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    <recommendedItem id="20100101_19_416"
                     title="For Diabetes, P4P Improves Patient Care, Outcomes (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/PracticeManagement/Reimbursement/tb/18328?impressionId=1265780582751"
                     
      &lt;p&gt;Measures of quality of care and clinical outcomes improved significantly when diabetic patients in a large private health plan were treated by physicians receiving pay-for-performance incentives, researchers said.&lt;/p&gt;
&lt;p&gt;The risk that diabetic patients would be hospitalized was 25% lower (incidence rate ratio 0.75, 95% CI 0.61 to 0.93) among those seen for three consecutive years by physicians who received extra pay for meeting quality-of-care targets, compared with the risk for patients whose physicians did not receive such incentives, reported Judy Ying Chen, MD, MSHS, of IMS Health in Woodland Hills, Calif., and colleagues.&lt;/p&gt;
&lt;p&gt;High-quality care  --  defined as receiving at least two tests for glycated hemoglobin (HbA1c) and one for LDL cholesterol during a given year  --  was delivered 16% more often by physicians in the pay-for-performance system (rate ratio 1.16, 95% CI 1.11 to 1.22), the researchers also reported online in the &lt;em&gt;American Journal of Managed Care&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;This study showed a robust, consistent, significant, and positive association between increased receipt of appropriate laboratory monitoring of A1c and LDL cholesterol levels and decreased hospitalization rates,&quot; Chen and colleagues declared.&lt;/p&gt;
&lt;p&gt;On the other hand, the researchers also found that quality of care diminished when patients saw multiple primary care physicians during a given year.&lt;/p&gt;
&lt;p&gt;&quot;This finding supports the hypothesis that patients have better outcomes when they have a medical home,&quot; Chen and colleagues indicated.&lt;/p&gt;
&lt;p&gt;The researchers examined records of diabetic patients enrolled with Hawaii Medical Services Association, a large preferred provider organization, from 1999 to 2006. The plan had about 19,600 such patients in 1999 and 32,365 in 2006.&lt;/p&gt;
&lt;p&gt;The plan offered physicians in the network the opportunity to earn bonuses of 1.5% to 7.5% of their base fees for meeting care-quality targets including HbA1c and LDL cholesterol testing of diabetic patients. Bonuses ranged from $10,000 to $16,000 annually. Starting in 2001, physicians could earn an extra $6,000 if their adherence to care-quality processes improved over the previous year.&lt;/p&gt;
&lt;p&gt;Bonuses were paid each year on the basis of administrative records for the previous year.&lt;/p&gt;
&lt;p&gt;The proportion of diabetic patients seen by physicians in the pay-for-performance plan increased from 78.7% in 1999 to 94.6% in 2006.&lt;/p&gt;
&lt;p&gt;As a result of the bonus structure, Chen and colleagues observed, improvements in care quality lagged implementation of these incentives by a year or two.&lt;/p&gt;
&lt;p&gt;The most substantial improvements in quality of care and patient outcomes were seen among patients seen continuously by a physician participating in the pay-for-performance system from 2004 to 2006.&lt;/p&gt;
&lt;p&gt;Compared with patients seen by physicians who chose not to participate in the system, those whose treatment was subject to the incentives were seen by primary care physicians and endocrinologists far more often: &lt;ul&gt; &lt;li&gt;Six to 10 outpatient visits in a year: odds ratio 2.16 (95% CI 2.00 to 2.33)&lt;/li&gt; &lt;li&gt;Eleven or more outpatient visits in a year: OR 2.35 (95% CI 2.14 to 2.57)&lt;/li&gt; &lt;li&gt;Visit to an endocrinologist: OR 1.56 (95% CI 1.38 to 1.75)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Among patients receiving quality care continuously from 2004 to 2006, the chance of being hospitalized in 2006 was reduced by 33% compared with patients whose care failed to meet the quality target at some point (rate ratio 0.67, 95% CI 0.61 to 0.75).&lt;/p&gt;
