Minority stroke patients are more likely than others to undergo life-sustaining procedures, researchers find, but less likely to receive curative interventions.
Minorities are less likely to receive "curative" stroke care than white patients, but are more likely to receive "life-sustaining procedures," according to a study from the John Hopkins University School of Medicine published in JAMA Neurology.
The researchers compared racial disparities in the delivery of procedures considered curative treatments, those "aiming at improving functional status," such as the use of blood thinners or "intravenous thrombolysis."
The use of carotid revascularization, angioplasty of the carotid artery to prevent future strokes, was also evaluated.
Researchers also looked at disparities in what they consider "life-sustaining" procedures aimed at preventing death, such as mechanical ventilation and hemicraniectomy to relieve pressure on the brain. In addition, the study covered the use of feeding tubes and tracheostomy to open airways.
Minority patients were more likely than others to undergo life-sustaining procedures than white patients. The odds of receiving a feeding tube were 56% higher. Minorities were also 36% more likely to undergo tracheostomy.
They were, however, 20% less likely undergo intravenous thrombolysis and 43% less likely to receive carotid revascularization, both considered curative interventions.
The researchers note that their finding have limitations: "These results persisted after accounting for severity of medical comorbidities, end-of-life care, and in-hospital mortality, but we acknowledge that certain clinical characteristics not captured in the Nationwide Inpatient Sample, such as stroke severity, stroke location, and time to presentation, may partially explain our results. "
They suggest that an examination of the "commonalities within and differences between" the procedures may lead to "the development of effective strategies aimed at eliminating racial disparities in the delivery of stroke care."
An advocacy group is aiming to close a loophole that enables providers to evade reporting requirements in the National Practitioner Data Base.
Public Citizen has filed suit to close a "corporate shield loophole" that it says undermines the accountability of physicians and the safety of patients.
The complaint, filed in U.S. District Court in Washington, D.C., asks a federal judge to order the Department of Health and Human Services and the Health Resources and Services Administration to act on a May 2014 citizen petition to close the loophole.
Currently, physicians and other providers are able to evade medical malpractice reporting requirements in the National Practitioner Data Bank, Public Citizen said Tuesday.
Michael Carome, MD, director of Public Citizen's Health Research Group, said NPDB rules are not consistent with the federal statute that established the NPDB, and create the "corporate shield loophole."
The loophole allows a physician to avoid being reported to the NPDB if a malpractice plaintiff agrees to dismiss the practitioner from a lawsuit or claim, leaving a hospital or other corporate entity as the sole defendant.
"It is well past time for HHS to issue a rule slamming the door on this loophole, as it should have done when it first acknowledged the problem more than 15 years ago when the agency issued a proposed rule to close the loophole," Carome said in a press release. "The agency later withdrew the proposal, leaving the loophole open."
The NPDB is used by state licensing boards, hospitals and health maintenance organizations to conduct background checks to learn if a physician or other healthcare providers have been sanctioned for misconduct by a hospital, have had their licenses to practice curtailed, or had malpractice payments made on their behalf.
"The NPDB was created to ensure patient safety by providing a comprehensive, reliable information center concerning the malpractice payment and disciplinary history of physicians and other health care practitioners," Carome said.
"The corporate shield loophole makes the NPDB's information less complete, less reliable and less useful."
Organizations must be authorized to access NPDB's reports. Individuals and organizations who are subjects of the reports may access their own information. Otherwise, the reports are not available to the public.
New guidelines aiming to reduce antibiotic resistance in hospitals call for shorter courses, and more targeted use of drugs for pneumonia.
Doctors should streamline treatment for hospital patients who develop pneumonia by targeting antibiotics to specific infections and offering a shorter course of treatment, according to new guidelines.
The Infectious Diseases Society of America and American Thoracic Society published the update of their 2005 guidelines in the July edition of the journal Clinical Infectious Diseases.
The previous guidelines called on doctors to adjust the length of antibiotic treatment based on the strain of bacterium causing the infection. The new guidelines call for treatment limits of seven days or fewer.
The panel notes that "newer evidence suggests that the shorter course of treatment does not reduce the benefits of therapy."
