Nov. 18 marks the 35th Great American Smokeout. The anniversary provides an excellent opportunity to take stock of how far we've come to reduce the costly blight of tobacco, how far we've yet to travel, and what we can do to help others kick the deadly habit.
The battle against tobacco use—particularly smoking in public places—has been so steady and incremental over the decades that it's possible to forget how widespread smoking was in this country only a generation ago.
The American Cancer Society—sponsor of the Great American Smokeout—provides a nice timeline of success. Unfortunately, the battle is far from over. The Campaign for Tobacco-Free Kids reports that 450,000 deaths each year are attributed to smoking or second-hand smoke. And although tobacco use continues to decline, one in five Americans—roughly 61 million people— still smoke.
Oddly, until the last decade or so, hospitals were notable laggards in the antismoking effort, with smoking policies that were less restrictive than those of steel mills.
In fairness to hospitals, they had to consider the stress associated with hospital visits for patients and their families—anxieties that could be at least temporarily relieved with a cigarette break.
Hospitals have moved from having designated indoor smoking areas to designated smoking areas outside the hospital doors, to butt-littered smokers' huts on the far reaches of the campus. Now, many hospitals are phasing out those enclaves—even banning smoking inside cars—and declaring their campuses tobacco-free zones.
Some healthcare organizations are taking the antismoking crusade one big step further. The Massachusetts Hospital Association declared this month that—effective Jan. 1—it would no longer hire tobacco users. MHA President/CEO Lynn Nicholas says the trade group for more than 100 hospitals in the Bay State decided to go public with the new ban—which takes effect Jan. 1—to raise awareness about the No. 1 cause of preventable death in the United States.
Nicholas unapologetically concedes that the ban on hiring smokers is "all stick" and no carrot because sticks—in the form of bans, fines, and high taxes on cigarettes—more effectively discourage smoking. "I love carrots but when carrots are shown not to work on an important health issue like this I'm not above using a stick," she says.
Nicholas' argument is understandable. However, where do we draw the line between workplace and personal life? Is this nanny state overreach?
Most smokers want to quit. They know they are in the clutches of an expensive, disgusting addiction that's sucking the life out of them one puff at a time. These are good people who don’t need to be browbeaten or threatened, especially because nicotine addiction is particularly tenacious.
In marked contrast to the MHA, Gundersen Lutheran Health System is more carrot than stick. Jeffrey E. Thompson, MD, CEO at the La Crosse, WI-based health system, says smokers are still hired there, but they're encouraged and incentivized early on to kick the habit. "We believe it is the employees' responsibility to say they want to get better, and it is our responsibility to try to help them get better, and between the two of us it works pretty well," Thompson says.
Employers have legitimate concerns about the costly effects of tobacco use, Thompson says, "but the question is whether it’s a justifiable action to tell people they can't do something when they are not working."
"There are precedents for employers to reach beyond the doors of the workplace, but my hope would be to go the other way; to educate and show how smoking affects productivity and long-term health and your family," he says. "My direction would be to expand the incentives for people not to smoke, to be clear in the hiring that there is an expectation down the road that no quarter is given for people who smoke."
Smokers at Gundersen are encouraged to join support groups, and they can get cash incentives for passing risk assessment tests that measure smoking.
"There are no penalties, but we have made it pretty clear that the organization is not responsible to support your habit by giving you any special breaks or times compared with coworkers," he says. "You have to carry your own load."
About 21% of Wisconsin adults smoke. At Gundersen, 12% of employees smoke. The health system boasts that it has seen a 40% decrease in the number of employees who continue to smoke once they've been in the organization at least five years.
As healthcare costs continue to soar well above the Consumer Price Index, Thompson—like Nicholas—believes more employers may take the hard-line stance against hiring smokers.
"Employers are going to get more and more anxious about how expensive the delivery of healthcare is and they will do things that they can control that they believe can help reduce costs," he says.
Perhaps even hard-pressed employees may soon call for a ban on hiring new coworkers who smoke, if it's determined that the policy provides some relief from crippling annual healthcare premium hikes. After all, 80% of Americans don't smoke, and that number is growing every day.
The Massachusetts Hospital Association unabashedly announced this month that it will no longer hire tobacco users, sending a very public get-tough message that it hopes will resonate with other employers looking to reduce healthcare costs.
MHA President/CEO Lynn Nicholas says the trade group for more than 100 hospitals in the Bay State decided to go public with the ban—which takes effect Jan. 1—to raise awareness about the No. 1 cause of preventable death in the United States.
