Better Living Through Well Being

In the past decade in the U.S. an increasingly strained primary care infrastructure for adults has resulted in greater use of the Emergency Room for first contact care. Also, a marked increase in use of new diagnostic technology and early adoption of electronic health records (EHRs) has led to sharper billing increases than in other clinical specialties. Concerns over this “upcoding” trend in medical billing prompted the Office of the Inspector General to investigate, resulting in a recently published report in The New England Journal of Medicine, “Higher-Complexity ED Billing Codes: Sicker Patients, More Intensive Practice, or Improper Payments?”

Although it is possible that upcoding facilitated by increasing use of EHRs has contributed to the trend, other causes such as changing demographics, shifting practice patterns, and the emergency department's (ED’s) evolving role in the health care system must also be considered. A lack of stable “medical homes” encourages ED physicians to seek greater diagnostic certainty before discharging a patient, particularly for the three most common and challenging diagnostic problems: Abdominal pain, chest pain, and shortness of breath. These often necessitate testing that is not available in office settings. Technological innovations, such as multidetector CT, now permit rapid risk assessment in the ED, averting the need for admission or further consultation. This diagnostic precision is increasingly expected by patients, physicians and the public, and ED may also be penalized for failure to diagnose.

The result of these changes is an increasingly interventionist ED practice style, illustrated not only by increased imaging, but also by increased laboratory testing and initiation of IV fluids. Whether this trend has truly improved patient safety and quality of care is unknown, but it has certainly increased the complexity of the medical decision-making component of documentation, which translates into higher billing.

The report shows ways in which use of the electronic health record has become a double-edged sword, potentially undermining its intended goal of reducing medical errors by requiring physicians to focus on elaborate documentation and less time assessing the patient. The EHR may facilitate clicking on multiple items in the “review of systems” that patients were not directly asked about. There is also a possibility of using easily selected templates designed to ensure billing at the highest possible level.

What should be done about this trend in medical billing? Among other recommendations, the report calls for development of a more effective business model for the digital era that allows ED practioners to get away from the computer and back to the bedside of sick and injured patients. In the broad sense of what has happened during the past decade, while Eds have remained the social safety net, they have also gradually been inheriting roles previously handled by office physicians. EDs have become a central staging area for acutely ill patients, for the use of diagnostic technology and for decisions about hospital admission, all of which makes ED care increasingly complex.

Other articles of interest in this Winter 2013 TMIS eNewsletter:

* A new survey finds that a majority of Americans feel they have to take a more proactive role in managing their own healthcare in order to ensure quality of care.

* Eight hospital employees were fired for refusing the flu vaccine.

* A new study published online in Nature shows how inherited mitochondrial disease may be prevented.

* Plant-based omega-3 fatty acid alpha-linolenic acid, such as found in walnuts, is cheaper and more effective than omega-3 fatty acid from fish in helping to prevent cardiovascular disease.

* Researchers have developed a specific blood test for autism spectrum disorders and have evidence that abnormal immunologic activity affecting brain development may explain some of autism’s origins.

* A company in Chicago is installing its automated external defibrillators and diagnostic cardiac monitoring devices to all Chicago-area Metra commuter trains.

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ERs Have Become Central Staging Area for Acutely Ill Patients: More Complex Care Provided in a Challenging Health Care Environment
Washington, District of Columbia

Lack of stable medical homes and reduced inpatient capacity are key factors that could be responsible for a shift toward higher billing levels over the past decade in U.S. emergency departments, according to a new report from the New England Journal of Medicine . Changing standards of care and the implementation of electronic medical records are additional potential factors in this shift that is accompanied by increases in higher-complexity, higher paid visits for Medicare emergency patients.

