ACS Surgery News

About 70% of U.S. physicians were using an electronic health record system to electronically transmit prescriptions to pharmacies as of April 2014, according to an analysis by the Office of the National Coordinator for Health Information Technology.

This represents a rapid scale-up in the use of EHRs with the passage of MIPPA [Medicare Improvements for Patients and Providers Act] in December 2008 (7%) and when the Medicare and Medicaid EHR Incentive Programs began (24%) in 2009, according to the ONCHIT report.

©istock/thinkstockphotos.com

The figures are based on an analysis of data from Surescripts, which provides IT network infrastructure that transmits electronic prescriptions and other health-related data.

Nearly all community pharmacies across the United States are enabled to accept e-prescriptions, according to the report.

"The growth of physicians and pharmacies e-prescribing has corresponded with a 14-fold increase in the growth of new and renewal prescriptions sent electronically," the report states, growing from 4% in 2008 to 57% in 2013. For 2013, this translates to 1 billion of the total 1.8 billion new and renewal prescriptions being sent electronically.

[email protected]

About 70% of U.S. physicians were using an electronic health record system to electronically transmit prescriptions to pharmacies as of April 2014, according to an analysis by the Office of the National Coordinator for Health Information Technology.

This represents a rapid scale-up in the use of EHRs with the passage of MIPPA [Medicare Improvements for Patients and Providers Act] in December 2008 (7%) and when the Medicare and Medicaid EHR Incentive Programs began (24%) in 2009, according to the ONCHIT report.

©istock/thinkstockphotos.com

The figures are based on an analysis of data from Surescripts, which provides IT network infrastructure that transmits electronic prescriptions and other health-related data.

Nearly all community pharmacies across the United States are enabled to accept e-prescriptions, according to the report.

"The growth of physicians and pharmacies e-prescribing has corresponded with a 14-fold increase in the growth of new and renewal prescriptions sent electronically," the report states, growing from 4% in 2008 to 57% in 2013. For 2013, this translates to 1 billion of the total 1.8 billion new and renewal prescriptions being sent electronically.

[email protected]

About 70% of U.S. physicians were using an electronic health record system to electronically transmit prescriptions to pharmacies as of April 2014, according to an analysis by the Office of the National Coordinator for Health Information Technology.

This represents a rapid scale-up in the use of EHRs with the passage of MIPPA [Medicare Improvements for Patients and Providers Act] in December 2008 (7%) and when the Medicare and Medicaid EHR Incentive Programs began (24%) in 2009, according to the ONCHIT report.

©istock/thinkstockphotos.com

The figures are based on an analysis of data from Surescripts, which provides IT network infrastructure that transmits electronic prescriptions and other health-related data.

Nearly all community pharmacies across the United States are enabled to accept e-prescriptions, according to the report.

"The growth of physicians and pharmacies e-prescribing has corresponded with a 14-fold increase in the growth of new and renewal prescriptions sent electronically," the report states, growing from 4% in 2008 to 57% in 2013. For 2013, this translates to 1 billion of the total 1.8 billion new and renewal prescriptions being sent electronically.

[email protected]

DANA POINT, CALIF.– Materials science meets medicine. That’s the new frontier for many specialties, thanks to advances in the understanding of native tissue dynamics and how bioengineered materials will perform in vivo.

Sarah Heilshorn, Ph.D., of the department of materials science and engineering and the department of bioengineering at Stanford (Calif.) University, was one of several presenters at this year’s Summit in Aesthetic Medicine, with a focus on the use of synthetic materials for reconstructive surgery and treatment for acute and traumatic tissue injury.

In this video, Dr. Heilshorn explains how materials science and bioengineering are promoting angiogenesis to help patients who have suffered spinal injuries, chronic wounds, and conditions involving severe tissue injury at the meeting held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications. She describes how revascularization, bone regeneration, and tissue growth are all possible through the use of highly specific and targeted biogels injected into the body to improve delivery of growth factors.

Dr. Heilshorn said she had no relevant financial conflicts to disclose.

DANA POINT, CALIF.– Materials science meets medicine. That’s the new frontier for many specialties, thanks to advances in the understanding of native tissue dynamics and how bioengineered materials will perform in vivo.

Sarah Heilshorn, Ph.D., of the department of materials science and engineering and the department of bioengineering at Stanford (Calif.) University, was one of several presenters at this year’s Summit in Aesthetic Medicine, with a focus on the use of synthetic materials for reconstructive surgery and treatment for acute and traumatic tissue injury.

In this video, Dr. Heilshorn explains how materials science and bioengineering are promoting angiogenesis to help patients who have suffered spinal injuries, chronic wounds, and conditions involving severe tissue injury at the meeting held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications. She describes how revascularization, bone regeneration, and tissue growth are all possible through the use of highly specific and targeted biogels injected into the body to improve delivery of growth factors.

Dr. Heilshorn said she had no relevant financial conflicts to disclose.

DANA POINT, CALIF.– Materials science meets medicine. That’s the new frontier for many specialties, thanks to advances in the understanding of native tissue dynamics and how bioengineered materials will perform in vivo.

Sarah Heilshorn, Ph.D., of the department of materials science and engineering and the department of bioengineering at Stanford (Calif.) University, was one of several presenters at this year’s Summit in Aesthetic Medicine, with a focus on the use of synthetic materials for reconstructive surgery and treatment for acute and traumatic tissue injury.

In this video, Dr. Heilshorn explains how materials science and bioengineering are promoting angiogenesis to help patients who have suffered spinal injuries, chronic wounds, and conditions involving severe tissue injury at the meeting held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications. She describes how revascularization, bone regeneration, and tissue growth are all possible through the use of highly specific and targeted biogels injected into the body to improve delivery of growth factors.

Dr. Heilshorn said she had no relevant financial conflicts to disclose.

Medical societies are joining the call for better support for telemedicine, stating that when appropriately used, it can help address physician shortages and improve quality of care.

The American Medical Association’s policy-making body – the House of Delegates – approved a set of guiding principles at its annual meeting in June, including the following:

• A physician should have a valid face-to-face relationship with the patient before telemedicine services are provided, except in the instance of on-call or cross-coverage situations.

Courtesy AMA

• Those who deliver telemedicine services must abide by state practice and licensure laws and should be licensed in the state where the patient receives services.

• Delivery of services should be consistent with in-person services in scope and standards and follow evidence-based practice guidelines.

• Services should be documented, including providing a visit summary to the patient and a copy of the record sent to a primary or referring physician.

"We believe that a patient-physician relationship must be established to ensure proper diagnoses and appropriate follow-up care," AMA President Robert M. Wah said in a statement. "This new policy establishes a foundation for physicians to utilize telemedicine to help maintain an ongoing relationship with their patients, and as a means to enhance follow-up care, better coordinate care and manage chronic conditions."

The AMA delegates also called for a study of the issues associated with the state-based licensure and the portability of state licensure for telemedicine services.

The Federation of State Medical Boards (FSMB) has drafted model legislation that would expedite licensing in multiple states in an effort to address the concerns of medical practices that straddle state lines.

Currently, according to the American Telemedicine Association, some states restrict the practice of telemedicine across state borders, while others have varying license requirements. The FSMB is hoping to complete a final draft of the model legislation within a few months; it will then work to convince state legislatures to adopt the model.

The American Academy of Neurology also seeks a streamlined licensing process, according to a recent position paper.

The AAN weighed in on telemedicine partly because neurologists are increasingly including the service as part of their practices, most often in emergency stroke care and other acute neurologic conditions. It also is being employed more often for treatment of chronic conditions, including migraines and epilepsy, according to the paper.

The policy also calls for clear liability policies. "The decision to administer or not administer thrombolysis for acute stroke is a prominent source of malpractice claims for neurologists, and telemedicine physicians managing acute stroke patients may be exposed to complex liability issues," the AAN said in the statement. Both physicians and patients need to be protected, it noted.

The organization also called for reimbursement that’s on par with traditional services.

The American Academy of Family Physicians recently said in a letter to members of the House Energy & Commerce Subcommittee on Health that, while it agrees with removing barriers to delivering telemedicine across state lines, it opposes a federal license. It is backing the FSMB process.

Payment Issues

More private insurers are starting to cover telemedicine, with 21 states and Washington, D.C., requiring coverage of the service and reimbursement on par with in-person visits, according to the American Telemedicine Association: Arizona, California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, Maryland, Michigan, Mississippi, Missouri, Montana, New Hampshire, New Mexico, Oklahoma, Oregon, Tennessee, Texas, Vermont, Virginia.

Five states – Massachusetts, Michigan, North Dakota, Pennsylvania, and South Dakota – do not allow out-of-state physician-to-physician consultations.

Licensure requirements vary. Maryland, New York, Virginia, and Washington, D.C., have licensure reciprocity for bordering states.

Ten states – Alabama, Louisiana, Minnesota, Montana, Nevada, New Mexico, Ohio, Oregon, Tennessee, and Texas – allow physicians to practice with a conditional license or a specific telemedicine license.

Medicaid coverage varies on a state-by-state basis but is better than Medicare in many states, according to the ATA. Medicare only pays for telemedicine services if a beneficiary lives in a rural Health Professional Shortage area; several additional requirements must be met:

• The service must be furnished via an interactive telecommunications system, which is defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.

• The practitioner furnishing the service must meet the telehealth requirements, as well as the usual Medicare requirements.

• The individual receiving the services must be in an eligible "originating" site.

Medicare then pays a fee to the originating site and a separate fee to the distant site practitioner.

Family physicians’ offices are "ideally suited" to be originating sites for the delivery of telemedicine, according to the AAFP, but the current originating site fee ($24.63) doesn’t begin to cover the investment needed to ensure that telemedicine equipment is in compliance with the Health Insurance Portability and Accountability Act (HIPAA). The originating site also should be defined broadly, so that the patient’s home can be considered one of the eligible telemedicine sites, according to the academy.

The Telehealth Enhancement Act of 2013 (H.R. 3306) would expand the definition to include all critical access and sole community hospitals and home-based video services for hospice care, home dialysis, and homebound beneficiaries. The AAFP said that it supports the bill, which was introduced by Rep. Gregg Harper (R-Miss.), Rep. Mike Thompson (D-Calif.), Rep. Devin Nunes (R-Calif.), and Rep. Peter Welch (D-Vt.). The bill has no companion in the Senate, and no hearings have been scheduled.

