Quality Update for February 20, 2004

Thompson Wants Health IT Plan by End of ‘04 Cost, Then Quality Top Health Care Concerns for Consumers Counseling To Quit Smoking Lowers Death Rates, But Patients Who Need It Most Study Shows Improvements In Diabetes Care, Outcomes Inappropriate Prescriptions ‘Substantial’ Problem for Seniors Diabetes Patients Skipping Out on Medications to Save Money Study Links Breast Cancer to Antibiotic Use American Heart Association Issues Guidelines for Women EHR Collaborative’s HL7 To Be Ready for Vote mid-March Utah Physician Practice Predicts EMRs Will Save $8.2M USP to Hold Patient Safety Presentations Thompson Wants Health IT Plan by End of ‘04 HHS Secretary Tommy G. Thompson has called for quick implementation of his plan to fund a health IT infrastructure with federal recoveries from health care fraud and abuse cases, Modern Healthcare reported yesterday. Thompson said he wants the plan operational “this year, before I leave.” The HHS Secretary has proposed using half of the $1.2 billion collected annually in settlements to standardize electronic medical records and other technology investments. At a Medicare conference, Modern Healthcare reported. Back to top Cost, Then Quality Top Health Care Concerns for Consumers A quarter of Americans surveyed on hospital concerns cited quality of care as a major issue, following cost as the primary concern, according to a survey released Feb. 10 by Siemens Medical Solutions. Siemens surveyed 2,000 Americans who were either hospitalized or responsible for assisting in the admittance of another person to the hospital within the last five years. While 41% cited cost as their greatest concern, 25% listed quality of care. Nearly two-thirds surveyed, or 63% said it would be “very valuable” to have their complete medical history stored electronically in one computer file that can be accessed anywhere in a hospital. Other findings of those surveyed include: 26% believe Electronic Health Records are already available to them and an additional 46% indicate they believe EHRs will be implemented for admissions and usage at their local hospitals within the next five years. 58% of those surveyed are concerned about the privacy of their medical records. Almost 20% of those surveyed did not think their doctor has all the necessary and important information regarding their medical history, but 89% of those over age 65 believe their doctor has all the necessary and important information about their history. For more info, www.usa.siemens.com/medicalpressroom. Back to top Counseling To Quit Smoking Lowers Death Rates, But Patients Who Need It Most A study conducted by Carolinas Center for Medical Excellence, the Quality Improvement Organization for North Carolina, shows that patients hospitalized with a heart attack who are counseled to stop smoking had lower death rates in the five years following their hospitalization than similar patients who were not counseled. But, the study also found that the majority of heart attack patients who were smokers were not provided with this life-saving counseling. These findings were recently published in an article published in The American Journal of Preventative Medicine, 2004, titled, “Inpatient Smoking-Cessation Counseling and All-Cause Mortality Among the Elderly.” Dr. Anna Schenck and Dr. Ross Simpson, Jr., MD of the Carolinas Center for Medical Excellence, conducted the study with David W. Brown, MSPH, formerly of MRNC, now with the Centers for Disease Control. Although smoking-cessation is essential to the management of acute myocardial infarction (heart attack), the study found that counseling in the inpatient setting was not provided to the majority of patients who were hospitalized with AMI who also smoked. Findings suggest that there was less physician advice and counseling provided to women and blacks and to those patients having a history of hypertension, heart failure or stroke. Being discharged to a skilled nursing facility also reduced an individual’s chances for smoking-cessation counseling. Patients who were counseled on smoking cessation had lower mortality rates. Current clinical practice guidelines recommend that clinicians provide smoking-cessation counseling at every clinical encounter, including during hospitalization. Even so, and despite the established benefits of smoking-cessation, only 40 % of the smokers in this study were counseled on smoking-cessation during hospitalization. Back to top Study Shows Improvements In Diabetes Care, Outcomes Diabetes patients who were enrolled in two collaborative efforts over three years to improve care among Washington state clinics showed substantial gains, according to two articles published in the February 2004 Joint Commission Journal on Quality and Safety. The articles report on Washington State Diabetes Collaboratives I and II, sponsored by Qualis Health of Seattle, the Washington State Department of Health, and the MacColl Institute for Healthcare Innovation at Group Health Cooperative of Puget Sound. Both initiatives employed the Breakthrough Series Collaborative developed by the Institute for Healthcare Improvement. One article reports on statewide diabetes collaboratives, while the second profiles two participating teams—Olympic Physicians, a rural clinic in Shelton, WA and The Polyclinic, a large urban specialty clinic in Seattle. Epidemiologist Dr. Donna Daniel of Qualis Health is lead author. The goal of the collaboratives is to create efficient, effective, patient-centered, evidence-based systems of care for