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HHS: Doctor-owned hospitals fall short on emergency care.

HHS: Doctor-owned hospitals fall short on emergency care

Many physician-owned specialty hospitals are doing a less-than-adequate job of providing emergency care, according to a recent report by the Office of the Inspector General in the Department of Health and Human Services.

The review of 109 physician-owned specialty hospitals was ordered by the U.S. Senate Finance Committee in response to concerns over two deaths at specialty hospitals where no doctor was on duty and 911 was called. Findings include:

  • 28% of hospitals had a physician on-site at all times;
  • 34% of hospitals rely on 911 for medical assistance to stabilize a patient;
  • 55% of hospitals had emergency departments; of those, 58% had just one emergency bed;
  • 7% didn't meet Medicare requirements to have a nurse on duty and have at least one physician on call if there are none in the hospital;
  • 24% don't have policies on the use of emergency medical equipment;
  • 6% don't have policies saying who should respond in a medical emergency.

The office reported to the CMS the names of those hospitals that failed to meet existing CMS guidelines on issues like inappropriate reliance on 911. It also recommended CMS set up a system to track physician-owned hospitals on emergency measures; CMS responded that it would do so.

Mistakes due to similarly named drugs on the rise

More than 1,400 commonly used pharmaceuticals were involved in medical errors from 2003-06 because their names look or sound like another drug name, according to a report from U.S. Pharmacopeia (USP).

In a review of 26,000 records from the MEDMARX database, 1,470 look-alike/sound-alike errors were found, 1.4% of which resulted in patient harm. Seven errors may have caused or contributed to patient deaths. MEDMARX is run by the nonprofit USP as an anonymous Internet program for hospitals to report, track and analyze medication errors.

Based on the report, USP compiled a list of 3,170 pairs of drug names that look or sound alike. The organization's previous report on the topic had identified 1,750 pairs. All of the top 10 most prescribed drugs in the U.S. made the list.

To reduce the incidence of these errors, USP has called on physicians and pharmacists to include an indication for use on all prescriptions and convey the information again at several points along the health care continuum. The USP also recommended that physicians use online decision-support tools. For patients, the report suggested that they check the indication for use on the drug label or ask their pharmacist for the information and, when taking any new drug, exercise their right to receive counseling from a pharmacist.

Cardiac rehab rates remain low in survivors of heart attack

Only about one-third of heart attack survivors participate in outpatient cardiac rehabilitation, despite evidence that it reduces morbidity and mortality and improves outcomes, according to a CDC survey.

As part of the CDC's 2005 Behavioral Risk Factor Surveillance System telephone survey, 129,416 people from 21 states and the District of Columbia responded to questions about heart attack history and cardiac rehab. Overall, 4.2% reported having had a heart attack and, of those, 34.7% said they had received cardiac rehab on an outpatient basis. Current guidelines from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation note that rehab reduces morbidity and mortality, improves clinical outcomes, enhances psychological recovery and decreases the risk for secondary cardiac events.

Cardiac rehab prevalence was 25.3% for patients younger than age 50 and ranged from 35.5% to 37.0% in older patients. Age-adjusted rehab prevalence was higher in men than in women and Hispanics reported a higher prevalence than non-Hispanic whites. Rehab was also more prevalent among patients living in urban areas and with higher levels of education and higher incomes. The results appeared in the Feb. 1 Morbidity and Mortality Weekly Report.

An accompanying editorial reiterated the importance of cardiac rehabilitation in patients who have had a heart attack and noted that the rate of receipt reported in this survey, approximately one-third, is consistent with that seen in other studies. Many factors could explain these low rates, the author wrote, including cost and lack of access. Future studies should examine barriers to rehab participation and ways to improve referral to these services, the editorialist concluded.

Domestic violence associated with chronic disease, risky behaviors

The results of the largest study to date on intimate partner violence in the U.S. add to mounting evidence that victims of domestic violence are prone to a host of serious chronic diseases and risky behaviors.

Results from the CDC's 2005 Behavioral Risk Factor Surveillance System telephone survey, which included 70,000 adults, revealed that 10,243 (24%) of female and 3,035 (12%) of male respondents had a lifetime history of intimate partner violence. Men and women with a history of domestic violence had significantly higher rates than other respondents of arthritis, asthma, activity limitations and stroke, as well as risky behaviors including heavy drinking, smoking and high-risk sexual behaviors. Women with a history of intimate partner violence also were more likely to have heart attacks, hypertension and heart disease.

The results underscore the need for primary care physicians to assess for intimate partner violence, especially when patients show signs or symptoms of ongoing stress, said the report. They also suggest that secondary intervention strategies are needed to address the health-related needs of victims of intimate partner violence.

While the survey cannot infer a causal relationship, said an editorial accompanying the article in the CDC's Feb. 8 Morbidity and Mortality Weekly Report (MMWR), evidence from other studies suggests that the biologic response to long-term stress might be an underlying factor. For example, said the editorialist, a link has been found between violence, stress and somatic disorders, such as fibromyalgia, and stress has been linked to chronic diseases such as cardiovascular disease and asthma.

Diabetes trials yield conflicting results on lowering HbA1c

A large government trial of diabetes treatments was halted in early February after it was found that intensive efforts to lower patients' blood sugar were associated with higher mortality rates. However, interim results from another large diabetes study did not confirm these findings, researchers reported in February.

The first trial, ACCORD (Action to Control Cardiovascular Risk in Diabetes), included more than 10,000 patients who had diabetes and at least two other risk factors for heart disease. The patients were randomly assigned to either intensively low blood sugar goals (hemoglobin A1c of less than 6%) or standard goals and treatment (hemoglobin A1c between 7% and 7.9%). Over the almost four-year study period, 257 patients in the intensive group had died, compared with 203 patients in the standard group, National Institutes of Health officials announced last week. Based on that survival difference (which works out to 3 deaths per 1,000 participants per year), officials decided to halt the intensive treatment arm of the trial.

The researchers had not yet uncovered an explanation for the difference in survival, although an investigation is ongoing. Overall, death rates in both groups were lower than in similar populations in other studies. Because of recent concerns, the researchers specifically looked at rosiglitazone for a link to the increased deaths, but they found no association. The standard treatment arm of the ACCORD study, as well as related trials of blood pressure and lipid treatment, will continue until the planned conclusion date of June 2009.

After the ACCORD trial stopped its intensive treatment arm, researchers on the ADVANCE study, an international trial involving 11,140 high-risk patients with diabetes, evaluated their data for a similar link.

They found no confirmation of the adverse mortality trend reported by the ACCORD trial, according to the chairman of the ADVANCE Data Monitoring and Safety Committee. He also noted that the ADVANCE trial was based on twice as much data and similar glucose targets as the ACCORD trial. Patients in the ADVANCE trial had a hemoglobin A1c goal of less than 6.5% while ACCORD patients in the low-target group had an average hemoglobin A1c of 6.4%.

Full data from the ADVANCE trial are not yet available, because the arm of the study that assessed the effects of intensive blood sugar treatment was only completed in January. The study began in July 2001 and patients were treated and followed for an average of five years. Researchers said that results are more than 99% complete, so the interim findings should be a reliable guide to the final results. The study should be available later in the spring, representatives said.

Doctors and patients should be reassured that the mortality trend found in the U.S. study was not confirmed by the international trial, although more definitive analyses are needed, said a representative of the ADVANCE trial. The results of a third trial, expected later this year, should help to clarify the issue, according to the American Diabetes Association. The association also reaffirmed its recommendation that most people with diabetes work toward a hemoglobin A1c of less than 7% and that high-risk individuals consult individually with their health care providers.