The guidelines apply to both hospital-acquired pneumonia and "ventilator-associated pneumonia." The groups estimate that these two conditions make up 20% to 25% of hospital-acquired infections, with 10% to 15% of those cases leading to death.
Targeting Pneumonia Treatment
Hospitals are urged to generate "antibiograms" to test the sensitivity of local bacterial strains to various antibiotics.
"We suggest that patients with suspected HAP (non-VAP) be treated according to the results of microbiologic studies performed on respiratory samples obtained noninvasively, rather than being treated empirically," the guidelines state.
The goal is to decrease the unnecessary use methicillin-resistant Staphylococcus aureus (MRSA) antibiotic treatment. The guidelines also call for "antibiotic de-escalation," where providers either discontinue antibiotics or switch to an agent that targets fewer strains.
The guidelines are voluntary, but rules proposed by the Centers for Medicare & Medicaid Services in June will require that hospitals have "antibiotic stewardship programs for the surveillance, prevention, and control of healthcare-associated infections."
In May, the National Quality Forum released an antibiotic "stewardship playbook" to help hospitals comply with Centers for Disease Control recommendations. Drug-resistant bacteria cause two million illnesses and 23,000 deaths annually, according to the CDC.
Less than half of health plans and health systems have identified solutions to assess the quality of their post-acute networks, survey data shows.
A survey of some 20 Medicare Advantage health plans operated by both health insurance companies and health systems shows that only 31% of them have identified solutions to help them assess the quality of their post-acute provider network.
More specifically, and perhaps more troubling: most plans and health systems are developing post-acute networks one provider type at a time. Rather than finding ways to integrate care management and accountability across settings, skilled nursing facilities are the most common area for initial focus.
The survey and interviews were conducted by Washington, D.C.-based consulting firm Avalere Health in cooperation with post-acute provider Kindred Healthcare. Post-acute providers include long-term acute care hospitals, inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies.
"Providers that can integrate data across the care continuum can drive better outcomes for patients and be better partners to Medicare," said Josh Seidman, a senior vice president in Avalere's Center for Payment and Delivery Innovation, in a media release.
Some of the findings suggest a reliance on interim measures, such as robust post-discharge follow-up by a variety of methods, to help encourage, if not ensure, good outcomes.
Clearly, better analytical and decision-assisting tools are needed, and organizations would probably benefit by constructing their post-acute networks more systematically rather than in an ad-hoc manner.
Avalere reached three broad conclusions about the survey data:
1.Reliable data are critical to advancing value-based post-acute contracts.
Unreliable provider quality data was a cited as a common challenge in some of the interviews conducted with health plan and health system representatives.
Payers also were skeptical about the capability of post-acute providers to enter into risk-based contracts with health plans directly. Health systems also cited a lack of data infrastructure to systematically channel patients to high-quality post-acute providers.
2.Incentives to redefine post-acutemanagement could be most prominent in arrangements where health systems are bearing financial risk.
All health systems placed a high priority on developing high-quality post-acute networks, and more than half were interested in discharging patients to lower-cost post-acute settings such as home health.
Interviewees indicated that entering into bundled payment or accountable care organization contracts, under which providers bear financial risk for the total cost of care, were important catalysts for this prioritization.
3.Reducing readmissions is an area of focus, but the role of post-acutein improving readmission rates is still evolving.
All interviewees reported investments to reduce hospital readmissions. Many are just beginning to think about how post-acute provider quality and accountability can contribute to those efforts.
Health systems are ramping up their focus on post-discharge follow-up, including exploring new uses for remote care technology.
The first mandatory bundled payment models for heart attack and coronary artery bypass procedures would begin in the summer of 2017.
First came Medicare's bundled payments program for joint replacements. Then came its oncology bundling model. On Monday, Medicare announced a program for cardiac-care bundled payments.
Under the proposed rule, cardiac-care bundled payments would begin next July in 98 randomly selected metropolitan areas.
During a conference call Monday with members of the media, Patrick Conway, MD, acting principal deputy administrator and chief medical officer of the Centers for Medicare & Medicaid Services, described three policies included in the proposal:
New bundled payment models for cardiac care and the extension of the joint model to include treatment for hip and femur fractures;
A new model to increase cardiac rehabilitation;
A proposed pathway for clinicians and physicians in bundled payment models to qualify for payment incentives under MACRA.
