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Many
Physicians Slow To Adopt Standard Practices
Many physicians
are slow to adopt standard care-management practices, reflecting a large gap between
medical knowledge and clinical practice, according to a study published in the
current issue of the Journal of the American Medical Association. That
gap—many researchers and large health care purchasers say—is a critical factor
in both cost and quality woes the health care system.
The study,
conducted by researchers at the University of Chicago, surveyed 1,040 medical
groups nationwide with at least 20 physicians to determine their use of 16 care-management
practices for treatment of chronic diseases, including guidelines linked to medical
records, patient registries, prescription renewal reminders and automatic prescription
drug interaction monitors.
According to
the study, the medical groups on average used five of the care-management practices,
and 16% of the groups used none of the practices. The study also found low investment
in clinical information systems by the medical groups. Half of the groups did
not have one of the seven features on their data systems, such as routine access
to laboratory results.
According to
the researchers, many physicians do not adopt standard care-management practices
because of cost.
For more info,
http://jama.ama-assn.org.
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Medicare
To Reward HMOs Treating Sicker Patients
Medicare is
developing a plan to reward HMOs for enrolling sicker patients thanks to a computer
program devised by Boston University statistician Arlene Ash. Dr. Ash has shown
that if her software knows what diseases you were treated for last year, it can
accurately predict what it will cost to treat you this year. For 15 years, she
has been touting her program as the ideal tool to reward insurers that take on
sick patients—and squeeze those that try to cherry-pick the healthy, according
to a report in the Wall Street Journal.
The Journal
reported that Medicare is using Dr. Ash’s computer models to adjust the payments
it makes to private insurers and HMOs that take elderly patients under Medicare
+ Choice plans.
Starting Jan.
1, 2004, 30% of Medicare’s payments will be "risk adjusted," and that
figure will rise to 100% by 2007—meaning insurers will get huge sums to take care
of very sick elderly people but minimal payments for those the computer predicts
won’t need expensive treatment.
The adjustment
is designed to fix what many experts see as a fundamental flaw of the current
Medicare + Choice program: insurers get roughly the same payment from the government
for taking on a chronically ill Medicare beneficiary as they get for treating
one in robust health. That has led to the classic insurance problem of "adverse
selection," where insurers seek to enroll healthy patients. As a result, the article
said, Medicare + Choice has failed to reduce costs or bring in innovative health-improvement
programs.
To predict
a patient’s cost, Dr. Ash’s program uses databases that show which diagnoses tend
to lead to the highest expenses in the next year. Programs now in use focus on
the previous year’s costs, leading to inaccurate predictions for patients who
suffered serious but transient illnesses or underwent one-time treatments.
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HHS
Unveils Home Health Quality Project
HHS today announced
its home health care quality initiative—the next care setting in which the agency
hopes to improve consumer choice and quality of care. The department is relying
on independent Quality Improvement Organizations (QIOs) to assist providers.
The Centers
for Medicare and Medicaid Services (CMS) at HHS plans to formally begin the home
health quality pilot in April and expand the initiative nationally in this fall.
In the pilot, CMS will publish information on 11 quality measures for home health
agencies in Florida, Massachusetts, Missouri, New Mexico, Oregon, South Carolina,
Wisconsin, and West Virginia.
Similar to
last year’s nursing home quality initiative, CMS will use newspaper ads to raise
public awareness of how performance differs among agencies and to help stimulate
quality improvement. QIOs will help consumers use the quality performance data.
QIOs in every state will soon begin training home health agencies in new quality
improvement techniques.
CMS worked
with the Agency for Healthcare Research and Quality and other stakeholders, including
the Delmarva Foundation, to identify appropriate measures derived from the Outcome
and Assessment Information Set. The measures include:
- Percent of patients
who get better at getting dressed without help.
- Percent of patients
who get better at bathing themselves without help.
- Percent of patients
who are confused less often.
- Percent of patients
who get better at correctly taking their medicines (by mouth) without help.