"We could have just implemented this policy and never said a word," Nicholas says. "I thought that by putting the example out there it would start a dialog."
Nicholas unapologetically concedes that the ban on hiring smokers follows an "all stick" and no carrot mantra because she believes sticks are more effective when it comes to discouraging smoking.
"We have had the carrots out there for years. I was in a debate with someone from the business community and they said it's all about carrots. Au contraire!" she adds. "What has caused people to quit smoking is public awareness, but more so the cost of smoking has gone way, way up, and the prohibitions on smoking on public places make it really hard to find a place other than your car. That is what has driven it. Those are all sticks."
Nicholas says MHA and its 45 employees also have an obligation to provide a high-profile role model for healthy living and to find way to reduce soaring healthcare costs.
"We are so proud in Massachusetts that we have enacted virtually universal coverage but that is costly and the pressure is now on to bring the cost of healthcare down," she says.
"This seemed to be obvious. There is such a cause and effect here. I'm in a position because of my leadership role working with hospitals to lead by example."
Smokers are not a protected class of workers, Nicholas says, so there is not fear of violating federal law with the ban, which will not affect MHA employees already on the payroll. While Massachusetts state law permits the ban, the National Conference of State Legislatures said that 29 states ban discriminatory hiring policies aimed at smokers.
Nicholas says she's not too concerned with infringing upon prospective workers rights by telling them what they cannot do off the clock. There are no subtleties when it comes to tobacco use, Nicholas says, so an anti-smoking strategy shouldn't be subtle either.
"It's voluntary whether you apply for a position here or not and you can choose to smoke or not," she says. "It's a known public health hazard and the leading cause of preventable death in the U.S. Our hospitals are filled with patients who are there directly and indirectly because of tobacco use. We know that half of all smokers die from their addiction and that people who smoke cigarettes die 14 years earlier on average than people who don't."
Smoking costs an estimated $6 billion each year in Massachusetts, including $4.3 billion in direct healthcare costs, and $1.7 billion for lost productivity related to premature death.
Nicholas wants other businesses and organizations in Massachusetts to follow her lead. "I hope that by leading by example and talking about it and giving them the chance to think about it they may have the same discussions we had," she says.
Beyond health policy, Nicholas says she is personally motivated to push for a tobacco free Massachusetts.
"I lost my own father from lung cancer. He smoked from a teenager to age 40. He quit cold turkey and died of lung cancer anyway at age 65," she says. "I lost a good chunk of my family, aunts, uncles and younger cousins to direct smoking and second-hand smoke. I have seen and felt it personally in my own family; that and the fact that I really care about our workforce here. They are like my extended family and the fact that there are such strong health policy imperatives mean it's a no brainer for me to say this is worth doing."
Despite widespread and well-publicized layoffs, the nation's hospitals reported 5,100 payroll additions in October, and 31,600 payroll additions so far this year. The rate of hospital job creation far exceeds the 19,900 hospital jobs created in the first 10 months of 2009, but is still well off the pace of hospital job growth for most of the decade, data released Friday by the Bureau of Labor Statistics shows.
After erratic hospital job growth in the first seven months of the year, hospitals have seen three straight months of growing employment, and have added 13,300 jobs since August. Overall, hospitals employed more than 4.7 million people in October.
BLS data from September and October is preliminary and may be considerably revised in the coming months.
The job growth comes even as hospitals "mass layoffs," defined as of 50 or more employees, are close to the same record pace set in 2009. BLS data show that the nation's hospitals reported 10 mass layoffs in September—the latest figures available—and the pace of these job cuts in 2010 lags slightly behind the record 152 mass layoffs in 2009.
In the first nine months of 2010, there have been 112 mass layoffs at hospitals, averaging more than 12 mass layoffs each month. At this pace, hospitals would record 149 mass layoffs in 2010.
Hospitals shed 1,900 jobs in July, added 5,700 jobs in June, and shed 1,400 jobs in May, after creating 15,900 jobs in the first four months of the year.
The sector reported 92,600 payroll additions in the first 10 months of 2008.
The healthcare sector—everything from hospitals, to chiropractors' offices, blood and organ donor banks, to walk-in clinics—added 24,100 jobs in October, and employed 13.8 million people that month. Healthcare has been one of the few areas of steady job growth during the recession and sputtering recovery, creating an average of 21,000 jobs each month, and 203,400 jobs in the first 10 months of 2010.
Healthcare created 215,300 jobs in 2009, and 738,000 jobs since the recession began in December 2007, BLS data show.
