Debra L. Beck

TORONTO – In the second year after the new Accreditation Council for Graduate Medical Education duty-hours rules became effective, mortality in patients hospitalized for four common medical conditions–acute myocardial infarction, heart failure, gastrointestinal bleeding, and stroke–were significantly reduced at more-teaching-intensive hospitals, compared with less-teaching-intensive hospitals.

This apparent survival benefit was not seen for surgical patients. No changes in mortality were seen in surgical patients during either the first or second year post reform, Dr. Kevin Volpp and his colleagues at the Philadelphia VA Medical Center and the University of Pennsylvania, Philadelphia, reported at the annual meeting of the Society of General Internal Medicine.

The Accreditation Council for Graduate Medical Education (ACGME) duty-hour reform policy went into effect in July 2003. Designed to improve patient safety, the rules limit the number of hours residents can work to 80 per week, with a minimum of 10 hours of time off between shifts.

The study cohort included all unique patients (n=320,685) admitted to acute-care VA hospitals between July 2000 and June 2005 with principal diagnoses of acute myocardial infarction (AMI), heart failure, gastrointestinal bleeding, stroke, or Diagnosis-Related Group classification of general, orthopedic, or vascular surgery.

In the first year after duty-hour reform, no significant relative changes in death rates were reported for either the medical or surgical patients. In the second year, a significant 26% reduction in mortality risk was seen at the more-teaching-intensive hospitals for patients with any of the four medical conditions. That change was predominantly driven by a highly significant 52% relative reduction in mortality risk in AMI patients.

For patients in hospitals in the 75th percentile of teaching intensity, mortality improved from prereform year 1 to postreform year 2 by 0.70 percentage points–or a relative improvement of 11.1% for medical patients–compared with patients in hospitals in the 25th percentile of teaching intensity, Dr. Volpp said.

At hospitals in the 90th percentile of teaching intensity, the improvement in mortality was even greater: about 0.88 percentage points, or a relative improvement of about 14%, compared with hospitals in the 10th percentile of teaching intensity.

VA hospitals are the largest single site for residency training in the United States, Dr. Volpp noted. The study was funded by the VA Health Services Research and Development Service.

TORONTO – In the second year after the new Accreditation Council for Graduate Medical Education duty-hours rules became effective, mortality in patients hospitalized for four common medical conditions–acute myocardial infarction, heart failure, gastrointestinal bleeding, and stroke–were significantly reduced at more-teaching-intensive hospitals, compared with less-teaching-intensive hospitals.

This apparent survival benefit was not seen for surgical patients. No changes in mortality were seen in surgical patients during either the first or second year post reform, Dr. Kevin Volpp and his colleagues at the Philadelphia VA Medical Center and the University of Pennsylvania, Philadelphia, reported at the annual meeting of the Society of General Internal Medicine.

The Accreditation Council for Graduate Medical Education (ACGME) duty-hour reform policy went into effect in July 2003. Designed to improve patient safety, the rules limit the number of hours residents can work to 80 per week, with a minimum of 10 hours of time off between shifts.

The study cohort included all unique patients (n=320,685) admitted to acute-care VA hospitals between July 2000 and June 2005 with principal diagnoses of acute myocardial infarction (AMI), heart failure, gastrointestinal bleeding, stroke, or Diagnosis-Related Group classification of general, orthopedic, or vascular surgery.

In the first year after duty-hour reform, no significant relative changes in death rates were reported for either the medical or surgical patients. In the second year, a significant 26% reduction in mortality risk was seen at the more-teaching-intensive hospitals for patients with any of the four medical conditions. That change was predominantly driven by a highly significant 52% relative reduction in mortality risk in AMI patients.

For patients in hospitals in the 75th percentile of teaching intensity, mortality improved from prereform year 1 to postreform year 2 by 0.70 percentage points–or a relative improvement of 11.1% for medical patients–compared with patients in hospitals in the 25th percentile of teaching intensity, Dr. Volpp said.

At hospitals in the 90th percentile of teaching intensity, the improvement in mortality was even greater: about 0.88 percentage points, or a relative improvement of about 14%, compared with hospitals in the 10th percentile of teaching intensity.

VA hospitals are the largest single site for residency training in the United States, Dr. Volpp noted. The study was funded by the VA Health Services Research and Development Service.

TORONTO – In the second year after the new Accreditation Council for Graduate Medical Education duty-hours rules became effective, mortality in patients hospitalized for four common medical conditions–acute myocardial infarction, heart failure, gastrointestinal bleeding, and stroke–were significantly reduced at more-teaching-intensive hospitals, compared with less-teaching-intensive hospitals.

This apparent survival benefit was not seen for surgical patients. No changes in mortality were seen in surgical patients during either the first or second year post reform, Dr. Kevin Volpp and his colleagues at the Philadelphia VA Medical Center and the University of Pennsylvania, Philadelphia, reported at the annual meeting of the Society of General Internal Medicine.

The Accreditation Council for Graduate Medical Education (ACGME) duty-hour reform policy went into effect in July 2003. Designed to improve patient safety, the rules limit the number of hours residents can work to 80 per week, with a minimum of 10 hours of time off between shifts.

The study cohort included all unique patients (n=320,685) admitted to acute-care VA hospitals between July 2000 and June 2005 with principal diagnoses of acute myocardial infarction (AMI), heart failure, gastrointestinal bleeding, stroke, or Diagnosis-Related Group classification of general, orthopedic, or vascular surgery.

In the first year after duty-hour reform, no significant relative changes in death rates were reported for either the medical or surgical patients. In the second year, a significant 26% reduction in mortality risk was seen at the more-teaching-intensive hospitals for patients with any of the four medical conditions. That change was predominantly driven by a highly significant 52% relative reduction in mortality risk in AMI patients.

For patients in hospitals in the 75th percentile of teaching intensity, mortality improved from prereform year 1 to postreform year 2 by 0.70 percentage points–or a relative improvement of 11.1% for medical patients–compared with patients in hospitals in the 25th percentile of teaching intensity, Dr. Volpp said.

At hospitals in the 90th percentile of teaching intensity, the improvement in mortality was even greater: about 0.88 percentage points, or a relative improvement of about 14%, compared with hospitals in the 10th percentile of teaching intensity.

VA hospitals are the largest single site for residency training in the United States, Dr. Volpp noted. The study was funded by the VA Health Services Research and Development Service.

TORONTO — Obesity did not increase the risk of adverse airway events associated with procedural sedation and analgesia in the emergency department in one large study.

The study of 1,112 patients between the ages of 0 and 21 years, 15% of whom were obese, was presented by Dr. Francesca Bullaro of Children's Hospital of Pittsburgh during a poster session at the annual meeting of the Pediatric Academic Societies.

Obese children may be at increased risk for partial or complete upper airway obstruction during sleep as a result of obstructive sleep apnea. No published studies have evaluated airway adverse events occurring in obese children during procedural sedation and analgesia (PSA) in the emergency department, Dr. Bullaro said.

To determine the incidence of airway adverse events during PSA in obese children, Dr. Bullaro and her colleagues conducted a secondary analysis of prospectively enrolled patients from a procedural sedation database. Obesity was defined as weight in the 95th percentile or higher for age and gender using Centers for Disease Control and Prevention growth charts.

Adverse airway events were seen in 179 of 1,112 patients (16%). These included hypoxia in 166, vomiting in 12, stridor in 5, apnea in 3, and laryngospasm in 1. Some patients had more than one adverse event.

Of the obese patients, 17% experienced an adverse airway event, not significantly more than nonobese patients (16%). In particular, in obese patients, the incidence of hypoxia was 90% versus 93% in nonobese patients, which was not a significant difference.

TORONTO — Obesity did not increase the risk of adverse airway events associated with procedural sedation and analgesia in the emergency department in one large study.

The study of 1,112 patients between the ages of 0 and 21 years, 15% of whom were obese, was presented by Dr. Francesca Bullaro of Children's Hospital of Pittsburgh during a poster session at the annual meeting of the Pediatric Academic Societies.

Obese children may be at increased risk for partial or complete upper airway obstruction during sleep as a result of obstructive sleep apnea. No published studies have evaluated airway adverse events occurring in obese children during procedural sedation and analgesia (PSA) in the emergency department, Dr. Bullaro said.

To determine the incidence of airway adverse events during PSA in obese children, Dr. Bullaro and her colleagues conducted a secondary analysis of prospectively enrolled patients from a procedural sedation database. Obesity was defined as weight in the 95th percentile or higher for age and gender using Centers for Disease Control and Prevention growth charts.

Adverse airway events were seen in 179 of 1,112 patients (16%). These included hypoxia in 166, vomiting in 12, stridor in 5, apnea in 3, and laryngospasm in 1. Some patients had more than one adverse event.

Of the obese patients, 17% experienced an adverse airway event, not significantly more than nonobese patients (16%). In particular, in obese patients, the incidence of hypoxia was 90% versus 93% in nonobese patients, which was not a significant difference.

