By Sandra G. Boodman
This story was produced in collaboration with 

Nights and weekends in hospitals can mean contending with the sparse staffing and slowed pace that can delay a response. Studies of hospitalized patients have found higher rates of errors and poorer outcomes for those treated at night or on the weekend compared with the day shift.

Here are some suggestions offered by experts to help patients and families protect themselves:

• Ask if the hospital employs hospitalists or nocturnists, doctors who specialize in treating inpatients. Check to see if a fully experienced physician, not just a resident, is on duty and at the hospital at night outside of the emergency room.

• If there is no experienced doctor on duty, ask how problems at night will be handled.

• Keep after-hours contact information for your doctor. While the doctor may not see you in the hospital, a call from him r her can expedite a response.

• Make sure to have an advocate present, especially the first night after surgery. Relatives or private duty nurses can spend the night in the room and be invaluable in summoning help, checking medication and helping things run more smoothly. Have visitors on weekends in shifts when staffing is sparse.

• Ask questions. Don’t automatically assume you’re getting the proper medication or the correct test.

• If possible, don’t schedule surgery for a Friday so that you’re not stuck in the hospital over the weekend.

• Take your list of medications to the hospital, along with relevant records.

• If something goes wrong, insist that a doctor in charge be called. Be persistent and if necessary ask to speak to a supervisor.

Sources: Consumer Reports Safe Patient Project; Chelko Consulting Group

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Nursing homes are unnecessarily administering powerful antipsychotic drugs to many elderly residents, including residents with dementia, according to a new report by the Health and Human Services inspector general.

The Food and Drug Administration in 2005 mandated that drug makers issue warning labels on atypical antipsychotics, noting that the drugs—which are generally FDA-approved for treating schizophrenia and bipolar disorder—increase the risk of death for elderly patients with dementia.

Yet when the government examined 1.4 million Medicare claims from 2007 for atypical antipsychotics for elderly nursing home residents, the government found that 88 percent of the time, the drugs were prescribed to individuals diagnosed with dementia.

Doctors and nursing homes aren’t the only ones to blame, according to HHS Inspector General Daniel Levinson. The report itself does not specifically examine ties between doctors, pharmacies, and nursing homes, but in a statement accompanying the report, Levinson faulted drug companies for aggressively—and illegally—marketing these products to doctors for treatment of dementia and other off-label uses. (It’s not illegal for doctors to prescribe drugs for off-label uses, but it is for drug companies to promote them as such.)

“Despite the fact that it is potentially lethal to prescribe antipsychotics to patients with dementia, there’s ample evidence that some drug companies aggressively marketed their products towards such populations, putting profits before safety,” Levinson said.

He noted that a number of drug companies have been accused of illegally promoting these drugs off-label to doctors and pharmacies, including those that serve nursing home residents. Some of the lawsuits have settled, but Levin said those settlements alone don’t negate the effects of years of off-label promotion.

“Money can’t make up for years of corporate campaigns that market drugs with questionable benefits and potentially deadly side effects for vulnerable, elderly patients,” according to Levinson.

The report also faulted the Center for Medicare and Medicaid Services (CMS), the agency that oversees Medicare and Medicaid, for failing to hold nursing homes accountable for unnecessary use of antipsychotic drugs.

Unnecessary uses can include inadequate rationale for using the drug as well as excessive doses, excessive duration, and inadequate monitoring of patients to whom the drug was given.

The report notes that the federal government paid more than $116 million more than $116 million for claims that violated its Medicare reimbursement criteria. These claims were only for the first half of 2007.

The inspector general recommends that CMS assess its safeguards for preventing unnecessary antipsychotic drug use in nursing homes. The agency acknowledged that better controls were needed.

In a letter to the inspector general, CMS Administrator Donald Berwick wrote that the agency is “very concerned about the nature of the contractual arrangements” involving nursing homes, the doctors and pharmacies that serve them, and pharmaceutical manufacturers.

We’ve reported on some of those ties in our series, Dollars for Docs. In particular, we highlighted the case of a psychiatrist who served Chicago-area nursing homes and made nearly a half million dollars promoting AstraZeneca’s best-selling antipsychotic.

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By Michelle Andrews

Nobody likes taking time out of a busy day to cool their heels in a doctor’s waiting room. Now you may not have to. Some primary-care practitioners are bringing their black bags directly to home or office, in some cases for as little as $30 to $35 a visit.

Experts agree that house calls are a great convenience, and for seriously ill patients who can’t get to a doctor’s office, they are often invaluable. But unless the practices offering house calls coordinate with patients’ other providers, they may only further splinter an already fragmented health-care system, experts warn.

With 600,000 members in three states —Texas, Massachusetts and Arizona — and plans to enter up to 10 new markets a year, Austin-based WhiteGlove House Call Health is one of the most visible players in the growing field of mobile primary care.

