After an eight-hour shift, there is no difference in contamination among physicians wearing long- and short-sleeved shirts, or on the skin at the physicians' wrists, according to a new study published today in the Journal of Hospital Medicine.
Researchers from the University of Colorado assessed the claim that longer sleeves lead to more contamination by testing the uniforms of 100 physicians at Denver Health who were randomly assigned to wearing a freshly washed, short-sleeved uniform or their usual long-sleeved white coat.
"We were surprised to find no statistical difference in contamination between the short- and long-sleeved workwear," said lead researcher Marisha Burden, MD, a hospitalist at Denver Health, and assistant professor of medicine at the University of Colorado Health Sciences Center. "We also found bacterial contamination of newly laundered uniforms occurs within hours of putting them on."
In the study, 50 physicians were asked to start the day of the trial in a standard, freshly washed, short-sleeved uniform. The 50 physicians wearing their usual long-sleeved white coats were not made aware of the trial date until shortly before the cultures were obtained, to ensure that they did not change or wash their coats. Cultures were taken from the physicians' wrists, cuffs and pockets. No significant differences were found in bacteria colony counts between each style.
The researchers also found that although the newly laundered uniforms were nearly sterile before putting them on, three hours into a shift nearly 50% of the bacteria counted at eight hours were already present.
"By the end of an eight-hour work day, we found no data supporting the contention that long-sleeved white coats were more heavily contaminated than short-sleeved uniforms," Burden said. "Our data do not support discarding white coats for uniforms that are changed on a daily basis, or for requiring healthcare workers to avoid long-sleeved garments."
Burden's study notes that some British government agencies have instituted guidelines banning physicians' white coats and the wearing of long-sleeved garments to decrease the transmission of bacteria in hospitals in the belief that cuffs of long-sleeved shirts carry more bacteria.
Motorcycle helmets, which dramatically reduce brain injuries and deaths from crashes, also lower the risk of spinal injuries, a Johns Hopkins study shows.
While that may seem as obvious as a bump on the head, Johns Hopkins researchers say their findings actually debunk a decades-old popular myth among anti-helmet lobbyists that wearing a helmet can hurt the spine during a crash.
“Using this new evidence, legislators should revisit the need for mandatory helmet laws,” said study leader Adil H. Haider, MD, a trauma surgeon, and assistant professor of surgery at the Johns Hopkins University School of Medicine. “There is no doubt that helmets save lives and reduce head injury. And now we know they are also associated with a decreased risk of cervical spine injury.”
Haider said the new data refutes a 1986 study by Jonathan P. Goldstein, an economics professor at Bowdoin College, that suggested that the weight of a helmet could cause significant torque on the neck that would be devastating to the spine. The Johns Hopkins study, published online in the Journal of the American College of Surgeons, shows that helmeted riders were 22% less likely to suffer cervical spine injury than those without helmets. The study reviewed the National Trauma Databank on more than 40,000 motorcycle collisions between 2002 and 2006.
Even with what he called mountains of evidence that helmets reduce mortality and traumatic brain injury after a collision, Haider said several states, including Florida, Pennsylvania and Texas, have over the past 15 years repealed mandatory helmet laws after lobbying from motorcyclists.
Anti-helmet groups often cite the Goldstein study which found more spine injuries in helmet wearers. The National Highway Traffic Safety Administration rapped the Goldstein study’s flawed statistical reasoning. “Additionally, helmet technology has significantly improved since that time; now helmets are much lighter, but even sturdier and more protective,” Haider says.
Forty years ago, Haider says, nearly all states required helmets for all motorcyclists. Today, helmets are mandatory for all riders in only 20 states, Puerto Rico and the District of Columbia.
Motorcycle use has risen sharply over the past 10 years in the United States. Since 1997, motorcycle injuries in the U.S. have increased by roughly 5,000 per year and motorcycle fatalities have nearly doubled, according to the new journal article.
Haider's study, like many others before, found a reduction in risk of traumatic brain injury in helmet wearers (65%) and decreased odds of death (37%). But the new paper is the strongest evidence yet that helmets significantly reduce cervical spine injury, which can result in paralysis, Haider said.