Conway described the models as a major step to improve care, which builds off of CMS's Million Hearts initiative. That program "is focused on prevention, and these new payment models, which are focused on medical services and rehabilitation, we are providing a comprehensive payment system that doesn't just emphasize treating a disease but instead on maintaining health," he said.
Medicare has an opportunity to promote value in the delivery of cardiac care, Conway added. "In 2014, more than 200,000 Medicare beneficiaries were hospitalized for heart attack treatment or underwent bypass surgery, costing Medicare over $6 billion. But the cost of treating patients varied by 50% across hospitals and the share of patients readmitted to the hospital within 30 days varied by more than 50%. And patient experience also varied."
Cardiac Care Bundled Payment Details
Under the proposed cardiac-care bundled payments, hospitals would receive quality-adjusted pricing for heart attack and bypass episodes of care including 90 days after a hospital inpatient stay, according to a CMS factsheet.
"Specifically, once the models are fully in effect, participating hospitals would be paid a fixed target price for each care episode, with hospitals that deliver higher-quality care receiving a higher target price," the factsheet says.
There would be a phased-in process for downside and upside risk in the cardiac-care bundled payments from July 2017 to December 2021, the factsheet says.
Downside risk is slated to start in 2018, beginning with a 5% downside payment penalty cap from April 2018 to December 2018, a 10% payment penalty cap in 2019, and a 20% payment penalty cap in 2020 and 2021.
Upside payment rewards are slated to start next July, with shared savings payments capped at 5% from July 2017 to December 2018, 10% in 2019, and 20% in 2020 and 2021.
In 45 geographic regions, hospitals would be given a payment incentive to provide cardiac rehabilitation services. "Hospitals may use this incentive payment to coordinate cardiac rehabilitation and support beneficiary adherence to the cardiac rehabilitation treatment plan to improve cardiovascular fitness," the CMS factsheet says.
Cardiac care patients would benefit significantly from higher utilization of rehabilitation services, Conway said.
"Currently, only 15% of heart attack patients receive cardiac rehabilitation, even though completing a rehabilitation program can lower the risk of a second heart attack or death. Patients who receive cardiac rehabilitation are assigned a team of healthcare professionals such as cardiologists, dietitians, and physical therapists to help the patient recover and regain cardiovascular fitness," he said.
The public comment period on the proposed bundled payments rule for cardiac care and expanded orthopedic surgery is expected to close at the end of September.
Under a Veterans Affairs proposal put forward this spring, advanced practice registered nurses would provide wider array of services without direct clinical oversight from a physician, and regardless of restrictions in state or local law.
Federal Trade Commission staff have issued written support for a Department of Veterans Affairs proposal that would grant advanced practice registered nurses a wider degree of authority and autonomy.
Staff of the FTC's Office of Policy Planning and its Bureaus of Competition and Economics responded to the VA's request for public comments and wrote that removing the remaining state law-based supervision restrictions for APRNs working within the Veterans Health Administration system could benefit VA patients nationwide "by improving access to care, containing costs, and expanding innovation in healthcare delivery," FTC said.
"To the extent that the VA's actions would spur additional competition among healthcare providers and generate additional data in support of safe APRN practice, we believe those benefits could spill over into the private healthcare market as well," FTC staff wrote.
When the VA released the proposal in May, it said that full practice authority would expand the pool of qualified healthcare professionals authorized to provide primary healthcare and other related health care services to the full extent of their education, training, and certification to Veterans without the clinical supervision of a physician.
The American Medical Association responded in May that " this proposal will significantly undermine the delivery of care within the VA" and urged the VA to maintain its physician-led model of care.
Under the new policy, APRNs would be able to evaluate VA patients, order diagnostic tests for them, and manage their treatments without physician involvement or approval as long as they do so within the limits of their professional education and training.
The four APRN roles are:
Certified Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse Anesthetist
Certified Nurse Midwife
All VA APRNs are required to obtain and maintain current national certification. The VA recognizes that CNPs, the main category of primary care APRNs, already have full practice authority under the laws of more than 20 states and the District of Columbia.
"The purpose of this proposed regulation is to ensure VA has authority to address staffing shortages in the future," said VA Under Secretary for Health David J. Shulkin, MD. "Implementation of the final rule would be made through VHA policy, which would clarify whether and which of the four APRN roles would be granted full practice authority."
