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Volume counts in stroke care

January 2016

Published in the January 2016 issue of Today’s Hospitalist

Volume counts 
in stroke care

JUST AS WITH surgical and endovascular procedures, how many stroke patients your hospital and physicians treat has a big impact on patient outcomes.

That’s according to a new study, which looked at data from 50 medical centers throughout the U.S. The authors compared patient outcomes of the 12 centers with the highest number of patients enrolled in the study to 38 centers with the lowest number enrolled.

The study endpoints were death or repeat stroke at 30 days and at two years. Among high-volume hospitals, the rate of death or repeat stroke
at 30 days was 1.8% vs. 9.8% for low-volume facilities. At two years, those figures were 7.3% vs. 20.9%. Results were posted in the Dec. 15 issue of Neurology.

Patients at hospitals with high stroke volumes also achieved targets for cholesterol and blood pressure significantly more often than stroke patients at hospitals with low stroke volumes: 64% vs. 49%. The results suggest, the authors wrote, that “experience with medical management is an important determinant of patient outcome.”

Sharp drop in rates 
of hospital-acquired conditions

LAST MONTH, the Health and Human Services department reported that the rate of hospital-acquired conditions fell 17% between 2010 and 2014.

That translates to 2.1 million fewer hospital-acquired conditions over that four-year period, as well as 87,000 fewer deaths and a savings of $19.8 billion in health care costs.

The figures represent a 40% reduction in adverse drug events, 28% fewer pressure ulcers and 16% fewer catheter-associated urinary tract infections. (During 2010, adverse drug events made up 34% of all reported hospital-acquired conditions, while pressure ulcers accounted for 27%.)

The data, which were published by the Agency for Healthcare Research and Quality, noted that the rate of central line-associated bloodstream infections over that timeframe also fell significantly.

According to coverage of the report from MedPage Today, however, rates of inpatient falls remained the same over those four years, while the rates for all hospital-acquired conditions leveled off in 2013 and did not fall further in 2014.

Residents and depression

THIS YEAR’S MEDICAL EDUCATION ISSUE from the Journal of the American Medical Association (JAMA) contained some bad news: More than one in four residents show signs of being depressed, a trend that’s getting worse.

A new meta-analysis included more than 50 studies published over more than 50 years. The pooled prevalence of depression or depressive symptoms was 28.8%, although rates in individual studies ranged from 20.9% to 43.2%, depending on the scoring system used. The authors also found that the prevalence of depression among residents is increasing each year. The study was published in the Dec. 8 issue.

The same JAMA issue also contains a viewpoint penned by authors
from Penn State College of Medicine, Hershey, discussing their “comics in medicine” elective course, where fourth-year medical students draw comics about their training.

Almost half depict supervising doctors as monsters and the students themselves as zombies. “Surgeons in particular were singled out for horrific behavior,” the authors wrote, “appearing as devils, demons, and even land sharks presiding over their dark confines with aggression and violence.”

What you’re doing wrong 
with physician incentives

WHAT DO QUITTING SMOKING and maxing out your IRA have to do with incentivizing doctors to provide better care? If you want to motivate people to change, you need to consider behavioral economics, according to a new piece published in the Nov. 24 issue of Annals of Internal Medicine.

The authors lay out nine factors of incentive design and delivery that affect behavior and incentive success. Those include immediacy, choice overload, loss aversion, inertia or bias toward the status quo, willpower limits, and relative social ranking.

Researchers also suggest ways to better design incentives. Those include revealing physician outliers to spur competition, providing separate bonus checks, recognizing good performance publicly, and paying incentives at particular times of the year like tax time or during the holiday shopping season.

“Efforts to reform physician payment have assumed that physicians are rational,” the authors write, but “human behavior is not always rational.”

Are doctors overusing 
IV antihypertensives?

WHILE EVIDENCE doesn’t support aggressively treating asymptomatic hypertension in the hospital, a retrospective study suggests that using IV antihypertensives to treat patients with modest blood-pressure elevations may be widespread.

Researchers looked at blood pressure thresholds associated with IV antihypertensive orders and administration, as well as the effect those orders had on both short-term blood pressure and adverse outcomes. They found that more than 98% of IV antihypertensives were administered to patients with a systolic blood pressure of less than 200 mm Hg, and that one-third of those patients (32.6%) had a blood pressure reduction of more than 25% within six hours. Results were posted online in November by the Journal of Hospital Medicine.

Most of the patients given IV antihypertensives may have at most needed a more intensive oral regimen or observation. “The use of unnecessary antihypertensives,” the authors concluded, “is associated with unnecessary risks and excess costs.”

COPD: Inhaled corticosteroids 
linked to pneumonia

DISCONTINUING INHALED CORTICOSTEROIDS reduces COPD patients’ risk of developing serious pneumonia by 37%, a new study finds. Researchers analyzed insurance data for COPD patients in Quebec who were treated with inhaled corticosteroids between 1990 and 2005.

Over that time, the authors found that nearly 104,400 COPD patients were taking inhaled corticosteroids. More than 14,000 (13.6%) of those patients developed a serious pneumonia event (defined as a first hospitalization or death from pneumonia) over 4.9 years of follow-up.

When inhaled corticosteroids were discontinued, patients’ risk of a serious pneumonia event fell 37%. Pneumonia risk dropped rapidly 20% in the first month after inhaled corticosteroids were discontinued and 50% by the fourth month. Results were published in the November issue of Chest.