For 2015, Medicare proposed to expand the types of services it will cover. Barring any changes in the final rule for the 2015 physician fee schedule, Medicare will cover several psychotherapy services, including psychoanalysis (CPT code 90845), family psychotherapy without the patient present (90846), and family psychotherapy with patient present (90847).

The agency also proposes to cover prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service (99354 and 99355), and the HCPCS codes G0438 (annual wellness visit; includes a personalized prevention plan of service, initial visit), and G0439, the subsequent annual wellness visit.

Other requests for coverage have been declined by Medicare, including various types of echocardiography interpretation, psychological testing, colposcopy, brief visit to monitor or change medications for mental illness, and urgent dermatologic conditions and wound care.

[email protected]

On Twitter @aliciaault

Medical societies are joining the call for better support for telemedicine, stating that when appropriately used, it can help address physician shortages and improve quality of care.

The American Medical Association’s policy-making body – the House of Delegates – approved a set of guiding principles at its annual meeting in June, including the following:

• A physician should have a valid face-to-face relationship with the patient before telemedicine services are provided, except in the instance of on-call or cross-coverage situations.

Courtesy AMA

• Those who deliver telemedicine services must abide by state practice and licensure laws and should be licensed in the state where the patient receives services.

• Delivery of services should be consistent with in-person services in scope and standards and follow evidence-based practice guidelines.

• Services should be documented, including providing a visit summary to the patient and a copy of the record sent to a primary or referring physician.

"We believe that a patient-physician relationship must be established to ensure proper diagnoses and appropriate follow-up care," AMA President Robert M. Wah said in a statement. "This new policy establishes a foundation for physicians to utilize telemedicine to help maintain an ongoing relationship with their patients, and as a means to enhance follow-up care, better coordinate care and manage chronic conditions."

The AMA delegates also called for a study of the issues associated with the state-based licensure and the portability of state licensure for telemedicine services.

The Federation of State Medical Boards (FSMB) has drafted model legislation that would expedite licensing in multiple states in an effort to address the concerns of medical practices that straddle state lines.

Currently, according to the American Telemedicine Association, some states restrict the practice of telemedicine across state borders, while others have varying license requirements. The FSMB is hoping to complete a final draft of the model legislation within a few months; it will then work to convince state legislatures to adopt the model.

The American Academy of Neurology also seeks a streamlined licensing process, according to a recent position paper.

The AAN weighed in on telemedicine partly because neurologists are increasingly including the service as part of their practices, most often in emergency stroke care and other acute neurologic conditions. It also is being employed more often for treatment of chronic conditions, including migraines and epilepsy, according to the paper.

The policy also calls for clear liability policies. "The decision to administer or not administer thrombolysis for acute stroke is a prominent source of malpractice claims for neurologists, and telemedicine physicians managing acute stroke patients may be exposed to complex liability issues," the AAN said in the statement. Both physicians and patients need to be protected, it noted.

The organization also called for reimbursement that’s on par with traditional services.

The American Academy of Family Physicians recently said in a letter to members of the House Energy & Commerce Subcommittee on Health that, while it agrees with removing barriers to delivering telemedicine across state lines, it opposes a federal license. It is backing the FSMB process.

Payment Issues

More private insurers are starting to cover telemedicine, with 21 states and Washington, D.C., requiring coverage of the service and reimbursement on par with in-person visits, according to the American Telemedicine Association: Arizona, California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, Maryland, Michigan, Mississippi, Missouri, Montana, New Hampshire, New Mexico, Oklahoma, Oregon, Tennessee, Texas, Vermont, Virginia.

Five states – Massachusetts, Michigan, North Dakota, Pennsylvania, and South Dakota – do not allow out-of-state physician-to-physician consultations.

Licensure requirements vary. Maryland, New York, Virginia, and Washington, D.C., have licensure reciprocity for bordering states.

Ten states – Alabama, Louisiana, Minnesota, Montana, Nevada, New Mexico, Ohio, Oregon, Tennessee, and Texas – allow physicians to practice with a conditional license or a specific telemedicine license.

Medicaid coverage varies on a state-by-state basis but is better than Medicare in many states, according to the ATA. Medicare only pays for telemedicine services if a beneficiary lives in a rural Health Professional Shortage area; several additional requirements must be met:

• The service must be furnished via an interactive telecommunications system, which is defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.

• The practitioner furnishing the service must meet the telehealth requirements, as well as the usual Medicare requirements.

• The individual receiving the services must be in an eligible "originating" site.

Medicare then pays a fee to the originating site and a separate fee to the distant site practitioner.

Family physicians’ offices are "ideally suited" to be originating sites for the delivery of telemedicine, according to the AAFP, but the current originating site fee ($24.63) doesn’t begin to cover the investment needed to ensure that telemedicine equipment is in compliance with the Health Insurance Portability and Accountability Act (HIPAA). The originating site also should be defined broadly, so that the patient’s home can be considered one of the eligible telemedicine sites, according to the academy.

The Telehealth Enhancement Act of 2013 (H.R. 3306) would expand the definition to include all critical access and sole community hospitals and home-based video services for hospice care, home dialysis, and homebound beneficiaries. The AAFP said that it supports the bill, which was introduced by Rep. Gregg Harper (R-Miss.), Rep. Mike Thompson (D-Calif.), Rep. Devin Nunes (R-Calif.), and Rep. Peter Welch (D-Vt.). The bill has no companion in the Senate, and no hearings have been scheduled.

For 2015, Medicare proposed to expand the types of services it will cover. Barring any changes in the final rule for the 2015 physician fee schedule, Medicare will cover several psychotherapy services, including psychoanalysis (CPT code 90845), family psychotherapy without the patient present (90846), and family psychotherapy with patient present (90847).

The agency also proposes to cover prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service (99354 and 99355), and the HCPCS codes G0438 (annual wellness visit; includes a personalized prevention plan of service, initial visit), and G0439, the subsequent annual wellness visit.

Other requests for coverage have been declined by Medicare, including various types of echocardiography interpretation, psychological testing, colposcopy, brief visit to monitor or change medications for mental illness, and urgent dermatologic conditions and wound care.

[email protected]

On Twitter @aliciaault

Medical societies are joining the call for better support for telemedicine, stating that when appropriately used, it can help address physician shortages and improve quality of care.

The American Medical Association’s policy-making body – the House of Delegates – approved a set of guiding principles at its annual meeting in June, including the following:

• A physician should have a valid face-to-face relationship with the patient before telemedicine services are provided, except in the instance of on-call or cross-coverage situations.

Courtesy AMA

• Those who deliver telemedicine services must abide by state practice and licensure laws and should be licensed in the state where the patient receives services.

• Delivery of services should be consistent with in-person services in scope and standards and follow evidence-based practice guidelines.

• Services should be documented, including providing a visit summary to the patient and a copy of the record sent to a primary or referring physician.

"We believe that a patient-physician relationship must be established to ensure proper diagnoses and appropriate follow-up care," AMA President Robert M. Wah said in a statement. "This new policy establishes a foundation for physicians to utilize telemedicine to help maintain an ongoing relationship with their patients, and as a means to enhance follow-up care, better coordinate care and manage chronic conditions."

The AMA delegates also called for a study of the issues associated with the state-based licensure and the portability of state licensure for telemedicine services.

The Federation of State Medical Boards (FSMB) has drafted model legislation that would expedite licensing in multiple states in an effort to address the concerns of medical practices that straddle state lines.

Currently, according to the American Telemedicine Association, some states restrict the practice of telemedicine across state borders, while others have varying license requirements. The FSMB is hoping to complete a final draft of the model legislation within a few months; it will then work to convince state legislatures to adopt the model.

The American Academy of Neurology also seeks a streamlined licensing process, according to a recent position paper.

The AAN weighed in on telemedicine partly because neurologists are increasingly including the service as part of their practices, most often in emergency stroke care and other acute neurologic conditions. It also is being employed more often for treatment of chronic conditions, including migraines and epilepsy, according to the paper.

The policy also calls for clear liability policies. "The decision to administer or not administer thrombolysis for acute stroke is a prominent source of malpractice claims for neurologists, and telemedicine physicians managing acute stroke patients may be exposed to complex liability issues," the AAN said in the statement. Both physicians and patients need to be protected, it noted.

The organization also called for reimbursement that’s on par with traditional services.

The American Academy of Family Physicians recently said in a letter to members of the House Energy & Commerce Subcommittee on Health that, while it agrees with removing barriers to delivering telemedicine across state lines, it opposes a federal license. It is backing the FSMB process.

Payment Issues

More private insurers are starting to cover telemedicine, with 21 states and Washington, D.C., requiring coverage of the service and reimbursement on par with in-person visits, according to the American Telemedicine Association: Arizona, California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, Maryland, Michigan, Mississippi, Missouri, Montana, New Hampshire, New Mexico, Oklahoma, Oregon, Tennessee, Texas, Vermont, Virginia.

Five states – Massachusetts, Michigan, North Dakota, Pennsylvania, and South Dakota – do not allow out-of-state physician-to-physician consultations.

Licensure requirements vary. Maryland, New York, Virginia, and Washington, D.C., have licensure reciprocity for bordering states.

Ten states – Alabama, Louisiana, Minnesota, Montana, Nevada, New Mexico, Ohio, Oregon, Tennessee, and Texas – allow physicians to practice with a conditional license or a specific telemedicine license.

Medicaid coverage varies on a state-by-state basis but is better than Medicare in many states, according to the ATA. Medicare only pays for telemedicine services if a beneficiary lives in a rural Health Professional Shortage area; several additional requirements must be met:

• The service must be furnished via an interactive telecommunications system, which is defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.

• The practitioner furnishing the service must meet the telehealth requirements, as well as the usual Medicare requirements.

• The individual receiving the services must be in an eligible "originating" site.

Medicare then pays a fee to the originating site and a separate fee to the distant site practitioner.

Family physicians’ offices are "ideally suited" to be originating sites for the delivery of telemedicine, according to the AAFP, but the current originating site fee ($24.63) doesn’t begin to cover the investment needed to ensure that telemedicine equipment is in compliance with the Health Insurance Portability and Accountability Act (HIPAA). The originating site also should be defined broadly, so that the patient’s home can be considered one of the eligible telemedicine sites, according to the academy.

