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Official Newspaper of the American College of Surgeons
The Rural Surgeon: A new column
Surgeons who treat patients in rural areas are a unique group, distinct from other surgeons because of scope of practice, environment, and resources. These surgeons address a vast range of surgical problems, work in relative professional isolation, and have fewer resources available to get the job done. Nevertheless, these physicians play critical roles in their profession and are irreplaceable assets in their communities.
Although poorly defined, often misunderstood, arguably unfairly characterized, and inadequately documented, surgery has a long distinguished history and tradition in rural communities.
What are the main challenges faced by rural surgeons and what can be done to strengthen their practices, professional lives, and longevity in the field? Rural patients are more likely than urban patients to be elderly and poor and have chronic illnesses (J. Am Coll. Surg. 2014;219:814-8). The average age of rural surgeons suggests that many will retire in the coming decade. Who will replace them and care for 60 million citizens who reside in rural America? How will the gradual decline of residents choosing general surgery and rural practice affect patient care?
This new monthly column, Rural Surgeons Speak, focuses on these questions and searches for answers. Rural Surgeons Speak will introduce to all readers the voices, concerns, questions, and opinions of surgeons practicing in the small towns and rural regions of the United States. Although many of the challenges faced by rural surgeons are unique to this group, there is overlap with issues encountered by urban surgeons and those in academic settings. In spite of problems ranging from a shift from independent practice to hospital employment and to treating the poor with pronounced chronic illnesses, rural surgeons are dedicated and committed. Although these matters are common to all surgeons, rural surgeons’ experiences tend to be singular because of the high percentages of such patients and fewer institutional resources.
I have practiced surgery in small and large rural locations for 37 years. Rural surgery is not a specialty. My case log, filled with endoscopies, laparoscopies, laparotomies, and breast operations, may be even more varied than the logs of urban colleagues. In my early years of practice, I did orthopaedic surgery and gynecology. As a conscious choice, I practiced surgery where I wanted, and how I wanted. My choice was not by default. When I started, I sought a location that would allow me to “have a more complete life with less tension, excellent schools, opportunity for economical living,” and a fulfilling surgery practice. Unknown to me, Dr. Edwin F. Cave, ACS president, made those statements about rural surgery in the Daily Clinical Bulletin for the 37th Annual Clinical Congress decades before I started.
Like other rural surgeons, I wanted to embrace and be embraced by my community. I also saw opportunities for personal advancement (involvement with ACS), and for the development of my surgical talents (lasers, laparoscopies, endoscopies). I live just a mile from the hospital. I know my patients by their first names. They speak to me on the telephone. My number is in the book. When they meet me in church or at the grocery store, I am “Doc.” Occasionally a PEx is performed in such locations. It is personal. It is comfortable. There is a real sense of community and of belonging. I am involved. I provide an invaluable service “right at home,” where my patients want to be treated. In return, I am valued and supported.
After becoming a FACS in 1979, I involved myself in many activities of the ACS. Most recently, I participated in the rural surgery renaissance from its beginning. As part of my participation, I routinely contacted rural surgeons around the United States and gained intimate and detailed knowledge about their practices, successes, and concerns. I bring insights from my background to the writing of this column.
While glamour is at a minimum in rural America, personal satisfaction for many of these surgeons is at a maximum. Unfortunately, isolation is a given in most rural practices, and therein lies the problem. In spite of offering much to their patients and, in turn, to the profession, rural surgeons are easy targets of negative assessments, ill-conceived policy changes, and misunderstandings.
Despite their vital role in treating patients, rural surgeons often regard themselves as unrecognized and unappreciated by their peers. There is a subtle bias in the profession against a surgeon who would choose this life of relative isolation, alleged nonspecialized surgery, and overwork in communities with fewer cultural resources and fewer employment options for spouses. Yet their work is essential to the health of millions of people who live in rural areas. Thankfully, the profession as a whole has stopped ignoring rural surgery in recent years as the ACS leadership has stepped in and begun to increase support for rural surgeons.
In May 2011, during the 5th Annual Rural Surgery Symposium and Workshop, I presented a talk, “The ACS and the Rural Surgeon.” Past President Dr. LaMar McGinnis acknowledged the educational value of the presentation, which then went on to wider distribution. The Board of Regents received another talk about rural surgery in February 2012: “Us vs. Them.” Based on the talk and because of their keen insights, the Regents formed the Advisory Council on Rural Surgery – the first new advisory council in 50 years. Subsequently, a College-developed rural listserv became the most highly successful communications program in ACS history and led to the creation of the rural surgery community. In the following 2 years, rural surgeons exchanged 9 million emails on numerous, varied topics. An article in the July 2014 ACS Bulletin describes the program (http://bulletin.facs.org/2014/07/acs-rural-listserv-an-underdog-success-story/). Finally, in his inaugural address at the 2012 Clinical Congress, Dr. Brent Eastman identified rural surgery as one of the four fundamental components of surgery for the next 100 years (http://bulletin.facs.org/2012/12/presidential-address/). Recognition of rural surgery obviously has increased.
My experience of moderating the rural listserv with nearly 1,000 subscribers has revealed the amazing diversity, passion, commitment, and perseverance of rural surgeons who have united in a true community. Their perspectives on their professional lives and the lives of their patients are well worth closer acquaintance by surgeons from all sectors. They have a lot to teach us all. To learn about rural surgery will be to learn about all surgery. Understand rural surgery in 2014 and, consequently, understand all surgery. Recognize the benefits of rural surgery and then instill them in all practices. Supporting rural surgery today supports all surgery.
The column aims to offer commentary on diverse topics confronting rural surgeons today. Opinions, editorials, letters, economics, and clinical matters, all from the rural perspective, will be included. Over 60 individual “threads” appeared on the listserv this year and the subjects of many of these threads could be covered in future columns. Uncommon subjects such as YKYAARSI (“You know you are a rural surgeon if…”) should be entertaining and informative. Guest authors who are experts on varying subjects will contribute articles.
While its roots are in the rural surgery community, the column’s scope will touch all surgical practices. Rural surgery will be better defined, positively characterized, and documented. In partnership with the ACS to achieve the general goal of supporting rural surgery, Rural Surgeons Speak aims to enable all ACS Fellows to realize that they belong to a community of all surgeons, regardless of location or practice type.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
Surgeons who treat patients in rural areas are a unique group, distinct from other surgeons because of scope of practice, environment, and resources. These surgeons address a vast range of surgical problems, work in relative professional isolation, and have fewer resources available to get the job done. Nevertheless, these physicians play critical roles in their profession and are irreplaceable assets in their communities.
Although poorly defined, often misunderstood, arguably unfairly characterized, and inadequately documented, surgery has a long distinguished history and tradition in rural communities.
What are the main challenges faced by rural surgeons and what can be done to strengthen their practices, professional lives, and longevity in the field? Rural patients are more likely than urban patients to be elderly and poor and have chronic illnesses (J. Am Coll. Surg. 2014;219:814-8). The average age of rural surgeons suggests that many will retire in the coming decade. Who will replace them and care for 60 million citizens who reside in rural America? How will the gradual decline of residents choosing general surgery and rural practice affect patient care?
This new monthly column, Rural Surgeons Speak, focuses on these questions and searches for answers. Rural Surgeons Speak will introduce to all readers the voices, concerns, questions, and opinions of surgeons practicing in the small towns and rural regions of the United States. Although many of the challenges faced by rural surgeons are unique to this group, there is overlap with issues encountered by urban surgeons and those in academic settings. In spite of problems ranging from a shift from independent practice to hospital employment and to treating the poor with pronounced chronic illnesses, rural surgeons are dedicated and committed. Although these matters are common to all surgeons, rural surgeons’ experiences tend to be singular because of the high percentages of such patients and fewer institutional resources.
I have practiced surgery in small and large rural locations for 37 years. Rural surgery is not a specialty. My case log, filled with endoscopies, laparoscopies, laparotomies, and breast operations, may be even more varied than the logs of urban colleagues. In my early years of practice, I did orthopaedic surgery and gynecology. As a conscious choice, I practiced surgery where I wanted, and how I wanted. My choice was not by default. When I started, I sought a location that would allow me to “have a more complete life with less tension, excellent schools, opportunity for economical living,” and a fulfilling surgery practice. Unknown to me, Dr. Edwin F. Cave, ACS president, made those statements about rural surgery in the Daily Clinical Bulletin for the 37th Annual Clinical Congress decades before I started.
Like other rural surgeons, I wanted to embrace and be embraced by my community. I also saw opportunities for personal advancement (involvement with ACS), and for the development of my surgical talents (lasers, laparoscopies, endoscopies). I live just a mile from the hospital. I know my patients by their first names. They speak to me on the telephone. My number is in the book. When they meet me in church or at the grocery store, I am “Doc.” Occasionally a PEx is performed in such locations. It is personal. It is comfortable. There is a real sense of community and of belonging. I am involved. I provide an invaluable service “right at home,” where my patients want to be treated. In return, I am valued and supported.
After becoming a FACS in 1979, I involved myself in many activities of the ACS. Most recently, I participated in the rural surgery renaissance from its beginning. As part of my participation, I routinely contacted rural surgeons around the United States and gained intimate and detailed knowledge about their practices, successes, and concerns. I bring insights from my background to the writing of this column.
While glamour is at a minimum in rural America, personal satisfaction for many of these surgeons is at a maximum. Unfortunately, isolation is a given in most rural practices, and therein lies the problem. In spite of offering much to their patients and, in turn, to the profession, rural surgeons are easy targets of negative assessments, ill-conceived policy changes, and misunderstandings.
Despite their vital role in treating patients, rural surgeons often regard themselves as unrecognized and unappreciated by their peers. There is a subtle bias in the profession against a surgeon who would choose this life of relative isolation, alleged nonspecialized surgery, and overwork in communities with fewer cultural resources and fewer employment options for spouses. Yet their work is essential to the health of millions of people who live in rural areas. Thankfully, the profession as a whole has stopped ignoring rural surgery in recent years as the ACS leadership has stepped in and begun to increase support for rural surgeons.
In May 2011, during the 5th Annual Rural Surgery Symposium and Workshop, I presented a talk, “The ACS and the Rural Surgeon.” Past President Dr. LaMar McGinnis acknowledged the educational value of the presentation, which then went on to wider distribution. The Board of Regents received another talk about rural surgery in February 2012: “Us vs. Them.” Based on the talk and because of their keen insights, the Regents formed the Advisory Council on Rural Surgery – the first new advisory council in 50 years. Subsequently, a College-developed rural listserv became the most highly successful communications program in ACS history and led to the creation of the rural surgery community. In the following 2 years, rural surgeons exchanged 9 million emails on numerous, varied topics. An article in the July 2014 ACS Bulletin describes the program (http://bulletin.facs.org/2014/07/acs-rural-listserv-an-underdog-success-story/). Finally, in his inaugural address at the 2012 Clinical Congress, Dr. Brent Eastman identified rural surgery as one of the four fundamental components of surgery for the next 100 years (http://bulletin.facs.org/2012/12/presidential-address/). Recognition of rural surgery obviously has increased.
My experience of moderating the rural listserv with nearly 1,000 subscribers has revealed the amazing diversity, passion, commitment, and perseverance of rural surgeons who have united in a true community. Their perspectives on their professional lives and the lives of their patients are well worth closer acquaintance by surgeons from all sectors. They have a lot to teach us all. To learn about rural surgery will be to learn about all surgery. Understand rural surgery in 2014 and, consequently, understand all surgery. Recognize the benefits of rural surgery and then instill them in all practices. Supporting rural surgery today supports all surgery.
The column aims to offer commentary on diverse topics confronting rural surgeons today. Opinions, editorials, letters, economics, and clinical matters, all from the rural perspective, will be included. Over 60 individual “threads” appeared on the listserv this year and the subjects of many of these threads could be covered in future columns. Uncommon subjects such as YKYAARSI (“You know you are a rural surgeon if…”) should be entertaining and informative. Guest authors who are experts on varying subjects will contribute articles.
While its roots are in the rural surgery community, the column’s scope will touch all surgical practices. Rural surgery will be better defined, positively characterized, and documented. In partnership with the ACS to achieve the general goal of supporting rural surgery, Rural Surgeons Speak aims to enable all ACS Fellows to realize that they belong to a community of all surgeons, regardless of location or practice type.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
Surgeons who treat patients in rural areas are a unique group, distinct from other surgeons because of scope of practice, environment, and resources. These surgeons address a vast range of surgical problems, work in relative professional isolation, and have fewer resources available to get the job done. Nevertheless, these physicians play critical roles in their profession and are irreplaceable assets in their communities.
