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The new wave of physician employment

May 2011

Published in the May 2011 issue of Today’s Hospitalist

The new wave of physician employment

A NEW ENGLAND JOURNAL OF MEDICINE PERSPECTIVE zeroed in on the red-hot market for hospitals buying outpatient primary and specialty practices, noting that the number of physicians directly employed by hospitals has soared 75% since 2000. The Perspective piece was posted online at the end of March.

The authors pointed out that in the 1990s, hospitals also purchased many outpatient practices. This time, however, the authors noted, hospitals are just as interested in employing specialists as primary care physicians. Part of the rush, they explained, is to integrate physician practices into hospital systems to form accountable care organizations.

In a New York Times Q&A, the authors also noted that outpatient physicians now have more at stake in becoming employed than in the 1990s. That’s because payment methodologies may switch significantly from fee-for-service to risk-based payment, and because mastery of information technology is now expected.

Those factors could make it harder for outpatient practices to unwind an employment agreement that doesn’t work out and re-enter traditional private practice.

Adverse drug events for one in three inpatients?

A NEW METHOD TO DETECT adverse events released by the Institute for Healthcare Improvement (IHI) finds that one in three hospital admissions is affected by an adverse event. That number is 10 times higher than previous estimates.

Researchers compared three methods of finding adverse events using the same data set from three hospitals. Voluntary reporting found only four events among the sample, while use of AHRQ patient safety indicators detected 35.

When the researchers used the IHI’s global trigger tool, which entails a review of medical records, they found 354 serious and confirmed events. The global trigger tool relies on a retrospective review of patient records and looks for specific “triggers” or sentinel words or events. Triggers include certain drug names as well as such words as “oversedation” and “over-anticoagulation,” and biomarker levels beyond certain thresholds.

Writing in the April issue of Health Affairs, the researchers claimed that trigger tools could be incorporated into electronic medical records. That would make detecting errors less costly and onerous than using a system that requires manual chart reviews.

Lowering troponin thresholds yields better outcomes

A NEW STUDY FOUND that lowering the diagnostic threshold for troponin assays led to better detection of acute coronary syndrome, lower mortality rates and fewer recurring MIs. The article appeared in the March 23/30 issue of the Journal of the American Medical Association.

Scottish researchers looked at patient outcomes before and after they lowered the diagnostic threshold from 0.20 ng/mL to 0.05. That new diagnostic threshold increased the number of MI diagnoses by 29%. Identifying more high-risk patients also led to better risk management because more patients were referred to cardiologists, were started on dual antiplatelet therapy or received coronary angiography.

The improvement of clinical management for patients identified with ACS, the authors wrote, was “immediate and substantial.” Implementing the lower threshold also lowered patients’ mortality risk to 21% from 39%. The authors pointed out that the subgroup of patients who had small increases in troponin concentration (0.05-0.19 ng/mL) had a 50% reduction in their rate of death or recurrent MI.

HHS: $1 billion to reduce complications, readmissions

THE DEPARTMENT OF HEALTH AND HUMAN SERVICES last month announced a $1 billion program targeting hospitals, physicians and consumer groups to reduce inpatient complications and preventable admissions.

The Partnership for Patients program was created by health care reform legislation. It has immediate funding for demonstration projects to test models of delivering safer care and preventing health care-acquired complications, such as adverse drug events, pressure ulcers and surgical site infections. Half of the funds will go to a CMS program looking at more effective transitions out of hospitals for high-risk patients to lower acuity settings.

Program goals include reducing the number of hospital-acquired complications by 40% by 2013 (from 2010 levels) and lowering the number of readmissions by 20%. More than 500 hospitals will take part in the demonstration projects.

Participants in the program include not only Medicare and hospitals, physicians and nurses, but employers, unions, health plans, state government purchasers, and consumer and patient organizations.

Mixed results from e-ICU coverage

A META-ANALYSIS looking at the impact of remote ICU coverage found that while telemedicine was associated with lower ICU mortality and shorter length of stay, e-ICUs did not reduce overall hospital LOS or mortality rates.

The review, which was published in the March 28 issue of Archives of Internal Medicine, looked at 13 studies involving more than 35 ICUs. The authors found that e-ICU coverage reduced ICU LOS by 1.26 days, but that reduction was eroded over the course of patients’ entire hospital stay.

An accompanying editorial noted that much of the data in the meta-analysis came from one-site, before-and-after studies, and that larger, randomized studies are needed.

The editorial also claimed that instead of using telemedicine to increase supervision of critically ill patients at night, as is common, ICUs would be better served using telemedicine during the day to remotely monitor the use of evidence-based practices for sedation and ventilator management. Boosting the use of best practices in critical care, the editorial said, could improve both ICU and in-hospital mortality rates.

AMA launches new CPT app, app contest

THE AMERICAN MEDICAL ASSOCIATION has unveiled a new, free CPT app for Apple devices to help physicians choose CPT codes for E/M services. The CPT Evaluation and Management Quick Reference app is the first version of a more comprehensive and customizable coding app that the AMA plans to release later this year.

The app includes decision-tree logic and quick search options for about 130 CPT codes. The AMA plans to release updates to make more CPT codes available for a fee. While this is the first app released by the AMA, the association plans this year to release two others.

The AMA also announced App Challenge, a contest for physicians to suggest potential medical apps. The AMA plans to develop and release the two winning app ideas it receives.

One contest category is for practicing physicians, while the other is for residents, fellows, and students. The deadline for app ideas is June 30.