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HospitalistWeekly 9-17-08

Highlights

• Hospitals score low on compliance with colon cancer guideline
• Residents looking for jobs with lifestyle perks, loan help, survey finds

Business of medicine

• Medical home model starts to pay off for large groups, hospitals

Quality of care

• Inadequate sign-out processes contribute to adverse events

FDA news

• Recalls of LifePak external defibrillators, Thymoglobulin
• New Rituxan prescribing information reflects fatal PML case

Annals of Internal Medicine

• Massage therapy provides relief for advanced cancer patients
• Respiratory drugs linked to increased death risk in veterans with COPD
• Early release: review of comparative effectiveness of premixed insulin for type 2 diabetes

Cartoon caption contest

• Put words in our mouth…

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Highlights

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Hospitals score low on compliance with colon cancer guideline

Pathology examination of 12 or more lymph nodes is associated with improved colon cancer survival, yet 38% of U.S. hospitals routinely complied with the guideline in 2004 and 2005, a study reported.

In the study published in the Sept. 9 online issue of the Journal of the National Cancer Institute, researchers examined data from 1,296 hospitals included in the National Cancer Database, identifying 74,669 colon cancer patients who underwent colectomy in 1996-1997 and 82,120 who underwent colectomy in 2004-2005. Compliance with the American Joint Committee on Cancer guideline, which requires that at least 75% of patients have 12 or more nodes examined, increased from 15% of hospitals in 1996-97 to 38% in 2004-05. Adherence between the two time periods increased in 900 hospitals, remained the same at six hospitals, and fell in 310 hospitals.

In 2004-05, hospitals designated by the National Cancer Institute as Comprehensive Care Centers were most likely to comply with the 12-node examination recommendation (78.1% compliance), followed by other academic institutions (52.4%), Veterans Administration hospitals (53.1%) and community hospitals (33.7%).

With nearly two-thirds of hospitals failing to meet the guideline's requirements, much improvement in lymph node examination rates is needed, the authors concluded. They noted that the measure soon may be used by insurers to assess hospital and physician performance.

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Residents looking for jobs with lifestyle perks, loan help, survey finds

A survey of final-year medical residents found that younger doctors value lifestyle over financial rewards when making career decisions and that most are looking for positions with large groups or hospitals.

Asked what they look for in a practice setting, more than 80% of respondents to the national survey, by Merritt Hawkins & Associates, rated "adequate call/personal time" high on their list. Other factors considered important were a good financial package and educational loan forgiveness.

Other findings from the survey included:

• A majority (58%) of respondents rated the Internet as their most important source for learning about job opportunities. Other sources included personal networking, physician recruiters and medical journals.
• 80% of respondents said they had been contacted by recruiters more than 25 times during their residency, while 40% reported being contacted more than 50 times.
• 82% of respondents start their job search more than one year before completing their residency.
• Most respondents (78%) are looking for compensation that includes a salary plus production bonus.
• 29% of respondents owed between $100,000 and $150,000 in student loans, up from 21% in 2006, while 35% rated repayment as a major concern (vs. 12% in 2006) and 40% said payment of loans would have a great effect on their decision to accept a position.

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Business of medicine

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Medical home model starts to pay off for large groups, hospitals

Large practices adopted the patient-centered medical home (PCMH) model sooner than small ones, but it's been slow going regardless, said one study. However, the model cut one health chain's hospital admissions by 20% and costs by 7%, according to another study.

The first study, from Health Affairs (subscription required), assessed how much infrastructure large practices have in place to support the PCMH concept. Acknowledging that infrastructure isn't necessarily implementation, researchers used data from the 2006-2007 National Study of Physician Organizations and the Management of Chronic Illness, a 30-minute phone survey of the heads of large practices. Researchers identified 291 medical groups who responded to the survey and treat four chronic ailments: asthma, diabetes, congestive heart failure and depression.

Results showed:

• One-third use primary care teams at a majority of their practice sites;
• 41% have a majority of physicians using a basic electronic medical record;
• 65% participate in quality-improvement collaboratives;
• Except for distributing guidelines, less than half of the groups use patient educators and other health promotions; and
• 30% use group visits for chronic illnesses.

"Early visions of the medical homes centered on smaller practice settings," the authors wrote. "Interestingly, our data demonstrate that the largest of the large medical groups, and those owned by larger entities such as a hospital or an HMO, have much higher levels of PCMH infrastructure than smaller groups do."

A second paper highlighted success from Geisinger Health System, a group of hospitals, employed physicians, clinics, programs and a health plan located in central and northeastern Pennsylvania. Administrators outlined their application of PCMH-like concepts in a second paper in Health Affairs.

As just one example of its efforts, Geisinger offers its physicians monthly payments of $1,800 per doctor to recognize an expanded scope of practice, and monthly stipends of $5,000 per thousand Medicare patients to pay for extra staff and extended hours. Monthly performance reports are reviewed and the payouts are then prorated to quality measures.

First-year results at two pilot sites showed a 20% reduction in all-cause hospital admissions and 7% total medical cost savings. Geisinger will roll out 10 more in-system sites and one non-system site.

The report outlines three implications to consider in applying Geisinger's experience to national health care reform:

Aligned incentives. Geisinger subsidizes "important but nonprofitable functions (such as primary care, autism treatment, and so forth.)" Commercial insurers would need to adopt similar methods to reap benefits.
Electronic infrastructure. EHRs offered benefits only years after installation.
Collaboration and integration. Geisinger can offer incentives otherwise not allowed by regulations that prohibit hospital-physician collaborations, the report said.

