This Week's News 5 August 2011

6

ERs Move to Speed Care; Not Everyone Needs a Bed

The Wall Street Journal

02/08/2011
By LAURA LANDRO

Hospitals are tackling a dangerous and costly side effect of emergency-room overcrowding and long wait times: the growing number of patients who get fed up and leave without treatment.

To speed patients through the system, emergency rooms are adopting so-called lean-management principles pioneered by such companies as Toyota Motor Corp. to increase efficiency, cut costs and provide better service.
That means streamlining the traditional methods of triage and reserving beds for only the sickest patients, abandoning the longstanding rule that every patient gets a bed. It also means staffing the ER with less-costly providers such as nurse practitioners and physician's assistants, so more expensive ER doctors can focus on care and not on paperwork, test ordering and discharge plans.
To let patients know where wait times are shortest, health systems with multiple locations are posting ER waiting times online, in their waiting rooms and even on highway billboards. Hospitals are trying personal touches, too, such as calling patients to coax them back if they bolt.
Waiting times that can run into several hours have become a fact of life in the U.S. The number of emergency departments has dropped by nearly a third over the last two decades, while the number of patients seeking care has risen almost 40% over the same time span. And the number of primary-care doctors is declining, even as more uninsured patients show up at ERs that are required by law to provide care.
The national average of those who leave without being seen—called LWBS—was about 2.7% in 2007-08, according to the most recent government data available. This is up from 1.7% between 1998 and 2006, according to an analysis by Johns Hopkins University researchers. In some areas, as much as a fifth of patients who show up for care end up leaving before they see a doctor. Many of these may go elsewhere for care or end up feeling better, but studies show that as many as half who left without treatment were judged to need immediate medical attention. One study found that 11% of patients required hospitalization within the next week, including some who underwent emergency surgery.
"People who walk out without being seen are a measure of how we are basically failing as a health system in our ability to deliver important care in emergency departments," says Renee Hsia, assistant professor of emergency medicine at the University of California San Francisco.
A recent study she led that was published in the Annals of Emergency Medicine shows the left-without-being-seen rate in California ranged as high as 20.3%. Visitors to hospitals serving a high proportion of low-income and poorly insured patients were far more likely to leave without being seen.
Patients who leave are a drag on hospitals' bottom lines. Revenue of about $450,000 is lost if even 1% of patients walk out of an emergency department with an annual volume of 50,000 patients, says Joseph Guarisco, chairman of the department of emergency medicine at New Orleans-based Ochsner Health Systems, which operates seven hospitals.
Dr. Guarisco saw the need for a more efficient way move patients through the ER after Hurricane Katrina, when the flagship Ochsner Medical Center's volume nearly doubled and its left-without-being-seen rate soared to 15%, from a historic rate of about 5%.
His team designed a protocol called qTrack to rely more on providers like physician's assistants for less-ill patients. Unlike traditional triage, which might take 10 minutes, qTrack has nurses giving a "quick look" evaluation to get basic information in three to five minutes.
Less-ill patients aren't given a bed, but are offered a recliner or chair in a Continuing Care area, or are sent back to the waiting room to await test results or procedures.
Dr. Guarisco says the changes have effectively doubled capacity in the unit and cut costs per patient visit in half. Average waiting times to see a provider have been slashed to about 33 minutes from hours previously, and the left-without-being-seen rate is below 1%. Ochsner Medical Center also posts ER waiting times at its other facilities near the registration desk. It will preregister patients who don't have a serious condition at another emergency department "so they can get in line before they leave the one they are in," says Dr. Guarisco.
R. Devlin Roussel, who runs a charter fishing company, came to the Ochsner ER last Sunday with a painful infection under a toenail that had been nearly ripped off when a 120-pound tuna fell on his foot.
After experiencing a long ER wait for a previous injury, he was surprised to find the waiting room empty. Within a few minutes he was registered and on an examination table.
Mr. Roussel, 40, says he noticed a dozen other patients in various exam areas getting evaluated and treated, and saw another six or seven people come in and get processed quickly. "I was borderline shocked at how efficiently it was running," he says.
A similar program, Door to Doc, which includes a model hospitals can use to match staffing levels to peak-demand periods, was developed by Banner Health, a 21-hospital system based in Phoenix, Ariz., with 680,657 ER visits last year. Kevin Roche, program director of process engineering, says that in some months before the program started up to 20% of patients left without being seen and the average time to see a doctor was more than four hours in some hospitals. At Banner Good Samaritan Medical Center, the Door to Doc program cut the rate of patients who left before being seen to 0.5% last winter from 8% in 2007, although the volume of patients in the department rose 4%.
The nonprofit Health Research and Educational Trust, with funding from the federal Agency for Healthcare Research and Quality, is now sponsoring programs around the country for hospitals to learn about methods such as Door to Doc and qTrack.
Sandra Schneider, president of the American College of Emergency Physicians, says doctors are receptive to efficiency programs, but warns they are just a "Band-Aid" on larger problems, such as the number of patients who are admitted to the hospital but left in beds in the ER because there are no inpatient rooms available. And being treated in waiting rooms and hallways, she says, can be "degrading and difficult" for patients.
Still, Holy Redeemer Health System's hospital near Philadelphia cut its rate of left-without-being-seen patients to 0.5% from 2.5% in 2007, says Henry Unger, chairman of emergency medicine. In addition to new fast-track protocols, the hospital also started using a staff "greeter" to circulate in the waiting room, check on patient and family concerns and notify a manager of any patient who leaves without being seen so they can follow up get them back in if need be.
"We don't want them to walk out the door for their own health, but it's also not a good business model," says Dr. Unger.

