Private health insurance companies have long since required patients to pay higher out-of-pocket fees when they see physicians who are not in the insurers’ contracted physicians network. In a more recent development, they have begun to rank physicians according to quality and cost parameters and offer enrollees lower out-of-pocket charges if they see physicians who fare better on these parameters.

In such programs for example, a doctor shown to order fewer imaging tests that are of questionable value would rank in a higher category.

Physicians have always objected to these practices. A March article in the New England Journal of Medicine brought the issue to a boil by showing that these tiered rating systems misclassified 22% of all doctors.

The study prompted provider organizations to release a letter protesting the payer’s practices. “Physicians’ reputations are being unfairly tarnished using unscientific methodologies and calculations,” the letter claimed.

“There are serious flaws in health insurers’ programs to try to rate individual physicians,” AMA President Cecil Wilson added in an interview with the Wall Street Journal.

The provider organizations implored payers to reevaluate their ranking programs.

Payers’ reactions to the letter were lukewarm. For example, Cigna told the Journal that its doctor-rating program already addressed issues raised in the study by focusing on physician groups rather than individuals. Besides that, “Some physicians do provide higher-quality or more-efficient care, and it makes sense to provide modest incentives for choosing that care,” said Dick Salmon, the company’s VP for network quality.

A spokesperson for WellPoint responded it has “taken a thorough, thoughtful approach in introducing measures of physician quality and cost effectiveness” and that the effort is “collaborative with the physician community.”

US News & World Report’s influential “top 50” list of US hospitals is driven by subjective reputations of the institutions rather than objective measures of hospital quality, according to a study by Ashwini Sehgal of Case Western Reserve University.

To establish subjective reputations of US hospitals, US News surveys 250 board-certified physicians from around the country. US News also uses objective data including nurse-to-patient ratios, availability of specific medical technology, risk-adjusted mortality for Medicare patients, and teaching status.

In analyzing the relative contributions of subjective vs. objective measures in determining which hospitals made the coveted list, Sehgal “found little relationship between rankings and objective quality measures for most specialties.”

Specifically, he found a strong correlation between a hospital’s rank in the US News list and the hospital’s “reputation score” as measured in the survey. By contrast, a hospital’s rank was variably correlated with the objective scores used by US News.

For example, the top five heart and heart-surgery hospitals based on reputation score alone were the same as those of the US News top five heart hospitals (Cleveland Clinic, Mayo Clinic–Rochester, Johns Hopkins University, Massachusetts General Hospital, and the Texas Heart Institute).

“Because reputation score is determined by asking approximately 250 specialists to identify the five best hospitals in their specialty, only nationally recognized hospitals are likely to be named frequently,” Sehgal told MedScape. “Users should understand that the relative standings of US News & World Report’s top 50 hospitals largely indicate national reputation, not objective measures of hospital quality.”

“Being well-known may be the result of many factors that are unrelated to the quality of day-to-day care,” commented Harlan Krumholz of the Yale University School of Medicine.

The write-up is in the Annals of Internal Medicine.

Diabetic patients treated by physicians who received pay-for-performance incentives received better care and had better clinical outcomes than those whose physicians were not involved in the program, according to researchers at IMS Health.

To reach these conclusions, Judy Chen and colleagues looked at the records of diabetic patients who received care from the Hawaii Medical Services Association, a large PPO between 1999 and 2006. HMSA had 19,600 diabetic at study onset and about 32,000 by 2006.

HMSA offered its physicians the opportunity to earn bonuses ranging between 1.5% and 7.5% of their base fees if they met quality-of-care targets including the use of HbA1c and LDL cholesterol testing for their diabetic patients. Beginning in 2001, participating physicians could earn nearly $6,000 in bonuses if their adherence to specified care requirements improved versus the previous year.

The provider organization defined high-quality care as receiving at least 2 tests for HbA1c and one test for LDL cholesterol in a given year.

