Hospitals that spend more on initial care following patient emergencies have better outcomes than hospitals that spend less at first and rely more on additional forms of long-term care, according to a new study co-authored by MIT economists.
More specifically, hospitals that invest more in inpatient care yield better results, per dollar spent, than those that assign relatively more patients to skilled nursing facilities upon discharge. Other things being equal, allocating a higher percentage of overall health care expenses to a hospital’s inpatient treatment is consistent with lower mortality rates among elderly Medicare recipients.
“We find that patients who go to hospitals that rely more on skilled nursing facilities after discharge, as opposed to getting them healthy enough to return home, are substantially less likely to survive over the following year,” says Joseph Doyle, the Erwin H. Schell Professor of Management at the MIT Sloan School of Management and co-author of a paper detailing the study.
Conversely, Doyle adds: “What types of hospitals are low-cost and have good outcomes? They spend a lot when you’re there, initially, but a lot less [after] you leave the hospital.”
The co-authors are Doyle; John A. Graves, an assistant professor at Vanderbilt University; and Jonathan Gruber, the Ford Professor of Economics at MIT.
The study aims, in part, to address the fact that the U.S. spends about 40 percent more on health care per capita than the next highest-spending country in the Organisation for Economic Co-operation and Development (OECD), a group of 35 major nations — a figure that leads many to wonder whether there are significant ineffeciencies in U.S. health care spending.
In devising their experiment, the researchers took advantage of ambulance company practices that essentially provided a randomized group of patients to study, making it possible to compare outcomes at different hospitals.
The study uses Medicare claims data for hospital admissions from 2002 to 2011, focusing on patients who were at least 66 years old, and tracking their one-year mortality statistics. The study’s final database comprised 1,575,273 patients.
In many parts of the U.S., multiple ambulance companies cover a given area, and their assignment to patients is essentially random; the first available company will take a patient. However, ambulance companies often have agreements or preferences concerning which hospitals they deliver patients to. That means the ambulance companies are essentially delivering a randomized set of people to certain hospitals.
For this reason, the study avoids a basic problem in comparing hospital outcomes — that patients admitted to one hospital may be significantly less healthy, on average, than the patients admitted to another. All told, there are about 2,500 ambulance companies and about 3,000 hospitals in the data set.
The average 90-day spending on patients in the study is almost $27,500; for every additional increase in spending of roughly $8,500, the researchers found a reduction in mortality risk of about 2 percentage points. However, the study finds about a 5 percentage-point increase in mortality at hospitals that have relatively high rates of spending on “downstream” nursing facilities.
“We see this as a potentially novel quality measure for hospitals,” Doyle says. “Hospitals that have that profile where they send patients to skilled nursing facilities have higher spending downstream, and they have worse outcomes.”
The paper is one of a series of studies by Doyle and his colleagues which use the random assignment of patients to hospitals, due to ambulance-dispatch practices, in order to evaluate hospital effectiveness. In a previous study more strictly focused on the intensity of emergency care treatments, Doyle also found that higher spending leads to better outcomes.

MIT
news.mit.edu/2017/hospitals-spend-more-emergency-care-yield-better-outcomes-0710

Although treatable, empyema is a potentially deadly accumulation of pus around the lungs, occurring most commonly as a complication of pneumonia. To better manage this disease in the face of rising demand for treatment, the American Association for Thoracic Surgery (AATS) Guidelines Committee called for the formation of the Empyema Management Guidelines Working Group. Comprised of experts from a variety of disciplines including thoracic surgery, pulmonary and critical care medicine, infectious diseases, and interventional radiology, the group was tasked with analysing the latest literature about empyema and issuing new evidence-based clinical guidelines. The resulting Consensus Statement is published in the www.jtcvsonline.org/.

In the United States, around 1 million patients each year are hospitalised with pneumonia. Of this group, around 20percent to 40percent develop a parapneumonic effusion and 5percent-10percent of these will progress to empyema. Patients who experience empyema face discouraging odds: approximately 15percent of them will die and 30percent will require surgical draining to clear the infection. While occurrences of empyema dropped dramatically during first half of the 20th century thanks to improved antibiotic regimens, that trend changed in the 1990s. Now, doctors are seeing more cases, making empyema an even more relevant subject for clinical study.

