ACS Surgery News

Practice mergers with physician groups and larger health systems are becoming commonplace as more doctors trade in their shingles for fewer business burdens and more stability. But as with all transactions, selling or merging a medical practice comes with legal risks.

"There are numerous complex issues, legal and otherwise, that the seller of a medical practice needs to consider, both in preparations for the sale and during the transaction," wrote health law attorney David N. Vozza in a recent article for Kern Augustine Conroy & Schoppmann, a health care litigation firm with offices in the East Coast.

One of the most significant legal considerations pertains to the correct transfer of medical records during sales and mergers, Mr. Vozza said in an interview. To meet privacy requirements, all current patients must be advised that the practice is being transferred and they must have the opportunity to obtain their original records if they desire a new physician, he said. Records also must not be released to third parties without the patient’s express authorization. In addition, physicians run the risk of an "abandonment" lawsuit, if patient care is compromised because of the sale or merger.

"If you know a patient has a pressing care or treatment need, that can’t be delayed because you’re in the middle of a sale," Mr. Vozza said. "It can’t get lost in the shuffle of the transaction."

Another key consideration when merging practices is the assessment of liability cases, said Mathew J. Levy, a health law attorney and principal at Kern Augustine Conroy & Schoppmann and a coauthor of the risk management article. Physicians combining practices should be aware of any pending malpractice cases or audits of their potential partners.

"When merging with a larger group, you should be concerned with how they are doing internally," Mr. Levy said. "Are they under any audits or investigations? Have they been disciplined by the state licensure board? You have to make sure you’re not accountable for" their debts or malpractice issues.

Physicians should also consider the effect their merger may have on their malpractice insurance, Mr. Levy adds. Coverage for prior actions can become challenging in the event that a physician has a claims-made policy, which offers protection only while the policy is in effect. If a claims-made policy is discontinued, the doctor must obtain "tail" coverage to cover past actions. While the physician likely will have new coverage from the hospital or health system, many hospitals are self-insured and do not provide incoming physicians with prior act or so-called nose coverage.

Along with discussing tail coverage during a merger, doctors should also be wary of "anti-compete" clauses in contracts with larger hospitals and health systems. Such clauses prohibit physicians from working for a competitor and/or in close proximity to the hospital. Mr. Levy encourages physicians to include an exception to the non-compete clause in their contracts and discuss options in case the relationship fails.

"If not, you would be stuck and be prohibited from working in a nearby location and generating patients for your career," he said. "That’s a significant issue."

Antitrust requirements should also be high on physicians’ radar long before a transaction proceeds.

The Federal Trade Commission in January revised the thresholds that determine whether health care providers must notify federal antitrust authorities about pending transactions under the Hart-Scott-Rodino (HSR) Antitrust Improvements Act. The HSR Act requires companies to notify government agencies if the size of the parties at issue and the value of a transaction exceed the filing thresholds. The 2014 FTC revision raised the threshold for reporting proposed mergers and acquisitions from $70.9 million to $75.9 million.

"If notification is required and "you proceed to complete a transaction without filing the required notification, than you’re in violation of the antitrust law," said Christine White, chair of the American Health Lawyers Association’s Antitrust Practice Group and a staff attorney in the FTC’s Northeast Regional Office.

Potential antitrust violations can result in government investigations, fines, legal settlements, or other discipline. Ms. White suggests that physicians review guidance on the FTC’s website for more information about the HSR Act and other antitrust requirements, such as when it’s acceptable to share confidential information with competitors.

"Not every sale of a physician practice will raise significant antitrust concerns. In fact, the vast majority of physician practice group consolidations do not raise major antitrust concerns. But, in certain circumstances, such as if a practice group is selling to a direct competitor or a potential competitor, the antitrust concerns may merit serious consideration," she said.

Practice mergers with physician groups and larger health systems are becoming commonplace as more doctors trade in their shingles for fewer business burdens and more stability. But as with all transactions, selling or merging a medical practice comes with legal risks.

"There are numerous complex issues, legal and otherwise, that the seller of a medical practice needs to consider, both in preparations for the sale and during the transaction," wrote health law attorney David N. Vozza in a recent article for Kern Augustine Conroy & Schoppmann, a health care litigation firm with offices in the East Coast.

One of the most significant legal considerations pertains to the correct transfer of medical records during sales and mergers, Mr. Vozza said in an interview. To meet privacy requirements, all current patients must be advised that the practice is being transferred and they must have the opportunity to obtain their original records if they desire a new physician, he said. Records also must not be released to third parties without the patient’s express authorization. In addition, physicians run the risk of an "abandonment" lawsuit, if patient care is compromised because of the sale or merger.

"If you know a patient has a pressing care or treatment need, that can’t be delayed because you’re in the middle of a sale," Mr. Vozza said. "It can’t get lost in the shuffle of the transaction."

Another key consideration when merging practices is the assessment of liability cases, said Mathew J. Levy, a health law attorney and principal at Kern Augustine Conroy & Schoppmann and a coauthor of the risk management article. Physicians combining practices should be aware of any pending malpractice cases or audits of their potential partners.

"When merging with a larger group, you should be concerned with how they are doing internally," Mr. Levy said. "Are they under any audits or investigations? Have they been disciplined by the state licensure board? You have to make sure you’re not accountable for" their debts or malpractice issues.

Physicians should also consider the effect their merger may have on their malpractice insurance, Mr. Levy adds. Coverage for prior actions can become challenging in the event that a physician has a claims-made policy, which offers protection only while the policy is in effect. If a claims-made policy is discontinued, the doctor must obtain "tail" coverage to cover past actions. While the physician likely will have new coverage from the hospital or health system, many hospitals are self-insured and do not provide incoming physicians with prior act or so-called nose coverage.

Along with discussing tail coverage during a merger, doctors should also be wary of "anti-compete" clauses in contracts with larger hospitals and health systems. Such clauses prohibit physicians from working for a competitor and/or in close proximity to the hospital. Mr. Levy encourages physicians to include an exception to the non-compete clause in their contracts and discuss options in case the relationship fails.

"If not, you would be stuck and be prohibited from working in a nearby location and generating patients for your career," he said. "That’s a significant issue."

Antitrust requirements should also be high on physicians’ radar long before a transaction proceeds.

The Federal Trade Commission in January revised the thresholds that determine whether health care providers must notify federal antitrust authorities about pending transactions under the Hart-Scott-Rodino (HSR) Antitrust Improvements Act. The HSR Act requires companies to notify government agencies if the size of the parties at issue and the value of a transaction exceed the filing thresholds. The 2014 FTC revision raised the threshold for reporting proposed mergers and acquisitions from $70.9 million to $75.9 million.

"If notification is required and "you proceed to complete a transaction without filing the required notification, than you’re in violation of the antitrust law," said Christine White, chair of the American Health Lawyers Association’s Antitrust Practice Group and a staff attorney in the FTC’s Northeast Regional Office.

Potential antitrust violations can result in government investigations, fines, legal settlements, or other discipline. Ms. White suggests that physicians review guidance on the FTC’s website for more information about the HSR Act and other antitrust requirements, such as when it’s acceptable to share confidential information with competitors.

"Not every sale of a physician practice will raise significant antitrust concerns. In fact, the vast majority of physician practice group consolidations do not raise major antitrust concerns. But, in certain circumstances, such as if a practice group is selling to a direct competitor or a potential competitor, the antitrust concerns may merit serious consideration," she said.

Practice mergers with physician groups and larger health systems are becoming commonplace as more doctors trade in their shingles for fewer business burdens and more stability. But as with all transactions, selling or merging a medical practice comes with legal risks.

"There are numerous complex issues, legal and otherwise, that the seller of a medical practice needs to consider, both in preparations for the sale and during the transaction," wrote health law attorney David N. Vozza in a recent article for Kern Augustine Conroy & Schoppmann, a health care litigation firm with offices in the East Coast.

One of the most significant legal considerations pertains to the correct transfer of medical records during sales and mergers, Mr. Vozza said in an interview. To meet privacy requirements, all current patients must be advised that the practice is being transferred and they must have the opportunity to obtain their original records if they desire a new physician, he said. Records also must not be released to third parties without the patient’s express authorization. In addition, physicians run the risk of an "abandonment" lawsuit, if patient care is compromised because of the sale or merger.

"If you know a patient has a pressing care or treatment need, that can’t be delayed because you’re in the middle of a sale," Mr. Vozza said. "It can’t get lost in the shuffle of the transaction."

Another key consideration when merging practices is the assessment of liability cases, said Mathew J. Levy, a health law attorney and principal at Kern Augustine Conroy & Schoppmann and a coauthor of the risk management article. Physicians combining practices should be aware of any pending malpractice cases or audits of their potential partners.

"When merging with a larger group, you should be concerned with how they are doing internally," Mr. Levy said. "Are they under any audits or investigations? Have they been disciplined by the state licensure board? You have to make sure you’re not accountable for" their debts or malpractice issues.

Physicians should also consider the effect their merger may have on their malpractice insurance, Mr. Levy adds. Coverage for prior actions can become challenging in the event that a physician has a claims-made policy, which offers protection only while the policy is in effect. If a claims-made policy is discontinued, the doctor must obtain "tail" coverage to cover past actions. While the physician likely will have new coverage from the hospital or health system, many hospitals are self-insured and do not provide incoming physicians with prior act or so-called nose coverage.

Along with discussing tail coverage during a merger, doctors should also be wary of "anti-compete" clauses in contracts with larger hospitals and health systems. Such clauses prohibit physicians from working for a competitor and/or in close proximity to the hospital. Mr. Levy encourages physicians to include an exception to the non-compete clause in their contracts and discuss options in case the relationship fails.

"If not, you would be stuck and be prohibited from working in a nearby location and generating patients for your career," he said. "That’s a significant issue."

Antitrust requirements should also be high on physicians’ radar long before a transaction proceeds.

The Federal Trade Commission in January revised the thresholds that determine whether health care providers must notify federal antitrust authorities about pending transactions under the Hart-Scott-Rodino (HSR) Antitrust Improvements Act. The HSR Act requires companies to notify government agencies if the size of the parties at issue and the value of a transaction exceed the filing thresholds. The 2014 FTC revision raised the threshold for reporting proposed mergers and acquisitions from $70.9 million to $75.9 million.

"If notification is required and "you proceed to complete a transaction without filing the required notification, than you’re in violation of the antitrust law," said Christine White, chair of the American Health Lawyers Association’s Antitrust Practice Group and a staff attorney in the FTC’s Northeast Regional Office.

Potential antitrust violations can result in government investigations, fines, legal settlements, or other discipline. Ms. White suggests that physicians review guidance on the FTC’s website for more information about the HSR Act and other antitrust requirements, such as when it’s acceptable to share confidential information with competitors.

"Not every sale of a physician practice will raise significant antitrust concerns. In fact, the vast majority of physician practice group consolidations do not raise major antitrust concerns. But, in certain circumstances, such as if a practice group is selling to a direct competitor or a potential competitor, the antitrust concerns may merit serious consideration," she said.

BOSTON – Relaxing eligibility criteria for cytoreductive surgery may improve overall survival among patients with carcinoid metastases to the liver, investigators report.

Lowering the debulking threshold from 90% to 70% and including patients with intermediate-grade disease and/or extrahepatic disease resulted in 5-year overall survival rates of 90%, compared with 61%-74% rates reported by other treatment centers, said Dr. Amanda N. Graff-Baker, a surgical oncology resident at the Oregon Health and Science University (OHSU), Portland.

Neil Osterweil/Frontline Medical News

"The use of expanded criteria would substantially increase the number of patients eligible for debulking without compromising survival," she reported at the annual meeting of the American Association of Endocrine Surgeons.

Carcinoid tumors, a subset of neuroendocrine tumors, originate in the enterochromaffin cells of the aerodigestive tract. Approximately 60% of these tumors occur in the gastrointestinal tract, most commonly in the small intestine.

Approximately 60%-80% of patients with small bowel carcinoid tumors will have metastases to the liver, with liver failure from hepatic replacement by tumor being the most common cause of death, she explained.

Although there are no standardized patient selection criteria for liver debulking surgery in these patients, many U.S. centers follow NANETS (North American Neuroendocrine Tumor Society) treatment guidelines, which recommend surgical excision of at least 90% of all visible tumor. In addition, many centers choose not to offer cytoreductive surgery to patients with extrahepatic disease, Dr. Graff-Baker said.

