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Patient safety and tort reform
Question: Developments in medical tort reform include:
A. Continued constitutional challenges to caps on damages.
B. An emphasis on patient safety.
C. Hillary Clinton’s Senate bill.
D. Linking medical tort reform to error reduction.
E. All of the above.
Answer: E. Recent years have witnessed a stabilizing environment for medical liability, although insurance premiums continue to vary greatly by specialty and geographic location.
Recent statistics from the American Medical Association show that 2014 ob.gyn. insurance rates range from less than $50,000 in some areas of California to a high of $215,000 in Nassau and Suffolk counties in New York. The highest average expense in 2013, around a quarter of a million dollars, was for those claims that resulted in plaintiff verdicts, while defendant verdicts were substantially lower and averaged $140,000.
As in the past, most claims were dropped, dismissed, or withdrawn. About one-quarter of claims were settled, with only 2% decided by an alternative dispute resolution. Less than 8% were decided by trial verdict, with the vast majority won by the defendant.
The plaintiff bar continues to mount constitutional challenges to caps on damages. The California Supreme Court had previously ruled that reforms under California’s historic Medical Injury Compensation Reform Act (MICRA)1, which limits noneconomic recovery to $250,000, are constitutional, because they are rationally related to the legitimate legislative goal of reducing medical costs.
However, the statute has again come under challenge, only to be reaffirmed by a California state appeals court. In November 2014, California voters rejected Proposition 46, which sought to increase the cap from $250,000 to $1.1 million.
Texas, another pro-reform state, sides with California, and Mississippi also ruled that its damage cap is constitutional. However, Florida and Oklahoma recently joined jurisdictions such as Georgia, Illinois, and Missouri in ruling that damage caps are unconstitutional.
Asserting that the current health care liability system has been an inefficient and sometimes ineffective mechanism for initiating or resolving claims of medical error, medical negligence, or malpractice, then-U.S. senators Hillary Clinton (D-N.Y.) and Barack Obama (D-Ill.) in 2005 jointly sponsored legislation (S. 1784) to establish a National Medical Error Disclosure and Compensation Program (National MEDiC Act). Although the bill was killed in Senate committee, its key provisions were subsequently published in the New England Journal of Medicine (2006;354:2205-8).
The senators noted that the liability system has failed to the extent that only one medical malpractice claim is filed for every eight medical injuries, that it takes 4-8 years to resolve a claim, and that “solutions to the patient safety, litigation, and medical liability insurance problems have been elusive.”
Accordingly, the bill’s purpose was to promote the confidential disclosure to patients of medical errors in an effort to improve patient-safety systems. At the time of disclosure, there would be negotiations for compensation and proposals to prevent a recurrence of the problem that led to the patient’s injury. However, the patient would retain the right to counsel during negotiations, as well as access to the courts if no agreement were reached. The bill was entirely silent on traditional tort reform measures.
Nearly 4 decades earlier, a no-fault proposal by Professor Jeffrey O’Connell made some of these points, but with sharper focus and specificity, especially regarding damages.2
In marked contrast to the Clinton-Obama bill, his proposal gave the medical provider the exclusive option to tender payment, which would completely foreclose future tort action by the victim. Compensation benefits included net economic loss such as 100% of lost wages, replacement service loss, medical treatment expenses, and reasonable attorney’s fees. But noneconomic losses, such as pain and suffering, were not reimbursable, and payment was net of any benefits from collateral sources.
This proposal elegantly combined efficiency and fairness, and would have ameliorated the financial and emotional toll that comes with litigating injuries arising out of health care. Legislation in the House of Representatives, the Alternative Medical Liability Act (H.R. 5400), incorporated many of these features, and came before the 98th U.S. Congress in 1984. It, too, died in committee.
There may be something to the current trend toward pairing tort reform with error reduction. Thoughtful observers point to “disclosure and offer” programs such as the one at the Lexington (Ky.) Veterans Affairs Medical Center, which boasts average settlements of approximately $15,000 per claim – compared with more than $98,000 at other VA institutions. Its policy has also decreased the average duration of cases, previously 2-4 years, to 2-4 months, as well as reduced costs for legal defense.
Likewise, the program at the University of Michigan Health System has reduced both the frequency and severity of claims, duration of cases, and litigation costs. Aware of these developments, some private insurers, such as the COPIC Insurance Company in Colorado, are adopting a similar approach.
In its updated 2014 tort reform position paper, the American College of Physicians continues to endorse caps on noneconomic and punitive damages, as well as other tort reform measures.
However, it now acknowledges that “improving patient safety and preventing errors must be at the fore of the medical liability reform discussion.” The ACP correctly asserts that “emphasizing patient safety, promoting a culture of quality improvement and coordinated care, and training physicians in best practices to avoid errors and reduce risk will prevent harm and reduce the waste associated with defensive medicine.”
This hybrid approach combining traditional tort reforms with a renewed attention to patient safety through medical error reduction may yet yield additional practical benefits.
Here, the experience in anesthesiology bears recounting: Its dramatic progress in risk management has cut patient death rate from 1 in 5,000 to 1 in 200,000 to 300,000 in the space of 20 years, and this has been associated with a concurrent 37% fall in insurance premiums.
References
1. Medical Injury Compensation Reform Act of 1975, Cal. Civ. Proc. Code § 3333.2 (West 1982).
2. O’Connell, J. No-Fault Insurance for Injuries Arising from Medical Treatment: A Proposal for Elective Coverage. Emory L. J. 1975;24:21.
Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. Currently, he directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: Developments in medical tort reform include:
A. Continued constitutional challenges to caps on damages.
B. An emphasis on patient safety.
C. Hillary Clinton’s Senate bill.
D. Linking medical tort reform to error reduction.
E. All of the above.
Answer: E. Recent years have witnessed a stabilizing environment for medical liability, although insurance premiums continue to vary greatly by specialty and geographic location.
Recent statistics from the American Medical Association show that 2014 ob.gyn. insurance rates range from less than $50,000 in some areas of California to a high of $215,000 in Nassau and Suffolk counties in New York. The highest average expense in 2013, around a quarter of a million dollars, was for those claims that resulted in plaintiff verdicts, while defendant verdicts were substantially lower and averaged $140,000.
As in the past, most claims were dropped, dismissed, or withdrawn. About one-quarter of claims were settled, with only 2% decided by an alternative dispute resolution. Less than 8% were decided by trial verdict, with the vast majority won by the defendant.
The plaintiff bar continues to mount constitutional challenges to caps on damages. The California Supreme Court had previously ruled that reforms under California’s historic Medical Injury Compensation Reform Act (MICRA)1, which limits noneconomic recovery to $250,000, are constitutional, because they are rationally related to the legitimate legislative goal of reducing medical costs.
However, the statute has again come under challenge, only to be reaffirmed by a California state appeals court. In November 2014, California voters rejected Proposition 46, which sought to increase the cap from $250,000 to $1.1 million.
Texas, another pro-reform state, sides with California, and Mississippi also ruled that its damage cap is constitutional. However, Florida and Oklahoma recently joined jurisdictions such as Georgia, Illinois, and Missouri in ruling that damage caps are unconstitutional.
Asserting that the current health care liability system has been an inefficient and sometimes ineffective mechanism for initiating or resolving claims of medical error, medical negligence, or malpractice, then-U.S. senators Hillary Clinton (D-N.Y.) and Barack Obama (D-Ill.) in 2005 jointly sponsored legislation (S. 1784) to establish a National Medical Error Disclosure and Compensation Program (National MEDiC Act). Although the bill was killed in Senate committee, its key provisions were subsequently published in the New England Journal of Medicine (2006;354:2205-8).
The senators noted that the liability system has failed to the extent that only one medical malpractice claim is filed for every eight medical injuries, that it takes 4-8 years to resolve a claim, and that “solutions to the patient safety, litigation, and medical liability insurance problems have been elusive.”
Accordingly, the bill’s purpose was to promote the confidential disclosure to patients of medical errors in an effort to improve patient-safety systems. At the time of disclosure, there would be negotiations for compensation and proposals to prevent a recurrence of the problem that led to the patient’s injury. However, the patient would retain the right to counsel during negotiations, as well as access to the courts if no agreement were reached. The bill was entirely silent on traditional tort reform measures.
Nearly 4 decades earlier, a no-fault proposal by Professor Jeffrey O’Connell made some of these points, but with sharper focus and specificity, especially regarding damages.2
In marked contrast to the Clinton-Obama bill, his proposal gave the medical provider the exclusive option to tender payment, which would completely foreclose future tort action by the victim. Compensation benefits included net economic loss such as 100% of lost wages, replacement service loss, medical treatment expenses, and reasonable attorney’s fees. But noneconomic losses, such as pain and suffering, were not reimbursable, and payment was net of any benefits from collateral sources.
This proposal elegantly combined efficiency and fairness, and would have ameliorated the financial and emotional toll that comes with litigating injuries arising out of health care. Legislation in the House of Representatives, the Alternative Medical Liability Act (H.R. 5400), incorporated many of these features, and came before the 98th U.S. Congress in 1984. It, too, died in committee.
There may be something to the current trend toward pairing tort reform with error reduction. Thoughtful observers point to “disclosure and offer” programs such as the one at the Lexington (Ky.) Veterans Affairs Medical Center, which boasts average settlements of approximately $15,000 per claim – compared with more than $98,000 at other VA institutions. Its policy has also decreased the average duration of cases, previously 2-4 years, to 2-4 months, as well as reduced costs for legal defense.
Likewise, the program at the University of Michigan Health System has reduced both the frequency and severity of claims, duration of cases, and litigation costs. Aware of these developments, some private insurers, such as the COPIC Insurance Company in Colorado, are adopting a similar approach.
In its updated 2014 tort reform position paper, the American College of Physicians continues to endorse caps on noneconomic and punitive damages, as well as other tort reform measures.
However, it now acknowledges that “improving patient safety and preventing errors must be at the fore of the medical liability reform discussion.” The ACP correctly asserts that “emphasizing patient safety, promoting a culture of quality improvement and coordinated care, and training physicians in best practices to avoid errors and reduce risk will prevent harm and reduce the waste associated with defensive medicine.”
This hybrid approach combining traditional tort reforms with a renewed attention to patient safety through medical error reduction may yet yield additional practical benefits.
Here, the experience in anesthesiology bears recounting: Its dramatic progress in risk management has cut patient death rate from 1 in 5,000 to 1 in 200,000 to 300,000 in the space of 20 years, and this has been associated with a concurrent 37% fall in insurance premiums.
References
1. Medical Injury Compensation Reform Act of 1975, Cal. Civ. Proc. Code § 3333.2 (West 1982).
2. O’Connell, J. No-Fault Insurance for Injuries Arising from Medical Treatment: A Proposal for Elective Coverage. Emory L. J. 1975;24:21.
Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. Currently, he directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: Developments in medical tort reform include:
A. Continued constitutional challenges to caps on damages.
B. An emphasis on patient safety.
C. Hillary Clinton’s Senate bill.
D. Linking medical tort reform to error reduction.
E. All of the above.
Answer: E. Recent years have witnessed a stabilizing environment for medical liability, although insurance premiums continue to vary greatly by specialty and geographic location.
Recent statistics from the American Medical Association show that 2014 ob.gyn. insurance rates range from less than $50,000 in some areas of California to a high of $215,000 in Nassau and Suffolk counties in New York. The highest average expense in 2013, around a quarter of a million dollars, was for those claims that resulted in plaintiff verdicts, while defendant verdicts were substantially lower and averaged $140,000.
As in the past, most claims were dropped, dismissed, or withdrawn. About one-quarter of claims were settled, with only 2% decided by an alternative dispute resolution. Less than 8% were decided by trial verdict, with the vast majority won by the defendant.
The plaintiff bar continues to mount constitutional challenges to caps on damages. The California Supreme Court had previously ruled that reforms under California’s historic Medical Injury Compensation Reform Act (MICRA)1, which limits noneconomic recovery to $250,000, are constitutional, because they are rationally related to the legitimate legislative goal of reducing medical costs.
However, the statute has again come under challenge, only to be reaffirmed by a California state appeals court. In November 2014, California voters rejected Proposition 46, which sought to increase the cap from $250,000 to $1.1 million.
Texas, another pro-reform state, sides with California, and Mississippi also ruled that its damage cap is constitutional. However, Florida and Oklahoma recently joined jurisdictions such as Georgia, Illinois, and Missouri in ruling that damage caps are unconstitutional.
Asserting that the current health care liability system has been an inefficient and sometimes ineffective mechanism for initiating or resolving claims of medical error, medical negligence, or malpractice, then-U.S. senators Hillary Clinton (D-N.Y.) and Barack Obama (D-Ill.) in 2005 jointly sponsored legislation (S. 1784) to establish a National Medical Error Disclosure and Compensation Program (National MEDiC Act). Although the bill was killed in Senate committee, its key provisions were subsequently published in the New England Journal of Medicine (2006;354:2205-8).
The senators noted that the liability system has failed to the extent that only one medical malpractice claim is filed for every eight medical injuries, that it takes 4-8 years to resolve a claim, and that “solutions to the patient safety, litigation, and medical liability insurance problems have been elusive.”
Accordingly, the bill’s purpose was to promote the confidential disclosure to patients of medical errors in an effort to improve patient-safety systems. At the time of disclosure, there would be negotiations for compensation and proposals to prevent a recurrence of the problem that led to the patient’s injury. However, the patient would retain the right to counsel during negotiations, as well as access to the courts if no agreement were reached. The bill was entirely silent on traditional tort reform measures.
Nearly 4 decades earlier, a no-fault proposal by Professor Jeffrey O’Connell made some of these points, but with sharper focus and specificity, especially regarding damages.2
In marked contrast to the Clinton-Obama bill, his proposal gave the medical provider the exclusive option to tender payment, which would completely foreclose future tort action by the victim. Compensation benefits included net economic loss such as 100% of lost wages, replacement service loss, medical treatment expenses, and reasonable attorney’s fees. But noneconomic losses, such as pain and suffering, were not reimbursable, and payment was net of any benefits from collateral sources.
This proposal elegantly combined efficiency and fairness, and would have ameliorated the financial and emotional toll that comes with litigating injuries arising out of health care. Legislation in the House of Representatives, the Alternative Medical Liability Act (H.R. 5400), incorporated many of these features, and came before the 98th U.S. Congress in 1984. It, too, died in committee.
There may be something to the current trend toward pairing tort reform with error reduction. Thoughtful observers point to “disclosure and offer” programs such as the one at the Lexington (Ky.) Veterans Affairs Medical Center, which boasts average settlements of approximately $15,000 per claim – compared with more than $98,000 at other VA institutions. Its policy has also decreased the average duration of cases, previously 2-4 years, to 2-4 months, as well as reduced costs for legal defense.
Likewise, the program at the University of Michigan Health System has reduced both the frequency and severity of claims, duration of cases, and litigation costs. Aware of these developments, some private insurers, such as the COPIC Insurance Company in Colorado, are adopting a similar approach.
In its updated 2014 tort reform position paper, the American College of Physicians continues to endorse caps on noneconomic and punitive damages, as well as other tort reform measures.
However, it now acknowledges that “improving patient safety and preventing errors must be at the fore of the medical liability reform discussion.” The ACP correctly asserts that “emphasizing patient safety, promoting a culture of quality improvement and coordinated care, and training physicians in best practices to avoid errors and reduce risk will prevent harm and reduce the waste associated with defensive medicine.”
This hybrid approach combining traditional tort reforms with a renewed attention to patient safety through medical error reduction may yet yield additional practical benefits.
Here, the experience in anesthesiology bears recounting: Its dramatic progress in risk management has cut patient death rate from 1 in 5,000 to 1 in 200,000 to 300,000 in the space of 20 years, and this has been associated with a concurrent 37% fall in insurance premiums.
References
1. Medical Injury Compensation Reform Act of 1975, Cal. Civ. Proc. Code § 3333.2 (West 1982).
2. O’Connell, J. No-Fault Insurance for Injuries Arising from Medical Treatment: A Proposal for Elective Coverage. Emory L. J. 1975;24:21.
Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. Currently, he directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
M.O.R.E. means less delirium in ICU
PHOENIX – Adding a protocol of bundled nonpharmacologic interventions to the currently recommended standard of care nearly halved the amount of time patients spent delirious in the intensive care unit, a study has shown.
The combination of soothing music, natural light, routine cognitive stimulation, and the use of any necessary patient vision or hearing aids, added to standard ICU mobility and sedation protocols, also reduced the odds of developing any delirium, when researchers controlled for age, dementia, APACHE II score, and mechanical ventilation.
The data are from a prospective pre- and post–quality improvement cohort evaluation of the percentage of time patients spent delirious during their total medical ICU stay, rather than just the prevalence of delirium.
“We think this study really brings something unique to the knowledge of ICU delirium,” Ryan Rivosecchi, Pharm.D., a second-year resident at the University of Pittsburgh, said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. “Delirium is a disease of a waxing and waning nature, and purely going on its prevalence may not tell the full story.”
Currently, the recommendation with the highest level of evidence for preventing ICU delirium, as noted in the 2013 updated SCCM guidelines for pain, agitation, and delirium, is early mobilization. There are scant other evidence-based recommendations for how to prevent and treat the condition, leaving “a lot of practitioners wondering how they should take care of their delirious patients,” Dr. Rivosecchi said.
Delirium experienced during ICU stays has been associated with some form of residual cognitive impairment in more than 70% of patients and increases in lengths of stay by as many as 15 days. Delirium in the ICU has also been associated with a nearly 20% increase in mortality rates 6 months after admission to the ICU.
Noting that his institution already adhered to the standard recommendations for early mobility and sedation algorithms, Dr. Rivosecchi said he and his colleagues conducted the study at the University of Pittsburgh’s 24-bed medical ICU, in hopes of providing an additional evidence-based intervention to reduce ICU delirium.
Among 729 adult patients screened between September 2013 and April 2014, 230 patients who had not been in the ICU prior to MICU admission, and who did not present with delirium or baseline cognitive impairment, were chosen for the pre–quality improvement phase.
The post–quality improvement arm of the study comprised 253 patients who met the same criteria as did those in the first arm. The median age for both groups was 59 years. Slightly more than half of all patients were male.
The primary outcome was the total time a patient spent delirious throughout the entire MICU stay, as measured six times daily, every 4 hours, via the Intensive Care Delirium Screening Checklist. “Patients evaluated as ‘delirious’ at time point A were considered delirious for the next 4 hours until they were evaluated again at time point B,” Dr. Rivosecchi said.
During the first 3 months of the study, nurses on the MICU floor were unaware that baseline data about their unit were being collected. In the fourth month, the investigators discussed their observations with the nursing staff, and with the nursing director and clinician on the unit.
Several unique interventions, distilled from these meetings and a review of protocols already in place, were combined with findings from a systematic review of the literature, into one preventive protocol named M.O.R.E.: Music; Opening of blinds; Reorientation and cognitive stimulation; Eye and ear protocol.
After the nurse meetings, another month passed before the post–quality improvement phase of the study began. The nurses were once again unaware data were being collected; however, according to Dr. Rivosecchi, not only did the entire medical staff, including the pharmacists, embrace the new protocol, but the nurses were so enthusiastic about it they collaborated on a poem to express their intentions to the patients and the patients’ families. Copies of the poem were placed in zippered pouches that included a sleep mask, ear plugs, and headphones, distributed to each MICU patient to help them block out unnecessary stimulation.
“The delirium prevention care bag was an idea the nurses came up with on their own to really help the patients out,” Dr. Rivosecchi said.
Signage detailing the specific actions included in the mnemonic M.O.R.E. was posted throughout the MICU to make it easier for the nursing staff to remember, although how the nurses implemented the protocol was left to them, Dr. Rivosecchi said.
The signs advised that MICU patients be exposed to at least 1 hour of “relaxing/soothing” music per nurse shift, and that if the patient were not actually viewing the television, it be kept off.
To help patients maintain a normal diurnal rhythm, nurses were advised to angle patients so that they could have a view of a window that was kept open from morning until evening to allow in as much natural light as possible.
Rather than employ the typical “alert and orient times three” protocol, the staff was instructed to create mental tasks for the patients, such as asking them their names and how they preferred to be addressed, and to reorient patients by discussing with them the status of their hospitalization.
If patients were accustomed to wearing visual or hearing aids, the nurses were asked to encourage them to use the aids while in the MICU.
The group of 230 studied before M.O.R.E. was in place had 36 patients who experienced delirium, compared with 24 of the 253 patients observed after the interventions were instituted.
The total reduction in the amount of time these patients spent in delirious states was 40.4%. The first arm’s total time spent delirious was 16.1% (1,088 out of 6,747 hours), compared with 9.6% (485 out of 5, 071 hours) of the total time in the second arm (P < .001).
The typical length of stay for the first arm was 58 hours, and 68 hours in the second.
At baseline, there was a statistically significant difference in illness severity as measured by APACHE II scores between the groups: The first had a score of 15, while the second had a score of 17 (P = .002), although according to Dr. Rivosecchi, both arms followed the same predictive value of mortality at 24 hours (7.5% vs. 11.1%, P = .21).
Also of note, Dr. Rivosecchi said, was that there was a higher use of the benzodiazepines lorazepam and midazolam, commonly associated with higher rates of delirium, in the second phase of the study.
In a subanalysis using risk factors reported in the literature, the investigators determined that age, severity of illness, the use of mechanical ventilation, home anticholinergic use, and home antipsychotic use increased the odds of delirium, as did baseline depression or respiratory disease. After the researchers controlled for these factors, the M.O.R.E. protocol reduced the risk of developing delirium by 57% (odds ratio, 0.43, 95% confidence interval 0.24 - 0.77).