The Telehealth Enhancement Act of 2013 (H.R. 3306) would expand the definition to include all critical access and sole community hospitals and home-based video services for hospice care, home dialysis, and homebound beneficiaries. The AAFP said that it supports the bill, which was introduced by Rep. Gregg Harper (R-Miss.), Rep. Mike Thompson (D-Calif.), Rep. Devin Nunes (R-Calif.), and Rep. Peter Welch (D-Vt.). The bill has no companion in the Senate, and no hearings have been scheduled.

For 2015, Medicare proposed to expand the types of services it will cover. Barring any changes in the final rule for the 2015 physician fee schedule, Medicare will cover several psychotherapy services, including psychoanalysis (CPT code 90845), family psychotherapy without the patient present (90846), and family psychotherapy with patient present (90847).

The agency also proposes to cover prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service (99354 and 99355), and the HCPCS codes G0438 (annual wellness visit; includes a personalized prevention plan of service, initial visit), and G0439, the subsequent annual wellness visit.

Other requests for coverage have been declined by Medicare, including various types of echocardiography interpretation, psychological testing, colposcopy, brief visit to monitor or change medications for mental illness, and urgent dermatologic conditions and wound care.

[email protected]

On Twitter @aliciaault

Concerns that electronic health records will result in an uptick in Medicare payments to hospitals – for legitimate or fraudulent reasons – appear to be unfounded.

Anecdotal reports have surfaced in the wake of a federal incentive program to push for the adoption of EHRs that hospitals might be using the systems to boost payments by more accurately capturing, and more accurately charging, for services rendered than previously recorded, by "upcoding" or selecting billing codes that reflect more intensive procedures or reflect a sicker patient population, or by simply "cloning" entries into an EHR to provide higher billing to multiple patients that might not reflect the care provided. These reports have led the Department of Health & Human Services Office of Inspector General to call for Medicare administrative and program integrity contractors to do more to detect potential fraud from the use of EHRs.

©istock/thinkstockphotos.com

However, research by Julia Adler-Milstein, Ph.D., of the University of Michigan, Ann Arbor, and Dr. Ashish Jha of the Harvard School of Public Health, Boston, suggests that this kind of fraud has not been an issue.

"We found that hospitals that adopted EHRs increased billing to Medicare, but at a rate comparable to that of matched controls of non-EHR adopters," the researchers wrote in the article appearing in the July issue of Health Affairs (July 2014 [doi:10.1377/hlthaff.2014.0023]).

Researchers looked at 393 hospitals that had newly adopted a basic EHR (181 that adopted between 2008 and 2009 and 212 that adopted between 2009 and 2010) and compared them to 782 control hospitals that did not adopt during the same periods. New adopters were predominantly nonteaching (61%), for-profit (70%), and medium-size (47%) hospitals.

In the research models, "we found no significant relationship between EHR adoption and patient acuity," the report states. Also, "adopters and controls had indistinguishable changes in Medicare payments. Between the pre- and postadoption periods, payment per discharge to adopters grew by $849 and to controls by $945. This $96 difference in difference was not in the predicted direction, but it was not significant, either (P = .673)," the researchers wrote.

They suggested that the results were due to hospitals heavily investing in optimizing coding before adopting EHRs.

"Hospitals operate on thin financial margins and therefore likely work hard to maximize reimbursement," the researchers wrote. "Thus, simply having more electronic data or better documentation may not provide as much of an opportunity to increase coding as has been postulated."

They concluded that while there will always be outliers that engage in fraudulent behavior, "our findings suggest that a large-scale policy effort targeting EHR-driven fraudulent coding, such as the one recently recommended by the HHS Office of Inspector General, is not likely to be useful. Substantial savings are unlikely to result even from a policy targeting certain subgroups of hospitals that might be expected to experience the greatest pressure to increase billing after investing in an EHR system."

[email protected]

Concerns that electronic health records will result in an uptick in Medicare payments to hospitals – for legitimate or fraudulent reasons – appear to be unfounded.

Anecdotal reports have surfaced in the wake of a federal incentive program to push for the adoption of EHRs that hospitals might be using the systems to boost payments by more accurately capturing, and more accurately charging, for services rendered than previously recorded, by "upcoding" or selecting billing codes that reflect more intensive procedures or reflect a sicker patient population, or by simply "cloning" entries into an EHR to provide higher billing to multiple patients that might not reflect the care provided. These reports have led the Department of Health & Human Services Office of Inspector General to call for Medicare administrative and program integrity contractors to do more to detect potential fraud from the use of EHRs.

©istock/thinkstockphotos.com

However, research by Julia Adler-Milstein, Ph.D., of the University of Michigan, Ann Arbor, and Dr. Ashish Jha of the Harvard School of Public Health, Boston, suggests that this kind of fraud has not been an issue.

"We found that hospitals that adopted EHRs increased billing to Medicare, but at a rate comparable to that of matched controls of non-EHR adopters," the researchers wrote in the article appearing in the July issue of Health Affairs (July 2014 [doi:10.1377/hlthaff.2014.0023]).

Researchers looked at 393 hospitals that had newly adopted a basic EHR (181 that adopted between 2008 and 2009 and 212 that adopted between 2009 and 2010) and compared them to 782 control hospitals that did not adopt during the same periods. New adopters were predominantly nonteaching (61%), for-profit (70%), and medium-size (47%) hospitals.

In the research models, "we found no significant relationship between EHR adoption and patient acuity," the report states. Also, "adopters and controls had indistinguishable changes in Medicare payments. Between the pre- and postadoption periods, payment per discharge to adopters grew by $849 and to controls by $945. This $96 difference in difference was not in the predicted direction, but it was not significant, either (P = .673)," the researchers wrote.

They suggested that the results were due to hospitals heavily investing in optimizing coding before adopting EHRs.

"Hospitals operate on thin financial margins and therefore likely work hard to maximize reimbursement," the researchers wrote. "Thus, simply having more electronic data or better documentation may not provide as much of an opportunity to increase coding as has been postulated."

They concluded that while there will always be outliers that engage in fraudulent behavior, "our findings suggest that a large-scale policy effort targeting EHR-driven fraudulent coding, such as the one recently recommended by the HHS Office of Inspector General, is not likely to be useful. Substantial savings are unlikely to result even from a policy targeting certain subgroups of hospitals that might be expected to experience the greatest pressure to increase billing after investing in an EHR system."

[email protected]

Concerns that electronic health records will result in an uptick in Medicare payments to hospitals – for legitimate or fraudulent reasons – appear to be unfounded.

Anecdotal reports have surfaced in the wake of a federal incentive program to push for the adoption of EHRs that hospitals might be using the systems to boost payments by more accurately capturing, and more accurately charging, for services rendered than previously recorded, by "upcoding" or selecting billing codes that reflect more intensive procedures or reflect a sicker patient population, or by simply "cloning" entries into an EHR to provide higher billing to multiple patients that might not reflect the care provided. These reports have led the Department of Health & Human Services Office of Inspector General to call for Medicare administrative and program integrity contractors to do more to detect potential fraud from the use of EHRs.

©istock/thinkstockphotos.com

However, research by Julia Adler-Milstein, Ph.D., of the University of Michigan, Ann Arbor, and Dr. Ashish Jha of the Harvard School of Public Health, Boston, suggests that this kind of fraud has not been an issue.

"We found that hospitals that adopted EHRs increased billing to Medicare, but at a rate comparable to that of matched controls of non-EHR adopters," the researchers wrote in the article appearing in the July issue of Health Affairs (July 2014 [doi:10.1377/hlthaff.2014.0023]).

Researchers looked at 393 hospitals that had newly adopted a basic EHR (181 that adopted between 2008 and 2009 and 212 that adopted between 2009 and 2010) and compared them to 782 control hospitals that did not adopt during the same periods. New adopters were predominantly nonteaching (61%), for-profit (70%), and medium-size (47%) hospitals.

In the research models, "we found no significant relationship between EHR adoption and patient acuity," the report states. Also, "adopters and controls had indistinguishable changes in Medicare payments. Between the pre- and postadoption periods, payment per discharge to adopters grew by $849 and to controls by $945. This $96 difference in difference was not in the predicted direction, but it was not significant, either (P = .673)," the researchers wrote.

They suggested that the results were due to hospitals heavily investing in optimizing coding before adopting EHRs.

"Hospitals operate on thin financial margins and therefore likely work hard to maximize reimbursement," the researchers wrote. "Thus, simply having more electronic data or better documentation may not provide as much of an opportunity to increase coding as has been postulated."

They concluded that while there will always be outliers that engage in fraudulent behavior, "our findings suggest that a large-scale policy effort targeting EHR-driven fraudulent coding, such as the one recently recommended by the HHS Office of Inspector General, is not likely to be useful. Substantial savings are unlikely to result even from a policy targeting certain subgroups of hospitals that might be expected to experience the greatest pressure to increase billing after investing in an EHR system."

[email protected]

QUESTION: The medical staff at the newly opened hospital is putting together a set of bylaws covering credentialing, peer review, and patient-care quality assurance. The doctors are mostly independent contractors and not hospital employees. The administration, obsessed with financial solvency, wishes to retain veto power over decisions affecting staff privileges. In potential disputes affecting the hospital and its medical staff, which of the following is true?

A. The Joint Commission subscribes to the view that hospital administration rather medical staff has overall authority over clinical privileges decisions.

B. Economic credentialing is universally regarded as unethical and illegal.

C. Medical bylaws are a contractual agreement.

D. A hospital can never make unilateral changes in the medical staff bylaws.

E. The medical staff is an integral part of the hospital’s organizational structure, with its powers wholly independent of the hospital’s governing board.

BEST ANSWER: A. Doctors with hospital privileges typically organize themselves into a formal medical staff, with its powers derived from the hospital’s governing board. Professional organizations such as the American Medical Association believe that the medical staff of a facility should be self governing, with its own enforceable set of bylaws. The general view is that these bylaws do not create a binding contractual agreement.

For example, when Dr. George T. O’Byrne sued Santa Monica–UCLA Medical Center where he held medical staff privileges, the California Court of Appeal ruled that the hospital’s fiduciary duty is to its shareholders and the public – but not to its physicians – and that the medical staff bylaws did not constitute a contract (OByrne v. Santa Monica-UCLA Medical Center, 114 Cal.Rptr.2d 575 [Cal. Ct. App. 2001]).

