Medscape.com, by Robert Lowes, November 8, 2011 — The care that patients receive immediately after they are discharged from the hospital is generally the main source of large cost variations for 4 kinds of surgery, lending credence to the suggestion that costs could be reduced through bundled payments, according to a study published online today in the journal Health Affairs.

Postdischarge care was the leading cause of payment differences for hip replacement, back surgery, and colectomy, accounting for 40.7% to 85.2% of the variation, depending on the kind of surgery, write David Miller, MD, MPH, and coauthors. For coronary artery bypass grafting, postdischarge care ranked second after hospitalization as the reason for cost variation. Physician services accounted for 8.6% to 12.8% of the variation among the 4 kinds of surgery.

Dr. Miller, an assistant professor of urology at the University of Michigan Medical School, Ann Arbor, and coauthors studied Medicare claims for the 4 surgeries from January 2005 through November 2007. They tallied payments for hospital, physician, and postdischarge care from the date of admission to 30 days after discharge. Excluded from the analysis were patients enrolled in Medicare managed care plans, those younger than age 65 years or older than age 99 years, and patients not enrolled in both Part A and Part B of Medicare at the time of the procedure.

Mean Medicare payments were $20,807 for elective hip replacement, $42,194 for coronary artery bypass grafting, $26,540 for back surgery, and $26,491 for colectomy.

The researchers ranked hospitals according to total episode payments and assigned them to 5 groups, or quintiles, adjusting the results for price, differences in demographic characteristics, comorbidity, and illness severity. After this tweaking, payments for hospitals in the highest-cost quintile were still 10% to 40% higher than those for hospitals in the lowest quintile, depending on the procedure. The biggest difference dollar-wise between the top and bottom hospitals was $7759 for back surgery. The smallest difference was $2549 for colectomy.

“Hospitals that were expensive for one procedure were not necessarily expensive for all surgical services,” the authors note. “Thus it appears that variations in episode payments are specialty-specific, perhaps driven by differences in quality or practice style.”

“We Don’t Know What the Right Payment Is”

Architects of healthcare policy are curious about the kind of cost variations analyzed in the Health Affairs study because by reducing the variation, especially at the high end, they can save a lot of money. Medicare could set its rates below the current mean payment of $20,807 for hip replacement, for example, and tell hospitals and physicians in the highest-cost quintile to perform more like their counterparts in the lowest-cost quintile.

The Centers for Medicare and Medicaid Services (CMS) will attempt to reap such savings in a bundled-payment pilot project scheduled to begin next year. Under one model of the pilot project, physicians and hospitals would split a single payment — determined prospectively — for an inpatient episode, such as a hip replacement, that would include postdischarge services. The hope is that hospitals and physicians will work together more closely to coordinate a patient’s care after discharge so that the patient will not bounce back as a readmission several weeks later.

The data from the Health Affairs study, write Dr. Miller and coauthors, suggest that hospitals have “considerable room to improve their cost efficiency.” For example, they should “look for patterns of excess utilization” among surgical specialists and other specialists performing inpatient consults.

However, in an interview with Medscape Medical News, Dr. Miller cautioned that more research is needed to determine where the cost efficiencies are exactly.

“There’s nothing in the study that compares payment level and quality,” said Dr. Miller. “It doesn’t provide any inferences on whether a practice pattern is right or wrong. That’s the work we’re currently doing.

“We don’t know what the right payment is for these different surgical episodes. What we do know is that there is an unsustainable trajectory in expenditures. We need to engage in some introspection to find opportunities to save money while improving quality.”

Find Out What “Adds Value”

In an interview with Medscape Medical News, Kevin Bozic, MD, MBA, chair of the healthcare systems committee of the American Academy of Orthopaedic Surgeons, said the Health Affairs study shows that there is “significant variability in the types of resources that patients utilize.”

“Some are under the control of the physician, and some are under control of the patient,” said Dr. Bozic, an associate professor of orthopaedic surgery at the University of California, San Francisco.

Dr. Bozic, whose specialty society views bundled payments as an opportunity for surgeons, said factoring a surgery patient’s living status into discharge plans is critical for both quality of care and cost control.

“Let’s say a patient lives alone in a walk-up apartment where there is no elevator,” Dr. Bozic said. “If you can come up with a plan to get him or her up and down the stairs, and have someone provide meals, and other home services, you might be able to keep the patient out of a post–acute-care facility, which would drive up costs.”

