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VHIG Digest: Volume 2, No. 1

Posted by on Monday, January 10, 2011 in Digest, Our Blog and Digest, Volume 2.

By Scott Hagan, VMS II

In the News

1. Wall Street Journal investigates controversy over rates of spinal fusion surgery

A December 20th article in the Wall Street Journal reported on an unusually high rate of spinal fusion surgeries at Norton Hospital in Louisville, Ky. Five spinal surgeons there contributed to giving Norton the distinction of having the third-highest rate of spinal fusion surgeries of any U.S. hospital. Central to this controversy is that in 2010 these surgeons received over $7 million from Medtronic, Inc, the manufacturer of the spinal fusion device the surgeons used.Spinal fusion surgery, which involves fusing 2 or more vertebrae in patients with significant back pain, is a particularly controversial operation due to limited evidence of its effectiveness, especially as an indication for patients with degenerative disk disease. The article touches on the problem of financial incentives and the extent to which they affect volume of procedures.

2. UK Report of Regional Variations in NHS Spending Mirror Dartmouth Atlas Findings

Christopher Weaver of NPR’s Health Blog Shots reports that the NHS has released an Atlas of Variation in Healthcare inspired by the Dartmouth Atlas of Health Care, which documented dramatic regional differences in the price, volume, and quality of health care in the United States. The NHS Atlas findings showed similar regional variations in the U.K. For example, hip replacements are performed at 16 times greater rates in Oxford than in London. These results surprised some who attribute most of the variations in healthcare in the United States to our fee-for-service system, whereas in the U.K. most physicians are salaried. Per the article, Jack Wennberg of the Dartmouth Atlas commented that variations in healthcare are “independent of the way health care’s organized and financed,” and Angela Coulter of the Foundation for Informed Medical Decision Making added that “it illustrates the fact… that doctors tend to favor the treatments they’re trained to provide.”

3. IOM commits to yearlong study on the effect of EMRs on patient safety

The Institute of Medicine will coordinate a yearlong study in 2011 to examine the effectiveness and potential for electronic medical record (EMRs) systems to improve patient safety. The Office of the National Coordinator for Health Information Technology (ONC), the federal agency responsible for the coordination of EMR adoption and meaningful use has awarded the IOM $989,000 to fund the study. The According to the IOM, the study is intended to examine the following:

  • summarize existing knowledge of the effects of HIT on patient safety;
  • identify approaches to promote the safety-enhancing features of HIT while protecting patients from any safety problems associated with HIT;
  • identify approaches for preventing HIT-related patient safety problems before they occur;
  • identify approaches for surveillance and reporting activities to bring about rapid detection and correction of patient safety problems;
  • address the potential roles of private-sector entities such as accrediting and certification bodies, as well as patient safety organizations and professional and trade associations; and
  • discuss existing authorities and potential roles for key federal agencies, including the Food and Drug Administration, the Agency for Healthcare Research and Quality, and the Centers for Medicare & Medicaid Services (CMS).

Meanwhile, the New York Times reports that F.D.A. may begin regulating EMR systems after finding over 260 malfunctions of health IT products causing at least 44 injuries and six reported deaths in 2008-2009. The findings of the IOM study may be the final impetus for the F.D.A. to begin regulating HIT products.


4. Several Provisions of the Health Care Reform Law Take Effect

Although much of the news related to the Patient Protection and Affordable Care Act (PPACA) this week relate to the efforts of House Republicans to repeal the health care reform law, another important news story related to health care reform is the implementation of several important provisions of the PPACA at the beginning of 2011. Per The Advisory Board Company, these new rules include:

  • Medicare beneficiaries who reach the “doughnut hole,” or gap in prescription drug coverage, will get a 50% discount on brand-name medications if their total drug costs fall between $2,840 and $6,448. At the same time, beneficiaries with annual incomes higher than $85,000 for individuals and $170,000 for couples will receive less in government subsidies for their drug coverage;
  • Drugmakers are subject to a $2.5 billion tax that will be assessed based on sales volume;
  • Medicare beneficiaries will be able to receive coverage for about 20 preventive health services, including screenings and smoking cessation services, at no cost. Medicare also will cover one no-cost “wellness visit” annually;
  • Medical-loss ratio rules require insurers to spend 80% of revenue from small-group plans and 85% of revenue from large-group plans on medical care;
  • The creation of the Center for Medicare and Medicaid Innovation, a new agency to slow down costs by fostering innovations in care and processing payments and claims;
  • Consumers will not be able to use flexible spending accounts to purchase most over-the-counter products, unless they have a prescription. However, some products, such as bandages, will still
    qualify; and
  • Certified midwives will be paid at the same rate as physicians providing similar services under Medicare (Adamy, Journal, 12/31; Fahrenthold,Washington Post,1/1).


