The Vitals - October 2015
Internal Medicine Alert - Infectious Disease Alert - Clinical Cardiology Alert
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Physician Practices Offer Mixed Reviews of ICD-10 Implementation
SAN FRANCISCO – With several weeks of using ICD-10 for billing under their belt, how do physician practices feel about it?
The early reviews were quite mixed.
While Practice Fusion, a cloud-based platform company, said a survey of its community indicated that only 17% of users reported that they found the overall ICD-10 transition "very disruptive" to their practice, other polls were much less positive.
When the physician social media site Sermo poll asked, “Has the transition to ICD-10 taken your time away from patient care?” 86% of the 194 respondents said “yes” and 14% said “no.”
Practice Fusion reported that community healthcare professionals using their system had charted 1 million patient visits with the ICD-10 system as of the first week. The most used ICD-10 codes on the Practice Fusion platform at that point were essential (primary) hypertension (I10), type 2 diabetes mellitus without complications (E11.9), hyperlipidemia, unspecified (E78.5), low back pain (M54.5), and anxiety disorder, unspecified (F41.9).
Interestingly, in a survey before the ICD-10 requirement went into effect, the company found that only 18% of healthcare professionals felt prepared for the transition, and 61% felt unsure.
It will be a while before anyone one officially knows how successful the transition has been, however.
Sean Cavanaugh, deputy administrator and director of CMS, notes in a blog posted on Oct. 1, “You may wonder when we’ll know how the transition is going. It will take a couple of weeks before we have the full picture of ICD-10 implementation because very few health care providers file claims on the same day a medical service is given. Most providers batch their claims and submit them every few days.”
Even then, a clear picture probably won’t emerge, he writes.
“Even after submission, Medicare claims take several days to be processed, and Medicare – by law – must wait two weeks before issuing payment,” Cavanaugh points out. “Medicaid claims can take up to 30 days to be submitted and processed by states. Because of these timeframes, we expect to know more about the transition to ICD-10 after completion of a full billing cycle.”
Related [On-Demand Webinar]: ICD-10: Be Ready
Generally Unnecessary Use of Imaging Reduced for Two Medical Conditions
WILMINGTON, DE – The Choosing Wisely campaign to reduce clinical services with minimal benefits to patients appears to be paying off somewhat – at least for two imaging-related options.
An analysis published recently in JAMA Internal Medicine finds reduced use of imaging for headaches and cardiac imaging in low risk patients. Study authors, led by researchers from HealthCore in Wilmington, DE, note that reducing the use of unnecessary medical procedures and treatments is critical for controlling healthcare expenditures.
Choosing Wisely, initiated by the American Board of Internal Medicine, includes more than 70 lists of about 400 recommendations of frequently used medical practices or procedures that are of minimal clinical benefit to patients.
For this study, researchers opted to examine the frequency and trends of some of the earliest Choosing Wisely recommendations from 2012. Using medical and pharmacy claims from Anthem-affiliated Blue Cross and Blue Shield health care plans for about 25 million members, they focused on seven services:
- Imaging tests for headache with uncomplicated conditions;
- Cardiac imaging for members without a history of cardiac conditions;
- Preoperative chest x-rays with unremarkable history and physical examination results;
- Low back pain imaging without red-flag conditions;
- Human papillomavirus (HPV) testing for women younger than 30;
- Antibiotics for acute sinusitis; and
- Prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for members with select chronic conditions, i.e., hypertension, heart failure or chronic kidney disease.
The number of members with medical and/or pharmacy claims for the included low-value services was assessed quarterly over a two- to three-year span through 2013.
Only two of the services showed declines: Use of imaging for headache decreased from 14.9% to 13.4%, while cardiac imaging decreased from 10.8% to 9.7%.
On the other hand, results indicate that use of NSAIDs went up from 14.4% to 16.2%, and usually unnecessary HPV testing in younger women increased from 4.8% to 6.0%.
Changes in three other services were not significant. Antibiotics for sinusitis remained essentially stable, decreasing slightly from 84.5% to 83.7%. The already high use of pre-operative chest X-rays, 91.5%, and imaging for low back pain, 53.7%, showed no meaningful changes, according to the investigation.
Study authors caution that the research was based on administrative claims data, which doesn’t always adequately capture the clinical circumstances that led to a medical decision.
"The relatively small use changes suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations in general practice,” study authors conclude. “Some of the additional interventions needed include data feedback, physician communication training, systems interventions (e.g., clinical decision support in electronic medical records), clinician scorecards, patient-focused strategies and financial incentives.”
Related [On-Demand Webinar]: New CMS Radiology & Nuclear Medicine CoPs
NPs, PAs Comparable to Physicians in Ongoing Cardiac Care
HOUSTON – Is this statement true or false: Cardiac patients receive the best ongoing care when they see their doctors not advanced practice providers such as physician assistants and nurse practitioners.
The answer, according to a new study published in the Journal of the American College of Cardiology, is that the care for coronary artery disease, heart failure and atrial fibrillation is comparable, no matter which of those is providing care. None of the providers met all performances measures, however, according to the study led by researchers from the Michael E. DeBakey Veterans Affairs Medical Center in Houston.
