In the News

IOM favors more limits on resident hours, and other medical updates.

IOM favors more limits on resident hours

The Institute of Medicine recommended that the workloads and schedules of medical residents be reduced in the interests of patient safety.

The new IOM report suggests that residents be allowed to work no more than 16 hours in a row without sleep and that their number of mandatory days off be increased. Medical moonlighting by residents should also be restricted, the report said. Under the proposed changes, residents could either work a shift of 16 continuous hours or they could work 30 hours if they received a 5-hour sleep break after working 16 hours. The sleep break would count toward the current 80-hour limit, which the group did not suggest changing.

The report also called for greater supervision by attendings, and recommended that first-year residents not be left on duty without immediate access to an on-site supervisor. Residency review committees for all medical specialties should set specific limits on how many patients residents can treat per shift, the IOM said. Currently, only internal medicine has such rules. To reduce the chance of hand-off errors, residents should be scheduled on overlapping shifts.

The committee which wrote the report noted that the proposed changes would require increases in the number of residents and other providers, including midlevels and trained physicians, caring for patients in the hospital. They estimated the additional personnel costs at $1.7 billion annually, but noted that a reduction in errors would also reduce the cost of the changes.

Rapid response teams fail to lower code, mortality rates

Rapid response teams do not appear to reduce the incidence of hospital-wide cardiopulmonary arrests or deaths, according to the results of a study published in the Dec. 3, 2008 Journal of the American Medical Association.

The study, which tests the Institute for Healthcare Improvement's (IHI) recommendation that hospitals implement rapid response teams as one of six strategies to reduce preventable in-hospital deaths, was performed over several years at a single mid-western hospital. Hospitals nationwide fell in line with IHI's recommendation, the authors noted, despite limited published data in support of its efficacy.

Over a three-year period, the study evaluated 24,193 adult patient admissions prior to the rapid response team intervention and 24,978 admissions after the intervention. Of the 376 rapid response team activation during 20-months following the intervention, most were triggered by altered neurological status, tachycardia exceeding 130 beats per minute, tachypnea exceeding 30 breaths per minute, and hypotension assessed as blood pressure lower than 90 mmHg.

Hospital-wide code rates per 1,000 admissions were 11.2 before and 7.5 after rapid response team intervention. A decrease in non-ICU code rates accounted for the majority of the difference. Fatality rates after cardiopulmonary arrest and hospital-wide mortality were similar prior to and after the rapid response team intervention.

Cleveland clinic lists physician-industry ties

Physicians who work for the Cleveland Clinic will now have to publicly release their business relationships with pharmaceutical and device manufacturers, the health system announced in December.

All of the clinic's 1,800 staff physicians and researchers will now be included in an online directory. With each name will be posted a list of any device or drug companies with which the physician collaborates. Disclosure will be required for any consulting relationship that pays $5,000 or more per year, as well as any equity, royalty or fiduciary interests.

The clinic began internally monitoring such relationships more than a year ago, according to the Dec. 3 New York Times. All Cleveland Clinic staff physicians report their industry relationships at least yearly and the hospital's Innovation Management and Conflict of Interest Committee reviews the collaborations to identify any potential conflicts. Less than one-quarter of the clinic's physicians have such relationships to report, a clinic representative told the New York Times.

The Cleveland Clinic is apparently the first academic medical center to publicly disclose individual physician-industry ties, said the hospital's chief of staff. Currently, the directory only lists company names and the type of relationship but there are plans to expand it next year to include specific dollar amounts.

Insurers support universal coverage with individual mandate

Two major health insurance groups announced in November that they will provide coverage for all Americans, if the government mandates that everyone purchase health insurance.

Under the proposal, the members of America's Health Insurance Plans (AHIP) and the BlueCross BlueShield Association would no longer reject applicants based on their health status or exclude pre-existing conditions from coverage. Their proposal is contingent on Congress enacting an enforceable individual coverage mandate.

Mandatory coverage, a controversial issue in the recent presidential election, was not a component of President-elect Barack Obama's health reform plan. In support of their proposal, the groups contend that requiring insurers to provide coverage to all applicants without forcing consumers to purchase insurance would provide an incentive for people to wait until they were sick to buy insurance, and thereby raise overall premiums. The AHIP statement also urged expansion of the Medicare and SCHIP programs.

Other components to the AHIP proposal for health care Reform include:

  • Establish an insurance coverage verification system, an automatic enrollment process and effective enforcement of the requirement that all individuals purchase and maintain coverage;
  • Promote affordability by: providing refundable, advanceable tax credits for moderate-income individuals and working families; and promoting tax equity whether coverage is obtained through an employer or the individual market; and
  • Ensure premium stability for those with existing coverage through a broadly funded reimbursement mechanism that spreads costs for the highest-risk individuals.

JUPITER takes center stage at AHA’S Scientific Sessions

While the JUPITER trial took center stage, several other drug and lifestyle modification studies created buzz at the American Heart Association's Scientific Sessions in New Orleans.

Among the studies presented were:

  • The HF-ACTION study, which found exercise training didn't reduce death or hospitalization rates for heart failure patients compared with usual care. There was an 11% reduction in death and hospitalization on adjusted analysis—but the main message from the study was that exercise in this population is safe, observers said. A sub-study found that the patients in the exercise group reported significantly better health status (quality of life, symptoms and physical/social limitations) at three months, and the difference lasted for three years. The study involved 2,331 heart failure patients (average age, 59 years) who were followed for about 2.5 years.
  • Compared with placebo, irbesartan (Avapro) didn't significantly lower the death and hospitalization rate of heart failure patients with an ejection fraction of greater than or equal to 45%. The I-PRESERVE study of 4,128 patients over 4.5 years found no difference between the groups, which at least showed the drug is safe for use in these patients to control hypertension, the authors said.
  • Two studies reported good news about surgery outcomes in the very elderly. One examined 1,062 patients age 80 years and older who had undergone coronary artery bypass grafts, and found that half lived for six years or more, and about a quarter lived for 10 years. A second study of octogenarians undergoing aortic valve replacement without CABG found that more than half were still alive nearly 11 years later, compared with nine years later for those who had valve replacement with CABG.
  • Warfarin patients who did weekly home INR testing had no more strokes, major bleeds or deaths than patients who were monitored monthly at a clinic. Home testing might be a better option for patients who have disabilities or live far from a clinic, the authors noted. The study involved 2,922 VA patients, nearly all of whom were men, and had an average follow-up of three years.