Clinical Decision Support
Physicians say more than 20% of medical care is unnecessary
The consensus of 2,106 surveyed doctors is that 20.6 percent of overall medical care provided to patients is unnecessary. Researchers published their survey results in the journal PLOS One. Of the specific types of medical care provided to patients, 24.9 percent of diagnostic tests, 22 percent of prescription medications and 11.1 percent of medical procedures are unnecessary, the doctors said. The physicians cited malpractice concerns, pressure or requests from patients and difficulty accessing patients’ medical records as the top three reasons for overtreatment of patients. The top three remedies, according to the doctors, are training medical residents on clinical treatment appropriateness criteria, improving access to patients’ medical records and developing additional practice guidelines.
Only 25% of physicians are aware of the Choosing Wisely campaign
Physician awareness of Choosing Wisely, a 5-year-old initiative to reduce unnecessary medical care, has yet to rise to a level that’s having an industry-wide impact. That’s the takeaway from a survey of physicians published in Health Affairs. Choosing Wisely, which the ABIM (American Board of Internal Medicine) Foundation launched in 2012, urges doctors and patients to limit care to services that are supported by evidence, that don’t duplicate other tests or procedures previously done, that are free from harm and that are truly necessary. Only 25 percent of 600 doctors surveyed this year said they knew about Choosing Wisely. That’s up from 21 percent in 2014, when researchers conducted a similar survey. Malpractice concerns, the desire for more information to reduce uncertainty and “just to be safe” were the top reasons cited for providing low-value care. The top two solutions were malpractice reform and access to evidence-based recommendations in a format that doctors could use to discuss possibly unnecessary care with patients.
Emergency Care
Nearly 50% of all hospital care is delivered to patients through the emergency department
Of the more than 3.5 billion patient visits to hospitals during a 15-year period, 47.7 percent of care was delivered through the hospital emergency room, according to a study published in the International Journal of Health Services. From 1996 through 2010, there were more than 3.5 billion hospital-patient care episodes, reported the researchers, who collected their data from surveys conducted by the National Center for Health Statistics. Of those episodes, 47.7 percent occurred in the emergency room, 37.6 percent were outpatient visits and 14.8 percent were inpatient admissions. That distribution changed little over the entire 15-year period.
Only slightly more than 3% of emergency department visits are “avoidable”
Given the volume of hospital care delivered through the emergency room, the question is how much of it is necessary. According to researchers, the answer is “most.” Studying 115,081 medical records representing 424 million ED visits from 2005 through 2011, the researchers said 3.3 percent of the visits met their definition of “avoidable.” Their definition was a visit that did not require a diagnostic or screening service, procedure or medication, with the patient being sent home. The study appeared in the International Journal for Quality in Healthcare. The top five patient complaints that led to an avoidable trip to the emergency room were toothache, back pain, headache, sore throat or a symptom related to mental illness. The researchers recommended expanding access to mental health and dental care as a possible solution.
Hospitals and Health Systems
Nearly 70% of hospitals are part of health systems
The independent, standalone hospital is a rarity. According to a report from the Agency for Healthcare Research and Quality, 69.7 percent of all U.S. hospitals were part of health systems at the end of 2016. In fact, the top 5 percent of all health systems each operated 18 or more hospitals and had 2,500 doctors or more each on staff. Of all the primary-care physicians in the U.S., 42.7 percent were affiliated with health systems, according to AHRQ’s Compendium of U.S. Health Systems. The report also said 91.6 percent of all hospital discharges in 2016 were from system-based hospitals. On the other end of the spectrum, more than half of the 626 systems in operation ran just one or two hospitals and had fewer than 250 physicians on staff, AHRQ said.
Hospitals and health systems spend nearly $39 billion each year to comply with federal regulations
Hospitals, health systems and post-acute care providers spend $38.6 billion each year to comply with federal regulations in nine areas, according to a report from the American Hospital Association. The areas of regulatory compliance are: quality reporting; new models of care/value-based payment models; meaningful use of EHRs; hospital conditions of participation; program integrity; fraud and abuse; privacy and security; post-acute care; and billing and coverage verification requirements. The AHA’s report, Regulatory Overload: Assessing the Regulatory Burden on Health Systems, Hospitals and Post-Acute Care Providers, is based on a survey of 190 hospitals that are part of systems or operate post-acute care facilities and interviews with 33 executives from four health systems. “Some of these rules do not improve care, and all of them raise costs,” the report said.
Long-Term Care
Hospitals with preferred long-term care networks benefit from faster declines in readmission rates
That’s according to a study in Health Affairs. Researchers compared readmission rates of 16 hospitals in eight U.S. markets. Four hospitals in two markets had built formal networks of preferred skilled-nursing facilities (SNFs) to which they steered patients who needed long-term care. Twelve hospitals in six markets had no preferred SNF network, leaving the choice of SNFs largely to patients and physicians. In 2009, the hospitals with preferred networks discharged 33.1 percent of patients to a SNF, and 23.8 percent were readmitted to the hospitals within 30 days. By 2013, the readmission rate dropped to 17.7 percent. The hospitals without networks discharged 23.9 percent of patients to a SNF in 2009, and 21.5 percent were readmitted. By 2013, their readmission rate dipped to 19.9 percent. The study credited the faster decline in readmission rates to enhanced care coordination and to using data to measure the clinical performance of SNFs in preferred networks.
64% of SNFs used an EHR system in 2016 but interoperability still lacking
As the study in Health Affairs suggests, the ability of SNFs to reduce hospital readmissions depends in large part on sharing patient data with other providers. A new report from HHS’ Office of the National Coordinator for Health Information Technology indicates that SNFs are making progress, but many have a long way to go. The report said 64 percent of SNFs had an electronic health record (EHR) system in place in 2016. However, only 62 percent said they “often” or “sometimes” have clinical information from other providers available electronically at the point of care, with 10 percent saying that “rarely” happens and 28 percent saying it “never” happens. Only 7 percent of SNFs said they have the ability to send, receive, find and integrate patient health information electronically—the four dimensions of interoperability.