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Hospitalists who spend more don’t have better outcomes

Plus, A fib and anticoagulation

April 2017

Spending more on patients? 
Don’t expect better outcomes

A STUDY that analyzed variations in patient spending across individual hospitalists finds that doctors who spend more money on their hospitalized patients don’t have any better outcomes in terms of 30-day mortality and readmission rates.

Study authors looked at a 20% sample of Medicare Part B spending in hospitals between 2011 and 2014, comparing spending levels on patients among hospitalists in the same facilities. The variation they found in spending across physicians within hospitals (8.4%) was greater than the spending variations across hospitals (7.0%).

Hospitalists in the top quartile spent 40% more than doctors in the lowest quartile ($1,055 vs. $743 per hospitalization), but had no improvement in outcomes. While federal initiatives, such as the readmission penalty program, target hospitals, the authors recommended that hospitals design in-house performance programs to measure and report on individual physicians’ resource use. The study was posted online in March by JAMA Internal Medicine.

Inadequate anticoagulation prevalent 
among A fib patients


RESEARCHERS ANALYZING a registry of patients with atrial fibrillation who had an ischemic stroke found that the vast majority (83.6%) were not receiving therapeutic anticoagulation prior to their stroke.

Among A fib patients taking warfarin before a stroke, 64% were taking subtherapeutic doses. Researchers also found that taking antiplatelets, subtherapeutic warfarin or no antithrombotics was significantly associated with worse stroke severity, compared to A fib patients who suffered a stroke while on therapeutic warfarin or a NOAC.

Patients included in the retrospective analysis were admitted between October 2012 and March 2015. Study results were published in the March 14 issue of the Journal of the American Medical Association.

In-hospital mortality was lower for A fib patients taking NOACs (6.3%) and therapeutic warfarin (6.4%) than those taking an antiplatelet (8.1%) or no therapy (9.3%). And two-thirds of patients not on anticoagulation had no documented reason for not being anticoagulated. Among patients with a documented reason for not receiving anticoagulation, 16.3% cited bleeding risk while 10.3% cited a risk of falls.

Wide variations in 
ED opiate prescribing

opiate prescribingSOME EMERGENCY PHYSICIANS are much more likely than their colleagues to prescribe opiates to older patients, putting those patients at higher risk of becoming chronic users.

A new study tracked 375,000 Medicare beneficiaries who presented to an ED with similar complaints between 2008 and 2011. Researchers also analyzed the frequency of opiate prescriptions, finding disparate prescribing patterns across physicians practicing in the same ED. Study results were published in the Feb. 16 issue of the New England Journal of Medicine.

“High-intensity” ED doctors discharged one in every four patients with an opiate prescription, while “low-intensity” prescribers issued an opioid prescription to only one in every 14. Patients treated by a high-intensity prescriber were 30% more likely to go on to use opiates long-term. Out of every 48 patients sent home with a prescription for an opioid, one ended up being a long-term user.

“Conversion to long-term use,” the authors wrote, “may be driven partly by clinical ‘inertia’ leading outpatient clinicians to continue providing previous prescriptions.”

Funky hospital floors are an infection threat

infection control hospital floorsA NEW STUDY reveals this often-overlooked source of infection: hospital floors, which are apparently awash with MRSA, VRE and C. diff.

In the study, researchers cultured more than 300 floor sites in 160 patient rooms across five Cleveland-area hospitals. Rooms sampled included both C. diff-isolation rooms and non-CDI rooms. The authors found a similar frequency of contamination in both patient rooms and bathrooms. C. diff was by far the most common pathogen found, present in about 55% of C. diff isolation rooms, as well as in more than 45% of non-CDI rooms.

Researchers found that high-touch objects such as blood pressure cuffs, call buttons, personal items and linens were in frequent contact with hospital floors. They recommend that personnel be educated to not place such high-touch items on the floor. They further recommend designing studies to test the most effective way to clean hospital floors, especially to reduce the amount of C. diff spores.

Knee-replacement: no benefit from inpatient rehab

_958690104.inddA STUDY from Australia looks at the impact of inpatient rehab for patients who’ve had a total knee replacement vs. a home program alone. The conclusion? These patients don’t derive any real benefits from inpatient rehab.

Published in the March 14 issue of the Journal of the American Medical Association, the study randomized 165 patients with uncomplicated knee replacements to either 10 days of inpatient rehab followed by an eight-week home care program or to the home program alone. At 26 weeks, the authors found no difference between members of the two groups in terms of their ability to walk a six-minute mile. Nor were there differences between the groups in complication rates or patient-reported pain levels.

