Entries for September 2008

Years in the making, a new Medicare rule that takes effect at midnight tonight should make hospital care a little safer. Here's how: If the cost of treating a Medicare patient is pushed up because one of a defined set of avoidable problems happened on the hospital's watch—such as a fall, bedsore, or urinary tract infection that occurred or arose after the patient was admitted—the Centers for Medicare and Medicaid Services will no longer reimburse the hospital for the additional expense. The incident will be considered a hospital-acquired condition, not a complication that up to now would have triggered a higher payment. (I described all this in detail in August of last year, when the rule was issued.)

Not only does this make sense—why should public funds be spent to prop up substandard hospital care?—but a very tangible financial incentive now exists for hospitals to do everything they can to avoid these events, which can bulk up expenses by tens or even hundreds of thousands of dollars. Some of the conditions on the CMS list are relatively rare, like the 24 instances last year of mismatched blood transfusions, but others are all too frequent, such as the 257,412 cases of advanced bedsores and 12,185 urinary tract infections in catheterized patients. (A major cause of these UTIs is that catheters are left in place too long, and one reason for this is that they are buried under the covers, so nurses and doctors can forget that they are there.)

Thanks to fellow blogger Bob Wachter, a hospitalist at the University of California, San Francisco Medical Center, for taking note on his blog, Wachter's World, of a story in yesterday's ModernHealthcare.com about a development that very well might solve the low rate of hand-washing by hospital caregivers. Because the solution involves video monitoring, however, it raises a question or two of its own.

I've blogged here and here and here about the need for all healthcare workers to scrub their hands or use a hand sanitizer before touching or approaching patients. Rather surprisingly, no one can say with authority how much the number or rate of hospital-acquired infections would drop if hand-washing compliance shot up, but certainly it would be significant, considering the room for improvement. Because of all the attention recently devoted to hand-washing, Wachter writes, "many hospitals, including my own, have seen hand-cleansing rates skyrocket, from previously mortifying levels of 20 to 30 percent to merely embarrassing rates of 60 to 80 percent."

Another year, another report on the ostensibly growing embrace by hospitals of complementary and alternative medicine—or integrative medicine, as many practitioners prefer to call CAM because "alternative" has dubious vibes. The American Hospital Association has just released a new survey showing that about 37 percent of the hospitals that responded offer one or more CAM therapies such as acupuncture, massage therapy, and guided imagery, up from about 26 percent in an AHA survey in 2005.

I requested the survey and looked it over. I've walked the CAM beat for more than three decades, and my antennae are always sniffing for data true and false. Early this year, a cover story I wrote about CAM's spread into academic medical centers took heat from CAM detractors (for buying into a passel of woo-woo nonsense) and supporters (for mindlessly rejecting effective treatments just because they haven't passed conventional standards of evidence) alike. There's no middle ground with these folks.

A study released today in the Journal of the National Cancer Institute gives me a chance to bring up the phenomenon of a guideline that gets cemented into place as a hospital quality measure even if the premise behind it is controversial or shaky. The study shows that almost two thirds of hospitals fall short of such a standard that took effect last year: A minimum of 12 lymph nodes should be cut out and sent to the pathology lab in all patients who have a section of cancerous colon removed.

No surgeon challenges the absolute necessity to put lymph node tissue under the microscope to see whether cancerous cells have spread beyond the colon or other organ. The guideline, moreover, is based on studies that seem to show a clear relationship between long-term survival after such surgery and the number of nodes excised. The logical explanation is that the more nodes examined, the greater the chance of finding at least one that is positive for cancer, which triggers aggressive treatment involving radiation and chemotherapy. Therefore, it is important to look at a large number of nodes to maximize the odds of finding an elusive positive one.

How about that—parking fees will be eliminated at most hospitals in Scotland! My eye almost slid past this week's announcement from the British Medical Association. But a closer look and a little digging turned up an interesting story that many U.S. patients will appreciate. I'd like to hear from you if you're one of them.

I found that hospital parking charges in the United Kingdom have been something of a hot button for years with patients and doctors. Care is free through the National Health Service, so why should patients have to pay to park at NHS hospitals? The fees are "an indirect tax on healthcare," says the BMA. "A stealth tax on illness," echoes Macmillan Cancer Support, a patient group.