotransmitter levels, which would disturb signaling within and between hippocampal cells. Information transfer between cells, which is indispensable for memory encoding, storage and retrieval, would then be compromised.”

Elevated blood sugar levels may also damage small and large vessels in the brain, leading to decreased blood and nutrient flow to brain cells or even brain infarcts, and this may further damage memory-relevant brain structures, added Dr. Flöel.

The current findings are in line with studies of patients with type 2 diabetes mellitus and IGT, but earlier research was unable to confirm the deleterious effects of nondiabetic glucose levels on cognition. This, said the authors, may be because of different methods for classifying glucose levels and varying cognitive tests used.

Prevention Research

The authors also pointed out that the current study used MRI with higher magnetic field strength, which offers a higher sensitivity of hippocampal volumetry and greater statistical power to observe significant associations.

Following a diet high in lean protein and complex carbohydrates (such as whole grains, vegetables, fruits, and fiber) and low in heavily refined foods will help lower blood glucose, said Dr. Flöel. Another important lifestyle strategy is regular physical activity.

How low is it safe to go in terms of blood glucose levels? According to Dr. Flöel, that depends in part on lifestyle. “If you’re used to low blood sugar levels, you can go quite low,” she said.

She likened this to the situation with blood pressure. “At one time, it was assumed that you needed a certain level to function, but that actually is not true. You can go very low and still maintain normal function, and it might actually be better in the long run.”

Although the study uncovers the protective potential of lower blood glucose levels, the relationship between high blood glucose and poor memory “seems to be more linear” and changing recommended cutoffs may not make much of a difference, said Dr. Flöel.

On the other hand, what could be key is prevention, she said.

“There have been some initiatives to put prevention more on the agenda of dementia research,” she said. “There has been so much money spent on treatment of Alzheimer’s disease and it has already been established that this is not very successful. “

Dementia prevention strategies could include taking measures at an earlier stage to encourage physical fitness and control hypertension, blood lipids (including cholesterol and triglycerides), and now, possibly, blood glucose levels, she said.

Patients should have their fasting glucose and HbA1c levels measured as part of a regular medical check-up starting at age 55 years, unless there’s a personal or family history of diabetes or the patient is obese, in which case the family doctor may opt for earlier and more intense monitoring, said Dr. Flöel. She pointed out that such tests are easy to do and are already carried out regularly in pregnant women.

Fresh Eyes

Commenting on the findings for Medscape Medical News, Marwan N. Sabbagh, director, Banner Sun Health Research Institute, Sun City, Arizona, said that the study looks at the link between glucose metabolism and cognition with fresh eyes.

“This is saying that immediate learning and A1c levels, and potentially even blood sugars, interact even in people who are nondemented, and I don’t think anyone has looked at it that way before,” said Dr. Sabbagh.

“The idea is that the lower the A1c the better your brain function. This is a very exciting development and clearly helps put a frame around the Alzheimer’s discussion, but more importantly, it talks about how blood sugar metabolism and cognitive function directly interact.”

The study opens “a whole new territory” because until now, HbA1c and blood glucose have been looked at only in the context of diabetes and the risk for diabetes, added Dr. Sabbagh. “Maybe we need to rethink our normalization of glucose with an eye toward cognition and not simply a diabetes risk.”

Tylenol Just Once A Month Raises A Child’s Asthma Risk 540%.

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The vast majority of babies are given Tylenol (acetaminophen) within the first six months of life. It is the go to medicine for modern parents whenever discomfort or fever strikes even very young children and its use is frequently encouraged by many pediatricians.

I

Now, a major study of over 20,000 children suggests that giving this popular medicine even as infrequently as once per year could have a permanent, life-threatening health effect.

Researchers at the University of A Coruna in Spain asked the parents of 10,371 children ages 6-7 and 10,372 adolescents aged 13-14 whether their children had asthma and how often they had been given acetaminophen within the previous year and when they were babies.
The children in the younger age group who had received the medicine only once per year were at 70% greater risk for asthma while those receiving Tylenol once a month or more were shockingly 540% more likely to have asthma.

