Clinical Insights/Professional Update

February 3, 2003



 

NEWS WATCH

PROFESSIONAL UPDATE

Jump to:Choose article section...Adverse drug events and malpractice claims Slow economy cited as reason physicians postpone retirement Surveys suggest that no capitation means more revenue Physicians face cuts in Medicare reimbursement rates Medicare considers paying physicians to improve quality What kinds of errors do office-based physicians make? CLINICAL INSIGHTS HPV vaccine prevents cervical Ca Family history increases ovarian Ca risk in women with breast Ca Total vs. subtotal abdominal hysterectomy Vaginal tape vs. colposuspension for stress incontinence Sildenafil vaginal suppositories significantly increase IVF success Latest recommendations for osteoporosis screening Radical mastectomy is no better than less radical approaches

Adverse drug events and malpractice claims

Most adverse drug events (ADEs) resulting in malpractice claims are preventable, according to a study in the Archives of Internal Medicine (11/25/02).

The study researchers found that 73% of the 129 claims involving ADEs were determined to be preventable. Of these preventable cases, 53% occurred in the inpatient setting and 47% among outpatients.

The researchers surmised that 40% of inpatient, preventable ADEs could have likely been prevented with the use of "computerized physician order entry with decision support." Moreover, having clinical pharmacists on hand during clinician rounds could have helped prevent 64% of inpatient ADEs.

According to the study, operational systems failures—such as poor team communication, inadequate handoffs, supervisory failures, inadequately trained staff, ergonomic problems (e.g., look-alike equipment), and failure to appropriately use consultants—were most commonly associated with preventable ADEs.

Among preventable ADEs, anesthetics, anxiolytic or sedative agents, and potassium supplements were most frequently involved in inpatient ADEs, while analgesics, anticoagulants, cardiovascular drugs, and antidepressants or antipsychotic drugs were most often involved in outpatient events.

The study was based on a retrospective analysis of claim records from a single New England malpractice insurance company between Jan. 1, 1990 and Dec. 31, 1999.

Slow economy cited as reason physicians postpone retirement

At least one physician recruiter believes that physician retirements have slowed down, according to MD Practice Alert (11/20/02). Why? The downturn in the economy and stock market, as well as a lack of consumer confidence may be to blame.

MD Practice Alert cites the observations of Mark Smith, executive vice president of Dallas-based Merritt Hawkins & Associates. Based on his contacts with employer clients and his firm's recruiters, Smith believes that many physicians who had planned to retire this year or next aren't because of the slowing economy. This contrasts with a survey conducted by the firm in 2000, which found that more than half of surveyed physicians over the age of 50 planned to retire or cut back their practice over the following 3 years.

Instead of taking full retirement, Smith told MD Practice Alert that physicians are restructuring their practices to suit their lifestyles. For example, physicians can:

  • withdraw from partnership in a group, and forgo administrative and business duties;

  • join a new group without buying into ownership;

  • cut down on the number of hours they put in per day, week, or year;

  • reduce or eliminate call-duty responsibilities; or

  • change their work environment by relocating or changing groups.

Surveys suggest that no capitation means more revenue

Physicians who work in groups receiving no capitation reimbursement earn more than their colleagues working in capitated groups, according to two surveys.

The American Medical Group Association's "Financial Operations Survey: 2002 Report Based on 2001 Data" found that groups with no capitation reimbursement spent $247,800 per physician for compensation and benefits—32% more than the $187,000 spent for physicians in groups with 35% or more in capitation revenues. (The AMGA data come from multispecialty groups, the majority of which are groups of 100 or more physicians.)

Similarly, the Medical Group Management Association's (MGMA) 2002 survey compared income figures of various specialists in multispecialty groups and found that nearly all no-capitation physicians earn more than their colleagues in groups with 50% or more in capitation revenues. For example, ob/gyns in no-capitation groups earned $270,500 in 2001 versus $214,500 for ob/gyns in over-50%-capitation groups.

The MGMA data are based on income figures by specialty, and for both single-specialty and multispecialty practices.

Physicians face cuts in Medicare reimbursement rates

Although the House of Representatives passed legislation last year that would have set Medicare physician payment updates at about 2% in 2003 and allowed updates for 2004 and 2005 to be calculated using a modified formula, the Senate adjourned without taking action on the bill. As a result, physicians face a 4.4% reduction in payment rates this year—yielding a nearly 10% cut for 2002 and 2003.

The bill, if it had passed, would have given the Centers for Medicare & Medicaid Services the authority to modify the formula used to determine physician reimbursement rates and fix the errors that resulted in the 5.4% reduction in Medicare payments to physicians last year.

