Reimbursement for Emergency Department Electrocardiography and Radiograph Interpretations: What Is It Worth for the Emergency Physician

Background: Physician reimbursement laws for diagnostic interpretive services require that only those services provided contemporaneously and /or contribute directly to patient care can be billed for. Despite these regulations, cardiologists and radiologists in many hospitals continue to bill for ECG and plain film diagnostic services performed in the emergency department (ED). The reimbursement value of this care, which is disconnected in time and place from the ED patient encounter, is unknown. In a California community ED with a 32,000 annual census, the emergency physicians (EPs) alone, by contract, bill for all ECG readings and plain film interpretations when the radiologists are not available to provide contemporaneous readings.Objectives: To determine the impact of this billing practice on actual EP reimbursement we undertook an analysis that allows calculation of physician reimbursement from billing data.Methods: An IRB-approved analysis of 12 months of billing data cleansed of all patient identifiers was undertaken for 2003. From the data we created a descriptive study with itemized breakdown of reimbursement for radiograph and ECG interpretive services (procedures) and the gross resultant physician income.Results: In 2003 EPs at this hospital treated patients during 32,690 ED visits. Total group income in 2003 for radiographs was $173,555 and$91,025 for ECGs, or $19/EP hour and$6/EP hour respectively. For the average full-time EP, the combined total is $2537/month or$30,444 per annum, per EP. This is $8/ED visit (averaged across all patients).Conclusion: As EP-reimbursement is challenged by rising malpractice premiums, uninsured patients, HMO contracts, unfunded government mandates and state budgetary shortfalls, EPs are seeking to preserve their patient services and resultant income. They should also be reimbursed for those services and the liability that they incur. The reimbursement value of ECGs and plain film interpretations to the practicing EP is substantial. In the ED studied, it represents$30,444 gross income per full-time EP annually. Plain film interpretation services produce three times the hourly revenue of ECG reading at the hospital studied.[WestJEM. 2009;10:178-183.

Prevalence of pain and its associated factors among the oldest-olds in different care settings – results of the AgeQualiDe study

Background; The prevalence of pain is very common in the oldest age group. Managing pain successfully is a key topic in primary care, especially within the ageing population. Different care settings might have an impact on the prevalence of pain and everyday life. Methods: Participants from the German longitudinal cohort study on Needs, Health Service Use, Costs and Health-related Quality of Life in a large Sample of Oldest-old Primary Care Patients (85+) (AgeQualiDe) were asked to rate their severity of pain as well as the impairment with daily activities. Besides gender, age, education, BMI and use of analgesics we focused on the current housing situation and on cognitive state. Associations of the dependent measures were tested using four ordinal logistic regression models. Model 1 and 4 consisted of the overall sample, model 2 and 3 were divided according to no cognitive impairment (NCI) and mild cognitive impairment (MCI). Results: Results show a decline in pain at very old age but nonetheless a high prevalence among the 85+ year olds. Sixty-three per cent of the participants report mild to severe pain and 69% of the participants mild to extreme impairment due to pain with daily activities. Use of analgesics, depression and living at home with care support are significantly associated with higher and male gender with lower pain ratings. Conclusions: Sufficient pain management among the oldest age group is inevitable. Outpatient care settings are at risk of overlooking pain. Therefore focus should be set on pain management in these settings

Post-intervention Status in Patients With Refractory Myasthenia Gravis Treated With Eculizumab During REGAIN and Its Open-Label Extension

