The Daily Briefing

News for Health Care Executives

Mapping the road to effective ICD-10 transition

November 7, 2011

The four drugs landing seniors in the hospital

Aspirin, warfarin among main culprits

November 28, 2011

About two-thirds of emergency hospitalizations for adverse drug events among seniors are attributable to four commonly prescribed medications, according to a recent study in NEJM.

For the study, CDC researchers analyzed data from 2007 to 2009 for 58 hospitals participating in an adverse drug-event surveillance project. According to the findings, nearly 100,000 seniors annually experience an emergency hospital admission for adverse drug events, with about 66% of hospitalizations resulting from unintentional medication overdoses. The most frequently cited drugs included:

    1. Warfarin, which accounted for 33% of hospitalizations;
    2. Insulin, which accounted for 14% of cases;
    3. Antiplatelet drugs—such as aspirin and Plavix—which were implicated in 13% of hospitalizations; and
    4. Oral diabetes medications, which were involved in 11% of cases.

Symptoms associated with hospitalization included bleeding—especially with blood thinning or antiplatelet drugs—and confusion, loss of consciousness, and seizures, which were associated insulin and other diabetes medications. Meanwhile, the study noted that drugs previously deemed "high-risk" were involved in only 1.2% of hospital admissions.

According to study author Dan Budnitz, the findings suggest that hospitals that focus "safety initiatives on a few medicines that commonly cause serious, measurable harms can improve care for many older Americans" (McKinney, Modern Healthcare, 11/24 [subscription required]; Goodwin, HealthDay, 11/23; Smith, MedPage Today, 11/23).

Meet Marilyn Tavenner—the next Medicare chief?

Berwick's intended replacement regarded as a 'pragmatist'

November 28, 2011

With Donald Berwick stepping down as CMS administrator, the Obama administration has nominated a replacement—Marilyn Tavenner—who industry wonks have called a pragmatist and a patient-centered manager.

Berwick’s 17-month tenure
Berwick has headed CMS since July 2010, when President Obama chose to sidestep the traditional confirmation process by using "recess appointment" procedures. As a recess appointee, Berwick has all the powers of a permanent appointee, but must be re-nominated and confirmed by the Senate to serve past 2011.

Although the Obama administration re-nominated Berwick in January, 42 GOP senators in March asked the White House to withdraw Berwick's nomination, writing in a letter that his "lack of experience in the areas of health plan operations and insurance regulation raise serious concerns about his qualifications for this position."

Because of the political impasse, Berwick will step aside on Dec. 2.

Getting to know Tavenner
According to CQ HealthBeat, Tavenner—who currently is CMS' principal deputy administrator—will serve as the agency's interim administrator during the confirmation process. In her post, Tavenner has been a "central leader" in managing the development of rules, overhauling payment systems, and issuing reform law and Medicare and Medicaid grants. A former nurse, Tavenner also oversaw two hospitals owned by Hospital Corporation of America before beginning her government service.

Industry officials and lobbyists have praised Tavenner's management skills. Richard Umbdenstock, president and CEO of the American Hospital Association, calls her "a very capable administrator," who has a "varied and rich background." Tavenner has a "unique perspective in understanding both the implications of public policy and their implementation," Umbdenstock said. "We have no doubt that she will provide strong leadership in these challenging times."

Meanwhile, former CMS Administrator Tom Scully, who served under President George W. Bush, calls her "smart, sharp, fair, organized," noting that "[u]nlike a lot of people in government, she actually had to run health care day to day for many years." Scully has predicted that Tavenner probably would be confirmed if she were nominated to lead CMS.

However, Politico notes that Tavenner now faces a confirmation battle, too—and it may ultimately resemble the fight that would have confronted Berwick. Beyond lingering tension over the health reform law, Senate Republicans have not explicitly endorsed Tavenner. Meanwhile, a Republican lobbyist tells Politico that the high-profile CMS role "always gets sucked into the controversy of the day," further complicating confirmation (Alonso-Zaldivar, AP/Google News, 11/23; Pecquet, "Healthwatch," The Hill, 11/23; Reichard, CQ HealthBeat, 11/23 [subscription required]; Feder/Haberkorn, Politico, 11/23; Kliff, Washington Post, 11/27).

