Monthly Archives: May 2017

Major teaching hospitals produce lower mortality rates than non-teaching hospitals

by Matt Kuhrt | FierceHealth
May 24, 2017 11:59am

Patients at major teaching hospitals experience better 30-day mortality rates for common conditions than those at non-teaching hospitals, according to a new study.
The research, published in JAMA, surveyed Medicare data of 21.4 million hospitalizations of patients aged 65 and older from 4,483 hospitals. Mortality rates at the 250 major teaching hospitals included in the study were over a percentage point better than those at other hospitals. The differences in adjusted mortality rates were higher among large hospitals than smaller ones, but teaching hospitals still maintained a statistically relevant advantage even after stratifying them by size. A similar result held when the researchers looked at seven-day and 90-day mortality rates.
“We found, to our surprise, that across a wide range of medical and surgical conditions, patients at teaching hospitals did better—they were less likely to die,” senior study author Ashish Jha, M.D., of the Harvard T.H. Chan School of Public Health in Boston, told Reuters.
The study complicates recent findings suggesting the irrelevance of cost to overall quality of care, since people generally acknowledge that teaching hospitals tend to be more expensive than non-teaching institutions, Laura Burke, M.D., one of the study’s authors, told STAT.
“When thinking about cost, taking into account outcomes needs to be part of the discussion,” she points out, suggesting that those who dismiss teaching hospitals out of hand due to their higher cost might be throwing the baby out with the bathwater.
However, Burke, an instructor at the Harvard T.H. Chan School of Public Health and an emergency medicine physician at Beth Israel Deaconess Medical Center in Boston, cautioned against reading the study as a call for people to prioritize teaching hospitals above others for all of their care. The study’s reliance on Medicare data raises questions about whether mortality rates for younger patients would mirror those of the older ones in the Medicare system, notes STAT.
The authors admit that the study sheds little light on why mortality rates at teaching hospitals would be better than those at non-teaching institutions. Burke told STAT she hopes her research will help uncover best practices that non-teaching hospitals might be able to use to improve their quality of care. She and her colleagues have reportedly already begun to study possible reasons that explain the disparity in mortality rates.

Early Activity Benefits ICU Patients — But Which Ones?