- Percent of patients
who get better at walking or moving around using less equipment (such as a cane,
walker, or wheelchair).
- Percent of patients
who get better getting to and from the toilet without help.
- Percent of patients
who get better at getting in and out of bed without help.
- Percent of patients
who have less pain when moving around.
- Percent of patients
who stay the same (don’t get worse) at bathing themselves.
- Percent of patients
who need emergency medical care (for any reason).
- Percent of patients
who had to be admitted to the hospital.
The National
Quality Forum will convene a Home Health Steering Committee later this year to
begin its consensus process for improving the home health quality measures.
More information:
www.ahqa.org.
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Outpatient
Care Errors Occur Almost As Frequently As Inpatient Mistakes
A
new study suggests that injuries stemming from mistakes made when patients are
discharged from hospitals or in their follow-up care may be more common than inpatient
errors, though not as serious.
For the study,
published in the current issue of The Annals of Internal Medicine, researchers
from Harvard and the University of Ottawa interviewed 400 randomly chosen patients
three weeks after they left hospitals and examined their records. About 20% of
the patients had harmful events related to their care, the researchers found,
and two-thirds of the injuries could have been prevented or limited.
Drug reactions,
particularly from antibiotics, were by far the most common problem, the study
reported.
About a third
of the patients who had problems were readmitted or turned to emergency rooms
for help, while half the affected group did not seek additional care, the study
found. Others received help at doctors’ offices or elsewhere.
The study pointed
to several problems, especially gaps in communication between the doctors who
provide care in the hospital and the doctors who provide follow-up care, and between
doctors and patients.
The study’s
authors advised patients to have a "low threshold" for seeking advice
or follow-up care.
For more info,
www.annals.org.
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Leapfrog
Group Plans To Help Hospitals Invest In Quality
A member of
the Leapfrog Group’s steering committee said the organization is developing plans
to help hospitals recoup some of the money they invest to meet Leapfrog recommendations.
Francois de
Brantes said the employer group recognizes that the cost of implementing Leapfrog
recommendations can exceed what hospitals get from payers as a result of making
those changes.
"Shame
on us purchasers, and shame on this country, to have created a system where better
quality costs hospitals money," de Brantes told a meeting of the Healthcare
Information and Management Systems Society in San Diego.
Leapfrog has
designed incentives to urge hospitals to implement computerized physician order
entry systems, employ intensivists, and use evidence-based hospital referral.
De Brantes
said Leapfrog is developing a procedure to examine the cost of fulfilling these
recommendations, forecast their fiscal impact, and help cover the difference,
usually through direct payments by Leapfrog members themselves or by telling their
insurers to redirect premium payments to the hospitals.
For more info,
www.leapfroggroup.org.
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AHRQ
Launches Web-Based Review Of Documented Medical Errors
The Agency
for Healthcare Research and Quality has launched a monthly peer-reviewed, Web-based
medical journal showcasing patient safety lessons from actual cases of medical
errors.
The journal,
at http://webmm.ahrq.gov, was developed
to educate health care providers about medical errors in a blame-free environment.
AHRQ said every month, five cases of medical errors and patient safety problems—one
each in medicine, surgery/anesthesiology, obstetrics-gynecology, pediatrics, and
other fields—will be posted along with commentaries from distinguished experts
and a forum for readers’ comments.
Each month,
one of the five cases will be expanded into an interactive learning module featuring
readers’ polls, quizzes and other multimedia elements, and offering continuing
medical education credits, the agency said.
Cases are limited
to near misses or those that involve no permanent harm. The inaugural issue will
feature a case involving a mistaken drug administration causing a patient to stop
breathing unexpectedly, among others.
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FDA
Unveils New Rule On Overuse Of Antibiotics
The Food and
Drug Administration has announced a final rule outlining new labeling regulations
designed to help reduce the development of drug-resistant bacterial strains.
The new rule
requires a statement in the labeling encouraging physicians to counsel patients
about the proper use of antibiotic drugs and the importance of taking them as
directed. The FDA said the final rule should reduce the inappropriate prescription
of antibiotics to children and adults for common ailments such as ear infections
and chronic coughs.
