Digest 49: New Year, New Learning, New Resolutions?

January 19, 2024 | By Nora Taranto

Welcome Back to The Curbsiders Digest!

In this issue, we feature  Ft. toothbrushing in the hospital, genetic testing in breast cancer, at-home STI testing, and quality care and private equity. Effortlessly absorb important medical news, with our twice monthly newsletter featuring easily digestible analysis of the latest practice-changing articles, and of course…bad puns. 

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Issue 49

01/19/2024

Appetizers (to whet your appetite) 

Palate Cleanser (aka the melon part of the meal) 

The Main Course

A Digestif or two

Appetizers

Brought to you hot off the stove, from a variety of specialties. Delivered in super tasty, bite-sized morsels. 
–Jennifer DeSalvo MD, Beth Garbitelli MD, Alyssa Mancini MD

• Simple 2 Test – STI testing from the comfort of your own home. The FDA just granted marketing authorization for the first at-home test for chlamydia and gonorrhea.  The Simple 2 Test, which is intended for use in adult patients and uses vaginal swabs and urine specimens, is available over the counter.  After purchase, the patient activates the kit online and submits a health questionnaire. The patient then collects the specimen, ships it to the lab, and receives results through the online platform. Follow-up from a health care provider then occurs with a positive or invalid test result. (AM) 
• New guidelines on genetic testing for patients with breast cancer. The American Society of Clinical Oncology (ASCO)/Society of Surgical Oncology recently updated recommendations for germline mutation testing in breast cancer in the Journal of Clinical Oncology. After review of 65 articles, the expert panel recommended that all patients with newly diagnosed breast cancer aged < 65 should be offered BRCA1/2 testing. Testing should be offered to some patients > 65 based on family or personal history, ancestry, or eligibility for PARP inhibitor therapy. All patients with recurrent breast cancer or who develop a second breast cancer should be offered testing, as should patients with a breast cancer history diagnosed at age <65, or age >65 if it will inform personal and family risk. Personal and family history should guide testing for other cancer-susceptibility genes. Patients with pathogenic variants should receive post-test counseling. (AM)
• Time for a new TARGET? Thromboprophylaxis in malignancy. The TARGET-TP phase 3 randomized clinical trial published in JAMA Oncology assessed the benefit of prophylactic enoxaparin in 328 adults on systemic anticancer therapy for lung or gastrointestinal cancer. Patients were divided into low-risk and high-risk thromboembolism cohorts using fibrinogen and d-dimer levels. High-risk patients were randomized to receive subcutaneous enoxaparin 40 mg daily for >3 months or no thromboprophylaxis (control).  Among high-risk patients, a lower percentage of those on prophylaxis experienced thromboembolic events (8% versus 23% in the control arm, HR 0.31, 95% CI 0.15-0.70, p=0.005, NNT 6.7), with low rates of major bleeding. There was a significant reduction in all-cause mortality among high-risk patients who received thromboprophylaxis, compared to high-risk controls. (JD)
• More than metformin for DM2 in pregnancy – A multinational population-based cohort study published in JAMA Internal Medicine evaluated the risk of major congenital malformations (MCMs) with periconceptual exposure to newer noninsulin antidiabetic medications besides metformin, which has become one of the standard agents used in pregnancy (often before insulin). This study assessed the risk of MCMs in > 15,000 women with Type 2 Diabetes Mellitus (DM2), of whom > 7700 were prescribed second-line anti-diabetic medications–including DPP-4 inhibitors, GLP1 agonists, SGLT2 inhibitors, sulfonylureas, or insulin–in the 3 months before/after conception. Even with increasing periconceptional use of noninsulin antidiabetic medications, there was not a greater risk of major congenital malformations with any of these second-line novel medications compared with insulin. (JD) 
• Fighting Pneumonia One Toothbrush At A Time: A recently published systematic review and meta-analysis of 15 randomized control trials evaluated toothbrushing in >2700 hospitalized patients. Patients randomized to receive daily toothbrushing had a lower risk of developing hospital acquired pneumonia (risk ratio [RR], 0.67 [95% CI, 0.56-0.81])–including among patients receiving invasive mechanical ventilation.  Toothbrushing was also associated with a significantly lower ICU mortality risk (RR, 0.81 [95% CI, 0.69-0.95]), shorter length of mechanical ventilation, and shorter ICU stays. It is worth noting that about half the studies were considered to have unclear or high risk of bias, and none of the studies were double-blinded, as it is difficult to conceal toothbrushing. (BG) 

Palate Cleanser

The melon part. To get rid of the taste of those pesky apps.  And to fill your brain with some fun facts.