Although poorly defined, often misunderstood, arguably unfairly characterized, and inadequately documented, surgery has a long distinguished history and tradition in rural communities.
What are the main challenges faced by rural surgeons and what can be done to strengthen their practices, professional lives, and longevity in the field? Rural patients are more likely than urban patients to be elderly and poor and have chronic illnesses (J. Am Coll. Surg. 2014;219:814-8). The average age of rural surgeons suggests that many will retire in the coming decade. Who will replace them and care for 60 million citizens who reside in rural America? How will the gradual decline of residents choosing general surgery and rural practice affect patient care?
This new monthly column, Rural Surgeons Speak, focuses on these questions and searches for answers. Rural Surgeons Speak will introduce to all readers the voices, concerns, questions, and opinions of surgeons practicing in the small towns and rural regions of the United States. Although many of the challenges faced by rural surgeons are unique to this group, there is overlap with issues encountered by urban surgeons and those in academic settings. In spite of problems ranging from a shift from independent practice to hospital employment and to treating the poor with pronounced chronic illnesses, rural surgeons are dedicated and committed. Although these matters are common to all surgeons, rural surgeons’ experiences tend to be singular because of the high percentages of such patients and fewer institutional resources.
I have practiced surgery in small and large rural locations for 37 years. Rural surgery is not a specialty. My case log, filled with endoscopies, laparoscopies, laparotomies, and breast operations, may be even more varied than the logs of urban colleagues. In my early years of practice, I did orthopaedic surgery and gynecology. As a conscious choice, I practiced surgery where I wanted, and how I wanted. My choice was not by default. When I started, I sought a location that would allow me to “have a more complete life with less tension, excellent schools, opportunity for economical living,” and a fulfilling surgery practice. Unknown to me, Dr. Edwin F. Cave, ACS president, made those statements about rural surgery in the Daily Clinical Bulletin for the 37th Annual Clinical Congress decades before I started.
Like other rural surgeons, I wanted to embrace and be embraced by my community. I also saw opportunities for personal advancement (involvement with ACS), and for the development of my surgical talents (lasers, laparoscopies, endoscopies). I live just a mile from the hospital. I know my patients by their first names. They speak to me on the telephone. My number is in the book. When they meet me in church or at the grocery store, I am “Doc.” Occasionally a PEx is performed in such locations. It is personal. It is comfortable. There is a real sense of community and of belonging. I am involved. I provide an invaluable service “right at home,” where my patients want to be treated. In return, I am valued and supported.
After becoming a FACS in 1979, I involved myself in many activities of the ACS. Most recently, I participated in the rural surgery renaissance from its beginning. As part of my participation, I routinely contacted rural surgeons around the United States and gained intimate and detailed knowledge about their practices, successes, and concerns. I bring insights from my background to the writing of this column.
While glamour is at a minimum in rural America, personal satisfaction for many of these surgeons is at a maximum. Unfortunately, isolation is a given in most rural practices, and therein lies the problem. In spite of offering much to their patients and, in turn, to the profession, rural surgeons are easy targets of negative assessments, ill-conceived policy changes, and misunderstandings.
Despite their vital role in treating patients, rural surgeons often regard themselves as unrecognized and unappreciated by their peers. There is a subtle bias in the profession against a surgeon who would choose this life of relative isolation, alleged nonspecialized surgery, and overwork in communities with fewer cultural resources and fewer employment options for spouses. Yet their work is essential to the health of millions of people who live in rural areas. Thankfully, the profession as a whole has stopped ignoring rural surgery in recent years as the ACS leadership has stepped in and begun to increase support for rural surgeons.
In May 2011, during the 5th Annual Rural Surgery Symposium and Workshop, I presented a talk, “The ACS and the Rural Surgeon.” Past President Dr. LaMar McGinnis acknowledged the educational value of the presentation, which then went on to wider distribution. The Board of Regents received another talk about rural surgery in February 2012: “Us vs. Them.” Based on the talk and because of their keen insights, the Regents formed the Advisory Council on Rural Surgery – the first new advisory council in 50 years. Subsequently, a College-developed rural listserv became the most highly successful communications program in ACS history and led to the creation of the rural surgery community. In the following 2 years, rural surgeons exchanged 9 million emails on numerous, varied topics. An article in the July 2014 ACS Bulletin describes the program (http://bulletin.facs.org/2014/07/acs-rural-listserv-an-underdog-success-story/). Finally, in his inaugural address at the 2012 Clinical Congress, Dr. Brent Eastman identified rural surgery as one of the four fundamental components of surgery for the next 100 years (http://bulletin.facs.org/2012/12/presidential-address/). Recognition of rural surgery obviously has increased.
My experience of moderating the rural listserv with nearly 1,000 subscribers has revealed the amazing diversity, passion, commitment, and perseverance of rural surgeons who have united in a true community. Their perspectives on their professional lives and the lives of their patients are well worth closer acquaintance by surgeons from all sectors. They have a lot to teach us all. To learn about rural surgery will be to learn about all surgery. Understand rural surgery in 2014 and, consequently, understand all surgery. Recognize the benefits of rural surgery and then instill them in all practices. Supporting rural surgery today supports all surgery.
The column aims to offer commentary on diverse topics confronting rural surgeons today. Opinions, editorials, letters, economics, and clinical matters, all from the rural perspective, will be included. Over 60 individual “threads” appeared on the listserv this year and the subjects of many of these threads could be covered in future columns. Uncommon subjects such as YKYAARSI (“You know you are a rural surgeon if…”) should be entertaining and informative. Guest authors who are experts on varying subjects will contribute articles.
While its roots are in the rural surgery community, the column’s scope will touch all surgical practices. Rural surgery will be better defined, positively characterized, and documented. In partnership with the ACS to achieve the general goal of supporting rural surgery, Rural Surgeons Speak aims to enable all ACS Fellows to realize that they belong to a community of all surgeons, regardless of location or practice type.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
Studies show few unsuspected sarcomas found during uterine surgery
VANCOUVER, B.C. – The incidence of unsuspected uterine sarcoma found during surgery for other conditions is low, according to three cohort studies reported at the meeting, sponsored by AAGL.
In one study, researchers at Mount Sinai Hospital in New York City retrospectively studied 815 consecutive women who underwent laparoscopic supracervical hysterectomy or laparoscopic myomectomy with power morcellation at the hospital between 2006 and 2013.
Pathology of the morcellated uteri identified endometrial carcinoma in two patients (one with prolapse and one with a presumed prolapsing fibroid), for an incidence of 0.25%, according to Dr. Charles J. Ascher-Walsh, associate professor of obstetrics, gynecology, and reproductive science at Mount Sinai, and lead author of the study.
None of the patients were found to have a uterine sarcoma or any other cancer.
“There’s obviously very little data sort of looking forward on the risk of morcellating endometrial cancers. It doesn’t seem so far to significantly worsen the prognosis in these patients. There have been a few reviews looking at a cost-effectiveness analysis in biopsying postmenopausal asymptomatic patients who are having prolapse surgery, and so far the conclusions in both of those studies have shown that it’s not cost-effective to biopsy these patients,” Dr. Ascher-Walsh said. “Now I know there are institutions that are biopsying them anyway, and certainly as part of the revamp of people’s protocols with the morcellation debate, I think more institutions are starting to automatically biopsy every patient before morcellation.”
Total laparoscopic hysterectomies were not included in the study, because Dr. Ascher-Walsh usually performs that operation by vaginal approach, he said. “I wanted to focus just on the intra-abdominal morcellation technique. But obviously, in the debate, whether you cut into it vaginally or cut into it with an open myomectomy, you can potentially have the same concerns and risks.”
Mount Sinai has modified its policy on performing morcellation, somewhat, as a result of the ongoing debate, Dr. Ascher-Walsh said.
“We continue to do morcellation, but before doing morcellation, if we don’t have documentation of a typically growing fibroid, or if somebody presents with a large fibroid without any evidence of slow growth over time, we will get an MRI, although the evidence isn’t supportive of MRIs being diagnostic, other than the one study that combined it with [lactate dehydrogenase],” he said.
In the second study, a team led by Dr. Nichole Mahnert, a fellow in obstetrics and gynecology at the University of Michigan, Ann Arbor, used the Michigan Surgical Quality Collaborative database to prospectively study 6,360 women who underwent hysterectomy for a benign indication during 2013.
Pathology identified unexpected uterine sarcoma in 0.22% of patients (1 in 454) overall, and in 0.27% of patients (1 in 370) whose indication for surgery was specifically fibroids. These values are generally on par with the 0.28% of women operated on for fibroids (1 in 352) seen in the Food and Drug Administration assessment, she said.
In the cohort overall, prior venous thromboembolism and preoperative blood transfusion tended to be more common among patients later found to have uterine sarcoma.
Other cancers identified in the entire cohort included endometrial cancer (1.02%), ovarian cancer (1.06%), cervical cancer (0.17%), and metastatic cancer (0.20%).
“Comprehensive preoperative surgical counseling is paramount, and it should include not only the usual risks of surgery, but also the risk of unexpected malignancy and the risk of inadvertent morcellation of an unexpected malignancy. One should also consider the risks and benefits of a laparoscopic versus and open procedure,” Dr. Mahnert recommended. “And until we can more reliably risk-stratify patients to identify those with unexpected uterine sarcomas, we need to support technologies to limit the dissemination of specimens during minimally invasive procedures.”
In the third study, Dr. Katherine A. Hartzell, an ob.gyn. at Kaiser Permanente in San Diego, and her colleagues retrospectively reviewed the charts of all 3,523 women undergoing laparoscopic hysterectomy at the institution between 2001 and 2012.
Of the 941 cases in which power morcellation was used, uterine sarcoma was found in 6 cases or 0.6%; half were endometrial stromal sarcoma and half were leiomyosarcoma. Five of these patients had no evidence of disease after at least 31 months of follow-up. The sixth patient, who had high-grade leiomyosarcoma, died from her disease 3 years after diagnosis.
The uterine sarcoma rate of 0.6% was roughly double the 0.28% estimated by the FDA, Dr. Hartzell noted.
“This higher incidence was probably due to the inclusion of three patients with a delayed presentation of uterine sarcoma when initial pathology was benign,” she said. “These patients were likely discovered because of the captive nature of the Kaiser health care system.”
None of a wide variety of factors evaluated predicted the risk of uterine sarcoma in these patients undergoing morcellation, Dr. Hartzell said.
Among the 2,582 women who did not undergo power morcellation, uterine sarcoma was identified in 5 patients, or 0.2%. Four were alive without evidence of disease after at least 37 months of follow-up. The fifth patient, who had high-grade leiomyosarcoma, died from her disease 2 years after diagnosis.
“The patient about to undergo a minimally invasive procedure with possible power morcellation should be counseled about the possible consequences of morcellation of an undiagnosed malignancy. Alternatives such as mini-laparotomy or an open procedure should be offered. At our institution, we are also now performing morcellation within a tissue containment bag,” she said.
“Given the well-known advantages of laparoscopic surgery and the rarity of uterine sarcomas, it is our opinion that the risk of morcellation of occult malignancy is insufficient to abandon power morcellation,” Dr. Hartzell added.
The researchers reported that they had no relevant conflicts of interest.
VANCOUVER, B.C. – The incidence of unsuspected uterine sarcoma found during surgery for other conditions is low, according to three cohort studies reported at the meeting, sponsored by AAGL.
In one study, researchers at Mount Sinai Hospital in New York City retrospectively studied 815 consecutive women who underwent laparoscopic supracervical hysterectomy or laparoscopic myomectomy with power morcellation at the hospital between 2006 and 2013.
Pathology of the morcellated uteri identified endometrial carcinoma in two patients (one with prolapse and one with a presumed prolapsing fibroid), for an incidence of 0.25%, according to Dr. Charles J. Ascher-Walsh, associate professor of obstetrics, gynecology, and reproductive science at Mount Sinai, and lead author of the study.
None of the patients were found to have a uterine sarcoma or any other cancer.
“There’s obviously very little data sort of looking forward on the risk of morcellating endometrial cancers. It doesn’t seem so far to significantly worsen the prognosis in these patients. There have been a few reviews looking at a cost-effectiveness analysis in biopsying postmenopausal asymptomatic patients who are having prolapse surgery, and so far the conclusions in both of those studies have shown that it’s not cost-effective to biopsy these patients,” Dr. Ascher-Walsh said. “Now I know there are institutions that are biopsying them anyway, and certainly as part of the revamp of people’s protocols with the morcellation debate, I think more institutions are starting to automatically biopsy every patient before morcellation.”
