Medicare's pay-for-performance incentives do not have a significant long-term impact on patient outcomes, according to a New England Journal of Medicine study.

Researchers at Harvard Business School compared 30-day mortality rates for more than 6 million patients treated between 2004 and 2009 at hospitals identified as pay-for-performance test sites, and compared the outcomes data with hospitals that did not receive incentives.

Pay-for-performance had no positive effect on mortality rates, according to the study, even for patients being treated for acute myocardial infarction or undergoing coronary bypass graft surgery, 2 conditions specifically incentivized by Medicare for improvement. Similar outcomes were observed in poor-performing hospitals, which researchers say had the most to gain from participating in the pay-for-performance program.

With CMS set to expand pay-for-performance's reach this year, say the researchers, collecting data about pay-for-performance's long-term impact is necessary because participating facilities have to change their underlying approach to patient care, the benefits of which could take years to realize.

"Our findings suggest that both the size of the incentives and the targets matter," says Ashish Jha, the study's lead author and associate professor of health policy and management at Harvard. "We need to better align financial incentives with delivery of high-quality care."

Daniel Cook

Cigarette smokers who undergo hip and knee replacements experience significantly higher complication and failure rates, according to 2 studies presented at the American Academy of Orthopaedic Surgeons' annual meeting.

The first study assessed clinical outcomes following surgery - including pain, function and range of motion - in 621 total knee replacement patients. The group included 131 smokers and a median patient age of 62. Thirteen patients (10%) who were smokers experienced knee replacement failures, compared to 5 failures (1%) among non-smoking patients. In addition, 21% of smokers experienced a medical complication, versus 12% of non-smokers. These complications included deep vein thrombosis or blood clots, anemia, cardiac problems and acute renal failure.

The second study analyzed patients that had undergone hip reconstruction with ultra-porous metal implants, which generally result in increased survival rates and fewer hip replacement failures in comparison to standard porous metal implants. Among the 533 hip replacement patients studied, 9.1% of smokers experienced a failure, versus 3.4% of non-smokers.

During a smoking cessation forum held at the AAOS meeting, orthopedic surgeons offered recommendations to encourage patients to stop smoking before surgery to ensure optimal recovery and better outcomes. Their suggestions included refusing to perform surgery on patients who smoke; having various staff members such as nurses, receptionists and physician assistants repeatedly ask patients about tobacco use; advising patients to quit; and offering information on free smoking cessation assistance hotlines.

"Smoking is the most costly and preventable risk factor in postoperative complications," said David O. Warner, MD, associate dean for clinical and translational science at the Mayo Clinic. "Surgery is a teachable moment - one we need to capitalize on."

Mark McGraw

Regional anesthesia can improve your perioperative efficiency, but dual guidance can improve your regional anesthesia, say experts. The benefits of using ultrasound imaging in conjunction with electrical stimulation to locate and target nerves include more effective anesthesia administration, the potential for faster discharges and increased patient safety, says anesthesiologist Gregg Melton, MD, medical director of the Slocum Center for Orthopedics & Sports Medicine in Eugene, Ore. Find out how in his overview of the technique in Outpatient Surgery Magazine.

David Bernard

Do you instruct your patients to use dilating drops at home before checking into your facility for cataract surgery? Tell us in this week's InstaPoll. You can also see what your colleagues do and sound off on this topic at our Second Opinions Bulletin Board.

Patients driving themselves home after surgery? Of course, discharge without an escort after anesthesia or sedation is not recommended, but you know all too well that some brazen patients get behind the wheel only minutes after undergoing surgery. Of 342 respondents to last week's poll, 14% have experienced patients drive themselves home - 3% say it happens frequently and 11% say it happens occasionally. Nearly half (46%) say it rarely happens and another 40% say it never happens.

"The follow-up question is, what do you do when you find out it happens?" says Margaret Kowalczuk Sherman, RN, BSN, administrator of the Hamilton (N.J.) Endsocopy & Surgery Center. "Do you call the police because they are 'under the influence?'"

Dan O'Connor