Using these criteria, centers have reported 5-year survival rates ranging from 61% to 74%, but only about 20% of patients with carcinoid metastases to the liver are eligible for resection.

The investigators hypothesized that expanded eligibility criteria used at OHSU for several years could improve both liver progression-free and disease-specific survival rates. The criteria include a lower liver debulking threshold (70% or greater) and allow inclusion of patients with extrahepatic disease and/or intermediate-grade tumors.

They tested this idea by reviewing records of patients with metastatic carcinoid tumors who underwent liver debulking procedures at their center from 2007 to 2011. A single pathologist rated the grade of primary and metastatic tumors, and investigators correlated clinical factors with outcomes.

They identified a total of 52 patients, ranging in age from 29 to 77 years. Of this group, 32 (62%) had carcinoid syndrome, and 34 (65%) had extrahepatic disease.

The patients underwent a total of 51 wedge resections and 16 anatomic resections.

The mean number of metastases resected was 22 (range, 1-131). The mean size of metastases was 3 cm (range, 0.3-16 cm).

On pathologic review, all primary tumors were found to be low grade, but one-third of patients had one or more intermediate-grade metastases, suggesting a significant degree of tumor heterogeneity, Dr. Graff-Baker said.

The median liver progression-free survival was 72 months. A comparison between patients with liver progression and those with stable liver disease showed that there were no significant differences between the groups in either the percentage of tumor resected, number of resections, tumor size, presence of one or more intermediate-grade metastases, or extrahepatic disease. The only factor associated with a significant difference between groups was age. The mean age of patients with stable disease was 60.1 years, compared with 52 years for patients with liver progression (P = .016).

A separate analysis by age confirmed the last finding, with patients 50 years and older having significantly better liver progression-free survival than patients under age 50 (P = .001).

The 5-year disease-specific survival rate among all patients was 90%. All deaths were due to liver failure caused by tumor progression.

An analysis of factors predicting disease-specific survival showed once again that older patients for a change fared better than their more youthful counterparts (P = .03).

"The number, size, grade, extent of resection, and presence of extrahepatic disease did not have an adverse impact on outcomes," Dr. Graff-Baker said.

The study was internally funded. Dr. Graff-Baker reported having no financial disclosures.

BOSTON – Relaxing eligibility criteria for cytoreductive surgery may improve overall survival among patients with carcinoid metastases to the liver, investigators report.

Lowering the debulking threshold from 90% to 70% and including patients with intermediate-grade disease and/or extrahepatic disease resulted in 5-year overall survival rates of 90%, compared with 61%-74% rates reported by other treatment centers, said Dr. Amanda N. Graff-Baker, a surgical oncology resident at the Oregon Health and Science University (OHSU), Portland.

Neil Osterweil/Frontline Medical News

"The use of expanded criteria would substantially increase the number of patients eligible for debulking without compromising survival," she reported at the annual meeting of the American Association of Endocrine Surgeons.

Carcinoid tumors, a subset of neuroendocrine tumors, originate in the enterochromaffin cells of the aerodigestive tract. Approximately 60% of these tumors occur in the gastrointestinal tract, most commonly in the small intestine.

Approximately 60%-80% of patients with small bowel carcinoid tumors will have metastases to the liver, with liver failure from hepatic replacement by tumor being the most common cause of death, she explained.

Although there are no standardized patient selection criteria for liver debulking surgery in these patients, many U.S. centers follow NANETS (North American Neuroendocrine Tumor Society) treatment guidelines, which recommend surgical excision of at least 90% of all visible tumor. In addition, many centers choose not to offer cytoreductive surgery to patients with extrahepatic disease, Dr. Graff-Baker said.

Using these criteria, centers have reported 5-year survival rates ranging from 61% to 74%, but only about 20% of patients with carcinoid metastases to the liver are eligible for resection.

The investigators hypothesized that expanded eligibility criteria used at OHSU for several years could improve both liver progression-free and disease-specific survival rates. The criteria include a lower liver debulking threshold (70% or greater) and allow inclusion of patients with extrahepatic disease and/or intermediate-grade tumors.

They tested this idea by reviewing records of patients with metastatic carcinoid tumors who underwent liver debulking procedures at their center from 2007 to 2011. A single pathologist rated the grade of primary and metastatic tumors, and investigators correlated clinical factors with outcomes.

They identified a total of 52 patients, ranging in age from 29 to 77 years. Of this group, 32 (62%) had carcinoid syndrome, and 34 (65%) had extrahepatic disease.

The patients underwent a total of 51 wedge resections and 16 anatomic resections.

The mean number of metastases resected was 22 (range, 1-131). The mean size of metastases was 3 cm (range, 0.3-16 cm).

On pathologic review, all primary tumors were found to be low grade, but one-third of patients had one or more intermediate-grade metastases, suggesting a significant degree of tumor heterogeneity, Dr. Graff-Baker said.

The median liver progression-free survival was 72 months. A comparison between patients with liver progression and those with stable liver disease showed that there were no significant differences between the groups in either the percentage of tumor resected, number of resections, tumor size, presence of one or more intermediate-grade metastases, or extrahepatic disease. The only factor associated with a significant difference between groups was age. The mean age of patients with stable disease was 60.1 years, compared with 52 years for patients with liver progression (P = .016).

A separate analysis by age confirmed the last finding, with patients 50 years and older having significantly better liver progression-free survival than patients under age 50 (P = .001).

The 5-year disease-specific survival rate among all patients was 90%. All deaths were due to liver failure caused by tumor progression.

An analysis of factors predicting disease-specific survival showed once again that older patients for a change fared better than their more youthful counterparts (P = .03).

"The number, size, grade, extent of resection, and presence of extrahepatic disease did not have an adverse impact on outcomes," Dr. Graff-Baker said.

The study was internally funded. Dr. Graff-Baker reported having no financial disclosures.

BOSTON – Relaxing eligibility criteria for cytoreductive surgery may improve overall survival among patients with carcinoid metastases to the liver, investigators report.

Lowering the debulking threshold from 90% to 70% and including patients with intermediate-grade disease and/or extrahepatic disease resulted in 5-year overall survival rates of 90%, compared with 61%-74% rates reported by other treatment centers, said Dr. Amanda N. Graff-Baker, a surgical oncology resident at the Oregon Health and Science University (OHSU), Portland.

Neil Osterweil/Frontline Medical News

"The use of expanded criteria would substantially increase the number of patients eligible for debulking without compromising survival," she reported at the annual meeting of the American Association of Endocrine Surgeons.

Carcinoid tumors, a subset of neuroendocrine tumors, originate in the enterochromaffin cells of the aerodigestive tract. Approximately 60% of these tumors occur in the gastrointestinal tract, most commonly in the small intestine.

Approximately 60%-80% of patients with small bowel carcinoid tumors will have metastases to the liver, with liver failure from hepatic replacement by tumor being the most common cause of death, she explained.

Although there are no standardized patient selection criteria for liver debulking surgery in these patients, many U.S. centers follow NANETS (North American Neuroendocrine Tumor Society) treatment guidelines, which recommend surgical excision of at least 90% of all visible tumor. In addition, many centers choose not to offer cytoreductive surgery to patients with extrahepatic disease, Dr. Graff-Baker said.

Using these criteria, centers have reported 5-year survival rates ranging from 61% to 74%, but only about 20% of patients with carcinoid metastases to the liver are eligible for resection.

The investigators hypothesized that expanded eligibility criteria used at OHSU for several years could improve both liver progression-free and disease-specific survival rates. The criteria include a lower liver debulking threshold (70% or greater) and allow inclusion of patients with extrahepatic disease and/or intermediate-grade tumors.

They tested this idea by reviewing records of patients with metastatic carcinoid tumors who underwent liver debulking procedures at their center from 2007 to 2011. A single pathologist rated the grade of primary and metastatic tumors, and investigators correlated clinical factors with outcomes.

They identified a total of 52 patients, ranging in age from 29 to 77 years. Of this group, 32 (62%) had carcinoid syndrome, and 34 (65%) had extrahepatic disease.

The patients underwent a total of 51 wedge resections and 16 anatomic resections.

The mean number of metastases resected was 22 (range, 1-131). The mean size of metastases was 3 cm (range, 0.3-16 cm).

On pathologic review, all primary tumors were found to be low grade, but one-third of patients had one or more intermediate-grade metastases, suggesting a significant degree of tumor heterogeneity, Dr. Graff-Baker said.

The median liver progression-free survival was 72 months. A comparison between patients with liver progression and those with stable liver disease showed that there were no significant differences between the groups in either the percentage of tumor resected, number of resections, tumor size, presence of one or more intermediate-grade metastases, or extrahepatic disease. The only factor associated with a significant difference between groups was age. The mean age of patients with stable disease was 60.1 years, compared with 52 years for patients with liver progression (P = .016).

A separate analysis by age confirmed the last finding, with patients 50 years and older having significantly better liver progression-free survival than patients under age 50 (P = .001).

The 5-year disease-specific survival rate among all patients was 90%. All deaths were due to liver failure caused by tumor progression.

An analysis of factors predicting disease-specific survival showed once again that older patients for a change fared better than their more youthful counterparts (P = .03).

"The number, size, grade, extent of resection, and presence of extrahepatic disease did not have an adverse impact on outcomes," Dr. Graff-Baker said.

The study was internally funded. Dr. Graff-Baker reported having no financial disclosures.

Caps on noneconomic damages in medical malpractice cases are coming under fire by courts, legislators, and trial attorneys in a number of states.

In March, the Florida Supreme Court struck down the state’s $1 million cap on noneconomic damages.

© BanksPhotos/iStockphoto

Meanwhile, a proposed ballot measure in California aims to quadruple that state’s $250,000 cap. And Missouri doctors are pushing to reinstate their state’s noneconomic damages cap after a court overturned the $350,000 limit in 2012.

"The courts have always swung back and forth in some states [on upholding caps], and that probably won’t change," said William Encinosa, Ph.D., a senior economist for the Center for Delivery, Organization and Markets at the Agency for Healthcare Research and Quality (AHRQ). "However, on the legislative side, as more states reform their Medicaid, they may be willing to pass caps to contain costs."

Close to 30 states limit award damages in medical malpractice cases; however, cap amounts and their application vary. For example, Texas caps pain and suffering at $250,000, while Nebraska has a $1.75 million limit on total damages. At least 16 state courts have upheld a noneconomic or total damages cap as constitutional, according to American Medical Association data. Judges in at least 12 states however, have overturned caps.

Florida physicians were disappointed to lose the wrongful death damages cap, said Jeff Scott, director for legal and government affairs for the Florida Medical Association. Since its enactment, the cap helped stabilize premiums in Florida and has supported the return of a number of liability insurers returning to the state, he said.

"We thought [the opinion] was fully reasoned and fully decided," Mr. Scott said in an interview. "It was unfortunate. Our Supreme Court has been on a roll of striking down good tort reform legislation and this wasn’t a very big surprise."

The Missouri Supreme Court ruled similarly in July 2012 when it threw out the state’s noneconomic damages cap. A doctor-backed bill that would restore the $350,000 limit passed the Missouri House in March. The state Senate discussed the proposed law in April, but had not reached an agreement by this article’s deadline.

California physicians also are defending the damages cap law in their state – the Medical Injury Compensation Reform Act (MICRA). The law has survived numerous legal challenges, but now faces a proposed ballot initiative that would significantly elevate the cap. California plaintiffs’ attorneys and other MICRA critics are advocating a ballot measure that would increase the noneconomic damage award to roughly $1 million. Trial attorneys filed signatures with county registrars in March to qualify the measure for the November ballot.

"The proposed ballot measure would increase costs for everyone in California," California Medical Association President Dr. Richard Thorp said in a statement. "This initiative would take money directly out of the health care delivery system and put it straight into the pockets of trial attorneys. That’s why such a broad coalition, including doctors, nurses, hospitals, community clinics, dentists, labor, local government and hundreds of others are all in opposition."

