ACP Hospitalist

After trauma, uninsured patients more apt to die

2009-11-20T08:00:00.001-05:00

Hospitalized trauma patients without insurance are more likely to die than those who are insured, a new study in the Archives of Surgery finds.

Most research has focused on access-to-care as a likely cause of care disparities between the insured and uninsured. By looking at hospitalized patients, however, this study suggests other factors may be at play.

Researchers analyzed records from the National Trauma Data Bank, assessing demographic info, medical history, injury severity, outcomes and charges for 687,091 adult admitted between 2002 and 2006. Patients were divided into five insurance categories: uninsured, a managed care organization, commercial indemnity insurance, Medicare or Medicaid. Overall, the uninsured had the highest death rates after controlling for sex, age, race and severity and type of injury. This held true for young adults (age 18-30 years), too, who were less apt to have co-morbid illnesses.

The study authors speculate that patients without insurance may be at higher risk due to treatment delay, lower health literacy, and receipt of fewer diagnostic tests. "Treatment often is initiated before payer status is recognized; thus, this provokes the question of whether differences exist in processes of care during the hospital stay,” the authors said.

Great American Smokeout is today

2009-11-19T10:22:00.007-05:00

As you may know, today is the Great American Smokeout....a great time to nag those co-workers who congregate outside the hospital and light up. (I don't know about other places, but despite rules that prohibit smoking within a certain distance of hospital entrances, plenty of folks here in Philly still puff away near the doors.)

By the way, look in the January issue of ACP Hospitalist for tips on helping hospitalized patients quit smoking. ACP Internist recently ran an article on smoking cessation tips, as well.

More jobs on the horizon for hospitalists?

2009-11-16T14:55:00.004-05:00

In what seems to be another vote of confidence that the worst of the recession is behind us, most hospital CEOs plan to hire more doctors and nurses in the next six months, a new survey reports.

In the survey of 285 hospital CEOs conducted by healthcare staffing company AMN Healthcare, a majority report a shortage of nurses (91%), pharmacists (86%) and allied healthcare professionals (79%). While 24% of CEOs report cutting back on nurse recruitment in the last six months, the same percentage report they have increased physician recruiting efforts in that time period.

Looking ahead, 93% expect to maintain or increase physician recruiting, while 89% expect to maintain or increase nurse recruiting, in the next six months. Only 11% say they will decrease recruitment of health professionals in the near future.

Medical news of the obvious

2009-11-16T09:00:00.000-05:00

Sadly, we found no news of the obvious for this week. Maybe that's a good thing for medicine, but it means we don't get to highlight one of our favorite features. Send us your ideas and check back every Monday.

Seeing red, or fading to black?

2009-11-13T16:27:00.005-05:00

Are hospitals starting to recover from the recession? Depends on whom you ask.

A report issued this week by Thomson Reuters states that the median profit margin for U.S. hospitals rose to 8.4% in the second quarter of 2009, compared to 0.37% in the third quarter of 2008. The recovery, says a news release, occurred in various settings, from large academic hospitals to small community hospitals.

But the AHA reports that 34% of community hospital CEOs surveyed in August expect losses for the first half of 2009, up from 29% in the first half of 2008. While 11% of those CEOs report an improvement in their hospitals' ability to access capital since December 2008, 31% say their ability to do so is "continuing to get worse" and 58% say it is the same.

Other findings from the Thomson Reuters analysis:

About 20% of hospitals had negative total margins in Q2 09-- similar to the rate seen before the recession started in late 2007. In Q1 09, 30% of hospitals were operating with negative margins. In Q3 08, half of U.S. hospitals were in the red.
Hospitals' median days-cash-on-hand has increased from 90 days in Q1 09 to 146 days in Q2 09, which is higher than the historic long-term average.
Hospitals have maintained a stable ratio of staffing levels per occupied bed during the recession, but total labor costs are down about 2.25% in Q2 09 due to reduced lengths of stay.
Mean patient discharge volumes for all hospitals began declining shortly after the recession started, but moved into positive territory in Q2 09.

Additional findings from the AHA survey of 768 community hospital CEOs:

52% of hospitals see an increased need for subsidized services.
51% have reduced staff in response to economic challenges.
46% report a moderate to significant decrease in operating margins.
39% report a decrease in days-cash-on-hand.
79% of hospitals have had doctors seek an increase in pay for on-call or other service to the hospital.

