Unnecessary hospitalisations of nursing home residents
This study, which is funded by the US National Institute of Aging, evaluates such hospitalisation in the USA. The authors start with the proposition that admission to an acute hospital in the last years of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment. They suggest that such hospital admissions have the potential for fragmentation of care, changes in the management of chronic diseases, duplication of diagnostic workups, and medical errors. They defined such admissions as burdensome if they occurred in the last 3 years of life, if there was a lack of continuity in nursing homes after hospitalisation in the last 90 days of life, or if there were multiple hospitalisations in the last 90 days of life.
They concluded that 19% of 474,829 nursing home residents had at least one burdensome admission. They believe that such patients would be better served by remaining in their nursing home.
N Engl J Med 2011;365:1212–21.
This meta-analysis reviews 20 trials comparing outcomes in the management of early breast cancer with or without tamoxifen. There were over 10,000 women with oestrogen receptor (ER)-positive disease and they report that 5 years of tamoxifen substantially reduced recurrence rates over 10 years (Relative Risk 0.53) and reduced breast cancer mortality by about a third throughout the first 15 years of follow-up.
Overall non-breast-cancer mortality was little affected, despite small absolute increases in thromboembolic and uterine cancer mortality (both only in women older than 55 years), so all-cause mortality was substantially reduced. In ER-negative disease, tamoxifen had little or no effect on breast cancer recurrence or mortality.
So tamoxifen still plays an important role bearing in mind that aromatase inhibitors are ineffective in women whose ovaries are still functioning.
The editor of the BMJ announced in August that the journal would no longer commission editorials and clinical reviews from authors with ties to industry. The issue was obviously conflicts of interest and the policy has prompted controversy. Nine letters, including one from a current editor of the American Family Physician (AFP), one from a former editor of the BMJ, and one from a former editor of theNEJM appear in a recent BMJ issue. The AFP and NEJM editors strongly endorse the new policy, seven oppose it, and one is undecided.
Your scribe is also undecided but notes one or two compelling arguments against the ban. For example readers might feel more confident about the assessment of a new drug in a clinical review article if the author, as a result of ties with industry, has direct experience with it—for example, as investigator in preregistration clinical trials or as adviser on its clinical development. On the other hand a completely unbiased reviewer might be ill-informed on the topic, lessening the merits of his/her review.
Interestingly we note that the NEJM had a similar ban in the 1990s but later reverted to “declaration of conflicting interest”.
In pre-antibiotic days, removal of the tonsils and adenoids was an almost mandatory procedure in infants as it was believed that such surgery would prevent recurrent upper respiratory tract infections. Whether it was or is efficacious is a moot point but the practice continues. This randomised controlled trial compared a strategy of adenoidectomy with or without myringotomy with a strategy of initial watchful waiting. The outcomes measured over 2 years were the number of upper respirator tract infections and middle ear complaints with fever.
There was no significant difference between the two cohorts. The children in the watch group who later had adenoidectomy also received no benefit from their surgery. The researchers conclude that immediate adenoidectomy confers no clinical benefits over initial watchful waiting as the prevalence of infections decreases equally over time in both groups.
It is generally acknowledged that complex polypharmacy heightens the risk of serious adverse drug events in the elderly. The authors of this paper point out that although frailer, older people are usually excluded from randomised controlled trials, prescribers often persist with evidence-based prescribing in end-of-life older patients. They suggest that lipid-lowering drugs are almost always inappropriate in end-of-life as their evidence-based benefits occur in a 5–10 year timeframe in a younger population.
Likewise, ACE-inhibitors and angiotensin receptor blockers to prevent diabetic nephropathy or to reduce mortality from heart failure are of little value when a patient’s life expectancy is severely curtailed as a result of other irreversible disorders. They also point out that medication intended for primary or secondary disease prevention are inappropriate in the frail elderly. Their trial conclusion is that the focus in prescribing for the elderly should be oligopharmacy.
Age and Ageing 2011;40:419–22.
4th November 2011, Volume 124 Number 1345