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Hospitalist comanagement: no improved outcomes

January 2011

Published in the January 2011 issue of Today’s Hospitalist

Comanagement: no improved outcomes

A STUDY looking at the impact of a hospitalist comanagement service for neurosurgery finds that while nurses and other providers perceive a higher quality of care, patients had no improved outcomes. The retrospective study was published in the Dec. 13/27 issue of Archives of Internal Medicine.

Researchers at the University of California, San Francisco measured outcomes and patient satisfaction both before and after a hospitalist comanagement service began in July 2007. The service did save more than $1,400 in costs for each patient comanaged, and authors said their study was the first to find cost savings. However, researchers found no difference in mortality or readmission rates, patient satisfaction or length of stay. They did note that hospitalist comanagement may have little effect on the outcomes of neurosurgery patients, particularly those with emergent problems.

A related editorial in the same issue argues that comanagement is being driven by economic factors that are shifting care from highly-paid surgeons to lower-paid internists. The editorialist questions whether, in the face of a hospitalist shortage, internists can afford to broaden their scope of practice.

The high cost of delayed surgeries

PATIENTS AND HOSPITALS that delay elective surgeries pay a high price in terms of complications and hospital costs.

A study in the December issue of the Journal of the American College of Surgeons looked at a sample of more than 163,000 patients in the U.S. who underwent CABG, colon resection or lung resection from 2003 to 2007. Researchers measured whether those patients had surgery done on the day of admission, day 1, days 2 through 5 or days 6 through 10.

Among CABG patients operated on the day they were admitted, 5.73% developed infections “typically pneumonia, UTI, postoperative sepsis or site infections “compared to 18.24% operated on days 6 through 10.

Hospital costs also rose considerably the longer surgeries were delayed. The range in costs for treating CABG patients ran from between $25,164 in patients whose procedures weren’t delayed to more than $42,000 for those who were. The authors found that delaying procedures also increased postoperative hospital mortality.

The authors concluded that hospitals need to move to reduce costs and infection rates by developing policies geared to preventing surgical delays.

Pending tests go AWOL in transfers to subacute care

A NEW STUDY FINDS that while one-third of patients being transferred to a skilled nursing facility, long-term acute care or rehabilitation hospital have pending lab tests, only 11% of those patients’ discharge summaries mention that fact.

The study, which was published online by the Journal of General Internal Medicine, says that such omissions make it easier to miss follow-up on those test results, both in the acute and subacute setting. The patients being transferred were stroke, cancer and hip fracture patients discharged from an academic center. The lab results most frequently missing were blood tests and urine cultures.

Other studies have found that more than 40% of patients who are discharged home from acute care hospitals likewise have pending test results, and that many of those patients’ discharge summaries don’t mention that tests are pending. The authors point out, though, that patients being discharged home may be able to follow up on pending test results more actively than patients discharged to subacute facilities.

Mortality higher for renal patients on weekends

PATIENTS WITH END-STAGE RENAL DISEASE who are admitted to hospitals on weekends run a 17% higher risk of dying in the hospital than renal patients admitted during the week.

Preliminary study findings on the “weekend effect” for renal patients were presented at an American Society of Nephrology meeting in November. Researchers also indicated that renal patients admitted on weekends had to wait about one-third of a day longer to be started on dialysis than patients admitted during the week. They hypothesized that electrolyte and fluid imbalances due to delays in dialysis may explain why renal patients have higher mortality.

According to the study, 20% of people hospitalized with end-stage renal disease in 2007 were admitted on a weekend. Researchers commented that like other studies for which weekend care has been linked to poorer patient outcomes, the results highlight the need for redesigning hospital staffing to ensure the availability of staff and dialysis resources on weekends.

Gainsharing: lower LOS and hospital costs

A program that combined pay-for-performance incentives and a CMS gainsharing project has posted lower lengths of stay and reduced hospital costs.

Researchers at New York’s Beth Israel Medical Center participated in a three-year pay-for-performance project from 2006 to 2009. While that project targeted only patients covered by private insurance, Medicare patients began to be included in October 2008 as a result of the hospital taking part in a CMS demonstration project on gainsharing.

More than 184 physicians participated in the project. Those physicians reduced hospital costs by $16 million over the three-year period, mainly through lower lengths of stay and reduced use of medical supplies.

(Interestingly, physicians at the center who did not participate in the projects also saved more than $9 million over the same time frame.)

Participating physicians shared gainsharing payouts of over $2 million as long as they met required thresholds on quality measures, including compliance with core measures and chart completion. Those payments averaged $1,900 per participating physician per quarter. Results appeared in the November/ December issue of the Journal of Hospital Medicine.

Women MDs have less time-off penalties than women MBAs

New findings indicate that women MDs who take 18 months off to be with children end up earning 16% less than their male colleagues. However, women MBAs taking the same amount of time off are penalized by earning 41% less.

Those are some of the conclusions of a study that was presented at a November conference on work flexibility. The study also indicated that women with PhDs taking time off earn 33% less than their male counterparts, while female lawyers earn 29% less. Researchers found that professional women have gravitated toward positions, such as veterinarian and pharmacist, that offer set schedules and no night or weekend hours.

According to the study, that same drive for flexibility has steered women MDs to specialties like ob-gyn, pediatrics, psychiatry, dermatology and medical genetics. A growing number of female MDs are also choosing gastroenterology because the specialty offers a set schedule.

Women MDs, however, are avoiding specialties that are perceived as having less scheduling flexibility. That list includes radiology, cardiology and surgical specialties.

Do patients value massages more than quality?

A DEC. 1 NEW ENGLAND JOURNAL OF MEDICINE ARTICLE finds that patients may be choosing hospitals on the basis of highly publicized amenities such as private rooms, room-service meals and massages. Such amenities are being marketed by hospitals in crowded urban markets.

The authors claim that patients can very readily understand the value of amenities, while they do not understand complex quality indicators. Surveys indicate that in choosing hospitals, patients give their nonclinical experience twice as much weight as a hospital’s clinical reputation.

Hospitals investing in amenities may also be reaping higher volumes than those that invest in quality improvements. The authors note that in Los Angeles from 2003 to 2004, for instance, many Medicare patients with pneumonia didn’t necessarily pick the hospital that was closest to them, but they also didn’t pick hospitals with the best mortality rates.

Researchers also note that if more process measures related to quality become publicly reported, patients might be better able to value clinical quality.

DVT and PE: new educational campaign for women

THE CDC AND THE VASCULAR DISEASE FOUNDATION are making available free materials that hospitals can use to host a women’s education program to increase awareness of deep vein thrombosis (DVT) and pulmonary embolism (PE). Program materials highlight DVT and PE risk factors that specifically affect women. The program is part of a national educational campaign to educate consumers about DVT and PE risk factors and symptoms.

The sponsoring organizations are encouraging hospitals to host events in March, which is DVT Awareness Month. Materials for the educational program “called “This is Serious” “include a how-to guide, draft e-mail invitations, powerpoint presentations, hospital discharge materials, a DVD, and a Web-based risk self-assessment tool for consumers.

Hospitals that want to participate or receive materials are encouraged to sign up at www.thisisserious.org/sign-up. Hospitals will be able to download all materials from the Web. As many as 600,000 patients every year suffer a DVT or a PE, and more than half of those clots are not detected.