OBJECTIVE: To evaluate whether eculizumab helps patients with anti-acetylcholine receptor-positive (AChR+) refractory generalized myasthenia gravis (gMG) achieve the Myasthenia Gravis Foundation of America (MGFA) post-intervention status of minimal manifestations (MM), we assessed patients' status throughout REGAIN (Safety and Efficacy of Eculizumab in AChR+ Refractory Generalized Myasthenia Gravis) and its open-label extension. METHODS: Patients who completed the REGAIN randomized controlled trial and continued into the open-label extension were included in this tertiary endpoint analysis. Patients were assessed for the MGFA post-intervention status of improved, unchanged, worse, MM, and pharmacologic remission at defined time points during REGAIN and through week 130 of the open-label study. RESULTS: A total of 117 patients completed REGAIN and continued into the open-label study (eculizumab/eculizumab: 56; placebo/eculizumab: 61). At week 26 of REGAIN, more eculizumab-treated patients than placebo-treated patients achieved a status of improved (60.7% vs 41.7%) or MM (25.0% vs 13.3%; common OR: 2.3; 95% CI: 1.1-4.5). After 130 weeks of eculizumab treatment, 88.0% of patients achieved improved status and 57.3% of patients achieved MM status. The safety profile of eculizumab was consistent with its known profile and no new safety signals were detected. CONCLUSION: Eculizumab led to rapid and sustained achievement of MM in patients with AChR+ refractory gMG. These findings support the use of eculizumab in this previously difficult-to-treat patient population. CLINICALTRIALSGOV IDENTIFIER: REGAIN, NCT01997229; REGAIN open-label extension, NCT02301624. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that, after 26 weeks of eculizumab treatment, 25.0% of adults with AChR+ refractory gMG achieved MM, compared with 13.3% who received placebo

Minimal Symptom Expression' in Patients With Acetylcholine Receptor Antibody-Positive Refractory Generalized Myasthenia Gravis Treated With Eculizumab

The efficacy and tolerability of eculizumab were assessed in REGAIN, a 26-week, phase 3, randomized, double-blind, placebo-controlled study in anti-acetylcholine receptor antibody-positive (AChR+) refractory generalized myasthenia gravis (gMG), and its open-label extension

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

The Sound of Lost Homes – Introducing the COVER Model – Theoretical Framework and Practical Insight into Music Therapy With Refugees and Asylum Seekers

El sonido de las casas perdidas - Presentación del modelo COVER - Marco teórico y conocimiento práctico de la musicoterapia con refugiados y solicitantes de asilo Resumen Debido a la difícil situación de los refugiados, trabajar con este grupo es un desafío. Sin embargo, la musicoterapia es un método adecuado para la intervención terapéutica temprana. Los autores presentan el modelo de clasificación sensible al contexto para las intervenciones musicoterapéuticas con refugiados, modelo COVER, que se basa en experiencias musicales terapéuticas prácticas utilizando un enfoque basado en el trauma con refugiados en Alemania. El modelo COVER puede servir como guía para los musicoterapeutas que trabajan con refugiados en circunstancias inseguras. El modelo COVER aplica intervenciones musicoterapéuticas al entorno natural de vida de los refugiados y permite intervenciones tempranas que pueden ser un beneficio crucial para la salud psicológica de los refugiados y musicoterapeutas que trabajan en esta área.Il suono delle case perdute – Presentazione del modello COVER – Quadro teorico e approfondimento pratico sulla musicoterapia con rifugiati e richiedenti asilo &nbsp;Abstract &nbsp;A causa della difficile situazione dei rifugiati, lavorare con questo gruppo è impegnativo. Tuttavia, la musicoterapia è un metodo adatto per un intervento terapeutico precoce. Gli autori presentano il modello di classificazione sensibile al contesto per interventi musicoterapici con i rifugiati, il modello COVER, il quale si basa su pratiche ed esperienze musicoterapiche che utilizzano un approccio di informazione sul trauma con i rifugiati in Germania. Il modello COVER può servire come linea guida per i musicoterapisti che lavorano con i rifugiati in circostanze insicure. Questo modello applica interventi musicoterapici all'ambiente di vita naturale dei rifugiati, consentendo interventi precoci che possono essere un beneficio cruciale per la salute psicologica sia dei rifugiati, sia dei musicoterapisti che lavorano in quest'area.Due to the difficult situation of refugees, working with this group is challenging. Yet, music therapy is a suitable method for early therapeutic intervention. The authors introduce the context-sensitive classification model for music therapeutic interventions with refugees—COVER model— which is based on practical music therapeutic experiences using a trauma-informed approach with refugees in Germany. The COVER model can serve as a guideline for music therapists who work with refugees in insecure circumstances. The COVER model applies music therapeutic interventions to the natural living environment of refugees and allows for early interventions which may be a crucial benefit to the psychological health of refugees and music therapists working in this area.Der Klang der verlassenen Heimat - Einführung in das COVER-Modell - Theoretischer Rahmen und praktischer Einblick in die Musiktherapie mit Flüchtlingen und Asylbewerbern Abstract Aufgrund ihrer schwierigen Situation stellt die Arbeit mit Flüchtlingen oft eine Herausforderung dar. Dennoch zeigt sich Musiktherapie eine geeignete Methode zur frühen therapeutischen Intervention. Die Autor:innen stellen das COVER-Modell als kontextorientiertes Klassifikationsmodell für musiktherapeutische Arbeit mit Flüchtlingen vor. Es basiert auf praktischen musiktherapeutischen Erfahrungen mit einem traumatherapeutischen Ansatz mit Flüchtlingen in Deutschland. Das COVER-Modell kann als Leitfaden für Musiktherapeuten dienen, die mit Flüchtlingen in unsicheren Verhältnissen arbeiten. Es wendet musiktherapeutische Interventionen direkt auf das natürliche Lebensumfeld von Flüchtlingen an und ermöglicht frühzeitige Interventionen, die sowohl für die psychische Gesundheit von Flüchtlingen und auch für die Musiktherapeut:innen, die in diesem Bereich arbeiten, von entscheidendem Nutzen sein können.《失去家园的声音》——介绍COVER模式——针对难民和避难者的音乐治疗理论框架和实践见解 摘要 由于难民的困难处境，与这一类群体工作是具有挑战性的。然而，音乐治疗是一种适合于早期治疗干预的方法。作者介绍了针对难民的音乐治疗干预的上下文敏感分类模型 —COVER模型— 基于实际的音乐治疗经验，对德国难民采用创伤知情的方法。COVER模型可以作为音乐治疗师如何在不安全的的情况下为难民工作的指引。COVER模型将音乐治疗干预应用于难民的自然生活环境，并允许早期干预，这可能对该地区的难民和在这一领域工作的音乐治疗师的心理健康带来至关重要的益处。 &nbsp

