Huge Variation in Protocols Among Top Hospitals

Using Medicare claims to analyze discrepancies in patient care throughout major US hospitals, a new report from the Dartmouth Atlas Project, a research effort by the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, Hanover, NH, has been published on the Web site of Health Affairs . It found extensive variation in the amount of care given to patients who suffered from three common chronic conditions: solid tumor cancers, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD).

“Rather than traditional methods of counting health care services provided, or how busy the hospital is in terms of full beds, this study looks at the level of hospital resources used by a specific level of population,” says Megan McAndrew, editor of the Dartmouth Atlas Project, and chief information officer for the Center for the Evaluative Clinical Sciences. “We knew there were huge regional health care variations in resources, utilization, and spending, but we’ve now looked at individual hospitals and seen that there are variations within the same market and these variations can be as dramatic as among national regions.”

The report, entitled “Use of Medicare Claims Data To Monitor Provider-Specific Performance Among Patients with Severe Chronic Illness,” looked specifically at the last 6 months of patients’ lives at 77 hospitals that ranked at the top of US News and World Report ‘s list of the best US geriatric hospitals in 2001. Researchers examined Medicare Denominator, and Medicare Provider Analysis and Review files of deceased patients to define a study group: only patients who were enrolled in Parts A and B, or both, and then those with one or more nonsurgical hospitalizations in the last 2 years of their life were chosen to be part of the study. Decedents were assigned to categories depending on the hospital they most frequently visited. A total of 90,616 decedents were assigned to 77 hospitals, ranging from 386 to 3,506 in each facility.

For analysis, researchers measured utilization, physician labor inputs, and Medicare spending. The measures of utilization included the number of days spent in the hospital, days spent in an intensive or coronary care unit (ICU), number of physician visits (by specialty), percentage of patients seeing 10 or more different physicians, and percentage of patients enrolled in hospice care. The intensity of terminal care was measured by the percentage of deaths occurring during an inpatient stay and the percentage of deaths occurring during a hospitalization that involved one or more ICU admissions. Physician labor input was measured by data from a national study of physician productivity to obtain estimates of the average annual number of work relative value units produced per physician on a specialty-specific basis. Medicare spending for each hospital was measured by summing Medicare program reimbursements for clinical services for each group.

Results showed that there was striking variation in utilization across hospitals within a given illness group. For example, in regard to the number of ICU days, utilization rates among cancer patients were much less than the rates for patients with COPD or CHF, meaning that cancer patients received significantly less care than patients with COPD or CHF. When analyzing data across hospitals, however, the study found that hospitals that had high utilization rates for one condition tended to have high rates for other conditions.

Overall, despite the high ranking of all the hospitals involved in this study, patient groups within the hospitals received very different amounts of care from the perspective of population-based use rates. In the last 6 months of life, patients receiving most of their care from Mount Sinai Medical Center, New York, spent almost twice as many days in the hospital as patients cared for by the Mayo Clinic hospitals, St. Mary’s and Rochester Methodist in Rochester, Minn. The intensity of use of technology, determined by the number of ICU days, was three times greater at the University of California, Los Angeles (UCLA) Medical Center than at Massachusetts General Hospital, Boston.

“The implications of this study are enormous both in terms of how hospitals in certain regions compare nationally, and what’s going on in terms of Medicare spending in one region versus another,” says McAndrew. “It also has big implications between hospitals and providers since some hospitals are providing services in a very different way than others, and this eventually makes a difference to the people who are paying for it. If consumers were more educated about these variations, they could choose a provider that would treat them efficiently, rather than a provider that was just trying to keep its beds filled up by admitting the consumer for inpatient treatment.”

Fluoroscopy Standards Set for Vertebroplasty

To address an increasing concern regarding the detrimental effects of prolonged radiation to patients during fluoroscopically guided interventional procedures, such as vertebroplasty and kyphoplasty, a new study, published in the September issue of Radiology , aimed to standardize dose values and establish associated risks related to the procedures.

