Conclusions
This ambitious study evaluated the quality of hospital care across the nation using information collected from both JCAHO and CMS. It demonstrated room for improvement, with hospitals as a whole providing 76% of the recommended measures for acute MI, CHF, and pneumonia. The study suggests that ownership characteristics, teaching status, JCAHO accreditation, technology investments, and nursing staff with degrees strongly correlates to success in meeting performance measures.
The authors conclude that the findings have implications for public policy and patient choice. They hypothesize that regions of the country and rural locations more often associated with low performance could use additional resources aimed at bolstering performance. Patients living in rural areas have little choice without traveling great distances. The authors also state that the characteristics of hospitals that influence performance, such as ownership, teaching status, JCAHO accreditation, technology investments, and nursing status, are remediable.
It is important to bear in mind, however, given the cross-sectional nature of the data, that the associations reported are not proof of causality. Quality performance measures were not highly correlated among hospitals for the three conditions studied, with only 3.8% in the top quintile for all three diseases; this result demonstrates the difficulty inherent in generically rating hospitals. Additionally, this study makes no attempt to examine how meeting performance measures affects clinical outcomes, an important part of this ongoing national debate.
Treat DVT
Kearon C, Ginsberg JS, Julian JA, et al. Comparison of fixed-dose weight-adjusted unfractionated heparin and low-molecular-weight heparin for acute treatment of venous thromboembolism. JAMA. 2006 Aug 23;296(8):935-942.
Background
The current practice of treating DVT involves starting the patient on LMW (low molecular weight) heparin administered subcutaneously or initiating an IV drip of unfractionated heparin. The latter prevents the patient from being discharged as soon as treatment is initiated and requires repeat checking of aPTTs and drip adjustments, which may lead to over-shoot and/or sub-therapeutic dosage. On the other hand, treatment with LMW heparin is costly and can be tricky for patients with varying degrees of renal failure. Using fixed-dose subcutaneous injections of unfractionated heparin is a novel idea and could be the solution to the above-mentioned issues.
Methods
Eight hospitals in Canada and New Zealand with a total of 708 eligible and willing participants were involved in the study. The study design was a randomized, controlled, non-inferiority trial; the adjudication and monitoring committees were blinded. Patients older than 18 with a new diagnosis of DVT and/or pulmonary embolism were considered eligible. Patients with any of the usual contraindications for anticoagulation, including recent major bleeding events, were excluded, as were patients with renal failure and pregnancy.
Computerized randomization was done at a central location, and patients were started on either twice daily weight-based dosing of LMW heparin (100 IU/kg) or twice daily dosing of weight-based unfractionated heparin (first dose of 333 U/kg, subsequent doses of 250 U/kg). No coagulation testing was done to modify these doses. The patients were treated for at least five days, until the International Normalized Ratio (INR) was in the therapeutic range for two consecutive days. Patients were concomitantly started on warfarin. Recurrent venous thromboses, bleeding episodes—described as drop of hemoglobin >2.0—and death were primary endpoints.
Results
The assumption of non-inferiority was supported by the analysis of recurrent VTEs, which were 12 (3.4%) in the LMW heparin group and 13 (3.8%) in the unfractionated heparin group—clinically, a non-significant difference. Bleeding rates at 10 days or at three months were not significantly different for the two groups. Number of deaths was 18 in the unfractionated heparin group and 22 in the LMW heparin group. No patients were reported to have developed heparin-induced thrombocytopenia, a serious and often life-threatening complication of unfractionated heparin use.