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Ethicon pulls morcellators off the market, citing ‘uncertain’ risk-benefit
Ethicon has initiated a worldwide withdrawal of the company’s morcellation devices because of the uncertainty over the risk-benefit profile of these devices when used in hysterectomies and myomectomies for women with fibroids, the company announced in a letter on July 30.
The withdrawal – which is voluntary – is an expansion of the company’s suspension of worldwide sales of these devices in April, following the Food and Drug Administration (FDA) announcement recommending that the use of power morcellation during laparoscopic hysterectomy or myomectomy to remove uterine fibroids should be "discouraged," because the procedure could spread cancerous tissue in women with an unsuspected sarcoma.
In its letter, Ethicon stated that the company believes that its morcellation devices "perform as intended and there are patients who can benefit from procedures using laparoscopic power morcellators."
However, the letter adds that "the risk-benefit assessment associated with the use of these devices in hysterectomy and myomectomy procedures remains uncertain," and the company believes that market withdrawal "is the appropriate course of action at this time until further medical guidelines are established and/or new technologies are developed to mitigate the risk."
The Ethicon withdrawal was announced less than 3 weeks after the FDA held a 2-day meeting of its Obstetrics and Gynecology Devices Advisory Panel to discuss the benefits, risks, and clinical role of laparoscopic power morcellators (LPMs) in the treatment of women with uterine fibroids.
Panelists also discussed strategies that might reduce the risks of morcellation disseminating cancerous tissue into the pelvis and abdomen of women with an unsuspected uterine sarcoma or leiomyosarcoma (LMS). Two panelists said that LPMs should not be used for gynecologic indications until better data are available, and during the open public hearing, Dr. Hooman Nourchashm, a cardiothoracic surgeon, reiterated his call for a worldwide moratorium on all gynecological tissue morcellation devices and on the practice of intracorporeal uterine morcellation during minimally invasive hysterectomy. He and his wife, anesthesiologist Dr. Amy Reed, who was diagnosed in 2013 with stage IV LMS after undergoing a hysterectomy with morcellation at the age of 40 for what was thought to be benign fibroids, are leading a campaign calling for the ban.
The Ethicon letter states that the discussion during the meeting "demonstrated the complexity of this issue, particularly with respect to the difficulty for medical professionals to preoperatively diagnose some malignancies, such as leiomyosarcoma ... [and] the risk of disseminating unsuspected malignant tissue while using power morcellation devices," as well as methods to mitigate this risk.
But to date, Ethicon, a Johnson & Johnson company, is the only manufacturer of morcellation devices used in gynecology to suspend and withdraw its products. There are five other manufacturers or distributors of LPMs with gynecologic indications that have been marketed in the past year, according to the FDA.
Dr. David Jaspan, chairman of the department of obstetrics and gynecology at Einstein Medical Center, Philadelphia, said in an interview that he views the Ethicon move to withdraw all morcellation devices as a business decision. This "may be the first domino to fall," and whether competing manufacturers of morcellation devices also decide to withdraw their products or choose an alternative path "remains to be seen."
At the Einstein health care network in Philadelphia, there is currently a moratorium prohibiting the use of power morcellation in gynecologic surgery, while a standard acceptable counseling form is being developed. Dr. Jaspan is working with robotic and minimally invasive surgeons "to create a document that we feel will provide patients with transparency, alternatives, and choice," he noted.
As a result of the FDA’s safety announcement, there has been an increase in open procedures for fibroids in patients who would have been "excellent candidates" for a robotic procedure; did not have a sarcoma; and would have avoided a prolonged length of stay, time away from work, delay in activities of daily living, more blood loss, and pain, he said.
But the FDA estimates that among women who undergo a hysterectomy or myomectomy for a presumed fibroid, about 1 in 350 has a uterine sarcoma, and about 1 in 500 has an LMS. Dr. Jaspan is among those who believe this is an overestimate.
Dr. Jaspan had no disclosures.
Ethicon can be contacted at 877-384-4266 for more information. Adverse events related to LPMs or other medical devices should be reported to the FDA at 800-332-1088 or here.
Ethicon has initiated a worldwide withdrawal of the company’s morcellation devices because of the uncertainty over the risk-benefit profile of these devices when used in hysterectomies and myomectomies for women with fibroids, the company announced in a letter on July 30.
The withdrawal – which is voluntary – is an expansion of the company’s suspension of worldwide sales of these devices in April, following the Food and Drug Administration (FDA) announcement recommending that the use of power morcellation during laparoscopic hysterectomy or myomectomy to remove uterine fibroids should be "discouraged," because the procedure could spread cancerous tissue in women with an unsuspected sarcoma.
In its letter, Ethicon stated that the company believes that its morcellation devices "perform as intended and there are patients who can benefit from procedures using laparoscopic power morcellators."
However, the letter adds that "the risk-benefit assessment associated with the use of these devices in hysterectomy and myomectomy procedures remains uncertain," and the company believes that market withdrawal "is the appropriate course of action at this time until further medical guidelines are established and/or new technologies are developed to mitigate the risk."
The Ethicon withdrawal was announced less than 3 weeks after the FDA held a 2-day meeting of its Obstetrics and Gynecology Devices Advisory Panel to discuss the benefits, risks, and clinical role of laparoscopic power morcellators (LPMs) in the treatment of women with uterine fibroids.
Panelists also discussed strategies that might reduce the risks of morcellation disseminating cancerous tissue into the pelvis and abdomen of women with an unsuspected uterine sarcoma or leiomyosarcoma (LMS). Two panelists said that LPMs should not be used for gynecologic indications until better data are available, and during the open public hearing, Dr. Hooman Nourchashm, a cardiothoracic surgeon, reiterated his call for a worldwide moratorium on all gynecological tissue morcellation devices and on the practice of intracorporeal uterine morcellation during minimally invasive hysterectomy. He and his wife, anesthesiologist Dr. Amy Reed, who was diagnosed in 2013 with stage IV LMS after undergoing a hysterectomy with morcellation at the age of 40 for what was thought to be benign fibroids, are leading a campaign calling for the ban.
The Ethicon letter states that the discussion during the meeting "demonstrated the complexity of this issue, particularly with respect to the difficulty for medical professionals to preoperatively diagnose some malignancies, such as leiomyosarcoma ... [and] the risk of disseminating unsuspected malignant tissue while using power morcellation devices," as well as methods to mitigate this risk.
But to date, Ethicon, a Johnson & Johnson company, is the only manufacturer of morcellation devices used in gynecology to suspend and withdraw its products. There are five other manufacturers or distributors of LPMs with gynecologic indications that have been marketed in the past year, according to the FDA.
Dr. David Jaspan, chairman of the department of obstetrics and gynecology at Einstein Medical Center, Philadelphia, said in an interview that he views the Ethicon move to withdraw all morcellation devices as a business decision. This "may be the first domino to fall," and whether competing manufacturers of morcellation devices also decide to withdraw their products or choose an alternative path "remains to be seen."
At the Einstein health care network in Philadelphia, there is currently a moratorium prohibiting the use of power morcellation in gynecologic surgery, while a standard acceptable counseling form is being developed. Dr. Jaspan is working with robotic and minimally invasive surgeons "to create a document that we feel will provide patients with transparency, alternatives, and choice," he noted.
As a result of the FDA’s safety announcement, there has been an increase in open procedures for fibroids in patients who would have been "excellent candidates" for a robotic procedure; did not have a sarcoma; and would have avoided a prolonged length of stay, time away from work, delay in activities of daily living, more blood loss, and pain, he said.
But the FDA estimates that among women who undergo a hysterectomy or myomectomy for a presumed fibroid, about 1 in 350 has a uterine sarcoma, and about 1 in 500 has an LMS. Dr. Jaspan is among those who believe this is an overestimate.
Dr. Jaspan had no disclosures.
Ethicon can be contacted at 877-384-4266 for more information. Adverse events related to LPMs or other medical devices should be reported to the FDA at 800-332-1088 or here.
Ethicon has initiated a worldwide withdrawal of the company’s morcellation devices because of the uncertainty over the risk-benefit profile of these devices when used in hysterectomies and myomectomies for women with fibroids, the company announced in a letter on July 30.
The withdrawal – which is voluntary – is an expansion of the company’s suspension of worldwide sales of these devices in April, following the Food and Drug Administration (FDA) announcement recommending that the use of power morcellation during laparoscopic hysterectomy or myomectomy to remove uterine fibroids should be "discouraged," because the procedure could spread cancerous tissue in women with an unsuspected sarcoma.
In its letter, Ethicon stated that the company believes that its morcellation devices "perform as intended and there are patients who can benefit from procedures using laparoscopic power morcellators."
However, the letter adds that "the risk-benefit assessment associated with the use of these devices in hysterectomy and myomectomy procedures remains uncertain," and the company believes that market withdrawal "is the appropriate course of action at this time until further medical guidelines are established and/or new technologies are developed to mitigate the risk."
The Ethicon withdrawal was announced less than 3 weeks after the FDA held a 2-day meeting of its Obstetrics and Gynecology Devices Advisory Panel to discuss the benefits, risks, and clinical role of laparoscopic power morcellators (LPMs) in the treatment of women with uterine fibroids.
Panelists also discussed strategies that might reduce the risks of morcellation disseminating cancerous tissue into the pelvis and abdomen of women with an unsuspected uterine sarcoma or leiomyosarcoma (LMS). Two panelists said that LPMs should not be used for gynecologic indications until better data are available, and during the open public hearing, Dr. Hooman Nourchashm, a cardiothoracic surgeon, reiterated his call for a worldwide moratorium on all gynecological tissue morcellation devices and on the practice of intracorporeal uterine morcellation during minimally invasive hysterectomy. He and his wife, anesthesiologist Dr. Amy Reed, who was diagnosed in 2013 with stage IV LMS after undergoing a hysterectomy with morcellation at the age of 40 for what was thought to be benign fibroids, are leading a campaign calling for the ban.
