Patients with in-hospital cardiac arrest during nights and weekends may have lower survival rates
According to a study published in the Journal of the American Medical Association, patients who have an in-hospital cardiac arrest during the day or evening on weekdays have a substantially higher rate of survival to discharge than hospitalized patients who experience a cardiac arrest event during the night or weekend.
Researchers analyzed data on 86,748 adult patients who experienced in-hospital cardiac arrest events at 507 healthcare facilities between January 2000 and February 2007 and evaluated the cardiac arrest events by time of day and day of the week. The researchers defined day/evening as 7 a.m. to 10:59 p.m., night as 11 p.m. to 6:59 a.m., and weekend as 11 p.m. on Friday to 6:59 a.m. on Monday.
With cardiac arrest events that took place during the night compared with the day/evening, patients had substantially lower rates of survival to discharge (14.7% versus 19.8%), return of spontaneous circulation for longer than 20 minutes (44.7% versus 51.1%), survival at 24 hours (28.1% versus 35.4%) and favorable neurological outcomes (11.0% versus 15.2%). Although survival to discharge at night was similar during the week and weekends (14.6% and 14.8%, respectively), survival during the day/evening on weekdays was higher than on weekends (20.6% versus 17.4%).
According to the researchers, the data suggest the need to focus on night and weekend hospital-wide resuscitation system processes of care that can potentially improve patient safety and survival after an in-hospital cardiac arrest event.
Survival rates among Level One trauma centers may differ
Level One trauma centers treating patient with similar injuries may have significantly different survival rates, according to a study published in the Archives of Surgery. Researchers analyzed data from 211,479 patients admitted to 47 Level One trauma centers between 1999 and 2003. They divided the patients into three groups based on the severity of their injuries and calculated the average percentage of patients who survived at all trauma centers; the researchers then compared this average to the survival rates for individual centers.
Survival rates for mild injuries were significantly worse at 11% of the trauma centers studied compared with the remainder of the trauma centers, and these outcome disparities worsened with increasing severity of injuries, with 15% and 21% of centers having significantly worse outcome rates for patients with moderate and severe injuries, respectively. In addition, these disparities in outcomes persisted in subgroups of patients with head injuries, patients sustaining penetrating injuries and patients 55 years of age and older.
The researchers hypothesize that the verification process for a facility becoming a Level One trauma center may not specify all the resources needed to provide optimal care or that having all the necessary resources does not ensure that they will be deployed adequately.
New rule proposed to combine HPSAs and MUPs
The Health Resources and Services Administration (HRSA) at the U.S. Department of Health and Human Services has proposed a new rule to consolidate the criteria for designating health professional shortage areas (HPSAs) and medically underserved populations (MUPs) into a single new methodology called the Index of Primary Care Underservice.
Currently, the MUP designation is primarily used to determine whether health centers, which are required to serve medically underserved populations, are eligible to receive federal grants. The National Health Service Corps uses the HPSA designation to assign clinicians who must serve in areas with shortages of health professionals, and the Centers for Medicare and Medicaid Services (CMS) uses HPSA designations to determine if a facility qualifies as a Rural Health Clinic, which results in more refined calculations of determining Medicare and Medicaid reimbursement.
The proposed rule will provide CMS and HRSA with a single measurement for identifying underserved areas and populations. In addition, it will help create a simpler system for those who seek designation as an HPSA or MUP. The proposed rule also will incorporate better measures of health status and access; minimize unnecessary disruption; and improve identification of new, currently undesignated areas of need and currently designated areas no longer in need.
The proposed rule is open for public comment through April 29, 2008.
United States, Mexico sign memorandum on cooperation in health matters
U.S. Department of Health and Human Services Secretary Michael O. Leavitt and Secretary of Health of the United Mexican States Dr. José Angel Córdova signed a memorandum of understanding on March 4 that will strengthen cross-border cooperation between the United States and Mexico to address public-health, medical and scientific issues.
The memorandum includes a focus on collaborative efforts to address public health emergency preparedness and response; the health concerns of vulnerable groups; training; disease prevention and health promotion; and the detection, surveillance and reporting of infectious and chronic diseases. This document updates a memorandum of understanding that was signed in 1996 and was revised in 2001.
Healthcare quality improves only marginally, but some disparities are decreasing
According to two reports from the Agency for Healthcare Research and Quality, the quality of healthcare improved an average of only 2.3% a year between 1994 and 2005, a decrease from the 3.1% average annual improvement rate previously reported for 1994 through 2004. Although the reports highlighted some notable gains in healthcare quality, such as improvements in the care of heart disease patients, measures of patient safety, including postoperative infections, showed an annual improvement of only 1% between 1994 and 2005. Healthcare expenditures, however, increased by a 6.7% average annual rate during the same period, indicating a need to improve the value Americans are getting for their healthcare dollars.