Reimbursement for Emergency Department Electrocardiography and Radiograph Interpretations: What Is It Worth for the Emergency Physician

Background: Physician reimbursement laws for diagnostic interpretive services require that only those services provided contemporaneously and /or contribute directly to patient care can be billed for. Despite these regulations, cardiologists and radiologists in many hospitals continue to bill for ECG and plain film diagnostic services performed in the emergency department (ED). The reimbursement value of this care, which is disconnected in time and place from the ED patient encounter, is unknown. In a California community ED with a 32,000 annual census, the emergency physicians (EPs) alone, by contract, bill for all ECG readings and plain film interpretations when the radiologists are not available to provide contemporaneous readings.Objectives: To determine the impact of this billing practice on actual EP reimbursement we undertook an analysis that allows calculation of physician reimbursement from billing data.Methods: An IRB-approved analysis of 12 months of billing data cleansed of all patient identifiers was undertaken for 2003. From the data we created a descriptive study with itemized breakdown of reimbursement for radiograph and ECG interpretive services (procedures) and the gross resultant physician income.Results: In 2003 EPs at this hospital treated patients during 32,690 ED visits. Total group income in 2003 for radiographs was $173,555 and$91,025 for ECGs, or $19/EP hour and$6/EP hour respectively. For the average full-time EP, the combined total is $2537/month or$30,444 per annum, per EP. This is $8/ED visit (averaged across all patients).Conclusion: As EP-reimbursement is challenged by rising malpractice premiums, uninsured patients, HMO contracts, unfunded government mandates and state budgetary shortfalls, EPs are seeking to preserve their patient services and resultant income. They should also be reimbursed for those services and the liability that they incur. The reimbursement value of ECGs and plain film interpretations to the practicing EP is substantial. In the ED studied, it represents$30,444 gross income per full-time EP annually. Plain film interpretation services produce three times the hourly revenue of ECG reading at the hospital studied.[WestJEM. 2009;10:178-183.

