Hospital Consult - July 2016

Insured Patients Paying Much Higher Percentage of Hospital Visits

ANN ARBOR, MI — Who pays what for visits to your hospital is undergoing some dramatic changes.

Cost sharing for insured adults increased 37% per inpatient hospitalization from 2009 to 2013, according to an article published online by JAMA Internal Medicine. It also found that variations in insurance policies sometimes resulted in a higher burden of out-of-pocket costs for some patients.

Background information in the article notes that while proponents argue that making patients increasingly responsible for a growing share of their healthcare expenditures has the potential to reduce overuse and inappropriate care, opponents respond that increased out-of-pocket spending can also impede access to care and affect treatment decisions.

For the study, University of Michigan Medical School-led researchers looked at 7.3 million hospitalizations, using 2009 to 2013 data from Aetna, UnitedHealthcare, and Humana, which represent about 50 million members. The nonelderly adults all were enrolled in employer-sponsored and individual-market health insurance plans.

Results indicate that cost-sharing per inpatient hospitalization increased from $738 in 2009 to $1,013 in 2013, primarily because more of the costs were applied to deductibles. That amount grew by 86% from $145 in 2009 to $270 in 2013, and by increases in coinsurance, which grew 33% from $518 in 2009 to $688 in 2013, the authors report.

The highest total cost-sharing was for those enrolled in individual market plans and consumer-directed health plans.

“These results open up the ‘black box’ of healthcare, and show all the costs of hospitalization that are billed to people with private insurance. For many, these may appear to be ‘hidden costs’ that they didn’t realize they would owe,” explained first author Emily Adrion, PhD, MSc. “It shows that even people with the most comprehensive insurance are paying thousands of dollars, at a time when they need hospital care and may not have time to shop around.”

Regions, diagnoses, and procedures varied in terms of cost-sharing. For example, the states in 2013 with the highest total cost-sharing per inpatient hospitalization were Utah, Alaska, and Oregon. In terms of diagnoses, out-of-pocket spending associated with emergency hospitalization for heart attack grew by 37% to $1,586 and for acute appendicitis by 40% to $1,509, according to the report.

One limitation of the study, according to the authors, is that it did not extend far enough to capture the implementation of several provisions of the Affordable Care Act of 2010. "With an estimated 85% of all commercial health insurance benefit packages requiring coinsurance for inpatient hospitalizations in addition to meeting an annual deductible, cost sharing for inpatient hospitalizations remains an important, if often overlooked, area for policy reform," the researchers concluded.

JAMA Internal Medicine Deputy Editor Mitchell H. Katz, MD, notes in an accompanying editor’s note, "To require consumers to pay large amounts of out-of-pocket expenses for healthcare may lead to delay or foregoing of needed care or to financial ruin, the latter of which insurance is supposed to protect you against. There are no easy answers for how to deal with the rising cost of medical care, but increasing out-of-pocket spending for unavoidable, necessary care is counter to the goals of a health insurance system."

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Measuring Infant Head Circumference Not Enough to Detect Zika Damage

PELOTAS, BRAZIL — Microcephaly screening alone is not sufficient to accurately diagnose Zika virus infection in newborns, according to new Brazilian research.

The largest study of its kind to date was published recently in The Lancet. The Universidade Federal de Pelotas-led research recommends, instead, that screening criteria used by neonatal units also include signs and symptoms of brain abnormalities, regardless of head circumference.

"Our study, which included all suspected cases of microcephaly in newborns in Brazil up to February, discarded three out of five cases after a full investigation as most suspected cases ended up being normal newborn babies with small heads,” explained lead author Cesar G. Victora, MD. “However, one in five definite or probable Zika cases had head circumference values in the normal range. Therefore, the current focus on microcephaly screening alone is too narrow.”

Zika virus is known to cause microcephaly, a birth defect marked by smaller head and brain size. Victora and colleagues used data from a Brazilian Ministry of Health (MOH) surveillance system, which has been hard-hit by the infection, to monitor nearly 6,000 suspected cases of microcephaly based on head circumference.

The researchers sought to determine the clinical — including sex, gestational age, imaging findings, maternal history of rash, and mortality — and anthropometric — including head circumference and birthweight — characteristics of live births.

The team focused on 1,501 live born cases that had been fully investigated by the MOH, with suspected cases divided into five categories according to diagnostic certainty of Zika infection: definite, highly probable, moderately probable, somewhat probable, and discarded (not deemed to be Zika).

Results indicate that, compared to 899 cases that were discarded, the 602 definite or probable cases had small head circumference at birth and their mothers had been more likely to experience a rash during pregnancy — 21% vs. 61%. Those babies also were four times more likely to die in the first week of life.

The study also reports that rashes in late pregnancy were linked with brain abnormalities, despite normal head sizes. Study authors point out that development of the cranium mostly occurs by week 30, so children with brain damage can be born with normal-sized heads, adding that their research raises the possibility that Zika virus infection in newborn babies might lead to brain damage.

The researchers emphasize that more than 100 of the definite or probable cases had head circumferences within normal range and would not have been included in an analysis for Zika if more limited cutoffs had been used.

“Zika virus congenital syndrome is a new teratogenic disease,” study author concluded. “Because many definite or probable cases present normal head circumference values and their mothers do not report having a rash, screening criteria must be revised in order to detect all affected newborn babies.”

