Embargoed news from Annals of Internal Medicine
Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
1. Adherence to CMS SEP-1 measures found to have variable effects on patient outcomes
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A longitudinal study found that adherence to the Medicare Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) had variable effects on sepsis treatment and patient outcomes in its current iteration, which requires that a patient receive all measure components for their treatment to be considered compliant. Policymakers could consider revisions to the measure that simplify the number of components of SEP-1 or restrict its application to a smaller number of patients who may be more likely to benefit. The findings are published in Annals of Internal Medicine.
The Centers for Medicare & Medicaid Services (CMS) implemented SEP-1 in 2015, requiring hospitals to collect and report data on their adherence to a multicomponent sepsis treatment bundle, including blood cultures, early antibiotics, serial lactate measurement, intravenous (IV) fluids, vasopressors for refractory hypotension, and documentation of a patient’s response to treatment. To be considered compliant, hospitals must include all treatments in the bundle. Whether or not SEP-1 improves patient outcomes is not known.
Researchers from the University of Pittsburgh School of Medicine studied electronic health record data for 54,225 patient encounters between January 2013 and December 2017 for adults with sepsis who were hospitalized through the emergency department to evaluate the effect of SEP-1 on treatment patterns and patient outcomes. They found that 2 years after its implementation, SEP-1 was associated with variable changes in process measures, with the greatest effect being an increase in lactate measurement within 3 hours of sepsis onset. There were small increases in antibiotic administration and fluid administration within 3 hours of sepsis onset. There was no change in vasopressor administration. There was a small increase in ICU admissions and no changes in mortality or discharge to home.
According to the researchers, these findings suggest that it may help clinicians to have some discretion in how to apply the components of SEP-1 at the bedside so that they may focus on the aspects of sepsis care that most directly drive improvements in patient outcomes.
2. Hospital-level care at home comparable to hospitalization for sick older adults
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Hospital-level care at home with a comprehensive geriatric assessment led to similar outcomes compared with hospitalization for medically unwell older persons referred to bed-based hospital care. Advantages of at-home care included a decrease in admission to long-term residential care at 6 months and delirium at 1-month follow-up. Results of a randomized trial are published in Annals of Internal Medicine.
Avoiding hospital admission is often a priority for frailer, older persons. Efforts to develop these services have accelerated during the past year as the COVID-19 pandemic challenges the capacity of health care facilities and increases the susceptibility of older persons to the risks associated with hospitals and care homes. However, the safety and clinical effectiveness of hospital-level care in the home is uncertain.
Researchers from the Nuffield Department of Population Health at the University of Oxford randomly assigned more than 1,000 sick older persons referred for a hospital admission at one of nine community and hospital sites in the United Kingdom to either admission avoidance hospital-at-home care with a comprehensive geriatric assessment or hospitalization. The assessment allowed a geriatric care team to evaluate patient characteristics and contribute to the care plan. Participants were eligible if they were 65 years or older and all had complex medical issues (but did not require emergency treatment, palliative care, or surgery) At 6 months, researchers assessed both groups to determine whether participants still lived at home.
The researchers found that outcomes were similar between the two groups. At 6-month follow-up, 78.6% of participants in the hospital at home group versus 75.3% of the participants in the hospital group were living at home; 16.9% versus 17.7% had died; 5.7% versus 8.7% were in long-term residential care. According to the study authors, these findings suggest that a health system that includes admission avoidance hospital at home with comprehensive geriatric assessment can create additional acute health care capacity for certain older people referred for a hospital admission.
Also in this issue:
A recent stroke: Can you decrease the risk of perioperative stroke?
Annals Consult Guys
Syncope: Who is at Risk for Poor Outcomes?
Annals On Call
DOACs in Cancer Patients: What Hospitalists Need to Know