TORONTO — Obesity did not increase the risk of adverse airway events associated with procedural sedation and analgesia in the emergency department in one large study.

The study of 1,112 patients between the ages of 0 and 21 years, 15% of whom were obese, was presented by Dr. Francesca Bullaro of Children's Hospital of Pittsburgh during a poster session at the annual meeting of the Pediatric Academic Societies.

Obese children may be at increased risk for partial or complete upper airway obstruction during sleep as a result of obstructive sleep apnea. No published studies have evaluated airway adverse events occurring in obese children during procedural sedation and analgesia (PSA) in the emergency department, Dr. Bullaro said.

To determine the incidence of airway adverse events during PSA in obese children, Dr. Bullaro and her colleagues conducted a secondary analysis of prospectively enrolled patients from a procedural sedation database. Obesity was defined as weight in the 95th percentile or higher for age and gender using Centers for Disease Control and Prevention growth charts.

Adverse airway events were seen in 179 of 1,112 patients (16%). These included hypoxia in 166, vomiting in 12, stridor in 5, apnea in 3, and laryngospasm in 1. Some patients had more than one adverse event.

Of the obese patients, 17% experienced an adverse airway event, not significantly more than nonobese patients (16%). In particular, in obese patients, the incidence of hypoxia was 90% versus 93% in nonobese patients, which was not a significant difference.

TORONTO — Older patients with atrial fibrillation do not have worse warfarin control than younger patients do and can be sustained on the drug without substantially more frequent international normalized ratio testing than is thought necessary in younger patients, Dr. Margaret C. Fang reported at the annual meeting of the Society of General Internal Medicine.

“Older patients with atrial fibrillation are at higher risk for stroke and have more clinical risk factors for stroke, yet many are not prescribed warfarin,” said Dr. Fang of the University of California, San Francisco. “We found that INR control and INR variability did not differ substantially in older and younger patients.

“Concerns about difficult warfarin control should not deter clinicians from prescribing warfarin to the oldest patients with atrial fibrillation,” she added.

Oral vitamin K antagonists, such as warfarin, greatly reduce the risk of atrial fibrillation-related stroke, which is more common in older patients. However, they also increase hemorrhagic risk.

“Older patients are less likely to receive warfarin in part due to hemorrhagic complications, high fall risk, cognitive decline, and frailty,” Dr. Fang said. “But there is also this perception that warfarin control is more difficult in the elderly patient.”

The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study was a cohort study involving 13,559 patients with nonvalvular atrial fibrillation enrolled in Kaiser Permanente of Northern California. The study was led by investigators at the University of California, San Francisco; the Kaiser Permanente Division of Research; and Massachusetts General Hospital, Boston. Patients were monitored for a median follow-up of 6 years.

Warfarin use and anticoagulation intensity were determined using validated algorithms based on warfarin prescriptions and serial outpatient INR test results. The primary outcomes were the amount of time in therapeutic INR ranges, INR variability, and median number of days between INR measurements, excluding the first 4 weeks of therapy.

At baseline, patients aged 80 years or older were significantly less likely to receive warfarin than were those younger than 80 years (43% vs. 56%), and more likely to have stroke risk factors or prior strokes.

Patients aged 80 years and older were just as likely to be in a therapeutic INR range of 2.0 to 3.0 as younger patients were: 64.0% of patients 80 years or older, compared with 66.0% of those younger than 80 years (adjusted odds ratio 1.0).

There were no significant differences by age in the proportion of INRs 4.0 and above (1.86% vs. 1.80%, respectively; adjusted OR 1.0). The median number of days between INR measurements was 21 for both older and younger patients, indicating no need for more frequent INR testing in older patients.

'There is … this perception that warfarin control is more difficult in the elderly patient.' DR. FANG

TORONTO — Older patients with atrial fibrillation do not have worse warfarin control than younger patients do and can be sustained on the drug without substantially more frequent international normalized ratio testing than is thought necessary in younger patients, Dr. Margaret C. Fang reported at the annual meeting of the Society of General Internal Medicine.

“Older patients with atrial fibrillation are at higher risk for stroke and have more clinical risk factors for stroke, yet many are not prescribed warfarin,” said Dr. Fang of the University of California, San Francisco. “We found that INR control and INR variability did not differ substantially in older and younger patients.

“Concerns about difficult warfarin control should not deter clinicians from prescribing warfarin to the oldest patients with atrial fibrillation,” she added.

Oral vitamin K antagonists, such as warfarin, greatly reduce the risk of atrial fibrillation-related stroke, which is more common in older patients. However, they also increase hemorrhagic risk.

“Older patients are less likely to receive warfarin in part due to hemorrhagic complications, high fall risk, cognitive decline, and frailty,” Dr. Fang said. “But there is also this perception that warfarin control is more difficult in the elderly patient.”

The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study was a cohort study involving 13,559 patients with nonvalvular atrial fibrillation enrolled in Kaiser Permanente of Northern California. The study was led by investigators at the University of California, San Francisco; the Kaiser Permanente Division of Research; and Massachusetts General Hospital, Boston. Patients were monitored for a median follow-up of 6 years.

Warfarin use and anticoagulation intensity were determined using validated algorithms based on warfarin prescriptions and serial outpatient INR test results. The primary outcomes were the amount of time in therapeutic INR ranges, INR variability, and median number of days between INR measurements, excluding the first 4 weeks of therapy.

At baseline, patients aged 80 years or older were significantly less likely to receive warfarin than were those younger than 80 years (43% vs. 56%), and more likely to have stroke risk factors or prior strokes.

Patients aged 80 years and older were just as likely to be in a therapeutic INR range of 2.0 to 3.0 as younger patients were: 64.0% of patients 80 years or older, compared with 66.0% of those younger than 80 years (adjusted odds ratio 1.0).

There were no significant differences by age in the proportion of INRs 4.0 and above (1.86% vs. 1.80%, respectively; adjusted OR 1.0). The median number of days between INR measurements was 21 for both older and younger patients, indicating no need for more frequent INR testing in older patients.

'There is … this perception that warfarin control is more difficult in the elderly patient.' DR. FANG

TORONTO — Older patients with atrial fibrillation do not have worse warfarin control than younger patients do and can be sustained on the drug without substantially more frequent international normalized ratio testing than is thought necessary in younger patients, Dr. Margaret C. Fang reported at the annual meeting of the Society of General Internal Medicine.

“Older patients with atrial fibrillation are at higher risk for stroke and have more clinical risk factors for stroke, yet many are not prescribed warfarin,” said Dr. Fang of the University of California, San Francisco. “We found that INR control and INR variability did not differ substantially in older and younger patients.

“Concerns about difficult warfarin control should not deter clinicians from prescribing warfarin to the oldest patients with atrial fibrillation,” she added.

Oral vitamin K antagonists, such as warfarin, greatly reduce the risk of atrial fibrillation-related stroke, which is more common in older patients. However, they also increase hemorrhagic risk.

“Older patients are less likely to receive warfarin in part due to hemorrhagic complications, high fall risk, cognitive decline, and frailty,” Dr. Fang said. “But there is also this perception that warfarin control is more difficult in the elderly patient.”

The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study was a cohort study involving 13,559 patients with nonvalvular atrial fibrillation enrolled in Kaiser Permanente of Northern California. The study was led by investigators at the University of California, San Francisco; the Kaiser Permanente Division of Research; and Massachusetts General Hospital, Boston. Patients were monitored for a median follow-up of 6 years.

Warfarin use and anticoagulation intensity were determined using validated algorithms based on warfarin prescriptions and serial outpatient INR test results. The primary outcomes were the amount of time in therapeutic INR ranges, INR variability, and median number of days between INR measurements, excluding the first 4 weeks of therapy.

At baseline, patients aged 80 years or older were significantly less likely to receive warfarin than were those younger than 80 years (43% vs. 56%), and more likely to have stroke risk factors or prior strokes.

Patients aged 80 years and older were just as likely to be in a therapeutic INR range of 2.0 to 3.0 as younger patients were: 64.0% of patients 80 years or older, compared with 66.0% of those younger than 80 years (adjusted odds ratio 1.0).

There were no significant differences by age in the proportion of INRs 4.0 and above (1.86% vs. 1.80%, respectively; adjusted OR 1.0). The median number of days between INR measurements was 21 for both older and younger patients, indicating no need for more frequent INR testing in older patients.

'There is … this perception that warfarin control is more difficult in the elderly patient.' DR. FANG

TORONTO – Only about one-third of weight-related comorbidities were identified by generalist providers before referral to a weight management program, Dr. Moises Auron-Gomez reported at the annual meeting of the Pediatric Academic Societies.

“The majority of obesity-related comorbid conditions appear not to be identified by primary pediatric providers,” said Dr. Auron-Gomez. These included some that are relatively easy to spot, such as acanthosis nigricans and hypertension.