Chen’s group found that physicians who were enrolled in the P4P program delivered high quality care 16% more frequently than physicians who were not so enrolled. The patients of physicians who participated in P4P for at least 3 consecutive years were also found to be 25% less likely to be hospitalized.

“This study showed a robust, consistent, significant, and positive association between increased receipt of appropriate laboratory monitoring of A1c and LDL cholesterol levels and decreased hospitalization rates,” Chen’s group wrote.

The proportion of diabetic patients seen by physicians enrolled in the P4P plan jumped from 79% in 1999 to 95% in 2006.

The write up is in the American Journal of Managed Care.

Patient risk factors like advanced age increase the likelihood of some so-called “never events” in hospitals, according to a report in last month’s Archives of Surgery. The findings do not support Medicare’s current policy of denying payments associated with treatments for such events.

To reach this conclusion, Donald Fry and colleagues analyzed 890,000 surgeries in 1,368 hospitals using the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample. They studied abdominal hysterectomy, aorto-femoral bypass, colon resection, coronary artery bypass grafting and total hip replacement.

The researchers looked for associations between patient factors like comorbidities, age and gender and 8 “never event” complications, including C. difficile, MRSA, and surgical site infections, catheter-associated vascular and urinary tract infections, mediastinitis after CABG, decubitus ulcers and post-operative pneumonia.

They found that patient age and comorbid conditions like renal failure and weight loss were associated with a much higher risk of many of these “never event” complications.

The odds ratios ranged from 1.8 for unscheduled admission as a predictor for C. difficile enterocolitis to 16.4 for malnutrition and weight loss as a risk factor for intravascular device infection.

“Calling these complications never events and refusing to pay for their treatment may advantage high-quality caregivers, but it also will penalize providers that care for the most vulnerable patients or that perform procedures with higher-than-average risk,” Fry’s group wrote.

Medicare’s “never events” list was implemented 2 years ago. It includes obvious mistakes like transfusing the wrong blood type and wrong-site surgeries.

But the list also features complications that may not be preventable. In addition to those mentioned above, the list includes falls in the hospital, inadequate blood glucose control, pulmonary embolism and drug-induced delerium.

More than 75% of kids have at least one ear infection before age 5 and earaches are among the most common reasons why kids visit pediatricians. But doctors don’t agree how earaches should be treated.

Guidelines promulgated by the American Academy of Pediatrics and the American Academy of Family suggest that many kids will get better without antibiotics.

A recent study in the British Medical Journal even hinted that kids who receive antibiotics might be at greater risk for recurrent infections.

Nevertheless, US doctors prescribe them for more than 80% of the children they diagnose with earaches, according to a study in Pediatrics.

“I’m not looking at a study, I’m looking at a patient,” William Corporon a Kansas-based family practitioner told the Wall Street Journal. Corporan prescribes antibiotics when he diagnoses a bacterial ear infection.

Antibiotic-prescribing doctors believe the drugs help kids recover faster, though they admit the marginal gain is a day or less, at best. They also doubt the veracity of clinical trials on the subject, because they include kids that don’t have bacterial ear infections.

Meanwhile, many parents are not comfortable leaving an ear infection untreated, and others want the quickest possible recovery so their kids can get back to school or day care. In a survey of PCPs for example, 65% said parents’ requests for antibiotics was the most important factor leading to the prescription.

Allan Lieberthal, a pediatrician at Kaiser and chairman of an AAP group tasked to update guidelines on the subject says 80% of children will improve within a few days without antibiotics, while 90% will get better with the antibiotic. Lieberthal typically gives parents a prescription they can fill after 48 hours if the kid still has a fever or pain.

The radiation produced by CT scans performed in 2007 will cause 29,000 cancers and kill 14,500 Americans, according to a study published in the Archives of Internal Medicine. 

To reach this conclusion, Amy Berrington de Gonzalez and colleagues from the National Cancer Institute used a computer simulation to estimate the impact of the 70 million or so CT scans that were performed in the US that year (only 3 million were performed in 1980).