For the study, researchers first used a humanoid phantom to measure the dose absorbed by each radiosensitive organ from fluoroscopic exposures during vertebroplasty and kyphoplasty. After establishing the dose-area product from the humanoid phantom, researchers studied total fluoroscopy time and resultant dose-area product from each fluoroscopic exposure in 11 consecutive patients (seven women and four men) undergoing kyphoplasty; the average age range of the patients was 41 to 78 years.

The study showed that though both vertebroplasty and kyphoplasty are usually performed in elderly patients who suffer from osteoporotic vertebral collapse, osteolytic metastatic myeloma, or aggressive hemangioma, younger patients who undergo these procedures experience greater risk of complications.

“Our study results may be helpful for vertebroplasty or kyphoplasty patients of any age; however, the younger the patient, the higher would be the risks for radiogenic stochastic effects,” says Kostas Perisinakis, PhD, lead author of the study. “Data are also presented regarding the possibility for nonstochastic radiogenic effects such as skin lesions, which are not uncommon in extended fluoroscopically guided procedures.” The onset of radiation-induced patient skin lesions is usually delayed up to 2 weeks after treatment, preventing operating physicians from observing possible damage to patients during treatment.

Results showed that the mean total fluoroscopy time for kyphoplasty was 10.1 minutes and mean effective dose to patients from kyphoplasty was 8.512.7 mSv, and mean gonadal dose was 0.0416.4 mGy, depending on the level of the treated vertebra. Skin injuries were likely to occur if the total fluoroscopy time per projection was extended and/or the source-to-skin distance was less than 35 cm during the procedure. Risk of radiation-related fatal cancer associated with kyphoplasty depended on age and sex: female patients less than 39 years of age had significantly higher risk than males of the same age; men older than 40 years were subject to slightly higher risk than women of the same age. Patients who were 20 to 29 years old showed twice as much risk than patients 60 to 69 years old.

Despite the results of the study, Perisinakis states that young age is not a contraindication for fluoroscopically guided vertebroplasty or kyphoplasty procedures.

Administrative Costs Prove Steep for Practices

The current health care management system has the average 10-physician practice spending more than $247,500 on administrative tasks that are redundant and wasteful, states a new report by the Medical Group Management Association (MGMA) Center for Research.

For the report, entitled “Cost Survey: 2004 Report Based on 2003 Data,” researchers questioned the practices about the time spent on various administrative tasks, including credentialing, interaction with insurance companies, and claims processing. Costs were calculated based on compensation, staff, and physician minutes spent, and the number of administrative tasks per year.

The average number of claims denied per week (because of lack of information or incorrect information) on coding policies, documentation requirements, etc, for each full-time-equivalent (FTE) physician was 4.6, while the average percentage of claims ultimately paid in whole or in part was 73.32%.

The average amount of time physicians spent per application for credentialing was 11.27 minutes; support staff spent 69.1 minutes per credentialing application. The total number of credentialing applications submitted for each physician each year to insurance companies, hospitals, and ambulatory surgery centers was 17.86; the total number of credentialing applications submitted for each nonphysician provider was 7.66.

The majority of the practices surveyed were single-specialty practices (65.93%), while 16.48% were multispecialty practices with primary and specialty care; multispecialties with only primary care or only specialty care made up 8.79% of the total each.

When working with insurers, practices reported to contract with 20.5 different health plans. The average amount of administrator’s time spent negotiating each insurance contract was 329.8 minutes per application; the average amount of physician’s time spent negotiating each insurance contract was 14.3 minutes per contract.

Overall costs per year for medical group practices with 10 physicians: $19,444 was spent on phone calls with pharmacies resolving drug formulary issues; $38,761 was spent verifying patient coverage, co-payments, and deductibles for various health plans; $9,248 was spent resubmitting denied claims; $7,618 was spent submitting credentialing applications for each physician; and $33,800 was spent negotiating insurance contracts with an average of 15 different health plans per year. Total costs, including expenses on tasks not shown in the graph, were more than $247,500. Source: MGMA study, ‘Cost Survey: 2004 Report Based on 2003 Data.’

