Hospitals Report Negative Financial Ramifications from Using Observation Status
As featured in the Daily Briefing, Medicare and private insurers are increasingly labeling patients as "observation cases," or outpatients, despite days-long hospital stays, a practice that is boosting costs for facilities and patients, the Pittsburgh Tribune-Review reports.
Although the observation label is not new--CMS applies the designation to patients admitted through the ED with symptoms that can be stabilized within 24 hours, such as asthma and chest pain--hospital leaders in Pennsylvania say the practice of classifying cases as outpatient despite longer hospital stays has grown and is burdening facilities with lower reimbursement. Federal law does not specify that a patient must be considered an inpatient admission after 24 hours in a hospital, according to a Medicare spokesperson. Payment for an observation case is 33% of payment for an inpatient admission, according to the CMO at Forbes Regional Hospital. The trend can also be particularly harmful to Medicare patients because it may lead to denied coverage for nursing home care, the Tribune-Review reports.
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According to an analysis in the March 25th issue of NEJM, hospitals with greater case volumes for AMI, HF and pneumonia demonstrate improved one-month survival rates in patients admitted for such conditions; however, there is an upper volume threshold beyond which point hospital volumes are no longer significantly correlated with reduced mortality rates.
Dr. Joseph Ross and researchers from the Mount Sinai School of Medicine analyzed 2004 to 2006 Medicare data, estimating, per each 100-patient increase in annual volumes, the change in 30-day mortality rates. All three conditions demonstrated significance in the inverse relationship of hospital volumes to 30-day mortality, but researchers identified the point at which the marginal benefit of increased cases became increasingly small, determined by the threshold at which a 100-patient volume increased did not significantly reduce 30-day mortality. These thresholds were found to be higher for AMI and HF than for pneumonia.
According to Ross, "a policy aimed at universally increasing hospital volume in order to reduce death rates would not have uniform benefits" since more than 60% of patients in the study were treated at hospitals in the highest case volume quartiles with 15% in the first two quartiles. Rather, it is essential to determine strategies used by large and small hospitals alike that lead to improved outcomes.
To access the full study, please follow this link [subscription required] (theheart.org, 3/24); Ross JS et al. N Engl J Med 2010; 362:1110-1118.
The New York Times examines how physicians are increasingly choosing not to pursue--and even abandon--private practice to integrate with hospitals and health systems and how this "quiet revolution" of care delivery may impact patient care and health care costs.
Physician-owned practices are fading from the medical landscape, the Times reports, noting that as of 2005, more than 66% of medical practices were physician owned; however, across the last three years, that figure has dipped to below 50%, according to data from the Medical Group Management Association. According to the Times, economic, political and personal factors are driving physicians away from the private-practice model to hospitals, which provide regular hours, a steady salary and are often free of the financial worries that come with running a business.
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The American College of Cardiology (ACC) and American Heart Association (AHA) have released the first guidelines for thoracic aortic disease (TAD).
The guidelines emphasize the need to identify and treat high-risk patients prior to acute presentation of the disease. As such, the guidelines recommend first-degree relatives of patients with thoracic aortic aneurysm and/ or dissection receive a transesophageal echo, CT or MRI to detect thoracic aortic disease and predict future complications. Patients with Marfan syndrome and Loeys-Dietz syndrome should also receive aortic imaging at the time of diagnosis, six months later, and annually thereafter. All patients presenting with TAD symptoms should receive a thorough initial examination (including evaluating of risk factors and an x-ray) and an urgent aortic imaging should be performed if the patient is deemed at high risk.
Initial management of thoracic aortic disease should be focused on decreasing the stress on the aortic wall by controlling heart rate and blood pressure with beta blockers or nondihydropyridine calcium channel blockers. In addition, smoking cessation and other atherosclerosis risk-reduction efforts should be implemented. For patients with ascending thoracic aortic dissection, all aneurysmal aorta and the proximal extent of the dissection should be resected. However, a partially dissected aortic root may be repaired with aortic valve resuspension. Finally, for patients with degenerative or traumatic aneurysms of the descending aorta exceeding 5.5cm, saccular aneurysms, or postoperative pseudoaneurysms, endovascular stent grafting should be considered when feasible.
For more details on the guidelines please click on the following links: Comprehensive Guidelines, Executive Summary [subscription required]
As reported in today's Daily Briefing, Plavix (clopidogrel) may improve survival for patients with heart failure (HF) and acute myocardial infarction (AMI) who have not undergone percutaneous coronary intervention, according to a study to be published in next week's Journal of the American College of Cardiology (JACC).
Although AMI patients who receive clopidogrel have a lower mortality risk than those who do not receive the treatment, use of the drug is low among patients after AMI with HF. To determine the drug's effectiveness for these patients, Danish researchers divided 31,251 patients hospitalized with AMI between 2000 and 2005 into four treatment groups: two groups with HF (one that received clopidogrel and one that did not) and two groups without HF (one that received clopidogrel and one that did not).
After an average 18-month follow-up, the researchers found that 32.2% of HF patients not treated with clopidogrel died, compared with 28.1% of HF patients who received the drug. A two-year follow-up of the patient groups without HF determined that clopidogrel did not affect mortality, which was just over 9% for both groups.
Noting clopidogrel's statistically significant effect on mortality rates among these high-risk patients, a researcher from the HeartDrug Research Labs at Johns Hopkins University in Baltimore writes in an accompanying editorial that the benefit of clopidogrel is of "unquestionable practical importance." In addition, he posits the drug's benefits--revealed in a relatively short 18-month follow-up--may have even greater benefits for long-term survival (Bonde et al., JACC, 3/30 [subscription required]; Kelland, Reuters, 3/22; Preidt, HealthDay, 3/22).