The Ethicon letter states that the discussion during the meeting "demonstrated the complexity of this issue, particularly with respect to the difficulty for medical professionals to preoperatively diagnose some malignancies, such as leiomyosarcoma ... [and] the risk of disseminating unsuspected malignant tissue while using power morcellation devices," as well as methods to mitigate this risk.
But to date, Ethicon, a Johnson & Johnson company, is the only manufacturer of morcellation devices used in gynecology to suspend and withdraw its products. There are five other manufacturers or distributors of LPMs with gynecologic indications that have been marketed in the past year, according to the FDA.
Dr. David Jaspan, chairman of the department of obstetrics and gynecology at Einstein Medical Center, Philadelphia, said in an interview that he views the Ethicon move to withdraw all morcellation devices as a business decision. This "may be the first domino to fall," and whether competing manufacturers of morcellation devices also decide to withdraw their products or choose an alternative path "remains to be seen."
At the Einstein health care network in Philadelphia, there is currently a moratorium prohibiting the use of power morcellation in gynecologic surgery, while a standard acceptable counseling form is being developed. Dr. Jaspan is working with robotic and minimally invasive surgeons "to create a document that we feel will provide patients with transparency, alternatives, and choice," he noted.
As a result of the FDA’s safety announcement, there has been an increase in open procedures for fibroids in patients who would have been "excellent candidates" for a robotic procedure; did not have a sarcoma; and would have avoided a prolonged length of stay, time away from work, delay in activities of daily living, more blood loss, and pain, he said.
But the FDA estimates that among women who undergo a hysterectomy or myomectomy for a presumed fibroid, about 1 in 350 has a uterine sarcoma, and about 1 in 500 has an LMS. Dr. Jaspan is among those who believe this is an overestimate.
Dr. Jaspan had no disclosures.
Ethicon can be contacted at 877-384-4266 for more information. Adverse events related to LPMs or other medical devices should be reported to the FDA at 800-332-1088 or here.
Docs to Congress: Licensure, payment are slowing telemedicine growth
A patchwork of sometimes-restrictive licensure requirements, combined with limited payment, continues to slow down the adoption of telemedicine in many small medical practices, physicians testified before a subcommittee of the House of Representatives.
On July 31, physicians testified about the versatile use of telemedicine – from managing high-risk pregnancies at home to treating acute stroke patients in critical access hospitals. But despite early evidence showing decreased cost and improved quality, the adoption is being stifled, they said.
Source: House Small Business Committee
One challenge comes from Medicare, which pays physicians for telemedicine services under limited circumstances, such as when the patient is in a health professional shortage area. Even when Medicare does pay, the current fee (about $25) is generally too low to cover the cost of setting up and maintaining a telemedicine service, according to Dr. Karen Rheuban of the University of Virginia Center for Telehealth, Charlottesville.
The impact on adoption is clear from the low level of total payments that Medicare made for telemedicine – less than $12 million nationally last year, Dr. Rheuban testified.
Other challenges include varying state board regulations, confusing credentialing regulations, the inability to employ telemedicine across state lines, HIPAA privacy and security regulations, evolving technology platforms, and the cost of adequate bandwidth.
"Telehealth is a valuable tool to address the significant challenges of access to high-quality care, to mitigate workforce shortages, improve population health, and lower the cost of care," Dr. Rheuban testified before the House Committee on Small Business Subcommittee on Health and Technology. "There are many opportunities for small practices to integrate telehealth into everyday practice. However, even for large health care systems such as our own, managing and navigating the complex legal and regulatory environment, which impacts telehealth, can be very challenging."
Dr. Brenda Dintiman, a dermatologist working in a small practice in Fairfax, Va., testified that she uses a tool that provides web-based and mobile access to telemedicine for her patients. But the lack of adequate payment is a barrier for her and other dermatologists, she said.
"While I face these barriers as a physician, it is ultimately the patients – often the most economically vulnerable – that are the most directly affected," Dr. Dintiman said.
Dr. Dintiman outlined some steps to expand the reach of telemedicine that are favored by the American Academy of Dermatology Association (AADA). For instance, Medicare could set an example for private insurers by expanding its payments for telemedicine services.
Changes in state licensure also are needed, she said. The AADA supports the telemedicine compact proposed by the Federation of State Medical Boards that would create a streamlined process for physicians to gain multiple state licenses. The AADA also favors further research on how telemedicine affects cost and quality, which could help make the case to insurers to begin making consistent and adequate payments for telemedicine services, Dr. Dintiman testified.
On Twitter @maryellenny
A patchwork of sometimes-restrictive licensure requirements, combined with limited payment, continues to slow down the adoption of telemedicine in many small medical practices, physicians testified before a subcommittee of the House of Representatives.
On July 31, physicians testified about the versatile use of telemedicine – from managing high-risk pregnancies at home to treating acute stroke patients in critical access hospitals. But despite early evidence showing decreased cost and improved quality, the adoption is being stifled, they said.
Source: House Small Business Committee
One challenge comes from Medicare, which pays physicians for telemedicine services under limited circumstances, such as when the patient is in a health professional shortage area. Even when Medicare does pay, the current fee (about $25) is generally too low to cover the cost of setting up and maintaining a telemedicine service, according to Dr. Karen Rheuban of the University of Virginia Center for Telehealth, Charlottesville.
The impact on adoption is clear from the low level of total payments that Medicare made for telemedicine – less than $12 million nationally last year, Dr. Rheuban testified.
Other challenges include varying state board regulations, confusing credentialing regulations, the inability to employ telemedicine across state lines, HIPAA privacy and security regulations, evolving technology platforms, and the cost of adequate bandwidth.
"Telehealth is a valuable tool to address the significant challenges of access to high-quality care, to mitigate workforce shortages, improve population health, and lower the cost of care," Dr. Rheuban testified before the House Committee on Small Business Subcommittee on Health and Technology. "There are many opportunities for small practices to integrate telehealth into everyday practice. However, even for large health care systems such as our own, managing and navigating the complex legal and regulatory environment, which impacts telehealth, can be very challenging."
Dr. Brenda Dintiman, a dermatologist working in a small practice in Fairfax, Va., testified that she uses a tool that provides web-based and mobile access to telemedicine for her patients. But the lack of adequate payment is a barrier for her and other dermatologists, she said.
"While I face these barriers as a physician, it is ultimately the patients – often the most economically vulnerable – that are the most directly affected," Dr. Dintiman said.
Dr. Dintiman outlined some steps to expand the reach of telemedicine that are favored by the American Academy of Dermatology Association (AADA). For instance, Medicare could set an example for private insurers by expanding its payments for telemedicine services.
Changes in state licensure also are needed, she said. The AADA supports the telemedicine compact proposed by the Federation of State Medical Boards that would create a streamlined process for physicians to gain multiple state licenses. The AADA also favors further research on how telemedicine affects cost and quality, which could help make the case to insurers to begin making consistent and adequate payments for telemedicine services, Dr. Dintiman testified.
On Twitter @maryellenny
A patchwork of sometimes-restrictive licensure requirements, combined with limited payment, continues to slow down the adoption of telemedicine in many small medical practices, physicians testified before a subcommittee of the House of Representatives.
On July 31, physicians testified about the versatile use of telemedicine – from managing high-risk pregnancies at home to treating acute stroke patients in critical access hospitals. But despite early evidence showing decreased cost and improved quality, the adoption is being stifled, they said.
Source: House Small Business Committee
One challenge comes from Medicare, which pays physicians for telemedicine services under limited circumstances, such as when the patient is in a health professional shortage area. Even when Medicare does pay, the current fee (about $25) is generally too low to cover the cost of setting up and maintaining a telemedicine service, according to Dr. Karen Rheuban of the University of Virginia Center for Telehealth, Charlottesville.
The impact on adoption is clear from the low level of total payments that Medicare made for telemedicine – less than $12 million nationally last year, Dr. Rheuban testified.
Other challenges include varying state board regulations, confusing credentialing regulations, the inability to employ telemedicine across state lines, HIPAA privacy and security regulations, evolving technology platforms, and the cost of adequate bandwidth.
"Telehealth is a valuable tool to address the significant challenges of access to high-quality care, to mitigate workforce shortages, improve population health, and lower the cost of care," Dr. Rheuban testified before the House Committee on Small Business Subcommittee on Health and Technology. "There are many opportunities for small practices to integrate telehealth into everyday practice. However, even for large health care systems such as our own, managing and navigating the complex legal and regulatory environment, which impacts telehealth, can be very challenging."
Dr. Brenda Dintiman, a dermatologist working in a small practice in Fairfax, Va., testified that she uses a tool that provides web-based and mobile access to telemedicine for her patients. But the lack of adequate payment is a barrier for her and other dermatologists, she said.
"While I face these barriers as a physician, it is ultimately the patients – often the most economically vulnerable – that are the most directly affected," Dr. Dintiman said.
Dr. Dintiman outlined some steps to expand the reach of telemedicine that are favored by the American Academy of Dermatology Association (AADA). For instance, Medicare could set an example for private insurers by expanding its payments for telemedicine services.
Changes in state licensure also are needed, she said. The AADA supports the telemedicine compact proposed by the Federation of State Medical Boards that would create a streamlined process for physicians to gain multiple state licenses. The AADA also favors further research on how telemedicine affects cost and quality, which could help make the case to insurers to begin making consistent and adequate payments for telemedicine services, Dr. Dintiman testified.
On Twitter @maryellenny
FROM A HOUSE SUBCOMMITTEE HEARING
Social media can help, harm liability cases
Physicians should be mindful of how social media can affect a medical malpractice case for better or worse and take steps to avoid legal dangers.
As a case proceeds through the legal process, social media "can be used to take the pulse of the parties, to discover public information that can be used in [cross examinations], and to explore themes for trials," said John E. Hall Jr., an Atlanta-based medical liability defense attorney, at the American Conference Institute’s obstetric malpractice claims forum in Philadelphia.