Average costs per year were broken down by type of employee: $14.50 per staff hour; $35 per administrator hour; $32.50 per nonphysician provider hour; and $100 per physician hour.

The results of the survey support MGMA’s proposal of the Simplified Payment System Conceptan alternative to the current health care system and a single-payor government-run health care systemwhich MGMA feels would help reduce administrative costs. Compared to the existing payment system that uses multiple, nonstandardized credentialing events, clinical guidelines, billing requirements, and more, the Simplified Payment System Concept proposes: a standardized process for physicians to participate in health plans; implementation of a single mechanism for contracting with payors; standardized insurance plans; competition among insurers on the basis of efficient administration and customer service; standardized clinical guidelines, disease management protocols, hospitalists for inpatient care, and drug formularies as tools to manage patient care; and uniform coding rules and documentation requirements.

CMS Rolls Out New Coding Process

The Centers for Medicare and Medicaid Services (CMS) has revised its process for updating code sets, expediting patients’ access to technology. Under the updated process, the codes will be used not only for Medicare, but also Medicaid, private insurers, providers, and suppliers. According to CMS, the new process will establish a more transparent coding process and improve the development of codes for new technologies, and make it easier to make decisions on coverage and payment for new technologies.

“We are delivering on our promise to our health care partners to create a more effective system for providing patients with faster access to the latest medical technologies,” said Mark B. McClellan, MD, PhD, CMS Administrator, in a statement. “By working with patient advocates, health care payors, and the suppliers and manufacturers of medical products, we have been able to identify many opportunities for improvements in the current coding process to keep coding issues from slowing the dissemination of new and improved treatments.”

The new major changes in the Healthcare Common Procedure Coding System (HCPCS) process include: the expansion of public meetings to include all public requests for HCPCS products, supplies, and services, enabling more opportunities for the public to become aware of coding changes under consideration; an appeals process, to be implemented in the 2007 coding cycle, where denied applicants can appeal decisions and have their applications reconsidered in the same cycle; the publication of all preliminary decisions on the CMS Web site prior to public meeting to allow effective public discussion and comment; the revision of the HCPCS Code Application Form to be more user-friendly; the elimination of the standard requirement for 6 months of marketing data for drugsapproval from the US Food and Drug Administration will be accepted after the application deadline; the reduction of marketing data for nondrug items, such as durable medical equipment, orthotics, and supplies, from 6 months to 3 months; and the development of a process, in collaboration with state Medicaid directors, to consider change that may be needed based on national Medicaid program operating needs.

The new changes to the coding system will be phased in over an 18-month period beginning with the 2006 coding cycle. The first change in the process is an earlier application deadline of January 3, 2005, which will permit expanded opportunities for public comment on preliminary coding decisions compared to the current coding update schedule.

Clinical Trial to Measure MRI Efficacy in Pediatric Cancer

A recently started trial, the American College of Radiology Imaging Network (ACRIN) Whole-Body MRI in the Evaluation of Pediatric Malignancies, will explore whether whole-body MRI more accurately detects malignancies in pediatric cancer patients than conventional imaging and/or enables physicians to more accurately focus treatment for these patients. Participants in the trial are required to be 21 years old or younger, with newly diagnosed solid small cell tumors, not of the central nervous system, including but not limited to rhabdomyosarcoma, Ewing’s sarcoma family of tumors (ESFT), and neuroblastoma. Site investigators for the study will work closely with the pediatric oncologists at their respective institutions to identify eligible patients.

“The ability to accurately stage and predict response to therapy for childhood tumors will help pediatric oncologists design patient-specific treatments that increase survival and improve quality of life,” said Marilyn J. Siegel, MD, of Mallinckrodt Institute of Radiology in St Louis, and the ACRIN trial’s principal investigator.