Statistically significant predictors of delirium were mechanical ventilation (OR 2.09, CI 1.11-3.91, P = .022), APACHE II score (1.07, CI 1.02 -1.11, P = .002) and dementia (5.12, CI 1.8 -14.3, P = .91).
“I was extremely surprised by the results, particularly since we had greater benzodiazepine use and arguably a sicker patient population in the post phase,” said Dr. Rivosecchi. “I definitely did not expect a 40% reduction.”
Despite the nurses’ enthusiasm, the study did not actually track their adherence to the protocol, a weakness Dr. Rivosecchi said he and his colleagues hoped to address in future evaluations of the protocol.
Meanwhile, according to Pamela Smithburger, Pharm.D., Dr. Rivosecchi’s mentor and the senior author on the paper, use of the M.O.R.E. protocol is now being rolled out across all ICUs within the University of Pittsburgh Medical Center’s entire system, which includes 13 hospitals, and that as the implementation continues, she will be collecting data on patient outcomes systemwide.
“Each ICU will be able to modify the M.O.R.E. protocol to best fit their work flow, culture, and environment,” Dr. Smithburger said in an interview.
The cost to do so comes down to time and staff education. “We utilized tools and resources already available, but by combining them into one protocol, improved outcomes.”
On Twitter @whitneymcknight
PHOENIX – Adding a protocol of bundled nonpharmacologic interventions to the currently recommended standard of care nearly halved the amount of time patients spent delirious in the intensive care unit, a study has shown.
The combination of soothing music, natural light, routine cognitive stimulation, and the use of any necessary patient vision or hearing aids, added to standard ICU mobility and sedation protocols, also reduced the odds of developing any delirium, when researchers controlled for age, dementia, APACHE II score, and mechanical ventilation.
The data are from a prospective pre- and post–quality improvement cohort evaluation of the percentage of time patients spent delirious during their total medical ICU stay, rather than just the prevalence of delirium.
“We think this study really brings something unique to the knowledge of ICU delirium,” Ryan Rivosecchi, Pharm.D., a second-year resident at the University of Pittsburgh, said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. “Delirium is a disease of a waxing and waning nature, and purely going on its prevalence may not tell the full story.”
Currently, the recommendation with the highest level of evidence for preventing ICU delirium, as noted in the 2013 updated SCCM guidelines for pain, agitation, and delirium, is early mobilization. There are scant other evidence-based recommendations for how to prevent and treat the condition, leaving “a lot of practitioners wondering how they should take care of their delirious patients,” Dr. Rivosecchi said.
Delirium experienced during ICU stays has been associated with some form of residual cognitive impairment in more than 70% of patients and increases in lengths of stay by as many as 15 days. Delirium in the ICU has also been associated with a nearly 20% increase in mortality rates 6 months after admission to the ICU.
Noting that his institution already adhered to the standard recommendations for early mobility and sedation algorithms, Dr. Rivosecchi said he and his colleagues conducted the study at the University of Pittsburgh’s 24-bed medical ICU, in hopes of providing an additional evidence-based intervention to reduce ICU delirium.
Among 729 adult patients screened between September 2013 and April 2014, 230 patients who had not been in the ICU prior to MICU admission, and who did not present with delirium or baseline cognitive impairment, were chosen for the pre–quality improvement phase.
The post–quality improvement arm of the study comprised 253 patients who met the same criteria as did those in the first arm. The median age for both groups was 59 years. Slightly more than half of all patients were male.
The primary outcome was the total time a patient spent delirious throughout the entire MICU stay, as measured six times daily, every 4 hours, via the Intensive Care Delirium Screening Checklist. “Patients evaluated as ‘delirious’ at time point A were considered delirious for the next 4 hours until they were evaluated again at time point B,” Dr. Rivosecchi said.
During the first 3 months of the study, nurses on the MICU floor were unaware that baseline data about their unit were being collected. In the fourth month, the investigators discussed their observations with the nursing staff, and with the nursing director and clinician on the unit.
Several unique interventions, distilled from these meetings and a review of protocols already in place, were combined with findings from a systematic review of the literature, into one preventive protocol named M.O.R.E.: Music; Opening of blinds; Reorientation and cognitive stimulation; Eye and ear protocol.
After the nurse meetings, another month passed before the post–quality improvement phase of the study began. The nurses were once again unaware data were being collected; however, according to Dr. Rivosecchi, not only did the entire medical staff, including the pharmacists, embrace the new protocol, but the nurses were so enthusiastic about it they collaborated on a poem to express their intentions to the patients and the patients’ families. Copies of the poem were placed in zippered pouches that included a sleep mask, ear plugs, and headphones, distributed to each MICU patient to help them block out unnecessary stimulation.
“The delirium prevention care bag was an idea the nurses came up with on their own to really help the patients out,” Dr. Rivosecchi said.
Signage detailing the specific actions included in the mnemonic M.O.R.E. was posted throughout the MICU to make it easier for the nursing staff to remember, although how the nurses implemented the protocol was left to them, Dr. Rivosecchi said.
The signs advised that MICU patients be exposed to at least 1 hour of “relaxing/soothing” music per nurse shift, and that if the patient were not actually viewing the television, it be kept off.
To help patients maintain a normal diurnal rhythm, nurses were advised to angle patients so that they could have a view of a window that was kept open from morning until evening to allow in as much natural light as possible.
Rather than employ the typical “alert and orient times three” protocol, the staff was instructed to create mental tasks for the patients, such as asking them their names and how they preferred to be addressed, and to reorient patients by discussing with them the status of their hospitalization.
If patients were accustomed to wearing visual or hearing aids, the nurses were asked to encourage them to use the aids while in the MICU.
The group of 230 studied before M.O.R.E. was in place had 36 patients who experienced delirium, compared with 24 of the 253 patients observed after the interventions were instituted.
The total reduction in the amount of time these patients spent in delirious states was 40.4%. The first arm’s total time spent delirious was 16.1% (1,088 out of 6,747 hours), compared with 9.6% (485 out of 5, 071 hours) of the total time in the second arm (P < .001).
The typical length of stay for the first arm was 58 hours, and 68 hours in the second.
At baseline, there was a statistically significant difference in illness severity as measured by APACHE II scores between the groups: The first had a score of 15, while the second had a score of 17 (P = .002), although according to Dr. Rivosecchi, both arms followed the same predictive value of mortality at 24 hours (7.5% vs. 11.1%, P = .21).
Also of note, Dr. Rivosecchi said, was that there was a higher use of the benzodiazepines lorazepam and midazolam, commonly associated with higher rates of delirium, in the second phase of the study.
In a subanalysis using risk factors reported in the literature, the investigators determined that age, severity of illness, the use of mechanical ventilation, home anticholinergic use, and home antipsychotic use increased the odds of delirium, as did baseline depression or respiratory disease. After the researchers controlled for these factors, the M.O.R.E. protocol reduced the risk of developing delirium by 57% (odds ratio, 0.43, 95% confidence interval 0.24 - 0.77).
Statistically significant predictors of delirium were mechanical ventilation (OR 2.09, CI 1.11-3.91, P = .022), APACHE II score (1.07, CI 1.02 -1.11, P = .002) and dementia (5.12, CI 1.8 -14.3, P = .91).
“I was extremely surprised by the results, particularly since we had greater benzodiazepine use and arguably a sicker patient population in the post phase,” said Dr. Rivosecchi. “I definitely did not expect a 40% reduction.”
Despite the nurses’ enthusiasm, the study did not actually track their adherence to the protocol, a weakness Dr. Rivosecchi said he and his colleagues hoped to address in future evaluations of the protocol.
Meanwhile, according to Pamela Smithburger, Pharm.D., Dr. Rivosecchi’s mentor and the senior author on the paper, use of the M.O.R.E. protocol is now being rolled out across all ICUs within the University of Pittsburgh Medical Center’s entire system, which includes 13 hospitals, and that as the implementation continues, she will be collecting data on patient outcomes systemwide.
“Each ICU will be able to modify the M.O.R.E. protocol to best fit their work flow, culture, and environment,” Dr. Smithburger said in an interview.
The cost to do so comes down to time and staff education. “We utilized tools and resources already available, but by combining them into one protocol, improved outcomes.”
On Twitter @whitneymcknight
PHOENIX – Adding a protocol of bundled nonpharmacologic interventions to the currently recommended standard of care nearly halved the amount of time patients spent delirious in the intensive care unit, a study has shown.
The combination of soothing music, natural light, routine cognitive stimulation, and the use of any necessary patient vision or hearing aids, added to standard ICU mobility and sedation protocols, also reduced the odds of developing any delirium, when researchers controlled for age, dementia, APACHE II score, and mechanical ventilation.
The data are from a prospective pre- and post–quality improvement cohort evaluation of the percentage of time patients spent delirious during their total medical ICU stay, rather than just the prevalence of delirium.
“We think this study really brings something unique to the knowledge of ICU delirium,” Ryan Rivosecchi, Pharm.D., a second-year resident at the University of Pittsburgh, said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. “Delirium is a disease of a waxing and waning nature, and purely going on its prevalence may not tell the full story.”
Currently, the recommendation with the highest level of evidence for preventing ICU delirium, as noted in the 2013 updated SCCM guidelines for pain, agitation, and delirium, is early mobilization. There are scant other evidence-based recommendations for how to prevent and treat the condition, leaving “a lot of practitioners wondering how they should take care of their delirious patients,” Dr. Rivosecchi said.
Delirium experienced during ICU stays has been associated with some form of residual cognitive impairment in more than 70% of patients and increases in lengths of stay by as many as 15 days. Delirium in the ICU has also been associated with a nearly 20% increase in mortality rates 6 months after admission to the ICU.
Noting that his institution already adhered to the standard recommendations for early mobility and sedation algorithms, Dr. Rivosecchi said he and his colleagues conducted the study at the University of Pittsburgh’s 24-bed medical ICU, in hopes of providing an additional evidence-based intervention to reduce ICU delirium.
Among 729 adult patients screened between September 2013 and April 2014, 230 patients who had not been in the ICU prior to MICU admission, and who did not present with delirium or baseline cognitive impairment, were chosen for the pre–quality improvement phase.
The post–quality improvement arm of the study comprised 253 patients who met the same criteria as did those in the first arm. The median age for both groups was 59 years. Slightly more than half of all patients were male.
The primary outcome was the total time a patient spent delirious throughout the entire MICU stay, as measured six times daily, every 4 hours, via the Intensive Care Delirium Screening Checklist. “Patients evaluated as ‘delirious’ at time point A were considered delirious for the next 4 hours until they were evaluated again at time point B,” Dr. Rivosecchi said.
During the first 3 months of the study, nurses on the MICU floor were unaware that baseline data about their unit were being collected. In the fourth month, the investigators discussed their observations with the nursing staff, and with the nursing director and clinician on the unit.
