Monday, August 20, 2007

More Medicare Mistakes

According to the New York Times, Medicare will not pay for many preventable complications of hospitalization. These include: falls; mediastinitis (an infection that generally develops after heart surgery); urinary tract infections that result from improper use of catheters; pressure ulcers; and vascular (blood stream) infections that result from improper use of catheters.

The new rules are scheduled to go into effect in October, 2008.

While the goal of reducing preventable infections is laudable, this plan is not. Unfortunately, the “You Broke It, You Bought It” mentality is too simplistic. It assumes that all falls and infections are preventable, which they are not. Particularly for patients who are in an intensive care unit and are on a mechanical ventilator, or who are immunosuppressed, sometimes nosocomial infections are unavoidable.

The logical consequence of the new urinary tract infection rule will be for everyone to get a urine culture on admission. This will lead to rounds of unnecessary antibiotics for asymptomatic infections, which will lead to more resistant organisms emerging or more complications from the antibiotic courses, such as rash or diarrhea. (Asymptomatic bacteriuria, as it is known, is particularly common in the elderly and diabetics.) Except for pregnant women and patients undergoing urologic procedures, the Infectious Diseases Society of America guidelines state,

“For all other adult populations, asymptomatic bacteriuria has not been shown to be harmful. Although persons with bacteriuria are at an increased risk of symptomatic urinary infection, treatment of asymptomatic bacteriuria does not decrease the frequency of symptomatic infection or improve other outcomes. Thus, in populations other than those for whom treatment has been documented to be beneficial, screening for or treatment of asymptomatic bacteriuria is not appropriate and should be discouraged.” Clinical Infectious Diseases 2005; 40:643-54

So while the expert recommendation is not to screen and not to treat, most docs I know (except for ID specialists) will be afraid to not respond to the culture for fear of some peer reviewer’s rebuke.

Some of the other catheter related complications for which Medicare will not pay, under the new policy, are caused by common strains of staphylococcus bacteria. Other life-threatening staphylococcal infections may be added to the list in the future, Medicare officials are reported as having said.

Given the expense of nosocomial (hospital-acquired) pneumonia, I would not be surprised if Medicare were also to add that as an exclusion in the future. Too bad that many pneumonias that are actually present on admission don’t show on initial x-rays because a patient is dehydrated or immunosuppressed. They will be assumed to have been acquired after admission.

Perhaps this is a diversion from the lack of universal health coverage and growing numbers of uninsured in this country. Now, even if you are insured, you can be undesirable from a hospital's perspective. I suspect that hospitals will cherry pick their elective surgical patients even more selectively. If you have risk factors for infection such as morbid obesity, diabetes, malnutrition, or cancer, you'll be on your own. After all, it is your personal responsibility.

Oh, by the way—who will be treating the patients with nosocomial infections in the future if Medicare won’t pay docs for treating these problems? For example, many of these infections now require the services of an Infectious Diseases specialist, a surgical specialist, etc., as they are difficult to cure. These physicians tend to be independent practitioners who are not in the employ of the hospitals where they practice. If neither Medicare nor the hospitals will pay for them to treat these infections, who will? [Remember that under Medicare rules, they are prohibited from billing the patient.] Can we realistically expect them to subsidize Medicare and the hospitals by providing unreimbursed treatment of these infections when they have staff salaries, rent, malpractice insurance etc., etc., that they must pay? This is an issue that does not appear to have been addressed, and which must be.

Setting a different system of rewards, with perks for good outcomes and penalties for mistakes, is a reasonable goal. What is missing from this proposal is that not all of the bad outcomes are preventable. Doctors (and others) should be responsible for significant errors in patient care but should not be held accountable for outcomes which occur due to circumstances beyond their control. While it is foolish to reward people for making mistakes, we also must ensure that patients don’t suffer in our haste to address these issues.

New NIAID Grants for Studying CA-MRSA

Recognizing the urgent need to develop antibiotics to address the explosion in community acquired MRSA (CA-MRSA) skin and soft tissue infections, NIAID announced two new grants to study the efficacy of older, off-patent agents in treating these infections. If inexpensive drugs such as Trimethoprim-Sulfamethoxazole or tetracyclines can be used, perhaps it will slow the use of expensive new drugs such as linezolid.

These older antibiotics are often used now by Infectious Diseases specialists, in an attempt to reserve new agents until absolutely necessary. Unfortunately, this trend goes against human nature. Many primary care physicians as well as some other specialists are anxious to use the new-fangled drugs. Some seem to need to boast that they are up to date by their use of the newest agents and scoff that use of inexpensive, older agents is behind the times.

The two new trials will be led by University of California, Los Angeles and the University of California, San Francisco. Each of the trials is designed to enroll up to 1,200 people. The associated contracts will total up to $19 million over five years.

While I am delighted to see the additional funding for this rapidly growing problem, the results of these studies will likely not be available for several years. In the interim, the excessive use of the new agents will continue, leading to further resistance. I sometimes wonder whether an urgent intervention, such as restricting the use of certain new drugs to specialists in the field, wouldn't be more rational, especially since there are almost no new antibiotics in the pipeline. I know this is heresy, but too much is at stake to squander our few resources in this battle. Perhaps we should be "unAmerican" and not allow business interests and free enterprise to win this battle but lose the global war.