You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Health politics

Primary Care Corner with Geoffrey Modest MD: 30-day hospital readmission rates, ?? an appropriate QI marker

30 Jan, 17 | by EBM

By Dr. Geoffrey Modest

A recent NIH study looked at the effect of the Medicare Hospital Readmissions Reduction Program (HRRP) on 30-day readmission rates after hospitalizations for acute myocardial infarction, congestive heart failure, or pneumonia, and in particular looking at whether the previously lowest performing hospitals improved more than the higher performing ones after the introduction of HRRP  (see doi:10.7326/M16-0185).

Details:

  • 15,170,008 Medicare patients discharged alive from US acute care hospitals between 2000 and 2013.
  • Mean age 79.5, 54% female, 85% white/10% black/4.7% other race, 19% admitted with acute MI/45% CHF/36% pneumonia, 52% discharged to home/18% to home with care/23% to nursing home, average length of stay 6 days, 25% rural hospitals/65% private nonprofit/9% major teaching hospitals, overall observed readmission rate 23%.
  • HRRP penalties for 30-day readmission rates were: 0% for the highest performing hospitals, 0-0.5% for average performing hospitals, 0.5-0.99% for low performing hospitals, and >1% for the lowest performing ones.
  • Of 2868 hospitals serving 1,109,530 Medicare discharges annually, 30.1% were highest performers, 44.0% were average performers, 16.8% were low performers, and 9.0% were lowest performers

Results:

  • Overall risk-standardized readmissions increased by an estimated 0.5 per 10,000 discharges per year prior to the passage of HRRP, then decreased by 76.6 per 10,000 discharges per year after passage.
    • For acute MI, risk-standardized readmissions decreased by 23.7 per 10,000 discharges per year before passage, then by 99.3 per 10,000 discharges per year after passage
    • For CHF, risk-standardized readmissions increased by 5.1 per 10,000 discharges per year before the passage and then decreased by 84.7 per 10,000 after.
    • For pneumonia, risk-standardized admissions increased by 3.1 per 10,000 discharges per year before passage and then decreased by 48.2 per 10,000 after.
  • After controlling for pre-HRRP trends, readmissions per 10,000 discharges that were averted and attributable to the law were:
    • 6 for the highest performing hospitals
    • 8 for the average performers
    • 4 for the low performers
    • 1 for the lowest performers

Commentary:

  • It does seem that after passage of the law, there was a pretty dramatic decrease in the 30-day readmission rate among all hospitals, but especially among those that had been the lowest performers.
  • It should be pointed out that the data overall on the utility of financial incentives in changing the “quality of care” metrics is pretty mixed. This study found that the lowest performing hospitals were able to change the most; however, other studies of financial incentives have not shown this to be true, often attributed to the fact that these hospitals had insufficient infrastructure to implement change. Also, this does raise the ideological concern that using financial incentives to make change in fact reinforces the conception and actuality in the US that health care is just a business and not a fundamental human right that should be managed as in most other industrialized (and may less resource-rich) countries: an essential governmental social program such as education.
  • However, and the reason I bring up the study, is that it really brings up to me some concerns about quality goals, especially when looking at surrogate markers.
    • For A1c: as mentioned in several blogs, using a target A1c goal is fraught with potential downsides
      • For patients who have really erratic blood sugars (often because of lack of dietary consistency), just increasing meds to lower the A1c (and get “credit” for better care) may well lead to significantly poorer real-world outcomes from hypoglycemia (e., over treating patients at times when their blood sugars are already low).
      • Some of the meds that decrease A1c may actually increase clinical morbidity (rosiglitazone increasing cardiac disease, —  see the many blogs on other new but concerning meds at: http://blogs.bmj.com/ebm/category/diabetes/ )
      • And those who use A1c as a metric do not include actual clinical outcomes as part of their assessment.
    • In terms of hospital 30-day readmission rates, there certainly should be a mechanism to make sure that hospitals don’t just discharge and readmit patients as a means to increase their earnings (e., getting paid for 2 admissions instead of 1), but there is also a real down-side to focusing on decreasing the readmission rate:
      • Hospitals are dangerous places to be because:
        • They are crawling with resistant bacteria
        • There is a tendency/imperative to do lots of testing for things that we in outpatient medicine might just observe and workup later as needed (this is due to several issues: specialists are often involved in the hospitalized patient’s care, and studies have shown that specialists order more tests than generalists; and, even if there is a lowish probability of a problem, it does in some ways make sense to get more tests in hospitalized patients to see what is going on, since putting off the tests might prolong the hospitalization. But the net result of more testing is the likelihood of more adverse events (either because of the test itself, or because of the downstream further testing/procedures for false positive findings)
        • And those who use hospital readmission rates as a metric do not include actual clinical outcomes as part of their assessment.​ interestingly, when there have been doctors’ strikes and dramatic decreases in hospital admissions, as in 1976 in California as well as others, there has been an attendant lower mortality (and, that is a clinical outcome…..)
      • So, I think it makes sense to avoid unnecessary hospitalizations, and, I would think, to keep the length-of-stay as short as possible
      • My practice until 2 years ago (when our health center was still doing in-patient rounding) was to discharge patients as soon as I felt they were stable (often during my rounding early the morning after their admission) when I felt they had a roughly 80% chance of doing well at home, but with aggressive outpatient follow-up (home visits, or seeing them in clinic the next day, ). And my experience was that it was really uncommon for patients to be readmitted. But with the incentives being strongly to avoid readmissions, I am afraid that might translate into longer in-hospital observation and lengths-of stay (at least it was clear that I discharged patients much sooner than the house staff would have, in large part because I could assure timely and appropriate outpatient follow-up). The point here is that we should be developing coherent integrated systems of care that would allow decreased hospitalizations overall, and lower lengths-of-stay if possible when hospitalizations happen. and, not simply using a single marker of “quality” for the complex and often highly individual decisions on how long to keep a patient in the hospital (for example, the same patient who is homeless or does not have adequate home supports may need to stay in the hospital longer appropriately.)
      • ​And, the other side of the issue: if a patient is really sick with end-stage heart failure, , they are likely to be readmitted within 30 days perhaps no matter what happens (though, of course, we should do as aggressive outpatient management as we can). And their being home as much as possible may have important value to them: being with family, in a friendly and supportive environment, etc., even if they are aware they might be back in the hospital soon

So, the real issue is how does one blend the need for some quality control issues (better care for diabetics or decreasing hospitalizations, in the above examples) but avoid using a blunt instrument (a1c levels, 30-day readmissions) which may well decrease real quality care????  This is certainly not easy to do by large-scale data-mining, looking just at numbers (a1c’s) or billing (readmission rates), but I think really requires looking at individual patients to see what an appropriate a1c might be for them, or whether they were really discharged too early and needed readmission because of poor clinical judgment. If you send me their emails, I can add them to the list

Primary Care Corner with Geoffrey Modest MD: A Follow-up on the Primary Care Initiative in UK

27 May, 16 | by EBM

By Dr. Geoffrey Modest

UK report on primary care from the House of Commons Health Committee (http://www.publications.parliament.uk/pa/cm201516/cmselect/cmhealth/408/408.pdf)

Basic issues addressed in the report:

