FDA: Avoid Powdered Pure Caffeine

Powdered caffeine, which is commonly sold over the internet and in other locations should be avoided, according to a Food and Drug Administration (FDA) release. Using ever stronger language, the FDA said the individuals with pre-existing heart conditions should not use the products. The FDA states that these products are almost 100 percent caffeine and even small amounts can be lethal. The FDA stated that it is aware of the death of a teenager in Ohio who consumed one of these products.

Dosage Amounts

The FDA said that consumption of a very small amount of these products can cause an accidental overdose. A single teaspoon of pure caffeine can be the equivalent of 25 cups of coffee. Furthermore, the FDA said that it is nearly impossible to accurately measure powdered caffeine with common kitchen tools. The Washington Post reported in a story on the death of an Ohio teenager that “a mere 1/16th of a teaspoon can contain 200 milligrams of caffeine, roughly the equivalent of two large cups of coffee.”


The symptoms of caffeine overdose include rapid or dangerously erratic heartbeat, seizures, vomiting, stupor, disorientation, and death, according to the FDA. The severity of these symptoms is much greater than simply drinking too much coffee, tea or other caffeinated beverage, said the FDA. An individual who believes they have consumed too much caffeine and are experiencing one of these reactions should seek immediate medical care.

Death of Teenager

A county coroner in Ohio ordered additional tests after a bag with white powder was discovered in the home of an Ohio teenager who unexpectedly died of seizures and an abnormal heart beat. Those tests revealed that the teenager had taken more than a teaspoon of the powder, or about 16 times the recommended dose, according to a report on Cleveland.com. The Washington Post article stated that the same corner’s report said that the teenager “had more than 70 micrograms of caffeine per milliliter of blood in his system, as much as 23 times the amount found in a typical coffee or soda drinker.”

The Substance Abuse and Mental Health Service (SAMHSA) reported that the number of emergency department visits associated with the use of energy drinks has doubled; going from 10,678 in 2007 to 20,783 in 2011. SAMHSA described energy drinks as flavored beverages containing high doses of caffeine. Caffeinated powder, which the FDA is advising people not to use and the cause of the death of the teenager in Ohio, is sold as a dietary supplement and as such is not as heavily regulated as other substances. Users routinely added it to drinks as a way of weight control.

The FDA would like people to report adverse events associated with the use of powdered caffeine by calling them at 240-402-2405 or by email at CAERS@cfsan.fda.gov.

CMS Asked to Exempt Pathologists from EHR’s Meaningful Use Requirements

A letter to CMS Administrator Marilyn Tavenner signed by 88 congressional representatives is asking CMS to grant a significant hardship exception to all eligible pathologists for the full five years allowed by the American Recovery and Reinvestment Act of 2009 (ARRA) (P.L. No. 111-5). Pathologists maintain that is difficult for them to meet the requirements for the electronic health record (EHR) meaningful use incentive program for Medicare and Medicaid since they do not have direct contact with patients and their work products end up in the EHRs of other physicians.

EHR Program

Hospitals and eligible professionals that fail to implement meaningful use of EHRs will be subject to a reduction in their reimbursement. Physicians, including pathologists, are subject to a 1 percent reduction in their reimbursement if they fail to meaningfully use EHR by 2015. The payment reduction will be increased to 2 percent in 2016 and 3 percent in 2017 and each subsequent year. Under stage 2 of the program, eligible professionals will have to demonstrate to CMS that they met 17 core objectives and 3 menu objectives. The stage 2 meaningful use requirements were designed to increase health information exchange between providers and patients. For example, one of the new core objectives is the use of secure messaging to provide patients with health information (see Stage 2 meaningful use requirements released).


In the Final rule implementing stage 2 meaningful use requirements, CMS granted pathologists a hardship exemption for 2015, exempting them from the 1 percent reduction for failing to meaningfully use EHR. In that Final rule, CMS acknowledged that pathologists face significant barriers in meeting the current meaningful use requirements. The ARRA gave CMS the authority to grant hardship extensions for up to five years to eligible professionals that will have difficulty because of the type of work they do in meeting the meaningful use requirements, and that is what these members of Congress are asking of CMS.

Pathologists argued that it would be difficult for them to meet these requirements since they have little contact with patients. “Pathologists use sophisticated computer laboratory systems (LISs) to support the work of analyzing patient specimens and generating test results. These LISs exchange laboratory and pathology data with EHRs,” said Gene N. Herbeck, MD, FCAP and President of the College of American Pathologists (CAP) in a press release. “The EHR meaningful use program overlooks the unique circumstances of pathology practice,” said Kathryn Teresa Knight, MD, FCAP and Chair of the CAP Federal and State Affairs Committee. “CMS has recognized this difference by exempting pathologists from the 2015 [meaningful use] penalty,” said Dr. Knight. “The circumstances have not changed and CMS must further grant pathologists a hardship exemption for the maximum amount of time allowed under current law,” she continued.

Legislative Fix

In addition, the CAP has endorsed a provision of legislation that would reform the sustainable growth rate (SGR) method to update the physician fee schedule which would remove pathologists from eligibility for payment incentives or penalties under the EHR program. That legislation would give the HHS Secretary the authority to create measures and activities to monitor and encourage the use of the EHR under a merit-based payment system that reflects the way pathologists and other physicians that do not have direct interaction with patients, practice medicine.

ACA Cuts Worry Hospital Executives; Cost Efficiencies Being Implemented

Hospital executives report an increase in confidence in the overall economy, but fear the impact of reimbursement cuts from the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) will not be offset by increases in volumes from insured patients, according to the Hospital Executive Confidence Index reported by ITG, a market research company. Executives were looking towards new reimbursement models and new technology solutions as a way to discover new efficiencies, according to the report. In addition, hospital executives report that purchase trends will continue for new equipment and capital improvements, but that the amount spent on large capital purchases will be less.