Keeping an electronic eye on handwashing

Video surveillance system improves compliance in hospital ICU

November 28, 2011

After installing a video monitoring system in its ICU, one New York hospital has boosted hand hygiene compliance to more than 80%—and kept it there, the New York Times reports.

Approximately one in 20 hospital patients will contract an infection during their stay, leading to more than 100,000 deaths annually. According to the Times, hospital-acquired infections are the fourth leading cause of death in the United States, surpassing car accidents, AIDS, and breast cancer. 

Traditional hand hygiene strategies
Most hospitals report hand hygiene compliance of roughly 40%, prompting many facilities to deploy measures to track employee hand hygiene.

For example, several hospitals have adopted wireless radio frequency identification and alcohol-sensing technology that beeps if a hospital employee forgets to wash his or her hands comes within seven feet of a patient.

Meanwhile, many hospitals dispatch "secret shoppers" to monitor their colleagues and record whether they wash their hands. However, experts note that this method is expensive and may produce distorted results, especially if employees discover they are being observed.

Videos keep tabs on staff
Manhasset, N.Y.-based North Shore University Hospital nearly four years ago installed a video surveillance system—manufactured by Arrowsight—that provides instant feedback on success in its ICU.

Ceiling cameras are pointed toward sinks and hand sanitizer dispensers outside of patient rooms, while a door sensor tracks when someone enters or leaves the room. Meanwhile, an Arrowsight employee monitors the video from a remote location and issues staff a pass or fail grade; anyone entering a patient room must wash his or her hands within 10 seconds to pass. Success rates are then emailed to the hospital's nurse manager twice per shift, and an LED display across from each nurses' station reports hand hygiene compliance.

According to a study published last week in Clinical Infectious Diseases, the video surveillance system has helped North Shore increase its hand hygiene compliance rate from 6.5% three years ago to more than 80% today. Although the study did not report infection rates, Bruce Farber, the head of infectious diseases at North Shore, said methicillin-resistant Staphylococcus aureus infections have dropped.

Nurses "look at the rates," says Isabel Law, the surgical ICU's nurse manager. "It becomes a positive competition. Seeing 'Great Shift!' is important. It's human nature that we all want to do well. Now we have a picture to see how we're doing" (Rosenberg, Times, 11/24).

OECD benchmarks U.S. health care

Nation lags in some areas, leads in others

November 28, 2011

Dan Diamond, Managing Editor  

A new Organization for Economic Cooperation and Development study revives a traditional debate for health policy experts: Does the United States provide too much or too little health care?

There's considerable evidence for both sides of the argument.

Contention: The United States does too little
OECD notes that the U.S. lags behind its peers on many common indicators of health quality. The organization represents 34 nations; the U.S. ranked near the bottom of categories that reflected access to care, like availability of hospital beds, physicians, and physician consultations.

Meanwhile, the U.S. fell behind in a smattering of public health-focused metrics. Among OECD nations, the U.S. ranks second-to-last for asthma-related hospital admissions, third-to-last for childhood pertussis vaccination rates, and fourth-to-last for health insurance coverage. 

Whether as a sign of efficiency or financial pressures, U.S. hospitals also were generally faster than their counterparts at turning patients around. Average length-of-stay following an acute myocardial infarction was just 5.3 days for U.S. patients, compared to 6.2 days in Canada, 7.6 days in Switzerland, and a seemingly luxurious 10.8 days in Germany.

Contention: The United States does too much
At the same time, OECD reiterates that the United States already spends more—much more—on health care than other developed nations. 

The nation's health spending exceeds $7,900 per person annually, or more than two-and-a-half times the all-OECD average of $3,223. The U.S. also devotes about 17.4% of its gross domestic product to health care, compared with an average of 9.6% for other OECD nations.

Altogether, the United States allocates a staggeringly disproportionate level of its spending for health care compared to its OECD brethren. The only comparable outlier: Luxembourg, the 500,000-person-strong city state and second-smallest OECD nation.

