The ECRI Institute, an independent nonprofit that researches the best approaches to improving patient care, released its list of Top 10 Health Technology Hazards for 2011(secure link). Available now as a free download with registration, the list features hazards that warrant critical attention by hospitals and other health care organizations in the coming year.   

The list is updated each year based on the prevalence and severity of incidents reported to ECRI Institute by health care facilities nationwide, information found in the Institute's medical device problem reporting databases; and the judgment, analysis and expertise of the organization's multidisciplinary staff. Many of the items on this year's list are well-recognized hazards with numerous reported incidents over the years.   

The 2011 list, originally published in ECRI Institute's Health Devices journal in November,, offers information about how these hazards occur, recommendations for prevention, and a comprehensive resource list for more in-depth information.

The top five hazards are:

  1. Radiation overdose and other dose errors during radiation therapy
  2. Alarm hazards
  3. Cross-contamination from flexible endoscopes
  4. The high radiation dose of CT scans
  5. Data loss, system incompatibilities, and other health IT complications 

"If a hospital or health system needs help prioritizing its technology-related patient safety efforts, our top 10 list is a good place to start," says James P. Keller Jr., vice president of health technology and safety, ECRI Institute.

"From dose errors during radiation therapy, to critical patient alarms that are set incorrectly, inappropriately silenced, or ignored, each of the problems on our list can be prevented or made less likely to occur if recommendations for effective risk-mitigation strategies are employed," says Keller in a one-minute overview video about the report.  

For questions about ECRI Institute's annual list of technology hazards, e-mail clientservices@ecri.org.

Study on cancer care transitions reveals challenges, solutions for hospitals and outpatient oncology groups

The Association of Community Cancer Centers recently announced results of a landmark study of how—and how well—the cancer patient's transition from the hospital inpatient setting to outpatient oncology group is managed. The study, designed to help hospitals and oncology groups improve their transition processes, was conducted by ACCC, with strategic research and analysis provided by Health2 Resources, a communication agency exclusively serving health care clients in the United States.

Findings from the study suggest that some community cancer programs have developed innovative solutions to manage various aspects of the transition process. Still, there is room for further improvement in developing specific processes and policies designed to manage the cancer patient's transition between care settings. H2R fielded two surveys for the project—one of hospitals with oncology programs and the other of community oncology physician practices—to gather data for statistical analysis.

Among the findings:

  • Few hospitals in the study monitor readmissions or follow up with their discharged patients.
  • Oncology-specific transition policies largely are nonexistent (3 percent of surveyed hospitals have one).
  • Transition checklists are rare (15 percent of surveyed hospitals manage the transition with a checklist).
  • While some organizations had transition programs in place, few of them are using survey and measurement tools to analyze those processes for quality improvement.
  • The transition challenge is to identify and manage the patient and family needs at a time and in a location in which neither system (hospital nor oncology group) has control, accountability or responsibility.

The study found that there has been substantial progress in recent years in introducing electronic health records and computerized physician order entry systems into hospitals and oncology practices. Those systems greatly have improved medication reconciliation and the ability of community oncologists to access appropriate medical records pertaining to their recently hospitalized patients.

Overall, a number of challenges remain: Patients move between two modes of care that generally are operated by two separate organizations, often without common information systems and sometimes with only limited shared information. Hospitals compete with each other for patients, as do physicians, and sometimes the competition can get in the way of good communication during the patient transition. The cost of managing the transition is not built into the reimbursement structure. And multiple challenges can occur in the electronic transfer of usable data between the hospital and the oncology group EHR systems, especially for medical groups admitting patients to several hospitals.

Nine community cancer programs were identified from among survey respondents as providing exemplary activities related to transitioning cancer patients between care settings. H2R conducted interviews and developed case examples from each of the sites. ACCC will profile these "exemplary"  programs as well as offer descriptions of processes that these programs use in patient transition, and include such practical tools as discharge instructions, patient hand-off sheet, and patient navigator checklist in the March/April issue of Oncology Issues.

In addition to the ACCC Care Transitions project, H2R has experience with research and strategic communications in employer-benefit design, use of EHRs and new models of care like the patient-centered medical home and accountable care organization. To learn more, click here.

Being overweight and obesity associated with increased risk of death

It is well-documented that people who are obese face increased risks of death from heart disease, stroke and certain cancers. However, a new study looking at deaths from any cause found that a body mass index between 20.0 and 24.9 is associated with the lowest risk of death in healthy nonsmoking adults. The research team included investigators from the National Cancer Institute, part of the National Institutes of Health, and collaborators from a dozen other major research institutions worldwide. The results appear in the Dec. 2, 2010, issue of the New England Journal of Medicine.