See graphic: http://online.wsj.com/article/SB10001424053111904888304576476242374040506.html?mod=djemHL_t

7

Report: rural Mo. has fewer doctors per capita

Forbes

28/07/2011
Associated Press
By DAVID A. LIEB
JEFFERSON CITY, Mo. -- Residents in rural Missouri tend to have access to fewer doctors than their counterparts in cities, and that could create problems as the new federal health care law is implemented, the Missouri Hospital Association said Thursday.
There is an average of one primary care physician for every 1,776 residents in rural areas, compared with an average of one doctor for every 962 residents in Missouri's metropolitan areas, the hospital association said in a report. Those doctors also tend to be older in rural areas, with 62 percent being age 50 or older compared with 55 percent in metro areas.
The hospital association based its statistics on definitions used by the U.S. Census Bureau, which categorizes 35 of Missouri's 114 counties and the city of St. Louis as metropolitan areas. Those metro areas include traditionally urban areas such as St. Louis County as well as some counties typically thought of as rural, such as Schuyler County in northern Missouri, which is considered part of the Kirksville area.
The hospital association said the figures show that rural residents could have more difficulty finding primary care physicians when a federal health care law expands Medicaid coverage, creates health-insurance exchanges for people to shop for policies and requires most people to have health insurance beginning in 2014.
"As health care reform increases access for those currently uninsured, there will be significant challenges to meet their needs in an area already strained by limited resources and services," the hospital association said in its report.
Access to primary care physicians matters to hospitals because people sometimes rely on their emergency rooms instead of first going to doctors' offices. Emergency room visits are more expensive than a typical trip to the doctor's office and, when people cannot afford to pay, those uncompensated costs can get passed on to the government or built into the rates charged by hospitals to people who do have insurance.
The hospital association contends Missouri needs to boost its incentives for medical students to go into practice in primary care and to locate in rural areas.
"This is something we have to look at as a policy or it's going to become impossible for people in rural areas to find a primary care physician," said hospital association spokesman Dave Dillon.

9

Provincial borders still barriers to doctors
CBC News, CA

01/08/2011

Health-care professionals are still having difficulty moving across borders within Canada despite provincial governments' efforts to reduce barriers to labour mobility.

Provincial governments agreed in December 2008 to a deal that was supposed to make it easier for professionals to transfer their licences between provinces.
But some doctors say the colleges who are responsible for approving licences aren't respecting the provincial agreement. "This is something that was agreed amongst the politicians but it was not agreed amongst the physicians," said Dr. Rubens Barbosa, a Brazilian-trained anaesthesiologist working in Edmundston, N.B., who recently had an application to transfer his licence to Ontario rejected.
The responsibility for who does and doesn't become licensed is left up to bodies that are run by physicians in each province.
The problem is that these colleges "are reluctant to accept a law that was proposed by the politicians and they're doing whatever they can to prevent this from happening," said Barbosa.
Provincial governments were hoping the changes would help fill in holes in the skilled workforce. Many provinces — including Ontario, Saskatchewan and Manitoba — are currently facing a shortage of doctors as many residents are unable to find a family physician.
About four million Canadians, or about 12 per cent of the population, don't have a family doctor, a 2009 poll conducted for the College of Family Physicians of Canada suggested.
A spokeswoman for the Ontario College of Physicians and Surgeons, the organization that rejected Barbosa's application, denied the charge that it doesn't respect the mobility law.
"The CPSO respects labour mobility," Kathryn Clarke wrote in an email.
But the body that represents colleges across the country said they are aware that those working to transfer special licences across provincial boundaries are still facing challenges.
Differing standards

The issue is that restrictions on special licences, which can include requiring the holders to be supervised by more experienced physicians and only allowing them to operate if the province has a shortage of the physicians' specialty, are not equivalent across provinces.

