2 Minute Medicine Rewind September 28 – October 5, 2014

In this section, we highlight the key high-impact studies, updates, and analyses published in medicine during the past week.

Effect of a Postdischarge Virtual Ward on Readmission or Death for High-Risk Patients

With the recent changes in reimbursement in America penalizing hospitals that have high readmission rates, there is now an increased emphasis on interventions that reduce the risk of readmission. The virtual ward, which includes an interprofessional team who meets daily in the goal of improving post-discharge health outcomes for patients with complex needs, has been pioneered in the United Kingdom as a method to decrease readmissions. In this Canadian randomized controlled trial, 1923 high-risk patients were randomized to usual care or to a virtual ward at the time of hospital discharge. Despite a rigorous support system, patients in the virtual ward group did not have a significantly different rate of hospital readmission or death within 30 days of discharge (21.2%) when compared to the group of patients receiving usual care (24.6%) (95% CI: −0.3% to 7.2%; P =  0.09). Rates of nursing home admission and emergency department visits were also not significantly different between the groups. The virtual hospital model was not shown to reduce hospital readmission and death in this study; however, ongoing research aiming to decrease hospital readmission and provide better non-hospital health care remains crucial.

Provision of No-Cost, Long-Acting Contraception and Teenage Pregnancy

In the United States, 3 in 10 teens become pregnant before they reach 20 years of age, the highest rate of any developed nation. To address this problem, President Obama created the Teen Pregnancy Prevention Initiative in 2010. Decreasing the cost of and increasing education of pregnancy prevention were at the root of this initiative. Long-acting, reversible contraceptive (LARC) methods, including intrauterine devices (IUDs) and implants, have been shown to have to reduce pregnancy among adolescents; however, the awareness of LARC methods for teenage pregnancy prevention remains limited. The Contraceptive CHOICE Project was a large cohort study of 1404 teenage girls between 2008 and 2013 designed to promote the use of LARC methods to reduce unintended pregnancy. After education on reversible contraception, 72% of teenagers chose a LARC method. The annual rates of pregnancy, birth, and abortion were 3.4% (95% CI: 2.6% to 4.4%), 1.9% (95% CI: 1.3% to 2.7%), and 1.0% (95% CI: 0.6% to 1.6%) in the CHOICE participants, compared to 15.9%, 9.4% and 4.2% amongst comparable sexually experienced U.S. teens in 2008, respectively. This study therefore shows that educating teenage girls about reversible contraception and providing them with free long-acting contraception decreases pregnancy rates in this this group.

Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock

The Surviving Sepsis Campaign recommends complex transfusion guidelines for patients with septic shock. This includes maintaining a hematocrit of more than 30% in the first 6 hours, followed by a transfusion threshold of hemoglobin (Hgb) less than 7g/dL in patients without heart disease. Given conflicting results in studies of transfusions in critically ill patients, the need for an higher initial transfusion threshold should be reevaluated. In this multicenter, randomized-controlled trial, 1005 ICU patients with septic shock and a Hgb concentration of 9g or less were randomized to a 7g/dL threshold (lower threshold) or a 9g/dL threshold (higher threshold). The 90-day mortality rate was similar for the lower threshold (43.0%) and higher threshold (45.0%) groups (RR: 0.94, 95% CI: 0.78 to 1.09; P = 0.44). Similarly, the number of ischemic events and severe adverse reactions were not significantly different between the two groups. Thus, given similar mortality rates in the two groups despite fewer transfusions in the lower threshold group, this study suggests no benefit in a higher initial transfusion threshold in septic shock patients.

Effect of Statin Use During Hospitalization for Intracerebral Hemorrhage on Mortality and Discharge Disposition

Shown to improve outcomes and to reduce the risk of a subsequent ischemic stroke by decreasing secondary brain injury, statins are commonly prescribed in patients with an ischemic stroke. Despite similar molecular mechanisms for secondary brain injury in hemorrhagic stroke, the data for statin-use in intracranial hemorrhage (ICH) has been conflicting. In this retrospective cohort study, data from 3481 hospitalized patients with ICH were reviewed. Patient who received statin as inpatients had a 30-day mortality rate of 18.4%, compared to 38.7% in those not treated with a statin (OR: 4.25,95% CI: 3.46-5.23; P <  0.001). Of the patients taking a statin as an outpatient prior to ICH, the 30-day mortality rate was 57.8% for those who discontinued statin use as an inpatient, compared to 18.9% for those who continued statin-use during hospitalization (OR: 0.16, 95% CI,:0.12-0.21; P  <  0.001). This study suggests that even after controlling for demographics, medical comorbidities, ICH severity, ICH complications, and DNR status, statin use improves outcomes in ICH.

Trial of the Route of Early Nutritional Support in Critically Ill Adults

Enteral feeding is the favored standard for nutritional support of critically ill patients, with a putative association with fewer infections and the belief that it is the most natural way to provide nutrition. However, enteral feeding is associated with gastrointestinal intolerance and underfeeding. Thus, given improvements in delivery, formulation, and monitoring of parenteral nutrition, it should be reevaluated as a possible route for early nutritional support. In this randomized-controlled trial, 2400 patients admitted to 33 English intensive care units and randomized being fed parenterally or enterally. Thirty-day mortality was 33.1% in the parenteral group, compared to 34.2% in the enteral group (RR: 0.97, 95% CI: 0.86 to 1.08; P = 0.57). The mean number of treated infectious complications per patient was also not significantly different in the parental and enteral groups (0.22 vs. 0.21; P = 0.72). The rates of hypoglycemia and vomiting, however, were significantly lower in the parenteral group (3.7% and 8.4%) than in the enteral group (6.2% and 16.2%) (P = 0.006 and P < 0.001). Thus, early nutritional support through the parenteral route, as it is typically administered, is neither more harmful nor more beneficial than enteral feeding, and is associated with lower rates of hypoglycemia and vomiting.

Image: PD

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