  • Improve access to primary care by extending hours of service, reaching out to those currently disenfranchised by the existing model of care
  • Improve record keeping and access to medical records as a means to improve patient safety, with patient consent for more general access to records
  • Facilitate phone and IT access for patients and for consultations
  • Quality improvement initiatives: Care Quality Commission inspection of primary care practices, helping practices improve
  • Ten-minute appointments do not allow adequate time for safe practice or to address whole person care. Relentless time pressure from short appointments tends to restrict patients to discussing only one problem with their GP and clinicians to working in a reactive rather than proactive manner. Given the increasing complexity of the long term conditions that are managed in primary care, allowing time to provide safe and holistic care must be a priority. We agree with the Primary Care Workforce Commission that reshaping primary care to give patients sufficient time to discuss their conditions with health professionals should be a central aim of the new models of care.”
  • Develop and extend the use of team-based care, including using “physician associates”
  • Increase access to consultant psychiatrists. increase communication with specialists overall by email and messaging
  • Continued vigilance at national and local level to make sure that conflicts of interest are not influencing decisions
  • Significantly increase the number of primary care doctors by attracting more doctors into the field. Look carefully at why doctors quit.
  • Promote primary care in medical schools, including expanding the criteria for med school admissions (e.g., including commitment to providing care to a community, not just purely scientific qualifications), increasing teaching of general practice, and stress that the career is as intellectually rewarding as any specialization
  • Use financial incentives/loan repayment to help place MDs and nurses in areas that historically have had trouble attracting them
  • Many similar approaches as above for attracting and retention of nurses, physician associates, physiotherapists, pharmacists in primary care
  • Look at other funding mechanisms, including capitated payment systems within primary care federations
  • A larger proportion of the health care money should go to primary care
  • Make sure that financial mechanisms reinforce primary care, instead of diverting patients inappropriately to secondary care

So, pretty impressive in many ways. Not only does it reinforce primary care as the crux of the health care system, but it suggests several specific reforms to enable that. Unfortunately, in the US we not only do not have a coherent and integrated system of care with universal access, but we have a system dominated by hospitals and procedure-oriented specialists. Even the move to capitation seems to situate hospitals and not primary care at its center. and the decision-makers for our reimbursement system is dominated by those who make lots of money from procedures (and, as I have said before, injecting a patient for carpal tunnel syndrome or painful joints takes me a few minutes and is not very complex. Taking care of my patient with uncontrolled hypertension, diabetes, etc., who is in an untenable social situation, and is depressed, is really intellectually and emotionally difficult and very time-consuming). But I think the kernel of the current UK initiatives is central to a major reorientation of our health care system (and extending the system to one of universal access is certainly another essential aspect).

Primary Care Corner with Geoffrey Modest MD: Increasing Disparities in Life Expectancy

24 Feb, 16 | by EBM

By Dr. Geoffrey Modest

The NY Times just featured an article on the growing longevity disparity associated with income disparity (see http://www.nytimes.com/2016/02/13/health/disparity-in-life-spans-of-the-rich-and-the-poor-is-growing.html?emc=edit_th_20160213&nl=todaysheadlines&nlid=67866768 ), based on a report released by the Brookings Institute. See http://www.brookings.edu/research/reports2/2016/02/life-expectancy-gaps-promise-social-security#recent/ for a brief review of the report and http://www.brookings.edu/~/media/Research/Files/Reports/2016/01/life-expectancy-gaps-promise-social-security/BosworthBurtlessZhang_retirementinequalitylongevity_012815.pdf?la=en for the full 174 page report.

Main points:

  • In the early 1970s, a 60-year old man in the top half of the earnings’ ladder had life expectancy 1.2 years longer than one in the bottom half. In 2001, the gap was 5.8 years.
  • The Brookings report found that, comparing life expectancy between those in the top vs bottom 10% of earners (data are based on life expectancy at age 50 yo):
    • For men born in 1920, there was a 6-year difference; for men born in 1950, there was a 14-year difference.
    • For women born in 1920, there was a 4.7-year difference; for women born in 1950, there was a 13-year difference.
    • In a separate analysis, the Brookings report noted that life expectancies in those born in 1920 vs 1940, comparing the bottom to the top 10% of mid-career income distribution were:
      • Those in the bottom 10%: 80.4 years for women (no change); 74.3 increasing to 76.0 in men
      • Those in the top 10%: 84.1 years for women increasing to 90.5!!!; 79.3 increasing to 88.0!!! In men
    • Why are the differences so great and getting dramatically greater? Hard to pinpoint exactly (and studies looked at different endpoints), but some differences:
      • Cigarette smoking: decreased more in wealthy, could explain 1/5 to 1/3 in the gap between men with college degrees vs those with high school degrees; 1/4 of the gap in women
      • Obesity: rates of obesity between rich and poor narrowed from 1990-2010, when 37% of poorer and 31% of richer adults were obese
      • ​Prescription drug abuse has disproportionately increased mortality in poor communities
      • Of note, limited access to care was not found to play much of a role (they reference an article by Steven Schroeder: N Engl J Med 2007; 357:1221), stating that only 10% of the disparity has to do with medical care [note that this statement was not footnoted, so I cannot check on the reliability of it].
    • One side note is that wealthier people live longer and therefore collect more years of social security payments as well as longer utilization of Medicare services, disproportionate financial benefits for the wealthy.
    • These longevity disparities are not necessarily reflected in other countries: in Canada, men in the poorest urban areas had the largest declines in heart disease mortality from 1971-1996, and the overall gaps in longevity decreased over this time period. Cancer survival rates in low-income residents in Toronto were significantly better than in Detroit, yet there was no difference for middle- and high-income residents (see Am J Public Health. 1997; 87(7): 1156).
    • The Brookings report also commented on the fact that higher wage earners are retiring later (they attribute this to the fact that their jobs are higher-paying which is especially important since most jobs now do not come with a pension or guaranteed income after retirement, the jobs usually are more rewarding, and social security benefits were pushed up a year to age 66). Lower age workers tend to retire earlier with only 13.8% getting social security at age 66. They do not comment explicitly (so, I will): the increase in age for social security from 65 to 66 is much less significant for an office worker than someone doing hard manual labor, where they likely have chronic musculoskeletal pains/problems, and the possibility of extending the work-life another year may be painful and undoable. But getting social security early adds to income inequality, since the payout is much less/yr.

—————————————————————————————-

In a (somewhat) related recent article (see JAMA. 2016;315(6):609), researchers looked at life expectancy from birth (vs from age 50 in above), as a means to evaluate mortality in younger people, where both the major causes of death are different from those >50yo (more from injury/trauma/drugs), and the impact is greater (more years of expected life are lost). They focused on motor vehicle traffic crashes (MVT), firearm injuries, and drug poisonings (e.g. overdoses). The table below shows the contribution of these injuries/traumas to the life expectancy of men and women, also comparing the US rates to those of a variety of other countries. From this data, overall death from injury accounted for 48% of the longevity gap in men (1.02 years of the 2.15 years of the all-cause difference), with firearm-related injuries accounting for 21% of the overall gap, drug poisonings 14% and MVT crashes 13%. For women injuries/traumas accounted for 19% of the gap, with 4% from firearms, 9% from drug poisonings, and 6% from MVT crashes. Overall, the impact of these injuries in the US is far greater than in a combination of other countries. The other table (not shown) details the specifics per country, showing for example that although Portugal is the only country in the list with an overall death rate higher than the US, their death rate from injuries is much lower than the US, so that Portugal still has a life-expectancy 0.5 years longer than the US (i.e., because there are fewer injuries/overdoses which disproportionately affect younger people). A caveat here is that they are relying on death coding across different countries.

A few comments:

  • There are very real reasons why lower wage earners have lower life expectancy, as noted in many prior blogs. Obesity is a major problem but is exacerbated by lack of access to good, affordable foods. Doing exercise can be an obstacle when people live in unsafe neighborhoods. Manual laborers tend to have more disabilities (I’m not sure I have met any construction workers, masons, plumbers, who do not have significant musculoskeletal problems by the age of 40). Air quality tends to be worse in poor neighborhoods. General stress tends to be higher.
  • I do have concerns about writing off access to medical care as not much of a factor in the longevity discrepancy. It is clear that inadequate access to care is an issue for the poor only. And there are huge discrepancies within that group. If you happen to live in Massachusetts, access is generally quite good. If you live in rural Mississippi or Louisiana, access is terrible/can be effectively nonexistent.
  • Though I do think that, overall, the predominant issue is that, though we spend lots of $$ in the US on health care, unlike other countries (including many with far fewer resources than in the US), we spend the vast majority on “medical care” (where in other countries a higher % of health care money goes to making sure people have good food, housing, jobs, and an array of social services –see The American Health Care Paradox, by E Bradley and L Taylor, published in 2013, noting that:
    • We spend almost twice as much money as the next most expensive health care system; yet we have really terrible comparable health outcomes, e.g. ranking 26th in life expectancy.
    • ​Countries with far better health outcomes spend much more money on social services to enhance well-being, such as “investments in housing, nutrition, education, the environment and unemployment support” (which dovetails with the way the World Health Organization defines health as “a state of complete physical, mental and social well-being”); we spend dramatically less than other countries on these social services.
    • ​And, if you add up the strictly medical as well as the social costs invested by different countries for health care, the US is somewhere in the middle of the pack in terms of per capita spending.
  • So,  I think this is why longevity of wealthier people in the US (who need fewer social services) is pretty much as good at those living in the highest ranking countries (Japan, Iceland), but poorer people have the life expectancy of those in Poland and the Czech republic.
  • There are several reports finding a temporal relationship between divergences in income inequality and longevity inequality over the past 40 years.
  • And the JAMA study reinforces the overall importance of traumatic or drug-related deaths overall (which is largely missed in the Brookings analysis), and especially in the young​.

Primary Care Corner with Geoffrey Modest MD: Doctors questions not covered by 1st amendment

20 Nov, 14 | by EBM

I was surprised to find out this summer that there are significant potential legal constraints on what doctors (and presumably other providers) ask during a patient encounter and that doctors speaking with patients is outside of “free speech” protected by the constitution and instead everything said is considered “treatment”. Turns out that the government has “broad authority to prohibit doctors from asking questions on particular topics” 

bmj

There is a case in Florida (Wollschlaeger v Governor of Florida). As they note in the article, this law ‘concerned the constitutionality of the Florida Firearm Owners Privacy Act. That 2011 law threatens doctors with professional discipline if they ask patients whether they own guns or record the resulting information in a patient’s files when doing so is not “relevant” to a patient’s medical care’. ​They do note that there may be reasonable disagreement as to what “relevant” means. not particularly shocking is that the NRA believes that asking if there are guns in the house is none of the doctor’s business (though the Am Acad of Pediatrics does include this as one of the questions that should be asked!!). By a 2-1 vote, the 11th circuit held that doctors asking questions is in fact “treatment” and not protected by the First Amendment. What if another powerful lobby (e.g. tobacco, or alcohol) lobbied successfully in some states to bar doctors from asking relevant questions about these substances?  

This is not just an archaic, marginal, not-particularly-relevant issue. In Texas, the veterinary board used this argument to prohibit licensed veterinarians about giving advice about an animal they did not examine. In Kentucky, the Board of Examiners of Psychology “sent a cease-and-desist letter to a newspaper columnist claiming that his widely syndicated parenting column was unlicensed — hence criminal — practice of psychology” !!!!!!

Geoff

Primary Care Corner with Dr. Geoffrey Modest: The Health Care Paradox

25 Nov, 13 | by EBM

in oct 28 boston globe there was a review of a book “the health care paradox”, by elizabeth bradley and lauren taylor, public-health specialists — see http://www.bostonglobe.com/arts/books/2013/10/27/book-review-the-american-health-care-paradox-why-spending-more-getting-less-elizabeth-bradley-and-lauren-taylor/ynV1Sl5n0jZ1FUN817j4XN/story.html, which promotes a broader critique of the health care system.

so, i must admit that in my past emails, i have railed against the US health care system, which spends more per person than any other (around 2x as much as next closest country) and has remarkably poor health outcomes (much worse than other industrialized countries and worse than several less-industrialized ones), and that has to do with the lack of a coordinated, coherent, accessible system of care, and unfettered profit-taking by drug companies, medical supply companies, hospitals, etc. And that the fix was to develop a public-sector coherent system, similar to other countries’ approximation to a one-payor system.

