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Differences in Symptom Presentation and Hospital Mortality According to Type of Acute Myocardial Infarction
404
Abstracts [John D. Anderson, MD Denver Health Medical Center, Denver, CO]
Comments: In this well-designed, large observational study, an association between nosocomial infection and MOF could not be established in trauma patients. Furthermore, no late peak of MOF was seen. This flies in the face of conventional wisdom and should prompt further investigations to determine if the use of SOPs are effective in obviating the anticipated late peak of MOF.
, IS THE MODIFIED EARLY WARNING SCORE (MEWS) SUPERIOR TO CLINICIAN JUDGMENT IN DETECTING CRITICAL ILLNESS IN THE PRE-HOSPITAL ENVIRONMENT? Fullerton JN, Price CL, Silvery NE, Brace SJ, Perkins GD. Resuscitation 2012;83:557–62. Physiologic track and trigger systems (PTTS) are increasingly common in hospitalized patients to enhance detection of serious illness. The authors of this article investigated whether a similar system could be used in the pre-hospital setting for determining optimal treatment facility destination, priority, and early implementation of key therapies in comparison to clinician assessment. This study was a retrospective observation cohort study conducted over 2 months at an inner-city hospital in the United Kingdom. Eligible patients were $ 16 years of age and had clinical observations recorded by ambulance staff before arrival at the hospital. Exclusions were patients without pre-hospital observations and patients in cardiac arrest. Adverse events were defined as the need for immediate surgery, intensive care unit admission, high-dependency unit, coronary care unit, requirement of medical emergency team attendance, transfer to tertiary center for definitive care (presence of a clinical emergency), cardiac arrest, or death. Correct pre-alerts were when an adverse event occurred, incorrect pre-alerts when one did not. Primary outcome was whether or not a patient suffered an adverse event within 24 h of admission. Individual MEWS scores using blood pressure, heart rate, respiratory rate, temperature, and mental status were calculated for each patient before arrival. Scores were based upon a 0–3 scale, with more points for vital signs further in either a positive or negative direction from the normal value. There were 5170 patients brought to the hospital over the study period; after exclusion, 3057 were included for analysis. Ambulance crews pre-alerted the hospital in 7.3% of cases, and 2.5% had an adverse event. After data extraction, imputation for missing values, and analysis, pre-hospital MEWS scores $ 3 vs. paramedics’ clinical judgment were shown to have higher sensitivity (71% vs. 61%) but lower specificity (76.2% vs. 94%) for detecting critically unwell patients. To limit improper alerts, MEWS score of $ 4 with clinical judgment overriding a negative decision increased sensitivity and specificity to 72.4% and 84.8%. [Matthew Taecker, MD Denver Health Medical Center, Denver, CO]
, IS AGGRESSIVE TREATMENT OF TRAUMATIC BRAIN INJURY COST-EFFECTIVE? Whitmore RG, Thawani JP, Grady S, et al. J Neurosurg 2012;116:1106–13. The purpose of this study was to determine if aggressive treatment of severe traumatic brain injury (TBI) was costeffective compared with less aggressive treatment strategies. The authors created a decision-analytical model to compare costs, outcomes, and cost-effectiveness of three strategies for treating severe TBI: aggressive care, routine care, and comfort care. Aggressive care was defined as following the Brain Trauma Foundation guidelines in at least 50% of cases; ‘‘routine care’’ corresponds to management following the guidelines in fewer than 50% of cases, and ‘‘comfort care’’ involves a single day of aggressive care but without invasive intracranial monitoring or decompressive craniectomy, followed by care on a medical-surgical floor. Glasgow Outcome Scale scores were converted to quality-adjusted life years (QALYs), and estimated direct (acute and long-term medical care) and indirect (loss of productivity) costs were calculated from the perspective of society. Sensitivity analyses employed a two-dimensional Monte Carlo simulation of 1000 trials, each with 1000 patients, then the model was used to estimate these values for patients 40, 60, and 80 years of age. For the average 20-year-old, aggressive care yielded 11.7 ( 6 1.6 [SD]) QALYs, compared with routine care (10.0 6 1.5 QALYs, p < 0.00001). Throughout all ages, aggressive care was significantly more effective, but diminished with age. When all costs were considered, aggressive care was also significantly less costly than routine care ($1,264,000 6 $118,000 vs. $1,361,000 6 $107,000) for the average 20-year-old. Aggressive care was less costly until age 80 years, at which age it cost more than routine care, however, the authors found that aggressive care was likely the more cost-effective approach. Comfort care for severe TBI was associated with poorer outcomes and higher costs for all age groups except 80-year-olds. [Douglas Melzer, MD Denver Health Medical Center, Denver, CO]
Comments: Although PTTS is becoming an increasingly important system to identify serious illness while in the hospital, out-of-hospital feasibility and utilization has yet to be demonstrated. This study was preliminary with only modest improvement in critical illness detection. Further studies are needed to evaluate the utility of PTTS.
