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Tag Archives: CMS

Choosing a Doctor

The December 29th edition of American Medical News has an article about how patients choose physicians. For primary care physicians, more than half of patients choose their doctor by word of mouth and another third choose their doctor based upon a referral from a health plan or from another health professional. With specialists, a vast majority of patients choose them based upon a referral from the primary care doctor or another physician. Almost 90% of the time a hospital is chosen based upon where a patient’s physician has privileges or based upon the recommendation of another physician. Friends and co-workers often ask me where they should go for treatment. One of the interesting things about this survey – which was a national survey of more than 13,500 adults – was that very few patients chose physicians based upon internet sites and only a little more than 4% of patients chose hospitals based upon either the internet or upon “books, magazines, or newspapers.” The Cliff Note’s version is as follows: 1. If you are a primary care physician, be nice to your patients and take good care of them. Not only will they stay your patients, but they will help you build your practice. 2. If you are a specialist, be nice to the primary care physicians. They account for more than two thirds of your business. 3. If you are a hospital administrator, see #1 above. Invest in your patients and your docs and the rest will follow. Oh, and all that advertising isn’t doing much to gain you market share. Likewise, no one is paying much attention to that comparison bullhokey at www.hospitalcompare.whatever.com. Stop worrying so much about “quality indicators” that have no basis in science and start worrying more about being good to your patients and your staff physicians. Word of mouth will get you a lot farther than that ad in the paper.

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Sticking Blood Cultures and "HospitalCompare"

Nice study in the Journal of Emergency Medicine by Shapiro et al. showing that many of the blood cultures performed in the emergency department are low-yield. At one institution the study was able to decrease the number of blood cultures by 27% and therefore decrease the health costs by nearly $125,000. At this single study institution’s emergency department, there were 3901 blood cultures drawn over a 1-year period. The study analyzed patient characteristics and determined which patient characteristics were associated with a greater likelihood of bacteremia or “bloodstream infections.” The symptoms more likely to be associated with bacteremia were divided into “major” and “minor” criteria. Major criteria included temperature > 39.5°C (103.0°F), indwelling vascular catheter, or clinical suspicion of endocarditis. Minor criteria included temperature 38.3-39.4°C (101-102.9°F), age > 65 years, chills, vomiting, hypotension (systolic blood pressure < 90 mm Hg), neutrophil% > 80, white blood cell count > 18 k, bands > 5%, platelets < 150 k, and creatinine > 2.0. If a patient has either one major criterion or two minor criteria, then blood cultures were indicated. Otherwise, patients were considered “low risk” and did not need blood cultures. Using study criteria, the researchers were able to reduce the number of blood cultures by 27%, resulting in  approximately 1053 fewer cultures per year. At an estimated cost of $15.91 per culture and a charge of $118 per culture set, there was a potential savings of $16,758 in costs and $124,286 in charges at ONE HOSPITAL. In addition to preventing low yield blood cultures, the study also noted additional cost savings. Nearly 5% of patients in the study had false positive cultures, meaning that the cultures grew out an organism when there really wasn’t an organism present. In other words, the samples were accidentally contaminated. The study cited another study showing that patients with contaminated blood cultures have a hospital stay that is an average of 4.5 days longer and costs an average of $4385 more. Contamination is one of those problems that it is difficult to guard against. Skin is cleansed with iodine and alcohol, but you can’t eradicate every single organism on the skin that could contaminate the needle. The more cultures you draw, statistically speaking, the more contaminated specimens you are going to get. This study enrolled 3730 patients. Out of those 3730, only about 8% had true bacteremia and more than half that many – almost 5% – had false positives. Using the study criteria, the researchers were able to identify more than 99% of patients who had positive bloodstream infections. Only 3 of the 3730 patients studied had infections in the blood that were not caught by using these criteria. Yet, the government requires that we draw blood cultures before starting antibiotics on every patient that might have pneumonia. I previously commented about how the CMS “Hospital Compare” website is a bunch of hooey. It doesn’t allow people to compare government hospitals with all the other hospitals. It purports to show which hospitals meet “quality” measures by performing certain tasks in a timely manner, yet many of the indicators it uses have little scientific basis. The whole blood culture requirement is just one of the site’s many big failures. Performing blood cultures before giving antibiotics in pneumonia patients has absolutely no effect on clinical outcome. False positive cultures increase the length of stay by 4.5 days and increase the cost of hospitalization by nearly $5000. Now researchers have come up with a way to decrease the number of blood cultures performed in the emergency department by 27%. Yet, the Department of Health and Human Services ...

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Clostridium difficile Not A Medical Error?

