Those arguing against universal healthcare in the U.S. argue that the indigent, homeless and uninsured can always go to a hospital emergency department to receive treatment. But EDs in the U.S. aren’t in particular good shape themselves, according to the most recent reports from the Centers for Disease Control and Prevention’s (Atlanta) “Ambulatory Medical Care Utilization Estimates for 2005” and “National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary.” The reports were released last month by the CDC’s National Center for Health Statistics (Hyattsville, Maryland) and serve to increase concerns as to overcrowding and the rise in the number of people who have nowhere else to go for their healthcare.

Those concerns also include such issues as psychiatric patients going first to emergency departments (EDs) for treatment — probably due to the fact that many such hospital psych units have closed — the fact that most visits were made by the very young and infants under 12 months; and the number of homeless individuals who turn to EDs for care.

The statistics come at a time when – from 1995 to 2005 – the number of hospital EDS decreased from 4,176 to 3,795, increasing the annual number of visits per ED from 23,119 in 1995 to 30,388 in 2005. An estimated total 115.3 million visits were made to hospital EDs in 2005, or about 39.6 visits for every 100 people.

Catharine Burt, chief of the ambulatory care statistics branch at the the National Center for Health Statistics and lead author of the study, told Biomedical Business & Technology that the statistics clearly explain ED “over-crowding... long waiting times... and patients leaving before they are treated by physicians.”

The hospital ambulatory/ED survey data are incorporated into the “Ambulatory Medical Care Utilization Estimates for 2005,” and Burt said the figures have gotten increased recent attention with the national release of the documentary film “Sicko,” Michael Moore’s indictment of the U.S. healthcare system. But Burt said there isn’t much new or startling about the data.

Many hospitals, she said, have closed because they could not continue to operate and continue to care for non-paying patients. Burt said that the emergency room “is a barometer for health in America,” but that it is “very hard to second guess” why people go to the ED because the surveys do not contain “all the denominators.” However, she said the answer typically comes down to “accessibility and cost.”

For example, the utilization report contains information on patient visits not only to EDs, but also to outpatient centers and physician offices and found the ED rate for patients with no insurance was about twice that of those with private insurance. Conversely, patient visits to physician officers were higher for individuals with private health insurance compared to uninsured persons.

Three age groups have shown an “increasing trend” in the number of visits to EDs since 1995: those ages 22-49 (up by 11%), 50 to 64 (up by 13%) and 65 years and older (up by 11%), the report found. Infants under 12 months of age accounted for 91.3 visits per 100 infants, representing about 3.8 million visits to EDs. The utilization rate for EDs was higher for non-Hispanic black persons than for non-Hispanic whites. The ED utilization rate for Asian and American Indian or Alaska Native individuals was less than for whites.

Also, in 2005, about 500,000 visits, or 0.4% of visits were made by homeless individuals, or 62.7 visits per 100 homeless people. And almost three-quarters, or 72.2% of ED visits were made to voluntary non-profit hospitals.

Private insurance was “the most frequent expected source of payment,” the report finds, accounting for 39.9% of all ED visits. Other sources included Medicaid or State Children’s Health Insurance Program (24.9%) and Medicare (16.6%). The visit rate for Medicaid patients was 88 per 100 persons with Medicaid coverage, which was higher than the rate for those with Medicare, 51 per 100 persons. In 16.7% of the visits, no insurance was reported.

Where the report focuses specifically on EDs, it finds that the most frequently diagnosed major disease categories were injuries and poisonings; symptoms, signs and “ill-defined” conditions (19.3%); and diseases of the respiratory system (11.0%). The “most frequently reported specific” reasons that patients gave for visiting the hospital were abdominal pain (6.8%); chest pain (5.0%) and fever (4.4%).

The ED study says that 1.8 million visits were attributed to the adverse effects of medical treatment, including complications of medical and surgical procedures, or 2.6% of injury visits, and adverse effects of medication, or 1.8% of injury visits.

Burt said that even though more medications are being prescribed, the number of adverse reactions to medication reported in EDs has “sort of leveled off, but what has really jumped” are the number of visits to EDs due to complications from surgical procedures, whether that be a surgical site infection or complications related to the insertion of shunts and stents, which she said do account for some of those visits.

SPORT trial arms offer mixed signals on back surgery

Views concerning the best therapies swing back and forth, and a recent report from the Spine Patients Outcomes Research Trial (SPORT) study suggests that for two diseases of the back, the pendulum is swinging yet again toward the efficacy of surgery.

An article appearing last November in the Journal of the American Medical Association took a negative view of surgery, based on the results of the first arm of the SPORT trial, which examined the comparative effectiveness of surgery versus therapy. The abstract of that article said that “conclusions about the superiority or equivalence of the treatments are not warranted, based on the intent-to-treat analysis.”

However, a statement issued recently in connection with the second arm of the SPORT trial suggests that further analysis may be changing minds. The second phase of the SPORT trial, a five-year, multi-center study supported in part by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), part of the National Institutes of Health, has now looked at the combination of degenerative spondylolisthesis and symptomatic spinal stenosis in more than 600 patients. Spondylolisthesis is a degeneration of spinal discs, which can cause a narrowing of the inside of the vertebrae in the spinal column, known as stenosis.

According to the numbers offered by NIAMS, 372 of the 601 enrollees opted for decompressive laminectomy while the remaining 235 chose other treatments, including physical therapy, injections of anti-inflammatory steroids and analgesic medications. (Neither the press release nor the abstract specified which medications were prescribed.) Two-year data from the second of the SPORT trials suggest that patients who elected non-surgical management “reported modest improvement in their condition,” but those who went under the knife “reported significantly reduced pain and improved function.” The latter group also reported that “relief from symptoms came quickly; some reported significant improvement as early as six weeks after the procedure.”

In keeping with the notion that no clinical trial ever comes off without some sort of hitch, this leg of the SPORT study ran into a substantial amount of patient crossover: 40% of all patients opted out of the control group and into the study group or vice-versa, which means the analysis loses the statistical rigor of an intent-to-treat trial.

In an article in the 2000 edition of Blood Purification, Robert Wolfe, PhD, a professor of biostatistics at the University of Michigan (Ann Arbor), took the position that “[i]f our objective is to spend a lot of money in order to achieve a slow and narrow advance in knowledge,” randomized controlled trials should be used “exclusively.”

However, Wolfe also said that while correlation “is almost always a marker” for causation, the direction of causation is not always clear and that “inferences from observation can be sharpened by isolating the effects of individual factors by changing one of them at a time in a controlled experiment.”

The report on the second arm of SPORT seems to echo that sentiment, stating that pooled results from the intent-to-treat study and a parallel observational study may end up creating “a more powerful osbservational study at the expense of information gained from the statistically rigorous study design originally planned.”

Report: Diabetes care benefits via ITDM seen, but not quite yet

The broad use of information technology (IT) has been touted as key to improving the efficiency of healthcare delivery, and thus reducing costs. And so IT-enabled diabetes management (ITDM) for patients should improve care processes, cut cost and delay Type-2 diabetes complications.

That’s the overall conclusion of a report titled “The Value of Information Technology-Enabled Diabetes Management” [ITDM] by the Center for Information Technology Leadership (CITL: Boston). But that conclusion may be somewhat time-delayed. Eric Pan, MD, senior scientist and director at CITL said that the sector has to play “catch-up” in terms of providing lower cost products for true cost savings to be seen. “The use of these technologies is in the minority right now,” Pan told Biomedical Business & Technology. “As more people use them and the devices become more available and the market is able to manufacture more of the devices, more people can benefit. What we can see from technology used five years ago is very promising.”

The report is based largely on projections by means of a computer-based model that simulated the outcomes for Type-2 diabetes patients in a diabetes management program over 10 years, along with literature reviews, assessments by experts and other market research.

Of existing technologies, electronic diabetes registries used by providers, followed by clinical decision support systems (CDSS) for providers, were projected as showing the greatest improvement in clinical outcomes.

While CITL found that all forms of ITDM improved the health of patients with diabetes and reduced healthcare expenditures, during a 10-year period, electronic diabetes registries saved the most, about $14.5 billion. Other technologies had varying degrees of savings, from hundreds of thousands to several billion dollars.

But the report came with a large proviso: Given the current costs of IT systems, national adoption of ITDM would cost more than it saves at this point.

Pan described the current ITDM market to be akin to the laptop environment 10 to 15 years ago. “Back then one laptop would consume my entire department’s budget,” he said. “I have three on my desk now — they’re more affordable.” Thus, he said that it will take a few years to provide actual figures concerning IT costs and the resultant savings with ITDMs.

CITL’s analysis shows that ITDM can improve compliance with standards of care, from the current rate of less than 50% to as high as 80%. As a result, millions of cases of diabetes complications, such as kidney failure, stroke, heart attacks, and blindness, can be avoided, and hundreds of thousands of lives could be saved. Another conclusion to be drawn from CITL’s report is that payers, especially Medicare, stand to benefit the most from ITDM since they bear the most financial risk.

Pan said, “[W]e need to find the means to lower the costs of these IT-enabled interventions. Ultimately, getting the most value from ITDM will require the coordination of provider, payer, and patient-based initiatives... and alignment of financial incentives will be key in this equation.”