Study authors were responding to a recent report by the Office of Inspector General, a watchdog organization of the U.S. Department of Health and Human Services, which suggested a widespread phenomenon of "upcoding" in all specialties, but especially emergency medicine. Subsequent reports in news organizations, including The New York Times and Washington Post, embellished this assertion with separate analyses and specific examples. The authors of this perspective piece, however, examined a nationally representative sample in order to refine these assertions, and concluded that blaming upcoding alone oversimplifies what is happening.

"Care that used to be provided on in-patient floors is now being done in emergency departments," said Dr. Andy Sama , president of the American College of Emergency Physicians (ACEP). "Also, in the past decade, primary care physicians increasingly have sent their patients to the emergency department for more prompt and definitive work-ups. They may simply be seriously concerned, overburdened, or the patient may have complex issues that can't be diagnosed easily in a primary care setting. But this puts the burden of accurate and efficient diagnosing on emergency physicians, which leads to higher complexity, and higher billed visits."
Full Story

New Poll Finds Millions Of Smokers Nationwide Resolving To Quit In The New Year
Washington, District of Columbia

New results from a national online public opinion poll of Americans 18 and older show that 34 percent of smokers plan to quit smoking as a New Year's resolution in 2013. Among survey respondents, only 18 percent reported that quitting smoking was a New Year's resolution in 2012, yet twice as many of these respondents will resolve to quit in 2013. The poll showed that increasing costs of cigarettes (67 percent) and concerns about the health risks associated with smoking (58 percent) are two of the key factors motivating smokers to contemplate quitting as a resolution for 2013.

The poll, conducted on behalf of Legacy, a national tobacco education foundation, found that on average, those who committed to quit in 2012 stayed quit for just about a month (30 days), and for more than half (59 percent) of those quitters, it was the longest they had ever stayed quit.

"Research has shown that most smokers who quit on January 1 struggle to stay quit as the days and weeks go on," said Cheryl G. Healton , DrPH, President and CEO of Legacy. "Many smokers may have begun their New Year's quit attempt and have already relapsed and that's okay. We need to encourage them to build a quit plan and then try to quit again. On average, research has shown that smokers make up to 6-9 attempts before they finally quit for good, which is why it is so important to remind smokers to quit with support and methods that have proven success."

While it is positive news that more of the surveyed smokers are planning to quit in 2013 than in 2012, data reveals that many of them are still overlooking resources and practices that can lead to successful quitting.
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Health Survey Shows Consumers Feel They Must Take a More Proactive Role in Their Healthcare to Ensure Quality of Care
Philadelphia, Pennsylvania

According to a new Wolters Kluwer Health survey, 80 percent of consumers believe the greater "consumerization" of healthcare, the trend of individuals taking a greater and more active role in their own healthcare, is positive for Americans. Survey data suggests many Americans feel that a greater role in their care is not only good, but necessary, with 86 percent of consumers reporting that they feel they have to take a more proactive role in managing their own healthcare in order to ensure better quality of care.

Most consumers also say they feel prepared to take on a greater role in managing their own healthcare, with 76 percent reporting that they have the information and tools to take a more proactive role in healthcare decisions ranging from choosing healthcare providers to researching treatment options. Despite feeling prepared, only 19 percent report that they have their own electronic Personal Health Record (PHR).

The Wolters Kluwer Health survey was conducted among 1,000 U.S. consumers ages 18 and older. Survey questions focused on exploring whether consumers want more control over their own healthcare and whether they feel prepared to take on more responsibility.

"With greater responsibility placed on patients to take a role in their own care, it's essential that consumers have access to evidence-based tools and resources to make informed decisions about their care in partnership with their healthcare providers," said Dr. Linda Peitzman , Chief Medical Officer, Wolters Kluwer Health. "Access to research-based medical information not only can positively impact quality of care, but it also can lead to improved doctor-patient communication and relationships."
Full Story

Nurses Fired; Flu Vaccine Exemptions Denied on Dubious Pretext, Doctors' Group Says
Tucson, Arizona

Eight employees, including at least three veteran nurses, have been fired by Goshen Hospital, in Goshen, Indiana, for refusing the flu vaccine. A religious exemption is available, but was denied because these employees did not meet the criteria for religious protection established by the Equal Employment Opportunity Commission.