Physicians, Dr. Bozic said, can help the cause by looking at every step of patient care to determine whether it “adds value.”

“If we routinely order a lab test, and it doesn’t change how we manage the patient, we should eliminate it,” he said. “But don’t eliminate it just on the basis of cost. You’ll end up cutting corners and impacting outcomes.”

The study was supported by the Agency for Healthcare Research and Quality and the National Institute on Aging. Coauthors John Birkmeyer, MD, and Justin Dimick, MD, have equity interests in ArborMetrix, which provides software and services for profiling hospital quality and episode cost efficiency. The authors report that the company was not involved with the study in any way.

Health Affairs. Published online November 7, 2011.

Some Probiotics Effectively Reduce Common GI Symptoms

 

Scanning electron micrograph (SEM) of Bifidobacterium bifidum. This image is from an article titled, “An Introduction to Probiotics,” from the NIH.  NCCAM Publication No. D345.Photo Credit: SciMAT/Photo Researchers, Inc.

 

 

Probiotics: live microorganisms (usually bacteria) that are similar to beneficial microorganisms found in the human gut that are taken as dietary supplements or found in foods. Most probiotics are bacteria similar to those naturally found in the intestine. Common examples are Lactobacillus and Bifidobacterium . They may occur naturally in yogurts and certain fermented foods. Probiotics have been used as treatment for various gastrointestinal conditions including irritable bowel syndrome and traveler’s diarrhea.

 

 

WebMD.com, by Sandra Yin, November 8, 2011 (National Harbor/Washington, DC) — Mounting evidence is building a strong case for the use of probiotics, or “good” bacteria, to alleviate common gastrointestinal (GI) symptoms, such as diarrhea, bloating, and inflammation, according to several studies highlighted during a press briefing here at the American College of Gastroenterology 2011 Annual Scientific Meeting and Postgraduate Course.

In one meta-analysis, researchers from the Maimonides Medical Center in Brooklyn, New York, found that in 22 studies of more than 3000 patients, probiotic prophylaxis significantly reduced the odds of developing antibiotic-associated diarrhea and Clostridium difficile–associated diarrhea by about 60%.

In another meta-analysis, researchers from Beth Israel Deaconess Medical Center and Harvard Medical School, in Boston, Massachusetts, analyzed 28 randomized controlled trials in which more than 3000 patients received a single or a combination of antibiotics for various indications. In adult and pediatric populations, the preventive effect of probiotic use was significant, regardless of the species used and regardless of the antibiotic administered.

In the largest study to date on probiotics in a nonpatient population, researchers from the University of North Carolina at Chapel Hill evaluated the efficacy of Bifidobacterium infantis 35624, a probiotic that has relieved symptoms in patients with irritable bowel syndrome, to see how well it relieved abdominal discomfort and bloating in nonpatients.

The double-blind randomized placebo controlled study involved a 2-week placebo phase followed by a 4-week intervention phase, and was conducted at 10 clinical centers in the United States. More than 300 nonpatients who had experienced abdominal discomfort and bloating more than twice weekly, on average, for at least 3 months were included in the study. They had not seen a physician or received prescribed medication for their symptoms in the previous 12 months.

In contrast to previous clinical studies of irritable bowel syndrome patients, the researchers saw no statistically significant improvement in mean severity of abdominal discomfort or bloating after the nonpatient population took B infantis 35624.

However, an Irish group found that a nonpatient population receiving B infantis 35624 experienced significantly more bloat-free days.

The researchers hypothesized that microbial imbalance could explain the increased incidence of a wide range of inflammatory disorders. To test whether altering the balance between good and bad bacteria in the gut raises the immune regulatory response, which could lower inflammation, researchers from the Alimentary Pharmabiotic Centre at University College Cork, and Alimentary Health Ltd in Cork, Ireland, conducted a double-blind placebo controlled study. Their goal was to see if B infantis affects systemic proinflammatory biomarkers in patients with inflammatory disease.

The results of their study suggest that probiotics exert antiinflammatory effects.

“By giving a specific probiotic orally, we could actually reduce the levels of these proinflammatory cytokines and actually enhance the production of an anti-inflammatory cytokine, which is the exact replication of what we identified in animal models and more basic models,” said principal investigator Eamonn Quigley, MD, FACG, professor of medicine at the National University of Ireland in Cork.

