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29-07-2012 | Article

The week in review, July 22-28, 2012

MedWire News: This week's stories include bragging rights for a venerable Boston institution, revelations about cardiac device lead failures, a survey showing that physicians are warming up to electronic health records, a look at the fallout of the Supreme Court's decision on the Affordable Care Act, and a plea for tighter reins on opioid prescribing.

MGH: 'Mankind's Greatest Hospital'?

After 21 years of playing second fiddle, Massachusetts General Hospital has earned bragging rights as the USA's "Best nationally ranked hospital."

Mass General joins its sister institution, Brigham & Women's Hospital, also in Boston, in the "honor roll" of 17 top US hospitals, according to annual rankings published in US News & World Report. Brigham & Women's ranked 9th overall in the national standings.

Mass General for the first time edged out the Johns Hopkins Hospital in Baltimore, Maryland, which held the top spot for the previous 21 years. John's Hopkins is ranked second this year.

Magazine staff surveyed nearly 10,000 specialists and examined data on 4793 US hospitals, ranking each hospital according to its expertise in 16 adult specialties. The rankings also included death rates, patient safety, hospital reputation, and patient satisfaction measures.

"To be nationally ranked, a hospital must excel across a range of tough cases within a given specialty," the magazine's editors write. "For example, a hospital nationally ranked in cardiology and heart surgery - one of 16 specialties in which US News evaluates medical centers - can be expected to have doctors with the talent and experience to replace a faulty heart valve in a patient well into his or her 90s. Most hospitals would decline to perform major surgery on such elderly patients, as they should if they aren't up to speed on the special techniques and precautions involved and don't see many such patients."

The report's authors also note that "at hospitals ranked in neurology and neurosurgery, surgeons face more spinal tumors in a couple of weeks than most community hospitals see in a year."

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Bigger leads, bigger failure rate

The maker of the recalled Riata-brand implantable cardioverter-defibrillator (ICD) leads says that larger diameter leads are more frequently subject to failure than thinner leads.

St Jude Medical (St Paul, Minnesota) announced the findings as part of its release of the North American results of the phase I Riata Lead Evaluation Study.

In 2010, the company stopped selling and voluntarily recalled its Riata and Riata ST Silicone Defibrillation ICD Leads following reports that the leads were subject to both inside-out and outside-in defects in the silicone insulation, which in some cases caused lead malfunction and externalization of electrical conductors.

Externalization is defined as the appearance on X-ray or fluoroscopy of conductors outside of the lead body due to an abrasion-related breach of the outer insulation. Reported rates of externalized conductors range from 12% to 33%, the company says.

Investigators studied the prevalence of externalized conductors in 724 patients enrolled at 19 sites in the USA and one in Canada. Of the 718 patients with retrievable or verifiable images, 459 had received eight French (8F) leads, and 259 had received 7F leads.

The investigators found that 24.0% of patients who received the larger 8F leads had externalized conductors, significantly more than the 9.3% of those with 7F leads.

When they looked at leads that had been implanted for less than 6 years, there were still significantly more externalizations among patients with 8F leads (17.9 vs 9.4%).

In univariate analysis, lead diameter was the only significant predictor for conductor externalization. Neither age, gender, left ventricular ejection fraction, body mass index, nor vascular access was significantly associated with externalization, the investigators found.

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Docs dig EHRs

More than half of all US physicians in office-based practices have adopted electronic health records (EHRs), shows a new report.

As with other technologies, younger physicians appear more ready to embrace EHRs than their colleagues aged 50 years and older, according to the US Centers for Disease Control and Prevention (CDC ). Nearly two-thirds (64%) of physicians younger than 50 years in a national sample have started using EHRs in their practices, compared with 49% of those at the half-century mark or older.

"The proportion of physicians who were adopters increased as the size of the practice increased. Compared with solo practitioners where fewer than one-third of physicians adopted EHR systems, those in two-physician or three-to-10-physician practices were twice as likely, and those in practices with 11 or more physicians were nearly three times as likely, to have adopted EHR systems," says a data brief from the CDC's National Center for Health Statistics.

