Relation Between Hospital Length of Stay and Quality of Care in Patients With Acute Coronary Syndromes (from the American Heart Association's Get With the Guidelines--Coronary Artery Disease Data Set).

Worries regarding short length of stay (LOS) adversely impacting quality of care prompted us to assess the relation between hospital LOS and inpatient guideline adherence in patients with acute coronary syndrome. We used the American Heart Association's Get with The Guidelines (GWTG)--Coronary Artery Disease data set. Data were collected from January 2, 2000, to March 21, 2010, for patients with acute coronary syndrome from 405 different sites. Of the 119,398 patients in the study, the mean LOS was 5.5 days with a median of 4 days. There was no difference in the LOS on the basis of hospital size, hospital type, or cardiac surgery availability. The population with an LOS <4 days were younger (63.8 ± 14.1 vs 70 ± 14.5, p <0.0001), men (63.8% vs 55.3%, p <0.0001) and had fewer clinical co-morbidities. The overall adherence was high in the GWTG participating hospitals. Those with the LOS <4 days were more likely to receive aspirin (adjusted odds ratio [OR] 1.12, 95% CI 1.06 to 1.19; p <0.001), clopidogrel (OR 1.77, 95% CI 1.60 to 1.95; p <0.001), lipid-lowering therapy if indicated (OR 1.13, 95% CI 1.05 to 1.21; p <0.001), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for left ventricular systolic dysfunction (OR 1.10, 95% CI 1.01 to 1.21; p = 0.04) and smoking cessation counseling (OR 1.17, 95% CI 1.1 to 1.24; p <0.001) compared to those with the LOS ≥ 4 days. In contrast, those with the LOS <4 days were less likely to receive beta blockers (OR 0.88, 95% CI 0.84 to 0.93; p <0.001). The odds of receiving defect-free care were greater for patients with the LOS <4 days (OR 1.15, 95% CI 1.1 to 1.21; p <0.001). In conclusion, in GWTG participating hospitals, a shorter LOS did not appear to adversely affect adherence to discharge quality of care measures.

Oral antidiabetic drugs and regression from prediabetes to normoglycemia: a meta-analysis.

BACKGROUND: Impaired glucose tolerance, impaired fasting glucose, and elevated hemoglobin A(1c) are intermediate stages, considered prediabetes, a precursor to overt type 2 diabetes mellitus. Prediabetes is associated with increased risk for cardiovascular disease, independent of diabetes development. Data have shown that various oral antidiabetic drugs can help people regress from prediabetes to normoglycemia. OBJECTIVE: To evaluate the efficacy of oral antidiabetic drugs in promoting regression from prediabetes to normoglycemia. METHODS: MEDLINE (1950-November 2011), EMBASE (1990-November 2011), and Cochrane Central Register of Controlled Trials (indexed September 2011) were systematically searched. A manual search of references from reports of clinical trials and review articles was performed to identify additional relevant studies. Randomized controlled trials 12 weeks or more in duration evaluating any of the oral antidiabetic drugs and studying regression from prediabetes to normoglycemia were included. A random-effects model was used to calculate pooled odds ratios with 95% confidence intervals. RESULTS: Thirteen studies (N = 11,600 participants) were included in the meta-analysis. Use of oral antidiabetic drugs in prediabetic patients was shown to double the odds of achieving normoglycemia compared to controls (OR 2.03, 95% CI 1.54 to 2.67). When individual classes of oral antidiabetic drugs were evaluated, use of thiazolidinediones (OR 2.33, 95% CI 1.93 to 2.81) and α-glucosidase inhibitors (OR 2.02, 95% CI 1.26 to 3.24) was associated with significantly increased odds. However, biguanides (OR 2.04) and sulfonylureas (OR 1.84) failed to reach statistical significance (p = 0.06 and p = 0.39, respectively). CONCLUSIONS: In patients with prediabetes, oral antidiabetic drugs were associated with increased odds of regression to normoglycemia versus placebo/control. Only thiazolidinediones and α-glucosidase inhibitors provided a statistically significant increase in odds of regressing to normoglycemia.

Utility of daily diuretic orders for identifying acute decompensated heart failure patients for quality improvement.

INTRODUCTION: Many studies have demonstrated gaps in adherence to American College of Cardiology (ACC)/American Heart Association (AHA) guidelines among patients with acute decompensated heart failure (ADHF). Quality improvement initiatives can improve compliance with guideline-recommended therapy yet a major challenge to such programs is identifying heart failure patients across the many wards and services of the complex hospital environment. METHODS AND RESULTS: Using our hospital's electronic order-entry system, we generated a daily list of all hospitalized patients receiving a loop diuretic. Over a 3-month period, each patient on this list was screened through chart review for a diagnosis of ADHF. For those patients with ADHF, a clinical reminder about ACC/AHA recommended therapies was placed in the chart. Patient outcomes were followed using the Get With The Guidelines heart failure database.During the study period, 98.6% of patients with ADHF were identified by the diuretics list. The diuretics list had a sensitivity of 98.6% and specificity of 92.2%. The diuretic list captured more ADHF patients than alternative methods such as chest x-ray and brain natriuretic peptide level. Use of the daily diuretic list and targeted reminders to clinicians was associated with an improvement in recommended therapies including smoking-cessation education and heart failure teaching. CONCLUSIONS: A daily list of inpatients receiving diuretics allowed real-time identification of most hospitalized heart failure patients at our institution. Targeted reminders to clinicians regarding ACC/AHA-recommended therapies for heart failure were associated with improvements in guideline adherence.