"We are working on how we could facilitate for them a mobility from one jurisdiction to another taking into account the fact that they don't have a full licensure," said Dr. Yves Robert, the president of the Federation of Medical Regulatory Authorities of Canada.
Robert said he expected a new agreement that would bring in a common set of standards for specially licensed physicians between provinces would be approved within a year.
The majority of physicians who practise with special licences in Canada are internationally trained, said Dr. William Lowe, a past president of the MRAC.
They usually use these as a stepping stone to becoming fully accredited and eventually helping to address the country's doctor shortages.
Barbosa said he has consulted with the Canadian Medical Protective Association, an organization that provides doctors with legal advice, and it is currently looking into the issue on his behalf.
Luce Lavoie, the director of communications for CMPA, did not confirm or deny that was the case. She also declined to comment on the overall issue of labour mobility for doctors because the organization has yet to issue a policy position on it.
Few approvals despite law

Numbers maintained by the colleges suggest the changes to the Agreement on Internal Trade, which was updated in April 2009 with the new labour mobility provisions, have done little to change the number of physicians moving from one province to another.

The College of Physicians and Surgeons of Nova Scotia has granted licences to about 250 applicants since April 2009, six of those under the labour mobility provisions.
"The numbers have not changed dramatically at all," said Bruce Thorne, manager of policy and communications for the college, referring to the approvals they've given since the new provisions were introduced.
The College of Physicians and Surgeons of Alberta has approved five applicants under the new labour mobility provisions out of a total of about a thousand approved in 2009 and 2010, said spokeswoman Kelly Eby.
They have another 22 who are currently in the application process.
The Ontario college rejected 26 applicants who had applied under the labour mobility provisions between January 2010 and April 2011, said Clarke. Most of these people had restricted licences.
Many other licensing bodies don't maintain numbers showing how many applicants who applied under the labour mobility provisions have been approved or rejected.
Barbosa had applied under the inter-provincial mobility rules the provinces had promised would bring an end to the restrictions for physicians.
The College of Physicians and Surgeons of Ontario rejected his application in December 2010.
Colleges are only required to accept an application under the labour mobility provisions if they have a similar category in their licensing process.
The Ontario college did not grant Barbosa a licence because they said there was no equivalent category in Ontario, a copy of the decision reached by the province's Health Professionals Appeals and Review Board reads.
But Barbosa disputed that claim, saying he already had a full licence he has been operating under for five years.

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Europe

1

Initiative seeks to halt country doctor drain

The Local, Germany

03/08/2011
The German government unveiled measures on Wednesday to try to stop a drain of doctors from country to city amid concerns that an ageing population will require ever more health care.
Chancellor Angela Merkel's centre-right coalition said it would introduce tax breaks to boost the salaries of doctors setting up or taking over practices in rural areas.
Currently some 138,000 doctors practice in Germany, a ratio of 38 doctors for 100,000 inhabitants compared to only 30 doctors for 100,000 inhabitants in 1990. But doctors set up practices in wealthy, urban areas, avoiding the poorer, rural areas where they are likely to earn less money.
The bad distribution of practitioners is especially problematic in eastern Germany, in the northern state of Lower Saxony, and in southern Bavaria.
Officials estimate that with at least 1,000 jobs currently finding no takers and tens of thousands of doctors headed for retirement over the coming years, the problem will only get worse.
Already 50 percent of patients living in the countryside must go to town for medical treatment, Andreas Köhler, the chairman of the National Association of Statutory Health Insurance Physicians, told ARD television.
"The main problem ... is that most practitioners no longer want to be on call 24 hours a day, seven days a week" as is often the case in rural areas, Stefan Gress, professor for health economics at Fulda technical school, told ARD.
And with a fast-ageing population, the number of Germans requiring regular care is expected to grow from 2.4 million today to 3.4 million in 2030 and four million in 2050. (AFP)

2

Moscow's worst clinics identified
The Moscow News

04/08/2011

by Alina Lobzina
Patients at Moscow’s clinics have helped to compile a blacklist of the capital’s worst state-run health centers.
Their findings have contributed to a hit list of 32 substandard institutions, forwarded to the city’s health chiefs.
But rather than publish the list, the authorities have opted against “stigmatizing” failing doctors and are hoping to get them to improve.
“We called chief doctors of those polyclinics and told them they had three months to fix the situation,” Leonid Pechatnikov told journalists adding that if things stay the same “these doctors will no longer be in that place.”
Rude and inattentive

The main part of complaints from patients has to do with rudeness and inattentiveness of doctors, according to the survey.