"What gives the EEOC the authority to define what constitutes an acceptable religious belief?" asks Jane M. Orient, M.D., executive director of the Association of American Physicians and Surgeons (AAPS).

AAPS opposes vaccine mandates, believing that patients and healthcare workers have the right to refuse medical treatment.

Hospitals may agree with the right to refuse treatment, but assert the right to determine conditions for employment. They cite concerns about protecting patients from transmission of influenza by unvaccinated staff.

"The scientific and religious concerns are in a sense backward," Dr. Orient stated. "Advocates of the mandate are full of evangelical zeal and are quick to portray skeptics as wicked and selfish. It's like a secular religion, based on faith in vaccine efficacy and safety."

In fact, the scientific case for flu vaccine mandates is very weak, Dr. Orient points out in an article in the winter issue of the Journal of American Physicians and Surgeons. A handful of studies show slight benefit in long-term care facilities. Hospitals have not been studied. Safety data are limited, and there are no long-term studies of the effects of annual vaccination. Serious, lifelong disability occasionally occurs. There is no evidence showing that vaccinated workers are less likely to transmit virus.
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Scientists at The New York Stem Cell Foundation and Columbia University Medical Center Develop Scientific Technique To Help Prevent Inherited Disorders in Humans
New York, New York

A new study published online in Nature shows how mitochondrial disease may be prevented. A joint team of scientists from The New York Stem Cell Foundation (NYSCF) Laboratory and Columbia University Medical Center (CUMC) has developed a technique that may prevent the inheritance of mitochondrial diseases in children.

Dieter Egli , PhD, and Daniel Paull , PhD, of the NYSCF Laboratory with Mark Sauer , MD, and Michio Hirano , MD, of CUMC demonstrated how the nucleus of a cell can be successfully transferred between human egg cells. This landmark achievement carries significant implications for those children who have the potential to inherit mitochondrial diseases.

Mitochondria are cellular organelles responsible for the maintenance and growth of a cell. They contain their own set of genes, passed from mother to child, and are inherited independently from the cell's nucleus. Although mitochondrial DNA accounts for only 37 out of more than 20,000 genes in an individual, mutations to mitochondrial genes carry harmful effects.

Mitochondrial disorders, due to mutations in mitochondrial DNA, affect approximately 1 in 10,000 people, while nearly 1 in 200 individuals carries mutant mitochondrial DNA. Symptoms, manifesting most often in childhood, may lead to stunted growth, kidney disease, muscle weakness, neurological disorders, loss of vision and hearing, and respiratory problems, among others. Worldwide, a child is born with a mitochondrial disease approximately every 30 minutes, and there are currently no cures for these devastating diseases.
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New Study Finds Alpha-Linolenic Acid (ALA), The Plant-Based Omega-3, Associated With Lower Risk Of Cardiovascular Disease
Folsom, California

A meta-analysis published in the recent issue of the American Journal of Clinical Nutrition evaluates how the plant-based omega-3 fatty acid alpha-linolenic acid (ALA) offers protective effects on cardiovascular diseases (CVD). The study found ALA to be associated with a lower risk of CVD, particularly coronary heart disease (CHD) death. These findings support the potential heart health benefits of ALA and suggest consumers should obtain adequate amounts of ALA in their diets. Walnuts are a key source of ALA and the only nut that provides a meaningful amount of the essential plant-based omega-3 fatty acid offering 2.5 grams of ALA in a mere handful.

