ACS Surgery News

The International Relations Committee of the American College of Surgeons (ACS) sponsors three academic surgeon exchange programs. Exchange arrangements are in place with the Royal Australasian College of Surgeons with the ACS Australia-New Zealand Chapter, the Japan Surgical Society with the ACS Japan Chapter, and the German Surgical Society with the ACS Germany Chapter. In all three programs, the College sends a talented young U.S. or Canadian Fellow to the annual surgical meeting of the participating country. Afterward, they tour several health care institutions that conduct research tailored to the Fellows’ specific interests. In exchange, the ACS makes it possible for young academic surgeon-scholars from the participating societies to attend the College’s Clinical Congress, which will take place October 26–30 in San Francisco, CA, this year.

The 2014 Australia-New Zealand Exchange Fellow is Alexander G. Heriot, MB, BChir, FRCSEd, FRCSEng, FRACS, director of surgical oncology and consultant colorectal surgeon at the Peter MacCallum Cancer Centre, Melbourne, Victoria. He has written extensively on major issues relating to surgery of the bowel, particularly colorectal and gastrointestinal oncological procedures. He is a reviewer for several notable surgery journals. His U.S. counterpart, Wei Zhou, MD, FACS, is professor of surgery, Stanford University, and chief of vascular surgery, Palo Alto Veterans Affairs Hospital, CA. She attended the Annual Scientific Congress of the Royal Australasian College of Surgeons held in Marina Bay Sands, Singapore, in May.

This October, the College will welcome Japan Exchange Fellow Yoshifumi Baba, MD, PhD, assistant professor of gastroenterological surgery at Kumamoto University’s Graduate School of Medical Science. Dr. Baba’s research focuses on colorectal, liver, and esophageal cancers. John T. Mullen, MD, FACS, assistant professor specializing in surgical oncology, Massachusetts General Hospital, Boston, attended the Japan Surgical Society meeting in Kyoto in April 2014. (Dr. Mullen’s report will be published in the September Bulletin.)

For the German exchange, Nadja Lehwald, MD, PhD, assistant professor of surgery, department of visceral, general, and pediatric surgery at Heinrich Heine University in Dusseldorf, will attend the ACS Clinical Congress this year and visit several surgical sites under the guidance of her mentors both in North America and in Germany. Dr. Lehwald is a surgical oncologist performing hepatic and pancreatic surgery and researching mitochondrial function in liver homeostasis and disease. ACS Traveling Fellow Jeffrey M. Farma, MD, FACS, co-director, cutaneous oncology, Fox Chase Cancer Center, Philadelphia, PA, attended the German Surgical Society’s annual meeting in Berlin in March 2014. (Dr. Farma’s report will be published in the October issue of the Bulletin.)

The International Relations Committee of the American College of Surgeons (ACS) sponsors three academic surgeon exchange programs. Exchange arrangements are in place with the Royal Australasian College of Surgeons with the ACS Australia-New Zealand Chapter, the Japan Surgical Society with the ACS Japan Chapter, and the German Surgical Society with the ACS Germany Chapter. In all three programs, the College sends a talented young U.S. or Canadian Fellow to the annual surgical meeting of the participating country. Afterward, they tour several health care institutions that conduct research tailored to the Fellows’ specific interests. In exchange, the ACS makes it possible for young academic surgeon-scholars from the participating societies to attend the College’s Clinical Congress, which will take place October 26–30 in San Francisco, CA, this year.

The 2014 Australia-New Zealand Exchange Fellow is Alexander G. Heriot, MB, BChir, FRCSEd, FRCSEng, FRACS, director of surgical oncology and consultant colorectal surgeon at the Peter MacCallum Cancer Centre, Melbourne, Victoria. He has written extensively on major issues relating to surgery of the bowel, particularly colorectal and gastrointestinal oncological procedures. He is a reviewer for several notable surgery journals. His U.S. counterpart, Wei Zhou, MD, FACS, is professor of surgery, Stanford University, and chief of vascular surgery, Palo Alto Veterans Affairs Hospital, CA. She attended the Annual Scientific Congress of the Royal Australasian College of Surgeons held in Marina Bay Sands, Singapore, in May.

This October, the College will welcome Japan Exchange Fellow Yoshifumi Baba, MD, PhD, assistant professor of gastroenterological surgery at Kumamoto University’s Graduate School of Medical Science. Dr. Baba’s research focuses on colorectal, liver, and esophageal cancers. John T. Mullen, MD, FACS, assistant professor specializing in surgical oncology, Massachusetts General Hospital, Boston, attended the Japan Surgical Society meeting in Kyoto in April 2014. (Dr. Mullen’s report will be published in the September Bulletin.)

For the German exchange, Nadja Lehwald, MD, PhD, assistant professor of surgery, department of visceral, general, and pediatric surgery at Heinrich Heine University in Dusseldorf, will attend the ACS Clinical Congress this year and visit several surgical sites under the guidance of her mentors both in North America and in Germany. Dr. Lehwald is a surgical oncologist performing hepatic and pancreatic surgery and researching mitochondrial function in liver homeostasis and disease. ACS Traveling Fellow Jeffrey M. Farma, MD, FACS, co-director, cutaneous oncology, Fox Chase Cancer Center, Philadelphia, PA, attended the German Surgical Society’s annual meeting in Berlin in March 2014. (Dr. Farma’s report will be published in the October issue of the Bulletin.)

The International Relations Committee of the American College of Surgeons (ACS) sponsors three academic surgeon exchange programs. Exchange arrangements are in place with the Royal Australasian College of Surgeons with the ACS Australia-New Zealand Chapter, the Japan Surgical Society with the ACS Japan Chapter, and the German Surgical Society with the ACS Germany Chapter. In all three programs, the College sends a talented young U.S. or Canadian Fellow to the annual surgical meeting of the participating country. Afterward, they tour several health care institutions that conduct research tailored to the Fellows’ specific interests. In exchange, the ACS makes it possible for young academic surgeon-scholars from the participating societies to attend the College’s Clinical Congress, which will take place October 26–30 in San Francisco, CA, this year.

The 2014 Australia-New Zealand Exchange Fellow is Alexander G. Heriot, MB, BChir, FRCSEd, FRCSEng, FRACS, director of surgical oncology and consultant colorectal surgeon at the Peter MacCallum Cancer Centre, Melbourne, Victoria. He has written extensively on major issues relating to surgery of the bowel, particularly colorectal and gastrointestinal oncological procedures. He is a reviewer for several notable surgery journals. His U.S. counterpart, Wei Zhou, MD, FACS, is professor of surgery, Stanford University, and chief of vascular surgery, Palo Alto Veterans Affairs Hospital, CA. She attended the Annual Scientific Congress of the Royal Australasian College of Surgeons held in Marina Bay Sands, Singapore, in May.

This October, the College will welcome Japan Exchange Fellow Yoshifumi Baba, MD, PhD, assistant professor of gastroenterological surgery at Kumamoto University’s Graduate School of Medical Science. Dr. Baba’s research focuses on colorectal, liver, and esophageal cancers. John T. Mullen, MD, FACS, assistant professor specializing in surgical oncology, Massachusetts General Hospital, Boston, attended the Japan Surgical Society meeting in Kyoto in April 2014. (Dr. Mullen’s report will be published in the September Bulletin.)

For the German exchange, Nadja Lehwald, MD, PhD, assistant professor of surgery, department of visceral, general, and pediatric surgery at Heinrich Heine University in Dusseldorf, will attend the ACS Clinical Congress this year and visit several surgical sites under the guidance of her mentors both in North America and in Germany. Dr. Lehwald is a surgical oncologist performing hepatic and pancreatic surgery and researching mitochondrial function in liver homeostasis and disease. ACS Traveling Fellow Jeffrey M. Farma, MD, FACS, co-director, cutaneous oncology, Fox Chase Cancer Center, Philadelphia, PA, attended the German Surgical Society’s annual meeting in Berlin in March 2014. (Dr. Farma’s report will be published in the October issue of the Bulletin.)

SAN DIEGO – Nurse practitioners are assuming expanded roles and responsibilities in the provision of critical care services, according to Thomas Farley, R.N., N.P.

At the University of California, San Diego, Critical Care Summer Session, Mr. Farley described the expanded role nurse practitioners (NPs) have played in critical care services for about a decade at the University of California, San Francisco (UCSF). In 2004, Dr. Michael Matthay, a pulmonologist, and Dr. Michael Gropper, a critical care anesthesiologist, spearheaded an effort to hire four NPs to work in the university’s medical-surgical intensive care unit (ICU). "At the time, there were increasing limitations on physician trainees, both in the number of trainees and their work-hour restrictions that were becoming more tight," recalled Mr. Farley of the UCSF School of Nursing. "The goal was to provide critical care at the bedside 24 hours per day, which is in line with the Leapfrog Group recommendations for critical care services. At the time, they had 60 adult ICU critical care beds."

Today, 18 NPs work in adult ICUs at UCSF, with expansion to 76 adult critical care beds, including the medical-surgical ICU, cardiothoracic ICU, and neuro ICU. "Initially the NPs were integrated with medical residents," Mr. Farley said. "Now there are teams that don’t have residents, so it’s an NP paired with an attending physician, or sometimes a fellow. There are always two NPs on service. Usually, during the day we have four NPs on, with two on at night." The program was described in 2011 (ICU Director 2011;2:16-19).

Practice trends driving the need for NPs in critical care include the increasing demand for intensivists and a reliance on a team-based approach to care delivery, "understanding that a single provider cannot provide all the needs that any individual critical care patient has," Mr. Farley explained. "I think we’re a little slow to incorporate the use of nurse practitioners on the West Coast. It’s certainly been done for quite some time on the East Coast."

