Research roundup: Hospital emergency room HIV screenings; Medical device reviews; Health law impact on docs and hospitals

Jul 26 2010

Annals of Family Medicine: Physician Satisfaction With Chronic Care Processes: A Cluster-Randomized Trial Of Guided Care - The authors randomly assigned teams of physicians and their chronically ill older patients into groups that either provided Guided Care - an educated registered nurse works with a primary care practice team to enhance quality of care - or usual care. One year later, they measured "physicians' satisfaction with chronic care processes, time spent on chronic care, knowledge of their chronically ill older patients, and care coordination provided by physicians and office staff."

"Compared with the physicians in the control group, those in the Guided Care group rated their satisfaction with patient/family communication and their knowledge of the clinical characteristics of their chronically ill older patients significantly higher," the authors report (Marsteller et al., July/August 2010).

Urban Institute: How Will Physicians Be Affected By Health Care Reform? - Authors of this paper (.pdf) write: "As a result of adding more than 30 million insured people to the population, it is likely that the demand for free or reduced-cost care will go down and this should have a positive impact on physician practice revenues and incomes." The paper also examines how the health reform law calls for a raise in "Medicaid services provided in 2013 and 2014 by family practitioners, general internists, and pediatricians to Medicare-fee levels" and "increase[s] in Medicare fees for primary care services."

"The likely effects of efforts to bend the cost curve are less clear. But, if they succeed in producing a more efficient health care system, physicians could gain relative to other providers and, among physicians, primary care physicians could gain relative to specialist" .(Zuckerman and Berenson, 7/15).

A second Urban Institute paper (.pdf) examines how hospitals will be affected by health reform. "The roughly 30 million newly insured Americans will generate about $40 billion in new revenues for all hospitals by 2019, about twice as much as the Medicare payment cuts and the reductions in payments that will be made to offset the reduced costs of uncompensated care. For the most part, the payment changes that affect hospitals represent a modest move in the direction of paying for value rather than volume" (Berenson and Zuckerman, 7/15).

The American Enterprise Institute: Overspending On Multisource Drugs in Medicaid - With Medicaid data, the author of this paper compared the sales of costly name-brand drugs with generic versions and found "that underutilization of available generics resulted in $271 million of unnecessary spending in 2009." He identified 20 medications and 139 national drug codes "for which a generic substitute was available in the identical dosage form, strength, package type, and package size." The author points out that "Medicaid spent $21.8 billion on prescription medicines [in 2009]. And total Medicaid spending—the federal share in particular—is certain to grow in the future. … An important and relatively simple approach to reducing wasteful spending is to maximize the use of available generic drugs in the Medicaid Drug Rebate Program" (Brill, 7/21).

Annals of Family Medicine: Primary Care, Economic Barriers To Health Care, And Use Of Colorectal Cancer Screening Tests Among Medicare Enrollees Over Time - In 2001, Medicare expanded coverage of screening colonoscopies. The authors compared screening use among patients 65 to 80, who had participated in a Medicare Current Beneficiary Survey in 2000, 2003 and 2005. "Despite expanding coverage for [Colorectal Cancer] screening, which primarily benefited those without supplemental insurance, Medicare enrollees who did not have supplemental insurance or a usual place of health care had disproportionally lower rates of CRC testing," the study authors write. "This finding suggests that expanding health insurance benefits without additional targeted efforts to improve utilization of appropriate health care services will not eliminate disparities" (Doubeni et al., July/August 2010).

Journal of the American Medical Association: Routine Opt-Out Rapid HIV Screening And Detection Of HIV Infection In Emergency Department Patients - This study examines whether widespread routine HIV screening in a busy hospital emergency department (ED) is "associated with identification of more patients with newly diagnosed HIV infection than physician-directed diagnostic rapid HIV testing." Denver Health Medical Center researchers examined the number of new HIV cases identified during three 4-month periods, during which ED patients, 16 or older, were told they would receive a rapid HIV test unless they declined to. Those results were compared with three 4-month periods during which rapid HIV testing occurred when physicians requested it.

Of the 28,043 patients eligible, 6,762 (about 24 percent) did not opt out of testing. Of those, 16 patients were found to have an HIV infection, including 10 who had new diagnoses. In the diagnostic phase, 29,925 patients were eligible and 243 patients (0.8 percent) were screened. HIV infections were confirmed in five of those patients and 4 had new diagnoses. The authors conclude: "Nontargeted opt-out rapid HIV screening in the ED, vs diagnostic testing, was associated with identification of a modestly increased number of patients with new HIV diagnoses, most of whom were identified late in the course of disease" (Haukoos et al., 7/21).

Annals of Internal Medicine: Effect Of An End-Of-Life Planning Intervention On The Completion Of Advance Directives In Homeless Persons - Authors compared two groups of Minneapolis homeless people: one got educational information and then filled out advance directives, the other received one-on-one counseling and completed an advance directive with a social worker. "The overall completion rate for advance directives was 26.7% …  with a higher rate in the counselor-guided group (37.9%) than in the self-guided group (12.8%). … This difference persisted across all sites and most subgroups," the authors of the study report. "Homeless persons can respond to an intervention to plan for end-of-life care and can express specific preferences for care or a surrogate decision" (Song et al., 7/20). 

PLoS Medicine: Left To Their Own Devices: Breakdowns In United States Medical Device Premarket Review - "Advances in medical device technologies have translated into significant improvements in the health of patients. Yet cracks in the device review system may threaten to undermine this progress," write the authors, adding that there are "eight specific potential weaknesses in the premarket review process," including "a lower approval standard than their drug counterparts, excessive reliance upon a fast-track process, and failure to conduct Congressionally-mandated device classifications."

"On the legislative front, US Congress should raise the standard for approval of devices intended to treat diseases to equal that required for drugs: 'substantial evidence' rather than 'reasonable assurance' of effectiveness. Such devices should be subject to the same regulatory scrutiny as drugs, such as more than one well-controlled trial" the authors write (Hines et al., 7/13).

Commonwealth Fund: State Case Studies Of Infant And Early Childhood Mental Health Systems: Strategies For Change - "In recent years, states have made progress in identifying and referring children for developmental and mental health problems at a young age, particularly through the Assuring Better Child Health and Development initiatives in primary care," write the authors of this report, that examines systems for children, 5 and under, in Colorado, Indiana, Massachusetts and Rhode Island. They conclude: "Although the initiatives we studied are innovative and exciting, in most cases, state funding has been cobbled together with time-limited federal and private grant support. When these sources end, states face significant challenges in sustaining initiatives and expanding them into statewide systems. ... states must make better use of existing resources through integration of funding sources, new methods of early identification, and innovative, cost-effective models of early intervention and family support" (Lyman, Holt and Dougherty, July 2010).