Kansas physicians, meanwhile, are applauding a new law that raises Kansas’ damages cap, but keeps it intact. The Kansas Supreme Court upheld the state’s $250,000 medical malpractice noneconomic damages limit in 2012, but the opinion warned the Legislature should raise the cap or face a likely reversal in the future, said Rachelle Colombo, director of government affairs for the Kansas Medical Society. To prevent this from happening, KMS led the creation of SB 311, a law that would gradually increase the cap to $350,000 over an 8-year span. The law was signed by Gov. Sam Brownback (R) on April 18.

"We’re thrilled," Ms. Colombo said in an interview. "It is very significant and provides stability for physicians in Kansas for decades to come. [The cap] has been the cornerstone of our positive malpractice environment. It has allowed for premiums to significantly decrease and we’ve seen physicians who have crossed over state lines to practice in Kansas."

Studies evaluating malpractice damages caps have found varying degrees of impact. A 2007 metaanalysis of more than 20 studies found nearly all rigorous, empirical studies conducted since 1990 have found that malpractice premiums are lower in the presence of damages caps (Milbank Q. 2007;85:259-86). A 2003 study by AHRQ researchers found that states with noneconomic damages caps had 12% more physicians per capita than did those without; however, states with relatively high caps were less likely to experience the same effect on physician supply.

Mr. Encinosa, a coauthor of the AHRQ study, said it’s clear that lower caps positively impact the medical malpractice environment for doctors.

"The high caps just limit the case with very large noneconomic damage verdicts," he said in an interview. "These cases are often only found among a handful of high-risk physicians, and so don’t impact a lot of physicians. The lower caps impact more physicians and thus encourage them to engage in less-defensive medicine. There are litigation savings as well as savings from reduced defensive medicine under lower caps."

Caps on noneconomic damages in medical malpractice cases are coming under fire by courts, legislators, and trial attorneys in a number of states.

In March, the Florida Supreme Court struck down the state’s $1 million cap on noneconomic damages.

© BanksPhotos/iStockphoto

Meanwhile, a proposed ballot measure in California aims to quadruple that state’s $250,000 cap. And Missouri doctors are pushing to reinstate their state’s noneconomic damages cap after a court overturned the $350,000 limit in 2012.

"The courts have always swung back and forth in some states [on upholding caps], and that probably won’t change," said William Encinosa, Ph.D., a senior economist for the Center for Delivery, Organization and Markets at the Agency for Healthcare Research and Quality (AHRQ). "However, on the legislative side, as more states reform their Medicaid, they may be willing to pass caps to contain costs."

Close to 30 states limit award damages in medical malpractice cases; however, cap amounts and their application vary. For example, Texas caps pain and suffering at $250,000, while Nebraska has a $1.75 million limit on total damages. At least 16 state courts have upheld a noneconomic or total damages cap as constitutional, according to American Medical Association data. Judges in at least 12 states however, have overturned caps.

Florida physicians were disappointed to lose the wrongful death damages cap, said Jeff Scott, director for legal and government affairs for the Florida Medical Association. Since its enactment, the cap helped stabilize premiums in Florida and has supported the return of a number of liability insurers returning to the state, he said.

"We thought [the opinion] was fully reasoned and fully decided," Mr. Scott said in an interview. "It was unfortunate. Our Supreme Court has been on a roll of striking down good tort reform legislation and this wasn’t a very big surprise."

The Missouri Supreme Court ruled similarly in July 2012 when it threw out the state’s noneconomic damages cap. A doctor-backed bill that would restore the $350,000 limit passed the Missouri House in March. The state Senate discussed the proposed law in April, but had not reached an agreement by this article’s deadline.

California physicians also are defending the damages cap law in their state – the Medical Injury Compensation Reform Act (MICRA). The law has survived numerous legal challenges, but now faces a proposed ballot initiative that would significantly elevate the cap. California plaintiffs’ attorneys and other MICRA critics are advocating a ballot measure that would increase the noneconomic damage award to roughly $1 million. Trial attorneys filed signatures with county registrars in March to qualify the measure for the November ballot.

"The proposed ballot measure would increase costs for everyone in California," California Medical Association President Dr. Richard Thorp said in a statement. "This initiative would take money directly out of the health care delivery system and put it straight into the pockets of trial attorneys. That’s why such a broad coalition, including doctors, nurses, hospitals, community clinics, dentists, labor, local government and hundreds of others are all in opposition."

Kansas physicians, meanwhile, are applauding a new law that raises Kansas’ damages cap, but keeps it intact. The Kansas Supreme Court upheld the state’s $250,000 medical malpractice noneconomic damages limit in 2012, but the opinion warned the Legislature should raise the cap or face a likely reversal in the future, said Rachelle Colombo, director of government affairs for the Kansas Medical Society. To prevent this from happening, KMS led the creation of SB 311, a law that would gradually increase the cap to $350,000 over an 8-year span. The law was signed by Gov. Sam Brownback (R) on April 18.

"We’re thrilled," Ms. Colombo said in an interview. "It is very significant and provides stability for physicians in Kansas for decades to come. [The cap] has been the cornerstone of our positive malpractice environment. It has allowed for premiums to significantly decrease and we’ve seen physicians who have crossed over state lines to practice in Kansas."

Studies evaluating malpractice damages caps have found varying degrees of impact. A 2007 metaanalysis of more than 20 studies found nearly all rigorous, empirical studies conducted since 1990 have found that malpractice premiums are lower in the presence of damages caps (Milbank Q. 2007;85:259-86). A 2003 study by AHRQ researchers found that states with noneconomic damages caps had 12% more physicians per capita than did those without; however, states with relatively high caps were less likely to experience the same effect on physician supply.

Mr. Encinosa, a coauthor of the AHRQ study, said it’s clear that lower caps positively impact the medical malpractice environment for doctors.

"The high caps just limit the case with very large noneconomic damage verdicts," he said in an interview. "These cases are often only found among a handful of high-risk physicians, and so don’t impact a lot of physicians. The lower caps impact more physicians and thus encourage them to engage in less-defensive medicine. There are litigation savings as well as savings from reduced defensive medicine under lower caps."

Caps on noneconomic damages in medical malpractice cases are coming under fire by courts, legislators, and trial attorneys in a number of states.

In March, the Florida Supreme Court struck down the state’s $1 million cap on noneconomic damages.

© BanksPhotos/iStockphoto

Meanwhile, a proposed ballot measure in California aims to quadruple that state’s $250,000 cap. And Missouri doctors are pushing to reinstate their state’s noneconomic damages cap after a court overturned the $350,000 limit in 2012.

"The courts have always swung back and forth in some states [on upholding caps], and that probably won’t change," said William Encinosa, Ph.D., a senior economist for the Center for Delivery, Organization and Markets at the Agency for Healthcare Research and Quality (AHRQ). "However, on the legislative side, as more states reform their Medicaid, they may be willing to pass caps to contain costs."

Close to 30 states limit award damages in medical malpractice cases; however, cap amounts and their application vary. For example, Texas caps pain and suffering at $250,000, while Nebraska has a $1.75 million limit on total damages. At least 16 state courts have upheld a noneconomic or total damages cap as constitutional, according to American Medical Association data. Judges in at least 12 states however, have overturned caps.

Florida physicians were disappointed to lose the wrongful death damages cap, said Jeff Scott, director for legal and government affairs for the Florida Medical Association. Since its enactment, the cap helped stabilize premiums in Florida and has supported the return of a number of liability insurers returning to the state, he said.

"We thought [the opinion] was fully reasoned and fully decided," Mr. Scott said in an interview. "It was unfortunate. Our Supreme Court has been on a roll of striking down good tort reform legislation and this wasn’t a very big surprise."

The Missouri Supreme Court ruled similarly in July 2012 when it threw out the state’s noneconomic damages cap. A doctor-backed bill that would restore the $350,000 limit passed the Missouri House in March. The state Senate discussed the proposed law in April, but had not reached an agreement by this article’s deadline.

California physicians also are defending the damages cap law in their state – the Medical Injury Compensation Reform Act (MICRA). The law has survived numerous legal challenges, but now faces a proposed ballot initiative that would significantly elevate the cap. California plaintiffs’ attorneys and other MICRA critics are advocating a ballot measure that would increase the noneconomic damage award to roughly $1 million. Trial attorneys filed signatures with county registrars in March to qualify the measure for the November ballot.

"The proposed ballot measure would increase costs for everyone in California," California Medical Association President Dr. Richard Thorp said in a statement. "This initiative would take money directly out of the health care delivery system and put it straight into the pockets of trial attorneys. That’s why such a broad coalition, including doctors, nurses, hospitals, community clinics, dentists, labor, local government and hundreds of others are all in opposition."

Kansas physicians, meanwhile, are applauding a new law that raises Kansas’ damages cap, but keeps it intact. The Kansas Supreme Court upheld the state’s $250,000 medical malpractice noneconomic damages limit in 2012, but the opinion warned the Legislature should raise the cap or face a likely reversal in the future, said Rachelle Colombo, director of government affairs for the Kansas Medical Society. To prevent this from happening, KMS led the creation of SB 311, a law that would gradually increase the cap to $350,000 over an 8-year span. The law was signed by Gov. Sam Brownback (R) on April 18.

"We’re thrilled," Ms. Colombo said in an interview. "It is very significant and provides stability for physicians in Kansas for decades to come. [The cap] has been the cornerstone of our positive malpractice environment. It has allowed for premiums to significantly decrease and we’ve seen physicians who have crossed over state lines to practice in Kansas."

Studies evaluating malpractice damages caps have found varying degrees of impact. A 2007 metaanalysis of more than 20 studies found nearly all rigorous, empirical studies conducted since 1990 have found that malpractice premiums are lower in the presence of damages caps (Milbank Q. 2007;85:259-86). A 2003 study by AHRQ researchers found that states with noneconomic damages caps had 12% more physicians per capita than did those without; however, states with relatively high caps were less likely to experience the same effect on physician supply.

Mr. Encinosa, a coauthor of the AHRQ study, said it’s clear that lower caps positively impact the medical malpractice environment for doctors.

"The high caps just limit the case with very large noneconomic damage verdicts," he said in an interview. "These cases are often only found among a handful of high-risk physicians, and so don’t impact a lot of physicians. The lower caps impact more physicians and thus encourage them to engage in less-defensive medicine. There are litigation savings as well as savings from reduced defensive medicine under lower caps."

Resistance against the American Board of Internal Medicine’s maintenance of certification process is growing, with an online petition to overturn the board’s most recent changes having collected more than 13,000 signatures at press time.

The petition was organized by Dr. Paul Teirstein, chief of cardiology and director of interventional cardiology for Scripps Clinic in La Jolla, Calif.

Dr. Teirstein said that he began the drive out of his own sense of frustration with the ABIM maintenance of certification (MOC) requirements. He e-mailed some physicians he knew and encouraged them to sign. The petition went viral soon after being posted on March 20, Dr. Teirstein said.

Those who sign the petition agree that:

• ABIM has made unreasonable changes in MOC requiring more frequent participation and higher fees.

• Scientific data demonstrating the benefit of MOC is lacking.

• MOC activities are complex, of questionable value, and detract from other worthwhile pursuits, including patient care and other educational activities.

• A test administered every 10 years for recertification is a sufficient metric for MOC.

The bottom line: Petition signers want the ABIM to overhaul the process and require recertification once every 10 years.

The ABIM took the effort seriously enough to respond on its Web site.

"As medical knowledge and practices continue to change, a continuous MOC program tells the community that a physician is staying up-to-date, has met a knowledge standard established by his or her physician peers, and is engaged in ongoing assessment of his or her practice," Dr. Richard Baron, ABIM president, said in the statement.

Physicians who commented on the petition did not agree.

Dr. Jesse Naghi, a third-year fellow at the University of California, San Diego, Sulpizio Cardiovascular Center, wrote, "Asking for more money on top of our already high recertification fees seems rather greedy."

"This is an arm-twisting and money-making scam by our own board," said Dr. Garrett Sanford, of Little Rock, Ark.

"We do recognize that there is a cost – for the large majority of our physicians, the entire program costs from $200 to $400 per year," said Dr. Baron, in his statement. "Our fee structure covers the costs of developing and administering the secure, computer-based exams at test centers nationwide, as well as the ongoing development and release of all ABIM self-assessment products," he said, adding, "I encourage the petition signers to visit ABIM’s revenue and expenses [Web page] for more information."