Dr. Auron-Gomez and colleagues found an average of 1.8 conditions per child upon referral for weight management; on average, 0.6 conditions were detected prior to referral and 1.2 conditions were detected after referral.”

“This means that most of the patients sent to our clinic had at least one [previously undetected] weight-related comorbidity,” said Dr. Auron-Gomez of the MetroHealth Medical Center in Cleveland, where the study was conducted.

Weight-related comorbid conditions noted in the primary care patient charts of 89 overweight children who were referred to a pediatric nutrition and exercise program were compared with conditions identified at the first clinic visit.

Children were referred to the clinic if they had body mass indexes above the 85th percentile for age, gender, height, and weight. Clinic screening was according to established guidelines for identifying comorbidities in overweight and obese pediatric patients.

In total, 168 conditions were identified. Of these, 57 (34%) were identified prior to the first weight management clinic visit, and 111 (66%) were detected at the first visit.

Only asthma (12 cases) was identified 100% of the time before referral for weight reduction.

Patients were generally seen within 1 month of referral, indicating that new conditions were unlikely to arise between the last primary care visit and the first specialist visit.

“Guidelines-based screening of children attending a weight management clinic can identify many previously undiagnosed weight-related comorbid conditions,” said Dr. Auron-Gomez.

The implications of these findings–if action is taken–include quicker referral for weight management in overweight and obese children, more effective weight management, and decreased weight-related morbidity, said Dr. Auron-Gomez.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO – Only about one-third of weight-related comorbidities were identified by generalist providers before referral to a weight management program, Dr. Moises Auron-Gomez reported at the annual meeting of the Pediatric Academic Societies.

“The majority of obesity-related comorbid conditions appear not to be identified by primary pediatric providers,” said Dr. Auron-Gomez. These included some that are relatively easy to spot, such as acanthosis nigricans and hypertension.

Dr. Auron-Gomez and colleagues found an average of 1.8 conditions per child upon referral for weight management; on average, 0.6 conditions were detected prior to referral and 1.2 conditions were detected after referral.”

“This means that most of the patients sent to our clinic had at least one [previously undetected] weight-related comorbidity,” said Dr. Auron-Gomez of the MetroHealth Medical Center in Cleveland, where the study was conducted.

Weight-related comorbid conditions noted in the primary care patient charts of 89 overweight children who were referred to a pediatric nutrition and exercise program were compared with conditions identified at the first clinic visit.

Children were referred to the clinic if they had body mass indexes above the 85th percentile for age, gender, height, and weight. Clinic screening was according to established guidelines for identifying comorbidities in overweight and obese pediatric patients.

In total, 168 conditions were identified. Of these, 57 (34%) were identified prior to the first weight management clinic visit, and 111 (66%) were detected at the first visit.

Only asthma (12 cases) was identified 100% of the time before referral for weight reduction.

Patients were generally seen within 1 month of referral, indicating that new conditions were unlikely to arise between the last primary care visit and the first specialist visit.

“Guidelines-based screening of children attending a weight management clinic can identify many previously undiagnosed weight-related comorbid conditions,” said Dr. Auron-Gomez.

The implications of these findings–if action is taken–include quicker referral for weight management in overweight and obese children, more effective weight management, and decreased weight-related morbidity, said Dr. Auron-Gomez.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO – Only about one-third of weight-related comorbidities were identified by generalist providers before referral to a weight management program, Dr. Moises Auron-Gomez reported at the annual meeting of the Pediatric Academic Societies.

“The majority of obesity-related comorbid conditions appear not to be identified by primary pediatric providers,” said Dr. Auron-Gomez. These included some that are relatively easy to spot, such as acanthosis nigricans and hypertension.

Dr. Auron-Gomez and colleagues found an average of 1.8 conditions per child upon referral for weight management; on average, 0.6 conditions were detected prior to referral and 1.2 conditions were detected after referral.”

“This means that most of the patients sent to our clinic had at least one [previously undetected] weight-related comorbidity,” said Dr. Auron-Gomez of the MetroHealth Medical Center in Cleveland, where the study was conducted.

Weight-related comorbid conditions noted in the primary care patient charts of 89 overweight children who were referred to a pediatric nutrition and exercise program were compared with conditions identified at the first clinic visit.

Children were referred to the clinic if they had body mass indexes above the 85th percentile for age, gender, height, and weight. Clinic screening was according to established guidelines for identifying comorbidities in overweight and obese pediatric patients.

In total, 168 conditions were identified. Of these, 57 (34%) were identified prior to the first weight management clinic visit, and 111 (66%) were detected at the first visit.

Only asthma (12 cases) was identified 100% of the time before referral for weight reduction.

Patients were generally seen within 1 month of referral, indicating that new conditions were unlikely to arise between the last primary care visit and the first specialist visit.

“Guidelines-based screening of children attending a weight management clinic can identify many previously undiagnosed weight-related comorbid conditions,” said Dr. Auron-Gomez.

The implications of these findings–if action is taken–include quicker referral for weight management in overweight and obese children, more effective weight management, and decreased weight-related morbidity, said Dr. Auron-Gomez.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Physician practices treating higher proportions of less-educated patients have consistently lower performance scores, reported Dr. Mark Friedberg of the division of general medicine at the Brigham and Women's Hospital and the Harvard School of Public Health, both in Boston.

In fact, an increase of one standard deviation in the proportion of non-college graduate patients is associated with a significant Health Employer Data and Information Set (HEDIS) performance score decrease of as much as 2.5%.

“Our concern is that practice sites caring for disproportionate shares of vulnerable patients may be penalized by public performance reporting and pay-for-performance contracts,” said Dr. Friedberg who presented preliminary research at the annual meeting of the Society of General Internal Medicine.

“Without adjusting HEDIS scores for patient sociodemographic characteristics—or adjusting some aspect of the way these scores are used—physicians may feel an incentive to avoid patients from vulnerable populations,” he said.

The measurement of primary care quality for public reporting has become a hot issue in recent years, with physicians who care for minority patients and those with lower incomes worried that they may be at a disadvantage in a system with a one-size-fits-all approach to quality measurement.

Dr. Friedberg noted a recent study (Health Aff. 2007;26:w405-w414 [Epub doi:10.1377/hlthaff.26.3.w405]) that found that 85% of physicians polled agreed with the statement: “At present, measures of quality are not adequately adjusted for patients' socioeconomic status.”

Fully 82% were concerned that measuring quality may deter physicians from treating high-risk patients.

Dr. Friedberg and his colleagues used the Massachusetts Health Quality Partners (MHQP) statewide reporting program, which supplied data from commercial insurers aggregated at the physician level on eight HEDIS measures: breast cancer, cervical cancer, chlamydia, asthma controller medications, HbA_1c testing, cholesterol testing, eye exams, and nephropathy.

MHQP is a statewide collaborative that includes the five largest health plans in Massachusetts, contracting with 90% of state primary care providers and covering 63% of Massachusetts residents, or about 4 million people.

Data were collected from 241 physician practice sites (including 1,489 physicians) that provided adult primary care to insured patients during 2004.

These data were linked to patient responses from the 2002–2003 Massachusetts Ambulatory Care Experiences Survey to calculate the prevalence of sociodemographic characteristics (age, gender, race, ethnicity, and education) within each practice site's patient panel. Practice site was used as the unit of analysis.

Median site-level HEDIS scores ranged from 94% for HbA_1c screening to 43% for chlamydia screening in women aged 21–25 years.

In bivariate analyses, lower site-level proportions of college graduate patients were significantly associated with lower HEDIS scores on all eight measures. These associations remained statistically significant for seven of the eight measures even after multivariate adjustment. Significant bivariate associations between sites' HEDIS scores and the age, racial, and ethnic composition of their patient panels existed for chlamydia screening, but these ties did not remain statistically significant after multivariate adjustment.

TORONTO — Physician practices treating higher proportions of less-educated patients have consistently lower performance scores, reported Dr. Mark Friedberg of the division of general medicine at the Brigham and Women's Hospital and the Harvard School of Public Health, both in Boston.

In fact, an increase of one standard deviation in the proportion of non-college graduate patients is associated with a significant Health Employer Data and Information Set (HEDIS) performance score decrease of as much as 2.5%.

“Our concern is that practice sites caring for disproportionate shares of vulnerable patients may be penalized by public performance reporting and pay-for-performance contracts,” said Dr. Friedberg who presented preliminary research at the annual meeting of the Society of General Internal Medicine.

“Without adjusting HEDIS scores for patient sociodemographic characteristics—or adjusting some aspect of the way these scores are used—physicians may feel an incentive to avoid patients from vulnerable populations,” he said.

The measurement of primary care quality for public reporting has become a hot issue in recent years, with physicians who care for minority patients and those with lower incomes worried that they may be at a disadvantage in a system with a one-size-fits-all approach to quality measurement.

