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If you’re a construction worker, you’re likely to experience one or more work-related injuries or illnesses during your lifetime, plus your risk of premature death is greater, according to a new study.

Using data from several national resources, including the Census of Fatal Occupational Injuries, researchers from The Center for Construction Research and Training estimate that over a 45-year career the likelihood of experiencing a disabling injury is about 75 percent for a construction worker.

Additionally, over the course of a career, the same worker has a one in 200 chance of being fatally injured on the job. And if you’re a Hispanic construction worker, you have a 20 percent higher likelihood of dying from a work-related injury.

The study also shows that a person who begins working in construction at 20 has about a 15 percent chance of developing chronic obstructive pulmonary disease over the course of their life and an 11 percent chance of developing dust-related parenchymal chest X-ray changes, or lung tissue scarring.

While researchers continue to make great strides in reducing construction-related injuries and illnesses, Pete Stafford, the executive director of the Center for Construction Research and Training, said the numbers are still too high.

“Workers and their families suffer the consequences of disabling injuries, and this research shows it’s far too common,” Stafford said in a news release. “So we must continue to raise awareness of the problems – and hope to see our research findings put to use to reduce construction fatalities, injuries and illnesses.”

Researchers note that their method of presenting risk over the course of a lifetime presents a more realistic estimate, rather than using just cross-sectional data, which is the traditional method that tends to underestimate risk.

For more on health safety issues, see the library of articles by Daytona Beach personal injury attorney.

Obese children require much smaller doses of the anesthetic propofol than normal-weight children to bring about a safe level of unconsciousness, according to a new study.

Because the commonly used drug propofol can cause low blood pressure, prolonged sleepiness and decreased breathing, this study’s results can help anesthesiologists safely treat a common type of surgical patient that is often misunderstood.

“Little information is available to assist anesthesiologists in determining the right dose of medication to give to an obese child,” said Dr. Olutoyin A. Olutoye, of Texas Children’s Hospital in Houston, and lead author of the study.

Companies that make these medications do not specifically study their effects in this group of children before the drug is released for general use,  researchers say.

Anesthesiologists now must decide whether anesthetic drug doses should be based on a child’s actual weight or lean body weight. In obese children, 75 percent of their excess body weight is comprised of fat tissue, which alters drug distribution.

“Obese adults often need a smaller dose of propofol than normal weight adults, but a correlation to children isn’t guaranteed since adults and kids handle medications differently,” said Dr. Olutoye in a news release.

For this study, 40 obese and 40 non-obese children were observed using a process called the biased coin design. This process requires fewer patients and provides greater accuracy in the calculation of dose requirements than other techniques.

After measuring each child’s response 20 seconds after the propofol was administered, researchers discovered obese children needed 2 mg/kg of propofol to bring about unconsciousness at the beginning of surgery, compared to the normal weight children who needed 50-60 percent more propofol (3.2mg/kg).

“When providing care for obese children with propofol, 95 percent of children will likely need only a smaller dose of propofol to initiate anesthesia for surgical procedures,” said Dr. Olutoye, commenting on the study‘s results.

This study is important, Dr. Olutove said,  because propofol can cause low blood pressure, which can be worsened if larger-than-needed amounts are given.

Researchers say more pediatric studies are needed to determine if there are other differences in medication responses for obese and non-obese children in clinical practice.

For more on child medical safety issues, see the library of articles by Daytona Beach child injury attorney.

Nearly a fourth of Americans are now forced to travel farther to a hospital trauma center than they once did, a new study shows.

And those most affected are African Americans, poor, uninsured and rural residents.

Researchers from the University of California, San Francisco examined changes in driving time to trauma centers, which have increasingly been shuttered in recent years. They found that by 2007, 69 million Americans — nearly one in four — had to travel farther to the nearest trauma center than they traveled in 2001.

“Trauma centers aren’t just for ‘certain’ people — if you sustain a serious injury from a car accident or fall off your roof, you need a trauma center,’’ said lead author Dr. Renee Y. Hsia, an assistant professor of emergency medicine at UCSF. She is also an attending physician in the emergency department at San Francisco General Hospital & Trauma Center and a Robert Wood Johnson Foundation Physician Faculty Scholar.

“We found evidence that vulnerable communities have less geographic access to trauma care, adding to their health disparities,’’ Hsia said in a news release. “This study will help us better understand how trauma center closures are affecting people.’’

