In the Literature: HM-Related Research You Need to Know

The Hospitalist. 2011 March;2011(03):

March 1, 2011|The Hospitalist

Steven Deitelzweig, MD, MMM, SFHM;Renee Meadows, MD, SFHM;David Lee, MD, MBA, FHM;Frank Wharton, MD, FHM Srinivas Vuppala, MD;William Carter, MD;Prasad Ravipati, MD;Department OF

In This Edition

Literature at a Glance

A guide to this month’s studies

Risk of adverse events with opioid use
Drug of choice for outpatient treatment of cellulitis
Preventing hospital falls
Post-hospital outcomes based on status of PCP follow-up
LOS, mortality, and readmission based on insurance
Antiplatelets added to warfarin for atrial fibrillation.
Cognitive effects of severe sepsis
Effect of preoperative furosemide use

ED Visits Are Higher among Recipients of Chronic Opioid Therapy

Clinical question: Is there an association between the use of prescription opioids and adverse outcomes?

Background: Chronic opioid therapy is a common strategy for managing chronic, noncancer pain. There has been an increase in overdose deaths and ED visits (EDV) involving the use of prescription opioids.

Study design: Retrospective study from claims records.

Setting: Population in the Health Core Integrated Research Database, containing large, commercial insurance plans in 14 states, and Arkansas Medicaid.

Synopsis: Patients 18 and older without cancer diagnoses who used prescription opioids for at least 90 continuous days within a six-month period from 2000 to 2005 were examined for risk factors for EDVs and alcohol- or drug-related encounters (ADEs) in the 12 months following 90 days or more of prescribed opioids.

Patients with diagnoses of headache, back pain, and pre-existing substance-use disorders had significantly higher EDVs and ADEs. Opioid dose at morphine-equivalent doses over 120 mg per day doubled the risk of ADEs. The use of short-acting Schedule II opioids was associated with EDVs (relative risk, 1.09-1.74). The use of long-acting Schedule II opioids was strongly associated with ADEs (relative risk, 1.64-4.00).

Bottom line: In adults with noncancer pain prescribed opioids for 90 days or more, short-acting Schedule II opioid use was associated with an increased number of EDVs, and long-acting opioid use was associated with an increased number of ADEs. Minimizing Schedule II opioid prescription in these higher-risk patients might be prudent to increase patient safety.

Citation: Braden JB, Russo J, Fan MI, et al. Emergency department visits among recipients of chronic opioid therapy. Arch Intern Med. 2010; 170(16):1425-1432.

Clinical Short

MORE THAN 3% OF PRESCRIPTIONS ARE ABANDONED AT THE PHARMACY

Cross-sectional cohort study shows new prescriptions, asthma medications, and those with copayments or delivered electronically are more frequently abandoned than opioids, antiplatelet medications, prescriptions without copayments, and those prescriptions not electronically transmitted.

Citation: Shrank WH, Choudhry NK, Fischer MA, et al. The epidemiology of prescriptions abandoned at the pharmacy. Ann Intern Med. 2010;153(10):633-640.

Empiric Outpatient Therapy with Trimethoprim-Sulfamethoxazole or Clindamycin Is Preferred for Cellulitis

Clinical question: What is the best empiric outpatient oral antibiotic treatment for cellulitis in areas with a high prevalence of community-associated MRSA infections?

Background: The increasing rates of community-associated MRSA skin and soft-tissue infections have raised concerns that such beta-lactams as cephalexin and other semisynthetic penicillins are not appropriate for empiric outpatient therapy for cellulitis.

Study design: Three-year, retrospective cohort study.

Setting: A teaching clinic of a tertiary-care medical center in Hawaii.

Synopsis: More than 540 patients with cellulitis were identified from January 2005 to December 2007. Of these, 139 patients were excluded for reasons such as hospitalization, surgical intervention, etc. In the final cohort of 405 patients, the three most commonly prescribed oral antibiotics were cephalexin (44%), trimethoprim-sulfamethoxazole (38%), and clindamycin (10%). Other antibiotics accounted for the remaining 8%.

MRSA was recovered in 62% of positive culture specimens. The success rate of trimethoprim-sulfamethoxazole was 91% vs. 74% in the cephalexin group (P<0.001). Clindamycin success rates were higher than those of cephalexin in patients who had subsequently confirmed MRSA infections (P=0.01) and moderately severe cellulitis (P=0.03) and were obese (P=0.04).