American College of Physicians: Internal Medicine — Doctors for Adults ®

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HospitalistWeekly 7-23-08

Highlights

  • Medicare claims to be adjusted following payment cut reversal
  • Commonwealth Fund rates U.S. system performance lower than past years

Cardiology

  • Poor blood sugar control associated with higher mortality after heart surgery
  • Beta-blockers improve outcomes in decompensated heart failure, study finds

Neurology

  • Bleeding risk after stroke may be higher with heparin and enoxaparin, study reports

FDA updates

  • CT scans could interfere with medical devices

From ACP Internist

  • Discuss mandatory e-prescribing on the blog

Cartoon caption contest


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Highlights

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Medicare claims to be adjusted following payment cut reversal

Physicians got a reprieve from a scheduled 10.6% Medicare payment cut last week when Congress voted to override a presidential veto of legislation to avert the cut scheduled to take effect July 1. As a result, payment rates will be unchanged in the second half of this year and will increase by 1.1% in 2009, instead of the planned 5.4% cut.

The legislation (H.R. 6331) will also increase payments for office and hospital visits, a provision specifically requested by ACP; allow internists to qualify for higher payments from quality reporting under the Physician Quality Reporting Initiative; and allocate funding for a Medicare medical home demonstration project. ACP’s Web site has more on the bill’s impact on internists and patients.

CMS is instructing contractors to automatically reprocess claims submitted between July 1, the date of the scheduled cut, and July 15, to reflect the new legislation. Claims submitted to Medicare during the first two weeks of July are likely to be processed at the reduced rate with the additional 10.6% mailed to physicians in later adjustments. July 1 could be the exception since CMS has not yet instructed contractors to hold claims for longer than the mandated 14 days following receipt.

The College has developed an online calculator for physicians to determine how the bill will affect their individual practices. Also, go online for more on how the legislation affects payment rates and claims processing.

A list of highlights of the legislation also is available on the American Medical Association’s Web site.

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Commonwealth Fund rates U.S. system performance lower than past years

The performance of the U.S. health care system is falling further behind that of other industrialized countries, especially on measures of access and preventable mortality, according to an annual scorecard from the Commonwealth Fund.

The U.S.’s overall scores have not improved since the private foundation began issuing the scorecards in 2006, and the country has fallen from 15th out of 19 to last place on a measure of mortality amenable to medical care. Compared with benchmarks of top performance achieved internationally and within the U.S., the average performance of the American health system scored 65 out of 100 in the 2008 report.

Exceptions to the overall trend were found in metrics that have been the focus of national improvement campaigns or public reporting, the report said. Such areas included hospital standardized mortality rates and control of diabetes and high blood pressure. Based on these findings, the authors suggested that similar attention should be paid to areas of U.S. health care which are particularly lacking, such as mental health care, primary care, hospital readmissions and adverse drug events.

The scorecard also found that the U.S. was particularly deficient in efficiency, scoring 53 out of 100 on inappropriate, wasteful or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology. Reducing insurance administration, improving primary care, and increasing care coordination could substantially reduce health care expenditures, the report said.

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Cardiology

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Poor blood sugar control associated with higher mortality after heart surgery

A recent large study found that poor glucose control was associated with a fourfold increase in mortality and major complications following cardiac surgery, regardless of whether patients had been diagnosed with diabetes.

In the study of more than 8,000 adults who underwent cardiac surgery between April 1996 and March 2004, researchers found that more than half of patients with moderate (200 to 250 mg/dL) to poor (>250 mg/dL) blood glucose control (BGC) were not previously identified as diabetic. Inadequate BGC was associated with in-hospital mortality (good, 1.8%; moderate, 4.2%; poor, 9.6%; adjusted odds ratio: poor versus good BGC, 3.90 [95% CI, 2.47 to 6.15]; moderate versus good BGC, 1.68 [95% CI, 1.25 to 2.25]) as well as postoperative myocardial infarction and pulmonary and renal complications in patients without known diabetes.

The study, led by researchers at the Bristol Heart Institute and published in the July 8 issue of Circulation, could have major implications for the treatment of all patients admitted for major surgery, said a July 8 Bristol University news release. The study’s lead author urged surgeons and intensive care specialists to use strict protocols of active BGC in all patients admitted for major surgery.

Hyperglycemia in Hospitalized Patients,” a CME supplement to the June 2008 ACP Hospitalist supported by a grant from Novo Nordisk, discusses the clinical management of hospitalized patients with diabetes.

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Beta-blockers improve outcomes in decompensated heart failure, study finds

Continuing beta-blocker therapy during hospitalization can improve outcomes in patients with decompensated heart failure, according to a new study.

Researchers from the OPTIMIZE-HF trial analyzed data from patients who were eligible to receive beta-blockers at discharge after hospitalization for systolic heart failure. The objective of the study was to determine whether such patients should continue beta-blocker therapy during their hospital stay or whether the drug should be withdrawn. The results appear in the July 15 Journal of the American College of Cardiology.