Canada provides a close-to-home illustration of the split in spending. The U.S. spends $2,922 on hospital care per capita; our northern neighbor spends just $1,643. Several common procedures further underscore the divide.

Procedure     Canada      United States 
Normal delivery           $2,800                 $4,451
Coronary artery bypass graft     $22,694                $34,358
Hip replacement     $11,983                $17,406

Mixed picture
Beyond suggesting that health prices in the U.S. are inflated, OECD doesn't render a verdict on the too-much or too-little debate.

The organization ultimately notes that the United States' surprising weakness in areas like primary care is balanced by strong performance in acute care. And sure, the U.S. has ready access to cutting-edge imaging equipment and a top-notch cancer care system.

But a child born in the United States in 2009 has a life expectancy of 78.2 years—essentially, the same as a child born in Chile (which spends one-seventh of what the U.S. does, per capita) and more than four years less than a child born in Germany or Japan.

"It's a very, very mixed pattern," OECD's Mark Pearson told Reuters. "You get a very high quality of care for your money in some areas. Very poor quality, compared to other countries, in other areas."

The appeal of one-stop shopping?

Monthly retail clinic visits jump tenfold

November 28, 2011

More patients are using retail clinics to address minor health needs, with the largest growth seen among healthy, high-income adults, according a recent study in the American Journal of Managed Care.

For the study, researchers examined Aetna claims data for 13.3 million patients in 22 different health care markets from 2007 to 2009. The study focused on patients' use of retail clinics for 11 acute conditions, such as sinus, upper respiratory, ear, and urinary tract infections.

Surging demand for services
Over the three-year study period, the monthly rate of retail clinic use increased from 0.6 visits per 1,000 patients in January 2007 to 6.5 visits per 1,000 patients in December 2009, National Journal reports. The study also found that retail clinic patients on average tended to be young, healthy adults who are "less likely to have a primary care provider and therefore might visit a retail clinic because they have no alternative," the researchers wrote.

Study author Scott Ashwood wrote, "It is clear that enrollees are 'voting with their feet' and that retail clinics are meeting an unmet need for simple acute care and/or addressing a shortage of traditional health care providers." The researchers added that if the trends continue, "health plans will see a dramatic increase in retail clinic utilization."

Unclear how utilization will affect overall costs
Although health care services offered at retail clinics are 30% to 40% less costly than those provided at a physician's office and 80% less expensive than those at an ED, the researchers could not determine how the trend would affect health care costs.

"If the growth in retail clinic visits that we noted represents substation for other sources of care, then the increase ... could lead to lower costs," Ashwood said. "However, if ... patients are seeking care when they would have otherwise stayed home -- then costs could increase" (Walker, MedPage Today, 11/18; Helfand, "Money & Company," Los Angeles Times, 11/22; Fox, National Journal, 11/22 [subscription required]).

Support for Medicare 'premium support'

Both parties back plan that could restructure Medicare program

November 28, 2011

During debt panel discussions, members of both parties stood behind adopting a "premium support" plan within Medicare, which could lead to major structural changes to the program, according to lawmakers and health policy experts.

Some experts say that even though the panel last week failed to reach a deficit-reduction deal, the group's work could frame the Medicare debate during next year's elections and beyond.

How premium support could work
As currently conceived, premium support would give Medicare beneficiaries a fixed amount of money to purchase coverage from competing private plans. Republicans traditionally have supported the idea, and GOP presidential candidates Newt Gingrich and Mitt Romney in the last two weeks have endorsed variations of such a program. Meanwhile, some Democrats on the debt panel said that a premium support plan could work if it included enough protections for Medicare beneficiaries.

The Democrats' support came despite objections to previous plans to institute premium support within Medicare. Democratic lawmakers sharply criticized a Medicare reform plan that was the centerpiece of the House-approved GOP FY 2012 budget resolution (H Con Res 34). The plan would have privatized the program by providing beneficiaries with fixed, lump-sum vouchers to purchase private health insurance.

Critics of the proposal often cited a report by the Congressional Budget Office that found the plan would cause most seniors to "pay more for their health care than they would under the current Medicare system." The report also found that some seniors would choose to not purchase coverage, which would increase the number of elderly residents without health plans.

