December 30, 2011
By Karl Thallner*
Should Your Doctor Be Napping on the Job?
In 1989, interns and residents who trained in New York were restricted to twenty-four consecutive hours in the hospital and eighty total work hours per week (on average). In 2003, the national organization that regulates medical education implemented similar, but somewhat watered-down, rules for the entire country. Many experts expected medical care would be improved in hospitals after the change in work rules. That assumption makes sense considering that sleep-deprived people tend to perform worse than the well-rested: one study found that after twenty-four consecutive hours of wakefulness, people's motor skills and judgment are as impaired as if they had a blood alcohol level over the legal driving limit.
However, the data on whether the new work limits save lives isn't so clear. Clever studies have compared death rates before and after the regulations were instituted in teaching hospitals, and also compared those trends to non-teaching hospitals, which presumably shouldn't be affected by work-hour restrictions for doctors in training. In large national investigations of surgical patients and medical patients, death rates didn't drop after the rules were implemented.
To really ensure that residents get rest when they need it, which would help them think clearly when they need to, maybe the solution is to institute napping on the job. Sleep scientists have demonstrated that naps (even as short as one hour of real sleep) can prevent performance error. One 2006 study randomly assigned medical residents to take optional naps and found that on average, they actually did manage to get extra rest. A newer, hopefully more definitive study is currently ongoing, testing the effect of required naps.
Dr. Zachary F. Meisel and Dr. Jesse M. Pines, Should Your Doctor Be Napping on the Job?, TIME (Dec. 30, 2011).
Less Prostate Cancer Surgery Complications at Academic Institutions
With the growing number of prostatectomies performed each year and increased scrutiny regarding healthcare outcomes and cost, many have focused on the efficacy and impact of prostatectomy on cancer, as well as side effect control. Past studies have found the volume of cases preformed annually impacts surgical outcomes like erectile function, urinary control, and cancer control. In line with the practice-makes-perfect hypothesis, hospitals and surgeons who log more cases have decreased instances of death and complications from surgery. Additionally, long-term continence, potency, and disease-free survival were found to be superior at high-volume centers and with high-volume surgeons.
Although academic institutions tend to have higher case volumes, the importance of an academic affiliation on surgical outcomes was examined for the first time last month in a report published in the Journal of Urology. The authors examined data from the Nationwide Inpatient Sample, which is a database comprised of inpatient discharges and associated charges for approximately 20% of the U.S. population. Using this data set, the authors were able to isolate patients who had a prostatectomy and patient experiences between academic and non-academic centers. The authors concluded that prostatectomies performed at academic institutions resulted in less overall complications.
This is not the first report to demonstrate a benefit to being treated within an academic institution. Deaths from heart failure, heart attack, and stroke were reduced at major teaching institutions. Being a patient at a teaching hospital however, can be frustrating. Due to the fact that there are students at various points in their training, patients are examined multiple times by medical students, residents, and attending physicians. However, with this process comes greater attention and critical analysis of every clinical decision made.
Dr. David B. Samadi, Picking the Right Hospital for Prostate Cancer Surgery, Fox News (Dec. 23, 2011).
Same Surgery, Widely Different Rates at CT Hospitals
Federal reimbursements for surgical procedures swing widely among Connecticut hospitals, a C-HIT analysis of available Medicare data shows, with Dempsey hospital receiving a higher rate than other hospitals for most procedures. Yale-New Haven, Bridgeport, and Windham hospitals were also consistently among the top five in Medicare reimbursements, according to the data. Experts say the variation in Medicare payments is due to a variety of factors, including the type of hospital (teaching or non-teaching), regional wages and salaries, the income mix and sickness of patients and the number of tests and services provided.
Various factors push up costs at some hospitals, including a higher use of intensive care beds, more visits by multiple doctors, and more tests such as MRIs and CT scans. Those treatment variables are attracting increasing scrutiny in Connecticut, as the state moves towards implementing healthcare reform and examines how hospitals are paid for services.