Of the 2,373 patients, 1,350 (56.9%) were taking beta-blockers before admission and continued taking them during their hospital stay, 632 (26.6%) began taking beta-blockers while in the hospital, 79 (3.3%) had beta-blockers withdrawn, and 302 (12.8%) were considered eligible for beta-blockers but did not receive them. Patients whose beta-blocker therapy was continued had a significantly lower risk for propensity-adjusted post-discharge death (hazard ratio, 0.60 [95% CI, 0.37 to 0.99]; P= 0.044) and death or rehospitalization (odds ratio, 0.69 [95% CI, 0.52 to 0.92]; P= 0.012) than those who did not receive beta-blockers. In addition, patients whose beta-blockers were continued had a lower adjusted risk for death than those whose beta-blockers were withdrawn during their hospital stay. The latter group and those who were eligible for beta-blockers but did not receive them had similar risks for death.

The authors concluded that continuing beta-blocker therapy during hospitalization for decompensated heart failure decreases mortality risk after hospital discharge and improves rates of treatment. Risk for death and poor outcomes worsens, however, in patients whose beta-blocker therapy is withdrawn.

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Neurology

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Bleeding risk after stroke may be higher with heparin and enoxaparin, study reports

Bridging with heparin and enoxaparin may increase risk for bleeding after cardioembolic stroke, a new study reported.

Most patients who have a cardioembolic stroke eventually require anticoagulation, but no consensus exists on how and when to begin such therapy. To compare anticoagulation strategies in this population, researchers retrospectively reviewed data from 204 patients who had been admitted to the University of Texas Health Science Center at Houston from April 1, 2004 to June 30, 2006 with cardioembolic stroke and had not received tissue plasminogen activator. Patients were grouped according to treatment: none (8 patients), aspirin alone (88 patients), aspirin plus warfarin (35 patients), IV heparin followed by warfarin (heparin bridging, 44 patients), and full-dose enoxaparin plus warfarin (enoxaparin bridging, 29 patients). The study was published online July 14 in Archives of Neurology.

Two patients (1%) experienced recurrent stroke. The most common serious adverse event, progressive stroke, occurred in 11 patients (5%), all but one of whom were in the aspirin-only group. Patients who received aspirin alone were 12.5 times as likely to have stroke progression as those who received anticoagulant therapy. Hemorrhagic transformation was seen in 23 patients; of these, three patients, all in the enoxaparin bridging group, had parenchymal hematoma. Two patients developed systemic bleeding, both in the heparin bridging group. Enoxaparin bridging was significantly associated with late symptomatic hemorrhagic transformation (P= 0.003), while heparin bridging was significantly associated with systemic bleeding (P= 0.04).

The authors acknowledged several limitations of their study, including its retrospective, nonrandomized design and its lack of long-term follow-up. However, they concluded that the data may be useful in guiding decisions about long-term anticoagulation after cardioembolic stroke. It seems safe to start anticoagulation with warfarin at any time during hospitalization, while risk for bleeding may be higher with full-dose enoxaparin or heparin bridging, they wrote.

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FDA updates

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CT scans could interfere with medical devices

CT scans may cause malfunctions in some implanted and external medical devices, according to a new public health notification from the FDA.

The agency reports having received a small number of adverse event reports in which CT scans may have interfered with devices including pacemakers, defibrillators, neurostimulators and implanted or externally worn drug infusion pumps. No deaths have been reported to date, and the FDA is continuing to investigate the issue.

The notification offered recommendations for CT procedures in which a medical device is in or immediately adjacent to the programmed scan range, including:

  • If practical, try to move external devices out of the scan range;
  • Ask patients with neurostimulators to shut off the device temporarily while the scan is performed;
  • Minimize X-ray exposure to the implanted or externally worn electronic medical device by:
  • Using the lowest possible X-ray tube current consistent with obtaining the required image quality; and
  • Making sure that the X-ray beam does not dwell over the device for more than a few seconds;

For CT procedures that require scanning over the medical device continuously for more than a few seconds, as with CT perfusion or interventional exams, attending staff should be ready to take emergency measures to treat adverse reactions if they occur, the FDA said. Patients should also be asked to check the function of their devices after scanning, and contact a health care provider if they suspect any problems. Problems with electronic medical devices that might be caused by CT scanner interference include:

  • generation of spurious signals, including cardiac defibrillation pulses,
  • misinterpretation of signals produced by the X-rays as actual biological signals,
  • missed detection of actual biological signals, and
  • resetting or reprogramming of device settings.

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From ACP Internist

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Discuss mandatory e-prescribing on the blog

The recent Medicare legislation included a mandate to e-prescribe, with financial incentives and penalties set to begin between 2009 and 2013. But many physicians can’t afford full electronic health records (EHRs) and are looking for alternatives. Hospitals are now allowed to offer full EHRs with e-prescribing systems to private practices in their communities. Read more about the issue on ACP Internist’s blog.

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Cartoon caption contest

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Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner.

Put words in our mouth

E-mail all entries to acphospitalist@acponline.org by July 25. ACP staff will choose three finalists and post them in the July 30 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Aug. 6 issue.

Pen the winning caption and win a $50 gift certificate good for any ACP product, program or service.

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