&lt;p&gt;But patients who saw more than two different primary care physicians in 2006 had a dramatically increased rate of hospitalizations (RR 6.13, 95% CI 5.33 to 7.04).&lt;/p&gt;
&lt;p&gt;Chen and colleagues noted several limitations to the study, including the fact that it was conducted in a PPO setting and might not be generalizable to health maintenance organizations or other frameworks.&lt;/p&gt;
&lt;p&gt;The researchers also had no data for years before the program started, leaving open the possibility that physicians participating in the pay-for-performance program were those who were already following treatment guidelines.&lt;/p&gt;
&lt;p&gt;The study also included only one clinical outcome; effects on others such as hypoglycemic episodes, cardiovascular events, and meeting HbA1c targets were not measured and might have been different.&lt;/p&gt;
&lt;p&gt;The researchers also acknowledged that the claims data underlying the study might not have been totally accurate, and they noted that it did not include other factors known to affect hospitalizations such as cardiovascular risk factors.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Hawaii Medical Service Association, the health plan that was the focus of the work.&lt;/p&gt;&lt;p&gt;IMS Health is a healthcare consulting firm that, among other services, advises health insurers on performance and quality programs.&lt;/p&gt;&lt;p&gt;Several co-authors were employees of the Hawaii Medical Service Association, and officials of the group reviewed the manuscript before submission. But the authors declared that the association had no influence on the study design, analysis, or results reported. No other potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_389"
                     title="Most Adults Go Online for Health Information"
                     score="0.013"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/tb/18281?impressionId=1265780582751"
                     
      &lt;p&gt;Just over half of U.S. adults under 65 used the Internet to look up health information over the course of a year, according to the first National Health Interview Survey to collect data on health information technology.&lt;/p&gt;
&lt;p&gt;Although Americans are still concerned about security of medical information, the survey showed that 5% of consumers had used e-mail to contact healthcare providers directly.&lt;/p&gt;
&lt;p&gt;The survey of 7,192 participants measured consumers&apos; use of health information technology. Specifically, CDC researchers asked when participants had used a computer to store, retrieve, share, or use healthcare information to make decisions and communicate, to conduct research, and to communicate with healthcare and prescription providers and engage in other forms of Internet dialog.&lt;/p&gt;
&lt;p&gt;The study found 51% of adults 18 to 64 used the Internet to look up health information at some point over a 12-month period. Previous research had shown that over 60% of all adults in the U.S. had, at some point, used the Internet to search for health or medical information.&lt;/p&gt;
&lt;p&gt;Not surprisingly, 18- to 49-year-olds were more likely than older adults to use health information technology.&lt;/p&gt;
&lt;p&gt;Women were more likely than men to use the Internet for health information in all surveyed categories, including: &lt;ul&gt; &lt;li&gt; Chatting online about health topics (2.5% of men versus 4.1% of women)&lt;/li&gt; &lt;li&gt;Researching health information (43.4% versus 58%)&lt;/li&gt; &lt;li&gt;Communicating with healthcare providers (4.2% versus 5.6%) or scheduling an appointment (1.8% versus 3.5%) by e-mail&lt;/li&gt; &lt;li&gt;Refilling prescriptions online (5.3% versus 6.6%)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The survey was conducted by the CDC and the National Center for Health Statistics.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_390"
                     title="Vegetative State May Still Harbor Consciousness (CME/CE)"
                     score="0.012"
                     href="http://www.medpagetoday.com/Neurology/GeneralNeurology/tb/18283?impressionId=1265780582751"
                     