Warming local anesthetics before injecting them significantly reduces the pain of the injection, according to a study published online this week in Annals of Emergency Medicine.
"Warming an injection is a cost-free step that emergency physicians can take to reduce pain from a shot," said Anna Taddio, MD, of the University of Toronto in Canada, and lead author of the study: Systematic Review and Meta-Analysis of the Effect of Warming Local Anesthetics on Injection Pain.
"Patients often dread the sight of a needle, but doing something as simple as warming the injection to body temperature can make a painful part of an emergency department visit more tolerable," Taddio said.
Taddio reviewed 18 previous studies involving 831 patients, and found that warming injections consistently produced a "clinically meaningful reduction in pain" regardless of whether the anesthetic had been buffered or not, regardless of whether the shot was administered subcutaneously or intradermally and regardless of whether the amount being injected was small or large.
Injections were warmed using controlled water baths, incubators, fluid warmers, baby food warmers, a warming tray and a syringe warmer. Some emergency physicians warm injections in their hands prior to administering them, the research found.
"Future research should examine the effects of warming local anesthetics for dental procedures and for procedures specifically involving children," Taddio said. "This is an area where a small change may make a big difference for a patient."
Kindred Healthcare, Inc., the Louisville, KY-based long-term healthcare services provider, will acquire RehabCare Group, Inc. in a $1.3 billion deal that will create the nation’s largest rehabilitation services company, the two companies announced jointly on Tuesday.
When the merger is finalized, the combined company will generate $6.2 billion in annual revenues, with operations in 46 states, including 118 long-term acute care hospitals with 8,492 licensed beds, 226 nursing and rehabilitation centers with 27,442 licensed beds, 121 inpatient rehabilitation hospitals, and 1,808 hospital, nursing center and assisted living rehabilitation therapy services contracts, the two companies said.
“The expansion of our size and scale and the opportunities to integrate RehabCare's LTAC and IRF hospitals and rehabilitation therapy contract business with our operations will create a stronger company both nationally and locally and create value for all of our constituents in the communities we serve,” said Paul J. Diaz, president/CEO of Louisville, KY-based Kindred.
“We are particularly excited about the opportunity to add RehabCare’s services in our cluster markets and inpatient rehabilitation services to our service offerings. Together with our growing home care and hospice businesses, the merger offers our patients an expanded continuum of services and the opportunity for us to ‘continue the care’ for our patients and residents through an entire episode of treatment and recovery,” Diaz said.
The merger agreement was unanimously approved by the board of directors of both Kindred and RehabCare. Two members of the RehabCare board will join the Kindred board when the deal is finalized.
Shareholders of St. Louis, MO-based RehabCare will get $26 per share in cash and 0.471 of a share of Kindred common stock, which the two companies said equates to about $35 per share.
“Our combination with Kindred delivers significant value to our stockholders and provides an opportunity to share in the future growth of the combined company,” RehabCare President/CEO John H. Short said. “We share the same commitment to delivering leading-edge post-acute care that improves lives, and we expect our patients, healthcare partners and professionals to benefit from the blending of our organizations.”
Kindred expects to issue approximately 12 million shares in connection with the transaction. The aggregate value of the pending transaction approximates $1.3 billion, including approximately $400 million of existing indebtedness.
The deal is expected to be finalized by June 30, but must still be approved by stockholders of both companies, and cleared by federal regulators.
Eight Miami-area nurses were sentenced to prison and ordered to pay hundreds of thousands of dollars in restitution after pleading guilty to their role in an $18.7 million Medicare home healthcare fraud scheme, the Department of Justice said.
The nurses were originally indicted in July 2010, along with Jorge Dieppa, MD, who awaits trial on charges of healthcare fraud, and making false statements related to Medicare payments.
According to prosecutors, the Miami-based healthcare agencies ABC Home Health Inc. and Florida Home Health Care Providers Inc. were owned by the nurses, and allegedly referred Medicare beneficiaries to Dieppa for prescriptions, medical certifications and care plans for therapy and home health services. ABC and Florida Home Health billed Medicare $18.7 million for services that were either medically unnecessary or never provided.