Petition signers also claim that contrary to the board’s contention, neither patients nor payers value the MOC process nor are they demanding that physicians prove they’ve met the requirements. They also say that there is no evidence that MOC improves quality of care.

The board does not agree. "There is a good deal of research demonstrating the value of MOC. From the validity of the examination, to the importance of independent assessments – clinicians are not good at evaluating their own weaknesses," according to Dr. Baron’s statement.

Dr. Baron also promised that the ABIM would create more ways for physicians to earn credit.

The ABIM’s open letter shows that "the petition has definitely had an impact," Dr. Teirstein said.

Dr. Ron Benbassat, a cofounder of Change Board Certification, a group that wants to scale back the MOC, called Dr. Baron’s remarks a "boilerplate political statement."

Courtesy of Dr. Benbassat

The MOC "should be eliminated, given the numerous CME programs that exist that are not only cost effective, but are incredibly successful, and do not take time away from patient care," said Dr. Benbassat, a board-certified internist in Beverly Hills, Calif., who has completed MOC once already.

Dr. Benbassat and the physicians who have joined Change Board Certification, believe that MOC should not be associated with hospital privileges, insurance reimbursement, or network participation. It should not be required for maintenance of licensure either, said Dr. Benbassat, who is concerned that ABIM is discussing tying licensure to MOC.

Meanwhile, the Association of American Physicians and Surgeons has filed suit against the American Board of Medical Specialties, claiming that the MOC process is a restraint of trade because it will effectively keep doctors from practicing if they do not participate. The suit was filed in the U.S. District Court for the District of New Jersey on April 23, and seeks to stop what it calls the ABMS’s "continuing violations of antitrust law and misrepresentations about the medical skills of physicians who decline to purchase and spend time on its program."

The organization is also aiming to get a refund of fees paid by its members to ABMS and its 24 member boards.

[email protected]

On Twitter @aliciaault

Resistance against the American Board of Internal Medicine’s maintenance of certification process is growing, with an online petition to overturn the board’s most recent changes having collected more than 13,000 signatures at press time.

The petition was organized by Dr. Paul Teirstein, chief of cardiology and director of interventional cardiology for Scripps Clinic in La Jolla, Calif.

Dr. Teirstein said that he began the drive out of his own sense of frustration with the ABIM maintenance of certification (MOC) requirements. He e-mailed some physicians he knew and encouraged them to sign. The petition went viral soon after being posted on March 20, Dr. Teirstein said.

Those who sign the petition agree that:

• ABIM has made unreasonable changes in MOC requiring more frequent participation and higher fees.

• Scientific data demonstrating the benefit of MOC is lacking.

• MOC activities are complex, of questionable value, and detract from other worthwhile pursuits, including patient care and other educational activities.

• A test administered every 10 years for recertification is a sufficient metric for MOC.

The bottom line: Petition signers want the ABIM to overhaul the process and require recertification once every 10 years.

The ABIM took the effort seriously enough to respond on its Web site.

"As medical knowledge and practices continue to change, a continuous MOC program tells the community that a physician is staying up-to-date, has met a knowledge standard established by his or her physician peers, and is engaged in ongoing assessment of his or her practice," Dr. Richard Baron, ABIM president, said in the statement.

Physicians who commented on the petition did not agree.

Dr. Jesse Naghi, a third-year fellow at the University of California, San Diego, Sulpizio Cardiovascular Center, wrote, "Asking for more money on top of our already high recertification fees seems rather greedy."

"This is an arm-twisting and money-making scam by our own board," said Dr. Garrett Sanford, of Little Rock, Ark.

"We do recognize that there is a cost – for the large majority of our physicians, the entire program costs from $200 to $400 per year," said Dr. Baron, in his statement. "Our fee structure covers the costs of developing and administering the secure, computer-based exams at test centers nationwide, as well as the ongoing development and release of all ABIM self-assessment products," he said, adding, "I encourage the petition signers to visit ABIM’s revenue and expenses [Web page] for more information."

Petition signers also claim that contrary to the board’s contention, neither patients nor payers value the MOC process nor are they demanding that physicians prove they’ve met the requirements. They also say that there is no evidence that MOC improves quality of care.

The board does not agree. "There is a good deal of research demonstrating the value of MOC. From the validity of the examination, to the importance of independent assessments – clinicians are not good at evaluating their own weaknesses," according to Dr. Baron’s statement.

Dr. Baron also promised that the ABIM would create more ways for physicians to earn credit.

The ABIM’s open letter shows that "the petition has definitely had an impact," Dr. Teirstein said.

Dr. Ron Benbassat, a cofounder of Change Board Certification, a group that wants to scale back the MOC, called Dr. Baron’s remarks a "boilerplate political statement."

Courtesy of Dr. Benbassat

The MOC "should be eliminated, given the numerous CME programs that exist that are not only cost effective, but are incredibly successful, and do not take time away from patient care," said Dr. Benbassat, a board-certified internist in Beverly Hills, Calif., who has completed MOC once already.

Dr. Benbassat and the physicians who have joined Change Board Certification, believe that MOC should not be associated with hospital privileges, insurance reimbursement, or network participation. It should not be required for maintenance of licensure either, said Dr. Benbassat, who is concerned that ABIM is discussing tying licensure to MOC.

Meanwhile, the Association of American Physicians and Surgeons has filed suit against the American Board of Medical Specialties, claiming that the MOC process is a restraint of trade because it will effectively keep doctors from practicing if they do not participate. The suit was filed in the U.S. District Court for the District of New Jersey on April 23, and seeks to stop what it calls the ABMS’s "continuing violations of antitrust law and misrepresentations about the medical skills of physicians who decline to purchase and spend time on its program."

The organization is also aiming to get a refund of fees paid by its members to ABMS and its 24 member boards.

[email protected]

On Twitter @aliciaault

Resistance against the American Board of Internal Medicine’s maintenance of certification process is growing, with an online petition to overturn the board’s most recent changes having collected more than 13,000 signatures at press time.

The petition was organized by Dr. Paul Teirstein, chief of cardiology and director of interventional cardiology for Scripps Clinic in La Jolla, Calif.

Dr. Teirstein said that he began the drive out of his own sense of frustration with the ABIM maintenance of certification (MOC) requirements. He e-mailed some physicians he knew and encouraged them to sign. The petition went viral soon after being posted on March 20, Dr. Teirstein said.

Those who sign the petition agree that:

• ABIM has made unreasonable changes in MOC requiring more frequent participation and higher fees.

• Scientific data demonstrating the benefit of MOC is lacking.

• MOC activities are complex, of questionable value, and detract from other worthwhile pursuits, including patient care and other educational activities.

• A test administered every 10 years for recertification is a sufficient metric for MOC.

The bottom line: Petition signers want the ABIM to overhaul the process and require recertification once every 10 years.

The ABIM took the effort seriously enough to respond on its Web site.

"As medical knowledge and practices continue to change, a continuous MOC program tells the community that a physician is staying up-to-date, has met a knowledge standard established by his or her physician peers, and is engaged in ongoing assessment of his or her practice," Dr. Richard Baron, ABIM president, said in the statement.

Physicians who commented on the petition did not agree.

Dr. Jesse Naghi, a third-year fellow at the University of California, San Diego, Sulpizio Cardiovascular Center, wrote, "Asking for more money on top of our already high recertification fees seems rather greedy."

"This is an arm-twisting and money-making scam by our own board," said Dr. Garrett Sanford, of Little Rock, Ark.

"We do recognize that there is a cost – for the large majority of our physicians, the entire program costs from $200 to $400 per year," said Dr. Baron, in his statement. "Our fee structure covers the costs of developing and administering the secure, computer-based exams at test centers nationwide, as well as the ongoing development and release of all ABIM self-assessment products," he said, adding, "I encourage the petition signers to visit ABIM’s revenue and expenses [Web page] for more information."

Petition signers also claim that contrary to the board’s contention, neither patients nor payers value the MOC process nor are they demanding that physicians prove they’ve met the requirements. They also say that there is no evidence that MOC improves quality of care.

The board does not agree. "There is a good deal of research demonstrating the value of MOC. From the validity of the examination, to the importance of independent assessments – clinicians are not good at evaluating their own weaknesses," according to Dr. Baron’s statement.

Dr. Baron also promised that the ABIM would create more ways for physicians to earn credit.

The ABIM’s open letter shows that "the petition has definitely had an impact," Dr. Teirstein said.

Dr. Ron Benbassat, a cofounder of Change Board Certification, a group that wants to scale back the MOC, called Dr. Baron’s remarks a "boilerplate political statement."

Courtesy of Dr. Benbassat

The MOC "should be eliminated, given the numerous CME programs that exist that are not only cost effective, but are incredibly successful, and do not take time away from patient care," said Dr. Benbassat, a board-certified internist in Beverly Hills, Calif., who has completed MOC once already.

Dr. Benbassat and the physicians who have joined Change Board Certification, believe that MOC should not be associated with hospital privileges, insurance reimbursement, or network participation. It should not be required for maintenance of licensure either, said Dr. Benbassat, who is concerned that ABIM is discussing tying licensure to MOC.

Meanwhile, the Association of American Physicians and Surgeons has filed suit against the American Board of Medical Specialties, claiming that the MOC process is a restraint of trade because it will effectively keep doctors from practicing if they do not participate. The suit was filed in the U.S. District Court for the District of New Jersey on April 23, and seeks to stop what it calls the ABMS’s "continuing violations of antitrust law and misrepresentations about the medical skills of physicians who decline to purchase and spend time on its program."

The organization is also aiming to get a refund of fees paid by its members to ABMS and its 24 member boards.

[email protected]

On Twitter @aliciaault

CHICAGO – The use of a sodium hyaluronate–carboxycellulose adhesion barrier during primary cesarean delivery was not associated with decreased delivery time or improved adhesion scores during a first repeat cesarean delivery in a cohort study involving 97 women.

The incision to delivery time among 71 women who did not receive sodium hyaluronate–carboxycellulose (HA-CC) barrier film during their primary cesarean delivery was 9.5 minutes, compared with 10.6 minutes in 26 women who did receive HA-CC barrier film, Dr. Maria Gaspar-Oishi of the University of Hawaii, Honolulu, reported at the annual meeting of the American Congress of Obstetricians and Gynecologists.

Average blood loss and adhesion scores also were similar in the two groups. Blood loss was 564 mL and 563 mL, in the groups, respectively; mean fascia adhesion scores were 1.45 and 1.31; and mean intraperitoneal adhesion scores were 1.11 and 0.92, said Dr. Gaspar-Oishi, whose paper received a Donald F. Richardson Memorial Prize Paper award as one of the best papers by a junior fellow at the meeting.

Patients included in the combined prospective/retrospective cohort study were women who gave birth at a single center. Intraoperative data were collected prospectively at the time of first repeat cesarean delivery, and a retrospective chart study was performed for each subject to determine whether HA-CC barrier film was used during the primary cesarean delivery. The two study groups were similar with respect to age, body mass index, parity, and gestational age.

HA-CC barrier film is commonly used in gynecologic and other surgeries in an effort to reduce the risk of postoperative adhesions, which can result in significant morbidity – including pain, infertility, and bowel obstruction, Dr. Gaspar-Oishi said.

Data with respect to the use of HA-CC barrier film for cesarean delivery, however, are limited. In fact, this is the first prospective study to show that barrier film use does not improve delivery time or adhesion severity in subsequent cesarean deliveries, she noted.

The findings support a recent commentary in Obstetrics & Gynecology, which stated that the routine use of HA-CC barrier film is ill advised because of a lack of evidence regarding clinical benefit, she noted.

Although limited by the fact that about 80% of the women in the study were Asian American (an accurate reflection of the population served by the study hospital), the findings are nonetheless important, because an estimated 90% of all primary cesarean deliveries will result in a repeat cesarean delivery, and because HA-CC barrier film use can be costly, she said.

Additional study in a more diverse population is needed to allow for more generalized conclusions, she noted.

Dr. Gaspar-Oishi reported having no relevant financial disclosures.

CHICAGO – The use of a sodium hyaluronate–carboxycellulose adhesion barrier during primary cesarean delivery was not associated with decreased delivery time or improved adhesion scores during a first repeat cesarean delivery in a cohort study involving 97 women.