Plaintiffs’ and defense attorneys both turn toward social media use by patients and physicians to search for ways to build their respective cases. For the defense, this could mean reviewing a patient’s Facebook or Twitter account for information that contradicts their alleged injury claim. For instance, a patient who alleges a serious leg injury may be posting pictures of recent running activities.
On the other hand, plaintiffs may search social media for evidence about physicians’ activities around the time the alleged malpractice occurred. For example, by arguing a doctor’s late-night posts suggest the doctor had little sleep and was less than attentive during the patient’s visit, said Adam J. Davis, a Cleveland-based medical liability defense attorney. He was a copresenter at the obstetric claims conference.
"The courts are viewing electronically stored information, such as Facebook profiles, no differently than a person’s photo album at home or a journal that relates to the care in question, all of which have been discoverable in litigation," Mr. Davis said in an interview. Judges "are treating electronically stored information in much the same way they treat real, [tangible] evidence. Once that information is out there in a public forum, it’s fair game."
To prevent social media postings from being used against them in court, physicians should considering making their personal accounts private, Mr. Davis said. They should also be wary about what information they are posting or forwarding on public websites or on their practice’s social media accounts.
Deleting or changing a social media posting because it may arise during a malpractice case is a bad idea. Data residing in social media sites is subject to the same "duty to preserve" as other types of electronically stored information, Mr. Davis said. The duty to preserve is triggered when a party reasonably foresees the information may be relevant to issues in litigation. Deleting Facebook posts or other social media texts could result in sanctions for physicians or a spoliation of evidence claim.
If physicians believe a medical malpractice lawsuit may be forthcoming, it might be helpful to monitor the social media landscape and review what is being said about their care or practices, legal experts add. Physicians can search mainstream media, blogger websites, online reviews or tweets for their names or facilities. Such information could help them be more prepared if a suit is filed and help them direct their attorneys to relevant online comments.
"Monitoring [social media] pre-, during, and post trial can give a variety of information from the opinion of the case in the community, the predispositions witnesses may have, and compliance with court directives and rules," Mr. Hall said in an interview.
However, doctors should leave to attorneys the searching of jurors on social media, especially during trial. Contacting jurors during trial – even accidently – can lead to serious legal consequences for physicians, such as a mistrial.
"The best practice is for doctors not to be checking on jurors during trial – leave that to counsel," Mr. Davis said. "It’s too risky for the physician. A physician’s inadvertent communication with a juror over social media – say they accidently send a friend request – that’s considered communication, and it could result in a mistrial or the [excusing] of the juror or the start a new trial."
On Twitter @legal_med
Physicians should be mindful of how social media can affect a medical malpractice case for better or worse and take steps to avoid legal dangers.
As a case proceeds through the legal process, social media "can be used to take the pulse of the parties, to discover public information that can be used in [cross examinations], and to explore themes for trials," said John E. Hall Jr., an Atlanta-based medical liability defense attorney, at the American Conference Institute’s obstetric malpractice claims forum in Philadelphia.
Plaintiffs’ and defense attorneys both turn toward social media use by patients and physicians to search for ways to build their respective cases. For the defense, this could mean reviewing a patient’s Facebook or Twitter account for information that contradicts their alleged injury claim. For instance, a patient who alleges a serious leg injury may be posting pictures of recent running activities.
On the other hand, plaintiffs may search social media for evidence about physicians’ activities around the time the alleged malpractice occurred. For example, by arguing a doctor’s late-night posts suggest the doctor had little sleep and was less than attentive during the patient’s visit, said Adam J. Davis, a Cleveland-based medical liability defense attorney. He was a copresenter at the obstetric claims conference.
"The courts are viewing electronically stored information, such as Facebook profiles, no differently than a person’s photo album at home or a journal that relates to the care in question, all of which have been discoverable in litigation," Mr. Davis said in an interview. Judges "are treating electronically stored information in much the same way they treat real, [tangible] evidence. Once that information is out there in a public forum, it’s fair game."
To prevent social media postings from being used against them in court, physicians should considering making their personal accounts private, Mr. Davis said. They should also be wary about what information they are posting or forwarding on public websites or on their practice’s social media accounts.
Deleting or changing a social media posting because it may arise during a malpractice case is a bad idea. Data residing in social media sites is subject to the same "duty to preserve" as other types of electronically stored information, Mr. Davis said. The duty to preserve is triggered when a party reasonably foresees the information may be relevant to issues in litigation. Deleting Facebook posts or other social media texts could result in sanctions for physicians or a spoliation of evidence claim.
If physicians believe a medical malpractice lawsuit may be forthcoming, it might be helpful to monitor the social media landscape and review what is being said about their care or practices, legal experts add. Physicians can search mainstream media, blogger websites, online reviews or tweets for their names or facilities. Such information could help them be more prepared if a suit is filed and help them direct their attorneys to relevant online comments.
"Monitoring [social media] pre-, during, and post trial can give a variety of information from the opinion of the case in the community, the predispositions witnesses may have, and compliance with court directives and rules," Mr. Hall said in an interview.
However, doctors should leave to attorneys the searching of jurors on social media, especially during trial. Contacting jurors during trial – even accidently – can lead to serious legal consequences for physicians, such as a mistrial.
"The best practice is for doctors not to be checking on jurors during trial – leave that to counsel," Mr. Davis said. "It’s too risky for the physician. A physician’s inadvertent communication with a juror over social media – say they accidently send a friend request – that’s considered communication, and it could result in a mistrial or the [excusing] of the juror or the start a new trial."
On Twitter @legal_med
Physicians should be mindful of how social media can affect a medical malpractice case for better or worse and take steps to avoid legal dangers.
As a case proceeds through the legal process, social media "can be used to take the pulse of the parties, to discover public information that can be used in [cross examinations], and to explore themes for trials," said John E. Hall Jr., an Atlanta-based medical liability defense attorney, at the American Conference Institute’s obstetric malpractice claims forum in Philadelphia.
Plaintiffs’ and defense attorneys both turn toward social media use by patients and physicians to search for ways to build their respective cases. For the defense, this could mean reviewing a patient’s Facebook or Twitter account for information that contradicts their alleged injury claim. For instance, a patient who alleges a serious leg injury may be posting pictures of recent running activities.
On the other hand, plaintiffs may search social media for evidence about physicians’ activities around the time the alleged malpractice occurred. For example, by arguing a doctor’s late-night posts suggest the doctor had little sleep and was less than attentive during the patient’s visit, said Adam J. Davis, a Cleveland-based medical liability defense attorney. He was a copresenter at the obstetric claims conference.
"The courts are viewing electronically stored information, such as Facebook profiles, no differently than a person’s photo album at home or a journal that relates to the care in question, all of which have been discoverable in litigation," Mr. Davis said in an interview. Judges "are treating electronically stored information in much the same way they treat real, [tangible] evidence. Once that information is out there in a public forum, it’s fair game."
To prevent social media postings from being used against them in court, physicians should considering making their personal accounts private, Mr. Davis said. They should also be wary about what information they are posting or forwarding on public websites or on their practice’s social media accounts.
Deleting or changing a social media posting because it may arise during a malpractice case is a bad idea. Data residing in social media sites is subject to the same "duty to preserve" as other types of electronically stored information, Mr. Davis said. The duty to preserve is triggered when a party reasonably foresees the information may be relevant to issues in litigation. Deleting Facebook posts or other social media texts could result in sanctions for physicians or a spoliation of evidence claim.
If physicians believe a medical malpractice lawsuit may be forthcoming, it might be helpful to monitor the social media landscape and review what is being said about their care or practices, legal experts add. Physicians can search mainstream media, blogger websites, online reviews or tweets for their names or facilities. Such information could help them be more prepared if a suit is filed and help them direct their attorneys to relevant online comments.
"Monitoring [social media] pre-, during, and post trial can give a variety of information from the opinion of the case in the community, the predispositions witnesses may have, and compliance with court directives and rules," Mr. Hall said in an interview.
However, doctors should leave to attorneys the searching of jurors on social media, especially during trial. Contacting jurors during trial – even accidently – can lead to serious legal consequences for physicians, such as a mistrial.
"The best practice is for doctors not to be checking on jurors during trial – leave that to counsel," Mr. Davis said. "It’s too risky for the physician. A physician’s inadvertent communication with a juror over social media – say they accidently send a friend request – that’s considered communication, and it could result in a mistrial or the [excusing] of the juror or the start a new trial."
On Twitter @legal_med
IOM report calls for redistribution of GME funding
The Medicare program should continue to fund graduate medical education for at least the next decade, but should gradually begin tying payments to performance, according to a report from the Institute of Medicine.
In the report, released July 29, an IOM panel recommended that the U.S. Department of Health & Human Services create a Graduate Medical Education Policy Council, loosely modeled after the Medicare Payment Advisory Committee (MedPAC). The council would be charged with developing a strategic plan for allocating graduate medical education (GME) funds, as well as sponsoring research to determine the best mix of physician specialties and the geographic areas where they are needed most.
The panel also recommended the establishment of a GME Center within the Centers for Medicare & Medicaid Services to manage the distribution of funds.
The IOM panel called for an end to the current system of providing both "direct" and "indirect" GME funds. Instead, the panel recommends the establishment of an "operations" fund that would pay for current residency slots and a "transformation" fund that would test alternative payment methods and validate performance measures.
Initially, about 90% of the funding would go toward operations and 10% toward transformation activities, according to Gail Wilensky, Ph.D., cochair of the IOM panel and a senior fellow at Project HOPE, an international health foundation. Dr. Wilensky was commissioner of Medicare and Medicaid programs from 1990 to 1992.
The panel recommended that Medicare payments, which account for about $9.7 billion of the $15 billion spent annually by the federal government on GME, continue at current levels with an adjustment for inflation. The organizations that sponsor GME programs would receive one payment based on a national per-resident amount equal to the total value of the new GME operational fund, divided by the current number of full-time Medicare-funded training slots.