Plasma levels of the anti-inflammatory cytokine interleukin (IL)-10 rose significantly in healthy volunteers and patients with psoriasis, but not in those who took the placebo for 8 weeks.

Plasma levels of 2 proinflammatory cytokines — tumor necrosis factor-alpha and IL-6 — dropped in all patients who received B infantis. C-reactive protein levels were also significantly lower in patients with psoriasis, ulcerative colitis, and chronic fatigue after treatment with the bacterium than after treatment with placebo.

Although not everybody who takes an antibiotic should also take a probiotic, the institutionalized elderly should, to minimize the chance of getting something like antibiotic-associated diarrhea or antibiotic-associated C difficile, said Fergus Shanahan, MD, FACG, a researcher involved in the Irish B infantis 35624 study, and professor and chair of the Department of Medicine at University College Cork.

Certain subsets of patients, such as those with cystic fibrosis or chronic urinary infections, who must take recurring courses of antibiotics might benefit from taking probiotics to minimize antibiotic-associated diarrhea.

“It’s ironic that we would worry about taking an organism when we’ve got billions of organisms in the GI tract” and the amount is relatively small, Dr. Shanahan observed. Instead of worrying about drug toxicity in that population, “we’re worried about something that has vanishingly low side effects. It can’t be zero, but it is very, very low.”

“If we paid more attention to prescribing antibiotics, we wouldn’t have a lot of these problems,” added Dr. Quigley.

According to Mark Mellow, MD, FACG, director of the Digestive Health Center at INTEGRIS Baptist Medical Center in Oklahoma City, Oklahoma, physicians aren’t the only ones to blame for the indiscriminate use of antibiotics. Edicts from hospital compliance committees often establish rules that patients who come in with community-acquired pneumonia be placed on antibiotics soon after admission. These rules can have unintended consequences.

“Someone comes in with a fever and a cough and because there’s not enough time to sort it out, they get put on an antibiotic,” he said, whether or not they have a bacterial infection.

Dr. Quigley reports financial relationships with Alimentary Health, Norgine, Merck, Procter and Gamble, Movetis/Shire, Shire, Yakult, and Ironwood/Almirall. Dr. Shanahan reports a financial relationship with Alimentary Health Ltd. Dr. Mellow has disclosed no relevant financial relationships.

American College of Gastroenterology (ACG) 2011 Annual Scientific Meeting and Postgraduate Course: Abstracts P650, P120, P60, P283. Presented November 1, 2011.

NCAM

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National Center for Complementary and Alternative Medicine

 

 

Two Studies Explore the Potential Health Benefits of Probiotics

 

 

Color enhanced scanning electron micrograph (SEM) of the bacteria Lactobacillus acidophilus. A spirochete bacteria can also be seen at center.

 

 

 

Two Studies Explore the Potential Health Benefits of Probiotics
The World Health Organization defines probiotics as “live microorganisms, which when administered in adequate amounts confer a health benefit on the host.” The most common types of these beneficial bacteria are Lactobacilli and Bifidobacteria. Previous studies indicate that probiotics may have a role in treating gastrointestinal illnesses, boosting immunity, and preventing or slowing the development of certain types of cancer. In two recent NCCAM-funded studies, researchers investigated how probiotics may promote such health benefits.

Researchers at Baylor College of Medicine and M.D. Anderson Cancer Center investigated how Lactobacillus reuteri ATCC PTA 6475 might work to slow the growth of certain cancerous tumors. Their study documented the molecular mechanisms of the probiotic’s effects in human myeloid leukemia-derived cells—i.e., how it regulates the proliferation of cancer cells and promotes cancer cell death. The researchers noted that a better understanding of these effects may lead to development of probiotic-based regimens for preventing colorectal cancer and inflammatory bowel disease.

In another study, researchers at Virginia Polytechnic Institute and Ohio State University looked at whether Lactobacillus acidophilus might enhance the immune-potentiating effects of an attenuated vaccine (a vaccine prepared from a weakened live virus) against human rotavirus infection—the most common cause of severe dehydrating diarrhea in infants and children worldwide. The investigators’ tests on newborn pigs found that animals given both a vaccine and the probiotic had a better immune response than the animals given the vaccine alone. The researchers concluded that probiotics may offer a safe way to increase the effectiveness of rotavirus vaccine in humans.

In both studies, the investigators called for additional research into the mechanisms behind the health-related effects of probiotics.