Total laparoscopic hysterectomies were not included in the study, because Dr. Ascher-Walsh usually performs that operation by vaginal approach, he said. “I wanted to focus just on the intra-abdominal morcellation technique. But obviously, in the debate, whether you cut into it vaginally or cut into it with an open myomectomy, you can potentially have the same concerns and risks.”
Mount Sinai has modified its policy on performing morcellation, somewhat, as a result of the ongoing debate, Dr. Ascher-Walsh said.
“We continue to do morcellation, but before doing morcellation, if we don’t have documentation of a typically growing fibroid, or if somebody presents with a large fibroid without any evidence of slow growth over time, we will get an MRI, although the evidence isn’t supportive of MRIs being diagnostic, other than the one study that combined it with [lactate dehydrogenase],” he said.
In the second study, a team led by Dr. Nichole Mahnert, a fellow in obstetrics and gynecology at the University of Michigan, Ann Arbor, used the Michigan Surgical Quality Collaborative database to prospectively study 6,360 women who underwent hysterectomy for a benign indication during 2013.
Pathology identified unexpected uterine sarcoma in 0.22% of patients (1 in 454) overall, and in 0.27% of patients (1 in 370) whose indication for surgery was specifically fibroids. These values are generally on par with the 0.28% of women operated on for fibroids (1 in 352) seen in the Food and Drug Administration assessment, she said.
In the cohort overall, prior venous thromboembolism and preoperative blood transfusion tended to be more common among patients later found to have uterine sarcoma.
Other cancers identified in the entire cohort included endometrial cancer (1.02%), ovarian cancer (1.06%), cervical cancer (0.17%), and metastatic cancer (0.20%).
“Comprehensive preoperative surgical counseling is paramount, and it should include not only the usual risks of surgery, but also the risk of unexpected malignancy and the risk of inadvertent morcellation of an unexpected malignancy. One should also consider the risks and benefits of a laparoscopic versus and open procedure,” Dr. Mahnert recommended. “And until we can more reliably risk-stratify patients to identify those with unexpected uterine sarcomas, we need to support technologies to limit the dissemination of specimens during minimally invasive procedures.”
In the third study, Dr. Katherine A. Hartzell, an ob.gyn. at Kaiser Permanente in San Diego, and her colleagues retrospectively reviewed the charts of all 3,523 women undergoing laparoscopic hysterectomy at the institution between 2001 and 2012.
Of the 941 cases in which power morcellation was used, uterine sarcoma was found in 6 cases or 0.6%; half were endometrial stromal sarcoma and half were leiomyosarcoma. Five of these patients had no evidence of disease after at least 31 months of follow-up. The sixth patient, who had high-grade leiomyosarcoma, died from her disease 3 years after diagnosis.
The uterine sarcoma rate of 0.6% was roughly double the 0.28% estimated by the FDA, Dr. Hartzell noted.
“This higher incidence was probably due to the inclusion of three patients with a delayed presentation of uterine sarcoma when initial pathology was benign,” she said. “These patients were likely discovered because of the captive nature of the Kaiser health care system.”
None of a wide variety of factors evaluated predicted the risk of uterine sarcoma in these patients undergoing morcellation, Dr. Hartzell said.
Among the 2,582 women who did not undergo power morcellation, uterine sarcoma was identified in 5 patients, or 0.2%. Four were alive without evidence of disease after at least 37 months of follow-up. The fifth patient, who had high-grade leiomyosarcoma, died from her disease 2 years after diagnosis.
“The patient about to undergo a minimally invasive procedure with possible power morcellation should be counseled about the possible consequences of morcellation of an undiagnosed malignancy. Alternatives such as mini-laparotomy or an open procedure should be offered. At our institution, we are also now performing morcellation within a tissue containment bag,” she said.
“Given the well-known advantages of laparoscopic surgery and the rarity of uterine sarcomas, it is our opinion that the risk of morcellation of occult malignancy is insufficient to abandon power morcellation,” Dr. Hartzell added.
The researchers reported that they had no relevant conflicts of interest.
VANCOUVER, B.C. – The incidence of unsuspected uterine sarcoma found during surgery for other conditions is low, according to three cohort studies reported at the meeting, sponsored by AAGL.
In one study, researchers at Mount Sinai Hospital in New York City retrospectively studied 815 consecutive women who underwent laparoscopic supracervical hysterectomy or laparoscopic myomectomy with power morcellation at the hospital between 2006 and 2013.
Pathology of the morcellated uteri identified endometrial carcinoma in two patients (one with prolapse and one with a presumed prolapsing fibroid), for an incidence of 0.25%, according to Dr. Charles J. Ascher-Walsh, associate professor of obstetrics, gynecology, and reproductive science at Mount Sinai, and lead author of the study.
None of the patients were found to have a uterine sarcoma or any other cancer.
“There’s obviously very little data sort of looking forward on the risk of morcellating endometrial cancers. It doesn’t seem so far to significantly worsen the prognosis in these patients. There have been a few reviews looking at a cost-effectiveness analysis in biopsying postmenopausal asymptomatic patients who are having prolapse surgery, and so far the conclusions in both of those studies have shown that it’s not cost-effective to biopsy these patients,” Dr. Ascher-Walsh said. “Now I know there are institutions that are biopsying them anyway, and certainly as part of the revamp of people’s protocols with the morcellation debate, I think more institutions are starting to automatically biopsy every patient before morcellation.”
Total laparoscopic hysterectomies were not included in the study, because Dr. Ascher-Walsh usually performs that operation by vaginal approach, he said. “I wanted to focus just on the intra-abdominal morcellation technique. But obviously, in the debate, whether you cut into it vaginally or cut into it with an open myomectomy, you can potentially have the same concerns and risks.”
Mount Sinai has modified its policy on performing morcellation, somewhat, as a result of the ongoing debate, Dr. Ascher-Walsh said.
“We continue to do morcellation, but before doing morcellation, if we don’t have documentation of a typically growing fibroid, or if somebody presents with a large fibroid without any evidence of slow growth over time, we will get an MRI, although the evidence isn’t supportive of MRIs being diagnostic, other than the one study that combined it with [lactate dehydrogenase],” he said.
In the second study, a team led by Dr. Nichole Mahnert, a fellow in obstetrics and gynecology at the University of Michigan, Ann Arbor, used the Michigan Surgical Quality Collaborative database to prospectively study 6,360 women who underwent hysterectomy for a benign indication during 2013.
Pathology identified unexpected uterine sarcoma in 0.22% of patients (1 in 454) overall, and in 0.27% of patients (1 in 370) whose indication for surgery was specifically fibroids. These values are generally on par with the 0.28% of women operated on for fibroids (1 in 352) seen in the Food and Drug Administration assessment, she said.
In the cohort overall, prior venous thromboembolism and preoperative blood transfusion tended to be more common among patients later found to have uterine sarcoma.
Other cancers identified in the entire cohort included endometrial cancer (1.02%), ovarian cancer (1.06%), cervical cancer (0.17%), and metastatic cancer (0.20%).
“Comprehensive preoperative surgical counseling is paramount, and it should include not only the usual risks of surgery, but also the risk of unexpected malignancy and the risk of inadvertent morcellation of an unexpected malignancy. One should also consider the risks and benefits of a laparoscopic versus and open procedure,” Dr. Mahnert recommended. “And until we can more reliably risk-stratify patients to identify those with unexpected uterine sarcomas, we need to support technologies to limit the dissemination of specimens during minimally invasive procedures.”
In the third study, Dr. Katherine A. Hartzell, an ob.gyn. at Kaiser Permanente in San Diego, and her colleagues retrospectively reviewed the charts of all 3,523 women undergoing laparoscopic hysterectomy at the institution between 2001 and 2012.
Of the 941 cases in which power morcellation was used, uterine sarcoma was found in 6 cases or 0.6%; half were endometrial stromal sarcoma and half were leiomyosarcoma. Five of these patients had no evidence of disease after at least 31 months of follow-up. The sixth patient, who had high-grade leiomyosarcoma, died from her disease 3 years after diagnosis.
The uterine sarcoma rate of 0.6% was roughly double the 0.28% estimated by the FDA, Dr. Hartzell noted.
“This higher incidence was probably due to the inclusion of three patients with a delayed presentation of uterine sarcoma when initial pathology was benign,” she said. “These patients were likely discovered because of the captive nature of the Kaiser health care system.”
None of a wide variety of factors evaluated predicted the risk of uterine sarcoma in these patients undergoing morcellation, Dr. Hartzell said.
Among the 2,582 women who did not undergo power morcellation, uterine sarcoma was identified in 5 patients, or 0.2%. Four were alive without evidence of disease after at least 37 months of follow-up. The fifth patient, who had high-grade leiomyosarcoma, died from her disease 2 years after diagnosis.
“The patient about to undergo a minimally invasive procedure with possible power morcellation should be counseled about the possible consequences of morcellation of an undiagnosed malignancy. Alternatives such as mini-laparotomy or an open procedure should be offered. At our institution, we are also now performing morcellation within a tissue containment bag,” she said.
“Given the well-known advantages of laparoscopic surgery and the rarity of uterine sarcomas, it is our opinion that the risk of morcellation of occult malignancy is insufficient to abandon power morcellation,” Dr. Hartzell added.
The researchers reported that they had no relevant conflicts of interest.
AT THE AAGL GLOBAL CONGRESS
Key clinical point: The incidence of occult cancers varied by cohort, but was generally low.
Major finding: Unsuspected uterine sarcoma was found in 0%-0.6% of patients.
Data source: A trio of cohort studies among 815 women, 6,360 women, and 3,523 women undergoing uterine surgery.
Disclosures: The researchers reported that they had no relevant conflicts of interest.
Reduced resident duty hours haven’t changed patient outcomes
Patient mortality and morbidity outcomes have not changed since the most recent round of reforms to medical residents’ duty hours in 2011, according to two of the first nationwide studies to assess these “improvements,” which both were published online Dec. 9 in JAMA.
In addition, one of the studies found no difference between pre-reform and post-reform scores or on pass rates for oral or written national in-training and board certification examinations.
Thus, two separate studies involving millions of hospitalized patients across the country have both found that these reforms had no discernible effect on patient care. However, both groups of researchers cautioned that their studies were observational and therefore subject to potential biases and that they covered only the first 2 years that the duty-hours reforms have been in place.
The 2011 requirements expanded on those enacted in 2003 by further restricting residents’ duty hours, in the hope of reducing medical errors attributed to exhausted residents. The hours of continuous in-hospital duty were reduced from 30 to 16 for first-year residents and to 24 for upper-year residents, and the interval between shifts was increased to at least 8 hours off for first-year residents and at least 14 hours off for upper-year residents.
“Duty hour reform is arguably one of the largest efforts ever undertaken to improve the quality and safety of patient care in teaching hospitals,” said Dr. Mitesh S. Patel of the University of Pennsylvania and the Veterans Affairs Hospital Center for Health Equity Research and Promotion, both in Philadelphia, and his associates.
They assessed 30-day mortality and readmissions among 2,790,356 Medicare patients who were treated either for acute MI, stroke, gastrointestinal bleeding, or heart failure, or who underwent general, orthopedic, or vascular surgery, at 3,104 hospitals between 2009 and 2012. The investigators found no significant associations, either positive or negative, between the reforms to residents’ duty hours and any patient outcomes. Sensitivity analyses confirmed the results of the primary data analyses.
“Our findings suggest that ... the goals of improving the quality and safety of patient care ... were not being achieved. Conversely, concerns that outcomes might actually worsen because of decreased continuity of care have not been borne out,” Dr. Patel and his associates said (JAMA 2014 Dec. 9 [doi:10.1001/jama.2014.15273]).
The investigators noted that their study was limited in that it could not take into account hospitals’ adherence to the new requirements. Their study also did not assess other outcomes such as patient safety indicators or complication rates, which “may better elucidate the relative effects of decreased resident fatigue and increased patient hand offs.” And their study couldn’t address any possible confounding effects from other concurrent policy initiatives aimed at improving care for Medicare beneficiaries, such as the Hospital Readmissions Reduction Program.
In the other study, a separate group of researchers used data from the American College of Surgeons National Surgical Quality Improvement Program to assess outcomes for 535,499 patients who underwent general surgery at 131 hospitals during the 2 years before and the 2 years after the reforms to residents’ duty hours were implemented. This included 23 teaching hospitals in which residents were involved in at least 95% of general surgeries, said Dr. Ravi Rajaram of the division of research and optimal patient care, American College of Surgeons, and the Institute for Public Health and Medicine at Northwestern University, both in Chicago, and his associates.