The recommendations were criticized by the Association of American Medical Colleges, which represents medical schools in the United States and Canada. Dr. Darrell G. Kirch, AAMC president and CEO, said the IOM panel’s plan for restructuring GME financing would essentially amount to a cut in funding for teaching hospitals and would create new government bureaucracies.
"By proposing as much as a 35% reduction in payments to teaching hospitals, the IOM’s recommendations will slash funding for vital care and services available almost exclusively at teaching hospitals, including Level 1 trauma centers, pediatric intensive care units, burn centers, and access to clinical trials," Dr. Kirch said. "In addition to hurting patient care, these cuts will limit critical training settings for future physicians, nurses, and other health professionals."
The AAMC instead supports increasing the number of federally supported GME training slots.
On Twitter @maryellenny
The Medicare program should continue to fund graduate medical education for at least the next decade, but should gradually begin tying payments to performance, according to a report from the Institute of Medicine.
In the report, released July 29, an IOM panel recommended that the U.S. Department of Health & Human Services create a Graduate Medical Education Policy Council, loosely modeled after the Medicare Payment Advisory Committee (MedPAC). The council would be charged with developing a strategic plan for allocating graduate medical education (GME) funds, as well as sponsoring research to determine the best mix of physician specialties and the geographic areas where they are needed most.
The panel also recommended the establishment of a GME Center within the Centers for Medicare & Medicaid Services to manage the distribution of funds.
The IOM panel called for an end to the current system of providing both "direct" and "indirect" GME funds. Instead, the panel recommends the establishment of an "operations" fund that would pay for current residency slots and a "transformation" fund that would test alternative payment methods and validate performance measures.
Initially, about 90% of the funding would go toward operations and 10% toward transformation activities, according to Gail Wilensky, Ph.D., cochair of the IOM panel and a senior fellow at Project HOPE, an international health foundation. Dr. Wilensky was commissioner of Medicare and Medicaid programs from 1990 to 1992.
The panel recommended that Medicare payments, which account for about $9.7 billion of the $15 billion spent annually by the federal government on GME, continue at current levels with an adjustment for inflation. The organizations that sponsor GME programs would receive one payment based on a national per-resident amount equal to the total value of the new GME operational fund, divided by the current number of full-time Medicare-funded training slots.
The recommendations were criticized by the Association of American Medical Colleges, which represents medical schools in the United States and Canada. Dr. Darrell G. Kirch, AAMC president and CEO, said the IOM panel’s plan for restructuring GME financing would essentially amount to a cut in funding for teaching hospitals and would create new government bureaucracies.
"By proposing as much as a 35% reduction in payments to teaching hospitals, the IOM’s recommendations will slash funding for vital care and services available almost exclusively at teaching hospitals, including Level 1 trauma centers, pediatric intensive care units, burn centers, and access to clinical trials," Dr. Kirch said. "In addition to hurting patient care, these cuts will limit critical training settings for future physicians, nurses, and other health professionals."
The AAMC instead supports increasing the number of federally supported GME training slots.
On Twitter @maryellenny
The Medicare program should continue to fund graduate medical education for at least the next decade, but should gradually begin tying payments to performance, according to a report from the Institute of Medicine.
In the report, released July 29, an IOM panel recommended that the U.S. Department of Health & Human Services create a Graduate Medical Education Policy Council, loosely modeled after the Medicare Payment Advisory Committee (MedPAC). The council would be charged with developing a strategic plan for allocating graduate medical education (GME) funds, as well as sponsoring research to determine the best mix of physician specialties and the geographic areas where they are needed most.
The panel also recommended the establishment of a GME Center within the Centers for Medicare & Medicaid Services to manage the distribution of funds.
The IOM panel called for an end to the current system of providing both "direct" and "indirect" GME funds. Instead, the panel recommends the establishment of an "operations" fund that would pay for current residency slots and a "transformation" fund that would test alternative payment methods and validate performance measures.
Initially, about 90% of the funding would go toward operations and 10% toward transformation activities, according to Gail Wilensky, Ph.D., cochair of the IOM panel and a senior fellow at Project HOPE, an international health foundation. Dr. Wilensky was commissioner of Medicare and Medicaid programs from 1990 to 1992.
The panel recommended that Medicare payments, which account for about $9.7 billion of the $15 billion spent annually by the federal government on GME, continue at current levels with an adjustment for inflation. The organizations that sponsor GME programs would receive one payment based on a national per-resident amount equal to the total value of the new GME operational fund, divided by the current number of full-time Medicare-funded training slots.
The recommendations were criticized by the Association of American Medical Colleges, which represents medical schools in the United States and Canada. Dr. Darrell G. Kirch, AAMC president and CEO, said the IOM panel’s plan for restructuring GME financing would essentially amount to a cut in funding for teaching hospitals and would create new government bureaucracies.
"By proposing as much as a 35% reduction in payments to teaching hospitals, the IOM’s recommendations will slash funding for vital care and services available almost exclusively at teaching hospitals, including Level 1 trauma centers, pediatric intensive care units, burn centers, and access to clinical trials," Dr. Kirch said. "In addition to hurting patient care, these cuts will limit critical training settings for future physicians, nurses, and other health professionals."
The AAMC instead supports increasing the number of federally supported GME training slots.
On Twitter @maryellenny
Federation issues revised draft of telemedicine compact
The Federation of State Medical Boards has released an updated draft of a proposed interstate compact that would expand the practice of telemedicine by streamlining physician licensure. The revised text includes new requirements for physicians who wish to participate in an expedited process for gaining multiple state licenses.
Under the draft, interested physicians would need to complete a background check including biometric data (fingerprints or other) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.
Additional new draft language alters specialty certification requirements of the compact to clarify that those with time-unlimited certification are eligible to participate in the compact.
"The goal of the compact is to ensure that qualified physicians are able to practice medicine in a safe and accountable manner, and that the strongest health care consumer protections are maintained," Dr. Humayun J. Chaudhry, FSMB president and CEO, said in a statement. "The revised compact helps ensure that as the practice of telemedicine continues to expand, patient protection remains a top priority. We look forward to sharing the revised compact with state medical boards across the country and look forward to working with them to achieve implementation."
The FSMB House of Delegates unanimously approved the development of an interstate compact to expedite medical licensure and facilitate multistate practice at its 2013 annual meeting. Under the proposed system, states and doctors would voluntarily enter into the compact, and approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight, according to the proposed compact.
The interstate compact system is expected to significantly reduce barriers to the process of gaining licensure in multiple states, while helping to facilitate licensure portability and telemedicine. The state boards of medicine intend to present the final compact draft to state legislators for their consideration in 2015 legislative sessions.
On Twitter @legal_med
The Federation of State Medical Boards has released an updated draft of a proposed interstate compact that would expand the practice of telemedicine by streamlining physician licensure. The revised text includes new requirements for physicians who wish to participate in an expedited process for gaining multiple state licenses.
Under the draft, interested physicians would need to complete a background check including biometric data (fingerprints or other) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.
Additional new draft language alters specialty certification requirements of the compact to clarify that those with time-unlimited certification are eligible to participate in the compact.
"The goal of the compact is to ensure that qualified physicians are able to practice medicine in a safe and accountable manner, and that the strongest health care consumer protections are maintained," Dr. Humayun J. Chaudhry, FSMB president and CEO, said in a statement. "The revised compact helps ensure that as the practice of telemedicine continues to expand, patient protection remains a top priority. We look forward to sharing the revised compact with state medical boards across the country and look forward to working with them to achieve implementation."
The FSMB House of Delegates unanimously approved the development of an interstate compact to expedite medical licensure and facilitate multistate practice at its 2013 annual meeting. Under the proposed system, states and doctors would voluntarily enter into the compact, and approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight, according to the proposed compact.
The interstate compact system is expected to significantly reduce barriers to the process of gaining licensure in multiple states, while helping to facilitate licensure portability and telemedicine. The state boards of medicine intend to present the final compact draft to state legislators for their consideration in 2015 legislative sessions.
On Twitter @legal_med
The Federation of State Medical Boards has released an updated draft of a proposed interstate compact that would expand the practice of telemedicine by streamlining physician licensure. The revised text includes new requirements for physicians who wish to participate in an expedited process for gaining multiple state licenses.
Under the draft, interested physicians would need to complete a background check including biometric data (fingerprints or other) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.
Additional new draft language alters specialty certification requirements of the compact to clarify that those with time-unlimited certification are eligible to participate in the compact.
"The goal of the compact is to ensure that qualified physicians are able to practice medicine in a safe and accountable manner, and that the strongest health care consumer protections are maintained," Dr. Humayun J. Chaudhry, FSMB president and CEO, said in a statement. "The revised compact helps ensure that as the practice of telemedicine continues to expand, patient protection remains a top priority. We look forward to sharing the revised compact with state medical boards across the country and look forward to working with them to achieve implementation."
The FSMB House of Delegates unanimously approved the development of an interstate compact to expedite medical licensure and facilitate multistate practice at its 2013 annual meeting. Under the proposed system, states and doctors would voluntarily enter into the compact, and approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight, according to the proposed compact.
The interstate compact system is expected to significantly reduce barriers to the process of gaining licensure in multiple states, while helping to facilitate licensure portability and telemedicine. The state boards of medicine intend to present the final compact draft to state legislators for their consideration in 2015 legislative sessions.
On Twitter @legal_med
Insurers play growing role in palliative care expansion
Health plans are starting to expand their coverage of palliative care, offering higher payments to physicians who meet certain standards or paying for home care for a wider range of seriously ill patients.
The offerings vary greatly by region and by plan, but the common theme is that these types of programs are on the rise.
Cambia Health Solutions, which operates six health plans in Oregon, Washington, Idaho, and Utah, recently garnered attention with the launch of a wide-ranging palliative care program.
Starting this year, Cambia plans will pay for services previously not covered, such as home health aides and advance care planning counseling. They are also partnering with the University of Washington to offer palliative care training to physicians, nurses, and social workers. Palliative care physicians will be able to earn certification through a 1-year program. There’s also a shorter training option in the works to teach primary care physicians how to start palliative care conversations and make referrals.
