William N. Southern

Hypoglycemia-associated mortality is not drug-associated but linked to comorbidities

OBJECTIVE Although tight glucose control is used widely in hospitalized patients, there is concern that medication-induced hypoglycemia may worsen patient outcomes. We sought to determine if the mortality risk associated with hypoglycemia in hospitalized noncritically ill patients is linked to glucose-lowering medications (drug-associated hypoglycemia) or merely an association mediated by comorbidities (spontaneous hypoglycemia). METHODS A retrospective cohort of patients admitted to the general wards of an academic center during 2007 was studied. The in-hospital mortality risk of a hypoglycemic group (at least 1 blood glucose ≤ 70 mg/dL) was compared with that of a normoglycemic group using survival analysis. Stratification by subgroups of patients with spontaneous and drug-associated hypoglycemia was performed. RESULTS Among 31,970 patients, 3349 (10.5%) had at least 1 episode of hypoglycemia. Patients with hypoglycemia were older, had more comorbidities, and received more antidiabetic agents. Hypoglycemia was associated with increased in-hospital mortality (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.33-2.09; P<.001). However, this greater risk was limited to patients with spontaneous hypoglycemia (HR, 2.62; 95% CI, 1.97-3.47; P<.001) and not to patients with drug-associated hypoglycemia (HR, 1.06; 95% CI, 0.74-1.52; P=.749). After adjustment for patient comorbidities, the association between spontaneous hypoglycemia and mortality was eliminated (HR, 1.11; 95% CI, 0.76-1.64; P=.582). CONCLUSION Drug-associated hypoglycemia was not associated with increased mortality risk in patients admitted to the general wards. The association between spontaneous hypoglycemia and mortality was eliminated after adjustment for comorbidities, suggesting that hypoglycemia may be a marker of disease burden rather than a direct cause of death.

Ischemic colitis has a worse prognosis when isolated to the right side of the colon

BACKGROUND:In general, ischemic colitis has a very good prognosis, but there is concern that when ischemia affects the right side of the colon in an isolated fashion, the prognosis may not be so favorable.OBJECTIVE:The aim of this study was to compare the clinical features and outcomes of ischemia isolated to the right side of the colon with those of ischemia involving other areas of the colon.METHODS:A retrospective study was undertaken of patients with colon ischemia hospitalized at the Moses and Weiler Divisions of the Montefiore Medical Center during the interval 1998–2005. Patients were identified using computerized searches of ICD-9 codes for colon ischemia and were divided into two groups: those with isolated right colon ischemia (IRCI) and those with colon ischemia not involving the right colon in an isolated fashion (non-IRCI). Only patients with biopsy-proven ischemic colitis were entered into our study.RESULTS:A total of 273 cases of biopsy-proven ischemic colitis were identified, of which 71 (26.0%) were isolated to the right side. Of these IRCI cases, 59.2% had an unfavorable outcome compared with 17.3% of cases of non-ICRI: 54.9% of IRCI patients required surgery compared with 10.9% of non-IRCI patients; mortality in patients with IRCI was 22.5% compared with 11.9% in patients with non-IRCI.CONCLUSIONS:A total of 273 cases of biopsy-proven ischemic colitis were identified of which 71 (26.0%) involved only the right side. Patients with IRCI had a worse outcome than those with colon ischemia involving other colon regions, including a fivefold need for surgery and a twofold mortality.

Increased Risk of Mortality and Readmission Among Patients Discharged Against Medical Advice

BACKGROUND Approximately 500,000 patients are discharged from US hospitals against medical advice annually, but the associated risks are unknown. METHODS We examined 148,810 discharges from an urban, academic health system between July 1, 2002 and June 30, 2008. Of these, 3544 (2.4%) were discharged against medical advice, and 80,536 (54.1%) were discharged home. We excluded inpatient deaths, transfers to other hospitals or nursing facilities or discharges with home care. Using adjusted and propensity score-matched analyses, we compared 30-day mortality, 30-day readmission, and length of stay between discharges against medical advice and planned discharges. RESULTS Discharge against medical advice was associated with higher mortality than planned discharge, after adjustment (odds ratio [OR](adj) 2.05; 95% confidence interval [CI], 1.48-2.86), and in propensity-matched analysis (OR(matched) 2.46; 95% CI, 1.29-4.68). Discharge against medical advice also was associated with higher 30-day readmission after adjustment (OR(adj) 1.84; 95% CI, 1.69-2.01), and in propensity-matched analysis (OR(matched) 1.65; 95% CI, 1.46-1.87). Finally, discharges against medical advice had shorter lengths of stay than matched planned discharges (3.37 vs 4.16 days, P <.001). CONCLUSIONS Discharge against medical advice is associated with increased risk for mortality and readmission. In addition, discharges against medical advice have shorter lengths of stay than matched planned discharges, suggesting that the increased risks associated with discharge against medical advice are attributable to premature discharge.