Several unique interventions, distilled from these meetings and a review of protocols already in place, were combined with findings from a systematic review of the literature, into one preventive protocol named M.O.R.E.: Music; Opening of blinds; Reorientation and cognitive stimulation; Eye and ear protocol.
After the nurse meetings, another month passed before the post–quality improvement phase of the study began. The nurses were once again unaware data were being collected; however, according to Dr. Rivosecchi, not only did the entire medical staff, including the pharmacists, embrace the new protocol, but the nurses were so enthusiastic about it they collaborated on a poem to express their intentions to the patients and the patients’ families. Copies of the poem were placed in zippered pouches that included a sleep mask, ear plugs, and headphones, distributed to each MICU patient to help them block out unnecessary stimulation.
“The delirium prevention care bag was an idea the nurses came up with on their own to really help the patients out,” Dr. Rivosecchi said.
Signage detailing the specific actions included in the mnemonic M.O.R.E. was posted throughout the MICU to make it easier for the nursing staff to remember, although how the nurses implemented the protocol was left to them, Dr. Rivosecchi said.
The signs advised that MICU patients be exposed to at least 1 hour of “relaxing/soothing” music per nurse shift, and that if the patient were not actually viewing the television, it be kept off.
To help patients maintain a normal diurnal rhythm, nurses were advised to angle patients so that they could have a view of a window that was kept open from morning until evening to allow in as much natural light as possible.
Rather than employ the typical “alert and orient times three” protocol, the staff was instructed to create mental tasks for the patients, such as asking them their names and how they preferred to be addressed, and to reorient patients by discussing with them the status of their hospitalization.
If patients were accustomed to wearing visual or hearing aids, the nurses were asked to encourage them to use the aids while in the MICU.
The group of 230 studied before M.O.R.E. was in place had 36 patients who experienced delirium, compared with 24 of the 253 patients observed after the interventions were instituted.
The total reduction in the amount of time these patients spent in delirious states was 40.4%. The first arm’s total time spent delirious was 16.1% (1,088 out of 6,747 hours), compared with 9.6% (485 out of 5, 071 hours) of the total time in the second arm (P < .001).
The typical length of stay for the first arm was 58 hours, and 68 hours in the second.
At baseline, there was a statistically significant difference in illness severity as measured by APACHE II scores between the groups: The first had a score of 15, while the second had a score of 17 (P = .002), although according to Dr. Rivosecchi, both arms followed the same predictive value of mortality at 24 hours (7.5% vs. 11.1%, P = .21).
Also of note, Dr. Rivosecchi said, was that there was a higher use of the benzodiazepines lorazepam and midazolam, commonly associated with higher rates of delirium, in the second phase of the study.
In a subanalysis using risk factors reported in the literature, the investigators determined that age, severity of illness, the use of mechanical ventilation, home anticholinergic use, and home antipsychotic use increased the odds of delirium, as did baseline depression or respiratory disease. After the researchers controlled for these factors, the M.O.R.E. protocol reduced the risk of developing delirium by 57% (odds ratio, 0.43, 95% confidence interval 0.24 - 0.77).
Statistically significant predictors of delirium were mechanical ventilation (OR 2.09, CI 1.11-3.91, P = .022), APACHE II score (1.07, CI 1.02 -1.11, P = .002) and dementia (5.12, CI 1.8 -14.3, P = .91).
“I was extremely surprised by the results, particularly since we had greater benzodiazepine use and arguably a sicker patient population in the post phase,” said Dr. Rivosecchi. “I definitely did not expect a 40% reduction.”
Despite the nurses’ enthusiasm, the study did not actually track their adherence to the protocol, a weakness Dr. Rivosecchi said he and his colleagues hoped to address in future evaluations of the protocol.
Meanwhile, according to Pamela Smithburger, Pharm.D., Dr. Rivosecchi’s mentor and the senior author on the paper, use of the M.O.R.E. protocol is now being rolled out across all ICUs within the University of Pittsburgh Medical Center’s entire system, which includes 13 hospitals, and that as the implementation continues, she will be collecting data on patient outcomes systemwide.
“Each ICU will be able to modify the M.O.R.E. protocol to best fit their work flow, culture, and environment,” Dr. Smithburger said in an interview.
The cost to do so comes down to time and staff education. “We utilized tools and resources already available, but by combining them into one protocol, improved outcomes.”
On Twitter @whitneymcknight
AT THE CRITICAL CARE CONGRESS
Key clinical point: Certain nonpharmacologic interventions bundled into a single protocol could serve as a cost-effective way to cut ICU delirium rates.
Major finding: Time spent delirious by MICU patients was reduced by more than 40% (16.1% vs. 9.6%, P < .001) using the M.O.R.E protocol.
Data source: Prospective, pre- and post–quality improvement study of 729 MICU patients at a single academic medical center.
Disclosures: None of the study authors had relevant disclosures.
HHS: Half of Medicare payments tied to value, quality by 2018
The move to value- and quality-based payments gained impetus as the Department of Health & Human Services called for half of all Medicare payments to be out of fee-for-service by the end of 2018.
“This is the first time in the history of the program that explicit goals for alternative payment models and value-based payment models have been set for Medicare,” HHS Secretary Sylvia Burwell said in an editorial Jan. 26 in the New England Journal of Medicine (doi 10.1056.NEJMp1500445).
The goal is “to move away from the old way of doing things, which amounted to, ‘the more you do, the more you get paid,’ by linking nearly all pay to quality and value in some way to see that we are spending smarter,” Ms. Burwell said in a blog post on the HHS website.
As interim goals, Ms. Burwell said HHS aims to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016.
Ms. Burwell identified three strategies that the agency will employ. “The first is incentives: a major thrust of our efforts is to create an environment in which hospitals, physicians, and other providers are rewarded for delivering high-quality health care and have the resources and flexibility they need to do so.”
The Affordable Care Act provides a number of alternative payment models – accountable care organizations, patient-centered medical homes, and new models of bundled payments – to get this started.
“Looking ahead, we plan to develop and test new payment models for specialty care, starting with oncology care, and institute payments to providers for care coordination for patients with chronic conditions,” she said.
That emphasis on care coordination, along with population health, is the second focus. HHS plans to invest up to $800 million in providing hands-on support to 150,000 physicians “for developing skills and tools needed to improve care delivery and transition to alternative payment models.”
Finally, the agency seeks to accelerate data availability to help clinical decision making. Ms. Burwell highlighted ongoing efforts, including the federal meaningful use efforts.
The announcement received early support from the National Quality Forum and the American Medical Association.
“In order for payment models based on value to really work, all providers need clear, consistent measures that drive improvements in care and provide meaningful information for patients, while being clinically relevant and actionable for providers,” Dr. Christine Cassel, NQF president and CEO said in a statement. “The health care community needs better measures faster. The more efficient NQF process is key to meeting this challenge.”
AMA President Robert Wah said in a statement that physicians “have many ideas for redesigning and improving the delivery of high-quality patient care in this country. We strongly support reform of the Medicare payment system, including elimination of Medicare’s flawed sustainable growth rate formula, which provides a pathway for physicians to innovate and develop new models of health care delivery for our patients.”
The traditional method of fee for service pays providers the same, regardless of the quality or effectiveness of the care rendered. Indeed, one could argue that worse service delivery generated more revenue for additional care associated with complications or misdiagnoses.
Arkansas Medicaid has initiated payment reform by explicitly rewarding those physicians and hospitals that achieve quality outcomes at lower total resource utilization for a given episode of care. For the most part, local clinical leaders have supported the notion that more effective care deserves better payment than lesser quality work.
Administrative and clinical data analytics will increasingly allow for more nuanced evaluation of clinical episodes to make such determination fair and risk adjusted. Fee for service may well survive, but with payments adjusted for accountability for outcomes determined by quality and effectiveness metrics.
Dr. William Golden is professor of medicine and public health at University of Arkansas, Little Rock, and medical director of Arkansas DHS/Medicaid.
The traditional method of fee for service pays providers the same, regardless of the quality or effectiveness of the care rendered. Indeed, one could argue that worse service delivery generated more revenue for additional care associated with complications or misdiagnoses.
Arkansas Medicaid has initiated payment reform by explicitly rewarding those physicians and hospitals that achieve quality outcomes at lower total resource utilization for a given episode of care. For the most part, local clinical leaders have supported the notion that more effective care deserves better payment than lesser quality work.
Administrative and clinical data analytics will increasingly allow for more nuanced evaluation of clinical episodes to make such determination fair and risk adjusted. Fee for service may well survive, but with payments adjusted for accountability for outcomes determined by quality and effectiveness metrics.
Dr. William Golden is professor of medicine and public health at University of Arkansas, Little Rock, and medical director of Arkansas DHS/Medicaid.
The traditional method of fee for service pays providers the same, regardless of the quality or effectiveness of the care rendered. Indeed, one could argue that worse service delivery generated more revenue for additional care associated with complications or misdiagnoses.
Arkansas Medicaid has initiated payment reform by explicitly rewarding those physicians and hospitals that achieve quality outcomes at lower total resource utilization for a given episode of care. For the most part, local clinical leaders have supported the notion that more effective care deserves better payment than lesser quality work.
Administrative and clinical data analytics will increasingly allow for more nuanced evaluation of clinical episodes to make such determination fair and risk adjusted. Fee for service may well survive, but with payments adjusted for accountability for outcomes determined by quality and effectiveness metrics.
Dr. William Golden is professor of medicine and public health at University of Arkansas, Little Rock, and medical director of Arkansas DHS/Medicaid.
The move to value- and quality-based payments gained impetus as the Department of Health & Human Services called for half of all Medicare payments to be out of fee-for-service by the end of 2018.
“This is the first time in the history of the program that explicit goals for alternative payment models and value-based payment models have been set for Medicare,” HHS Secretary Sylvia Burwell said in an editorial Jan. 26 in the New England Journal of Medicine (doi 10.1056.NEJMp1500445).
The goal is “to move away from the old way of doing things, which amounted to, ‘the more you do, the more you get paid,’ by linking nearly all pay to quality and value in some way to see that we are spending smarter,” Ms. Burwell said in a blog post on the HHS website.
As interim goals, Ms. Burwell said HHS aims to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016.
Ms. Burwell identified three strategies that the agency will employ. “The first is incentives: a major thrust of our efforts is to create an environment in which hospitals, physicians, and other providers are rewarded for delivering high-quality health care and have the resources and flexibility they need to do so.”
The Affordable Care Act provides a number of alternative payment models – accountable care organizations, patient-centered medical homes, and new models of bundled payments – to get this started.
“Looking ahead, we plan to develop and test new payment models for specialty care, starting with oncology care, and institute payments to providers for care coordination for patients with chronic conditions,” she said.
That emphasis on care coordination, along with population health, is the second focus. HHS plans to invest up to $800 million in providing hands-on support to 150,000 physicians “for developing skills and tools needed to improve care delivery and transition to alternative payment models.”