The scientists estimated that about a third of the future cancers will occur in people who were between the ages of 35 and 54 when they received their CT, and 15% of them will develop in people who were children or teens when the scan was performed.

About two-thirds of the new cancers will develop in women, since they are more vulnerable to radiation.

“There is a significant amount of radiation with these CT scans, more than what we thought, and there is a significant number of cancers,” Rita Redberg, the editor of the Archives of Internal Medicine, told the LA Times.

“While certainly some of the scans are incredibly important and life saving, it is also certain that some of them were not necessary,” Redberg added.

CT scans provide pristine images by combining data from multiple x-ray images. They can also expose patients to up to 400 times more DNA-damaging radiation than conventional chest x-rays. 

In another study, Rebecca Smith-Bindman and colleagues from UCSF found that radiation exposure varies almost 13-fold for different kinds of CT studies, from about 2 millisieverts for a routine head CT scan to 31 millisieverts for a scan of the abdomen and pelvis.

The average American receives about 3 millisieverts of radiation per year, a level not considered to be a health risk.

Inappropriate use of antibiotics and consequent antibiotic-resistant infections waste $20 billion per year, according to a study published in Clinical Infectious Diseases.

To reach this conclusion, Rebecca Roberts and colleagues at Cook County (Stroger) Hospital quantified antibiotic resistant infections (ARIs), total costs, length of stay, length of ICU stay, surgeries and mortality rates for 1,391 high-risk adult patients that were hospitalized in the year 2000. 

The scientists found that 188 (13.5%) patients developed an ARI. The medical costs attributable to ARIs ranged from $18,588 to $29,069 per patient. In these patients, length of stay was 6.4–12.7 days longer than in those who did not develop ARIs. Excess mortality in the ARI group was 6.5%.

Common ARIs include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), as well as many other bacteria that are becoming resistant to common antibiotics.

“Significant health and economic benefits could be realized through effective interventions to reduce antimicrobial-resistant and healthcare-associated infections,” said Roberts in a press release.

Stuart Levy, a senior author on the paper added that his study “demonstrates the enormous cost savings that could be realized for both the health care system and to individuals and their families…these costs will continue to increase if we don’t practice a more prudent usage of antibiotics.”

Levy added that more studies are needed to determine how much could be saved at a national level if we took steps to slow the rise of resistant infections, especially those acquired in hospital settings.

Many believe that healthy people should examine themselves regularly or submit to cancer screening because early detection saves lives.

That’s likely true for women, who should begin cervical cancer (Pap) screening by the age of 21, and for adults 50 years or older, who should get colonoscopy.

And it’s probably true for women at least 40 years old, for whom many suggest it’s wise to get mammograms annually to screen for breast cancer.

But that’s about it, at least according to today’s best evidence.

Which brings us to a well-meaning but ultimately dangerous PR campaign by the Light of Life Foundation to raise awareness about thyroid cancer.

“Confidence kills. Thyroid cancer doesn’t care how healthy you are,” read ads in People magazine, Sports Illustrated and elsewhere.  “Ask your doctor to check your neck.”

Thyroid cancer kills about 1,600 Americans per year. In other words, it’s responsible for about 0.3% of all cancer deaths in this country.

And there’s not a shred of evidence that routine neck exams cut the risk of death from thyroid cancer, according to Barnett Kramer, an associate director for disease prevention at NIH.

Most thyroid cancers grow slowly and are curable surgically no matter when they’re found, and the remaining ones are so aggressive that early detection doesn’t’ improve outcomes anyway, according to Kramer. 

A routine thyroid screening program would trigger thousands of unnecessary ultrasounds and needle biopsies not to mention thyroidectomies that risk damaging the vocal cords.

And there’s no guarantee that cursory palpations of the gland by busy PCPs would detect more than a small percentage of the tumors anyway.

Healthy people should consult with their physicians about cancer screening. And they should contact their physicians if new symptoms develop or if their health status changes in any way.

