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ACP HospitalistWeekly 10-14-09

Highlights

• Influenza update: Vaccine arrives, hard-hit cities see fewer cases, how to code
• AHRQ offers free tools for disaster planning

Quality improvement

• SHM begins new glucose control project

Cardiology

• Three-point prediction model may help diagnose AHF in the ED
• ICD soon after heart attack doesn't help survival

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

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Highlights

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Influenza update: Vaccine arrives, hard-hit cities see fewer cases, how to code

Health departments in three states began administering the first of the 7 million currently available H1N1 flu vaccines. Next, 40 million doses will be available by mid-October and 10 million to 20 million will become available each week after that.

Meanwhile, health officials from the federal government and cities hit hard by H1N1 in the spring—New York, Boston and Philadelphia—are contemplating whether the outbreaks conveyed some amount of herd immunity leading to fewer than expected cases so far this fall.

More patient and physician resources on influenza are available at flu.gov, including one-pagers for people who are pregnant or have children and patients who have asthma, diabetes or are immunocompromised, and advice specific to doctors and other providers. Another patient resource includes Emory University's interactive Web site to screen potential H1N1 cases using the same triage calculations their doctors and the CDC use. Questions about fever, symptoms and underlying health then determine whether patients have H1N1 flu, and what to do next—rest, call a doctor or seek immediate treatment.

ACP addressed how to code for administering the H1N1 vaccine. In preparation for an H1N1 influenza outbreak, the CDC will be providing the vaccine and ancillary supplies for free to CDC Public Health Emergency Preparedness grantees, otherwise known as project area designated sites.

Because the federal government will be paying for the vaccine itself, health insurers are only planning to reimburse for administration of the vaccine. Most of the country’s large insurers, including Medicare, will be covering the administration, but with varying degrees of comprehensiveness.

One of several different CPT procedure codes will apply to the immunization administration:

• CPT codes 90465-90468, Immunization administration for patients younger than 8 years
• CPT code 90470, H1N1 immunization administration (intramuscular, intranasal), including counseling when performed
• CPT codes 90471-90474, Immunization administration
• HCPCS code G9141, Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)

When billing Medicare or Medicaid, the new HCPCS code, G9141, should be used. If you do not use this code, the portion of the claim for the vaccine will be denied. Medicare and Medicaid reimbursement will be similar to the seasonal influenza vaccine administration in that the beneficiaries’ deductibles and copayments do not apply to the vaccine administration. CMS offers additional information on its Web site.

While most private payers will be covering the vaccine administration, most are still in the process of developing their guidelines. CIGNA has already issued guidance and it will be covering the vaccine administration for insured-plan customers at 100% with no copayment, prior authorization or co-insurance. CIGNA is also working with its self-insured employers in its role as third-party administrator to encourage them to cover the full cost of the vaccine administration. Further information about CIGNA's guidance is
available online.

The College will provide additional information as more plans begin to announce their guidelines.

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AHRQ offers free tools for disaster planning

The Agency for Healthcare Research and Quality has released two free tools to assist hospitals in disaster planning.

The interactive computer-based tools will help emergency responders and planners select and equip alternate care sites and determine which patients can be moved to these sites. The Disaster Alternate Care Facilities Selection Tool allows users to evaluate potential sites, such as college campuses, schools or convention centers, and determine what would need to be done to prepare them for use in a disaster. The Disaster Alternate Care Facility Patient Selection Tool helps clinicians match hospitalized patients with a potential alternate care facility, freeing up space in the hospital for incoming patients.

"Identifying alternate care facilities ahead of time and knowing what it takes to get these sites up and running quickly is critical to ensuring the safest and best possible care for the public during a disaster," AHRQ director Carolyn M. Clancy, MACP, said in a press release.

The tools were developed by Denver Health under contract to AHRQ, with input from the Office of the Assistant Secretary for Preparedness and Response. They are available free of charge online.

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Quality improvement

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SHM begins new glucose control project

The launch of a new glycemic control program was announced last week by the Society of Hospital Medicine (SHM).