The eight nurses each previously pleaded guilty to one count of conspiracy to commit healthcare fraud and were sentenced in US District Court:
Diana Sanabia, 36, RN, was sentenced to 30 months in prison, three years of supervised release and ordered to pay $594,000 in restitution;
Daisy Santos, 43, RN, was sentenced to 30 months in prison, three years of supervised release and ordered to pay $699,000;
Roberto Rodriguez, 44, RN, was sentenced to 30 months, three years of supervised release and ordered to pay $603,900;
Marlene Magadan, 36, RN, was sentenced to 24 months, three years of supervised release and ordered to pay $334,200;
Maria Perez, 49, RN, was sentenced to 18 months, three years of supervised release and ordered to pay $180,600;
Alberto Alvarez, 55, RN, was sentenced to 15 months, three years of supervised release and ordered to pay $101,800;
Yanisley Chao, 32, LPN, was sentenced to 5 months, two years of supervised release and ordered to pay $66,800;
Leonardo Malagon, 40, LPN, was sentenced to 5 months, two years of supervised release and ordered to pay $65,900.
According to plea documents, Perez and Chao worked for Florida Home Health; Santos, Magadan and Malagon worked for ABC; and Sanabia, Rodriguez and Alvarez worked for both ABC and Florida Home Health. They falsified patient files for Medicare beneficiaries to make it appear that the beneficiaries qualified for services from Florida Home Health or ABC that were prescribed by Dieppa. In fact, the nurses knew that the services were not medically necessary and /or were not rendered, DOJ said.
Sanabia and Santos also recruited Medicare beneficiaries for the agencies and received kickbacks for the recruitments, even though the pair knew that the beneficiaries they recruited did not qualify for the home health services, DOJ said.
Co-defendant Alfredo Zayas, 76, a Medicare beneficiary who pleaded guilty to one count of conspiracy to commit healthcare fraud, was also sentenced to two years of probation. Zayas solicited and accepted kickbacks and bribes for allowing his Medicare number to be used to bill Medicare for the bogus treatments, DOJ said.
Sanabia, Santos, Magadan, Perez, Rodriguez, Alvarez, Chao, Malagon and Zayas were responsible for fraudulently billing to Medicare the following approximate amounts, respectively: $594,000, $699,000, $381,100, $180,600, $603,900, $101,800, $66,800, $65,900 and $23,800, DOJ said.
The sentences were imposed by U.S. District Court Judge Ursula Ungaro in Miami.
Since their inception in March 2007, Medicare Fraud Strike Force operations in seven districts have obtained indictments of more than 850 individuals who collectively have falsely billed the Medicare program for more than $2.1 billion, DOJ said.
Turnover among first-year nurses remains a huge cost driver and source of frustration for hospital managers. It's hard enough to find these skilled clinicians, and even more annoying that they quit, just when they should be settling into their new careers. That leaves harried HR staff to start the process anew and with no more assurances of retaining the next new recruit.
Beyond the hard-and-fast cost of finding and on-boarding replacements or hiring temps, first-year nurse turnover impacts patient care. It also signals larger workforce management issues, most notably a failure to effectively engage employees and sell them on the mission.
There are theories about why first-year nurses quit. Perhaps some of these new nurses weren't trained well in school, a cold fact that comes home quickly in the life-and-death hospital setting. Some new nurses probably have unrealistic expectations that collide with on-the-job realities. Some nurses get better offers elsewhere for their high-in-demand skills. Maybe, just maybe, your hospital is not a good place to work. Whatever the reason, the problem persists.
If it's any consolation, Shebani Patel, a director with PwC Saratoga, the workforce research arm of PricewaterhouseCoopers LLP, says retaining new workers is a challenge not unique to healthcare.
"First year turnover tends to be the most problematic length of service for most organizations across most industries," she says. "What is occurs is the assimilation process -- that is really critical for organizations -- but sometimes the goal is just filling positions and getting people in the door and the steps aren't always done in the best way possible."
"With this economy, what we have experienced is a nurse gets an offer they are going to take it. But if there is a lot of competition in the area, they are going to take the job to get the experience and then jump at the next best offer," Patel says.