Medicare reimburses Dempsey for most surgeries at a higher rate than any other hospital in the state, including other teaching hospitals, the C-HIT analysis shows. Dempsey was paid a median amount of $21,569 for major joint replacement surgery, for example, compared to a statewide median payment of $15,255. The lowest rate was paid to Day Kimball Hospital, at $13,343. For a major cardiovascular surgery, Medicare paid Dempsey a median of $54,655, compared to $36,966 for the Hospital of Central Connecticut.
Employee pay and fringe benefits, facility size, and the number of poor people treated contribute to Dempsey's top reimbursement rate, said Cassandra Mitchell, associate vice president for reimbursement and financial systems at the University of Connecticut Health Center. Medicare also paid Dempsey more per patient because it's a smaller teaching hospital than Yale-New Haven, Hartford, and others. Medicare reimburses teaching hospitals based on the ratio of medical residents to beds, and Dempsey's ratio of 1.073 (meaning about one medical resident for each bed) is the highest in the state. The next highest is Yale-New Haven, at 0.6161, followed by Hartford, at 0.3803. In addition, Medicare pays hospitals a greater amount if they have a "disproportionate share" of low-income patients. Dempsey's Medicare reimbursements were higher, in part, because low-income patients' stays were longer in its neo-natal intensive care unit, and it treats patients with sickle-cell anemia and other blood disorders, which tend to require longer hospitalizations.
Rob Gurwitt, Hospitals: Same Surgery, Widely Different Rates, New Haven Independent (Dec. 25, 2011).
Security Breach Affects 1,300-Plus Patients
The private medical records of more than 1,300 patients and/or their guarantors were endangered for a time earlier this month when a Loma Linda University Medical Center employee took home documents against hospital policy. The records have been secured and the employee fired, spokeswoman for the medical center Briana Pastorino said in a news release.
The records of 1,336 patients or those responsible for paying the patients' bills were breached on or around December 19, Pastorino said. Records included birth dates, addresses, medical records numbers, driver's license numbers and, in come cases, Social Security numbers. The hospital is conducting an internal investigation to determine how the breach happened and how it can be prevented in the future, said Jemellee Ambrose, the medical center's director of communications. Preliminary investigation provided hospital officials with enough evidence to warrant the employee's dismissal, Ambrose said.
Steven Barrie, Loma Linda: Security Breach Affects 1,300-plus Patients, The Press Enterprise (Dec. 28, 2011).
Academic Medical Centers Use National Marketing
Only a few hospitals such as Cleveland Clinic advertise from coast to coast. But now academic medical centers are trying out national marketing, including for the first time Vanderbilt. Chief marketing officer Jill Austin says the messages are meant to do more than lure patients. "Ultimately it helps us attract students to Vanderbilt, faculty and staff. We ourselves are proud of the work that we do, so it's really focused in that direction."
Austin declined to say how much Vanderbilt is spending on the national ad campaign, but she says it appears to be having the intended effect. Market research indicates what Austin calls a "statistically significant change" in the positive views of Vanderbilt around the country.
Despite what the institution claims, Joel English of the Milwaukee-based marketing firm BVK says the ads are almost certainly intended to get more sick people traveling to Vanderbilt. "There are ancillary benefits to an effective national or regional campaign. That said, during a time in health care where dollars are precious, I don't believe those would be the key reasons for a national campaign. I think the key reason is to attract more patients."
Vanderbilt isn't the only academic medical center that has tried to broaden its horizons through national ads. The University of Pittsburgh Medical Center launched a multi-million dollar campaign in 2005. According to Kantar Media, advertising by hospitals, clinics, and medical centers rose more than 20% in the first half of 2011. The New York Times reports more than $700 million was spent over the six-month period.
Blake Farmer, Vanderbilt Reports Bump From First National Ad Campaign, WPLN News (Dec. 29, 2011).
AHLA Teaching Hospital Updates are intended to provide quick summaries of cutting-edge issues of interest to teaching hospitals and their counsel. Additional information and more in-depth coverage on these topics may be available from AHLA Health Lawyers Weekly and appropriate AHLA Practice Groups.