Monday, February 6, 2012

Would Free Medications Help?

It's too bad this study doesn't actually look at what I would have hoped it would - but it's interesting, nonetheless.  One of my hospitals is a true safety-net hospital and we see, repeatedly, repeatedly, repeatedly, the complications of neglected chronic disease.  One of our frequent laments is whether the costs of recurrent acute hospitalization wouldn't be prevented a hundred times over if we'd simply sink some costs into preventative maintenance care, free medications, etc.

This study almost looks at that.  This is from the NEJM which compared the outcomes of patients following myocardial infarction, and they follow a group which receives completely free medication and a group that does not.  Unfortunately, the group that does not receive free medications is still receiving heavily subsidized medication support, and is only responsible for a co-pay.

Despite only needing to come up with a co-pay, there's a significant difference in medication compliance, with an average absolute difference in full adherence with medications of ~5-6%.  With this minimal absolute difference in adherence, the full adherence group had significantly fewer future vascular events - mostly from stroke and myocardial infarction - approximately a 1% absolute decrease.  There was a non-significant decrease in total costs associated with the patients who were on the full-coverage medication plan.

Now, they don't follow-up any medication-related adverse events, so this is the most optimistic interpretation of benefits of full-coverage, but it would seem that it is overall cheaper and more beneficial to supply medications for free.  And, it makes me wonder what the results of a similar cost/health-benefit study would show in our safety-net population.

"Full Coverage for Preventive Medications after Myocardial Infarction"

Saturday, February 4, 2012

Safety-Nets & ED Length of Stay

This is a relatively intriguing public policy article in JAMA following up in a timely fashion regarding the new CMS Emergency Department quality measures.  These new measures include various time-to-X measures, including length of stay, length of time to admission from bed request, etc.  There is some concern that these quality measures may be tied to federal funding, unfairly targeting "safety-net" hospitals that are not at baseline provided with the resources to address patient flow issues.

This article is a review of the NHAMCS database, a national probability sample survey of patient visits, looking at independent predictors of increased length of stay in patients admitted and discharged from the Emergency Department.  Based on the review of this sample, they do not see a significant difference in ED length of stay - and conclude that these quality measures should not be of concern to "safety net" EDs.  However, these general time-based measures mask most of the problems encountered in "safety net" institutions.

There are some baseline differences in patient characteristics between the safety-net and non-safety-net hospitals in their sample, and they tend to work in favor of safety-net hospitals.  The safety net hospitals in this sample tended to have younger patients with lower triage acuities, which should work in favor of reduced ED overall average length of stay.  My anecdotal experience suggests that, once the quality measures track more detailed ED transit times, I believe we will see more significant deficiencies drop out in the safety-net group.

"Association of Emergency Department Length of Stay With Safety-Net Status"

Thursday, February 2, 2012

Half of Fractures Received No Analgesia

One of the new CMS quality measures involves measuring time to receipt of pain medication for patients diagnosed with long bone fractures.  While this isn't the most exciting quality measure in terms of outcomes, it is probably a reasonable expectation that fractures receive pain control, and it might be a plausible surrogate marker for overall Emergency Department operations - at least, until the powers that be focus solely on these few measures at the expense of other clinical operations.

This article is a retrospective review of all pediatric long bone fractures evaluated at their facility.  They used the electronic medical record to track the timing of any "adequate" pain medication.  They have a specific weight-based definition of "adequate" for IV narcotics, PO narcotics, and non-narcotic analgesics, and they specifically break down pain medication received within 1 hour of arrival.

They identified 773 cases in their records, and by their definitions, 75 patients received an "adequate" dose of pain medication within 1 hour.  One can quibble with their definition of "adequate" because there is a range of pain needs that don't necessarily require maximal dosing.  But, you cannot quibble with the fact that 353 children received no pain medication at all within an hour of ED arrival (or prior to ED arrival).  Certainly, some individual factors at play would result in reasonable delays to pain medication, but definitely not nearly half.

"Analgesic Administration in the Emergency Department for Children Requiring Hospitalization for Long-Bone Fracture"
http://www.ncbi.nlm.nih.gov/pubmed/22270501