He said that NPs are already incorporated into critical care delivery programs at Memorial Sloan Kettering Cancer Center and Columbia University, both in New York; Emory University, Atlanta; Henry Ford Hospital, Detroit; the Cleveland Clinic; and Vanderbilt University, Nashville, Tenn. Adopters out West include UCSF, UC Davis; UC Los Angeles; UC Fresno; and Oregon Health & Science University, Portland.

At UCSF, critical care NP duties include a consultative role to admitting services, a consultative role to bedside RNs, guidance of house staff, responding to code blue activations, assisting with rapid response consultations, serving on hospital-wide multidisciplinary committees, precepting adult care NP students, as well as attending morning teaching and monthly morbidity and mortality conferences. Procedures performed include insertion of central venous catheters, arterial catheters, chest tubes, and PICC (peripherally inserted central catheter) lines; lumbar puncture; suture and drain removal; and airway intubation.

The use of NPs in critical care "works because we have appropriate conduits for collaboration and supervision that are explained, understood, and taken to heart," Mr. Farley said. "The NPs need to know that they have supportive attending physicians who will assist them when questions arise. We’ve also had buy-in from the ICU nurses."

A growing body of medical literature suggests that this trend is having an effect. A retrospective study of 600 admissions at two ICUs in New York found that patients managed by nurse practitioner/physician assistant teams had no worse outcomes than patients managed by physicians (Chest 2011;139:1347-53). In addition, a recent survey of critical care program directors at academic medical centers found that 86% believe NPs and other advanced practice providers contribute to the continuity of care, 78% believe they save time during rounds and evaluating new patients, and 73% believe they assist in maintaining work flow (J. Crit. Care 2014; 29:112-5).

In the years ahead, Mr. Farley predicted that NPs and other advanced practice providers "are certainly going to be in the ICU, probably even in greater numbers and perhaps in broader roles than they are now."

Mr. Farley said he had no relevant financial conflicts.

[email protected]

On Twitter @dougbrunk

SAN DIEGO – Nurse practitioners are assuming expanded roles and responsibilities in the provision of critical care services, according to Thomas Farley, R.N., N.P.

At the University of California, San Diego, Critical Care Summer Session, Mr. Farley described the expanded role nurse practitioners (NPs) have played in critical care services for about a decade at the University of California, San Francisco (UCSF). In 2004, Dr. Michael Matthay, a pulmonologist, and Dr. Michael Gropper, a critical care anesthesiologist, spearheaded an effort to hire four NPs to work in the university’s medical-surgical intensive care unit (ICU). "At the time, there were increasing limitations on physician trainees, both in the number of trainees and their work-hour restrictions that were becoming more tight," recalled Mr. Farley of the UCSF School of Nursing. "The goal was to provide critical care at the bedside 24 hours per day, which is in line with the Leapfrog Group recommendations for critical care services. At the time, they had 60 adult ICU critical care beds."

Today, 18 NPs work in adult ICUs at UCSF, with expansion to 76 adult critical care beds, including the medical-surgical ICU, cardiothoracic ICU, and neuro ICU. "Initially the NPs were integrated with medical residents," Mr. Farley said. "Now there are teams that don’t have residents, so it’s an NP paired with an attending physician, or sometimes a fellow. There are always two NPs on service. Usually, during the day we have four NPs on, with two on at night." The program was described in 2011 (ICU Director 2011;2:16-19).

Practice trends driving the need for NPs in critical care include the increasing demand for intensivists and a reliance on a team-based approach to care delivery, "understanding that a single provider cannot provide all the needs that any individual critical care patient has," Mr. Farley explained. "I think we’re a little slow to incorporate the use of nurse practitioners on the West Coast. It’s certainly been done for quite some time on the East Coast."

He said that NPs are already incorporated into critical care delivery programs at Memorial Sloan Kettering Cancer Center and Columbia University, both in New York; Emory University, Atlanta; Henry Ford Hospital, Detroit; the Cleveland Clinic; and Vanderbilt University, Nashville, Tenn. Adopters out West include UCSF, UC Davis; UC Los Angeles; UC Fresno; and Oregon Health & Science University, Portland.

At UCSF, critical care NP duties include a consultative role to admitting services, a consultative role to bedside RNs, guidance of house staff, responding to code blue activations, assisting with rapid response consultations, serving on hospital-wide multidisciplinary committees, precepting adult care NP students, as well as attending morning teaching and monthly morbidity and mortality conferences. Procedures performed include insertion of central venous catheters, arterial catheters, chest tubes, and PICC (peripherally inserted central catheter) lines; lumbar puncture; suture and drain removal; and airway intubation.

The use of NPs in critical care "works because we have appropriate conduits for collaboration and supervision that are explained, understood, and taken to heart," Mr. Farley said. "The NPs need to know that they have supportive attending physicians who will assist them when questions arise. We’ve also had buy-in from the ICU nurses."

A growing body of medical literature suggests that this trend is having an effect. A retrospective study of 600 admissions at two ICUs in New York found that patients managed by nurse practitioner/physician assistant teams had no worse outcomes than patients managed by physicians (Chest 2011;139:1347-53). In addition, a recent survey of critical care program directors at academic medical centers found that 86% believe NPs and other advanced practice providers contribute to the continuity of care, 78% believe they save time during rounds and evaluating new patients, and 73% believe they assist in maintaining work flow (J. Crit. Care 2014; 29:112-5).

In the years ahead, Mr. Farley predicted that NPs and other advanced practice providers "are certainly going to be in the ICU, probably even in greater numbers and perhaps in broader roles than they are now."

Mr. Farley said he had no relevant financial conflicts.

[email protected]

On Twitter @dougbrunk

SAN DIEGO – Nurse practitioners are assuming expanded roles and responsibilities in the provision of critical care services, according to Thomas Farley, R.N., N.P.

At the University of California, San Diego, Critical Care Summer Session, Mr. Farley described the expanded role nurse practitioners (NPs) have played in critical care services for about a decade at the University of California, San Francisco (UCSF). In 2004, Dr. Michael Matthay, a pulmonologist, and Dr. Michael Gropper, a critical care anesthesiologist, spearheaded an effort to hire four NPs to work in the university’s medical-surgical intensive care unit (ICU). "At the time, there were increasing limitations on physician trainees, both in the number of trainees and their work-hour restrictions that were becoming more tight," recalled Mr. Farley of the UCSF School of Nursing. "The goal was to provide critical care at the bedside 24 hours per day, which is in line with the Leapfrog Group recommendations for critical care services. At the time, they had 60 adult ICU critical care beds."

Today, 18 NPs work in adult ICUs at UCSF, with expansion to 76 adult critical care beds, including the medical-surgical ICU, cardiothoracic ICU, and neuro ICU. "Initially the NPs were integrated with medical residents," Mr. Farley said. "Now there are teams that don’t have residents, so it’s an NP paired with an attending physician, or sometimes a fellow. There are always two NPs on service. Usually, during the day we have four NPs on, with two on at night." The program was described in 2011 (ICU Director 2011;2:16-19).

Practice trends driving the need for NPs in critical care include the increasing demand for intensivists and a reliance on a team-based approach to care delivery, "understanding that a single provider cannot provide all the needs that any individual critical care patient has," Mr. Farley explained. "I think we’re a little slow to incorporate the use of nurse practitioners on the West Coast. It’s certainly been done for quite some time on the East Coast."

He said that NPs are already incorporated into critical care delivery programs at Memorial Sloan Kettering Cancer Center and Columbia University, both in New York; Emory University, Atlanta; Henry Ford Hospital, Detroit; the Cleveland Clinic; and Vanderbilt University, Nashville, Tenn. Adopters out West include UCSF, UC Davis; UC Los Angeles; UC Fresno; and Oregon Health & Science University, Portland.

At UCSF, critical care NP duties include a consultative role to admitting services, a consultative role to bedside RNs, guidance of house staff, responding to code blue activations, assisting with rapid response consultations, serving on hospital-wide multidisciplinary committees, precepting adult care NP students, as well as attending morning teaching and monthly morbidity and mortality conferences. Procedures performed include insertion of central venous catheters, arterial catheters, chest tubes, and PICC (peripherally inserted central catheter) lines; lumbar puncture; suture and drain removal; and airway intubation.

The use of NPs in critical care "works because we have appropriate conduits for collaboration and supervision that are explained, understood, and taken to heart," Mr. Farley said. "The NPs need to know that they have supportive attending physicians who will assist them when questions arise. We’ve also had buy-in from the ICU nurses."

A growing body of medical literature suggests that this trend is having an effect. A retrospective study of 600 admissions at two ICUs in New York found that patients managed by nurse practitioner/physician assistant teams had no worse outcomes than patients managed by physicians (Chest 2011;139:1347-53). In addition, a recent survey of critical care program directors at academic medical centers found that 86% believe NPs and other advanced practice providers contribute to the continuity of care, 78% believe they save time during rounds and evaluating new patients, and 73% believe they assist in maintaining work flow (J. Crit. Care 2014; 29:112-5).

In the years ahead, Mr. Farley predicted that NPs and other advanced practice providers "are certainly going to be in the ICU, probably even in greater numbers and perhaps in broader roles than they are now."

Mr. Farley said he had no relevant financial conflicts.

[email protected]

On Twitter @dougbrunk

Compared with open radical cystectomy, robot-assisted laparoscopic radical cystectomy did not reduce the number or severity of complications among patients with bladder cancer enrolled in a single-center randomized clinical trial, according to a letter to the editor in the New England Journal of Medicine.