For a science project, Morgan DiSanto-Ranney, a 16 year-old Virginia high school student recently purchased 7 glucose monitors and asked her diabetic father to use them all.

“What I found was that the meters were off from one another by 60 to 75 points,” she told the New York Times.

About the same time, government researchers found that the results from 5 widely-used monitors varied by up to 32%.

Inaccuracies like this expose patients to seizures, loss of consciousness and rarely, death, so the American Association of Clinical Endocrinologists asked the FDA to act on the matter.

“Because of the highly variable quality of the meters and the glucose testing strips in widespread use, the safety of our patients who depend upon those meters is threatened,” it wrote in a letter obtained by the New York Times.

Nothing happened immediately but as it turned out, Morgan’s mother works for Iowa Republican Senator Charles Grassley, and before long the Iowa Republican had fired off a letter asking the FDA to investigate.

The FDA had for decades punted glucose QA responsibilities to the International Organization for Standardization, whose regulations permit the devices to be off by up to 20%.

Upon receipt of Grassley’s love letter, the FDA began pressing the IOS to tighten its standards, and warned that if it refused to do so, the FDA “may instead promulgate other (higher) performance standards” on its own.

As the matter simmers, glucose monitor manufacturers have warned that more stringent accuracy requirements would force them to jack up prices which would, in turn, discourage their use.

For his part, Morgan’s father has lost faith in his glucose monitors. “He doesn’t use them as much anymore,” sighed the high school student.

Readmissions to hospitals, defined as a second admission within 30 days of hospital discharge for the same or a similar medical condition, cost Medicare $17 billion per year.

Many readmissions can be prevented by coordinating post-discharge care more effectively and implementing simple home monitoring programs.

The problem is that when hospitals implement such programs, it sets them back financially. Payers like Medicare reap all the benefits. 

Take Park Nicollet Health Services, for example. The Minnesota-based hospital and clinic system has long-since established a reputation for its innovations in the quality of care. Four years ago, the provider began spending $750,000 per annum on nurses and special software to reduce readmissions for congestive heart failure.

The program reduced such readmissions from 16% to 4%.

The program saved Medicare $5 million per year, but Park Nicollet received not a cent for its efforts. In fact, fewer admissions for the condition actually cut revenues for the intrepid quality leader.

“We’ve kept it up out of a sense of moral obligation to these patients, but we’re getting killed,” Park Nicollet’s chief executive David Wessner told the New York Times.

“We have a reimbursement system for health care that is not aligned with providing high-quality care,” said Barry Straube, Medicare’s CMO. “Unequivocally, there has to be payment reform.”

Michael Connelly, chief executive of Catholic Healthcare, which has similar programs, says payers need to bundle payments for a hospital stay and the follow-up care.

“One of my frustrations is it’s taking so long to do this,” he told the Times. 

“Hospitals who say they are penalized for doing the right thing are right,” concurred Robert Berenson, a policy analyst at the Urban Institute. “If we can’t do this, we can’t do much of anything in health reform.”

Harvard scientists have found that as people age to a point where they become eligible for Medicare, the improved access to care it assures is associated with reductions in racial and socioeconomic disparities in health status.

That supports a contention made by many that universal coverage could narrow the US’ appalling gaps in the quality and outcomes of care for non-whites and the poor.
 
Before reaching these conclusions, John Ayanian and colleagues performed observational and quasi-experimental analyses of cross-sectional data from the National Health and Nutrition Examination Survey. Data had been collected between 1999 and 2006 from adults aged 40 to 85 years old.
 
The scientists found that measures of disease control improved significantly across all racial and socioeconomic subsets during the 7-year study period, which had the effect of preserving racial disparities noted at study onset…until that is, people reached an age where they qualified for Medicare.

That’s when the gaps narrowed dramatically.

Once people with hypertension enrolled in Medicare, Black vs. white disparities in systolic blood pressure dropped by 4.2 mm Hg, a 60% reduction.

Similarly, Medicare enrollment was associated with a 70% reduction in Black-white disparities for hemoglobin A1c levels, a measure of diabetes control. There were similar reductions in disparities when people were stratified according to educational status. 