Comments: As with all cost-effectiveness studies, the most important determinant of the size of the impact of the intervention is the assumptions made about costs and effects of the intervention itself. Although it is not hard to imagine that the results of this study would be reproducible, it is not a given. Clearly, a randomized trial would be unethical, and so studies like this one are the only way to answer such sticky policy questions.
, DIFFERENCES IN SYMPTOM PRESENTATION AND HOSPITAL MORTALITY ACCORDING TO TYPE OF ACUTE MYOCARDIAL INFARCTION. Canto AJ, Kiefe CI, Goldberg RJ, et al. Am Heart J 2012;163:572–9. Acute myocardial infarction (AMI) is usually associated with chest pain, but not all AMI patients have chest pain. Investigators in this retrospective chart review examined National
The Journal of Emergency Medicine Registry of Myocardial Infarction data from 1994 to 2006, hypothesizing that a substantial portion of AMI patients do not have chest pain. The study enrolled 1,143,513 patients, of whom approximately half were ST-segment elevation myocardial infarction (STEMI) and half were non-ST-segment elevation myocardial infarction (NSTEMI). AMI was defined by elevated cardiac biomarkers, electrocardiographic evidence of AMI or alternative enzymatic, nuclear cardiac imaging, or autopsy evidence of AMI. Chest pain was defined as any chest discomfort, sensation or pressure, or arm, neck, or jaw pain. Of those with STEMI, 27.1% presented without chest pain, and of those with NSTEMI, 43.6% presented without chest pain. AMI patients who presented without chest pain were also more likely to be female, be older in age, and have diabetes, although the single most influential factor for atypical presentation was type of AMI, specifically NSTEMI. A secondary outcome measured was association of AMI patients without chest pain and mortality. STEMI patients without chest pain had 38% higher odds of mortality than those with chest pain, and NSTEMI patients without chest pain had 31% higher odds of mortality than those with pain. Additionally, patients without chest pain were less likely to receive aspirin, other antiplatelet agents, heparin, beta-blockers, and invasive cardiac procedures. These patients also had a longer time to initiation of diagnostic (e.g., electrocardiogram) and therapeutic measures. [John D. Anderson, MD Denver Health Medical Center, Denver, CO] Comments: It has been previously established that AMI can present without typical chest pain symptoms, and that certain populations are more likely to have atypical presentations. This study not only quantifies the extent of this issue, but also highlights the differences in management of patients that present with or without chest pain and the potential effect of this management on mortality. As such, providers must be diligent in both diagnostic and therapeutic management when considering AMI and should approach those at higher risk for atypical presentation with care. , IS 15 DAYS AN APPROPRIATE CUT-OFF AGE FOR CONSIDERING SERIOUS BACTERIAL INFECTION IN THE MANAGEMENT OF FEBRILE INFANTS? Garcia S, Mintegi S, Gomez B, et al. Pediatr Infect Dis J 2012;31:455–8. The goal of this study was to determine whether 15 days is a suitable cut-off age for different approaches to the management of infants with fever. This was a cross-sectional descriptive study of infants 3 months of age with fever without a source (FWS) seen in the Pediatric Emergency Department (PED) of a tertiary teaching hospital during 7 consecutive years (September 2003–August 2010). Infants < 3 months of age with FWS ($ 38 C) were included and data collected were age, sex, temperature, diagnosis, management in PED, and outcome. During the study period, 1575 infants < 3 months of age with FWS were included, of whom 311 (19.7%, 95% confidence interval [CI] 17.7–21.7) were found to have a serious bacterial infection (SBI). The rate of SBI in the patients who were 15–21 days of age was 33.3% (95% CI 23.7–42.9%), similar to that among infants who were 7–14 days of age (31.9%, 95% CI 21.1–42.7%),
405 and higher than among those older than 21 days of age (18.3%, 95% CI 16.3–20.3%). The authors concluded that febrile infants 15–21 days of age had a rate of SBI similar to younger infants and higher than older-age infants, and therefore, it was not appropriate to establish the approach to management of infants with fever based on a cut-off age of 2 weeks. [Douglas Melzer, MD Denver Health Medical Center, Denver, CO] Comments: Although the authors provide evidence to support the dogma of broad work-ups for FWS in the very young, it should be noted that the vast majority of these patients defined as having SBI actually had urinary tract infections (UTIs) and almost none had associated bacteremia. The real question then becomes does one need to do the full work-up if a UTI has been diagnosed? This question remains unanswered by this study. , HOSPITALIZATIONS, COSTS, AND OUTCOMES OF SEVERE SEPSIS IN THE