Finally, the agency seeks to accelerate data availability to help clinical decision making. Ms. Burwell highlighted ongoing efforts, including the federal meaningful use efforts.
The announcement received early support from the National Quality Forum and the American Medical Association.
“In order for payment models based on value to really work, all providers need clear, consistent measures that drive improvements in care and provide meaningful information for patients, while being clinically relevant and actionable for providers,” Dr. Christine Cassel, NQF president and CEO said in a statement. “The health care community needs better measures faster. The more efficient NQF process is key to meeting this challenge.”
AMA President Robert Wah said in a statement that physicians “have many ideas for redesigning and improving the delivery of high-quality patient care in this country. We strongly support reform of the Medicare payment system, including elimination of Medicare’s flawed sustainable growth rate formula, which provides a pathway for physicians to innovate and develop new models of health care delivery for our patients.”
The move to value- and quality-based payments gained impetus as the Department of Health & Human Services called for half of all Medicare payments to be out of fee-for-service by the end of 2018.
“This is the first time in the history of the program that explicit goals for alternative payment models and value-based payment models have been set for Medicare,” HHS Secretary Sylvia Burwell said in an editorial Jan. 26 in the New England Journal of Medicine (doi 10.1056.NEJMp1500445).
The goal is “to move away from the old way of doing things, which amounted to, ‘the more you do, the more you get paid,’ by linking nearly all pay to quality and value in some way to see that we are spending smarter,” Ms. Burwell said in a blog post on the HHS website.
As interim goals, Ms. Burwell said HHS aims to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016.
Ms. Burwell identified three strategies that the agency will employ. “The first is incentives: a major thrust of our efforts is to create an environment in which hospitals, physicians, and other providers are rewarded for delivering high-quality health care and have the resources and flexibility they need to do so.”
The Affordable Care Act provides a number of alternative payment models – accountable care organizations, patient-centered medical homes, and new models of bundled payments – to get this started.
“Looking ahead, we plan to develop and test new payment models for specialty care, starting with oncology care, and institute payments to providers for care coordination for patients with chronic conditions,” she said.
That emphasis on care coordination, along with population health, is the second focus. HHS plans to invest up to $800 million in providing hands-on support to 150,000 physicians “for developing skills and tools needed to improve care delivery and transition to alternative payment models.”
Finally, the agency seeks to accelerate data availability to help clinical decision making. Ms. Burwell highlighted ongoing efforts, including the federal meaningful use efforts.
The announcement received early support from the National Quality Forum and the American Medical Association.
“In order for payment models based on value to really work, all providers need clear, consistent measures that drive improvements in care and provide meaningful information for patients, while being clinically relevant and actionable for providers,” Dr. Christine Cassel, NQF president and CEO said in a statement. “The health care community needs better measures faster. The more efficient NQF process is key to meeting this challenge.”
AMA President Robert Wah said in a statement that physicians “have many ideas for redesigning and improving the delivery of high-quality patient care in this country. We strongly support reform of the Medicare payment system, including elimination of Medicare’s flawed sustainable growth rate formula, which provides a pathway for physicians to innovate and develop new models of health care delivery for our patients.”
Nine states introduce telemedicine legislation
Legislators in nine states have introduced legislation that would expand the practice of telemedicine by streamlining physician licensure.
Lawmakers in Iowa, Minnesota, Nebraska, Oklahoma, South Dakota, Texas, Utah, Vermont, and Wyoming have proposed bills based on the Interstate Medical Licensure Compact. This model bill was crafted by the Federation of State Medical Boards (FSMB) in an effort to speed the process of issuing licenses for physicians who wish to practice across state lines
The compact offers an effective solution to balancing patient safety and quality care with the needs of a growing and changing health care market, Dr. Humayun J. Chaudhry, president and CEO of FSMB said in a statement. “The growing number of introductions in state legislatures represents the desire for a dynamic system of expedited licensure that simultaneously respects the inherent role of state regulatory agencies in protecting the public,” Dr. Chaudhry said. “At a time when some within the telemedicine industry seek to implement licensing frameworks that undermine and circumvent state licensing rules and practice requirements, the compact is a key element to ensuring state sovereignty while providing the license portability necessary to enhance the delivery of health care.”
The FSMB House of Delegates unanimously approved the development of an interstate compact to expedite medical licensure and facilitate multistate practice at its 2013 annual meeting. Under the proposed system, states and doctors would voluntarily enter into the compact, and approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction.
State boards of medicine would retain their individual authority for discipline and oversight, according to the compact. Interested physicians would also need to complete a background check including biometric data (such as fingerprints) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.
More than 25 medical and osteopathic boards have publicly expressed support for the model legislation, according to the FSMB.
On Twitter @legal_med
Legislators in nine states have introduced legislation that would expand the practice of telemedicine by streamlining physician licensure.
Lawmakers in Iowa, Minnesota, Nebraska, Oklahoma, South Dakota, Texas, Utah, Vermont, and Wyoming have proposed bills based on the Interstate Medical Licensure Compact. This model bill was crafted by the Federation of State Medical Boards (FSMB) in an effort to speed the process of issuing licenses for physicians who wish to practice across state lines
The compact offers an effective solution to balancing patient safety and quality care with the needs of a growing and changing health care market, Dr. Humayun J. Chaudhry, president and CEO of FSMB said in a statement. “The growing number of introductions in state legislatures represents the desire for a dynamic system of expedited licensure that simultaneously respects the inherent role of state regulatory agencies in protecting the public,” Dr. Chaudhry said. “At a time when some within the telemedicine industry seek to implement licensing frameworks that undermine and circumvent state licensing rules and practice requirements, the compact is a key element to ensuring state sovereignty while providing the license portability necessary to enhance the delivery of health care.”
The FSMB House of Delegates unanimously approved the development of an interstate compact to expedite medical licensure and facilitate multistate practice at its 2013 annual meeting. Under the proposed system, states and doctors would voluntarily enter into the compact, and approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction.
State boards of medicine would retain their individual authority for discipline and oversight, according to the compact. Interested physicians would also need to complete a background check including biometric data (such as fingerprints) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.
More than 25 medical and osteopathic boards have publicly expressed support for the model legislation, according to the FSMB.
On Twitter @legal_med
Legislators in nine states have introduced legislation that would expand the practice of telemedicine by streamlining physician licensure.
Lawmakers in Iowa, Minnesota, Nebraska, Oklahoma, South Dakota, Texas, Utah, Vermont, and Wyoming have proposed bills based on the Interstate Medical Licensure Compact. This model bill was crafted by the Federation of State Medical Boards (FSMB) in an effort to speed the process of issuing licenses for physicians who wish to practice across state lines
The compact offers an effective solution to balancing patient safety and quality care with the needs of a growing and changing health care market, Dr. Humayun J. Chaudhry, president and CEO of FSMB said in a statement. “The growing number of introductions in state legislatures represents the desire for a dynamic system of expedited licensure that simultaneously respects the inherent role of state regulatory agencies in protecting the public,” Dr. Chaudhry said. “At a time when some within the telemedicine industry seek to implement licensing frameworks that undermine and circumvent state licensing rules and practice requirements, the compact is a key element to ensuring state sovereignty while providing the license portability necessary to enhance the delivery of health care.”
The FSMB House of Delegates unanimously approved the development of an interstate compact to expedite medical licensure and facilitate multistate practice at its 2013 annual meeting. Under the proposed system, states and doctors would voluntarily enter into the compact, and approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction.
State boards of medicine would retain their individual authority for discipline and oversight, according to the compact. Interested physicians would also need to complete a background check including biometric data (such as fingerprints) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.
More than 25 medical and osteopathic boards have publicly expressed support for the model legislation, according to the FSMB.
On Twitter @legal_med
Ibuprofen superior to morphine following pediatric tonsillectomy
Ibuprofen appears to be an effective and safer pain reliever than morphine in children undergoing tonsillectomies, according to a recent study.
Although the two medications, administered with acetaminophen, treated pain about equally, morphine showed a greater risk for oxygen desaturation the night after surgery.
“Given the unpredictable posttonsillectomy respiratory response to opioids (codeine, morphine, and hydrocodone) and the analgesic effectiveness of ibuprofen, perhaps the time has come to question the postoperative use of all opioids in this population,” wrote Lauren Kelly, Ph.D., of Western University in London, Ontario, and her associates. The study was published online Jan. 26 (Pediatrics 2014 Jan. 26 [doi: 10.1542/peds.2014-1906].
The researchers randomized 91 children aged 1-10 years to acetaminophen (10-15 mg/kg per dose every 4 hours) with either an age appropriate dose of 0.2-0.5 mg/kg oral morphine every 4 hours or 10 mg/kg of oral ibuprofen every 6 hours after the children underwent a tonsillectomy with or without an adenoidectomy to treat sleep disordered breathing. The study ran from September 2012 to January 2014.
Parents put pulse oximeters on their children the nights before and after surgery to monitor oxygen saturation and apnea events.
The first evening after the surgery, 68% of children receiving ibuprofen showed improvement in oxygen desaturations, compared with 14% of children receiving morphine. The children receiving ibuprofen experienced an average 1.79 fewer desaturation events per hour, compared to an average 11.17 more desaturation events per hour in the morphine group.
No differences in average postsurgical oxygen saturation, pain relieving effectiveness, tonsillar bleeding or drug adverse events were identified.
“The results of this study support effective posttonsillectomy analgesia in children by using ibuprofen in combination with acetaminophen,” Dr. Kelly and her team wrote.
Ibuprofen appears to be an effective and safer pain reliever than morphine in children undergoing tonsillectomies, according to a recent study.
Although the two medications, administered with acetaminophen, treated pain about equally, morphine showed a greater risk for oxygen desaturation the night after surgery.
“Given the unpredictable posttonsillectomy respiratory response to opioids (codeine, morphine, and hydrocodone) and the analgesic effectiveness of ibuprofen, perhaps the time has come to question the postoperative use of all opioids in this population,” wrote Lauren Kelly, Ph.D., of Western University in London, Ontario, and her associates. The study was published online Jan. 26 (Pediatrics 2014 Jan. 26 [doi: 10.1542/peds.2014-1906].
The researchers randomized 91 children aged 1-10 years to acetaminophen (10-15 mg/kg per dose every 4 hours) with either an age appropriate dose of 0.2-0.5 mg/kg oral morphine every 4 hours or 10 mg/kg of oral ibuprofen every 6 hours after the children underwent a tonsillectomy with or without an adenoidectomy to treat sleep disordered breathing. The study ran from September 2012 to January 2014.
Parents put pulse oximeters on their children the nights before and after surgery to monitor oxygen saturation and apnea events.
The first evening after the surgery, 68% of children receiving ibuprofen showed improvement in oxygen desaturations, compared with 14% of children receiving morphine. The children receiving ibuprofen experienced an average 1.79 fewer desaturation events per hour, compared to an average 11.17 more desaturation events per hour in the morphine group.