Figuring out who should get physical therapy can be tricky
by Joyce Frieden
News Editor, MedPage Today May 24, 2017
WASHINGTON — Striving for early mobilization of intensive care unit (ICU) patients is generally safe, but it is difficult to tell which patients will benefit from it, Marc Moss, MD, of the University of Colorado in Denver, said at American Thoracic Society meeting.
“I think we can [provide mobilization] safely and I don’t think it’s a risk,” he said. “However, with limited resources [we have to make sure there’s a benefit to them].”
Moss showed data from his own institution, which found that the total cost of providing physical therapy (PT) to acute respiratory failure patients was $66,000 per year. Multiplied by many hospitals, “That’s hundreds of millions we’re spending on providing physical therapy to these patients. So how do we allocate resources to the patients who will truly benefit? It’s not a risk/benefit [assessment], it’s more of a cost/benefit [issue].”
The five largest trials looking at the benefits of mobilizing ICU patients have been mixed, Moss noted: two showed positive effects from early mobilization and exercise, while three showed negative effects. “We might want to know, which of these is correct?”
The answer is that “there’s not one that’s correct; they all give us information,” he said. “We want to learn from these studies and design better trials.”
The issue with these studies is that they each look at a different aspect of what PT does for these patients, Moss continued. “Some showed it was beneficial to achieve independent functional status at the time of hospital discharge; that’s an important outcome variable. Some showed we were able to do PT and move [ICU patients] around more — that’s a somewhat important outcome, and others looked at longer-term outcomes.”
There are a lot of issues to consider in terms of PT for these patients: “When should we start it? How long should we do it for and at what intensity? Who should deliver the therapy?” said Moss. “I think we’re in our infancy in this area; we’ve learned a lot but there’s more that we can learn.”
Another consideration is whether there are different phenotypes of ICU-acquired weakness and if so, whether these patients might respond differently to early mobilization and PT. For example, “Studies have shown that people lose muscle mass in the ICU due to inflammation and inactivity, and that’s pretty pervasive, but a subset [of patients] develop myopathy and a subset develop neuropathy, and most that do that will develop both,” he said.
The bottom line, Moss concluded, is that “it’s not practical to treat all ICU patients [with PT] … It’s likely to benefit certain patients but not all, and we need to determine how to benefit those patients and implement a personalized treatment strategy.”
Will Schweickert, MD, of the University of Pennsylvania in Philadelphia, presented a stronger case for early physical activity. “Only one out of every three to five previously independent people with acute respiratory failure lasting 48 hours or more will be able to walk out of the hospital independently,” he said.
Patients on mechanical ventilation are of particular concern, he noted. About 25%-50% of patients on mechanical ventilation develop weakness acquired as a result of being in the ICU; the weakness prolongs ventilation time and length of stay and is independently associated with short-term mortality. In addition, 50%-75% of ventilation patients develop delirium.
And overall, ICU patients get very little activity or socialization. Schweickert cited a study that found patients in the ICU from less than 72 hours up to 7 days were in bed 100% of the time, inactive 92% of the time, and — “pathetically” — alone 36% of the time.
Does exercise help these patients? Studies on the subject are tricky, but five out of seven important trials of early mobilization showed improved patient outcomes, particularly in physical function, he said. However, narrowing that down to trials featuring interventions that begin within 5 days of the illness leaves three trials, all of which found improved outcomes. One of those studies, performed by Schweickert and his colleagues, found that the percentage of patients walking independently at hospital discharge doubled from 25% to 50% with early mobilization.