The program also aims to address the social needs of seriously ill patients by forming case management units with specially trained nurses and social workers who can assist members with issues such as home food delivery, according to Dr. Csaba Mera, chief medical officer at Cambia.
The new program’s goal is to build a "best in class" model that could be used nationally, Dr. Mera said. At the core of the program, he noted, is the goal of honoring the wishes of seriously ill patients.
"That has not been happening in health care," he said. "It’s amazing how often somebody decides they don’t want certain kinds of treatment, and they still get it."
While Cambia’s program is wide reaching, the health plan is not the only payer active in palliative care. The insurance giant Aetna has a decade of experience with specialized case management services designed to help patients and caregivers coping with advanced illness.
Through Aetna’s Compassionate Care Program, nurses and social workers work with physicians’ offices and patients and their families to provide education, assistance with pain medications, and other psychosocial support. They also work to ensure that advance directives are in place and followed. In most cases, the case managers are located in call centers. But increasingly, the health plan has embedded them in the offices of participating medical groups.
The case managers are "almost a lifeline" to patients and their families, explained Dr. Randall Krakauer, Aetna’s vice president and national medical director for medical strategy.
It’s also been a no-brainer for Aetna financially. The specialized case managers, who are used in both commercial and Medicare Advantage plans, have significantly reduced costly hospital stays and the use of the emergency department. There’s typically a $12,000 decrease in costs for each person enrolled in the case management program, according to Aetna.
Among Aetna Medicare Advantage members, there has been an 82% drop in days spent in the hospital for acute care, an 86% drop in days spent in the intensive care unit, and a 78% drop in use of the emergency department.
"If there is an opportunity for favorable impact at the intersection of quality and cost, particularly in Medicare, this is in fact the mother lode," Dr. Krakauer said.
Some regional payers have also begun to partner with physicians and other providers in the community to offer more than just traditional hospice coverage. For instance, Excellus BlueCross BlueShield, which operates in upstate New York, worked with the University of Rochester Medical Center to develop courses for physicians that focus on advance care planning, how to use the Medical Orders for Life-Sustaining Treatment (MOLST) protocol, and myths about CPR and life-sustaining treatment. Physicians who complete the online training and a testing module about it can qualify for bonus payments.
Highmark, which operates in Pennsylvania, Delaware, and West Virginia, set up a palliative care indicator to measure the performance of its contracted hospitals. The insurer measures the percentage of patients who have a palliative care consult, and the percentage of adult intensive care unit patients who have a documented resuscitation status, designated health care proxy, and documented interdisciplinary family meeting.
What’s driving the expansion into palliative care? Part of the reason is demographics, noted J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Organization. Baby boomers are aging and will demand health care on their own terms, including having help with both their medical and psychosocial needs when dealing with serious illness.
"I think it’s great the health plans are doing it," he said. "People are asking for good pain and symptom management now more than ever before."
The growth of accountable care organizations (ACOs) is also driving the expansion of palliative care programs. Because ACOs assume risk for the total cost of their members’ health care, expanding palliative care services in the community offers the potential to lower costly hospital admissions and readmissions, Dr. Schumacher said. Even though ACOs are developing very differently depending on the local community, they all seem interested in hospice and palliative care programs, he said.
Dr. Diane E. Meier, director of the Center to Advance Palliative Care, recently created a toolkit for payers outlining the rationale for establishing a palliative program and elements with a proven track record of improving quality and decreasing costs. For instance, a meaningful 24/7 clinical response is an essential element, she said, because it keeps patients from calling 911 frequently and ending up in the emergency department.
"Payers are recognizing that the reason their members don’t get access to palliative care in the community is because no one will pay for it – and they can fix that," said Dr. Meier, who is also a professor of geriatrics and palliative medicine at Mount Sinai Hospital in New York.
But expanding access to palliative care is likely to take more than just financial incentives, said Dr. Krakauer. The difficulty in making changes to health care delivery is one obstacle, he said. Another issue is that palliative care still runs contrary to the medical culture.
"A physician might feel that this represents personal failure as a professional, and he may feel that this is not what his patients would expect of him," Dr. Krakauer said. "We know this isn’t true, but I think that this type of feeling is persistent."
On Twitter @maryellenny
Health plans are starting to expand their coverage of palliative care, offering higher payments to physicians who meet certain standards or paying for home care for a wider range of seriously ill patients.
The offerings vary greatly by region and by plan, but the common theme is that these types of programs are on the rise.
Cambia Health Solutions, which operates six health plans in Oregon, Washington, Idaho, and Utah, recently garnered attention with the launch of a wide-ranging palliative care program.
Starting this year, Cambia plans will pay for services previously not covered, such as home health aides and advance care planning counseling. They are also partnering with the University of Washington to offer palliative care training to physicians, nurses, and social workers. Palliative care physicians will be able to earn certification through a 1-year program. There’s also a shorter training option in the works to teach primary care physicians how to start palliative care conversations and make referrals.
The program also aims to address the social needs of seriously ill patients by forming case management units with specially trained nurses and social workers who can assist members with issues such as home food delivery, according to Dr. Csaba Mera, chief medical officer at Cambia.
The new program’s goal is to build a "best in class" model that could be used nationally, Dr. Mera said. At the core of the program, he noted, is the goal of honoring the wishes of seriously ill patients.
"That has not been happening in health care," he said. "It’s amazing how often somebody decides they don’t want certain kinds of treatment, and they still get it."
While Cambia’s program is wide reaching, the health plan is not the only payer active in palliative care. The insurance giant Aetna has a decade of experience with specialized case management services designed to help patients and caregivers coping with advanced illness.
Through Aetna’s Compassionate Care Program, nurses and social workers work with physicians’ offices and patients and their families to provide education, assistance with pain medications, and other psychosocial support. They also work to ensure that advance directives are in place and followed. In most cases, the case managers are located in call centers. But increasingly, the health plan has embedded them in the offices of participating medical groups.
The case managers are "almost a lifeline" to patients and their families, explained Dr. Randall Krakauer, Aetna’s vice president and national medical director for medical strategy.
It’s also been a no-brainer for Aetna financially. The specialized case managers, who are used in both commercial and Medicare Advantage plans, have significantly reduced costly hospital stays and the use of the emergency department. There’s typically a $12,000 decrease in costs for each person enrolled in the case management program, according to Aetna.
Among Aetna Medicare Advantage members, there has been an 82% drop in days spent in the hospital for acute care, an 86% drop in days spent in the intensive care unit, and a 78% drop in use of the emergency department.
"If there is an opportunity for favorable impact at the intersection of quality and cost, particularly in Medicare, this is in fact the mother lode," Dr. Krakauer said.
Some regional payers have also begun to partner with physicians and other providers in the community to offer more than just traditional hospice coverage. For instance, Excellus BlueCross BlueShield, which operates in upstate New York, worked with the University of Rochester Medical Center to develop courses for physicians that focus on advance care planning, how to use the Medical Orders for Life-Sustaining Treatment (MOLST) protocol, and myths about CPR and life-sustaining treatment. Physicians who complete the online training and a testing module about it can qualify for bonus payments.
Highmark, which operates in Pennsylvania, Delaware, and West Virginia, set up a palliative care indicator to measure the performance of its contracted hospitals. The insurer measures the percentage of patients who have a palliative care consult, and the percentage of adult intensive care unit patients who have a documented resuscitation status, designated health care proxy, and documented interdisciplinary family meeting.
What’s driving the expansion into palliative care? Part of the reason is demographics, noted J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Organization. Baby boomers are aging and will demand health care on their own terms, including having help with both their medical and psychosocial needs when dealing with serious illness.
"I think it’s great the health plans are doing it," he said. "People are asking for good pain and symptom management now more than ever before."
The growth of accountable care organizations (ACOs) is also driving the expansion of palliative care programs. Because ACOs assume risk for the total cost of their members’ health care, expanding palliative care services in the community offers the potential to lower costly hospital admissions and readmissions, Dr. Schumacher said. Even though ACOs are developing very differently depending on the local community, they all seem interested in hospice and palliative care programs, he said.
Dr. Diane E. Meier, director of the Center to Advance Palliative Care, recently created a toolkit for payers outlining the rationale for establishing a palliative program and elements with a proven track record of improving quality and decreasing costs. For instance, a meaningful 24/7 clinical response is an essential element, she said, because it keeps patients from calling 911 frequently and ending up in the emergency department.
"Payers are recognizing that the reason their members don’t get access to palliative care in the community is because no one will pay for it – and they can fix that," said Dr. Meier, who is also a professor of geriatrics and palliative medicine at Mount Sinai Hospital in New York.
But expanding access to palliative care is likely to take more than just financial incentives, said Dr. Krakauer. The difficulty in making changes to health care delivery is one obstacle, he said. Another issue is that palliative care still runs contrary to the medical culture.
"A physician might feel that this represents personal failure as a professional, and he may feel that this is not what his patients would expect of him," Dr. Krakauer said. "We know this isn’t true, but I think that this type of feeling is persistent."
On Twitter @maryellenny
Health plans are starting to expand their coverage of palliative care, offering higher payments to physicians who meet certain standards or paying for home care for a wider range of seriously ill patients.
The offerings vary greatly by region and by plan, but the common theme is that these types of programs are on the rise.
Cambia Health Solutions, which operates six health plans in Oregon, Washington, Idaho, and Utah, recently garnered attention with the launch of a wide-ranging palliative care program.
Starting this year, Cambia plans will pay for services previously not covered, such as home health aides and advance care planning counseling. They are also partnering with the University of Washington to offer palliative care training to physicians, nurses, and social workers. Palliative care physicians will be able to earn certification through a 1-year program. There’s also a shorter training option in the works to teach primary care physicians how to start palliative care conversations and make referrals.
