Clinical question: What testing modality is most appropriate for acute obscure GI bleeding: capsule endoscopy (CE) or angiography?
Background: Acute obscure GI bleeding (OGIB): remains a diagnostic challenge, accounting for 7% to 8% of patients presenting with GI bleeding. CE enables direct visualization of small bowel mucosa but lacks the ability for therapeutic intervention. Angiography is frequently chosen for massive bleeding; however, it is invasive and does not enable visualization of the bowel.
Study design: Prospective, randomized, controlled, blinded, single-center study.
Setting: Prince of Wales Hospital, Hong Kong.
Synopsis: Ninety-one patients with active OGIB from June 2005 to November 2007 were assessed for eligibility; 60 met the criteria and were randomized to either CE or angiography. Overt OGIB was defined as patients who had nondiagnostic upper endoscopy and colonoscopy.
The primary outcome was diagnostic yield of CE or mesenteric angiography in identifying the bleeding source. Secondary outcomes were long-term rebleeding rates, readmissions for bleeding or anemia, blood transfusions, and death.
CE was positive in 16 patients (53.3%) and angiography was positive in six patients (20%). The diagnostic yield of CE was significantly higher than angiography (difference=33.3%, 95% CI 8.9-52.8%, P=0.016). The mean follow-up period was 48.5 months. The cumulative risk of rebleeding was higher in the angiography group, but this was not statistically significant. There was no significant difference in rates of subsequent hospitalization, death, or transfusions between the two groups.
The study based the sample-size estimation on the diagnostic yield rather than clinical outcomes and, hence, was underpowered to detect any significant differences in clinical outcomes.
Bottom line: CE has a higher diagnostic yield than angiography in patients with active overt OGIB.
Citation: Leung WK, Ho S, Suen B, et al. Capsule endoscopy of angiography in patients with acute overt gastrointestinal bleeding: a prospective randomized study with long term follow up. Am J Gastroenterol. 2012;107:1370-1376.
Perceptions of Readmitted Patients Transitioning from Hospital to Home
Clinical question: What are patient-reported reasons for readmission to the hospital after discharge?
Background: Reducing readmissions is a critical component to improving the value of healthcare. While readmission reduction is a goal of all hospitals, there is much to be gleaned from evaluating patients’ view of the problem. This study used a survey to assess the patient’s viewpoint.
Study design: Cross-sectional survey.
Setting: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center, Philadelphia.
Synopsis: A survey of 36 questions was posed to 1,084 patients who were readmitted within 30 days of discharge from November 2010 to July 2011 (32% of eligible patients). The data were subdivided based on socioeconomic status and medical versus surgical patients.
Some issues patients raised regarding discharge planning included difficulty with paying for medications, challenges with travel to pharmacies, and concern over medication side effects.
Patients with low socioeconomic status had more difficulty taking medications and following instructions, had more depression, and had less social support.
Bottom line: Readmission rates are affected by a patient’s social situation. A team approach to discharge planning might mitigate some of these factors.
Citation: Kangovi S, Grande D, Meehan P, Mitra N, Shannon R, Long JA. Perceptions of readmitted patients on the transition from hospital to home. J Hosp Med. 2012 [Epub ahead of print].
30-Day Readmissions after Acute Myocardial Infarction
Clinical question: What are potential predictors of 30-day readmissions after acute myocardial infarction (MI)?
Background: Much attention has been given to evaluate the causes of readmissions of heart failure, acute MI, and pneumonia. This study looked at 30-day readmissions after an acute myocardial infarction (AMI).