Hsia’s research centers on illustrating inequalities in accessing trauma care as well as the decline of emergency care in the United States. She has documented that tens of millions of Americans do not have ready access to a certified trauma center, and that nearly a third of urban and suburban emergency rooms have closed in the last two decades.

Trauma services are not, as commonly believed, available in all hospitals. They are hospitals with emergency departments that provide specialty care for injured patients, regardless of ability to pay. As a result, trauma centers face greater financial jeopardy depending on the surrounding patient population.

For their new study, the researchers analyzed 31,475 ZIP codes in the United States, covering some 283 million people, nearly the entire nation.

Overall, nearly three-quarters of the U.S. lives within 10 miles of a trauma center. Of the remainder, 14 percent live more than 30 miles from a trauma center.

Communities with a higher number of residents under the federal poverty level, black residents, uninsured residents and rural residents faced longer drives compared to communities with a low share of these vulnerable populations.

For nearly 16 million people, the extra driving time amounts to about 30 minutes — a critical period for people facing life-threatening injuries such as stroke and gunshot wounds.

In 1990 there were 1,125 trauma centers in the United States; by 2005, about 30 percent of them had closed primarily because of the high costs and fewer patients able to pay the bills. The majority of closures took place in urban areas but rural communities have also been affected.

The authors recommend policy makers should subsidize trauma centers that treat a large number of African American, uninsured or poor people. In rural areas, they recommend that hospitals establish agreements with nearby trauma centers to ease transfers of seriously injured patients.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

According to a “Report Card” published by the Center to Advance Palliative Care, the nation overall gets a “B” grade for caring for our sickest Americans, up from a “C,” when the report was first released in 2008.

“The good news is that over the last ten years hospital palliative care teams have more than doubled,” said Dr. Diane E. Meier, director of the Center and co-author of the study, in a news release. “The bad news is that despite its enormous benefits to patients and care givers, millions of seriously ill Americans still do not have access to palliative care. Given the will of Congress to assure patients receive high quality care while reducing costs, it seems that palliative care should be a natural part of that prescription.”

Palliative care is a medical specialty that helps people facing serious and chronic illness more comfortable by alleviating pain, treating a host of other symptoms and focusing on their quality of life. It is appropriate at any age and any stage of a serious illness and can be provided along with curative treatment.

Approximately 90 million Americans are living with serious and chronic illnesses, such as cancer, heart disease, diabetes, Parkinson’s, stroke, and Alzheimer’s.

The Report Card demonstrates considerable improvement in the growth of palliative care. (Out of a total of 2,489 hospitals nationwide who participated in this survey, about 1,500 provide palliative care services.) This number is expected to grow significantly over the next five years, but barriers continue to exist in three key areas: Workforce, Research and Access.

Of course, you can’t get palliative care from a hospital that does not offer it.
Meier and colleagues graded states on the percentage of hospitals that have palliative care teams. They counted only hospitals with 50 or more beds, as palliative care savings may not offset costs for very small hospitals.

States got an A for having palliative care teams in 83 percent or more of their hospitals, a B for 61 to 80 percent of hospitals, a C for 42 to 60 percent of hospitals, a D for 28 to 38 percent of hospitals, and an F for 0 to 20 percent of hospitals.

The report gives seven states plus the District of Columbia an A: Maryland, Minnesota, Nebraska, Oregon, Rhode Island, Vermont and Washington. Only three states, Vermont, Montana and New Hampshire, received an A in 2008.

More than half of the fifty states received a grade of B, including Florida. Seven states improved from a D to a C (Georgia, Kentucky, New Mexico, Texas, South Carolina, Louisiana and Wyoming).

Nevada saw dramatic gains, rising from a D to a B grade. Only two states – Delaware and Mississippi – got an F. Oklahoma, Alabama and Arkansas improved from an F in the last report card to a D in 2011.

Findings from a separate 2011 Public Opinion Strategies survey found that most Americans believe palliative care should be made available at all hospitals. Once informed about it, 92 percent of respondents said they would consider it for a seriously ill loved one.

“America’s hospitals have a strong history of caring for patients and families during the most difficult of times,” said Rich Umbdenstock, President and CEO of the American Hospital Association. “Hospitals and other health care organizations are taking the lead in ensuring health care is patient-centered, reflecting patient’s desires including palliative care assistance.”