PACS Market Outlook

According to a new analysis by Frost & Sullivan on the US medical imaging industry, revenue for the North American turnkey PACS Markets totaled $1 billion in 2003 and is projected to reach $2.01 billion by 2010.

The report, US Medical Imaging Industry Outlook, cited the growing need for imaging procedures among the aging population as a driving factor in the medical imaging industry, as well as use of less-invasive diagnostic imaging procedures that are attracting interest from different sectors outside the radiology department, such as cardiology, oncology, and private physicians,

The report also stated that development of new contrast agents and radiopharmaceuticals will open up new application areas for existing imaging technologies, for example, the development of agents to detect neurological disorders such as Alzheimer’s and attention deficit hyperactivity disorder; new agents are expected to drive imaging procedure volumes in the near future.


Richard M. Levy

Richard M. Levy, chairman, president, and CEO of Varian Medical Systems, Palo Alto, Calif, received the 2004 Medal of Achievement Award from the American Electronics Association, which honors individuals who make significant contributions to the advancement and service of their community, the high-tech industry, and humankind. Levy is the first recipient from the medical technology sector and fiftieth recipient of the prestigious award. Chris Hanna has joined Varian Medical Systems as vice president of its Oncology Information Systems unit, a new division within Varian’s Oncology Systems business, which is aimed at developing and marketing the company’s informatics software for the management of radiology oncology and medical oncology practices…H. William Strauss, MD, has been appointed as chairman of the Scientific and Medical Advisory Board of Gamma Medica Corp, Northridge, Calif. Strauss is the clinical chief of nuclear medicine at New York City’s Memorial Sloan Kettering Cancer Center and professor of radiology at Cornell University’s Weill School of Medicine, Manhattan, NY. Gamma Medica designs, develops, and manufactures nuclear medical imaging systems for clinical and preclinical applications…Marc Nicholas was named western region sales manager for Dunlee, Aurora, Ill, a division of Philips Medical Systems, Andover, Mass…Dan Lord has joined IMCO Technologies, Pewaukee, Wis, as general manager of its sales management team. Lord has more than 20 years of experience in the health care industry, and has previously worked with Merge eFilm, Milwaukee; SwissRay, Elmsford, NY; and Agfa Healthcare, Greenville, SC.

Industry News

Siemens Medical Solutions, Malvern, Pa, has signed a 2-year contract with Oncology Services International, Ramsey, NJ, to provide service, installation, and upgrade support to Siemens oncology customers in the United States. This enables Siemens to offer service support for its own systems and also for equipment from other major manufacturers of linear accelerators…FujiFilm Medical Systems USA, Stamford, Conn, has added storage consulting to its services portfolio offered to Synapse® PACS customers. Storage consulting will include evaluation of individual Synapse PACS customers’ needs, storage analysis, and recommendations in storage decisions…Eastman Kodak Co, Rochester, NY, will install a Kodak computed radiography (CR) system in the Miller Park stadium training room to provide digital x-ray images of injured Milwaukee Brewers baseball players. The CR system, which will be for use by both the home team and visiting teams, will allow physicians to immediately view images on a workstation, securely transmit images to remote physicians, and print images to film…NightHawk Radiology, Coeur D’Alene, Idaho, will establish a new development, Parkside, encompassing commercial, residential, and retail spaces; the ground-breaking is scheduled for April 2005, with completion in September 2006. Additionally, the company received a $25 million investment from Summit Partners, and is opening a new reading center in Zurich, Switzerland…The American Healthcare Radiology Administrators released the results of the July 2004 Certified Radiology Administrator (CRA) examination, announcing that 91% of the 32 radiology administrators who took the examination received a passing score. The CRA is the industry’s first certification program designed to raise professional standards and enhance individual performance of administrators…MarCap Corp, Chicago, a health care financing company that specializes in outpatient imaging and surgery centers, has moved into new offices in Chicago’s financial district…Bringing its total number of imaging facilities to nine, Trinity Health Care Corp, Newport Beach, Calif, acquired four diagnostic imaging centers in Southern California that were formerly owned by the Comprehensive Medical Imaging business unit of Cardinal Health, Dublin, Ohio…Stentor Inc, San Francisco, received clearance by the Food and Drug Administration for its iSite PACS for use in the diagnostic reading, enterprise distribution, and archiving of digital mammography images; the new mammography functions will be included in version 3.3 of iSite PACS…StorageTek®, Louisville, Colo, has acquired all intellectual property, software license agreements, customer contracts, and other assets of Storability® Software, Southborough, Mass, a provider of enterprise storage resource management solutions… The Memorial Sloan-Kettering Cancer Center , New York, has begun construction of a new outpatient cancer treatment facility in Basking Ridge, NJ, a convenient location for patients in Somerset County and other central New Jersey areas. The center will offer chemotherapy, comprehensive diagnostic radiology, radiation oncology, medical and surgical consultations, cancer screening and patient education, ambulatory surgery, and integrative medicine. Scheduled to open in summer 2006, the new 85,000-square-foot center will be located on a wooded 26-acre site…ORS Diagnostic, Plymouth, Minn, has acquired exclusive rights to the patented method to detect and measure blood pressure sounds in noisy external environments developed by its partner BP Sure LLC , Middleton, Wis.

