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    <recommendedItem id="20100101_19_457"
                     title="Long-Term Safety of Drug-Eluting Stents Affirmed (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/Cardiology/Atherosclerosis/tb/18374?impressionId=1265749435581"
                     
      &lt;p&gt;Using sirolimus-eluting stents for the treatment of in-stent restenosis appears safe and effective over four years of follow-up, a study of an Italian registry showed.&lt;/p&gt;
&lt;p&gt;Through four years, there were low rates of target lesion revascularization (11.1%) and stent thrombosis (2.8%), according to Francesco Liistro, MD, of San Donato Hospital in Arezzo, Italy, and colleagues.&lt;/p&gt;
&lt;p&gt;About one in 10 patients (9.8%) died, and 3.2% had a nonfatal myocardial infarction.&lt;/p&gt;
&lt;p&gt;Survival free from a major adverse cardiac event was 80.3% at the end of follow-up, the researchers reported in the Feb. 16 issue of the&lt;em&gt; Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Although drug-eluting stents have been shown to be safe and better than balloon angioplasty and vascular brachytherapy for in-stent restenosis in the short term, most previous studies have had limited follow-up.&lt;/p&gt;
&lt;p&gt;Reports of late stent thrombosis following implantation with drug-eluting stents have raised some concern about the long-term safety of these devices in unselected patient groups, according to Liistro and his colleagues.&lt;/p&gt;
&lt;p&gt;To explore the issue, the researchers turned to the Tuscany Registry of Unselected In-Stent Restenosis (TRUE), a prospective, two-center registry.&lt;/p&gt;
&lt;p&gt;All 244 patients included in the analysis underwent antiplatelet therapy with aspirin and either ticlopidine or clopidogrel (Plavix) for at least six months after the sirolimus-eluting stent was implanted.&lt;/p&gt;
&lt;p&gt;An earlier, nine-month analysis of this registry showed safety and effectiveness for the stent. This study confirmed the benefits through four years.&lt;/p&gt;
&lt;p&gt;Of 24 recorded deaths, 11 were from cardiac causes.&lt;/p&gt;
&lt;p&gt;Definite stent thrombosis occurred in five patients, four of whom had stopped taking clopidogrel more than a month before the event.&lt;/p&gt;
&lt;p&gt;Another two patients who were taking aspirin and clopidogrel had probable stent thrombosis.&lt;/p&gt;
&lt;p&gt;Patients who had diabetes were significantly more likely to have target lesion revascularization (OR 0.32, 95% CI 0.14 to 0.71) and major adverse cardiac events (OR 0.38, 95% CI 0.20 to 0.71) through four years.&lt;/p&gt;
&lt;p&gt;A left ventricular ejection fraction less than 50% was associated with higher odds of major adverse cardiac events (OR 0.32, 95% CI 0.13 to 0.80), as was creatinine greater than 1.5 mg/dL (OR 0.23, 95% CI 0.11 to 0.48).&lt;/p&gt;
&lt;p&gt;And patients with peripheral or carotid arterial disease were more likely to need target lesion revascularization (OR 0.35, 95% CI 0.14 to 0.88).&lt;/p&gt;
&lt;p&gt;The authors noted that the registry study was limited by the lack of valid control groups.&lt;/p&gt;
&lt;p&gt;In addition, in patients with a late occurrence of target lesion revascularization, the researchers could not determine whether a stenotic lesion inside the stented segment was a new atherosclerotic lesion or a restenosis.&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 authors did not make any financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <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=1265749435581"
                     
      &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_228"
                     title="Nurses Should Have a Bigger Leadership Role in Healthcare"
                     score="-0.001"
                     href="http://www.medpagetoday.com/PracticeManagement/StaffingScheduling/tb/18080?impressionId=1265749435581"
                     
      &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>
    <recommendedItem id="20090101_19_952"
                     title="ACC: Cardiologists Plan to Cut Heart Failure Hospital Readmits by 20%"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/ACC/tb/13475?impressionId=1265749435581"
                     
