Archive for the ‘New England Journal of Medicine’ Category

The Growing Role of Emergency Departments in Hospital Admissions

July 12, 2012 Comments off

The Growing Role of Emergency Departments in Hospital Admissions

Source: New England Journal of Medicine

Growing use of U.S. emergency departments (EDs), cited as a key contributor to rising health care costs, has become a leading target of health care reform. ED visit rates increased by more than a third between 1997 and 2007, and EDs are increasingly the safety net for underserved patients, particularly adult Medicaid beneficiaries.1 Although much attention has been paid to increasing ED use, the ED’s changing role in our health care system has been less thoroughly examined. EDs serve as a hub for prehospital emergency medical systems, an acute diagnostic and treatment center, a primary safety net, and a 24/7 portal for rapid inpatient admission. Approximately a quarter of all acute care outpatient visits in the United States occur in EDs, a proportion that has been growing since 2001.2 We examined the proportion of hospital admissions that come through the ED, hypothesizing that use of the ED as the admission portal had increased across conditions.

We analyzed data from the Nationwide Inpatient Sample (NIS), the largest all-payer database of U.S. inpatient care, from 1993 to 2006 (the most recent year for which the ED admission data are available on HCUPnet, an interactive Web-based tool that uses data from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality). The NIS contains data from approximately 8 million hospital stays each year and is weighted to produce national estimates. We used HCUPnet to query the NIS regarding trends in the 20 clinical conditions for which patients were most frequently admitted to the hospital in 2006. Clinical Classifications Software was used to group the conditions into clinically meaningful categories. We excluded two conditions for which patients are rarely admitted through the ED (osteoarthritis and back problems), one psychiatric condition that was not consistently coded in claims data (affective disorder), and four obstetrical diagnoses that are generally evaluated in other care settings, such as labor-and-delivery triage areas (liveborn infant, maternal birth trauma, other complications of birth, other complications of pregnancy).

The number of hospital admissions increased by 15.0%, from 34.3 million in 1993 to 39.5 million in 2006; admissions from the ED increased by 50.4%, from 11.5 million to 17.3 million. The proportion of all inpatient stays involving admission from the ED increased from 33.5 to 43.8% (P<0.001). In 12 of the 13 conditions for which patients were most frequently admitted and that met our inclusion criteria, an increased proportion of admitted patients came through the ED (P<0.001), regardless of the trend in overall admissions; the exception was coronary atherosclerosis, for which rapid “rule-out” protocols and ED-based chest-pain observation units have reduced the need for inpatient admission.

The Long-Term Effect of Premier Pay for Performance on Patient Outcomes

March 31, 2012 Comments off
Source:  New England Journal of Medicine
Pay for performance has become a central strategy in the drive to improve health care. We assessed the long-term effect of the Medicare Premier Hospital Quality Incentive Demonstration (HQID) on patient outcomes.
We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest.

Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes

March 29, 2012 Comments off

Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes
Source: New England Journal of Medicine

In obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone. Further study will be necessary to assess the durability of these results.

Full Coverage for Preventive Medications after Myocardial Infarction

November 14, 2011 Comments off

Full Coverage for Preventive Medications after Myocardial Infarction
Source: New England Journal of Medicine

In conclusion, in this randomized trial, the elimination of patient copayments for secondary prevention after myocardial infarction did not significantly reduce rates of the composite primary outcome. We did observe beneficial effects on secondary clinical outcomes, including rates of total major vascular events or revascularization procedures, as well as on rates of first major vascular events and patients’ out-of-pocket spending. The intervention did not change overall health spending. This simple strategy may contribute to ongoing efforts to improve the quality of care for patients after myocardial infarction.

Breast-Cancer Adjuvant Therapy with Zoledronic Acid

September 28, 2011 Comments off

Breast-Cancer Adjuvant Therapy with Zoledronic Acid
Source: New England Journal of Medicine

Metastasis is a complex process that is dependent on both the biologic features of the primary tumor and cellular interactions within host tissues. In the bone microenvironment, cancer cells stimulate osteoblasts to release receptor activator of nuclear factor κB ligand (RANKL), which binds to its receptor, RANK, on both precursor and mature osteoclasts. The resulting increase in osteoclastic bone resorption leads to the release of bone-derived growth factors that may provide a fertile environment for survival and growth of adjacent cancer cells.1 Thus, targeting bone-cell function provides a potential additional approach to preventing bone metastases as a component of standard adjuvant therapy.2 In many in vivo models, bisphosphonates prevent or delay metastasis.3 In addition, synergistic interactions between aminobisphosphonates and cytotoxic drugs have been shown in preclinical models.4,5