PwC Saratoga found that first-year nursing turnover can run as high as 60% in some of the 40 healthcare systems that participate in its Human Capital Effectiveness Benchmarking Report. The median first-year turnover was 17.1% for the report's "best practices" health systems, and PwC Saratoga interviewed them to find a common theme for their relatively successful nurse retention.
Here's what they found:
1.Schedule competency-based interview processes/selection testing that includes cultural fit.
Best practice hospitals use competency-based interviews/selection testing based on a standard set of questions to identify qualities and skills. One system grades "B" or "C" level candidates for certain roles but must hire only "A" candidates for others. These systems have found a correlation between those who meet the requirements of the upfront selection process and lower turnover.
Successful health systems also are increasingly aware of the importance of creating a good fit along cultural and ethical lines. The candidate assessment includes behavioral questions and bringing other nurses in for a team interview. One system job shadows during the interview to give candidates a firsthand view of the work environment and culture.
2. Build relationships with nursing schools and a robust nurse resident program.
Hospitals with nurse resident programs swear by them. Nurses hired from these programs are generally strong performers because the systems assess their clinical performance before hiring them. These nurses are also less likely to leave because they are familiar with the culture. One health system fills most of its nursing slots from its nurse resident program, which pays for participants' tuition. The program begins after the first quarter of school and offers flexible hours. New nurses attend orientation and are partnered with preceptors. Another system offers outreach to nursing graduates, including a forum for nurse graduates to network and stay connected as they look for jobs. The system beats competitors by strengthening its pipeline of potential candidates and developing its employer brand.
3.Conduct extensive orientation followed by employee feedback.
New nurses are encouraged to maintain contact with and provide feedback to human resources staff through orientation programs that last up to a full year. Orientation may be customized by department/unit, and touch points typically occur after 30/45 and 90 days, six months, and a year. One system offers a week of orientation and follow-up with the same group of employees at 45 days and 90 days. At 45 days, nurses complete a satisfaction questionnaire. Another system conducts "re-interviews" at three and 10 months to ensure nurse satisfaction and fit. One system hosts reunions for recent hires at four months and a year and offers off-site retreats by nursing unit. Another system has recent hires lunch with the hospital president after one month and one year.
4.Implement new hire support programs.
Systems link new nurses to non-supervisor "buddies" who provide confidential support and guidance. One system offers a nurse retention contact on HR staff who provides a "safe haven" where employees can air concerns.
5.Track and measure criteria that to drive accountability.
Successful systems use metrics to drive retention. One system tracks data on turnover, engagement, and patient satisfaction on a unit level, and will intervene for units that do not meet the metrics. Another system measures key performance indicators that reflect retention, such as patient satisfaction. Managers select indicators each year, and attainment is tied to a bonus-sharing program.
Patel says accountability is a common theme for all hospitals with high retention rates. "There is a drive to be measurement oriented," she says. "Management owns this. They believe that their management is a huge contributing force toward retaining talent."
Obviously, different hospitals face different challenges, but Patel says good management has been shown to overcome outside pressures beyond the hospital walls. "I talked to organizations – and not just in healthcare – where there is high turnover versus those who have a low turnover and you can definitely tell there is a difference between the programs," she says. "The way they speak about their programs, the depth of their programs and how they manage the new hires, there is a difference."
Hospital job growth was flat in January, with only 700 payroll additions reported in the sector for the first month of 2011, Bureau of Labor Statistics preliminary data shows.
Overall, the healthcare sector – everything from hospitals to podiatrists' offices to kidney dialysis centers – created 10,600 payroll additions in January, which is half the average of more than 22,000 new healthcare jobs created each month in 2010. Ambulatory services continued to be the main catalyst for job growth in healthcare, recording 8,000 payroll additions in January. Ambulatory services accounted for 160,200 of the 265,800 payroll additions in the healthcare sector in 2010, while hospitals created 50,100 for the year.
January's preliminary totals are in stark contrast to December's job growth numbers. Healthcare recorded 35,700 payroll additions in the last month of 2010, including 8,000 hospital jobs, and 20,600 ambulatory healthcare services jobs.
BLS data from December and January is preliminary and may be considerably revised in the coming months.
Overall, the healthcare sector employed 13.9 million people in January, including 4.7 million jobs at hospitals, 6 million jobs in ambulatory services, and 2.3 million in physicians' offices, BLS preliminary data show.
