EFFECTS OF COMPUTED TOMOGRAPHY OF THE APPENDIX ON THE TREATMENT PATIENTS AND THE USE OF HOSPITAL RESOURCES
Summary:
BACKGROUND: In patients with clinically suspected appendicitis, computed tomography (CT) is diagnostically accurate. However, the effect of routine CT of the appendix on the treatment of such patients and the use of hospital resources is unknown. METHODS: We performed appendiceal CT on 100 consecutive patients in the emergency department who, on the basis of history, physical examination, and laboratory results, were to be hospitalized for observation for suspected appendicitis or for urgent appendectomy. Outcomes were determined at surgery and by pathological examination in 59 patients, and by clinical follow-up two months later in 41 patients. Treatment plans made before CT were compared with the patients' actual treatment. We also determined the costs of surgery that revealed no appendicitis (from data on 61 patients), one day of observation in the hospital (from data on 350 patient-days in patients with suspected appendicitis), and appendiceal CT (from data on all pelvic CT examinations in 1996). RESULTS: Fifty-three patients had appendicitis, and 47 did not. The interpretations of the appendiceal CT scans were 98 percent accurate. The results of CT led to changes in the treatment of 59 patients. These changes resulted in the prevention of unnecessary appendectomy in 13 patients, admission to the hospital for observation in 18 patients, admission to the hospital for observation before necessary appendectomy in 21 patients, and admission to the hospital for observation before the diagnosis of other conditions by CT in 11 patients. The effects of performing appendiceal CT on the use of hospital resources included the prevention of unnecessary appendectomy in 13 patients (for a savings of $47,281) and the prevention of unnecessary hospital admission for 50 patient-days (for a savings of $20,250). After the cost of 100 appendiceal CT studies ($22,800) was subtracted, the overall savings was $447 per patient. CONCLUSIONS: Routine appendiceal CT performed in patients who present with suspected appendicitis improves patient care and reduces the use of hospital resources.
Comments:
This is one paper I had secretly hoped I would never see. Now I fear it might become a source of reference for many generations of doctors, and patients.
Acute appendicitis (and chronic appendicitis-if there is such an entity) is the last remaining abdominal condition which is examination. The clinical experience of the surgeon-some call it the "Art of medicine" is the decisive factors, and the diagnosis in this manner is accurate about 80-85% of the time. It should be accuracy of diagnosing acute appendicitis with CT scan is more than 90%.
My concern is not that CT scanning will become an adjunctive diagnostic tool for acute appendicitis, but that it will replace the clinical surgeon’s examination and decision making for this very common condition. And my fear is that in the near future junior doctors and established surgeons, patients themselves will want a CT scan for any type of abdominal pain. I doubt very much that radiologists will attempt to bar the stampede.The economic issue has been used as another argument in support of CT scanning for the diagnosis of acute appendicitis.
What has not been stressed, however, is that savings incurred with the use of CT scanning reside in avoidance of unnecessary operations, not in making the diagnosis. The cost to society, if every child or adult with suspected acute appendicitis is ordered to have a CT scan, is enormous. The cost of depriving surgeons from developing the required clinical and experience to make the unaided diagnosis of acute appendicitis is incalculable.
Farrokh Saidi MD, Tehran Iran
Source: Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ N Engl J Med, 1998; 338: 141-146
PROTECTIVE EFFECT OF HEPATITIS B VACCINE IN CHRONIC HEMODIALYSIS PATIENTS
Summary:
Hepatitis B virus (HBV) infection is a well-recognized risk in chronic hemodialysis patients. Although the risk has declined dramatically since the 1970s, outbreaks of HBV infection among these patients continue to occur. The Centers for Disease Control and Prevention (CDC) has recommended hepatitis B vaccination of hemodialysis patients since 1982; however, by 1996, only 36% of the approximately 200,000 US chronic hemodialysis patients had received the vaccine, perhaps in part because of doubts among dialysis personnel of its efficacy. We performed a case-control study to determine whether receipt of hepatitis B vaccine was associated with a decreased risk of acquiring HBV infection. We determined the vaccination status of all chronic hemodialysis patients at 98 US hemodialysis centers that reported patients with acute HBV infection on a nationwide mailed survey in 1995. A total of 111 hepatitis B surface antigen (HbsAg) positive case patients were compared with 12,500 control patients. Case patients were significantly less likely than control patients to gave received hepatitis B vaccine (10.8% v 23.6%; odds ratio, 0.39; 95% confidence interval, 0.22-0.72). After stratifying by dialysis center to control for differing community and dialysis center risks of HBV infection, we found that the risk for HBV infection was 70% lower in vaccinated patients (adjusted odds ratio, 0.30; 95% confidence interval, 0.18-0.50). These results suggest that hepatitis B vaccine has a significant protective effect against acquiring HBV infection in chronic hemodialysis patients, and efforts should be expanded to increase the use of hepatitis B vaccine in this patient population.