In patients with early-stage breast cancer, several clinical trials have suggested that the adjuvant use of bisphosphonates reduces rates of recurrence and death.6-8 In addition, despite a lack of regulatory approval in most health care systems, the inclusion of a bisphosphonate as part of adjuvant therapy has become increasingly widespread. In this randomized, controlled, open-label phase 3 study, called the Adjuvant Zoledronic Acid to Reduce Recurrence (AZURE) trial, we evaluated the adjuvant use of zoledronic acid in a broad population of patients with stage II or III early-stage breast cancer.

See: Zoledronic Acid Reduces the Recurrence of Breast Cancer in Post-Menopausal Women, Study Finds (Science Daily)

Electronic Health Records and Quality of Diabetes Care

September 5, 2011 Comments off

Electronic Health Records and Quality of Diabetes Care
Source: New England Journal of Medicine

We compared EHRs with paper-based records in a long-term regional collaborative that seeks to improve care and outcomes for patients with chronic conditions. EHR sites were associated with higher levels of achievement of and improvement in regionally vetted standards for diabetes care and outcomes. Our findings focus on composite standards, although the results were similar for virtually all component standards. Because the study was observational, it may be subject to selection bias, although our results were similar after adjustment for the more favorable socioeconomic profiles of patients cared for in organizations with EHRs. The association of type of medical record with quality standards was significant across all insurance types. As in other studies, the association was stronger for care — which is largely under the direction of providers — than for outcomes, which also require supportive home and neighborhood environments, active patient engagement, and other resources that foster adherence to prescribed regimens. The association was generally weakest for the uninsured, a vulnerable group that is underrepresented in other studies of EHRs and quality of care.

Apixaban versus Warfarin in Patients with Atrial Fibrillation

August 29, 2011 Comments off

Apixaban versus Warfarin in Patients with Atrial Fibrillation
Source: New England Journal of Medicine

In patients with atrial fibrillation, apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and resulted in lower mortality. (Funded by Bristol-Myers Squibb and Pfizer; ARISTOTLE number, NCT00412984.)

Malpractice Risk According to Physician Specialty

August 22, 2011 Comments off

Malpractice Risk According to Physician Specialty
Source: New England Journal of Medicine

Each year during the study period, 7.4% of all physicians had a malpractice claim, with 1.6% having a claim leading to a payment (i.e., 78% of all claims did not result in payments to claimants). The proportion of physicians facing a claim each year ranged from 19.1% in neurosurgery, 18.9% in thoracic–cardiovascular surgery, and 15.3% in general surgery to 5.2% in family medicine, 3.1% in pediatrics, and 2.6% in psychiatry. The mean indemnity payment was $274,887, and the median was $111,749. Mean payments ranged from $117,832 for dermatology to $520,923 for pediatrics. It was estimated that by the age of 65 years, 75% of physicians in low-risk specialties had faced a malpractice claim, as compared with 99% of physicians in high-risk specialties.

Genomics and the Eye

August 5, 2011 Comments off

Genomics and the Eye
Source: New England Journal of Medicine

The eye has had a pivotal role in the evolution of human genomics. At least 90% of the genes in the human genome are expressed in one or more of the eye’s many tissues and cell types at some point during a person’s life. Consistent with this impressive genomic footprint is the observation that about a third of entries in the Online Mendelian Inheritance in Man database for which a clinical synopsis is provided include a term that refers to the structure or function of the eye. Moreover, the phenotypic effects of even small genetic variations are made readily apparent by the many layers of amplification in the human visual system. For example, a single-nucleotide change in PAX6 can cause an anatomic abnormality of the macula less than a millimeter in diameter that results in noticeably reduced visual acuity and nystagmus.

The heritable inability to correctly perceive the color green, known as Daltonism (after the English chemist John Dalton, who himself was affected), was the first human trait mapped to the X chromosome. The Coppock cataract was the first human trait mapped to an autosome, and Leber’s hereditary optic neuropathy was the first human disease shown to be caused by a mutation in mitochondrial DNA. More recently, age-related macular degeneration (AMD) and glaucoma — two common causes of human blindness — have been shown to be largely genetic, as has Fuchs’ endothelial dystrophy,8 the most common cause of corneal transplantation in developed countries. Here, we review discoveries in mendelian and complex ophthalmic disorders and their implications for genetic testing and therapeutic intervention.

