PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.
This week’s topics include best treatment for atrial fibrillation in people with heart failure, the consequences of penalties for hospital readmission, pain relief for those with knee osteoarthritis, and comprehensive care for dementia patients.
0:50 Penalties for readmissions
1:59 Significant increase in 30-day post-discharge mortality
2:53 Contributed to increased mortality
3:50 Diverts attention from evidence base
4:18 Managing pain in knee osteoarthritis
5:18 Only two medications helped
6:18 Need better studies
6:30 Comprehensive care for dementia patients
7:30 Kept people out of long-term care facilities
8:30 Prefer to be in community
9:02 Treating atrial fibrillation in folks with heart failure
10:02 Ablation superior in many parameters
11:01 Small number of randomized trials
Elizabeth Tracey: Is the road to hell paved with good intentions?
Rick Lange, MD: Which medications provide long-term pain control in patients with knee osteoarthritis?
Elizabeth: How can a comprehensive program for Alzheimer’s disease help?
Rick: The best treatment of atrial fibrillation in patients with heart failure.
Elizabeth: That’s what we’re talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on December 28th, 2018.
Rick: Happy holidays to our listeners! This is Richard Lange, president of the Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Okay, Rick, with your taunting, I served up one of the studies we’re going to talk about this week. It’s in the Journal of the American Medical Association as “The road to hell is paved with good intentions.” That’s relative to the Hospital Readmissions Reduction Program, which was instituted a while ago, actually, trying to penalize hospitals for readmitting patients within a certain time period. That’s specifically within 30 days of discharge.
They took a look at this really pretty significant study, including 8.3 million hospitalizations for heart failure, acute myocardial infarction, and pneumonia. During that time period, while they were looking at this dataset, there were 270,000-plus deaths within 30 days of discharge for heart failure, 128,000-plus for myocardial infarction, and almost 250,000 for pneumonia. They said, “What’s going on here with regard to discharging people and then their re-hospitalization?” The upshot of the whole thing is that among the Medicare beneficiaries with the Hospital Readmission Reduction Program there was a significant increase in 30-day post-discharge mortality after heart failure and pneumonia hospitalization, but not for MIs. It looks like these programs that are attempting to keep people from coming back to the hospital may, in fact, result in a greater rate of mortality.
Rick: This plan to prevent hospital readmissions imposes a financial penalty on the hospitals, so since 2012, that financial penalty has amounted to $2 billion. The thought being is that if we prevented readmissions, we’d actually improve the quality of care delivered to patients. What you describe is just the opposite. Since we’ve instituted this penalty program, the hospital readmission rate has, in fact, gone down. However, post-discharge mortality has gone up. It wasn’t the people that were being readmitted, it’s the people that never got admitted again.
Other studies have shown that the number of people presenting to the emergency department and being in observation status has increased, but they were never admitted to the hospital. This implies that the Hospital Readmission Prevention Program has actually contributed to increased mortality, not lowered it. This doesn’t show causality, but it certainly infers that.
Elizabeth: I find it interesting that for MI, for heart attack, this was not an association that was seen, and I’m wondering if that’s because — I’m going to call it the robustness — of discharge instructions relative to someone who’s had an MI.
Rick: Previous studies, not this one, but previous studies that have looked at the quality of care imply that it’s not directly related to hospital readmissions, and that’s because at least half of the hospital readmissions aren’t due to the initial diagnosis, but some other cause. For example, someone could have pneumonia and get readmitted with a hip fracture and that would count as a readmission. At least half of the readmissions have nothing to do with the initial diagnosis. Unfortunately, what the Hospital Readmission Program does is it penalizes hospitals that probably need the money the most, especially those safety-net hospitals. Secondly, it diverts our attention from doing evidence-based therapy and instead it invests in a program that doesn’t seem to be helpful, that is preventing hospital readmissions.
Elizabeth: I think those are great points, and I’d still like you to address why you think the association did not appear with MI.
Rick: Elizabeth, I wish I had a good answer for that. I really don’t.
Elizabeth: Okay, more on that, no doubt. Let’s turn to another study in the Journal of the American Medical Association. Gosh, lots of folks have a problem with knee osteoarthritis, and what about managing pain?
Rick: Millions of individuals have knee osteoarthritis, and this is one of the most common reasons why people have orthopedic surgery. We talked before about the fact that physical therapy and use of medications can be just as effective in many individuals, not all, but many that have knee osteoarthritis. Many of those studies were done short-term, in the first weeks or months after treatment, which medications are effective? But this is one of the few studies that looks at what the long-term treatment is, and it’s a meta-analysis. It examined all randomized control trials, so people with knee osteoarthritis that had treatment that lasted for a year or longer. They identified 47 different randomized control trials of over 22,000 patients with all types of medications, analgesics, antioxidants, bone-acting agents such as bisphosphonates, non-steroidal anti-inflammatory medications, even intra-articular injections.
What they determined was the evidence showed when they looked at just knee pain, only two of the medications, glucosamine sulfate and one of the COX-2 inhibitors, celecoxib, actually had long-term effects of reducing pain. After they eliminated studies that they thought weren’t particularly good, the only one that fell out as being helpful was glucosamine sulfate. They also looked at functional status and joint-space narrowing. Again, glucosamine sulfate ended up being particularly helpful.