“Universal health insurance may reduce persistent disparities we’ve seen for far too long in Americans from different racial or ethnic groups,” Ayanian told BurrillReport. He’s a professor of medicine and health care policy at Harvard Medical School and Brigham and Women’s Hospital.
 
The write-up is in the Annals of Internal Medicine.

“The results of this study make it clear that guaranteeing access to affordable insurance for all Americans is the essential first step toward…a healthier America,” said Karen Davis, president of the Commonwealth Fund, which funded the study.

Everyone agrees that controlling health care cost escalation is vital to cutting our budget deficit.

The problem is that no one agrees how to do it, and yesterday’s kumbayah press release by key stakeholders certainly hasn’t addressed the issue substantively.

The Big O has already ticked-off Big Insurance by cutting payments to Medicare Advantage plans, and the $1.1 billion he tucked into his Economic Hail Mary for comparative effectiveness research has garnered similarly negative reviews from Big Pharma and the Device Makers.

Obama believes cost-effectiveness research can help physicians reduce wasteful or ineffective treatments, especially if they are reminded about the findings at time they write orders.

This could be done by incorporating reminder systems into those newfangled EMRs he’s incentivizing physicians to adopt.

The Hail Mary allocated $400 million to the National Institutes of Health, $300 million to the Agency for Healthcare Research and Quality, and another $400 million to Health and Human Services.

This amounts to a budget increase, not a policy shift for AHRQ. For example, its 2007 guide to pain medication for osteoarthritis explained how a 30-day supply of Lodine cost $170 whereas the same course of treatment with aspirin cost $10.

And CMS has long-since established the precedent of using AHRQ-sponsored research in reaching coverage decisions for Medicare and Medicaid.

Still, the decision raised red flags for Big Pharma, whose trade group was one of the signees in yesterday’s kumbaya press release, and the device makers as well.

Teresa Lee, a VP at the Advanced Medical Technology Association, warned the Wall Street Journal for example that using “this research to deny access to appropriate treatments for patients with (specific) medical histories and needs should not be the objective.”

And on the Hill, Republican Senator Jon Kyl just missed passing legislation that would have prevented CMS from relying on comparative effectiveness research to deny coverage.

Charles Grassley and Russ Feingold, 2 key actors in health reform legislation, voted for that one.

Outcomes data can be confounded by patient factors like burden of illness, and they are time consuming and expensive to collect.

That’s why many quality measurement programs focus on process quality and cross their fingers that the link between process and outcomes actually holds true.

Uh, guys…can we huddle up a minute?

Leslie Kernisan and colleagues at UCSF just finished a study to determine whether performance on a set of process measures known as Safe Practices for Better Healthcare could predict hospital mortality.

They couldn’t.

Hospitals with higher scores on the Safe Practices indices did not have lower inpatient mortality than those with lower scores. Progressing from the worst to the best quartile on Safe Practices, inpatient death rates bounced around from 1.97% to 2.04%, to 1.96% to 2.00%.

Data from more than 1,000 hospitals were analyzed. These data were adjusted for patient and hospital variables that could impact the results.

“It is possible that inviting hospitals to self-report on their patient safety practices and then assigning them to quartiles of score is not an effective way to assess hospital quality and safety,” stated the authors.

That may be, but it’s more likely that inpatient mortality rates are not sensitive enough as measures of quality. Before throwing in the towel on these process measures, scientists would be wise to see how well they predict other, more sensitive outcome measures like readmission rates, functional status at discharge and 6 months, and so forth.

Then again, they could be lousy process measures, or the data collection tools could have been flawed.

The Safe Practice Guidelines have been endorsed by the National Quality Forum. The write-up appears in JAMA.

Eight months after an astute cardiologist discovered a potentially life-threatening problem involving cables that connected Medtronic’s Sprint Fidelis defibrillator to the heart, the medical device giant pulled the product off the market.

