QD: News Every Day--dry, boring health care reform? Think again.

ACP Internist's daily digest of news and events continues with how health care reform issues play out in real life, how the next generation of doctors view primary care careers, and how hospitalists are changing primary care.

Health care reform
Health care reform debates might at times seem esoteric, appealing only to economists and actuaries. For political wonks, the issue is about balancing what's possible vs. what's achievable. But the impact of reform plays out in real life and upon real lives, as profiles in Maine show. There, the need for health care reform has never been more acute. (New York Times, CBS News)

H1N1 influenza
Just in time for Christmas: flu vaccines. Drugmaker Sanofi-Aventis expects to ship 75 million doses to the U.S. market by late December, their CEO told reporters. (Reuters)

If a smartphone made its way onto your holiday gift list, an app in development could diagnose colds and flus by how the user sounds when coughing into it. (Daily Telegraph)

Primary care shortage
An internal medicine resident in San Francisco relates his eyewitness accounts of how a lack of primary care plays out in multiple care settings. A University of Alaska Anchorage student chooses to answer the call. (Los Angeles Times, The Northern Light)

Hospital medicine
Winneshiek Medical Center finished its first year with a hospitalist program. The results:
--$72,000 profit,
--decreased emergency room transfers to other facilities of 15%,
--decreased patient length of stays and an increase in observation stays by 65%,
--steady patient satisfaction of 88%, with better discharge timing,
--happier inpatient nurses, and
--approval from primary care doctors and emergency room staff.

But hospitalists aren't universally appreciated. Marcy Zwelling-Aamot, ACP Member in Los Angeles, calls them a "substitute" brought in when patients most need their existing primary care doctor. Her editorial decries all the barriers that create a wall between patients and doctors. (Decorah Newspapers of Winneshiek County, Iowa, Press-Telegram of Long Beach, Calif.)

In case you missed it ...
Do we need health care reform or health insurance reform? More than health care politics, doctors are fed up with insurance companies--paperwork, arguing on the phone, fights for what patients need. Some say they'd take pay cuts if there was a model that let them practice medical care differently. In Connecticut, internists discuss the issue in terms of health insurance reform, not health care reform. (Philadelphia Inquirer, Greenwich Time)

An Indiana health clinic is letting those who can't afford care pay for treatments by volunteering elsewhere in the community. (NPR)

Labels: H1N1, health care reform, health insurance, hospital medicine, primary care shortage, QD

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posted by Ryan DuBosar at 10:28 AM   0 Comments

QD: News Every Day--health reform ready to reconcile

ACP Internist's daily digest of news and events continues with updates from the weekend's passage of health reform in the U.S. House, a global look at H1N1 influenza, and a look at a local hospitals attempt to make a profit by hiring an internist.

Health care reform
Health care passed in the U.S. House over the weekend, and now pressure is on to reconcile it all in the Senate and with the White House. (Kaiser Health News, New York Times, Los Angeles Times)

H1N1 influenza
It hasn't been just H1N1 influenza vaccines in short supply. Hand sanitizers are also evaporating in the face of increased demand. One manufacturer is running its plants around the clock with increased workers, and has asked customers not to stockpile. (CNN)

Globally, an Amazon tribe faces hundreds of infected members and possibly seven deaths from H1N1. Meanwhile, Saudi Arabia's health minister received the H1N1 vaccination on television to calm fears and encourage vaccination among those participating in the Hajj, the once-a-lifetime pilgrimage required of Muslims. (BBC, CNN International)

New Scientist examines H1N1's impact throughout history.

Smoking cessation
America's new "anti-smoking czar" lays out his goals as head of the FDA's new agency, the Center for Tobacco Products: reduce youth smoking rates, reduce tobacco-related disease, and inform the public about tobacco products' ingredients. (Courier-Journal, Louisville, Ky.)

In case you missed it ...
Unicoi County Memorial Hospital in Tennessee was losing money. The hospital's auditor helpfully suggested, "We'd always like to see the hospital have an income." So board members hired an internist and a surgeon to join the staff. Read about their gamble to break even. (The Erwin Record)

Labels: H1N1, health care reform, hospital medicine, QD, smoking cessation

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posted by Ryan DuBosar at 12:34 PM   1 Comments

QD: News Every Day--health care reform splits urban, rural hospitals

ACP Internist's daily digest of news and events continues with the focus of health care reform shifting toward the U.S. House of Representatives. Also, urban and rural hospitals eye each other for the lion's share of reimbursement.