According to this article in American Medical News, researchers at McGill University in Montreal discovered that less than half of 836 patients with Clostridium difficile infections had been exposed to antibiotics in the 45 days prior to their hospitalizations. The study is in CMAJ, but the link isn’t working at the time of this post. The study also showed that, just like MRSA, the rate of community-acquired Clostridium difficile is rising. The rate per 100,000 person-years among people 65 and older in Quebec rose from 0.5 in 1997 to 57.2 in 2004. If Clostridium difficile infections occur more than half the time without any preceding antibiotic therapy, what exactly is the “error” that needs to be corrected to cease the occurrence of this “never event”? “Never events” aren’t about patient safety. Never events aren’t about evidence-based medicine. Never events are all about the Benjamins. The joke’s on CMS, though. Now we’re going to spend so much money testing hospitalized patients for “C. diff” that the money CMS saves by not paying for the few positive instances of this “never event” will pale in comparison. Addendum The link to the CMAJ article is here. Commentary about the article is here. Factiods from these two articles include: C. difficile can be “cultured from the stool of 3% of healthy adults and up to 80% of healthy newborns and infants.” Is the birth of a health child with C. difficile in its colon the next “never event”? Will all healthy newborns be given Flagyl and Vancomycin to eradicate these organisms? Admitted patients may have C. difficile, but will not all have symptoms of C. difficile-associated diarrhea during their hospital stay. In other words, people might have C. diff prior to admission, but might not develop symptoms until after they’re hospitalized. Hospital gets dinged for an “error” that wasn’t its fault. In addition to antibiotic use, C. difficile is also associated with use of a proton pump inhibitor, presence of inflammatory bowel disease, presence of irritable bowel syndrome, and presence of renal failure. What are we going to do with people who take Prilosec and have Crohn’s disease? Refuse to admit them to avoid the “never event”?

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Yet Another Patient Dies Waiting For Emergency Care

Michael Herrera, who founded many Tex-Mex restaurants across North Texas, went to the Parkland Hospital emergency department after a golf game. He was having severe stomach pains. Unfortunately for Mr. Herrera, 270 other people also checked into the Parkland Hospital emergency department that day. Mr. Herrera waited 19 hours for care and still had not seen a doctor when he went into a cardiac arrest and died. Mr. Herrera was uninsured and Parkland Hospital is reportedly the only hospital in the Dallas area to provide care for patients without insurance (I do not know this to be a fact, but am stating this due to several comments in the comment sections of the articles below). Here are some other articles about the story from Dallas News, Pegasus News, Fort Worth Star Telegram, and WFAA.com from Dallas/Fort Worth. Still think funding for emergency care is unimportant? Still think socialized medicine and “free” care is the way to go? We’re going to see more and more people die waiting for care until our lawmakers increase funding for emergency care and create a system that provides adequate reimbursement to medical providers while protecting everyone from jackpot justice. More ED patients, less available EDs, more medical providers getting fed up with practicing emergency medicine. Hospitals trying to stay afloat by limiting care to indigent patients. First it’s Beatrice Vance Then it’s Esmin Green Just today, Kevin MD linked to another story about Brian Sinclair who died in Winnipeg after waiting 34 hours to be seen in a Canadian emergency department. See another version of the story here. Now Michael Herrera is dead. Think about this question when you enter the voting booths this November: How many people have to die waiting for medical treatment before our elected leaders address funding for medical care? We’re getting what we pay for. It is sad that some people are getting it sooner than others. Boy am I glad I’m a doctor. Picture credit here UPDATE SEPTEMBER 30, 2008 An autopsy showed that Mr. Herrera died from complications due to diabetes, heart disease, and morbid obesity. “I would suspect that with his presentation, he would have been attended to and sent home,” said Dr. Ron Anderson, president and chief executive officer of the Parkland Health and Hospital System.