The incision to delivery time among 71 women who did not receive sodium hyaluronate–carboxycellulose (HA-CC) barrier film during their primary cesarean delivery was 9.5 minutes, compared with 10.6 minutes in 26 women who did receive HA-CC barrier film, Dr. Maria Gaspar-Oishi of the University of Hawaii, Honolulu, reported at the annual meeting of the American Congress of Obstetricians and Gynecologists.

Average blood loss and adhesion scores also were similar in the two groups. Blood loss was 564 mL and 563 mL, in the groups, respectively; mean fascia adhesion scores were 1.45 and 1.31; and mean intraperitoneal adhesion scores were 1.11 and 0.92, said Dr. Gaspar-Oishi, whose paper received a Donald F. Richardson Memorial Prize Paper award as one of the best papers by a junior fellow at the meeting.

Patients included in the combined prospective/retrospective cohort study were women who gave birth at a single center. Intraoperative data were collected prospectively at the time of first repeat cesarean delivery, and a retrospective chart study was performed for each subject to determine whether HA-CC barrier film was used during the primary cesarean delivery. The two study groups were similar with respect to age, body mass index, parity, and gestational age.

HA-CC barrier film is commonly used in gynecologic and other surgeries in an effort to reduce the risk of postoperative adhesions, which can result in significant morbidity – including pain, infertility, and bowel obstruction, Dr. Gaspar-Oishi said.

Data with respect to the use of HA-CC barrier film for cesarean delivery, however, are limited. In fact, this is the first prospective study to show that barrier film use does not improve delivery time or adhesion severity in subsequent cesarean deliveries, she noted.

The findings support a recent commentary in Obstetrics & Gynecology, which stated that the routine use of HA-CC barrier film is ill advised because of a lack of evidence regarding clinical benefit, she noted.

Although limited by the fact that about 80% of the women in the study were Asian American (an accurate reflection of the population served by the study hospital), the findings are nonetheless important, because an estimated 90% of all primary cesarean deliveries will result in a repeat cesarean delivery, and because HA-CC barrier film use can be costly, she said.

Additional study in a more diverse population is needed to allow for more generalized conclusions, she noted.

Dr. Gaspar-Oishi reported having no relevant financial disclosures.

CHICAGO – The use of a sodium hyaluronate–carboxycellulose adhesion barrier during primary cesarean delivery was not associated with decreased delivery time or improved adhesion scores during a first repeat cesarean delivery in a cohort study involving 97 women.

The incision to delivery time among 71 women who did not receive sodium hyaluronate–carboxycellulose (HA-CC) barrier film during their primary cesarean delivery was 9.5 minutes, compared with 10.6 minutes in 26 women who did receive HA-CC barrier film, Dr. Maria Gaspar-Oishi of the University of Hawaii, Honolulu, reported at the annual meeting of the American Congress of Obstetricians and Gynecologists.

Average blood loss and adhesion scores also were similar in the two groups. Blood loss was 564 mL and 563 mL, in the groups, respectively; mean fascia adhesion scores were 1.45 and 1.31; and mean intraperitoneal adhesion scores were 1.11 and 0.92, said Dr. Gaspar-Oishi, whose paper received a Donald F. Richardson Memorial Prize Paper award as one of the best papers by a junior fellow at the meeting.

Patients included in the combined prospective/retrospective cohort study were women who gave birth at a single center. Intraoperative data were collected prospectively at the time of first repeat cesarean delivery, and a retrospective chart study was performed for each subject to determine whether HA-CC barrier film was used during the primary cesarean delivery. The two study groups were similar with respect to age, body mass index, parity, and gestational age.

HA-CC barrier film is commonly used in gynecologic and other surgeries in an effort to reduce the risk of postoperative adhesions, which can result in significant morbidity – including pain, infertility, and bowel obstruction, Dr. Gaspar-Oishi said.

Data with respect to the use of HA-CC barrier film for cesarean delivery, however, are limited. In fact, this is the first prospective study to show that barrier film use does not improve delivery time or adhesion severity in subsequent cesarean deliveries, she noted.

The findings support a recent commentary in Obstetrics & Gynecology, which stated that the routine use of HA-CC barrier film is ill advised because of a lack of evidence regarding clinical benefit, she noted.

Although limited by the fact that about 80% of the women in the study were Asian American (an accurate reflection of the population served by the study hospital), the findings are nonetheless important, because an estimated 90% of all primary cesarean deliveries will result in a repeat cesarean delivery, and because HA-CC barrier film use can be costly, she said.

Additional study in a more diverse population is needed to allow for more generalized conclusions, she noted.

Dr. Gaspar-Oishi reported having no relevant financial disclosures.

A new subspecialty is drawing physicians from diverse medical backgrounds and career settings who aim to combine informatics with providing health care. More than 400 physicians recently became board certified in clinical informatics – the first class of diplomates in the freshly minted subspecialty.

Clinical informatics (CI) has "now become a subspecialty because there are so many people who believe it’s important," said Dr. William Hersh, an internist and chair of the department of medical informatics and clinical epidemiology at Oregon Health and Science University, Portland.

"More and more health care organizations and certainly, almost every large health care organization, have someone who plays the role of chief medical informatics officer. By having a subspecialty, you then give professional recognition to those physicians who play this role. It really takes expertise by someone who understands medicine and understands information systems to make sure things run smoothly."

CI is the application of informatics and information technology to the delivery of health care services. The domain includes a wide spectrum of areas including clinical documentation, order entry systems, system design, system implementation, and adoption issues. While already incorporated into many practices, CI was not a recognized subspecialty until it was approved by the American Board of Medical Specialties in 2011. The American Medical Informatics Association (AMIA) spearheaded the new subspecialty, working for more than 5 years to define and help design the discipline. Physicians who are board certified by any of the 24 American Board of Medical Specialties (ABMS) member boards can now also certify in CI through an exam offered by the American Board of Preventive Medicine. In December 2013, 455 new subspecialists across the country became certified.

One of those alumni is Dr. Hersh, who also serves as director of the AMIA’s clinical informatics board review course.

"I’m proud to be a part of the pioneer class of leaders in this field," Dr. Hersh said in a statement. "When you look at the Accreditation Council for Graduate Medical Education’s (ACGME’s) definition of the informatics discipline, the operative word is ‘transform.’ Every day, informaticians are working in their health care settings to change how we do things, to improve patient care and population health."

Having a far-reaching, positive impact on health populations has long been a primary objective of Dr. Katherine Schneider, a family physician who recently became CI certified. The Pennsylvania doctor started her medical career as the head of a community medicine program, accessing outreach initiatives and working to improve care for the uninsured. She then took on a senior vice president position at AtlantiCare, where she led the system’s strategic transformational work toward accountable care. Dr. Schneider did not hesitate when she learned of the opportunity to become board certified in CI.

"It’s the birth of a new specialty; why not get involved at the very beginning?" said Dr. Schneider, who now serves as chief medical officer for Medecision, a national provider of health care management solutions. CI "by definition, it’s in my everyday work. It’s my role to help make sure we are helping customers use this correctly, understand what our pain points are, and build the right kind of tools to solve problems of effectiveness and efficiency."

Along with bringing new information and technology terms to her current position, her CI training has enabled Dr. Schneider to expand her professional network of clinical informaticians and industry experts, she said.

"One really great benefit is that you meet other people that either do something similar to you or understand the role that you’re in," she said. "Having that peer network is going to be really nice. It’s nice to have recognition that you have expertise in a field. It’s fun to be there at the beginning and participate in the debate about what’s relevant and where it’s going to be in a few years."

Vanderbilt University Medical Center

For other recently certified physicians, the subspecialty is a door to countless professional paths.

"I became certified to update my skill set and expand my career options," said Dr. Gretchen Purcell Jackson, of the department of pediatric surgery at Vanderbilt University Medical Center, Nashville, Tenn. "I found the quality improvement and project management part of the certification really useful."

In her current practice, Dr. Jackson’s CI training aids in a range of projects, such as helping with a grant she received to study information needs and information management practices of pregnant women and their caregivers.

"The project management aspect of my CI training has been very useful in helping me organize a large clinical study," said Dr. Jackson, who has a PhD in medical information sciences from Stanford (Calif.) University. In addition, "I have recently been asked to help oversee a project that involves coordinating the efforts and technologies from Vanderbilt health information systems, a corporate partner, a non-profit research foundation, and a large funded research project. I use every aspect of my CI training to guide this project. It requires leadership, project management, quality improvement, and clinical and technological expertise."

Meanwhile, Dr. Peter Killoran, a Texas anesthesiologist, is using his CI training to help track patient outcomes and evaluate data for the University of Texas Health Science Center at Houston, School of Biomedical Informatics. Dr. Killoran’s work includes improving health care quality and safety through health information technology and biomedical informatics.

"Quality improvement is a big part of the curriculum for this specialty," said Dr. Killoran, an assistant professor of anesthesiology at the UTHealth Medical School. "That’s because increasingly, medicine is focusing on improving outcomes and the rational use of heath care resources, and all of that comes down to the data."

As the field of CI continues to grow, health providers are needed to participate in the subspecialty and add their voices, said Dr. Genevieve Melton-Meaux, of the department of surgery at the University of Minnesota, Minneapolis, and a faculty fellow for the university’s Institute for Health Informatics. She was recently CI certified.

"The electronic health record and health information technology are the ‘nervous system’ of clinical care," she said. "There are important opportunities to improve the design, implementation, optimization, and use of these technologies and their resultant data, which will ultimately help to improve the efficiency and safety of health care, as well as improve the process of clinical discovery."

A new subspecialty is drawing physicians from diverse medical backgrounds and career settings who aim to combine informatics with providing health care. More than 400 physicians recently became board certified in clinical informatics – the first class of diplomates in the freshly minted subspecialty.

Clinical informatics (CI) has "now become a subspecialty because there are so many people who believe it’s important," said Dr. William Hersh, an internist and chair of the department of medical informatics and clinical epidemiology at Oregon Health and Science University, Portland.

"More and more health care organizations and certainly, almost every large health care organization, have someone who plays the role of chief medical informatics officer. By having a subspecialty, you then give professional recognition to those physicians who play this role. It really takes expertise by someone who understands medicine and understands information systems to make sure things run smoothly."

CI is the application of informatics and information technology to the delivery of health care services. The domain includes a wide spectrum of areas including clinical documentation, order entry systems, system design, system implementation, and adoption issues. While already incorporated into many practices, CI was not a recognized subspecialty until it was approved by the American Board of Medical Specialties in 2011. The American Medical Informatics Association (AMIA) spearheaded the new subspecialty, working for more than 5 years to define and help design the discipline. Physicians who are board certified by any of the 24 American Board of Medical Specialties (ABMS) member boards can now also certify in CI through an exam offered by the American Board of Preventive Medicine. In December 2013, 455 new subspecialists across the country became certified.

One of those alumni is Dr. Hersh, who also serves as director of the AMIA’s clinical informatics board review course.

"I’m proud to be a part of the pioneer class of leaders in this field," Dr. Hersh said in a statement. "When you look at the Accreditation Council for Graduate Medical Education’s (ACGME’s) definition of the informatics discipline, the operative word is ‘transform.’ Every day, informaticians are working in their health care settings to change how we do things, to improve patient care and population health."

Having a far-reaching, positive impact on health populations has long been a primary objective of Dr. Katherine Schneider, a family physician who recently became CI certified. The Pennsylvania doctor started her medical career as the head of a community medicine program, accessing outreach initiatives and working to improve care for the uninsured. She then took on a senior vice president position at AtlantiCare, where she led the system’s strategic transformational work toward accountable care. Dr. Schneider did not hesitate when she learned of the opportunity to become board certified in CI.

"It’s the birth of a new specialty; why not get involved at the very beginning?" said Dr. Schneider, who now serves as chief medical officer for Medecision, a national provider of health care management solutions. CI "by definition, it’s in my everyday work. It’s my role to help make sure we are helping customers use this correctly, understand what our pain points are, and build the right kind of tools to solve problems of effectiveness and efficiency."

Along with bringing new information and technology terms to her current position, her CI training has enabled Dr. Schneider to expand her professional network of clinical informaticians and industry experts, she said.