The agency
said the danger associated with prescribing antibiotics to children with viral
infections is that it can hasten the development of bacterial strains that are
antibiotic resistant. In older adults, the use of antibiotics to treat chronic
coughs when sputum thickens is a common example of the over-prescription of antibiotics,
the FDA said.
For more info,
www.fda.gov/OHRMS/DOCKETS/98fr/00n-1463-nfr00001.pdf.
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More
Medicare Funds May Not Aid Health Quality
Increased Medicare
spending does not necessarily translate into high quality of care or improved
health, according to a new study. Researchers found dramatic regional differences
in Medicare spending, with hospital patients in higher-spending areas receiving
60% more care than patients in lower-spending ones.
Yet that didn’t
result in better medical outcomes, leading the authors to question whether Medicare
dollars are being spent efficiently. They said Medicare could reduce spending
by 30% without jeopardizing beneficiaries’ health, adding that more research is
needed on how to "safely reduce" spending levels.
"There
is a lot of money at stake, but doing something about it will not be particularly
easy," said the lead researcher, Dr. Elliott Fisher of Dartmouth Medical
School.
Nationwide,
Medicare spending grew 7.8% to $242 billion in 2001, partly because of increased
payments to Medicare providers. Last month, President Bush said he would ask Congress
for $400 billion to overhaul the program.
The study in
Feb. 18 Annals of Internal Medicine involved 614,500 patients with hip
fractures, 195,400 patients with colorectal cancer and 159,400 heart-attack patients
hospitalized between 1993 and 1995. Dividing the nation into 306 health care markets,
researchers determined how much money the Medicare system spent on the patients
in the last six months of life.
Per-capita
Medicare spending was $14,644 in the highest-spending markets. Patients in these
markets underwent more tests, had more procedures and saw more specialists than
ones in the lowest-spending markets, where per-capita spending was $9,074.
But the additional
measures did little or nothing to improve survival rates, slow the progression
of illness or improve patient satisfaction, the study found. In fact, patients
in the high-spending areas were less likely to get preventive care—such as flu
and pneumococcal vaccines and Pap smears—than those in low-spending areas.
The authors
attributed some of the differences in spending to health care capacity—the number
of hospital beds and especially the number of doctors in a given region. The more
specialists, the higher the "intensity of care," Dr. Fisher said.
The researchers
"convincingly demonstrated that excellent outcomes for patients can be achieved
in regions that do less, but do it right," Dr. Kenneth Shine of RAND Corp.
wrote in an accompanying editorial. "The challenge is to convince the public
that this is not about rationing but about better care."
According to
Nancy Foster, a policy analyst at the American Hospital Association, change is
already happening. She said the rise of evidence-based medicine has helped doctors
and hospitals become more efficient in recent years. She added that she suspects
the study results might have been different had they been drawn from more recent
data.
For more info,
www.annals.org.
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AHA
Redesigns HospitalConnect
The American
Hospital Association has announced the redesign of HospitalConnect, a Web portal
uniting 50 Internet sites from 22 organizations that serve health care providers.
The prototype
for HospitalConnect went live for fine-tuning and adjusting in July. It has been
redesigned to better serve a diverse audience and enable health leaders to better
share ideas and innovations.
For example,
the site now features an interactive hospital finder that enables users to find
the closest hospitals to any address in the U.S., and provides a powerful search
engine. The redesigned front page includes guides to HIPAA, disaster readiness
and other key issues.
The portal
contains information on best practices, research, educational materials, news
and products.
For more info,
www.hospitalconnect.com.
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New
HEDIS Draft Measures Include Appropriate Use Of Antibiotics
The National
Committee for Quality Assurance has released for public comment draft changes
to its performance measures used in the health care industry, including new standards
for appropriate use of antibiotics and outpatient management of heart failure.