Job growth in the healthcare sector continues to be powered by ambulatory services, which accounted for 13,000 payroll additions in October, and 127,900 payroll additions in the first 10 months of 2010. Nursing and residential care facilities reported 6,000 payroll additions in October, and physicians' offices reported 2,700 payroll additions, BLS preliminary data show.
The larger economy gained 151,000 jobs in October, as the nation's jobless rate held at 9.6%. Since December 2009 nonfarm employment has increased by 847,000 jobs. However, 14.8 million people were unemployed in October, and 6.2 million of them were long-term unemployed who had been without a job for at least 27 weeks, BLS preliminary data show.
Simi Valley Hospital in Los Angeles has paid the federal government $5.15 million to resolve whistleblower allegations that the hospital filed false claims with Medicare over a six-year period.
The lawsuit, which was originally filed by a former employee at the hospital, alleged that its Behavioral Medicine Services unit knowingly submitted false claims to Medicare for chemical dependency and psychiatric patient services performed between 1991 and 1997.
Simi Valley Hospital paid the settlement last week but admitted no wrongdoing.
The Department of Justice intervened and negotiated the settlement, and a federal judge in Los Angeles dismissed the lawsuit Wednesday after being told the settlement was finalized last month.
The lawsuit was originally filed in October 2001 by Timothy Field, the former program director and then the administrative director for Simi Valley Hospital's Behavioral Medicine Services unit.
Field's lawsuit alleged that Simi Valley Hospital improperly billed Medicare and Medi-Cal for:
psychiatric care, even though the patients were receiving chemical dependency detoxification services;
psychiatric overnight stays and inpatient services, even though the patients did not meet the criteria for inpatient hospitalization; and
paying a medical director $12,000 per month to establish, and to get patients admitted into, a non-existent program for women dealing with post-traumatic stress disorder.
A statement released by the hospital Thursday, said, in part: "The government's allegations did not relate to the quality of patient care provided—the matter is strictly billing-related. We believe that our hospital follows fair and accurate billing practices, and are settling to avoid the expense and inconvenience of lengthy litigation."
Magnetic resonance imaging of the brain could increase the number of stroke patients eligible for a potentially life-saving treatment, according to a study in the December issue of Radiology.
The Patient:
Some patients who suffer an acute ischemic stroke, when a blood clot or other obstruction blocks blood flow in the brain, can be treated with a drug called tissue plasminogen activator, or tPA, that dissolves the clot and restores blood flow.
However, the clot-busting drug can only be administered within four and a half hours of a stroke. Any time longer than that and the drug can cause bleeding in the brain.
"As many as a quarter of all stroke patients cannot be given tPA because they wake up with stroke symptoms or are unable to tell their doctor when their stroke began," said lead researcher Catherine Oppenheim, MD, professor of radiology at Université Paris Descartes in France.
The Stats:
The American Stroke Association says strokes are the third leading cause of death in the U.S. behind diseases of the heart and cancer. Approximately 795,000 Americans suffer a new or recurrent stroke each year.
Oppenheim and her researchers reviewed data from consecutive patients with acute ischemic stroke treated at Sainte-Anne Hospital in Paris between May 2006 and October 2008. The time of stroke onset was well defined in all patients and each underwent MRI within 12 hours.
The Study:
The 130 patients in the study included 77 men and 53 women with a mean age 64.7. Of those, 63 patients underwent MRI within three hours of stroke onset and 67 were imaged between three and 12 hours after stroke onset.
The radiologists analyzed three different types of MRI data on the patients:
Fluid-attenuated inversion recovery
Diffusion-weighted imaging
Apparent diffusion coefficient ratios
Using the MRI data alone, the radiologists could predict with greater than 90% accuracy which patients had experienced stroke symptoms for longer than three hours.
"When the time of stroke onset is unknown, MRI could help identify patients who are highly likely to be within the three-hour time window when tPA is proven effective and approved for use," Oppenheim says. Adding that using MRI to determine the duration of a stroke would change the way stroke is managed in the emergency setting.
"With the use of MRI, all stroke patients could be managed urgently, not just those patients with a known onset of symptoms," she adds.
Oppenheim says clinical trials are needed to validate the use of MRI as a surrogate marker of stroke duration.
Sibley Memorial Hospital in Washington, DC, has joined The Johns Hopkins Health System in a deal that involves no financial exchanges, the hospital and the Baltimore-based health system said in a joint announcement.
“Sibley is strong financially, very highly regarded in its community and located in the nation’s capital,” says JHHS President Ronald R. Peterson. “Having it as part of the Hopkins family provides us the critical mass to better position ourselves to provide an integrated, regional approach to care, which we anticipate the future will demand.”
