Research roundup: Surgical care at critical access hospitals; Digging into the cost of emergency medicine; Getting what you want for end-of-life care

May 4 2013

Each week, KHN reporter Alvin Tran compiles a selection of recently released health policy studies and briefs.

JAMA Surgery: Utilization And Outcomes Of Inpatient Surgical Care At Critical Access Hospitals In The United States – During the past 15 years, the number of critical access hospitals (CAHs) – those with fewer than 25 acute care beds that receive higher reimbursements and other considerations from Medicare to help sustain them – has increased substantially, representing a quarter of all U.S. acute care hospitals in 2011. But there is also growing interest in the quality of care and the costs. Using surgical data from 2005 to 2009, researchers found that "compared with non-CAH facilities, CAHs are less likely to provide inpatient surgical care in specialty fields" and that "in-hospital mortality for common low-risk procedures is indistinguishable between CAHs and non-CAHs." Although patients at CAHs were less likely to have a prolonged stay, the costs at CAHs were 9.9% to 30.1% higher than at non-CAHs. They conclude: "The higher costs associated with surgical care at CAHs identify potential opportunities for cost savings" but worry that "changes in payment policy for CAHs could diminish access to essential surgical care for rural populations" (Gadzinski et al., 5/1). 

Annals Of Emergency Medicine: Owning The Cost Of Emergency Medicine: Beyond 2% – Emergency room care is often cited as overused and one of the drivers of the increasing health spending. However, emergency room physicians have countered that argument, estimating that ER costs make up just 2 percent of the nation's health care spending. But: "We have presented calculations demonstrating that aggregate ED expenditures are higher than previously published," the authors write. "A conservative estimate is approximately 5% of national health expenditures, although it could be as high as 10%. These results may invite further criticism that the expense of emergency care represents unnecessary, inefficient care. However, we offer a more sanguine interpretation: the high share of spending affirms the importance of emergency medicine." They suggest current estimates are based on outdated models and suggest instead that researchers use activity-based cost accounting, which involves mapping patients' entire clinical, administrative and diagnostic encounters. "Rather than minimizing the issue of cost, we should recognize the economic and strategic importance of the ED within the health care system and demonstrate that costs are commensurate with value," the authors conclude (Lee, Schuur and Zink, 4/26).

Rand Corp.: Oral Health In The District Of Columbia: Parental And Provider Perspectives – Many areas in the District of Columbia suffer from a shortage of dentists and other barriers to oral health care, especially those with a large low-income population, according to this study.  Researchers interviewed parents, dentists, pediatricians, and school health nurses to assess the barriers to better oral health in the city. Health providers said they felt parents did not view their children's oral health as a priority. Parents, on the other hand, told researchers they felt the care provided by clinics serving Medicaid patients was lower in quality and they had trouble getting access to that care. The researchers recommended providing incentives to encourage dentists to accept Medicaid patients to expand their clinic hours. They add that there is "a need to expand health promotion in schools and in the greater District metropolitan area to better educate parents about the importance of preventive care" and that "such promotion should include community-based and culturally and linguistically appropriate media campaigns" (Blanchard, Towe, and Donald, 4/26).

Dartmouth Atlas Project/California HealthCare Foundation: End-Of-Life Care In California: You Don't Always Get What You Want -- The report presents research findings from 2003 to 2010 which show that end-of-life care for Medicare patients varied widely across California. "Most striking is the increase in intensity of care in some regions and hospitals but not others," the author notes. She writes that on some measures, care more closely matches patient preferences than it did in 2003: dying patients spend less time in the hospital and were more likely to receive hospice care. However, the findings also show an increase in the percentage of patients seeing more than 10 physicians during the last six months of life and the days spent in the intensive care unit during that time. Compared to the rest of the country, the state of California had a higher percentage of patients dying in the hospitals, patients with more days spent in the ICU, and patient deaths that involved an ICU stay. "The disparate findings point to the important role of the local delivery system in determining the care patients receive," she concludes (Brownlee, 4/2013).

Here is a selection of news coverage of other recent research:

CBS News: Lying To Doctors Could Be Harmful For Patients
Telling a white lie to a friend is not always the best idea. Telling one to your doctor could lead to serious health problems, but many still seem to do it. CBS News medical contributor Dr. Holly Phillips told "CBS This Morning: Saturday" that people go into their doctor's office with a problem and do not always tell the whole truth simply because they do not want to feel criticized. "Research shows that, again, people don't want to feel judged. It is a reflex," she said. "When you're in an interview setting, you want to make a good impression, but ultimately it's not about that." According to a study conducted with the Cleveland Clinic, 28 percent of patients say they "lie or omit facts" when visiting their health care providers (Davis, 4/27).

Reuters: MedEvac Cost Effective With Modest Use Improvements
Emergency helicopter transport is expensive, but could become cost effective if it's used mainly for cases where it will make a measurable difference in trauma patients' survival or long-term disabilities, according to a new analysis. "For the routine use of helicopter emergency medical services to be considered good value for our health care dollars, there needs to be a modest reduction in mortality or some reduction in disability among patients who are flown out with serious injuries," said study author Dr. Kit Delgado, an instructor of emergency medicine at Stanford University Medical School (Stokes, 5/2).

MedPage Today: Doc Pay: More $$$ For Primary Care
The pay disparity between primary care physicians and their specialty counterparts -- which is often cited as a reason for the shortage of primary care providers -- is lessening, according to a survey. Primary care physicians reported a first-year guaranteed compensation of $180,000 in 2012, up from $175,000 in 2011. Meanwhile, the average first-year compensation of all specialists combined dropped over that same time from $255,000 to $247,437, according to the MGMA Physician Placement Starting Salary Survey: 2013 Report Based on 2012 Data (Pittman, 5/2).

Reuters: Healthcare Costs To Negate State, Local Budget Improvements: Outlook
State and local governments can expect ever-widening budget gaps through 2060, as rising healthcare costs for both citizens and public employees surpass recent improvements in their revenue, the Government Accountability Office said on Monday. Closing the gap may require drastic action (Lambert, 4/29).

Reuter: Task Force Calls For Routine HIV Testing For All Adults
An influential U.S. panel is calling for HIV screening for all Americans aged 15 to 65, regardless of whether they are considered to be at high risk, a change that may help lift some of the stigma associated with HIV testing. The new guidelines from the U.S. Preventive Services Task Force (USPSTF), a government-backed panel of doctors and scientists, now align with longstanding recommendations by the U.S. Centers for Disease Control and Prevention (Steenhuysen, 4/29).