End-of-Life Hospitalizations: New data

2009-11-12T12:23:00.000-05:00

Septicemia was the major cause of mortality in the hospital in 2007, accounting for 15% of total deaths, according to some cheery new data by the AHRQ.

The other top causes were respiratory failure (8% of deaths), stroke (6% of deaths), pneumonia (5%), heart attack (5%); and congestive heart failure (4%).

More interesting facts, courtesy of AHRQ's analysis of more than 765K in-hospital deaths:

32% of all deaths in the U.S. in 2007 were inpatient hospital deaths.
12% of patients who died had been admitted for elective procedures or other non-urgent reasons; 72% were ED admissions.
The average cost of hospital stays that led to death was $26,035. For those discharged alive, the average cost was $9,447. The cost difference is mainly due to length of stay: 8.8 days for those who died, compared to 4.5 days for those who lived.
67% of patients who died in the hospital were on Medicare; 20% were privately insured; 2% were on Medicaid; 3% were uninsured. Not sure about that other 8%.
A Medicaid patient who died cost $38,939, on average, which is about $15,000 more than a Medicare or uninsured patient, and $10,000 more than a privately insured patient.

The above information comes from the AHRQ report The Costs of End-of-Life Hospitalizations, 2007.

Medical news of the obvious

2009-11-09T09:00:00.000-05:00

Men who get their sleep apnea treated golf better. Twelve golfers with moderate to severe obstructive sleep apnea who started nasal positive airway pressure (NPAP) treatment saw a drop in their mean handicap from 12.4 to 11.0 (P=0.01), compared to 12 controls. The rested duffers said they felt more alert, and NPAP compliance was 85%, said researcher, who added he wants to conduct a larger, multicenter study to explore what drives high treatment compliance. (It must be those really powerful tee shots.)

Ties that bind, and make you gag

2009-11-04T12:30:00.004-05:00

Here's a complex solution to a simple problem. Doctors wear ties, which may carry germs that may add to the problem of health care acquired infections. British hospitals banned ties. In America, we made them germ resistant.

SafetyTies claims to make ties and scarves with a built-in barrier for dirt, liquids and bacteria. The company describes its "nanotechnology" and cites "independent studies" that show 99.95% resistance to H1N1 influenza.

Whether the ties are attractive enough to wear is a matter of opinion, however. Patterns include those of MRSA microbes and other common germs. Do write us or send pictures if you actually buy one of these and wear it to your health care facility.

"In our effort to stop the spread of H1N1, we need every tool at our disposal," said SafeSmart co-founder April Strider in a press release. "While vaccinations and handwashing are obviously the first line of defense, SafetyTies and SafetyScarves are an easy, sensible and fashionable way for individuals to help reduce the spread of H1N1."

Or, doctors can stop wearing them. We've covered this issue before. ACP Hospitalist has a bit more practical advice from our magazine and our weekly e-news about serious efforts to reduce health care acquired infections. And, others have suggested using dedicated stethoscopes in rooms dedicated to treating resistant infections.

UPDATE: Doctors are buying these ties. Some feel a tie conveys respect to the patient and have chosen to adopt their use.

Medical News of the Obvious

2009-11-02T09:27:00.000-05:00

Why are athletes young? Why are couch potatoes out of shape? If questions like these have been plaguing you, not to worry, researchers have the answer.

A new study from the Archives of Internal Medicine finds that "men and women become gradually less fit with age" and that "maintaining a healthy body mass index (BMI), not smoking and being physically active are associated with higher fitness levels throughout adult life."

The study authors also make a pretty dramatic leap from these findings to proposed interventions. “These data indicate the need for physicians to recommend to their patients the necessity to maintain their weight, engage in regular aerobic exercise and abstain from smoking,” they concluded. Call me overly cautious, but I think we should see some data from controlled trials first. Bet there'd be no problem finding volunteers for the eating, sitting around and smoking arm.

It's a party! Bring your own alcohol (gel).

2009-10-30T13:11:00.003-04:00

I learned about a new holiday today at IDSA. The WHO has declared May 5 to be hand-hygiene day. I'd suggest that we all celebrate by washing our hands, but apparently the point is that health care workers should be cleaning their hands all the time--specifically at 5 moments in the patient encounter. (See, 5 moments for the cinco de Mayo.)