Development of a patient assessment to meet the needs of patients suffering from advanced non-oncological diseases – the KOPAL study

Background To develop an aide memoire for patients diagnosed with advanced non-oncological chronic diseases, the KOPAL conversation guide, to foster interprofessional counselling between GPs and specialist palliative home care teams. Methods As part of the multi-centre, two-arm, cluster randomised controlled KOPAL study, the draft of the conversation guide was discussed and consented in three focus groups with 4 patients, 7 health care providers, and 5 stakeholders. Results The final version of the KOPAL conversation guide contains eight key topics: living with the illness, physical situation, emotional situation, personal situation, social situation, information and communication, control and autonomy, emergency management. Each topic refers to different general points, which are listed on top of the respective thematic section. The conversation should start by addressing the patient’s today’s well-being and end by asking for the patient’s main topic based on the discussed issues. Conclusions The KOPAL conversation guide is a broad evaluation and communication tool that covers potential palliative care (PC) needs of non-oncological patients and provides a basis for interprofessional case planning and counselling. Applying the KOPAL conversation guide may help to bridge the communicative gap between general and specialist PC professionals and between professionals and patients

Entwicklung eines Gesprächsleitfadens zur Beurteilung palliativer Versorgungsbedarfe bei Patient*innen mit nicht-onkologischen chronischen Erkrankungen im Rahmen der KOPAL-Studie

Marx G, Pohontsch NJ, Mallon T, et al. Entwicklung eines Gesprächsleitfadens zur Beurteilung palliativer Versorgungsbedarfe bei Patient*innen mit nicht-onkologischen chronischen Erkrankungen im Rahmen der KOPAL-Studie

Medical centres for the homeless in Hamburg – consultation reasons and diagnoses compared to primary care patients in the regular health care system

Abstract Background In Germany, homeless people are entitled to health care within the regular health care system. However, due to their specific living conditions they make little use of these services. In 2013, three Medical centres for the homeless (MCH) were opened in Hamburg to provide general health care. This study aims to analyse the consultation reasons and diagnoses prevalent among the homeless in comparison to regular primary care patients. It also examines the means and obstacles of integrating the homeless into Germany’s regular health care system. Methods From 2013 to 2014, routine medical data of all patients of the MCH consenting to participate in the study were analysed descriptively, in particular consultation reasons (categorised by ICPC-2), ICD-10 diagnoses and data on health insurance status and the use of the regular health care system. Consultation reasons and diagnoses of homeless patients were compared descriptively with data from regular general practices. Additionally, anonymous data on patient numbers, gender and insurance status was exported from the MCH’s software and analysed descriptively for the years 2013 to 2020. Results A total of 840 homeless patients in 2013 and 2014 gave consent to the evaluation of consultation reasons and diagnoses. The most frequent consultation reasons in the MCH in 2013 were skin conditions (24%), musculoskeletal conditions (16%) and psychological disorders (14%), in GP practices these were musculoskeletal conditions (22%), conditions affecting the digestive system (14%) and skin conditions (12%). Essential (primary) hypertension, diabetes mellitus type 2 and back pain are among the top-10-diagnoses in GP practices, as well as in MCH. With regard to the other top-10-diagnoses, there are clear differences between GP practices and MCH: “Psychological behavioural disorder due to alcohol” and diagnoses in connection with trauma, skin infections and acute respiratory infections stand out in MCH. 35% of the homeless patients reported a lack of health insurance as the reason for “not making use of” the regular health care system, while 10% reported they were unable to visit a regular general practitioner due to physical or psychological reasons. In the years 2013–2020 46% to 73% of the 8.380 MCH patients had no health care insurance. Conclusion Patients consulting the MCH suffer from medical conditions typical for the homeless, namely skin diseases, wounds, injuries and behavioural disorders due to alcohol abuse, but also from “typical” symptoms in regular GP care as cough or lower back symptoms. Consultation reasons mostly are acute illnesses. Chronic diseases are equally present in regular GP and MCH patients, but pose a great challenge for the homeless among other things due to their irregular contact with the health care system. The lack of health insurance poses the greatest hurdle to the integration of the homeless into the regular health care system