The reforms were not associated with any change in rates of patient mortality or serious morbidity, either in the study population as a whole or in the subgroups of high-risk and low-risk patients. They also had no effect on secondary outcomes such as surgical-site infection or sepsis. These results remained consistent across several sensitivity analyses.
Neither mean scores for in-training, written board, and oral board examinations nor pass rates for those examinations showed any significant changes during the study period.
“Moreover, first-year trainees, who were most directly affected by the 2011 reforms, did not improve their ABSITE [American Board of Surgery In-Training Examination] scores, despite presumably more free time to prepare,” Dr. Rajaram and his associates said (JAMA 2014 Dec. 9 [doi:10.1001/JAMA.2014.15277]).
They cautioned that their study assessed only the first 2 years following duty-hour reform, and “there may be differences in patient care or resident examination performance that are evident only several years after implementation and adoption of new duty-hour requirements.” In addition, a retrospective observational study such as this one could not produce the high-level evidence needed to guide policy decisions. “To that end, a national multicenter cluster-randomized trial is being conducted (the Flexibility In duty hour Requirements for Surgical Trainees [FIRST] trial), comparing current duty-hour requirements with flexible duty hours to assess the effects of this intervention on patient outcomes and resident well-being. This trial may further inform the debate of how to optimally structure postgraduate training,” they said.
The results of these two large studies are aligned with those of most previous research into the effects of duty hour requirements on patient outcomes. There is a consistent theme: a lack of a major beneficial effect.
Complex problems often demand complex answers. The goal is for the medical profession to move forward with more comprehensive and nuanced approaches to help fulfill its responsibility to provide trainees with the necessary skills to manage fatigue and allow the safest environment for quality care.
Dr. James A. Arrigh is chair of the Accreditation Council for Graduate Medical Education (ACGME) residency review committee for internal medicine. Dr. James C. Hebert is chair of the ACGME Council of Review Committee Chairs. They made these remarks in an editorial accompanying the studies.
The results of these two large studies are aligned with those of most previous research into the effects of duty hour requirements on patient outcomes. There is a consistent theme: a lack of a major beneficial effect.
Complex problems often demand complex answers. The goal is for the medical profession to move forward with more comprehensive and nuanced approaches to help fulfill its responsibility to provide trainees with the necessary skills to manage fatigue and allow the safest environment for quality care.
Dr. James A. Arrigh is chair of the Accreditation Council for Graduate Medical Education (ACGME) residency review committee for internal medicine. Dr. James C. Hebert is chair of the ACGME Council of Review Committee Chairs. They made these remarks in an editorial accompanying the studies.
The results of these two large studies are aligned with those of most previous research into the effects of duty hour requirements on patient outcomes. There is a consistent theme: a lack of a major beneficial effect.
Complex problems often demand complex answers. The goal is for the medical profession to move forward with more comprehensive and nuanced approaches to help fulfill its responsibility to provide trainees with the necessary skills to manage fatigue and allow the safest environment for quality care.
Dr. James A. Arrigh is chair of the Accreditation Council for Graduate Medical Education (ACGME) residency review committee for internal medicine. Dr. James C. Hebert is chair of the ACGME Council of Review Committee Chairs. They made these remarks in an editorial accompanying the studies.
Patient mortality and morbidity outcomes have not changed since the most recent round of reforms to medical residents’ duty hours in 2011, according to two of the first nationwide studies to assess these “improvements,” which both were published online Dec. 9 in JAMA.
In addition, one of the studies found no difference between pre-reform and post-reform scores or on pass rates for oral or written national in-training and board certification examinations.
Thus, two separate studies involving millions of hospitalized patients across the country have both found that these reforms had no discernible effect on patient care. However, both groups of researchers cautioned that their studies were observational and therefore subject to potential biases and that they covered only the first 2 years that the duty-hours reforms have been in place.
The 2011 requirements expanded on those enacted in 2003 by further restricting residents’ duty hours, in the hope of reducing medical errors attributed to exhausted residents. The hours of continuous in-hospital duty were reduced from 30 to 16 for first-year residents and to 24 for upper-year residents, and the interval between shifts was increased to at least 8 hours off for first-year residents and at least 14 hours off for upper-year residents.
“Duty hour reform is arguably one of the largest efforts ever undertaken to improve the quality and safety of patient care in teaching hospitals,” said Dr. Mitesh S. Patel of the University of Pennsylvania and the Veterans Affairs Hospital Center for Health Equity Research and Promotion, both in Philadelphia, and his associates.
They assessed 30-day mortality and readmissions among 2,790,356 Medicare patients who were treated either for acute MI, stroke, gastrointestinal bleeding, or heart failure, or who underwent general, orthopedic, or vascular surgery, at 3,104 hospitals between 2009 and 2012. The investigators found no significant associations, either positive or negative, between the reforms to residents’ duty hours and any patient outcomes. Sensitivity analyses confirmed the results of the primary data analyses.
“Our findings suggest that ... the goals of improving the quality and safety of patient care ... were not being achieved. Conversely, concerns that outcomes might actually worsen because of decreased continuity of care have not been borne out,” Dr. Patel and his associates said (JAMA 2014 Dec. 9 [doi:10.1001/jama.2014.15273]).
The investigators noted that their study was limited in that it could not take into account hospitals’ adherence to the new requirements. Their study also did not assess other outcomes such as patient safety indicators or complication rates, which “may better elucidate the relative effects of decreased resident fatigue and increased patient hand offs.” And their study couldn’t address any possible confounding effects from other concurrent policy initiatives aimed at improving care for Medicare beneficiaries, such as the Hospital Readmissions Reduction Program.
In the other study, a separate group of researchers used data from the American College of Surgeons National Surgical Quality Improvement Program to assess outcomes for 535,499 patients who underwent general surgery at 131 hospitals during the 2 years before and the 2 years after the reforms to residents’ duty hours were implemented. This included 23 teaching hospitals in which residents were involved in at least 95% of general surgeries, said Dr. Ravi Rajaram of the division of research and optimal patient care, American College of Surgeons, and the Institute for Public Health and Medicine at Northwestern University, both in Chicago, and his associates.
The reforms were not associated with any change in rates of patient mortality or serious morbidity, either in the study population as a whole or in the subgroups of high-risk and low-risk patients. They also had no effect on secondary outcomes such as surgical-site infection or sepsis. These results remained consistent across several sensitivity analyses.
Neither mean scores for in-training, written board, and oral board examinations nor pass rates for those examinations showed any significant changes during the study period.
“Moreover, first-year trainees, who were most directly affected by the 2011 reforms, did not improve their ABSITE [American Board of Surgery In-Training Examination] scores, despite presumably more free time to prepare,” Dr. Rajaram and his associates said (JAMA 2014 Dec. 9 [doi:10.1001/JAMA.2014.15277]).
They cautioned that their study assessed only the first 2 years following duty-hour reform, and “there may be differences in patient care or resident examination performance that are evident only several years after implementation and adoption of new duty-hour requirements.” In addition, a retrospective observational study such as this one could not produce the high-level evidence needed to guide policy decisions. “To that end, a national multicenter cluster-randomized trial is being conducted (the Flexibility In duty hour Requirements for Surgical Trainees [FIRST] trial), comparing current duty-hour requirements with flexible duty hours to assess the effects of this intervention on patient outcomes and resident well-being. This trial may further inform the debate of how to optimally structure postgraduate training,” they said.
Patient mortality and morbidity outcomes have not changed since the most recent round of reforms to medical residents’ duty hours in 2011, according to two of the first nationwide studies to assess these “improvements,” which both were published online Dec. 9 in JAMA.
In addition, one of the studies found no difference between pre-reform and post-reform scores or on pass rates for oral or written national in-training and board certification examinations.
Thus, two separate studies involving millions of hospitalized patients across the country have both found that these reforms had no discernible effect on patient care. However, both groups of researchers cautioned that their studies were observational and therefore subject to potential biases and that they covered only the first 2 years that the duty-hours reforms have been in place.
The 2011 requirements expanded on those enacted in 2003 by further restricting residents’ duty hours, in the hope of reducing medical errors attributed to exhausted residents. The hours of continuous in-hospital duty were reduced from 30 to 16 for first-year residents and to 24 for upper-year residents, and the interval between shifts was increased to at least 8 hours off for first-year residents and at least 14 hours off for upper-year residents.
“Duty hour reform is arguably one of the largest efforts ever undertaken to improve the quality and safety of patient care in teaching hospitals,” said Dr. Mitesh S. Patel of the University of Pennsylvania and the Veterans Affairs Hospital Center for Health Equity Research and Promotion, both in Philadelphia, and his associates.
They assessed 30-day mortality and readmissions among 2,790,356 Medicare patients who were treated either for acute MI, stroke, gastrointestinal bleeding, or heart failure, or who underwent general, orthopedic, or vascular surgery, at 3,104 hospitals between 2009 and 2012. The investigators found no significant associations, either positive or negative, between the reforms to residents’ duty hours and any patient outcomes. Sensitivity analyses confirmed the results of the primary data analyses.
“Our findings suggest that ... the goals of improving the quality and safety of patient care ... were not being achieved. Conversely, concerns that outcomes might actually worsen because of decreased continuity of care have not been borne out,” Dr. Patel and his associates said (JAMA 2014 Dec. 9 [doi:10.1001/jama.2014.15273]).
The investigators noted that their study was limited in that it could not take into account hospitals’ adherence to the new requirements. Their study also did not assess other outcomes such as patient safety indicators or complication rates, which “may better elucidate the relative effects of decreased resident fatigue and increased patient hand offs.” And their study couldn’t address any possible confounding effects from other concurrent policy initiatives aimed at improving care for Medicare beneficiaries, such as the Hospital Readmissions Reduction Program.
In the other study, a separate group of researchers used data from the American College of Surgeons National Surgical Quality Improvement Program to assess outcomes for 535,499 patients who underwent general surgery at 131 hospitals during the 2 years before and the 2 years after the reforms to residents’ duty hours were implemented. This included 23 teaching hospitals in which residents were involved in at least 95% of general surgeries, said Dr. Ravi Rajaram of the division of research and optimal patient care, American College of Surgeons, and the Institute for Public Health and Medicine at Northwestern University, both in Chicago, and his associates.
The reforms were not associated with any change in rates of patient mortality or serious morbidity, either in the study population as a whole or in the subgroups of high-risk and low-risk patients. They also had no effect on secondary outcomes such as surgical-site infection or sepsis. These results remained consistent across several sensitivity analyses.
Neither mean scores for in-training, written board, and oral board examinations nor pass rates for those examinations showed any significant changes during the study period.
“Moreover, first-year trainees, who were most directly affected by the 2011 reforms, did not improve their ABSITE [American Board of Surgery In-Training Examination] scores, despite presumably more free time to prepare,” Dr. Rajaram and his associates said (JAMA 2014 Dec. 9 [doi:10.1001/JAMA.2014.15277]).
They cautioned that their study assessed only the first 2 years following duty-hour reform, and “there may be differences in patient care or resident examination performance that are evident only several years after implementation and adoption of new duty-hour requirements.” In addition, a retrospective observational study such as this one could not produce the high-level evidence needed to guide policy decisions. “To that end, a national multicenter cluster-randomized trial is being conducted (the Flexibility In duty hour Requirements for Surgical Trainees [FIRST] trial), comparing current duty-hour requirements with flexible duty hours to assess the effects of this intervention on patient outcomes and resident well-being. This trial may further inform the debate of how to optimally structure postgraduate training,” they said.
Key clinical point: The newest (2011) reforms to resident duty hours haven’t changed patient mortality or morbidity outcomes.
Major finding: 30-day mortality and readmissions among almost 3 million Medicare patients at 3,104 hospitals did not change between 2009 and 2012.
Data source: Two observational cohort studies of millions of hospitalized adults across the country, comparing patient outcomes before with those after the 2011 reforms in duty hours for residents.
Disclosures: Dr. Patel’s study was funded in part by the National Heart, Lung, and Blood Institute, the Department of Veterans Affairs, and the Robert Wood Johnson Foundation. Dr. Rajaram’s study was supported by the Agency for Healthcare Research and Quality, the American College of Surgeons, and Merck. All of the investigators reported having no relevant financial conflicts of interest.
