geoffrey modest medical blogs

do NOT intensify BP meds at hospital discharge  You forwarded this message on Wed 9/4/2019 7:35 AM G      Geoff A. Modest, M.D. Wed 9/4/2019 7:33 AM Geoff A. Modest, M.D.  A recent article found that intensification of antihypertensives in inpatients led to several adverse outcome (see  htn not intensify meds at hosp discharge jamaintmed2019  in dropbox, or doi:10.1001/jamainternmed.2019.3007).  Details:    --VA study of patients >65yo hospitalized from 2011-2014 for noncardiac conditions, comparing those who had intensification of their antihypertensive meds at hospital discharge (a new or higher dose of meds) with those who did not, in a retrospective observational study  --BP med intensification was defined as >20% increase in dose  --mean age 77; 98% men; 75% white/20% black; B...

A recent NIH study looked at the effect of the Medicare Hospital Readmissions Reduction Program (HRRP) on 30-day readmission rates after hospitalizations for acute myocardial infarction, congestive heart failure, or pneumonia, and in particular looking at whether the previously lowest performing hospitals improved more than the higher performing ones after the introduction of HRRP  (see  hospital readmission aim2016 in dropbox , or doi:10.7326/M16-0185). Details: -- 15,170,008 Medicare patients discharged alive from US acute care hospitals between 2000 and 2013. -- Mean age 79.5, 54% female, 85% white/10% black/4.7% other race, 19% admitted with acute MI/45% CHF/36% pneumonia, 52% discharged to home/18% to home with care/23% to nursing home, average length of stay 6 days, 25% rural hospitals/65% private nonprofit/9% major teaching hospitals, overall observed readmission rate 23%. -- HRRP penalties for 30-day readmission rates were: 0% for the highest perfo...

recent systematic review/meta-analysis of interventions to prevent readmissions for pts with heart failure (see  chf  interventions to decrease readmissions  annals2014  in  dropbox , or Ann Intern Med. 2014;160:774-784). review was funded by Agency for Healthcare Research and Quality ( AHRQ ) background:     --heart failure ( chf ) is leading cause of hospitalizations (and health care utilization) in US     --25% of pts admitted with  chf  are readmitted within 30 days (35% of them readmitted with diagnosis of  chf . rest with renal  dz , pneumonia, etc) results:     --47 trials of diverse interventions to prevent readmission. pts with moderate to severe  chf . mean age 70.     --at 30 days, high intensity home-visiting program (nurse or pharmacist usually) reduced all-cause readmission and combo of that plus death, though low quality of evidence    ...

Agency for Healthcare Research and Quality just came out with draft report on interventions to prevent readmissions for people with heart failure, with a systematic review of the literature through May 2013 (see  http://www.effectivehealthcare.ahrq.gov/ehc/products/510/1738/Heart-Failure-Transition-Care-Draft-131029.pdf  for document). this review included 47 randomized controlled trials, most with patients with moderate to severe heart failure, with mean age in the 70s. the individual reports in the literature have highly mixed results, so this review is a welcome review. the background is that heart failure is a leading cause of hospitalization   and  has a significant mortality with approximately 50% dying within 5 years of diagnosis (30% of Medicare beneficiaries with heart failure die within one year after hospitalization), and up to 25% of patients hospitalized with heart failure are readmitted within 30 days. this systematic review assesse s  several ke...

there have been an array of articles recently on hospital readmissions and length-of-stays, one in the annals and several in the latest JAMA. 1. the question has come up that by our attempts to decrease hospital length-of-stay, are we creating more hospital re-admissions and perhaps increased mortality ?  (see hospital LOS and readmission rate annals 2013  in dropbox).  big study in the VA system o f  129 hosp it als from 1997-2010 with >4M admissions, looking at 2 chronic diseases (chf, copd) and 3 acute dz (acute MI, comm-acq pneumonia, GI hemorrhage). results:     --LOS decreased from 5.44 to 3.98 days overall     --LOS also decreased for the 5 target admissions above, e s p ecially  for acute MI (dec 2.85 days) and pneumonia (2.22 days)     --during this 14 year period, the 30-day readmission rate decreaesd from 16.5% to 13.8%, including in these 5 target diagnoses (greatest reduction ...