Established in 1927 by the American College of Physicians


1 October 2013 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in the September 17 issue of Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.

1. Regular primary care visits lower colorectal cancer incidence, death, and all-cause mortality

Medicare beneficiaries with more visits to their primary care physician (PCP) have lower colorectal cancer (CRC) incidence, CRC-specific mortality, and all-cause mortality. CRC is preventable with appropriate screening and polypectomy, yet many of the people who could benefit from it either are not screened, or do not start screening early enough. Recommendations from physicians are the strongest predictors of adherence to CRC screening guidelines. Researchers hypothesized that patients with few or no visits to a PCP would have higher CRC incidence and mortality due to never having been screened or having a polypectomy. Medicare records for patients aged 67-85 who were diagnosed with CRC between 1994 and 2004 in U.S. Surveillance, Epidemiology, and End Results (SEER) regions were compared with health records of control patients to examine the association of utilization of PCPs with CRC incidence and actual mortality. The researchers found that the likelihood of CRC diagnosis, CRC-specific death, and all-cause mortality decreased with increasing primary care visits. These rates were also lower for patients frequently seeing any type of provider. The authors suggest that increasing and promoting access to primary care for Medicare beneficiaries may reduce the national burden of CRC. Editorialists agree that access to care is paramount. However, they caution that other factors, such as patient non-adherence to scheduled care, may affect CRC screening rates and subsequent outcomes. They also point out that “healthy user” bias is a shortcoming of observational studies.

2. Patient outcomes are not affected by early discharge from busy ICUs

Doctors in strained ICUs are more likely to make high-value care decisions

Physicians in resource-strained intensive care units (ICUs) are likely to discharge patients more efficiently without negatively affecting outcomes. Health care costs in the U.S. are likely to increase strain on ICU resources. Strain on ICU capacity may influence care providers to discharge patients as soon as possible to open beds, and communication may suffer during patient handoffs. Researchers reviewed heath records for 200,730 adults discharged from 155 ICUs in the U.S. to determine how ICU capacity strain on day of patient discharge affects ICU length-of-stay and post-ICU discharge outcomes. ICU capacity was measured by ICU census, number of new admissions, and average number of patients. The researchers found that when ICUs were busy, patients stayed for a shorter time and were somewhat more likely to be readmitted to the ICU. However, there were no increases in patient mortality rates, no greater overall length of hospital stay, and no decreases in patients' odds of being discharged home from the hospital. The authors suggest that physicians are more likely to practice high-value care, efficiently discharging those patients who do not actually require ICU treatment.

3. Medicare Advantage plans underreport high-risk prescribing practices

Under the Patient Protection and Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) are required to publicly report quality and performance measures so that providers and patients are fully informed about cost and quality of care. However, the accuracy of these reports is not known. Medicare Advantage plans report clinical performance using Healthcare Effectiveness Data Information Set (HEDIS) quality indicators. Researchers reviewed 172 Medicare Advantage Plans to compare reported HEDIS rates of high-risk prescribing (prescribing drugs that should be avoided in elderly patients) to rates calculated using Medicare Part D claims. They found that, on average, plans underreported high-risk prescribing by 5.8 percentage points. When ranking plans according to their calculated versus reported performance, plans with the most accurate reporting had the greatest penalty and those with the least accurate reporting had the greatest gain. The researchers also found that the rate of high-risk prescribing was the same for Medicare Advantage and Medicare fee-for-service beneficiaries. However, policymakers evaluating plan-reported rates would erroneously conclude that Medicare Advantage program has relative rates of high-risk prescribing that are approximately 20 percent lower than fee-for-service. This analysis suggests that reported performance measures should be regularly audited to ensure accuracy.