Retrospective studies have suggested that the robot-assisted laparoscopic approach reduces the complication rate and shortens the length of hospitalization in patients with bladder cancer, many of whom are older, are smokers, and have coexisting conditions. This trial was designed to compare that approach against open radical cystectomy, with both procedures using extracorporeal urinary diversion, in 118 patients who had stage Ta-3N0-3M0 bladder cancer, said Dr. Bernard H. Bochner and his associates at Memorial Sloan Kettering Cancer Center, New York.

Courtesy Wikimedia Commons/Nimur/Creative Commons

The primary outcome – the rate of complications of grade 2-5 within 90 days of surgery—was 62% (37 of 60 patients) with robot-assisted laparoscopic surgery, which was not significantly different from the 66% rate (38 of 58 patients) with open surgery. Similarly, the rates of high-grade complications were not significantly different (22% vs 21%), and the mean length of hospitalization was identical (8 days) in both groups. The amount of intraoperative blood loss was smaller with the robot-assisted surgery (mean difference, 159 cc), but the duration of surgery was shorter with open surgery (mean difference, 127 minutes).

"Because the trial was performed by experienced surgeons at a single, high-volume referral center, the results may not be generalizable to all clinical settings. Nonetheless, these results highlight the need for randomized trials to inform the benefits and risks of new surgical technologies before widespread implementation," Dr. Bochner and his associates said (N. Engl. J. Med. 2014;371:389-90).

This work was supported by the Sidney Kimmel Center for Prostate and Urologic Cancers at Memorial Sloan Kettering Cancer Center, Pin Down Bladder Cancer, and the Michael A. and Zena Wiener Research and Therapeutics Program in Bladder Cancer. Dr. Bochner and his associates reported no financial conflicts of interest.

Compared with open radical cystectomy, robot-assisted laparoscopic radical cystectomy did not reduce the number or severity of complications among patients with bladder cancer enrolled in a single-center randomized clinical trial, according to a letter to the editor in the New England Journal of Medicine.

Retrospective studies have suggested that the robot-assisted laparoscopic approach reduces the complication rate and shortens the length of hospitalization in patients with bladder cancer, many of whom are older, are smokers, and have coexisting conditions. This trial was designed to compare that approach against open radical cystectomy, with both procedures using extracorporeal urinary diversion, in 118 patients who had stage Ta-3N0-3M0 bladder cancer, said Dr. Bernard H. Bochner and his associates at Memorial Sloan Kettering Cancer Center, New York.

Courtesy Wikimedia Commons/Nimur/Creative Commons

The primary outcome – the rate of complications of grade 2-5 within 90 days of surgery—was 62% (37 of 60 patients) with robot-assisted laparoscopic surgery, which was not significantly different from the 66% rate (38 of 58 patients) with open surgery. Similarly, the rates of high-grade complications were not significantly different (22% vs 21%), and the mean length of hospitalization was identical (8 days) in both groups. The amount of intraoperative blood loss was smaller with the robot-assisted surgery (mean difference, 159 cc), but the duration of surgery was shorter with open surgery (mean difference, 127 minutes).

"Because the trial was performed by experienced surgeons at a single, high-volume referral center, the results may not be generalizable to all clinical settings. Nonetheless, these results highlight the need for randomized trials to inform the benefits and risks of new surgical technologies before widespread implementation," Dr. Bochner and his associates said (N. Engl. J. Med. 2014;371:389-90).

This work was supported by the Sidney Kimmel Center for Prostate and Urologic Cancers at Memorial Sloan Kettering Cancer Center, Pin Down Bladder Cancer, and the Michael A. and Zena Wiener Research and Therapeutics Program in Bladder Cancer. Dr. Bochner and his associates reported no financial conflicts of interest.

Compared with open radical cystectomy, robot-assisted laparoscopic radical cystectomy did not reduce the number or severity of complications among patients with bladder cancer enrolled in a single-center randomized clinical trial, according to a letter to the editor in the New England Journal of Medicine.

Retrospective studies have suggested that the robot-assisted laparoscopic approach reduces the complication rate and shortens the length of hospitalization in patients with bladder cancer, many of whom are older, are smokers, and have coexisting conditions. This trial was designed to compare that approach against open radical cystectomy, with both procedures using extracorporeal urinary diversion, in 118 patients who had stage Ta-3N0-3M0 bladder cancer, said Dr. Bernard H. Bochner and his associates at Memorial Sloan Kettering Cancer Center, New York.

Courtesy Wikimedia Commons/Nimur/Creative Commons

The primary outcome – the rate of complications of grade 2-5 within 90 days of surgery—was 62% (37 of 60 patients) with robot-assisted laparoscopic surgery, which was not significantly different from the 66% rate (38 of 58 patients) with open surgery. Similarly, the rates of high-grade complications were not significantly different (22% vs 21%), and the mean length of hospitalization was identical (8 days) in both groups. The amount of intraoperative blood loss was smaller with the robot-assisted surgery (mean difference, 159 cc), but the duration of surgery was shorter with open surgery (mean difference, 127 minutes).

"Because the trial was performed by experienced surgeons at a single, high-volume referral center, the results may not be generalizable to all clinical settings. Nonetheless, these results highlight the need for randomized trials to inform the benefits and risks of new surgical technologies before widespread implementation," Dr. Bochner and his associates said (N. Engl. J. Med. 2014;371:389-90).

This work was supported by the Sidney Kimmel Center for Prostate and Urologic Cancers at Memorial Sloan Kettering Cancer Center, Pin Down Bladder Cancer, and the Michael A. and Zena Wiener Research and Therapeutics Program in Bladder Cancer. Dr. Bochner and his associates reported no financial conflicts of interest.

The Open Payments system has been temporarily taken offline because of technical glitches that have called into question the accuracy of reported data.

"After an assessment of the data resulting from a complaint, we discovered that a limited number of physician payment records submitted by at least one manufacturer incorrectly contained information about other physicians," officials at the Centers for Medicare & Medicaid Services said in a statement. "CMS takes physician privacy very seriously and we have taken the system offline temporarily and will work with the industry to eliminate incorrect payment records."

The Open Payments Program, created under the Affordable Care Act, aims to increase transparency about financial relationships between the drug, device, and biological industry and physicians and teaching hospitals. Under the program, the industry reports payment data, which can be reviewed and disputed by physicians and teaching hospitals. The goal was for the agency to release the data to the public on Sept. 30.

Agency officials first took the website offline on Aug. 3. On Aug. 7, CMS officials sent an e-mail announcing that physicians and representatives from teaching hospitals would be unable to register or review data while the system was offline. Officials pledged that for each day the system was offline, the agency would accordingly adjust the deadlines for reviews and disputes, and the following 15-day corrections period.

Agency officials found that at least one manufacturer submitted incorrect data by matching the name, address, and National Provider Identifier of a physician with the wrong state medical license. Though the medical license was valid, it belonged to another physician with the same first and last names.

Once that information was entered into the Open Payments website, the system combined the data, allowing one of the physicians to see all the payments, including those made to the other physician.

CMS officials contend the problem is limited to a small number of physicians, but in an effort to keep physicians from viewing another provider’s information, they are temporarily suspending registration in the program and the ability to review data. They have not announced an estimate for when the system will be back online.

[email protected]

On Twitter @maryellenny

The Open Payments system has been temporarily taken offline because of technical glitches that have called into question the accuracy of reported data.

"After an assessment of the data resulting from a complaint, we discovered that a limited number of physician payment records submitted by at least one manufacturer incorrectly contained information about other physicians," officials at the Centers for Medicare & Medicaid Services said in a statement. "CMS takes physician privacy very seriously and we have taken the system offline temporarily and will work with the industry to eliminate incorrect payment records."

The Open Payments Program, created under the Affordable Care Act, aims to increase transparency about financial relationships between the drug, device, and biological industry and physicians and teaching hospitals. Under the program, the industry reports payment data, which can be reviewed and disputed by physicians and teaching hospitals. The goal was for the agency to release the data to the public on Sept. 30.

Agency officials first took the website offline on Aug. 3. On Aug. 7, CMS officials sent an e-mail announcing that physicians and representatives from teaching hospitals would be unable to register or review data while the system was offline. Officials pledged that for each day the system was offline, the agency would accordingly adjust the deadlines for reviews and disputes, and the following 15-day corrections period.

Agency officials found that at least one manufacturer submitted incorrect data by matching the name, address, and National Provider Identifier of a physician with the wrong state medical license. Though the medical license was valid, it belonged to another physician with the same first and last names.

Once that information was entered into the Open Payments website, the system combined the data, allowing one of the physicians to see all the payments, including those made to the other physician.

CMS officials contend the problem is limited to a small number of physicians, but in an effort to keep physicians from viewing another provider’s information, they are temporarily suspending registration in the program and the ability to review data. They have not announced an estimate for when the system will be back online.

[email protected]

On Twitter @maryellenny

The Open Payments system has been temporarily taken offline because of technical glitches that have called into question the accuracy of reported data.

"After an assessment of the data resulting from a complaint, we discovered that a limited number of physician payment records submitted by at least one manufacturer incorrectly contained information about other physicians," officials at the Centers for Medicare & Medicaid Services said in a statement. "CMS takes physician privacy very seriously and we have taken the system offline temporarily and will work with the industry to eliminate incorrect payment records."

The Open Payments Program, created under the Affordable Care Act, aims to increase transparency about financial relationships between the drug, device, and biological industry and physicians and teaching hospitals. Under the program, the industry reports payment data, which can be reviewed and disputed by physicians and teaching hospitals. The goal was for the agency to release the data to the public on Sept. 30.

Agency officials first took the website offline on Aug. 3. On Aug. 7, CMS officials sent an e-mail announcing that physicians and representatives from teaching hospitals would be unable to register or review data while the system was offline. Officials pledged that for each day the system was offline, the agency would accordingly adjust the deadlines for reviews and disputes, and the following 15-day corrections period.