Just 50% of those in physician-owned practices reported adopting EHRs in 2011 ‑ a lower rate than seen for physicians employed by health maintenance organizations (100%), community health centers (74%), or academic health centers (70%).

A large majority (77%) of EHR adopters had systems that satisfy current Centers for Medicare and Medicaid Services criteria for "meaningful use," signifying that the systems met all or most objectives specified by the agency. Practices with qualifying EHR systems, whether stand-alone or web-based, are eligible for incentive payments under the Department of Health and Human Service's Health Information Technology for Economic and Clinical Health Act, explains the report.

In all, 38% of physicians reported being "very satisfied" with their EHR systems, and 47% said they were "somewhat satisfied." Moreover, only a minority of physicians appeared to have buyer's remorse, as 71% said they would purchase their EHR system again. Additionally, 74% of respondents who use EHR said that their systems enhanced overall patient care.

The data come from the 2011 Physician Workflow mail survey of 3180 US physicians who care for ambulatory patients in an office setting.

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Roberts' rules may imperil access to care for the poor

The US Supreme Court ruling on the Affordable Care Act (ACA), with a majority opinion written by Chief Justice John Roberts, will translate into lower federal healthcare outlays, but it may come at the cost of access to care for millions of the nation's poorest citizens, a study says.

According to the nonpartisan Congressional Budget Office (CBO) and the Joint Committee for Taxation (JCT), some states, for political or other reasons, may refuse to expand or may delay expansion of Medicaid services when the Act is fully implemented in 2014. In those states, residents who earn less than the federal poverty level may be out of luck, the Congressional Budget Office (CBO) estimates.

"The CBO estimates that the ACA, as approved by the Court, will result in approximately 6 million individuals being removed from state Medicaid and Child Health Insurance Program (CHIP) rolls. At the same time, enrollment in state insurance exchanges, a key provision of the law, would increase by approximately 3 million, leaving an estimated 3 million people ineligible for Medicaid and uninsured in 2022," the CBO projects.

Although federal spending on subsidies for people insured through the state health exchanges would increase over the next 10 years, it would be more than offset by reductions in Medicaid and CHIP spending. The total cost of insurance coverage expansion would thus be about $ 1.168 trillion, $ 84 billion less than the $ 1.252 trillion previously estimated by the CBO.

In a separate letter to Speaker of the House John Boehner, the CBO notes that the stated goal of congressional Republicans to repeal the ACA would increase the federal deficit by approximately $ 109 billion over the next decade

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MDs to FDA: Spell out opioid risk

In an open letter to the FDA's Dockets Management Branch, a coalition of clinicians, researchers, and health officials say that for both instant- and extended-release opioids (eg, OxyContin), the current indications are too broad.

"Unfortunately, many clinicians are under the false impression that chronic opioid therapy (COT) is an evidence-based treatment for chronic noncancer pain (CNCP) and that dose-related toxicities can be avoided by slow upward titration. These misperceptions lead to over-prescribing and high dose prescribing.

"By implementing the label changes proposed in this petition, FDA has an opportunity to reduce harm caused to chronic pain patients as well as societal harm caused by diversion of prescribed opioids. In addition, FDA will be able to reinforce adherence to dosing limits that have been recommended by the United States Centers for Disease Control, the state of Washington, and the New York City Department of Health and Mental Hygiene," write the members of Physicians for Responsible Opioid Prescribing.

Specifically, the group is asking the FDA to drop the word "moderate" from the approved indication of instant-release opioids for "moderate to severe pain." Additionally, it requests that the agency adds a maximum daily dose for noncancer pain equivalent to 100 mg of morphine, and a maximum duration of 90 days for continuous daily opioids for noncancer pain.

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By Neil Osterweil, MedWire Reporter