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Top-ranked hospitals have 70% fewer deaths, and other medical updates.

Top-ranked hospitals have 70% fewer deaths

The death rate at top-ranked U.S. hospitals is 70% lower, on average, than at the lowest-ranked hospitals, according to an annual report that ranks hospitals on 17 conditions and procedures from 2005 to 2007.

Healthgrades, which prepared the report, examined 41 million Medicare patient records at the nation's approximately 5,000 hospitals. The company estimated that 237,420 deaths could potentially have been prevented if all hospitals performed at the “five star” level (the report gives one, three or five stars to each hospital based on how many patients develop complications and die after being treated).

More than half (54%) of the deaths during the study period were associated with four conditions: sepsis, pneumonia, heart failure and respiratory failure, according to a Healthgrades news release. The report noted that the overall in-hospital risk-adjusted mortality rate declined by almost 15% from 2005 to 2007.

However, top-performing hospitals reduced their death rates more significantly than low performing hospitals, 13.2% vs. 12.3%. The data illustrate that significant gaps persist between the best and the worst hospitals, according to the report. Five-star hospitals had significantly lower risk-adjusted mortality across all procedures and diagnoses that were studied. Patients have a 50% lower chance of dying in a five-star rated hospital compared with the U.S. hospital average, according to the release.

The report also found regional differences: the East-North- Central region had the lowest overall risk-adjusted mortality while the East-South-Central region had the highest mortality.

Uninsured wrongly blamed for ER over-crowding

The widely held belief that uninsured patients are responsible for U.S. hospital emergency room overcrowding is a fallacy based on mostly unsupported assumptions, according to a study in the Oct. 22/29 Journal of the American Medical Association.

While just 17% of the approximately 115 million annual ER visits are made by patients without insurance, uninsured patients are often blamed for the growing demand for emergency services. Yet these patients are actually less likely than insured patients to visit the ER for non-urgent problems, and a higher proportion of Medicaid and Medicare patients use emergency departments than the uninsured.

Researchers performed a literature review of clinical topics concerning uninsured patients and ER care and found that out of 127 articles, 53 had at least one assumption about uninsured ER patients, with a mean of three assumptions per article. The six most frequent assumptions found were that uninsured patients present with non-urgent problems, lack primary care, are increasingly presenting to ERs, cause crowding, present more often than insured patients, and are more expensive to treat in the ER. Of these six assumptions, three were not clearly supported by current data and three were true for both insured and uninsured patients.

The authors point out that if potential solutions to ER overcrowding are based on inaccurate information, problems will remain.

Americans cut back on doctor appointments to save money

Nearly half of Americans say they or a family member have skipped pills, and/or postponed or cut back on health care appointments and screenings in the past year to save money, a recent Kaiser Family Foundation poll found.

Thirty-six percent of interviewees said they or a family member didn't pursue medical care they needed, and 31% skipped a recommended test or treatment as of early October, the report said. That compares to 29% and 24%, respectively, in April 2008. About 20% of those who reported skipping care in October said their conditions got worse as a result.

In addition, 27% said they or a family member didn't fill a prescription, and 22% said they cut pills or skipped doses compared to 23% and 19% in April, the poll said. Twelve percent had problems getting mental health care, up 4% from April.

About one in three reported their family has had problems paying medical bills in the past year, up from about 25% two years ago. Of those who make less than $30,000 per year, 46% reported problems paying medical bills, according to the October Kaiser Health Tracking Poll: Election 2008. Those who reported problems said the bills were in the thousands of dollars, not the hundreds. Lower-income families were more likely to skip or postpone appointments.

U.S. hospitals are also reporting an increase in emergency room patients recently, including more uninsured patients, and elective surgeries and diagnostic tests at hospitals have fallen 1- 2% in recent months, compared to a usual increase of 2-4% per year, the Oct. 22 Washington Post reported.

End-of-life talks lead to less aggressive patient care

Patients who had end-of-life discussions with physicians received less aggressive medical care and had higher quality-of-life scores in their final weeks of life, a study found.

The prospective longitudinal cohort study involved 332 patients with advanced cancer, and their informal caregivers, at multiple sites from September 2002 through February 2008. Patients were followed from enrollment until death, with outcomes being aggressive medical care (like resuscitation and ventilation), hospice in the final week of life and mental health.

Caregivers were also assessed about six months after death for mental illness and quality of life. The study was published in the Oct. 8 Journal of the American Medical Association.