Agency officials found that at least one manufacturer submitted incorrect data by matching the name, address, and National Provider Identifier of a physician with the wrong state medical license. Though the medical license was valid, it belonged to another physician with the same first and last names.

Once that information was entered into the Open Payments website, the system combined the data, allowing one of the physicians to see all the payments, including those made to the other physician.

CMS officials contend the problem is limited to a small number of physicians, but in an effort to keep physicians from viewing another provider’s information, they are temporarily suspending registration in the program and the ability to review data. They have not announced an estimate for when the system will be back online.

[email protected]

On Twitter @maryellenny

Adoption of electronic health records reached 78% of office-based physicians in 2013, but use of two key functions that are expected to help improve health outcomes and lower the cost of health care – health information exchange and patient engagement functions – lag behind from an uptake perspective.

Primary care physicians are adopting faster than other specialty providers, with 53% of primary care physicians adopting at least a basic EHR by the end of 2013, compared with 43% of physicians in other specialties, according to a recent study published online Aug. 8 on the Health Affairs website (doi:10.1377/hlthaff.2014.0445).

© pandpstock001 / ThinkStock.com

The size of a practice is a determining factor, with two-thirds of physicians in large practices using a basic EHR, compared with 37% of solo practitioners, Michael Furukawa of the Department of Health and Human Services and his associates reported.

But while adoption is growing, information is not being shared at an equally high rate. Thirty-nine percent of office-based physicians reported having any electronic health information exchange with other ambulatory providers or hospitals in 2013, with physicians in larger practices having 36%-99% higher odds of any electronic health information exchange (HIE), compared with solo practitioners. Physicians in practices owned by academic medical centers or health maintenance organizations had 146%-185% higher odds of any HIE relative to physician-owned practices, and multispecialty practices had 110% higher odds of any HIE, compared with single-specialty practices.

"There are many reasons why physicians may not be sharing clinical data with other providers, especially with those outside their organization," the authors wrote. "There are privacy concerns and technical barriers because of incompatible systems. ... Additionally, HIE often requires the redesign of work flow, which is inherently disruptive and may be difficult to justify in the absence of a clear business case for HIE."

On the patient engagement side, about two-thirds of office-based physicians had the capability to electronically provide patients with visit summaries or patient-specific educational resources, and about half were able to exchange secure messages with patients. About 40% had the capability to allow patients to view, download, or transmit their information electronically, but only half of these physicians did so. Similarly, only a third of physicians with secure message capabilities used it on a regular basis.

The authors cited several factors, including the low uptake of patient portals and lack of awareness of capabilities, as well as poor usability. Also, "physicians may worry that patient portals might generate a large volume of clinical issues that require responses (time for which the physician cannot bill). And finally, some providers are concerned that accessing these data might make patients confused or worried," the authors wrote.

Stage 2 meaningful use criteria require the adoption of computerized capabilities for patient engagement.

The analysis was based on the 2009 National Ambulatory Medical Care Survey and the 2009-2013 Electronic Health Record Surveys, conducted by the National Center for Health Statistics. No conflicts of interest were disclosed by the authors.

[email protected]

Adoption of electronic health records reached 78% of office-based physicians in 2013, but use of two key functions that are expected to help improve health outcomes and lower the cost of health care – health information exchange and patient engagement functions – lag behind from an uptake perspective.

Primary care physicians are adopting faster than other specialty providers, with 53% of primary care physicians adopting at least a basic EHR by the end of 2013, compared with 43% of physicians in other specialties, according to a recent study published online Aug. 8 on the Health Affairs website (doi:10.1377/hlthaff.2014.0445).

© pandpstock001 / ThinkStock.com

The size of a practice is a determining factor, with two-thirds of physicians in large practices using a basic EHR, compared with 37% of solo practitioners, Michael Furukawa of the Department of Health and Human Services and his associates reported.

But while adoption is growing, information is not being shared at an equally high rate. Thirty-nine percent of office-based physicians reported having any electronic health information exchange with other ambulatory providers or hospitals in 2013, with physicians in larger practices having 36%-99% higher odds of any electronic health information exchange (HIE), compared with solo practitioners. Physicians in practices owned by academic medical centers or health maintenance organizations had 146%-185% higher odds of any HIE relative to physician-owned practices, and multispecialty practices had 110% higher odds of any HIE, compared with single-specialty practices.

"There are many reasons why physicians may not be sharing clinical data with other providers, especially with those outside their organization," the authors wrote. "There are privacy concerns and technical barriers because of incompatible systems. ... Additionally, HIE often requires the redesign of work flow, which is inherently disruptive and may be difficult to justify in the absence of a clear business case for HIE."

On the patient engagement side, about two-thirds of office-based physicians had the capability to electronically provide patients with visit summaries or patient-specific educational resources, and about half were able to exchange secure messages with patients. About 40% had the capability to allow patients to view, download, or transmit their information electronically, but only half of these physicians did so. Similarly, only a third of physicians with secure message capabilities used it on a regular basis.

The authors cited several factors, including the low uptake of patient portals and lack of awareness of capabilities, as well as poor usability. Also, "physicians may worry that patient portals might generate a large volume of clinical issues that require responses (time for which the physician cannot bill). And finally, some providers are concerned that accessing these data might make patients confused or worried," the authors wrote.

Stage 2 meaningful use criteria require the adoption of computerized capabilities for patient engagement.

The analysis was based on the 2009 National Ambulatory Medical Care Survey and the 2009-2013 Electronic Health Record Surveys, conducted by the National Center for Health Statistics. No conflicts of interest were disclosed by the authors.

[email protected]

Adoption of electronic health records reached 78% of office-based physicians in 2013, but use of two key functions that are expected to help improve health outcomes and lower the cost of health care – health information exchange and patient engagement functions – lag behind from an uptake perspective.

Primary care physicians are adopting faster than other specialty providers, with 53% of primary care physicians adopting at least a basic EHR by the end of 2013, compared with 43% of physicians in other specialties, according to a recent study published online Aug. 8 on the Health Affairs website (doi:10.1377/hlthaff.2014.0445).

© pandpstock001 / ThinkStock.com

The size of a practice is a determining factor, with two-thirds of physicians in large practices using a basic EHR, compared with 37% of solo practitioners, Michael Furukawa of the Department of Health and Human Services and his associates reported.

But while adoption is growing, information is not being shared at an equally high rate. Thirty-nine percent of office-based physicians reported having any electronic health information exchange with other ambulatory providers or hospitals in 2013, with physicians in larger practices having 36%-99% higher odds of any electronic health information exchange (HIE), compared with solo practitioners. Physicians in practices owned by academic medical centers or health maintenance organizations had 146%-185% higher odds of any HIE relative to physician-owned practices, and multispecialty practices had 110% higher odds of any HIE, compared with single-specialty practices.

"There are many reasons why physicians may not be sharing clinical data with other providers, especially with those outside their organization," the authors wrote. "There are privacy concerns and technical barriers because of incompatible systems. ... Additionally, HIE often requires the redesign of work flow, which is inherently disruptive and may be difficult to justify in the absence of a clear business case for HIE."

On the patient engagement side, about two-thirds of office-based physicians had the capability to electronically provide patients with visit summaries or patient-specific educational resources, and about half were able to exchange secure messages with patients. About 40% had the capability to allow patients to view, download, or transmit their information electronically, but only half of these physicians did so. Similarly, only a third of physicians with secure message capabilities used it on a regular basis.

The authors cited several factors, including the low uptake of patient portals and lack of awareness of capabilities, as well as poor usability. Also, "physicians may worry that patient portals might generate a large volume of clinical issues that require responses (time for which the physician cannot bill). And finally, some providers are concerned that accessing these data might make patients confused or worried," the authors wrote.

Stage 2 meaningful use criteria require the adoption of computerized capabilities for patient engagement.

The analysis was based on the 2009 National Ambulatory Medical Care Survey and the 2009-2013 Electronic Health Record Surveys, conducted by the National Center for Health Statistics. No conflicts of interest were disclosed by the authors.

[email protected]

Physicians and teaching hospitals have until Aug. 27 to review and dispute payment data from drug, device, and biological manufacturers under the federal government’s new Open Payments Program. But recent technical problems with the online system could push that deadline back by a few days.

The Centers for Medicare & Medicaid Services had been scheduled to publish information on industry payments to physicians and teaching hospitals on Sept. 30 as part of the new transparency initiative created under the Affordable Care Act.

AMA

On Aug. 7, CMS announced that the Open Payments website had been taken offline temporarily and that physicians and other providers would not be able to review data until the system was again operational. For each day that the system is offline, CMS said it will accordingly adjust the review and dispute deadline.

CMS did not explain why the system had to be taken offline, but Dr. Robert M. Wah, president of the American Medical Association, said in an interview that CMS officials had discovered earlier in the week a problem in which a manufacturer had attributed payment data to the wrong physician.

While CMS is planning for a small delay because of the technical problems, the AMA and more than 100 specialty and state medical societies are pushing for a 6-month delay on the public release of the payment data, a move that would change the scheduled publication date to March 31, 2015.

In an Aug. 5 letter to CMS, the AMA and the other organizations wrote that while they have "no issue" with efforts to increase transparency in the interactions between physicians and industry, they do have "serious concerns" about the implementation of the program.

A top concern for the groups is the length and complexity of the registration process required for physicians and teaching hospitals to access their data in the Open Payments systems.

CMS officials have told physicians to expect to spend 30-45 minutes to complete a 5-step registration process. But the AMA and the other societies contend that the process is much more involved. They estimate that after the initial preregistration step to verify a physician’s identify, there are another 11 steps in the registration process. And reviewing and disputing data is another 5 steps, they wrote.