And there’s another benefit: improved staff morale. Once your staff sees these very sick patients walking, “this is the stuff that changes a unit,” Schweickert said. “Make a difference; get them moving early.”
• Primary Source
American Thoracic Society

How to Safely Dispose of Leftover Painkillers and Other Medications

By Douglas Throckmorton, MD, deputy director for Regulatory Programs, Center for Drug Evaluation and Research, FDA

Each year, Americans fill several billion prescriptions, including those for strong pain medications, but some of them go unused or expire before being consumed. The bottles may get pushed to the back of the medicine cabinet and forgotten until that space is needed for something else. So what should be done with them?
Most patients know not to share medications with others. They know that their medications are prescribed based on individual symptoms and specific medical history. What works for one person could be dangerous for someone else. Certain medications, especially strong painkillers, are especially harmful if taken by someone other than the person for whom they were prescribed. If a prescription medication falls into the wrong hands—a child’s, for instance—serious consequences, like hospitalization and possibly death, can result. In fact, there have been reports of tragic outcomes for children who were inadvertently exposed to fentanyl patches or other opioids. Pets are also at risk. Hanging on to certain medications—especially those with addictive properties—also increases the risk of prescription drug abuse.
The good news is that there are several ways to responsibly dispose of unwanted, unused and expired prescription medications. One is by participating in drug take-back programs. Since 2010, the Drug Enforcement Administration’s (DEA’s) National Prescription Drug Take-Back Initiative has organized events to help us clean out our medicine cabinets by collecting unneeded prescription drugs. The drugs are collected at many sites throughout the country and then safely incinerated. The DEA’s efforts have been paying off, as the volume of drugs collected has grown exponentially. During its first drug take-back event in October 2010, the agency collected 242,000 pounds of prescription drugs from 4,000 sites. In April 2016, nearly 900,000 pounds of drugs were collected from 5,400 sites. The most recent drug take-back day was April 29, 2017.
Drug take-back events only happen twice a year, usually in the spring and fall. At other times of the year, there are alternative ways to safely dispose of drugs. First, check the drug’s labeling; there might be specific instructions for disposal. If not, the best choice for disposal depends on the drug itself. Many prescription drugs can be thrown safely into the trash, provided these simple safety measures are taken:
First, mix medicines with an unpalatable substance such as dirt, kitty litter or used coffee grounds. Do not crush tablets or capsules, however.
Then, place the mixture in a container, such as a sealed plastic bag, and throw the container in the trash.
To protect medical privacy, labels containing personal information should be removed or scratched out before the empty pill bottle or medicine packaging is tossed.
A small number of prescription medications should never be thrown in the trash, and are better off being flushed down the toilet or sink. Generally, the FDA does not recommend flushing medication—we don’t want pharmaceuticals unnecessarily ending up in our water supply—but the potential risks in the home associated with certain drugs outweigh the environmental risks. For example, opioids like fentanyl, oxycodone and other strong painkillers should be flushed and not left in the medicine cabinet. The FDA describes what medicines should be flushed to avoid risks to people and pets in the home.  Please visit the Disposal of Unused Medicines: What You Should Know page at www.fda.gov for more information.
We all have a responsibility to make sure drugs are disposed of properly when they expire or are no longer needed. The DEA has more information about the National Prescription Drug Take-Back Initiative. Local authorities can also help identify medication disposal options in your area during the rest of the year.