"One really great benefit is that you meet other people that either do something similar to you or understand the role that you’re in," she said. "Having that peer network is going to be really nice. It’s nice to have recognition that you have expertise in a field. It’s fun to be there at the beginning and participate in the debate about what’s relevant and where it’s going to be in a few years."

Vanderbilt University Medical Center

For other recently certified physicians, the subspecialty is a door to countless professional paths.

"I became certified to update my skill set and expand my career options," said Dr. Gretchen Purcell Jackson, of the department of pediatric surgery at Vanderbilt University Medical Center, Nashville, Tenn. "I found the quality improvement and project management part of the certification really useful."

In her current practice, Dr. Jackson’s CI training aids in a range of projects, such as helping with a grant she received to study information needs and information management practices of pregnant women and their caregivers.

"The project management aspect of my CI training has been very useful in helping me organize a large clinical study," said Dr. Jackson, who has a PhD in medical information sciences from Stanford (Calif.) University. In addition, "I have recently been asked to help oversee a project that involves coordinating the efforts and technologies from Vanderbilt health information systems, a corporate partner, a non-profit research foundation, and a large funded research project. I use every aspect of my CI training to guide this project. It requires leadership, project management, quality improvement, and clinical and technological expertise."

Meanwhile, Dr. Peter Killoran, a Texas anesthesiologist, is using his CI training to help track patient outcomes and evaluate data for the University of Texas Health Science Center at Houston, School of Biomedical Informatics. Dr. Killoran’s work includes improving health care quality and safety through health information technology and biomedical informatics.

"Quality improvement is a big part of the curriculum for this specialty," said Dr. Killoran, an assistant professor of anesthesiology at the UTHealth Medical School. "That’s because increasingly, medicine is focusing on improving outcomes and the rational use of heath care resources, and all of that comes down to the data."

As the field of CI continues to grow, health providers are needed to participate in the subspecialty and add their voices, said Dr. Genevieve Melton-Meaux, of the department of surgery at the University of Minnesota, Minneapolis, and a faculty fellow for the university’s Institute for Health Informatics. She was recently CI certified.

"The electronic health record and health information technology are the ‘nervous system’ of clinical care," she said. "There are important opportunities to improve the design, implementation, optimization, and use of these technologies and their resultant data, which will ultimately help to improve the efficiency and safety of health care, as well as improve the process of clinical discovery."

A new subspecialty is drawing physicians from diverse medical backgrounds and career settings who aim to combine informatics with providing health care. More than 400 physicians recently became board certified in clinical informatics – the first class of diplomates in the freshly minted subspecialty.

Clinical informatics (CI) has "now become a subspecialty because there are so many people who believe it’s important," said Dr. William Hersh, an internist and chair of the department of medical informatics and clinical epidemiology at Oregon Health and Science University, Portland.

"More and more health care organizations and certainly, almost every large health care organization, have someone who plays the role of chief medical informatics officer. By having a subspecialty, you then give professional recognition to those physicians who play this role. It really takes expertise by someone who understands medicine and understands information systems to make sure things run smoothly."

CI is the application of informatics and information technology to the delivery of health care services. The domain includes a wide spectrum of areas including clinical documentation, order entry systems, system design, system implementation, and adoption issues. While already incorporated into many practices, CI was not a recognized subspecialty until it was approved by the American Board of Medical Specialties in 2011. The American Medical Informatics Association (AMIA) spearheaded the new subspecialty, working for more than 5 years to define and help design the discipline. Physicians who are board certified by any of the 24 American Board of Medical Specialties (ABMS) member boards can now also certify in CI through an exam offered by the American Board of Preventive Medicine. In December 2013, 455 new subspecialists across the country became certified.

One of those alumni is Dr. Hersh, who also serves as director of the AMIA’s clinical informatics board review course.

"I’m proud to be a part of the pioneer class of leaders in this field," Dr. Hersh said in a statement. "When you look at the Accreditation Council for Graduate Medical Education’s (ACGME’s) definition of the informatics discipline, the operative word is ‘transform.’ Every day, informaticians are working in their health care settings to change how we do things, to improve patient care and population health."

Having a far-reaching, positive impact on health populations has long been a primary objective of Dr. Katherine Schneider, a family physician who recently became CI certified. The Pennsylvania doctor started her medical career as the head of a community medicine program, accessing outreach initiatives and working to improve care for the uninsured. She then took on a senior vice president position at AtlantiCare, where she led the system’s strategic transformational work toward accountable care. Dr. Schneider did not hesitate when she learned of the opportunity to become board certified in CI.

"It’s the birth of a new specialty; why not get involved at the very beginning?" said Dr. Schneider, who now serves as chief medical officer for Medecision, a national provider of health care management solutions. CI "by definition, it’s in my everyday work. It’s my role to help make sure we are helping customers use this correctly, understand what our pain points are, and build the right kind of tools to solve problems of effectiveness and efficiency."

Along with bringing new information and technology terms to her current position, her CI training has enabled Dr. Schneider to expand her professional network of clinical informaticians and industry experts, she said.

"One really great benefit is that you meet other people that either do something similar to you or understand the role that you’re in," she said. "Having that peer network is going to be really nice. It’s nice to have recognition that you have expertise in a field. It’s fun to be there at the beginning and participate in the debate about what’s relevant and where it’s going to be in a few years."

Vanderbilt University Medical Center

For other recently certified physicians, the subspecialty is a door to countless professional paths.

"I became certified to update my skill set and expand my career options," said Dr. Gretchen Purcell Jackson, of the department of pediatric surgery at Vanderbilt University Medical Center, Nashville, Tenn. "I found the quality improvement and project management part of the certification really useful."

In her current practice, Dr. Jackson’s CI training aids in a range of projects, such as helping with a grant she received to study information needs and information management practices of pregnant women and their caregivers.

"The project management aspect of my CI training has been very useful in helping me organize a large clinical study," said Dr. Jackson, who has a PhD in medical information sciences from Stanford (Calif.) University. In addition, "I have recently been asked to help oversee a project that involves coordinating the efforts and technologies from Vanderbilt health information systems, a corporate partner, a non-profit research foundation, and a large funded research project. I use every aspect of my CI training to guide this project. It requires leadership, project management, quality improvement, and clinical and technological expertise."

Meanwhile, Dr. Peter Killoran, a Texas anesthesiologist, is using his CI training to help track patient outcomes and evaluate data for the University of Texas Health Science Center at Houston, School of Biomedical Informatics. Dr. Killoran’s work includes improving health care quality and safety through health information technology and biomedical informatics.

"Quality improvement is a big part of the curriculum for this specialty," said Dr. Killoran, an assistant professor of anesthesiology at the UTHealth Medical School. "That’s because increasingly, medicine is focusing on improving outcomes and the rational use of heath care resources, and all of that comes down to the data."

As the field of CI continues to grow, health providers are needed to participate in the subspecialty and add their voices, said Dr. Genevieve Melton-Meaux, of the department of surgery at the University of Minnesota, Minneapolis, and a faculty fellow for the university’s Institute for Health Informatics. She was recently CI certified.

"The electronic health record and health information technology are the ‘nervous system’ of clinical care," she said. "There are important opportunities to improve the design, implementation, optimization, and use of these technologies and their resultant data, which will ultimately help to improve the efficiency and safety of health care, as well as improve the process of clinical discovery."

CHICAGO – Bariatric surgery has made great strides in safety and efficacy – so many, in fact, that the field is ready to focus on a new range of quality goals, explained Dr. John Morton.

In an interview at the annual Digestive Disease Week, Dr. Morton, chief of bariatric surgery at Stanford (Calif.) University, discussed how new quality targets, such as 30-day readmissions, could improve bariatric surgery outcomes and boost patient satisfaction.

[email protected]

On Twitter @sherryboschert

CHICAGO – Bariatric surgery has made great strides in safety and efficacy – so many, in fact, that the field is ready to focus on a new range of quality goals, explained Dr. John Morton.

In an interview at the annual Digestive Disease Week, Dr. Morton, chief of bariatric surgery at Stanford (Calif.) University, discussed how new quality targets, such as 30-day readmissions, could improve bariatric surgery outcomes and boost patient satisfaction.

[email protected]

On Twitter @sherryboschert

CHICAGO – Bariatric surgery has made great strides in safety and efficacy – so many, in fact, that the field is ready to focus on a new range of quality goals, explained Dr. John Morton.

In an interview at the annual Digestive Disease Week, Dr. Morton, chief of bariatric surgery at Stanford (Calif.) University, discussed how new quality targets, such as 30-day readmissions, could improve bariatric surgery outcomes and boost patient satisfaction.

[email protected]

On Twitter @sherryboschert

BOSTON – Hospital size and operative volume were significantly associated with satisfaction among general surgery patients in an analysis of 171 U.S. hospitals.

Surprisingly, all other safety and effectiveness measures, with the exception of low hospital mortality index, did not reliably reflect patient satisfaction, "indicating that the system plays perhaps a bigger role than anything else we can do," Dr. Gregory D. Kennedy said at the annual meeting of the American Surgical Association.

Moreover, a clean room and well-controlled pain were the best predictors of high patient satisfaction.

If it’s "the quality of the hotel, not the quality of the surgeon that drives patient satisfaction," and given that this is tied to reimbursement, what should the message be to hospital CEOs? asked discussant Dr. John J. Ricotta, chief of surgery at MedStar Washington (D.C.) Hospital Center.

Patrice Wendling/Frontline Medical News

Dr. Kennedy said the message he takes to the C-suite is that patient satisfaction cannot be a surrogate marker for safety and effectiveness or the only measure of quality because, in doing the right thing, surgeons often make patients unhappy. As a colorectal surgeon, he said he has unhappy patients every day, and remarked that he sometimes feels like a used car salesman where the only thing that he worries about is whether the patient is having a good experience when they drive off the lot, not whether it’s a safe, reliable car.

Dr. Kennedy, vice chair of quality at the University of Wisconsin School of Medicine, Madison, suggested that future quality measures also may need to make the distinction between satisfied and engaged, well-informed patients because a disengaged patient can be highly satisfied, while a highly engaged patient may not.

For the current study, the investigators examined federal Hospital Consumer Assessment Healthcare Providers and Systems (HCAHPS) survey results from 171 hospitals in the University Health System Consortium database from 2011 to 2012. Patients can check one of four boxes for each question on the 27-item survey, with high satisfaction defined as median responses above the 75th percentile on the top box score. This cutoff was used because the Centers for Medicare & Medicaid Services, which developed the HCAHPS, uses only the top box score, Dr. Kennedy explained.

The median hospital size was 421 beds (range, 25-1,280 beds), the median operative volume was 6,341 cases (range, 192-24,258 cases), and the mortality index was 0.83 (range, 0-2.61).

In all, 62% of high-volume hospitals, defined as those with an operative volume above the median, achieved high patient satisfaction, compared with 38% of low-volume hospitals (P less than .001). Similar results were seen for operative volume, he said.

Other system measures such as number of ICU cases and Surgical Care Improvement Project (SCIP) compliance were not associated with high HCAHPS scores.

Among patient safety indicators, only low mortality index was associated with high satisfaction (P less than .001), while complications, early mortality, and overall mortality were not.

Interestingly, hospitals with a higher number of Patient Safety Indicator cases – those involving accidental puncture, laceration, and venous thromboembolism – had higher rates of patient satisfaction, "suggesting that unsafe care is perhaps correlated with high satisfaction," Dr. Kennedy said.

Discussant Dr. Fabrizio Michelassi, chair of surgery at Weill Cornell Medical College and surgeon-in-chief, New York–Presbyterian Hospital/Weill Cornell Medical Center, in New York City, questioned whether "unsafe care gives more options for physicians to show their compassionate side," and said the overall findings are not that surprising to practicing surgeons, who frequently hear patient complaints, despite having performed a quality operation.

Dr. Kennedy said a recent paper from the Cleveland Clinic (Dis. Colon Rectum. 2013;56:219-25) suggests that Patient Safety Indicator cases are really a reflection of surgical complexity and not unsafe care at all.

Finally, other discussants criticized the study for failing to tie satisfaction to patient outcomes; for failing to control for factors influencing patient satisfaction such as age, sex, or social status; and for not looking at geographic differences or nursing-to-staff ratios.