By that time, five people had died and the toxic asset had been deposited into the bodies of 250,000 patients where they remain to this day.

Physicians are left to decide on a case-by-case basis whether to ride out the storm or risk a dangerous procedure to remove the cables.

The cables tend to crack causing the charge-box to either deliver shocks at inopportune times or fail to discharge at the moment of truth. Medtronic estimates a 5% cable failure rate at 45 months after implantation.

Cable extraction is dangerous because they end up becoming encased by fibrous overgrowth in the veins draining directly into the heart. The tricky dissection has already been associated with 4 deaths due to hemorrhage.

“We are just seeing the tip of the iceberg,” Ohio State University cardiologist Charles Love told the New York Times.

The procedure is best performed by cardiologists skilled in such removals, but such experts are harder to find than a PCP in Boston.

Medtronic has so far been protected from lawsuits by a Supreme Court decision involving another device in which it was decided that device makers can’t be held liable for products that have been approved by the FDA, a decision that seems inconsistent with its findings in Wyeth v. Levine. 

Medtronic’s position is that the cables should be replaced only as a last resort. It covers the costs of replacement cables, but not the procedure which typically runs a cool 15 grand.

Michigan State University scientists have found that brand name information and marketing claims overshadow fine print safety warnings on OTC medications, despite Federal regulations requiring that display of the latter should be “prominent” and “conspicuous.” 
 
Laura Bix and colleagues used an eye-tracking device to quantify the visual inspection patterns of subjects as they scanned package labels on OTC pain killers and subsequently assessed the extent to which subjects could recall the information.

The scientists focused on five elements of the package label: brand name, the statement of claims such as “extra strength,” drug facts information, the child-resistant warning and the tamper-evident warning.
 
They observed that subjects focused primarily on the brand name and much less on the 2 warnings.  For example, 67% of the subjects were able to remember one or more brands they had observed during the study, but only 18% recalled alcohol-related warnings.

A dismal 8% remembered the warning that the product shouldn’t be used in homes where young children were around and not one single participant recalled the warning about tamper-evident features.
 
Part of the explanation, according to Bix and Co., is that the brand and product claims were more legible than the warning statements.

Their write-up appears in Proceedings of the National Academies of Science.

“To be effective, warnings about the lack of a child-resistant feature, or those that alert consumers to potential tampering of the product, need to be read and comprehended at the time of purchase,” Bix told BurrillReport.

“Little guidance exists from the federal government regarding what it means to be ‘prominent’ or ‘conspicuous,’ yet, this term is used quite frequently in the regulations that dictate labeling for a variety of product,” Bix added.

Massachusetts General Hospital can’t seem to get out of its own way lately.

Already in the doghouse with Bay state public health officials for high mortality rates in its cardiac cath program, the prestigious Harvard Medical School affiliate has suspended its pediatric cardiac surgery program after errors during 2 open-heart surgery procedures caused serious complications.

The public health officials, who have to be considering monthly parking permits in the lot on Fruit Street as a way to control costs, began looking into the incidents shortly after the General notified them last week.

Both babies survived the mishaps, although one sustained neurological damage and required transfer to Children’s Hospital across town.

Just 2 years ago, the General beefed up what had been a tiny pediatric cardiac surgery program by recruiting Jeff Myers, a specialist in the field.

The unfortunate development has reignited debate concerning the extent to which patient outcomes are compromised by policies, or the absence of same, that foster proliferation of multiple low-volume providers for complex, risky procedures like this one.

Children’s Hospital is located just 4 miles west of the General. It does 1,100 pediatric open-heart cases per year, making it the highest-volume program in the country.

The General has managed to log 90 cases in the last 20 months. Meanwhile, about 3 miles south of the General, Tufts Medical Center has a program that did 24 last year.

The General’s “numbers are pretty small” Peter Manning told the Boston Globe. The director of CT surgery at Cincinnati Children’s Hospital added, “when you get below 100 cases you really worry… whether the [surgeon] is doing enough to keep their skills up.”