In most cases, the company contracts with businesses and insurers to offer its services to employees or plan members. Companies pay an annual fee of $300 per member; the covered individuals pay up to $35 to have a WhiteGlove nurse practitioner make a house (or office) call. (The service is available from 8 a.m. to 8 p.m. every day of the year.) Individuals can also sign
up with WhiteGlove, for $420 annually and the same $35 fee.

The visit fee also covers any generic prescription medications that are provided. In addition, the nurse practitioner leaves behind a “well kit” with chicken soup, crackers, Tylenol, cough drops, tissues and other incidentals.

Companies like the service because it controls their costs, says Bob Fabbio, WhiteGlove’s chief executive and co-founder. “We’ve turned variable, unpredictable expenses . . . into a capped event,” he says.

Individuals, of course, like the convenience. When Emily and Moody Alexander’s 14-year-old son Hill developed a fever and sore throat on Easter Sunday, they called WhiteGlove.

A nurse practitioner arrived at their Arlington, Tex., home within two hours, did a rapid strep test and pricked his finger to see if Hill had mononucleosis. The test for strep was positive, so the nurse practitioner gave Hill a generic antibiotic on the spot.

“I think it’s the most genius idea,” says Emily Alexander, who would otherwise have had to get her son into a nearby urgent care clinic with a $100 co-payment that day or get him in to see their regular pediatrician the following morning. The Alexanders’ insurance company covers visits by WhiteGlove.

More From This Series: Insuring Your Health

While the convenience of a house call has undoubted appeal, some experts say nurse practitioners may miss subtle signs of underlying illness in what seems to be a routine cold or other minor ailment.

“They don’t have the same level of academic or hands-on training as a physician,” says Ann O’Malley, a physician and senior researcher at the Center for Studying Health System Change, a think tank based in Washington.

In some states, nurse practitioners can work independently of physicians; other states require varying degrees of oversight by physicians. Texas requires some degree of doctor supervision.

The other area that experts flag as worrisome has to do with the importance of coordinating a patient’s medical care.

Health-policy experts agree that everybody needs a medical home, a primary-care practice that helps ensure that patients get routine and preventive care and that acts as a hub for care coordination with other providers when necessary. This is particularly important for people with such chronic conditions as diabetes who may see a number of specialists in addition to their primary-care provider.

WhiteGlove provides many wellness services, from back-to-school physicals to vaccinations, and it’s moving into chronic disease management as well. “We aim to serve as our members’ primary- and chronic-care provider, for the scope of care we provide,” says Fabbio.

The company doesn’t routinely coordinate members’ care, however, or pass along information to other providers unless requested to do so by a member, he says.

Emily Alexander says she has no plans to use WhiteGlove for regular primary care for her six kids. In fact, if her son got strep again or something else that she thought ought to be followed by a doctor, she would take him to see their regular pediatrician, she says.

One of the challenges for patients is that house-call practices vary widely and patients may not know what to expect, says Constance Row, executive director of the American Academy of Home Care Physicians.

Many providers now doing house calls see only the sickest Medicare beneficiaries, those who are unable to get to a doctor’s office. Medicare pays for these visits because they’re considered medically necessary.

At the other end of the spectrum are “concierge” practices whose doctors are available 24/7 to patients who can afford to pay thousands of dollars a year for services that may include house calls.

The key is to understand what a house-call practice does and doesn’t do, says Row. Since it may not be clear how a service handles important things such as care coordination and follow-up, the crucial advice for consumers is simple: Ask.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Ostrom writes:

The CMS report, triggered by a state finding of deficiencies in hospital procedures, said transport nurses appeared to be confused about what they were allowed to do and whether they could administer medications without a doctor’s order. It said the hospital’s review of the cases didn’t pick up that documentation was inaccurate and incomplete or that doctors’ orders — required by law — were missing.

“CMS has accepted the hospital’s plans to correct the deficiencies in the quality improvement process and others noted in that survey, as well as for additional problems cited in a more wide-ranging follow-up survey done in March,” Ostrom reports.

To learn more:

• Read Carol Ostrom’s article Children’s hospital says it’s fixing flaw found in survey.

Dr. Pho

Medical blogger Dr. Kevin Pho argues today on his weblog KevinMD.com that Seattle Children’s erred when it fired Kimberly Hiatt, the pediatric critical care nurse whose medication error has been blamed for the death of infant being cared for at the Seattle medical center.

Hiatt, 50, took her own life last month. Friends reported that she had despaired of ever finding a nursing job again.

Dr. Pho writes:

Kimberly Hiatt made a mathematical error that led to the tragic death of an infant patient. Firing her simply absolved the hospital from their share of the blame. Instead, she should have been involved with the subsequent improvement process to prevent future errors.

For more:

• Read Dr. Pho’s commentary Should nurses be fired for fatal medication errors?
• Read Carol Ostrom’s article in the Seattle Times about Hiatt’s death Nurse’s suicide follows tragedy.