Using the American College of Cardiology’s PINNACLE Registry, the researchers compared quality of coronary artery disease (CAD), heart failure, and atrial fibrillation care delivered by physicians and advanced practice providers (APPs) for outpatient visits between Jan. 1, 2012, and Dec. 31, 2012. Included in the study were 716 physicians and 167 APPs in 41 practices, caring for 459,669 patients.
The mean number of patients seen by APPs (260.7) was lower compared with that seen by physicians (581.2). Compliance with most CAD, heart failure, and atrial fibrillation measures was comparable, except that the NPs and Pas were more likely than physicians to urge smoking cessation screening and intervention (adjusted rate ratio: 1.14) and cardiac rehabilitation referral (rate ratio: 1.40) among CAD patients.
Yet none of the healthcare professionals had high compliance with all eligible CAD measures, according to the results, with 12.1% for APPs and 12.2% for physicians. The results didn’t vary when the 41 physician practices with APPs were compared to the 49 practices without.
“Apart from minor differences, a collaborative care delivery model, using both physicians and APPs, may deliver an overall comparable quality of outpatient cardiovascular care compared with a physician-only model,” study authors conclude.
"Our findings indicate that a collaborative care delivery model which employs both physicians and advanced practice providers appears to provide a care quality that is comparable to a physician-only model," lead author Salim S. Virani, MD, PhD, said in an American College of Cardiology press release.
"Our results also have health care policy implications," Virani points out. "It should be reassuring that the quality of care for uncomplicated outpatient cardiovascular disease is at least equivalent between advanced practice providers and physicians, even in states with independent scope of practice laws for advanced practice providers and between practices with both advanced practice providers and physicians compared with physician-only practices."
"I am uncertain that these findings can be generalized across the varied health systems of the United States," added Valentin Fuster, MD, PhD, editor-in-chief of the Journal of the American College of Cardiology. "However, I am certain that team-based delivery models will provide the basis of the highest quality care."
In an accompanying editorial, Robert A. Harrington, MD, Arthur L. Bloomfield Professor and chairman of the department of medicine at Stanford University, said the study generally supported team-based care between advanced practice providers and physicians, but he pointed out several limitations. Harrington called for future studies about the organization of the care delivery teams and nurse practitioners and physician assistants to provide more insight about potential differences in quality of care.
Young Relatives of Late-Onset Colon Cancer Patients Also at Higher Risk
SALT LAKE CITY, UT – Recommended screening of first-degree family members of patients with colorectal cancer might not be broad enough, according to a new study finding that the age of onset could be less important than current guidelines suggest.
The study, published online recently by Clinical Gastroenterology and Hepatology, finds that all relatives of colorectal cancer patients are at increased risk for the cancer, regardless of the index patient’s age at diagnosis.
University of Utah researchers suggest their discovery could affect future guidelines regarding colorectal cancer screening.
"Most surprising, we identified a more than two-fold increase in risk of colorectal cancer among young first-degree relatives (under 50 years of age) of individuals diagnosed with colorectal cancer at advanced ages (60 to 80 years)," explained lead study author N. Jewel Samadder, MSc, MD, from Huntsman Cancer Institute at the University of Utah.
"This risk is not currently appreciated,” Samadder said in an American Gastroenterological Association press release. “Increased awareness of this risk may serve as incentive to increase screening intensity for all patients with a first-degree family history of colorectal cancer.”
For the population-based case-control study, the researchers used the Utah Cancer Registry to identify 18,208 index patients diagnosed with colorectal cancer between 1980 and 2010; age- and sex-matched cancer-free individuals were selected to create the comparison group.
Increased risk was observed in all relatives regardless of age of the family member's cancer diagnosis, although the risk was greatest for young relatives (under 50 years) of individuals who were diagnosed with colorectal cancer before 40. Yet, results indicate, familial risk was increased in first-degree relatives even when the index case was diagnosed with cancer at an advanced age older than 80.
“All relatives of individuals with CRC are at increased risk for this cancer, regardless of the age of diagnosis of the index patient,” study authors conclude. “Although risk is greatest among young relatives of early-onset CRC cases, relatives of patients diagnosed at advanced ages also have an increased risk.”
The researchers suggest their findings support current guidelines, which call for more aggressive screening for first-degree relatives of persons with colorectal cancer at an age younger than 60. The point out, however, that, colorectal cancer diagnosis even in an older patient can be a predictor of higher risk of the cancer in their relatives, and that family members might benefit from knowing the moderate risk and avoid known modifiable risk factors.
UPCOMING [LIVE] WEBINARS
TJC Leadership Standards Essential to Engage Staff, Support Operations and Provide Quality Care
Live: October 27 Credits: 2 CNE
Revised CMS Guidelines for Medical Staff & Board Changes
Live: October 28 Credits: 1.5 CNE
Safe Injection Practices and IV Push Guidelines: Compliance with CDC and CMS Standards
Live: November 3 Credits: 1.5 CNE
Infection Prevention & Control Standards from CMS: the Latest
Live: November 10 Credits: 2 CNE
Human Trafficking in Healthcare: Awareness & Combating
Live: November 12 Credits: 1 CNE
Advance Directives Update: What Every Healthcare Provider Should Know
Live: November 12 Credits: 2 CNE
[ON-DEMAND] WEBINARS
ICD-10: Be Ready
Credits: 1 CNE
Prepare for the Healthcare-Specific Federal OSHA National Emphasis Program
Credits: 1.5 CME & 1.5 CNE
