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ACP HospitalistWeekly

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In the News for the Week of 6-8-11

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Highlights

IOM report: Geographic adjustment methods for Medicare payments need revisions

The methods for calculating geographic adjustments of Medicare payments to hospitals and private practice health professionals need revisions, which will increase or reduce payment amounts to many facilities, a new Institute of Medicine (IOM) report suggests. More...

Clinical decision rules for PE equally accurate

Four clinical decision rules for diagnosing pulmonary embolism (PE) perform similarly when combined with D-dimer testing. More...

Community-acquired pneumonia

Dexamethasone with antibiotics shortens hospital stay for CAP patients

Adding dexamethasone to antibiotic treatment reduced the length of stay by one day for inpatients with community-acquired pneumonia (CAP), a study found. More...

Delirium

Guidelines for preventing delirium offered by U.K. experts

Guidelines for preventing delirium in inpatients have been developed by the British National Clinical Guideline Centre, and a synopsis of them was published in the June 7 Annals of Internal Medicine. More...

From ACP Hospitalist

Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our fourth annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2011, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, leadership, mentorship or quality improvement. More...

Cartoon caption contest

Vote for your favorite caption

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner. More...

Physician editor: A. Scott Keller, FACP

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Highlights

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IOM report: Geographic adjustment methods for Medicare payments need revisions

The methods for calculating geographic adjustments of Medicare payments to hospitals and private practice health professionals need revisions, which will increase or reduce payment amounts to many facilities, a new Institute of Medicine (IOM) report suggests.

The rationale for adjusting payments based on regional variations in wages, rents and other costs is solid, but nearly 40% of hospitals have gotten exceptions to how these adjustments are calculated. This suggests an overall change is needed in the data used and the way adjustments are calculated, the report said.

For one, the Centers for Medicare and Medicaid Services (CMS) should use data from the Bureau of Labor Statistics to develop indexes for calculating wage adjustments, as these are "more accurate, independent and appropriate…than the hospital cost reports, physician surveys, census data, and other information currently used," an IOM press release said. Doing so will require Congress to revise a section of the Social Security Act, it said.

Other recommended changes in data sources include using:

• median wage data for all kinds of workers in the health care workforce to calculate payments, rather than basing wage differences only on data for registered nurses, licensed practical nurses, health technicians and administrative staff;
• metropolitan statistical areas (MSAs) to uniformly adjust payments based on the labor market in which a hospital or practitioner operates. Currently, different market data are used for hospitals and for practitioners in the same labor market; and
• commercial rent information to assess variation in the price of office space, instead of the current practice of using information on median subsidized rents for a two-bedroom apartment.

Since federal law requires that geographic adjustments be budget-neutral, any increase in the amount paid to one hospital or practitioner must be offset by a decrease to others. A supplemental report that provides greater detail about physician payment will be issued later this summer, the release said. The current report is one of three to address geographic adjustment. The next one, expected in April 2012, will address the impact of such adjustment on workforce distribution in rural and urban areas, and will consider the physician work adjustment in the larger context of fee-for-service clinical practice, the report said.

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Clinical decision rules for PE equally accurate

Four clinical decision rules for diagnosing pulmonary embolism (PE) perform similarly when combined with D-dimer testing.

Researchers compared the performance of the Wells rule, the simplified Wells rule, the revised Geneva score and the simplified revised Geneva score in about 800 consecutive patients seen at hospitals in the Netherlands for suspected acute PE. A computer program calculated the probability that each patient had PE using all four rules. D-dimer tests were also performed and the combined results of the rules and the D-dimer tests were used to determine whether patients should get a CT scan and treatment for PE.

Overall prevalence of PE among the patients was 23%, according to CT testing and three-month follow-up. The four rules offered concordant results in 70% of patients. PE was ruled out by the combination of concordant results on the tests and a normal D-dimer in 21% of patients. In the other 79% of patients, CT scanning was indicated either because at least one of the rules indicated that PE was likely (373 patients) or because the D-dimer was abnormal (265 patients). PE was not detected in any of the patients who had discordant results from the rules but a normal D-dimer.

The study also found that, when combined with a normal D-dimer, the four rules excluded PE in similar proportions of patients, ranging from 22% to 24%. The rates of failure (venous thromboembolism within three-month follow-up) did not differ among the different rule and D-dimer combinations. Researchers concluded that all of the rules showed equivalent performance, including the recently introduced simplified versions. This finding is significant because the simplified rules enable easier computation of scores during daily clinical care, the study authors noted. Physicians should choose which rule to use based on preference and acquaintance, they advised.

The study's results may be applicable in a wide range of clinical settings, but, the researchers cautioned, the study was not able to definitively validate the rules for use in excluding PE in inpatients. Only 20% of the studied patients were already admitted to the hospital when PE was suspected. The study also differed from typical clinical practice in that management decisions were based on the results of all four rules, instead of just one, combined with D-dimer. The study appeared in the June 7 Annals of Internal Medicine.