chronic diseases. The outcome measures showed an absolute improvement of 12% among those patients whose blood sugar levels dropped, a 13% improvement in numbers of patients who lowered their LDL (“bad”) cholesterol, and a 7% improvement in numbers of patients who decreased their blood pressure reading in the first diabetes collaborative. Similar improvements were noted in process measures in the first collaborative. For example, there was an across-the-board 50% improvement in the number of diabetes patients who received foot exams, a 49% improvement in numbers of patients who received blood pressure readings, and a 35% improvement in numbers of patients who received blood cholesterol tests. The second collaborative showed different outcomes, with absolute improvements in the percentage of patients with documented self-management goals, percentage of patients who showed improvement in blood pressure readings and percentage of patients with improved blood sugar readings. For more info, www.jcrinc.com/subscribers/journal.asp?durki=32. Back to top Inappropriate Prescriptions ‘Substantial’ Problem for Seniors A study commissioned by the Centers for Disease Control to examine potentially inappropriate prescriptions to the elderly found that medication errors continue to remain a substantial problem, especially with women, where rates of inappropriate prescriptions are twice as high. The study examined trends in the prevalence of potentially inappropriate drug prescribing during ambulatory care visits by elderly persons from 1995 to 2000 with data from office-based physicians in the National Ambulatory Medical Care Survey and from hospital outpatient departments in the National Hospital Ambulatory Medical Care Survey. Dr. Marie Rauch Goulding, who conducted the study, found that in the five-year period, at least one drug considered inappropriate was prescribed at 7.8% of ambulatory care visits by elderly patients, or 16.7 million doctor visits. At least one drug classified as never or rarely appropriate was prescribed at 3.7% and 3.8% of these visits in 1995 and 2000, respectively. Results indicated that a large share of the problem is related to prescription of pain relievers and central nervous system drugs. Goulding also found that the odds of potentially inappropriate prescribing were higher for visits with multiple drugs and double for female visits, which she attributed to more prescribing of potentially inappropriate pain relievers and central nervous system drugs “Potentially inappropriate prescribing at ambulatory care visits by elderly patients, particularly women, remains a substantial problem,” Goulding wrote. She suggested that interventions could target more appropriate drug selection by physicians when prescribing pain relievers, anti-anxiety agents, sedatives, and antidepressants to elderly patients. For more info, http://archinte.ama-assn.org. Back to top Diabetes Patients Skipping Out on Medications to Save Money The cost of diabetes medications is forcing about 15% of older patients to cut back on filling prescriptions, causing increased credit card debt and even leading some older patients to cut back on food and heat, according to a study released last week. Researchers at the University of Michigan conducted a national survey of 875 diabetes patients across the United States who used prescription drugs to control their blood sugar. Participants were asked if they had ever taken less of their diabetes medications or any other prescription drugs in the last year because of cost concerns. Half of the participants reported using at least seven different prescription drugs, including treatments for hypertension, high cholesterol, arthritis or depression, as well as their glucose control. More than one-quarter of those surveyed said their prescriptions cost them $50-$99 a month, while 29% spent $100 or more each month out-of-pocket for their prescription drugs. Patients who used seven or more drugs were four times more likely than those with one or two prescriptions to cut back on their medications at least once per month. Cost-related medication adherence problems were especially common among patients without prescription drug coverage, and those who were younger than 65. The researchers found many doctors may be unaware of patients’ problems due to medication costs. More than one-third of patients who reported cutting back on their medication use never talked to their doctor or nurse about it. These patients often said they were never asked about possible problems paying for their prescriptions or they did not think their doctor could help with medication costs. Patients also reported feeling embarrassed or rushed for time. Nearly one in five older adults with diabetes in the survey reported cutting back on prescription medication in the prior year because of costs, and 15% used less of their medication at least once per month because of the cost. By not taking their medications as prescribed, patients had poorer diabetes control, more symptoms and worse physical and mental functioning, researchers found. In the second study, published in the February issue of Medical Care, 766 adults with diabetes from Veterans Affairs health systems, a county health system, and a university-based health system were asked about their medication use and costs. Patients who reported using less diabetes medication because of cost had higher blood glucose levels than those who took their medication as prescribed. Those who cut back on other medications had more than twice as many