The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.

Dr. Kennedy reported no conflicting interests.

[email protected]

BOSTON – Hospital size and operative volume were significantly associated with satisfaction among general surgery patients in an analysis of 171 U.S. hospitals.

Surprisingly, all other safety and effectiveness measures, with the exception of low hospital mortality index, did not reliably reflect patient satisfaction, "indicating that the system plays perhaps a bigger role than anything else we can do," Dr. Gregory D. Kennedy said at the annual meeting of the American Surgical Association.

Moreover, a clean room and well-controlled pain were the best predictors of high patient satisfaction.

If it’s "the quality of the hotel, not the quality of the surgeon that drives patient satisfaction," and given that this is tied to reimbursement, what should the message be to hospital CEOs? asked discussant Dr. John J. Ricotta, chief of surgery at MedStar Washington (D.C.) Hospital Center.

Patrice Wendling/Frontline Medical News

Dr. Kennedy said the message he takes to the C-suite is that patient satisfaction cannot be a surrogate marker for safety and effectiveness or the only measure of quality because, in doing the right thing, surgeons often make patients unhappy. As a colorectal surgeon, he said he has unhappy patients every day, and remarked that he sometimes feels like a used car salesman where the only thing that he worries about is whether the patient is having a good experience when they drive off the lot, not whether it’s a safe, reliable car.

Dr. Kennedy, vice chair of quality at the University of Wisconsin School of Medicine, Madison, suggested that future quality measures also may need to make the distinction between satisfied and engaged, well-informed patients because a disengaged patient can be highly satisfied, while a highly engaged patient may not.

For the current study, the investigators examined federal Hospital Consumer Assessment Healthcare Providers and Systems (HCAHPS) survey results from 171 hospitals in the University Health System Consortium database from 2011 to 2012. Patients can check one of four boxes for each question on the 27-item survey, with high satisfaction defined as median responses above the 75th percentile on the top box score. This cutoff was used because the Centers for Medicare & Medicaid Services, which developed the HCAHPS, uses only the top box score, Dr. Kennedy explained.

The median hospital size was 421 beds (range, 25-1,280 beds), the median operative volume was 6,341 cases (range, 192-24,258 cases), and the mortality index was 0.83 (range, 0-2.61).

In all, 62% of high-volume hospitals, defined as those with an operative volume above the median, achieved high patient satisfaction, compared with 38% of low-volume hospitals (P less than .001). Similar results were seen for operative volume, he said.

Other system measures such as number of ICU cases and Surgical Care Improvement Project (SCIP) compliance were not associated with high HCAHPS scores.

Among patient safety indicators, only low mortality index was associated with high satisfaction (P less than .001), while complications, early mortality, and overall mortality were not.

Interestingly, hospitals with a higher number of Patient Safety Indicator cases – those involving accidental puncture, laceration, and venous thromboembolism – had higher rates of patient satisfaction, "suggesting that unsafe care is perhaps correlated with high satisfaction," Dr. Kennedy said.

Discussant Dr. Fabrizio Michelassi, chair of surgery at Weill Cornell Medical College and surgeon-in-chief, New York–Presbyterian Hospital/Weill Cornell Medical Center, in New York City, questioned whether "unsafe care gives more options for physicians to show their compassionate side," and said the overall findings are not that surprising to practicing surgeons, who frequently hear patient complaints, despite having performed a quality operation.

Dr. Kennedy said a recent paper from the Cleveland Clinic (Dis. Colon Rectum. 2013;56:219-25) suggests that Patient Safety Indicator cases are really a reflection of surgical complexity and not unsafe care at all.

Finally, other discussants criticized the study for failing to tie satisfaction to patient outcomes; for failing to control for factors influencing patient satisfaction such as age, sex, or social status; and for not looking at geographic differences or nursing-to-staff ratios.

The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.

Dr. Kennedy reported no conflicting interests.

[email protected]

BOSTON – Hospital size and operative volume were significantly associated with satisfaction among general surgery patients in an analysis of 171 U.S. hospitals.

Surprisingly, all other safety and effectiveness measures, with the exception of low hospital mortality index, did not reliably reflect patient satisfaction, "indicating that the system plays perhaps a bigger role than anything else we can do," Dr. Gregory D. Kennedy said at the annual meeting of the American Surgical Association.

Moreover, a clean room and well-controlled pain were the best predictors of high patient satisfaction.

If it’s "the quality of the hotel, not the quality of the surgeon that drives patient satisfaction," and given that this is tied to reimbursement, what should the message be to hospital CEOs? asked discussant Dr. John J. Ricotta, chief of surgery at MedStar Washington (D.C.) Hospital Center.

Patrice Wendling/Frontline Medical News

Dr. Kennedy said the message he takes to the C-suite is that patient satisfaction cannot be a surrogate marker for safety and effectiveness or the only measure of quality because, in doing the right thing, surgeons often make patients unhappy. As a colorectal surgeon, he said he has unhappy patients every day, and remarked that he sometimes feels like a used car salesman where the only thing that he worries about is whether the patient is having a good experience when they drive off the lot, not whether it’s a safe, reliable car.

Dr. Kennedy, vice chair of quality at the University of Wisconsin School of Medicine, Madison, suggested that future quality measures also may need to make the distinction between satisfied and engaged, well-informed patients because a disengaged patient can be highly satisfied, while a highly engaged patient may not.

For the current study, the investigators examined federal Hospital Consumer Assessment Healthcare Providers and Systems (HCAHPS) survey results from 171 hospitals in the University Health System Consortium database from 2011 to 2012. Patients can check one of four boxes for each question on the 27-item survey, with high satisfaction defined as median responses above the 75th percentile on the top box score. This cutoff was used because the Centers for Medicare & Medicaid Services, which developed the HCAHPS, uses only the top box score, Dr. Kennedy explained.

The median hospital size was 421 beds (range, 25-1,280 beds), the median operative volume was 6,341 cases (range, 192-24,258 cases), and the mortality index was 0.83 (range, 0-2.61).

In all, 62% of high-volume hospitals, defined as those with an operative volume above the median, achieved high patient satisfaction, compared with 38% of low-volume hospitals (P less than .001). Similar results were seen for operative volume, he said.

Other system measures such as number of ICU cases and Surgical Care Improvement Project (SCIP) compliance were not associated with high HCAHPS scores.

Among patient safety indicators, only low mortality index was associated with high satisfaction (P less than .001), while complications, early mortality, and overall mortality were not.

Interestingly, hospitals with a higher number of Patient Safety Indicator cases – those involving accidental puncture, laceration, and venous thromboembolism – had higher rates of patient satisfaction, "suggesting that unsafe care is perhaps correlated with high satisfaction," Dr. Kennedy said.

Discussant Dr. Fabrizio Michelassi, chair of surgery at Weill Cornell Medical College and surgeon-in-chief, New York–Presbyterian Hospital/Weill Cornell Medical Center, in New York City, questioned whether "unsafe care gives more options for physicians to show their compassionate side," and said the overall findings are not that surprising to practicing surgeons, who frequently hear patient complaints, despite having performed a quality operation.

Dr. Kennedy said a recent paper from the Cleveland Clinic (Dis. Colon Rectum. 2013;56:219-25) suggests that Patient Safety Indicator cases are really a reflection of surgical complexity and not unsafe care at all.

Finally, other discussants criticized the study for failing to tie satisfaction to patient outcomes; for failing to control for factors influencing patient satisfaction such as age, sex, or social status; and for not looking at geographic differences or nursing-to-staff ratios.

The complete manuscript of this study and its presentation at the American Surgical Association’s 134th Annual Meeting, April 2014, in Boston, is anticipated to be published in the Annals of Surgery, pending editorial review.

Dr. Kennedy reported no conflicting interests.

[email protected]

CHICAGO – Grade 2 or 3 hepatic fibrosis in the setting of nonalcoholic fatty liver disease resolved or improved in 56% of affected patients following their bariatric surgery for severe obesity, according to a large blinded, paired-biopsy study.

Bariatric surgery in patients with nonalcoholic fatty liver disease (NAFLD) also achieved a high rate of resolution of steatosis and steatohepatitis, but it was the improvement in advanced fibrosis, including stage 3 or bridging fibrosis, that was particularly impressive. Traditionally, liver fibrosis was thought to be an irreversible finding, Dr. Andrew A. Taitano observed at the annual Digestive Disease Week.

"Our data provide strong evidence that bariatric surgery improves liver histology in NAFLD," he said. "We conclude that bariatric surgery should be considered one of the treatments for NAFLD in patients with severe obesity."

Dr. Taitano presented a retrospective, single-center study of 160 patients with NAFLD at the time they underwent bariatric surgery for weight loss, all of whom had follow-up liver biopsies when they underwent abdominal operations for any reason an average of 31 months later. Their mean body-mass index was 52 kg/m² at bariatric surgery, with a 62% excess body weight loss at the time of their subsequent abdominal surgery.

At bariatric surgery, 65% of patients had hepatic fibrosis. At follow-up, two blinded pathologists reported that only 36% of patients had liver fibrosis. Fibrosis was resolved or improved by at least one grade in 56% of patients, worse in 16%, and unchanged in the rest, reported Dr. Taitano, a bariatric surgery fellow at the University of South Florida, Tampa.

Of 56 patients without baseline liver fibrosis, only 12 had developed fibrosis at follow-up.

Steatosis was present in 77% of patients at bariatric surgery and in 21% at follow-up. Steatosis was resolved in 86% of patients at follow-up, the same in 8%, and worse in 6%, he said.

Steatohepatitis was found on liver biopsies at bariatric surgery in 26% of patients but was present in only 3% at follow-up. This form of histopathology was resolved or improved at follow-up in 93% of affected patients; fibrosis was worse in none.

NAFLD is the most common liver disorder in Western countries. The rate has doubled in the last 20 years. Risk factors include type 2 diabetes, central obesity, and dyslipidemia – all features of the metabolic syndrome. NAFLD is a progressive disease. Previous studies indicate that up to half of patients with NAFLD develop fibrosis within 13 years, and it’s estimated that one in five patients with NAFLD with steatohepatitis will develop cirrhosis within 20 years.

Discussant Dr. Guilherme M. Campos, a surgeon at the University of Wisconsin, Madison, commented, "It’s important to underscore that the magnitude of histologic improvements observed here is far greater than seen with maximum nonoperative therapy."

Asked if the study data pointed to any particular type of bypass surgery or any patient characteristics that correlate with change in NAFLD histopathology, Dr. Taitano replied that gastric bypass was the predominant operation. Although the limited patient numbers didn’t permit meaningful comparisons, he said, "as an overall recommendation, I would advise a weight-loss procedure that has a metabolic effect, such as gastric bypass, because I think both the amount of weight loss and the operation’s metabolic effect are improving this disease."

He reported having no financial conflicts regarding this study, which was conducted using institutional funds.

[email protected]

CHICAGO – Grade 2 or 3 hepatic fibrosis in the setting of nonalcoholic fatty liver disease resolved or improved in 56% of affected patients following their bariatric surgery for severe obesity, according to a large blinded, paired-biopsy study.

Bariatric surgery in patients with nonalcoholic fatty liver disease (NAFLD) also achieved a high rate of resolution of steatosis and steatohepatitis, but it was the improvement in advanced fibrosis, including stage 3 or bridging fibrosis, that was particularly impressive. Traditionally, liver fibrosis was thought to be an irreversible finding, Dr. Andrew A. Taitano observed at the annual Digestive Disease Week.

"Our data provide strong evidence that bariatric surgery improves liver histology in NAFLD," he said. "We conclude that bariatric surgery should be considered one of the treatments for NAFLD in patients with severe obesity."

Dr. Taitano presented a retrospective, single-center study of 160 patients with NAFLD at the time they underwent bariatric surgery for weight loss, all of whom had follow-up liver biopsies when they underwent abdominal operations for any reason an average of 31 months later. Their mean body-mass index was 52 kg/m² at bariatric surgery, with a 62% excess body weight loss at the time of their subsequent abdominal surgery.

At bariatric surgery, 65% of patients had hepatic fibrosis. At follow-up, two blinded pathologists reported that only 36% of patients had liver fibrosis. Fibrosis was resolved or improved by at least one grade in 56% of patients, worse in 16%, and unchanged in the rest, reported Dr. Taitano, a bariatric surgery fellow at the University of South Florida, Tampa.

