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Availability of Consumer Prices From US Hospitals for a Common Surgical Procedure
Availability of Consumer Prices From US Hospitals for a Common Surgical Procedure
Source: Archives of Internal Medicine (JAMA Internal Medicine)
Importance
Many proposals for health care reform incentivize patients to play a more active role in selecting health care providers on the basis of quality and price. While data on quality are increasingly available, availability of pricing data is uncertain.Objective
To examine whether we could obtain pricing data for a common elective surgical procedure, total hip arthroplasty (THA).Design
We randomly selected 2 hospitals from each state (plus Washington, DC) that perform THA, as well as the 20 top-ranked orthopedic hospitals according to US News and World Report rankings. We contacted each hospital by telephone between May 2011 and July 2012. Using a standardized script, we requested from each hospital the lowest complete “bundled price” (hospital plus physician fees) for an elective THA that was required by one of the author’s 62-year-old grandmother. In our scenario, the grandmother did not have insurance but had the means to pay out of pocket. We explained that we were seeking the lowest complete price for the procedure. When we encountered hospitals that could provide the hospital fee only, we contacted a random hospital affiliated orthopedic surgery practice to obtain the physician fee. Each hospital was contacted up to 5 times in efforts to obtain pricing information.Setting/Participants
All top-ranked and a sample of non–top-ranked US hospitals performing THA.Main Outcome Measures
Percentage of hospitals able to provide a complete price estimate for THA (physician and hospital fee) for top-ranked and non–top-ranked hospitals and range of prices quoted by each group.Results
Nine top-ranked hospitals (45%) and 10 non–top-ranked hospitals (10%) were able to provide a complete bundled price (P < .001). We were able to obtain a complete price estimate from an additional 3 top-ranked hospitals (15%) and 54 non–top-ranked hospitals (53%) (P = .002) by contacting the hospital and physician separately. The range of complete prices was wide for both top-ranked ($12 500-$105 000) and non–top-ranked hospitals ($11 100-$125 798).Conclusions and Relevance
We found it difficult to obtain price information for THA and observed wide variation in the prices that were quoted. Many health care providers cannot provide reasonable price estimates. Patients seeking elective THA may find considerable price savings through comparison shopping.
Integrating Technology Into Standard Weight Loss Treatment
Integrating Technology Into Standard Weight Loss Treatment
Source: Archives of Internal Medicine
Background
A challenge in intensive obesity treatment is making care scalable. Little is known about whether the outcome of physician-directed weight loss treatment can be improved by adding mobile technology.
Methods
We conducted a 2-arm, 12-month study (October 1, 2007, through September 31, 2010). Seventy adults (body mass index >25 and ≤40 [calculated as weight in kilograms divided by height in meters squared]) were randomly assigned either to standard-of-care group treatment alone (standard group) or to the standard and connective mobile technology system (+mobile group). Participants attended biweekly weight loss groups held by the Veterans Affairs outpatient clinic. The +mobile group was provided personal digital assistants to self-monitor diet and physical activity; they also received biweekly coaching calls for 6 months. Weight was measured at baseline and at 3-, 6-, 9-, and 12-month follow-up.
Results
Sixty-nine adults received intervention (mean age, 57.7 years; 85.5% were men). A longitudinal intent-to-treat analysis indicated that the +mobile group lost a mean of 3.9 kg more (representing 3.1% more weight loss relative to the control group; 95% CI, 2.2-5.5 kg) than the standard group at each postbaseline time point. Compared with the standard group, the +mobile group had significantly greater odds of having lost 5% or more of their baseline weight at each postbaseline time point (odds ratio, 6.5; 95% CI, 2.5-18.6).
Conclusions
The addition of a personal digital assistant and telephone coaching can enhance short-term weight loss in combination with an existing system of care. Mobile connective technology holds promise as a scalable mechanism for augmenting the effect of physician-directed weight loss treatment.
Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population
Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population
Source: Archives of Internal Medicine
Background
Despite extensive data about physician burnout, to our knowledge, no national study has evaluated rates of burnout among US physicians, explored differences by specialty, or compared physicians with US workers in other fields.Methods
We conducted a national study of burnout in a large sample of US physicians from all specialty disciplines using the American Medical Association Physician Masterfile and surveyed a probability-based sample of the general US population for comparison. Burnout was measured using validated instruments. Satisfaction with work-life balance was explored.Results
Of 27 276 physicians who received an invitation to participate, 7288 (26.7%) completed surveys. When assessed using the Maslach Burnout Inventory, 45.8% of physicians reported at least 1 symptom of burnout. Substantial differences in burnout were observed by specialty, with the highest rates among physicians at the front line of care access (family medicine, general internal medicine, and emergency medicine). Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both). Highest level of education completed also related to burnout in a pooled multivariate analysis adjusted for age, sex, relationship status, and hours worked per week. Compared with high school graduates, individuals with an MD or DO degree were at increased risk for burnout (odds ratio [OR], 1.36; P < .001), whereas individuals with a bachelor's degree (OR, 0.80; P = .048), master's degree (OR, 0.71; P = .01), or professional or doctoral degree other than an MD or DO degree (OR, 0.64; P = .04) were at lower risk for burnout.Conclusions
Burnout is more common among physicians than among other US workers. Physicians in specialties at the front line of care access seem to be at greatest risk.
Environmental Causes of Breast Cancer and Radiation From Medical Imaging Findings — From the Institute of Medicine Report
Source: Archives of Internal Medicine
Susan G. Komen for the Cure asked the Institute of Medicine (IOM) to perform a comprehensive review of environmental causes and risk factors for breast cancer. Interestingly, none of the consumer products (ie, bisphenol A, phthalates), industrial chemicals (ie, benzene, ethylene oxide), or pesticides (ie, DDT/DDE) considered could be conclusively linked to an increased risk of breast cancer, although the IOM acknowledged that the available evidence was insufficient to draw firm conclusions for many of these exposures, calling for more research in these areas. The IOM found sufficient evidence to conclude that the 2 environmental factors most strongly associated with breast cancer were exposure to ionizing radiation and to combined postmenopausal hormone therapy. The IOM’s conclusion of a causal relation between radiation exposure and cancer is consistent with a large and varied literature showing that exposure to radiation in the same range as used for computed tomography will increase the risk of cancer. It is the responsibility of individual health care providers who order medical imaging to understand and weigh the risk of any medical procedures against the expected benefit.
Susan G. Komen for the Cure, the largest grassroots network of breast cancer survivors and activists in the United States, asked the Institute of Medicine (IOM) to perform a comprehensive and evidence-based review of environmental causes and risk factors for breast cancer, with a focus on identifying evidence-based actions that women can take to reduce their risk.1 Environmental exposures were defined broadly to include all factors not genetically inherited, and the IOM committee appointed to write this report included academicians and chairs from departments of environmental health, toxicology, cancer epidemiology, preventive medicine, and biostatistics in addition to advocates for patients with breast cancer. Committee members conducted their own reviews of the peer-reviewed epidemiological and basic science literature, commissioned several papers specifically for their report, and drew on evidence-based reviews already completed by organizations such as the Agency for Research on Cancer and the World Cancer Research Fund International. The publication Breast Cancer and the Environment: A Life Course Approach was released online in December 2011.
Application of “Less Is More” to Low Back Pain
Application of “Less Is More” to Low Back Pain
Source: Archives of Internal Medicine
An initiative of the National Physicians Alliance, the project titled “Promoting Good Stewardship in Clinical Practice,” developed a list of the top 5 activities in primary care for which changes in practice could lead to higher-quality care and better use of finite clinical resources. One of the top 5 recommendations was “Don’t do imaging for low back pain within the first 6 weeks unless red flags are present.” This article presents data that support this recommendation. We selectively reviewed the literature, including recent reviews, guidelines, and commentaries, on the benefits and risks of routine imaging in low back pain. In particular, we searched PubMed for systematic reviews or meta-analyses published in the past 5 years. We also assessed the cost of spine imaging using data from the National Ambulatory Medical Care Survey. One high-quality systematic review and meta-analysis focused on clinical outcomes in patients with low back pain and found no clinically significant difference in pain or function between those who received immediate lumbar spine imaging vs usual care. Published data also document harms associated with early imaging for low back pain, including patient “labeling,” unneeded follow-up tests for incidental findings, irradiation exposure, unnecessary surgery, and significant cost. Routine imaging should not be pursued in acute low back pain. Not imaging patients with acute low back pain will reduce harms and costs, without affecting clinical outcomes.