Weight Loss May Hinge on When You Eat (CNN)

As important as what and how much
by MedPage Today Staff
May 19, 2017
Successful weight loss may depend as much on when you eat as it does on what you eat and how much, as reported by CNN.
After watching patients do a good job of restricting calories during the day only to start bingeing and gorging later in the day, New York City nutritionist Tamara Duker Freuman developed a “circadian-synced diet.” The timing-based — rather than calorie-based — approach has helped many of her patients lose weight over the past decade.
“It was the ongoing grazing into the night,” she said. “That’s what kept undermining them … If they just ate a little more at breakfast and lunch, if they just added a few hundred extra calories in the morning, they would get their eating under control and lose weight.”

AAP: No Fruit Juice for Infants

Risks of excessive weight gain, tooth decay too great
by Alexandria Bachert
Staff Writer, MedPage Today May 22, 2017

Fruit juice offers no nutritional benefits over whole fruit for infants and children and has no essential role in the healthy, balanced diets of children, said an American Academy of Pediatrics (AAP) policy statement.
While 100% fresh or reconstituted fruit juice can be healthy when consumed as part of a well-balanced diet for children older than 1 year, it offers no nutritional benefit to children under 1 year and should not be included in their diet, reported Melvin B. Heyman, MD, and colleagues from the AAP Committee on Nutrition.
Published in Pediatrics, the statement is the first change in recommendations on fruit juice since 2001.
“Parents may perceive fruit juice as healthy, but it is not a good substitute for fresh fruit and just packs in more sugar and calories. Small amounts in moderation are fine for older kids, but are absolutely unnecessary for children under 1,” stated Heyman.
According to the U.S. Food and Drug Administration, a product must be 100% fruit juice in order to be labeled as fruit juice, and juices that are reconstituted from concentrate must be labeled accordingly. Any beverage that is less than 100% fruit juice must list the percentage of the product that is fruit juice and include a descriptive term, such as “drink,” “beverage,” or “cocktail,” noted the authors.
The AAP policy statement recommended that daily intake of juice should be limited to:
• 4 ounces for toddlers ages 1-3
• 4 to 6 ounces for children ages 4-6
• 8 ounces or 1 cup of the recommended 2 to 2½ cups of fruit servings per day for children ages 7-18
Human milk or a prepared infant formula should be the only nutrients fed to infants until approximately 6 months of age. Offering juice before solid foods are introduced into a child’s diet could risk having juice replace human milk or infant formula — which could result in reduced intakes of protein, fat, vitamins, and minerals such as iron, calcium, and zinc.
The AAP statement encouraged pediatricians to become more knowledgeable about fruit juice and fruit drinks in order to better inform parents and patients on the appropriate uses. For example, the committee promoted advocating for a reduction in fruit juice in the diets of young children, as well as a complete elimination in children with abnormal (poor or excessive) weight gain.
Heyman’s team also wrote that children should consume more whole fruits than fruit juice, which lacks dietary fiber and may contribute to weight gain. Additionally, excessive juice consumption may be associated with malnutrition (over-nutrition and under-nutrition), as well as diarrhea, flatulence, abdominal distention, and tooth decay.
“Pediatricians have a lot of information to share with families on how to provide the proper balance of fresh fruit within their child’s diet,” said another co-author, Steven A. Abrams, MD, director of the Pediatric Research Institute at the University of Texas at Austin.
As part of the initiative, the authors suggested that pediatricians support policies that work to reduce the consumption of fruit juice and instead promote whole fruit for toddlers and young children already exposed to juices. The authors specifically mentioned policies for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), provided that they do not have negative nutritional consequences for children without access to fresh fruit.
Other recommendations for monitoring juice consumption among children included:
• Not giving toddlers juice from bottles or easily transportable covered cups that allow them to consume juice easily throughout the day, nor giving juice at bedtime
• Strongly discouraging consumption of unpasteurized juice product in infants, children, and adolescents
• Avoiding grapefruit juice in any child taking medication that is metabolized by CYP3A4, as it has been shown to reduce the activity of intestinal cytochrome P450 3A4