The larger U.S. economy gained 36,000 jobs in January and the nation's jobless rate fell from 9.4% to 9% for the month as the number of unemployed people decreased by 600,000 to 13.9 million. The number of long-term unemployed - people jobless for 27 weeks or longer – fell from 6.4 in December to 6.2 million in January and accounted for 43.8% of the unemployed, BLS preliminary data shows.
Even with the relatively slower job growth in January, healthcare has been one of the few areas of steady job growth during the recession and slow recovery, averaging 22,150 new jobs each month in 2010, and creating 828,900 jobs since the recession began in December 2007. In 2009, healthcare created 215,300 payroll additions, including 25,700 hospital payroll additions, and 138,700 payroll additions in ambulatory healthcare services, BLS data show.
The relatively slow job growth in the healthcare sector in January comes even though The Conference Board reports that online job ads for healthcare practitioners and technical workers surged in January by 78,500 listings for the month, and ads for healthcare support jobs also grew by 16,600 listings. Healthcare jobs led a strong first month of 2011 that saw 438,000 new job listings in the overall economy, The Conference Board reported.
Call them a Medicare rogues' gallery or a Fraud Hall of Shame. Federal prosecutors just call them 'Wanted.'
The Office of the Inspector General for the Department of Health and Human Resources has for the first time issued a Most Wanted Fugitives list for Medicare fraud. The Top 10 suspects – representing the worst of the worst from a list of 170 fugitives -- are allegedly responsible for about $124 million in fraudulent claims against the federal healthcare program, OIG said.
Inspector General Daniel R. Levinson said he hopes the Top 10 list will draw public attention to the crime. "With our Most Wanted Fugitives List, OIG is asking the public's help in tracking down fugitives. The public has a stake in the fight against fraud, waste, and abuse," Levinson said.
The Most Wanted Fugitives List on the OIG Web site includes photos and profiles of each featured fugitive. The site includes an online fugitive tip form and the OIG hotline number for reporting fugitive-related information in English or Spanish, 24 hours a day, 365 days a year. The site will show when a fugitive's status changes, including when he or she is arrested.
"Individuals who steal from federal healthcare programs and then flee from the consequences of their crimes must be held accountable. We hope our new Web page will encourage the public to help us apprehend these fugitives," said Gerald T. Roy, OIG Deputy Inspector General for Investigations.
The 10 people on the most wanted list have allegedly cost taxpayers more than $124 million in fraud, OIG said.
Suspects on the list include:
"The Benitez Brothers," who, working through their Miami-area HIV infusion clinics, are accused of submitting fraudulent claims to Medicare totaling about $110 million. OIG alleges that the services for which Carlos, Luis, and Jose Benitez billed were medically unnecessary or never administered.
Leonard Nwafor, and co-conspirators, who are accused of billing Medicare for $1.1 million and collecting $525,000 in fraudulent claims for durable medical equipment, including motorized wheelchairs, scooters, and hospital beds. This investigation was led by the Medicare Fraud Strike Force, including OIG investigators, which was created to identify and prosecute fraudulent DME companies and laboratories in the Greater Los Angeles area.
Susan Bendigo who is accused of billing Medi-Cal, California's Medicaid program, for $17.1 million, $10 million of which she actually collected. Working as director of nursing for a company providing nurses for home health agencies, Bendigo is said to have sent unlicensed nurses to treat Medi-Cal patients, though she knew Medi-Cal required licensed nurses to perform this work.
Starting salaries for female physicians are much less than those of their male counterparts, and the gender gap is widening by the year, regardless of the medical specialty, a study in Health Affairs finds.
The disparity in starting salaries has been growing steadily since 1999, increasing from a difference of $3,600 in 1999 to $16,819 in 2008. This gap exists even after accounting for gender differences in determinants of salary including medical specialty, hours worked, and practice type, the study found.
The authors based their conclusions on survey data from physicians exiting training programs in New York State, which has more residency programs and resident physicians than any other state. The physician survey sample included 4,918 men and 3,315 women.
In 1999, new women physicians earned $151,600 on average compared to $173,400 for men—a 12.5% salary difference. That difference grew to nearly 17% by 2008, with women starting out at $174,000 compared to $209,300 for men, the study found.