This international effort is trying to make hand hygiene "easy, convenient and even sexy," according to Didier Pittet, MD. The project is very country-specific--in some developing countries, they're teaching how to make your own hand gel, while in others the focus is on humorous education to improve compliance. The importance of localizing humor was made clear by a French cartoon of a germ on a couch that Dr. Pittet presented. "Dr. Freud, in this hospital, it's become impossible to cause infections anymore," the germ said. It sure wouldn't win the ACP Internist/Hospitalist cartoon caption contest.

Infectious tidbits

2009-10-30T13:11:00.001-04:00

More hot stuff in infectious disease, this time from Bennett Lorber, MD. Dr. Lorber reviewed an array of recent research yesterday at IDSA. Here's the super-condensed version of his conclusions:

It's pretty clear that acid-suppressive medications are increasing the risk of pneumonia, and thereby causing excess hospital deaths, so they should not be prescribed so broadly. "We need to tell our medicine and hospital colleagues that acid-suppression should be a carefully considered decision," Dr. Lorber told the infectious disease docs.

Prescribing prophylactic antibiotics before catheter removal, on the other hand, is supported by new evidence. A recent trial found a NNT of 6 to prevent symptomatic infection. "We don't like this idea, but it's a pretty good study," Dr. Lorber said.

However, if you're trying to prevent infections after cardiac surgery, there's not enough evidence to justify putting patients on a statin before the procedure. A recent cohort study found that statins weren't associated with reduced post-op infections.

And finally, if you suspect a prosthetic joint infection, tell the lab to hold on to the specimen for at least 2 weeks, because a recent study showed that about a quarter of bacteria grown in cultures didn't show up until after a week had passed.

Get your darn flu shot!

2009-10-29T18:53:00.000-04:00

The press conference I attended today at the Infectious Disease Society of America's annual meeting had a clear message and it was pretty much a more polite version of this post's title.

Researchers presented data showing that flu vaccination of pregnant women (seasonal, not pandemic, by the way) makes their babies less likely to be premature, small or admitted to the hospital for flu early in their lives. So, such vaccinations would solve the problem of not having a vaccination for newborns and achieve the cost-effectiveness of protecting two people with one shot. The scientists expressed hope that their findings would increase the currently "dismal" rates of expectant-mother vaccination. "If they're not doing it for themselves, maybe they'll do it for their babies," said Marietta Vasquez, MD.

I wouldn't count on it, based on the results presented about vaccination attitudes among hospital workers. The one-hospital survey found that plenty of health care workers, and even some physicians, believe that flu vaccines aren't safe and could give you the flu. In addition, many of them were not aware that one can transmit the flu without having symptoms. Depressing.

On the bright side, even though vaccine expert Paul Offit, MD, termed his part of the press conference a "mini-rant," he actually had some positive news to offer. "The pendulum is starting to swing the other way," he said. Concerns from parents of immunocompromised kids and the refusal by some docs to see unvaccinated children, among other factors, are putting the anti-vaccine troops on the defense, he thinks.

Patient uses Twitter as he undergoes appendectomy

2009-10-16T10:46:00.001-04:00

Today, live, patient Marc Needham is tweeting his hospital visit, which he just learned will result in an appendectomy. He's Scripps Health's Corporate Director of Web Technology. Also today, live, Henry Ford Hospital is again using Twitter to "broadcast" a surgery, in this case a kidney transplant. The first surgery was "tweeted" this morning, and the recipient surgery will follow this afternoon.

Measuring retention

2009-10-13T09:57:00.002-04:00

The next issue of ACP Hospitalist will feature a cover story about retaining hospitalists, which cites a national average of 13% turnover. That number comes from SHM surveying. But at a hospitalist roundtable here at the Medical Group Management Association, a woman who said she was involved in crunching the numbers (sorry, didn't catch her name) offered a little more explanation. She said that there are a lot of programs with almost no turnover, and another group with huge turnover, so the overall 13% figure can be a little deceptive. So if your program is nowhere near the average, on either end, you're probably not alone.

Medical News of the Obvious

2009-10-12T09:00:00.000-04:00

Kids are more likely than their peers to become addicted to the Internet if they're depressed, hostile or have attention deficit hyperactivity disorder or a social phobia. On the positive side, they also use it as therapy to overcome their face-to-face limitations or find kids like themselves.

Medical News of the Obvious

2009-10-05T09:00:00.000-04:00

Two of this week's highlights are best described by their headlines: "Study Finds Fish Won't Prevent Heart Failure" and "Eating in America Still Unhealthy: CDC."