The program also aims to address the social needs of seriously ill patients by forming case management units with specially trained nurses and social workers who can assist members with issues such as home food delivery, according to Dr. Csaba Mera, chief medical officer at Cambia.
The new program’s goal is to build a "best in class" model that could be used nationally, Dr. Mera said. At the core of the program, he noted, is the goal of honoring the wishes of seriously ill patients.
"That has not been happening in health care," he said. "It’s amazing how often somebody decides they don’t want certain kinds of treatment, and they still get it."
While Cambia’s program is wide reaching, the health plan is not the only payer active in palliative care. The insurance giant Aetna has a decade of experience with specialized case management services designed to help patients and caregivers coping with advanced illness.
Through Aetna’s Compassionate Care Program, nurses and social workers work with physicians’ offices and patients and their families to provide education, assistance with pain medications, and other psychosocial support. They also work to ensure that advance directives are in place and followed. In most cases, the case managers are located in call centers. But increasingly, the health plan has embedded them in the offices of participating medical groups.
The case managers are "almost a lifeline" to patients and their families, explained Dr. Randall Krakauer, Aetna’s vice president and national medical director for medical strategy.
It’s also been a no-brainer for Aetna financially. The specialized case managers, who are used in both commercial and Medicare Advantage plans, have significantly reduced costly hospital stays and the use of the emergency department. There’s typically a $12,000 decrease in costs for each person enrolled in the case management program, according to Aetna.
Among Aetna Medicare Advantage members, there has been an 82% drop in days spent in the hospital for acute care, an 86% drop in days spent in the intensive care unit, and a 78% drop in use of the emergency department.
"If there is an opportunity for favorable impact at the intersection of quality and cost, particularly in Medicare, this is in fact the mother lode," Dr. Krakauer said.
Some regional payers have also begun to partner with physicians and other providers in the community to offer more than just traditional hospice coverage. For instance, Excellus BlueCross BlueShield, which operates in upstate New York, worked with the University of Rochester Medical Center to develop courses for physicians that focus on advance care planning, how to use the Medical Orders for Life-Sustaining Treatment (MOLST) protocol, and myths about CPR and life-sustaining treatment. Physicians who complete the online training and a testing module about it can qualify for bonus payments.
Highmark, which operates in Pennsylvania, Delaware, and West Virginia, set up a palliative care indicator to measure the performance of its contracted hospitals. The insurer measures the percentage of patients who have a palliative care consult, and the percentage of adult intensive care unit patients who have a documented resuscitation status, designated health care proxy, and documented interdisciplinary family meeting.
What’s driving the expansion into palliative care? Part of the reason is demographics, noted J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Organization. Baby boomers are aging and will demand health care on their own terms, including having help with both their medical and psychosocial needs when dealing with serious illness.
"I think it’s great the health plans are doing it," he said. "People are asking for good pain and symptom management now more than ever before."
The growth of accountable care organizations (ACOs) is also driving the expansion of palliative care programs. Because ACOs assume risk for the total cost of their members’ health care, expanding palliative care services in the community offers the potential to lower costly hospital admissions and readmissions, Dr. Schumacher said. Even though ACOs are developing very differently depending on the local community, they all seem interested in hospice and palliative care programs, he said.
Dr. Diane E. Meier, director of the Center to Advance Palliative Care, recently created a toolkit for payers outlining the rationale for establishing a palliative program and elements with a proven track record of improving quality and decreasing costs. For instance, a meaningful 24/7 clinical response is an essential element, she said, because it keeps patients from calling 911 frequently and ending up in the emergency department.
"Payers are recognizing that the reason their members don’t get access to palliative care in the community is because no one will pay for it – and they can fix that," said Dr. Meier, who is also a professor of geriatrics and palliative medicine at Mount Sinai Hospital in New York.
But expanding access to palliative care is likely to take more than just financial incentives, said Dr. Krakauer. The difficulty in making changes to health care delivery is one obstacle, he said. Another issue is that palliative care still runs contrary to the medical culture.
"A physician might feel that this represents personal failure as a professional, and he may feel that this is not what his patients would expect of him," Dr. Krakauer said. "We know this isn’t true, but I think that this type of feeling is persistent."
On Twitter @maryellenny
Enteral contrast did not add diagnostic benefit in suspected appendicitis
Enteral contrast did not augment the accuracy of computed tomography in appendectomy patients, compared with intravenous contrast CT alone, according to a large multihospital study published in Annals of Surgery.
"Enteral contrast should be eliminated in IV-enhanced CT scans performed for suspected appendicitis," said Dr. Frederick Drake at the University of Washington Medical Center in Seattle and his associates. "We conclude that IV contrast alone is sufficient for the diagnosis of appendicitis in a wide variety of hospitals, outside of tertiary centers and strict research protocols."
The investigators studied 9,047 adults who underwent nonelective appendectomies at 56 hospitals in the state of Washington during a 2-year period. Patients were identified through the Surgical Care Outcomes and Assessment Program (SCOAP), which is based on direct reviews of clinical records and captures more than 85% of nonelective appendectomies performed in the state, the researchers said (Ann. Surg. 2014;260:311-6).
The primary outcome measure was concordance between a patient’s final pathology and the final radiologic report, they said.
Almost 90% of patients underwent CT before surgery. Among these patients, 54% received only IV contrast and 28.5% received both IV and enteral contrast, said the investigators. After controlling for age, sex, comorbidities, weight, hospital type, and perforation, they found no significant difference in concordance rates for IV-only contrast versus IV with enteral contrast (odds ratio, 0.95; 95% confidence interval, 0.72-1.25). Pathology and radiographic findings correlated in 90% of patients who received IV and enteral contrast, and in 90.4% of patients who received only IV contrast, they added, noting that eliminating enteral contrast could improve patients’ safety and comfort, and the efficiency of emergency departments.
The Life Discovery Fund of Washington State, the Agency for Healthcare Research and Quality, and the National Institutes of Health funded the research. The authors reported having no conflicts of interest.
Enteral contrast did not augment the accuracy of computed tomography in appendectomy patients, compared with intravenous contrast CT alone, according to a large multihospital study published in Annals of Surgery.
"Enteral contrast should be eliminated in IV-enhanced CT scans performed for suspected appendicitis," said Dr. Frederick Drake at the University of Washington Medical Center in Seattle and his associates. "We conclude that IV contrast alone is sufficient for the diagnosis of appendicitis in a wide variety of hospitals, outside of tertiary centers and strict research protocols."
The investigators studied 9,047 adults who underwent nonelective appendectomies at 56 hospitals in the state of Washington during a 2-year period. Patients were identified through the Surgical Care Outcomes and Assessment Program (SCOAP), which is based on direct reviews of clinical records and captures more than 85% of nonelective appendectomies performed in the state, the researchers said (Ann. Surg. 2014;260:311-6).
The primary outcome measure was concordance between a patient’s final pathology and the final radiologic report, they said.
Almost 90% of patients underwent CT before surgery. Among these patients, 54% received only IV contrast and 28.5% received both IV and enteral contrast, said the investigators. After controlling for age, sex, comorbidities, weight, hospital type, and perforation, they found no significant difference in concordance rates for IV-only contrast versus IV with enteral contrast (odds ratio, 0.95; 95% confidence interval, 0.72-1.25). Pathology and radiographic findings correlated in 90% of patients who received IV and enteral contrast, and in 90.4% of patients who received only IV contrast, they added, noting that eliminating enteral contrast could improve patients’ safety and comfort, and the efficiency of emergency departments.
The Life Discovery Fund of Washington State, the Agency for Healthcare Research and Quality, and the National Institutes of Health funded the research. The authors reported having no conflicts of interest.
Enteral contrast did not augment the accuracy of computed tomography in appendectomy patients, compared with intravenous contrast CT alone, according to a large multihospital study published in Annals of Surgery.
"Enteral contrast should be eliminated in IV-enhanced CT scans performed for suspected appendicitis," said Dr. Frederick Drake at the University of Washington Medical Center in Seattle and his associates. "We conclude that IV contrast alone is sufficient for the diagnosis of appendicitis in a wide variety of hospitals, outside of tertiary centers and strict research protocols."
The investigators studied 9,047 adults who underwent nonelective appendectomies at 56 hospitals in the state of Washington during a 2-year period. Patients were identified through the Surgical Care Outcomes and Assessment Program (SCOAP), which is based on direct reviews of clinical records and captures more than 85% of nonelective appendectomies performed in the state, the researchers said (Ann. Surg. 2014;260:311-6).
The primary outcome measure was concordance between a patient’s final pathology and the final radiologic report, they said.
Almost 90% of patients underwent CT before surgery. Among these patients, 54% received only IV contrast and 28.5% received both IV and enteral contrast, said the investigators. After controlling for age, sex, comorbidities, weight, hospital type, and perforation, they found no significant difference in concordance rates for IV-only contrast versus IV with enteral contrast (odds ratio, 0.95; 95% confidence interval, 0.72-1.25). Pathology and radiographic findings correlated in 90% of patients who received IV and enteral contrast, and in 90.4% of patients who received only IV contrast, they added, noting that eliminating enteral contrast could improve patients’ safety and comfort, and the efficiency of emergency departments.
The Life Discovery Fund of Washington State, the Agency for Healthcare Research and Quality, and the National Institutes of Health funded the research. The authors reported having no conflicts of interest.
FROM ANNALS OF SURGERY
Key clinical point: Enteral contrast is not of additional diagnostic benefit in appendectomy patients undergoing intravenous contrast computed tomography.
Major finding: After adjustment for age, sex, comorbidities, weight, hospital type, and perforation, there was no significant difference in rates of pathologic and radiologic concordance for patients who underwent IV-only contrast CT versus IV and enteral contrast CT (odds ratio, 0.95; 95% confidence interval, 0.72-1.25).
Data Source: Prospective cohort study of 9,047 adults who underwent nonelective appendectomies at 56 hospitals in the state of Washington between Jan. 1, 2010, and Dec. 31, 2011.