No differences in average postsurgical oxygen saturation, pain relieving effectiveness, tonsillar bleeding or drug adverse events were identified.
“The results of this study support effective posttonsillectomy analgesia in children by using ibuprofen in combination with acetaminophen,” Dr. Kelly and her team wrote.
Ibuprofen appears to be an effective and safer pain reliever than morphine in children undergoing tonsillectomies, according to a recent study.
Although the two medications, administered with acetaminophen, treated pain about equally, morphine showed a greater risk for oxygen desaturation the night after surgery.
“Given the unpredictable posttonsillectomy respiratory response to opioids (codeine, morphine, and hydrocodone) and the analgesic effectiveness of ibuprofen, perhaps the time has come to question the postoperative use of all opioids in this population,” wrote Lauren Kelly, Ph.D., of Western University in London, Ontario, and her associates. The study was published online Jan. 26 (Pediatrics 2014 Jan. 26 [doi: 10.1542/peds.2014-1906].
The researchers randomized 91 children aged 1-10 years to acetaminophen (10-15 mg/kg per dose every 4 hours) with either an age appropriate dose of 0.2-0.5 mg/kg oral morphine every 4 hours or 10 mg/kg of oral ibuprofen every 6 hours after the children underwent a tonsillectomy with or without an adenoidectomy to treat sleep disordered breathing. The study ran from September 2012 to January 2014.
Parents put pulse oximeters on their children the nights before and after surgery to monitor oxygen saturation and apnea events.
The first evening after the surgery, 68% of children receiving ibuprofen showed improvement in oxygen desaturations, compared with 14% of children receiving morphine. The children receiving ibuprofen experienced an average 1.79 fewer desaturation events per hour, compared to an average 11.17 more desaturation events per hour in the morphine group.
No differences in average postsurgical oxygen saturation, pain relieving effectiveness, tonsillar bleeding or drug adverse events were identified.
“The results of this study support effective posttonsillectomy analgesia in children by using ibuprofen in combination with acetaminophen,” Dr. Kelly and her team wrote.
FROM PEDIATRICS
Key clinical point: Ibuprofen safely and effectively replaces morphine for children’s pain relief following tonsillectomy.
Major finding: Among children receiving ibuprofen, 68% improved the first night post surgery, compared with 14% of children receiving morphine.
Data source: A prospective randomized clinical trial of 91 children, aged 1-10 years, assigned to receive 10-15 mg/kg acetaminophen with either 0.2-0.5 mg/kg oral morphine or 10 mg/kg of oral ibuprofen following a tonsillectomy with or without adenoidectomy.
Disclosures: The Canadian Institutes for Health Research Drug Safety and Effectiveness Network funded the study. The authors reported no relevant financial disclosures.
Analysis examines glossectomy as solo treatment for sleep apnea
CORONADO, CALIF. – Results from a new meta-analysis suggest that glossectomy significantly improves sleep outcomes when performed as part of a multi-level surgery for adults with obstructive sleep apnea.
However, “there is insufficient evidence to analyze the role of glossectomy as a stand-alone procedure for the treatment of sleep apnea,” lead study author Dr. Alexander W. Murphey said in an interview in advance of The Triological Society’s Combined Sections meeting, where the work was presented. “The lack of available data for glossectomy as a single treatment was disappointing, and points to the need for further studies in this population.”
Glossectomy for OSA was first reported in 1991 as a salvage surgery after uvulopalatopharyngoplasty, said Dr. Murphey, who is completing a clinical research fellowship in the department of otolaryngology-head and neck surgery at Medical University of South Carolina, Charleston, under the mentoring of Dr. Marion B. Gillespie and Dr. Shaun A. Nguyen. Since that time, “many modifications have been made regarding technique and instrumentation with recent focus on minimally invasive techniques aimed at maximizing tissue reduction while limiting the inherent morbidity associated with glossectomy,” he said. “The aim of our study was to review and analyze all of the available literature on partial glossectomy for OSA in one study. Overall, there is a significant lack of research into glossectomy, and what literature is available include small, case-series that analyze glossectomy as part of complex, multi-level surgeries. This study represents the first large scale meta-analysis on the role of glossectomy, and attempts to determine the role of glossectomy both as part of multi-level surgery, and as a single, stand-alone sleep apnea treatment.”
Dr. Murphey used the PubMed-NCBI literature database to identify studies with 10 or more patients and reported preoperative and postoperative apnea-hypopnea index (AHI) scores. The primary endpoint was change in AHI while secondary endpoints included predefined surgical success rates, and changes in additional reported sleep outcomes such as Epworth Sleep Scores (ESS), Lowest Oxygen Saturation (LSAT), and snoring visual analog scale (VAS). The researchers reported results from 15 articles with 442 patients treated with three glossectomy techniques (midline glossectomy, lingualplasty, and submucosal minimally invasive lingual excision (SMILE). In pooled analyses that compared baseline vs. post-surgery, investigators observed significant reductions in AHI (from 48 to 20); ESS (from 12 to 5), and VAS (from 9 to 3; all with a P of less than .0001). In addition, they observed a significant increase in LSAT (from 77% to 84%; P less than .0001), according to the findings, presented at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons.
Surgical success, which was defined as an AHI less than 20 and a greater than 50% reduction in AHI, was achieved in 56% of cases, while complications occurred in 18% of patients. Only 24 patients (5%) were treated with glossectomy as sole therapy for OSA. Among these 24 patients, significant reductions occurred in AHI (from 42 to 25; P=.0345) and ESS (from 12 to 7; P less than .0001).
Dr. Murphey acknowledged certain limitations of the analysis, including “a lack of quality research involving glossectomy, with the majority of available published data drawn from small, case-series without control arms,” he said. “Additionally, studies varied in surgical approach, inclusion criteria, and accompanying procedures in multi-level treatment. This makes it extremely difficult to truly compare treatments.”
The researchers reported having no relevant financial conflicts.
On Twitter @dougbrunk
CORONADO, CALIF. – Results from a new meta-analysis suggest that glossectomy significantly improves sleep outcomes when performed as part of a multi-level surgery for adults with obstructive sleep apnea.
However, “there is insufficient evidence to analyze the role of glossectomy as a stand-alone procedure for the treatment of sleep apnea,” lead study author Dr. Alexander W. Murphey said in an interview in advance of The Triological Society’s Combined Sections meeting, where the work was presented. “The lack of available data for glossectomy as a single treatment was disappointing, and points to the need for further studies in this population.”
Glossectomy for OSA was first reported in 1991 as a salvage surgery after uvulopalatopharyngoplasty, said Dr. Murphey, who is completing a clinical research fellowship in the department of otolaryngology-head and neck surgery at Medical University of South Carolina, Charleston, under the mentoring of Dr. Marion B. Gillespie and Dr. Shaun A. Nguyen. Since that time, “many modifications have been made regarding technique and instrumentation with recent focus on minimally invasive techniques aimed at maximizing tissue reduction while limiting the inherent morbidity associated with glossectomy,” he said. “The aim of our study was to review and analyze all of the available literature on partial glossectomy for OSA in one study. Overall, there is a significant lack of research into glossectomy, and what literature is available include small, case-series that analyze glossectomy as part of complex, multi-level surgeries. This study represents the first large scale meta-analysis on the role of glossectomy, and attempts to determine the role of glossectomy both as part of multi-level surgery, and as a single, stand-alone sleep apnea treatment.”
Dr. Murphey used the PubMed-NCBI literature database to identify studies with 10 or more patients and reported preoperative and postoperative apnea-hypopnea index (AHI) scores. The primary endpoint was change in AHI while secondary endpoints included predefined surgical success rates, and changes in additional reported sleep outcomes such as Epworth Sleep Scores (ESS), Lowest Oxygen Saturation (LSAT), and snoring visual analog scale (VAS). The researchers reported results from 15 articles with 442 patients treated with three glossectomy techniques (midline glossectomy, lingualplasty, and submucosal minimally invasive lingual excision (SMILE). In pooled analyses that compared baseline vs. post-surgery, investigators observed significant reductions in AHI (from 48 to 20); ESS (from 12 to 5), and VAS (from 9 to 3; all with a P of less than .0001). In addition, they observed a significant increase in LSAT (from 77% to 84%; P less than .0001), according to the findings, presented at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons.
Surgical success, which was defined as an AHI less than 20 and a greater than 50% reduction in AHI, was achieved in 56% of cases, while complications occurred in 18% of patients. Only 24 patients (5%) were treated with glossectomy as sole therapy for OSA. Among these 24 patients, significant reductions occurred in AHI (from 42 to 25; P=.0345) and ESS (from 12 to 7; P less than .0001).
Dr. Murphey acknowledged certain limitations of the analysis, including “a lack of quality research involving glossectomy, with the majority of available published data drawn from small, case-series without control arms,” he said. “Additionally, studies varied in surgical approach, inclusion criteria, and accompanying procedures in multi-level treatment. This makes it extremely difficult to truly compare treatments.”
The researchers reported having no relevant financial conflicts.
On Twitter @dougbrunk
CORONADO, CALIF. – Results from a new meta-analysis suggest that glossectomy significantly improves sleep outcomes when performed as part of a multi-level surgery for adults with obstructive sleep apnea.
However, “there is insufficient evidence to analyze the role of glossectomy as a stand-alone procedure for the treatment of sleep apnea,” lead study author Dr. Alexander W. Murphey said in an interview in advance of The Triological Society’s Combined Sections meeting, where the work was presented. “The lack of available data for glossectomy as a single treatment was disappointing, and points to the need for further studies in this population.”
Glossectomy for OSA was first reported in 1991 as a salvage surgery after uvulopalatopharyngoplasty, said Dr. Murphey, who is completing a clinical research fellowship in the department of otolaryngology-head and neck surgery at Medical University of South Carolina, Charleston, under the mentoring of Dr. Marion B. Gillespie and Dr. Shaun A. Nguyen. Since that time, “many modifications have been made regarding technique and instrumentation with recent focus on minimally invasive techniques aimed at maximizing tissue reduction while limiting the inherent morbidity associated with glossectomy,” he said. “The aim of our study was to review and analyze all of the available literature on partial glossectomy for OSA in one study. Overall, there is a significant lack of research into glossectomy, and what literature is available include small, case-series that analyze glossectomy as part of complex, multi-level surgeries. This study represents the first large scale meta-analysis on the role of glossectomy, and attempts to determine the role of glossectomy both as part of multi-level surgery, and as a single, stand-alone sleep apnea treatment.”
Dr. Murphey used the PubMed-NCBI literature database to identify studies with 10 or more patients and reported preoperative and postoperative apnea-hypopnea index (AHI) scores. The primary endpoint was change in AHI while secondary endpoints included predefined surgical success rates, and changes in additional reported sleep outcomes such as Epworth Sleep Scores (ESS), Lowest Oxygen Saturation (LSAT), and snoring visual analog scale (VAS). The researchers reported results from 15 articles with 442 patients treated with three glossectomy techniques (midline glossectomy, lingualplasty, and submucosal minimally invasive lingual excision (SMILE). In pooled analyses that compared baseline vs. post-surgery, investigators observed significant reductions in AHI (from 48 to 20); ESS (from 12 to 5), and VAS (from 9 to 3; all with a P of less than .0001). In addition, they observed a significant increase in LSAT (from 77% to 84%; P less than .0001), according to the findings, presented at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons.
