Patient and Hospital Characteristics Associated with Inappropriate Percutaneous Coronary Interventions

878 averages below 54 mm until day 1. There was variation in these biomarkers between all patients with no identifiable trend during the bleeding period. The average FFP:PRBC ratio was 0.4 for the 0–4 units PRBCs, 0.9 for patients receiving 5–8 units PRBCs, 0.7 for patients receiving 9–12 units PRBCs, and 0.7 at hour 12. The authors concluded that HR does not correct hypoperfusion or coagulopathy based on the abnormal values that were measured during the resuscitations and no correction to normal in the laboratory values until day 1 after hemorrhage control. FFP:PRBC ratios were > 1:2 and did not improve coagulopathy. Overall tissue perfusion and coagulopathy did not improve until hemorrhage control was achieved. A significant limitation of this study was that blood samples were not collected after more than 12 units PRBCs were given and therefore, could not be trended and included in the analysis. [Julia Dixon, MD Denver Health Medical Center, Denver, CO] Comment: The authors of this study suggest that HR does not actually lead to improved tissue perfusion or improve coagulopathies in trauma patients. There are several limitations to this study, including a lack of discussion about the patients that died and using the last transfusion as a surrogate time of hemorrhage control. The overall inclusion is intuitive, massive hemorrhage causes coagulopathy and poor tissue perfusion, and these will not improve until the hemorrhage is controlled. , EFFECTIVE REDUCTION OF BLOOD PRODUCT USE IN A COMMUNITY TEACHING HOSPITAL: WHEN LESS IS MORE. Politsmakher A, Doddapaneni V, Seeratan R, et al. Am J Med 2013;126:894–902. As transfusion of blood products is not a benign intervention and their supply is limited, culling inappropriate transfusions is appropriate. This article reports the transfusion usage at a single institution in the year before (Year 0) and the subsequent 2 years (Years 1 and 2) after implementation of a protocol and monitoring program that restricted the ordering of blood products. After initiation of the program, when a provider at New York Methodist Hospital ordered a transfusion of blood products, blood bank technologists could reject requests for products that did not meet the protocol. If the ordering physician felt it was necessary to transfuse products in a manner that did not fit the protocol, they could appeal to an experienced departmental reviewer who could then approve the transfusion if deemed appropriate. In comparison to Year 0, there was a 33.2% and 38.1% decrease in the total number of transfusions between Year 1 and Year 2, respectively. Decreases were made in the number of transfusions of packed red blood cells, platelets, fresh frozen plasma, and cryoprecipitate. This decrease in transfusions was responsible for a 28.6% reduction in transfusion complications, as well as a savings of over two million dollars in cost of blood products. The authors conclude that successful implementation of an evidence-based protocol and monitoring system can successfully reduce the number of unnecessary blood product transfusions. This leads to greater patient safety as well as a significant reduction in hospital expenses. [David Otten, MD Denver Health Medical Center, Denver, CO]

Abstracts Comment: This article serves as a reminder that there is evidence that we as clinicians can use to guide our use of blood product transfusion. Implementation of a protocol similar to the one presented in this article may help limit unnecessary transfusions, ultimately improving patient care and reducing hospital costs. , PATIENT AND HOSPITAL CHARACTERISTICS ASSOCIATED WITH INAPPROPRIATE PERCUTANEOUS CORONARY INTERVENTIONS. Chan PS, Rao SV, Bhatt DL, et al. J Am Coll Cardiol 2013;62:2274–81. Previous studies have found that black people, women, and those without health insurance were less likely to undergo nonemergent percutaneous coronary intervention (PCI) than white people, men, and those with private health insurance. This study sought to investigate whether these differences were due to underuse in the former population or overuse in the latter. The authors of this study retrospectively examined the PCI data submitted to the National Cardiovascular CathPCI Registry between July 2009 and March 2011. They identified 211,254 nonacute PCIs performed in this time period. The appropriateness of these PCIs was assessed by comparing them to the Appropriate Use Criteria previously developed by national cardiovascular societies. Of the 211,254 nonacute PCIs, 25,749 (12.2%) were classified as inappropriate. They found that men (adjusted odds ratio [OR] 1.08) and Whites (OR 1.09) were more likely to undergo inappropriate PCI (p < 0.001) than women and non-Whites, respectively. Compared with patients with private health insurance, those with Medicare (OR 0.85), other public insurance (OR 0.78), or no insurance (OR 0.56) were less likely to undergo inappropriate PCI (p < 0.001). The authors conclude that one in eight nonacute PCIs were classified as inappropriate, and these are most likely to be performed in men, Whites, and those with private insurance. They also point out that there may still be underuse of appropriate treatment in Blacks, women, and patients with public or no health insurance, which was not investigated in this study. [David Otten, MD Denver Health Medical Center, Denver, CO] Comment: This study emphasizes the importance of recognizing that although disparities in care still exist between traditional privileged groups and vulnerable groups in many health care interventions, including percutaneous coronary intervention, overuse in the privileged group may at least partially contribute to this difference. Inappropriate procedures add to health care costs and may put patients at risk of unnecessary complications. , ELEVATED CARDIAC TROPONIN T LEVELS IN CRITICALLY ILL PATIENTS WITH SEPSIS. Vasile VC, Chai HS, Abdeldayem D, et al. Am J Med 2013;126:1114–21. Prior studies have shown that troponin elevations provide prognostic information in critically ill patients. The aim of this study was to evaluate for an association between cardiac troponin T elevations in patients with sepsis and in-hospital, short-term, and long-term mortality. The investigators retrospectively examined the Acute Physiology and Chronic Health