Dr. Friedberg noted a recent study (Health Aff. 2007;26:w405-w414 [Epub doi:10.1377/hlthaff.26.3.w405]) that found that 85% of physicians polled agreed with the statement: “At present, measures of quality are not adequately adjusted for patients' socioeconomic status.”

Fully 82% were concerned that measuring quality may deter physicians from treating high-risk patients.

Dr. Friedberg and his colleagues used the Massachusetts Health Quality Partners (MHQP) statewide reporting program, which supplied data from commercial insurers aggregated at the physician level on eight HEDIS measures: breast cancer, cervical cancer, chlamydia, asthma controller medications, HbA_1c testing, cholesterol testing, eye exams, and nephropathy.

MHQP is a statewide collaborative that includes the five largest health plans in Massachusetts, contracting with 90% of state primary care providers and covering 63% of Massachusetts residents, or about 4 million people.

Data were collected from 241 physician practice sites (including 1,489 physicians) that provided adult primary care to insured patients during 2004.

These data were linked to patient responses from the 2002–2003 Massachusetts Ambulatory Care Experiences Survey to calculate the prevalence of sociodemographic characteristics (age, gender, race, ethnicity, and education) within each practice site's patient panel. Practice site was used as the unit of analysis.

Median site-level HEDIS scores ranged from 94% for HbA_1c screening to 43% for chlamydia screening in women aged 21–25 years.

In bivariate analyses, lower site-level proportions of college graduate patients were significantly associated with lower HEDIS scores on all eight measures. These associations remained statistically significant for seven of the eight measures even after multivariate adjustment. Significant bivariate associations between sites' HEDIS scores and the age, racial, and ethnic composition of their patient panels existed for chlamydia screening, but these ties did not remain statistically significant after multivariate adjustment.

TORONTO — Physician practices treating higher proportions of less-educated patients have consistently lower performance scores, reported Dr. Mark Friedberg of the division of general medicine at the Brigham and Women's Hospital and the Harvard School of Public Health, both in Boston.

In fact, an increase of one standard deviation in the proportion of non-college graduate patients is associated with a significant Health Employer Data and Information Set (HEDIS) performance score decrease of as much as 2.5%.

“Our concern is that practice sites caring for disproportionate shares of vulnerable patients may be penalized by public performance reporting and pay-for-performance contracts,” said Dr. Friedberg who presented preliminary research at the annual meeting of the Society of General Internal Medicine.

“Without adjusting HEDIS scores for patient sociodemographic characteristics—or adjusting some aspect of the way these scores are used—physicians may feel an incentive to avoid patients from vulnerable populations,” he said.

The measurement of primary care quality for public reporting has become a hot issue in recent years, with physicians who care for minority patients and those with lower incomes worried that they may be at a disadvantage in a system with a one-size-fits-all approach to quality measurement.

Dr. Friedberg noted a recent study (Health Aff. 2007;26:w405-w414 [Epub doi:10.1377/hlthaff.26.3.w405]) that found that 85% of physicians polled agreed with the statement: “At present, measures of quality are not adequately adjusted for patients' socioeconomic status.”

Fully 82% were concerned that measuring quality may deter physicians from treating high-risk patients.

Dr. Friedberg and his colleagues used the Massachusetts Health Quality Partners (MHQP) statewide reporting program, which supplied data from commercial insurers aggregated at the physician level on eight HEDIS measures: breast cancer, cervical cancer, chlamydia, asthma controller medications, HbA_1c testing, cholesterol testing, eye exams, and nephropathy.

MHQP is a statewide collaborative that includes the five largest health plans in Massachusetts, contracting with 90% of state primary care providers and covering 63% of Massachusetts residents, or about 4 million people.

Data were collected from 241 physician practice sites (including 1,489 physicians) that provided adult primary care to insured patients during 2004.

These data were linked to patient responses from the 2002–2003 Massachusetts Ambulatory Care Experiences Survey to calculate the prevalence of sociodemographic characteristics (age, gender, race, ethnicity, and education) within each practice site's patient panel. Practice site was used as the unit of analysis.

Median site-level HEDIS scores ranged from 94% for HbA_1c screening to 43% for chlamydia screening in women aged 21–25 years.

In bivariate analyses, lower site-level proportions of college graduate patients were significantly associated with lower HEDIS scores on all eight measures. These associations remained statistically significant for seven of the eight measures even after multivariate adjustment. Significant bivariate associations between sites' HEDIS scores and the age, racial, and ethnic composition of their patient panels existed for chlamydia screening, but these ties did not remain statistically significant after multivariate adjustment.

TORONTO – If accepting free pens or lunches from industry represents a potential conflict of interest for physicians, what do you call it when a medical school dean is also the corporate director of a large, for-profit health care company?

“An academic medical leader serving on the board of directors of a health care corporation could entail huge conflicts of interest,” Dr. Roy M. Poses said at the annual meeting of the Society of General Internal Medicine.

“Directors of a for-profit corporation have legally enforceable fiduciary responsibilities to its stockholders for the corporation's direction and financial viability, including its profitability,” said Dr. Poses, president of the Foundation for Integrity and Responsibility in Medicine, a not-for-profit educational group.

In a cross-sectional study, Dr. Poses and his colleagues scrutinized the biographies of all board members of “pure” health care companies among the Standard & Poor's (S&P) 1500. Their data came from publicly available company proxy statements, annual reports, and Web sites.

In 2005, there were 164 U.S. health care companies in the S&P 1500, and 125 U.S. medical schools. The investigators identified 198 people who served on the companies' boards of directors and had faculty or leadership positions at a medical school. Of the 125 medical schools, 65 (52%) had at least one faculty member and/or academic leader who also served on a health care corporation's board of directors. Four schools had 10 or more such individuals, and 15 schools had 5 or more.

Of the 125 medical schools, 7 reported to university presidents who also were directors of health care corporations, 11 reported to vice presidents for health affairs who were corporate directors, and 5 were lead by deans who also were health care corporate directors.

Also, 11 schools had academic medical center CEOs who were corporate directors, and 22 schools had at least one top leader who also was a director of a health care corporation.

“There are a lot of factors at play, including how aware you are of the potential conflict and how much transparency protects you from acting in a conflicted way if you are conflicted,” said Dr. Nicole Lurie, codirector for public health at the Center for Domestic and International Health Security, in an interview.

“Many physicians in practice don't perceive a conflict at all. The first thing is to open yourself up, look at yourself, and examine the issue. Then you have to think, if these relationships exist, are there things you can do to make them work, because I don't think as a matter of public policy that we're going to succeed in obliterating all these relationships,” Dr. Lurie said.

Amid efforts to prevent physicians from accepting small gifts, meals, and travel reimbursement from company sales representatives, the new study highlights a potentially much bigger problem.

“The bottom line is that a substantial portion of medical schools are led or influenced by people who are also obligated to have 'unyielding loyalty' to stockholders of for-profit health care corporations,” Dr. Poses said.

The study used readily accessible public data only and did not collect data on board members of smaller U.S. health care corporations, other U.S. corporations with major health care activities, corporations outside the United States, or privately held corporations. “So, our data really only give lower-bound estimates of the number of medical schools influenced or led by people who also have fiduciary duties to health care corporations that may conflict with their academic leadership obligations,” Dr. Poses said.

“At a minimum, all in academia who also serve on boards of directors for health-related for-profit corporations should fully disclose their relationships in any context in which such relationships could possibly be considered influential,” he suggested.

TORONTO – If accepting free pens or lunches from industry represents a potential conflict of interest for physicians, what do you call it when a medical school dean is also the corporate director of a large, for-profit health care company?

“An academic medical leader serving on the board of directors of a health care corporation could entail huge conflicts of interest,” Dr. Roy M. Poses said at the annual meeting of the Society of General Internal Medicine.

“Directors of a for-profit corporation have legally enforceable fiduciary responsibilities to its stockholders for the corporation's direction and financial viability, including its profitability,” said Dr. Poses, president of the Foundation for Integrity and Responsibility in Medicine, a not-for-profit educational group.

In a cross-sectional study, Dr. Poses and his colleagues scrutinized the biographies of all board members of “pure” health care companies among the Standard & Poor's (S&P) 1500. Their data came from publicly available company proxy statements, annual reports, and Web sites.

In 2005, there were 164 U.S. health care companies in the S&P 1500, and 125 U.S. medical schools. The investigators identified 198 people who served on the companies' boards of directors and had faculty or leadership positions at a medical school. Of the 125 medical schools, 65 (52%) had at least one faculty member and/or academic leader who also served on a health care corporation's board of directors. Four schools had 10 or more such individuals, and 15 schools had 5 or more.

Of the 125 medical schools, 7 reported to university presidents who also were directors of health care corporations, 11 reported to vice presidents for health affairs who were corporate directors, and 5 were lead by deans who also were health care corporate directors.

Also, 11 schools had academic medical center CEOs who were corporate directors, and 22 schools had at least one top leader who also was a director of a health care corporation.