VIDEO: Curative surgery possible for some kids with LGS epilepsy
SEATTLE– Surgery may cure, or at least greatly help, children with Lennox-Gastaut syndrome who have an abnormality on their brain MRI, according to researchers from the Cleveland Clinic Epilepsy Center.
LGS is a severe form of epilepsy that medications often do not help. Children have multiple seizures per day, with concomitant developmental problems. Until now, surgery has been considered only a palliative option. That may be about to change.
Investigator Dr. Ahsan Valappil, a pediatric epileptologist at the Cleveland Clinic, explained why in an interview at the annual meeting of the American Epilepsy Society.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SEATTLE– Surgery may cure, or at least greatly help, children with Lennox-Gastaut syndrome who have an abnormality on their brain MRI, according to researchers from the Cleveland Clinic Epilepsy Center.
LGS is a severe form of epilepsy that medications often do not help. Children have multiple seizures per day, with concomitant developmental problems. Until now, surgery has been considered only a palliative option. That may be about to change.
Investigator Dr. Ahsan Valappil, a pediatric epileptologist at the Cleveland Clinic, explained why in an interview at the annual meeting of the American Epilepsy Society.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SEATTLE– Surgery may cure, or at least greatly help, children with Lennox-Gastaut syndrome who have an abnormality on their brain MRI, according to researchers from the Cleveland Clinic Epilepsy Center.
LGS is a severe form of epilepsy that medications often do not help. Children have multiple seizures per day, with concomitant developmental problems. Until now, surgery has been considered only a palliative option. That may be about to change.
Investigator Dr. Ahsan Valappil, a pediatric epileptologist at the Cleveland Clinic, explained why in an interview at the annual meeting of the American Epilepsy Society.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT AES 2014
ONC strategic plan keeps focus on adoption, interoperability
Adoption and interoperability of electronic health records continue to be a primary focus of efforts by the Office of the National Coordinator for Health Information Technology.
“There will be a strong emphasis on interoperability,” said Dr. Karen DeSalvo, National Coordinator for Health IT, during a press conference Dec. 8 to release the updated Federal Health IT Strategic Plan 2015-2020.
Dr. DeSalvo noted that the federal government aims to make data usable across the spectrum of health care – on a one-on-one basis between doctors and patients, all the way to using Big Data to help advance population health objectives. She also emphasized a need for data to be interoperable to help individuals to become “engaged, empowered, [and] real partners in their health and health care and that is, I think an exciting frontier for all of us.”
Specific details on how ONC plans to address interoperability going forward will come with the agency’s release of its interoperability road map, expected in the early part of 2015. An overview of that road map was released earlier this year.
The plan emphasizes efforts to reach health care providers who are currently not eligible for financial incentives under the current meaningful use program.
Other goals identified in the plan include strengthening the health care delivery system; advancing the health and well-being of individuals and communities; and advancing research, scientific knowledge, and innovation.
The plan also targets technology beyond EHRs to include other types of health IT applications, such as telehealth, and calls for looking at other incentives that the 35 federal agencies who contributed to the plan can offer beyond the meaningful use program to help continue the adoption and use of health IT.
Public comments on this strategic plan are due Feb. 6, 2015.
Adoption and interoperability of electronic health records continue to be a primary focus of efforts by the Office of the National Coordinator for Health Information Technology.
“There will be a strong emphasis on interoperability,” said Dr. Karen DeSalvo, National Coordinator for Health IT, during a press conference Dec. 8 to release the updated Federal Health IT Strategic Plan 2015-2020.
Dr. DeSalvo noted that the federal government aims to make data usable across the spectrum of health care – on a one-on-one basis between doctors and patients, all the way to using Big Data to help advance population health objectives. She also emphasized a need for data to be interoperable to help individuals to become “engaged, empowered, [and] real partners in their health and health care and that is, I think an exciting frontier for all of us.”
Specific details on how ONC plans to address interoperability going forward will come with the agency’s release of its interoperability road map, expected in the early part of 2015. An overview of that road map was released earlier this year.
The plan emphasizes efforts to reach health care providers who are currently not eligible for financial incentives under the current meaningful use program.
Other goals identified in the plan include strengthening the health care delivery system; advancing the health and well-being of individuals and communities; and advancing research, scientific knowledge, and innovation.
The plan also targets technology beyond EHRs to include other types of health IT applications, such as telehealth, and calls for looking at other incentives that the 35 federal agencies who contributed to the plan can offer beyond the meaningful use program to help continue the adoption and use of health IT.
Public comments on this strategic plan are due Feb. 6, 2015.
Adoption and interoperability of electronic health records continue to be a primary focus of efforts by the Office of the National Coordinator for Health Information Technology.
“There will be a strong emphasis on interoperability,” said Dr. Karen DeSalvo, National Coordinator for Health IT, during a press conference Dec. 8 to release the updated Federal Health IT Strategic Plan 2015-2020.
Dr. DeSalvo noted that the federal government aims to make data usable across the spectrum of health care – on a one-on-one basis between doctors and patients, all the way to using Big Data to help advance population health objectives. She also emphasized a need for data to be interoperable to help individuals to become “engaged, empowered, [and] real partners in their health and health care and that is, I think an exciting frontier for all of us.”
Specific details on how ONC plans to address interoperability going forward will come with the agency’s release of its interoperability road map, expected in the early part of 2015. An overview of that road map was released earlier this year.
The plan emphasizes efforts to reach health care providers who are currently not eligible for financial incentives under the current meaningful use program.
Other goals identified in the plan include strengthening the health care delivery system; advancing the health and well-being of individuals and communities; and advancing research, scientific knowledge, and innovation.
The plan also targets technology beyond EHRs to include other types of health IT applications, such as telehealth, and calls for looking at other incentives that the 35 federal agencies who contributed to the plan can offer beyond the meaningful use program to help continue the adoption and use of health IT.
Public comments on this strategic plan are due Feb. 6, 2015.
Ultrasound bests elastography for specificity of thyroid cancer diagnosis
CORONADO, CALIF.– Compared with elastography, ultrasound predictors of malignancy were more specific for presurgical diagnosis and in differentiating between benign and malignant thyroid nodules, results from a pooled analysis showed.
“Elastography is controversial,” Dr. Parisha Bhatia said in an interview during the annual meeting of the American Thyroid Association. “Some studies have reported that it has better sensitivity and specificity, compared with conventional ultrasound, but others have found it not to be helpful.”
In an effort to compare the efficacy of elastography and ultrasound in determining benign and malignant thyroid nodules, and to determine if elastography has a complementary role to fine needle aspiration (FNA), Dr. Bhatia and her associates searched Embase and PubMed databases for articles involving more than 50 nodules using specimen histology as the reference standard. They discovered 14 prospective studies and organized them into one of two groups. Group 1 included nodules with FNA cytology–proven “benign/malignant” result. Group 2 included nodules with FNA cytology as “intermediate.” The elasticity score was compared with ultrasound features such as taller than wide, irregular margins, internal vascularity, calcification, and absence of halo to determine validity measures and likelihood ratios.
Dr. Bhatia, an endocrine surgeon at Tulane University, New Orleans, reported on findings from 2,732 nodules in the pooled analysis. Of these, 64% were benign, 25% were malignant, and 11% were indeterminate.
In group 1, elastography showed a sensitivity of 75%, a specificity of 80%, a positive predictive value (PPV) of 61%, a negative predictive value (NPV) of 89%, and a likelihood ratio of 5.7, with a higher predictive value for nodules smaller than 1 cm in diameter (PPV of 79% and NPV of 83%). The strongest ultrasound-related predictor of malignancies was “taller than wide” (a specificity of 92%, a NPV of 51%, yet a sensitivity of only 24%), followed by irregular margins (a specificity of 91%, sensitivity of 48%, and a PPV of 64%). Combination of elastography and ultrasound had the highest sensitivity (96%) and NPV (96%), yet lower specificity (46%) and PPV (46%).
In group 2, elastography yielded a higher sensitivity (90%) and NPV (92%), while ultrasound features were highly specific, with the highest values for “taller than wide” shape (85%) in these thyroid nodules.
“Ultrasound predictors of malignancy prove to be more specific for presurgical diagnosis and differentiation of benign and malignant thyroid nodules,” the researchers wrote in their abstract. “When used as an adjunct, the higher sensitivity and NPV of combination of both the techniques can lead to better selection of candidates for FNA.”
Dr. Bhatia acknowledged certain limitations of the study, including the fact that the pooled data contained little information on indeterminate thyroid nodules. She reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF.– Compared with elastography, ultrasound predictors of malignancy were more specific for presurgical diagnosis and in differentiating between benign and malignant thyroid nodules, results from a pooled analysis showed.
“Elastography is controversial,” Dr. Parisha Bhatia said in an interview during the annual meeting of the American Thyroid Association. “Some studies have reported that it has better sensitivity and specificity, compared with conventional ultrasound, but others have found it not to be helpful.”
In an effort to compare the efficacy of elastography and ultrasound in determining benign and malignant thyroid nodules, and to determine if elastography has a complementary role to fine needle aspiration (FNA), Dr. Bhatia and her associates searched Embase and PubMed databases for articles involving more than 50 nodules using specimen histology as the reference standard. They discovered 14 prospective studies and organized them into one of two groups. Group 1 included nodules with FNA cytology–proven “benign/malignant” result. Group 2 included nodules with FNA cytology as “intermediate.” The elasticity score was compared with ultrasound features such as taller than wide, irregular margins, internal vascularity, calcification, and absence of halo to determine validity measures and likelihood ratios.
Dr. Bhatia, an endocrine surgeon at Tulane University, New Orleans, reported on findings from 2,732 nodules in the pooled analysis. Of these, 64% were benign, 25% were malignant, and 11% were indeterminate.
In group 1, elastography showed a sensitivity of 75%, a specificity of 80%, a positive predictive value (PPV) of 61%, a negative predictive value (NPV) of 89%, and a likelihood ratio of 5.7, with a higher predictive value for nodules smaller than 1 cm in diameter (PPV of 79% and NPV of 83%). The strongest ultrasound-related predictor of malignancies was “taller than wide” (a specificity of 92%, a NPV of 51%, yet a sensitivity of only 24%), followed by irregular margins (a specificity of 91%, sensitivity of 48%, and a PPV of 64%). Combination of elastography and ultrasound had the highest sensitivity (96%) and NPV (96%), yet lower specificity (46%) and PPV (46%).
In group 2, elastography yielded a higher sensitivity (90%) and NPV (92%), while ultrasound features were highly specific, with the highest values for “taller than wide” shape (85%) in these thyroid nodules.
“Ultrasound predictors of malignancy prove to be more specific for presurgical diagnosis and differentiation of benign and malignant thyroid nodules,” the researchers wrote in their abstract. “When used as an adjunct, the higher sensitivity and NPV of combination of both the techniques can lead to better selection of candidates for FNA.”
Dr. Bhatia acknowledged certain limitations of the study, including the fact that the pooled data contained little information on indeterminate thyroid nodules. She reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF.– Compared with elastography, ultrasound predictors of malignancy were more specific for presurgical diagnosis and in differentiating between benign and malignant thyroid nodules, results from a pooled analysis showed.
“Elastography is controversial,” Dr. Parisha Bhatia said in an interview during the annual meeting of the American Thyroid Association. “Some studies have reported that it has better sensitivity and specificity, compared with conventional ultrasound, but others have found it not to be helpful.”
In an effort to compare the efficacy of elastography and ultrasound in determining benign and malignant thyroid nodules, and to determine if elastography has a complementary role to fine needle aspiration (FNA), Dr. Bhatia and her associates searched Embase and PubMed databases for articles involving more than 50 nodules using specimen histology as the reference standard. They discovered 14 prospective studies and organized them into one of two groups. Group 1 included nodules with FNA cytology–proven “benign/malignant” result. Group 2 included nodules with FNA cytology as “intermediate.” The elasticity score was compared with ultrasound features such as taller than wide, irregular margins, internal vascularity, calcification, and absence of halo to determine validity measures and likelihood ratios.
Dr. Bhatia, an endocrine surgeon at Tulane University, New Orleans, reported on findings from 2,732 nodules in the pooled analysis. Of these, 64% were benign, 25% were malignant, and 11% were indeterminate.
In group 1, elastography showed a sensitivity of 75%, a specificity of 80%, a positive predictive value (PPV) of 61%, a negative predictive value (NPV) of 89%, and a likelihood ratio of 5.7, with a higher predictive value for nodules smaller than 1 cm in diameter (PPV of 79% and NPV of 83%). The strongest ultrasound-related predictor of malignancies was “taller than wide” (a specificity of 92%, a NPV of 51%, yet a sensitivity of only 24%), followed by irregular margins (a specificity of 91%, sensitivity of 48%, and a PPV of 64%). Combination of elastography and ultrasound had the highest sensitivity (96%) and NPV (96%), yet lower specificity (46%) and PPV (46%).
In group 2, elastography yielded a higher sensitivity (90%) and NPV (92%), while ultrasound features were highly specific, with the highest values for “taller than wide” shape (85%) in these thyroid nodules.
“Ultrasound predictors of malignancy prove to be more specific for presurgical diagnosis and differentiation of benign and malignant thyroid nodules,” the researchers wrote in their abstract. “When used as an adjunct, the higher sensitivity and NPV of combination of both the techniques can lead to better selection of candidates for FNA.”
Dr. Bhatia acknowledged certain limitations of the study, including the fact that the pooled data contained little information on indeterminate thyroid nodules. She reported having no financial disclosures.
On Twitter @dougbrunk
AT THE ATA ANNUAL MEETING
Key clinical point: Ultrasound is more specific than elastography in helping clinicians make a presurgical diagnosis of thyroid cancer.
Major finding: Compared with elastography, ultrasound was more specific in presurgical diagnosis and in differentiating between benign and malignant thyroid nodules (specificity of 92% vs. 80%, respectively).
Data source: A pooled analysis of 14 prospective studies involving findings from 2,732 thyroid nodules.
Disclosures: Dr. Bhatia reported having no financial disclosures.
VIDEO: Drug cocktail stops uterine AVM bleeding
VANCOUVER, B.C. – Bleeding from uterine arteriovenous malformations was stopped with a combination of tranexamic acid, gonadotropin-releasing hormone agonist, and an aromatase inhibitor in a small case series in Canada.
The cocktail appears to be a safe alternative to uterine artery embolization and hysterectomy, which allows women to remain fertile, said Dr. Angelos Vilos, an ob.gyn. at Western University in London, Ontario, and the study’ lead investigator.
Dr. Vilos and his team used uterine tamponade to control bleeding, then gave the women oral tranexamic acid for 5 days. Patients also received a GnRH agonist – usually one injection of leuprolide – with oral letrozole for 5 days after the injection. In all cases, the arteriovenous malformations resolved within 3 months.
In a video interview at the AAGL meeting, Dr. Vilos said the approach could be a “game changer” if it holds up in future testing.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
VANCOUVER, B.C. – Bleeding from uterine arteriovenous malformations was stopped with a combination of tranexamic acid, gonadotropin-releasing hormone agonist, and an aromatase inhibitor in a small case series in Canada.
The cocktail appears to be a safe alternative to uterine artery embolization and hysterectomy, which allows women to remain fertile, said Dr. Angelos Vilos, an ob.gyn. at Western University in London, Ontario, and the study’ lead investigator.
Dr. Vilos and his team used uterine tamponade to control bleeding, then gave the women oral tranexamic acid for 5 days. Patients also received a GnRH agonist – usually one injection of leuprolide – with oral letrozole for 5 days after the injection. In all cases, the arteriovenous malformations resolved within 3 months.
In a video interview at the AAGL meeting, Dr. Vilos said the approach could be a “game changer” if it holds up in future testing.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
VANCOUVER, B.C. – Bleeding from uterine arteriovenous malformations was stopped with a combination of tranexamic acid, gonadotropin-releasing hormone agonist, and an aromatase inhibitor in a small case series in Canada.
The cocktail appears to be a safe alternative to uterine artery embolization and hysterectomy, which allows women to remain fertile, said Dr. Angelos Vilos, an ob.gyn. at Western University in London, Ontario, and the study’ lead investigator.
Dr. Vilos and his team used uterine tamponade to control bleeding, then gave the women oral tranexamic acid for 5 days. Patients also received a GnRH agonist – usually one injection of leuprolide – with oral letrozole for 5 days after the injection. In all cases, the arteriovenous malformations resolved within 3 months.
In a video interview at the AAGL meeting, Dr. Vilos said the approach could be a “game changer” if it holds up in future testing.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT THE AAGL GLOBAL CONFERENCE
Palliative consult helps geriatric trauma patients avoid futile interventions
SAN FRANCISCO – Obtaining palliative medicine consultations for geriatric trauma patients may help avoid futile interventions, suggests a retrospective cohort study reported at the annual clinical congress of the American College of Surgeons.
“The bulk of trauma in the United States has become geriatrics, and it’s falls from standing height,” noted lead investigator Dr. Christine C. Toevs, a trauma surgeon at Allegheny General Hospital in Pittsburgh; these older patients often have multiple comorbidities and are frail, and thus have a poor prognosis even with the best of care. “Clearly, this is a patient population that would benefit greatly from routine palliative medicine consultation,” she said.
Dr. Toevs and her colleagues performed a retrospective study of the charts of 5,261 trauma patients treated at their Level 1 trauma center during 2011-2013. One-third were geriatric, defined as aged 65 years or older.
Overall, 15% of geriatric patients and 2% of nongeriatric patients received a palliative medicine consult. The majority in both groups had a traumatic brain injury.
Within the geriatric age-group, about 90% of the patients who had a consult did not undergo tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. Mortality was about 8% in this age-group overall, but 16% in the subset who received a consult.
“It seems that palliative medicine consult within the geriatric patient population does result in [fewer] procedures,” Dr. Toevs commented. “And studies have shown that when we talk to families and patients who participate in their care, they really do not want these procedures.”
Within the nongeriatric age–group, roughly 60% of patients with a consult did not undergo tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. Mortality was about 3% in this age-group overall but 30% for those receiving the consult.
“Younger patients who receive palliative medicine consults seem to have the most severe injuries, not unexpectedly. These tend to be patients with the most severe traumatic brain injuries who still during their hospitalization are not demonstrating any signs of waking up. I think we all agree younger patients need a little more time than older patients, but some families don’t want to go down that route at all,” Dr. Toevs said. “So it’s reasonable before placing a trach in these patients with brain injuries, young or old, to have these discussions.”
Among all patients with a palliative medicine consult, geriatric patients were more likely to be discharged to a skilled nursing facility (32% vs. 15%), whereas nongeriatric patients were more likely to be discharged to a long-term acute care facility (13% vs. 5%) or rehabilitation facility (18% vs. 12%).
Whether avoiding long-term acute care facilities is a better outcome for geriatric patients “depends on how you look at it,” according to Dr. Toevs. “The bulk of the data suggest that 90% of all patients say that they really don’t want all that we do for them at the end of life, so most of us would consider this a better outcome.”
Three-fourths of all geriatric patients with a tracheostomy were discharged to a long-term acute care facility, although data suggest that few such patients survive to discharge. “So what we are doing is we are relocating the death rather than actually addressing the issues of what kind of life do they want,” she commented. “Do they really want the end of their lives to be in an ICU or a step-down ICU in a long-term acute care hospital? So if the patients ultimately get trached, the outcomes tend to be much worse as you can imagine and, in my mind, we have not done nearly as good a job as we should have initially; we should have in some way preempted this, and we didn’t explain to everyone well enough that this really was not considered a good outcome.”
The investigators plan further research in this area, according to Dr. Toevs, who disclosed that she had no relevant conflicts of interest. “We are looking at long-term survival data if we do send them to places after geriatric trauma – what really happens to them, what’s their survival at 6 months and a year – so that we can give [these] data to their families,” she elaborated. “We are also working with our rehab doctors to look at functional assessments and prognostication of these patients, and ultimately, really being able to quantify the benefits of palliative medicine and the goals of care discussions with these patients.”
Invited discussant Dr. Henri R. Ford, chief of surgery at the Children’s Hospital Los Angeles asked, “What were the specific criteria used, on average, to decide whether somebody should get a palliative medicine consultation? Have you tried to standardize that pretty much across the board for all of your trauma patients?”
Use of these consults at her hospital has increased since she began pushing for them, according to Dr. Toevs. “What I would like to do is to make it as routine as possible – every person on the trauma service gets a rehab consult; to some degree, every person on the trauma service should get a palliative medicine consult. It ought to be a checkbox. We are not quite there yet. But right now, I’m pushing for 80% and above, just to make it routine to begin the discussion: Do they have an advance directive? Do they have a power of attorney? Have they thought about these things long term?”
“Did you also compare the injury severity scores for the various patients, not only for the geriatric but also for those who received palliative medicine consultations versus those who did not?” Dr. Ford further asked. “That would be very, very interesting for us in terms of understanding selection bias.”
The investigators looked at these scores in another study, finding that they were lower for geriatric patients than for nongeriatric patients, as expected. “But because of their frailty, they do much poorer. And we are trying to correlate that long term when we are working with our rehab doctors and trying to look at the ability to prognosticate basically upon functional status prior to injury.”
Dr. Toevs disclosed that she had no relevant conflicts of interest.
SAN FRANCISCO – Obtaining palliative medicine consultations for geriatric trauma patients may help avoid futile interventions, suggests a retrospective cohort study reported at the annual clinical congress of the American College of Surgeons.
“The bulk of trauma in the United States has become geriatrics, and it’s falls from standing height,” noted lead investigator Dr. Christine C. Toevs, a trauma surgeon at Allegheny General Hospital in Pittsburgh; these older patients often have multiple comorbidities and are frail, and thus have a poor prognosis even with the best of care. “Clearly, this is a patient population that would benefit greatly from routine palliative medicine consultation,” she said.
Dr. Toevs and her colleagues performed a retrospective study of the charts of 5,261 trauma patients treated at their Level 1 trauma center during 2011-2013. One-third were geriatric, defined as aged 65 years or older.
Overall, 15% of geriatric patients and 2% of nongeriatric patients received a palliative medicine consult. The majority in both groups had a traumatic brain injury.
Within the geriatric age-group, about 90% of the patients who had a consult did not undergo tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. Mortality was about 8% in this age-group overall, but 16% in the subset who received a consult.
“It seems that palliative medicine consult within the geriatric patient population does result in [fewer] procedures,” Dr. Toevs commented. “And studies have shown that when we talk to families and patients who participate in their care, they really do not want these procedures.”
Within the nongeriatric age–group, roughly 60% of patients with a consult did not undergo tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. Mortality was about 3% in this age-group overall but 30% for those receiving the consult.
“Younger patients who receive palliative medicine consults seem to have the most severe injuries, not unexpectedly. These tend to be patients with the most severe traumatic brain injuries who still during their hospitalization are not demonstrating any signs of waking up. I think we all agree younger patients need a little more time than older patients, but some families don’t want to go down that route at all,” Dr. Toevs said. “So it’s reasonable before placing a trach in these patients with brain injuries, young or old, to have these discussions.”
Among all patients with a palliative medicine consult, geriatric patients were more likely to be discharged to a skilled nursing facility (32% vs. 15%), whereas nongeriatric patients were more likely to be discharged to a long-term acute care facility (13% vs. 5%) or rehabilitation facility (18% vs. 12%).
Whether avoiding long-term acute care facilities is a better outcome for geriatric patients “depends on how you look at it,” according to Dr. Toevs. “The bulk of the data suggest that 90% of all patients say that they really don’t want all that we do for them at the end of life, so most of us would consider this a better outcome.”
Three-fourths of all geriatric patients with a tracheostomy were discharged to a long-term acute care facility, although data suggest that few such patients survive to discharge. “So what we are doing is we are relocating the death rather than actually addressing the issues of what kind of life do they want,” she commented. “Do they really want the end of their lives to be in an ICU or a step-down ICU in a long-term acute care hospital? So if the patients ultimately get trached, the outcomes tend to be much worse as you can imagine and, in my mind, we have not done nearly as good a job as we should have initially; we should have in some way preempted this, and we didn’t explain to everyone well enough that this really was not considered a good outcome.”
The investigators plan further research in this area, according to Dr. Toevs, who disclosed that she had no relevant conflicts of interest. “We are looking at long-term survival data if we do send them to places after geriatric trauma – what really happens to them, what’s their survival at 6 months and a year – so that we can give [these] data to their families,” she elaborated. “We are also working with our rehab doctors to look at functional assessments and prognostication of these patients, and ultimately, really being able to quantify the benefits of palliative medicine and the goals of care discussions with these patients.”
Invited discussant Dr. Henri R. Ford, chief of surgery at the Children’s Hospital Los Angeles asked, “What were the specific criteria used, on average, to decide whether somebody should get a palliative medicine consultation? Have you tried to standardize that pretty much across the board for all of your trauma patients?”