Under the deal finalized Nov. 1, Sibley—a 328-bed acute care nonprofit hospital open since 1890—becomes a wholly owned subsidiary of JHHS and a member of Johns Hopkins Medicine. The hospital, located in northwest Washington, DC, near the Maryland state line, will retain its name, medical staff, leadership, board of trustees, community mission, and it will operate under the JHHS governance structure in the same way as other JHHS affiliates.
"The alliance between Sibley Memorial Hospital and Johns Hopkins Medicine is an important step in advancing health care delivery and quality in the local community and the greater Washington, DC, region,” says Robert L. Sloan, Sibley’s president/CEO.
JHHS and its affiliates, including The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center Inc., Howard County General Hospital Inc., and Suburban Hospital, and the Johns Hopkins University School of Medicine, make up Johns Hopkins Medicine.
“As a member of Johns Hopkins Medicine, Sibley will be a key force in the development of an integrated system of care for the national capital region, focused on improving health by providing access to state-of-the-art clinical medicine that’s supported by a strong base of research and medical education,” says Edward D. Miller, MD, dean/CEO of Johns Hopkins Medicine.
“This alliance strengthens each institution’s ability to serve patients along the full continuum of care, creating new opportunities to provide the right care, at the right time and at the right place,” Miller says.
A Rhode Island Hospital report shows that 33 patients needed 305 medical interventions to remove foreign objects, including knives, razor blades, and batteries that were intentionally swallowed, resulting in more than $2 million in hospital costs over eight years.
Through a retrospective case study, the most common items were pens (24%), batteries (9%), knives (7%) and razor blades (7%). Most of the removals were successful during the initial endoscopic extraction except for 20 cases. Two cases eventually required a surgical extraction. The 305 cases involved 33 patients, of which 79% were previously diagnosed with a psychiatric disorder.
"Intentional foreign body ingestion occurs among a relatively small number of patients with psychiatric disorders and is costly," says Steven Moss, MD, in a statement. Moss is a gastroenterologist at RIH, and lead author of the study. "While endoscopic retrieval is relatively safe and effective, it often requires general anesthesia and utilizes significant hospitals resources."
In 237 cases, the foreign objects were retrieved most commonly from the stomach or esophagus. Complications arose in 10 cases and surgical consultations were required. There were no cases of perforations or patient deaths. Hospital costs incurred in the patients' care from these 305 cases totaled $2,018,073, paid primarily by Medicare/Medicaid. The biggest cost drivers were nursing care (56%), followed by endoscopy, emergency department, and surgical services.
"Our study shows that intentional ingestion of foreign bodies is a relatively common event at our hospital. Intentional, rather than accidental, swallowing is a poorly recognized and underappreciated problem which is potentially avoidable," Moss said.
Moss said 58% of the patients were male, and the mean age for the patients at the time of ingestion was 35. One patient was responsible for 67 of the 305 cases, and four patients accounted for 179 cases. Fifty-three percent of the patients were admitted from residential institutions, mostly from a state-run chronic psychiatric inpatient facility. Thirty-eight percent of the patients were from private homes, and 9% were from prison.
More than half of the patients were diagnosed with a mood disorder, while others suffered from anxiety, substance abuse, psychotic or impulse control disorders.
"The reasons for foreign body ingestion vary and it is one of many forms of self-injurious behavior. Foreign body ingestion can be a behavioral element of cognitive disorders, mental retardation syndromes, psychotic disorders, and mood disorders," said co-author Colin Harrington, MD, a psychiatrist at RIH. "Various personality disorder diagnoses are also associated with foreign body ingestion where motivations are thought to include communication of internal distress, acting out due to anger, or even manipulation of the environment with a related secondary gain, such as transfer out of chronic institutional settings like prison or long-term treatment facilities."
Harrington said most cases of foreign object ingestion do not represent suicide attempts and that "repetitive foreign body ingestion occurs in a very small group of patients and is typically difficult to treat and prevent."
Stroke patients admitted to the hospital on weekends are slightly more likely to die compared to stroke patients admitted on weekdays, regardless of the severity of the stroke, according to a Canadian study published by the American Academy of Neurology.
"We wanted to test whether the severity of strokes on weekends compared to weekdays would account for lower survival rates on the weekends," says Moira K. Kapral, MD, of the University of Toronto in Ontario. Kapral was with the Institute for Clinical Evaluative Sciences in Ontario when the research was done. "Our results suggest that stroke severity is not necessarily the reason for this discrepancy."