About 37% of patients reported having end-of-life discussions, which were associated with lower rates of ventilation, resuscitation, ICU admission and earlier hospice enrollment.

Adjusted analyses showed more aggressive medical care was associated with lower patient quality-of-life scores and higher risk of major depressive order for caregivers. Better patient quality of life was associated with better caregiver quality of life at follow-up, as well.

End-of-life discussions between patients and physicians may make patients more realistic about the benefits of aggressive therapies, thus reducing the chances that they will opt for such therapies, the authors said. More than 60% of the patients didn't recall having end-of-life conversations, especially if they were at major academic centers, so there is an apparent need to step up these discussions, the authors concluded.

Online toolkit offers chronic care business model

A free toolkit to help safety-net hospitals improve their care of chronically ill patients and their financial returns is available online from the Agency for Healthcare Research and Quality.

The toolkit, Integrating Chronic Care and Business Strategies in the Safety Net, is designed to improve patient satisfaction and loyalty; increase staff satisfaction and retention; streamline workflow; enhance efficiency; position practices to capture pay-for performance and quality improvement bonuses; and improve financial return. The kit also includes flow charts, worksheets, slides, fact sheets, and other forms developed by AHRQ, the Institute for Healthcare Improvement, the California Healthcare Foundation, the American Medical Association, and others.

The toolkit is online.

Web tool helps hospitals predict emergency response needs

A new AHRQ Web-based interactive tool for hospitals and emergency planners helps identify resource requirements for treating an influx of patients due to major disasters like an influenza pandemic or a terrorist attack.

The Hospital Surge Model allows hospitals to estimate the number and flow of casualties needing medical attention during various scenarios. It helps determine:

How many patients each hospital unit will need to treat each day following an event;

  • Casualty arrival patterns and peak days of patient care;
  • Day-by-day use of the personnel, equipment and supplies needed by each hospital to treat casualties; and
  • A daily count of anticipated deaths and patient discharges.

The tool is online.

Medical home model starts to pay off for large groups, hospitals

Large practices adopted the patient-centered medical home (PCMH) model sooner than small ones, but it's been slow going regardless, said one study. However, the model cut one health chain's hospital admissions by 20% and costs by 7%, according to another study.

The first study, from the Sept/Oct Health Affairs, assessed how much infrastructure large practices have in place to support the PCMH concept. Acknowledging that infrastructure isn't necessarily implementation, researchers used data from the 2006-2007 National Study of Physician Organizations and the Management of Chronic Illness, a 30-minute phone survey of the heads of large practices. Researchers identified 291 medical groups who responded to the survey and treat four chronic ailments: asthma, diabetes, congestive heart failure and depression.

Results showed:

One-third use primary care teams at a majority of their practice sites;

  • 41% have a majority of physicians using a basic electronic medical record;
  • 65% participate in quality improvement collaboratives;
  • Except for distributing guidelines, less than half of the groups use patient educators and other health promotions; and
  • 30% use group visits for chronic illnesses.

“Early visions of the medical homes centered on smaller practice settings,” the authors wrote. “Interestingly, our data demonstrate that the largest of the large medical groups, and those owned by larger entities such as a hospital or an HMO, have much higher levels of PCMH infrastructure than smaller groups do.”

A second paper highlighted success from Geisinger Health System, a group of hospitals, employed physicians, clinics, programs and a health plan located in central and northeastern Pennsylvania. Administrators outlined their application of PCMH-like concepts in a second paper in the Sept/Oct Health Affairs.

As just one example of its efforts, Geisinger offers its physicians monthly payments of $1,800 per doctor to recognize an expanded scope of practice, and monthly stipends of $5,000 per thousand Medicare patients to pay for extra staff and extended hours. Monthly performance reports are reviewed and the payouts are then prorated to quality measures.

First-year results at two pilot sites showed a 20% reduction in all-cause hospital admissions and 7% total medical cost savings. Geisinger will roll out 10 more in-system sites and one non-system site.

The report outlines three implications to consider in applying Geisinger's experience to national health care reform:

Aligned incentives. Geisinger subsidizes “important but nonprofitable functions (such as primary care, autism treatment, and so forth)”. Commercial insurers would need to adopt similar methods to reap benefits.

Electronic infrastructure. EHRs offered benefits only years after installation.

Collaboration and integration. Geisinger can offer incentives otherwise not allowed by regulations that prohibit hospital- physician collaborations, the report said.