My Heart and I: Mr. Richard Waring captures his hospital experience through poetry and prose in this poignant reflection published in NEJM. 

– Beth Garbitelli, MD 

The Main Course

Alexander Chaitoff MD, MPH  

The Business of Healthcare is Changing
The healthcare sector, with total health expenditures at $4.5 trillion dollars, is big business. But the business of healthcare has changed.  Long gone are the days of a doctor hanging out their shingle in a small town, with mergers and acquisitions taking over the industry, and bigger hospital systems buying up independent physicians and smaller hospitals.  This decades-long story of the corporatization of healthcare, and of healthcare transforming from independent physicians into HMOs, has been told most famously in Paul Starr’s “The Social Transformation of American Medicine.”  A recent New England Journal of Medicine perspective piece described how the healthcare industry is changing further, with the rise of financialization, or healthcare entities being increasingly turned into assets traded by the financial sector for profit. This has meant a flood of capital – and ownership stakes – into healthcare by entities like Private Equity (PE) firms.

So, is the changing business of healthcare good for the health of patients? The data is in, and the answer seems to be a resounding no.

Private equity in healthcare
PE firms often raise capital from institutions or high net-worth individuals to purchase mature companies (as opposed to venture capital firms that typically focus on earlier-stage startups). PE firms are increasingly buying healthcare companies – from nursing homes to hospitals – with the goal of extracting value in the short term and selling within ~4-7 years. Unfortunately, to increase income quickly and achieve these goals, companies must often use tactics that some might think antithetical to quality healthcare, such as cutting staff and increasing costs to patients and payers. And while occasional cohort studies suggest PE-acquired hospitals might perform better on a select few quality metrics, the aggregate scientific evidence and patient stories make clear the potential harms.

Patient Outcomes and Private Equity
More high quality evidence that PE-ownership of hospitals might harm patients has now been published in JAMA by Kannan et al. The authors conducted a difference-in-difference analysis to assess whether being acquired by a PE firm led to a subsequent increase in hospital-acquired conditions, such as falls and central line-associated bloodstream infections. Generally, a difference-in-difference analysis can answer such a question by looking at the rates at which outcomes occur before and after an event in an intervention group, versus a matched control group over that same time period. This design overcomes time-invariant differences and mitigates other biases compared to a design looking only at an intervention group without a matched control over the same period.

In this study using Medicare claims data, the rate of hospital-acquired conditions (the primary outcome) was first calculated for hospitals that would go on to be bought by PE firms (the intervention group) and for matched hospitals that were not bought by PE firms (the control group). Rates of hospital-acquired conditions were then calculated in both groups after the timepoint of PE firm acquisition. The differences in rate of hospital-acquired conditions were compared between the two groups over the time period spanning PE acquisition (for up to 3 years before and after PE acquisition).  Compared to those at control hospitals, patients at PE-acquired hospitals were less likely to be enrolled on both Medicare and Medicaid, were slightly younger, and were more likely to be transferred to other acute care hospitals.  The authors ultimately found a 25% increase in hospital-acquired conditions after PE acquisition compared with control hospitals, with a 27% increase in falls (P=0.02) and a 38% increase in central line-associated bloodstream infections (P=0.04) at PE-acquired hospitals, despite a decrease in central line placement.  Surgical site infection rates also increased (though this difference was not statistically significant) at PE-acquired hospitals despite overall surgical volume reduction after acquisition. 

Consider this another study–in a growing list–to suggest that prioritizing profit may not beget quality care, and that it may in fact come at the cost of health and patient outcomes.

Read The Latest Article in JAMA HERE

Digestifs

Before you go….
we’ve got a few nibbles!

Consolidate your learning with a Quiz!  

This week on The Curbsiders: We have a live (and fabulous) one. Episode #422 covers the inpatient management of Sickle Cell with guest Dr. Yoo Mee Shin – from acute chest, pain management, to transfusion recommendations. Chock full of myriad useful management pearls, for some of our most vulnerable patients.  

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Until next time, keep that brain hole digesting! 

The Curbsiders Digest

Issue 49

Editor in Chief: Nora Taranto MD

Banner: Kate Grant  MBChB, DipGUMed

Disclosures:

Beth Garbitelli,, Jennifer DeSalvo,  Alyssa Mancini, Hannah Smith, and Nora Taranto report no disclosures.

Alexander Chaitoff reports consultancy for Alosa Health.

Kate Grant reports no disclosures

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