      Researchers in England are reporting they have been able to establish limited communication with a man in a persistent vegetative state by using functional magnetic resonance imaging (fMRI).&lt;br&gt;
&lt;br&gt;The 34-year-old man was able to answer simple Yes or No questions by imagining different types of activity, which caused changes in brain activity that could be seen in the machine, according to Martin Monti, PhD, of the Medical Research Council Cognition and Brain Sciences Unit in Cambridge, England, and colleagues.&lt;br&gt;
&lt;br&gt;The finding shows that at least some patients who are otherwise unresponsive may have some residual awareness, the researchers reported online in the &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;&quot;The incredible thing is that we could never do something like that at the bedside,&quot; Monti told &lt;em&gt;MedPage Today&lt;/em&gt;. Outside of the fMRI machine, he said, the patient remained unresponsive to standard tests.&lt;br&gt;
&lt;br&gt;The study is likely to arouse controversy, Monti conceded, especially in the light of such high-profile cases as that of Terry Schiavo, which eventually went to the U.S. Supreme Court.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;In the Schiavo case, relatives were bitterly divided on whether to withdraw&lt;strong&gt; &lt;/strong&gt;life support for the woman, who had been in a persistent vegetative state for several years.&lt;/p&gt;
&lt;p&gt;&quot;People will have a tendency to overinterpret this,&quot; Monti said, adding &quot;this finding in one patient does not imply that all patients may or may not have the ability to do this.&quot;&lt;/p&gt;
&lt;p&gt;Indeed, the researchers tested 54 people and found only five who could apparently respond to direction by imagining either motor or spatial activity. Imagining those activities uses different parts of the brain and their activation can be seen by the fMRI scan.&lt;/p&gt;
&lt;p&gt;Several of the responders were already what is called &quot;minimally responsive,&quot; meaning that occasionally they were able to react to external stimuli.&lt;/p&gt;
&lt;p&gt;Of those five, the researchers only tried to communicate with one  --  the man in a persistent vegetative state  --  using his ability to reliably activate different brain areas when asked to imagine either playing tennis or looking around a room in his house.&lt;/p&gt;
&lt;p&gt;While in the machine, he was asked simple questions, such whether his father&apos;s name was Alexander. To answer Yes, he was to imagine playing tennis, while for No he was to imagine looking around the room.&lt;/p&gt;
&lt;p&gt;He was able to answer five out of six questions, the researchers reported, adding it was unclear why he was unable to answer the sixth but no brain activity was seen in response to the question.&lt;/p&gt;
&lt;p&gt;Outside experts also cautioned against overinterpreting the results.&lt;/p&gt;
&lt;p&gt;&quot;The percentage of patients showing a response was low, and longer-term follow-up studies are needed to determine whether such fMRI findings by themselves have meaningful predictive value,&quot; argued Alan Faden, MD, of the University of Maryland School of Medicine in Baltimore.&lt;/p&gt;
&lt;p&gt;&quot;This study may well raise questions for some with regard to medical or legal decisions based upon state of consciousness,&quot; Faden said in an e-mail, &quot;but the findings primarily underscore the limitations of current categorizations for diminished states of consciousness.&quot;&lt;/p&gt;
&lt;p&gt;He said that as technology gets better, it will likely mean that doctors will have to modify their diagnostic categories for what he called &quot;states of diminished consciousness.&quot;&lt;/p&gt;
&lt;p&gt;In an accompanying editorial in the journal, Allan Ropper, MD, of Brigham and Women&apos;s Hospital in Boston, wrote that such research is &quot;easily subject to overinterpretation and sensationalism.&quot;&lt;/p&gt;
&lt;p&gt;He cautioned that brain activation was seen only in a few patients and only in those with a traumatic brain injury, rather than global ischemia and anoxia.&lt;/p&gt;