By Chris Jablonski | November 8, 2011

Summary: Robotics researchers in Munich have developed a new robot face that displays realistic 3D heads on a transparent plastic mask, opening a new frontier in human-machine communication.

 

Credit: Uli Benz / Technical University of Munich

 

A team of researchers at the Institute for Cognitive Systems (ICS) at TU München have collaborated with a group in Japan to develop Mask-bot, a 3D image of a human face projected onto the backside of a plastic mask, creating very realistic features that can be seen from various angles, including the side.

“Mask-bot will influence the way in which we humans communicate with robots in the future,” predicts Prof. Gordon Cheng, head of the ICS team.

One key distinction between comparable approaches to three-dimensional heads, note the researchers, is that rather than using a front projection, Mask-bot uses an on-board rear projection to ensure a seamless face-to-face interaction. The projector uses a high-compression fish-eye lens to spread the beam to a wide angle while a macro adapter shortens the focal distance to the transparent mask roughly 4.7 inches away.

Mask-bot can create facial expressions and simple dialog. For instance, when you say “rainbow”, Mask-bot flutters its eyelids and responds with: “When the sunlight strikes raindrops in the air, they act like a prism and form a rainbow.” And when it talks, it also moves its head a little and raises its eyebrows to create a knowledgeable impression.

 

 

Is this the remote boss of the future? (Credit: Jeff Bots)

 

Mask-bot comes with additional bells and whistles. It is bright enough to function in daylight thanks to the strong projector and coating of luminous paint sprayed on the inside of the plastic mask. This aspect means that it can potentially be used in video conferencing.

“Usually, participants are shown on screen. With Mask-bot, however, you can create a realistic replica of a person that actually sits and speaks with you at the conference table. You can use a generic mask for male and female, or you can provide a custom-made mask for each person,” explains Takaaki Kuratate, creator of the Mask-bot.

Mask-bot doesn’t need a video image of the person speaking in order to work. A program converts a normal two-dimensional photograph into a correctly proportioned projection for a three-dimensional mask. Additional algorithms add in voice and facial expressions based on a motion capture system.

Finally, Mask-bot can realistically reproduce content typed via a keyboard–in English, Japanese and soon German–using a text-to-speech system. It can produce a female or male voice, which can then be set to quiet or loud, happy or sad, all at the touch of a button.

Compared to mechanical faces which require dozens of actuators and compressors to appear lifelike, Mask-bot will be able to combine expression and voice much faster. Mask-bot 2, the next generation of the prototype will see the mask, projector and computer control system all contained inside a mobile robot, say the Munich researchers. The cost for the new version will also drop from about EUR 3,000 ($4,123) to EUR 400 ($550).

Besides video conferencing, “These systems could soon be used as companions for older people who spend a lot of time on their own,” said Kuratate.

 

By Heather Clancy | November 8, 2011

Summary: United Airlines sponsors first commercial flight of a plane powered by biofuels created by Solazyme, using a Honeywell process.

United became the first commercial airline airline today to operate a passenger flight powered by a combination of biofuel and petroleum-derived diesel fuel. The split was 60 percent to 40 percent, respectively.

 

Flight 1403 from Houston to Chicago, a Boeing 737-800, comes just four months after the approval of renewable fuels for commercial usage. The biofuel used for the flight was processed by San Francisco-based Solazyme, using algae-derived oil reprocessed with technology from Honeywell. United, which is a subsidiary of United Continental Holdings, has signed a letter of intent to purchase 20 million gallons of the algae-derived fuel annually starting as early as 2014.

Said Pete McDonald, executive vice president of United and chief operations officer:

“United is taking a significant step forward to advance the use of environmentally responsible and cost-efficient alternative fuels. Sustainable biofuels, produce on a large scale at an economically viable price, can one day play a meaningful role in power everyone’s trip on an airplane.”

The plan to use Solazyme’s biofuels is part of United’s Eco-Skies sustainability program. Since 1994, the company has improved its fuel efficiency by 32 percent. Together, United and Continental already use 3,600 alternative fuel or zero emissions ground vehicles.

The new fuel used in Monday’s flight is what is referred to as “Hydroprocessed Esters and Fatty Acids” (HEFA) fuel. The Solazyme brand of this fuel is called Solajet, and it has been approved by the Federal Aviation Administration as a drop-in replacement for petroleum-based fuels. That means no engine modifications are required and no special action is required on the part of the pilots.