Primary care-based interventions are associated with increases in hepatitis C virus testing for patients at risk

BACKGROUND An estimated 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S. Effective treatment is available, but approximately 50% of patients are not aware that they are infected. Optimal testing strategies have not been described. METHODS The Hepatitis C Assessment and Testing Project (HepCAT) was a serial cross-sectional evaluation of two community-based interventions designed to increase HCV testing in urban primary care clinics in comparison with a baseline period. The first intervention (risk-based screener) prompted physicians to order HCV tests based on the presence of HCV-related risks. The second intervention (birth cohort) prompted physicians to order HCV tests on all patients born within a high-prevalence birth cohort (1945-1964). The study was conducted at three primary care clinics in the Bronx, New York. RESULTS Both interventions were associated with an increased proportion of patients tested for HCV from 6.0% at baseline to 13.1% during the risk-based screener period (P<0.001) and 9.9% during the birth cohort period (P<0.001). CONCLUSIONS Two simple clinical reminder interventions were associated with significantly increased HCV testing rates. Our findings suggest that HCV screening programs, using either a risk-based or birth cohort strategy, should be adopted in primary care settings so that HCV-infected patients may benefit from antiviral treatment.

Hepatitis C testing practices and prevalence in a high-risk urban ambulatory care setting.

Summary.  Approximately 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S.; most are not aware of their infection. Our objectives were to examine HCV testing practices to determine which patient characteristics are associated with HCV testing and positivity, and to estimate the prevalence of HCV infection in a high‐risk urban population. The study subjects were all patients included in the baseline phase of the Hepatitis C Assessment and Testing Project (HepCAT), a serial cross‐sectional study of HCV screening strategies. We examined all patients with a clinic visit to Montefiore Medical Center from 1/1/08 to 2/29/08. Demographic information, laboratory data and ICD‐9 diagnostic codes from 3/1/97–2/29/08 were extracted from the electronic medical record. Risk factors for HCV were defined based on birth date, ICD‐9 codes and laboratory data. The prevalence of HCV infection was estimated assuming that untested subjects would test positive at the same rate as tested subjects, based on risk‐factors. Of 9579 subjects examined, 3803 (39.7%) had been tested for HCV and 438 (11.5%) were positive. The overall prevalence of HCV infection was estimated to be 7.7%. Risk factors associated with being tested and anti‐HCV positivity included: born in the high‐prevalence birth‐cohort (1945–64), substance abuse, HIV infection, alcohol abuse, diagnosis of cirrhosis, end‐stage renal disease, and alanine transaminase elevation. In a high‐risk urban population, a significant proportion of patients were tested for HCV and the prevalence of HCV infection was high. Physicians appear to use a risk‐based screening strategy to identify HCV infection.

Serum Alkaline Phosphatase and Phosphate and Risk of Mortality and Hospitalization

BACKGROUND AND OBJECTIVES Elevated alkaline phosphatase (AlkPhos) and phosphate levels are associated with cardiovascular morbidity and mortality in patients receiving dialysis. A retrospective cohort study was conducted to test these associations in outpatients with an estimated GFR > or =60 ml/min/1.73 m(2). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with serum AlkPhos and phosphate levels measured between 2000 and 2002 (n = 10,743) at Montefiore Medical Center (MMC) clinics were followed through September 11, 2008 (median 6.8 years). Mortality data were obtained via Social Security Administration records (n = 949 deaths). Hospitalization data were obtained from MMC records. RESULTS The mean age was 51 years, 64% were women, 22% were white, 26% were non-Hispanic black, 16% were Hispanic, 13% had a diagnosis of hypertension, 9% had diabetes mellitus, and 8% had cardiovascular disease at baseline. AlkPhos and phosphate were independently associated with mortality and cardiovascular-related hospitalization after multivariable adjustment. Comparing patients in the highest (> or =104 U/L) versus lowest quartile of AlkPhos (< or =66 U/L), the adjusted hazard ratio (HR) for mortality was 1.65 (P trend across quartiles <0.001). For the highest compared with the lowest quartile of serum phosphate (> or =3.8 mg/dl versus < or =3.0 mg/dl), the adjusted HR for mortality was 1.29 (P trend across quartiles = 0.008). High AlkPhos but not phosphate levels were also associated with all-cause, infection-related, and fracture-related hospitalization. CONCLUSIONS Higher levels of serum AlkPhos and phosphate were associated with increased mortality and cardiovascular-related hospitalization in an inner-city clinic population. Further studies are needed to elucidate mechanisms underlying these associations.

Longer Lengths of Stay and Higher Risk of Mortality among Inpatients of Physicians with More Years in Practice

BACKGROUND More physician years in practice have been associated with less frequent guideline adherence, but it is unknown whether years in practice are associated with patient outcomes. METHODS We examined all inpatients on the teaching service of an urban hospital from July 1, 2002 through June 30, 2004. Admissions were assigned to attending physicians quasi-randomly. Years in practice was defined as the number of years the attending physician held a medical license. We divided physicians into 4 groups (0-5, 6-10, 11-20, and >20 years in practice), and used negative binomial and logistic regression to adjust for patient characteristics and estimate associations between years in practice and length-of-stay, readmission, and mortality. RESULTS Fifty-nine physicians and 6572 admissions were examined. Although the 4 inpatient groups had similar demographic and clinical characteristics, physicians with more years in practice had longer mean lengths of stay (4.77, 5.29, 5.42, and 5.31 days for physicians with 0-5, 6-10, 11-20, and >20 years in practice, respectively, P=.001). After adjustment, inpatients of physicians with more than 20 years in practice had higher risk for both in-hospital mortality (odds ratio 1.71; 95% confidence interval, 1.06-2.76) and 30-day mortality (odds ratio 1.51, 95% confidence interval, 1.06-2.16) than inpatients of physicians with 0-5 years in practice. CONCLUSION Inpatient care by physicians with more years in practice is associated with higher risk of mortality. Quality-of-care interventions should be developed to maintain inpatient skills for physicians.