&lt;p&gt;And, he wrote, the brain activity seen in the patients is not evidence of such things as memory, self-awareness, anxiety, or despair. &quot;We cannot be certain whether we are interacting with a sentient, much less a competent, person&quot; Ropper wrote.&lt;/p&gt;
&lt;p&gt;Despite such caveats, the research is &quot;critically important,&quot; according to Michael DeGeorgia, MD, of University Hospitals Case Medical Center in Cleveland.&lt;/p&gt;
&lt;p&gt;It &quot;illustrates both the complexities of this area and the limitations of our bedside clinical examination,&quot; he said in an e-mail, adding that more research will be needed to figure out how to use the technology and how to interpret the results.&lt;/p&gt;
&lt;p&gt;The research &quot;does raise difficult medical and legal questions,&quot; DeGeorgia said.&lt;/p&gt;
&lt;p&gt;&quot;We always need to be upfront and honest with families about what we know for certain and what we do not know for certain,&quot; he said. &quot;In many of these cases, the honest answer is that we cannot be absolutely 100% certain that their loved one isn&apos;t &apos;in there somewhere.&apos;&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study had support from the Medical Research Council, the European Commission, Fonds de la Recherche Scientifique, the James S. McDonnell Foundation, the Mind Science Foundation, the Reine Elisabeth Medical Foundation, the Belgian French-Speaking Community Concerted Research Action, University Hospital of Liege, the University of Liege, and the National Institute for Health Research Biomedical Research Centre.&lt;/p&gt;&lt;p&gt;The researchers said they had no potential conflicts.&lt;/p&gt;&lt;p&gt;Hopper did not report any conflicts.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_287"
                     title="COLUMN: Outliers: The Story of Success"
                     score="0.005"
                     href="http://www.medpagetoday.com/Columns/18148?impressionId=1265780582751"
                     
      &lt;p&gt;Popular author Malcolm Gladwell has become something of a fixture on the healthcare speaking circuit and it&apos;s easy to understand why. Taken collectively, his books go further than most in explaining the factors that influence and facilitate societal change.&lt;/p&gt;
&lt;p&gt;In his groundbreaking book, &lt;em&gt;The Tipping Point&lt;/em&gt;, Gladwell challenged  --  and eventually changed  --  the way we understand the world. He contends that one imaginative person applying a well-placed lever can move the world.&lt;/p&gt;
&lt;p&gt;His second book, &lt;em&gt;Blink&lt;/em&gt;, examined the power of intuition and its influence on our thinking. One concept that particularly struck me was the idea of &quot;thin slicing&quot;  --  filtering the few factors that matter from an overwhelming number of variables. In the context of medical malpractice, Gladwell advises readers to &quot;thin slice&quot; new physicians, trusting their intuition if they sense a physician is not listening to them.&lt;/p&gt;
&lt;p&gt;Gladwell has done it again! His newest book, &lt;em&gt;Outliers&lt;/em&gt;, is destined to transform the way we understand success.&lt;/p&gt;
&lt;p&gt;In &lt;em&gt;Outliers&lt;/em&gt;, Gladwell explains the extraordinary success of the Beatles and Bill Gates in the context of generation, family, culture, and class. The lives of these Outliers  --  people whose achievements fall outside normal experience  --  actually follow a peculiar and unexpected logic, suggesting that context and background matter a great deal.&lt;/p&gt;
&lt;p&gt;How does this apply to healthcare? The answer is in a chapter entitled, &quot;The Ethnic Theory of Plane Crashes.&quot;&lt;/p&gt;
&lt;p&gt;In the late 1990s, Korean Air was internationally admonished following a series of dramatic cockpit failures and subsequent crashes. Multiple investigations led to the same conclusion: poor cockpit communication, rooted in deep cultural barriers, led to circumstances that became deadly.&lt;/p&gt;
&lt;p&gt;The chapter discusses three important messages regarding communication: mitigation, crew resource management (CRM), and a concept known as the power distance index (PDI).&lt;/p&gt;
