COVID-19: A learning moment for patients and health professionals

A hospital physician from Northern Italy describes his own experience as caregiver of COVID-19 patients and as a patient himself who required treatment in urgent care. From this experience he learned that an untapped reserve of human solidarity exists in a team of caregivers in the midst of a crisis where they find an unsuspected shared energy. He never would have believed to be able to work long hours patiently and without sleep until he was challenged by the demands of the COVID crisis. As such, he discovers that to be effective the team leader should lead by example rather than by commandments! His experience as a patient allowed him to face his own mortality, to learn that healing rather than cure is the ultimate goal of caregiving.

The Association between Hospital-Physician Vertical Integration and Outpatient Physician Prices Paid by Commercial Insurers: New Evidence

This study assessed the relationship between hospital ownership of physician organizations (known as hospital-physician vertical integration) and facility fees billed to commercial insurers and physician service prices. Healthcare claims came from the IBM® MarketScan® Commercial Database (2012-2016, N = 30,716,800 office visit claims [CPT codes 99211-99215]), and hospital-physician vertical integration measures were from SK&A Office Based Physicians Database provided by IQVIA. Multi-variate, fixed-effect models were used to regress prices on market-level hospital-physician vertical integration; models included geographic market and year fixed effects, claim-level variables, and time-varying market-level variables. Analyses did not find that market-level hospital-physician vertical integration was associated with the billing of facility fees for office visits. However, vertical integration was associated with office visit physician prices for some specialties. A 10-percentage-point increase in vertical integration was associated with a 1.0% price increase for primary care, a 0.6% increase for orthopedics, and a 0.5% increase for cardiology; no such association was found for obstetrics/gynecology or oncology. When comparing metropolitan statistical areas (MSAs) in the bottom quartile of changes in vertical integration from 2012 to 2016 to MSAs in the top quartile, we found the following relative price increases based on predicted values for claims in the top quartile: $1.64 (1.9% of mean 2012 predicted price) for primary care to $2.30 (3.1%) for orthopedics to $3.13 (3.4%) for cardiology. Differences in predicted price accounted for an estimated $45.8 million in additional expenditure on primary care office visits in the top quartile of MSAs in 2016. In summary, market-level hospital-physician vertical integration was positively associated with physician prices for select specialties, but was not associated with changes in the use of facility-fee billing. More evidence on the quality effects of hospital-physician vertical integration is needed, as price increases that are not accompanied by measurable quality improvements should be part of any regulatory review.

Vertical Integration and Physician Practice Labor Composition

With the growth of vertical integration among physician practices (i.e., hospital–physician integration), there have been many studies of its effects on health care treatments and spending. It is unknown if integration shapes provider configurations, especially against the backdrop of increasing employment of nurse practitioners (NPs) and physician assistants (PAs) across specialties. Using a longitudinal panel of 144,289 practices (2008-2015), we examined the association of vertical integration with NP and PA employment. We find positive associations between vertical integration and newly employing NPs and PAs within physician practices; however, the relationships differ by practice specialty type as well as timing of vertical integration. Supplementary analyses offer supporting evidence for coinciding enhancements to practice productivity, diversification, and provider task allocation. Our results suggest that vertical integration may promote interdisciplinary provider configurations, which has the potential to improve care delivery efficiency.

A Cross-Sectional Study Analyzing the Quality of YouTube Videos as a Source of Patient Education for Treatments on Psoriasis

Background: YouTube is currently the second most popular website in the world, with over 1 billion hours watched each day. Unlike peer-reviewed journals, there is no process to ensure the quality of YouTube videos that cover medical and treatment information, which could lead to patient misinformation. Objective: We set out to use the DISCERN instrument, which has previously been used in studies to assess the quality of consumer health information regarding treatment choices, to systematically evaluate the quality of the information. Methods: A YouTube search was performed on April 12, 2020, using the keyword “psoriasis treatments.” Since 90% of YouTube users do not view past the first 30 videos, only the first 30 results were selected. Non-English videos, advertisements, and videos that were too specific for the search criteria entered were excluded. Results: The average total DISCERN score was 38.3, which categorizes the videos overall as “poor” quality of content. There was a statistically significant difference in total DISCERN scores between the videos created by patients and those created by hospital/physician sources ( P < .015), with hospital-/physician-made videos scoring higher. However, regardless of the source of the video, there were still significant shortcomings in all the videos assessed. Conclusion: We feel we have a responsibility and an opportunity as a specialty to provide high-quality information, with a specific focus on the areas identified by the DISCERN tool as lacking, to help guide patients on evidence-based therapeutic options.

The effects of hospital-physician financial integration on adverse incident rate: An agency theory perspective

Background Patient safety is an important aspect of quality of care. Physicians’ alignment with hospitals by means of financial integration may possibly help hospitals achieve their quality goals. Most research examines the effects of financial integration on financial performance. There is a need to understand whether financial integration has an effect on quality and safety. Purpose The aim of this study is to examine the association between hospital physician financial integration (employment, joint ventures, and ownership) and Adverse Incident Rate. Methodology: A longitudinal panel study design was used. A random effects model with hospital, year, and state effects was used. Our sample contained 3,528 hospitals observations within U.S. from 2013–2015. Findings Contrary to our hypotheses, hospital physician financial integration does not influence AIR. Besides financial integration, hospitals need to have a high commitment towards quality and safety to influence a lower AIR.

Similar levels of symptoms and problems were found among patients referred to specialized palliative care by general practitioners and hospital physicians: A nationwide register-based study of 31,139 cancer patients

Background: Previous studies suggest that the symptomatology threshold (i.e. the level and types of symptoms) for a referral to specialized palliative care might differ for doctors in different parts of the healthcare system; however, it has not yet been investigated. Aim: To investigate if the number and level of symptoms/problems differed for patients referred from the primary and secondary healthcare sectors (i.e. general practitioner versus hospital physician). Setting/participants: Adult cancer patients registered in the Danish Palliative Care Database who reported their symptoms/problems at admittance to specialized palliative care between 2010 and 2017 were included. Ordinal logistic regression analyses were performed with each symptom/problem as outcome to study the association between referral sector and symptoms/problems, controlled for the effect of gender, age, cancer diagnosis and the specialized palliative care service referred to. Results: The study included 31,139 patients. The average age was 69 years and 49% were women. Clinically neglectable associations were found between referral sector and pain, appetite loss, fatigue, number of symptoms/problems, number of severe symptoms/problems (odds ratios between 1.05 and 1.20, all p < 0.05) and physical functioning (odds ratio = 0.81 (inpatient care) and 1.32 (outpatient), both p < 0.05). The remaining six outcomes were not significantly associated with referral sector. Conclusion: Differences across healthcare sectors in, for example, competences and patient population did not seem to result in different symptomatology thresholds for referring patients to palliative care since only small, and probably not clinically relevant, differences in symptomatology was found across referral sectors.

Radiological manifestations of COVID-19: key points for the physician

The emergence of the SARS-CoV-2 virus at the end of 2019 has led to unprecedented demand on healthcare systems around the world. Healthcare workers, including doctors, have found themselves having to work in unfamiliar environments in the effort to control this pandemic. This article gives the hospital physician an overview of the radiological manifestations of COVID-19 disease, to improve knowledge and increase familiarity when reviewing radiographic images.

Exploring the role of hospitals and office-based physicians in timely provision of statins following acute myocardial infarction: a secondary analysis of a nationwide cohort using cross-classified multilevel models

ObjectivesTo examine the role of hospitals and office-based physicians in empirical networks that deliver care to the same population with regard to the timely provision of appropriate care after hospital discharge.DesignSecondary data analysis of a nationwide cohort using cross-classified multilevel models.SettingTransition from hospital to ambulatory care.ParticipantsAll patients discharged for acute myocardial infarction (AMI) from Germany’s largest statutory health insurance fund group in 2011.Main outcome measurePatients’ odds of receiving a statin prescription within 30 days after hospital discharge.ResultsWe found significant variation in 30-day statin prescribing between hospitals (median OR (MOR) 1.40; 95% credible interval (CrI) 1.36 to 1.45), hospital-physician pairs caring for the same patients (MOR 1.32; 95% CrI 1.26 to 1.38) and to a lesser extent between physicians (MOR 1.14; 95% CrI 1.11 to 1.19). About 67% of the variance between hospital-physician pairs and about 45% of the variance between hospitals was explained by hospital characteristics including a rural location, teaching status and the number of beds, the number of patients shared between a hospital and an office-based physician as well as 16 patient characteristics, including multimorbidity and dementia. We found no impact of physician characteristics.ConclusionsTimely prescription of appropriatesecondary prevention pharmacotherapy after AMI is subject to considerable practice variation which is not consistent with clinical guidelines. Hospitals contribute more to the observed variation than physicians, and most of the variation lies at the patient level. To ensure care continuity for patients, it is important to strengthen hospital capacity for discharge management and coordination between hospitals and office-based physicians.

Acute thrombocytopenia: picking a way through a paucity of platelets

Thrombocytopenia is defined as a platelet count under 150x109/litre. It may be found as a bystander to other pathology or directly related to an underlying haematological condition. Apart from laboratory artefact, it should be treated seriously as it often reflects serious underlying disease. This review uses short case histories to illustrate how to approach thrombocytopenia during the initial presentation of an adult patient to hospital. This article guides the general hospital physician through the narrow but potentially confusing differential diagnoses related to thrombocytopenia, with particular focus on immune thrombocytopenia, disseminated intravascular coagulation and thrombotic thrombocytopenic purpura. Thrombocytopenia in pregnancy deserves special consideration and will not be discussed in this article.