Published in the February 2011 issue of Today’s Hospitalist
CMS spells out value-based purchasing incentives
THE CMS HAS RELEASED its long-anticipated proposed incentives for value-based purchasing, which would apply to acute hospitals beginning in October 2012. Hospitals will be able to initially earn an additional 1% in DRG payments ” or be penalized that same amount “based on how they perform on 17 clinical process measures and eight HCAHPS survey measures. The bonus/penalty amount is expected to rise to 2% by fiscal year 2017.
The process measures target five conditions: AMI, heart failure, pneumonia, health care-associated infections and surgical care. Incentives for FY 2014 may additionally include some outcome measures and metrics related to hospital-acquired conditions.
The comment period on the proposed incentives ends March 8. Hospitals have already expressed concerns that as much as 30% of the proposed incentives would be tied to publicly reported patient satisfaction scores. Hospitals have pointed out that Press Ganey surveys reveal a regional bias in patient satisfaction scores, with only 64% of patients in New York, New Jersey and Pennsylvania saying they would “definitely” recommend the facility where they were hospitalized vs. 73% of patients in New England.
Should patients know how long surgeons sleep?
AN ARTICLE IN THE DEC. 30 NEW ENGLAND JOURNAL OF MEDICINE written by a sleep medicine expert calls for mandatory disclosure when surgeons who are sleep deprived are scheduled to perform elective surgeries. Such disclosures would allow patients to opt for another surgeon or to postpone surgery.
The problem is not just surgical residents or fellows, the article states. Studies show that patients of any surgeon on call the previous night who may have had fewer than six hours of sleep run an 83% increased risk of surgical complications.
The author notes that making disclosure mandatory and allowing patients to demand another surgeon for an elective surgery could damage the physician-patient relationship. Instead, the author writes, hospitals should put policies in place prohibiting surgeons from performing elective surgeries after being on-call overnight, particularly in busy hospitals.
Comments in the same issue by the American College of Surgeons (ACS) acknowledge errors due to surgeon fatigue, but do not endorse mandatory disclosure. The ACS instead maintains that surgeons should be trained to recognize when they’re sleep deprived to determine whether they should operate.
How much evidence is behind guidelines?
AN ANALYSIS OF MORE THAN 40 GUIDELINES issued by the Infectious Diseases Society of America finds that more than half of the recommendations contained in those guidelines are based on expert opinion, not randomized trial evidence.
The authors of a study published in the Jan. 10 Archives of Internal Medicine looked at the evidence behind IDSA guidelines issued between January 1994 and May 2010. The study found that only 14% of those recommendations were backed by level 1 evidence, which refers to data derived from at least one randomized trial. The study did find that 55% of the recommendations were based on expert opinion or descriptive studies. The authors also note that randomized trials on many infectious diseases are not practical, given that many of those infections may be infrequent.
While the researchers describe the present guidelines as “a great and reliable source of information,” they urged physicians to use caution when relying only on guidelines to help guide medical decision-making. They also recommended that further research should target those areas that have lower levels of quality evidence.
Meds missed on 60% of inpatient transfers
JUST OVER 60% OF PATIENTS transferred between inpatient units have at least one medication discrepancy, according to a study of internal transfers done at two Canadian tertiary care centers.
The study, published online by the Annals of Pharmacotherapy, found that the most common problem was a medication omission, which accounted for half of all problems. Just over one-third of patients could have suffered discomfort or clinical deterioration as a result of the medication reconciliation problems.
Researchers also found that discrepancies in medication reconciliation were present in transfers between units that used only paper-based ordering, those that used only computerized physician-order entry systems, and those that used a combination of the two. The authors found that the use of CPOE led to no significant reduction in the number of discrepancies at transfers.
Factors that increased the risk of a medication discrepancy included a higher number of transfer medications or home medications, and the lack of an accurate medication history.
The ABIM eases up on imposed sanctions
THE AMERICAN BOARD OF INTERNAL MEDICINE (ABIM) is apparently minimizing some of the sanctions it imposed last year on physicians who, the board claimed, had passed along ABIM exam questions when participating with a board-preparation company.
Last January, the ABIM sued Arora Board Review, saying that physicians involved in the board-review company were passing along or receiving actual exam questions culled from ABIM exams. In June 2010, according to an ABIM press release, 139 physicians who took the review course had their certification suspended for between one and five years or were prohibited from sitting for an exam for a defined period of time. The ABIM also sent letters to 2,700 physicians who attended courses through that board-review company, although those letters did not accuse the physicians of any wrongdoing.
After sanctioned physicians went through the ABIM’s appeals process, some of the sanctions were rescinded. Other sanctions were reduced to community service to ensure that physicians won’t run the risk of losing staff privileges or their ability to participate with third-party payers.
No indication for one in five ICDs
A NEW STUDY THAT COMBED THROUGH REGISTRY DATA for patients receiving implantable cardioverter-defibrillators (ICDs) found that 22% of those patients did not meet evidence-backed guidelines for the procedure.
The study points out that ICDs are not recommended for primary prevention in patients recovering from a heart attack, for those with severe heart failure symptoms or for patients who’ve been recently diagnosed with heart failure. However, many patients in the registry met those conditions. Patients receiving non-evidence-based ICDs had higher rates of complications and increased risk of in-hospital death.
Among specialists who place ICDs, electrophysiologists had the lowest rate of non-evidence based implants at 20.8% vs. 24.8% for nonelectrophysiologists, 36.1% for thoracic surgeons and 24.9% for other specialists.
The registry data analyzed were entered between Jan. 1, 2006, and June 30, 2009. Authors noted that there wasn’t any significant increase in the percentage of non-evidence-based implants over that time period. The study was published in the Jan. 5 issue of the Journal of the American Medical Association.
Want to boost capacity? Reengineer surgical schedules
A NEW ANALYSIS IN HEALTH AFFAIRS looks at ways that hospitals have boosted their throughput and bed capacity without adding staff or beds.
The authors write that bed occupancy in the U.S. runs about 65%, even though EDs are often on divert and ICU beds are often not available. One major culprit that prevents hospitals from optimizing bed capacity: allowing elective surgeries to be scheduled only a few days a week.
Researchers found that one hospital was able to boost its surgical volume 7% by re-distributing the volume of elective surgeries, while another hospital improved patient flow and bed capacity by dedicating ORs to either scheduled or emergent procedures.
The issue of hospital capacity will become increasingly critical, the authors write, as health care reform adds millions more to the rolls of insured patients. With proper streamlining of patient flow, the authors claim, hospitals should be able to routinely achieve bed occupancy rates of between 80% and 90%.
Is your hospital among the most wired?
PHYSICIANS AND CIOS ARE NOW INVITED to fill out surveys to determine the 2011 list of the Most Wired hospitals. The survey is sponsored by Hospitals & Health Networks magazine, a publication of the American Hospital Association.
The publication also names the 25 Most Improved hospitals in terms of their information technology capacity, as well as the Most Wired small and rural hospitals. Also named will be three winners and three finalists for the Most Wired Innovator Awards, which are designed to acknowledge unique information technology projects.
To determine who makes the Most Wired lists, hospital systems are assessed according to several factors, including their technological infrastructure and clinical quality and safety features. Hospitals that fill out the survey will also receive a report showing how their organization scored compared to other respondents on different survey questions.
The deadline for completely the survey or applying for an Innovator Award is March 15.