It's a little surprising that our third study of the week didn't get such a catchy headline since it's easy to imagine one: Sex Makes People Happy. The intrepid scientists found that "women who are happy with their sex lives have higher well-being scores and more vitality than women who are sexually dissatisfied," according to HealthDay. But that's not all. It also turns out that getting some in itself is not sufficient to make women happy. Rather, some of them are having unsatisfying sex. "Frequency of sexual activity in women cannot be employed as a reliable indicator of sexual well-being," a researcher concluded.

Medical News of the Obvious

2009-09-28T11:57:00.002-04:00

It's time for another medical-education themed journal issue (thanks, JAMA), which means it's time for more Obvious Facts about Med Students:

They say stupid stuff on Facebook.
They make mistakes when they're tired and upset.
Cutting people open makes them nervous.
If they're well-trained, they'll do a better job.

Readers polarized about town hall meetings on health reform

2009-09-25T08:00:00.001-04:00

About half of ACP Internist and ACP Hospitalist readers saw the summer's town hall meeting on health care reform as a failure, according to results of a survey. The reasons why were as polarized as the open-ended responses readers gave.

Some perceived the meetings as a success because they saw the meetings reflect their own points of view on health care, pro or con. Others saw the meetings as failures because of their tenor, or the outcomes of specific events.

The angry rhetoric caused respondents to express concerns not only for health care reform, but for democracy. One said, "They were a success in that people came out to speak; they were a failure in that the democratic process of debate was cast aside for emotional rhetoric."

Some called for more physician and hospital leadership on the issue, and from ACP itself. "Physicians must become leaders in this debate so that Americans get meaningful, full reform that benefits the majority of our citizens."

Some respondents provided eyewitness reports on their own town hall meetings, or in one case, a lack of meeting. Rep. John Tierney (D-Mass.) instead had a telephone conference.

Another reader related opinions from Alaska, where "There were standing ovations opposing 'socialized medicine' and increased taxation. The senator's response to a young uninsured mother's plea to 'What should I do?' for her child with asthma was disappointing. It boiled down to: 'Contact my office, I may be able to get samples from the drug company, and in this country the emergency room will never turn you away.'"

Another reader complemented Rep. Charles A. Gonzalez (D-Texas) on his town hall in San Antonio at the end of August. "The opposition (some brought in on charter buses) was loud and intermittently disruptive. Rep. Gonzalez did an excellent job of explaining HR 3200 and answering questions. If there were any initially neutral persons in attendance, I think they might have had their questions answered."

But the disruptions misinformation prompted many readers to view the meetings as a failure, from either hecklers or from the congress people themselves. Others cited the lack of focus on solutions, as well. "Misinformation, incorrect perceptions and strangely focused ideology ruled the day rather than any real conversation."

Others saw success despite the messy process.

"While many [meetings] were devastated by hecklers and got the bulk of the media coverage, some were successful and educated people and got the issue out there. ... It is rejuvenating to see Americans participating in democracy by discussing issues relevant to the future of our nation."

Another summed up, "They gave the public a chance to express concerns and fears. Whether this helped the legislators is yet to be seen."

Medical News of the Obvious

2009-09-21T09:25:00.000-04:00

This may come as news to those of you who were unsure of the purpose of that black rectangular thing in your living room, but not to the rest of us. Researchers put toddlers and parents in a room either with no TV or one where they could pick a show to watch.

"The study authors found that while the TV was on, parents spent about 20 percent less time talking to their children and were less active, attentive and responsive to their kids, resulting in a decrease in the quality of the interactions," reports HealthDay. Only 20 percent? Clearly this sample didn't include any fathers watching playoff games.

Medical News of the Obvious

2009-09-14T16:00:00.000-04:00

It's like the scientists think if they keep reporting the same evidence, eventually someone will listen. A new study in Archives found that exercise is still good for you. And it's never too late to start. "The benefits associated with physical activity were observed not only in those who maintained an existing level of physical activity, but also in those who began exercising between ages 70 and 85," said the press release. Actually, sounds like a good excuse to wait another couple of decades before starting that workout routine.

Or maybe you can get your exercise in the bedroom. As long as you don't have allergies, that is. A new study, reported by HealthDay, finds that snot is not sexy. According to a study of 350 untreated sufferers of allergic rhinitis, 83% said that their allergies affected their sex lives. Perhaps the most obvious part of the study was the solution offered by researchers: shut the bedroom window.