"What we’re hearing from physicians is [that] this process is extremely time consuming and difficult," Dr. Wah said. "The user guide to go through this multistep process is 359 pages long. And the time that it’s taking people is in the hours, not minutes, to get through it."

The complexity of the process makes it "effectively impossible" for physicians to review and dispute payment data within the July 14-Aug. 27 window provided by CMS, the organizations wrote in their letter. After Aug. 27, physicians and teaching hospitals can continue to dispute data, but any subsequent corrections would not be reflected in the first publication of data on Sept. 30.

The groups also noted that many physicians are not aware of the program or its deadlines. The medical societies wrote that CMS has not done an adequate job of notifying physicians about the need to review their data. Further, delays by the government in setting a date for physicians to register for the program have made it difficult for medical societies to get information out to their members.

"It takes time to get the word out about these kinds of things, even in our electronically connected world," Dr. Wah said.

[email protected]

On Twitter @maryellenny

Physicians and teaching hospitals have until Aug. 27 to review and dispute payment data from drug, device, and biological manufacturers under the federal government’s new Open Payments Program. But recent technical problems with the online system could push that deadline back by a few days.

The Centers for Medicare & Medicaid Services had been scheduled to publish information on industry payments to physicians and teaching hospitals on Sept. 30 as part of the new transparency initiative created under the Affordable Care Act.

AMA

On Aug. 7, CMS announced that the Open Payments website had been taken offline temporarily and that physicians and other providers would not be able to review data until the system was again operational. For each day that the system is offline, CMS said it will accordingly adjust the review and dispute deadline.

CMS did not explain why the system had to be taken offline, but Dr. Robert M. Wah, president of the American Medical Association, said in an interview that CMS officials had discovered earlier in the week a problem in which a manufacturer had attributed payment data to the wrong physician.

While CMS is planning for a small delay because of the technical problems, the AMA and more than 100 specialty and state medical societies are pushing for a 6-month delay on the public release of the payment data, a move that would change the scheduled publication date to March 31, 2015.

In an Aug. 5 letter to CMS, the AMA and the other organizations wrote that while they have "no issue" with efforts to increase transparency in the interactions between physicians and industry, they do have "serious concerns" about the implementation of the program.

A top concern for the groups is the length and complexity of the registration process required for physicians and teaching hospitals to access their data in the Open Payments systems.

CMS officials have told physicians to expect to spend 30-45 minutes to complete a 5-step registration process. But the AMA and the other societies contend that the process is much more involved. They estimate that after the initial preregistration step to verify a physician’s identify, there are another 11 steps in the registration process. And reviewing and disputing data is another 5 steps, they wrote.

"What we’re hearing from physicians is [that] this process is extremely time consuming and difficult," Dr. Wah said. "The user guide to go through this multistep process is 359 pages long. And the time that it’s taking people is in the hours, not minutes, to get through it."

The complexity of the process makes it "effectively impossible" for physicians to review and dispute payment data within the July 14-Aug. 27 window provided by CMS, the organizations wrote in their letter. After Aug. 27, physicians and teaching hospitals can continue to dispute data, but any subsequent corrections would not be reflected in the first publication of data on Sept. 30.

The groups also noted that many physicians are not aware of the program or its deadlines. The medical societies wrote that CMS has not done an adequate job of notifying physicians about the need to review their data. Further, delays by the government in setting a date for physicians to register for the program have made it difficult for medical societies to get information out to their members.

"It takes time to get the word out about these kinds of things, even in our electronically connected world," Dr. Wah said.

[email protected]

On Twitter @maryellenny

Physicians and teaching hospitals have until Aug. 27 to review and dispute payment data from drug, device, and biological manufacturers under the federal government’s new Open Payments Program. But recent technical problems with the online system could push that deadline back by a few days.

The Centers for Medicare & Medicaid Services had been scheduled to publish information on industry payments to physicians and teaching hospitals on Sept. 30 as part of the new transparency initiative created under the Affordable Care Act.

AMA

On Aug. 7, CMS announced that the Open Payments website had been taken offline temporarily and that physicians and other providers would not be able to review data until the system was again operational. For each day that the system is offline, CMS said it will accordingly adjust the review and dispute deadline.

CMS did not explain why the system had to be taken offline, but Dr. Robert M. Wah, president of the American Medical Association, said in an interview that CMS officials had discovered earlier in the week a problem in which a manufacturer had attributed payment data to the wrong physician.

While CMS is planning for a small delay because of the technical problems, the AMA and more than 100 specialty and state medical societies are pushing for a 6-month delay on the public release of the payment data, a move that would change the scheduled publication date to March 31, 2015.

In an Aug. 5 letter to CMS, the AMA and the other organizations wrote that while they have "no issue" with efforts to increase transparency in the interactions between physicians and industry, they do have "serious concerns" about the implementation of the program.

A top concern for the groups is the length and complexity of the registration process required for physicians and teaching hospitals to access their data in the Open Payments systems.

CMS officials have told physicians to expect to spend 30-45 minutes to complete a 5-step registration process. But the AMA and the other societies contend that the process is much more involved. They estimate that after the initial preregistration step to verify a physician’s identify, there are another 11 steps in the registration process. And reviewing and disputing data is another 5 steps, they wrote.

"What we’re hearing from physicians is [that] this process is extremely time consuming and difficult," Dr. Wah said. "The user guide to go through this multistep process is 359 pages long. And the time that it’s taking people is in the hours, not minutes, to get through it."

The complexity of the process makes it "effectively impossible" for physicians to review and dispute payment data within the July 14-Aug. 27 window provided by CMS, the organizations wrote in their letter. After Aug. 27, physicians and teaching hospitals can continue to dispute data, but any subsequent corrections would not be reflected in the first publication of data on Sept. 30.

The groups also noted that many physicians are not aware of the program or its deadlines. The medical societies wrote that CMS has not done an adequate job of notifying physicians about the need to review their data. Further, delays by the government in setting a date for physicians to register for the program have made it difficult for medical societies to get information out to their members.

"It takes time to get the word out about these kinds of things, even in our electronically connected world," Dr. Wah said.

[email protected]

On Twitter @maryellenny

SAN FRANCISCO – The greater benefits of laparoscopic gastric banding surgery compared with medical treatment for obese patients were maintained for up to 17 years in a study of data on 1,490 patients.

The 527 obese patients (with or without diabetes) who underwent laparoscopic banding were significantly less likely to die of cardiovascular or noncardiovascular causes and were less likely to develop new cases of type 2 diabetes or cardiovascular disease, compared with the 963 nonsurgery patients, Dr. Antonio E. Pontiroli and his associates reported at the annual scientific sessions of the American Diabetes Association.

Patients underwent laparoscopic banding surgery or were seen for a first visit for medical therapy in 1995-2001, and were followed for 11-17 years, through September 2012.

Three percent of the surgery group and 10% of the nonsurgery group died during follow-up, reported Dr. Pontiroli, chair of internal medicine at Università Degli Studi de Milano and San Paolo Hospital, Milan.

To track morbidity, the investigators analyzed records to see which patients got "exemptions" for specific diseases, an Italian government system in which development of a chronic disease exempts someone from having to pay for exams or treatments for that disease. Any exemption obtained after the first surgical or medical visit was considered a proxy of new disease.

New exemptions were granted to 25% in the surgery group and 42% in the nonsurgery group.

Subset analyses divided 385 surgery patients based on the presence or absence of diabetes, and matched the subgroups separately with 681 nonsurgery patients by sex, age, blood pressure, and body mass index.

In the matched comparisons, 3% of the surgery group and 10% of the nonsurgery group died, and exemptions were granted to 22% of the surgery group and 28% of the nonsurgery group, which were statistically significant differences in the intention-to-treat analyses.

Patients in the surgery group were 66% less likely to die than the nonsurgery patients. Patients without diabetes at the first visit were 67% less likely to die than matched nonsurgery patients, and those with diabetes at the first visit were 56% less likely to die compared with matched nonsurgery patients.

Cardiovascular disease, noncardiovascular disease, or neoplasia were significantly less likely to be the causes of death in the surgery group compared with the nonsurgery group. The surgery group recorded significantly fewer hospitalizations during follow-up (120) than the nonsurgery group (273).

New cases of cardiovascular disease (defined by exemptions) appeared in 13% of the surgery group and 22% of the nonsurgery group. In the matched subgroups, 13% who underwent surgery and 18% in the nonsurgery group developed cardiovascular disease.

Among patients without diabetes at baseline, 5% of 454 in the surgery group and 10% of 724 in the nonsurgery group developed diabetes during follow-up. In the subset analysis of matched patients without diabetes at baseline, 4% of 333 in the surgery group and 9% in the nonsurgery group developed diabetes.

The investigators plan another data assessment in 2017 to confirm these long-term findings. Similar studies are needed for other bariatric surgery techniques, he suggested.

Dr. Pontiroli reported financial associations with Sanofi, Eli Lilly, and other companies.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – The greater benefits of laparoscopic gastric banding surgery compared with medical treatment for obese patients were maintained for up to 17 years in a study of data on 1,490 patients.

The 527 obese patients (with or without diabetes) who underwent laparoscopic banding were significantly less likely to die of cardiovascular or noncardiovascular causes and were less likely to develop new cases of type 2 diabetes or cardiovascular disease, compared with the 963 nonsurgery patients, Dr. Antonio E. Pontiroli and his associates reported at the annual scientific sessions of the American Diabetes Association.

Patients underwent laparoscopic banding surgery or were seen for a first visit for medical therapy in 1995-2001, and were followed for 11-17 years, through September 2012.

Three percent of the surgery group and 10% of the nonsurgery group died during follow-up, reported Dr. Pontiroli, chair of internal medicine at Università Degli Studi de Milano and San Paolo Hospital, Milan.

