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February 24, 2011 Volume VII, No. 32

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

This week, learn which radiologists deliver more accurate breast cancer screenings and how Michigan ICUs reduced pneumonia rates in patients on ventilators. Also, learn about the new focus of the American Heart Association's updated heart disease prevention guidelines for women for 2011.

Your colleague in the business of healthcare,
Jessica Papay
Editor, Disease Management Update

This week's DM news:

Table of Contents

  1. Accurate Breast Cancer Screenings
  2. Reducing Pneumonia Rates
  3. Primary Care & Payment Reform
  4. Heart Failure & the Primary Care Nurse
  5. Top 10 Tactics to Improve Medication Adherence
  6. Healthcare Transparency
  7. Heart Disease Prevention Update
  8. Health & Wellness Incentives Use in 2011

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Interpreting More Mammograms Could Make Breast Cancer Screenings More Accurate

Radiologists who interpret more mammograms and spend some time reading diagnostic mammograms do better at determining which suspicious breast lesions are cancer, according to a new report from Group Health Research Institute. Funded largely through a unique collaboration between the American Cancer Society and the National Cancer Institute, the study examined information from 120 radiologists who interpreted 783,965 screening mammograms at six mammography registries in the Breast Cancer Surveillance Consortium (BCSC) over five years. The researchers looked at how screening outcomes were related to four different measures of each radiologist’s annual volume: the number of screening and diagnostic mammograms — separately and in combination — and the percentage of total mammograms that were for screening rather than diagnosis.

“We found that radiologists who interpreted more mammograms a year had clinically and statistically significantly fewer false-positive findings — without missing more cancers,” said researchers. “That means radiologists with higher ‘interpretive volumes’ could identify the same number of cancers, while making fewer women come in for extra tests that showed they did not have cancer.” On average, for every cancer detected, 22.3 women were called back for more testing. False-positive findings — when a mammogram suggests a breast cancer is present, but it turns out not to be — cause women anxiety and spur extra testing, which amounts to at least $1.6 billion in healthcare costs each year. Often, there’s a tradeoff between minimizing false positives and maximizing sensitivity, which is the ability to identify cancer when present. But in this study, despite their lower false-positive rates, the high-volume radiologists had sensitivities and cancer-detection rates that resembled those of their lower-volume colleagues.

The researchers also found that radiologists were more accurate at interpreting mammograms if they also interpreted some diagnostic mammograms. Diagnostic mammograms evaluate breast symptoms or abnormalities seen on a prior screening mammogram. The cancer-detection rate was highest when at least one in five of the mammograms that a radiologist read a diagnostic, not screening, mammogram — instead of their focusing more exclusively on reading screening mammograms.

This report’s findings also have policy implications. The FDA requires radiologists who interpret mammograms to read only 960 mammograms in two years, with no requirement about the type of mammograms they read (screening or diagnostic). In Europe and Canada, where volume requirements are five to 10 times higher, screening mammography programs have lower false-positive rates — but similar cancer-detection rates — than the United States. According to the researchers, “Based on these data, it would be beneficial if the United States volume requirements could be increased to 1,000 or 1,500 screening mammograms per year, while adding a minimal requirement for diagnostic interpretation, which would optimize sensitivity and false-positive rates.” According to the study’s simulations, raising annual requirements for screening volume could lower the number of American women with false-positive workups by more than 71,000 for annual minimums of 1,000 or by more than 117,000 year for annual minimums of 1,500, without hindering the detection of breast cancer. On the other hand, raising the volume requirements could cause low-volume radiologists to stop reading mammograms. Concerns have been raised that the cadre of U.S. radiologists who read mammograms is aging and retiring. In this study, for instance, radiologists’ median age was 54, and 38 percent of them interpreted fewer than 1,500 mammograms a year.

To learn more about this research, please visit:

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Quality Improvement Initiative Reduces Pneumonia Rates in Patients on Ventilators

Hospital staff in Michigan ICUs cut the rate of pneumonia by more than 70 percent in patients who are on ventilators by using a targeted quality improvement initiative funded by the AHRQ. This reduction in the rate of ventilator-associated pneumonia was sustained for the duration of the study's follow-up, a period of up to two and a half years. The study includes data from 112 ICUs in Michigan.

The researchers also noted a marked increase — from 32 to 84 percent — in the routine use of five evidence-based therapies to prevent complications, including pneumonia, associated with ventilator use. Ventilator-associated pneumonia is a lung infection that occurs in patients who are on ventilators to help them breathe and is a common cause of increased rates of patient illness and death, as well as increased healthcare costs.

The quality improvement initiative, known as the Comprehensive Unit-based Safety Program (CUSP), includes tools to improve communication and teamwork among ICU staff teams and implement practices based on guidelines by the CDC, such as checklists and hand washing, to reduce rates of catheter-related bloodstream infections and ventilator-associated pneumonia. The program also measures if ICUs reduce healthcare associated infections (HAIs) and reports these results so they can improve care. The CUSP approach was used and studied in the Keystone Intensive Care Unit Project, an AHRQ-funded initiative to reduce HAIs in Michigan ICUs. Previous research from the Keystone Project has shown that Michigan hospitals using CUSP sharply reduced the number of blood stream infections from central lines and reduced the risk that patients will die in the ICU.