Steroid Shots Seem Less Effective in Severe Knee OA

Presence of synovitis may not predict steroid therapy success
by Judy George
Contributing Writer, MedPage Today May 21, 2017
Osteoarthritis (OA) patients who had severe knee damage were less likely than patients with mild structural damage to respond to intra-articular steroid injections, according to a study from England.
In an open-label study to discover whether structural factors affected steroid injections for knee OA in the short term (2 weeks) and longer term (6 months), Higher meniscal damage (OR=0.74, 95% CI 0.55-0.98), increasing Kellgren-Lawrence (KL) maximal grade (OR=0.43, 95% CI 0.23-0.82), and joint space narrowing maximal score (OR=0.60, 95% CI 0.36-0.99) were each associated with lower odds of longer-term response to knee steroid injections. As maximal joint space narrowing score increased from grade 0 to grade 3, the odds of longer-term response dropped from 38% to 12%, according to Terence O’Neill of the University of Manchester, and colleagues.
In addition, the presence of synovitis did not appear to predict whether steroid injection therapy would be successful, they noted.
“There are few studies that have looked at the influence of structural factors on response to intra-articular steroid injections,” the authors wrote in Arthritis Research & Therapy. “Our study of intra-articular steroid injection predictor of response was larger in scale and longer in follow-up than prior studies, and also involved scoring of individual features through contrast-enhanced MRI, offering the opportunity to identify other OA features and synovial factors affecting intra-articular steroid injection treatment.”
The O’Neill group studied 199 patients who reported moderate knee pain for more than 48 hours or met criteria based on Knee Injury and Osteoarthritis Outcome Score (KOOS). They confirmed OA either radiologically with a KL score of at least 2, or by MRI or arthroscopy. In the MRI and arthroscopy cases, the researchers looked for changes typically associated with OA and evidence of cartilage loss. Patients with gout, septic arthritis, or inflammatory arthritis were excluded, as were those who had hyaluronic acid or steroid injections in the previous 3 months or knee surgery in the previous 6 months.
The average age of study participants was 63.2 and 51.6% were female. At baseline, median KOOS was 44.4 points.
Of the 199 patients studied, 188 had knee x-rays and 120 had MRI scans. Among the MRI patients, the researchers looked at the whole-organ MRI score (WORMS) of 109 people and synovial tissue volume of 111 individuals.
The researchers assessed short-term and long-term response rate using Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria, based KOOS and a global Likert scale. They defined a “responder” as someone who had one of the following:
• At least 20% change in KOOS and a “slightly” or “much better” score on a 5-point Likert scale for pain
• At least 50% change in KOOS
Patients whose pain rebounded to within 20% of their baseline KOOS were considered to be “relapsed.” The authors classified patients whose pain did not return to this level at 6 months of follow-up as “longer-term responders.”
Overall, 73.4% of patients responded in the short term after an intra-articular steroid injection, and 20.1% were longer-term responders. Using OMERACT-OARSI criteria, the investigators saw no-short term structural predictors of response.
However, they observed that in the longer term, patients with severe knee damage on MRI scans and x-rays were less likely to respond to steroid injections than patients with mild structural damage.
Using radiographic and MRI data, O’Neill’s group derived a predictive table of short-term and longer-term response to steroid injections, but warned that short-term x-ray probabilities should be viewed with caution due to non-significant results and wide confidence intervals.
“Our predictive probabilities suggest people with advanced radiographic disease are unlikely to benefit from intra-articular steroid injections in the longer term,” they wrote. “Based on the degree of joint space narrowing observed on radiographs, the odds of having longer-term response is increased from around 10% to almost 40% as the disease becomes less severe.”
The authors also noted that as maximal meniscal scores increased from 0 to 6, the odds of longer-term response dropped from 28% to 6%.
The study had several limitations. Because it evaluated individuals who had steroid injections only, some response may be due to a placebo effect. The researchers used conventional non-standardized images to evaluate malalignment, not full-limb weight-bearing x-rays, which are the gold standard.
In addition, they optimized MRI sequences to detect bone marrow lesions, which might have contributed to negative findings with other knee structures. Finally, x-rays could have been taken up to 24 months before the steroid injections. This means that OA severity might have been underestimated and misclassified in a small proportion of patients.

