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AAOS Now

Published 10/1/2013

Second Look - Advocacy

FDA announces Beacon Hill Medical Pharmacy/Rxtra Solutions recall
The U.S. Food and Drug Administration (FDA) has notified health professionals and consumers of the recall of all lots of certain sterile injectable products compounded by Beacon Hill Medical Pharmacy/Rxtra Solutions. The list of recalled products includes methylprednisolone acetate, buprenorphine, and others. The FDA has raised a question of sterility assurance for the affected products, which were distributed nationwide. The products can be identified by lot numbers 01012013@1 to 07262013@99.

FDA issues warning on NuVision Pharmacy of Dallas products
The FDA stated that healthcare providers should not administer any sterile drug products made and distributed by NuVision Pharmacy of Dallas, Texas, because the products’ sterility is not ensured. An FDA notice on May 18, 2013, recommended that NuVision Pharmacy sterile products be quarantined and not administered to patients. The FDA lacks the authority to require the company to recall the products, and the agency states that NuVision has repeatedly refused to do so voluntarily.

Occupational injuries among orthopaedic surgeons
According to findings in the Journal of Bone & Joint Surgery (Aug. 7), many orthopaedic surgeons sustain occupational injuries during their careers. The survey of 140 surgeons from a variety of orthopaedic specialties found that 44 percent (n = 61) of respondents reported sustaining at least one workplace injury. A significant association was found between years performing surgery and prevalence of injury, with surgeons who had worked between 21 and 30 years reporting the most injuries. Overall, 25 percent of respondents reported sustaining an injury to the hand; 19 percent, to the lower back; 10 percent, to the neck; 7 percent, to the shoulder; and 6 percent, to another area. In addition, 14 (10 percent) of all surgeons reported missing work as a result of a workplace injury, and 5 (4 percent) missed at least 3 weeks. Finally, 23 surgeons (38 percent of injured respondents) reported that no institutional resources were available to support their recovery from the injury.

Impact of reference-pricing insurance system
A study in Health Affairs (August) suggested that implementation of a reference-pricing insurance system, which establishes limits on the amount an employer will pay for certain procedures and makes the employee responsible for any overage, may encourage patients to select lower-priced facilities and indirectly encourage higher-priced facilities to reduce prices to increase patient volume. An evaluation of the impact of reference pricing on the use of and the prices paid for knee and hip arthroplasty surgery by members of the California Public Employees’ Retirement System (CalPERS) between 2008 and 2012 found that, compared to enrollees in a private plan, surgical volumes for CalPERS members increased by 21.2 percent at lower-priced facilities and decreased by 34.3 percent at higher-priced facilities. In addition, the prices charged to CalPERS members declined by 5.6 percent at lower-priced facilities and by 34.3 percent at higher-priced facilities.

Shadowing programs for medical students
A study published online in JAMA Surgery suggested that implementation of a voluntary overnight shadowing program may improve medical students’ perceptions of trauma surgery and increase their likelihood of applying to a surgical residency. The authors instituted a voluntary trauma call program to expose students to the field. After 3 years, 68 of 126 participants completed a survey about their experience. Interest in trauma surgery among students not previously planning on a career in surgery improved after participation. Surgical experience, exposure to a higher number of trauma cases, and time with residents were associated with increased interest in trauma surgery, and witnessing patient death for the first time was associated with decreased interest in trauma surgery.

Medical groups support IOAS exemptions
A number of medical organizations have voiced their opposition to the Promoting Integrity in Medicare Act (HR 2914), which would, if enacted, remove many exemptions for in-office ancillary services (IOAS) under the Stark Law. In a letter to all members of Congress, more than 30 national medical organizations—including the American Association of Orthopaedic Surgeons (AAOS) and the American Medical Association—argue that the Stark Law exemptions encourage care coordination and that removing those exemptions would create barriers to more integrated care delivery. The legislation was proposed after a recent Government Accountability Office report that suggested that the use of advanced imaging services, expensive prostate cancer radiation therapy, and certain anatomic pathology services greatly increased after some physicians began to self-refer.

Impact of resident work-hour limits
Two studies in the Journal of General Internal Medicine (August) examine the effect of resident work-hour restrictions, and find no increase in patient mortality, but do note a reduction in time spent caring for patients. The first study—an observational study of 13,678,956 Medicare patients admitted to short-term, acute care, nonfederal hospitals from July 1, 2000, through June 30, 2008—found that duty-hour reform was associated with no significant change in mortality in the early years after implementation of work-hour limits in 2003, with a trend toward improved mortality among medical patients in the fourth and fifth years after implementation.

The second study—a descriptive, observational study on inpatient ward rotations at two internal medicine residency programs during January 2012—found that interns spent a minority of time directly caring for patients and, compared against time-motion studies of interns conducted prior to 2003, interns now spend less time in direct patient care and sleeping, and more time talking with other providers and documenting.

Access to care for Medicare beneficiaries
Data presented in an issue brief released by the U.S. Department of Health and Human Services (HHS) suggest that access to care among Medicare beneficiaries has been and continues to remain relatively high. The report finds that about 90 percent of all office-based physicians report accepting new Medicare patients, and the share of physicians who accept new Medicare patients has remained relatively stable from 2005 through 2012. HHS reports that the total number of providers participating in and billing Medicare has increased overall since 2007. An increase in the number of providers who have chosen to opt out of Medicare appears to have been mitigated by an increase in the share of other physicians accepting new Medicare patients.

Physician confidence and diagnostic accuracy
Data from a study published online in JAMA Internal Medicine suggest that physician confidence levels may not be linked with diagnostic accuracy or case difficulty. The authors asked 118 general internists to diagnose four previously validated case vignettes of variable difficulty. The participants correctly diagnosed the two easier cases 55.3 percent of the time but were correct just 5.8 percent of the time with regard to the two more difficult cases. Despite the large difference in diagnostic accuracy, “the difference in confidence was relatively small […] and likely clinically insignificant.” Higher confidence was related to decreased requests for additional diagnostic tests, while higher case difficulty was related to more requests for additional reference materials.

Payment inequities continue
Research published online in JAMA Internal Medicine suggests that female physicians currently earn less than male physicians. Based on data from the Current Population Survey—a nationally representative survey conducted between 1987 and 2010—earning gaps among non-healthcare workers reduced over time, but that was not the case for physicians and certain other healthcare professionals. Female physicians had a median annual income of $165,278 from 2006 to 2010, compared to $221,297 for male physicians. The data do not differentiate between practice types, which could account for some of the pay differences.

These items originally appeared in AAOS Headline News Now, a thrice-weekly enewsletter that keeps AAOS members up to date on clinical, socioeconomic, and political issues, with links to more detailed information. Subscribe at www.aaos.org/news/news.asp (member login required)