&lt;p&gt;Mitigation is a term used by linguists to describe an attempt to downplay or sugarcoat the meaning of what is being said. According to Gladwell, &quot;We mitigate when we&apos;re being polite, when we are ashamed or embarrassed, and when we are being deferential to authority.&quot;&lt;/p&gt;
&lt;p&gt;Although mitigation may be appropriate or even desirable in some situations, it can be disastrous in a cockpit on a stormy night, or an operating room or trauma bay. For the past 15 years, combating mitigation has been a major crusade in commercial aviation.&lt;/p&gt;
&lt;p&gt;Gladwell contends that the unprecedented decline in airline accidents in recent years is attributable, in part, to this war on mitigation.&lt;/p&gt;
&lt;p&gt;CRM training is designed to teach junior crew members how to communicate clearly and assertively in order to reduce dangerous mitigation. Airlines teach copilots how to challenge the pilot if he or she thinks something is going awry.&lt;/p&gt;
&lt;p&gt;For example, the copilot might begin with &quot;Captain, I&apos;m concerned about...,&quot; then proceed to &quot;Captain, I&apos;m uncomfortable with...,&quot; and if the Captain still doesn&apos;t respond, &quot;Captain, I believe this situation is unsafe.&quot;&lt;/p&gt;
&lt;p&gt;Today, CRM is also playing a major role in efforts to improve healthcare quality and safety.&lt;/p&gt;
&lt;p&gt;One staunch proponent is John Nance, a decorated Vietnam pilot, attorney, and author of &lt;em&gt;Why Hospitals Should Fly&lt;/em&gt;, a clever book depicting a fictional hospital wherein the tenets of CRM have been completely internalized by the administrative leadership, medical staff, and all front-line caretakers.&lt;/p&gt;
&lt;p&gt;The third key communication concept outlined in &lt;em&gt;Outliers&lt;/em&gt;, PDI, is one aspect of a model developed by Dutch psychologist, Geert Hofstede. It is rooted in cross-cultural psychology and concerns attitudes toward hierarchy, especially those relating to how much a particular culture values and respects authority.&lt;/p&gt;
&lt;p&gt;In cultures with low PDI, power holders try to underplay their power. In cultures with high PDI, the leader&apos;s authority is unassailable.&lt;/p&gt;
&lt;p&gt;Gladwell relates the impact of Hofstede&apos;s findings on aviation industry research. Their battle over mitigated speech and teamwork was actually an attempt to reduce power distance in the cockpit! He notes that Hofstede&apos;s work &quot;suggested something that had not occurred to anyone in the aviation world; that the task of convincing first officers to assert themselves was going to depend ... on their culture&apos;s power distance rating.&quot;&lt;/p&gt;
&lt;p&gt;So, what does PDI have to do with healthcare? I think that lowering the PDI  --  by means as simple as introducing one another and referring to one another by first names  --  can be helpful in improving communication on patient rounds, the intensive care unit, and elsewhere in the hospital setting.&lt;/p&gt;
&lt;p&gt;Surely, this may be provocative and threatening to the status quo. It might not work everywhere, but solid ethnographic research has concluded that when things go awry in a cockpit it is much easier to address a captain by his first name than by his title.&lt;/p&gt;
&lt;p&gt;I am not suggesting that we must suddenly become buddies on rounds, but knowing who is who and taking a moment to recognize everyone&apos;s role on the team would go a long way to improving communication  --  and, perhaps, clinical outcomes.&lt;/p&gt;
&lt;p&gt;&lt;em&gt;&lt;/em&gt;Gladwell&apos;s books, and their provocative messages regarding how we think, challenge many of the tightly held, seemingly scientific aspects of our clinical decision-making at the bedside.&lt;/p&gt;
&lt;p&gt;But irrespective of varying reactions to &lt;em&gt;Outliers&lt;/em&gt;, I believe it would enhance our individual and collective ability to improve communication if we knew a little bit more about CRM and PDI.&lt;/p&gt;
&lt;p&gt;Maybe &lt;em&gt;Outliers&lt;/em&gt; and &lt;em&gt;Why Hospitals Should Fly&lt;/em&gt; should be required reading for every medical student and house officer as a part of the training experience.&lt;/p&gt;