Some health policy experts said these problems were specific to the House-approved budget resolution, and would not necessarily result from all premium support plans. For example, the GOP budget resolution eventually would have eliminated traditional Medicare for new beneficiaries (Pear, New York Times, 11/24).

What's the link between emotion and illness?

Doc says, 'Ask Shakespeare'

November 28, 2011

William Shakespeare routinely used physical symptoms to illustrate his characters' emotions, which one British physician says could help modern-day doctors better understand the mind-body link.

For his research, Dr. Kenneth Heaton, a former gastroenterologist and Shakespeare expert, analyzed 42 Shakespeare poems and plays and compared them with 46 works penned by other 16th century authors.

According to the findings—which were published last week in Medical Humanities—Shakespeare was more likely than his colleagues to describe his characters as having physical symptoms that stemmed from emotional distress, including dizziness, faintness, or sensitivity to touch.

For example, characters in "Taming of the Shrew," "Romeo and Juliet," "Henry VI Part 1," "Cymbeline," and "Troilus and Cressida" suffer from vertigo, giddiness, or dizziness, while only one work by another 16th century author described similar symptoms. In addition, Heaton notes that Shakespeare connected shock with bodily coldness and faintness in works such as "Julius Caesar" and "Richard III."

According to Heaton, the findings suggest that Shakespeare "was an exceptionally body-conscious writer," who can remind physicians that physical symptoms may have psychological causes. "Many doctors are reluctant to attribute physical symptoms to emotional disturbance, and this results in delayed diagnosis, over-investigation and inappropriate treatment," Heaton says (BBC News, 11/23; Preidt, HealthDay, 11/23).

Weekly review

Key articles from Nov. 21-Nov. 23

November 28, 2011

Missed a day of the Daily Briefing? Here's a quick round-up of top stories and research highlights from last week’s issues.

After Super Committee meltdown, health leaders brace for deeper cuts  (Nov. 22)
Congress' Super Committee failed to reach a deal last week—triggering billions of dollars in spending cuts—but experts warn that more health rollbacks loom as lawmakers continue to search for a federal deficit fix.

Donald Berwick to step aside as CMS administrator (Nov. 23)
The Obama administration is expected to nominate Marilyn Tavenner to succeed Donald Berwick as CMS administrator, after Senate Republicans vowed to block his confirmation.

Three health care organizations win 2011 Baldrige Award  (Nov. 23)
Henry Ford Health System, Schneck Medical Center, and the Southcentral Foundation are among the four winners of the 2011 Malcolm Baldrige National Quality Award, the nation's highest presidential honor for innovation and performance excellence.

Group rallies to defend ICD-10 after AMA vote  (Nov. 21)
After the American Medical Association voted to "work vigorously" to prevent ICD-10 implementation, the American Health Information Management Association fired back, arguing the new codes offer "countless benefits."

What will 2012 hold for Medicare physician payment? (Nov. 21)
Already facing the threat of a 27.4% Medicare Sustainable Growth Rate payment reduction, physicians are unsure what the likely failure of the congressional “Super Committee” to cut the federal budget by upwards of $1.2 trillion will mean to them. Many are now wondering how these developments, coupled with other reimbursement updates in the recently released Medicare Physician Fee Schedule Final Rule, will combine to impact physicians’ bottom lines.

Why doorways may cause memory lapses  (Nov. 21)
A study in the Quarterly Journal of Experimental Psychology found that doorways may serve as event boundaries that consequently cause declines in memory, CBS News reports.

Coming to work sick: Study highlights why ill employees still clock in  (Nov. 22)
Why do staff clock in despite feeling under the weather? A recent study in the Journal of Occupational Health Psychology highlights several factors that might drive employee "presenteeism."

Meet us at the Institute for Healthcare Improvement National Forum

November 28, 2011

Visit Booth #1112 at IHI's National Forum to see how Crimson has evolved into a comprehensive solution to manage value-based care across the continuum. More.

