Research Roundups: Racial Disparities at end of life; stopping medicine mistakes; Grand Junction, Colorado's Cost Lessons

Archives of Internal Medicine: Racial Disparities In The Outcomes Of Communication On Medical Care Received Near Death - "Black patients receive more life-prolonging measures and less comfort-directed care at the end of life (EOL) than white patients," such as "increased rates of resuscitation, intensive care unit hospitalization, and feeding tube use at the EOL," write the authors of this study that examined whether differences in patient-physician communication contribute to these differences.

Based on a study of 71 black patients and 261 white patients with advanced cancer, the authors found, "Black patients reported similar rates of EOL discussions to white patients (35.3% and 38.4%), but less terminal illness awareness (31.8% and 47.3%)." Additionally, the authors write, "Despite similar rates of EOL discussions, white patients were more likely than black patients to prefer symptom-directed care over life-prolonging EOL care (78.5% vs 63.2%) and to have DNR orders in place (50.4% vs 30.9%). … Similarly, black patients who had DNR orders in place were no more likely than other black patients to receive EOL care that reflected their preferences. Although EOL discussions and communication goals assist white patients in receiving less burdensome life-prolonging care at the EOL, black patients tend to receive more aggressive care regardless of their preferences" (Mack et al., 9/27).

Archives of Internal Medicine: Unintended Effects Of A Computerized Physician Order Entry Nearly Hard-Stop Alert To Prevent A Drug Interaction - This study examines the effectiveness of a computerized physician order entry (CPOE) system alert that temporarily blocked a hospital physician's order when it would result in a patient getting two drugs -- warfarin, an anticoagulant, and trimethoprim-sulfamethoxazole, an antibiotic, that when taken together can harmful side effects -- and compared the results to "the standard practice of a pharmacist intervention program."

For the study, researchers conducted a randomized clinical trial at two academic hospitals, involving 1,981 clinicians who either received the system alert that temporarily blocked the physician's order, known as the "nearly hard stop alert," or received the standard intervention. The study authors report that 194 hard stop alerts were given and that in 111 of those, the physician failed to reorder the alert-triggering drug within 10 minutes, for a 57 percent "desired response in that group. The control group's desired response was 13.5% (20 of 148).  "However, the study was terminated early because of 4 unintended consequences identified among patients in the intervention group: a delay of treatment with trimethoprim-sulfamethoxazole in 2 patients and a delay of treatment with warfarin in another 2 patients." Though, "we showed that a computerized decision support intervention—a nearly hard-stop alert—was markedly effective in reducing the prescribing of an undesired drug-drug combination … this intervention had unintended adverse consequences that were deemed sufficiently serious to warrant discontinuation of the intervention and early termination of the study," the authors write. "This emphasizes the need for formal evaluation and monitoring of programmatic interventions rather than simply assuming that they will be effective" (Strom et al., 9/27).

American Journal of Public Health: Unhealthy Competition: Consequences Of Health Plan Choice In California Medicaid - "[C]hoice and associated market-like competition are seen by many as an essential component of strategies to improve quality and efficiency and to increase the responsiveness of health care systems," write the authors of this study that compares the quality of the care received by Medicaid beneficiaries in counties in California that provide beneficiaries with a choice of health plans versus those with a single health plan.

Researchers used a "cross-sectional study among California Medicaid beneficiaries" conducted in 2002 and a "multivariate Poisson model to calculate adjusted rates of hospital admissions for ambulatory care-sensitive conditions by duration of plan enrollment." The authors report, "[a]mong beneficiaries with continuous Medicaid coverage, the percentage with 12 months of continuous enrollment in a health plan was significantly lower in counties with a choice of plans than in counties with no choice (79.2% vs 95.2%)." Additionally, they report, "Among beneficiaries continuously enrolled in Medicaid, annual [ambulatory care-sensitive] ACS admission rates adjusted for age, gender, and race/ethnicity were significantly higher (indicating worse quality of care) for beneficiaries living in counties with a choice of health plans (6.58 admissions per 1,000 beneficiaries) than for beneficiaries living in no-choice counties (6.27 admissions per 1,000 beneficiaries)" (Millett et al., 9/23).

New England Journal of Medicine: Low-Cost Lessons from Grand Junction, Colorado - The authors examine how this city manages to have among the lowest health costs in the nation: "We believe that seven interrelated features of the health care system that may explain the relatively low health care costs could be adopted elsewhere. These are leadership by the primary care community; a payment system involving risk sharing by physicians; equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients; regionalization of services into an orderly system of primary, secondary, and tertiary care; limits on the supply of expensive resources, including specialists, beds, and equipment; payment of primary care physicians for hospital visits; and robust end-of-life care. These features could be replicated in other markets — though generally not without political battles" (Bodenheimer and West, 9/29).

Related, earlier KHN story: Grand Junction, Colorado: Still The Health Care Poster Child (Scanlon, 8/19)

Medical Care Research and Review: Electronic Health Records And The Reliability And Validity Of Quality Measures: A Review of the Literature - This article summarizes a review of 35 empirical studies published since January 2004 on electronic health record data quality. Of the studies reviewed, the authors report, "Sixty-six percent evaluated data accuracy, 57% data completeness, and 23% data comparability. The diversity in data element, study setting, population, health condition, and EHR system studied within this body of literature made drawing specific conclusions regarding EHR data quality challenging." The authors propose, "Future research should focus on the quality of data from specific EHR components and important data attributes for quality measurement such as granularity, timeliness, and comparability" (Chan et al., October 2010).