In the News

Gender gap in hospitalist pay, residents and costs, guideline update on endovascular treatment of acute ischemic stroke, and more.

Hospitalist pay still has a gender gap, survey finds

Female hospitalists continue to make less than their male peers, although the difference may result in part from whether physicians prioritize high pay when choosing a job, a survey found.

Researchers used data from the 2009-2010 Hospital Medicine Physician Worklife Survey to examine gender differences in work characteristics, job satisfaction priorities, and earnings among U.S. hospitalists. Their data included 776 respondents and were published by the Journal of Hospital Medicine on June 30.

Female hospitalists were younger than male hospitalists (mean age of 42 vs. 45 years) and less likely to be hospitalist leaders (24% vs. 34%). They were more likely to work less than full time (18% vs. 12%). They reported a mean of 14 daily billable encounters, compared to 15 by men. Women respondents were also more likely to be pediatricians, work for a university, and live in the Western U.S. For fiscal year 2009, they reported a median earnings of $185,000, compared to $202,000 for the male hospitalists (adjusted difference, $14,581; P<0.01).

The survey respondents were also asked to choose domains that were most important to their job satisfaction. Both genders ranked optimal workload first, but men chose substantial pay next, while women prioritized collegiality with physicians and control over personal time above pay. Women were also more likely to prioritize optimal variety of tasks, choosing it sixth, while men ranked it 10th among their priorities.

A 1999 survey of hospitalists also found a gender pay disparity, the study authors noted, although it was greater than that found in this study. The observed differences in workload and other characteristics may account for some of the difference in pay, they said, but the pay gap persisted after adjustment for such factors. Given the difference in reported priorities, women may self-select into lower-paying jobs, but “implicit bias and differences in negotiations, social networks and mentoring opportunities may also contribute,” the authors said, and they called for strategies to assess and address fair compensation.

Most medicine residents don't know costs of tests or treatments, survey finds

Only about a quarter of internal medicine residents know where to find estimated costs of tests and treatments and a similar proportion share that information with patients, a recent survey found.

Researchers gave a survey about high-value care practices and knowledge to residents who took the Internal Medicine In-Training Examination in October 2012. Of the 23,617 residents who received the survey, 83.7% completed it. Results were published by Academic Medicine on June 16.

Most of the residents (88.2%) said that they incorporate patients' values and concerns into clinical decisions, and 71.7% said that they avoid ordering unnecessary tests and treatment for patients. The majority of residents also said that they offer patients alternatives of care, considering benefits, harms, and costs, and that they know the benefits and harms associated with common tests and treatments (81.3% and 84.9%, respectively). However, while 45.7% said they incorporate cost into clinical decisions, only 26.3% reported knowing where to find costs of tests and treatments, and 23.8% share this information with patients.

The residents also reported their exposure to education about high-value care. Most said they had been instructed by faculty at least some on the issue, and the 40.1% of residents who said they had these discussions with faculty during patient care at least a few times a week were more likely to practice high-value care themselves. This “speaks to the importance of educational and other interventions that target the practice environment,” the authors said.

It's not surprising that many residents don't know where to find costs or share that information with patients, the authors concluded. However, they added, the finding that almost 30% of the residents reported not avoiding unnecessary care is notable and suggests that residents need more education about the potential harms of such practice. “The habits that residents learn during training have been shown to stay with them throughout their professional careers,” noted Cynthia “Daisy” Smith, MD, FACP, coauthor of the study and a senior physician educator at ACP, in a press release.

ACP has an initiative on high-value care, which includes a curriculum for residents co-developed with the Alliance for Academic Internal Medicine, designed to help doctors and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices. More information is available online.

Focused guideline update addresses endovascular treatment for early management of acute ischemic stroke

The American Heart Association/American Stroke Association recently issued a focused update to their 2013 guidelines on early management of acute ischemic stroke.

The update, which looked specifically at endovascular treatment, considered results from 8 randomized, clinical trials and other clinically relevant data published since 2013, along with evidence used in the development of the 2013 guidelines. The authors noted that they did not intend to base the update on a complete literature review but instead aimed “to include pivotal new evidence that justifies changes in current recommendations.”