Daily roundup: Nov. 28, 2011

Bite-sized hospital and health industry news

November 28, 2011

  • California: The California Hospital Association (CHA) has requested a preliminary injunction to prevent certain Medicaid reimbursement cuts from taking effect. CMS earlier this year approved the cut, which state officials say will save $623 million. In response, CHA filed a lawsuit in federal district court in an effort to block the reimbursement cuts. CHA now is seeking to prevent the state Department of Health Care Services from implementing Medicaid cuts for skilled nursing facilities in acute-care hospitals. According to CHA, DHCS and HHS failed to consider health care provider costs or whether reimbursement was consistent with economy, efficiency, and quality of care. The complaint also argues that an assessment of how potential rate reductions would affect access to care was "fatally flawed," and that the cuts could be significantly higher because they are based on fiscal year 2008-2009 rates (Goldberg, KPBS News, 11/22; Evans, Modern Healthcare, 11/22 [subscription required]; CHA release, 11/22).
  • District of Columbia: The Family Health and Birth Center and Washington Hospital Center have partnered to provide hospital privileges to midwives who also offer out-of-hospital births. The arrangement allows women to choose midwives without forgoing services, such as epidurals, that typically are offered only at hospitals. It also allows women with high-risk pregnancies—who normally are not eligible for care at birth centers—to have the birth center experience during pre- and postnatal care but deliver at the hospital. Participating midwives must fulfill certain requirements, such as attending 75 births, passing a background check and getting licenses from the district's nursing board. According to the Washington Post, the collaboration between the birth center and hospital is unusual because of "numerous legal and policy issues, stereotypes, and tensions between obstetrician/gynecologists and midwives" (Miller, Post, 11/21).
  • Georgia: Despite their opposition to the federal health reform law, Georgia lawmakers are developing a plan to launch a state health insurance exchange in accordance with the overhaul's requirements. If the law is not overturned by the U.S. Supreme Court, states will have to implement their own insurance exchanges or cede developmental control to the federal government. Georgia is participating in the multistate lawsuit that the high court will review in 2012, but officials continue to develop the exchange in an effort to avoid federal control if the law is upheld (Gugliotta, Kaiser Health News/ Washington Post, 11/21).
  • Illinois: The Federal Trade Commission (FTC) has filed an administrative complaint and intends to try to block OSF HealthCare's plan to acquire Rockford Health System based on antitrust issues. According to the agency, the acquisition would give the health organizations 64% of the inpatient services market and reduce overall health care competition in Rockford. An evidentiary hearing on the matter is scheduled for April 17. OSF and Rockford Health officials say they plan to challenge FTC's request for a preliminary injunction (Westphal, Rockford Register Star, 11/18).

Fewer Americans using the Web for health information

The percentage of U.S. residents who used the Internet to look up health information has grown at a slower pace in recent years, according to a study by the Center for Studying Health System Change.

For the study—which was funded by the Robert Wood Johnson Foundation—researchers analyzed telephone surveys of about 17,000 U.S. residents in 2010, 18,000 residents in 2007, and 60,000 residents in 2001.

The study found that the percentage of U.S. adults who sought health information from sources other than their physicians increased from 38.8% in 2001 to 55% in 2007, but dropped to about 50% in 2010.

Researchers noted that the decline between 2007 and 2010 stemmed from fewer people seeking health information from friends and relatives, print media, and TV and radio.

During the study period, the Internet was the only category to see a steady increase in consumer interest, although the interest slowed toward the end of the decade. The percentage of U.S. residents who used the Internet to look up health information jumped from 15.9% in 2001 to 31.1% in 2007, then increased slightly to 32.6% in 2010.

Ha Tu—a researcher from the Center for Studying Health System Change—said researchers did not expect the percentage of U.S. residents using the Internet for health information to "keep growing as fast as it did earlier in the decade." However, Tu added that the extent of the slowdown was surprising, especially considering that significantly more U.S. households had Internet access in 2010 than in 2007.

Tu said, "The very abundance of information sources available about health—particularly on the Internet—may well be contributing to information overload, anxiety, and confusion by some consumers," which could be causing fewer people to look beyond their physicians for health information (Conn, Modern Healthcare, 11/23 [subscription required]; Lowes, Medscape, 11/22; Versel, InformationWeek, 11/22).