Elizabeth: We, of course, have talked about glucosamine in the past and reported, also, that it looked like it was beneficial. I guess, though, for me, it calls out the need to do additional long-term studies on this issue because this is not an issue that’s going to go away.
Rick: Elizabeth, I’m glad you brought that up, because even though there were 47 trials, only 13 of them studied a medication more than once. Most of these trials included less than 100 individuals, and many of them had a high degree of bias. This is a topic that deserves much better studies, larger randomized control trials with a larger number of patients. This is not the definitive word, but I call this the preliminary evidence.
Elizabeth: Let’s turn now to JAMA Internal Medicine. This study, I served it up as, gosh, does it help if we take a comprehensive approach to the management of dementia? In this study, that’s exactly what they did. This was a case-controlled study. They took a look at just under 1,100 Medicare fee-for-service beneficiaries in California and compared those with almost 2,200 similar patients with dementia who were not participating in this particular program that was under investigation.
They had a comprehensive dementia care program that those in the second group were privy to, and they were co-managed by nurse practitioners and physicians. They had a structured need assessment of patients and their caregivers, which I think is a really pivotal point. They created and implemented individualized dementia care plans with input from primary care physicians, also with the plans, and referral-to-community organizations. They had advice that was on hand 24 hours a day, 7 days per week.
They said, “Gosh, can we keep these people out of a long-term care facility?” They found out that that comprehensive plan did reduce the number of admissions to long-term care facilities, and it could be either cost-neutral or cost-saving with regard to the care of folks with dementia. I would add, just from my perspective as a chaplain, also seems to me to be a good deal more humane.
Rick: This was a comprehensive dementia care program. It created and implemented very individualized dementia care programs. It monitored and revised the care programs. That sounds like it could be pretty expensive, but when they analyzed it and looked at not only the medical care, but the cost of the program, in fact, it was not more expensive. This shows that for institutions that can provide that comprehensive care it does provide some benefit and is cost neutral to the overall health system.
Elizabeth: As I suggested, it’s also a good deal more humane, at least in my estimation, because when I see people in those facilities, it’s not that the care is not excellent or what have you, but people don’t like to be rooted out of where they’re comfortable. They prefer to be in the community when they’re asked those questions.
Rick: I would focus not only on the patient, but I think it’s also more humane for the caregivers as well. We talked about the stress that they’re under and sometimes they don’t have adequate resources, but this comprehensive-care pattern improves care for the patient and for the caregivers as well. I appreciate the fact you picked this study and how comprehensive it is not only in looking at utilization of care, but the cost of care as well.
Elizabeth: Another problem, just like knee osteoarthritis, that’s only going to expand as time goes on. Let’s turn to the final one, then. That’s in Annals of Internal Medicine, in folks with heart failure and atrial fibrillation, what’s the best treatment?
Rick: Atrial fibrillation, an irregular heart rhythm where the upper chamber doesn’t contract synchronously with the rest of the heart, is associated with stroke and embolism and decompensated heart failure. In fact, heart failure and atrial fibrillation oftentimes occur concomitantly. The question is, in those patients that have heart failure, what’s the best strategy for treating atrial fibrillation? Is it using medications or is catheter ablation of atrial fibrillation, an invasive procedure, more helpful?
This study compared the benefits and harms between catheter ablation and drug therapy in adult patients that had both atrial fibrillation and heart failure. They looked at six different randomized controlled trials that were all published in English journals of patients that had at least six months of follow up, and they compared their outcomes. What they discovered was that catheter ablation was superior to conventional drug therapy in improving all-cause mortality, heart failure hospitalizations, heart function as measured by what’s called the ejection fraction. It improved the functional status measured by the 6-minute walk test, and it also improved quality of life as well, with no statistically significant increase in serious adverse events.
Elizabeth: Now the point I would like you to expand on further is one that we have also reported on, and that is the relative difficulty of identifying exactly where the ablation should take place and the number of times somebody needs to have that done more than once.
Rick: It varies. There are some people that are more suited and respond better than others, and we know what some of those risk factors are. Some of it has to do with age, duration of atrial fibrillation, some of it is the size of the heart. If we were just going to generalize, I’d say that catheter ablation is successful in between 80% to 90% of individuals, although a substantial portion, as many as a third, may need more than one ablation.
This study takes into account really all the randomized control trials, and I’d point out that there’s a relatively small number. There are six that included under 800 patients, and most of these results were driven by one particular trial. This isn’t the definitive word. I think what it does tell us is that catheter ablation is as safe as medications, and it’s probably more effective, but we have four other randomized control trials that are bigger that we’ll have the results in over the next several years.
Elizabeth: That’ll help us out and plus we’ve also reported on techniques for identifying the specific area that requires ablation much more precisely.
Rick: Absolutely, and we have specialized physicians, that is electrophysiologists, that have expertise in this particular area. It’s not something I expect the routine cardiologist or even the patients to understand, but our specialists understand it well.
Elizabeth: On that note, then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: I’m Rick Lange. Y’all listen up and make healthy choices.