2011 Potpourri XXVII

An article in the Annals of Internal Medicine discusses a very basic part of medical care–taking blood pressure measurements.  The accuracy of these is very important because the results will guide how physicians treat a patient, particularly those with hypertension.  Measurements taken in a clinic can be affected by anxiety and mistakes can be made in the taking and recording of measurements.  Home measurements may more accurately reflect real-life blood pressure but can also have errors.  The study compared 6-month research BP measures; clinic measures during outpatient visits and home measures taken and transmitted electronically.  There was wide variability across and within methods and measures taken in a clinic would give the highest indication that BP was out of control, likely leading to more medication.  The authors conclude it is best to use 5-6 measures, with some not in the clinic.  Just a showing of how little is known for even a very elementary aspect of medical care.   (Annals Article)

A blog post from the Medicus Firm discloses preliminary findings from a survey of 2,339 physicians across specialties in regard to compensation.  Compensation overall was basically flat from 2009-10, although Emergency Medicine doctors and psychiatrists reported the largest increases.  Only 2% of physicians said their income exceeded their expectations and only 35% said they were satisfied with their income given the amount of work they put in.  About 6% of the doctors said they were so dissatisfied with compensation that they might quit medical practice.  That won’t help access.   (Blog Post)

Research reported in the Archives of Internal Medicine examined a common practice of physicians and other providers copying and pasting visit notes in EMRs.  The study looked at diabetes patients who supposedly received lifestyle counseling.  The copying and pasting indicated counseling occurred at multiple visits, but the patients who supposedly had the repeat counseling had no better outcomes, as measured by HbA1c, than patients who had no counseling.  This suggests that the counseling is either pro forma or non-existent.  Another example of how EMRs could be misused and provide inaccurate information.   (EMR Article)

CMS and other payers are using “never events” as one way to supposedly improve the quality of health care.  These events are things that supposedly could be avoided by better procedures and other tactics and CMS won’t pay when they do occur.  One such event is patient falls in a hospital.  A new study challenges the notion that these falls are in fact preventable.  The study, published in the Journal of the American Academy of Orthopaedic Surgeons, found first that the risk of falls is only slightly greater in hospitals than in the home, and secondly, that even very elaborate prevention programs appeared to have little effect on the number of falls.  The authors conclude that most falls are probably not avoidable, undermining the notion that they should be treated as never events.   (Falls Article)

In yet another example of overuse of a common and fairly expensive medical procedure,the Journal of the American Medical Association published a study regarding percutaneous coronary interventions, mostly stenting.  About 600,000 of these are performed a year in the US, costing $12 billion.  There are significant risks associated with the procedure.  Six professional organizations recently issued guidelines on PCI use and the study compared those guidelines to actual practice.  Of over 500,000 procedures examined, about 70% were for acute indications and 30% for sub-acute.  Almost all the acute uses were appropriate.  Only about half the sub-acute ones were clearly appropriate and about 12% were for clearly inappropriate ones.   There was almost twofold variation in appropriateness rates among hospitals.  (JAMA Article)

In its annual proposed rule on physician reimbursement for the next fiscal year, in this case 2012, CMS usually looks at its policy on telemedicine coverage.  A few changes are made this time, but overall coverage continues to be very stinting and in general CMS does not have an innovative approach that could maximize the cost and quality benefits of encouraging widespread use of telemedicine and other forms of telecommunication in health care.  CMS did change the rule to only require a showing of clinical benefit to the patient, not that telemedicine would be as good or better as in-person services.  One hangup may be that the total cost to CMS of telemedicine services may be more than for an in-person visit, because it pays both an in-person and distant site fee, which isn’t completely rational.   (CMS Proposed Rule)