Research roundup: Doctors' industry ties; Patient safety and residents' hours; Designing a medical home

Nov 12 2010

Archives of Internal Medicine: Physician Professionalism And Changes in Physician-Industry Relationships From 2004 to 2009 -"During the last 6 years a number of efforts have aimed to reduce, and in some cases eliminate, certain types of physician-industry relationships (PIRs)," including policies "that forbid physicians from accepting samples and receiving food and beverages in offices, limiting company representatives' access to physicians' offices and clinical areas, and banning faculty participation in speaker bureaus and other forms of promotional activity," write the authors. They explored the effect of such changes by asking nearly 3,000 primary care physicians about payments or gifts "from drug, device, or other medically related companies," meetings with industry representatives and prescribing habits for brand-name drugs when a generic equivalent was available. Two-thirds completed the survey.

"Overall, 83.8% of all respondents reported some type of relationship with industry during the previous year. … Approximately two-thirds of physicians (63.8%) received drug samples in the last year. Slightly more (70.8%) received gifts from industry, primarily food and beverages in their offices. … A total of 14.1% received payments for professional services to pharmaceutical companies." The authors conclude: "Overall, this study shows that PIRs have been decreasing in the United States—at least for the last 5 years." But they suggest, "These findings support the ongoing need for a national system of disclosure of PIRs" (Campbell et al., 11/8).

Centers for Disease Control and Prevention: Vital Signs: Health Insurance Coverage And Health Care Utilization --- United States, 2006--2009 and January--March 2010 - This report examines National Health Interview Survey (NHIS) data "to determine the number of persons without health insurance or with gaps in coverage and to assess whether lack of insurance coverage was associated with increased levels of forgone health care. ... In 2009, an estimated 58.7 million (19.5%) persons of all ages had no health insurance for at least part of the year preceding their interview." Of that group, about 49 million (83 percent) were adults aged 18 or older. The number of children without coverage for at least part of the year in 2009 fell 5 percent from the previous year to 9.5 million. The researchers also found the ranks of the uninsured continuing to grow this year (Fox and Richards, 11/9).

KHN summarized news coverage of the CDC report.

Annals of Family Medicine: Implications Of Reassigning Patients For The Medical Home: A Case Study - Some of patients in the Group Health Cooperative, "a large, nonprofit, integrated delivery system" in Washington state, were reassigned to new physicians as part of a "medical home pilot" project that aimed to strengthen doctor-patient "continuity" relationships by, among other things, expanding standard visit time from 20 to 30 minutes, and allocating an hour each day for secured messaging and telephone communication with patients."

The authors noted that "physicians chose those who were oldest, sickest, and with whom they had the longest relationship ... reassigned patients used primary care services less often but appear to have used expensive emergency department visits as often as their counterparts. The decrease in primary care, after controlling for past usage, is worrisome, as one of the goals of a medical home implementation is to strengthen the connection between patients and their primary care physician to prevent episodes requiring emergency care. It is unclear whether this decrease in primary care usage represents a transitory effect of reassigning patients to new physician or a long-term disruption to relational continuity" (Coleman et al., November/December 2010).

Journal of General Internal Medicine: The Impact Of Resident Duty Hour Reform On Hospital Readmission Rates Among Medicare Beneficiaries - "One of the intended goals of resident duty hour reform, instituted by the Accreditation Council for Graduate Medical Education (ACGME) on July 1, 2003, was to improve outcomes of care. Critics of the new policy, however, were concerned that the potential for discontinuous care and frequent handoffs would adversely affect patient outcomes," according to the authors, who examined records from more than 8 million Medicare patients admitted to acute care hospitals in the U.S. between July 1, 2000 and June 30, 2005, "with a principal diagnosis of acute myocardial infarction (AMI), stroke, gastrointestinal bleeding, or congestive heart failure (CHF) or with a diagnostic related group (DRG) classification of general, orthopedic, or vascular surgery." They found that "readmission rates neither improved nor worsened in association with ACGME duty hour reform" (Press et al., 11/6).

New England Journal of Medicine: Effect Of A Comprehensive Surgical Safety System On Patient Outcomes - This study examines the effects of the use of the Surgical Patient Safety System (SURPASS) checklist, "a multidisciplinary checklist that follows the surgical pathway from admission to discharge … on patient outcomes … in a controlled, multicenter, prospective study comparing outcomes before and after implementation of the intervention." The study looks at six hospitals in the Netherlands.

The authors report that the checklist reduced the "postoperative complication rate from 27.3 per 100 patients before implementation to 16.7 per 100 afterward and ... in-hospital mortality from 1.5 to 0.8% ... This hypothesis is further supported by the significantly lower complication rate among patients for whom 80% or more of the checklist items were completed than among those for whom a smaller proportion of the checklist items were completed" (de Vries et al., 11/11).

Journal of General Internal Medicine: Validation Of Self-Reported Health Literacy Questions Among Diverse English And Spanish-Speaking Populations - "[A]lthough limited HL [health literacy] is associated with a range of health outcomes, it is often not feasible to measure directly in clinical, epidemiologic, or public health studies because standard measurement tools are lengthy and cannot be administered by telephone," according to this study that evaluated the effectiveness of three self-reported questions: "'How confident are you filling out medical forms?'; 'How often do you have problems learning about your medical condition because of difficulty understanding written information?'; and 'How often do you have someone help you read hospital materials?'" to assess health literacy in a population of Spanish-speaking and English-speaking adults with type 2 diabetes.

"We found that three self-reported HL questions could identify those with inadequate, and inadequate plus marginal HL within this ethnically diverse, English and Spanish-speaking population with a moderate degree of discrimination" (Sarkar et al., 11/6).

Robert Wood Johnson Foundation/State Health Access Data Assistance Center: Participation In The New Mexico State Coverage Insurance (SCI) Program: Lessons From Enrollees - New Mexico's State Coverage Insurance (SCI) program, "a public/private partnership," provides access to "subsidized health insurance for uninsured whose household incomes below 200 percent of the federal poverty level. The program targets small businesses with 50 or fewer eligible employees," who "may sponsor group enrollment into SCI for employees." Since the new federal health law seeks to encourage owners of small businesses to offer health coverage to their employees, the researchers examined the New Mexico program to see what lessons can be learned there. They drew from a 2008 survey and found that "SCI is helping uninsured state residents with low incomes obtain health insurance, and that most of the employed SCI enrollees did not have health insurance in the year prior to enrolling.their findings ...  These findings highlight the importance of financial subsidies and size constraints for small businesses and should be considered as [the health law] implementation moves forward" (Spicer et al., 11/3).

Engelberg Center for Health Care Reform at the Brookings Institution: Achieving Better Chronic Care At Lower Costs Across the Health Care Continuum for Older Americans - "Improvements in the efficiency and quality of care delivered by the U.S. health care system is largely dependent on reforming the way that care is supported, reimbursed, and delivered to older Americans, who often have multiple chronic illnesses and are in need of long-term services and supports (such as home and community-based services, intermediate care facilities for people with mental retardation/developmental disabilities, or nursing homes)," write the authors. They call for "robust health IT infrastructure ... a team of providers that include doctors, nurses, health aides, family caregivers, and the patient. Third, care delivery strategies need to be accurately evaluated using performance measures that incorporate individual patient goals and consider quality of life ... Finally, care delivery strategies should be supported by payment reforms that incentivize quality care rather than volume and intensity of services" (October 2010).