Surgical success, which was defined as an AHI less than 20 and a greater than 50% reduction in AHI, was achieved in 56% of cases, while complications occurred in 18% of patients. Only 24 patients (5%) were treated with glossectomy as sole therapy for OSA. Among these 24 patients, significant reductions occurred in AHI (from 42 to 25; P=.0345) and ESS (from 12 to 7; P less than .0001).
Dr. Murphey acknowledged certain limitations of the analysis, including “a lack of quality research involving glossectomy, with the majority of available published data drawn from small, case-series without control arms,” he said. “Additionally, studies varied in surgical approach, inclusion criteria, and accompanying procedures in multi-level treatment. This makes it extremely difficult to truly compare treatments.”
The researchers reported having no relevant financial conflicts.
On Twitter @dougbrunk
AT THE COMBINED SECTIONS WINTER MEETING
Key clinical point: Among adults with obstructive sleep apnea, glossectomy significantly improved sleep outcomes when performed as part of a multi-level surgery, though evidence is sparse.
Major finding: There are no available data on the role of glossectomy as a stand-alone procedure for the treatment of OSA.
Data source: A meta-analysis of 15 articles concerning 442 patients treated with three glossectomy techniques (midline glossectomy, lingualplasty, and submucosal minimally invasive lingual excision.
Disclosures: The researchers reported having no financial disclosures.
2014 Clinical Congress webcast sessions now available
Webcasts of select Clinical Congress 2014 sessions are available for viewing on demand through the American College of Surgeons (ACS) Division of Education. The webcasts offer continuing medical education (CME) and self-assessment credit. Purchasers of the sessions may choose from three packages:
•Complete Webcast Package, which includes 113 sessions and audio recordings, available at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=659
•Webcast Package, which provides access to 113 sessions, available at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=660
•Webcast Pick 25, which allows the purchaser to select 25 out of 113 webcast sessions from 2014, available at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=661
The ACS also offers Clinical Congress Audio Recordings only (no CME). Visit the ACS website for details at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=658.For more information, contact [email protected].
Webcasts of select Clinical Congress 2014 sessions are available for viewing on demand through the American College of Surgeons (ACS) Division of Education. The webcasts offer continuing medical education (CME) and self-assessment credit. Purchasers of the sessions may choose from three packages:
•Complete Webcast Package, which includes 113 sessions and audio recordings, available at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=659
•Webcast Package, which provides access to 113 sessions, available at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=660
•Webcast Pick 25, which allows the purchaser to select 25 out of 113 webcast sessions from 2014, available at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=661
The ACS also offers Clinical Congress Audio Recordings only (no CME). Visit the ACS website for details at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=658.For more information, contact [email protected].
Webcasts of select Clinical Congress 2014 sessions are available for viewing on demand through the American College of Surgeons (ACS) Division of Education. The webcasts offer continuing medical education (CME) and self-assessment credit. Purchasers of the sessions may choose from three packages:
•Complete Webcast Package, which includes 113 sessions and audio recordings, available at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=659
•Webcast Package, which provides access to 113 sessions, available at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=660
•Webcast Pick 25, which allows the purchaser to select 25 out of 113 webcast sessions from 2014, available at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=661
The ACS also offers Clinical Congress Audio Recordings only (no CME). Visit the ACS website for details at https://web4.facs.org/eBusiness/ProductCatalog/product.aspx?ID=658.For more information, contact [email protected].
Peter N. Bretan, Jr., MD, FACS, receives AMA Benjamin Rush Award
Peter N. Bretan, Jr., MD, FACS, a urological and transplant surgeon, Novato, CA, received the Benjamin Rush Award for Citizenship and Community Service from the American Medical Association (AMA) in November 2014. The award recognizes physicians who have performed beyond expectations and made extraordinary public service contributions. Dr. Bretan received the award during the opening session of the 2014 AMA interim meeting in Dallas, TX.
The award honors Dr. Bretan for his innovative work as a renal transplant surgeon and urologist, as well as his participation in global disaster relief efforts. He is the founder of Life Plant International, a charitable organization that promotes disaster preparedness, organ donation, and early disease screening worldwide. Following the devastation of Hurricane Katrina in New Orleans, LA, in 2005, Dr. Bretan provided free medical care as part of “Team Orleans.”
Since 2002, he also has made nearly 20 medical mission trips to the Philippines to perform and teach local physicians about kidney transplant and laparoscopic kidney removal operations. More recently, he served as part of a medical mission to the Philippines to provide care to victims of Typhoon Halyan. View the AMA press release announcing the award to Dr. Bretan at www.ama-assn.org/ama/pub/news/news/2014/2014-11-10-peter-bretan-receives-benjamin-rush-award.page.
Peter N. Bretan, Jr., MD, FACS, a urological and transplant surgeon, Novato, CA, received the Benjamin Rush Award for Citizenship and Community Service from the American Medical Association (AMA) in November 2014. The award recognizes physicians who have performed beyond expectations and made extraordinary public service contributions. Dr. Bretan received the award during the opening session of the 2014 AMA interim meeting in Dallas, TX.
The award honors Dr. Bretan for his innovative work as a renal transplant surgeon and urologist, as well as his participation in global disaster relief efforts. He is the founder of Life Plant International, a charitable organization that promotes disaster preparedness, organ donation, and early disease screening worldwide. Following the devastation of Hurricane Katrina in New Orleans, LA, in 2005, Dr. Bretan provided free medical care as part of “Team Orleans.”
Since 2002, he also has made nearly 20 medical mission trips to the Philippines to perform and teach local physicians about kidney transplant and laparoscopic kidney removal operations. More recently, he served as part of a medical mission to the Philippines to provide care to victims of Typhoon Halyan. View the AMA press release announcing the award to Dr. Bretan at www.ama-assn.org/ama/pub/news/news/2014/2014-11-10-peter-bretan-receives-benjamin-rush-award.page.
Peter N. Bretan, Jr., MD, FACS, a urological and transplant surgeon, Novato, CA, received the Benjamin Rush Award for Citizenship and Community Service from the American Medical Association (AMA) in November 2014. The award recognizes physicians who have performed beyond expectations and made extraordinary public service contributions. Dr. Bretan received the award during the opening session of the 2014 AMA interim meeting in Dallas, TX.
The award honors Dr. Bretan for his innovative work as a renal transplant surgeon and urologist, as well as his participation in global disaster relief efforts. He is the founder of Life Plant International, a charitable organization that promotes disaster preparedness, organ donation, and early disease screening worldwide. Following the devastation of Hurricane Katrina in New Orleans, LA, in 2005, Dr. Bretan provided free medical care as part of “Team Orleans.”
Since 2002, he also has made nearly 20 medical mission trips to the Philippines to perform and teach local physicians about kidney transplant and laparoscopic kidney removal operations. More recently, he served as part of a medical mission to the Philippines to provide care to victims of Typhoon Halyan. View the AMA press release announcing the award to Dr. Bretan at www.ama-assn.org/ama/pub/news/news/2014/2014-11-10-peter-bretan-receives-benjamin-rush-award.page.
ACS Clinical Scholars in Residence Program: Celebrating 10 years of training surgeons
The American College of Surgeons (ACS) is now accepting applications for the 2016–2018 Clinical Scholar in Residence positions, and celebrating the 10th year of this well-recognized program. The ACS Clinical Scholars in Residence Program is a two-year on-site fellowship in surgical outcomes research, health services research, and health care policy. It was initiated in 2005 to advance ACS quality improvement initiatives and to offer opportunities for residents to work on these programs and do related research. More specifically, ACS Clinical Scholars in Residence perform research relevant to ongoing projects in the ACS Division of Research and Optimal Patient Care.
About the program
The primary objective of the fellowship is to address issues in health care quality, patient safety, and health policy, with the goal of helping the ACS Clinical Scholar in Residence prepare for a research career in academic surgery. The ACS Clinical Scholars in Residence have worked on projects and research within the ACS National Surgical Quality Improvement Program, the National Cancer Data Base, the National Trauma Data Bank®, the Surgeon Specific Registry, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, measure and guideline development initiative, and accreditation programs. Scholars are assigned to the appropriate group within the ACS based on their interests and the College’s needs.
In addition, participants earn a master’s degree in health services and outcomes research or health care quality and patient safety from Northwestern University during their two years at the ACS headquarters in Chicago, IL. The goal of this aspect of the program is to educate clinicians to become effective health services and outcomes researchers with a strong fundamental knowledge of research methods. The health services and outcomes research curriculum focuses on these issues within institutional and health care delivery systems, as well as in external environments that shape health policy centered on quality and safety issues. The program takes approximately two years to complete. All coursework is done at Northwestern University’s Chicago campus, one block from the ACS headquarters. The ACS also offers a variety of educational programs that may benefit the Clinical Scholars, including Outcomes Research and Clinical Trials courses.
The ACS assigns internal mentors to meet regularly with each ACS Clinical Scholar in Residence. Scholars also have opportunities to interact with various surgeons who are affiliated with the ACS and the Division of Research and Optimal Patient Care. Mentorship is one of the most important aspects of this fellowship. Guidance and interaction with multiple individuals from diverse backgrounds will provide the best opportunity for success. In addition, a core of ACS and Northwestern staff statisticians and project analysts serve as invaluable resources to the ACS Clinical Scholars in Residence.
Past successes
Surgical residents from throughout the U.S. have participated in the ACS Clinical Scholars in Residence program. These individuals report excellent, productive experiences that have been useful in launching their careers in the field of academic surgery. Eleven scholars have already completed the program, and six scholars are currently participating, with three more beginning in July 2015. The ACS Clinical Scholars in Residence have demonstrated great dedication to outcomes research and the improvement of the quality of surgical care.
The ACS Clinical Scholars in Residence have presented their findings at numerous major national meetings and published in high-impact, peer-reviewed publications, including several recent publications, in the Journal of the American Medical Association and other top surgical journals. In addition, the scholars contribute a great deal to the ACS quality improvement programs.
Apply now
The 2016–2018 scholars will begin their work on July 1, 2016. Applications for these positions are due April 3, 2015. Currently, applicants are required to have funding from their institution or another grant mechanism. For more information about the program and the application requirements, go to www.facs.org/ropc/clinicalscholars.html, or send an e-mail to [email protected].
Dr. Bilimoria is a Faculty Scholar at the ACS; director, Surgical Outcomes and Quality Improvement Center, and vice-chair for quality, department of surgery, Feinberg School of Medicine, Northwestern University, Chicago. Dr. Ko is the Director of the ACS Division of Research and Optimal Patient Care and ACS NSQIP. Dr. Winchester is Medical Director of ACS Cancer Programs.