BMI, the most commonly used measure for body fat, is calculated by dividing a person's weight in kilograms by the square of his/her height in meters (kg/m2). Current guidelines from the Centers for Disease Control and Prevention and the World Health Organization define a normal BMI range as 18.5 to 24.9. Overweight is defined as a BMI of 25.0 to 29.9; obesity is defined as a BMI over 30.0; and severe obesity is defined as BMI of 35 or higher. To calculate your BMI, click here.

Currently, two-thirds of adults are overweight or obese. Even more worrisome, 17 percent of women and 11 percent of men are severely obese.

In this analysis, investigators pooled data from 19 long-term studies designed to follow participants over time, from five to 28 years, depending on the study.

They found that healthy women who had never smoked and who were overweight were 13 percent more likely to die during the study follow-up period than those with a BMI between 22.5 and 24.9. Women categorized as obese or severely obese had a dramatically higher risk of death. As compared with those having a BMI of 22.5 to 24.9, the researchers report a 44 percent increase in risk of death for participants with a BMI of 30.0 to 34.9; an 88 percent increase in risk for those with a BMI of 35.0 to 39.9; and a 2.5 times (250 percent) higher risk of death for participants whose BMI was 40.0 to 49.9.  Results were broadly similar for men. Overall, for men and women combined, for every five-unit increase in BMI, the researchers observed a 31 percent increase in risk of death.

"By combining data on nearly 1.5 million participants from 19 studies, we were able to evaluate a wide range of BMI levels and other characteristics that may influence the relationship between excess weight and risk of death," said NCI's Amy Berrington de Gonzalez, D.Phil., lead author of the study. "Smoking and pre-existing illness or disease are strongly associated with the risk of death and with obesity. A paramount aspect of the study was our ability to minimize the impact of these factors by excluding those participants from the analysis."

The investigators gathered information about BMI and other characteristics from questionnaires participants completed at the beginning of each study. Causes of death were obtained from death certificates or medical records. This analysis was restricted to non-Hispanic whites aged 19 to 84. The investigators noted the relationship between BMI and mortality may differ across racial and ethnic groups.  Other efforts are under way to study the effect of BMI on mortality in other racial and ethnic groups.

See the full list of research institutions and studies participating in NCI's BMI and All-Cause Mortality Pooling Project.

Workplace clinics: a sign of growing employer interest in wellness

Interest in workplace clinics has intensified in recent years, with employers moving well beyond traditional niches of occupational health and minor acute care to offering clinics that provide a full range of wellness and primary care services, according to a new study by the Center for Studying Health System Change.

Employers view workplace clinics as a tool to contain medical costs, boost productivity and enhance their reputations as employers of choice, according to the study funded by the Robert Wood Johnson Foundation's Changes in Health Care Financing and Organization Initiative, which is administered by AcademyHealth.

Many experts interviewed for the study said most workplace clinics try to achieve a "trusted clinician" primary care model that offers much shorter appointment and in-office wait times and much longer clinician-patient encounters. Experts said that longer clinic visits allow the clinician—sometimes, but not always, a physician—to listen to patients, diagnose their conditions and discuss different treatment options with them. In addition, the clinician has time to screen for other problems unrelated to the immediate visit.

Estimates of clinic prevalence vary, with some recent employer surveys indicating that more than one-third of large employers offer on-site or near-site clinics, while another survey reported one-fifth of large employers doing so. According to HSC's 2007 Health Tracking Household Survey, 8 percent of American families had at least one family member who had used a workplace clinic, and 4 percent had a family member who had used a clinic in the past year.

The availability of simple, routine care at work can be a valued perk for employees, but most experts observed that clinics' direct cost-saving potential for employers is limited, if it exists at all. Instead, experts noted that what generates savings for employers is the ability to change practice patterns, such as drug prescribing, ordering of tests and procedures, and specialist referrals, along with the potential for early diagnosis and treatment to avoid emergency department visits, hospitalizations and other costly downstream complications.

"While well-designed, well-implemented workplace clinics likely will achieve positive returns over the long term, expecting clinics to be a game changer in bending the overall health care cost curve may be unrealistic," said Ha T. Tu, MPA, an HSC senior health researcher and coauthor of the study with Ellyn R. Boukus, MA, an HSC health research analyst; and Genna R. Cohen, a former HSC health research analyst.

Based on a literature review and more than 35 interviews between February and July 2010 with workplace clinic indus­try experts and representatives of benefits consulting firms, clinic vendors and employers sponsoring on-site clinics, the study's findings are detailed in a new HSC Research BriefWorkplace Clinics: A Sign of Growing Employer Interest in Wellness.

New study suggests that private insurers control health care spending better than Medicare 

Whether Medicare or private insurance pays for health care appears to make a significant difference in health spending variation, according to a new study published in the December issue of Health Affairs. The study, a follow-up to a highly publicized 2009 New Yorker article by Atul Gawande, shows that in two Texas cities, sharp differences in Medicare's per capita health care spending were diminished significantly when private insurance paid the bill.   