Earlier Antibiotics in ED Reduced In-Hospital Sepsis Deaths

Pluses and minuses of New York state’s sepsis care mandate
• by Salynn Boyles
Contributing Writer May 21, 2017
• This article is a collaboration between MedPage Today® and:
WASHINGTON — Earlier administration of antibiotics, but not intravenous fluids, was associated with lower in-hospital death rates among patients with suspected sepsis treated in New York state emergency departments following the adoption of statewide hospital mandates known as “Rory’s Regulations.”
The first-in-the-nation regulations requiring the early assessment and treatment of sepsis in the hospital emergency department setting were implemented in 2013, following the death of 12-year-old Rory Staunton from sepsis undiagnosed in a hospital ED until it was too late to save him.
The study findings support the association between time to treatment and outcome among patients with sepsis or septic shock treated in emergency departments under the statewide initiative, said researcher Christopher W. Seymour, MD, of the University of Pittsburgh School of Medicine.
Each 1-hour delay in completing the mandated protocol or administering antibiotics was associated with a 4% increase in the odds of in-hospital death, Seymour said.
Seymour presented the findings May 21 at ATS 2017 International Conference, the annual meeting of the American Thoracic Society. They were published simultaneously in the New England Journal of Medicine.
Seymour told MedPage Today that the move toward requiring protocolized early treatment of suspected sepsis or septic shock has been controversial within emergency medicine. Studies examining the impact of early treatment have been mixed, with a 2015 meta-analysis of 11 observational studies showing no mortality benefit with early antibiotic administration (within three hours of ED triage).
He said the New York mandate presented a unique opportunity to study the impact of early treatment of suspected sepsis in very different hospital ED settings.
In addition to legally requiring guideline-based clinical protocols for timely fluid resuscitation, antibiotic administration and frequent assessment of hemodynamic response to treatment, the mandate requires that the state’s department of health perform audits to determine if the treated patients actually had sepsis.
The study included data from patients with sepsis and septic shock reported to the New York State Department of Health between April 1, 2014, and June 30, 2016.
The primary outcome was in-hospital mortality, and the primary exposure was the time to completion of the 3-hour bundle, which includes measurement of lactate levels, prompt blood culture followed by administration of broad spectrum antibiotics and administration of intravenous fluids.
Among 49,331 patients treated at 149 hospitals, 40,696 (82.5%) were treated according to protocol within three hours. The median time to completion of the 3-hour bundle was 1.30 hours (IQR 0.65-2.35) and the median time to administration of antibiotics was 0.95 hours (IQR 0.35-1.95). The median time to completion of the fluid bolus was 2.56 hours (IQR 1.33-4.20).
Among patients who had the 3-hour bundle completed within 12 hours:
• Longer time to bundle completion was associated with higher risk-adjusted in-hospital mortality (OR 1.04 per hour, 95% CI 1.02-1.05; P<0.001)
• Longer time to antibiotic administration was also associated with higher adjusted in-hospital mortality (OR 1.04 per hour, 95% CI 1.03-1.06; P<0.001)
• Longer time to bolus fluid was not associated with a statistically significant increase in mortality (OR 1.01; 95% CI 0.99-1.02; P=0.21)
The analysis also showed large variations in protocol completion times from hospital to hospital, despite the fact that all hospitals in the state were legally required to follow the mandate, Seymour said.
“This is a really important finding and we need to understand more about why some hospitals are much better at providing this emergency department care,” Seymour said, adding that smaller hospitals in more rural areas tended to provide faster bundled care than larger, urban hospitals.
And an editorial published with the study in NEJM, expressed caution about broadly adopting Rory’s Regulations nationwide.
“Recent clinical trials suggest that protocolized resuscitation strategies, which are also mandated by Rory’s Regulations, may paradoxically lead to increased lengths of stay in the ICU and in the hospital and higher costs,” wrote Tina B. Hershey, MD, MPH and Jeremy M. Kahn, MD, of the University of Pittsburgh. “The regulations may also lead to antibiotic overuse, if hospitals, in an attempt to increase their adherence to guidelines, give antibiotics to patients who are not infected.”
They added that, “more broadly, there are insidious risks to turning clinical practice guidelines into policy mandates.”
“Clinical practice guidelines may make strong recommendations based on rigorous scientific evidence, but they are also inherently flexible, allowing physicians to exercise considerable professional judgment,” they wrote. “Legislation and regulation, however, are inherently inflexible, forcing clinicians to adopt certain care practices independent of clinical judgment.”
The research was funded by the National Institutes of Health, Veteran’s Affairs Services, and others.