Researchers analyzed five years of data from the Canadian Stroke Network on 20,657 patients with acute stroke from 11 stroke centers in Ontario. Only the first stroke a person experienced was included in the study. The study was published in the Nov. 2 issue of Neurology, the medical journal of the AAN.
People with moderate to severe stroke were just as likely to be admitted to the hospital on weekends and weekdays, but those with mild stroke were less likely to be admitted on weekends in the study. Those who were seen on weekends were slightly older, more likely to be taken by ambulance and experienced a shorter time from the onset of stroke symptoms to hospital arrival on average, the study shows.
Seven days after a stroke, people seen on weekends had an 8.1% risk of dying compared to a 7% risk of dying for those seen on weekdays. The results stayed the same regardless of age, gender, stroke severity, other medical conditions and the use of blood clot-busting medications. "Stroke is not the only condition in which lower survival rates have been linked for people admitted to hospitals on the weekends. The reason for the differences in rates could be due to hospital staffing, limited access to specialists and procedures done outside of regular hours," Kapral says. "More research needs to be done on why the rates are different so that stroke victims can have the best possible chance of surviving."
The study found no differences in the quality of stroke care, including brain scans and admission time, between weekends and weekdays.
Online ads for healthcare practitioners and technical workers rose by 26,800 listings to 543,100 in October, posting the largest increase of any job sector for the month, and breaking three consecutive months of declines. Vacancies continue to outnumber skilled healthcare job seekers by more than 2 to 1, a report shows.
The Conference Board's Help Wanted Online Data Series, which tracks more than 1,000 online job boards across the United States, attributed the uptick to increases in advertised vacancies for registered nurses and occupational and physical therapists.
Healthcare support vacancy listings also reversed a three-month decline and saw an increase of 7,800 listings to 111,600, primarily reflecting an increase in demand for occupational and physical therapist assistants. However, there were 2.3 unemployed people for every advertised vacancy in healthcare support, The Conference Board reports.
The average wage advertised for healthcare practitioners and technical workers was $33.51 an hour, and the average wage for healthcare support occupations was $12.84 an hour, the report says.
The U.S. Bureau of Labor Statistics, which will release on Friday its employment statistics for October, has shown that the healthcare sector is one of the few areas in the economy that has seen monthly job growth throughout the recession, although that growth has slowed considerably since 2009.
In the overall economy, online advertised vacancies rose 113,700 in October to 4,409,800, following an increase of 59,900 in September, with 40 of 50 states reporting increases in online job postings, The Conference Board reports.
The nation’s supply/demand rate stood at 3.44 unemployed for every advertised vacancy in September (the last available unemployment data), down from a peak of 4.73 in October 2009. Nationally, there are 10.5 million more unemployed than advertised vacancies, The Conference Board reports.
"In this slow economic recovery, the October rise is welcome news that the trend in labor demand continues to move in a positive direction, albeit at a very moderate pace," said June Shelp, vice president at The Conference Board. "The October increase reflected a moderate rise in a range of occupations and geographically across the nation. The slow but steady upward trend of the last seven months points to modest growth in employment through the end of 2010."
Shelp said online job postings across all sectors of the economy have increased by 1 million advertised vacancies since the end of the recession in June 2009. "Following the rapid HWOL rises in labor demand in the 4th quarter 2009 and 1st quarter 2010, labor demand has now settled into more modest growth, pointing to a moderate growth in employment through the end of 2010," she said.
In addition to the high demand for healthcare practitioners and technical workers, The Conference Board also reported high demand for management workers, and computer and mathematical science.
St. David's HealthCare on Monday finalized its $83.8 million purchase of Heart Hospital of Austin.
"St. David's HealthCare has completed the necessary steps required to move forward with its purchase of Heart Hospital of Austin," Jon M. Foster, president/CEO of St. David's, said in a media release. "Heart Hospital of Austin has demonstrated that it is one of the top providers of cardiovascular care in the state and nation, and we believe this is a logical extension of St. David's HealthCare's long-standing tradition of excellence in this field."
HHA's cardiac services and includes a 24-hour full-service emergency center. HHA President/CEO David Laird, called the acquisition by St. David's "a perfect fit for our organization."
St. David's purchased the 58-bed HHA from MedCath Corp.—the former manager and majority owner based in Charlotte, NC—for $83.8 million. HHA will maintain its current leadership, including Laird, but its staff of about 400 medical, technical and support workers will become employees of St. David's.
Six-hospital St. David's is one of the largest health systems in Texas, and is the fifth-largest private employer in Austin with more than 6,700 employees.