Reforming the Regulations Governing Research with Human Subjects

July 28, 2011 Comments off

Reforming the Regulations Governing Research with Human Subjects
Source: New England Journal of Medicine

In the wake of the scandal surrounding the Tuskegee syphilis study, Congress established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The commission investigated and made recommendations regarding basic ethical principles guiding research with human beings and the special principles relating to research with fetuses, prisoners, and children. In 1981, on the basis of the National Commission’s recommendations, the Department of Health and Human Services (DHHS) revised and expanded its regulations regarding the protection of human subjects, which were entered into the Code of Federal Regulations (title 45, part 46). In 1991, subpart A of those regulations, delineating the general rules for informed consent and for the operation of institutional review boards (IRBs), was extended to 14 other federal departments, thus creating what came to be called the Common Rule. (Similar, but not identical regulations, title 21, parts 50 and 56, govern research with human beings regulated by the Food and Drug Administration [FDA].)

Since 1991, there has been almost no change to the Common Rule. Yet research with humans has substantially increased in volume, with more international and multisite studies, more health-services research, and more research with biospecimens. Decades of experience have revealed a great deal about the functioning — and limitations — of existing regulations, and have prompted critical evaluations by the Institute of Medicine, the Government Accountability Office, and many scholars.

Two themes emerge from these critiques. First, there are complaints that the regulations impose a variety of burdensome bureaucratic procedures that seem to do little to protect research participants, yet consume substantial resources. These impediments are claimed to be particularly vexing for researchers conducting studies that pose few physical or psychological risks. More important, critics have noted that current regulations could be doing a significantly better job in protecting research subjects.

Constrictive Bronchiolitis in Soldiers Returning from Iraq and Afghanistan

July 25, 2011 Comments off

Constrictive Bronchiolitis in Soldiers Returning from Iraq and Afghanistan
Source: New England Journal of Medicine

Among the soldiers who were referred for evaluation, a history of inhalational exposure to a 2003 sulfur-mine fire in Iraq was common but not universal. Of the 49 soldiers who underwent lung biopsy, all biopsy samples were abnormal, with 38 soldiers having changes that were diagnostic of constrictive bronchiolitis. In the remaining 11 soldiers, diagnoses other than constrictive bronchiolitis that could explain the presenting dyspnea were established. All soldiers with constrictive bronchiolitis had normal results on chest radiography, but about one quarter were found to have mosaic air trapping or centrilobular nodules on chest CT. The results of pulmonary-function and cardiopulmonary-exercise testing were generally within normal population limits but were inferior to those of the military control subjects.

Smoking and Mental Illness — Breaking the Link

July 23, 2011 Comments off

Smoking and Mental Illness — Breaking the Link
Source: New England Journal of Medicine

Since smoking and mental illness commonly occur together, many clinicians see them as inextricably linked and believe that smoking in the mentally ill is therefore particularly challenging to treat. Little examined are the systemic and treatment factors that have contributed to disparities in tobacco use and tobacco-related morbidity and mortality among people with mental illness.

Twenty years ago, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO, now the Joint Commission) proposed a national ban on tobacco use in hospitals, noting the contradiction between hospitals’ health care mission and their exposing of patients, staff members, and visitors to the harms of secondhand smoke. Patient-advocacy groups for the mentally ill strongly opposed the ban, arguing that tobacco’s therapeutic, calming effect was valuable and warning that psychiatric patients who were denied their cigarettes would revolt. JCAHO conceded and exempted psychiatric and drug-treatment units from the smoking ban. Psychiatric hospitals that voluntarily adopted such bans, however, have documented both little-to-no disturbance in patients’ behavior and time savings for staff members.

Yet even in smoke-free psychiatric settings, treatment of tobacco use remains relatively rare. In my group’s recent studies, among 337 smokers recruited from inpatient psychiatry units, 82% reported having attempted to quit, and 42% reported having done so within the previous year; only 4% reported receiving assistance with quitting smoking from a mental health care or general health care provider. Moreover, there are still outpatient mental health programs that provide cigarettes as an incentive for patients to comply with treatment.

