State-by-state breakdown of rural health clinics

From Becker’s:

Rural health clinics deliver primary care and preventive services to underserved and rural areas, and are staffed at least 50 percent of the time by nurse practitioners, physician assistants or other certified nurses.

Here is the breakdown of rural health clinics in all 50 states:

Missouri: 369
Texas: 306
California: 282
Kentucky: 250
Illinois: 241
Iowa: 190

Do Physicians Influence Each Other’s Performance?Evidence from the Emergency Department

From Harvard (pdf):

Understanding potential ways through which physicians impact each other’s performance can yield new insights into better management of hospitals’ operations. We use evidence from Emergency Medicine to study whether and how physicians who work alongside each other during same shifts affect each other’s performance. We find strong empirical evidence that physicians affect each other’s speed and quality, and scheduling diverse peers during the same shift could have a positive net impact on the operations of a hospital Emergency Department (ED). Specifically, our results show that a faster (slower) peer decreases (increases) the average speed of a focal physician compared to a same-speed peer. Similarly, a higher- (lower-) quality peer decreases (increases) a focal physician’s average quality. Furthermore, the presence of a less-experienced peer improves a focal physician’s average speed. However, in contrast to the conventional wisdom, we do not find any evidence that more-experienced physicians can affect the performance of their less-experienced peers. We investigate various mechanisms that might be the driving force behind our findings, including psychological channels such as learning, social influence, and homophily as well as resource spillover. We identify resource spillover as the main driver of the effects we observe and show that, under high ED volumes (i.e., when the shared resources are most constrained), the magnitude of the observed effects increases. While some of these observed effects tend to be long-lived, we find that their magnitudes are fairly heterogeneous among physicians. In particular, our results show that newly-hired and/or high-performing physicians are typically more influenced than others by their peers. Finally, we draw conclusions from our results and discuss how they can be utilized by hospital administrators to improve the overall performance of physicians via better scheduling patterns and/or training programs that require physicians to work during same shifts

Clinical Transformation Through Change Management Case Study: Chest Pain in the Emergency Department

From the Lancet:


Adults with chest pain presenting to an emergency department are high-risk and high-volume. A methodology which gathers practicing physicians together to review evidence and share practice experience to formulate a written algorithm with key decision points and measures is discussed with implementation, based on change management principles, and results.


A methodology was followed to “establish the standard-of-care”. Literature and data were reviewed, a written consensus algorithm was designed with ability to track adherence and deviations. We performed a before and after analysis of a performance improvement intervention in adult patients with undifferentiated chest pain in our nine-campus hospital system in Florida between January 1st, 2014 and December 31st, 2018.


A total of 200,691 patients were identified as adults with chest pain and the algorithm was used. A dramatic change in the disposition decision rate was noted. When the ‘Baseline-Year’ was compared with the ‘Performance-Year’, chest pain patients discharged from the ED increased by 99%, those going to the ‘Observation’ status decreased by 20%, and inpatient admissions decreased by 63% (p < 0.0001) All patients were tracked for 30-days for major adverse cardiac event (MACE) or return to the ED within the same system. If the s emergency physicians had not changed their practice/behavior and the Baseline-Year decision rate during the entire Performance-Year was unchanged, then 4563 more patients would have gone to Observation and 7986 patients to Inpatient. The opportunity costs avoided would be approximately $31million (US$.


For successful clinical transformation through change management, we learned: select strategic topics, get active physicians together, write a consensus algorithm with freedom to deviate, identify and remove barriers, communicate vision, pilot with feedback, implement, sustain by “hard wiring” into the electronic medical record and measure outputs.

Involuntary patient length-of-stay at a suburban emergency department

From the American Journal of Emergency Medicine:


Patients who may be a danger to themselves or others often are placed on involuntary hold status in the Emergency Department (ED). Our primary objective was to determine if there are demographic and/or clinical variables of involuntary hold patients which were associated with an increased ED LOS.


Records of ED patients evaluated while on involuntary hold from January 1, 2014 through November 30, 2015 at a suburban acute-care hospital ED were reviewed. Data collected included demographics information, LOS, suicidal or homicidal ideation, suicide attempt, blood alcohol concentration (BAC), urine drug test (UDT), psychiatric disorder, substance use, medical illness, violence in the ED, and hospital admission. Linear regression based on the log of LOS was used to identify factors associated with increased LOS.


Two-hundred and fifty-one patients were included in the study. ED LOS (median) was 6 h (1, 49). Linear regression analysis showed increased LOS was associated with BAC (p = 0.05), urine drug test (UDT) (p = 0.05) and UDT positive for barbiturates (p = 0.01). There was no significant difference in ED LOS with respect to age, gender, housing, psychiatric diagnosis, suicidal or homicidal ideation, suicide attempt, violence, medical diagnosis, or admission status.


Involuntary hold patients had an increased ED LOS associated with alcohol use, urine drug test screening, and barbiturate use. Protocol development to help stream-line ED evaluation of alcohol and drug use may improve ED LOS in this patient population.

Women in cardiac arrest less likely than men to get help from bystanders

From Reuters:

Women who suffer cardiac arrest outside of a hospital are less likely to receive help from bystanders and have less chance of survival than men, a recent Dutch study showed.

The results align with what a separate study found in the United States last year: men had an increased likelihood of receiving bystander support and greater chances of survival than women.

For the new study, conducted in a province in The Netherlands, Dr. Hanno Tan at the University of Amsterdam and colleagues looked at data on more than 5,700 people who had cardiac arrests in the community. All were treated by the local emergency medical services (EMS) – but before EMS arrived on the scene, only about 68 percent of women had received resuscitation attempts by bystanders, compared to about 73 percent of men.