Shulkin stressed in May that the VA is not seeking to change its policy on the role of APRNs "at this time… but would consider a policy change in the future to utilize full practice authority when and if such conditions require such a change."
"This is good news for our APRNs, who will be able to perform functions that their colleagues in the private sector are already doing," he said.
The President of the American Association of Nurse Practitioners, Cindy Cooke, DNP, FNP-C, FAANP, said in a statement Monday that AANP "is pleased that the FTC filed comments in support of the VA's proposed rule. The FTC's comments recognize that granting veterans direct access to nurse practitioners at VA facilities across the nation will increase access to care and improve efficiencies in health care delivery."
Many requirements of the healthcare reform law have effectively raised premiums, but others serve to save consumers money, including the individual mandate, researchers say.
Despite news coverage about rapidly increasing premiums on the individual market, prices would be higher and coverage would be less without the law, a Brookings Institution report says.
Yes, premiums continue to escalate at rates far exceeding the rate of inflation into 2017, but a study conducted by the nonpartisan think tank says that premiums will still be far lower than they would be in absence of the law.
Conventional wisdom is that the Patient Protection and Affordable Care Act increased premiums in the individual, non-group insurance market, if only because it increase the scope of coverage.
The report concedes that many of these new rules did indeed have the effect of increasing premiums. Notably, the PPACA mandates issue regardless of health status, requires certain "essential" benefits that were not previously required, and prevents limits on lifetime coverage, and does limit yearly out of pocket costs an enrollee can pay for covered services in a given year.
Meanwhile, other requirements of the healthcare reform law serve to save consumers money, including the individual mandate, which expanded the number of people purchasing overage in the individual market, consequently served to hold down premiums.
It created relatively transparent marketplaces where insurers must compete on premiums for products standardized by actuarial value, allowing competition to drive down prices.
The report says, essentially, that the latter factors outweigh those that served to increase prices, and despite the fact that premiums are increasing dramatically in nominal terms, they are much less than they would be had the law not been enacted.
"According to our analysis, average premiums for the second-lowest cost silver-level marketplace plan in 2014, which serves as a benchmark for ACA subsidies, were between 10% and 21% lower than average individual market premiums in 2013, before the ACA, even while providing enrollees with significantly richer coverage and a broader set of benefits," said report authors Loren Adler and Paul Ginsburg from the Brookings Center for Health Policy.
"Silver-level ACA plans cover roughly 17% more of an enrollee's health expenses than pre-ACA plans did, on average. In essence, then, consumers received more coverage at a lower price."
"Silver-level ACA plans cover roughly 17% more of an enrollee's health expenses than pre-ACA plans did, on average. In essence, then, consumers received more coverage at a lower price."
Significantly, the analysis does not include the effects of premium and cost-sharing subsidies that serve to make PPACA marketplace plans even more affordable.
The best nudges optimize medical decisions and improve the value of care. They "influence decisions, but they don't restrict choice," says study author.
It's not always easy to tell physicians how to practice medicine, which is why a subtle nudge often can be more effective than a shove.
With generic prescribing, for instance, researchers at the Perelman School of Medicine at the University of Pennsylvania discovered that making a simple change to prescription default options in electronic health records systems immediately boosted generic prescribing rates from 75% to 98%, according to a study in JAMA Internal Medicine.
The research is one of the first from the Penn Medicine Nudge Unit, which is testing ways that "nudges" can be used to optimize medical decisions and improve the value of care.
"The general concept of the nudge unit is something first popularized in the UK by former prime minister David Cameron to improve policies and programs," says study lead author and Penn's Nudge Unit Director Mitesh S. Patel, MD, MBA, MS.
"We wanted to try to structure this more formally within our healthcare system. Nudges are really moving past education and reminders" to think about how people are influenced and make decisions, he says.
The Unit also determines whether providers are using their "fast-thinking" or "slow-thinking" brains."
"Many of the things we do, especially in healthcare, we use our fast-thinking or automatic brain," Patel says, such as getting into the habit of automatically ordering a chemistry panel every day for a patient.