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Quality of care

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Inadequate sign-out processes contribute to adverse events

Faulty sign-out processes used by medical residents contributed to inefficiencies, delayed treatment and adverse patient events, according to a study published in Sept. 8 Archives of Internal Medicine.

Researchers conducted a prospective audiotape study of 12 days of sign-out of clinical information among eight internal medicine housestaff teams. Of 84 sign-out sessions, postcall interns identified 24 sign-out-related problems involving delays in diagnosis or treatment (5 patients), intensive care unit transfer (1 patient), near misses (4 patients), and 15 inefficiencies or redundancies in work. Sign-outs also omitted key information, such as a patient's clinical condition, recent scheduled events (such as tests or surgeries), tasks to complete, plan or action, or rationale for assigned tasks.

While the study was limited by its size (it was performed at one academic medical center), the results suggest an inability among some residents to accurately convey an overall patient assessment or to provide enough information to assist with overnight decisions, researchers noted. According to the authors, improvements to patient care transfer processes require a focus on higher-order synthesis and judgment. One author noted the need to establish standards for successful hand-offs and systems to ensure that all important information is transmitted to the person who is assuming responsibility for the patients during transfer of care.

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FDA news

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Recalls of LifePak external defibrillators, Thymoglobulin

The FDA issued a Class I recall of LifePak CR Plus Automated External Defibrillators (AED) because a flaw in the product's design makes it difficult to operate, according to an alert last week.

Specifically, the AED's voice prompt says to press a shock button which is not visible because it is covered. The device should be removed from service, or the manufacturer-provided diagram should be consulted to remove and discard the shock button cover, the FDA said.

Separately, the FDA issued a recall of 25 mg/vial Thymoglobulin (generic name: anti-thymocyte globulin [Rabbit]) with lot number C7010C01, because it failed a periodic stability test based upon the appearance of the product. Providers and hospitals should return the product to its manufacturer, Genzyme Corporation, an FDA notice said. A similar recall of three other lots of Thymoglobulin was issued last April.

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New Rituxan prescribing information reflects fatal PML case

Prescribing information for Rituxan (generic name: rituximab) has been revised to reflect a fatal case of progressive multifocal leukoencephalopathy (PML) that developed in a patient with rheumatoid arthritis, the FDA said in an alert.

This is the first reported case of PML in a Rituxan-treated patient with rheumatoid arthritis, the company said in a letter to healthcare providers. The patient, who received the drug in a long-term safety extension clinical study, died 18 months after taking the last dose of Rituxan. S/he first developed a JC virus infection, then PML. The drug's prescribing information already includes reports of PML in patients with hematologic malignancies and autoimmune diseases.

Providers who treat patients with rituximab should consider PML in any patient who presents with new onset neurologic symptoms. Brain MRI, lumbar puncture and consultation with a neurologist should also be considered, if indicated.

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Annals of Internal Medicine

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Massage therapy provides relief for advanced cancer patients

A new study from the National Institutes of Health finds that massage therapy may have immediate benefits on pain and mood among patients with advanced cancer. In a randomized trial of 380 advanced cancer patients at 15 U.S. hospices, improvement in pain and mood immediately following treatment was greater with massage than with simple touch.

Researchers speculated that massage may interrupt the cycle of distress, offering brief physical and psychological benefits. Physically, massage may decrease inflammation and edema, increase blood and lymphatic circulation, and relax muscle spasms. Psychologically, massage may promote relaxation, release endorphins, and create a positive experience that distracts temporarily from pain and depression. Researchers cautioned that while massage may offer some immediate relief for patients with advanced cancer, the effects do not last over time, demonstrating the need for more effective strategies to manage pain at the end of life. A report in streaming video format is online.

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Respiratory drugs linked to increased death risk in veterans with COPD

In a large-scale, case-control study examining associations between commonly prescribed respiratory medications and risk for death in veterans with newly diagnosed COPD, researchers followed a cohort of patients enrolled in the U.S. Veterans Health Administration health care system to assess mortality rates at one year. Inhaled corticosteroids were associated with decreased risk for death, while theophyline and ipratropium were associated with increased risk for respiratory and cardiovascular death, respectively. Ipratropium was associated with an 11% increase in the risk for death, raising researchers’ concerns about the potential harm associated with the drug rather than simply a lack of effectiveness. Researchers urge more research to weigh the benefits of these medications against the risk for death.

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Early release: review of comparative effectiveness of premixed insulin for type 2 diabetes

According to a National Health Interview Survey, 28% of patients with type 2 diabetes use insulin alone or in combination with oral antidiabetic agents to control their glucose levels. Because of the increasing prevalence of type 2 diabetes, the number of patients who use insulin for glycemic control, and the importance of glycemic control in decreasing mortality and morbidity, researchers wanted to establish the weight of evidence for the safety and effectiveness of premixed insulin compared with other antidiabetic agents. Researchers at the Agency for Healthcare Research and Quality found that premixed insulin provides tighter glycemic control than long-acting insulin and non-insulin antidiabetic agents. However, researchers cautioned that studies with longer follow-up are needed to determine long-term outcomes. The article will be published in the October 21 print issue of Annals of Internal Medicine.

The current issue of Annals is online.

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Cartoon caption contest

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Put words in our mouth …

ACP Hospitalist Weekly and ACP InternistWeekly want readers to create captions for this cartoon and help choose the winner. Craft your caption “Mad Libs” style by filling in the blanks to the caption we’ve started.

“It’s _______ [noun]. They’re ____ [adjective] about their _____ [noun].”

E-mail all entries to acphospitalist@acponline.org by Sept. 19. ACP staff will choose three finalists and post them in the Sept. 23 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Sept. 30 issue.

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

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated