Joint Commission Highlights Patient Health Literacy
How You Can Help Overcome the Silent Health Epidemic
You often communicate vital information with specialized language, through complex documents and under extreme time constraints. Patients who don't fully grasp the meaning and importance of this information - whether that's due to a lack of medical knowledge, low literacy skills or the physical and emotional burdens of illness or recovery - run the risk of compromising their care. It's a risk that you must take seriously, says the Joint Commission, which describes American patients' difficulties in understanding healthcare as a "silent health epidemic."

To that end, last month the commission released "What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety." The report offers 35 tips on bridging the communication gap between providers and patients. Some examples:

• You should assess the literacy levels and language needs of the communities you serve.
• Staff should receive training on health literacy issues and patient-centered communications.
• Insurance enrollment forms and benefits explanations, informed consent forms and processes, facility navigational aids and other textual materials should be redesigned for easier patient understanding.
• Clinicians should use "teach-back" or "show me" methods of communication to ensure patient understanding.
• Clinicians should regularly and continuously teach their patients self-management skills.

"The patient who smiles at you and nods his head doesn't necessarily understand what you said," says J. James Rohack, MD, a member of the Joint Commission's board of commissioners. "The patient has to feel comfortable that we in the [healthcare] community aren"t blaming patients and aren't shaming patients."

- David Bernard

Benchmarking Snapshot
How Do Your Gross Charges and Net Revenue Per Case Stack Up?
Here's some benchmarking data for you to chew on. This month, we look at gross versus net revenue per case across several specialties based on an aggregated case volume of nearly 1 million cases performed around the country, courtesy of InforMed and AAASC. The mean, or average, gross charges represent the summation of the total amounts billed for all cases and procedures, giving no effect for write-downs or contractual adjustments. The average net revenue represents the net revenue by specialty for all cases and procedures after having taken into account all write-downs and contractual adjustments. A few interesting notes:

• Orthopedics ($2,269), ENT ($1,968) and podiatry ($1,686) had the highest net revenues per case, while oral surgery ($890), pain management ($834) and GI/endoscopy ($773) had the lowest net revenues per case.
• Specialties with the highest net ratios: GI/endoscopy (38 percent), urology (38 percent), oral surgery (37 percent) and orthopedics (37 percent).
• Specialties with the lowest net ratios: ophthalmology (28 percent), podiatry (29 percent), ENT (32 percent) and pain management (33 percent).

Source: InforMed's 2006 Multi-Specialty ASC Intellimarker, developed in collaboration with the AAASC.

In the Know

• Antibiotic OK'd to Prevent SSIs in Colorectal Procedures. New antibiotic Invanz (ertapenem) significantly outperformed cefotetan in preventing SSIs after colorectal surgery, according to a study published in the December issue of the New England Journal of Medicine. The results of the largest prospective, randomized comparative clinical trial ever conducted in antibiotic prophylaxis for elective open colorectal surgery earned the drug, made by Merck, the go-ahead from the FDA in December. Invanz is generally indicated for use in adults as a 1g dose administered by IV infusion or intramuscular injection once a day or one hour before elective colorectal surgery.
• Montana Bill Would Ban Specialty Hospitals. Senate Bill 417, which would prevent specialty hospitals from starting over the next two years, was unanimously passed by the Montana Senate's Health and Public Safety Committee last month. In 2005, the legislature passed a moratorium on specialty hospitals in the state that is set to expire this year. SB 417 would extend the ban for another two years while the state studies the effects of specialty hospitals on services and healthcare prices.
• Iowa Hospitals Might Need CON to Move Across Town. If a hospital wants to relocate within a county, does it need state permission in the form of a certificate of need? That's the question at the center of a lawsuit that stands in the way of two hospitals that would like to move across town. Wellmark Blue Cross/Blue Shield has filed suit to force Iowa Health-Des Moines and Mercy Medical Center to seek state permission for such a move. Separately, the Iowa Senate introduced a bill that would force hospital groups relocating their facilities to receive CONs. The Iowa Hospital Association opposes the bill, saying replacement hospitals don't expand capacity or alter market competition and therefore don't require oversight under the CON law. "Any changes to the CON law open it up for unintended consequences," says an IHA spokesperson.
• Minnesota Mulls Plastic Surgery Tax. Even though the tax on cosmetic surgery yielded only a fraction of what was expected in New Jersey, Minnesota is considering a similar measure. A new bill sponsored by State Rep. Phyllis Kahn calls for a 6.5 percent sales tax on elective cosmetic surgery and appearance-enhancing procedures including chemical skin peels, laser hair removal and cosmetic injections.

Post-op Pain Management
Are IV Pain Pumps on the Outs?
Patient-controlled analgesia is losing favor as an answer to getting surgical patients on their feet and on their way faster, and multi-modal, opioid-avoiding techniques are in. A survey of 351 nurses and 507 patients conducted by the American Society of PeriAnesthesia Nurses (and funded by Ortho-McNeil, Inc.) found that both agreed that IV PCA can hinder care, recovery time and comfort. Highlights of the study, released last month:

• The vast majority of nurses (98 percent) and patients (78 percent) said they believed that patient control of medication is a benefit of pain pumps.
• However, 63 percent of nurses and 56 percent of patients felt lack of mobility - a key to recovery - with the pumps was a problem.
• Forty-six percent of patients reported that IV PCA was uncomfortable.
• Finally, there are problems with basic use of the devices: 49 percent of nurses reported one or two programming errors per month; 50 percent reported having experienced a needlestick injury; 51 percent reported one or two interruptions in analgesia per month due to pump malfunctions and 62 percent reported up to five leakages of IV fluid into subcutaneous tissue per month.

Speaking separately at the American Academy of Orthopedic Surgeons annual meeting in Chicago, a group of presenters on pain management in knee replacement surgery echoed those sentiments and went one step further, saying that patient-controlled IV pain pumps actually delay recovery for their patients.

"PCA is falling from favor. It has some benefits because it smoothes some extremes [of pain], but it's plagued by substantial side effects, including over-sedation and under-medication" says Mark Pagano, MD, an orthopedic surgeon at the Mayo Clinic in Rochester, Minn.

The goal, says Daniel J. Berry, MD, orthopedic surgeon and professor and chairman of orthopedics at the Mayo Clinic, is to "get away from narcotics" - which are inherent to pain pump use - "and their side effects. They leave patients sedated, nauseated and miserable even when they"re getting relief from pain."

There have been three recent gains in pain management, they say: There are now multiple pathways for addressing pain at the same time in an attempt to stay below threshold; there are more specific ways to target pain, including using regional rather then general or, ideally, a peripheral nerve block; and there's evidence to preemptively control pain, which leads to the ideal benefit of less pain and less medication given overall.

- Stephanie Wasek