Early Stress Tests for Low-risk Chest Pain Admissions Not an Effective Strategy for Reducing Readmissions or Healthcare Costs
Patients who underwent a stress test during their first hospitalization for chest pain had higher costs overall than patients who did not.
Kristine Scruggs, MD
October 2013 – Patients who received a stress test during their first admission with low-risk chest pain were less likely to return to the emergency department (ED) with complaints of chest pain. However, those who did return were just as likely to be readmitted as patients who did not receive stress testing. Furthermore, overall healthcare costs were higher in patients who underwent stress testing during their index hospitalization.
Jaya Mallidi, MD, MHS, of the Division of Cardiology in the Department of Medicine at Baystate Medical Center in Springfield, Massachusetts, presented his findings in conjunction with several colleagues in a retrospective cohort study published in the Journal of Hospital Medicine in October 2013.
Patients presenting with low-risk chest pain comprise a significant portion of hospital admissions and readmissions each year. The likelihood of a positive stress test or major cardiovascular event in this patient population is extremely low. An evidence-based algorithm is needed to guide in the care of this patient population in order to reduce unnecessary healthcare spending.
The authors reviewed the records of 3315 patients who presented to the hospital with low-risk chest pain from January 2007 to July 2009. Patients were included in the trial if they were over 18 years of age, had an admitting diagnosis of “chest pain,” and were admitted under observation status. Patients were excluded from the trial if they had a discharge diagnosis of “acute myocardial infarction” or had a chest pain admission or stress test within the past year.
Patients who had a stress test during their first admission were 40% less likely to return to the ED for evaluation of chest pain than those who did not (OR: 0.6, 95% confidence interval: 0.5 to 0.9). However, the cost of stress testing was not offset by the decrease in subsequent ED visits.
Among patients who did return to the ED, there was no difference in readmission rates between the two groups (OR: 0.8, 95% confidence interval: 0.4 to 1.4), and the overall cost of care for patients who received a stress test during their index admission was roughly $1000 more than those who did not.
“In an era of rising healthcare costs and limited resources, the care of low-risk chest pain is an attractive target for cost-reduction strategies,” the authors noted. While early stress testing does not appear to reduce overall healthcare costs for patients with low-risk chest pain, further studies could be helpful in determining the most appropriate use of resources to maximize patient safety while minimizing healthcare costs.
The authors reported no conflicts of interest.
Journal of Hospital Medicine. Published October, 2013.
Link Suggested Between Zika Virus Infection In Utero and Microcephaly
Possible association between vertical transmission of the virus and certain fetal anomalies.
Kristine Scruggs, MD
March 10, 2016 – A fetus with confirmed Zika virus (ZIKV) infection in utero was found on autopsy to have microcephaly and other destructive neurologic changes that have previously been associated with other flaviviruses.
Jernej Mlakar, MD, from the Institute of Pathology, University of Ljubljana, Slovenia, and colleagues described their findings in a case report published in The New England Journal of Medicine on March 10, 2016.
Northeast Brazil has experienced a recent twenty-fold increase in microcephaly, which has coincided with a dramatic increase in incidence of Zika virus infections in the same area of the country. This pattern has raised concerns for a possible causal relationship between the virus and microcephaly.
In the case report, a 25-year-old woman living in Brazil was found to have an abnormal prenatal ultrasound at 29 weeks gestation with intrauterine growth retardation, placental calcifications, and microcephaly. She had experienced clinical signs and symptoms of Zika virus infection late in her first trimester. The pregnancy was terminated at 32 weeks gestation at the patient’s request, and an autopsy was performed.
The fetus was noted on autopsy to have significant microcephaly along with agyria and hydrocephalus. Neuronal calcifications were also noted. Polymerase chain reaction for Zika virus was positive, confirming in utero infection. Importantly, multiple other endemic viruses known to affect the central nervous system were also ruled out using PCR. These findings seemed to support a possible link between the Zika virus and microcephaly.
“Further research is needed to better understand the potential implications of these observations,” the author said in closing. “It is likely that the rapid spread of ZIKV around the globe will be a strong impetus for collaborative research on the biologic properties of the virus.”
Dr. Mlakar and his colleagues reported no relevant disclosures.
N Engl J Med. Published March 10, 2016.
Apatinib as Third-line Therapy Shows Benefit in Gastric Adenocarcinoma
Patients with metastatic gastric or gastroesophageal junction adenocarcinoma in whom second-line chemotherapy failed showed longer overall and progression-free survival with apatinib.
Kristine Scruggs, MD.
May 2016 – Apatinib given for refractory metastatic gastric and gastroesophageal (GE) junction adenocarcinoma showed improved survival compared with placebo in a recent phase 3 trial.
Jin Li, of Fudan University Shanghai Cancer Center, and colleagues presented the findings from their randomized, double-blind, placebo-controlled phase 3 trial in the May 2016 issue of the Journal of Clinical Oncology. The results were also published online in February 2016.
Currently, there is no widely accepted therapy for advanced gastric cancer that has not responded to first- and second-line chemotherapy. Apatinib, an oral tyrosine kinase inhibitor, has shown promise against advanced or metastatic gastric adenocarcinoma in phase 2 trials. It works by binding to vascular endothelial growth factor receptor 2 (VEGF-2) and inhibiting angiogenesis.
In this phase 3 study, researchers enrolled 267 patients in the study between January 2011 and November 2012. Patients were eligible for the trial if they had advanced gastric or GE junction adenocarcinoma that had failed at least two prior treatment regimens. They were assigned to either apatinib or placebo in a 2:1 ratio through a randomized, double-blinded process.
Primary end points were overall survival and progression-free survival. The apatinib arm showed a median overall survival of 6.5 months in comparison with the placebo group, whose median survival was 4.7 months (P = .0149), representing a 1.8 month increase in survival with apatinib. Progression-free survival was also higher in the apatinib group, at 2.6 months versus 1.8 months in the placebo arm (P <.001).
Serious adverse reactions included hand-foot skin reaction, proteinuria, and hypertension and resulted in dose modifications for 21% of patients receiving apatinib. Other common adverse effects included decreases in all hematologic cell lines as well as gastrointestinal side effects, including abdominal pain, diarrhea, and abnormalities in various hepatic function tests.
“These data demonstrate that apatinib could be a new treatment option for patients with metastatic gastric cancer experiencing progression after two or more lines of chemotherapy,” the study authors concluded. “A series of additional studies designed to assess the potential application of apatinib in other solid tumors such as non-small-cell lung cancer and hepatocellular carcinoma is ongoing.”
Dr. Li receives research funding from Merck and Amgen.
Journal of Clinical Oncology. May 1, 2016.