      ORLANDO, March 28 -- Medicare spends $40 billion a year on hospital treatment for heart failure and a sizable chunk of that money is spent on readmissions.
              &lt;p&gt; 
              &lt;p&gt;A common reason is a failed hand-off from inpatient to community care, according the American College of Cardiology, which is launching an ambitious initiative to cut the Medicare heart failure readmission rate by 20% by December 2012.
              &lt;p&gt; 
              &lt;p&gt;Known as Hospital-to-Home, or H2H, the program is designed to save taxpayer dollars, improve patient care, and help realize the Obama administration&apos;s goal of cutting the Medicare readmissions.
              &lt;p&gt; 
              &lt;p&gt;But H2H is not confined to Medicare patients. Alfred Bove, M.D., Ph.D., president-elect of the ACC, said the program will target all systems and all patients.
              &lt;p&gt; 
              &lt;p&gt;John S. Rumsfeld, M.D., Ph.D., an associate professor at the University of Colorado Health Sciences Center in Denver and a staff cardiologist at the Denver VA Medical Center, said H2H is being launched by the ACC and the Institute for Healthcare Improvement, but other partners -- including the American Heart Association -- are being actively pursued.
              &lt;p&gt; 
              &lt;p&gt;Dr. Rumsfeld said that VA &quot;was a certain partner and we are hoping to get Kaiser to sign on as well.&quot;
              &lt;p&gt; 
              &lt;p&gt;Dr. Rumsfeld, who is also the chief medical officer for the National Cardiovascular Disease Registry (NCDR), said H2H would focus on improving communication between hospital-based physicians and community-based doctors so that heart failure patients &quot;don&apos;t fall between the cracks&quot; once they leave the hospital.
              &lt;p&gt; 
              &lt;p&gt;Jack Lewin, M.D., CEO of the ACC, said a patient&apos;s primary care physician often knows nothing about the patient&apos;s hospitalization or discharge, so follow-up care is at best spotty.
              &lt;p&gt; 
              &lt;p&gt;Asked if readmission problems have escalated with the growth of the hospitalist movement, Dr. Lewin said he suspected that they might be related, but he had no data to confirm that suspicion.
              &lt;p&gt; 
              &lt;p&gt;Dr. Rumsfeld said his family experienced the problem first-hand when his father, a pulmonologist, was hospitalized with heart failure. 
              &lt;p&gt; 
              &lt;p&gt;On discharge, he said, the elder Rumsfeld &quot;was confused. He didn&apos;t know if he should be taking the medicines he took before he was hospitalized or those that he took in the hospital. This is a doctor, and he couldn&apos;t figure it out!&quot;
              &lt;p&gt; 
              &lt;p&gt;Janet Wright, M.D., the ACC&apos;s senior vice president of science and quality, said the problem is often a matter of failing to complete the hand-off of the patient from hospital to home.
              &lt;p&gt; 
              &lt;p&gt; &quot;The patient gets dropped,&quot; she said. &quot;So rather than a hand-off, I think we need a handshake.&quot;
              &lt;p&gt; 
              &lt;p&gt;That handshake would include a detailed discharge plan that includes at least two physician follow-ups in the 30 days after discharge, as well as follow-ups by telephone or telemetry with nurses or nurse-practitioners.
              &lt;p&gt; 
              &lt;p&gt;Drs. Rumsfeld and Lewin noted that the Obama administration has targeted all hospital readmissions for Medicare savings. Dr. Rumsfeld said the administration has also hinted that it would reduce both hospital and physician reimbursements when patients are readmitted. 
             
    </recommendedItem>
    <recommendedItem id="20100101_19_82"
                     title="Appointment with the Pharmacist May Be Beneficial (CME/CE)"
                     score="-0.006"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/PracticeManagement/tb/17873?impressionId=1265749435581"
                     