symptoms and scored lower on tests of physical and mental functioning. More than half of the participants had at least three other chronic health problems, in addition to their diabetes, and these patients were especially at risk for not taking medication because of cost problems. Researchers also recommend social workers, nurses or pharmacists be enlisted to help link patients with sources of low-cost treatment and other forms of assistance available to them. For more info, http://care.diabetesjournals.org Back to top Study Links Breast Cancer to Antibiotic Use A study published this week in the Journal of the American Medical Association indicates that use of antibiotics may be linked to an increased risk of breast cancer. The authors - from Group Health Cooperative (GHC) in Seattle; the National Cancer Institute (NCI), a part of the National Institutes of Health in Bethesda, MD; the University of Washington, Seattle; and the Fred Hutchinson Cancer Center, also in Seattle - concluded that the more antibiotics the women in the study used, the higher their risk of breast cancer. Researchers noted that the results of this study do not mean that antibiotics cause breast cancer. “These results only show that there is an association between the two,” explained co-author Dr. Stephen H. Taplin, M.D., of NCI’s Division of Cancer Control and Population Sciences and formerly of the GHC. “More studies must be conducted to determine whether there is indeed a direct cause-and-effect relationship.” The authors of this JAMA study found that women who took antibiotics for more than 500 days—or had more than 25 prescriptions—over an average period of 17 years had more than twice the risk of breast cancer as women who had not taken any antibiotics. The risk was smaller for women who took antibiotics for fewer days. However, women who had between one and 25 prescriptions over an average period of 17 years had an increased risk were about 1.5 times more likely to be diagnosed with breast cancer than women who didn’t take any antibiotics. The authors found an increased risk in all classes of antibiotics that they studied. To gather the necessary data, the researchers used computerized pharmacy and breast cancer screening databases at GHC, a large, non-profit health plan in Washington state. They compared the antibiotic use of 2,266 women with breast cancer to similar information from 7,953 women without breast cancer. All the women in the study were age 20 and older, and the researchers examined a wide variety of the most frequently prescribed antibiotic medications. The results of the study are consistent with an earlier Finnish study of almost 10,000 women, but researchers stress that further studies must be conducted to understand the full implications of the findings. They said studies are also necessary to clarify whether specific indications for antibiotic use, such as respiratory infection or urinary tract infection, or times of use, such as adolescence, pregnancy or menopause, are associated with increased breast cancer risk. Breast cancer risks also could differ between women who take low-dose antibiotics for a long period of time and women who take high-dose antibiotics only once in a while. Antibiotics are regularly prescribed for conditions such as respiratory infections, acne, and urinary tract infections, in addition to a wide range of other conditions or illnesses. In this JAMA study, for example, more than 70% of women had used between one and 25 prescriptions for antibiotics to treat various conditions over an average 17-year period, and only 18% of women in the study had not filled any antibiotic prescriptions during their enrollment in the health plan. Researchers stressed that that women should not stop using antibiotics to treat bacterial infections. For more info, at www.cancer.gov/newscenter/pressreleases/AntibioticsQandA. Back to top American Heart Association Issues Guidelines for Women The American Heart Association announced this month new guidelines for preventing heart disease and stroke in women based on a woman’s individual cardiovascular health. “The concept of cardiovascular disease (CVD) as a ‘have-or-have-not’ condition has been replaced with the idea that CVD develops over time and every woman is somewhere on the continuum,” said Dr. Lori Mosca, MD, director of preventive cardiology at New York-Presbyterian Hospital/Columbia University Medical Center. According to the new recommendations, the aggressiveness of treatment should be linked to whether a woman has low, intermediate or high risk of having a heart attack in the next 10 years, based on a standardized scoring method developed by the Framingham Heart Study. “This provides a very individual approach to preventing CVD throughout the population,” Mosca said. Low risk means a woman has a less than 10 % chance of having a heart attack in the next 10 years, intermediate risk is a 10-20% chance, and high risk is a greater than 20% chance. Aspirin recommendations illustrate how recommended therapy varies across three levels of risk. For all high-risk women and for those who have documented cardiovascular disease, aspirin is recommended, but is not recommended for low-risk women. Among intermediate-risk women, aspirin can be considered as long as blood pressure is controlled and the benefit is likely to outweigh the risk of side effects such as gastrointestinal bleeding or hemorrhagic stroke. Lifestyle interventions such as smoking cessation, regular physical activity, heart-healthy diet and weight maintenance were