Friday, October 12, 2007

CHF & hospice; Hyponatremia & prognosis; Benzos for grief; Hip fractures & prognosis; Back pain; NYT

Several items from Archives of Internal Medicine (& more).

To begin with are two about heart failure. The first is a look at characteristics of patients hospitalized for heart failure who are referred for hospice care. The data comes from a large, nation-wide, prospectively gathered database of hospitalized heart failure patients, and the researchers compared characteristics of those patients discharged to hospice care (1.6% of the 180,000 hospitalizations) with the rest of the patients. The results are pretty straightforward: those enrolling in hospice tended to be older and sicker, and have more cancer (making one wonder if they were being enrolled in hospice for end stage heart failure or cancer); they also received less invasive/aggressive care during their index hospitalization (inotropes, cardiac catheterizations, etc.). More notable is that the rates of hospice referral increased over time (from tiny to tiny) and that rates of hospice referral varied widely across the hospitals (0% to 9% of discharges). This large variation likely reflects a total lack of consensus (or awareness...) amongst clinicians about which heart failure patients are appropriate for hospice care.

The second is a look at the prognostic value of persistent hyponatremia in heart failure patients. The data come from a large, randomized trial looking at hospitalized heart failure patients with low ejection fractions ( less than 30%) and class IV symptoms (dyspnea at rest). Persistent hyponatremia was defined as a [Na] less than 134mEq/L the entire hospital stay (424 people total in the study; 103 had baseline hyponatremia; 71 had persistent hyponatremia). Persistent hyponatremia was associated with poorer outcomes in several analyses. As far as numbers go: at 6 months 31% of the persistent hyponatremia patients were dead compared to 16% of the normonatremic patients. Notably, 28% of the patients who presented with hyponatremia that was corrected were dead at 6 months also. Low sodium levels have long been known to portend a worse prognosis in a variety of disease states, including CHF, but it's nice to see some contemporary support for this, as well as some 6 month mortality rates. It's hard, however, to know how to generalize these data: these were hospitalized, very sick patients, who however were game to having pulmonary artery catheters placed (this was what the randomized trial was about)--I don't know what to do with that. My gloss would be: yes hyponatremia is a definite poor prognostic sign but I wouldn't put too much weight on the figure of 30% 6 month mortality.

There is a very brief research 'commentary' by some researchers who were looking into physician prescribing of benzodiazepines in the elderly. This commentary was about their unanticipated finding (which they weren't even particularly looking for) that benzos are liberally prescribed to the elderly for acute grief. They also noted that their research into long-term benzodiazepine users (users, not necessarily abusers) suggested that about a fifth of them were initially prescribed them for acute grief.

They note:
"We found this extraordinary for several reasons. First, there is no evidence base supporting this practice or any medication for either normal grief or complicated grief, which has duration of at least 6 months by current consensus. Second, given how common loss is in the general population, this practice might unnecessarily expose large numbers of people who are having normal reactions to loss, including high-risk populations such as the elderly, to inappropriate treatment. Third, based on the posttraumatic stress disorder literature and because posttraumatic stress disorder may be highly comorbid with complicated grief, it is theoretically possible that benzodiazepines might actually lead to worse outcomes by impeding the normative grieving process, especially at higher doses. In one small randomized controlled trial, low doses of diazepam neither helped nor hindered the course of bereavement. However, those who received diazepam had significantly less resolution of sleep problems compared with the placebo group."

(& Dr. Sean Marks alerted me to commentary about this on a NY Times blog.)

The final one is about the natural history of sustaining a second hip fracture, which contains some prognostic data. It comes from the Framingham Study, a large, prospective, decades long observational study of people in & around Framingham, MA which was designed to look at risk factors for heart disease long-term. The data generated also provides opportunities for looking at risk factors for and outcomes of many other diseases. In this analysis, the researchers looked at patients who sustained a hip fracture (481 in all, median age 81 years) and followed them out and looked at 1) rates of second hip fractures , 2) mortality, and 3) a bunch of other things. It should be noted that they included hip fractures from motor vehicle accidents and other injuries but these represented only a tiny percent of the cohort. There was a median of 4.2 years of follow-up for those sustaining an initial hip fracture (which makes one wonder if the median survival of those patients was ~4.2 years) and ~15% went on to have another fracture.

Survival findings: "15.9% of subjects died within 1 year of an initial fracture, and 45.4% of subjects died within 5 years of an initial fracture. Following an initial hip fracture, men had greater mortality compared with women, particularly during the first year of follow-up (24.4% in men vs 13.8% in women, P = .03). The 1-year and 5-year mortality following a second hip fracture was 24.1% and 66.5%, respectively."

I'm mentioning this because when I was in training (med school & residency, not palliative medicine training) I was told several times that the median survival after a hip fracture was 6 months (and I've heart it repeated a few times since) - a finding which is clearly not supported by this study. I was double struck by this when I noticed this e-pub of a paper in JAGS about survival getting worse recently for patients who have hip fractures (this is a Danish study using a national administrative database). One year survival (despite declining a little in this cohort over the decades) was in the ~72% range. Either way, it would be hard to see how median survival could be 6 months in these populations.

So I'm curious: has anyone else heard this statistic? Or used it? And where does it come from? (Yes I'm too lazy to lit search it.) The studies underlying that figure may be legit - the patient population looked at might be quite distinct from these large, community/nation-wide databases - but I'd like to know....please leave a comment.

Annals of Internal Medicine has published guidelines (from the ACP and the American Pain Society) about the evaluation and treatment of low back pain (consensus recommendations here; review of nonpharmacologic treatments here; review of pharmacologic treatments here). I'm not going to comment on these much other than to say together they represent a wide-ranging summary of the evidence and while they demonstrate the astonishing breadth of therapies evaluated (and found to be somewhat effective for low back pain) they also demonstrate the reality that it is an astonishingly complicated phenomenon with no really good treatment. Everything reviewed in these tomes has been shown to be, at best, 'mildly' or 'moderately' effective.

4 notable articles recently from the NY Times (now freely and indefinitely available online). First is another piece about inadequate availability of analgesics in 'poor' countries, and an associated article about the WHO's planning document on care of the dying. Third is a profile of a 59 year old woman with sickle cell disease which talks about the evolution of recognition and treatment of the disease, as well as pain control for it. Finally is a very sad article about the problems older gay couples face as they age, particularly when they have to go through transitions in places of care or residence; many feel forced to 're-enter the closet' when they enter a nursing home.

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