but the point of this book is appropriately more expansive: social issues (eg for adequate housing, affordable daycare, home-based services for disabled, food security, etc, and i might add, income inequality) are at least as important as the health care system itself as the foundation for peoples’ health and well-being. if one includes social costs with the direct health care expenditures,  the US sinks to be 13th in spending (ie, we are way below most other industrialized countries in social program spending).

so a major part of the problem extends beyond the specific deficiencies of our health care system per se as noted above and very much into the social sphere overall (it is rather telling that as the median income since 2008 has fallen 4% for the bottom 93% of the population but increased 28% for the top 7%, yet in this situation even the Democratic-controlled senate is pushing for a $4 billion cut over 10 years in food stamps — though still better than the $40 billion cut proposed by the Republican-controlled house). and it stresses that we think about health much more broadly than just the health care system itself. perhaps the most important deficiency of the “health care system” is the seemingly relentless attack on social programs.

sounds like a good book to read…..

 

geoff

Primary Care Corner with Geoffrey Modest: Medicare

30 Jul, 13 | by EBM

Editor’s note: For those of you outside the US this story will seem ridiculous…also, as after this post was written, the Boston Globe also published a front page article on how a hospital will pay a >$5 million fine for using “observation” status too little (the status that leads to patients paying more) with no mention of the issues below.  See  http://bo.st/13UYDFu 

Medicare

recent reports have shown that Medicare inflation (3.9%) is significantly below that of private insurors.  a recent article in the Boston Globe (see http://www.bostonglobe.com/opinion/2013/07/18/medicare-disguised-form-rationing/W6sF7dkTW08oGOlSekzlFI/story.html?s_campaign=email_BG_TodaysHeadline) notes a major part of the reason: cost-shifting to consumers. key points:

— editorial writer presents case of his 99yo mother admitted to hosp after fall and kept there 4 days for severe maxillofacial bruising.  Medicare reassessed care after she was already admitted for several days and decided it was “observation”, resulting in her being considered an outpatient (Medicare B), with 20% co-pay of the $20,000 physician fees. and, since the admission was effectively denied, no access to rehab facility or skilled nursing through Medicare

–this after-the-fact review is done by “recovery audit contractors”, for-profit vendors hired by Medicare and whose payment is linked to their denying claims!!!  Although their denials can be appealed, it is a long and expensive process for the hospitals or the patients.  The American Hosp Assn has a pending lawsuit against this practice

–the above system is part of George Bush (the second) approach to reducing Medicare costs using market incentives.  this same George Bush also enacted Medicare C and D. Medicare C allows commercial HMOs to skim: targeting healthy seniors and thereby reaping large profits. and Medicare D is the senior drug program, with seniors responsible for often large medicine co-pays and perhaps descending into the abyss of the “donut hole” requiring full medication payments. this was done through the for-profit drug system, an unmanageably huge array of profitable cvs/walgreen/etc/etc supporting remarkably profitable drug companies, instead of through bulk governmental drug purchasing as through the VA system, which would have saved on the order of 70% of the drug costs!!!!.   these private sector approaches to Medicare C&D cost hundreds of billions of dollars more than if done through rational public-sector solutions.  and now to decrease Medicare program costs, patients get hit with cost-shifting from Medicare to them!

and, so, yet again, our health care system [in the US]  is not the cohesive, coherent system of care that we all need.  the above, unfortunately, affects Medicare, which not only is the basic health insurer for our vulnerable elders but is also (if fixed) the potential starting point for developing an all-inclusive government-sponsored single payer system.

geoff

EBM blog homepage

Evidence-Based Medicine blog

Analysis and discussion of developments in Evidence-Based Medicine Visit site



Creative Comms logo

Latest from Evidence-Based Medicine

Latest from EBM