Effectiveness of a Risk Screener in Identifying Hepatitis C Virus in a Primary Care Setting

OBJECTIVES We evaluated an intervention designed to identify patients at risk for hepatitis C virus (HCV) through a risk screener used by primary care providers. METHODS A clinical reminder sticker prompted physicians at 3 urban clinics to screen patients for 12 risk factors and order HCV testing if any risks were present. Risk factor data were collected from the sticker; demographic and testing data were extracted from electronic medical records. We used the t test, χ(2) test, and rank-sum test to compare patients who had and had not been screened and developed an analytic model to identify the incremental value of each element of the screener. RESULTS Among screened patients, 27.8% (n = 902) were identified as having at least 1 risk factor. Of screened patients with risk factors, 55.4% (n = 500) were tested for HCV. Our analysis showed that 7 elements (injection drug use, intranasal drug use, elevated alanine aminotransferase, transfusions before 1992, ≥ 20 lifetime sex partners, maternal HCV, existing liver disease) accounted for all HCV infections identified. CONCLUSIONS A brief risk screener with a paper-based clinical reminder was effective in increasing HCV testing in a primary care setting.

Postoperative Clostridium difficile-associated diarrhea.

BACKGROUND Abdominal surgery is thought to be a risk factor for Clostridium difficile-associated diarrhea (CDAD). The aims of this study were to discern pre-operative factors associated with postoperative CDAD, examine outcomes after postoperative CDAD, and compare outcomes of postoperative versus medical CDAD. METHODS Data from 3904 patients who had abdominal operations at Montefiore Medical Center were extracted from Montefiores clinical information system. Cases of 30-day postoperative CDAD were identified. Pre-operative factors associated with developing postoperative CDAD were identified using logistic regression. Medical patients and surgical patients with postoperative CDAD were compared for demographic and clinical characteristics, CDAD recurrence, and 90-day postinfection mortality. RESULTS The rate of 30-day postoperative CDAD was 1.2%. After adjustment for age and comorbidities, factors significantly associated with postoperative CDAD were: antibiotic use (OR: 1.94), proton pump inhibitor (PPI) use (OR: 2.32), prior hospitalization (OR: 2.27), and low serum albumin (OR: 2.05). In comparison with medical patients with CDAD, postoperative patients with CDAD were significantly more likely to have received antibiotics (98% vs 85%), less likely to have received a PPI (39% vs 58%), or to have had a prior hospitalization (43% vs 67%). Postoperative patients with CDAD had decreased risk of mortality when compared with medical patients with CDAD (HR 0.36). CONCLUSION CDAD is an infrequent complication after abdominal operations. Several avoidable pre-operative exposures (eg, antibiotic and PPI use) were identified that increase the risk of postoperative CDAD. Postoperative CDAD is associated with decreased risk of mortality when compared with CDAD on the medical service.

Hospitalization rates of people living with HIV in the United States, 2009

Objectives. We determined hospitalization rates and disparities among people with HIV, which may have been underestimated in previous studies, as only those in medical care were included. Methods. We estimated the hospitalization rate of people with diagnosed HIV infection in the U.S. in 2009 using two nationally representative datasets. We took the number of hospitalizations from the Nationwide Inpatient Sample and searched each discharge for International Classification of Diseases, Ninth Revision codes for HIV infection and opportunistic infections (OIs). We divided the number of hospitalizations by the number of prevalent diagnosed HIV cases estimated by CDC to produce hospitalization rates, and then compared those rates using Z-tests. Results. The estimated nationwide hospitalization rate was 26.6 per 100 population. Women had a 51% higher rate than men (35.5 vs. 23.5 per 100 population, p=0.002). Black people (31.2 per 100 population, p=0.01) had a 42% higher rate, and Hispanic people (18.2 per 100 population, p=0.23) had an 18% lower rate than white people (22.1 per 100 population) of hospitalization for any illness. Of hospitalizations with an OI, females with HIV had a 50% higher rate than males with HIV (5.0 vs. 3.4 per 100 population, p=0.003). Black people with HIV (4.7 per 100 population, p<0.001) had a 72% higher rate and Hispanic people with HIV (2.9 per 100 population, p=0.78) had a similar rate of hospitalization with an OI compared with white people with HIV (2.7 per 100 population). Conclusions. Hospitalization rates among people living with HIV in the U.S. are higher than have been previously estimated. Substantial gender and racial/ethnic disparities in hospitalization rates exist, suggesting that the benefits of antiretroviral therapy have not been realized across all groups equally.