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Do Your Pain Patients Use Complementary Therapies? Just Ask

PORTLAND, OR – What are your chronic pain patients not telling you?

A study, published recently in the American Journal of Managed Care, finds that many patients use alternative measures to control pain but don’t discuss them with their primary care providers.

The information also is not documented in electronic medical records as often as it should be, according to the report.

Kaiser Permanente researchers surveyed more than 6,000 health plan members in Oregon and Washington from 2009-11 who had three or more outpatient visits for chronic pain within 18 months, determining that 58% had used chiropractic care, acupuncture or both.

While a majority of patients told their primary care providers about their use of alternative therapy, 35% of those who had acupuncture only and 42% who had chiropractic care only didn’t let them know.

“The use of acupuncture and chiropractic care among HMO chronic pain patients responding to our survey was substantial,” the authors write. “Those using neither acupuncture nor chiropractic care (42%) were in the minority. The data also suggest that a substantial percentage of acupuncture and chiropractic use is not documented by the EMR, and/or is not reported by patients to their HMO clinicians.”

Yet nearly all said they would have readily shared the information if their provider had only asked. Most of the patients in the study, 71%, were female with a mean age of 61; common complaints included back pain, joint pain, arthritis, extremity, neck and muscle pain, and headache.

"Our study confirms that most of our patients with chronic pain are seeking complementary treatments to supplement the care we provide in the primary care setting," said lead author Charles Elder, MD, MPH, affiliate investigator at the Kaiser Permanente Center for Health Research. "The problem is that too often, doctors don't ask about this treatment, and patients don't volunteer the information."

For the study, researchers examined the medical records of patients who received acupuncture or chiropractic care in 2011. The majority of the acupuncture patients, 66%, accessed the services through their health plan, using a clinician referral or self-referral benefit. The same was true for about half, 45%, of patients getting chiropractic care.

Study participants completed online or by mail a survey that included 17 questions about the type of pain patients experienced, and their use of acupuncture, chiropractic care, and other alternative and complementary therapies.

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Physician Habits Contribute Most to Antibiotic Overuse

SALT LAKE CITY – Who’s most responsible for the problem of antibiotic over-prescription? About 10% of physicians might find the answer by looking in the mirror.

A study published recently in the Annals of Internal Medicine notes that 10% of healthcare providers write an antibiotic prescription for 95% or more of patients diagnosed with a cold, bronchitis or other acute respiratory infection (ARI).

On the other hand, another 10% of providers prescribe antibiotics during 40% or fewer patient visits with those diagnoses, according to the study led by researchers from the Veterans Affairs (VA) Salt Lake City Health Care System and the University of Utah and funded by the CDC.

Surprising as it might seem, preferences of individual providers have a greater effect on antibiotic prescribing than patient characteristics, standards of practice at different hospitals, or clinical settings such as emergency department, primary care or urgent care, according to the study.

"We were able to see that even if Dr. A works just down the hall from Dr. B, they may practice medicine very differently," lead author Barbara Jones, MD, MS, said in a University of Utah press release. "We all receive similar training, but we can practice differently. The extent of this variation has been hard to measure in the past."

In this study, 68% of all visits for ARI resulted in an antibiotic prescription – similar to other U.S. healthcare systems other than the VA. What was unique was the researchers’ ability to describe practice patterns of individual health care providers – made possible by applying advanced statistical analysis to big data housed within the VA electronic health record.

For the study, researchers analyzed 1,044,523 patient visits for ARIs at 990 clinics or EDs at 130 VA medical centers across the United States from 2005 to 2012. Over the eight-year period, the overall percentage visits in which providers prescribed antibiotics increased by 2%, with a 10% increase in the proportion of broad-spectrum antibiotics prescribed.

That increase was contrary to guidelines urging more judicious prescribing of antibiotics in general as well as recommendations against using broad spectrum antibiotics as a first line of defense for most respiratory infections.

Overall, 59% of the variation in how often antibiotics were prescribed was attributable to the habits of individual providers, according to the research, with 28% of the variation related to differences in practice among clinics, and 13% to differences in practice among hospital centers.

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New CMS Guidance Helps Ease ICD-10 Transition for Physician Offices

CHICAGO – The process of implementing ICD-10 coding in your practice by Oct. 1 has become a little less daunting.

For that, you can thank the American Medical Association. At the association’s request, CMS issued a guidance document with some important provisions. Chief among them is the assurance that, for the first year, physician offices will have some leeway on coding without facing reimbursement denials.

“While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation,” according to the CMS guidance. “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”

Both Medicare administrative contractors and recovery audit contractors will be required to follow this policy, according to the AMA.

CMS also agreed not to subject physicians to penalties for the Physician Quality Reporting System based on the specificity of diagnosis codes as long as a code from the correct ICD-10 family of codes is used. In addition, no penalties will be applied if the agency has difficulty calculating quality scores for the programs as a result of ICD-10 implementation.

Furthermore, if problems with ICD-10 implementation cause problems that prevent Medicare contractors from processing claims, CMS said it will authorize advance payments to physicians.

Finally, CMS consented to establish a communication center to monitor issues and resolve them as quickly as possible, including appointing what it calls an “ICD-10 ombudsman” devoted to triaging physician issues.

Getting those and other concessions was a hard fought battle.

In a blog post, AMA President Steven J. Stack, MD, noted, “These provisions are a culmination of vigorous efforts to convince the agency of the need for a transition period to avoid financial disruptions during this time of tremendous change. These provisions are a testament to the power of organized medicine and what we can achieve when we band together for the good of our patients and our profession.”

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Health Providers Biased Toward Patients With Same Sexual Preferences

SEATTLE – As hard as you might try to treat all patients equally, chances are that your bias is showing when it comes to sexual preference.

That’s according to a new study, published recently in the American Journal of Public Health, which looked at a range of healthcare providers and their implicit attitudes towards lesbian women and gay men.

The study, led by University of Washington researchers, found moderate to strong implicit preferences for straight people over lesbian and gay people among heterosexual providers. At the same time, lesbian and gay health providers expressed implicit and explicit preferences for lesbian and gay people over straight people. Bisexual providers, meanwhile, were found to have mixed preferences.

Mental health providers had the weakest implicit bias for heterosexual patients over those who are lesbian or gay, while nurses held the strongest implicit bias for heterosexuals, according to the research.

In essence, according to the authors, healthcare providers, similar to others in society, hold a bias for people who share their own sexual identity.

"We want all providers to be proficient in treating diverse populations, including the LGBT population," said lead author Janice Sabin, PhD, MSW, research associate professor in biomedical informatics and medical education, adding that the clinical care of the LGBT population is a somewhat neglected area in curriculum in nursing, medicine and other areas of healthcare education.

For the study, researchers used results from the Sexuality Implicit Association Test to assess presence of implicit bias towards either heterosexual or homosexual individuals in more than 200,000 participants between May 2006 and December 2012.

Voluntarily accessing the survey online, test takers were asked to indicate their explicit preferences towards heterosexual, lesbian and gay people by endorsing statements ranging from "I strongly prefer straight people to gay people” to "I strongly prefer gay people to straight people." The study categorized respondents by their profession –medical doctor, nurse, mental health provider, other treatment provider or non-provider – to specifically address healthcare provider attitudes.

Sabin pointed out in a University of Washington press release that "training for healthcare providers about treating sexual minority patients is an area in great need of attention."

“Implicit preferences for heterosexual people versus lesbian and gay people are pervasive among heterosexual healthcare providers,” the authors conclude, “Future research should investigate how implicit sexual prejudice affects care.”

In general, the study found explicit preferences to be much weaker than implicit ones.

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