The study, by authors Luisa Franzini and Osama Mikhail, both of the University of Texas Health Science Center at Houston, and Jonathan Skinner of Dartmouth College, examined 2008 claims data from Blue Cross Blue Shield of Texas, the state's largest commercial health insurer.

For those younger than 65 insured by Blue Cross, total spending per member year in McAllen was 7 percent lower than in El Paso. In contrast, Gawande's article, which used data from the Dartmouth Atlas of Health Care on variations in Medicare spending, showed that per capita spending in McAllen was 86 percent higher than in El Paso.

Although the new study cannot explain definitively why variations in health care spending drop off dramatically under private coverage, the authors suggest that mechanisms for utilization review and management used by private insurers could play a prominent role.

Gawande attributes the nearly twofold spending difference to a change in McAllen during the mid-1990s when health care providers adopted a more pronounced entrepreneurial spirit and a "culture of money." The authors of the Health Affairs study sought to determine whether those same health care providers would demonstrate similar patterns of care for people younger than 65. They obtained data from Blue Cross Blue Shield of Texas, making this study among the first published studies to explore whether the variations seen in Medicare spending hold true for this patient population.

The results were surprising, the study authors say. Medicare spending in McAllen was 63 percent higher than in El Paso for inpatient care, 32 percent higher for outpatient care and 65 percent higher for Part B professional services. The largest difference was for home health care: McAllen was 4.63 times higher than the average in El Paso and 7.14 times higher than the national average. On the other hand, hospice spending in McAllen was just a quarter of the level in El Paso and the national average.

Medicare enrollees in McAllen were far more likely to be admitted to the hospital and to die in the hospital than they were in El Paso. They also were much more likely to be seen near the end of life by more than 10 physicians

But for those younger than 65, spending on professional and inpatient services was similar in both cities, and spending for outpatient services in McAllen was 31 percent less. Use of medical services also was similar or somewhat lower in McAllen compared with that of El Paso. Inpatient admissions in McAllen were 84 percent of admissions in El Paso; professional and outpatient services in McAllen were 94 percent and 72 percent, respectively, of those in El Paso.

The Health Affairs researchers found that neither differences in health care prices nor population disease burden between the two cities accounted for these spending variations.

The most probable explanation, they speculate, has to do with which payers are better at controlling costs around what Mikhail calls the "grey zone of treatment"—areas where legitimate medical judgments can be quite variable. Medicare exercises very little utilization management, whereas private insurers, such as Blue Cross Blue Shield of Texas, can be much more assertive about controlling service use.

Mikhail notes that health care needs and service use generally increase as the population ages, thereby expanding the grey zone of treatment and opening the door to greater variation. That could explain why private insurance spending for people ages 50–64 in McAllen is so much higher than in El Paso.

See the full text of the December Health Affairs article.

New AMA survey finds insurer preauthorization policies impact patient care

Policies that require physicians to ask permission from a patient's insurance company before performing a treatment negatively impact patient care, according to a new survey released by the American Medical Association. This is the first national physician survey by the AMA to quantify the burden of insurers' preauthorization requirements for a growing list of routine tests, procedures and drugs.  

"Intrusive managed care oversight programs that substitute corporate policy for physicians' clinical judgment can delay patient access to medically necessary care," says AMA Immediate Past President J. James Rohack, M.D. "According to the survey, 78 percent of physicians believe insurers use preauthorization requirements for an unreasonable list of tests, procedures and drugs."

The survey of approximately 2,400 physicians indicates that health insurer requirements to preauthorize care have delayed or interrupted patient care, consumed significant amounts of time, and complicated medical decisions. Survey highlights include:

  • More than one-third (37 percent) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for tests and procedures. More than half (57 percent) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for drugs.
  • Nearly half (46 percent) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for tests and procedures. More than half (58 percent) of physicians experience difficulty in obtaining approval from insurers on 25 percent or more of preauthorization requests for drugs.
  • Nearly two-thirds (63 percent) of physicians typically wait several days to receive preauthorization from an insurer for tests and procedures, while one in eight (13 percent) wait more than a week. More than two-thirds (69 percent) of physicians typically wait several days to receive preauthorization from an insurer for drugs, while one in 10 (10 percent) wait more than a week. 
  • Nearly two-thirds (64 percent) of physicians report it is difficult to determine which test and procedures require preauthorization by insurers. More than two-thirds (67 percent) of physicians report it is difficult to determine which drugs require preauthorization by insurers.

Preauthorization policies deliver costly bureaucratic hassles that take time from patient care. Physicians spend 20 hours per week on average just dealing with preauthorizations. Studies show that navigating the managed care maze costs physicians $23.2 billion to $31 billion a year. 

"Nearly all physicians surveyed said that streamlining the preauthorization process is important, and 75 percent believe an automated process would increase efficiency," said Rohack. "The AMA is urging health insurers to automate and streamline the current cumbersome preauthorization process so physicians can manage patient care more efficiently."