Nature and Impact of Grief Over Patient Loss on Oncologists’ Personal and Professional Lives
Nature and Impact of Grief Over Patient Loss on Oncologists’ Personal and Professional Lives (PDF)
Source: Archives of Internal Medicine
Caring for critically ill and terminal patients can generate grief reactions in health care professionals (HCPs). While all HCPs can potentially experience grief over patient loss, oncologists face unique pressures because they are legally responsible for the patients’ care and may be blamed when patients die.5 Despite the evidence that grief over patient loss is an intrinsic part of clinical oncology, there are no qualitative studies examining the nature and extent of oncologists’ grief over patient loss nor the impact of this grief on oncologists’ lives. The objectives of our study were to explore and identify oncologists’ grief over patient loss and the ways in which this grief may affect their personal and professional lives.
Red Meat Consumption and Mortality
Red Meat Consumption and Mortality
Source: Archives of Internal Medicine
Background
Red meat consumption has been associated with an increased risk of chronic diseases. However, its relationship with mortality remains uncertain.Methods
We prospectively observed 37 698 men from the Health Professionals Follow-up Study (1986-2008) and 83 644 women from the Nurses’ Health Study (1980-2008) who were free of cardiovascular disease (CVD) and cancer at baseline. Diet was assessed by validated food frequency questionnaires and updated every 4 years.Results
We documented 23 926 deaths (including 5910 CVD and 9464 cancer deaths) during 2.96 million person-years of follow-up. After multivariate adjustment for major lifestyle and dietary risk factors, the pooled hazard ratio (HR) (95% CI) of total mortality for a 1-serving-per-day increase was 1.13 (1.07-1.20) for unprocessed red meat and 1.20 (1.15-1.24) for processed red meat. The corresponding HRs (95% CIs) were 1.18 (1.13-1.23) and 1.21 (1.13-1.31) for CVD mortality and 1.10 (1.06-1.14) and 1.16 (1.09-1.23) for cancer mortality. We estimated that substitutions of 1 serving per day of other foods (including fish, poultry, nuts, legumes, low-fat dairy, and whole grains) for 1 serving per day of red meat were associated with a 7% to 19% lower mortality risk. We also estimated that 9.3% of deaths in men and 7.6% in women in these cohorts could be prevented at the end of follow-up if all the individuals consumed fewer than 0.5 servings per day (approximately 42 g/d) of red meat.Conclusions
Red meat consumption is associated with an increased risk of total, CVD, and cancer mortality. Substitution of other healthy protein sources for red meat is associated with a lower mortality risk.
The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality
The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality
Source: Archives of Internal Medicine
Background
Patient satisfaction is a widely used health care quality metric. However, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes remains ill defined.Methods
We conducted a prospective cohort study of adult respondents (N = 51 946) to the 2000 through 2007 national Medical Expenditure Panel Survey, including 2 years of panel data for each patient and mortality follow-up data through December 31, 2006, for the 2000 through 2005 subsample (n = 36 428). Year 1 patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. We estimated the adjusted associations between year 1 patient satisfaction and year 2 health care utilization (any emergency department visits and any inpatient admissions), year 2 health care expenditures (total and for prescription drugs), and mortality during a mean follow-up duration of 3.9 years.Results
Adjusting for sociodemographics, insurance status, availability of a usual source of care, chronic disease burden, health status, and year 1 utilization and expenditures, respondents in the highest patient satisfaction quartile (relative to the lowest patient satisfaction quartile) had lower odds of any emergency department visit (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.00), higher odds of any inpatient admission (aOR, 1.12; 95% CI, 1.02-1.23), 8.8% (95% CI, 1.6%-16.6%) greater total expenditures, 9.1% (95% CI, 2.3%-16.4%) greater prescription drug expenditures, and higher mortality (adjusted hazard ratio, 1.26; 95% CI, 1.05-1.53).Conclusion
In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.
Likelihood That a Woman With Screen-Detected Breast Cancer Has Had Her “Life Saved” by That Screening
Likelihood That a Woman With Screen-Detected Breast Cancer Has Had Her “Life Saved” by That Screening
Source: Archives of Internal Medicine
Background Perhaps the most persuasive messages promoting screening mammography come from women who argue that the test “saved my life.” Because other possibilities exist, we sought to determine how often lives were actually saved by mammography screening.
Methods We created a simple method to estimate the probability that a woman with screen-detected breast cancer has had her life saved because of screening. We used DevCan, the National Cancer Institute’s software for analyzing Surveillance Epidemiology and End Results (SEER) data, to estimate the 10-year risk of diagnosis and the 20-year risk of death—a time horizon long enough to capture the downstream benefits of screening. Using a range of estimates on the ability of screening mammography to reduce breast cancer mortality (relative risk reduction [RRR], 5%-25%), we estimated the risk of dying from breast cancer in the presence and absence of mammography in women of various ages (ages 40, 50, 60, and 70 years).