Health care reform
Legislation released in the House faces opposition from abortion and immigration. The $1.2 trillion price tag over 10 years made many take a second look at what Americans would get for their money. Meanwhile, the deadline for potentially passing legislation is slipping into next year. (AP, Politico)

Rural and urban hospitals would fare differently under health care reform. For example, New York City facilities are worried about losing money to Iowa; Iowa, in turn, is already worried about subsidizing urban areas. (New York Times, WQAD.com)

H1N1 influenza
Pregnant women and children ages 10-17 need only one dose to inoculate against H1N1 influenza. But children ages 6 months to nine years still need two doses for best efficacy. Anne Schuchat, FACP, reports that half of all vaccinations have gone to minors. While the World Health Organization is recommending one dose for all kids and the use of adjuvanted vaccines to stretch supplies, U.S. officials are still recommending two doses. Adjuvanted doses have not been cleared for use in the U.S. Research on them was reported in the Sept. 15 ACP InternistWeekly. (Washington Post, Washington Times, New York Times)

Scientists have used a supercomputer to predict a third wave of H1N1 coming this spring. But others want to use handheld devices to predict which individuals might get sick before they actually do. (Wall Street Journal)

Labels: flu, H1N1, health care reform, hospital medicine, QD

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posted by Ryan DuBosar at 1:28 PM   0 Comments

QD: News Every Day--public option in da House!

ACP Internist's daily digest of news and events covers how health care reform is being reconciled in Congress, how the primary care shortage impacts local emergency rooms, and how community doctors in Bermuda are reacting to the introduction of hospitalists.

Health care reform
While the Senate stares down a threatened filibuster of legislation that includes a public option, the House introduced its version, which includes it. As the House and Senate reconcile their respective bills into one per each chamber,
Cecil B. Wilson, MACP, who is also the American Medical Association's president-elect, told Floridians at a union-sponsored rally that the majority of Americans, including physicians and AMA members, want reform. (Washington Post, Miami Herald)

Primary care shortage
A column in The Olympian (Olympia, Wash.) points out that the community already has universal health care. Unfortunately, it's the local emergency room. In Palm Beach, Fla., county commissioners are considering whether to build a public hospital for just that purpose. Jose Arrascue, ACP Member, representing the Palm Beach County Medical Society, told commissioners, "We believe the health care delivery system in Palm Beach County is in critical condition. We have escalating numbers of uninsured, diminished access to care, an aging physician population and a lack of specialty care." (Palm Beach Post)

University of Pennsylvania bioethicist Arthur Caplan told an audience in Bakersfield, Calif., that one way to alleviate the primary care shortage is to forgive medical school loans. (Bakersfield.com)

H1N1 influenza
Now, there's an app for that. Harvard Medical School has launched an iPhone application that includes information on the pandemic's spread, practical steps people can take to mitigate their risk of infection, key symptoms to watch for, and what to do in case of infection. The application includes text, video and links to government databases. It also provides information to businesses for managing through the pandemic. People need all the help they can get. Richard Wenzel, MACP, reports that half of all outpatient H1N1 influenza cases don't develop a fever, so the patients don't take precautions. Even among hospitalized patients, 15% don't get a fever. (Minnesota Public Radio)

In case you missed it ...
Family doctors claim that the switch to hospitalists has shut them out of their community hospital ... in Bermuda. The chief of staff at King Edward VII Memorial Hospital feared being hanged in effigy outside his office after general practitioners lost their hospital privileges and communication suffered between community and hospital doctors. But, the chief said outcomes have improved and the move is needed as his facility moves from being a rural provider to a modern metropolitan facility. (Bermuda Sun)

Labels: flu, H1N1, health care reform, hospital medicine, primary care shortage, QD

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posted by Ryan DuBosar at 11:46 AM   0 Comments

Primary Care "Provider"

I am ashamed to admit that I actually felt annoyed tonight over being referred to as a "primary care provider." It is hard to explain that after 21 years of education and another 23 years of practice as a specialist in Internal Medicine, I would be bothered by this.

One of my patients that I have cared for for 20 years was admitted to the hospital after going to the ER with abdominal pain. I was not informed of his admission and the hospitalist became the attending physician. The patient called me today from his hospital bed to inform me. He actually had a previously scheduled appointment with me in the office today and, good patient that he is, was calling to say he couldn't make it. He assumed I already knew he was admitted to the hospital. I asked him to have the attending doctor call me as soon as he/she made rounds.

I got the call from a young-sounding hospitalist who did not know my name and wondered if I was the "primary care provider." When I replied that I was his physician, she then said, "Oh, I don't usually call the primary care provider." That phrase just stopped me cold. It is so "insurance" sounding. So contrived and replaceable. Primary care provider ... delivery man ... vacuum cleaner salesman ... Roto-Rooter man. It's the doctor you can dismiss if you are a hospitalist, one or two years out of training.

"I don't usually call the primary care provider."

Guess I better get thicker skin.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Labels: hospital medicine, primary care

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posted by Toni Brayer MD at 4:37 PM   16 Comments

Nurse shortage turns into a glut

For years we have heard there is a shortage of nurses and as recently as today, the California Senate Education Committee approved a bill (AB867) to "address a severe nursing shortage in California." The Health Resources and Services Administration (HRSA) projects that 90% more RNs must be produced in order to meet the predicted need for one million new nurses in the American health care system by 2020.

So if there is such a shortage ... why can't new nurse graduates find a position? I was pleased to pass on the name of a new RN school graduate who had great references from previous allied health care work and was told by the hospital:

"Virtually no one is doing a new grad training program at this time. We have made the commitment to "trickle in" some new grads this fall and received over 1,000 applications for five positions. I might suggest this individual get their foot in the door as a nurse's aide, phlebotomist or some other non-nursing job. Unfortunately, the economy has turned our profound nursing shortage into a glut, virtually overnight."