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Pay Up Or Else

I was going to take the day off from blogging today, but Sam had an interesting comment that made me want to start writing. Even as I type this, I’m not sure how I feel about the whole situation. If you read through Sam’s blog, he has had a lot of things happen in his life that he didn’t deserve. The latest problems seems to have been a sudden medical event that caused him a significant amount of medical debt. Now he is in the process of filing bankruptcy because he did not have health insurance. Despite all this, with help from God, he has persevered and seems to have a close loving relationship with his kids. His case reminds me of another blogger, Steph, who I wrote about back in February. She, too had a tremendous amount of medical debt and was trying to climb out of her “debt hole.” Unfortunately it looks like she has fallen upon harder times as well. The plight of these bloggers is not uncommon. Hospitals seem more and more willing to sue for medical debts. Should hospitals be able to force people into bankruptcy for the medical services that they provide? A hospital is a business. Without money, the business goes bankrupt. If you walk into a lawyer’s office, many times you’ll need a retainer or the lawyer won’t take your case. If the retainer runs out and you don’t pay, then the lawyer stops providing services. If you walk into a supermarket, fill up your basket, and leave without paying, you’ll be arrested for theft. Stop paying the guy to cut your lawn and you’ll have to do it yourself. Why do people expect that medical care should be free if they don’t have any money? Part of the answer to that question appears to be the sentiment that some people get medical care for free, so therefore I should get medical care for free. No one walks into the supermarket and walks out without paying for their groceries, so the general public does not expect that they should be able to do the same. People don’t regularly get free services from their accountants or their attorneys, so the public doesn’t expect that going to an accountant or an attorney should be free. On the other hand, a lot of people get “free” medical care. Those in similar financial situations but who are forced to pay for their medical care then feel cheated. That idea seems to be at the center of the deportation issue I wrote about yesterday. If you look at the comments to the Chicago Tribune article, you’ll see that many people state things to the effect that “these people pay nothing into the system and take everything out of the system” and “we have to take care of our own citizens before we take care of foreign nationals.” I agree. The “system” has to be more equitable. The problem is that for all the beliefs that “we” have as individuals and that “we” project to others as moral directives, “we” don’t want to be personally involved in advancing those beliefs. There are many homeless people that deserve shelter, but “we” don’t offer them a place to stay in our basement because although “we” believe the homeless deserve a place to live, “we” don’t want to be personally involved. In fact, “we” don’t even want a homeless shelter anywhere near us because that would affect our property values. It’s OK to provide these services as long as it isn’t in our back yard. More and more families are finding ...

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More On Medicare Never Events

I have to stop reading Kevin’s blog. Lately, every time I read through his posts, I get all riled up over something. The most recent thing to get my blood boiling was Kevin’s link to a nice rant on Buckeye Surgeon’s blog about these looming Medicare “Never Events.” There’s a journalist in Cleveland named Diane Suchetka who published a “blind leading the blind” article about “never events” in the Health News section of Cleveland.com. I know that I’ve beaten this whole “never event” horse before, but the whole concept is just so remarkably brain dead that I had to get my whip out again. The thing that concerns me the most about the “never event” concept right now is that many members of the general public are jumping on this bandwagon. Like foie gras ducks being force-fed corn, the citizens of this country are being force fed the notion of “never events” by the government and insurance agencies. Even more disconcerting is that the feeble minded among us actually believe that all of these “never events” should never happen. Just look at the comments to Ms. Suchetka’s article. After reading the article and the comments, I added my own comment: It is unfortunate that someone so misinformed about the effects of “never events” on the practice and accessibility to medical care is allowed to publish an article like this. It is even more unfortunate that so many of the members of the general public support Ms. Suchetka’s ramblings. First of all, look at the contradictions contained within this article itself. She quotes someone from “SHIC” as saying that “If hospitals were to set up efforts to follow these longstanding practices, the vast majority of these medical errors and infections could be prevented.” Wait a second. “Vast majority?” I thought that these were “never events.” Shouldn’t Captain Obvious have stated that the events would “never” happen if the policies were followed? Medicare calls the “errors” “reasonably preventable.” If they are “never events,” shouldn’t they be called “entirely preventable”? If they are “never events” then I want to see the people who came up with that term treat patients for a year and show me their results in preventing them. There are other misstatements. Realitynurse states that “C. diff is a medical mistake.” Uninformed and untrue statement. C. diff is an organism that lives and grows just like every other organism on this planet. Antibiotic use may increase the prevalence of C. diff, but antibiotic use does not “cause” C. diff. Your statement is akin to saying “mosquitoes are a mistake” or “uninformed nurses are a mistake.” Why has C. difficile become so ominous? Up to 20% of people prescribed clindamycin can develop C. difficile. What exactly should we do to make sure that not one single patient ever develops a C. difficile infection? Go on. I want all you smart people to tell me. Stop prescribing all antibiotics? Sounds like a plan. Then Medicare will deem all the other infections as “never events,” too. If any of the people reading this column want to avoid never events, here’s how to do it: Don’t go to doctors and stay away from hospitals. That’s right. Boycott us. If you want to create a manual on how to provide perfect medical care while you’re treating yourself for a ruptured appendix, I’d be happy to read it. Ms. Suchetka is right that these Medicare rules will affect all of us, but she has the wrong reasoning. They will affect all of you that develop these conditions because physicians and hospitals will avoid you like the ...

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