A similar situation appears to hold in Minnesota, where the medical staff accused Avera Marshall Regional Medical Center of unilateral credentialing and revision of the bylaws, and interference with quality assurance operations (Avera Marshall Medical Staff v. Avera Marshall Regional Medical Center, 836 N.W.2d 549 [Minn. Ct. App. 2013]). Both the trial court and the court of appeals have held that the medical staff lacked the legal capacity to bring a lawsuit and that the bylaws were not a contract (the final decision of the Minnesota Supreme Court is pending).

The Joint Commission’s view is that the hospital administration has the ultimate authority over clinical privileges of its medical staff, in support of the legal doctrine that a hospital can be held liable for the torts of its practitioners. This notion of corporate liability, which includes negligent credentialing, stemmed from the seminal Darling case (Darling v. Charleston Community Hospital, 211 N.E.2d 253 [Ill. 1965]) where the court held the hospital liable for failing to adequately review the qualifications and performance of a negligent medical staff member. Dr. Alexander, the doctor at issue, had applied a plaster cast too tightly, which caused the college football player to eventually lose his leg.

Other cases followed, including the infamous California case of Gonzales v. Nork, 573 P.2d 458 (Cal. 1978), in which a drug-abusing doctor misrepresented himself as being qualified to perform laminectomies. Even in jurisdictions such as Minnesota, which does not specifically recognize negligent credentialing as a legal cause of action, its supreme court has allowed this legal theory to go forward.

Two recurring issues tending to embroil hospital and staff in conflict are unilateral actions by a medical center and the use of economic credentialing.

The usual procedure for amending the bylaws is for the medical staff to initiate and approve changes before subjecting them for final endorsement by the hospital board. Thus, when a Florida hospital unilaterally refused to re-credential two qualified radiation oncologists because of its intention to exclusively contract with the University of Miami School of Medicine for all radiation oncology procedures, the jury found in favor of the aggrieved doctors, awarding them $2.5 million in lost profits and $20.25 million in punitive damages (Columbia/JFK Medical Center v. Spunberg, 784 So.2d 541 (Fla. App. Ct. 2001).

Likewise, a small Georgia hospital tried to close its cardiology department in order to enter into an exclusive contract with a separate group of cardiologists. The Georgia Court of Appeals held that a hospital could not deprive physicians of access to its facilities unless stated in the bylaws or specifically agreed to in an individual contract (Satilla Health Services v. Bell, 633 S.E.2d 575 [Ga. Ct. App. 2006]).

However, under some narrow circumstances, a hospital can act unilaterally, without medical staff agreement, especially where the bylaws are silent on the point. Illinois recently ruled that a medical center could, without physician assent, increase physician malpractice premium limits to $1,000,000 per occurrence and $3,000,000 aggregate for multiple occurrences (from $200,000 and $600,000, respectively). Its appellate court allowed the change, holding that physician enforcement of its bylaws were restricted only to matters of clinical competence (Fabrizio v. Provena United Samaritans, 857 N.E.2d 670 [Ill. S.Ct. 2006]).

And in Lo v. Provena Covenant Hospital, 796 N.E.2d 607 (Ill. App. Ct. 2003), a hospital unilaterally and summarily suspended a cardiovascular surgeon who allegedly had twice the national mortality rate. The medical staff leadership had not been responsive to the hospital’s concern of imminent danger to patients. The Illinois Appellate Court made the finding that in this "anomalous" case, the hospital’s actions were neither arbitrary, capricious, nor in violation of the bylaws.

A second area of conflict between doctors and hospitals is hospitals’ use of economic factors in credentialing, where financial factors are used to profile – and determine – a physician’s application for privileges.

For example, a staff gynecologist risked losing her 19-year membership at Baptist Health Medical Center in Little Rock, Ark., because her physician-husband owned an interest in a competing hospital specializing in spinal surgery. The case settled when the husband divested his competing ownership. In Arkansas, the courts have ruled that Baptist Health’s policy wherein a physician who holds a financial interest in a competing hospital is ineligible for privileges at any Baptist Health hospital is both unconscionable and illegal, and the hospital economic credentialing policy tortiously interfered with the physicians’ existing and prospective business relationships (Murphy v. Baptist Health, 373 S.W.3d 269 [Ark. 2010]).

But other jurisdictions have not adopted this view. The South Dakota Supreme Court has ruled that a hospital administration may refuse applicants to the medical staff based on economic criteria (

<cf number="\"2\"">’</cf>

Mahan v. Avera St. Lukes, 621 N.W.2d 150 [S.D. S.Ct. 2001]). The court questioned the legal right of certain members of the medical staff to open a competing ambulatory surgery center. In a subsequent case, the same court held that in the absence of specific prohibitions in the bylaws, a hospital could use economic credentialing in its staffing determinations.

Even for physicians with only an occasional hospital practice, the following pointers from the book "The Biggest Legal Mistakes Physicians Make and How to Avoid Them," edited by Steven Babitsky and James J. Mangraviti Jr., may prove useful:

1) Failing to practice in a collegial manner.

2) Impugning the quality of care of the hospital, nurses, and other physicians.

3) Not knowing the hospital’s policies and procedures.

4) Not involving consultants when the issue is out of one’s specialty.

5) Not accepting constructive criticism and suggestions.

6) Failing to seek approval before prescribing unorthodox drugs or treatment.

7) Failing to respond promptly to inquiries about care or behavior.

8) Failing to follow up on an agreement resolving an issue.

9) Acting as though the hospital is lucky to have such a physician.

10) Not calling a lawyer when necessary.

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, "Medical Malpractice: Understanding the Law, Managing the Risk," and his 2012 Halsbury treatise, "Medical Negligence and Professional Misconduct." For additional information, readers may contact the author at [email protected].

QUESTION: The medical staff at the newly opened hospital is putting together a set of bylaws covering credentialing, peer review, and patient-care quality assurance. The doctors are mostly independent contractors and not hospital employees. The administration, obsessed with financial solvency, wishes to retain veto power over decisions affecting staff privileges. In potential disputes affecting the hospital and its medical staff, which of the following is true?

A. The Joint Commission subscribes to the view that hospital administration rather medical staff has overall authority over clinical privileges decisions.

B. Economic credentialing is universally regarded as unethical and illegal.

C. Medical bylaws are a contractual agreement.

D. A hospital can never make unilateral changes in the medical staff bylaws.

E. The medical staff is an integral part of the hospital’s organizational structure, with its powers wholly independent of the hospital’s governing board.

BEST ANSWER: A. Doctors with hospital privileges typically organize themselves into a formal medical staff, with its powers derived from the hospital’s governing board. Professional organizations such as the American Medical Association believe that the medical staff of a facility should be self governing, with its own enforceable set of bylaws. The general view is that these bylaws do not create a binding contractual agreement.

For example, when Dr. George T. O’Byrne sued Santa Monica–UCLA Medical Center where he held medical staff privileges, the California Court of Appeal ruled that the hospital’s fiduciary duty is to its shareholders and the public – but not to its physicians – and that the medical staff bylaws did not constitute a contract (OByrne v. Santa Monica-UCLA Medical Center, 114 Cal.Rptr.2d 575 [Cal. Ct. App. 2001]).

A similar situation appears to hold in Minnesota, where the medical staff accused Avera Marshall Regional Medical Center of unilateral credentialing and revision of the bylaws, and interference with quality assurance operations (Avera Marshall Medical Staff v. Avera Marshall Regional Medical Center, 836 N.W.2d 549 [Minn. Ct. App. 2013]). Both the trial court and the court of appeals have held that the medical staff lacked the legal capacity to bring a lawsuit and that the bylaws were not a contract (the final decision of the Minnesota Supreme Court is pending).

The Joint Commission’s view is that the hospital administration has the ultimate authority over clinical privileges of its medical staff, in support of the legal doctrine that a hospital can be held liable for the torts of its practitioners. This notion of corporate liability, which includes negligent credentialing, stemmed from the seminal Darling case (Darling v. Charleston Community Hospital, 211 N.E.2d 253 [Ill. 1965]) where the court held the hospital liable for failing to adequately review the qualifications and performance of a negligent medical staff member. Dr. Alexander, the doctor at issue, had applied a plaster cast too tightly, which caused the college football player to eventually lose his leg.

Other cases followed, including the infamous California case of Gonzales v. Nork, 573 P.2d 458 (Cal. 1978), in which a drug-abusing doctor misrepresented himself as being qualified to perform laminectomies. Even in jurisdictions such as Minnesota, which does not specifically recognize negligent credentialing as a legal cause of action, its supreme court has allowed this legal theory to go forward.

Two recurring issues tending to embroil hospital and staff in conflict are unilateral actions by a medical center and the use of economic credentialing.

The usual procedure for amending the bylaws is for the medical staff to initiate and approve changes before subjecting them for final endorsement by the hospital board. Thus, when a Florida hospital unilaterally refused to re-credential two qualified radiation oncologists because of its intention to exclusively contract with the University of Miami School of Medicine for all radiation oncology procedures, the jury found in favor of the aggrieved doctors, awarding them $2.5 million in lost profits and $20.25 million in punitive damages (Columbia/JFK Medical Center v. Spunberg, 784 So.2d 541 (Fla. App. Ct. 2001).

Likewise, a small Georgia hospital tried to close its cardiology department in order to enter into an exclusive contract with a separate group of cardiologists. The Georgia Court of Appeals held that a hospital could not deprive physicians of access to its facilities unless stated in the bylaws or specifically agreed to in an individual contract (Satilla Health Services v. Bell, 633 S.E.2d 575 [Ga. Ct. App. 2006]).

However, under some narrow circumstances, a hospital can act unilaterally, without medical staff agreement, especially where the bylaws are silent on the point. Illinois recently ruled that a medical center could, without physician assent, increase physician malpractice premium limits to $1,000,000 per occurrence and $3,000,000 aggregate for multiple occurrences (from $200,000 and $600,000, respectively). Its appellate court allowed the change, holding that physician enforcement of its bylaws were restricted only to matters of clinical competence (Fabrizio v. Provena United Samaritans, 857 N.E.2d 670 [Ill. S.Ct. 2006]).