“There are a lot of factors at play, including how aware you are of the potential conflict and how much transparency protects you from acting in a conflicted way if you are conflicted,” said Dr. Nicole Lurie, codirector for public health at the Center for Domestic and International Health Security, in an interview.

“Many physicians in practice don't perceive a conflict at all. The first thing is to open yourself up, look at yourself, and examine the issue. Then you have to think, if these relationships exist, are there things you can do to make them work, because I don't think as a matter of public policy that we're going to succeed in obliterating all these relationships,” Dr. Lurie said.

Amid efforts to prevent physicians from accepting small gifts, meals, and travel reimbursement from company sales representatives, the new study highlights a potentially much bigger problem.

“The bottom line is that a substantial portion of medical schools are led or influenced by people who are also obligated to have 'unyielding loyalty' to stockholders of for-profit health care corporations,” Dr. Poses said.

The study used readily accessible public data only and did not collect data on board members of smaller U.S. health care corporations, other U.S. corporations with major health care activities, corporations outside the United States, or privately held corporations. “So, our data really only give lower-bound estimates of the number of medical schools influenced or led by people who also have fiduciary duties to health care corporations that may conflict with their academic leadership obligations,” Dr. Poses said.

“At a minimum, all in academia who also serve on boards of directors for health-related for-profit corporations should fully disclose their relationships in any context in which such relationships could possibly be considered influential,” he suggested.

TORONTO – If accepting free pens or lunches from industry represents a potential conflict of interest for physicians, what do you call it when a medical school dean is also the corporate director of a large, for-profit health care company?

“An academic medical leader serving on the board of directors of a health care corporation could entail huge conflicts of interest,” Dr. Roy M. Poses said at the annual meeting of the Society of General Internal Medicine.

“Directors of a for-profit corporation have legally enforceable fiduciary responsibilities to its stockholders for the corporation's direction and financial viability, including its profitability,” said Dr. Poses, president of the Foundation for Integrity and Responsibility in Medicine, a not-for-profit educational group.

In a cross-sectional study, Dr. Poses and his colleagues scrutinized the biographies of all board members of “pure” health care companies among the Standard & Poor's (S&P) 1500. Their data came from publicly available company proxy statements, annual reports, and Web sites.

In 2005, there were 164 U.S. health care companies in the S&P 1500, and 125 U.S. medical schools. The investigators identified 198 people who served on the companies' boards of directors and had faculty or leadership positions at a medical school. Of the 125 medical schools, 65 (52%) had at least one faculty member and/or academic leader who also served on a health care corporation's board of directors. Four schools had 10 or more such individuals, and 15 schools had 5 or more.

Of the 125 medical schools, 7 reported to university presidents who also were directors of health care corporations, 11 reported to vice presidents for health affairs who were corporate directors, and 5 were lead by deans who also were health care corporate directors.

Also, 11 schools had academic medical center CEOs who were corporate directors, and 22 schools had at least one top leader who also was a director of a health care corporation.

“There are a lot of factors at play, including how aware you are of the potential conflict and how much transparency protects you from acting in a conflicted way if you are conflicted,” said Dr. Nicole Lurie, codirector for public health at the Center for Domestic and International Health Security, in an interview.

“Many physicians in practice don't perceive a conflict at all. The first thing is to open yourself up, look at yourself, and examine the issue. Then you have to think, if these relationships exist, are there things you can do to make them work, because I don't think as a matter of public policy that we're going to succeed in obliterating all these relationships,” Dr. Lurie said.

Amid efforts to prevent physicians from accepting small gifts, meals, and travel reimbursement from company sales representatives, the new study highlights a potentially much bigger problem.

“The bottom line is that a substantial portion of medical schools are led or influenced by people who are also obligated to have 'unyielding loyalty' to stockholders of for-profit health care corporations,” Dr. Poses said.

The study used readily accessible public data only and did not collect data on board members of smaller U.S. health care corporations, other U.S. corporations with major health care activities, corporations outside the United States, or privately held corporations. “So, our data really only give lower-bound estimates of the number of medical schools influenced or led by people who also have fiduciary duties to health care corporations that may conflict with their academic leadership obligations,” Dr. Poses said.

“At a minimum, all in academia who also serve on boards of directors for health-related for-profit corporations should fully disclose their relationships in any context in which such relationships could possibly be considered influential,” he suggested.

TORONTO — Physician practices treating higher proportions of less-educated patients have consistently lower HEDIS performance scores, according to preliminary research presented at the annual meeting of the Society of General Internal Medicine.

In fact, an increase of just one standard deviation in the proportion of non-college graduate patients is associated with a significant Health Employer Data and Information Set (HEDIS) performance score decrease of as much as 2.5%, according to the findings.

“Our concern is that practice sites caring for disproportionate shares of vulnerable patients may be penalized by public performance reporting and pay-for-performance contracts,” reported Dr. Mark Friedberg, of the division of general medicine at Brigham and Women's Hospital and Harvard School of Public Health, both in Boston.

“Without adjusting HEDIS scores for patient sociodemographic characteristics—or adjusting some aspect of the way these scores are used—physicians may feel an incentive to avoid patients from vulnerable populations,” he said.

The measurement of primary care quality for public reporting has become a hot issue in recent years, with physicians who care for minority patients and those with lower incomes worried that they may be at a disadvantage in a system with a one-size-fits-all approach to quality measurement.

Dr. Friedberg noted a recent study (Health Aff. 2007;26:w405-w414 [Epub doi:10.1377/hlthaff.26.3.w405]) that found that 85% of physicians polled agreed with the statement: “At present, measures of quality are not adequately adjusted for patients' socioeconomic status.”

Fully 82% were concerned that measuring quality may deter physicians from treating high-risk patients.

Dr. Friedberg and his colleagues used the Massachusetts Health Quality Partners (MHQP) statewide reporting program, which supplied data from commercial insurers aggregated at the physician level on eight HEDIS measures: breast cancer, cervical cancer, chlamydia, asthma controller medications, HbA_1c testing, cholesterol testing, eye exams, and nephropathy.

MHQP is a statewide collaborative that includes the five largest health plans in Massachusetts, contracting with 90% of state primary care providers and covering 63% of Massachusetts residents, or about 4 million people.

Data were collected from 241 physician practice sites (including 1,489 physicians) that provided adult primary care to insured patients during 2004.

These data were linked to patient responses from the 2002–2003 Massachusetts Ambulatory Care Experiences Survey to calculate the prevalence of sociodemographic characteristics (age, gender, race, ethnicity, and education) within each practice site's patient panel. Practice site was used as the unit of analysis.

Median site-level HEDIS scores ranged from 94% for HbA_1c screening (interquartile range, 90%–96%) to 43% for chlamydia screening in women aged 21–25 years (interquartile range 34%–52%).

In bivariate analyses, lower site-level proportions of college graduate patients were significantly associated with lower HEDIS scores on all eight measures. These associations remained statistically significant for seven of the eight measures even after multivariate adjustment.

Significant bivariate associations between sites' HEDIS scores and the age, racial, and ethnic composition of their patient panels were present for chlamydia screening, but these associations did not remain statistically significant after multivariate adjustment.

“Primary care practice sites with disproportionate shares of patients having lower educational attainment may incur a 'performance measure penalty' on widely used HEDIS quality measures,” Dr. Friedberg concluded.

TORONTO — Physician practices treating higher proportions of less-educated patients have consistently lower HEDIS performance scores, according to preliminary research presented at the annual meeting of the Society of General Internal Medicine.

In fact, an increase of just one standard deviation in the proportion of non-college graduate patients is associated with a significant Health Employer Data and Information Set (HEDIS) performance score decrease of as much as 2.5%, according to the findings.

“Our concern is that practice sites caring for disproportionate shares of vulnerable patients may be penalized by public performance reporting and pay-for-performance contracts,” reported Dr. Mark Friedberg, of the division of general medicine at Brigham and Women's Hospital and Harvard School of Public Health, both in Boston.

“Without adjusting HEDIS scores for patient sociodemographic characteristics—or adjusting some aspect of the way these scores are used—physicians may feel an incentive to avoid patients from vulnerable populations,” he said.

The measurement of primary care quality for public reporting has become a hot issue in recent years, with physicians who care for minority patients and those with lower incomes worried that they may be at a disadvantage in a system with a one-size-fits-all approach to quality measurement.

Dr. Friedberg noted a recent study (Health Aff. 2007;26:w405-w414 [Epub doi:10.1377/hlthaff.26.3.w405]) that found that 85% of physicians polled agreed with the statement: “At present, measures of quality are not adequately adjusted for patients' socioeconomic status.”

Fully 82% were concerned that measuring quality may deter physicians from treating high-risk patients.

Dr. Friedberg and his colleagues used the Massachusetts Health Quality Partners (MHQP) statewide reporting program, which supplied data from commercial insurers aggregated at the physician level on eight HEDIS measures: breast cancer, cervical cancer, chlamydia, asthma controller medications, HbA_1c testing, cholesterol testing, eye exams, and nephropathy.

