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ACP HospitalistWeekly 11-3-10
Highlights
- Sepsis often followed by cognitive and functional decline
- MGMA conference coverage: Revenue varies with ownership, EHR use
Preoperative evaluation
- Gait speed preoperatively predicts cardiac surgery outcomes
VTE
- VTE recurrence more likely with nonsurgical transient risk factors, but not enough to change practice
From ACP Internist
- The next issue is online and coming to your mailbox
From the College
- Council of Young Physicians now recruiting
Cartoon caption contest
- And the winner is …
Physician editor: A. Scott Keller, FACP
Highlights
.Sepsis often followed by cognitive and functional decline
Hospitalization for severe sepsis was associated with increasing cognitive impairment and functional disability, according to a new study of Medicare patients.
The prospective cohort study used data on hospitalizations and cognitive and functional assessments from the Health and Retirement Study, a survey of U.S. residents between 1998 and 2006. The study population included 516 patients hospitalized for severe sepsis and 4,517 patients who survived a nonsepsis hospitalization. Results were published in the Oct. 27 Journal of the American Medical Association.
After an episode of severe sepsis, patients’ risk of having moderate to severe cognitive impairment increased more than threefold (odds ratio, 3.34, 95% CI, 1.53 to 7.25). The postsepsis patients also showed an increase in their number of functional limitations, especially if they had no or few limitations to start (mean of 1.57 new limitations in patients with no prior problems [95% CI, 0.99 to 2.15] and 1.50 new limitations for those with existing mild to moderate limitations [95% CI, 0.87 to 2.12]). These declines persisted for at least eight years.
The study also compared the sepsis patients to the cohort of patients that had been hospitalized for any other condition. Nonsepsis hospitalizations were not associated with the development of moderate to severe cognitive impairment, and while the nonsepsis patients did develop some new limitations, they were significantly fewer than those found in the sepsis patients (P=0.001 for the difference between sepsis and nonsepsis patients).
The cognitive and functional declines seen in these sepsis survivors represent a substantial, underrecognized public health problem, the study authors concluded. Extrapolating from the data, the authors estimated that in the U.S., 20,000 new cases of moderate to severe cognitive impairment may be attributable to sepsis annually. The complications may be partially preventable by greater efforts at sepsis prevention and improvements in sepsis care such as sedation management and early rehabilitation, the authors suggested. The results of the study may also be useful to physicians who are assessing care options and predicting outcomes for sepsis patients, an accompanying editorial concluded.
.MGMA conference coverage: Revenue varies with ownership, EHR use
NEW ORLEANS—Hospital-owned practices and the specialist physicians employed by them report lower revenue than practices not owned by hospitals or integrated delivery systems (IDS), according to new survey data released by the Medical Group Management Association (MGMA) at its annual meeting last week.
A survey found that hospital- and IDS-owned practices reported considerably lower revenue than non-hospital-owned groups for 2009. The median revenue for a multispecialty practice not owned by a hospital was $798,608, compared to $448,597 for a hospital-owned group, per full-time equivalent (FTE).
“A lot of it is how you account for revenue,” said William Jessee, MD, MGMA president and CEO, at a press conference. “Non-hospital-owned practices count [revenue from] ancillaries, for example; hospital-owned practices don’t.”
Specialists in hospital- and IDS-owned practices reported median total compensation of $294,984, compared to $353,549 in non-hospital and IDS-owned practices. Yet primary care physicians working in the former type of practice reported a median income of $192,116, compared to $179,688 in the latter, the survey found.
“The need for primary care coverage and referrals in hospital- and IDS-owned practices may contribute to the overall difference in compensation,” said Jeffrey Milburn of the MGMA Health Care Consulting Group, in a press release.
Both types of practices reported better financial performance associated with the implementation of EHRs, according to another survey. Specifically, hospital and IDS practices using electronic health records (EHRs) reported $42,042 more in operating margin per FTE doctor than practices using paper records. EHR-using practices not owned by a hospital or IDS reported $49,916 more in operating margin. Further, non-hospital and IDS-owned practices that had had an EHR for five years reported 10.1% higher operating margins than those who were in the first year of having an EHR.
Practices may be loathe to implement EHRs, however, given the looming threat of reimbursement cuts due to Medicare’s sustainable growth rate (SGR) formula, a third survey found. Forty-five percent of practices reported they would likely delay buying an EHR system in response to the 23.6% cut set for Dec. 1, and the additional 6.5% cut set for Jan. 1, 2011. “It’s a supreme irony that, on the one hand, the government is offering incentives to practices to purchase EHRs, but then plans to cut the SGR so they can’t buy EHRs,” said Dr. Jessee.
About half of survey respondents also said they would stop seeing new Medicare patients if the cuts go through, and 28% said they would stop treating all Medicare patients altogether. Sixty-one percent said they were likely to reduce administrative support staff; 54% would reduce clinical staff; and 77% would delay buying new clinical equipment and/or facilities, the survey found. Indeed, data from August show about a third of practices already started reducing the number of new appointments for Medicare patients, and cut staff, once Congress failed to definitively act on Medicare cuts by a June 1 deadline.
—Jessica Berthold, editor
Preoperative evaluation
.Gait speed preoperatively predicts cardiac surgery outcomes
Elderly patients with a slow gait speed have a threefold greater risk of experiencing a major complication or death following cardiac surgery than those who walk at a normal pace, and they are twice as likely to be discharged to another health care facility or have a prolonged postoperative stay.
Adding an assessment of the time it takes a person to walk five meters at a comfortable pace to existing cardiac surgery risk models appears to improve the predictive value of these models, helping clinicians identify vulnerable patients who might have been missed by using conventional measures such as ejection fraction alone, according to a new study published in the Nov. 9 Journal of the American College of Cardiology.