And in Lo v. Provena Covenant Hospital, 796 N.E.2d 607 (Ill. App. Ct. 2003), a hospital unilaterally and summarily suspended a cardiovascular surgeon who allegedly had twice the national mortality rate. The medical staff leadership had not been responsive to the hospital’s concern of imminent danger to patients. The Illinois Appellate Court made the finding that in this "anomalous" case, the hospital’s actions were neither arbitrary, capricious, nor in violation of the bylaws.

A second area of conflict between doctors and hospitals is hospitals’ use of economic factors in credentialing, where financial factors are used to profile – and determine – a physician’s application for privileges.

For example, a staff gynecologist risked losing her 19-year membership at Baptist Health Medical Center in Little Rock, Ark., because her physician-husband owned an interest in a competing hospital specializing in spinal surgery. The case settled when the husband divested his competing ownership. In Arkansas, the courts have ruled that Baptist Health’s policy wherein a physician who holds a financial interest in a competing hospital is ineligible for privileges at any Baptist Health hospital is both unconscionable and illegal, and the hospital economic credentialing policy tortiously interfered with the physicians’ existing and prospective business relationships (Murphy v. Baptist Health, 373 S.W.3d 269 [Ark. 2010]).

But other jurisdictions have not adopted this view. The South Dakota Supreme Court has ruled that a hospital administration may refuse applicants to the medical staff based on economic criteria (

<cf number="\"2\"">’</cf>

Mahan v. Avera St. Lukes, 621 N.W.2d 150 [S.D. S.Ct. 2001]). The court questioned the legal right of certain members of the medical staff to open a competing ambulatory surgery center. In a subsequent case, the same court held that in the absence of specific prohibitions in the bylaws, a hospital could use economic credentialing in its staffing determinations.

Even for physicians with only an occasional hospital practice, the following pointers from the book "The Biggest Legal Mistakes Physicians Make and How to Avoid Them," edited by Steven Babitsky and James J. Mangraviti Jr., may prove useful:

1) Failing to practice in a collegial manner.

2) Impugning the quality of care of the hospital, nurses, and other physicians.

3) Not knowing the hospital’s policies and procedures.

4) Not involving consultants when the issue is out of one’s specialty.

5) Not accepting constructive criticism and suggestions.

6) Failing to seek approval before prescribing unorthodox drugs or treatment.

7) Failing to respond promptly to inquiries about care or behavior.

8) Failing to follow up on an agreement resolving an issue.

9) Acting as though the hospital is lucky to have such a physician.

10) Not calling a lawyer when necessary.

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, "Medical Malpractice: Understanding the Law, Managing the Risk," and his 2012 Halsbury treatise, "Medical Negligence and Professional Misconduct." For additional information, readers may contact the author at [email protected].

QUESTION: The medical staff at the newly opened hospital is putting together a set of bylaws covering credentialing, peer review, and patient-care quality assurance. The doctors are mostly independent contractors and not hospital employees. The administration, obsessed with financial solvency, wishes to retain veto power over decisions affecting staff privileges. In potential disputes affecting the hospital and its medical staff, which of the following is true?

A. The Joint Commission subscribes to the view that hospital administration rather medical staff has overall authority over clinical privileges decisions.

B. Economic credentialing is universally regarded as unethical and illegal.

C. Medical bylaws are a contractual agreement.

D. A hospital can never make unilateral changes in the medical staff bylaws.

E. The medical staff is an integral part of the hospital’s organizational structure, with its powers wholly independent of the hospital’s governing board.

BEST ANSWER: A. Doctors with hospital privileges typically organize themselves into a formal medical staff, with its powers derived from the hospital’s governing board. Professional organizations such as the American Medical Association believe that the medical staff of a facility should be self governing, with its own enforceable set of bylaws. The general view is that these bylaws do not create a binding contractual agreement.

For example, when Dr. George T. O’Byrne sued Santa Monica–UCLA Medical Center where he held medical staff privileges, the California Court of Appeal ruled that the hospital’s fiduciary duty is to its shareholders and the public – but not to its physicians – and that the medical staff bylaws did not constitute a contract (OByrne v. Santa Monica-UCLA Medical Center, 114 Cal.Rptr.2d 575 [Cal. Ct. App. 2001]).

A similar situation appears to hold in Minnesota, where the medical staff accused Avera Marshall Regional Medical Center of unilateral credentialing and revision of the bylaws, and interference with quality assurance operations (Avera Marshall Medical Staff v. Avera Marshall Regional Medical Center, 836 N.W.2d 549 [Minn. Ct. App. 2013]). Both the trial court and the court of appeals have held that the medical staff lacked the legal capacity to bring a lawsuit and that the bylaws were not a contract (the final decision of the Minnesota Supreme Court is pending).

The Joint Commission’s view is that the hospital administration has the ultimate authority over clinical privileges of its medical staff, in support of the legal doctrine that a hospital can be held liable for the torts of its practitioners. This notion of corporate liability, which includes negligent credentialing, stemmed from the seminal Darling case (Darling v. Charleston Community Hospital, 211 N.E.2d 253 [Ill. 1965]) where the court held the hospital liable for failing to adequately review the qualifications and performance of a negligent medical staff member. Dr. Alexander, the doctor at issue, had applied a plaster cast too tightly, which caused the college football player to eventually lose his leg.

Other cases followed, including the infamous California case of Gonzales v. Nork, 573 P.2d 458 (Cal. 1978), in which a drug-abusing doctor misrepresented himself as being qualified to perform laminectomies. Even in jurisdictions such as Minnesota, which does not specifically recognize negligent credentialing as a legal cause of action, its supreme court has allowed this legal theory to go forward.

Two recurring issues tending to embroil hospital and staff in conflict are unilateral actions by a medical center and the use of economic credentialing.

The usual procedure for amending the bylaws is for the medical staff to initiate and approve changes before subjecting them for final endorsement by the hospital board. Thus, when a Florida hospital unilaterally refused to re-credential two qualified radiation oncologists because of its intention to exclusively contract with the University of Miami School of Medicine for all radiation oncology procedures, the jury found in favor of the aggrieved doctors, awarding them $2.5 million in lost profits and $20.25 million in punitive damages (Columbia/JFK Medical Center v. Spunberg, 784 So.2d 541 (Fla. App. Ct. 2001).

Likewise, a small Georgia hospital tried to close its cardiology department in order to enter into an exclusive contract with a separate group of cardiologists. The Georgia Court of Appeals held that a hospital could not deprive physicians of access to its facilities unless stated in the bylaws or specifically agreed to in an individual contract (Satilla Health Services v. Bell, 633 S.E.2d 575 [Ga. Ct. App. 2006]).

However, under some narrow circumstances, a hospital can act unilaterally, without medical staff agreement, especially where the bylaws are silent on the point. Illinois recently ruled that a medical center could, without physician assent, increase physician malpractice premium limits to $1,000,000 per occurrence and $3,000,000 aggregate for multiple occurrences (from $200,000 and $600,000, respectively). Its appellate court allowed the change, holding that physician enforcement of its bylaws were restricted only to matters of clinical competence (Fabrizio v. Provena United Samaritans, 857 N.E.2d 670 [Ill. S.Ct. 2006]).

And in Lo v. Provena Covenant Hospital, 796 N.E.2d 607 (Ill. App. Ct. 2003), a hospital unilaterally and summarily suspended a cardiovascular surgeon who allegedly had twice the national mortality rate. The medical staff leadership had not been responsive to the hospital’s concern of imminent danger to patients. The Illinois Appellate Court made the finding that in this "anomalous" case, the hospital’s actions were neither arbitrary, capricious, nor in violation of the bylaws.

A second area of conflict between doctors and hospitals is hospitals’ use of economic factors in credentialing, where financial factors are used to profile – and determine – a physician’s application for privileges.

For example, a staff gynecologist risked losing her 19-year membership at Baptist Health Medical Center in Little Rock, Ark., because her physician-husband owned an interest in a competing hospital specializing in spinal surgery. The case settled when the husband divested his competing ownership. In Arkansas, the courts have ruled that Baptist Health’s policy wherein a physician who holds a financial interest in a competing hospital is ineligible for privileges at any Baptist Health hospital is both unconscionable and illegal, and the hospital economic credentialing policy tortiously interfered with the physicians’ existing and prospective business relationships (Murphy v. Baptist Health, 373 S.W.3d 269 [Ark. 2010]).

But other jurisdictions have not adopted this view. The South Dakota Supreme Court has ruled that a hospital administration may refuse applicants to the medical staff based on economic criteria (

<cf number="\"2\"">’</cf>

Mahan v. Avera St. Lukes, 621 N.W.2d 150 [S.D. S.Ct. 2001]). The court questioned the legal right of certain members of the medical staff to open a competing ambulatory surgery center. In a subsequent case, the same court held that in the absence of specific prohibitions in the bylaws, a hospital could use economic credentialing in its staffing determinations.

Even for physicians with only an occasional hospital practice, the following pointers from the book "The Biggest Legal Mistakes Physicians Make and How to Avoid Them," edited by Steven Babitsky and James J. Mangraviti Jr., may prove useful:

1) Failing to practice in a collegial manner.

2) Impugning the quality of care of the hospital, nurses, and other physicians.

3) Not knowing the hospital’s policies and procedures.

4) Not involving consultants when the issue is out of one’s specialty.

5) Not accepting constructive criticism and suggestions.

6) Failing to seek approval before prescribing unorthodox drugs or treatment.

7) Failing to respond promptly to inquiries about care or behavior.

8) Failing to follow up on an agreement resolving an issue.

9) Acting as though the hospital is lucky to have such a physician.

10) Not calling a lawyer when necessary.

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, "Medical Malpractice: Understanding the Law, Managing the Risk," and his 2012 Halsbury treatise, "Medical Negligence and Professional Misconduct." For additional information, readers may contact the author at [email protected].

BOSTON – Endovascular interventions for ruptured visceral artery aneurysms are associated with reduced morbidity and mortality, compared with open interventions, according to findings from a retrospective chart review.

Both endovascular and open repairs are safe and durable for intact visceral artery aneurysms, Dr. Ankur J. Shukla reported at a meeting hosted by the Society for Vascular Surgery.