Medical Cannabidiol Board Report

From the Iowa Osteopathic Medical Association

By Jacqueline Stoken, D.O.

The Iowa Medical Cannabidiol Advisory Board had an urgent meeting on April 16, 2019 to discuss HF 732. The Board had made recommendations to the legislature including the limits of amounts

of THC to be contained in the CBD products. While the legislature accepted some of our recommendations, they did not accept our limits of THC. The bill came out of the House with

limits of 25 gm/90days that could be purchased by the patient.

After review and a thorough discussion of the medical literature, the Board made the following recommendations:

  1. Eliminate the 3% THC cap on medical cannabidiol products currently codified in Iowa Code section 124E.2.

  2. Establish a THC purchase limit for patients of 4.5 G (4,500 mg) THC every 90 days. This is 50 mg/d of THC which is well into the psychoactive range for all but the most experienced and tolerant patients. This covers the full range of doses supported in the medical literature for Iowa’s approved debilitating medical conditions. (Note – the average amount of THC estimated in a marijuana joint is @ 20mg.)

  3. For Pediatric patients under 18 years of age, limit access to THC by allowing pediatric patients to only purchase products with a 20:1 ratio of CBD:THC, and establish a maximum CBD dose for pediatric patients of 10 mg CBD/kg (weight of patient)/d.

However, the Senate passed HF 732 allowing the 90-day limit of THC to be 25 gm. (25 grams of THC as a 90-day limit was startling to me and every provider I have encountered. 25 grams is 25,000 milligrams (mg))

As you can imagine, we are all upset by this. This is 5.6X the safe limits that we had recommended. The legislature is now referring to CBD/THC as a medicine/drug. Note that it is out of our hands in how much to recommend as all that our duty, if we choose, is to certify the allowed condition of the patient. The person who works at the dispensary will be recommending the dose, route and frequency of use to the patient. The person who works at the dispensary is not required to be a medical professional but is to have minimum amount of training done by the distributor.

As physicians, we are concerned of serious side effects of large dose of CBD/THC which include but are not limited to cannabinoid hyperemesis syndrome (CHS) and psychosis. THC can also cause brain damage when used chronically.

The Board member take its advisory role seriously. Please contact me at or the Iowa Department of Public Health, Office of Medical Cannabidiol, if you have any questions.

What your hospital knows about you

From Axios:

Every trip to a doctor’s office or hospital adds more information to a deep, comprehensive record of who you are — physically, emotionally and even financially.

Why it matters: Health care data breaches are more common than ever, putting our most sensitive personal information at risk of exposure and misuse.

Senate committee unveils sweeping healthcare bill package

From Modern Healthcare:

On the most visible level, this package is the Senate vehicle for the much debated ban on surprise medical bills. However, this discussion draft doesn’t settle the contentious question of how Congress should implement the ban and instead posits three ideas that the committee still needs to decide upon.

The first option would require a hospital to guarantee patients that, for practical purposes, all its physicians are in-network. To make good on this guarantee, physicians could either contract with the hospital’s insurers or stay out of network but submit their charges through the hospital so the insurer gets only one bill and the hospital has to incorporate the doctor’s fee. Specialists and those that employ them have opposed this idea.

Under the second option, insurers, hospitals or physicians could choose arbitration to resolve disputed charges higher than $750, and the arbiter would have to look at median insurer-negotiated rates from the same geographical area as a guideline.

The third option is identical to the proposal the House Energy and Commerce Committee offered last week: An insurer would pay the surprise bill at the median contracted rate for that region to the hospital or doctor in question.

There’s no clear way to fix surprise medical bills

From Axios:

Solving surprise billing isn’t just about protecting the patients who receive those bills. It’s also about addressing market distortions that drive up premiums.

  • Threatening to leave an insurer’s network gives providers more leverage to negotiate higher rates, experts say, driving up costs across the board.
  • “The problem is that we’ve allowed these specialties to engage in behavior that has so distorted the market that correcting it is rather salient for those folks,” the American Enterprise Institute’s Ben Ippolito said.

How Great Nursing Improves Doctors’ Performance

From the Harvard Business Review:

In our research, we looked at the association  between superior nursing (as indicated by Magnet status) and hospital scores on the national HCAHPS patient satisfaction survey as well as within Press Ganey’s database of over 2,000 health care organizations. HCAHPS gathers patients’ feedback on many aspects of their hospital experience from the hospital environment, quality of the food, and staff responsiveness to how well doctors and nurses communicate with them (Do they listen? Are they respectful? Do they explain things well?).  The survey also asks for an overall rating of the hospital. Ratings are often expressed in terms of the “top box” score — the percentage of patients who give the hospital a superior score on a given measure. We found that Magnet hospitals outperformed the non-magnet hospitals on patients’ “likelihood to recommend” top box scores (75.7 compared to 70.8) and we saw a similar spread on the “overall rating score” (76.0 vs. 72.8). We also saw a smaller but significant difference on patient assessment of physician concern about the patient’s questions or worries, which gauges courtesy and respect, listening, and explaining.

Press Ganey’s proprietary survey also revealed a meaningful association between Magnet status and higher patient ratings of physicians’ skill, response to concerns, time spent with the patient, friendliness and courtesy and other measures.  Mean scores for Magnet facilities ranged from 84.6 for “time physician spent with you” to 93.2 for “skill of the physician” while mean scores for non-Magnet facilities ranged from 83.6 to 92.1 for the same questions. These may appear to be subtle differences but they are meaningful. Even a few points change in mean score has a dramatic effect on the percentile rank due the tight compression of scores nationally; for example, an increase of just two points on a mean score (from, say about 88 to 90) can mean the difference between being in the 50th percentile versus the 75th.