Of the 131 patients included in the study (mean age, 75.8±4.4 years), 60 (46%) had slow gait speed, defined as taking more than six seconds to walk five meters, using a cane or walker if needed. Treating physicians were blinded to the gait speed test results so as not to influence their decision to proceed with surgery or determine postoperative management.
Slow walkers had an less favorable profile overall, facing higher death rates, taking a longer time to recover and be discharged from hospital, and requiring more rehabilitation facilities. Slow walkers were more likely to be female (43% of women vs. 25% of men; P=0.03) and diabetic (50% vs. 28%, P=0.01).
Two different logistical regression models showed that slow gait speed improved the performance of the models in predicting morbidity and mortality. Independent predictors of discharge to a health care facility were slow gait speed (adjusted odds ratio [OR], 3.19; 95% CI, 1.40 to 8.41) and age 80 years and older (adjusted OR, 3.19; 95% CI, 1.19 to 8.60). Age 80 years and older was also an independent predictor of prolonged postoperative length of stay (adjusted OR, 2.95; 95% CI, 1.15 to 7.59). Slow gait speed showed a trend, but not a significant association toward longer length of stay (adjusted OR, 2.32; 95% CI, 0.95 to 5.67).
Slow walking appeared to be more predictive in female patients, with an adjusted odds ratio for mortality or major morbidity of 8.62 (95% CI, 1.46 to 51.00) in women and 1.65 (95% CI, 0.50 to 5.43) in men (P=0.18).
While walking speed should not be used in and of itself, measurement of gait speed does add incremental improvement to existing risk models, the authors concluded. An editorialist wrote, "Their new screening tool, consisting of an observer, a stopwatch and a well-lit hallway, is reproducible and I believe will be extraordinarily cost-effective.”
VTE
.VTE recurrence more likely with nonsurgical transient risk factors, but not enough to change practice
Risk for recurrent venous thromboembolism (VTE) is higher when the index event is provoked by a nonsurgical versus a surgical risk factor, but not high enough to warrant extended prophylaxis, according to a new study.
It is usually considered safe to stop VTE prophylaxis three months after an index event triggered by a transient risk factor, such as pregnancy or surgery, but recurrence risk in this subgroup may vary by risk factor type. Researchers performed a systematic review to determine rates of VTE recurrence after stopping anticoagulant therapy in patients whose VTE was provoked by any transient risk factor, surgery, or a nonsurgical risk factor. Recurrence rates in patients with a first VTE related to a transient risk factor and patients with an unprovoked index VTE were also compared.
The researchers identified 15 prospective cohort and randomized trials for analysis, involving patients who had symptomatic VTE related to a transient risk factor and were treated for at least three months. Rates of recurrent VTE were calculated at 0- to 12-month and 12- to 24-month intervals after treatment was stopped. The study results appear in the Oct. 25 Archives of Internal Medicine.
Twenty-four months after withdrawal of treatment, recurrence rates were 3.3% per patient-year for those with any transient risk factor, 0.7% per patient-year for those with a surgical transient risk factor and 4.2% per patient-year for those with a nonsurgical transient risk factor. After unprovoked VTE, the recurrence rate was 7.4% per patient-year. At 24 months, the authors calculated rate ratios of 3.0 for nonsurgical compared with surgical risk factors and 1.8 for unprovoked VTE compared with a nonsurgical risk factor.
Study limitations included use of differing definitions of “provoked” and “unprovoked” VTE and lack of continuous enrollment of patients with provoked VTE in the included trials. The authors concluded that risk for recurrence is highest for unprovoked VTE and that among those with transient risk factors, VTE provoked by a nonsurgical event confers a higher recurrence risk than VTE provoked by surgery. Nevertheless, the authors wrote, the rate of recurrence in those with a nonsurgical transient risk factor is still low enough to justify withdrawal of anticoagulant treatment after three months, per current recommendations.
From ACP Internist
.The next issue is online and coming to your mailbox
The November/December issue of ACP Internist is online, featuring stories about:
Marijuana requests: Relief or ‘permission’?
Fourteen states have legalized medical marijuana. Internists who have issued the controversial authorizations describe how they sort out legitimate uses from trivial requests.
Know the patient to achieve statin benefits.
That statins work is without question. And with costs falling due to many drugs in the class going generic, physicians are now refining when to prescribe the ubiquitous drug class based on the degree of risk.
Wisconsin clinic’s patients save time by ‘rooming’ themselves.
An outpatient family practice clinic tried to reduce wait times by letting patients direct themselves to open exam rooms. As a result, wait times fell by half and patient satisfaction rose to its highest levels in 11 months.
More stories and Test Yourself with the MKSAP Quiz are available online.
From the College
.Council of Young Physicians now recruiting
The Council of Young Physicians (CYP) is currently recruiting two new representatives to represent the following U.S. regions for three-year terms beginning in April 2011: Northeast and West. Young physician hospitalists who are active at the chapter level are encouraged to run. ACP defines a young physician as any ACP Member or Fellow who is within 16 years of medical school graduation and no longer in training.
The CYP is responsible for planning programs for the annual meeting for young physicians and providing a young physician perspective on current issues impacting the field of internal medicine. Think you might qualify? For more information, please visit our website.
Cartoon caption contest
.And the winner is …
ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.
"I thought we were going to have problems with the capitated system."
This issue's winning cartoon caption was submitted by Daniel Bendetowicz, FACP, of Ft. Meyers, Fla. Readers cast 187 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 47.1% of the votes.
The runners-up were:
"I liked it better when you guys just gave us pens."
"Dr. Granzinski's meeting with the head of the hospital."
About ACP HospitalistWeekly
ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. Please forward any comments or suggestions to acphospitalist@acponline.org.
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Copyright 2010 by the American College of Physicians.
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