Upon investigation I find that there is actually an overabundance of nurses in Canada, the Philippines as well as across the United States. There may be openings for experienced critical care nurses, but medical-surgical nurses are pounding the pavement looking for work and finding few or no jobs available. There are hundreds of nurses vying for every opening. The jobs just aren't there.

The downturn in the economy means more older nurses are keeping their jobs and delaying retirement. Hospital census is down and staffing is lean. Is that enough to turn a shortage into a glut? Apparently it is, or the prior predictions just weren't true.

Experts are still saying there will be a shortage after the recession is over that will only get worse in coming years. But for now, it looks like nurses are not in demand and there are thousands of unemployed RNs looking for work.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Labels: hospital medicine, Workplace issues

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posted by Toni Brayer MD at 1:26 AM   2 Comments

Best care doesn't always get best ratings, doc finds

Medicare's Hospital Compare Web site attempts to help the public compare hospitals based on quality of care, but it can also make good doctors look bad, WhiteCoat blogs.

Case in point #1: Docs are required by offical quality indicators to give thrombolytics within 30 minutes of a heart attack patient's arrival. But what if that patient also just suffered a significant head injury? Does the doc try to meet the 30-minute window by skipping the CT scan, thus risking the patient's life if there is internal bleeding? Of course not, says WhiteCoat, but according to Hospital Compare, "my decision made me a bad doctor."

Don't trust everything you read on the comparison site, WhiteCoat concludes.
But how do patients separate the wheat from the chafe?

Labels: hospital medicine, quality reporting

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posted by Janet Colwell at 1:02 PM   0 Comments

Not for the squeamish

We profiled the new field of NOTES (natural orifice transluminal endoscopic surgery) in ACP Hospitalist a while back. Diseased gallbladders, kidneys and the like were being taken out through mouths, vaginas and other pre-existing holes in the body. Now surgeons at Johns Hopkins have made a great leap forward, removing a kidney from a donor through her vagina and implanting it in her niece. How'd it go? "Easier than childbirth," the donor told the Washington Post. Reportedly, the next expected advance in the field will be to remove usable organs through the rectum. We don't want to know what donors will compare that experience to.

Labels: hospital medicine, surgery

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posted by Stacey Butterfield at 11:00 AM   0 Comments

Where no one knows your name

Do your patients know your name? According to a new Archives study of inpatients at an academic center, probably not. When researchers asked hospital patients to name one of the physicians caring for them, 75% couldn't come up with anything. Of the 700 who had an answer, only 40% got at least one name (out of the attendings, hospitalists, interns and residents caring for them) correct.

Study authors suggested hanging photos of treating physicians in patient rooms to remedy the problem, or having everyone wear more obvious explanatory nametags. They don't discuss the aesthetic downsides of these solutions. After all, if patients don't even bother to learn your name, how likely is that they want to lie in bed staring at your face all day?

Perhaps supporting this argument, the study also found that patients who could name a physician were most likely to be dissatisfied with their care. If they're only learning your name so they can complain, maybe you'd be better off stuffing that nametag in your pocket.

Labels: hospital medicine

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posted by Stacey Butterfield at 12:28 PM   1 Comments

More surgical procedures occurring outside of hospitals

More and more surgical procedures are being performed in freestanding ambulatory centers as opposed to hospitals, according to the recently released 2006 National Survey of Ambulatory Surgery by the CDC's National Center for Health Statistics. The rate of visits to freestanding ambulatory surgery centers increased by 300% between 1996 and 2006, while at the same time the rate of visits to hospitals remained virtually unchanged.

Other notable findings from the survey include:

• Females had significantly more ambulatory surgery visits
  than men.
• Although the majority of visits had only one (56.3%) or two (28.5%) procedures performed, 2.6% had five or more procedures performed.
• Frequently performed procedures on ambulatory patients included endoscopy of large intestine, endoscopy of the small intestine, extraction of lens, injection of agent into spinal canal, and insertion of prosthetic lens.

There are many more interesting statistics in the CDC's Winter Quarterly Fact Sheet, which focuses on heart disease.

Labels: heart disease, hospital medicine, statistics, surgery

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posted by Janet Colwell at 8:46 AM   0 Comments

Work areas can be breeding ground for C-diff

A study in the February issue of the American Journal of Infection control found that the surfaces in hospital rooms are often contaminated with spores, even outside of Clostridium difficile infection isolation rooms. Of the 105 non-isolation rooms studied, researchers discovered that 17 (16%) were contaminated with toxin-producing C-diff.

The study also looked at surfaces in hospital work areas and equipment such as oximetry devices and electrocardiogram machines. They found that 23% were contaminated, including 31% in physician work areas, 10% in nurse work areas, and 21% on portable pieces of equipment.

Commenting on his blog, Kevin MD said the study reinforces the importance of old-fashioned soap-and-water handwashing. "Alcohol-based sanitizers aren't effective in killing the spores."

Labels: c-difficile, hospital medicine, infectious disease

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posted by Janet Colwell at 9:47 AM   0 Comments