News Briefs
News Briefs
Albumin may increase mortality, study finds
Human albumin is often given to ICU patients with life-threatening hypovolemia because its high osmotic pressure will help retain fluid in the patient’s vascular system. A recent British review of 30 trials (1,400 patients in all) shows, however, that its administration increases mortality.1 There were on average six extra deaths for every 100 patients treated with albumin. The reasons are unclear, but the investigators propose these possibilities:
• Pulmonary edema can occur suddenly due to rapid volume expansion with albumin, even in hemorrhagic shock.
• The capillaries of seriously ill patients often become more permeable to albumin, and the addition may worsen interstitial edema.
• Albumin has anti-hemostatic and platelet-lowering properties and may increase blood loss in postsurgical and trauma patients.
Reference
1. Cochrane Injuries Group Reviewers. Human albumin administration in critically ill patients: Systematic review of randomized controlled trials. BMJ 1998; 317:235-240.
Day carve-outs’ move east
If you live and work on the East Coast, you may soon see managed care companies crack down on what they consider long lengths of stay in a new way: by refusing to pay for avoidable days, such as that first day or evening when the patient has a shower, a complete blood count, a urinalysis, and a chest X-ray. All of those could be done in a less acute setting, explains Joel Mattison, MD, physician advisor for St. Joseph’s Hospital in Tampa, FL.
While insurers in California have been carving out days for years, the day carve-outs’ are now affecting New York hospitals, according to an Oct. 19, 1999, New York Times report. Three years ago, hospitals in New York state received reimbursement based on diagnosis, not on the number of days a patient spent in the hospital. Day carve-outs accounted for only about 5% a year ago, but over the past nine months, they have accounted for up to a third of days submitted. In most cases, insurers will deny payment for the last night of a patient stay, but the practice also can apply to one or more mid-stay days if the insurers "deem that the time was spent inefficiently," according to the report.
Because the costs from denied days cannot by law be transferred to patients, this new tactic can put a paperwork burden on you as well as cut into hospital profits. One "avoidable" day can represent a loss of income for the hospital that is greater than the current Medicaid per diem of $812, says Mattison. The New York Times report states that the Greater New York Hospital Association has asked the state Attorney General’s office to investigate the carve-out practice.
For more information, contact Joel Mattison, MD, physician advisor, Department of Utilization Man age ment and Quality Assurance, St. Joseph’s Hospi tal, Tampa, FL. Telephone: (813) 870-4933. E-mail: [email protected].
Amputation rates rising among older Americans
Older Americans with advanced low-extremity vascular disease are at increased risk of leg or foot amputation, reports a recent study out of Northwestern University in Evanston, IL.1
According to the investigators, the increase is the result of three factors: prevalence of diabetes, hospitals’ declining capacity to perform lower-extremity bypass surgery and angioplasty, and increased longevity of patients with cardiovascular disease. The team looked at rates of amputation procedures between 1979 and 1996 and found that rising rates at the beginning of the study period were reversed following introduction in the early 1980s of procedures for dilating or bypassing blocked leg arteries. By the mid-1990s, however, the trend began rising again. By 1996 the combined rates for above- and below-knee amputations were 11% higher than they had been in 1979.
Reference
1. Feinglass J, Brown JL, LoSasso A, et al. Rates of lower extremity amputation and arterial reconstruction in the United States. J Am Publ Health Assoc 1999; 89:1222-1227.
Guidelines not guiding as well as hoped
Patients are not receiving the care recommended in clinical guidelines, according to a recent nationwide study conducted by The Medstat Group, a division of Thomson Health care in Ann Arbor, MI. Investigators compared care actually received to care recommended for individuals with asthma, diabetes, and heart failure. Results revealed a significant gap between what is recommended by leading health care organizations and what actually occurs.
Nearly 16,000 diabetics were followed. Only 29% received an annual eye exam and only 46% received an annual total cholesterol test, both of which are recommended by the Alexandria, VA-based American Diabetes Association. Those rates are significantly below expectations. "While we might not expect 100% of patients to receive the care recommended, we must certainly expect most patients to receive it," says Louis H. Diamond, MD, vice president and medical director at The Medstat Group.
The study also showed that care delivered to individuals with heart failure varies significantly compared to what is recommended:
• Of nearly 4,000 heart failure patients, only 40% received an echocardiography within three months of their initial diagnosis, despite its recommendation by the Agency for Health Care Policy and Research.
• Of about 2,500 heart failure patients, only 46% received a chest X-ray — recommended by the American Board of Family Practice — during the 12-month period following diagnosis.
• In addition, a review of about 6,500 asthma cases showed that only 27% received an inhaled anti-inflammatory drug as recommended by the National Heart, Lung and Blood Institute.
Perinatal ZDV: No silver bullet for HIV infants
Five years ago, investigators in the ACTG 076 trial reported in the New England Journal of Medicine that perinatal zidovudine (ZDV) treatment of HIV-infected pregnant women reduced transmission of HIV to their infants from 22.6% to 7.6%. The women received ZDV or placebo during pregnancy and labor, and their infants received ZDV or placebo for six weeks. The protocol was implemented nationally, and there was a major decline in childhood AIDS.
A new report has been published by investigators from New Jersey Medical School in Newark, NJ, about the infants who became infected while they and their mothers received ZDV preventive therapy or placebo in the ACTG 076 trial.1 The researchers set out to describe the effect of ZDV on the course of disease. There were 14 in the treatment group and 43 in the placebo group. Median birth weights, gestational age, and maternal viral load at delivery were similar in each group. The investigators followed the babies for up to age 78 weeks or death. They assessed the development of genotypic ZDV resistance among the infants in the treatment group.
Progression of HIV disease did not differ significantly between the two groups. Both had the same proportion of viral isolates resistant to ZDV. The perinatal ZDV did not appear to affect the course of infection; it failed to have a major effect on rapid progression of disease, timing of transmission, and viral replication in HIV-infected infants. When the ZDV regimen failed to prevent maternal-infant transmission of HIV, resistance to ZDV did not develop during study treatment. The investigators report, "Our study supports the safety of zidovudine use in pregnancy and in the newborn period but demonstrates the continued need for more potent antiretroviral treatment of the infected infant."
Reference
1. McSherry GD, Shapiro DE, Coombs RW, et al. The effects of zidovudine in the subset of infants infected with human immunodeficiency virus type-1. J Pediatr 1999; 134: 717-724.
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