Patients finding shopping around for medical costs easier online

2009-09-10T14:25:00.003-04:00

Patients looking to save some money on expected medical procedures have taken to comparison shopping and planning ahead for high costs and co-pays. Hospital systems, Web sites and the states are compiling the costs of procedures and posting them online so patients can comparison shop or budget ahead before their procedure or test.

The list of comparison services available is extensive, as are their lists of tests and procedures: maternity, knee replacement, appendectomies, colonoscopies; some systems compare hundreds of providers and services.

Consumers are driving this trend, but so is the Internet. Hospitals see it as one more way of making more informed decisions, while one Web site founder compared it (crassly, I thought) to buying a car, including haggling over prices to get steep discounts.

Medical News of the Obvious

2009-09-08T12:14:00.000-04:00

It seems safe to assume that this week's researchers of the already-known have been to a bar before, given that they're grad students at one of the top-ranked party schools in the country. Perhaps, in fact, their hypothesis was cooked up over a happy hour pitcher or two. Because even they are not denying the obviousness of their undertaking.

"It may seem intuitive that cheaper alcohol can lead to higher intoxication levels and related consequence--such as fighting, drunk driving, sexual victimization, injury, even death--especially among the vulnerable college student population," a study author told HealthDay.

Yes, after intensive study (read: hanging out in bars) the researchers concluded that higher drink prices were associated with a decreased risk of patrons being inebriated. Might this also correlate with the lower incidence of vomiting on the floor seen in four-star restaurants as compared to college bars? Further research is clearly needed.

Hospital tweets updates to surgical patient's waiting family

2009-09-03T08:00:00.002-04:00

St. Luke's Hospital in Cedar Rapids, Iowa, used Twitter to keep family members aprised of a surgical patient's status during her hysterectomy and uterine prolapse operation.

St. Luke's is following the lead of other hospitals that have used Twitter during a surgery to educate and inform the family or the general public. A member of the hospital's PR department sent 310 tweets during the surgery to the family--and to anyone subscribed to its feed. St. Luke's also posted pictures intraoperatively.

St. Luke's also uses the web to post wait times for its urgent care clinics and ER.

And while we're on the subject, our readers can follow ACP Hospitalist on Twitter as well.

Patients just as likely to sue after apologies

2009-09-02T10:57:00.001-04:00

Apologizing for a medical error in full and accepting responsibility may boost patients' perceptions of physicians but may not stop them from suing, according to simulations conducted at Johns Hopkins and reported in the Sept. 1 issue of the Journal of General Internal Medicine.

Researchers created simulated scenarios of three medical mistakes: a year-long delay in noticing a malignant-looking lesion on a mammogram, a chemotherapy overdose 10 times the intended amount and a slow response to pages by a pediatric surgeon for a patient who eventually codes and is rushed to emergency surgery. Actors played out levels of physician apology (full, non-specific and none) and acceptance of responsibility (full or none). 200 adult viewers then evaluated the simulations and reported their impressions. Sample videos used in this study are online.

Viewers who thought that the doctor had fully apologized and taken responsibility gave the doctors much higher ratings (81% vs. 38%; P<0.05) and would refer the doctor (56% vs. 27%; P<0.05), but weren't significantly moved not to sue (43% vs. 47%).

What's not reported in this study was whether the doctor could avoid being named in the eventual lawsuit. ACP's news magazines have reported in the past on ways to apologize and how it affects malpractice litigation.

Pinpointing the transition from human to doctor

2009-08-26T18:00:00.000-04:00

"When they embark on the journey to become physicians, most students are enthusiastic, filled with idealism and a genuine intention to serve those in need of help," says a new study in Academic Medicine. What happens to them, you wonder? The study authors did too, so they set out to analyze the loss of empathy in a group of medical students.

Turns out empathy takes a big hit during the third year of medical school, when the students start really interacting with patients. And no, it's not just because real patients are more obnoxious and difficult than hypotheticals. Researchers attribute the problem to a number of factors, including a lack of role models, too much to learn, lack of sleep, technology and a focus on the science of medicine. The article suggests several methods for teaching empathy to med students (including keeping them away from the really obnoxious patients) and calls on medical educators to take action.

"Most of us in medical education advocate empathy, but the effect of simply advocating empathy without embracing it and living with it, and without implementing targeted programs to enhance it, is analogous to singing a lovely song only in one's own mind without others ever enjoying it!"