Of 56 patients without baseline liver fibrosis, only 12 had developed fibrosis at follow-up.

Steatosis was present in 77% of patients at bariatric surgery and in 21% at follow-up. Steatosis was resolved in 86% of patients at follow-up, the same in 8%, and worse in 6%, he said.

Steatohepatitis was found on liver biopsies at bariatric surgery in 26% of patients but was present in only 3% at follow-up. This form of histopathology was resolved or improved at follow-up in 93% of affected patients; fibrosis was worse in none.

NAFLD is the most common liver disorder in Western countries. The rate has doubled in the last 20 years. Risk factors include type 2 diabetes, central obesity, and dyslipidemia – all features of the metabolic syndrome. NAFLD is a progressive disease. Previous studies indicate that up to half of patients with NAFLD develop fibrosis within 13 years, and it’s estimated that one in five patients with NAFLD with steatohepatitis will develop cirrhosis within 20 years.

Discussant Dr. Guilherme M. Campos, a surgeon at the University of Wisconsin, Madison, commented, "It’s important to underscore that the magnitude of histologic improvements observed here is far greater than seen with maximum nonoperative therapy."

Asked if the study data pointed to any particular type of bypass surgery or any patient characteristics that correlate with change in NAFLD histopathology, Dr. Taitano replied that gastric bypass was the predominant operation. Although the limited patient numbers didn’t permit meaningful comparisons, he said, "as an overall recommendation, I would advise a weight-loss procedure that has a metabolic effect, such as gastric bypass, because I think both the amount of weight loss and the operation’s metabolic effect are improving this disease."

He reported having no financial conflicts regarding this study, which was conducted using institutional funds.

[email protected]

CHICAGO – Grade 2 or 3 hepatic fibrosis in the setting of nonalcoholic fatty liver disease resolved or improved in 56% of affected patients following their bariatric surgery for severe obesity, according to a large blinded, paired-biopsy study.

Bariatric surgery in patients with nonalcoholic fatty liver disease (NAFLD) also achieved a high rate of resolution of steatosis and steatohepatitis, but it was the improvement in advanced fibrosis, including stage 3 or bridging fibrosis, that was particularly impressive. Traditionally, liver fibrosis was thought to be an irreversible finding, Dr. Andrew A. Taitano observed at the annual Digestive Disease Week.

"Our data provide strong evidence that bariatric surgery improves liver histology in NAFLD," he said. "We conclude that bariatric surgery should be considered one of the treatments for NAFLD in patients with severe obesity."

Dr. Taitano presented a retrospective, single-center study of 160 patients with NAFLD at the time they underwent bariatric surgery for weight loss, all of whom had follow-up liver biopsies when they underwent abdominal operations for any reason an average of 31 months later. Their mean body-mass index was 52 kg/m² at bariatric surgery, with a 62% excess body weight loss at the time of their subsequent abdominal surgery.

At bariatric surgery, 65% of patients had hepatic fibrosis. At follow-up, two blinded pathologists reported that only 36% of patients had liver fibrosis. Fibrosis was resolved or improved by at least one grade in 56% of patients, worse in 16%, and unchanged in the rest, reported Dr. Taitano, a bariatric surgery fellow at the University of South Florida, Tampa.

Of 56 patients without baseline liver fibrosis, only 12 had developed fibrosis at follow-up.

Steatosis was present in 77% of patients at bariatric surgery and in 21% at follow-up. Steatosis was resolved in 86% of patients at follow-up, the same in 8%, and worse in 6%, he said.

Steatohepatitis was found on liver biopsies at bariatric surgery in 26% of patients but was present in only 3% at follow-up. This form of histopathology was resolved or improved at follow-up in 93% of affected patients; fibrosis was worse in none.

NAFLD is the most common liver disorder in Western countries. The rate has doubled in the last 20 years. Risk factors include type 2 diabetes, central obesity, and dyslipidemia – all features of the metabolic syndrome. NAFLD is a progressive disease. Previous studies indicate that up to half of patients with NAFLD develop fibrosis within 13 years, and it’s estimated that one in five patients with NAFLD with steatohepatitis will develop cirrhosis within 20 years.

Discussant Dr. Guilherme M. Campos, a surgeon at the University of Wisconsin, Madison, commented, "It’s important to underscore that the magnitude of histologic improvements observed here is far greater than seen with maximum nonoperative therapy."

Asked if the study data pointed to any particular type of bypass surgery or any patient characteristics that correlate with change in NAFLD histopathology, Dr. Taitano replied that gastric bypass was the predominant operation. Although the limited patient numbers didn’t permit meaningful comparisons, he said, "as an overall recommendation, I would advise a weight-loss procedure that has a metabolic effect, such as gastric bypass, because I think both the amount of weight loss and the operation’s metabolic effect are improving this disease."

He reported having no financial conflicts regarding this study, which was conducted using institutional funds.

[email protected]

Laparoscopic-assisted colonoscopic polypectomy works as well as standard laparoscopic hemicolectomy to remove difficult to reach polyps in the right colon, with fewer complications and shorter hospital stays, according to data from a recent trial.

Instead of taking out a section of the ascending colon to remove the polyp, a surgeon uses a laparoscope to mobilize and position the right colon during laparoscopic-assisted colonoscopic polypectomy (LACP) so that an endoscopist can reach, snare, and remove it.

The team randomized 14 patients to LACP and 14 to laparoscopic hemicolectomy (LHC). The LACP group had shorter mean operating times (95 vs. 179 min.), less blood loss (13 vs. 63 mL), and required less intravenous fluid (2.1 vs. 3.1 L). LACP patients were also quicker to pass flatus (1.44 vs. 2.88 days), resume solid food (1.69 vs. 3.94 days), and leave the hospital (2.63 vs. 4.94 days), all statistically significant differences.

One LACP patient required conversion to LHC, while four LHC patients required conversion to laparotomy. There were no significant between-group differences in postoperative complications, readmissions, or second operations.

"That ability to remove polyps with LACP was as effective and safe as the standard laparoscopic hemicolectomy ... and patients were discharged from the hospital earlier. We think this is a very exciting change in how we deal with these difficult to remove colon polyps," said Dr. Jonathan Buscaglia, director of advanced endoscopy at Stony Brook (N.Y.) University.

There are a few case series in the literature about the technique, but uptake seems to have been slow so far. "I think the biggest roadblock is the ability of a surgeon to coordinate with a gastroenterologist. You need good working relationships, and schedules able to accommodate [both]. That’s not always easy, depending on where one works," Dr. Buscaglia said at a teleconference in advance of the annual Digestive Disease Week.

The patients in the trial had benign polyps with lift signs and generally tubular or tubulovillous adenomas. The groups were evenly matched for age, sex, body mass index, American Society of Anesthesiologists physical status, and previous abdominal surgery, plus polyp morphology, location, size, and histology.

It’s too soon after the procedures for serial surveillance colonoscopies and to know if any of the patients went on to develop cancer after their operations.

The right side is technically an easier place for laparoscopic surgeons to operate; with the left colon, operators have to worry more about diverticulitis, scarring, and tight anatomy. Even so, LACP may still be useful. "We are looking forward to conducting" a larger, possibly multicenter study on its application to polyps "in all areas of the colon," Dr. Buscaglia said.

The investigators have no disclosures.

[email protected]

Laparoscopic-assisted colonoscopic polypectomy works as well as standard laparoscopic hemicolectomy to remove difficult to reach polyps in the right colon, with fewer complications and shorter hospital stays, according to data from a recent trial.

Instead of taking out a section of the ascending colon to remove the polyp, a surgeon uses a laparoscope to mobilize and position the right colon during laparoscopic-assisted colonoscopic polypectomy (LACP) so that an endoscopist can reach, snare, and remove it.

The team randomized 14 patients to LACP and 14 to laparoscopic hemicolectomy (LHC). The LACP group had shorter mean operating times (95 vs. 179 min.), less blood loss (13 vs. 63 mL), and required less intravenous fluid (2.1 vs. 3.1 L). LACP patients were also quicker to pass flatus (1.44 vs. 2.88 days), resume solid food (1.69 vs. 3.94 days), and leave the hospital (2.63 vs. 4.94 days), all statistically significant differences.

One LACP patient required conversion to LHC, while four LHC patients required conversion to laparotomy. There were no significant between-group differences in postoperative complications, readmissions, or second operations.

"That ability to remove polyps with LACP was as effective and safe as the standard laparoscopic hemicolectomy ... and patients were discharged from the hospital earlier. We think this is a very exciting change in how we deal with these difficult to remove colon polyps," said Dr. Jonathan Buscaglia, director of advanced endoscopy at Stony Brook (N.Y.) University.

There are a few case series in the literature about the technique, but uptake seems to have been slow so far. "I think the biggest roadblock is the ability of a surgeon to coordinate with a gastroenterologist. You need good working relationships, and schedules able to accommodate [both]. That’s not always easy, depending on where one works," Dr. Buscaglia said at a teleconference in advance of the annual Digestive Disease Week.

The patients in the trial had benign polyps with lift signs and generally tubular or tubulovillous adenomas. The groups were evenly matched for age, sex, body mass index, American Society of Anesthesiologists physical status, and previous abdominal surgery, plus polyp morphology, location, size, and histology.

It’s too soon after the procedures for serial surveillance colonoscopies and to know if any of the patients went on to develop cancer after their operations.

The right side is technically an easier place for laparoscopic surgeons to operate; with the left colon, operators have to worry more about diverticulitis, scarring, and tight anatomy. Even so, LACP may still be useful. "We are looking forward to conducting" a larger, possibly multicenter study on its application to polyps "in all areas of the colon," Dr. Buscaglia said.

The investigators have no disclosures.

[email protected]

Laparoscopic-assisted colonoscopic polypectomy works as well as standard laparoscopic hemicolectomy to remove difficult to reach polyps in the right colon, with fewer complications and shorter hospital stays, according to data from a recent trial.

Instead of taking out a section of the ascending colon to remove the polyp, a surgeon uses a laparoscope to mobilize and position the right colon during laparoscopic-assisted colonoscopic polypectomy (LACP) so that an endoscopist can reach, snare, and remove it.

The team randomized 14 patients to LACP and 14 to laparoscopic hemicolectomy (LHC). The LACP group had shorter mean operating times (95 vs. 179 min.), less blood loss (13 vs. 63 mL), and required less intravenous fluid (2.1 vs. 3.1 L). LACP patients were also quicker to pass flatus (1.44 vs. 2.88 days), resume solid food (1.69 vs. 3.94 days), and leave the hospital (2.63 vs. 4.94 days), all statistically significant differences.

One LACP patient required conversion to LHC, while four LHC patients required conversion to laparotomy. There were no significant between-group differences in postoperative complications, readmissions, or second operations.

"That ability to remove polyps with LACP was as effective and safe as the standard laparoscopic hemicolectomy ... and patients were discharged from the hospital earlier. We think this is a very exciting change in how we deal with these difficult to remove colon polyps," said Dr. Jonathan Buscaglia, director of advanced endoscopy at Stony Brook (N.Y.) University.

There are a few case series in the literature about the technique, but uptake seems to have been slow so far. "I think the biggest roadblock is the ability of a surgeon to coordinate with a gastroenterologist. You need good working relationships, and schedules able to accommodate [both]. That’s not always easy, depending on where one works," Dr. Buscaglia said at a teleconference in advance of the annual Digestive Disease Week.

The patients in the trial had benign polyps with lift signs and generally tubular or tubulovillous adenomas. The groups were evenly matched for age, sex, body mass index, American Society of Anesthesiologists physical status, and previous abdominal surgery, plus polyp morphology, location, size, and histology.

It’s too soon after the procedures for serial surveillance colonoscopies and to know if any of the patients went on to develop cancer after their operations.

The right side is technically an easier place for laparoscopic surgeons to operate; with the left colon, operators have to worry more about diverticulitis, scarring, and tight anatomy. Even so, LACP may still be useful. "We are looking forward to conducting" a larger, possibly multicenter study on its application to polyps "in all areas of the colon," Dr. Buscaglia said.

The investigators have no disclosures.

[email protected]