The American College of Surgeons (ACS) is now accepting applications for the 2016–2018 Clinical Scholar in Residence positions, and celebrating the 10th year of this well-recognized program. The ACS Clinical Scholars in Residence Program is a two-year on-site fellowship in surgical outcomes research, health services research, and health care policy. It was initiated in 2005 to advance ACS quality improvement initiatives and to offer opportunities for residents to work on these programs and do related research. More specifically, ACS Clinical Scholars in Residence perform research relevant to ongoing projects in the ACS Division of Research and Optimal Patient Care.
About the program
The primary objective of the fellowship is to address issues in health care quality, patient safety, and health policy, with the goal of helping the ACS Clinical Scholar in Residence prepare for a research career in academic surgery. The ACS Clinical Scholars in Residence have worked on projects and research within the ACS National Surgical Quality Improvement Program, the National Cancer Data Base, the National Trauma Data Bank®, the Surgeon Specific Registry, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, measure and guideline development initiative, and accreditation programs. Scholars are assigned to the appropriate group within the ACS based on their interests and the College’s needs.
In addition, participants earn a master’s degree in health services and outcomes research or health care quality and patient safety from Northwestern University during their two years at the ACS headquarters in Chicago, IL. The goal of this aspect of the program is to educate clinicians to become effective health services and outcomes researchers with a strong fundamental knowledge of research methods. The health services and outcomes research curriculum focuses on these issues within institutional and health care delivery systems, as well as in external environments that shape health policy centered on quality and safety issues. The program takes approximately two years to complete. All coursework is done at Northwestern University’s Chicago campus, one block from the ACS headquarters. The ACS also offers a variety of educational programs that may benefit the Clinical Scholars, including Outcomes Research and Clinical Trials courses.
The ACS assigns internal mentors to meet regularly with each ACS Clinical Scholar in Residence. Scholars also have opportunities to interact with various surgeons who are affiliated with the ACS and the Division of Research and Optimal Patient Care. Mentorship is one of the most important aspects of this fellowship. Guidance and interaction with multiple individuals from diverse backgrounds will provide the best opportunity for success. In addition, a core of ACS and Northwestern staff statisticians and project analysts serve as invaluable resources to the ACS Clinical Scholars in Residence.
Past successes
Surgical residents from throughout the U.S. have participated in the ACS Clinical Scholars in Residence program. These individuals report excellent, productive experiences that have been useful in launching their careers in the field of academic surgery. Eleven scholars have already completed the program, and six scholars are currently participating, with three more beginning in July 2015. The ACS Clinical Scholars in Residence have demonstrated great dedication to outcomes research and the improvement of the quality of surgical care.
The ACS Clinical Scholars in Residence have presented their findings at numerous major national meetings and published in high-impact, peer-reviewed publications, including several recent publications, in the Journal of the American Medical Association and other top surgical journals. In addition, the scholars contribute a great deal to the ACS quality improvement programs.
Apply now
The 2016–2018 scholars will begin their work on July 1, 2016. Applications for these positions are due April 3, 2015. Currently, applicants are required to have funding from their institution or another grant mechanism. For more information about the program and the application requirements, go to www.facs.org/ropc/clinicalscholars.html, or send an e-mail to [email protected].
Dr. Bilimoria is a Faculty Scholar at the ACS; director, Surgical Outcomes and Quality Improvement Center, and vice-chair for quality, department of surgery, Feinberg School of Medicine, Northwestern University, Chicago. Dr. Ko is the Director of the ACS Division of Research and Optimal Patient Care and ACS NSQIP. Dr. Winchester is Medical Director of ACS Cancer Programs.
The American College of Surgeons (ACS) is now accepting applications for the 2016–2018 Clinical Scholar in Residence positions, and celebrating the 10th year of this well-recognized program. The ACS Clinical Scholars in Residence Program is a two-year on-site fellowship in surgical outcomes research, health services research, and health care policy. It was initiated in 2005 to advance ACS quality improvement initiatives and to offer opportunities for residents to work on these programs and do related research. More specifically, ACS Clinical Scholars in Residence perform research relevant to ongoing projects in the ACS Division of Research and Optimal Patient Care.
About the program
The primary objective of the fellowship is to address issues in health care quality, patient safety, and health policy, with the goal of helping the ACS Clinical Scholar in Residence prepare for a research career in academic surgery. The ACS Clinical Scholars in Residence have worked on projects and research within the ACS National Surgical Quality Improvement Program, the National Cancer Data Base, the National Trauma Data Bank®, the Surgeon Specific Registry, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, measure and guideline development initiative, and accreditation programs. Scholars are assigned to the appropriate group within the ACS based on their interests and the College’s needs.
In addition, participants earn a master’s degree in health services and outcomes research or health care quality and patient safety from Northwestern University during their two years at the ACS headquarters in Chicago, IL. The goal of this aspect of the program is to educate clinicians to become effective health services and outcomes researchers with a strong fundamental knowledge of research methods. The health services and outcomes research curriculum focuses on these issues within institutional and health care delivery systems, as well as in external environments that shape health policy centered on quality and safety issues. The program takes approximately two years to complete. All coursework is done at Northwestern University’s Chicago campus, one block from the ACS headquarters. The ACS also offers a variety of educational programs that may benefit the Clinical Scholars, including Outcomes Research and Clinical Trials courses.
The ACS assigns internal mentors to meet regularly with each ACS Clinical Scholar in Residence. Scholars also have opportunities to interact with various surgeons who are affiliated with the ACS and the Division of Research and Optimal Patient Care. Mentorship is one of the most important aspects of this fellowship. Guidance and interaction with multiple individuals from diverse backgrounds will provide the best opportunity for success. In addition, a core of ACS and Northwestern staff statisticians and project analysts serve as invaluable resources to the ACS Clinical Scholars in Residence.
Past successes
Surgical residents from throughout the U.S. have participated in the ACS Clinical Scholars in Residence program. These individuals report excellent, productive experiences that have been useful in launching their careers in the field of academic surgery. Eleven scholars have already completed the program, and six scholars are currently participating, with three more beginning in July 2015. The ACS Clinical Scholars in Residence have demonstrated great dedication to outcomes research and the improvement of the quality of surgical care.
The ACS Clinical Scholars in Residence have presented their findings at numerous major national meetings and published in high-impact, peer-reviewed publications, including several recent publications, in the Journal of the American Medical Association and other top surgical journals. In addition, the scholars contribute a great deal to the ACS quality improvement programs.
Apply now
The 2016–2018 scholars will begin their work on July 1, 2016. Applications for these positions are due April 3, 2015. Currently, applicants are required to have funding from their institution or another grant mechanism. For more information about the program and the application requirements, go to www.facs.org/ropc/clinicalscholars.html, or send an e-mail to [email protected].
Dr. Bilimoria is a Faculty Scholar at the ACS; director, Surgical Outcomes and Quality Improvement Center, and vice-chair for quality, department of surgery, Feinberg School of Medicine, Northwestern University, Chicago. Dr. Ko is the Director of the ACS Division of Research and Optimal Patient Care and ACS NSQIP. Dr. Winchester is Medical Director of ACS Cancer Programs.
YFA announces 2014–2015 Chair, Governing Council
The Young Fellows Association (YFA) of the American College of Surgeons (ACS) recently announced its new Chair for 2014–2015, as well as newly appointed members selected to serve on the YFA Governing Council. Michael Sutherland, MD, FACS, a general surgeon and assistant professor, University of Arkansas for Medical Sciences College of Medicine, Little Rock, will serve a one-year term as YFA Chair. Jacob Moalem, MD, FACS, a general surgeon and assistant professor, University of Rochester Medical Center, NY, will serve a one-year term as Vice-Chair.
New members of the YFA Governing Council are Ashley Vergis, MD, FACS, a minimally invasive and bariatric surgeon and assistant professor, University of Manitoba Faculty of Medicine, Winnipeg; Gerald R. Fortuna, Jr., MD, FACS, Lieutenant Colonel, U.S. Air Force, Senior Flight Surgeon, University of Texas Houston Memorial Hospital, department of cardiothoracic and vascular surgery; Paula Ferrada, MD, FACS, a trauma surgeon and assistant professor, Medical College of Virginia, Richmond; and Edie Chan, MD, FACS, a transplant surgeon and assistant professor, Rush Medical College of Rush University Medical Center, Chicago, IL.
For more information, go to www.facs.org/member-services/yfa/leadership.
The Young Fellows Association (YFA) of the American College of Surgeons (ACS) recently announced its new Chair for 2014–2015, as well as newly appointed members selected to serve on the YFA Governing Council. Michael Sutherland, MD, FACS, a general surgeon and assistant professor, University of Arkansas for Medical Sciences College of Medicine, Little Rock, will serve a one-year term as YFA Chair. Jacob Moalem, MD, FACS, a general surgeon and assistant professor, University of Rochester Medical Center, NY, will serve a one-year term as Vice-Chair.
New members of the YFA Governing Council are Ashley Vergis, MD, FACS, a minimally invasive and bariatric surgeon and assistant professor, University of Manitoba Faculty of Medicine, Winnipeg; Gerald R. Fortuna, Jr., MD, FACS, Lieutenant Colonel, U.S. Air Force, Senior Flight Surgeon, University of Texas Houston Memorial Hospital, department of cardiothoracic and vascular surgery; Paula Ferrada, MD, FACS, a trauma surgeon and assistant professor, Medical College of Virginia, Richmond; and Edie Chan, MD, FACS, a transplant surgeon and assistant professor, Rush Medical College of Rush University Medical Center, Chicago, IL.
For more information, go to www.facs.org/member-services/yfa/leadership.
The Young Fellows Association (YFA) of the American College of Surgeons (ACS) recently announced its new Chair for 2014–2015, as well as newly appointed members selected to serve on the YFA Governing Council. Michael Sutherland, MD, FACS, a general surgeon and assistant professor, University of Arkansas for Medical Sciences College of Medicine, Little Rock, will serve a one-year term as YFA Chair. Jacob Moalem, MD, FACS, a general surgeon and assistant professor, University of Rochester Medical Center, NY, will serve a one-year term as Vice-Chair.
New members of the YFA Governing Council are Ashley Vergis, MD, FACS, a minimally invasive and bariatric surgeon and assistant professor, University of Manitoba Faculty of Medicine, Winnipeg; Gerald R. Fortuna, Jr., MD, FACS, Lieutenant Colonel, U.S. Air Force, Senior Flight Surgeon, University of Texas Houston Memorial Hospital, department of cardiothoracic and vascular surgery; Paula Ferrada, MD, FACS, a trauma surgeon and assistant professor, Medical College of Virginia, Richmond; and Edie Chan, MD, FACS, a transplant surgeon and assistant professor, Rush Medical College of Rush University Medical Center, Chicago, IL.
For more information, go to www.facs.org/member-services/yfa/leadership.