Women had lower starting salaries than men in nearly all specialties, said study lead author Anthony Lo Sasso, a professor and senior research scientist at the School of Public Health of the University of Illinois at Chicago.
“It is not surprising to say that women physicians make less than male physicians because women traditionally choose lower-paying jobs in primary care fields or they choose to work fewer hours,” Lo Sasso said. “What is surprising is that even when we account for specialty and hours and other factors, we see this growing unexplained gap in starting salary. The same gap exists for women in primary care as it does in specialty fields.”
The differences in pay persist even when adjusting for differences in work hours, specialty choice, practice location, and numerous other factors. Potential reasons that cannot be ruled out include an increase in gender discrimination and that women are not as skilled as men at negotiating salaries, the study said.
Lo Sasso said the divergence may reflect the fact that women physicians want greater flexibility and family-friendly benefits, such as not being on call after certain hours. He said women may be negotiating these conditions at the same time that they are negotiating starting salaries. “It may be that lifestyle factors are increasingly important to newer physicians. It could be that women in particular want to have more of a lifestyle balance in their medical careers,” he said.
Women represent nearly half of all medical students and are projected to make up about one-third of all practicing physicians at the beginning of this coming decade. Historically, women have disproportionately chosen primary care fields. But the percentage of women entering primary care dropped from nearly 50% in 1999 to just over 30% in 2008. Despite entering higher-paying specialties, the widening gap in pay persisted. For example, the study found that:
Female heart surgeons were paid $27,103 less on average than males.
Female otolaryngologists made $32,207 less than males. Women specializing in pulmonary disease made $44,320 less than men.
Lo Sasso said physicians and specialty groups need to understand what is motivating the gender gap in physician pay and address it, especially given the increased need for physicians, particularly in the primary care field. He said policy makers and physician practices should reconsider how to attract providers, the structure of working arrangements, and how to pay providers.
Most commercial health insurance markets in the United States are dominated by one or two health insurers, according to report this week by the American Medical Association.
The 2010 edition of Competition in Health Insurance: A Comprehensive Studyof U.S. Markets found that 99% of health insurance markets in the U.S. are “highly concentrated,” based on the 1997 U.S. Department of Justice and Federal Trade Commission Horizontal Merger Guidelines. This indicates a significant absence of competition among insurers. In 48% of metropolitan statistical areas, at least one insurer had a market share of 50% or more, AMA reported.
“The market power of health insurers places physicians and patients at a significant disadvantage,” said AMA President Cecil B. Wilson, MD. “When insurers dominate a market, people pay higher health insurance premiums than they should, and physicians are pressured to accept unfair contract terms and corporate policies, which undermines the physician role as patient advocate.”
Robert Zirkelbach, press secretary for America’s Health Insurance Plans, disputed the findings. “Competition is vigorous among health plans across the country,” he said. “They operate in highly competitive markets in which consumers have numerous choices among plan types and insurers. Moreover, research examining competition in healthcare markets increasingly points to provider consolidation as a significant factor contributing to rising healthcare costs.”
AMA said the concentration of health plans is in stark contrast to that of physicians, who it said are the least concentrated segment of the health care sector, with 78% of office-based physicians working in practices with nine physicians or less. Most of those are in either solo practices or practices of two to four physicians.
“The market power of health insurers continues to prompt anti-competitive concerns among physicians,” Wilson said. “To help restore a competitive balance to health insurance markets, the AMA urges the federal and state agencies to prohibit harmful insurance company mergers and adopt policies that would level the playing field between small physician practices and large insurers.”
Zirkelbach said an analysis by AHIP of last year’s AMA study was beset with errors of fact and methodology. “For example, the AMA data exclude some types of self-funded plans, a large and growing portion of the market, and show significantly higher market concentration than data available from the National Association of Insurance Commissioners,” he said. “Moreover, a simple search on the new HealthCare.gov shows that in every state, families and employers have multiple choices of both insurance plans and types of coverage.”
Zirkelbach said that AHIP’s analysis showed that the states that are often cited as examples of high market concentration actually have some of the lowest premiums in the nation.