Comments:
Hemodialysis (HD) patients are immune-compromised hosts, who enjoy a prolonged survival thanks to high technology medicine. In spite of preventive measures, HD patients remain prone to various infections including viral hepatitis. On account of profound immunosupression, a rise in the level of protective antibodies is abolished after hepatitis B vaccination, and hence, continuing doubts exist as to its efficacy. Furthermore, unlike the general population, seropositivity for hepatitis B surface antigen is neither associated with cirrhosis nor chronic active hepatitis. It is also neither a contraindication for renal transplantation nor a predictor of shortened survival. Moreover, vaccination for hepatitis B and associated assays to confirm its efficacy are laborious and costly. Considering an annual mortality rate of at least 10% among HD-patients, even in the best centers, (a figure which is probably higher in third world countries), it would be wiser, initially, to proceed with improvements in the restricted medical and hygienic facilities in this part of the world rather than follow the recommendation put forward by the CDC to promote the use of hepatitis B vaccine among HD-patients. It would be more prudent to improve and promote preventive measures for easily preventable diseases such as polio, small pox, tetanus, measles, diphtheria, tuberculosis, malaria, and cholera, that are still ravaging most of the developing world, before launching along the path of immunization against the hepatitis B virus which is of limited benefit. Efforts to expand high technology medicine in developing countries are only justified when the basic hygienic problems are fully solved. This, would ensure that the continuous drain on limited resources in developing countries would cease, and the gap between the rich and the poor is not further widened.
Parviz Khajehdehi, MD, Department of Medicine, Shiraz University of Medical Sciences
Source: Miller ER, Alter MJ, Tokars JI. Am J Kidney Dis. 1999 Feb; 33(2): 356-60.
Oral anticoagulation in patients with atrial fibrillation: adherence with guidelines in an elderly cohort
Summary:
PURPOSE: To determine adherence with practice guidelines in a population-based cohort of elderly persons aged 70 years or older with atrial fibrillation. SUBJECTS AND METHODS: This was a cross-sectional analysis of a subgroup of participants in the Cardiovascular Health Study, a prospective observational study involving four communities in the United States. Subjects were participants with atrial fibrillation on electrocardiogram at one or more yearly examinations from 1993 to 1995. The outcome measure was self-reported use of warfarin in 1995. RESULTS: In 1995, 172 (4.1%) participants had atrial fibrillation together with information regarding warfarin use and no preexisting indication for its use. Warfarin was used by 63 (37%) of these participants. Of the 109 participants not reporting warfarin use, 92 (84%) had at least one of the clinical risk factors (aside from age) associated with stroke in patients with atrial fibrillation. Among participants not taking warfarin, 47% were taking aspirin. Several characteristics were independently associated with warfarin use, including age [odds ratio (OR) = 0.6 per 5-year increment, 95% CI 0.5-0.9], a modified mini-mental examination score <85 points [OR = 0.3, 95% confidence interval (CI) 0.1-0.9], and among patients without prior stroke, female sex (OR = 0.5, 95% CI 0.2-1.0). CONCLUSIONS: Despite widely publicized practice guidelines to treat patients who have atrial fibrillation with warfarin, most participants who had atrial fibrillation were at high risk for stroke but were not treated with warfarin. More studies are needed to determine why elderly patients with atrial fibrillation are not being treated with warfarin.
Comments:
No matter what is the cause of atrial fibrillation (AF), it can carry a high risk of mortality and morbidity. Practice guidelines published as early as 1992, recommended long-term oral anticoagulant therapy for all patients with paroxismal or chronic AF in whom anticoagulant therapy was deemed safe, expect for those younger than 60 years of age who had no associated cardiovascular disease ("lone AF"). Although, for the lower life expectancy of people living in developing countries, the disease is expected to occur at a lower rate, due to higher prevalence of rheumatic valvular heart disease, the incidence of AF among persons younger than 70 years of age is not low. The rather low prevalence of warfarin use among individuals with AF has several explanations. There might have been concerns about the difficulty and cost of providing appropriate anticoagulation follow-up care. However, I believe, the most important cause of underutilization of warfarin for these patients, is the fear of apparent hemorrhagic events that makes both the physician and the patient much reluctant to initiate the therapy, and not to mention the danger of unseen thromboembolic events.
Farrokh Habibzadeh, M.D, Shiraz, Iran
Source: White RH, McBurnie MA, Manolio T, Furberg CD, Gardin JM, Kittner SJ, Bovill E, Knepper L, Am J Med, 1999; 106: 165-171