“Studies suggest that in states with more hospital-based palliative care programs, patients are less likely to die in the hospital, are likely to spend fewer days in the ICU, have better pain management and higher satisfaction with their healthcare,” said Dr. Sean Morrison, director of the National Palliative Care Research Center and the study’s lead author. “Some studies have reported that palliative care may also prolong life. And beyond patient benefits, the overall cost savings to hospitals have been well documented.”

For more on patient safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

Just because a patient has not had any complications during her pregnancy, does not mean the risk of complications should be ignored.

Unfortunately for this young 24-year-old mother, lack of attention to complications and warning signs, and lack of communication between a nurse and doctor, resulted in the delayed birth and permanent brain damage to her baby.

When the young woman with full term pregnancy began to experience pain and leak fluid, she called her obstetrician to confirm if she was in labor. Her doctor advised her to use a peripad, rest, and call back if the symptoms increased.

About two hours later she went to the emergency room in severe pain. She was admitted at 8:15 p.m. with leaking green/brown fluid.
The nurse placed an electronic fetal monitor (EFM). The patient was 1-2cm dilated and 50 percent effaced. Per EFM, the fetus was showing heart rate decelerations to 90 and decreased beat-to-beat variability. Meconium, or the earliest stools from the baby, was present on the patient’s peri-pad.

The patient requested analgesics for pain, and the RN called the obstetrician. She advised him that the EFM strip looked good, and requested an order for Nubain IM for pain, which was administered shortly thereafter.

The obstetrician arrived at 9:20 p.m. Meconium was still present, and the EFM strip showed some decelerations and decreased variability. The obstetrician questioned if it might be due to either the Nubain or to the EFM picking up the maternal pulse. He decided to treat her conservatively with hydration and oxygen. The patient was 3cm dilated, and she received an epidural.

At 10:50 p.m., as the EFM showed late decelerations and decreased variability, the RN called the obstetrician to the patient’s room. The patient was now 5cm dilated. Fetal scalp PH tests were performed by the obstetrician, and results were abnormal at 7.15. The obstetrician determined the fetus was in distress, and ordered an emergency C-section.

An infant girl was born at 11:24 p.m., weighing 6.4 pounds, with Apgar scores of 1 at 1 minute, 5 at 5 minutes and 7 at 10 minutes. Her heart rate was less than 80, and she required vigorous resuscitation.
The infant ultimately developed seizures and was diagnosed with hypoxic ischemic encephalopathy or lack of blood flow to the brain. She suffers neurological defects from cerebral palsy, such as: right sided hemi paresis – injury to the left side of the brain, which controls language and speaking; cognitive difficulty and speech delays.

Important factors which led to the settlement of this medical malpractice case include:

The nurse did not accurately communicate the maternal-fetal status to the obstetrician. This negatively effected the physician’s decisions and caused a delay in diagnosis of fetal distress. Specific significant results, such as EFM tracings must be shared during the phone consult. An incomplete status report may lead the physician in charge to miss important clues necessary to understand what is needed next, as was the case here.

Early recognition of fetal distress signs require baseline measures to assess trends. New medications initiated at the hospital can complicate ongoing patient evaluation.

The obstetrician initially told her to stay home during her first call. Telephone assessments in a case that is perceived as “low-risk” present a risk of under-evaluation of what the patient is experiencing. Probing questions that a high-risk pregnancy requires may be important for any pregnancy. Good documentation of all phone conversations that have taken place will result in better flow of information and ultimately better care of the patient.

Lack of a process for relaying important details. Care teams need to develop an understanding of what needs to be communicated during patient status reports over the telephone. In order to consider more urgent possibilities in the differential diagnosis, all providers must understand the value of their observations. Physicians and nurses can use mental or written checklists to make sure everyone knows about the presence of significant symptoms.

Older patients receiving carotid artery stenting from lesser experienced physicians had an increased risk of death 30 days after stent placement, according to a new study.

An analysis of Medicare data showed a higher death risk if the stent was inserted by a doctor who performed less than six procedures a year, or if the procedure was conducted early in the physician’s career.

Carotid stenting is increasingly being used to treat severe carotid atherosclerosis, an important cause of ischemic stroke. Since approval of the first carotid stent system by the U.S. Food and Drug Administration in 2004, use of carotid stenting has more than doubled in Medicare beneficiaries.

