Research roundup: Assessing new hospital observation rule; doctors' view of DNR orders for kids

Each week, KHN compiles a selection of recently released health policy studies and briefs.

JAMA Internal Medicine: "Observation Status" For Hospitalized Patients
Hospitalized patients in the United States are increasingly placed on "observation status." The Centers for Medicare & Medicaid Services (CMS) state that observation should rarely exceed 48 hours. At our hospital, however, observation stays frequently exceed 48 hours, particularly for adult general medicine patients, as our research group recently reported in this journal. Reimbursement has not covered the costs, resulting in operating losses. After our study was completed, CMS proposed a rules change, assigning inpatient status and Medicare Part A coverage to all hospital stays of 2 midnights ("2 days") or longer, assuming medical necessity supported a 2 midnights-or-longer stay. ... We used our data to assess the implications of the proposed rules change (Sheehy et al., 8/26).

Science: Confronting the Sorry State of U.S. Health
In January 2013, the U.S. National Research Council (NRC) and Institute of Medicine (IOM) issued U.S. Health in International Perspective: Shorter Lives, Poorer Health, a stunning depiction of how, over the past four decades, the comparative health status of Americans has declined. ... President Obama recently declared that growing social inequalities are tearing at the social fabric of the nation. He must now create a National Commission on the Health of Americans charged with holding public hearings and determining vigorous steps that must be taken to address, not simply the health of those at the bottom, but the comparative status of America as a whole. There is a strong evidentiary basis for action beyond interventions at the individual behavioral level  (Bayer, Fairchild, Hopper and Nathanson, 8/29).

JAMA Pediatrics: Clinician Perspectives Regarding The Do-Not-Resuscitate Order
While data exist regarding the frequency and timing of the do-not-resuscitate (DNR) order in children, little is known about clinician attitudes and behaviors regarding this order. ... In theory, many physicians and nurses in our study believe that the DNR order should guide therapeutic decisions only during a cardiopulmonary arrest. Yet in reality, most believe that care changes beyond resuscitative interventions. ... Many physicians and nurses in our study reported that the care of a patient changes on implementation of a DNR order. ... more than half reported that care changes beyond resuscitative measures and focusing on comfort, including limitation or withdrawal of diagnostic and therapeutic interventions and, most concerning, decreased attentiveness from the clinical team (Sanderson, Zurakowski and Wolfe, 8/26).

Kaiser Family Foundation/JAMA: Visualizing Health Policy: A Short Look At Long-Term Care for Seniors
This month's Visualizing Health Policy provides an informational snapshot of long-term services and support (LTSS) for seniors in the United States. This includes information about the number and proportion of seniors who will need LTSS because of physical and cognitive impairment, the role of unpaid family caregivers in providing the majority of LTSS, the role of Medicaid (not Medicare) as the primary payer for LTSS, the shifting of Medicaid spending from institutional-based care toward community-based care, and the fact that only 35% of US adults 40 years or older say they have set aside money for their long-term needs (Rousseau, Firth and Jankiewicz, 8/28).

Here is a selection of news coverage of other recent research:

NPR: Patients Love A Gentler Approach To Surgery, But Surgeons Balk
Surgery can be a necessary misery, endured in hope of health. But what if you took away the misery, and kept the benefits? When hospitals quit subjecting patients to prolonged fasting, nasogastric tubes, abdominal drains, and other commonplaces of surgical care, a study finds, patients feel less pain and recover faster. Women who had major abdominal surgery at the Mayo Clinic under a protocol to enhance recovery went home sooner and needed less pain medication than women who had the surgery the usual way. ... Patient care cost $7,600 less, on average, with the new protocol. The results were published in the journal Obstetrics & Gynecology (Shute, 8/27).

Medscape: Leaving Hospital Against Medical Advice Increases Death Risk
In an analysis of more than 1.9 million hospital admissions over the course of 20 years, leaving the hospital against medical advice (AMA) more than doubled the odds of 90-day mortality and 30-day readmission compared with complying with medical advice, lead author Allan Garland, MD, from the Departments of Internal Medicine and Community Health Sciences and the Manitoba Center for Health Policy, University of Manitoba, Winnipeg, Canada, and colleagues explain in an article published online August 26 in the Canadian Medical Association Journal (MacReady, 8/26).

Medscape: Pediatric Readmissions, Revisits May Not Reflect Performance
Pediatric readmission and revisit rates are less valuable for quality assessment than in adult hospitals, as few children's hospitals are high- or low-performers for condition-specific rates, according to a retrospective analysis published online August 26 in Pediatrics. "As a national way of assessing and tracking hospital quality, pediatric readmissions and revisits, at least for specific diagnoses, are not useful to families trying to find a good hospital, nor to the hospitals trying to improve their pediatric care," lead author Naomi Bardach, MD, assistant professor of pediatrics at University of California, San Francisco, Benioff Children's Hospital, said (Barclay, 8/26).

American Medical News: Men In High-Deductible Health Plans Put Off Serious Care
For men enrolled in high-deductible health insurance plans, serious events such as a kidney stone or chest pain might not be enough for them to seek emergency care, according to a study in the August issue of the journal Medical Care. ... Researchers noted a 34% reduction in visits by men for serious problems and a 21% reduction for minor to moderate issues in the year after a move to an HDHP, compared with men who remained in an HMO. Conversely, this trend was reversed the following year, with a 30% increase in hospital admissions for men in an HDHP (Phalen Tomaselli, 8/26).

MedPage Today: Patients With Prostheses Cost Medicare Less
Medicare recipients given orthotic and prosthetic devices were more likely to remain active in the community and avoid facility-based care than similar Medicare patients who didn't receive such devices, a retrospective study found (Pittman, 8/29).