ACA Concerns

More than 60 percent of hospital executives continue to be concerned about Medicare and Medicaid reimbursement cuts from the ACA. While they report an increase in volume of insured patients in their outpatient departments, they are worried about a decrease in inpatient volumes. “The implication is that executives are concerned that any increase in volume of insured patients from the new healthcare law will not offset the significant cuts they are seeing in reimbursement,” said Graeme Christianson, Director of Healthcare Market Research at ITG. Most acknowledge, however, that the full impacts of the ACA changes have yet to be realized.

New Payment Methods

To address these concerns, many executives are looking for efficiencies in newer reimbursement methodologies. Executives report a growing interest in entering into risk-based relationships with private and public payers, which they expect to have a dramatic impact on their cost management. Risk-based contracting has penetrated a small proportion of the market, according to the hospital executives, but almost half of the executives surveyed plan to begin implementation of risk-based contracting within the next year. The most common risk-based models currently in use are shared savings and bundled payment programs, but a number of hospitals are entering into accountable care organizations and group purchasing organizations, as well. In the short-term, a third of the executives report that they will be putting staffing cuts in place during the next year as a way to reduce cost, as well.

Infrastructure Investments

Nearly 90 percent of the executives surveyed indicated that their hospitals have a fully functioning electronic medical records system, but many of the executives according to the report are asking, “O.K. so what’s next?” To that end, many executives are investing in new health care information technology (IT) to use that data to uncover efficiencies and cost management benefits. The report showed that executives are also investing in robotic surgical equipment and a variety of cardiovascular, orthopedic, and spine implant equipment. Even with these new expenditures on equipment, over 40 percent of the executives surveyed said they expect to spend less on large capital equipment over the next year.

“There has been a promising uptick in executive confidence about the overall economy,” said Christianson. “But executives are now asking when this economic lift will translate into improvements in the financial performance of their hospitals or health systems,” continued Christianson.

QIOs Helping to Prevent Readmissions and Improve Quality

When Quality Improvement Organizations (QIOs) and providers work together, the rate of hospital readmission is less than in areas where QIOs do not work with providers, according to the American Health Quality Association (AHQA). The data provided by the AHQA shows that this collaboration has prevented more than 95,000 hospitalization and 27,000 hospital readmissions among Medicare beneficiaries resulting in a cost savings of nearly $1 billion.  In addition, recent data shows that QIOs have helped improve care at nursing homes as well by reducing the uses of restraints and the rate at which pressure sores develop.

Readmission Reduction

From October 2010 to March 2013 readmission rates among Medicare beneficiaries declined by 13.22 percent when the provider worked with a QIO, reported the AHQA.  The readmission rate for Medicare beneficiaries for providers who did not work with a QIO declined by 12.55 percent.  Similarly the AHQA reported that overall hospital admissions for Medicare beneficiaries declined by 8.39 percent when the provider worked with a QIO as opposed to 8.12 percent reduction in hospital admissions for Medicare beneficiaries when the provider did not work with a QIO.

An earlier study in the Journal of the American Medical Association (JAMA) came to similar conclusions. That study found that rehospitalizations were cut in half when providers worked with QIOs. In these cases QIOs implemented strategies aimed at (1) developing effective community coalitions that work to help keep patients healthy; (2) develop standard transition process as patients move from one care setting to another; (3) transferring patient clinical information between providers in a timely fashion; and (4) helping patients and their family members become actively engaged in the transition from one care setting to another.   The study involved 6,800 hospitalizations and averted 1,800 rehospitalizations.


A QIO is usually a non-profit organization staffed by doctors trained in medical review;  ensures that services provided to Medicare beneficiaries are medically necessary, reasonable, effective, and economical; and that the services meet professionals accepted standards of care. QIOs have been around since the 1980′s and there is generally one QIO per state. QIOs, among other things, are required to establish Memoranda of Agreements with providers and health plans that are consistent with the goals of the Health Care Quality Improvement Program.  They are  also to implement quality improvement projects on a standardized set of quality indicators and initiate local projects to improve quality.

“QIOs work in close partnership with physicians, nurses, and other members of the interdisciplinary team across settings–forming a network that helps patients remain healthy long after they leave the hospital,” said Adrienne Mimms Vice President and Chief Medical Officer of Atlanta-based Alliant GMCF, the QIO for Georgia and president of the AHQA.

HAIs. A greater reduction in hospital acquired infections (HAIs) has been reported in areas where QIOs work with providers as well, according to the AHQA.  From February 2011 to August 2013, QIOs’ efforts resulted in a 53 percent reduction in central line associated blood stream infections.  In addition, hospitals that work with QIOs have reduced the total number of Medicare patient days in which a catheter was used by more that 85,000 days. A major source of HAIs is catheter associated urinary infections.

Improvements at Nursing Homes

In another QIO project the rate of pressure sore development in nursing homes has been dramatically reduced according to a report in McKnights. Nursing homes working with QIOs have achieved a 38 percent reduction in the rate of pressure sore development from 2011 to 2014.  The use of restraints in nursing homes working with QIOs has been reduced by 76 percent under a separate initiative involving 1,000 nursing facilities working with QIOs.

“As the rates of chronic disease increase and the baby boom generation ages, it’s essential that we improve the quality of health care provided to  America’s seniors,” said Todd Ketch, executive director of AHQA. “Quality Improvement Organizations have driven major improvements in the quality of care across the nation, and in the years ahead, our work with QIOs will focus on  coordinating patient care across settings, reducing health care associated infections, improving care for common conditions like diabetes and heart disease, and more,” said Patrick Conway, MD, MSc, Chief Medical Officer for CMS, and Deputy Administrator for Innovation and Quality.