Of 261 patients who presented with visceral artery aneurysms (VAAs), 174 underwent repair: 74 who presented with ruptured VAA and 100 who presented with intact VAA. The majority – 73% of ruptured VAA and 62% of intact VAA – were repaired with an endovascular approach.

Among those with ruptured VAA, 30-day mortality was 7.4% following endovascular repair, compared with 28.6% following open repair, a significant difference, said Dr. Shukla of the University of Pittsburgh Medical Center.

Survival at 3 years of ruptured VAA was about 70% vs. 46.4% in the endovascular and open repair groups, respectively, he said.

About 65% of patients with ruptured VAA presented with pain, and about 30% presented in hemodynamic shock. The most commonly identified etiology was "inflammatory/pancreatitis inflammatory," and 80% of the aneurysms were pseudoaneurysmal in nature.

A large proportion of the aneurysms were in the splenic and arterial beds, but 26% were located in the pancreaticoduodenal arcade, and those had a mean size of 12.7 mm. Most (95%) were pseudoaneurysms.

The outcomes with ruptured VAA were quite good, Dr. Shukla said, noting that the technical success rate was 98.7%.

Although the 30-day reintervention rate with endovascular repair was higher, the difference between the groups was not statistically significant, and there was a trend toward a lower rate of major complications with endovascular repair.

Factors found to be predictors of mortality risk were older age and steroid use, while endovascular repair was found to be protective.

As for the patients with intact VAA, most presented without symptoms, and the most common etiology was atherosclerosis.

"When we looked at the distribution, this was very consistent with what has been reported in the literature, with the splenic and arterial beds really making up the lion’s share of this group. Notable is the fact that 6.7% of our patients had intact aneurysms in the pancreaticoduodenal arcade," he said.

Outcomes in those with intact aneurysms were good. A slightly higher 30-day reintervention rate in those who underwent endovascular repair did not reach statistical significance, and both the endovascular and open repair groups had low rates of major complications.

Survival at 3 years for intact aneurysms did not differ in the endovascular and open repair groups. This was partly due to a 0% 30-day mortality, and – despite the fact that the overall mortality in those with intact aneurysms was 10% – there was zero overall aneurysm-related mortality, he said.

Patients in the study were treated at a single institution between 2003 and 2013. Most were in their mid to late 50s, and there were more men and more individuals on immunosuppressive therapy in the ruptured VAA group. However, comorbidities were similar in the ruptured and intact VAA groups.

Visceral artery aneurysms occur only rarely, affecting 0.1% to 2% of the general population, but because of the increasing use of noninvasive imaging, more of these aneurysms are being detected incidentally.

When they are not found incidentally, they often go undetected and present when they rupture, Dr. Shukla said.

"Because of the increasing utilization and improvement of endovascular technology, we now have a lot of options to fix these aneurysms. But the outcomes are not well defined. Even less well defined is the outcome of ruptured visceral artery aneurysms," he said, noting that most studies have a small sample size or look only at endovascular or open repairs.

Overall, the current study showed that there is "an acute and sharp drop-off in survival with open repair," related, most likely, to operative mortality, he said.

"Based on the findings, we recommend aggressive treatment of pseudoaneurysms and true aneurysms in the pancreaticoduodenal arcade, and advocate for an endovascular-first approach to treating ruptured visceral artery aneurysms, acknowledging that success in this is really predicated on good planning based on advanced imaging and endovascular set-up," he concluded.

Dr. Shukla reported having no disclosures.

BOSTON – Endovascular interventions for ruptured visceral artery aneurysms are associated with reduced morbidity and mortality, compared with open interventions, according to findings from a retrospective chart review.

Both endovascular and open repairs are safe and durable for intact visceral artery aneurysms, Dr. Ankur J. Shukla reported at a meeting hosted by the Society for Vascular Surgery.

Of 261 patients who presented with visceral artery aneurysms (VAAs), 174 underwent repair: 74 who presented with ruptured VAA and 100 who presented with intact VAA. The majority – 73% of ruptured VAA and 62% of intact VAA – were repaired with an endovascular approach.

Among those with ruptured VAA, 30-day mortality was 7.4% following endovascular repair, compared with 28.6% following open repair, a significant difference, said Dr. Shukla of the University of Pittsburgh Medical Center.

Survival at 3 years of ruptured VAA was about 70% vs. 46.4% in the endovascular and open repair groups, respectively, he said.

About 65% of patients with ruptured VAA presented with pain, and about 30% presented in hemodynamic shock. The most commonly identified etiology was "inflammatory/pancreatitis inflammatory," and 80% of the aneurysms were pseudoaneurysmal in nature.

A large proportion of the aneurysms were in the splenic and arterial beds, but 26% were located in the pancreaticoduodenal arcade, and those had a mean size of 12.7 mm. Most (95%) were pseudoaneurysms.

The outcomes with ruptured VAA were quite good, Dr. Shukla said, noting that the technical success rate was 98.7%.

Although the 30-day reintervention rate with endovascular repair was higher, the difference between the groups was not statistically significant, and there was a trend toward a lower rate of major complications with endovascular repair.

Factors found to be predictors of mortality risk were older age and steroid use, while endovascular repair was found to be protective.

As for the patients with intact VAA, most presented without symptoms, and the most common etiology was atherosclerosis.

"When we looked at the distribution, this was very consistent with what has been reported in the literature, with the splenic and arterial beds really making up the lion’s share of this group. Notable is the fact that 6.7% of our patients had intact aneurysms in the pancreaticoduodenal arcade," he said.

Outcomes in those with intact aneurysms were good. A slightly higher 30-day reintervention rate in those who underwent endovascular repair did not reach statistical significance, and both the endovascular and open repair groups had low rates of major complications.

Survival at 3 years for intact aneurysms did not differ in the endovascular and open repair groups. This was partly due to a 0% 30-day mortality, and – despite the fact that the overall mortality in those with intact aneurysms was 10% – there was zero overall aneurysm-related mortality, he said.

Patients in the study were treated at a single institution between 2003 and 2013. Most were in their mid to late 50s, and there were more men and more individuals on immunosuppressive therapy in the ruptured VAA group. However, comorbidities were similar in the ruptured and intact VAA groups.

Visceral artery aneurysms occur only rarely, affecting 0.1% to 2% of the general population, but because of the increasing use of noninvasive imaging, more of these aneurysms are being detected incidentally.

When they are not found incidentally, they often go undetected and present when they rupture, Dr. Shukla said.

"Because of the increasing utilization and improvement of endovascular technology, we now have a lot of options to fix these aneurysms. But the outcomes are not well defined. Even less well defined is the outcome of ruptured visceral artery aneurysms," he said, noting that most studies have a small sample size or look only at endovascular or open repairs.

Overall, the current study showed that there is "an acute and sharp drop-off in survival with open repair," related, most likely, to operative mortality, he said.

"Based on the findings, we recommend aggressive treatment of pseudoaneurysms and true aneurysms in the pancreaticoduodenal arcade, and advocate for an endovascular-first approach to treating ruptured visceral artery aneurysms, acknowledging that success in this is really predicated on good planning based on advanced imaging and endovascular set-up," he concluded.

Dr. Shukla reported having no disclosures.

BOSTON – Endovascular interventions for ruptured visceral artery aneurysms are associated with reduced morbidity and mortality, compared with open interventions, according to findings from a retrospective chart review.

Both endovascular and open repairs are safe and durable for intact visceral artery aneurysms, Dr. Ankur J. Shukla reported at a meeting hosted by the Society for Vascular Surgery.

Of 261 patients who presented with visceral artery aneurysms (VAAs), 174 underwent repair: 74 who presented with ruptured VAA and 100 who presented with intact VAA. The majority – 73% of ruptured VAA and 62% of intact VAA – were repaired with an endovascular approach.

Among those with ruptured VAA, 30-day mortality was 7.4% following endovascular repair, compared with 28.6% following open repair, a significant difference, said Dr. Shukla of the University of Pittsburgh Medical Center.

Survival at 3 years of ruptured VAA was about 70% vs. 46.4% in the endovascular and open repair groups, respectively, he said.

About 65% of patients with ruptured VAA presented with pain, and about 30% presented in hemodynamic shock. The most commonly identified etiology was "inflammatory/pancreatitis inflammatory," and 80% of the aneurysms were pseudoaneurysmal in nature.

A large proportion of the aneurysms were in the splenic and arterial beds, but 26% were located in the pancreaticoduodenal arcade, and those had a mean size of 12.7 mm. Most (95%) were pseudoaneurysms.

The outcomes with ruptured VAA were quite good, Dr. Shukla said, noting that the technical success rate was 98.7%.

Although the 30-day reintervention rate with endovascular repair was higher, the difference between the groups was not statistically significant, and there was a trend toward a lower rate of major complications with endovascular repair.

Factors found to be predictors of mortality risk were older age and steroid use, while endovascular repair was found to be protective.

As for the patients with intact VAA, most presented without symptoms, and the most common etiology was atherosclerosis.

"When we looked at the distribution, this was very consistent with what has been reported in the literature, with the splenic and arterial beds really making up the lion’s share of this group. Notable is the fact that 6.7% of our patients had intact aneurysms in the pancreaticoduodenal arcade," he said.

Outcomes in those with intact aneurysms were good. A slightly higher 30-day reintervention rate in those who underwent endovascular repair did not reach statistical significance, and both the endovascular and open repair groups had low rates of major complications.

Survival at 3 years for intact aneurysms did not differ in the endovascular and open repair groups. This was partly due to a 0% 30-day mortality, and – despite the fact that the overall mortality in those with intact aneurysms was 10% – there was zero overall aneurysm-related mortality, he said.

Patients in the study were treated at a single institution between 2003 and 2013. Most were in their mid to late 50s, and there were more men and more individuals on immunosuppressive therapy in the ruptured VAA group. However, comorbidities were similar in the ruptured and intact VAA groups.

Visceral artery aneurysms occur only rarely, affecting 0.1% to 2% of the general population, but because of the increasing use of noninvasive imaging, more of these aneurysms are being detected incidentally.

When they are not found incidentally, they often go undetected and present when they rupture, Dr. Shukla said.

"Because of the increasing utilization and improvement of endovascular technology, we now have a lot of options to fix these aneurysms. But the outcomes are not well defined. Even less well defined is the outcome of ruptured visceral artery aneurysms," he said, noting that most studies have a small sample size or look only at endovascular or open repairs.