The authors noted that the amount of inpatient rehab that patients underwent in the study was comparable to rehab stays in the U.S. They also pointed out that the study included only those patients who were cleared for discharge within five days after surgery.

Hospitalists make one-half 
of all palliative care referrals

palliative care IN 2015, hospitalists were by far the physicians making the highest number of palliative care referrals, accounting for 48% of such referrals that year.

That’s according to a new report issued in February by the National Palliative Care Registry on 2009-15 trends in palliative care. Among specialties making referrals, internists/family physicians were a very distant second with 14% of all referrals, while oncologists made only 7%.

The report also found that 4.8% of all patients admitted to a hospital
in 2015 received palliative care, up from 2.7% in 2009, and that 41% of all referrals were made on medical-surgical units. Further, about one-quarter (26%) of patients with a palliative care referral in 2015 had a primary cancer diagnosis, down from 35% of all referrals in 2009.

Among palliative care programs in 2015, 46% provided 24/7 coverage, with Monday-Friday consultation and around-the-clock telephone support. In 2015, the report also noted, 14% of palliative care patients were readmitted within 30 days.

Family reports
 go missing in safety surveillance

pediatric patient ACCORDING TO a new study, families report the same number of errors and adverse events as clinicians, at least in pediatric hospitals. However, family-generated incidents are often not included in hospital incident reports. If family reports were included, the study concludes, error detection rates in hospitals would increase 16%, while adverse-event detection rates would rise 10%.

Researchers identified potential errors and adverse events in four pediatric hospitals and reviewed clinician reports. They found that families reported five-fold more errors and three-fold more adverse events than were cited in hospital incident reports. The authors note that previous studies have found that voluntary hospital incident reports may detect between 1% and 14% of adverse events.

Patient and family reporting seems to vary, depending on reporting mode, which can include post-discharge interviews or in-hospital surveys.

To improve safety interventions, the authors recommend that hospitals find ways to more systematically gather patient and family reports and to incorporate that information in safety surveillance systems. Results were posted online in February by JAMA Pediatrics.

Why doctors should head up hospitals

Doctor leadership A RECENT Harvard Business Review article points out that the country’s best hospitals are led by physician CEOs, citing both the Mayo Clinic and the Cleveland Clinic.

According to the article, studies show that quality scores may be 25% higher in physician-run hospitals than in those managed by administrators. Reasons for why doctors may make better hospital leaders include greater credibility among clinicians and a stronger focus on patient care.

The authors note, however, that physicians have not been traditionally trained in collaboration or leadership and that there is “a clear need to train physicians more systematically.” The Cleveland Clinic has been giving physician leaders in-house training for many years, while similar programs have been developed around the country by institutions including Virginia Mason in Seattle and the University of Kentucky. Several business schools and medical societies have also launched leadership training for physicians.

Bumper crop of interns face 
longer hours

Interns LAST MONTH’S Match Day broke records, not only for the number of people participating, but for the number of positions offered. In this year’s Match, 35,969 U.S. and international medical graduates vied for 31,757 residency positions.

Also last month, the Accreditation Council for Graduate Medical Education (ACGME) announced that it is reversing its 2011 policy limiting interns’ shifts to only 16 hours. Beginning with the 2017-18 academic year, first-year residents will once again be allowed to work 24-hour shifts, the same shift duration as other residents and fellows.

Another change the ACGME voted in: Work that residents do at home will count toward their 80-hour weekly cap. The ACGME left in place a rule that gives residents and fellows one day out of every seven off from clinical experience or education, and a rule that allows residents and fellows to be on in-house call no more than every third night.

Advocacy group: Get patients up 
and moving

ambulatory patientsA NEW POSITION PAPER makes the case for early ambulation in hospitals, noting that early mobility can both improve patient wellbeing and reduce length of stay.

Issued in February by the Physician-Patient Alliance for Health & Safety, a patient-safety advocacy group, the statement notes that early ambulation can have a dramatic impact on patients who’ve undergone procedures that directly affect mobility, such as knee and hip replacement. Early ambulation also benefits patients with other conditions, with one study finding that getting ICU patients who have acute respiratory failure out of bed and moving can cut their length of stay by more than three days.

The statement notes, however, that nurses and therapists have limited time to help patients ambulate. To counteract that, the group calls for making ambulation a priority in hospitals, backed by policies and protocols.

The statement also calls for the use of enhanced monitoring technologies such as wearable and wireless devices, as well as new technologies to help identify high-priority patients and to track and measure ambulation efforts.

Published in the April 2017 issue of Today’s Hospitalist
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