      When pharmacists take a more active role in patient care, disease outcomes are improved  --  particularly for diabetes patients, a new study shows.&lt;br&gt;
&lt;br&gt;Diabetics who had an intensive consultation with a pharmacist regarding their medications, as well as subsequent follow-up, saw significant improvements in hemoglobin A1c and fasting plasma glucose, Erin Slazak, PharmD, of the University at Buffalo, and colleagues reported online in the &lt;em&gt;Journal of the American Pharmacists Association&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;The pilot study was small, with only 50 patients, and it lacked a control group, but Slazak said she and colleagues collected the data &quot;because we wanted to show that we were having a positive effect on patient outcomes at the primary care level.&quot;&lt;br&gt;
&lt;br&gt;Adding a pharmacist to a patient&apos;s healthcare management team is not a new idea. Prior studies  --  including the Asheville Project and the Diabetes Ten City Challenge  --  have shown it improves disease outcomes and cost-effectiveness.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;&quot;There is an increasing body of evidence to support that pharmacists provide an effective and unique role in a collaborative disease management model,&quot; said Toni Fera, PharmD, of HealthMapRx and the lead investigator of the Diabetes Ten City Challenge.&lt;/p&gt;
&lt;p&gt;&quot;Medication adherence is critical to the management of chronic diseases, and pharmacists are uniquely trained to help patients understand why they need to take their medications,&quot; Fera said. &quot;And it helps them overcome barriers that prevent patients from taking their medications appropriately.&quot;&lt;/p&gt;
&lt;p&gt;Fera said there&apos;s &quot;growing momentum&quot; to include pharmacists in patient care. Medicare Part D plans, for example, allow pharmacists to provide medication therapy management services, which include a review of medications and proper use.&lt;/p&gt;
&lt;p&gt;Some state-level programs exist, such as the one run by Slazak and colleagues.&lt;/p&gt;
&lt;p&gt;Slazak said patients receive a one-hour consultation in which they bring in all their medication bottles  --  prescription and nonprescription  --  and have a thorough history taken. Pharmacists explain why each medication is relevant to treatment, and discuss necessary diet and lifestyle changes.&lt;/p&gt;
&lt;p&gt;&quot;We make sure the patient leaves with a solid understanding of why they&apos;re taking the medications they&apos;re taking,&quot; Slazak said.&lt;/p&gt;
&lt;p&gt;She and colleagues will then make recommendations to the patient&apos;s physician regarding medications (in New York state, pharmacists don&apos;t have prescribing power, but in some states they can adjust medications as necessary, without consulting the patient&apos;s doctor).&lt;/p&gt;
&lt;p&gt;They&apos;ll also follow up with the patient, either over the phone or in person, on a monthly or weekly basis, depending on the patient.&lt;/p&gt;
&lt;p&gt;In their study, Slazak and colleagues found significant reductions in hemoglobin A1c and fasting plasma glucose after both six months and one year, compared with baseline (A1c -1.1%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001 and fasting plasma glucose -39 mg/dL, &lt;em&gt;P&lt;/em&gt;=0.003; and A1c -1.1%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001 and fasting plasma glucose -35 mg/dL, &lt;em&gt;P&lt;/em&gt;=0.005, respectively).&lt;/p&gt;
&lt;p&gt;There were no significant decreases in other metabolic parameters, including blood pressure and cholesterol.&lt;/p&gt;
&lt;p&gt;&quot;There are a lot of possible reasons for that, mostly because we&apos;re focused on diabetes,&quot; Slazak said. &quot;And our program was fairly new at the time, so we weren&apos;t working as closely with the providers as we are now.&quot;&lt;/p&gt;
&lt;p&gt;She said the relationship between pharmacists and primary care providers is key to this type of collaboration. While physicians may have heeded 50% of pharmacists&apos; recommendations at the beginning of the study, Slazak said, they now heed more than 90%.&lt;/p&gt;
&lt;p&gt;The program also tended to reduce costs. Geometric mean costs tended to decrease versus baseline at six-month (&amp;#8211;$84; &lt;em&gt;P&lt;/em&gt;=0.785) and 12-month (&amp;#8211;$216; &lt;em&gt;P&lt;/em&gt;=0.414) assessments, despite nominal increases in diabetes and total medication costs. None of the changes was statistically significant.&lt;/p&gt;
&lt;p&gt;The researchers have since matched the 50 patients in this study, which was conducted between 2006 and 2007, with 50 controls, for a more complete report, but the data has not yet been published.&lt;/p&gt;
&lt;p&gt;While programs like this one have been appearing around the country, Fera said remaining challenges included determining how to incorporate the pharmacist into the existing healthcare system and how to coordinate care and sharing of information among providers.&lt;/p&gt;
&lt;p&gt;&quot;It really hinges on having the pharmacist prove a cost-benefit ratio to a physician group or third-party payer,&quot; Slazak said.&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;A co-author reported relationships with Bayer, Cadence, Cubist, Forest, Optimer, Ortho-McNeil, Schering-Plough, and Wyeth.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>