Overall, the current study showed that there is "an acute and sharp drop-off in survival with open repair," related, most likely, to operative mortality, he said.

"Based on the findings, we recommend aggressive treatment of pseudoaneurysms and true aneurysms in the pancreaticoduodenal arcade, and advocate for an endovascular-first approach to treating ruptured visceral artery aneurysms, acknowledging that success in this is really predicated on good planning based on advanced imaging and endovascular set-up," he concluded.

Dr. Shukla reported having no disclosures.

COPENHAGEN – Almost half of patients with mild cognitive impairment progressed to dementia within 1 year of undergoing either arthroplasty or coronary angiography, according to a small Australian study.

Baseline cognitive impairment appeared to be the main driver of progression, increasing the risk more than sevenfold – significantly more than age or heart attack, Lisbeth Evered, Ph.D., said at the annual Alzheimer’s Association International Conference.

"After 12 months, 42% met the criteria for dementia," said Dr. Evered, a researcher at the University of Melbourne. "The expected annual progression from mild cognitive impairment [MCI] to dementia would be about 10%-12% per year."

Her study included 67 patients with a mean age of 70 years. All had MCI at baseline, with a mean score of 23 on the Mini-Mental State Exam (MMSE). They underwent either arthroplasty (26 patients) or coronary angiography (41 patients).

A year after surgery, about 34% of the arthroplasty patients and 46% of the angiography patients had progressed to dementia. Baseline cognitive impairment was the only factor significantly associated with the change.

Postsurgical cognitive decline, both transient and long lasting, is a well-documented phenomenon, with studies going back to the late 1800s. Although the causative link isn’t entirely clear, anesthetics have long been implicated, said Dr. Evered. In animal models, some anesthesia drugs do seem to precipitate an Alzheimer’s-like amyloidosis and tau hyperphosphorylation.

More recent animal data suggest that inflammation might be a powerful influence.

"When a patient has surgery with a general anesthetic, they experience peripheral inflammation," Dr. Evered explained. "In a healthy normal brain, there’s plenty of cognitive reserve, and although there might be some cognitive decline afterward, the person won’t really notice and will certainly recover."

In a vulnerable brain, however, the inflammation may be amplified and may cause significant collateral damage that accelerates cognitive decline. "The problem is, we don’t know why they are vulnerable or what we might do about it," she noted.

The best approach now is to routinely assess cognition before surgery and monitor it afterward, Dr. Evered explained. "Then, the perioperative period is not something occurring in isolation," she noted. "We will be better able to identify those at risk and implement strategies to improve their outcomes."

In a video interview, Dr. Evered and Dr. Brendan Silbert of St. Vincent’s Hospital, Melbourne, discuss the study and its implications.

Dr. Evered had no financial disclosures

[email protected]

On Twitter @alz_gal

COPENHAGEN – Almost half of patients with mild cognitive impairment progressed to dementia within 1 year of undergoing either arthroplasty or coronary angiography, according to a small Australian study.

Baseline cognitive impairment appeared to be the main driver of progression, increasing the risk more than sevenfold – significantly more than age or heart attack, Lisbeth Evered, Ph.D., said at the annual Alzheimer’s Association International Conference.

"After 12 months, 42% met the criteria for dementia," said Dr. Evered, a researcher at the University of Melbourne. "The expected annual progression from mild cognitive impairment [MCI] to dementia would be about 10%-12% per year."

Her study included 67 patients with a mean age of 70 years. All had MCI at baseline, with a mean score of 23 on the Mini-Mental State Exam (MMSE). They underwent either arthroplasty (26 patients) or coronary angiography (41 patients).

A year after surgery, about 34% of the arthroplasty patients and 46% of the angiography patients had progressed to dementia. Baseline cognitive impairment was the only factor significantly associated with the change.

Postsurgical cognitive decline, both transient and long lasting, is a well-documented phenomenon, with studies going back to the late 1800s. Although the causative link isn’t entirely clear, anesthetics have long been implicated, said Dr. Evered. In animal models, some anesthesia drugs do seem to precipitate an Alzheimer’s-like amyloidosis and tau hyperphosphorylation.

More recent animal data suggest that inflammation might be a powerful influence.

"When a patient has surgery with a general anesthetic, they experience peripheral inflammation," Dr. Evered explained. "In a healthy normal brain, there’s plenty of cognitive reserve, and although there might be some cognitive decline afterward, the person won’t really notice and will certainly recover."

In a vulnerable brain, however, the inflammation may be amplified and may cause significant collateral damage that accelerates cognitive decline. "The problem is, we don’t know why they are vulnerable or what we might do about it," she noted.

The best approach now is to routinely assess cognition before surgery and monitor it afterward, Dr. Evered explained. "Then, the perioperative period is not something occurring in isolation," she noted. "We will be better able to identify those at risk and implement strategies to improve their outcomes."

In a video interview, Dr. Evered and Dr. Brendan Silbert of St. Vincent’s Hospital, Melbourne, discuss the study and its implications.

Dr. Evered had no financial disclosures

[email protected]

On Twitter @alz_gal

COPENHAGEN – Almost half of patients with mild cognitive impairment progressed to dementia within 1 year of undergoing either arthroplasty or coronary angiography, according to a small Australian study.

Baseline cognitive impairment appeared to be the main driver of progression, increasing the risk more than sevenfold – significantly more than age or heart attack, Lisbeth Evered, Ph.D., said at the annual Alzheimer’s Association International Conference.

"After 12 months, 42% met the criteria for dementia," said Dr. Evered, a researcher at the University of Melbourne. "The expected annual progression from mild cognitive impairment [MCI] to dementia would be about 10%-12% per year."

Her study included 67 patients with a mean age of 70 years. All had MCI at baseline, with a mean score of 23 on the Mini-Mental State Exam (MMSE). They underwent either arthroplasty (26 patients) or coronary angiography (41 patients).

A year after surgery, about 34% of the arthroplasty patients and 46% of the angiography patients had progressed to dementia. Baseline cognitive impairment was the only factor significantly associated with the change.

Postsurgical cognitive decline, both transient and long lasting, is a well-documented phenomenon, with studies going back to the late 1800s. Although the causative link isn’t entirely clear, anesthetics have long been implicated, said Dr. Evered. In animal models, some anesthesia drugs do seem to precipitate an Alzheimer’s-like amyloidosis and tau hyperphosphorylation.

More recent animal data suggest that inflammation might be a powerful influence.

"When a patient has surgery with a general anesthetic, they experience peripheral inflammation," Dr. Evered explained. "In a healthy normal brain, there’s plenty of cognitive reserve, and although there might be some cognitive decline afterward, the person won’t really notice and will certainly recover."

In a vulnerable brain, however, the inflammation may be amplified and may cause significant collateral damage that accelerates cognitive decline. "The problem is, we don’t know why they are vulnerable or what we might do about it," she noted.

The best approach now is to routinely assess cognition before surgery and monitor it afterward, Dr. Evered explained. "Then, the perioperative period is not something occurring in isolation," she noted. "We will be better able to identify those at risk and implement strategies to improve their outcomes."

In a video interview, Dr. Evered and Dr. Brendan Silbert of St. Vincent’s Hospital, Melbourne, discuss the study and its implications.

Dr. Evered had no financial disclosures

[email protected]

On Twitter @alz_gal

Damage control resuscitation practices, adopted by the U.S. military in 2006, appear to have resulted in fewer deaths of salvageable patients in combat hospitals, according to results of a new study.

DCR, based on the principle that the coagulopathy of trauma is worsened when the balance of whole blood is disrupted, involves early administration of blood products in a balanced ratio, aggressive correction of coagulopathy, and minimization of the use of crystalloid fluids. DCR was first introduced in U.S. combat hospitals in Iraq and Afghanistan in 2005, and widely adopted the following year.

In research published online July 16 in JAMA Surgery (doi: 10.1001/jamasurg.2014.940), Dr. Nicholas R. Langan and his colleagues at Madigan Army Medical Center in Tacoma, Wash., used data from the military’s Joint Theater Trauma Registry database to analyze records from 2,565 soldiers who died in forward combat hospitals between 2002 and 2011. The researchers looked at injury types and Injury Severity Scores (ISSs); the timing and location of death; and initial (24-hour) and total volume of blood products and fluid administered before and after DCR became standard care.

The investigators found that the wide adoption of DCR resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and an increase in fresh frozen plasma use (3.2-10.1 U) (P less than .05 for both). The mean ratio of packed red blood cells to fresh frozen plasma changed from 2.6:1 during the pre-DCR period to 1.4:1 (P less than .01). The researchers also saw mean ISS increase between cohorts (23 before DCR vs. 27; P less than .05), and a shift in injury patterns favoring more severe head trauma in the DCR-era cohort.

"We believe that this represents a logical second-order effect of improved early care and resuscitation (namely, that there is improved salvage of less severely injured patients and a decreased number of deaths among those with potentially survivable injuries)," Dr. Langan and his colleagues wrote in their analysis.

Comparing the pre-DCR and DCR periods, the researchers found that both the mean ISS and the percentage of patients with severe injury increased (from a mean ISS of 22.5 to 26.7 and from 63.5% to 79.7%, respectively; P less than .05). The mean Revised Trauma Score was lower (indicating more severe injury) for the DCR cohort (4.76) than for the pre-DCR cohort (5.67) (P less than .001). And the mean probability of survival based on trauma and injury scores dropped from 77% in the pre-DCR period to 64% after 2006 (P less than .001).

There remains "significant debate about the efficacy and application of DCR that will require prospective controlled studies to resolve," the researchers wrote.

Dr. Langan and his colleagues disclosed no conflicts of interest.

Damage control resuscitation practices, adopted by the U.S. military in 2006, appear to have resulted in fewer deaths of salvageable patients in combat hospitals, according to results of a new study.

DCR, based on the principle that the coagulopathy of trauma is worsened when the balance of whole blood is disrupted, involves early administration of blood products in a balanced ratio, aggressive correction of coagulopathy, and minimization of the use of crystalloid fluids. DCR was first introduced in U.S. combat hospitals in Iraq and Afghanistan in 2005, and widely adopted the following year.