The reports also showed that although healthcare disparities according to race, ethnicity and income still exist, some of these disparities decreased between 2000-2001 and 2004-2005. Those disparities that decreased significantly or were eliminated included rates of Hispanics getting delayed care or no care for an illness and black children between 19 and 35 months receiving all recommended vaccines. Many of the largest disparities, however, still remain, including a 3.8 times greater likelihood that black children will be hospitalized for asthma compared to white children and a 3.5 times greater likelihood of new AIDS cases among Hispanics compared to whites.
Patients with COPD may have higher survival after transplantation of both lungs
Younger patients with end stage chronic obstructive pulmonary disease (COPD) may have longer survival after undergoing transplantation of both lungs rather than only one lung, according to a study published in the Lancet. Although bilateral lung transplantation preceded single lung transplantation as a treatment for COPD, single lung transplantation became the more common procedure after it was shown to be feasible in 1988.
Researchers analyzed survival for 3,525 COPD patients who underwent bilateral lung transplantation and 6,358 COPD patients who received single lung transplantations. The researchers found that, overall, survival after bilateral lung transplantation was significantly higher at 6.41 years compared with the 4.59 year survival rate for single lung transplantation, though the survival benefit was largely limited to patients younger than 60 years of age. The year of the procedure also significantly affected median survival after lung transplantation, with patients treated before and after 1998 having median survival rates of 4.5 and 5.3 years, respectively.
In addition, the results showed that bilateral lung transplantation has again become the more common procedure for COPD, with the proportion of transplantations involving both lungs rising from 21.6% in 1993 to 56.2% in 2006. Although the researchers assert that bilateral lung transplantation should be preferred to single lung transplantation for patients younger than 60, they note that this practice is likely to increase the shortage of lung donors and therefore reduce the number of COPD patients who undergo lung transplantation.
GERD surgery may provide long-term improvement
A study published in the American Journal of Gastroenterology shows that patients with gastroesophageal reflux disease (GERD) who undergo antireflux surgery may experience long-term improvement and resolution of symptoms. Previous studies have shown that antireflux surgery provides excellent control of GERD symptoms in the short term for 85% to 95% of patients.
In 2004, researchers contacted 288 patients who had undergone antireflux surgery between September 1993 and September 1999; the median follow-up period was 69 months. The researchers found that heartburn, the most common symptom of GERD, had improved in 90% of patients and had resolved in 67%, regurgitation was improved in 92% of patients and resolved in 70%, and dysphagia also improved and resolved in the majority of patients. Although hoarseness and cough were improved in 69% of patients each, most patients did not experience resolution of these symptoms. Long-term resolution of GERD symptoms was most likely in patients who were younger, male and did not have dysphagia at the outset.
Side effects after surgery included 2% of patients developing dysphagia, which they did not have before surgery; 11% developing new or increased diarrhea; and 9% experiencing bloating. In addition, 41% of patients reported that they continued to take antacid medications and 3% of patients required a second surgical procedure.
MICR may improve survival rates for people experiencing cardiac arrest
According to a study in the Journal of the American Medical Association, individuals who experience a cardiac arrest have a higher survival rate if they receive minimally interrupted cardiac resuscitation (MICR) compared with standard measures of treatment. Current standards call for people with cardiac arrest to receive an electric shock followed by periodic chest compression; MICR, on the other hand, emphasizes near-constant chest compression, with patients receiving chest compressions both before and after an electric shock is administered, as well as a dose of epinephrine.
Researchers analyzed data on 2,460 individuals who experienced a cardiac arrest outside of the hospital in two Arizona cities. Of these individuals, 1,799 were treated before emergency personnel were trained in MICR, and only 69 of these patients survived. In contrast, 60 of the 661 cardiac arrest patients who received MICR survived. In addition, in a subgroup of patients who experienced both cardiac arrest and ventricular fibrillation, survival before implementation of MICR procedures was approximately 12%, but survival after implementation was 28.4%.
The researchers assert that the blood flow produced by standard chest compression techniques simply do not provide sufficient blood to the heart and brain compared with MICR. In addition, unlike many new treatment modalities, implementing the MICR technique does not involve high costs for new technology, though the effort needed to train people in the new technique should not be underestimated.
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