Use of these consults at her hospital has increased since she began pushing for them, according to Dr. Toevs. “What I would like to do is to make it as routine as possible – every person on the trauma service gets a rehab consult; to some degree, every person on the trauma service should get a palliative medicine consult. It ought to be a checkbox. We are not quite there yet. But right now, I’m pushing for 80% and above, just to make it routine to begin the discussion: Do they have an advance directive? Do they have a power of attorney? Have they thought about these things long term?”
“Did you also compare the injury severity scores for the various patients, not only for the geriatric but also for those who received palliative medicine consultations versus those who did not?” Dr. Ford further asked. “That would be very, very interesting for us in terms of understanding selection bias.”
The investigators looked at these scores in another study, finding that they were lower for geriatric patients than for nongeriatric patients, as expected. “But because of their frailty, they do much poorer. And we are trying to correlate that long term when we are working with our rehab doctors and trying to look at the ability to prognosticate basically upon functional status prior to injury.”
Dr. Toevs disclosed that she had no relevant conflicts of interest.
SAN FRANCISCO – Obtaining palliative medicine consultations for geriatric trauma patients may help avoid futile interventions, suggests a retrospective cohort study reported at the annual clinical congress of the American College of Surgeons.
“The bulk of trauma in the United States has become geriatrics, and it’s falls from standing height,” noted lead investigator Dr. Christine C. Toevs, a trauma surgeon at Allegheny General Hospital in Pittsburgh; these older patients often have multiple comorbidities and are frail, and thus have a poor prognosis even with the best of care. “Clearly, this is a patient population that would benefit greatly from routine palliative medicine consultation,” she said.
Dr. Toevs and her colleagues performed a retrospective study of the charts of 5,261 trauma patients treated at their Level 1 trauma center during 2011-2013. One-third were geriatric, defined as aged 65 years or older.
Overall, 15% of geriatric patients and 2% of nongeriatric patients received a palliative medicine consult. The majority in both groups had a traumatic brain injury.
Within the geriatric age-group, about 90% of the patients who had a consult did not undergo tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. Mortality was about 8% in this age-group overall, but 16% in the subset who received a consult.
“It seems that palliative medicine consult within the geriatric patient population does result in [fewer] procedures,” Dr. Toevs commented. “And studies have shown that when we talk to families and patients who participate in their care, they really do not want these procedures.”
Within the nongeriatric age–group, roughly 60% of patients with a consult did not undergo tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. Mortality was about 3% in this age-group overall but 30% for those receiving the consult.
“Younger patients who receive palliative medicine consults seem to have the most severe injuries, not unexpectedly. These tend to be patients with the most severe traumatic brain injuries who still during their hospitalization are not demonstrating any signs of waking up. I think we all agree younger patients need a little more time than older patients, but some families don’t want to go down that route at all,” Dr. Toevs said. “So it’s reasonable before placing a trach in these patients with brain injuries, young or old, to have these discussions.”
Among all patients with a palliative medicine consult, geriatric patients were more likely to be discharged to a skilled nursing facility (32% vs. 15%), whereas nongeriatric patients were more likely to be discharged to a long-term acute care facility (13% vs. 5%) or rehabilitation facility (18% vs. 12%).
Whether avoiding long-term acute care facilities is a better outcome for geriatric patients “depends on how you look at it,” according to Dr. Toevs. “The bulk of the data suggest that 90% of all patients say that they really don’t want all that we do for them at the end of life, so most of us would consider this a better outcome.”
Three-fourths of all geriatric patients with a tracheostomy were discharged to a long-term acute care facility, although data suggest that few such patients survive to discharge. “So what we are doing is we are relocating the death rather than actually addressing the issues of what kind of life do they want,” she commented. “Do they really want the end of their lives to be in an ICU or a step-down ICU in a long-term acute care hospital? So if the patients ultimately get trached, the outcomes tend to be much worse as you can imagine and, in my mind, we have not done nearly as good a job as we should have initially; we should have in some way preempted this, and we didn’t explain to everyone well enough that this really was not considered a good outcome.”
The investigators plan further research in this area, according to Dr. Toevs, who disclosed that she had no relevant conflicts of interest. “We are looking at long-term survival data if we do send them to places after geriatric trauma – what really happens to them, what’s their survival at 6 months and a year – so that we can give [these] data to their families,” she elaborated. “We are also working with our rehab doctors to look at functional assessments and prognostication of these patients, and ultimately, really being able to quantify the benefits of palliative medicine and the goals of care discussions with these patients.”
Invited discussant Dr. Henri R. Ford, chief of surgery at the Children’s Hospital Los Angeles asked, “What were the specific criteria used, on average, to decide whether somebody should get a palliative medicine consultation? Have you tried to standardize that pretty much across the board for all of your trauma patients?”
Use of these consults at her hospital has increased since she began pushing for them, according to Dr. Toevs. “What I would like to do is to make it as routine as possible – every person on the trauma service gets a rehab consult; to some degree, every person on the trauma service should get a palliative medicine consult. It ought to be a checkbox. We are not quite there yet. But right now, I’m pushing for 80% and above, just to make it routine to begin the discussion: Do they have an advance directive? Do they have a power of attorney? Have they thought about these things long term?”
“Did you also compare the injury severity scores for the various patients, not only for the geriatric but also for those who received palliative medicine consultations versus those who did not?” Dr. Ford further asked. “That would be very, very interesting for us in terms of understanding selection bias.”
The investigators looked at these scores in another study, finding that they were lower for geriatric patients than for nongeriatric patients, as expected. “But because of their frailty, they do much poorer. And we are trying to correlate that long term when we are working with our rehab doctors and trying to look at the ability to prognosticate basically upon functional status prior to injury.”
Dr. Toevs disclosed that she had no relevant conflicts of interest.
AT THE ACS CLINICAL CONGRESS
Key clinical point: Geriatric patients who receive a palliative medicine consult usually forgo procedures.
Major finding: About 90% of patients aged 65 years or older who had a consult did not undergo tracheostomy or PEG tube placement.
Data source: A retrospective cohort study of 5,261 trauma patients.
Disclosures: Dr. Toevs disclosed that she had no relevant conflicts of interest.
CDC predicts bad flu season, stresses vaccination, antiviral treatment
The 2014-2015 flu season may be particularly severe, and the 2014-2015 vaccine will provide important, but limited protection, according to a health advisory from the Centers for Disease Control and Prevention that is based on early analyses of reported disease cases.
The advisory also stresses the importance of antiviral treatment in those with confirmed or suspected influenza, particularly those at risk of developing complications, including young children, adults aged 65 years and older, pregnant women, and those with chronic health conditions, such as asthma, diabetes, or heart, lung, or kidney disease.
Influenza A viruses, mainly H3N2, predominate thus far during the 2014-2015 flu season, comprising more than 91% of the specimens collected and analyzed, and only about half of those have been antigenically similar to H3N2 components included in the 2014-2015 vaccine, according to the advisory.
This doesn’t bode well for the effectiveness of the vaccine, which is particularly troubling given that H3N2-predominate seasons historically have been associated with up to twice the rate of overall and age-specific flu-related hospitalizations and deaths, CDC director Dr. Thomas R. Frieden explained during a press briefing.
Still, vaccination remains the best line of defense against infection, he said.
The vaccine will protect against circulating strains that have not undergone significant antigenic drift, including the influenza B viruses, which have comprised about 9% of those collected to date. In addition, the vaccine has been found to provide some protection against the antigenically drifted H3N2 viruses, he said.
“We continue to recommend flu vaccine as the single best way to protect yourself against the flu,” he said.
Dr. Frieden also stressed the importance of antiviral use.
“Antivirals aren’t a substitute for vaccinations … but they are an important second line of defense for treating the flu, and this year, treatment with antiviral drugs is especially important, particularly for people who are at high risk for serious flu complications or for people who are very sick with flu,” he said.
These agents are greatly underprescribed, with fewer than one in six severely ill patients receiving antiviral treatment, he noted.
“It’s very important that we do better for people who are severely ill or who could become severely ill with influenza,” he said, adding that antiviral use is even more important during seasons such as this one when the circulating viruses are different from the vaccine viruses.
The two neuraminidase inhibitor antiviral medications currently approved for treating influenza – oseltamivir and zanamivir – shorten the duration of fever and illness symptoms by about a day and can reduce the risk of severe outcomes, he said.
Treatment should be provided withing 2 days of symptoms onset when possible, but it may also provide benefit to hospitalized patients even if taken later in the course of illness.
“We strongly recommend that if doctors suspect the flu in someone who may be severely ill from the flu, they don’t wait for the results of a flu test before starting antivirals,” he said.
“There is no way to predict with certainly what will happen. We have four different strains of flu circulating. The B strain, the H1 strain, the well-matched H3 strain, and the poorly matched H3 strain. Only time will tell which of them, if any, will predominate for the coming weeks and months of this year’s flu season,” he said.
However, already this season there have been five pediatric deaths from influenza, including three in patients with H3N2 disease, and one in a patient with influenza type B.
“We’ve also heard of outbreaks in schools and in nursing homes,” Dr. Frieden said, adding that “getting a vaccine, even if it doesn’t provide as good protection as we would hope, would be more important than ever, and remains the single most effective way to protect yourself against the flu.”
Physicians should continue to vaccinate patients, he said, noting that nearly 150 million doses have been distributed by manufacturers, and that the supply is expected to meet the demand. The supply of antiviral medications is also expected to be adequate.
Patients should also be advised to stay home when they are sick to avoid spreading influenza, and to seek treatment promptly for flu symptoms, including fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, and fatigue, he said.
 |
| Dr. Daniel R. Ouellette |
Dr. Daniel R. Ouellette, FCCP, comments: "Every time I take the vaccine, I get the flu. Besides, it doesn't work this year. I heard it on the news."
Sheila, a woman in her 50s with asthma, responded to my advice to be inoculated with the influenza vaccine this fall with this refrain. Refrain indeed, because my patients sing this song on a daily basis. Simply telling them that I know that the vaccine doesn't cause the flu isn't effective. Responding with an anecdote about patients who have been under my care in the ICU, who were previously healthy, and who died of influenza, works better. Following this with the statement that 'I make sure that I get vaccinated every year' seems to work the best.
And yet, there is some truth to the statement above. The CDC has informed us that not all strains of influenza will be covered by this year's version of the vaccine. Despite this, our patients will have increased protection by getting vaccinated, and we must be advocates for this measure. However, we also must be vigilant this year so that we may identify influenza cases early, and start antiviral treatment when appropriate, to limit the effects of this disease.
Dr. Ouellette is with the Pulmonary Disease Service at Henry Ford Hospital in Detroit, MI.
|
| Dr. Daniel R. Ouellette |
Dr. Daniel R. Ouellette, FCCP, comments: "Every time I take the vaccine, I get the flu. Besides, it doesn't work this year. I heard it on the news."
Sheila, a woman in her 50s with asthma, responded to my advice to be inoculated with the influenza vaccine this fall with this refrain. Refrain indeed, because my patients sing this song on a daily basis. Simply telling them that I know that the vaccine doesn't cause the flu isn't effective. Responding with an anecdote about patients who have been under my care in the ICU, who were previously healthy, and who died of influenza, works better. Following this with the statement that 'I make sure that I get vaccinated every year' seems to work the best.
And yet, there is some truth to the statement above. The CDC has informed us that not all strains of influenza will be covered by this year's version of the vaccine. Despite this, our patients will have increased protection by getting vaccinated, and we must be advocates for this measure. However, we also must be vigilant this year so that we may identify influenza cases early, and start antiviral treatment when appropriate, to limit the effects of this disease.
Dr. Ouellette is with the Pulmonary Disease Service at Henry Ford Hospital in Detroit, MI.
|
| Dr. Daniel R. Ouellette |
Dr. Daniel R. Ouellette, FCCP, comments: "Every time I take the vaccine, I get the flu. Besides, it doesn't work this year. I heard it on the news."
Sheila, a woman in her 50s with asthma, responded to my advice to be inoculated with the influenza vaccine this fall with this refrain. Refrain indeed, because my patients sing this song on a daily basis. Simply telling them that I know that the vaccine doesn't cause the flu isn't effective. Responding with an anecdote about patients who have been under my care in the ICU, who were previously healthy, and who died of influenza, works better. Following this with the statement that 'I make sure that I get vaccinated every year' seems to work the best.
And yet, there is some truth to the statement above. The CDC has informed us that not all strains of influenza will be covered by this year's version of the vaccine. Despite this, our patients will have increased protection by getting vaccinated, and we must be advocates for this measure. However, we also must be vigilant this year so that we may identify influenza cases early, and start antiviral treatment when appropriate, to limit the effects of this disease.
