Bottom line: From 2002 to 2010, mortality rates at U.S. critical-access hospitals rose while rates fell at non-critical access hospitals.
Citation: Joynt KE, Orav EJ, Jha AK. Mortality rates for Medicare beneficiaries admitted to critical access and non-critical access hospitals, 2002-2010. JAMA. 2013;309(13):1379-1387.
Physicians Fail to Discuss Advance-Care Planning with Hospitalized Elderly, Relatives
Clinical question: Do elderly patients who are at high risk for death have documented advance-care plans, and do their physicians discuss goals of care with them?
Background: While studies indicate that most sick, elderly patients prefer a better quality of life to life-sustaining treatment, many patients still die in the hospital, often in the ICU. It is unclear whether this is due to the absence of advance-care planning or the lack of communicating goals of care.
Study design: Multicenter prospective cohort study.
Setting: Canada.
Synopsis: A validated questionnaire was used to evaluate advance-care planning both before hospitalization and on admission. Patients and their families were enrolled if they were considered at high risk for dying, including patients with advanced disease, or aged >80 years. Of the 278 patients enrolled, 76.3% had thought about advance-care planning. Approximately 47.9% of patients had written an advance-care plan, and 73.3% had formally documented a surrogate health-care decision-maker. Only a quarter of patients reported that they had been asked about advance-care planning on admission to the hospital. Patients’ stated preferences for end-of-life care were notably incongruent with goals-of-care orders documented in the hospital records. While 28% of patients preferred comfort-only care, this was documented in the hospital records for only 4.5% of patients.
In this study of mostly white, English-speaking hospitalized patients, many had considered and made advance-care plans but few had discussed this with their health-care providers. Not surprisingly, the goals-of-care orders that were documented did not match patients’ previously stated end-of-life preferences.
Bottom line: Physicians routinely fail to discuss patients’ advance-care planning, which may have profound effects on their inpatient care.
Citation: Heyland DK, Barwich D, Pichora D, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med. 2013;173(9):778-787.
Ultrasound Use Reduces Lumbar Puncture and Epidural Catheterization Failure
Clinical question: Does ultrasound imaging for lumbar puncture and epidural catheterization reduce risk of procedure failures?
Background: Numerous studies have compared ultrasound-guided lumbar puncture and epidural catheterization with standard techniques, but they have been underpowered to evaluate whether ultrasound use reduces lumbar puncture and epidural catheterization failure.
Study design: Systematic review and meta-analysis of randomized controlled trials.
Setting: Hospitals in North America, Europe, and Asia.
Synopsis: Among 14 trials, a total of 1,334 patients (including one pediatric study group) were randomly assigned either to receive ultrasound imaging or to a control group (using manual palpation or loss of resistance). Ultrasound imaging comprised a preprocedure marking approach, real-time visual guidance, or both. In the 12 trials in which the primary outcome was available, ultrasound imaging significantly reduced the risk of failed procedures with a risk ratio of 0.21 (95% confidence interval 0.10 to 0.43). A total of 16 ultrasound-guided procedures were needed to avoid one procedure failure. Ultrasound guidance also reduced the number of traumatic procedures, needle reinsertions, and needle redirections. These results were consistent across multiple subgroup analyses.
Only one of the studies included in the meta-analysis was double-blind, and in all of the studies, ultrasound imaging was performed by a clinician with high-level ultrasound experience. While this study suggests that ultrasound does reduce the frequency of procedure failure, the investigators did not include cost-effectiveness analyses.