The devastating consequences of tobacco use among smokers with mental illness are evident. Smokers with serious mental illness are at increased risk for cancer, lung disease, and cardiovascular disease, and they die 25 years sooner, on average, than Americans overall. Tobacco use also complicates psychiatric treatment. Components in tobacco smoke accelerate the metabolism of some antidepressant and antipsychotic medications, resulting in lowered blood levels and probably reduced therapeutic benefit. Studies have revealed higher hospitalization rates, higher medication doses, and more severe psychiatric symptoms among patients with schizophrenia who smoke than among those who do not. Though the mechanism is unclear, tobacco use also is one of the strongest predictors of future suicidal behavior.1 Smoking results in substantial social and financial costs to patients, their families, and society. As greater restrictions on exposure to secondhand smoke are implemented in many public areas, tobacco use is further isolating an already-marginalized group.

The Clean Air Act and Health — A Clearer View from 2011

July 23, 2011 Comments off

The Clean Air Act and Health — A Clearer View from 2011
Source: New England Journal of Medicine

From my office, I have views of downtown Los Angeles and the San Gabriel Mountains. Air pollution infrequently obscures these views, and only rarely are my eyes and throat irritated by smog when I’m outdoors. The Los Angeles air of today is far better than that of the mid-20th century, when severe oxidant pollution, initially of unknown origins, threatened the health and welfare of the city’s residents. Severe smog was a common occurrence. Today, throughout the United States, air quality has improved greatly, and the last century’s severe, life-threatening episodes of air pollution, such as one that caused about 20 deaths in Donora, Pennsylvania, over a 3-day period in 1948, have largely been forgotten. The Clean Air Act of 1970 (CAA) has driven this progress, but we now face new challenges in air-quality management.

Nowhere Left to Hide? The Banishment of Smoking from Public Spaces

June 25, 2011 Comments off

Nowhere Left to Hide? The Banishment of Smoking from Public Spaces
Source: New England Journal of Medicine

On May 23, smoking in any New York City park, beach, or pedestrian mall — from Van Cortlandt Park in the Bronx to Brighton Beach in Brooklyn — became illegal. The city council passed the ban last fall by a vote of 36 to 12, rejecting a compromise proposal that small areas remain available to people who wanted to smoke. “I think in the future,” the city’s health commissioner, Thomas Farley, said at a public hearing, “we will look back on this time and say `How could we have ever tolerated smoking in a park?’”

New York City has often been a bellwether for the passage of public health laws, and there was symbolic significance in the fact that such iconic public spaces as Central Park and the pedestrian plazas of Times Square would be closed to smoking. Yet though the city’s action may prove influential, it was not radical. According to the American Nonsmokers’ Rights Foundation, more than 500 municipalities in the United States have passed some type of law banning smoking in outdoor recreation areas.

The elimination of cigarettes from parks, beaches, and other outdoor spaces represents the most recent phase in a trend that began four decades ago, when the demarcation of areas where smoking would be allowed or prohibited emerged as the central point of conflict for tobacco-control efforts. Initial restrictions focused on enclosed spaces where nonsmokers faced prolonged exposure to secondhand smoke. In 1973, the Civil Aeronautics Board required airlines to designate nonsmoking sections of airplanes for domestic flights; similar rules for interstate buses soon followed. Over the next several years, cities began requiring that restaurants set aside seats for nonsmokers. The stated rationale for these early measures was not a paternalistic one — that smokers must abstain for their own good — but rather the protection of nonsmoking bystanders. Strikingly, these early restrictions were implemented in the absence of scientific data that secondhand smoke posed a health threat to nonsmokers. Instead, the measures advanced on the premise that secondhand smoke was unpleasant and annoying.

Epidemiologic research eventually documented associations between exposure to secondhand smoke and a host of health problems, including elevated risks of lung cancer, cardiovascular disease, and acute episodes of asthma; the Environmental Protection Agency classified secondhand smoke as a Class A carcinogen in 1993. As the scientific basis for restrictions grew, so did the number of places that became off-limits to smoking, including schools, stadiums, convention centers, and private workplaces.

Front-of-Package Nutrition Labeling — An Abuse of Trust by the Food Industry?

