Bottom line: The implementation of a hospitalist-neurosurgery comanagement service did not improve patient outcomes or satisfaction, but it did appear to improve providers’ perception of care quality and reduce hospital costs.
Citation: Auerbach AD, Wachter RM, Cheng HQ, et al. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med. 2010;170(22):2004-2010.
Comparable Mortality Between Hemodialysis and Peritoneal Dialysis
Clinical question: What effect does the initial dialysis modality used have on mortality for patients with end-stage renal disease (ESRD)?
Background: Despite the substantially lower annual per-person costs of peritoneal dialysis (PD) as compared with hemodialysis (HD), only 7% of dialysis patients were treated with PD in 2008. It is unknown whether there are differences in mortality between those using PD and HD when examined in contemporary cohorts.
Study design: Retrospective cohort study.
Setting: National cohort.
Synopsis: Data for patients with incident ESRD over a nine-year period were obtained from the U.S. Renal Data Systems (USRDS), a national registry of all patients with ESRD. Initial dialysis modality was defined as the dialysis modality used 90 days after initiation of dialysis. Patients were divided into three three-year cohorts (1996-1998, 1999-2001, and 2002-2004) based on the date dialysis was initiated and followed for up to five years.
A substantial and consistent reduction in mortality was seen for PD patients across the three time periods. No such improvements were observed across the time periods for the HD patients. PD patients were, on average, younger, healthier, and more likely to be white. In an analysis of the most recent cohort adjusting for these factors, there was no significant difference in the risk of death between HD and PD patients. The median life expectancy of HD and PD patients was 38.4 and 36.6 months, respectively.
Limitations of the study include a lack of randomization and failure to consider switches from one dialysis modality to the other.
Bottom line: Patients beginning their renal replacement therapy with PD had similar mortality after five years compared to patients using in-center HD.
Citation: Mehrotra R, Chiu YW, Kalantar-Zadeh K, Bargman J, Vonesh E. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med. 2011;171(2):110-118.
Pneumococcal Urinary Antigen Test Might Guide Community-Acquired Pneumonia Treatment
Clinical question: What is the diagnostic accuracy and clinical utility of pneumococcal urinary antigen testing in adult patients hospitalized with community-acquired pneumonia (CAP)?
Background: Although CAP is common, our ability to determine its etiology is limited, and empirical broad-spectrum antibiotic therapy is the norm. Pneumococcal urinary antigen testing could allow for the more frequent use of narrow-spectrum pathogen-focused antibiotic therapy.
Study design: Prospective cohort study.
Setting: University-affiliated hospital in Spain.
Synopsis: This study included consecutive adult patients hospitalized with CAP from February 2007 though January 2008. A total of 464 patients with 474 episodes of CAP were included. Pneumococcal urinary antigen testing was performed in 383 (80.8%) episodes of CAP. Streptococcus pneumoniae was felt to be the causative pathogen in 171 cases (36.1%). It was detected exclusively by urinary antigen test in 75 of those cases (43.8%).
For the urine antigen test, specificity was 96% (95% CI, 86.5 to 99.5), and the positive predictive value was 96.5% (95% CI, 87.9 to 99.5). The results of the test led clinicians to reduce the spectrum of antibiotics in 41 patients, and pneumonia was cured in all 41 of these patients. Treatment was not modified despite positive antigen test results in 89 patients.
Limitations of this study include a lack of complete microbiological data for all patients. The study also highlighted the difficulty in changing clinicians’ prescribing patterns, even when test results indicate the need for treatment modification.