"These results help to advance the field of quality improvement. We knew the CUSP approach reduced blood stream infections; however, we did not know if it could be applied to other types of preventable harm," said the researchers. "This study demonstrates that it is equally effective at reducing pneumonia. Broad implementation of this program may largely prevent the thousands of deaths from pneumonia each year."

To learn more about this research, please visit:

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Rewarding Primary Care Practice Reform with Physician Payment Reform: A Medical Home's Experience

Capital District Physicians' Health Plan’s (CDPHP) medical home pilot began in 2008, with the dual goals of reforming both the practice of primary care in the CDPHP network and payments to these physicians. Dr. Bruce Nash, CDPHP's senior vice president of medical affairs and chief medical officer, explains what sets the two-phase CDPHP program apart from other medical home pilots, how participants met the challenge of practice transformation, and why preliminary pilot results mirror what's going on in the industry today.

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Empowering the Primary Care Nurse in Heart Failure Care

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is Lenore Blank, M.S.N., N.P-C., administrative manager of the heart failure team and pulmonary hypertension program at Hackensack University Medical Center (HUMC).

Question: In the HUMC care model for the heart failure unit, the nurse must intervene when predetermined practice guidelines are not followed. How do you educate nurses and physicians about these roles?

Response: We saw it was important to empower the primary care nurse — the nurse that’s actually doing the daily hands-on work with that patient. We educate and empower this nurse to be able to communicate to the physician what the patient needs — for example, if certain quality indicators were not met. We tried to empower everyone and bring everyone into the loop and make it a multidisciplinary team and shared by all so that everybody was on the same page. If the primary care nurse is not effective with the physician, he or she can ask the advanced practice nurse (APN) to speak with the physician. If there is still some obstruction, we have an avenue to bring it up to our rounding physician on multidisciplinary rounds and upwards.

We’ve been fairly successful with this because our administration embraced this early on. We’ve had huge administrative support in this regard, so it’s been a cultural change in our institution. Everybody knows that these things are required and that this does improve patient care and outcomes. We’ve worked very well as a group and as a team.

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Top 10 Tactics to Improve Medication Adherence

Medication adherence programs can improve patient care and lower healthcare costs by more effectively managing chronic medication utilization. We wanted to see the key components of medication adherence programs.

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Healthcare Transparency: Cost and Quality Report Cards

The concept of public disclosure of quality assessment information has become a highly reliable and valid tool for not only attracting the discerning consumer but also for sizing up the competition. In an e-survey, the Healthcare Intelligence Network polled health plans and hospitals on their quality performance data publishing efforts and asked consumers to discuss their usage of and satisfaction with such measures.

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New Focus of AHA's 2011 Heart Disease Prevention Guidelines

Practical medical advice that works in the “real world” may more effectively prevent cardiovascular disease in women than recommendations based only on findings in clinical research settings, according to the 2011 update to the American Heart Association’s (AHA) cardiovascular disease prevention guidelines for women. First published in 1999, the guidelines until now have been primarily based on findings observed in clinical research. That alone often doesn’t consider the personal and socioeconomic factors that can keep women from following medical advice and treatment. The 2011 update identifies barriers that hinder both patients and doctors from following guidelines, while outlining key strategies for addressing those obstacles.

To evaluate patient risk, the guidelines incorporate illnesses linked to higher risk of cardiovascular disease in women, including lupus and rheumatoid arthritis, and pregnancy complications such as preeclampsia, gestational diabetes or pregnancy-induced hypertension. According to researchers, women with a history of preeclampsia face double the risk of stroke, heart disease and dangerous clotting in veins during the five to 15 years after pregnancy. Essentially, having pregnancy complications can now be considered equivalent to having failed a stress test.

The updated guidelines also emphasize the importance of recognizing racial and ethnic diversity and its impact on cardiovascular disease. For example, hypertension is a particular problem among African-American women and diabetes among Hispanic women.

Although putting clinical research into practical, everyday adherence can be challenging, solid scientific evidence is still the basis for many of the guidelines, said the researchers. Some commonly considered therapies for women are specifically noted in the guidelines as lacking strong clinical evidence in their effectiveness for preventing cardiovascular disease and, in fact, may be harmful to some women. Those include the use of hormone replacement therapy, antioxidants and folic acid. The update also includes depression screening as part of an overall evaluation of women for cardiovascular risk, because while treating depression has not been shown to directly improve cardiovascular health, depression might affect whether women follow their doctor’s advice.

Despite a growing body of clinical evidence to fight heart disease and stroke in women, more is needed, said the researchers. Coronary heart disease death rates in women dropped by two-thirds from 1980 to 2007, due to both effective treatment and risk factor reduction, according to the American Heart Association, but cardiovascular disease still kills about one woman every minute in the United States. In future studies, researchers should look at interventions during specific times throughout a woman’s lifespan — including puberty, pregnancy and menopause — to identify risks and determine effective prevention opportunities during those critical times, said the researchers. More cost-effective analyses and clinical trial research with male- and female-specific results are also needed, especially regarding risks posed by preventive therapies.

To learn more about this research, please visit:

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Health & Wellness Incentives Use in 2011

Healthcare companies have become increasingly creative in their use of incentives to drive engagement and participation in health and wellness programs. Please share your experiences with incentives by completing HIN's third annual survey on this topic by March 15, 2011. You'll receive a free executive summary of the compiled results, and your responses will be kept strictly confidential.

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