Despite the promise of this procedure, its increasing use has raised potential concerns.

“Carotid stenting is a technically demanding procedure and earlier studies have demonstrated a substantial learning curve with it,” says lead study author Dr. Brahmajee K. Nallamothu, cardiologist at the University of Michigan Cardiovascular Center, in a news release. “The total number of operators currently performing carotid stenting in routine clinical practice and their overall experiences and outcomes with the procedure remain largely unknown.

Nallamothu and colleagues at the U-M Health System, Mayo Clinic, Dartmouth-Hitchcock Medical Center, and Yale University School of Medicine conducted a study to examine recent patterns of utilization and outcomes for carotid stenting in the U.S. among elderly patients.

The researchers used administrative data from fee-for-service Medicare beneficiaries ages 65 years or older who underwent carotid stenting between 2005 and 2007. Among the outcomes the researchers measured were 30-day mortality and treatment early vs. late during an operator’s experience.

Analysis of the data identified 24,701 patients who underwent carotid stenting by 2,339 operators. Average age of the patients in the study was 76.2 years.

Compared with patients treated by operators performing 24 or more procedures per year, those treated by operators performing less than six procedures per year were nearly twice as likely to die within 30 days of the stent placement, the study showed.

The authors found higher 30-day mortality in patients treated early vs. late during a new operator’s experience (2.3 percent vs. 1.4 percent, respectively). Compared with patients who were their operator’s 12th procedure or higher, those who were among their operator’s first 11 procedures had a 1.7 times higher odds of dying within 30 days of the procedure.

“In conclusion, many physicians have begun performing carotid stenting in Medicare beneficiaries during recent years, although most operators appear to have developed limited experience with the procedure over time, “ study authors write. “This finding is important since adjusted outcomes following the procedure are worse among very low-volume operators and early during an operator’s experience. Given limitations of these data, caution should be exerted when using our findings to set specific targets for operator experience.”

Collecting more detailed data about operator experience during the early dissemination of new procedures, like carotid stenting, may help optimize outcomes, according to the researchers.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

A new survey shows hospital patients want to know if medical trainees are going to be participating in their surgery.

Although most patients would allow residents and medical students to be involved in their operation, researchers say the rates of consent vary depending on the type of surgery and the trainee’s level of participation

Dr. Christopher R. Porta and colleagues from Madigan Army Health System, Tacoma, Wash., conducted an anonymous questionnaire at a tertiary-level U.S. Army hospital and referral center, to evaluate patient perceptions and willingness to participate in surgical resident education and training programs.

“Currently, no widely accepted guidelines or policies exist for providing information regarding the role of surgical trainees to the patient during the informed consent process,” the authors write. “The accepted standard is to provide information that ‘a reasonable patient’ would want and would need to know to make an informed decision, but this counseling may vary widely by health care professional, setting, and type of surgical procedure.”

The authors distributed 500 surveys, 316 (63.2 percent) of which were returned and included in the study. Most patients indicated no preference for a private hospital versus a teaching hospital, however of those who did, more preferred a teaching hospital to a private facility for overall care (24.9 percent vs. 8.8 percent) and minor surgical procedures (28.2 percent vs. 12 percent), but hospital preference for major surgical procedures was similar (24.7 percent vs. 26.6 percent).

Additionally, 91.2 percent of those patients who indicated a facility preference reported that their care in a teaching hospital would be equivalent to or better than that of a private hospital.

Patients also indicated they overwhelmingly preferred to be informed of resident participation in their surgical procedure, regardless of whether it was a major procedure (95.7 percent) or a minor surgery (87.5 percent).

A total of 94 percent of respondents indicated they would consent to involvement of a surgical resident, however this decreased to 85 percent for a surgical intern and 79.9 percent for medical student involvement.

When provided with specific scenarios involving trainee participation, 57.6 percent of patients consented to having a junior resident act as the first assistant, 25.6 percent consented to the resident acting as the operation surgeon with direct staff observation, and 18.2 percent consented to resident participation without direct staff observation.

“Although most patients express an overall willingness to participate in surgical education, wide variations can be observed in the actual consent rates for specific training situations, “ the authors said. “This decreased willingness to consent and the potential effect on training programs must be considered when discussing policy initiatives aimed at improving informed consent.”

For more on medical safety issues, see the library of  articles by Daytona Beach medical malpractice attorney.