‘The management of empyema has historically varied significantly from hospital to hospital and across the many different medical specialists who may care for patients with this disease,’ remarked lead author K. Robert Shen, MD, Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN. ‘These new guidelines formulated by the AATS are important because they represent an attempt to develop recommendations that are based upon the best available current scientific evidence.

The guidelines encompass empyema presentation, diagnosis, and treatment presenting a comprehensive strategy for doctors treating empyema patients. There are several top-level takeaways from their findings:

Patients with pneumonia that fail to respond to established antibiotic therapy or unexplained sepsis should always be evaluated for a possible pleural effusion. If either a parapneumonic effusion or empyema is found, patients should undergo immediate treatment.
According to the group’s findings, surgery remains the most effective method for management of most patients with empyema despite advances in radiologic imaging, antibiotics, and other medications that have made it possible to treat without undergoing a surgical procedure.
Management of paediatric empyema differs significantly from treatment in adults. Investigators acknowledge there is currently disagreement about the best treatment protocols for children with empyema. After a comprehensive analysis of current literature, the group issued a recommendation that pediatric patients should initially be treated with a tube thoracostomy with or without the subsequent instillation of fibrinolytic agents.

As empyema cases become increasingly common, investigators hope these guidelines can help make diagnosis and treatment protocols more uniform across the country to help offer patients the best care possible. ‘Despite the widespread use of antibiotics and availability of pneumococcal vaccines, empyema remains the most common complication of pneumonia and an important cause of morbidity and mortality worldwide,’ concluded Dr. Shen. ‘It is hoped that these guidelines will provide clinicians who care for pneumonia patients with practical guidelines on the best way to treat their patients who develop empyema.’

EurekAlert www.eurekalert.org/pub_releases/2017-04/aaft-ain042017.php

A study by the University of Birmingham has revealed a treatment gap in patients suffering from a heart condition that causes an irregular or abnormally fast heartbeat.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a major global public health problem. It is associated with a five-fold increase in risk of stroke.
There are three types of AF – paroxysmal, persistent or permanent. In paroxysmal AF, episodes come and go, and usually stop without any treatment.
With persistent AF episodes can last for periods of more than seven days and are treated with medication or a medical procedure called cardioversion.
In permanent AF, the irregular heartbeat is present all the time and cardioversion has failed to restore a normal heart rhythm.
All patients with AF, including paroxysmal AF, are at an increased risk of stroke. UK guidelines recommend anticoagulant treatment, such as the blood-thinning drug warfarin, for patients with all types of AF in order to reduce the risk of stroke.
Now a study, carried out by the University of Birmingham’s Institute of Applied Health Research, has discovered that patients with paroxysmal AF are significantly less likely to receive anticoagulants for stroke prevention than patients with persistent or permanent AF.
Corresponding author Dr Nicola Adderley said: “Our team of researchers analysed the records of 14 million patients from 648 GP surgeries from across the country, looking specifically at records covering a 15-year period between 2000 and 2015.
“We found that patients with paroxysmal AF were consistently less likely to be prescribed anticoagulants than those with persistent or permanent AF.
“Although the proportion of AF patients prescribed anticoagulants increased considerably, in 2015 fewer paroxysmal AF patients were prescribed anticoagulants – a treatment gap of 13%.
“While the anticoagulant treatment gap has narrowed over the years, from 15% in 2000 to 13% in 2015, over the same period a diagnosis of paroxysmal AF became three times more common.
“This means that the number of paroxysmal AF patients missing out on anticoagulants is greater now than 16 years ago.
“Underuse of anticoagulants in patients with paroxysmal AF is likely to result in preventable strokes among this group, leading to greater levels of avoidable death and disability.”

Birmingham University
www.birmingham.ac.uk/news/latest/2017/06/irregular-heartbeat-stroke.aspx