In research published online July 16 in JAMA Surgery (doi: 10.1001/jamasurg.2014.940), Dr. Nicholas R. Langan and his colleagues at Madigan Army Medical Center in Tacoma, Wash., used data from the military’s Joint Theater Trauma Registry database to analyze records from 2,565 soldiers who died in forward combat hospitals between 2002 and 2011. The researchers looked at injury types and Injury Severity Scores (ISSs); the timing and location of death; and initial (24-hour) and total volume of blood products and fluid administered before and after DCR became standard care.

The investigators found that the wide adoption of DCR resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and an increase in fresh frozen plasma use (3.2-10.1 U) (P less than .05 for both). The mean ratio of packed red blood cells to fresh frozen plasma changed from 2.6:1 during the pre-DCR period to 1.4:1 (P less than .01). The researchers also saw mean ISS increase between cohorts (23 before DCR vs. 27; P less than .05), and a shift in injury patterns favoring more severe head trauma in the DCR-era cohort.

"We believe that this represents a logical second-order effect of improved early care and resuscitation (namely, that there is improved salvage of less severely injured patients and a decreased number of deaths among those with potentially survivable injuries)," Dr. Langan and his colleagues wrote in their analysis.

Comparing the pre-DCR and DCR periods, the researchers found that both the mean ISS and the percentage of patients with severe injury increased (from a mean ISS of 22.5 to 26.7 and from 63.5% to 79.7%, respectively; P less than .05). The mean Revised Trauma Score was lower (indicating more severe injury) for the DCR cohort (4.76) than for the pre-DCR cohort (5.67) (P less than .001). And the mean probability of survival based on trauma and injury scores dropped from 77% in the pre-DCR period to 64% after 2006 (P less than .001).

There remains "significant debate about the efficacy and application of DCR that will require prospective controlled studies to resolve," the researchers wrote.

Dr. Langan and his colleagues disclosed no conflicts of interest.

Damage control resuscitation practices, adopted by the U.S. military in 2006, appear to have resulted in fewer deaths of salvageable patients in combat hospitals, according to results of a new study.

DCR, based on the principle that the coagulopathy of trauma is worsened when the balance of whole blood is disrupted, involves early administration of blood products in a balanced ratio, aggressive correction of coagulopathy, and minimization of the use of crystalloid fluids. DCR was first introduced in U.S. combat hospitals in Iraq and Afghanistan in 2005, and widely adopted the following year.

In research published online July 16 in JAMA Surgery (doi: 10.1001/jamasurg.2014.940), Dr. Nicholas R. Langan and his colleagues at Madigan Army Medical Center in Tacoma, Wash., used data from the military’s Joint Theater Trauma Registry database to analyze records from 2,565 soldiers who died in forward combat hospitals between 2002 and 2011. The researchers looked at injury types and Injury Severity Scores (ISSs); the timing and location of death; and initial (24-hour) and total volume of blood products and fluid administered before and after DCR became standard care.

The investigators found that the wide adoption of DCR resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and an increase in fresh frozen plasma use (3.2-10.1 U) (P less than .05 for both). The mean ratio of packed red blood cells to fresh frozen plasma changed from 2.6:1 during the pre-DCR period to 1.4:1 (P less than .01). The researchers also saw mean ISS increase between cohorts (23 before DCR vs. 27; P less than .05), and a shift in injury patterns favoring more severe head trauma in the DCR-era cohort.

"We believe that this represents a logical second-order effect of improved early care and resuscitation (namely, that there is improved salvage of less severely injured patients and a decreased number of deaths among those with potentially survivable injuries)," Dr. Langan and his colleagues wrote in their analysis.

Comparing the pre-DCR and DCR periods, the researchers found that both the mean ISS and the percentage of patients with severe injury increased (from a mean ISS of 22.5 to 26.7 and from 63.5% to 79.7%, respectively; P less than .05). The mean Revised Trauma Score was lower (indicating more severe injury) for the DCR cohort (4.76) than for the pre-DCR cohort (5.67) (P less than .001). And the mean probability of survival based on trauma and injury scores dropped from 77% in the pre-DCR period to 64% after 2006 (P less than .001).

There remains "significant debate about the efficacy and application of DCR that will require prospective controlled studies to resolve," the researchers wrote.

Dr. Langan and his colleagues disclosed no conflicts of interest.

SAN FRANCISCO – Hypoglycemic episodes were common and largely unnoticed after bariatric surgery, a controlled study of 45 patients found.

During a 3-day period of "normal living," symptomatic hypoglycemias occurred in 22% of 15 patients after gastric bypass surgery, 20% of 15 patients after biliopancreatic diversion with duodenal switch, and in none of 15 obese, nondiabetic control patients matched to the surgical patients by body mass index.

Continuous glucose monitoring showed that patients in both postsurgery groups spent significant amounts of time in hypoglycemia, Dr. Niclas Abrahamsson and his associates reported at the annual scientific session of the American Diabetes Association.

After gastric bypass, patients averaged 42 minutes per day with glucose levels lower than 3.3 mmol/L and 21 minutes per day with levels lower than 2.8 mmol/L. After duodenal switch surgery, patients averaged 85 minutes per day with glucose levels lower than 3.3 mmol/L and 39 minutes per day with levels lower than 2.8 mmol/L. No patients in the control group had glucose levels that low, reported Dr. Abrahamsson of the University of Uppsala, Sweden.

"We were very surprised that they had so many hypoglycemic episodes, especially since the controls had none," he said. Patients were unaware of approximately 80% of the hypoglycemic episodes, he added.

"The clinical significance should be that one should be alert to any hypoglycemia symptoms," Dr. Abrahamsson said.

Patients in the post–duodenal switch group had the lowest mean glucose level (4.6 mmol/L) and mean hemoglobin A_1c level (29 mmol/mol), compared with the post–gastric bypass group (mean glucose 5.3 mmol/L and HbA_1c 36 mmol/mol) and the control group (mean glucose 5.9 mmol/L and HbA_1c 38 mmol/mol).

Glucose curves on continuous monitoring were more variable in the post–gastric bypass group, compared with controls, and less variable in the post–duodenal switch group, compared with controls. That difference between the two surgical groups probably relates to the different glucose absorption capabilities after surgery, he suggested.

Dr. Abrahamsson has been a speaker for Eli Lilly and Sanofi and has held stock in AstraZeneca.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Hypoglycemic episodes were common and largely unnoticed after bariatric surgery, a controlled study of 45 patients found.

During a 3-day period of "normal living," symptomatic hypoglycemias occurred in 22% of 15 patients after gastric bypass surgery, 20% of 15 patients after biliopancreatic diversion with duodenal switch, and in none of 15 obese, nondiabetic control patients matched to the surgical patients by body mass index.

Continuous glucose monitoring showed that patients in both postsurgery groups spent significant amounts of time in hypoglycemia, Dr. Niclas Abrahamsson and his associates reported at the annual scientific session of the American Diabetes Association.

After gastric bypass, patients averaged 42 minutes per day with glucose levels lower than 3.3 mmol/L and 21 minutes per day with levels lower than 2.8 mmol/L. After duodenal switch surgery, patients averaged 85 minutes per day with glucose levels lower than 3.3 mmol/L and 39 minutes per day with levels lower than 2.8 mmol/L. No patients in the control group had glucose levels that low, reported Dr. Abrahamsson of the University of Uppsala, Sweden.

"We were very surprised that they had so many hypoglycemic episodes, especially since the controls had none," he said. Patients were unaware of approximately 80% of the hypoglycemic episodes, he added.

"The clinical significance should be that one should be alert to any hypoglycemia symptoms," Dr. Abrahamsson said.

Patients in the post–duodenal switch group had the lowest mean glucose level (4.6 mmol/L) and mean hemoglobin A_1c level (29 mmol/mol), compared with the post–gastric bypass group (mean glucose 5.3 mmol/L and HbA_1c 36 mmol/mol) and the control group (mean glucose 5.9 mmol/L and HbA_1c 38 mmol/mol).

Glucose curves on continuous monitoring were more variable in the post–gastric bypass group, compared with controls, and less variable in the post–duodenal switch group, compared with controls. That difference between the two surgical groups probably relates to the different glucose absorption capabilities after surgery, he suggested.

Dr. Abrahamsson has been a speaker for Eli Lilly and Sanofi and has held stock in AstraZeneca.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Hypoglycemic episodes were common and largely unnoticed after bariatric surgery, a controlled study of 45 patients found.

During a 3-day period of "normal living," symptomatic hypoglycemias occurred in 22% of 15 patients after gastric bypass surgery, 20% of 15 patients after biliopancreatic diversion with duodenal switch, and in none of 15 obese, nondiabetic control patients matched to the surgical patients by body mass index.

Continuous glucose monitoring showed that patients in both postsurgery groups spent significant amounts of time in hypoglycemia, Dr. Niclas Abrahamsson and his associates reported at the annual scientific session of the American Diabetes Association.

After gastric bypass, patients averaged 42 minutes per day with glucose levels lower than 3.3 mmol/L and 21 minutes per day with levels lower than 2.8 mmol/L. After duodenal switch surgery, patients averaged 85 minutes per day with glucose levels lower than 3.3 mmol/L and 39 minutes per day with levels lower than 2.8 mmol/L. No patients in the control group had glucose levels that low, reported Dr. Abrahamsson of the University of Uppsala, Sweden.

"We were very surprised that they had so many hypoglycemic episodes, especially since the controls had none," he said. Patients were unaware of approximately 80% of the hypoglycemic episodes, he added.

"The clinical significance should be that one should be alert to any hypoglycemia symptoms," Dr. Abrahamsson said.

Patients in the post–duodenal switch group had the lowest mean glucose level (4.6 mmol/L) and mean hemoglobin A_1c level (29 mmol/mol), compared with the post–gastric bypass group (mean glucose 5.3 mmol/L and HbA_1c 36 mmol/mol) and the control group (mean glucose 5.9 mmol/L and HbA_1c 38 mmol/mol).

Glucose curves on continuous monitoring were more variable in the post–gastric bypass group, compared with controls, and less variable in the post–duodenal switch group, compared with controls. That difference between the two surgical groups probably relates to the different glucose absorption capabilities after surgery, he suggested.

Dr. Abrahamsson has been a speaker for Eli Lilly and Sanofi and has held stock in AstraZeneca.

[email protected]

On Twitter @sherryboschert