The study, published in the European Journal of Public Health, also found that children who had even a single dose of Tylenol before their first birthday had a 60% risk of developing asthma.

In the older age group of 13 and 14 year-olds, asthma was 40 percent more likely if they had taken acetaminophen within the previous 12 months. The young teenagers were 250% more at risk if they took it once a month.

The researchers speculated that Tylenol, called paracetamol in the UK, may reduce a potent antioxidant called glutathione in the lungs and blood, which results in damage to the lung tissue. Glutathione is produced by the body (it is a combination of three amino acids:  cysteine, glycine and glutamine) and is referred to as the “mother” of all antioxidants by Dr. Mark Hyman MD.
While Tylenol use is strongly associated with a significant increase in asthma and the effect is greater the more often the drug is taken, no causal link is yet established via randomized-controlled trials. Does this mean the results of this large study should be dismissed and parents should continue favoring use of the popular over the counter medication for fever and pain?
Not so fast.

It would certainly be the wise and cautious approach for parents to investigate alternatives to Tylenol while additional follow-up research is performed.

Asthma rates have been on the increase for decades at the same time Tylenol use became more widespread. The potential link cannot and should not be ignored.

Examination of 20,000 children establishing such a strong associative risk must be taken seriously and the dismissal of the research by some doctors is irresponsible given the seriousness and life altering outcome of an asthma diagnosis.

New Data Dispute Calcium Cardiovascular Risk in Both Sexes.

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Two new studies contribute further to the debate over the cardiovascular risk associated with supplementary or dietary calcium, each decidedly coming down on the side of no significant risk — to men or women.

“[Based on these findings], clinicians should continue to evaluate calcium intake, encourage adequate dietary intake, and if necessary, use supplements to reach but not exceed recommended intakes,” Douglas C. Bauer, MD, from the University of California, San Francisco, the lead author of the first study, toldMedscape Medical News.

Results of both studies were reported at the recent American Society for Bone and Mineral Research (ASBMR) 2013 Annual Meeting.

Dr. Bauer’s observational trial is one of few contemporary studies to evaluate the level of risk among men, who are often poorly represented in calcium studies, he noted. The results showed no association between calcium dietary intake or supplementation and total or cardiovascular mortality. The second study was an updated meta-analysis of calcium supplementation among women and similarly demonstrated no increased risk for ischemic heart disease (with adjudicated outcomes) or total mortality in elderly women. It did draw some criticism for potential bias and contamination, however.

Nevertheless, says Robert Marcus, MD, a retired Stanford University bone specialist, the 2 studies are “powerful. The one involving men had very elegant, accurate reports of death and validated diagnosis of myocardial infarction, and the [study involving women] was also excellent work,” he commented.

“This field has been the subject of an enormous amount of controversy, ambiguity, and confusion for the past several years, and I think the most important thing is to help us come up with what is true,” he said. The quality of data to suggest an adverse effect of calcium is “very poor,” and there is now compelling evidence that there is little to substantiate this, he noted. But despite these reassuring new findings, public anxiety over a potential risk with calcium is unlikely to go away, he believes.

In recommendations issued in 2010, the ASBMR said that most adults 19 years of age and older require about 600 to 800 IUs of vitamin D daily and 1000 to 1200 mg of calcium daily through food and with supplements, if needed.

Contemporary Data on Calcium Intake in Men

The use of calcium supplements, predominantly with vitamin D, is an important therapy for the prevention of osteoporosis and its clinical consequences. But concerns about the cardiovascular safety of calcium have emerged periodically; in 2 alarming meta-analyses published in 2010 and 2011 by Dr. Mark Bolland and colleagues, for example, there was a 27% increase in MI among individuals allocated to calcium supplements in the first study and a 24% increased risk in the second.

More recently, a 40% increase in total mortality and up to a 50% increase in cardiovascular mortality was seenamong women from a Swedish mammography cohort with a calcium intake exceeding 1400 mg per day. In that study, the effect on mortality appeared to be especially strong if a high dietary intake of calcium was combined with calcium supplements.