MHQP is a statewide collaborative that includes the five largest health plans in Massachusetts, contracting with 90% of state primary care providers and covering 63% of Massachusetts residents, or about 4 million people.

Data were collected from 241 physician practice sites (including 1,489 physicians) that provided adult primary care to insured patients during 2004.

These data were linked to patient responses from the 2002–2003 Massachusetts Ambulatory Care Experiences Survey to calculate the prevalence of sociodemographic characteristics (age, gender, race, ethnicity, and education) within each practice site's patient panel. Practice site was used as the unit of analysis.

Median site-level HEDIS scores ranged from 94% for HbA_1c screening (interquartile range, 90%–96%) to 43% for chlamydia screening in women aged 21–25 years (interquartile range 34%–52%).

In bivariate analyses, lower site-level proportions of college graduate patients were significantly associated with lower HEDIS scores on all eight measures. These associations remained statistically significant for seven of the eight measures even after multivariate adjustment.

Significant bivariate associations between sites' HEDIS scores and the age, racial, and ethnic composition of their patient panels were present for chlamydia screening, but these associations did not remain statistically significant after multivariate adjustment.

“Primary care practice sites with disproportionate shares of patients having lower educational attainment may incur a 'performance measure penalty' on widely used HEDIS quality measures,” Dr. Friedberg concluded.

TORONTO — Physician practices treating higher proportions of less-educated patients have consistently lower HEDIS performance scores, according to preliminary research presented at the annual meeting of the Society of General Internal Medicine.

In fact, an increase of just one standard deviation in the proportion of non-college graduate patients is associated with a significant Health Employer Data and Information Set (HEDIS) performance score decrease of as much as 2.5%, according to the findings.

“Our concern is that practice sites caring for disproportionate shares of vulnerable patients may be penalized by public performance reporting and pay-for-performance contracts,” reported Dr. Mark Friedberg, of the division of general medicine at Brigham and Women's Hospital and Harvard School of Public Health, both in Boston.

“Without adjusting HEDIS scores for patient sociodemographic characteristics—or adjusting some aspect of the way these scores are used—physicians may feel an incentive to avoid patients from vulnerable populations,” he said.

The measurement of primary care quality for public reporting has become a hot issue in recent years, with physicians who care for minority patients and those with lower incomes worried that they may be at a disadvantage in a system with a one-size-fits-all approach to quality measurement.

Dr. Friedberg noted a recent study (Health Aff. 2007;26:w405-w414 [Epub doi:10.1377/hlthaff.26.3.w405]) that found that 85% of physicians polled agreed with the statement: “At present, measures of quality are not adequately adjusted for patients' socioeconomic status.”

Fully 82% were concerned that measuring quality may deter physicians from treating high-risk patients.

Dr. Friedberg and his colleagues used the Massachusetts Health Quality Partners (MHQP) statewide reporting program, which supplied data from commercial insurers aggregated at the physician level on eight HEDIS measures: breast cancer, cervical cancer, chlamydia, asthma controller medications, HbA_1c testing, cholesterol testing, eye exams, and nephropathy.

MHQP is a statewide collaborative that includes the five largest health plans in Massachusetts, contracting with 90% of state primary care providers and covering 63% of Massachusetts residents, or about 4 million people.

Data were collected from 241 physician practice sites (including 1,489 physicians) that provided adult primary care to insured patients during 2004.

These data were linked to patient responses from the 2002–2003 Massachusetts Ambulatory Care Experiences Survey to calculate the prevalence of sociodemographic characteristics (age, gender, race, ethnicity, and education) within each practice site's patient panel. Practice site was used as the unit of analysis.

Median site-level HEDIS scores ranged from 94% for HbA_1c screening (interquartile range, 90%–96%) to 43% for chlamydia screening in women aged 21–25 years (interquartile range 34%–52%).

In bivariate analyses, lower site-level proportions of college graduate patients were significantly associated with lower HEDIS scores on all eight measures. These associations remained statistically significant for seven of the eight measures even after multivariate adjustment.

Significant bivariate associations between sites' HEDIS scores and the age, racial, and ethnic composition of their patient panels were present for chlamydia screening, but these associations did not remain statistically significant after multivariate adjustment.

“Primary care practice sites with disproportionate shares of patients having lower educational attainment may incur a 'performance measure penalty' on widely used HEDIS quality measures,” Dr. Friedberg concluded.

TORONTO — Older patients with atrial fibrillation do not have worse warfarin control than do younger patients; international normalized ratio control and variability did not differ substantially in older and younger patients, Dr. Margaret C. Fang reported at the annual meeting of the Society of General Internal Medicine.

The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study was a cohort study involving 13,559 patients with nonvalvular atrial fibrillation enrolled in Kaiser Permanente of Northern California. The study was led by investigators at the University of California, San Francisco; the Kaiser Permanente Division of Research; and Massachusetts General Hospital, Boston. Patients were monitored for a median follow-up of 6 years.

Warfarin use and anticoagulation intensity were determined using validated algorithms based on warfarin prescriptions and serial outpatient INR test results. The primary outcomes were the amount of time in therapeutic INR ranges, INR variability, and median number of days between INR measurements, excluding the first 4 weeks of therapy.

At baseline, patients aged 80 years or older were significantly less likely to receive warfarin than were those younger than 80 years (43% vs. 56%), and more likely to have stroke risk factors or prior strokes.

Patients aged 80 years and older were just as likely to be in a therapeutic INR range of 2.0–3.0 as younger patients were: 64.0% of patients 80 years or older, compared with 66.0% of those younger than 80 years (adjusted odds ratio 1.0; 95% confidence interval 0.9–1.0).

There were no significant differences by age in the proportion of INRs 4.0 and above (1.86% vs. 1.80%, respectively, adjusted OR 1.0 [CI 0.7–1.4]). The median number of days between INR measurements was 21 for both older and younger patients, indicating no need for more frequent INR testing in older patients.

In discussing the limitations of her study, Dr. Fang said most of the patients were managed by organized anticoagulation clinics, so the findings may not be generalizable to other clinical settings. Because this was not a randomized trial, more adherent and easier to manage patients may have been selected, possibly leading to “overly optimistic results.”

Patients aged 80 years and older were as likely to be in a therapeutic INR range of 2.0–3.0 as were younger patients. DR. FANG

TORONTO — Older patients with atrial fibrillation do not have worse warfarin control than do younger patients; international normalized ratio control and variability did not differ substantially in older and younger patients, Dr. Margaret C. Fang reported at the annual meeting of the Society of General Internal Medicine.

The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study was a cohort study involving 13,559 patients with nonvalvular atrial fibrillation enrolled in Kaiser Permanente of Northern California. The study was led by investigators at the University of California, San Francisco; the Kaiser Permanente Division of Research; and Massachusetts General Hospital, Boston. Patients were monitored for a median follow-up of 6 years.

Warfarin use and anticoagulation intensity were determined using validated algorithms based on warfarin prescriptions and serial outpatient INR test results. The primary outcomes were the amount of time in therapeutic INR ranges, INR variability, and median number of days between INR measurements, excluding the first 4 weeks of therapy.

At baseline, patients aged 80 years or older were significantly less likely to receive warfarin than were those younger than 80 years (43% vs. 56%), and more likely to have stroke risk factors or prior strokes.

Patients aged 80 years and older were just as likely to be in a therapeutic INR range of 2.0–3.0 as younger patients were: 64.0% of patients 80 years or older, compared with 66.0% of those younger than 80 years (adjusted odds ratio 1.0; 95% confidence interval 0.9–1.0).

There were no significant differences by age in the proportion of INRs 4.0 and above (1.86% vs. 1.80%, respectively, adjusted OR 1.0 [CI 0.7–1.4]). The median number of days between INR measurements was 21 for both older and younger patients, indicating no need for more frequent INR testing in older patients.

In discussing the limitations of her study, Dr. Fang said most of the patients were managed by organized anticoagulation clinics, so the findings may not be generalizable to other clinical settings. Because this was not a randomized trial, more adherent and easier to manage patients may have been selected, possibly leading to “overly optimistic results.”

Patients aged 80 years and older were as likely to be in a therapeutic INR range of 2.0–3.0 as were younger patients. DR. FANG

TORONTO — Older patients with atrial fibrillation do not have worse warfarin control than do younger patients; international normalized ratio control and variability did not differ substantially in older and younger patients, Dr. Margaret C. Fang reported at the annual meeting of the Society of General Internal Medicine.

The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study was a cohort study involving 13,559 patients with nonvalvular atrial fibrillation enrolled in Kaiser Permanente of Northern California. The study was led by investigators at the University of California, San Francisco; the Kaiser Permanente Division of Research; and Massachusetts General Hospital, Boston. Patients were monitored for a median follow-up of 6 years.

Warfarin use and anticoagulation intensity were determined using validated algorithms based on warfarin prescriptions and serial outpatient INR test results. The primary outcomes were the amount of time in therapeutic INR ranges, INR variability, and median number of days between INR measurements, excluding the first 4 weeks of therapy.

At baseline, patients aged 80 years or older were significantly less likely to receive warfarin than were those younger than 80 years (43% vs. 56%), and more likely to have stroke risk factors or prior strokes.

Patients aged 80 years and older were just as likely to be in a therapeutic INR range of 2.0–3.0 as younger patients were: 64.0% of patients 80 years or older, compared with 66.0% of those younger than 80 years (adjusted odds ratio 1.0; 95% confidence interval 0.9–1.0).

There were no significant differences by age in the proportion of INRs 4.0 and above (1.86% vs. 1.80%, respectively, adjusted OR 1.0 [CI 0.7–1.4]). The median number of days between INR measurements was 21 for both older and younger patients, indicating no need for more frequent INR testing in older patients.

In discussing the limitations of her study, Dr. Fang said most of the patients were managed by organized anticoagulation clinics, so the findings may not be generalizable to other clinical settings. Because this was not a randomized trial, more adherent and easier to manage patients may have been selected, possibly leading to “overly optimistic results.”

Patients aged 80 years and older were as likely to be in a therapeutic INR range of 2.0–3.0 as were younger patients. DR. FANG

TORONTO — Physician practices treating higher proportions of less-educated patients have consistently lower HEDIS performance scores, according to preliminary research presented at the annual meeting of the Society of General Internal Medicine.

In fact, an increase of one standard deviation in the proportion of non-college graduate patients is associated with a significant Health Employer Data and Information Set (HEDIS) performance score decrease of as much as 2.5%.

“Our concern is that practice sites caring for disproportionate shares of vulnerable patients may be penalized by public performance reporting and pay-for-performance contracts,” reported Dr. Mark Friedberg, of the division of general medicine at Brigham and Women's Hospital and Harvard School of Public Health, both in Boston.

“Without adjusting HEDIS scores for patient sociodemographic characteristics—or adjusting some aspect of the way these scores are used—physicians may feel an incentive to avoid patients from vulnerable populations,” he said.

The measurement of primary care quality for public reporting has become a hot issue in recent years, with physicians who care for minority patients and those with lower incomes worried that they may be at a disadvantage in a system with a one-size-fits-all approach to quality measurement.

Dr. Friedberg noted a recent study (Health Aff. 2007;26:w405-w414 [Epub doi:10.1377/hlthaff.26.3.w405]) that found that 85% of physicians polled agreed with the statement: “At present, measures of quality are not adequately adjusted for patients' socioeconomic status.”

Fully 82% were concerned that measuring quality may deter physicians from treating high-risk patients.

Dr. Friedberg and his colleagues used the Massachusetts Health Quality Partners (MHQP) statewide reporting program, which supplied data from commercial insurers aggregated at the physician level on eight HEDIS measures: breast cancer, cervical cancer, chlamydia, asthma controller medications, HbA_1c testing, cholesterol testing, eye exams, and nephropathy.

MHQP is a statewide collaborative that includes the five largest health plans in Massachusetts, contracting with 90% of state primary care providers and covering 63% of Massachusetts residents, or about 4 million people.

Data were collected from 241 physician practice sites (including 1,489 physicians) that provided adult primary care to insured patients during 2004.

These data were linked to patient responses from the 2002–2003 Massachusetts Ambulatory Care Experiences Survey to calculate the prevalence of sociodemographic characteristics (age, gender, race, ethnicity, and education) within each practice site's patient panel. Practice site was used as the unit of analysis.

Median site-level HEDIS scores ranged from 94% for HbA_1c screening (interquartile range, 90%–96%) to 43% for chlamydia screening in women who were aged 21–25 years (interquartile range 34%–52%).

In bivariate analyses, lower site-level proportions of college graduate patients were significantly associated with lower HEDIS scores on all eight measures. These associations remained statistically significant for seven of the eight measures even after multivariate adjustment.

Significant bivariate associations between sites' HEDIS scores and the age, racial, and ethnic composition of their patient panels were present for chlamydia screening, but these associations did not remain statistically significant after multivariate adjustment.

“Primary care practice sites with disproportionate shares of patients having lower educational attainment may incur a 'performance measure penalty' on widely used HEDIS quality measures,” Dr. Friedberg concluded.

TORONTO — Physician practices treating higher proportions of less-educated patients have consistently lower HEDIS performance scores, according to preliminary research presented at the annual meeting of the Society of General Internal Medicine.

In fact, an increase of one standard deviation in the proportion of non-college graduate patients is associated with a significant Health Employer Data and Information Set (HEDIS) performance score decrease of as much as 2.5%.

“Our concern is that practice sites caring for disproportionate shares of vulnerable patients may be penalized by public performance reporting and pay-for-performance contracts,” reported Dr. Mark Friedberg, of the division of general medicine at Brigham and Women's Hospital and Harvard School of Public Health, both in Boston.

“Without adjusting HEDIS scores for patient sociodemographic characteristics—or adjusting some aspect of the way these scores are used—physicians may feel an incentive to avoid patients from vulnerable populations,” he said.

The measurement of primary care quality for public reporting has become a hot issue in recent years, with physicians who care for minority patients and those with lower incomes worried that they may be at a disadvantage in a system with a one-size-fits-all approach to quality measurement.

Dr. Friedberg noted a recent study (Health Aff. 2007;26:w405-w414 [Epub doi:10.1377/hlthaff.26.3.w405]) that found that 85% of physicians polled agreed with the statement: “At present, measures of quality are not adequately adjusted for patients' socioeconomic status.”

Fully 82% were concerned that measuring quality may deter physicians from treating high-risk patients.

Dr. Friedberg and his colleagues used the Massachusetts Health Quality Partners (MHQP) statewide reporting program, which supplied data from commercial insurers aggregated at the physician level on eight HEDIS measures: breast cancer, cervical cancer, chlamydia, asthma controller medications, HbA_1c testing, cholesterol testing, eye exams, and nephropathy.

MHQP is a statewide collaborative that includes the five largest health plans in Massachusetts, contracting with 90% of state primary care providers and covering 63% of Massachusetts residents, or about 4 million people.

Data were collected from 241 physician practice sites (including 1,489 physicians) that provided adult primary care to insured patients during 2004.

These data were linked to patient responses from the 2002–2003 Massachusetts Ambulatory Care Experiences Survey to calculate the prevalence of sociodemographic characteristics (age, gender, race, ethnicity, and education) within each practice site's patient panel. Practice site was used as the unit of analysis.

Median site-level HEDIS scores ranged from 94% for HbA_1c screening (interquartile range, 90%–96%) to 43% for chlamydia screening in women who were aged 21–25 years (interquartile range 34%–52%).

In bivariate analyses, lower site-level proportions of college graduate patients were significantly associated with lower HEDIS scores on all eight measures. These associations remained statistically significant for seven of the eight measures even after multivariate adjustment.

Significant bivariate associations between sites' HEDIS scores and the age, racial, and ethnic composition of their patient panels were present for chlamydia screening, but these associations did not remain statistically significant after multivariate adjustment.

“Primary care practice sites with disproportionate shares of patients having lower educational attainment may incur a 'performance measure penalty' on widely used HEDIS quality measures,” Dr. Friedberg concluded.

TORONTO — Physician practices treating higher proportions of less-educated patients have consistently lower HEDIS performance scores, according to preliminary research presented at the annual meeting of the Society of General Internal Medicine.

In fact, an increase of one standard deviation in the proportion of non-college graduate patients is associated with a significant Health Employer Data and Information Set (HEDIS) performance score decrease of as much as 2.5%.

“Our concern is that practice sites caring for disproportionate shares of vulnerable patients may be penalized by public performance reporting and pay-for-performance contracts,” reported Dr. Mark Friedberg, of the division of general medicine at Brigham and Women's Hospital and Harvard School of Public Health, both in Boston.

“Without adjusting HEDIS scores for patient sociodemographic characteristics—or adjusting some aspect of the way these scores are used—physicians may feel an incentive to avoid patients from vulnerable populations,” he said.

The measurement of primary care quality for public reporting has become a hot issue in recent years, with physicians who care for minority patients and those with lower incomes worried that they may be at a disadvantage in a system with a one-size-fits-all approach to quality measurement.

Dr. Friedberg noted a recent study (Health Aff. 2007;26:w405-w414 [Epub doi:10.1377/hlthaff.26.3.w405]) that found that 85% of physicians polled agreed with the statement: “At present, measures of quality are not adequately adjusted for patients' socioeconomic status.”

Fully 82% were concerned that measuring quality may deter physicians from treating high-risk patients.

Dr. Friedberg and his colleagues used the Massachusetts Health Quality Partners (MHQP) statewide reporting program, which supplied data from commercial insurers aggregated at the physician level on eight HEDIS measures: breast cancer, cervical cancer, chlamydia, asthma controller medications, HbA_1c testing, cholesterol testing, eye exams, and nephropathy.