June 24, 2011 Comments off

Front-of-Package Nutrition Labeling — An Abuse of Trust by the Food Industry?
Source: New England Journal of Medicine

On January 24, 2011, two major food-industry trade associations, the Grocery Manufacturers of America (GMA) and the Food Marketing Institute, announced a new and voluntary nutrition-labeling system that major food and beverage companies would use on the front of packages to “help busy consumers make informed choices.” The chair of the board of GMA said, “Our industry has stepped up to the plate in a big way to help improve public health and combat obesity, and this program is a very important step in the right direction.” The industry will spend $50 million to “educate” the public about the new system.

This program, called Nutrition Keys, follows on the heels of an industry free-for-all in which different companies used different, and in many cases self-serving, symbols to communicate how healthful their products were. An example is the Smart Choices program, whereby industry established nutrition criteria that would qualify products for a special Smart Choices label. This enterprise was met with disbelief when products such as Froot Loops and Cocoa Krispies qualified as Smart Choices, and after an investigation by Connecticut’s attorney general, critical comments from the Food and Drug Administration (FDA), and negative press, the industry discontinued the program.

The question now is whether the latest industry action is good for public health or should be challenged and stopped. Much is at stake, since tens of thousands of products would carry the new Nutrition Keys symbols. With obesity rates so high, some foods specifically associated with an increased risk of weight gain (see article by Mozaffarian et al. in this issue of the Journal, pages 2392–2404), and other foods linked to diseases such as hypertension and stroke, new ways to help consumers quickly judge the nutritional quality of products could be beneficial.

At first glance, the industry action might seem positive — a single standardized system with objective nutrition information might guide better food choices. The industry plans to list the amount and percentage of the recommended daily value (%DV), when available, for calories, saturated fat, sodium, and sugars. This is justifiable because the population should limit its intake of each of these components. Companies will also have the option of listing two additional “nutrients to encourage,” choosing at their discretion from among potassium, fiber, protein, vitamin A, vitamin C, vitamin D, calcium, and iron. The label prototype is shown in Figure 1.

There are, however, major flaws in this approach. First, the timing of this action by the food industry is suspicious at best, and the move is being made in a political context where the industry is pitted against both government and the public health community. The White House and the FDA have been in discussions with industry about an optimal labeling system, but the industry proceeded in a unilateral manner nonetheless.

Auditing Access to Specialty Care for Children with Public Insurance

June 16, 2011 Comments off

Auditing Access to Specialty Care for Children with Public Insurance
Source: New England Journal of Medicine

We found a disparity in access to outpatient specialty care between children with public insurance and those with private insurance. Policy interventions that encourage providers to accept patients with public insurance are needed to improve access to care.

The Threat of Menthol Cigarettes to U.S. Public Health

June 11, 2011 Comments off

The Threat of Menthol Cigarettes to U.S. Public Health
Source: New England Journal of Medicine

The 2009 Family Smoking Prevention and Tobacco Control Act gave the Food and Drug Administration (FDA) authority to regulate certain tobacco products with the goal of protecting public health. The law provides the FDA with regulatory tools for reducing harm to health from products that cause nicotine addiction and disease. It specifically banned flavored cigarettes, except those containing menthol, which account for about 30% of the current U.S. cigarette market. It also created the Tobacco Products Scientific Advisory Committee (TPSAC), consisting of nine voting members and three nonvoting members representing the tobacco industry, and charged it with preparing a report on “the impact of use of menthol cigarettes on the public health including such use among children, African Americans, Hispanics, and other racial and ethnic minorities.”

Menthol, a naturally occurring monocyclic terpene alcohol, has long been used in consumer and medicinal products because of its minty taste and aroma and its cooling and analgesic properties. It acts primarily on transient receptor potential channels that contribute to the detection of physical stimuli, including temperature and chemical irritation. Mentholation of cigarettes resulted from a chance discovery made in the 1920s by Lloyd “Spud” Hughes, an Ohio man who smoked cigarettes that had been stored in a tin containing menthol crystals. Hughes accidentally identified an additive whose pharmacologic actions reduce the irritating properties of smoke generally and nicotine specifically. Menthol contributes to perceptions of cigarettes’ strength, harshness or mildness, smoothness, coolness, taste, and aftertaste. Research also shows that menthol has druglike characteristics that interact at the receptor level with the actions of nicotine.

The TPSAC, on which we serve, submitted its menthol report to the FDA on March 23, 2011, with a conclusion that menthol cigarettes damage public health and a general recommendation that “removal of menthol cigarettes would benefit public health in the United States.” The report has generated controversy that reflects misunderstanding of the roles of the TPSAC and the FDA.