Dr. Ouellette is with the Pulmonary Disease Service at Henry Ford Hospital in Detroit, MI.
The 2014-2015 flu season may be particularly severe, and the 2014-2015 vaccine will provide important, but limited protection, according to a health advisory from the Centers for Disease Control and Prevention that is based on early analyses of reported disease cases.
The advisory also stresses the importance of antiviral treatment in those with confirmed or suspected influenza, particularly those at risk of developing complications, including young children, adults aged 65 years and older, pregnant women, and those with chronic health conditions, such as asthma, diabetes, or heart, lung, or kidney disease.
Influenza A viruses, mainly H3N2, predominate thus far during the 2014-2015 flu season, comprising more than 91% of the specimens collected and analyzed, and only about half of those have been antigenically similar to H3N2 components included in the 2014-2015 vaccine, according to the advisory.
This doesn’t bode well for the effectiveness of the vaccine, which is particularly troubling given that H3N2-predominate seasons historically have been associated with up to twice the rate of overall and age-specific flu-related hospitalizations and deaths, CDC director Dr. Thomas R. Frieden explained during a press briefing.
Still, vaccination remains the best line of defense against infection, he said.
The vaccine will protect against circulating strains that have not undergone significant antigenic drift, including the influenza B viruses, which have comprised about 9% of those collected to date. In addition, the vaccine has been found to provide some protection against the antigenically drifted H3N2 viruses, he said.
“We continue to recommend flu vaccine as the single best way to protect yourself against the flu,” he said.
Dr. Frieden also stressed the importance of antiviral use.
“Antivirals aren’t a substitute for vaccinations … but they are an important second line of defense for treating the flu, and this year, treatment with antiviral drugs is especially important, particularly for people who are at high risk for serious flu complications or for people who are very sick with flu,” he said.
These agents are greatly underprescribed, with fewer than one in six severely ill patients receiving antiviral treatment, he noted.
“It’s very important that we do better for people who are severely ill or who could become severely ill with influenza,” he said, adding that antiviral use is even more important during seasons such as this one when the circulating viruses are different from the vaccine viruses.
The two neuraminidase inhibitor antiviral medications currently approved for treating influenza – oseltamivir and zanamivir – shorten the duration of fever and illness symptoms by about a day and can reduce the risk of severe outcomes, he said.
Treatment should be provided withing 2 days of symptoms onset when possible, but it may also provide benefit to hospitalized patients even if taken later in the course of illness.
“We strongly recommend that if doctors suspect the flu in someone who may be severely ill from the flu, they don’t wait for the results of a flu test before starting antivirals,” he said.
“There is no way to predict with certainly what will happen. We have four different strains of flu circulating. The B strain, the H1 strain, the well-matched H3 strain, and the poorly matched H3 strain. Only time will tell which of them, if any, will predominate for the coming weeks and months of this year’s flu season,” he said.
However, already this season there have been five pediatric deaths from influenza, including three in patients with H3N2 disease, and one in a patient with influenza type B.
“We’ve also heard of outbreaks in schools and in nursing homes,” Dr. Frieden said, adding that “getting a vaccine, even if it doesn’t provide as good protection as we would hope, would be more important than ever, and remains the single most effective way to protect yourself against the flu.”
Physicians should continue to vaccinate patients, he said, noting that nearly 150 million doses have been distributed by manufacturers, and that the supply is expected to meet the demand. The supply of antiviral medications is also expected to be adequate.
Patients should also be advised to stay home when they are sick to avoid spreading influenza, and to seek treatment promptly for flu symptoms, including fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, and fatigue, he said.
The 2014-2015 flu season may be particularly severe, and the 2014-2015 vaccine will provide important, but limited protection, according to a health advisory from the Centers for Disease Control and Prevention that is based on early analyses of reported disease cases.
The advisory also stresses the importance of antiviral treatment in those with confirmed or suspected influenza, particularly those at risk of developing complications, including young children, adults aged 65 years and older, pregnant women, and those with chronic health conditions, such as asthma, diabetes, or heart, lung, or kidney disease.
Influenza A viruses, mainly H3N2, predominate thus far during the 2014-2015 flu season, comprising more than 91% of the specimens collected and analyzed, and only about half of those have been antigenically similar to H3N2 components included in the 2014-2015 vaccine, according to the advisory.
This doesn’t bode well for the effectiveness of the vaccine, which is particularly troubling given that H3N2-predominate seasons historically have been associated with up to twice the rate of overall and age-specific flu-related hospitalizations and deaths, CDC director Dr. Thomas R. Frieden explained during a press briefing.
Still, vaccination remains the best line of defense against infection, he said.
The vaccine will protect against circulating strains that have not undergone significant antigenic drift, including the influenza B viruses, which have comprised about 9% of those collected to date. In addition, the vaccine has been found to provide some protection against the antigenically drifted H3N2 viruses, he said.
“We continue to recommend flu vaccine as the single best way to protect yourself against the flu,” he said.
Dr. Frieden also stressed the importance of antiviral use.
“Antivirals aren’t a substitute for vaccinations … but they are an important second line of defense for treating the flu, and this year, treatment with antiviral drugs is especially important, particularly for people who are at high risk for serious flu complications or for people who are very sick with flu,” he said.
These agents are greatly underprescribed, with fewer than one in six severely ill patients receiving antiviral treatment, he noted.
“It’s very important that we do better for people who are severely ill or who could become severely ill with influenza,” he said, adding that antiviral use is even more important during seasons such as this one when the circulating viruses are different from the vaccine viruses.
The two neuraminidase inhibitor antiviral medications currently approved for treating influenza – oseltamivir and zanamivir – shorten the duration of fever and illness symptoms by about a day and can reduce the risk of severe outcomes, he said.
Treatment should be provided withing 2 days of symptoms onset when possible, but it may also provide benefit to hospitalized patients even if taken later in the course of illness.
“We strongly recommend that if doctors suspect the flu in someone who may be severely ill from the flu, they don’t wait for the results of a flu test before starting antivirals,” he said.
“There is no way to predict with certainly what will happen. We have four different strains of flu circulating. The B strain, the H1 strain, the well-matched H3 strain, and the poorly matched H3 strain. Only time will tell which of them, if any, will predominate for the coming weeks and months of this year’s flu season,” he said.
However, already this season there have been five pediatric deaths from influenza, including three in patients with H3N2 disease, and one in a patient with influenza type B.
“We’ve also heard of outbreaks in schools and in nursing homes,” Dr. Frieden said, adding that “getting a vaccine, even if it doesn’t provide as good protection as we would hope, would be more important than ever, and remains the single most effective way to protect yourself against the flu.”
Physicians should continue to vaccinate patients, he said, noting that nearly 150 million doses have been distributed by manufacturers, and that the supply is expected to meet the demand. The supply of antiviral medications is also expected to be adequate.
Patients should also be advised to stay home when they are sick to avoid spreading influenza, and to seek treatment promptly for flu symptoms, including fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, and fatigue, he said.
CMS expands ability to deny provider enrollments
The Centers for Medicare & Medicaid Services is tightening scrutiny of providers enrolling in Medicare in an effort to curb fraudulent billing and keep providers with unpaid Medicare debt from reentering the program.
New rules announced Dec. 3 by the CMS strengthen the agency’s ability to deny or revoke the enrollment of entities and individuals believed to pose a program integrity risk to Medicare. The regulations come after the February 2011 revision of CMS’s enrollment policy, a revamp aimed at increasing the integrity of Medicare. Under the Dec. 3 enrollment provisions, the CMS can now:
• Deny the enrollment of providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt (existing overpayment or another form of financial obligation).
• Deny the enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felonies (murder, rape, assault, extortion, embezzlement, income tax evasion).
• Revoke the billing privileges of providers and suppliers who have a pattern or practice of billing for services that do not meet Medicare requirements.
The new rules will prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program, and then reenroll as a new business to avoid repayment of the outstanding Medicare debt, according to the agency.
Physicians and other prospective enrollees who owe Medicare money can avoid being denied by agreeing to a CMS-approved extended repayment schedule for the entire outstanding Medicare debt or by repaying it in full.
In its final rule, the CMS acknowledged that the majority of Medicare provider enrollees submit valid claims that meet the CMS guidelines.
“A small percentage of providers and suppliers are engaging in fraudulent, wasteful, inappropriate, or abusive activities,” the agency wrote in the Federal Register. “Our provider enrollment revisions are directed at such providers and suppliers, and we believe that removing them, as necessary, from the Medicare program will only serve to benefit Medicare beneficiaries, the trust funds, the taxpayers, and the hundreds of thousands of legitimate Medicare providers and suppliers that have proven to be reliable partners of the program.”
The final rules will be published in the Federal Register Dec. 5. A preliminary version of the regulations is available on the Federal Register website.
On Twitter @legal_med
The Centers for Medicare & Medicaid Services is tightening scrutiny of providers enrolling in Medicare in an effort to curb fraudulent billing and keep providers with unpaid Medicare debt from reentering the program.
New rules announced Dec. 3 by the CMS strengthen the agency’s ability to deny or revoke the enrollment of entities and individuals believed to pose a program integrity risk to Medicare. The regulations come after the February 2011 revision of CMS’s enrollment policy, a revamp aimed at increasing the integrity of Medicare. Under the Dec. 3 enrollment provisions, the CMS can now:
• Deny the enrollment of providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt (existing overpayment or another form of financial obligation).
• Deny the enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felonies (murder, rape, assault, extortion, embezzlement, income tax evasion).
• Revoke the billing privileges of providers and suppliers who have a pattern or practice of billing for services that do not meet Medicare requirements.
The new rules will prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program, and then reenroll as a new business to avoid repayment of the outstanding Medicare debt, according to the agency.
Physicians and other prospective enrollees who owe Medicare money can avoid being denied by agreeing to a CMS-approved extended repayment schedule for the entire outstanding Medicare debt or by repaying it in full.
In its final rule, the CMS acknowledged that the majority of Medicare provider enrollees submit valid claims that meet the CMS guidelines.
“A small percentage of providers and suppliers are engaging in fraudulent, wasteful, inappropriate, or abusive activities,” the agency wrote in the Federal Register. “Our provider enrollment revisions are directed at such providers and suppliers, and we believe that removing them, as necessary, from the Medicare program will only serve to benefit Medicare beneficiaries, the trust funds, the taxpayers, and the hundreds of thousands of legitimate Medicare providers and suppliers that have proven to be reliable partners of the program.”
The final rules will be published in the Federal Register Dec. 5. A preliminary version of the regulations is available on the Federal Register website.
On Twitter @legal_med
The Centers for Medicare & Medicaid Services is tightening scrutiny of providers enrolling in Medicare in an effort to curb fraudulent billing and keep providers with unpaid Medicare debt from reentering the program.
New rules announced Dec. 3 by the CMS strengthen the agency’s ability to deny or revoke the enrollment of entities and individuals believed to pose a program integrity risk to Medicare. The regulations come after the February 2011 revision of CMS’s enrollment policy, a revamp aimed at increasing the integrity of Medicare. Under the Dec. 3 enrollment provisions, the CMS can now:
• Deny the enrollment of providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt (existing overpayment or another form of financial obligation).
• Deny the enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felonies (murder, rape, assault, extortion, embezzlement, income tax evasion).
• Revoke the billing privileges of providers and suppliers who have a pattern or practice of billing for services that do not meet Medicare requirements.
The new rules will prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program, and then reenroll as a new business to avoid repayment of the outstanding Medicare debt, according to the agency.
Physicians and other prospective enrollees who owe Medicare money can avoid being denied by agreeing to a CMS-approved extended repayment schedule for the entire outstanding Medicare debt or by repaying it in full.
In its final rule, the CMS acknowledged that the majority of Medicare provider enrollees submit valid claims that meet the CMS guidelines.
“A small percentage of providers and suppliers are engaging in fraudulent, wasteful, inappropriate, or abusive activities,” the agency wrote in the Federal Register. “Our provider enrollment revisions are directed at such providers and suppliers, and we believe that removing them, as necessary, from the Medicare program will only serve to benefit Medicare beneficiaries, the trust funds, the taxpayers, and the hundreds of thousands of legitimate Medicare providers and suppliers that have proven to be reliable partners of the program.”
The final rules will be published in the Federal Register Dec. 5. A preliminary version of the regulations is available on the Federal Register website.
On Twitter @legal_med