Disclosures: The Life Discovery Fund of Washington State, the Agency for Healthcare Research and Quality, and the National Institutes of Health funded the research. The authors reported having no conflicts of interest.
Laparoscopy found effective alternative to open IBD surgery
In an urban colorectal surgery department, a near-doubling in the proportion of surgical procedures performed laparoscopically accompanied significant declines in both severe postoperative morbidity and conversions to laparotomy, in a 14-year, single-hospital study reported in Annals of Surgery.
"This study demonstrated that a laparoscopic approach is a safe and effective alternative to open surgery" for management of inflammatory bowel disease (IBD), wrote Dr. León Maggiori and his associates at the Assistance Publique-Hôpitaux de Paris.
"Associated postoperative morbidity was comparable to reported rates after open approach," the researchers added.
Dr. Maggiori and his associates studied 790 consecutive intestinal resections for IBD performed on 633 patients between June 1998 and July 2012. About two-thirds of the procedures were for Crohn’s disease, and one-third were for ulcerative colitis, the investigators said (Ann. Surg. 2014;260:305-10). The proportion of laparoscopically performed procedures rose from 42% to 80% during the study period (P less than .001), and the trend occurred both for Crohn’s and for ulcerative colitis cases, they added.
As surgeons accrued experience, the rate of complex cases performed laparoscopically also approximately doubled (from 16% to 33%; P less than .023), the researchers said. Furthermore, the mean adjusted risk of conversion to open surgery fell significantly (from 18% to 6%; P less than .001), as did the rate of severe postoperative morbidity (from 14% to 8%; P less than .001).
In all, 12% of laparoscopic cases required conversion, most often because of abscesses or fistulas found during surgery or difficulty dissecting adhesions, the investigators said. Thirteen percent of laparoscopies led to severe postoperative morbidity, defined as Clavien-Dindo grade 3 or 4 complications, they added. The single postoperative death occurred in a patient who developed peritonitis and septic shock 3 days after laparoscopic colectomy with ileosigmoidostomy, the researchers said.
The hospital now uses laparoscopy as the standard approach for surgical management of IBD, except in cases of complicated acute colitis, Dr. Maggiori and his associates said.
The limited number of straight open surgical cases meant that they could not directly be compared with laparoscopy, said the investigators, adding that they lacked data on long-term outcomes because many patients underwent surgery in 2008 or later.
The Association François Aupetit partially funded the study. The authors reported having no conflicts of interest.
In an urban colorectal surgery department, a near-doubling in the proportion of surgical procedures performed laparoscopically accompanied significant declines in both severe postoperative morbidity and conversions to laparotomy, in a 14-year, single-hospital study reported in Annals of Surgery.
"This study demonstrated that a laparoscopic approach is a safe and effective alternative to open surgery" for management of inflammatory bowel disease (IBD), wrote Dr. León Maggiori and his associates at the Assistance Publique-Hôpitaux de Paris.
"Associated postoperative morbidity was comparable to reported rates after open approach," the researchers added.
Dr. Maggiori and his associates studied 790 consecutive intestinal resections for IBD performed on 633 patients between June 1998 and July 2012. About two-thirds of the procedures were for Crohn’s disease, and one-third were for ulcerative colitis, the investigators said (Ann. Surg. 2014;260:305-10). The proportion of laparoscopically performed procedures rose from 42% to 80% during the study period (P less than .001), and the trend occurred both for Crohn’s and for ulcerative colitis cases, they added.
As surgeons accrued experience, the rate of complex cases performed laparoscopically also approximately doubled (from 16% to 33%; P less than .023), the researchers said. Furthermore, the mean adjusted risk of conversion to open surgery fell significantly (from 18% to 6%; P less than .001), as did the rate of severe postoperative morbidity (from 14% to 8%; P less than .001).
In all, 12% of laparoscopic cases required conversion, most often because of abscesses or fistulas found during surgery or difficulty dissecting adhesions, the investigators said. Thirteen percent of laparoscopies led to severe postoperative morbidity, defined as Clavien-Dindo grade 3 or 4 complications, they added. The single postoperative death occurred in a patient who developed peritonitis and septic shock 3 days after laparoscopic colectomy with ileosigmoidostomy, the researchers said.
The hospital now uses laparoscopy as the standard approach for surgical management of IBD, except in cases of complicated acute colitis, Dr. Maggiori and his associates said.
The limited number of straight open surgical cases meant that they could not directly be compared with laparoscopy, said the investigators, adding that they lacked data on long-term outcomes because many patients underwent surgery in 2008 or later.
The Association François Aupetit partially funded the study. The authors reported having no conflicts of interest.
In an urban colorectal surgery department, a near-doubling in the proportion of surgical procedures performed laparoscopically accompanied significant declines in both severe postoperative morbidity and conversions to laparotomy, in a 14-year, single-hospital study reported in Annals of Surgery.
"This study demonstrated that a laparoscopic approach is a safe and effective alternative to open surgery" for management of inflammatory bowel disease (IBD), wrote Dr. León Maggiori and his associates at the Assistance Publique-Hôpitaux de Paris.
"Associated postoperative morbidity was comparable to reported rates after open approach," the researchers added.
Dr. Maggiori and his associates studied 790 consecutive intestinal resections for IBD performed on 633 patients between June 1998 and July 2012. About two-thirds of the procedures were for Crohn’s disease, and one-third were for ulcerative colitis, the investigators said (Ann. Surg. 2014;260:305-10). The proportion of laparoscopically performed procedures rose from 42% to 80% during the study period (P less than .001), and the trend occurred both for Crohn’s and for ulcerative colitis cases, they added.
As surgeons accrued experience, the rate of complex cases performed laparoscopically also approximately doubled (from 16% to 33%; P less than .023), the researchers said. Furthermore, the mean adjusted risk of conversion to open surgery fell significantly (from 18% to 6%; P less than .001), as did the rate of severe postoperative morbidity (from 14% to 8%; P less than .001).
In all, 12% of laparoscopic cases required conversion, most often because of abscesses or fistulas found during surgery or difficulty dissecting adhesions, the investigators said. Thirteen percent of laparoscopies led to severe postoperative morbidity, defined as Clavien-Dindo grade 3 or 4 complications, they added. The single postoperative death occurred in a patient who developed peritonitis and septic shock 3 days after laparoscopic colectomy with ileosigmoidostomy, the researchers said.
The hospital now uses laparoscopy as the standard approach for surgical management of IBD, except in cases of complicated acute colitis, Dr. Maggiori and his associates said.
The limited number of straight open surgical cases meant that they could not directly be compared with laparoscopy, said the investigators, adding that they lacked data on long-term outcomes because many patients underwent surgery in 2008 or later.
The Association François Aupetit partially funded the study. The authors reported having no conflicts of interest.
FROM ANNALS OF SURGERY
Key clinical point: Laparoscopic approaches are becoming standard for the surgical management of inflammatory bowel disease (IBD), except in cases of complicated acute colitis.
Major finding: The proportion of IBD procedures performed laparoscopically increased from 42% to 80% (P less than .001). The rate of complex laparoscopies also increased (P = .023), while the mean adjusted risks of conversion and severe postoperative morbidity dropped (P less than .001 for both).
Data source: Prospective analysis of 790 consecutive resections for IBD performed during a 14-year period, including 574 (73%) laparoscopic procedures.
Disclosures: The Association François Aupetit partially funded the study. The authors reported having no conflicts of interest.
Trustees’ report: Medicare hospital fund solvent until 2030
The Medicare hospital trust fund will be depleted in 2030 unless Congress takes action to shore it up financially, according to a new report from the program’s trustees.
The latest projection adds 4 years of solvency to the Hospital Insurance (Part A) side of the program, compared with last year’s estimate. The trustees – administration officials and public representatives appointed by the president – gave credit to cost containment measures in the Affordable Care Act for providing some extra solvency to the Medicare program. The overall slowdown in health care spending also played a role, they said.
For Medicare Part B, which covers physician visits, the trustees predicted that beneficiary costs would remain stable. In 2015, Part B premiums are projected to stay about the same as in 2013 and 2014.
Despite the improvement in Medicare’s financial health, however, the trustees called on Congress to take action sooner rather than later to shore up the program’s finances.
"Projections of health expenditures, both in the public and private sectors, remain highly uncertain. The projected trust fund depletion date can bounce around a good deal from year to year," Robert Reischauer, Ph.D., a public trustee, said in a press conference July 28.
The depletion date moved 6 years into the future over the last three reports but moved 5 years back between the 2010 and 2011 reports, Dr. Reischauer said. He noted that the hospital trust fund solvency is so volatile because it depends on the strength of the economy, technology, and health care delivery changes, among other factors.
"The sooner lawmakers face reality, the better," he said.
On Twitter @maryellenny
The Medicare hospital trust fund will be depleted in 2030 unless Congress takes action to shore it up financially, according to a new report from the program’s trustees.
The latest projection adds 4 years of solvency to the Hospital Insurance (Part A) side of the program, compared with last year’s estimate. The trustees – administration officials and public representatives appointed by the president – gave credit to cost containment measures in the Affordable Care Act for providing some extra solvency to the Medicare program. The overall slowdown in health care spending also played a role, they said.
For Medicare Part B, which covers physician visits, the trustees predicted that beneficiary costs would remain stable. In 2015, Part B premiums are projected to stay about the same as in 2013 and 2014.
Despite the improvement in Medicare’s financial health, however, the trustees called on Congress to take action sooner rather than later to shore up the program’s finances.
"Projections of health expenditures, both in the public and private sectors, remain highly uncertain. The projected trust fund depletion date can bounce around a good deal from year to year," Robert Reischauer, Ph.D., a public trustee, said in a press conference July 28.
The depletion date moved 6 years into the future over the last three reports but moved 5 years back between the 2010 and 2011 reports, Dr. Reischauer said. He noted that the hospital trust fund solvency is so volatile because it depends on the strength of the economy, technology, and health care delivery changes, among other factors.