And clinic heads are to be held responsible for their staff, officials believe.
“He or she has to be not only a doctor, but a manager who will explain to subordinates how they need to work and creates the right atmosphere,” Pechatnikov said, Komsomolskaya Pravda reported.
Many patients complain when doctors refuse to give prescriptions for free medicines and don’t explain why, he continued.
“We start looking into that and find out that these particular drugs have side-effects but doctors just can’t explain it for some reason,” Moscow’s health department head said. “The person leaves offended, but it’s just a basic thing to do!”
Lack of facilities

Other things that leave patients disgruntled are long queues and badly-organised reception desks.

Moscow’s infrastructure can’t keep pace with the fast-growing city and the problem is more acute in capital’s newest districts.
Both prestigious Kurkino in the north-west and less prominent Shcherbinka in the south have the most critical situation with the shortage of medical facilities with 50,000 Muscovites waiting for three new polyclinics to open there.

3

Twelve maternity units shut since election leaves labour wards in crisis

Mirror, UK

31/07/2011
by Nick Owens
Britain's over-stretched maternity service is in ­meltdown – at a time when the birth rate is the highest for over 40 years.
A shocking shortage of midwives and ­the axing of hundreds of beds on labour wards has led rising numbers of new mums to complain of the appalling ­standards in care.
Many are being left alone during labour because midwives are too busy to give them one-to-one ­treatment. ­Others have to travel up to 30 miles because their nearest ­maternity unitis full up.
A third of all new mothers describe their experience of giving birth in NHS hospitals – which are short of 4,700 midwives – as “traumatic”.
A Sunday Mirror investigation today reveals how 12 maternity units have been shut due to the economic crisis.
Flying in the face of Prime Minister David Cameron’s pledge to protect midwives, chronic staff shortages, a lack of training and inadequate equipment are putting the lives of mothers and babies at risk.
The crisis often ends in tragedy. As many as 17 women died on maternity wards following ­blunders at one London NHS trust over the past two years. That is double the number of deaths watchdogs would expect to see on a maternity ward.
Elsewhere, 14 NHS trusts now have baby-death rates which are twice the national average.
Yesterday the Royal College of ­Midwives warned the service is now at “breaking point”.
The turmoil comes as the NHS tries to cope with a rising birth rate. One baby is born every 40 seconds – the highest number for 42 years. It means midwives deliver 1,981 babies every day compared to 1,630 in 2001.
Experts say immigration is one of the main reasons, with a quarter of the babies in England and Wales now born to mothers from outside the UK.
As demands have escalated the ­Government has repeatedly vowed to protect maternity services from cuts.
Earlier this year the Prime Minister pledged: “We need more ­midwives, we need more resources and we are making sure they are going in.”
But the Sunday Mirror can reveal how, since the election, maternity units up and down the country have been shut.
The closure of the maternity unit at Wycombe Hospital, Bucks, led to two women giving birth in ambulances en route to another hospital.
The crisis is leading to rising number of blunders. Last year there were 2,792 complaints lodged about maternity care leading to the NHS paying out more than £41m in compensation.
Louise Silverton, deputy leader of the RCM, lays the blame squarely at the door of the Prime Minister.
“Mr Cameron’s promises have sunk without trace, and midwives feel ­betrayed and forgotten,” she said.
“The number of births is skyrocketing. The RCM went into the general election confident that this increase was being recognised. David Cameron even made a specific, personal pledge to recruit 3,000 more midwives.
“But this promise has sunk without trace, leaving many midwives feeling forgotten and betrayed. The Government must act. The Prime Minister must honour his word. We need more midwives.”

