A supervised hospital walking program may reduce nursing facility admissions for older adults

1. A supervised hospital walking program may reduce nursing facility admissions for older adults
Abstract: https://www.acpjournals.org/doi/10.7326/M22-3679
URL goes live when the embargo lifts
A randomized trial of older veterans found that hospitalized persons enrolled in a supervised walking program known as STRIDE (AssiSTed EaRly MobIlity for HospitalizeD VEterans) were less likely to be discharged to a skilled nursing facility. However, the authors noted that participation in the program was low and there was no change associated with length of hospital stay or inpatient falls. The study is published in Annals of Internal Medicine.

Inactivity during hospitalization has been recognized as a key contributor to hospital-associated disability and other harms for decades. Low mobility has been linked to delirium, falls, longer lengths of stay (LOS), greater risk for readmission, and functional decline resulting in discharge to skilled nursing facilities. In previous trials, hospital walking programs have been shown to improve functional ability after discharge, but little evidence exists about their effectiveness under routine practice conditions.

Researchers from Durham VA Health Care System and Duke University conducted a stepped-wedge, cluster randomized trial of persons aged 60 and older admitted to 8 Veterans Affairs hospitals to evaluate the effect of implementation of a supervised walking program on discharge to a skilled nursing facility, length of stay, and inpatient falls. Participating hospitals received structured guidance to help plan and launch their programs but were responsible for identifying and training their clinical personnel to assess patients and conduct walks. The authors found that the proportion of patients discharged to a skilled nursing facility pre-STRIDE (n=6,722) was 13 percent while the proportion of patients discharged to a skilled nursing facility post-STRIDE (n=6,141) was 8 percent. However, participation in the program was low and variable, with participation of potentially eligible patients ranging from 0.6 percent to 22.7 percent and 2 hospitals pausing or discontinuing the program after it was launched. Still, the authors say their findings suggest that health systems should consider hospital walking programs as a reasonable means to improve quality of care for older adults. Further development of strategies to support hospitals in implementation of new clinical programs are needed to enhance their effect.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Susan N. Hastings, M.D., MHSc, please email Chris Camacho at christopher.camacho@va.gov.
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2. Nirmatrelvir–ritonavir and molnupiravir each associated with 77% reduced risk for death from COVID-19
Abstract: https://www.acpjournals.org/doi/10.7326/M22-3565
URL goes live when the embargo lifts
Three trial emulation studies have found that the use of nirmatrelvir-ritonavir for treatment of COVID-19 reduced the risk of death or hospitalization by 77 and 27 percent, respectively. However, molnupiravir was only associated with a benefit for reduced risk of mortality, not hospitalization. The findings are published in Annals of Internal Medicine.

Two pharmacotherapies--nirmatrelvir packaged with the boosting agent ritonavir (nirmatrelvir–ritonavir), and molnupiravir—received emergency use authorization from the U.S. Food and Drug Administration (FDA) in December 2021 for treatment of nonhospitalized persons with symptomatic COVID-19 who are at high risk for progression to severe COVID-19. Previous trials showed a reduction in COVID-19–related hospitalization or death with nirmatrelvir–ritonavir, but there is less evidence of benefit for molnupiravir. Additionally, information about the effectiveness of these antivirals in the setting of Omicron variant transmission is limited.

Researchers from Veterans Affairs Portland Health Care System and Oregon Health & Science University conducted 3 retrospective target trial emulation studies comparing the effectiveness of nirmatrelvir–ritonavir versus no treatment, molnupiravir versus no treatment, and nirmatrelvir–ritonavir versus molnupiravir. Participants included nonhospitalized veterans at risk of progressing to severe COVID-19 between January and July 2022. The authors found that nirmatrelvir–ritonavir was effective at preventing 30-day all-cause mortality, hospitalization, ICU admission, and mechanical ventilation, whereas risk reduction associated with molnupiravir was limited to all-cause mortality. They note that both nirmatrelvir-ritonavir and molnupiravir were associated with a 77 percent lower risk of death, but only nirmatrelvir–ritonavir was also associated with a 27 percent lower risk for hospitalization.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Kristina L. Bajema, M.D., MSc, please contact Rene LaFleur at Rene.LaFleur@va.gov.

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3. Coronary CT angiography associated with similar health effects to invasive coronary angiography and with a health benefit compared with noninvasive functional tests for diagnosing stable coronary artery disease
Abstract: https://www.acpjournals.org/doi/10.7326/M23-0231
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A review of 15 clinical trials has found that the use of coronary computed tomography angiography (CCTA) to diagnose stable coronary artery disease was associated with similar health effects to direct invasive coronary angiography (ICA) and had a health benefit compared with exercise electrocardiography (ECG) and stress single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). The analysis is published in Annals of Internal Medicine.

ICA is currently the benchmark for diagnosing coronary artery disease, but its cost, invasiveness, potential complications, and low diagnostic yield for the initial assessment of suspected stable coronary artery disease have called its large-scale use into question. For this reason, noninvasive diagnostic tests are increasingly being used in the diagnostic process.

Researchers from Catholic University of the Sacred Heart, Rome, Italy conducted a systemic review and meta-analysis of 15 clinical trials evaluating the use of alternative diagnostic strategies for the initial assessment of patients with suspected stable coronary artery disease. The authors found that compared with direct ICA referral, CCTA was associated with no difference in direct health outcomes but less referral to index ICA and index revascularization. They also found that compared with exercise ECG or SPECT-MPI, CCTA was associated with a reduction in the risk for cardiovascular death and myocardial infarction. However, CCTA was associated with more index revascularization but less downstream testing than exercise ECG. Direct health and clinical management outcomes did not differ significantly between functional tests, except for a reduction in downstream testing with SPECT-MPI in comparison with exercise ECG and CMR (cardiac magnetic resonance) imaging.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Francesco Burzotta, MD, PhD, please email Nicola Cerbino at nicola.cerbino@unicatt.it.
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