The Glycemic Control Mentored Implementation (GCMI) is intended to improve early detection and treatment of hyper- or hypoglycemia in hospitalized patients. By addressing pertinent clinical and systems issues, GCMI aims to improve care of patients with diabetes and to reduce its associated complications. The effort, which is supported by funding from sanofi-aventis, uses mentors who are glycemic control and quality improvement experts to provide direct support to hospitalist-led teams.

Each team enrolled in the two-year project receives a dedicated mentor, as well as Web-based and print resources on glycemic control. The project will address the use of both subcutaneous and intravenous insulin, the two most common methods for managing glycemic levels in the hospital.

Specific topics include:

• access to subcutaneous insulin on the general medical/surgical floor,
• intravenous insulin infusion in the intensive care unit,
• transitioning patients from intravenous to subcutaneous insulin, and
• transitioning patients home on insulin therapy.

The project will include 30 hospitals in 22 states. A full list of participating sites is online.

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Cardiology

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Three-point prediction model may help diagnose AHF in the ED

A prediction model that combines biomarkers and clinical judgment may improve diagnosis of acute heart failure in the emergency department, a study concluded.

In the study, physician estimates of probability of acute heart failure (AHF) in 500 patients treated in the emergency department were taken from the Improved Management of Patients with Congestive Heart Failure trial. A model using the variables of age, pre-test probability and log N-terminal pro-B-type natriuretic peptide (NT-proBNP) correctly reclassified 44% of patients initially estimated at intermediate probability of AHF to either low or high probability. The study appears in the Oct. 13 Journal of the American College of Cardiology.

Findings suggest that interpreting biomarkers such as NT-proBNP as continuous variables, as opposed to categorical tests, is a superior approach, the authors said. The strategy may be particularly useful in patients for whom the diagnosis is unclear and who often need ancillary tests. In the study, use of the model led almost half of patients classified as intermediate risk to be redirected, with 99% accuracy, the authors said.

The study confirms many physicians’ belief that clinical judgment must be incorporated into prediction rules, the authors continued. This model is easy to use because it doesn’t require elaborate clinical information and can quickly provide guidance when a physician is undecided about an AHF diagnosis, they said.

The applicability of the study is limited by excluding patients with acute coronary syndrome, the most common etiology in AHF patients, as well as those with infection, obstructive airway disease or moderate renal dysfunction, noted an accompanying editorial. In addition, the editorial continued, considering the difficulty of obtaining unanimous consensus on AHF diagnoses, questions surround the study’s use of a “gold standard” diagnosis, especially since redirection of patients depended on subjective judgment.

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ICD soon after heart attack doesn't help survival

Patients who received an implantable cardioverter-defibrillator (ICD) within 40 days after a myocardial infarction had no better survival than those who were treated with medical therapy alone, a new study found.

The randomized, prospective trial included 898 patients with a recent myocardial infarction (MI) who had a reduced left ventricular ejection fraction (ÿ40%) and either a heart rate of 90 or more beats per minute on the first available electrocardiogram or nonsustained ventricular tachycardia during Holter monitoring or both. Of those patients, 445 were randomly assigned to receive an ICD and 453 were assigned to medical therapy only. After a mean follow-up of 37 months, the groups had no significant difference in overall mortality: 116 patients in the ICD group died compared to 117 in the other group. The ICD patients had a reduced risk of sudden cardiac death (hazard ratio [HR], 0.55; P=0.049), but an increased risk of non-sudden cardiac death (HR, 1.92; P=0.001).

The study's results confirmed the findings of the Defibrillator in Acute Myocardial Infarction Trial (DINAMIT) and offered no evidence that implantation of an ICD improved survival in this high-risk group of patients who were receiving optimal medical therapy, the authors concluded. They speculated that the increase in non-sudden cardiac deaths could be due to untoward effects of the ICD shocks, the substrate of MI studied, other effects of the ICD, or differences in the use of other therapies, but said that further research would be required to determine which factor is responsible.

The study shows the value of confirmatory trials in comparative effectiveness research, an accompanying editorial noted. Such trials can direct research and clinical efforts away from ineffective procedures toward new or established alternatives, the editorialist said. The study was published in the Oct. 8 New England Journal of Medicine.

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

E-mail all entries by October 22. ACP staff will choose three finalists and post them in the Oct. 28 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Nov. 4 edition.

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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