UNITED STATES 2003 TO 2007. Lagu T, Rothberg MB, Shieh M-S, Pekow PS, Steingrub JS, Lindenauer PK. Crit Care Med 2012;40:754–61. Severe sepsis is a leading cause of in-hospital mortality in the United States. Researchers in this study examined changes in the incidence, hospitalizations, outcomes, and cost for severe and non-severe sepsis from 2003 to 2007. They focused on organ-specific dysfunctions, cost of care, and the impact of new International Classification of Disease (ICD, Ninth Revision) codes for severe sepsis. This study used data from the Nationwide Inpatient Sample, the largest all-payer, publicly available, national hospital database with 5–8 million discharges per year. Included patients were aged $ 18 years and had a primary or secondary ICD diagnosis of severe sepsis. Primary outcomes were: changes in population incidence, number of hospitalizations, length of stay, in-hospital mortality, and cost of care. Secondary outcomes were: demographic changes of patients with severe sepsis, number and type of organ dysfunction, and discharge disposition. Analysis was conducted using National Census Bureau data to calculate age- and sex-adjusted population incidences and mortality. Indirect standardization was used to adjust in-hospital mortality for various demographics with logistical regression models to predict in-hospital mortality, and linear trend analysis to observe rates and trends over time and amongst subgroups. Hospital costs based upon (where attainable) cost-to-charge ratios were calculated and group averaged to determine likely cost of residual hospitals, then corrected for inflation using the 2007 Consumer Price Index. Costs using arithmetic and weighted geometric means were tabulated and adjusted to account for missing data and then trends were assessed using linear regression. Researchers identified 161,140,024 hospitalizations: 4,799,565 for sepsis, and 2,899,917 for severe sepsis, and a 71% increase from 2003 to 2007. Among severe sepsis, women were older than men (60 vs. 57 years), Whites older than Blacks or Hispanics (73 vs. 63 and 64 years), and the proportion of severe sepsis with at least three-organ system involvement increased (1.19–1.51 times, with particular increase in renal and cardiovascular subcategories), whereas incidences without organ dysfunction
Abstracts [John D. Anderson, MD Denver Health Medical Center, Denver, CO]
Comments: In this well-designed, large observational study, an association between nosocomial infection and MOF could not be established in trauma patients. Furthermore, no late peak of MOF was seen. This flies in the face of conventional wisdom and should prompt further investigations to determine if the use of SOPs are effective in obviating the anticipated late peak of MOF.
, IS THE MODIFIED EARLY WARNING SCORE (MEWS) SUPERIOR TO CLINICIAN JUDGMENT IN DETECTING CRITICAL ILLNESS IN THE PRE-HOSPITAL ENVIRONMENT? Fullerton JN, Price CL, Silvery NE, Brace SJ, Perkins GD. Resuscitation 2012;83:557–62. Physiologic track and trigger systems (PTTS) are increasingly common in hospitalized patients to enhance detection of serious illness. The authors of this article investigated whether a similar system could be used in the pre-hospital setting for determining optimal treatment facility destination, priority, and early implementation of key therapies in comparison to clinician assessment. This study was a retrospective observation cohort study conducted over 2 months at an inner-city hospital in the United Kingdom. Eligible patients were $ 16 years of age and had clinical observations recorded by ambulance staff before arrival at the hospital. Exclusions were patients without pre-hospital observations and patients in cardiac arrest. Adverse events were defined as the need for immediate surgery, intensive care unit admission, high-dependency unit, coronary care unit, requirement of medical emergency team attendance, transfer to tertiary center for definitive care (presence of a clinical emergency), cardiac arrest, or death. Correct pre-alerts were when an adverse event occurred, incorrect pre-alerts when one did not. Primary outcome was whether or not a patient suffered an adverse event within 24 h of admission. Individual MEWS scores using blood pressure, heart rate, respiratory rate, temperature, and mental status were calculated for each patient before arrival. Scores were based upon a 0–3 scale, with more points for vital signs further in either a positive or negative direction from the normal value. There were 5170 patients brought to the hospital over the study period; after exclusion, 3057 were included for analysis. Ambulance crews pre-alerted the hospital in 7.3% of cases, and 2.5% had an adverse event. After data extraction, imputation for missing values, and analysis, pre-hospital MEWS scores $ 3 vs. paramedics’ clinical judgment were shown to have higher sensitivity (71% vs. 61%) but lower specificity (76.2% vs. 94%) for detecting critically unwell patients. To limit improper alerts, MEWS score of $ 4 with clinical judgment overriding a negative decision increased sensitivity and specificity to 72.4% and 84.8%. [Matthew Taecker, MD Denver Health Medical Center, Denver, CO]
, IS AGGRESSIVE TREATMENT OF TRAUMATIC BRAIN INJURY COST-EFFECTIVE? Whitmore RG, Thawani JP, Grady S, et al. J Neurosurg 2012;116:1106–13. The purpose of this study was to determine if aggressive treatment of severe traumatic brain injury (TBI) was costeffective compared with less aggressive treatment strategies. The authors created a decision-analytical model to compare costs, outcomes, and cost-effectiveness of three strategies for treating severe TBI: aggressive care, routine care, and comfort care. Aggressive care was defined as following the Brain Trauma Foundation guidelines in at least 50% of cases; ‘‘routine care’’ corresponds to management following the guidelines in fewer than 50% of cases, and ‘‘comfort care’’ involves a single day of aggressive care but without invasive intracranial monitoring or decompressive craniectomy, followed by care on a medical-surgical floor. Glasgow Outcome Scale scores were converted to quality-adjusted life years (QALYs), and estimated direct (acute and long-term medical care) and indirect (loss of productivity) costs were calculated from the perspective of society. Sensitivity analyses employed a two-dimensional Monte Carlo simulation of 1000 trials, each with 1000 patients, then the model was used to estimate these values for patients 40, 60, and 80 years of age. For the average 20-year-old, aggressive care yielded 11.7 ( 6 1.6 [SD]) QALYs, compared with routine care (10.0 6 1.5 QALYs, p < 0.00001). Throughout all ages, aggressive care was significantly more effective, but diminished with age. When all costs were considered, aggressive care was also significantly less costly than routine care ($1,264,000 6 $118,000 vs. $1,361,000 6 $107,000) for the average 20-year-old. Aggressive care was less costly until age 80 years, at which age it cost more than routine care, however, the authors found that aggressive care was likely the more cost-effective approach. Comfort care for severe TBI was associated with poorer outcomes and higher costs for all age groups except 80-year-olds. [Douglas Melzer, MD Denver Health Medical Center, Denver, CO]
Comments: Although PTTS is becoming an increasingly important system to identify serious illness while in the hospital, out-of-hospital feasibility and utilization has yet to be demonstrated. This study was preliminary with only modest improvement in critical illness detection. Further studies are needed to evaluate the utility of PTTS.
Comments: As with all cost-effectiveness studies, the most important determinant of the size of the impact of the intervention is the assumptions made about costs and effects of the intervention itself. Although it is not hard to imagine that the results of this study would be reproducible, it is not a given. Clearly, a randomized trial would be unethical, and so studies like this one are the only way to answer such sticky policy questions.
, DIFFERENCES IN SYMPTOM PRESENTATION AND HOSPITAL MORTALITY ACCORDING TO TYPE OF ACUTE MYOCARDIAL INFARCTION. Canto AJ, Kiefe CI, Goldberg RJ, et al. Am Heart J 2012;163:572–9. Acute myocardial infarction (AMI) is usually associated with chest pain, but not all AMI patients have chest pain. Investigators in this retrospective chart review examined National
The Journal of Emergency Medicine Registry of Myocardial Infarction data from 1994 to 2006, hypothesizing that a substantial portion of AMI patients do not have chest pain. The study enrolled 1,143,513 patients, of whom approximately half were ST-segment elevation myocardial infarction (STEMI) and half were non-ST-segment elevation myocardial infarction (NSTEMI). AMI was defined by elevated cardiac biomarkers, electrocardiographic evidence of AMI or alternative enzymatic, nuclear cardiac imaging, or autopsy evidence of AMI. Chest pain was defined as any chest discomfort, sensation or pressure, or arm, neck, or jaw pain. Of those with STEMI, 27.1% presented without chest pain, and of those with NSTEMI, 43.6% presented without chest pain. AMI patients who presented without chest pain were also more likely to be female, be older in age, and have diabetes, although the single most influential factor for atypical presentation was type of AMI, specifically NSTEMI. A secondary outcome measured was association of AMI patients without chest pain and mortality. STEMI patients without chest pain had 38% higher odds of mortality than those with chest pain, and NSTEMI patients without chest pain had 31% higher odds of mortality than those with pain. Additionally, patients without chest pain were less likely to receive aspirin, other antiplatelet agents, heparin, beta-blockers, and invasive cardiac procedures. These patients also had a longer time to initiation of diagnostic (e.g., electrocardiogram) and therapeutic measures. [John D. Anderson, MD Denver Health Medical Center, Denver, CO] Comments: It has been previously established that AMI can present without typical chest pain symptoms, and that certain populations are more likely to have atypical presentations. This study not only quantifies the extent of this issue, but also highlights the differences in management of patients that present with or without chest pain and the potential effect of this management on mortality. As such, providers must be diligent in both diagnostic and therapeutic management when considering AMI and should approach those at higher risk for atypical presentation with care. , IS 15 DAYS AN APPROPRIATE CUT-OFF AGE FOR CONSIDERING SERIOUS BACTERIAL INFECTION IN THE MANAGEMENT OF FEBRILE INFANTS? Garcia S, Mintegi S, Gomez B, et al. Pediatr Infect Dis J 2012;31:455–8. The goal of this study was to determine whether 15 days is a suitable cut-off age for different approaches to the management of infants with fever. This was a cross-sectional descriptive study of infants 3 months of age with fever without a source (FWS) seen in the Pediatric Emergency Department (PED) of a tertiary teaching hospital during 7 consecutive years (September 2003–August 2010). Infants < 3 months of age with FWS ($ 38 C) were included and data collected were age, sex, temperature, diagnosis, management in PED, and outcome. During the study period, 1575 infants < 3 months of age with FWS were included, of whom 311 (19.7%, 95% confidence interval [CI] 17.7–21.7) were found to have a serious bacterial infection (SBI). The rate of SBI in the patients who were 15–21 days of age was 33.3% (95% CI 23.7–42.9%), similar to that among infants who were 7–14 days of age (31.9%, 95% CI 21.1–42.7%),
405 and higher than among those older than 21 days of age (18.3%, 95% CI 16.3–20.3%). The authors concluded that febrile infants 15–21 days of age had a rate of SBI similar to younger infants and higher than older-age infants, and therefore, it was not appropriate to establish the approach to management of infants with fever based on a cut-off age of 2 weeks. [Douglas Melzer, MD Denver Health Medical Center, Denver, CO] Comments: Although the authors provide evidence to support the dogma of broad work-ups for FWS in the very young, it should be noted that the vast majority of these patients defined as having SBI actually had urinary tract infections (UTIs) and almost none had associated bacteremia. The real question then becomes does one need to do the full work-up if a UTI has been diagnosed? This question remains unanswered by this study. , HOSPITALIZATIONS, COSTS, AND OUTCOMES OF SEVERE SEPSIS IN THE UNITED STATES 2003 TO 2007. Lagu T, Rothberg MB, Shieh M-S, Pekow PS, Steingrub JS, Lindenauer PK. Crit Care Med 2012;40:754–61. Severe sepsis is a leading cause of in-hospital mortality in the United States. Researchers in this study examined changes in the incidence, hospitalizations, outcomes, and cost for severe and non-severe sepsis from 2003 to 2007. They focused on organ-specific dysfunctions, cost of care, and the impact of new International Classification of Disease (ICD, Ninth Revision) codes for severe sepsis. This study used data from the Nationwide Inpatient Sample, the largest all-payer, publicly available, national hospital database with 5–8 million discharges per year. Included patients were aged $ 18 years and had a primary or secondary ICD diagnosis of severe sepsis. Primary outcomes were: changes in population incidence, number of hospitalizations, length of stay, in-hospital mortality, and cost of care. Secondary outcomes were: demographic changes of patients with severe sepsis, number and type of organ dysfunction, and discharge disposition. Analysis was conducted using National Census Bureau data to calculate age- and sex-adjusted population incidences and mortality. Indirect standardization was used to adjust in-hospital mortality for various demographics with logistical regression models to predict in-hospital mortality, and linear trend analysis to observe rates and trends over time and amongst subgroups. Hospital costs based upon (where attainable) cost-to-charge ratios were calculated and group averaged to determine likely cost of residual hospitals, then corrected for inflation using the 2007 Consumer Price Index. Costs using arithmetic and weighted geometric means were tabulated and adjusted to account for missing data and then trends were assessed using linear regression. Researchers identified 161,140,024 hospitalizations: 4,799,565 for sepsis, and 2,899,917 for severe sepsis, and a 71% increase from 2003 to 2007. Among severe sepsis, women were older than men (60 vs. 57 years), Whites older than Blacks or Hispanics (73 vs. 63 and 64 years), and the proportion of severe sepsis with at least three-organ system involvement increased (1.19–1.51 times, with particular increase in renal and cardiovascular subcategories), whereas incidences without organ dysfunction