“Risk reduction was particularly marked with fluticasone,” the authors wrote, “but less so with budesonide.” Commenters noted that as many as 85% of COPD patients receive inhaled corticosteroids.

Post-discharge care
 drives episode costs

WHEN IT COMES TO 30-day care episodes, the big difference between low- and high-cost hospitals often comes down to post-discharge care.

Researchers analyzed the 2014-15 publicly-reported Medicare spending per beneficiary data for 3,200 hospitals. Those data look at the costs of episodes beginning three days before an admission and ending 30 days after. Results were published online in November by JAMA Internal Medicine.

The study found that only 4% of hospitals were considered low-cost, while 51% were medium-cost and 45% were high-cost. Low-cost hospitals averaged $4,596 for post-discharge care, while high-cost hospitals spent $9,287. (High-cost hospitals also spent more on preadmission and index admissions, but those differences were not as dramatic as for post-discharge spending.) Among total episode costs, 3% was spent preadmission, while hospital costs accounted for 53% and post-discharge care made up 44%.

Thirty-eight percent of post-discharge costs went to SNFs, the authors noted, while 30% were chalked up to readmissions. The average total cost of a 30-day episode was $18,247.

Bundled payments on tap 
for new hips, knees

A NEW FINAL RULE issued late last year by the Centers for Medicare and Medicaid Services (CMS) will require hospitals in many parts of the country to be paid via bundled payments for knee and hip replacements, beginning April 2016.

Those payments will cover an episode of care that will begin when patients are admitted for a joint replacement and end 90 days post-discharge. According to a CMS press release, joint replacements are the most common procedure that Medicare pays for, with prices ranging per procedure from $16,500 to $33,000. Quality is also highly variable, with some facilities having more than three times the number of complications and implant failures than others.

Under the new rule, hospitals in 67 metropolitan areas across the country will be at financial risk. The CMS intends to assess hospitals’ performance on quality and cost, giving some facilities additional payments and penalizing others.

Time to take a closer look
 at direct admissions?

A GREAT DEAL OF RESEARCH has analyzed hospital discharges to improve care transitions and quality. But a new study makes the case that the same effort should be brought to bear on direct admissions to determine best practices for that care transition.

In a perspective posted online in November by the Journal of Hospital Medicine, authors pointed out that as the number of hospitalists has risen in the country, the number of direct admissions has declined. However, direct admissions still account for 15% of all nonelective adult hospitalizations and 25% of all nonelective pediatric ones.

In studies, direct admissions have been associated with higher mortality for time-sensitive conditions including sepsis and myocardial infarction. Such patients should continue to first be evaluated in the ED, the authors wrote, but mortality differences have not been seen with direct admissions for other conditions including pneumonia and asthma, among others.

Direct admissions for those patients offer potential benefits including reducing the number of care sites and providers, improving inpatient-outpatient care coordination, and lowering ED volumes and costs.

Care transitions 
for heart failure patients

A NEW META-ANALYSIS that looked at randomized data on transitional care interventions for heart failure patients has found that intensity and duration of interventions have a big impact.

In the November/December issue of the Annals of Family Medicine, Canadian researchers assessed the effect of transitional-care interventions on readmission rates and ED visits after discharge among heart failure patients. The authors found that interventions cut the rates of readmissions and ED visits by 8% and 29%, respectively.

But high-intensity interventions “such as combining home visits with telephone follow-up or clinic visits, or both “reduced patients’ readmission risk regardless of how long the intervention was put in place. Moderate-intensity interventions, which included home visits only or a combination of telephone and clinic follow-up, did reduce readmission and ED-visit rates, but only when implemented for at least six months.

And low-intensity strategies with only telephone or clinic follow-up were found to not be effective. “It is therefore essential,” the authors wrote, “to provide individualized transitional care interventions to patients, and to triage patients for high-intensity or moderate-intensity intervention.”

Who’s funding clinical trials?

THE NUMBER OF clinical trials funded by the National Institutes of Health (NIH) is on the decline, while the number of industry-funded trials is rising sharply. That’s the conclusion of a new research letter that looks at 2006-14 data from ClinicalTrials.gov.

Over that period, the number of trials doubled from 9,321 to 18,400. The number of industry-funded trials rose 43% while the number of NIH-funded trials fell 24%. Other funding categories in ClinicalTrials.gov include “other U.S. federal agency” and “all others.” In 2006, other U.S. federal agencies funded only 2.8% of the trials registered, an amount that fell more than 26% by 2014. However, the number of trials from “all others” “which includes non-U.S. government agencies, universities and organizations “rose more than 225% in 2006-14. Among a sample of those, the majority of funders (71%) were not from the U.S.

The authors noted that the results indicate that research is a global enterprise. Between 2006 and 2014, NIH funding dropped 14%. Results were published in the Dec. 15 issue of the Journal of the American Medical Association.

Scribes: big demand, few standards

THE USE OF medical scribes in health care is growing rapidly as more doctors look to offload electronic documentation. But the scribe industry has no regulation or licensure and very few standards, and only one-third of scribes seek voluntary certification.

An article published last month by Kaiser Health News states that 15,000 medical scribes are now working in the U.S., a figure that one scribe company predicts will hit 100,000 within five years.

At least 20 companies provide scribes, all with wide-ranging standards. One company prefers to hire only pre-med, nursing or EMT students with at least two years of college, while other companies look only for a high school diploma. The time allotted to training and to supervised hours also varies widely.

The article also pointed out that some scribes “particularly those working in small and busy EDs “face pressure to enter electronic orders.