To track morbidity, the investigators analyzed records to see which patients got "exemptions" for specific diseases, an Italian government system in which development of a chronic disease exempts someone from having to pay for exams or treatments for that disease. Any exemption obtained after the first surgical or medical visit was considered a proxy of new disease.

New exemptions were granted to 25% in the surgery group and 42% in the nonsurgery group.

Subset analyses divided 385 surgery patients based on the presence or absence of diabetes, and matched the subgroups separately with 681 nonsurgery patients by sex, age, blood pressure, and body mass index.

In the matched comparisons, 3% of the surgery group and 10% of the nonsurgery group died, and exemptions were granted to 22% of the surgery group and 28% of the nonsurgery group, which were statistically significant differences in the intention-to-treat analyses.

Patients in the surgery group were 66% less likely to die than the nonsurgery patients. Patients without diabetes at the first visit were 67% less likely to die than matched nonsurgery patients, and those with diabetes at the first visit were 56% less likely to die compared with matched nonsurgery patients.

Cardiovascular disease, noncardiovascular disease, or neoplasia were significantly less likely to be the causes of death in the surgery group compared with the nonsurgery group. The surgery group recorded significantly fewer hospitalizations during follow-up (120) than the nonsurgery group (273).

New cases of cardiovascular disease (defined by exemptions) appeared in 13% of the surgery group and 22% of the nonsurgery group. In the matched subgroups, 13% who underwent surgery and 18% in the nonsurgery group developed cardiovascular disease.

Among patients without diabetes at baseline, 5% of 454 in the surgery group and 10% of 724 in the nonsurgery group developed diabetes during follow-up. In the subset analysis of matched patients without diabetes at baseline, 4% of 333 in the surgery group and 9% in the nonsurgery group developed diabetes.

The investigators plan another data assessment in 2017 to confirm these long-term findings. Similar studies are needed for other bariatric surgery techniques, he suggested.

Dr. Pontiroli reported financial associations with Sanofi, Eli Lilly, and other companies.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – The greater benefits of laparoscopic gastric banding surgery compared with medical treatment for obese patients were maintained for up to 17 years in a study of data on 1,490 patients.

The 527 obese patients (with or without diabetes) who underwent laparoscopic banding were significantly less likely to die of cardiovascular or noncardiovascular causes and were less likely to develop new cases of type 2 diabetes or cardiovascular disease, compared with the 963 nonsurgery patients, Dr. Antonio E. Pontiroli and his associates reported at the annual scientific sessions of the American Diabetes Association.

Patients underwent laparoscopic banding surgery or were seen for a first visit for medical therapy in 1995-2001, and were followed for 11-17 years, through September 2012.

Three percent of the surgery group and 10% of the nonsurgery group died during follow-up, reported Dr. Pontiroli, chair of internal medicine at Università Degli Studi de Milano and San Paolo Hospital, Milan.

To track morbidity, the investigators analyzed records to see which patients got "exemptions" for specific diseases, an Italian government system in which development of a chronic disease exempts someone from having to pay for exams or treatments for that disease. Any exemption obtained after the first surgical or medical visit was considered a proxy of new disease.

New exemptions were granted to 25% in the surgery group and 42% in the nonsurgery group.

Subset analyses divided 385 surgery patients based on the presence or absence of diabetes, and matched the subgroups separately with 681 nonsurgery patients by sex, age, blood pressure, and body mass index.

In the matched comparisons, 3% of the surgery group and 10% of the nonsurgery group died, and exemptions were granted to 22% of the surgery group and 28% of the nonsurgery group, which were statistically significant differences in the intention-to-treat analyses.

Patients in the surgery group were 66% less likely to die than the nonsurgery patients. Patients without diabetes at the first visit were 67% less likely to die than matched nonsurgery patients, and those with diabetes at the first visit were 56% less likely to die compared with matched nonsurgery patients.

Cardiovascular disease, noncardiovascular disease, or neoplasia were significantly less likely to be the causes of death in the surgery group compared with the nonsurgery group. The surgery group recorded significantly fewer hospitalizations during follow-up (120) than the nonsurgery group (273).

New cases of cardiovascular disease (defined by exemptions) appeared in 13% of the surgery group and 22% of the nonsurgery group. In the matched subgroups, 13% who underwent surgery and 18% in the nonsurgery group developed cardiovascular disease.

Among patients without diabetes at baseline, 5% of 454 in the surgery group and 10% of 724 in the nonsurgery group developed diabetes during follow-up. In the subset analysis of matched patients without diabetes at baseline, 4% of 333 in the surgery group and 9% in the nonsurgery group developed diabetes.

The investigators plan another data assessment in 2017 to confirm these long-term findings. Similar studies are needed for other bariatric surgery techniques, he suggested.

Dr. Pontiroli reported financial associations with Sanofi, Eli Lilly, and other companies.

[email protected]

On Twitter @sherryboschert

President Obama has signed a bill that promises to give veterans faster access to medical care, in part by reimbursing services given by physicians and hospitals outside the Veterans Affairs health care system.

The Veterans Access, Choice and Accountability Act of 2014 makes $10 billion available through the "Veterans Choice Fund." The money is available until the funds are spent or until August 2017, whichever comes first.

U.S. Senate

Under the act, the VA is required to authorize non-VA care for any veteran who is enrolled in the VA system as of Aug. 1 or who is a newly discharged combat veteran if they can’t get an appointment at a VA medical facility within 30 days, or if they live more than 40 miles from the nearest VA medical facility.

The law also will take a closer look at care delivered within the VA, by requiring an independent assessment and establishing a congressional commission that will evaluate access to care throughout the system. It also provides $5 billion to hire new physicians and other medical staff to help increase access to care.

"This will not and cannot be the end of our effort," said President Obama at a signing ceremony Aug. 7 at Ft. Belvoir, Va. He also said that change would not happen overnight. "Implementing this law will take time," said the president.

Physician groups praised the legislation when lawmakers reached a compromise on the act, leading to passage by the House July 30, followed by the Senate July 31.

The American Medical Association supported the bill "because it is an important step to connecting veterans with physicians who can help them right now," AMA President Robert M. Wah said in a statement.

There are a number of reasons to be pleased with the law, added Dr. Reid Blackwelder, president of the American Academy of Family Physicians. Payment will be negotiated at rates not to exceed Medicare, except in very rural areas, he noted in a statement. The law also establishes 1,500 new residency slots in the VA system, with priority given to primary care and mental health.

"While the challenges associated with the current and future physician workforce within the VA will take time to fully resolve, this legislation will allow America’s civilian physicians to fill the void right away, ensuring that those who have served their country will no longer have to wait for primary care," said Dr. Blackwelder.

The American Psychiatric Association also applauded the increase in residency slots, and it welcomed the news that the VA will be able to prioritize hiring each year based on its identification of the five biggest staffing shortage areas. "In 2012, the VA Office of the Inspector General identified recruiting and retaining psychiatrists as the VA’s greatest challenge in the mental health area," said APA President Paul Summergrad in a statement.

"This legislation puts in place several actions to directly address that shortage, and will result in many more veterans having timely access to needed psychiatric services," he said.

The two congressmen who helped shepherd the legislation through the House and Senate also said they were gratified.

"I am pleased President Obama has finally recognized what we have been telling administration officials for years: that VA’s widespread and systemic lack of accountability is jeopardizing the health of veterans and contributing to all of the department’s most pressing problems," said Rep. Jeff Miller (R-Fla.), chairman of the House Committee on Veterans Affairs, in a statement.

"To prevent history from repeating itself, President Obama must become personally involved in solving VA’s many problems," Rep. Miller said. "A good place for him to start would be to meet with family members and veterans who have been struck by the VA scandal, order the department to cooperate with the congressional committees investigating VA, and force [the Department of Defense] and VA to work together to establish a joint electronic health record integrated across all DoD and VA components."

"In a dysfunctional Congress, I’m glad we accomplished something significant for veterans," Sen. Bernie Sanders (I-Vt.) said in a statement. This legislation will go a long way toward ending unacceptably long waiting times for veterans to access health care, and allow the VA the resources to hire the doctors, nurses, and other medical staff it needs to address these problems over the long term."

[email protected]

On Twitter @aliciaault

President Obama has signed a bill that promises to give veterans faster access to medical care, in part by reimbursing services given by physicians and hospitals outside the Veterans Affairs health care system.

The Veterans Access, Choice and Accountability Act of 2014 makes $10 billion available through the "Veterans Choice Fund." The money is available until the funds are spent or until August 2017, whichever comes first.

U.S. Senate

Under the act, the VA is required to authorize non-VA care for any veteran who is enrolled in the VA system as of Aug. 1 or who is a newly discharged combat veteran if they can’t get an appointment at a VA medical facility within 30 days, or if they live more than 40 miles from the nearest VA medical facility.

The law also will take a closer look at care delivered within the VA, by requiring an independent assessment and establishing a congressional commission that will evaluate access to care throughout the system. It also provides $5 billion to hire new physicians and other medical staff to help increase access to care.

"This will not and cannot be the end of our effort," said President Obama at a signing ceremony Aug. 7 at Ft. Belvoir, Va. He also said that change would not happen overnight. "Implementing this law will take time," said the president.

Physician groups praised the legislation when lawmakers reached a compromise on the act, leading to passage by the House July 30, followed by the Senate July 31.

The American Medical Association supported the bill "because it is an important step to connecting veterans with physicians who can help them right now," AMA President Robert M. Wah said in a statement.

There are a number of reasons to be pleased with the law, added Dr. Reid Blackwelder, president of the American Academy of Family Physicians. Payment will be negotiated at rates not to exceed Medicare, except in very rural areas, he noted in a statement. The law also establishes 1,500 new residency slots in the VA system, with priority given to primary care and mental health.

