The United States. should significantly reform the federal system for financing physician training and residency programs to ensure that the public's $15 billion annual investment is producing the doctors that the nation needs, according to a report by the Institute of Medicine. Current financing — provided largely through Medicare — requires little accountability, allocates funds independent of workforce needs or educational outcomes, and offers insufficient opportunities to train physicians in the health care settings used by most Americans, the report says.
All medical school graduates must complete at least one year of "graduate medical education," or residency training, to become licensed to practice. Board certification in a specialty often requires three to seven years of training. Medicare and Medicaid provide more than 90 percent of federal funding to support physician residency training, with Medicare providing $9.7 billion per year.
Public financing of this training should remain at its current level for now, but Congress should amend Medicare laws and regulations to move to an accountable, modernized financing system over the next decade that rewards performance and spurs innovation, said the committee that wrote the report. Continued Medicare funding should be contingent on its demonstrated value and contribution to the nation's health needs. Although public funding also comes from other federal and state sources, the committee focused primarily on Medicare because as the largest funder, it provides the most leverage.
For decades, teaching hospitals have received the majority of Medicare's funding for physician training, and these hospitals control how the funding is spent. Funds are distributed through complicated formulas linked to the volume of Medicare patients treated.
The funding formulas discourage training at clinics or community-based settings where most people now seek care, including children's hospitals and other institutions that care for non-elderly patients. Several surveys indicate that recently trained physicians in some specialties have difficulty performing simple office-based procedures or managing routine conditions, the report says.
Lack of research makes basic questions about the costs, effectiveness or outcomes of the training programs "unanswerable," the committee said, and teaching hospitals are only required to report data used to calculate funding amounts. Physician training programs must meet accreditation and certification standards, but antitrust and fair trade prohibitions preclude accreditors from addressing broader national objectives such as the makeup of the physician workforce or the geographic distribution of resources.
The mix of available physician training slots may be more driven by the needs or priorities of individual teaching hospitals rather than U.S. health care needs, the report says. Between 2003 and 2013, for example, there was a disproportionate increase of physicians being trained as specialists despite a greater demand for generalists. Training opportunities are highly concentrated in specific geographic regions and urban areas, and the training system is not increasing the number of physicians willing to locate to rural areas or treat other underserved populations.
Data Quality, Other Issues Pose Challenges to Med Reconciliation
While electronic health records can help standardize medication reconciliation for hospitalized patients, data quality, technical problems and workflow issues continue to pose challenges, according to a new qualitative study from the nonpartisan, nonprofit National Institute for Health Care Reform.
Designed to reduce errors, medication reconciliation is a systematic way to ensure accurate patient medication lists at admission, during a hospitalization and at discharge. Previous research has found unintended medication discrepancies are common, affecting up to 70 percent of hospital patients at admission or discharge, with almost a third of discrepancies potentially causing patient harm.
Despite hospital accreditation and other requirements, use of medication reconciliation has lagged for many reasons, including insufficient physician engagement, which stems, in part, from lack of professional consensus about which physician is responsible for managing a patient's medication list and the value of medication reconciliation as a clinical tool to improve care.
Conducted for NIHCR by researchers at the former Center for Studying Health System Change — Joy M. Grossman, Rebecca Gourevitch and Dori A. Cross — the study examined how 19 hospitals across the United States were using EHRs to support medication reconciliation.
According to the study, key challenges to effective medication reconciliation include improving access to reliable medication histories, refining EHR usability, engaging physicians more fully and routinely sharing patient information with the next providers of care.
The study's findings are detailed in a new NIHCR Research Brief — Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation — available online.
Debriefs prepare team for future cases, boost cardiac arrest outcomes for kids
A study found that staff members who joined structured team debriefings after emergency care for children suffering in-hospital cardiac arrests improved their CPR performance and substantially increased the rates of patients surviving with favorable neurological outcomes.
The study team at The Children's Hospital of Philadelphia said their research suggests that including all members of the intensive care unit team, not just those immediately involved in the cardiac arrests, broadens learning and may improve compliance with standardized national guidelines for performing CPR. "Bringing together all members of the multidisciplinary team for a post-event debrief better prepares everyone who could come in future contact with a patient in sudden cardiac arrest," said lead author Heather Wolfe, M.D., a critical care physician at The Children's Hospital of Philadelphia.
More than 200,000 cardiac arrests occur every year in U.S. hospitals. And while survival outcomes have improved over the last 10 years, still more than 60 percent of these patients will not make it out of the hospital alive. This fact highlights how important it will be to disseminate the team's successful findings. he current study appears in a recent issue of Critical Care Medicine.
The researchers performed a single-center prospective study of children who received chest compressions in the ICU at CHOP between December 2008 and June 2012, encompassing 120 CPR events. The study team compared a historical control group, up to June 2010, with an intervention group of patients receiving CPR between December 2010 and June 2012, following the implementation of the post-arrest debriefing program. Patient survival with favorable neurologic outcome increased to 50 percent among the intervention group, compared to 29 percent during the pre-intervention period.
"The team debriefings were associated with a near-doubling of good neurological survival for children who suffer a cardiac arrest in our ICU," said Wolfe, who added, "Our unique, interdisciplinary debriefing program resulted in improvements of CPR technique to levels of American Heart Association Guideline compliance previously not thought possible — this was truly a stellar achievement." For more information, click here.