See also: A Lost Opportunity for Public Health — The FDA Advisory Committee Report on Menthol
+ Menthol Cigarettes and Public Health: Review of the Scientific Evidence and Recommendations (FDA; PDF)

Bending the Cost Curve in Cancer Care

June 1, 2011 Comments off

Bending the Cost Curve in Cancer Care
Source: New England Journal of Medicine

Annual direct costs for cancer care are projected to rise — from $104 billion in 2006 to over $173 billion in 2020 and beyond. This increase has been driven by a dramatic rise in both the cost of therapy and the extent of care. In the United States, the sales of anticancer drugs are now second only to those of drugs for heart disease, and 70% of these sales come from products introduced in the past 10 years. Most new molecules are priced at $5,000 per month or more, and in many cases the cost-effectiveness ratios far exceed commonly accepted thresholds6 This trend is not sustainable.

We must find ways to reduce the costs of everyday care to allow more people and advances to be covered without bankrupting the health care system. Brody recently challenged each medical specialty to identify at least the top five tests or treatments for which costs could be substantially reduced without depriving any patient of meaningful benefit. Medical oncologists directly or indirectly control or influence the majority of cancer care costs, including the use and choice of drugs, the types of supportive care, the frequency of imaging, and the number and extent of hospitalizations. Here, we respond to Brody’s challenge by suggesting five changes in medical oncologists’ behavior (Table 1) and five changes in their attitudes and practice (Table 2) that will bend the cancer-cost curve downward. We recognize that these changes will cause discomfort and adjustments, since all of them will inevitably result in dissatisfaction for important constituents such as patients, physicians, or payers. Unless otherwise stated, our recommendations are restricted to the care of patients with incurable solid tumors and not those with curable cancers.

Hospitals’ Race to Employ Physicians — The Logic behind a Money-Losing Proposition

May 16, 2011 Comments off

Hospitals’ Race to Employ Physicians — The Logic behind a Money-Losing Proposition
Source: New England Journal of Medicine

U.S. hospitals have begun responding to the implementation of health care reform by accelerating their hiring of physicians. More than half of practicing U.S. physicians are now employed by hospitals or integrated delivery systems, a trend fueled by the intended creation of accountable care organizations (ACOs) and the prospect of more risk-based payment approaches. Whether physicians, hospitals, or payers end up leading ACOs will depend on local market factors, competitive behaviors, and first-mover advantage, but employment decisions made by physicians today will have long-term repercussions for the practice and management of medicine.1

In the 1990s, hospitals acquired many physician practices of which they subsequently divested themselves. After the current cycle of physician-practice acquisitions, it will be harder to revert to private practice if relationships sour, since new payment structures and care models will make it increasingly difficult for traditional private practices to remain profitable. Many clinicians are unaware that hospitals lose money on their employed physicians, though hiring them may be a wise long-term investment. Understanding the economics of these decisions will help physicians to anticipate the evolution of their employment situations and see why hospitals are making increasingly aggressive plans to acquire physician practices.

Hospitals lose $150,000 to $250,000 per year over the first 3 years of employing a physician — owing in part to a slow ramp-up period as physicians establish themselves or transition their practices and adapt to management changes. The losses decrease by approximately 50% after 3 years but do persist thereafter. New primary care physicians (PCPs) contribute nearly $150,000 less to hospitals than their more-established counterparts; among specialists, the difference is $200,000. For hospitals to break even, newly hired PCPs must generate at least 30% more visits, and new specialists 25% more referrals, than they do at the outset. After 3 years, hospitals expect to begin making money on employed physicians when they account for the value of all care, tests, and referrals. Skeptics note that often they already capture this value from physicians without employing them, through stable referral networks and hospital practice choices. Outpatient office practices of employed physicians seldom turn a profit for hospitals.

Probable Zoonotic Leprosy in the Southern United States

April 27, 2011 Comments off

Probable Zoonotic Leprosy in the Southern United States
Source: New England Journal of Medicine

Wild armadillos and many patients with leprosy in the southern United States are infected with the same strain of M. leprae. Armadillos are a large natural reservoir for M. leprae, and leprosy may be a zoonosis in the region.


Get every new post delivered to your Inbox.

Join 361 other followers