Based on the results of the Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) trial, an FDA advisory panel has recently recommended that indications for cardiac resynchronization therapy (CRT) be expanded to include NYHA class 2 and class 1 ischemic patients with an LVEF <30% and a QRS duration >130 ms. (CRT is currently approved for class 3-4 heart failure, LVEF <35%, and a QRS >120 ms indications.) Though there was some dissent among the panelists, left-bundle-branch-block (LBBB) was also added to the list of criteria to ensure the therapy is used on mild heart failure patients that will receive the greatest benefit. Industry experts suggest CRT would be appropriate for approximately 20% of class 1-2 patients with the expanded indication.
MADIT-CRT suggests resynchronization therapy in mild heart failure has the ability to reduce risk of death and events by one-third across 2.5 years. The most significant benefits were seen in heart failure related events as opposed to mortality alone. Despite benefits in preventing hospitalizations, however, some panelists remained concerned about the increased risk of complications.
The remote monitoring of EP devices has grown considerably in recent years. Today, hundreds of thousands of patients are implanted with cardiac rhythm management (CRM) devices that are capable of being monitored remotely (i.e., outside of a device clinic). The operational advantages of remote monitoring are obvious and easily demonstrated: a remote device-check takes less than half the time as an in-office check and eliminates 50 to 75 percent of clinic visits for routine check-ups. For these reasons, electrophysiologists have been quick to adopt the technology.
With the operational advantages well-understood, physicians are now trying to determine the clinical advantages of the technology. Today in Atlanta, Dr. George Crossley presented findings from the Clinical Evaluation Of Remote Notification to Reduce Time to Clinical Decision (CONNECT) trial. The trial used a wireless remote monitoring and notification system available through Medtronic's Conexus-enabled ICDs and CRT-Ds and compared its use to standard in-person clinic visits. The study showed that remote monitoring with automatic notification cut the time to clinical decision making by nearly two-thirds.
The largest randomized, prospective study designed to quantify the advantages of remote monitoring with automatic notifications, CONNECT followed nearly two thousand ICD and CRT-D patients at 136 sites in the United States. Data from the study showed a sizeable reduction in the time between the onset of an arrhythmic problem and a clinical decision on how to manage it (an average of 29.5 days in the standard-care group vs. 10.5 days in the remote-monitoring group). There was also a reduction in length of stay (LOS) for remote-monitored patients that had to be hospitalized, which Dr. Crossley estimated resulted in hospital savings of approximately one million dollars.
One interesting aspect of the remote-monitoring data was the gap in time between a notification and a clinical decision, which could be as long as 4 to 5 days. Dr. Crossley suggested this may show a 'Laissez-Faire' attitude among physicians to respond to data, but it may also reflect that the data does not carry an imperative for immediate action. We often hear complaints about data overload, a complaint that will only grow as more and more devices start transmitting an endless stream of bits and bytes. Could it be that the speed of data transmission may have out-paced its clinical need?
As reported in The Pipeline, researchers from the Medco Research Institute in conjunction with the Mayo Clinic reported findings today from the first national, prospective comparative effectiveness study that used genetic testing to determine warfarin dose levels. One of the most common anticoagulants used in high-risk patients, warfarin exhibits a large inter-individual dosing requirement because of the wide variety of sensitivities to the drug. Decisions about dosing requirements can have a serious clinical impact--patients with high-sensitivity to Warfarin are at a high risk of bleeding while patients with a low-sensitivity are at risk of thromboembolism. Genetic testing provides a potential proactive solution to determine appropriate dose.
Using a known genetic expression of Warfarin sensitivity, the Medco-Mayo Warfarin Effectiveness Study (MM-WES) recruited patients across the country that were about to start on the drug. Patients underwent testing and were classified according to their sensitivity to warfarin based on their genotype. Based on this genetic expression, physicians were advised to adjust the dose levels of their patients. After six months, the trial results showed a substantial reduction in all-cause hospitalization (31 percent) and in hospitalization for bleeding or thromboembolism (29 percent) for those patients that had undergone genetic testing.
While the findings are indeed impressive, Dr. Mandeep Mehra, who commented on the study expressed concern that the trial design had some troublesome flaws. His largest concern stemmed from a perceived Hawthorne effect, in which subjects improve behavior as a reaction to being studied. In this case, the physicians of the patients being studied were believed to have provided additional care and oversight to their patients simply because they were under investigation. Dr. Mehra believed that this extra layer of protection, realized through a more aggressive management of warfarin therapy may have made the impact less emblematic of true 'real world' warfarin patients. If this is the case, the improved results seen in the study may be less about the response to the genotypic expression and more about an uncommon increase in vigilance among the physicians caring for these patients.
A striking aspect of the study was the physician interest in participation. Physicians had a 75 percent response rate when contacted by the trial investigators. Despite a lack of familiarity with the genetic test for warfarin, physicians were willing to send genetic samples for analysis and to respond to recommendations based on the genotypic expression. This may be evidential of the dawning age of personalized medicine, though operational imepediments still exist. The cost of the test, at $200-$400, can quickly add up considering the volume of patients being treated with Warfarin--approximately 2 million individuals start on the drug each year. However, with expanded availability and lower cost, widespread use of genetic testing prior to the start of drug therapy may grow quickly.