5. Quality improvement initiative saves 22,000 lives

Premier, Inc., a quality improvement alliance of over 2400 U.S. nonprofit hospitals, has released the preliminary results of The QUEST Initiative. The initiative, now two years old,
is a collaboration between 157 small, mid-size and large hospitals in 31 states who have agreed to share data and best practices. Areas of hospital care like surgical infections, septicemia, respiratory failure, and acute coronary syndrome were the focus of specific improvement measures that were coordinated across all hospitals via conference calls and webinars, and all data on quality improvement and patient safety was shared between hospitals so that high-performing hospitals could be identified and their best practices disseminated. The results are impressive: 22,165 lives saved, or a 25% drop in inpatient death rates; $2.1 billion in hospital savings; a 13% improvement in the use evidence-based care, all in just 2 years time. The initiative suggests how dramatic the economic savings and lives saved can be from quality improvement collaborations, especially as a NEJM study released last November (described in Vol.1 No. 3 of this digest) suggests that hospitals continue to fail to address the harms that patients face in our medical system.


Download the Premier, Inc. Powerpoint of these results here

In the Literature

1. Clostridium difficile Infection in Hospitalized Children in the United States

Health care social media has been ablaze this month with the news of an online report released in the Archive of Pediatric and Adolescent Medicine on January 3rd finding increased rates of C. Diff infection in hospitalized children. C. Diff is a potentially life-threatening infection causing severe diarrhea that can lead topseudomembranous colitis. The authors have suggested that the increased rates of C. Diff might be attributed to a more virulent strain of the bacteria.

Findings: There was an increasing trend in cases of CDI, from 3565 cases in 1997 to 7779 cases in 2006 (P < .001). Patients with CDI had an increased risk of death (adjusted odds ratio [OR], 1.20; 95% confidence interval [95% CI], 1.01-1.43),colectomy (adjusted OR, 1.36; 95% CI, 1.04-1.79), a longer length of hospital stay (adjusted OR, 4.34; 95% CI, 3.97-4.83), andhigher
hospitalization charges (adjusted OR, 2.12; 95% CI, 1.98-2.26). There was no trend in death, colectomy, length of hospital stay, or hospitalization charges during the 4 time periods (ie, 1997, 2000, 2003, and 2006). The risk of comorbid diagnoses associated with CDI included inflammatory bowel disease, with an OR of 11.42 (95% CI, 10.16-12.83), and other comorbid diagnoses associated with immunosuppression or antibiotic administration. There is an increasing trend in CDI among hospitalized children, and this disease is having a significant effect on these children. In contrast to adults, there is no increasing trend in the severity of CDI in children. Children with medical conditions (including inflammatory bowel disease and immunosuppression) or conditions requiring antibiotic administration are at high risk of CDI.

For more articles on this news story:

2. Is Better Patient Safety Associated with Less Malpractice Activity? Evidence from California

The RAND Corporation has released a free eBook of a report by Greenberg et al. analyzing the association between the frequency of adverse safety outcomes and volume of malpractice claims.

Findings: In principle, efforts to improve patient safety, if they are successful, should lead to reductions in claims of medical malpractice. In practice, however, this has not yet been systematically demonstrated to be so. The authors of this report examined the relationship between safety outcomes in hospitals and malpractice claiming against providers, using administrative data and measures for California from 2001 to 2005. They found that decreases in the county-level frequency of adverse safety outcomes were positively and significantly associated with decreases in the
volume of malpractice claims, as captured by records from four of the largest malpractice insurers in the state. This result suggests that policy options that improve patient safety may offer a new avenue for reducing malpractice pressure on physicians, at the same time that they improve clinical outcomes.

3. Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus

study published on January 7th in the New England Journal of Medicineexamined the benefit of screening and treating nasal carriers of S. aureus in order to prevent surgical-site infections in hospitalized patients. The double blind, randomized control trial utilized a rapid detection RT-PCR assay to detect nasal carriers of S. aureus, and positive carriers were treated with mupirocin
nasal ointment
and chlorhexidine soap. The rate of S. aureus surgical-site infection in the treatment group was 3.4% (17 of 504 patients) compared to 7.7% (32 of 413 patients) in the control group (relative risk of infection, 0.42; 95% confidence interval [CI], 0.23 to 0.75). Although there was no significant effect on in-hospital mortality, the intervention significantly reduced length of hospital stay by almost 2 days, suggesting that rapid detection and treatment of nasal carriers of S. aureusin hospitalized surgery patients could provide significant savings for hospitals.