MHQP is a statewide collaborative that includes the five largest health plans in Massachusetts, contracting with 90% of state primary care providers and covering 63% of Massachusetts residents, or about 4 million people.

Data were collected from 241 physician practice sites (including 1,489 physicians) that provided adult primary care to insured patients during 2004.

These data were linked to patient responses from the 2002–2003 Massachusetts Ambulatory Care Experiences Survey to calculate the prevalence of sociodemographic characteristics (age, gender, race, ethnicity, and education) within each practice site's patient panel. Practice site was used as the unit of analysis.

Median site-level HEDIS scores ranged from 94% for HbA_1c screening (interquartile range, 90%–96%) to 43% for chlamydia screening in women who were aged 21–25 years (interquartile range 34%–52%).

In bivariate analyses, lower site-level proportions of college graduate patients were significantly associated with lower HEDIS scores on all eight measures. These associations remained statistically significant for seven of the eight measures even after multivariate adjustment.

Significant bivariate associations between sites' HEDIS scores and the age, racial, and ethnic composition of their patient panels were present for chlamydia screening, but these associations did not remain statistically significant after multivariate adjustment.

“Primary care practice sites with disproportionate shares of patients having lower educational attainment may incur a 'performance measure penalty' on widely used HEDIS quality measures,” Dr. Friedberg concluded.

TORONTO — In the second year after the new Accreditation Council for Graduate Medical Education duty-hours rules became effective, mortality in patients hospitalized for four common medical conditions—acute myocardial infarction, heart failure, gastrointestinal bleeding, and stroke—were significantly reduced at more-teaching-intensive hospitals, compared with less-teaching-intensive hospitals.

This apparent survival benefit was not seen for surgical patients. No changes in mortality were seen in surgical patients during either the first or second year post reform, Dr. Kevin Volpp and his colleagues at the Philadelphia VA Medical Center and the University of Pennsylvania, Philadelphia, reported at the annual meeting of the Society of General Internal Medicine.

The Accreditation Council for Graduate Medical Education (ACGME) duty-hour reform policy went into effect in July 2003. Designed to improve patient safety, the rules limit the number of hours residents can work to 80 per week, with a minimum of 10 hours of time off between shifts.

The study cohort included all unique patients (n=320,685) admitted to acute-care VA hospitals between July 2000 and June 2005 with principal diagnoses of acute myocardial infarction (AMI), heart failure, gastrointestinal bleeding, stroke, or Diagnosis-Related Group classification of general, orthopedic, or vascular surgery.

Logistic regression analysis was used to examine the change in mortality for patients in more- versus less-teaching-intensive hospitals before and after duty-hour reform. The primary study outcome was all-cause mortality within 30 days of hospital admission.

In the first year after duty-hour reform, no significant relative changes in death rates were reported for either the medical or surgical patients. In the second year, a significant 26% reduction in mortality risk was seen at the more-teaching-intensive hospitals for patients with any of the four medical conditions. That change was predominantly driven by a highly significant 52% relative reduction in mortality risk in AMI patients.

For patients in hospitals in the 75th percentile of teaching intensity, mortality improved from prereform year 1 to postreform year 2 by 0.70 percentage points—or a relative improvement of 11.1% for medical patients—compared with patients in hospitals in the 25th percentile of teaching intensity, Dr. Volpp said.

At hospitals in the 90th percentile of teaching intensity, the improvement in mortality was even greater: about 0.88 percentage points, or a relative improvement of about 14%, compared with hospitals in the 10th percentile of teaching intensity.

Dr. Volpp noted during his presentation that the study was limited because “we don't have any information on compliance with the ACGME rules or actual number of hours worked.”

VA hospitals are the largest single site for residency training in the United States, Dr. Volpp noted. Ongoing studies are assessing mortality and other outcomes in non-VA settings, he added.

The study was funded by the VA Health Services Research and Development Service.

TORONTO — In the second year after the new Accreditation Council for Graduate Medical Education duty-hours rules became effective, mortality in patients hospitalized for four common medical conditions—acute myocardial infarction, heart failure, gastrointestinal bleeding, and stroke—were significantly reduced at more-teaching-intensive hospitals, compared with less-teaching-intensive hospitals.

This apparent survival benefit was not seen for surgical patients. No changes in mortality were seen in surgical patients during either the first or second year post reform, Dr. Kevin Volpp and his colleagues at the Philadelphia VA Medical Center and the University of Pennsylvania, Philadelphia, reported at the annual meeting of the Society of General Internal Medicine.

The Accreditation Council for Graduate Medical Education (ACGME) duty-hour reform policy went into effect in July 2003. Designed to improve patient safety, the rules limit the number of hours residents can work to 80 per week, with a minimum of 10 hours of time off between shifts.

The study cohort included all unique patients (n=320,685) admitted to acute-care VA hospitals between July 2000 and June 2005 with principal diagnoses of acute myocardial infarction (AMI), heart failure, gastrointestinal bleeding, stroke, or Diagnosis-Related Group classification of general, orthopedic, or vascular surgery.

Logistic regression analysis was used to examine the change in mortality for patients in more- versus less-teaching-intensive hospitals before and after duty-hour reform. The primary study outcome was all-cause mortality within 30 days of hospital admission.

In the first year after duty-hour reform, no significant relative changes in death rates were reported for either the medical or surgical patients. In the second year, a significant 26% reduction in mortality risk was seen at the more-teaching-intensive hospitals for patients with any of the four medical conditions. That change was predominantly driven by a highly significant 52% relative reduction in mortality risk in AMI patients.

For patients in hospitals in the 75th percentile of teaching intensity, mortality improved from prereform year 1 to postreform year 2 by 0.70 percentage points—or a relative improvement of 11.1% for medical patients—compared with patients in hospitals in the 25th percentile of teaching intensity, Dr. Volpp said.

At hospitals in the 90th percentile of teaching intensity, the improvement in mortality was even greater: about 0.88 percentage points, or a relative improvement of about 14%, compared with hospitals in the 10th percentile of teaching intensity.

Dr. Volpp noted during his presentation that the study was limited because “we don't have any information on compliance with the ACGME rules or actual number of hours worked.”

VA hospitals are the largest single site for residency training in the United States, Dr. Volpp noted. Ongoing studies are assessing mortality and other outcomes in non-VA settings, he added.

The study was funded by the VA Health Services Research and Development Service.

TORONTO — In the second year after the new Accreditation Council for Graduate Medical Education duty-hours rules became effective, mortality in patients hospitalized for four common medical conditions—acute myocardial infarction, heart failure, gastrointestinal bleeding, and stroke—were significantly reduced at more-teaching-intensive hospitals, compared with less-teaching-intensive hospitals.

This apparent survival benefit was not seen for surgical patients. No changes in mortality were seen in surgical patients during either the first or second year post reform, Dr. Kevin Volpp and his colleagues at the Philadelphia VA Medical Center and the University of Pennsylvania, Philadelphia, reported at the annual meeting of the Society of General Internal Medicine.

The Accreditation Council for Graduate Medical Education (ACGME) duty-hour reform policy went into effect in July 2003. Designed to improve patient safety, the rules limit the number of hours residents can work to 80 per week, with a minimum of 10 hours of time off between shifts.

The study cohort included all unique patients (n=320,685) admitted to acute-care VA hospitals between July 2000 and June 2005 with principal diagnoses of acute myocardial infarction (AMI), heart failure, gastrointestinal bleeding, stroke, or Diagnosis-Related Group classification of general, orthopedic, or vascular surgery.

Logistic regression analysis was used to examine the change in mortality for patients in more- versus less-teaching-intensive hospitals before and after duty-hour reform. The primary study outcome was all-cause mortality within 30 days of hospital admission.

In the first year after duty-hour reform, no significant relative changes in death rates were reported for either the medical or surgical patients. In the second year, a significant 26% reduction in mortality risk was seen at the more-teaching-intensive hospitals for patients with any of the four medical conditions. That change was predominantly driven by a highly significant 52% relative reduction in mortality risk in AMI patients.

For patients in hospitals in the 75th percentile of teaching intensity, mortality improved from prereform year 1 to postreform year 2 by 0.70 percentage points—or a relative improvement of 11.1% for medical patients—compared with patients in hospitals in the 25th percentile of teaching intensity, Dr. Volpp said.

At hospitals in the 90th percentile of teaching intensity, the improvement in mortality was even greater: about 0.88 percentage points, or a relative improvement of about 14%, compared with hospitals in the 10th percentile of teaching intensity.

Dr. Volpp noted during his presentation that the study was limited because “we don't have any information on compliance with the ACGME rules or actual number of hours worked.”

VA hospitals are the largest single site for residency training in the United States, Dr. Volpp noted. Ongoing studies are assessing mortality and other outcomes in non-VA settings, he added.

The study was funded by the VA Health Services Research and Development Service.