The focused update looked at endovascular interventions, imaging, and systems of stroke care. New recommendations include the following:

  • Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria: prestroke Modified Rankin Scale (MRS) score of 0 to 1; acute ischemic stroke treated with guideline-directed intravenous recombinant tissue plasminogen activator (r-tPA) within 4.5 hours of onset; causative occlusion of the internal carotid artery or proximal middle cerebral artery (M1); age 18 years or older; National Institutes of Health Stroke Scale (NIHSS) score of 6 or greater; Alberta Stroke Program Early CT Score (ASPECTS) of 6 or greater; and ability to initiate treatment (groin puncture) within 6 hours of symptom onset (Class I recommendation; Level A evidence).
  • When treatment is initiated beyond 6 hours from symptom onset, the effectiveness of endovascular therapy is uncertain for patients with acute ischemic stroke who have causative occlusion of the internal carotid artery or proximal middle cerebral artery (M1) (Class IIb recommendation; Level C evidence).
  • Observing patients after intravenous r-tPA to assess for clinical response before pursuing endovascular therapy is not required to achieve beneficial outcomes and is not recommended (Class III recommendation; Level B-Randomized evidence).
  • If endovascular therapy is contemplated, a noninvasive intracranial vascular study is strongly recommended during the initial imaging evaluation of the acute stroke patient but should not delay intravenous r-tPA if indicated. For patients who qualify for intravenous r-tPA according to guidelines from professional medical societies, initiating intravenous r-tPA before noninvasive vascular imaging is recommended in those who have not had noninvasive vascular imaging as part of their initial imaging assessment for stroke. Noninvasive intracranial vascular imaging should then be obtained as quickly as possible (Class I recommendation; Level A evidence).

The complete update was published June 29 by Stroke.

Readmissions after AMI higher among young women than young men

Younger women have a higher risk of readmission within 30 days of acute myocardial infarction (AMI) than men the same age, a recent study found.

Researchers used data on 42,518 Californians ages 18 to 64 who were hospitalized with a principal diagnosis of AMI. About a quarter (26.4%) of the studied patients were female, and 11.2% were readmitted at least once within 30 days of discharge. The study results were published in Circulation on July 21.

The women had 15.5% rate of all-cause 30-day readmissions, compared to 9.7% among the men (P<0.0001). The difference between the sexes could be attributed in part to socioeconomic differences, including that women were more likely to be African-American and federally insured, the authors found. However, after adjustment for these factors and others, including comorbidities, women had a significantly increased hazard ratio of 30-day readmission (1.22; 95% CI, 1.15 to 1.30).

For both sexes, the risk of admission was highest 2 to 4 days after discharge, and readmissions for noncardiac causes were common. Women were more likely to have a noncardiac reason for readmission (44.4% vs. 40.6%; P=0.01). The authors offered several possible reasons for the observed differences in readmissions, including women having more complications from AMI, more stressful experiences of hospitalization, and less support for recovery after discharge. The findings show the need to develop risk assessments and interventions for these patients, which may need to occur in the hospital or be planned as part of discharge, given how soon readmissions occurred after discharge, the study authors said.

An accompanying editorial noted that these readmissions could be an example of post-hospital syndrome. The authors emphasized that the care of these patients should include “careful discharge planning, utilizing a holistic approach, which addresses the disease underlying the acute index hospitalization, but also other comorbidities, social supports, access to prompt medical attention and education post-discharge and the psychological stress associated with hospitalizations for acute medical conditions.”

Mental health, chronic conditions often land superutilizers in hospital, report says

A recently published statistical brief analyzed how often and for what reasons superutilizers are admitted and readmitted to the hospital.

In the brief, superutilizers were defined as privately insured patients with 3 or more hospital stays per year or patients covered by Medicare or Medicaid with 4 or more annual stays. An average superutilizer had about 4 times as many stays per year as did other patients, according to the Agency for Healthcare Research and Quality (AHRQ), which used Healthcare Cost and Utilization Project data from 2012 to inform its brief.

The average all-cause 30-day readmission rate for superutilizers was 4 to 8 times higher than the readmission rate for other patients, according to the brief. Superutilizers accounted for more than half of all 30-day readmissions among patients 1 to 64 years old, the brief stated. Superutilizers were also more likely to be admitted for medical conditions, rather than surgical or other reasons, according to the brief.

The AHRQ also delved into hospital utilization and costs among superutilizers, who accounted for a “disproportionate share” of hospital stays, days, costs, and 30-day readmissions compared with other patients. Compared to other patients with the same payers, Medicaid and privately insured superutilizers stayed longer (4.5 vs. 6.1 days and 3.6 vs. 5.9 days, respectively) and had higher average hospital costs per stay ($9,000 vs. $11,800 and $10,200 vs. $14,600, respectively). No such pattern was seen among Medicare patients.

Regardless of payer, mental health and substance use disorders also ranked among the top 10 diagnoses for superutilizers age 1 to 64 years. Mood disorders ranked in the top 10 for this group across all payers, but not for Medicare superutilizers, who were more likely to have congestive heart failure, septicemia, and chronic obstructive pulmonary disease and bronchiectasis, among other conditions, the brief stated.

Among Medicaid patients younger than 65, mood disorders were the most common diagnosis for superutilizers, according to the brief. Schizophrenia was the second most common condition for superutilizers 1 to 64 years old covered by Medicare or Medicaid, the brief stated. Medicaid superutilizers were older than the average of Medicaid beneficiaries and less likely to be female.