In their new study, Dr. Bauer and his colleagues set out to assess rates of dietary calcium intake, use of supplements, and mortality in a prospective cohort of 5967 men over the age of 65 years in the Osteoporotic Fractures in Men (MrOS) study.

The participants completed extensive surveys at baseline on their dietary calcium intake, and supplementation was verified by a review of pill bottles by trained staff.

Mean dietary calcium intake was 1142 ± 590 mg/day, with more than half — 65% — of participants reporting use of calcium supplements.

Over the 10-year follow-up, among 2022 men who died, 687 deaths were caused by cardiovascular disease. The highest mortality for CVD was seen in the quartile with the lowest intake from calcium supplementation.

And in models that adjusted for age, energy intake, and calcium use, men in the lowest quartile of total calcium intake (less than 621 mg per day) had higher total mortality compared with those in the highest quartile (more than 1565 mg of calcium per day).

Adjustment for additional confounding factors showed no association between calcium dietary intake and total or cardiovascular mortality (P for trend .51 and .79, respectfully). Likewise, there was no association between calcium supplementation and total or cardiovascular mortality.

The authors also conducted an additional analysis of calcium intake and adjudicated cardiovascular disease events in a subcohort of the study, MrOS Sleep, involving 3120 patients who took part in a 7-year follow-up, and again there was no higher risk for cardiovascular events associated with calcium intake.

The study did have is limitations, Dr. Bauer acknowledged, including the observational design, calcium intake being assessed with a food frequency questionnaire, and cause of death not being formally adjudicated. Nevertheless, the findings are important in demonstrating the level of risk among men in a contemporary setting, he pointed out.

“Contrary to the Swedish study of women, we found no evidence that calcium supplementation is harmful to men, even among those with the highest dietary calcium intake,” he concluded, recommending that future studies should include adjudicated outcomes.

Study in Men as Expected, but Female Research Questioned

In the second study reported at the ASBMR meeting, Joshua Lewis, MD, PhD, from the University of Western Australia, Perth, and colleagues reported a meta-analysis of 19 randomized controlled trials involving women over the age of 50 years who had received calcium supplementation for more than a year.

Importantly, the analysis included reports of adjudicated cardiovascular outcomes, which the researchers note is important because gastrointestinal events can be misreported as cardiac ones. They also assessed all-cause mortality.

Among 59,844 participants in the studies, there were 4646 deaths, and the relative risk for death among those randomized to calcium supplements was 0.96 (P = .18).

The relative risk for 3334 ischemic heart disease events among 46,843 participants was 1.02 (P = .053), and the risk for 1097 MI events among 49,048 participants was 1.09 (P =.21).

“The data from this meta-analysis does not support the concept that calcium supplementation with or without vitamin D increases the risk of ischemic heart disease or total mortality in elderly women,” concluded Dr. Lewis.

But bone specialist Ian Reid, MD, from the University of Auckland, New Zealand, who was a coauthor on some of the Bolland studies, said this analysis essentially repeats previous ones, but with the inclusion of 20,000 patients from the Women’s Health Initiative (WHI), many of whom continued to take their own calcium tablets, regardless of whether they were randomized to calcium or placebo.

These “contaminated” WHI data have the potential to mask the effect of calcium, he told Medscape Medical News. In addition, in a study from Denmark also included in the meta-analysis, subjects were not properly blinded to treatment assignment and the calcium and control groups were not comparable at baseline for cardiovascular risk, which introduced “major potential bias,” he added.

Regarding the results from the study in men by Dr. Bauer and colleagues, Dr. Reid said they were not surprising to him. “Generally, people who take calcium supplements have more health-conscious behaviors than those who do not and so have a lower baseline risk of heart disease” that can “obscure small adverse effects of drugs such as calcium,” he observed.

An effect has to be “very substantial” before it can be picked up in an observational study, because of the many confounders that can obscure such an effect, he concluded.

Source: Medscape.com