NCQA developed
HEDIS, or the Health Plan Employer Data and Information Set, as a set of standard
performance measures designed to ensure that purchasers and consumers can compare
the performance of managed care organizations.
The draft of
"HEDIS 2004" includes 11 new performance measures, eight of which focus
on clinical and public health, and three of which focus on performance in key
areas of customer service, according to NCQA.
Comments on
the draft HEDIS 2004 are due March 21. NCQA said it developed the new standards
with the input and support of a broad cross section of health care stakeholders,
including representatives of the business community, "which has increasingly
shown interest in using performance data to promote and reward quality."
Suzanne Paranjpe,
senior vice president for strategic development at the National Business Coalition
on Health, said the new measures will give employers the information they need
to appropriately reward quality and ensure that people get better care and service.
The proposed
new measures are:
- Three service
measures: claims timeliness, call answer timeliness, and call abandonment.
- Two antibiotic
use measures: appropriate treatment of children with upper respiratory infection
and appropriate antibiotic treatment for children with pharyngitis.
- Outpatient management
of heart failure.
- Colorectal cancer
screening.
- Management of
urinary incontinence in older adults.
- Osteoporosis management
in women who have had a fracture.
- Two substance
abuse treatment measures: identification of alcohol and other drug services, and
initiation and engagement of alcohol and other drug treatment.
NCQA is proposing
changes to several other specifications, including comprehensive diabetes care,
use of appropriate medications for asthma, and antidepressant medication management.
Overall, HEDIS
2004 will have more than 50 measures in broad categories such as effectiveness,
access/availability, satisfaction, plan stability (such as practitioner turnover),
use of services, and health plan descriptive information.
For more info,
www.ncqa.org/Programs/HEDIS/HEDIS2004/publiccomment.htm.
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HSC:
Physicians View Treatment Guidelines Positively
The Center
for Studying Health System Change says half of all physicians in 2001 viewed treatment
guidelines for specific medical conditions and patient satisfaction surveys as
positive for affecting quality of care.
The HSC study
found similar positive results for practice profiling, where individual physicians’
treatment patterns and use of medical resources are compared with other physicians.
In 2001, 62%
of physicians said patient satisfaction surveys had a moderate, large or very
large effect on their practice. The study also found that physicians in practices
with revenue from managed care were more likely to report care management tools
had affected their practice of medicine.
For more on
the study, www.hschange.org.
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Recently
Trained Radiologists May Read Mammograms Best
A new study
found that newly trained radiologists, not doctors who read the most mammograms
each year, are the most proficient in accurately detecting cancer. The research,
published in the Journal of the National Cancer Institute, said other factors
that may give a more reliable mammogram include: using a center that requires
two radiologists to read each X-ray, and that performs more sophisticated breast-imaging
procedures as well as routine mammograms.
Study authors
stressed that the findings don't mean a doctor fresh out of school does a better
job than a seasoned veteran. But it does raise questions about how some veterans
keep up as the years pass.
Mammograms
are considered the best tool available for spotting breast cancer early, when
it’s most treatable. Federal regulations require that radiologists read 480 mammograms
a year for certification—although many read many more.
A year ago,
California researchers compared British radiologists with U.S. counterparts who
read varying numbers of mammograms. That study concluded doctors who performed
the most mammograms found more cancer with fewer false alarms. And other studies
have found that young radiologists have higher rates of unnecessary biopsies than
older colleagues.
In the new
study, 110 radiologists were asked to examine the mammograms of 148 women, 43%
of whom had breast cancer. How many mammograms the radiologists had read the previous
year had no impact, the study found. However, researchers found a small but significant
drop in cancer detection for each year beyond a doctor’s residency training, plus
better accuracy among radiologists who practiced in the more sophisticated centers.
For more info,
http://jncicancerspectrum.oupjournals.org/jnci.
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New
Study Backs Docs Use Of ACE Inhibitors To Lower Blood Pressure
Some doctors
say the results from the recent 10-year study, called Allhat, overstated the case
for diuretics and contradicted much of their own clinical experience with the
pills, which are an older, generally cheaper hypertension treatment.