"The sooner lawmakers face reality, the better," he said.
On Twitter @maryellenny
The Medicare hospital trust fund will be depleted in 2030 unless Congress takes action to shore it up financially, according to a new report from the program’s trustees.
The latest projection adds 4 years of solvency to the Hospital Insurance (Part A) side of the program, compared with last year’s estimate. The trustees – administration officials and public representatives appointed by the president – gave credit to cost containment measures in the Affordable Care Act for providing some extra solvency to the Medicare program. The overall slowdown in health care spending also played a role, they said.
For Medicare Part B, which covers physician visits, the trustees predicted that beneficiary costs would remain stable. In 2015, Part B premiums are projected to stay about the same as in 2013 and 2014.
Despite the improvement in Medicare’s financial health, however, the trustees called on Congress to take action sooner rather than later to shore up the program’s finances.
"Projections of health expenditures, both in the public and private sectors, remain highly uncertain. The projected trust fund depletion date can bounce around a good deal from year to year," Robert Reischauer, Ph.D., a public trustee, said in a press conference July 28.
The depletion date moved 6 years into the future over the last three reports but moved 5 years back between the 2010 and 2011 reports, Dr. Reischauer said. He noted that the hospital trust fund solvency is so volatile because it depends on the strength of the economy, technology, and health care delivery changes, among other factors.
"The sooner lawmakers face reality, the better," he said.
On Twitter @maryellenny
Women are not seeking care for urinary incontinence, and physicians can be a barrier
WASHINGTON – Women are not seeking care for even moderate to severe urinary incontinence because they have a fear of treatment and lack knowledge of the etiology of the condition and available treatment options, according to a qualitative focus group study at Kaiser Permanente Orange County (Calif.).
Embarrassment is another barrier. So are physicians themselves, said Dr. Jennifer K. Lee, a urogynecologist at Kaiser in Anaheim, Calif., who reported the findings at the annual meeting of the American Urogynecologic Society.
"Providers were mentioned (in the focus groups) to be barriers," Dr. Lee said. "Patients were either dismissed, or they were given misinformation."
By 2050, an estimated 50 million Americans will have urinary incontinence. Previous research has shown, however, that less than 50% of women with moderate incontinence seek care.
The focus group study involved 19 women – 11 who had not sought care but were found after recruitment to have moderate to severe incontinence by the Sandvik severity index, and 8 who had previous treatment or had been evaluated for urinary incontinence.
A moderator led discussions among small groups of these women, all of whom were fluent in English and most of whom (90%) had a college education or higher. The participants were of varying ethnicities, including Caucasian, Hispanic, and Asian.
A fear of medical or surgical treatment, including medication side effects and recovery time for surgery, was one of the themes to emerge. Women also said they felt embarrassed and were therefore not likely to raise the issue, particularly with time constraints in their medical visits.
There was a prevailing idea that urinary incontinence is a normal part of aging or childbearing, or that it is hereditary, and that other health issues take priority. Physicians, moreover, did not ask about the issue, and in cases in which it was mentioned, physicians were dismissive or gave misinformation, the study showed.
Dr. Lee said the barriers are significant, and that "there’s a lot of work to be done" to facilitate communication and change practices.
Leaders at Kaiser Permanente Orange County, Anaheim, Calif., plan to give physicians question prompts to incorporate into routine and primary care visits, she noted during a press conference at the meeting. "We also want to work on educational tools for the public," she said.
"There are urinary incontinence questions [for] the Medicare wellness visit, but these are for women over 65," she said. "There certainly are plenty of women under 65 who have incontinence."
Food and Drug Administration warnings about complications associated with transvaginal placement of surgical mesh did not come up in the focus group discussions, but Dr. Lee said that in her practice she has seen this controversy feed patients’ fear of incontinence and its treatment.
Study participants were recruited through e-mail research announcements and flyers, as well as more actively through the offices of urogynecology providers.
Dr. Lee said she had no disclosures to report. Her coauthors and research colleagues at the University of California, Irvine, reported numerous disclosures ranging from speakers’ bureau participation and consulting fees at Hospira and Cadence Pharmaceuticals to consultant positions with Medtronic and Boston Scientific.
WASHINGTON – Women are not seeking care for even moderate to severe urinary incontinence because they have a fear of treatment and lack knowledge of the etiology of the condition and available treatment options, according to a qualitative focus group study at Kaiser Permanente Orange County (Calif.).
Embarrassment is another barrier. So are physicians themselves, said Dr. Jennifer K. Lee, a urogynecologist at Kaiser in Anaheim, Calif., who reported the findings at the annual meeting of the American Urogynecologic Society.
"Providers were mentioned (in the focus groups) to be barriers," Dr. Lee said. "Patients were either dismissed, or they were given misinformation."
By 2050, an estimated 50 million Americans will have urinary incontinence. Previous research has shown, however, that less than 50% of women with moderate incontinence seek care.
The focus group study involved 19 women – 11 who had not sought care but were found after recruitment to have moderate to severe incontinence by the Sandvik severity index, and 8 who had previous treatment or had been evaluated for urinary incontinence.
A moderator led discussions among small groups of these women, all of whom were fluent in English and most of whom (90%) had a college education or higher. The participants were of varying ethnicities, including Caucasian, Hispanic, and Asian.
A fear of medical or surgical treatment, including medication side effects and recovery time for surgery, was one of the themes to emerge. Women also said they felt embarrassed and were therefore not likely to raise the issue, particularly with time constraints in their medical visits.
There was a prevailing idea that urinary incontinence is a normal part of aging or childbearing, or that it is hereditary, and that other health issues take priority. Physicians, moreover, did not ask about the issue, and in cases in which it was mentioned, physicians were dismissive or gave misinformation, the study showed.
Dr. Lee said the barriers are significant, and that "there’s a lot of work to be done" to facilitate communication and change practices.
Leaders at Kaiser Permanente Orange County, Anaheim, Calif., plan to give physicians question prompts to incorporate into routine and primary care visits, she noted during a press conference at the meeting. "We also want to work on educational tools for the public," she said.
"There are urinary incontinence questions [for] the Medicare wellness visit, but these are for women over 65," she said. "There certainly are plenty of women under 65 who have incontinence."
Food and Drug Administration warnings about complications associated with transvaginal placement of surgical mesh did not come up in the focus group discussions, but Dr. Lee said that in her practice she has seen this controversy feed patients’ fear of incontinence and its treatment.
Study participants were recruited through e-mail research announcements and flyers, as well as more actively through the offices of urogynecology providers.
Dr. Lee said she had no disclosures to report. Her coauthors and research colleagues at the University of California, Irvine, reported numerous disclosures ranging from speakers’ bureau participation and consulting fees at Hospira and Cadence Pharmaceuticals to consultant positions with Medtronic and Boston Scientific.
WASHINGTON – Women are not seeking care for even moderate to severe urinary incontinence because they have a fear of treatment and lack knowledge of the etiology of the condition and available treatment options, according to a qualitative focus group study at Kaiser Permanente Orange County (Calif.).
Embarrassment is another barrier. So are physicians themselves, said Dr. Jennifer K. Lee, a urogynecologist at Kaiser in Anaheim, Calif., who reported the findings at the annual meeting of the American Urogynecologic Society.
"Providers were mentioned (in the focus groups) to be barriers," Dr. Lee said. "Patients were either dismissed, or they were given misinformation."
By 2050, an estimated 50 million Americans will have urinary incontinence. Previous research has shown, however, that less than 50% of women with moderate incontinence seek care.
The focus group study involved 19 women – 11 who had not sought care but were found after recruitment to have moderate to severe incontinence by the Sandvik severity index, and 8 who had previous treatment or had been evaluated for urinary incontinence.
A moderator led discussions among small groups of these women, all of whom were fluent in English and most of whom (90%) had a college education or higher. The participants were of varying ethnicities, including Caucasian, Hispanic, and Asian.
A fear of medical or surgical treatment, including medication side effects and recovery time for surgery, was one of the themes to emerge. Women also said they felt embarrassed and were therefore not likely to raise the issue, particularly with time constraints in their medical visits.
There was a prevailing idea that urinary incontinence is a normal part of aging or childbearing, or that it is hereditary, and that other health issues take priority. Physicians, moreover, did not ask about the issue, and in cases in which it was mentioned, physicians were dismissive or gave misinformation, the study showed.
Dr. Lee said the barriers are significant, and that "there’s a lot of work to be done" to facilitate communication and change practices.
Leaders at Kaiser Permanente Orange County, Anaheim, Calif., plan to give physicians question prompts to incorporate into routine and primary care visits, she noted during a press conference at the meeting. "We also want to work on educational tools for the public," she said.
"There are urinary incontinence questions [for] the Medicare wellness visit, but these are for women over 65," she said. "There certainly are plenty of women under 65 who have incontinence."
Food and Drug Administration warnings about complications associated with transvaginal placement of surgical mesh did not come up in the focus group discussions, but Dr. Lee said that in her practice she has seen this controversy feed patients’ fear of incontinence and its treatment.
Study participants were recruited through e-mail research announcements and flyers, as well as more actively through the offices of urogynecology providers.
Dr. Lee said she had no disclosures to report. Her coauthors and research colleagues at the University of California, Irvine, reported numerous disclosures ranging from speakers’ bureau participation and consulting fees at Hospira and Cadence Pharmaceuticals to consultant positions with Medtronic and Boston Scientific.
AT THE AUGS ANNUAL MEETING
Key clinical finding: Be sure to ask women about urinary incontinence.
Major finding: There are significant but modifiable barriers to women seeking care for incontinence.
Data source: A small focus group study involving 19 insured women.
Disclosures: Lead author Jennifer K. Lee, MD, reported that she had no disclosures. Her coauthors and research colleagues at the University of California, Irvine, reported numerous disclosures ranging from speakers’ bureau participation and consulting fees at Hospira and Cadence Pharmaceuticals to consultant positions with Medtronic and Boston Scientific.