This systematic review incorporated 27 original studies and included 251,049 individuals and found that overall ALA exposure was associated with lower risk of CVD. In fact, in the pooled dietary analysis, each 1 gram per day increment of ALA intake was associated with a 10% lower risk of CHD death. Previously, the majority of research funding of omega-3 fatty acids have been directed towards marine sources; however, recently increased attention has been given to its plant-based counterpart ALA and has been suggesting that ALA consumption also offers cardiovascular benefits. The researchers believe that there may be a direct or indirect antiarrythmic effect of ALA that could partially explain why ALA appeared protective against CHD. Previous studies have found ALA consumption may lower cholesterol levels, positively affect thrombosis, improve endothelial function and decrease inflammation.

The type of omega-3s found in walnuts and other plant sources are different from the type of omega-3s found in fish. According to Penny Kris-Etherton , Ph.D., Distinguished Professor of Nutrition at The Pennsylvania State University, consumers need to understand the nutritional benefits of plant-based omega-3 fatty acids. She notes that "research is showing that the effects of ALA may have unique and independent benefits important to our wellbeing."
Full Story

A Better Early Blood Test for Autism: Genetic signatures point to disrupted neuro-immune pathways
Boston, Massachussetts

Researchers at Boston Children's Hospital have developed a blood test for autism spectrum disorders (ASDs) that outperforms existing genetic tests, while presenting evidence that abnormal immunologic activity affecting brain development may help explain some of autism's origins. The findings also suggest a new direction for genetic research on autism and the search for treatments.

The blood test, described December 5 in the online open access journal PLOS ONE and based on the largest gene-chip investigation ever done in autism, could enable early diagnosis of autism in about two thirds of patients before clear symptoms start to appear (the average age of diagnosis in the U.S. is 5 years).

Researchers led by Sek Won Kong , MD, of the Boston Children's Hospital Informatics Program (CHIP) analyzed blood samples from 66 male patients with ASDs (from Boston Children's and several other hospitals in collaboration with the Autism Consortium of Boston) and compared them with 33 age-matched boys without ASDs. Using microarrays, they looked for RNA signatures reflecting differences in gene activity, or expression, between the two groups.

"Since brain biopsy isn't a viable option for research, we asked whether blood could serve as a proxy for gene expression in the brain," says Isaac Kohane , MD, PhD, director of CHIP and senior investigator on both studies. "We found that it could, though we and others were initially skeptical."
Full Story

Cardiac Science to Supply Powerheart G3 AEDs to Chicago Metra: Metra becomes second transit agency in country to deploy AEDs on all its commuter trains
Waukesha, Wisconsin

Cardiac Science Corporation, an Opto Circuits group company and a global leader in automated external defibrillators (AEDs) and diagnostic cardiac monitoring devices, will supply Powerheart G3 AEDs to all Chicago-area Metra commuter trains and other Metra facilities by the end of January.

Under terms of the agreement, Cardiac Science will deploy 440 AEDs in Metra passenger cars, work facilities, and police vehicles; Cardiac Science also donated 30 AEDs to Metra. The deployment was made possible with a grant from the Regional Transportation Authority, sponsorship of Northwestern Medicine, and support of Illinois Governor Patrick Quinn .

Metra recorded nearly 82.7 million passenger trips in 2011, and is now the second transit system in the country to deploy AEDs on all of its trains.

"We are honored that Metra chose Cardiac Science to be the AED provider in its public access defibrillator (PAD) program," said Neal Long , Cardiac Science president and chief executive officer. "Allowing passengers, workers, and emergency personnel with easy access to defibrillators will combat sudden cardiac arrest and save lives."

At a press conference at a downtown Chicago Metra station on Dec. 27, Governor Quinn further underscored the importance of AEDs. "Having AEDs readily available on Metra cars will save lives," said Governor Quinn. "By being prepared, we can be ready to respond swiftly and safely in the unfortunate event of a medical emergency. By working together, we can get these critical devices in public spaces everywhere."

Governor Quinn signed the Good Samaritan Act into law in 2011 to provide Good Samaritan coverage for anyone who has successfully completed American Heart Association or American Red Cross AED training. It protects trained AED users from liability as long as they act in good faith.
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