With 16 percent of Americans unable to afford medical care, patients today need to think of themselves as consumers or buyers of health care, shopping around and using haggling strategies with doctors and hospitals.

A new report from Consumer Reports features advice on this very topic.

“Americans are overwhelmed by health costs and many people simply can’t pay their bills, can’t afford their medications,” says Dr. John Santa, director of the Consumer Reports Health Ratings Center, in a news release. “The last thing most patients want to do is haggle with their doctors, but a little bit of negotiating can go a long way.

“It’s also important to know that there are tremendous variations in health care costs —knowing this can help a consumer get a hand up and politely insist on the fairest possible price.”

Consumer Reports offers this advice for three possible scenarios:

You’re healthy. The optimal time for patients to talk with their healthcare providers about costs is before any have been incurred. While doctors have a professional obligation to take a patient’s financial resources into account, patients should raise the issue with their doctors to let them know that costs are important to them.

“For a variety of reasons, doctors are likely to suggest the most expensive options first. But you might be surprised by your doctor’s willingness to change course, for example prescribing fewer expensive brand name drugs or choosing watchful waiting over a costly diagnostic test,”  Santa said.

The unexpected occurs. A patient lands in the hospital without the benefit of any planning and gets slammed with a huge bill, say $15,000 for a coronary angiogram, and insurance ends up covering only a fraction of the bill.

These approaches are recommended to get the greatest reduction to their bill:

• Sit down with the doctor who ordered or performed the hospital services to find out how the hospital costs ran so high. Were all the services needed and reasonably priced? Consumers can judge for themselves by checking www.healthcarebluebook.com which lists the going rates for many medical services for free. Closely examine each bill to identify errors, which are common.
• Consumers should not assume the price on their bill is set in stone. Providers often discount rates substantially to insurers and others, so why shouldn’t a consumer ask for the same rate reduction? Consumers should dispute any charges they think their insurance company ought to cover.
• Patients should not pay their bill until they have exhausted all of their options, but they should make clear to the hospital’s billing department that reaching a resolution is important to them. They might consider making a discounted offer they think would be manageable within a set time period. Consumers can consult one of the reputable groups that, for a fee, can help reduce the size of medical bills, such as INSNET (www.myinsnet.com) or Medical Cost Advocate (www.medicalcostadvocate.com).

You’re having an elective surgery. This situation allows for more planning and research into the best procedure, doctor, hospital, drug or other option. As you do research, keep in mind this advice:

• Consumers should shop around, talk to different providers, and bargain for what they think is a fair price.
• Consumers shouldn’t hesitate to ask for the price upfront and get it in writing. Request an itemized list of all potential charges.
• As with any purchase, consumers should beware of any offer that sounds too good to be true. If a provider suggests a shortcut, be wary and ask a lot of questions, and check out providers that are unfamiliar.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

Many U.S. adults believe that only extremely effective drugs without serious adverse effects are approved, but providing more information about the uncertainties of a drug’s benefits may help consumers make better choices, a new study shows.

Approval from the U.S. Food and Drug Administration (FDA) does not necessarily ensure that a drug has a large or important benefit, or that all serious adverse effects of the drug are known, according to the report published in the September issue of Archives of Internal Medicine.

“Uncertainties are greatest in the first few years after approval and for drugs approved solely on the basis of a surrogate outcome,” the authors note.

Researchers point out that the cholesterol-lowering drugs Zetia and Vytorin reached $1.8 billion in sales in 2007 before a study found no clinical benefit from these drugs, and that the anti-inflammatory medication Vioxx reached $2.4 billion in sales by 2003 before being withdrawn from the market due to its association with myocardial infarctions (heart attacks) and strokes.

“The FDA has never required advertisements to acknowledge uncertainties inherent in all new drugs,” write the authors. “Enthusiasm for Zetia and Vioxx might have been dampened had consumers known to look for drugs approved based on patient outcomes or drugs with a longer safety record.”

Dr. Lisa Schwartz  and Dr. Steven Woloshin, from the VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt., and the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, N.H., conducted an Internet-based, randomized, controlled trial of U.S. adults’ beliefs and choices regarding prescription drug uncertainties.

The 2,944 participants were randomized to three explanations about a pair of cholesterol drugs, one that was approved because of a surrogate outcome (lower cholesterol) and another that was approved because of a patient outcome (reduced myocardial infarctions).