Those critics
are getting some substantial backing in a new report in the New England Journal
of Medicine. The study suggests that newer drugs called ACE inhibitors are
a better first choice for elderly patients, leading to fewer deaths, heart attacks,
strokes and other cardiovascular problems.
The results
likely will increase debate over how to best treat the more than 50 million Americans
who have high blood pressure. The conflicting results of the two reports also
underscore the difficulty of using evidence from major studies to standardize
medical practice—a foundation of the drive to improve the quality of health care.
The new report,
by Australian researchers, is based on 6,083 hypertensive patients over age 65
who were randomly assigned to start treatment on either a diuretic or an ACE inhibitor
and followed for a median of 4.1 years. Those on diuretics had an 11% higher risk
of a major medical problem than those on ACE inhibitors.
The study was
funded by the Australian government and Merck
& Co.,
which pioneered ACE inhibitors.
The Allhat
study, which tested calcium channel blockers in addition to ACE inhibitors and
diuretics found few differences in heart attacks or heart-related deaths. But
Allhat patients on diuretics had better blood pressure control, fewer strokes
and less congestive heart failure, among other benefits.
Doctors who
were skeptical of the Allhat study feel vindicated by the new report.
The two studies
aren’t directly comparable. Allhat included patients as young as 55. And about
35% of Allhat patients were African-American, who studies indicate are particularly
responsive to diuretics.
In both studies,
most patients ended up on more than one drug. In Allhat, researchers took pains
to make sure that patients started on an ACE inhibitor didn’t also get a diuretic.
In the Australian study, there was significant crossover: 25% of diuretic patients
eventually also took an ACE inhibitor, and vice versa, potentially muddling interpretation
of the findings. In addition, the two studies used different types of diuretics
and ACE inhibitors.
For more info,
www.nejm.org.
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RWJF
Seeks Proposals For Changing Health Care Financing, Organization
The Robert
Wood Johnson Foundation, through a grant program administered by AcademyHealth,
seeks proposals for its Changes in Health Care Financing and Organization program.
The three-year,
$15 million initiative is seeking projects that examine health care financing
and organizational interventions and their effects on costs, quality, and access.
The initiative will also fund projects to develop and test new ways to finance
health care that have the potential to improve access to more affordable and higher
quality services.
Funded projects
should provide public and private decision leaders with usable and timely information
on health care policy and financing issues.
Grants are
awarded on a rolling basis.
For more info,
www.hcfo.net.
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ACGME
Issues Resident Work Limits
Doctors-in-training
in the United States—many of whom work marathon shifts that critics say lead to
medical mistakes—cannot work more than an average of 80 hours a week, according
to the organization that accredits medical residents. Under new rules approved
by the nonprofit Accreditation Council for Graduate Medical Education, medical
residents must also get one day off out of seven.
The regulations
also require a 10-hour rest between being on-call and working a shift. The rules,
which schools must follow to be certified, take effect July 1.
The vote by
the council's board of directors means that the standards "go from being
a should, to a must" in order to pass muster with the accrediting body, said
ACGME.
Medical residents
and consumer groups have called for federal standards, saying a private group
lacks teeth to enforce the rules. But the government rejected a petition to a
federal agency on that front last year.
The Committee
on Interns and Residents, a union that represents 12,000 residents in the United
States, commended the move but noted the difficulty in enforcing such standards.
Another potential flaw involves loopholes that allow residents to extend, for
example, the 24-hour shift limit by six additional hours.
Critics say
residents are overworked, clocking an average 120 hours per week, a situation
they say leads to medical errors and deaths. By making the standards mandatory,
the accrediting group and the American Medical Assn. hope to head off federal
legislation on residents’ hours.
Certification
with the council is voluntary, but many medical colleges seek it for recognition,
state board certification and to qualify for federal Medicare funding. The group
accredits about 7,800 residency programs involving 100,000 trainees.
For more info,
www.acgme.org.
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