"While the challenges associated with the current and future physician workforce within the VA will take time to fully resolve, this legislation will allow America’s civilian physicians to fill the void right away, ensuring that those who have served their country will no longer have to wait for primary care," said Dr. Blackwelder.

The American Psychiatric Association also applauded the increase in residency slots, and it welcomed the news that the VA will be able to prioritize hiring each year based on its identification of the five biggest staffing shortage areas. "In 2012, the VA Office of the Inspector General identified recruiting and retaining psychiatrists as the VA’s greatest challenge in the mental health area," said APA President Paul Summergrad in a statement.

"This legislation puts in place several actions to directly address that shortage, and will result in many more veterans having timely access to needed psychiatric services," he said.

The two congressmen who helped shepherd the legislation through the House and Senate also said they were gratified.

"I am pleased President Obama has finally recognized what we have been telling administration officials for years: that VA’s widespread and systemic lack of accountability is jeopardizing the health of veterans and contributing to all of the department’s most pressing problems," said Rep. Jeff Miller (R-Fla.), chairman of the House Committee on Veterans Affairs, in a statement.

"To prevent history from repeating itself, President Obama must become personally involved in solving VA’s many problems," Rep. Miller said. "A good place for him to start would be to meet with family members and veterans who have been struck by the VA scandal, order the department to cooperate with the congressional committees investigating VA, and force [the Department of Defense] and VA to work together to establish a joint electronic health record integrated across all DoD and VA components."

"In a dysfunctional Congress, I’m glad we accomplished something significant for veterans," Sen. Bernie Sanders (I-Vt.) said in a statement. This legislation will go a long way toward ending unacceptably long waiting times for veterans to access health care, and allow the VA the resources to hire the doctors, nurses, and other medical staff it needs to address these problems over the long term."

[email protected]

On Twitter @aliciaault

President Obama has signed a bill that promises to give veterans faster access to medical care, in part by reimbursing services given by physicians and hospitals outside the Veterans Affairs health care system.

The Veterans Access, Choice and Accountability Act of 2014 makes $10 billion available through the "Veterans Choice Fund." The money is available until the funds are spent or until August 2017, whichever comes first.

U.S. Senate

Under the act, the VA is required to authorize non-VA care for any veteran who is enrolled in the VA system as of Aug. 1 or who is a newly discharged combat veteran if they can’t get an appointment at a VA medical facility within 30 days, or if they live more than 40 miles from the nearest VA medical facility.

The law also will take a closer look at care delivered within the VA, by requiring an independent assessment and establishing a congressional commission that will evaluate access to care throughout the system. It also provides $5 billion to hire new physicians and other medical staff to help increase access to care.

"This will not and cannot be the end of our effort," said President Obama at a signing ceremony Aug. 7 at Ft. Belvoir, Va. He also said that change would not happen overnight. "Implementing this law will take time," said the president.

Physician groups praised the legislation when lawmakers reached a compromise on the act, leading to passage by the House July 30, followed by the Senate July 31.

The American Medical Association supported the bill "because it is an important step to connecting veterans with physicians who can help them right now," AMA President Robert M. Wah said in a statement.

There are a number of reasons to be pleased with the law, added Dr. Reid Blackwelder, president of the American Academy of Family Physicians. Payment will be negotiated at rates not to exceed Medicare, except in very rural areas, he noted in a statement. The law also establishes 1,500 new residency slots in the VA system, with priority given to primary care and mental health.

"While the challenges associated with the current and future physician workforce within the VA will take time to fully resolve, this legislation will allow America’s civilian physicians to fill the void right away, ensuring that those who have served their country will no longer have to wait for primary care," said Dr. Blackwelder.

The American Psychiatric Association also applauded the increase in residency slots, and it welcomed the news that the VA will be able to prioritize hiring each year based on its identification of the five biggest staffing shortage areas. "In 2012, the VA Office of the Inspector General identified recruiting and retaining psychiatrists as the VA’s greatest challenge in the mental health area," said APA President Paul Summergrad in a statement.

"This legislation puts in place several actions to directly address that shortage, and will result in many more veterans having timely access to needed psychiatric services," he said.

The two congressmen who helped shepherd the legislation through the House and Senate also said they were gratified.

"I am pleased President Obama has finally recognized what we have been telling administration officials for years: that VA’s widespread and systemic lack of accountability is jeopardizing the health of veterans and contributing to all of the department’s most pressing problems," said Rep. Jeff Miller (R-Fla.), chairman of the House Committee on Veterans Affairs, in a statement.

"To prevent history from repeating itself, President Obama must become personally involved in solving VA’s many problems," Rep. Miller said. "A good place for him to start would be to meet with family members and veterans who have been struck by the VA scandal, order the department to cooperate with the congressional committees investigating VA, and force [the Department of Defense] and VA to work together to establish a joint electronic health record integrated across all DoD and VA components."

"In a dysfunctional Congress, I’m glad we accomplished something significant for veterans," Sen. Bernie Sanders (I-Vt.) said in a statement. This legislation will go a long way toward ending unacceptably long waiting times for veterans to access health care, and allow the VA the resources to hire the doctors, nurses, and other medical staff it needs to address these problems over the long term."

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On Twitter @aliciaault

SEATTLE – Arthroscopic Bankart lesion repairs don’t seem to work well in patients who have lost more than 13.5% of their glenoid fossa after dislocating their shoulders; an open inferior capsular shift or Latarjet procedure is likely to be a better bet, according to a review of 72 consecutive soldiers at Tripler Army Medical Center in Honolulu, who had an arthroscopic Bankart repair after shoulder dislocation.

Seven of the 29 patients (24%) who went into the operation with greater levels of bone loss redislocated over an average of about 4 years of follow-up, versus 2 of 37 (5%) who had less than 13.5% of their glenoid fossa missing. When patients who redislocated were excluded, the mean Western Ontario Shoulder Instability (WOSI) score was 43% of normal in the 13.5% or more bone loss group, but about 80% of normal in those who had lost less bone.

In short, bone loss of 13.5% led to "unacceptable clinical outcomes. Patients with bone loss beyond this threshold should be counseled accordingly with consideration for alternative surgical procedures," the investigators concluded.

Surgeons "have to pay a lot more attention to how much bone loss is there. We have traditionally defined the level of bone loss" that triggers an open procedure at 20%. "In today’s world, everybody agrees that 20% is too high, but the" question has been by how much. At 13.5% – judged by preoperative MRI or CT – "two things become clear. They redislocate at too high a level, and they" report too much instability on the WOSI," said lead investigator Dr. John Tokish, now an orthopedic surgeon at the Greenville (S.C.) Health System.

"If you are just evaluating your results based on whether or not the person redislocates, you missed the point. When we evaluate function in these patients with well below 20% bone loss, they have pain and apprehension. Even if their shoulders don’t come out again, these patients are self-limiting," he said.

When arthroscopic Bankart repair is ruled out, Dr. Tokish cautioned, it "doesn’t necessarily mean we should jump right away to a Latarjet," in which the tip of the coracoid process is repositioned to increase glenoid surface area. "Some would argue that a Latarjet is too big a step. An open inferior capsular shift" may be enough, or even superior.

There were 73 operated shoulders in the 72 patients, 68 of whom were men. The average age at surgery was 26.3 years. Glenoid bone loss was calculated by overlaying a circle onto preop images of the fossa. Patients were excluded if they had a previous shoulder operation.

Dr. Tokish had no disclosures. The work was funded internally.

[email protected]

SEATTLE – Arthroscopic Bankart lesion repairs don’t seem to work well in patients who have lost more than 13.5% of their glenoid fossa after dislocating their shoulders; an open inferior capsular shift or Latarjet procedure is likely to be a better bet, according to a review of 72 consecutive soldiers at Tripler Army Medical Center in Honolulu, who had an arthroscopic Bankart repair after shoulder dislocation.

Seven of the 29 patients (24%) who went into the operation with greater levels of bone loss redislocated over an average of about 4 years of follow-up, versus 2 of 37 (5%) who had less than 13.5% of their glenoid fossa missing. When patients who redislocated were excluded, the mean Western Ontario Shoulder Instability (WOSI) score was 43% of normal in the 13.5% or more bone loss group, but about 80% of normal in those who had lost less bone.

In short, bone loss of 13.5% led to "unacceptable clinical outcomes. Patients with bone loss beyond this threshold should be counseled accordingly with consideration for alternative surgical procedures," the investigators concluded.

Surgeons "have to pay a lot more attention to how much bone loss is there. We have traditionally defined the level of bone loss" that triggers an open procedure at 20%. "In today’s world, everybody agrees that 20% is too high, but the" question has been by how much. At 13.5% – judged by preoperative MRI or CT – "two things become clear. They redislocate at too high a level, and they" report too much instability on the WOSI," said lead investigator Dr. John Tokish, now an orthopedic surgeon at the Greenville (S.C.) Health System.

"If you are just evaluating your results based on whether or not the person redislocates, you missed the point. When we evaluate function in these patients with well below 20% bone loss, they have pain and apprehension. Even if their shoulders don’t come out again, these patients are self-limiting," he said.

When arthroscopic Bankart repair is ruled out, Dr. Tokish cautioned, it "doesn’t necessarily mean we should jump right away to a Latarjet," in which the tip of the coracoid process is repositioned to increase glenoid surface area. "Some would argue that a Latarjet is too big a step. An open inferior capsular shift" may be enough, or even superior.

There were 73 operated shoulders in the 72 patients, 68 of whom were men. The average age at surgery was 26.3 years. Glenoid bone loss was calculated by overlaying a circle onto preop images of the fossa. Patients were excluded if they had a previous shoulder operation.