Medicare Failed To Investigate Suspicious Infection Cases From 96 Hospitals

The lapse was discovered as by an OIG study designed to address concerns over whether hospitals are “gaming” a system in which it falls to the hospitals to report patient-infection rates.

This article first appeared May 09, 2017 on Kaiser Health News.
By Christina Jewett May 9, 2017

Almost 100 hospitals reported suspicious data on dangerous infections to Medicare officials, but the agency did not follow up or examine any of the cases in depth, according to a report by the Health and Human Services inspector general’s office.
Most hospitals report how many infections strike patients during treatment, meaning the infections are likely contracted inside the facility. Each year, Medicare is supposed to review up to 200 cases in which hospitals report suspicious infection-tracking results.
The IG said Medicare should have done an in-depth review of 96 hospitals that submitted “aberrant data patterns” in 2013 and 2014. Such patterns could include a rapid change in results, improbably low infection rates or assertions that infections nearly always struck before patients arrived at the hospital.
The IG’s study, released Thursday, was designed to address concerns over whether hospitals are “gaming” a system in which it falls to the hospitals to report patient-infection rates and, in turn, the facilities can see a bonus or a penalty worth millions of dollars. The bonuses and penalties are part of Medicare’s Inpatient Quality Reporting program, which is meant to reward hospitals for low infection rates and give consumers access to the information at the agency’s Hospital Compare website.
The report zeroes in on a persistent concern about deadly infections that patients develop as a result of being in the hospital. A recent British Medical Journal report identified medical errors as the third-leading cause of death in the U.S. Hospital infections particularly threaten senior citizens with weakened immune systems.
Rigorous review of hospital-reported data is important to protect patients, said Lisa McGiffert, director of the Consumers Union’s Safe Patient Project.
“There’s a certain amount of blind faith that the hospitals are going to tell the truth,” McGiffert said. “It’s a bit much to expect that if they have a bad record they’re going to ’fess up to it.”
Yet there are no uniform standards for reviewing the data that hospitals report, said Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine.
“There are greater requirements for what a company says about a washing machine’s performance than there is for a hospital on quality of care, and this needs to change,” Pronovost said. “We require auditing of financial data, but we don’t require auditing of [health care] quality data, and what that implies is that dollars are more important than deaths.”
In 2015, Medicare and the Centers for Disease Control and Prevention issued a joint statement cautioning against efforts to manipulate the infection data. The report said CDC officials heard “anecdotal” reports of hospitals declining to test apparently infected patients — so there would be no infection to report. They also warned against overtesting, which helps hospitals assert that patients came into the hospital with a preexisting infection, thus avoiding a penalty.
In double-checking hospital-reported data from 2013 and 2014, Medicare reviewed the results from 400 randomly selected hospitals, about 10 percent of the nation’s more than 4,000 hospitals. Officials also examined the data from 49 “targeted” hospitals that had previously underreported infections or had a low score on a prior year’s review.
All told, only six hospitals failed the review, which included a look at patients’ medical records and tissue sample analyses. Those hospitals were subject to a 0.6 percent reduction in their Medicare payments. Medicare did not specify which six hospitals failed the data review, but it did identify dozens of hospitals that received a pay reduction based on their reports on the quality of care.
The new IG report recommended that Medicare “make better use of analytics to ensure the integrity of hospital-reported quality data.” A response letter from Centers for Medicare & Medicaid Services Administrator Seema Verma says Medicare concurs with the finding and will “continue to evaluate the use of better analytics … as feasible, based on [Medicare’s] operational capabilities.”
Questions about truth in reporting hospital infections have percolated for years, as reports have trickled out from states that double-check data.
In Colorado, one-third of the central-line infections that state reviewers found in 2012 were not reported to the state by hospitals, as required. Central lines are inserted into a patient’s vein to deliver nutrients, fluids or medicine. Two years later, though, reviewers found that only 2 percent of central-line infections were not reported.
In Connecticut, a 2010 analysis of three months of cases found that hospitals reported about half — 23 out of 48 — of the central-line infections that made patients sick. Reviewers took a second look in 2012 and found improved reporting — about a quarter of the cases were unreported, according to the state public health department.
New York state officials have a rigorous data-checking system that they described in a report on 2015 infection rates. In 2014, they targeted hospitals that were reporting low rates of infections and urged self-audits that found underreporting rates of nearly 11 percent.
Not all states double-check the data, though, which Pronovost said underscores the problem with data tracking the quality of health care. He said common oversight standards, like the accounting standards that apply to publicly traded corporations, would make sense in health care, given that patients make life-or-death decisions based on quality ratings assigned to hospitals.
“You’d think, given the stakes, you’d have more confidence that the data is reliable,” he said.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Nationwide model to stop deadly superbugs may not work so well after all

by Ilene MacDonald | FierceHealth
May 18, 2017 9:03am
Infection control experts are rethinking a long-held strategy to prevent deadly superbug infections after an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in a California hospital’s neonatal intensive care unit.
The strategy, developed in 2013 by Susan Huang, M.D., an infection control expert at UC Irvine Medical Center, is now used in 65% to 80% of hospitals across the country. The protocol treats all patients in the ICU with daily disinfectant baths and antibiotic nasal swipes. But the method didn’t work at the California hospital’s intensive care unit, where seven infants became sick in December, the Los Angeles Times reports.
In addition to bathing all infants in the ICU with a disinfectant and swabbing their noses with an antibiotic, the hospital also isolated the infected babies and made sure nurses washed their hands, according to the article. But the measures didn’t work. Three more infants tested positive for MRSA in February and March.
Huang declined an interview with the Los Angeles Times, but in a written statement told the newspaper, “We want the strategies we employ to work 100% of the time, but that’s not always possible.”
Still, the protocol’s failure has fueled the ongoing debate on whether the established method is the best way to stop the superbug. Experts have worried that treating all patients with the disinfectant and antibiotic could make bacteria more resistant to drugs. And some advocate for hospitals to screen all inpatients for MRSA, a costly but effective method for reducing the incidence of the often-deadly bacteria.
Recent research has also pointed to hospital floors and sinks as potential culprits in the spread of MRSA. Researchers hope the results of that study will bring more attention to the infection risk posed by floors, which are not often considered in the conversation on infection control

