Published in the August 2017 issue of Today’s Hospitalist
Mortality: It pays to have health insurance
WITH THE SENATE VERSION of health care reform dead at press time, a new review of evidence on the benefits of being insured concludes that having coverage is associated with improved mortality.
In a 2002 review, the Institute of Medicine found that gaining insurance coverage improved all-cause mortality. The new study, which was posted online in June by Annals of Internal Medicine, looks at evidence published since that report. It finds that newer studies support the same conclusion.
However, researchers found only one well-conducted randomized trial: a 2008 lottery held in Oregon to grant a limited number of Medicaid slots to uninsured residents. One year later, the difference in death rates between lottery winners and losers was statistically insignificant, although winners did self-rate their health higher and were more likely to have conditions like diabetes treated.
Study authors also note that focusing only on mortality ignores other key benefits, including better financial protection. “Overall, the case for coverage is strong,” the authors write. “Even skeptics who suggest that insurance doesn’t improve outcomes seem to vote differently with their feet.”
One in five obs patients bounces back
A RETROSPECTIVE STUDY of Medicare beneficiaries admitted to observation in the U.S. between 2006 and 2011 finds that 20.1% of those patients returned to the hospital within 30 days.
That 20% who bounced back broke down into 11.2% (or more than one-half) who became inpatient admissions, 8.4% who visited the ED and were discharged, and 2.9% who had a repeat observation stay. The study also found that 30-day revisit rates are rising over time, and that the rate of adverse events after observation stays is similar to that after ED visits, with patients in both groups running a 1.8% risk of 30-day mortality. Results were published online in June by the British Medical Journal.
Given the fact that revisit rates after being in observation are similar to those after ED visits, the authors recommend using strategies shown to “enhance emergency department transitional care” to improve outcomes for observation patients.
Penicillin allergies: Hospitalists have “limited” management know-how
HOSPITALISTS may not have a good handle on how to manage inpatient penicillin allergies, according to new survey results.
Attendings, residents, pharmacists, NPs and PAs in two community teaching hospitals were surveyed about how to treat such patients. Among nearly 300 respondents, 46% indicated that they weren’t familiar with the cross-reactivity rate between penicillin and cephalosporin, carbapenem (42%) and monobactam (48%).
Responding to vignettes on evaluating the role of penicillin skin testing and drug-tolerance induction, only 41% and 19% respectively considered those key management options. And while clinicians acknowledged the need to get an allergy/immunology consult for such patients in clinical scenarios, 86% admitted that they never get such consults in actual practice or do so only once a year.
Among respondents, 45% were attendings, 53% of whom had been practicing more than 10 years. Results were posted in the July issue of Annals of Allergy, Asthma & Immunology.
How old is too old to practice?
A GROWING NUMBER of hospitals are adopting policies that require older doctors to have their physical and mental abilities tested before they’ll be able to continue their privileges, a move that’s led some older physicians to push back.
An article originally published in June in the Wall Street Journal notes that the American Medical Association has signed off on the idea of screening older physicians, particularly because almost one-quarter of U.S. doctors are 65 or older.
But some physicians facing such assessments claim it’s discriminatory. They argue that all physicians should be tested for impairment, not just those who are older, citing drug and alcohol problems among younger colleagues.
Other critics of such policies note that the challenge for older doctors is often outdated knowledge, not cognitive dysfunction. But proponents of age-related testing quoted in the article say that older doctors who have mild cognitive impairment may not recognize it and that their colleagues won’t report it.