Results We found that for a 50-year-old woman, the estimated risk of having a screen-detected breast cancer in the next 10 years is 1910 per 100 000. Her observed 20-year risk of breast cancer death is 990 per 100 000. Assuming that mammography has already reduced this risk by 20%, the risk of death in the absence of screening would be 1240 per 100 000, which suggests that the mortality benefit accrued to 250 per 100 000. Thus, the probability that a woman with screen-detected breast cancer avoids a breast cancer death because of mammography is 13% (250/1910). This number falls to 3% if screening mammography reduces breast cancer mortality by 5%. Similar analyses of women of different ages all yield probability estimates below 25%.
Conclusions Most women with screen-detected breast cancer have not had their life saved by screening. They are instead either diagnosed early (with no effect on their mortality) or overdiagnosed.
Diagnostic Blood Loss From Phlebotomy and Hospital-Acquired Anemia During Acute Myocardial Infarction
Diagnostic Blood Loss From Phlebotomy and Hospital-Acquired Anemia During Acute Myocardial Infarction
Source: Archives of Internal Medicine
To our knowledge, our study is the first to directly assess the association between DBL and HAA in a large, unselected cohort of patients with AMI from hospitals across the United States. Diagnostic blood loss was substantial, particularly among individuals with HAA, and varied widely across hospitals, suggesting that process-of-care differences may influence DBL. It is important to note that DBL was independently associated with a higher risk of HAA and that this association remained robust after multivariable adjustment and in several sensitivity analyses.
Prior studies have shown that HAA is common and associated with higher mortality and worse health status after AMI.4, 6, 24 In our study, 1 in 5 patients who did not have baseline anemia (and did not undergo coronary bypass surgery) developed moderate to severe HAA. Several factors contribute to development of HAA. Some of these are not modifiable (age, sex, chronic kidney disease, acute inflammation from AMI),4, 25 but 2 are clearly under the control of health care providers: prevention of periprocedural bleeding and minimization of phlebotomy. Alternative anticoagulants such as bivalirudin, closure devices, and radial access for coronary angiography all reduce the incidence of periprocedural bleeding.26-29 However, no clear bleeding event is identified in many patients with HAA.4, 6 Although phlebotomy has been suggested as a cause of in-hospital hemoglobin level declines in patients with AMI,30 to our knowledge, our study is the first to identify DBL as an independent predictor of HAA in a contemporary cohort reflecting real-world patient care and highlights phlebotomy as a potentially modifiable risk factor.
Our findings have important clinical implications. Among patients who developed HAA, the mean estimated phlebotomy volume was 173.8 mL, which is equivalent to nearly half a unit of whole blood, and over 12% had more than 300 mL of blood drawn over the course of hospitalization. Diagnostic blood loss remained relatively constant throughout the course of hospital stay after the first 2 days of hospitalization and was particularly high among patients with long lengths of stay. Since most diagnostic evaluation and therapeutic interventions often occur early during AMI hospitalization, it is likely that much of the blood taken later during hospitalization represents routine, scheduled laboratory draws that could lead to ongoing blood loss. Our findings are likely generalizable to other populations of seriously ill medical patients. In this regard, further studies that establish whether minimizing DBL can prevent HAA and improve patient outcomes could have broad implications for hospitalized patients.
Airport Full-Body Screening: What Is the Risk?
Airport Full-Body Screening: What Is the Risk?
Source: Archives of Internal Medicine
In the past year, the Transportation Security Administration has deployed full-body scanners in airports across the United States in response to heightened security needs. Several groups have opposed the scans, citing privacy concerns and fear of the radiation emitted by the backscatter x-ray scanners, 1 of the 2 types of machines in use. The radiation doses emitted by the scans are extremely small; the scans deliver an amount of radiation equivalent to 3 to 9 minutes of the radiation received through normal daily living. Furthermore, since flying itself increases exposure to ionizing radiation, the scan will contribute less than 1% of the dose a flyer will receive from exposure to cosmic rays at elevated altitudes. The estimation of cancer risks associated with these scans is difficult, but using the only available models, the risk would be extremely small, even among frequent flyers. We conclude that there is no significant threat of radiation from the scans.