The Nudge Unit is studying whether nudges influence certain choices, such as whether including cost information in the EHR will limit physicians from ordering unnecessary tests, or the effect of including a "yes" or "no" choice within the EHR for orders such as mammograms.
Importantly, these nudges "influence decisions, but they don't restrict choice," Patel says.
Effect on Prescribing Practices
In the generic prescribing study, researchers tracked prescribing rates for oral medications given for 10 common medical conditions and used an opt-out checkbox in the EHR.
When a physician prescribed a drug for a patient, the EHR would default to an equivalent generic. The physician, however, could still prescribe the brand name when warranted, by selecting the "dispense as written" checkbox.
For most drugs, physicians specified that the brand name should be prescribed only 2% of the time.
There was an exception when physicians prescribed Synthroid for patients with thyroid conditions because it has different hormone levels than its generic version, Levothyroxine.
In this case, physicians opted out and selected the brand name 22% of the time, illustrating that the system preserved the physician's ability to choose.
Patel notes that part of what the Nudge Unit is studying is how to improve the manner in which physicians are already being influenced.
"Defaults exist throughout the environment no matter what," he says. Physicians are "already being nudged. We're just making sure we're doing a better job of that."
Pharmacy review, adherence counseling during discharge, and ongoing telephone follow up identify safety concerns, prove cost-effective, researchers find.
Hospital-based medication reconciliation programs that include a pharmacy review and adherence counseling during discharge slash readmissions in half, according to a new study published in the July issue of Health Affairs.
The study evaluated the effect of an insurer-supported medication reconciliation program on clinical outcomes and healthcare spending.
The CVS Health Research Institute analyzed hospital readmissions of more than 260 members of a national health plan who were hospitalized over a five-month period.
Researchers compared readmission rates for patients enrolled in a medication reconciliation program upon hospital discharge to a control group of patients who received no additional support following their hospital stay.
Program participants received an initial in-home or telephone consultation based on their readmission risk and were offered ongoing telephone support for 30 days after discharge.
During the initial consultations, pharmacists
Compared members' pre- and post-hospitalization medication regimens
Identified discrepancies, redundancies, and safety concerns
Provided education and support on medication use and adherence
The researchers found that risk of hospital readmission at 30 days was cut by 50%, lowering overall risk of hospital readmission from 22% to 11% for those in the medication reconciliation program.
Additionally, the health plan saved $2 for every $1 spent on the program, resulting in a total savings of more than $1,300 per member.
"These results represent real-world evidence that insurer-initiated, pharmacist-led care transition programs, focused on, but not limited to medication reconciliation, have the potential to both improve clinical outcomes and reduce total costs of care," the study abstract said.
Similarly, a 2014 study showed that patients who participated in the Walgreens WellTransitions program were 46% less likely to be readmitted within 30 days.
Study shows that families of patients with chronic critical illnesses saw little benefit from meetings led by palliative care specialists, and higher symptoms of post-traumatic stress disorder compared to families that met with standard ICU teams.
Palliative care is supposed to provide relief from the symptoms and stress of serious illness, so a study suggesting that it doesn't comes as a surprise.
Despite what researchers were expecting, data collected from four medical intensive care units over four years found no difference in reported in levels of anxiety and depression for the families of patients with chronic critical illness who received informational and emotional support meetings led by palliative care clinicians.
One group had structured family meetings led by palliative care specialists including palliative care physicians, nurse practitioners, and social workers. The other who had routine family meetings with the standard ICU team. Both groups also received an information brochure.
During these palliative care-led meetings, the patient's prognosis, values, goals, and care preferences were discussed.
PTSD Symptoms Seen in Families
Three months after the intervention, however, there was no significant difference in reports of anxiety and depression among surrogate decision makers in the two groups, no significant effect on duration of mechanical ventilation and length of hospital stay, and no effect on survival rates.
Instead, the group in the meetings led by palliative care specialists reported higher symptoms of post-traumatic stress disorder compared to the group that met with standard ICU teams.
The results of this study do not support mandatory meetings with palliative care specialists, write the study's authors, nor do the results suggest that palliative care consultations are unnecessary.
Instead, the study authors suggest that palliative care specialists should focus on patients who need assistance with pain and symptom management and patients and families at who are at high risk for poor emotional outcomes.