Dr. Tokish had no disclosures. The work was funded internally.

[email protected]

SEATTLE – Arthroscopic Bankart lesion repairs don’t seem to work well in patients who have lost more than 13.5% of their glenoid fossa after dislocating their shoulders; an open inferior capsular shift or Latarjet procedure is likely to be a better bet, according to a review of 72 consecutive soldiers at Tripler Army Medical Center in Honolulu, who had an arthroscopic Bankart repair after shoulder dislocation.

Seven of the 29 patients (24%) who went into the operation with greater levels of bone loss redislocated over an average of about 4 years of follow-up, versus 2 of 37 (5%) who had less than 13.5% of their glenoid fossa missing. When patients who redislocated were excluded, the mean Western Ontario Shoulder Instability (WOSI) score was 43% of normal in the 13.5% or more bone loss group, but about 80% of normal in those who had lost less bone.

In short, bone loss of 13.5% led to "unacceptable clinical outcomes. Patients with bone loss beyond this threshold should be counseled accordingly with consideration for alternative surgical procedures," the investigators concluded.

Surgeons "have to pay a lot more attention to how much bone loss is there. We have traditionally defined the level of bone loss" that triggers an open procedure at 20%. "In today’s world, everybody agrees that 20% is too high, but the" question has been by how much. At 13.5% – judged by preoperative MRI or CT – "two things become clear. They redislocate at too high a level, and they" report too much instability on the WOSI," said lead investigator Dr. John Tokish, now an orthopedic surgeon at the Greenville (S.C.) Health System.

"If you are just evaluating your results based on whether or not the person redislocates, you missed the point. When we evaluate function in these patients with well below 20% bone loss, they have pain and apprehension. Even if their shoulders don’t come out again, these patients are self-limiting," he said.

When arthroscopic Bankart repair is ruled out, Dr. Tokish cautioned, it "doesn’t necessarily mean we should jump right away to a Latarjet," in which the tip of the coracoid process is repositioned to increase glenoid surface area. "Some would argue that a Latarjet is too big a step. An open inferior capsular shift" may be enough, or even superior.

There were 73 operated shoulders in the 72 patients, 68 of whom were men. The average age at surgery was 26.3 years. Glenoid bone loss was calculated by overlaying a circle onto preop images of the fossa. Patients were excluded if they had a previous shoulder operation.

Dr. Tokish had no disclosures. The work was funded internally.

[email protected]

Comparative effectiveness research results are not making their way into medical practices, even when guidelines are updated to include the insights.

Practice patterns shifted little in the 12 months following the publishing of study results and in the 12 months following incorporation into clinical practice guidelines, based on an analysis of four comparative effectiveness research case studies, funded by the National Pharmaceutical Council (NPC).

The case studies, published in the American Journal of Managed Care (Am. J. Manag. Care 2014;20:e208-e220), looked at practice changes after the 2004 PROVE-IT study on statin therapies, the 2004 Mammography With MRI study on breast cancer surveillance methods in women with BRCA1 or BRCA2 mutations, the 2006 SPORT study comparing standard open diskectomy versus nonoperative treatments for patients with intervertebal disk herniation, and the 2007 COURAGE trial comparing optimal medical therapy and percutaneous coronary intervention versus optimal medical therapy alone.

"In some cases, we might have expected an uptick or change in what was happening," said report author and NPC Director of Comparative Effectiveness Research Jennifer Graff, Pharm.D., speaking in an interview. "For instance, in the PROVE-IT study, we would have expected, based upon the results, that you would have seen many more providers and patients using intensive statin therapy, ... [but it took] 3 years after the study’s publication before you started to see the change in which types of statins were being used."

The report authors developed suggestions on how to get clinicians to more quickly incorporate the results of comparative effectiveness research.

Involve clinicians, payers, policy makers, and patients in the research design "to make sure we are asking the right questions," said Dr. Graff. This approach is now being taken at the Food and Drug Administration to spur drug development and at the Patient-Centered Outcomes Research Institute, a comparative effectiveness research body created as part of the Affordable Care Act.

Perform more confirmatory studies. "One single study probably won’t change the mind of a provider who is seeing many patients and has in their mind what treatments work," Dr. Graff said. "Similarly, we need to fund studies when clinical opinion is shifting."

Align financial incentives with study results. This can be accomplished through value-based insurance design or incentivized provider pay based on outcomes. Bundled payments as well as incentivizing the use of clinical pathways, such as WellPoint’s recently announced program to provide bonus payments in oncology, are examples of such options, Dr. Graff said.

The study was funded by the NPC. Authors Teresa Gibson, Emily Ehrlich, and Amanda Farr reported employment with Truven Health Analytics, which received consulting fees from NPC. Authors Dr. Robert Dubois and Dr. Jennifer Graff are employees of the NPC. The remaining authors reported no financial conflicts of interest.

[email protected]

Comparative effectiveness research results are not making their way into medical practices, even when guidelines are updated to include the insights.

Practice patterns shifted little in the 12 months following the publishing of study results and in the 12 months following incorporation into clinical practice guidelines, based on an analysis of four comparative effectiveness research case studies, funded by the National Pharmaceutical Council (NPC).

The case studies, published in the American Journal of Managed Care (Am. J. Manag. Care 2014;20:e208-e220), looked at practice changes after the 2004 PROVE-IT study on statin therapies, the 2004 Mammography With MRI study on breast cancer surveillance methods in women with BRCA1 or BRCA2 mutations, the 2006 SPORT study comparing standard open diskectomy versus nonoperative treatments for patients with intervertebal disk herniation, and the 2007 COURAGE trial comparing optimal medical therapy and percutaneous coronary intervention versus optimal medical therapy alone.

"In some cases, we might have expected an uptick or change in what was happening," said report author and NPC Director of Comparative Effectiveness Research Jennifer Graff, Pharm.D., speaking in an interview. "For instance, in the PROVE-IT study, we would have expected, based upon the results, that you would have seen many more providers and patients using intensive statin therapy, ... [but it took] 3 years after the study’s publication before you started to see the change in which types of statins were being used."

The report authors developed suggestions on how to get clinicians to more quickly incorporate the results of comparative effectiveness research.

Involve clinicians, payers, policy makers, and patients in the research design "to make sure we are asking the right questions," said Dr. Graff. This approach is now being taken at the Food and Drug Administration to spur drug development and at the Patient-Centered Outcomes Research Institute, a comparative effectiveness research body created as part of the Affordable Care Act.

Perform more confirmatory studies. "One single study probably won’t change the mind of a provider who is seeing many patients and has in their mind what treatments work," Dr. Graff said. "Similarly, we need to fund studies when clinical opinion is shifting."

Align financial incentives with study results. This can be accomplished through value-based insurance design or incentivized provider pay based on outcomes. Bundled payments as well as incentivizing the use of clinical pathways, such as WellPoint’s recently announced program to provide bonus payments in oncology, are examples of such options, Dr. Graff said.

The study was funded by the NPC. Authors Teresa Gibson, Emily Ehrlich, and Amanda Farr reported employment with Truven Health Analytics, which received consulting fees from NPC. Authors Dr. Robert Dubois and Dr. Jennifer Graff are employees of the NPC. The remaining authors reported no financial conflicts of interest.

[email protected]

Comparative effectiveness research results are not making their way into medical practices, even when guidelines are updated to include the insights.

Practice patterns shifted little in the 12 months following the publishing of study results and in the 12 months following incorporation into clinical practice guidelines, based on an analysis of four comparative effectiveness research case studies, funded by the National Pharmaceutical Council (NPC).

The case studies, published in the American Journal of Managed Care (Am. J. Manag. Care 2014;20:e208-e220), looked at practice changes after the 2004 PROVE-IT study on statin therapies, the 2004 Mammography With MRI study on breast cancer surveillance methods in women with BRCA1 or BRCA2 mutations, the 2006 SPORT study comparing standard open diskectomy versus nonoperative treatments for patients with intervertebal disk herniation, and the 2007 COURAGE trial comparing optimal medical therapy and percutaneous coronary intervention versus optimal medical therapy alone.

"In some cases, we might have expected an uptick or change in what was happening," said report author and NPC Director of Comparative Effectiveness Research Jennifer Graff, Pharm.D., speaking in an interview. "For instance, in the PROVE-IT study, we would have expected, based upon the results, that you would have seen many more providers and patients using intensive statin therapy, ... [but it took] 3 years after the study’s publication before you started to see the change in which types of statins were being used."

The report authors developed suggestions on how to get clinicians to more quickly incorporate the results of comparative effectiveness research.

Involve clinicians, payers, policy makers, and patients in the research design "to make sure we are asking the right questions," said Dr. Graff. This approach is now being taken at the Food and Drug Administration to spur drug development and at the Patient-Centered Outcomes Research Institute, a comparative effectiveness research body created as part of the Affordable Care Act.

Perform more confirmatory studies. "One single study probably won’t change the mind of a provider who is seeing many patients and has in their mind what treatments work," Dr. Graff said. "Similarly, we need to fund studies when clinical opinion is shifting."

Align financial incentives with study results. This can be accomplished through value-based insurance design or incentivized provider pay based on outcomes. Bundled payments as well as incentivizing the use of clinical pathways, such as WellPoint’s recently announced program to provide bonus payments in oncology, are examples of such options, Dr. Graff said.

The study was funded by the NPC. Authors Teresa Gibson, Emily Ehrlich, and Amanda Farr reported employment with Truven Health Analytics, which received consulting fees from NPC. Authors Dr. Robert Dubois and Dr. Jennifer Graff are employees of the NPC. The remaining authors reported no financial conflicts of interest.

[email protected]