5

Child brides face 'silent health emergency'-experts

Trustlaw/Reuters

04/08/2011
This story is part of a TrustLaw special report on child marriage
By Lisa Anderson
NEW YORK (TrustLaw) - From horrific childbirth injuries to death in the delivery room, millions of teen brides worldwide face a “silent health emergency” as their young bodies struggle to cope with pregnancy, rights groups say.
Poverty, poor healthcare and a higher risk of contracting sexually transmitted diseases compound the threats for about 10 million girls under 18 who get married each year, mostly in Africa and South Asia.
"Child marriage is a silent health emergency in the sense that it's often overlooked as a root cause of maternal mortality and morbidity (illness)," said Jeffrey Edmeades, a social demographer with the International Center for Research on Women (ICRW), a Washington-based think tank.
A girl under the age of 18 is married every three seconds, often without her consent and sometimes to a much older man, according to children's charity Plan UK.
Though illegal in many countries, the practice is fuelled by endemic poverty and is often seen as a way of securing a girl's future, both financially and socially.
Girls under 15, their bodies still developing and their pelvises narrow, are five times more likely to die during pregnancy or childbirth than women over 20, the United States Agency for International Development estimates.
The vast majority of those deaths are in the developing world, where a lack of pre- and post-natal care and advanced procedures such as Caesarean sections makes pregnancy and childbirth far more risky than in rich countries.
In Africa, for example, 60 percent of women and girls give birth without a skilled medical professional present, according to the U.N. World Population Fund.
Worldwide, 70,000 girls aged 15-19 die each year during pregnancy or childbirth, UNICEF says. The U.N. World Population Fund considers pregnancy the leading cause of death in that age group, citing complications of childbirth and unsafe abortions as major factors.
CHILDREN OF CHILDREN

Fatou Diakhate in western Senegal was one of the lucky ones.

Married at 13 and pregnant by 16, she survived the birth of 12 children and went on to rally the people of her village, Keur Issa, to ban child marriage in 1998.
"What you often see is that a girl gets married and within a month she becomes pregnant," she says in a TrustLaw documentary, Child marriage: Denying girls' rights, perpetuating poverty. "That's where the problems start because your body is not ready... Their reproductive organs aren't mature enough."
Children of child brides also are at risk, health experts say. Babies born to mothers younger than 18 are more likely to be underweight or stillborn, Plan UK says.
Such babies are 60 percent more likely to die before their first birthday than are children born to mothers older than 19, according to the Elders, an influential group of leaders founded by former South African President Nelson Mandela.
Girls forced into early marriage are also at an increased risk for sexually transmitted diseases and HIV/AIDS.
“Often they are married to older, more sexually experienced men with whom it is difficult to negotiate safe sexual behaviours, especially when under pressure to bear children,” Anju Malhotra, a senior researcher at ICRW, said in testimony to the U.S. House of Representatives Human Rights Commission last year.
HORRIFIC INJURIES

Married girls aged 15-19 are 75 percent more likely to become infected with HIV than their sexually active but unmarried contemporaries, according to a 2004 study conducted in Kenya and Zambia.

Similar rates were found in 29 countries across Africa and Latin America in a 2006 report by the U.S.-based Guttmacher Institute on the link between HIV/AIDS and early marriage.
Because their bodies are still immature and many give birth unattended at home, child brides are at increased risk of obstructed or prolonged labour, experts say.
Without necessary medical intervention, such as a caesarean section, this can cause obstetric fistula, a tear in the tissue between the vagina and the rectum or bladder.
In places where female genital mutilation is practiced and the vaginal opening is almost completely stitched closed, efforts to reopen it during labour can also produce fistula.
The condition causes a constant leaking of faeces and/or urine, creating discomfort and odour and restricting activity outside the home.
Without corrective surgery, “the condition lasts the rest of the girl’s life,” the ICRW's Malhotra said in her testimony to the U.S. House of Representatives.
Many women and girls with the condition are abandoned by their husbands, shunned by their communities and plunged into deep depression.
"People would ask who is making that bad smell, coughing and covering their noses," said Farhiya Mohamed Farah, a 20-year-old Somali refugee who was treated for fistula at Nairobi's Kenyatta National Hospital after living with the condition for several years.
"So I was always isolating myself... This problem has separated me from my husband and forced him to divorce me."
The World Health Organisation estimates that fistula affects 2 million women worldwide, mostly in Africa.
A survey of nine African countries by the U.N. Population Fund found that most fistula patients were poor, uneducated teens who developed the condition giving birth to their first child.
Child brides also are more vulnerable to domestic violence and sexual abuse, a recent ICRW report showed.
And, if not broken, the cycle of lifelong health problems caused by child marriage will continue.
“Girls from poverty are the most likely to become child brides, and child brides are more likely to live in poverty and raise children in poverty,” Malhotra said.
Kanta Devi, 26, was 16 when she got married in Badakakahera village in India's Rajasthan state.
"It's not a good thing for such young children," she said. "It ruins their health. Young children have babies -- your life is ruined, your education is ruined. You become upset with everything in your life."

(Additional reporting by George Fominyen in Senegal, Katy Migiro in Kenya and Nita Bhalla in India)