Study design: Systematic review and meta-analysis.
Setting: Varied.
Synopsis: Studies that compared commercial rapid influenza tests versus reference standards of PCR or viral culture were included. The 159 rapid tests were evaluated in 119 studies representing 26 different brands of commercial tests. Sixty-two of 119 studies included both adults and children, and 41 studies included children only. Overall, rapid influenza tests had a sensitivity of 62.3% and a specificity of 98.2%. There was a higher sensitivity for children than adults (67% vs. 54%) and a higher sensitivity for influenza A than influenza B (65% vs. 52%). The brand of rapid test made little difference. Most articles reviewed did not include a direct comparison between individual brands of RIDTs.
Bottom line: Rapid influenza diagnostic tests have low sensitivity and high specificity. A positive rapid test indicates likely influenza, but a negative test does not rule it out.
Citation: Chartrand C, Leeflang MM, Minion J, Brewer T, Pai M. Accuracy of rapid influenza diagnostic tests: a meta-analysis. Ann Intern Med. 2012;156:500-511.
Multifaceted QI Intervention Increases Adherence to Evidence-Based Therapy in Acute Coronary Syndrome
Clinical question: Does a multipronged approach to QI interventions improve the adherence to evidence-based therapies in acute coronary syndromes?
Background: Despite evidence-based recommendations for the use of antiplatelet medication, anticoagulants, beta-blockers, and statins in the setting of an acute coronary syndrome, adherence to these recommendations is poor, especially in low- to middle-income patients.
Study design: Cluster-randomized, prospective, blinded trial.
Setting: Thirty-six urban, public hospitals in Brazil.
Synopsis: Hospitals were randomly allocated to a multifaceted QI strategy versus routine practice. At each hospital, patients were enrolled in a consecutive manner when they presented to the emergency department with an acute coronary syndrome. The QI intervention included multiple modalities, including checklists in the ED, reminders, case management (by a trained RN) to ensure compliance, and educational materials to the staff (pocket algorithms and interactive web programs).
The primary endpoint was adherence to all available evidence-based therapies in the first 24 hours of management. Patients were more likely to receive all evidence-based therapies in hospitals that received the intervention (67.9% vs. 49.5%, P=0.01). The secondary endpoint (adherence at 24 hours and at discharge) was also significantly in favor of the intervention group (50.9% vs. 31.9%, P=0.03).
The findings might not be applicable to institutions with high adherence rates to evidence-based therapy.
Bottom line: A multifaceted QI intervention improves adherence to evidence-based therapies in urban hospitals in medium-income countries.
Citation: Berwanger O, Guimaraes HP, Lanranjeira LN, et al. Effect of a multifaceted intervention on use of evidence-based therapies in patients with acute coronary syndromes in Brazil: the BRIDGE-ACS randomized trial. JAMA. 2012 [Epub ahead of print].
Rivaroxaban for the Treatment of Acute Pulmonary Embolism
Clinical question: How does the efficacy and safety of rivaroxaban compare with low-molecular-weight heparin (LMWH) plus vitamin K antagonist (VKA) for treatment of acute pulmonary embolism (PE)?
Background: Data support the use of rivaroxaban for stroke prevention in atrial fibrillation, for VTE prophylaxis after orthopedic surgery, and for the treatment of acute coronary syndromes and acute deep vein thromboses. The EINSTEIN-PE investigators now study rivaroxaban for the treatment of acute symptomatic PE.
Study design: Randomized, open-label, noninferiority trial.
Setting: Two hundred sixty-three sites in 38 countries.
Synopsis: The investigators enrolled 4,832 patients with acute symptomatic PE (with or without DVT). Rivaroxaban alone was compared with standard therapy (enoxaparin followed by VKA to an international normalized ratio [INR] of 2 to 3) for three, six, or 12 months. The mean study duration was nine months. INR was in the therapeutic range 62.7% of the time.