Victora added, "Our findings suggest that among pregnancies affected by Zika virus, some foetuses will have brain abnormalities and microcephaly, other will have abnormalities with normal head sizes, and others will not be affected. A surveillance system aimed at detecting all affected newborns should not just focus on microcephaly and rash during pregnancy and should be revised, and examination of all newborns during epidemic waves should be considered."

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Mobility Program Helps Undo ‘Toxic’ Effects of Hospitalization for Elderly

BIRMINGHAM, AL — After hospitalization, about 40% of older adults experience a decline in the ability to perform activities of daily living (ADL), with a third failing to recover within a year after discharge. Furthermore, decreased mobility during hospitalization for older adults is associated with increased risk of death, nursing home admission, and functional decline.

That’s why a mobility program tested at the University of Alabama at Birmingham is so important. A study published online by JAMA Internal Medicine found that participants were able to maintain their prehospitalization community mobility status in the month following discharge from the hospital.

Yet, a control group receiving usual care suffered a clinically significant decline in their community mobility, according to the UAB researchers.

"It is important for patients to move around and try to do what they normally do by themselves while they are in the hospital," said lead author Cynthia Brown, MD, MSPH, director of the UAB Division of Gerontology, Geriatrics, and Palliative Care. "Our goal is to make sure that they leave the hospital with the same mobility as when they came in to maintain their quality of life."

The mobility program recommended by Brown offers assistance with walking or moving from place to place at least twice a day while also including a behavioral intervention focused on goal setting and addressing mobility barriers.

For the study conducted from Jan. 12, 2010, through June 29, 2011, researchers examined the effect of an in-hospital mobility program on post-hospitalization function and community mobility in 100 patients 65 years of age or older who were hospitalized at the Birmingham Veterans Affairs Medical Center. All patients were without cognitive difficulties and able to walk two weeks prior to hospitalization, which lasted an average of three days.

Results indicate that, at one month after hospitalization, the University of Alabama at Birmingham Study of Aging Life-Space Assessment (LSA) score was significantly higher in the mobility program (MP) group, 52.5, compared with the usual care (UC) group, 41.6. While the LSA score one month post-hospitalization was similar to the score at admission for the MP program group, it dropped about 10 points for the usual care group, study authors pointed out.

“A simple MP intervention had no effect on ADL function,” study authors concluded. “However, the MP intervention enabled patients to maintain their prehospitalization community mobility, whereas those in the UC group experienced clinically significant declines. Lower life-space mobility is associated with increased risk of death, nursing home admission, and functional decline, suggesting that declines such as those observed in the UC group would be of great clinical importance.”

S. Ryan Greysen, MD, MHS, of the University of California, San Francisco, argues in a linked commentary that more research should be conducted on mobility issues after hospitalization.

“Bedrest is toxic to older adults. Initially a clinical observation,” Greysen wrote. “This statement has become axiomatic in geriatric medicine and now rests on nearly three decades of rigorous scientific investigation demonstrating underlying pathophysiologic mechanisms of immobility and clinical outcomes research demonstrating associations with disability, nursing home placement, and mortality. Indeed, half of permanent disability in older adults begins with hospitalization, and two of three older adults who experience hospital-acquired disability will be placed in a nursing home or dead within a year of discharge.”

He asked, “If low hospital mobility is an epidemic, why haven’t more interventional studies been performed? Why hasn’t practice changed in recent decades in light of the existing evidence about the toxic effects of bedrest?”

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Why Radial Access Appears to Be Better than Femoral in Heart Procedures

ROZZANO, ITALY — Based on a new meta-analysis, an international study team is recommending that radial access through the wrist be used when inserting stents to restore blood flow in heart disease patients, not femoral access through the groin.

The study, published in JACC: Cardiovascular Interventions, said that approach has fewer complications and should be the default methods. Previous randomized trials comparing the two access locations for percutaneous coronary interventions have provided conflicting evidence, however, prompting investigators to try to come up with a more definitive answer.

A team led by researchers from Humanitas Research Hospital in Italy and also including U.S. colleagues from the Duke Clinical Research Institute in Durham, NC, looked at 24 studies involving 22,843 participants to conduct a comprehensive meta-analysis across the range of heart disease.

Compared with femoral access, radial access was associated with a significantly lower risk for all-cause mortality with an odds ratio (OR) of 0.71, major adverse cardiovascular events (MACE) (OR 0.84), major bleeding (OR: 0.53) and major vascular complications (OR 0.23). The rates of myocardial infarction or stroke were similar in the two groups, according to the study authors, who added that effects of radial access were consistent across the whole spectrum of patients with coronary artery disease for all appraised endpoints.

Study authors determined that there was "strong to very strong" evidence that major bleeding and vascular complications were reduced and "moderate to strong" evidence that all-cause death rates were reduced when using radial vs. femoral access.

“Compared with femoral access, radial access reduces mortality and MACE and improves safety, with reductions in major bleeding and vascular complications across the whole spectrum of patients with CAD,” study authors concluded.

Radial access is a newer procedure that involves a longer learning curve to develop the technical skills necessary, according to background information in the report.

JACC: Cardiovascular Interventions Editor-in-Chief Spencer King, MD, pointed out, however, "as radial access is increasingly adopted, the benefits seen in trials has been weighed against the learning curve necessary for some operators. This most complete analysis of the value of radial access may convince some doubters to switch."

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