&lt;p&gt;Could the way we address one another have an impact on clinical outcomes? If this is the case  --  and I believe it is  --  we should learn how to communicate appropriately in a simulated training environment so that it becomes routine in the hurly burly of everyday work.&lt;/p&gt;
&lt;p&gt;Gladwell asks why it is so difficult to acknowledge the fact that each of us comes from a culture with its own distinctive mix of strengths and weaknesses, tendencies, and predispositions. &quot;Who we are cannot be separated from where we are from  --  and when we ignore that fact, planes crash.&quot;&lt;/p&gt;
&lt;p&gt;And patients die.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Want More on Health Policy?&lt;/strong&gt; &lt;a href=&quot;http://nashhealthpolicy.blogspot.com/&quot; mce_href=&quot;http://nashhealthpolicy.blogspot.com/&quot; target=&quot;_blank&quot;&gt;Read David Nash&apos;s blog&lt;/a&gt;.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_228"
                     title="Nurses Should Have a Bigger Leadership Role in Healthcare"
                     score="-0"
                     href="http://www.medpagetoday.com/PracticeManagement/StaffingScheduling/tb/18080?impressionId=1265780582751"
                     
      &lt;p&gt;Opinion leaders across a wide variety of groups think nurses should have more influence in health policy, planning, and management, according to a new Gallup survey.&lt;/p&gt;
&lt;p&gt;Although nurses are viewed as being the most valued source of health information behind physicians, survey respondents rank them as the least likely of healthcare stakeholders  --  including patients  --  to have a great deal of influence in healthcare reform over the next 10 years.&lt;/p&gt;
&lt;p&gt;This despite the fact that among the 1,504 thought leaders in academia, insurance, health services, government, industry, and the corporate world polled, 51% said nurses are very important in reducing medical errors and improving patient safety, and 50% said they are very influential in improving the quality of patient care.&lt;/p&gt;
&lt;p&gt;The major barriers to increased nurse influence, nearly 70% of respondents said, are perceptions that they are lower on the totem pole than physicians when it comes to decision-making and revenue generation.&lt;/p&gt;
&lt;p&gt;When asked what could be done to ensure that nurses take on more leadership responsibility, the first priority, respondents said, was that they make their voices heard  --  56% had said that nursing lacks a single voice in speaking on national issues. More than half of respondents also noted that there was a lack of opportunities for nurses to advance into leadership positions.&lt;/p&gt;
&lt;p&gt;The survey, conducted by Gallup for the Robert Wood Johnson Foundation, examined professional views of nursing, nursing leadership, the future of the industry, and potential barriers to leadership roles for nurses among various healthcare-related groups. It included responses from opinion leaders in academia (276), health services (253), government (253), industry (253), insurance (237), and the corporate world (232).&lt;/p&gt;
&lt;p&gt;Nine out of 10 said nurses should have more influence in increasing the quality of care and reducing medical errors.&lt;/p&gt;
&lt;p&gt;About 85% said they wanted nurses to have more influence in promoting wellness and preventive care, improving efficiency and cost, coordinating care through the healthcare system, and adjusting care to meet an aging population.&lt;/p&gt;
&lt;p&gt;Additionally, 72% thought increased nurse influence would help the healthcare system adapt to the growing change in ethnic, racial, and cultural diversity in patient populations.&lt;/p&gt;
&lt;p&gt;The opinion leaders were also asked whether they feel there is a nursing shortage in the U.S. Just over 80% said Yes and of those, only 2% said it was not a serious problem.&lt;/p&gt;
&lt;p&gt;To blame for the shortage? Respondents cited a stressful/poor work environment (44% see that as a very important reason), not enough openings in nursing schools (40%), and too many nurses leaving the profession (37%). Only 22% cited low pay as very instrumental in causing the shortage.&lt;/p&gt;

    </recommendedItem>
</recommendedContent>