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Community-acquired pneumonia

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Dexamethasone with antibiotics shortens hospital stay for CAP patients

Adding dexamethasone to antibiotic treatment reduced the length of stay by one day for inpatients with community-acquired pneumonia (CAP), a study found.

In a double-blind trial, Dutch researchers randomly assigned 304 adults with confirmed CAP at two hospitals to receive a daily intravenous bolus of 5 mg (1 mL) of dexamethasone or 1 mL of sterile water (placebo) for four days from admission. Patients were excluded if they were immunocompromised, needed immediate transfer to the ICU, or were already receiving corticosteroids or other immunosuppressive drugs. All patients received antibiotics before study treatment was given. Selection, duration and administration of the antibiotics were decided by the medical team and were based on national guidelines. The primary endpoint was length of stay until hospital discharge or death. Results were published online June 1 in The Lancet.

Median length of stay in the dexamethasone group was 6.5 days compared to 7.5 days in the placebo group (13% reduction; P=0.0480). Hospital mortality and rates of admission to ICUs didn't differ between groups. Hyperglycemia was more common in the dexamethasone group compared to the control group (44% vs. 23%, P<0.0001), but only 5% of patients in the former group and 3% in the latter needed additional glucose-lowering treatment during their stay. Thirty-eight patients didn't complete the treatment course because they were admitted to the ICU, had protocol violations or died. Antibiotic treatment was similar in both groups. In a secondary analysis, patients in the dexamethasone group had better quality of life than those in the control group in terms of social functioning by day 30 after hospital admission. Serious adverse events were rare, though one patient in the dexamethasone group developed a gastric perforation on day three that the authors said could be attributed to use of the drug.

Pneumonia severity index risk classes 4 and 5 were more common in the treatment group, an imbalance that may have led to underestimating the effect of dexamethasone, since a higher risk class usually leads to a longer length of stay, the authors noted. The study is limited in that results can't be generalized to all CAP patients; for example, chronic obstructive pulmonary disease (COPD) patients were underrepresented since they usually need treatment with systemic corticosteroids (which was an exclusion for study participation). Eleven percent of enrolled patients had COPD compared to 21% in the screened population. Also, guidelines for antibiotic treatment in the Netherlands differ from the U.S. In the former, amoxicillin is standard therapy for CAP of severity risk 1 and 2, and is combined with a fluoroquinolone or macrolide antibiotics for higher severity patients, the authors noted. The apparent benefit of dexamethasone seen in this study should be weighed against potential disadvantages of this drug class, such as gastric disturbances and superinfections, they concluded.

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Delirium

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Guidelines for preventing delirium offered by U.K. experts

Guidelines for preventing delirium in inpatients have been developed by the British National Clinical Guideline Centre, and a synopsis of them was published in the June 7 Annals of Internal Medicine.

The synopsis describes guidelines developed by a multidisciplinary group under the methodology of the National Institute for Health and Clinical Excellence (NICE) and includes 13 specific recommendations for preventing delirium. The full guidelines, which were published in July 2010, also address diagnosis and management of delirium.

The prevention recommendations call for at-risk patients to be treated by a trained multidisciplinary team familiar with the patient. The team should provide a tailored multi-component intervention to help the patient avoid dehydration, constipation, hypoxia, infection and immobility. Clinicians should also assess patients for pain, perform medication reviews, provide nutrition support when appropriate and not disturb patients' sleep. Sensory impairment should also be addressed by resolving any reversible causes and making visual and hearing aids available to patients who need them.

The guidelines also recommend that clinicians address cognitive impairment or disorientation by providing appropriate lighting and clear signage, including a visible clock and calendar, and communicating with the patient—reorienting him or her when necessary, introducing cognitively stimulating activities, and facilitating visits from family and friends. The components of the intervention may not seem challenging, the synopsis authors noted, but the real challenge is to "do all of these things all the time to all of the patients who are risk," they said.

An accompanying editorial explained that the synopsis was published in Annals of Internal Medicine as the start of a new effort to publish "thoughtful synopses of guidelines initially released in other venues but whose topics are highly relevant to the practice of internal medicine and its subspecialties."

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From ACP Hospitalist

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Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our fourth annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2011, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, leadership, mentorship or quality improvement.

Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 18, 2011, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2011 issue.

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Cartoon caption contest

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Vote for your favorite caption

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner.

"I wanted to evaluate your prostate, not evaluate you prostrate."

"I believe in a patient-centered medical home, but you don't need to do the floors."

"In an orthopod's office, you can hide, but you can't run."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, June 13, with the winner announced in the June 15 issue.

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