Medicare considers paying physicians to improve quality

This year, the Centers for Medicare & Medicaid Services will begin a 3-year demonstration project, which will pay incentives to physicians for improving the quality of care to Medicare beneficiaries.

According to American Medical News (11/4/02), physician groups will be paid on a fee-for-service basis. They can earn bonuses from the savings derived from better quality of care or by meeting certain quality benchmarks. If a group generates more than 2% savings over average Medicare Part A and B treatment costs, it can keep a portion of those savings, reported AMNews.

The demonstration project is open to groups with at least 200 physicians. The project was mandated by Congress in 2000 through the Benefits Improvement and Protection Act.

What kinds of errors do office-based physicians make?

The variety of errors found in office settings are different from those identified in the hospital setting, say the authors of a recent study in Quality and Safety in Health Care (9/02). After much ado about hospital medical errors, this study has finally attempted to create a preliminary taxonomy of medical errors observed by office-based physicians.

The study categorized 344 errors reported by 42 family physicians across the United States. An error was defined as something in the practice that should not have happened, that was not anticipated, and that made the participating physician say, "that should not happen in my practice, and I don't want it to happen again."

The authors of the study found that the vast majority of errors reported—nearly 83%—dealt with problems in the process of delivering health care. Administrative mistakes, such as missing contact information for a patient whose biopsy was positive for melanoma or failing to make a timely appointment for a seriously ill child, are examples of "process" errors. Other examples include investigative failures and communication lapses.

Lack of clinical knowledge or skills on the part of the physician, such as a wrong or missed diagnosis, resulted in nearly 14% of errors reported. The remaining errors were reports of adverse events, not errors.

Although the authors of the study note that about 56% of the errors reported seemed trivial in that no patient was harmed, "an event that is trivial on one occasion may be non-trivial on another." To illustrate the point, the authors cite a single death as one serious consequence that resulted from a mere "failure in message handling."

CLINICAL INSIGHTS

HPV vaccine prevents cervical Ca

In a landmark study, three doses of a human papillomavirus virus (HPV)-16 virus-like–particle vaccine (40 µg per dose at 0, 2, and 6 months) reduced the incidence of both HPV infection and HPV-16–related cervical intraepithelial neoplasia, according to a double-blind study of 2,392 women between the ages of 16 and 23 years.

The incidence of persistent HPV-16 infection was 3.8 per 100 woman-years at risk in the placebo group versus zero in the vaccine group. All nine cases of HPV-16–related CIN occurred in the women receiving placebo.

Considering that HPV-16 is present in 50% of cervical cancers and high-grade CINs, eventually immunizing HPV-16–negative women may significantly reduce the incidence of cervical cancer.

Koutsky LA, Ault KA, Wheeler CM, et al. A controlled trial of a human papillomavirus type 16 vaccine. N Engl J Med. 2002;347:1645-1651.

Family history increases ovarian Ca risk in women with breast Ca

A family history of breast or ovarian cancer greatly increases the risk of ovarian cancer in young women with breast cancer, according to a population-based cohort study of more than 30,000 Swedish women.

Overall, the researchers found a twofold risk of ovarian cancer in the study cohort. Women without a family history of breast or ovarian cancer had a 60% increased risk overall. Women with an immediate family member who had been diagnosed with breast or ovarian cancer had a fourfold increase in risk for ovarian cancer; those diagnosed before the age of 40 years were at seven times the risk.

The authors of the study recommend close medical surveillance in such women with consideration given to prophylactic oophorectomy.

Bergfeldt K, Rydh B, Granath F, et al. Risk of ovarian cancer in breast-cancer patients with a family history of breast or ovarian cancer: a population-based cohort study. Lancet. 2002;360:891-894.

Total vs. subtotal abdominal hysterectomy

There are no significant differences in bladder, bowel, and sexual function at 12 months postsurgery, regardless of whether a woman has had a subtotal or total abdominal hysterectomy, according to a randomized, double-blind trial of 279 mostly premenopausal women.

The rates of urinary frequency (defined as urinating more than seven times/day) were 33% for the subtotal-hysterectomy group and 31% for the total-hysterectomy group before surgery; these rates fell to 24% and 20%, respectively, at 12 months postsurgery. Reduction in nocturia and stress incontinence and improvement in bladder capacity were similar in the two groups. Likewise bowel symptoms and sexual function did not change significantly in either group after surgery.