Advances in diagnostic imaging technology have meant that more trauma patients are being diagnosed with blunt cerebrovascular injuries, and as a result, stroke and related death rates in these patients have declined significantly over the past 30 years. These changes are due to the evolution of imaging technology, namely CT-scanning, and its wide availability in hospitals large and small, according to a new study from the University of Tennessee Health Science Center (UTHSC), Memphis.
The researchers found that the percentage of blunt trauma patients diagnosed with blunt cerebrovascular injury (BCVI), a type of severe injury to main vessels that supply blood to the brain, increased six-fold: from 0.33 percent to 2 percent from the beginning of the study period in 1985 to the end in 2015. However, the percentage of these patients who went on to have a stroke due to these injuries declined from 37 percent to 5 percent over the same period, and those who died from BCVI declined from 24 percent to zero in that time. The researchers evaluated 564 patients diagnosed with BCVI from hospital records and the trauma registry at the Elvis Presley Regional Trauma Center, Memphis.
The researchers evaluated results in three separate 10-year eras over which the average age of trauma victims increased from 34 to 43 years. The overall group with BCVI was predominantly male (65 percent) with an average age of 41 years and an average injury severity score (ISS) of 27 (major trauma is defined as an ISS of 15 or greater). However, the study noted that males made up 68 percent of all blunt trauma patients over the 30-year period, indicating that female blunt trauma victims may be predisposed to BCVI. Females were also significantly more likely to be victims of a motor vehicle accident, the most common cause of BCVI, the authors stated.
The researchers noted that before 1990, fewer than 100 cases of BCVI had been reported in the medical literature. Over the last 30 years, however, the study identified three trends that have led to an increase in its diagnosis: the emergence of regional trauma centres; advances in imaging first with digital subtraction angiography and more recently computed tomographic angiography (CTA); and greater awareness of the risk of stroke with vertebral artery injuries and the screening methods that focus on these injuries.
The researchers explained that angiography involves injection of a contrast dye that appears highlighted under radiographic imaging to show tears, ruptures and blockages in the blood vessels. Digital subtraction angiography is more invasive than CTA, which can be done under many widely available CT scanners.
“Clearly the advances in CT-scanning technology that developed since the first CT scanners came out to being able to do CT angiography—which is really a non-invasive form of angiography—have significantly improved diagnosis,” said lead study author Louis J. Magnotti, noting that conventional angiography is still the “gold standard” for diagnosis of BCVI, but that newer generations of CT scanners may in time replace the older technology.
The bottom line of their study, Dr. Magnotti said, is that physicians and other members of the trauma team must constantly re-evaluate their processes and protocols to improve quality of care. “It is important to not get bogged down in managing or treating or diagnosing patients the same way as times change,” he said. “Even though you may have had good results, you should always look to do better.”

American College of Surgeonshttp://tinyurl.com/y9szyk9a

In a significant advance in improving the safety of donor stem cell transplants, a major clinical trial led by researchers at Dana-Farber Cancer Institute and Brigham and Women’s Hospital (BWH) has shown that a novel agent can protect against the most common viral infection that patients face after transplantation.

The results represent a breakthrough in a decade-long effort to identify an effective drug for the prevention of cytomegalovirus (CMV) infection in transplant patients that doesn’t produce side effects that negate the benefit of the drug itself, the study authors said.

The study, which involved 565 adult patients at 67 research centres in 20 countries, compared letermovir to placebo in preventing an active CMV infection following transplant with donor stem cells. The patients, who were undergoing transplant as treatment for blood-related cancers or other disorders, all carried a CMV infection from earlier in life that had been wrestled into dormancy by their immune system. Twenty-four weeks after completing up to 14 weeks of treatment, 61 percent of the patients receiving a placebo had developed a CMV infection serious enough to require treatment or had discontinued the trial. By contrast, only 38 percent of those treated with letermovir developed that level of CMV infection or did not complete the trial.

Unlike other drugs able to forestall active CMV infection in stem cell transplant patients, letermovir did so without producing unacceptable toxicities. Most of the side effects associated with letermovir were tolerable, including mild cases of nausea or vomiting, and some swelling, investigators found. Letermovir also conferred a survival benefit: at the 24-week mark, 15 percent of the placebo patients had died, compared to 10 percent of those receiving letermovir.

‘For the first time, we seem to have a drug that is a true safe and effective preventive for CMV infection in stem cell transplant patients,’ said the study’s lead author, Francisco Marty, MD, an infectious disease specialist at Dana-Farber and BWH. ‘Letermovir will allow many patients to avoid infection, usually with no or mild side effects, and seems to provide a survival benefit in the first six months post-transplant.’

Dana Farber Cancer Institute www.dana-farber.org/Newsroom/News-Releases/new-antiviral-drug-cuts-cytomegalovirus-infection-improves-survival-in-donor-stem-cell-transplant-patients.aspx