Celebrating 50 Years of Physician Assistants

Annual conference will be ‘a hoot and a half’ says AAPA president
by Shannon Firth
Washington Correspondent, MedPage Today May 12, 2017

LAS VEGAS — Recertification battles, the future of practice authority, and stamping out the opioid crisis will be core issues for discussion at the American Academy of PAs conference here next week.
The leading organization for physician assistants will celebrate 50 years of the profession at its annual conference, where the theme is “Beyond.”
The first ever class of PAs graduated on Oct. 6, 1967, said Josanne Pagel, MPAS, PA-C, president and chair of the board of directors for the AAPA and executive director of Physician Assistant Services at the Cleveland Clinic.
While remembering their half-century of history, PAs will also look ahead to the next 50 years, to ways they can transform healthcare “beyond their wildest dreams, Pagel said in a phone interview, during which a press representative was present.
One of the buzz words at this year’s conference will be “optimal team practice.”
A resolution on the future of practice authority will be debated and voted on during the AAPA’s House of Delegates meeting.
“We know going into the future, [medicine] is all about team care,” Pagel said. “So, we really emphasize our commitment to that.”
While committed to working with physicians, optimal team practice also means rejecting laws and regulations that require PAs to have or report a supervisory agreement with a physician in order to practice, she said, and lobbying for autonomous state boards — voting bodies with a majority of PAs.
“We want to make sure that the PAs have a voice in their governance to license, to regulate and to discipline PAs,” Pagel said.
The AAPA also wants to ensure PAs are eligible for direct reimbursement from insurers instead of remaining “hidden providers” under a physician’s schedule.
The resolution amends AAPA’s Guidelines for State Regulation of PAs to let individual states decide which provisions work for them.
Continuing medical education sessions will begin on Monday morning, with poster sessions and a special open forum on the future of PA recertification that afternoon, a subject on which the AAPA is currently battling with the National Commission on Certification of Physician Assistants (NCCPA).
The latter recently announced that it was exploring alternative models for maintenance of certification — an idea Pagel applauds — but the NCCPA continues to lobby to make recertification a condition for maintaining licensure in at least three states: Illinois, West Virginia, and New Mexico.
NCCPAs’s lobbying efforts, and its push for continual recertification via “high stakes exams” are “jeopardizing the ability of PAs to practice,” she said.
The Monday forum will explore the feasibility of establishing a new certifying body, and later the AAPA’s House of Delegates will take up a resolution addressing the NCCPA’s lobbying efforts.
The conference has devoted several sessions to the opioid abuse epidemic including presentations on appropriate opioid prescribing and non-opioid pain management.
Pagel, as someone whose family has been personally affected by the epidemic and whose home state of Ohio is at the “top of the charts” in terms of opioid deaths, sees these presentations as very important.
“The PAs are jumping on this to be able to lead and show other professions how to be responsible prescribers.”
The meeting will also include several sessions on leveraging data and new technologies.
More than 6,500 attendees are expected at the conference and 99 poster presentations.
AAPA will host a special champagne toast to commemorate 50 years of the PA profession with a live performance from the Texas Tenors on Monday evening.
Other conference highlights include the AAPA’s National Medical Challenge Bowl on Wednesday and keynote speaker Zubin Damania, MD — a.k.a “ZDoggMD” — who will illustrate the comic side of medicine on Tuesday afternoon.
“It’s going to be … a hoot and a half,” Pagel said.