Home News Briefs The high price of new duty-hour rules

The high price of new duty-hour rules

October 2011

Published in the October 2011 issue of Today’s Hospitalist

The price-tag for new duty-hour rules

RESEARCHERS FROM UCLA estimate that implementing new duty-hour rules could easily cost teaching hospitals $1 billion a year or more.

Since July 1, residents can no longer work more than 16 hours. According to the new analysis, which was posted online in September by the Journal of General Internal Medicine, the cost of new duty-hour rules depends on the type of substitute coverage that teaching facilities use to replace residents. The cost would be $1.34 billion a year if additional coverage was made up by NPs and PAs, but $1.64 billion if provided by attendings.

The researchers also estimated that the net costs to teaching hospitals would be zero if the number of preventable adverse events under new duty-hour rules drops between 7.2% and 25.8%. But if fewer adverse events are averted, the authors wrote, teaching hospitals will lose money.

Stroke patients need a month of VTE prophylaxis

AN ANALYSIS OF DATA on immobilized stroke patients found that while most individuals who develop clots do so in their first week post-stroke, patients continued to need prophylaxis for at least a month.

Writing in the Journal of Thrombosis and Haemostasis, researchers indicated that 11.4% of immobilized stroke patients developed clots within a week. However, 3.1% of patients developed DVT a month later. Only one-third (35%) of patients with a DVT had symptoms of leg swelling or pain, while 5% were found to have a pulmonary embolism and 17% had bilateral DVTs.

Of the DVTs detected, 39% were restricted to the calf veins, while 40% were femoral and 21% were popliteal. Among DVTs detected early, researchers wrote, 9% progressed, 47% regressed and 44% stayed the same.

The authors recommended that prophylaxis continue for at least four weeks. Results were based on randomizing more than 5,600 patients in 135 hospitals in nine countries.

How many physicians get immunized?

A CDC SURVEY OF HEALTH CARE PERSONNEL indicated that staff working in hospitals have a higher rate of being vaccinated against the flu (71.1%) than providers working in outpatient settings (61.5%). Overall, just under two-thirds (63.5%) of health care personnel were vaccinated during last year’s flu season.

Among health care personnel, physicians racked up the highest percentage of vaccinations last year, at 84.2%. Among nurse practitioners and physician assistants, the percentage vaccinated last year was 82.6%.

Survey responses also showed that 13% of health care personnel reported working for an employer with a mandatory vaccination policy. In hospitals that required vaccination, 98.1% of all personnel received vaccine, compared to 58.3% of those in facilities without mandatory vaccination.

Factors associated with high vaccination rates in hospitals that don’t mandate vaccinations included reminders from administrators, free vaccines and vaccination campaigns that lasted more than one day. Results were reported in the CDC’s Morbidity and Mortality Weekly Report.

ICU admissions and med interruptions

CANADIAN RESEARCHERS HAVE FOUND that hospitalized patients face a risk of having medications for chronic conditions unintentionally discontinued. That risk is even higher for patients admitted to ICUs.

The study looked at hospitalizations and outpatient prescriptions in Ontario from 1997 to 2009 and targeted patients taking at least one of five medications: statins, antiplatelets/anticoagulation, levothyroxine, an inhaler or acid-suppressing drugs. Researchers compared administrative data for patients who’d spent time in the ICU, patients who’d been hospitalized but didn’t go to an ICU, and patients who weren’t hospitalized at all. The study endpoint was failure to renew a prescription within 90 days of hospital discharge.

The highest rate of unintentional discontinuation was 22.8% for patients admitted to an ICU who had come into the hospital on antiplatelets/anticoagulation.

Among patients whose medications had been discontinued, one-year follow-up showed a higher incidence of death, ED visits and emergency hospitalizations. The study appeared in the Sept. 14 Journal of the American Medical Association.

Many IM residents burning out

THE FIRST LARGE-SCALE NATIONAL STUDY of internal medicine residents indicates that more than one-half reported at least one symptom of burnout. One-third (32.9%) were somewhat or very unhappy with their work-life balance, and almost 46% reported being emotionally exhausted.

Researchers looked at self-assessments made during the 2008-09 academic school year for nearly three-quarters (74.1%) of all IM residents that year. The residents answered questions about quality of life and work-life balance as part of their internal medicine in-training examination (IM-ITE). Interns were more likely than older residents to report emotional exhaustion, although the number of residents reporting depersonalization increased with training levels.

The residents’ self-reported levels of emotional exhaustion and burnout also increased with their amount of educational debt. At the same time, residents with higher self-reported burnout and educational debt had lower IM-ITE scores.

The authors, writing in the Sept. 14 Journal of the American Medical Association, also found that IMGs were less likely to report high levels of emotional exhaustion than U.S. graduates.

Mayo, Cleveland Clinic look to partner with physician practices BOTH THE MAYO CLINIC AND THE CLEVELAND CLINIC are now in the market to affiliate with physician practices around the country.

The two powerhouse systems want to partner with medium- to large-size single specialty practices, which would pay the clinics a subscriber fee in return for using their brand and clinical resources. According to an article in AM News, the move is in part a reaction to the rise of hospital medicine. Because outpatient physicians now have more options about where to refer patients, the clinics want to expand their outpatient affiliations.

Both health care systems also recently began affiliating with hospital systems around the country; Mayo forged an affiliation earlier this year with Altru Health System in Grand Fork, N.D. Experts see the move on the part of health systems with national name recognition to affiliate with other hospital networks and physician practices as part of the trend toward consolidation. As part of that trend, many hospital systems this year have been buying physician practices.

Cumulative antibiotic use increases C. diff risk

PATIENTS TAKING MORE THAN ONE ANTIBIOTIC run a commensurately greater risk of developing C. diff in hospitals, according to a retrospective analysis of hospital data from 2005.

The study looked at hospitalizations for nearly 7,800 patients who received antibiotics for at least two consecutive days. Researchers found that compared to patients taking only one antibiotic, the adjusted hazard ratios for contracting C. diff for those taking two, three to four, or five different antibiotics were 2.5, 3.3 and 9.6. (The overall incidence of C. diff was 4.3 per 10,000 patient-days.)

Fluoroquinolones were associated with higher risk, as were IV vancomycin, sulfa drugs, IV cephalosporins and beta-lactamase inhibitor combinations. Metronidazole, on the other hand, was linked to lower C. diff risk.

Findings were published in a recent issue of Clinical Infectious Diseases. The authors recommended reducing the number and doses of antibiotics to decrease total antibiotic dosages. They also recommended substituting low-risk classes of antibiotics for higher-risk ones to reduce C. diff incidence.

When will meaningful use become meaningful?

WITH THE FEDERAL GOVERNMENT offering financial incentives to hospitals to get computer ordering up and running, a new analysis claims that it will probably be a while before electronic ordering makes an impact on mortality rates.

In the September issue of Health Affairs, RAND researchers analyzed both hospital-reported mortality rates and hospitals’ electronic-ordering capacity. The authors pointed out that the first threshold being used for meaningful use “electronic ordering for at least 30% of eligible patients “won’t deliver a statistically significant reduction in mortality from heart failure and heart attack for Medicare patients.

However, the authors noted that reaching the second threshold of meaningful use implementation, having electronic ordering in place for at least 60% of eligible patients, should have a demonstrable impact. (Stage 3 of meaningful use would have hospitals using electronic ordering for 80% of patients.) The researchers pointed out, however, that critics claim that a threshold of 60% of patients will be too difficult to reach.