Participants in the control group received no explanation, those in the nondirective group were told that surrogate outcomes do not always translate into patient outcomes and those in the directive group received the same explanation as well as advice to “Ask for a drug shown to reduce heart attacks.”

In a second randomization, participants received one of three explanations about a pair of heartburn drugs, one that was newly approved and another that was approved eight years earlier. Participants in the control group received no explanation, those in the nondirective group were told “It takes time to establish the safety of new drugs” and those in the directive group were advised to “Ask for a drug with a longer track record.”

The primary outcome was choice of the drug for which there was less uncertainty. In the cholesterol drug example, the better choice would be the drug that had a beneficial effect on patient outcome (reducing myocardial infarction) instead of surrogate outcome (lowering cholesterol).

In the heartburn drug example, the better choice would be the drug that was approved eight years earlier instead of the recently approved drug.

Researchers also asked participants, “What would you do if your doctor recommended the drug with the surrogate outcome? Do you think new — or old — drugs are safer?” and assessed their understanding of FDA approval with four true/false questions.

One-quarter of participants mistakenly believed that the FDA approves only drugs without serious side effects, and more than one-third mistakenly believed that the FDA approves only “extremely effective” drugs.

Equal percentages of participants in the directive and nondirective groups (71 percent in the cholesterol drug example and 53 percent in the heartburn drug example) chose the drug for which there was less uncertainty. In both examples, choice of the drug for which there was less uncertainty was lowest among the control group (59 percent and 34 percent, respectively).

When asked what they would do if their physician recommended the drug approved for a surrogate outcome, 61 percent, 58 percent and 49 percent of participants in the directive, nondirective and control groups, respectively, said they would request the drug approved for a patient outcome.

When asked which of the heartburn drugs was safer, 46 percent, 45 percent and 31 percent of the directive, nondirective and control groups, respectively, selected the older drug. The proportion of participants who chose the older heartburn drug and said it was safer was 40 percent, 41 percent and 26 percent, respectively. One limitation the authors note is “participants were making hypothetical choices between drugs.”

“There are important gaps in what people know about prescription drugs — gaps that undoubtedly contribute to the rapid uptake of drugs despite uncertainty about benefit and harm,” write the authors. “Our findings show that simple explanations (ones that are brief enough even for television advertisements) help consumers make better decisions.”

Researchers recommend that the FDA more effectively communicate what it knows and does not know about how well drugs work.

For more on medication safety, see the library of articles by Daytona Beach medical malpractice attorney.

While the use of financial incentives continues to grow as a way to encourage primary care physicians to do their jobs better, a new study shows there is no evidence to support that such incentives are working.

According to Australian researchers who collected data from studies of incentive programs in the U.S., the UK and Germany, it’s not even  clear if the incentives always do more good than harm.

“Despite the popularity of these schemes, there is currently little rigorous evidence of their success in improving the quality of primary health care, or of whether such an approach is cost-effective relative to other ways to improve the quality of care,” the authors write.

Seven studies were included in this review. Three of the studies evaluated single-threshold target payments, one examined a fixed fee per patient achieving a specified outcome, one study evaluated payments based on the relative ranking of medical groups’ performance (tournament-based pay), one study examined a mix of tournament-based pay and threshold payments, and one study evaluated changing from a blended payments scheme to salaried payment.

Researchers looked at randomized controlled trials (RCT) for smoking cessation, controlled before and after studies (CBA) for cervical screening and mammography screening, and a series of interrupted time series analyses (ITS), one focused on four outcomes in diabetes and one examined cervical screening, childhood immunizations, chlamydia screening and appropriate asthma medication. Quality of care was defined as patient reported outcome measures, clinical behaviors, and intermediate clinical and physiological measures.

Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures, but not all. One study found no effect on quality of care.

Poor study design led to substantial risk of bias in most studies. In particular, none of the studies addressed issues of selection bias as a result of the ability of primary care physicians to select into or out of the incentive scheme or health plan.

The study authors concluded there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care.

“Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation,“ the authors write. “More rigorous study designs need to be used to account for the selection of physicians into incentive schemes.”

Researchers say future studies should more consistently describe:

• The type of payment scheme at baseline or in the control group
• How payments to medical groups were used and distributed within the groups
• The size of the new payments as a percentage of total revenue.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.