given a strong priority in all women, not only because of their potential to reduce existing CVD, but also because heart-healthy lifestyles may prevent major risk factors from developing. ACE inhibitors and beta-blockers were recommended for all high-risk women. The guidelines also include a strong recommendation that high-risk women, even those with low-density lipoprotein (LDL) cholesterol levels below 100 mg/dL, should receive cholesterol-lowering drugs, preferably statins. Routine statin therapy has not previously been recommended for these women, but recent studies have shown a benefit in this subgroup. The use of niacin and fibrates, other cholesterol-lowering drugs of particular benefit in specific cases, is also discussed. The guidelines represent a major collaborative effort by representatives of the American Heart Association and 11 other professional and governmental co-sponsoring organizations. Another 22 organizations, including some lay organizations, endorsed the guidelines. For more info, www.americanheart.org. Back to top EHR Collaborative’s HL7 To Be Ready for Vote mid-March The EHR Collaborative announced Feb. 6 that an improved version of HL7’s electronic health record (EHR) functional model should be ready for vote by mid-March. The current draft holds approximately 200 functions, compared to the 1,600 functions included in the initial draft voted down in the fall of 2003. The latest version of the second draft ballot was scheduled for release in early February so that the EHR Collaborative can collect final industry feedback before the formal HL7 voting process begins. A series of open meetings will be held at the Healthcare Information and Management Systems Society Annual Conference and Exhibition next week in Orlando, FL. Those unable to attend can provide comment at www.ehrcollaborative.org. The model is tentatively set for HL7 ballot voting on March 15. If the second draft standard is passed, it will then be adopted for trial use. This would allow the government, vendors, and providers to collaborate on any product, implementation, and reimbursement issues over a two-year review period before the proposal of a fully accredited HL7 standard of the EHR model. “The industry shouldn’t expect any vendor to be fully compliant with the draft model if and when the draft standard is approved,” said Don Mon, PhD, vice president of practice leadership for the American Health Information Management Association. “The model combines existing EHR functions along with future-focused functions. Therefore few, if any, products will currently contain 100% of the functions in the model. “The two-year period will allow vendors to understand the draft model and standard better. This will help them set a direction for enhancing their products, and to begin migration to the draft standard,” said Pat Wise, director of EHR initiatives at HIMSS. “While the EHR standard can assist providers in constructing their request for proposals (RFP) during an EHR selection process, there is a difference between listing an EHR function as a business requirement in an RFP and stating that it is mandatory because of the standard.” For more info, www.ehrcollaborative.org. Back to top Utah Physician Practice Predicts EMRs Will Save $8.2M A large physician practice in Utah conducted a study on its new electronic medical records system and found it would save at least $8.2 million. Central Utah Multi-Specialty Clinic, a nine-location, 59-physician practice, said that estimate is conservative. The study analyzed costs related to paper records in the 12 months before and after implementation of the practice’s EMR system from Allscripts Healthcare Solutions, and found that the positive financial impact, in increased revenue and decreased operating costs, was $952,000 during the first year with EMRs. The system reduced transcription services by allowing doctors to use note templates to record parts of a patient visit. For more complex notes, the system electronically captures dictation, sends it to the practice’s transcription service and stores it in the system with an electronic signature for future access. The practice reduced transcription costs by 35%, or $380,000, during the study period. The researchers estimate that CUMC will reduce its use of dictation by 90% for $4.5 million in savings over five years. Other projected savings include: $60,000 in the first year and $375,000 over five years in labor and supply costs for maintaining paper charts; More than $975,000 in labor and supplies needed to create new paper charts; Billable gain of $26 per patient in more accurate coding; $1.7 million over five years in better documentation and coding practices; $248,000 by eliminating the need for records storage space in new facilities. For more info, www.himss.org/asp/publications_jhim.asp. Back to top USP to Hold Patient Safety Presentations The United States Pharmacopeia (USP) has scheduled a series of patient safety presentations between now and June 29 to be given by the organization’s Center for the Advancement of Patient Safety. Upcoming presentations include an analysis of medication errors in the emergency department setting as reported to MEDMARX and MER Feb. 28 at Salt Lake City, UT, and high-alert medications in the perioperative setting: a case-based approach to understanding the problems and crafting solutions on March 25 in San Diego. A complete list of events is available online. For more info, www.usp.org/patientSafety. Back to top

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