In terms of differences, the subtotal-hysterectomy group had on average a 1-day shorter hospital stay, less blood loss during surgery, a shorter operative time, and one third the rate of fever as the women in the total-hysterectomy group, but had a higher rate of cyclical bleeding and cervical prolapse.

Thakar R, Ayers S, Clarkson P, et al. Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med. 2002;347:1318-1325.

Vaginal tape vs. colposuspension for stress incontinence

Surgery with tension-free vaginal tape is as effective as colposuspension for the primary treatment of stress incontinence, but is associated with more instances of bladder injury. Colposuspension, on the other hand, is associated with longer operation, hospital, and recovery time and more delayed resumption of micturition, according to a recent multicenter randomized trial.

The trial, conducted in the United Kingdom and Ireland, involved 344 women with urodynamic stress incontinence. After 6 months of follow up, the researchers found that approximately 66% of the women receiving the vaginal tape procedure were objectively cured, versus 57% in the colposuspension group. These numbers were lower than the cure rates quoted in a number of other studies, perhaps because the number of patients recruited fell short of the target.

In addition, the researchers caution that longer term follow-up is needed to assess the long-term success of the two procedures, particularly with regard to prolapse and tape erosion.

Ward K, Hilton P. Prospective multicentre randomised trial of tension-free vaginal tape and colposuspension as primary treatment for stress incontinence. BMJ. 2002;325:67.

Sildenafil vaginal suppositories significantly increase IVF success

In women who have experienced multiple in vitro fertilization (IVF) failures, sildenafil vaginal suppositories significantly increase implantation and pregnancy rates associated with IVF by increasing endometrial thickness.

Researchers conducted a retrospective analysis of 105 infertile women under the age of 40 years. They gave the women sildenafil vaginal suppositories (25 mg, four times per day for 3 to 10 days) in addition to a long GnRH-a IVF protocol.

Seventy percent of the women attained an endometrial thickness of 9 mm or more. Implantation and ongoing pregnancy rates for the women in this group were 29% and 45%, respectively. Implantation and ongoing pregnancy rates for the 30% of women who achieved less than a 9-mm endometrial thickness were 2% and 0, respectively.

Sher G, Fisch JD. Effect of vaginal sildenafil on the outcome of in vitro fertilization (IVF) after multiple IVF failures attributed to poor endometrial development. Fertil Steril. 2002;78:1073-1076.

Latest recommendations for osteoporosis screening

According to the latest US Preventive Services Task Force (USPSTF) recommendations, all women aged 65 years and older should be routinely screened (approximately every 2 years) for osteoporosis. Those at increased risk for fractures should be screened routinely beginning at age 60. It is still unclear as to the age at which screening and treatment cease to be cost-effective. African-American women are less likely to benefit from screening since, at any age, they have higher bone mineral density than white women.

The task force specifies body weight of less than 70 kg as the single best predictor of low bone mineral density, followed by no current use of estrogen therapy. The best predictor of hip fracture is bone density measured at the femoral neck by dual-energy x-ray absorptiometry.

For more information, see the USPSTF Web site ( www.preventiveservices.ahrq.gov ). US Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: Recommendations and rationale. Ann Intern Med. 2002;137:526-528.

Radical mastectomy is no better than less radical approaches

A 25-year follow-up of a randomized trial initiated in 1971 indicates that radical mastectomy confers no significant survival advantage to women with breast cancer, when compared to total mastectomy with or without radiation.

Researchers studied just over 1,000 women with negative axillary nodes who received radical mastectomy, total mastectomy without axillary dissection but with postoperative irradiation, or total mastectomy plus axillary dissection if their nodes became positive. They also studied 586 women with positive nodes who received either radical mastectomy or total mastectomy without axillary dissection but with postoperative irradiation.

The researchers observed no significant differences among the three negative-node groups or the two positive-node groups with respect to disease-free survival (DFS), relapse-free survival, distant-DFS, or overall survival.

In addition, the findings indicated no significant survival advantage from removing occult positive nodes at the time of initial surgery. About 40% of the women who underwent total mastectomy alone had pathologically-confirmed positive nodes that were not removed during the initial surgical event because they were clinically negative. Since delays in the switch from negative to positive nodes are common, some experts believe that all women should receive axillary dissection during initial surgery, regardless of node status. This study indicates, however, that while this strategy may improve local disease control, it does not seem to affect the rate of distant recurrence or mortality.

Fisher B, Jeong JH, Anderson S, et al. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347:567-575.

 

Professional Update/Clinical Insights. Contemporary Ob/Gyn 2003;2:14-20.