Presented at SNM – The 51st Annual Meeting of the Society of Nuclear Medicine, June 19-23, 2004.

MRI for Coronary Heart Disease . In his lecture, New Directions in Coronary Artery Disease and Cancer, Valentin Fuster, MD, discussed the importance of imaging in cardiovascular disease, specifically in arterio-thrombotic disease as it applies to coronary arteries. When angiography failed to detect occlusion in patients with myocardial infraction, Fuster and his team looked unsuccessfully to different imaging technologies that were too low in resolution for the extremely small lesions of plaque. In studies involving the identification of vulnerable plaque, angiogram showed the vessel walls as normal though severe disease existed; this explained why plaque ruptures occurred in arteries, which angiography found normal. MRI, however, proved to be the best noninvasive technology for Fuster’s research in terms of resolution; Fuster used CT as a guide of where to look with MRI. MRI was also more capable of identifying microphages, enabling physicians to inject HCL into the microphages. Fuster predicted that MRI and CT would soon be available in a single machine.

Advantages of Cardiac MRI . In his lecture, Cardiac MR with CT, SPECT, and PET Correlation, Steven D. Wolff, MD, PhD, emphasized the role of CT and MRI to detect aspects of heart disease, including assessing valves, cardiac structure, perfusion, and viability. Wolff showed that MRI can be functional, as well as diagnostic. He used a slide of a young child, who was hit by a car and developed a heart murmur. There was a defect in the ventricular septum and blood insistently flowed from the left ventricle to the right ventricle. The flow in the aorta and pulmonary artery was measured simultaneously using velocity information from the MRI scanner. The flow of blood was then plotted as a function of time to retrieve velocity. According to Wolff, MRI may be the technique of choice for quantifying the severity of the disease. With regards to ischemic heart disease, Wolff showed that MRI can provide assessment of perfusion and viability, or the ability to assess infarct size and type. He cited a study, which showed that compared to SPECT, MRI was very sensitive in detecting infarcts that were less than half the cardiac wall thickness. Wolff predicted that MRI would become a routine test for patients with ischemic heart disease.

The Quiet Revolution . According to Arthur Caplan, PhD, who delivered a lecture on ethical issues in brain imaging, the genomic revolution is overshadowing a more quiet revolution that is emerging in neuroscience-the mapping of the human brain. Despite the lack of media attention and the national funding that the human genome project receives, imaging technology has led to great strides in brain imaging. However, according to Caplan, no one has spent enough time thinking about the consequences of brain imaging. What if physicians could test for the pre-Alzheimer’s brain? Or for individuals who will be prone to violent behavior? Caplan stressed that ethical questions, standards, risk, and safety measures regarding brain imaging must be addressed before brain imaging tests become mainstream.