ACS Surgery News

Bariatric surgery doesn’t reduce long-term health care costs, according to a report in the June issue of JAMA Surgery.

In a 6-year follow-up study comparing nearly 30,000 patients who underwent bariatric surgery against the same number of well-matched patients who did not have the surgery, the surgery group showed decreases in costs for office visits and prescriptions, but these were offset by their significant increases in inpatient costs, said Jonathan P. Weiner, Dr.P.H., of the department of health policy and management, Johns Hopkins Bloomberg School of Public Health, Baltimore, and his associates.

Health care costs for the bariatric surgery patients did fall off somewhat during the fourth, fifth, and sixth years following the operation, but not enough to outweigh the expenses incurred during the first 3 postoperative years, the investigators said.

Taken together with the results of two other recent studies of the total health care costs related to bariatric surgery, these findings indicate that "to assess the value of bariatric surgery, future studies should focus on the potential benefit of improved health and well-being of persons undergoing the procedure rather than on cost savings," they noted.

It seems intuitive that bariatric surgery, which produces considerable weight loss and alleviates or eliminates many obesity-related disorders such as hypertension and diabetes, would of course save future health care costs, at least in the long term. But studies of the impact of the procedure on such costs have shown mixed results.

"Many uncertainties remain about whether and when a return on investment can be expected, which type of bariatric surgical procedure produces the greatest cost reduction, and whether cost reductions are sustained over time," Dr. Weiner and his colleagues said.

To clarify the issue, they analyzed health care costs in a large cohort of privately insured people covered by seven Blue Cross Blue Shield plans in seven states, of which 29,820 underwent a variety of bariatric procedures during a 6-year period. Each of these subjects was matched for age, sex, area of residence, and 33 markers of obesity with a control subject who did not have bariatric surgery.

Surgical trends shifted during the course of the study. At the beginning, 72% of the procedures were open gastric bypass operations; by the end, laparoscopic procedures were predominant.

Although laparoscopic operations were associated with lower costs in the short term than other procedures, this advantage lasted only for a brief period. So overall, health care costs were not significantly different by type of bariatric surgery.

In an unadjusted analysis of the data, the surgical group showed an approximately 30% decrease in pharmacy costs during the first 3 years after the procedure. The control group showed no such drop.

However, the surgical group had significantly more hospital admissions for GI-related diagnoses than the control group during all 6 years of follow-up, which were concentrated during the second and third years following the procedure. Most of these admissions likely were for surgery-related complications, the investigators said.

In an analysis that adjusted for multiple possible confounders, inpatient costs remained higher for the surgical group than the control group throughout follow-up, but particularly during year 2 and year 3 following the procedure. Pharmacy and office visit costs were significantly lower for the surgery group but did not offset the excess in inpatient costs, Dr. Weiner and his associates reported (JAMA Surg. 2013;148:555-61).

This study "adds substantially to the existing literature on cost of bariatric surgery" because the study population was the largest to date and was representative of a broad cross section of the commercially insured U.S. population. The study also boasts one of the longest follow-ups of bariatric surgery outcomes in the United States, since previous studies generally had follow-ups of only 6 months to 2 years, the researchers said.

In a Clinical Review & Education piece accompanying this report (JAMA Surg. 2013;310:742-3), Matthew L. Maciejewski, Ph.D., and Dr. David E. Arterburn said that bariatric surgery may still be cost-effective even if it is not cost-saving.

"Does bariatric surgery need to be cost-effective (i.e., more effective but more costly than usual care), or does it need to achieve the higher standard of cost savings (i.e., more effective and less costly than usual care) to justify broader insurance coverage?" they asked.

The procedures are so expensive that they are unlikely to meet the threshold of "cost saving" for most patients. Even if a patient’s total health care costs are cut by half after the surgery, "it may take up to 20 years to achieve cost neutrality," said Dr. Maciejewski of the Center for Health Services Research in Primary Care, Durham (N.C.) VA Medical Center, and Dr. Arterburn of the Group Health Research Institute, Seattle.

This lack of cost savings shouldn’t be surprising, given that Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are invasive procedures that carry high early complication rates. It is possible that newer procedures such as sleeve gastrectomy might eventually yield cost savings because of relatively low complication rates, but these operations haven’t yet undergone long-term economic evaluation, they added.

This study was supported in part by Ethicon Endo-Surgery (a division of Johnson & Johnson), Pfizer, and GlaxoSmithKline, as well as by the National BlueCross BlueShield Association and the seven local plans that participated. No other financial conflicts of interest were reported.

Bariatric surgery doesn’t reduce long-term health care costs, according to a report in the June issue of JAMA Surgery.

In a 6-year follow-up study comparing nearly 30,000 patients who underwent bariatric surgery against the same number of well-matched patients who did not have the surgery, the surgery group showed decreases in costs for office visits and prescriptions, but these were offset by their significant increases in inpatient costs, said Jonathan P. Weiner, Dr.P.H., of the department of health policy and management, Johns Hopkins Bloomberg School of Public Health, Baltimore, and his associates.

Health care costs for the bariatric surgery patients did fall off somewhat during the fourth, fifth, and sixth years following the operation, but not enough to outweigh the expenses incurred during the first 3 postoperative years, the investigators said.

Taken together with the results of two other recent studies of the total health care costs related to bariatric surgery, these findings indicate that "to assess the value of bariatric surgery, future studies should focus on the potential benefit of improved health and well-being of persons undergoing the procedure rather than on cost savings," they noted.

It seems intuitive that bariatric surgery, which produces considerable weight loss and alleviates or eliminates many obesity-related disorders such as hypertension and diabetes, would of course save future health care costs, at least in the long term. But studies of the impact of the procedure on such costs have shown mixed results.

"Many uncertainties remain about whether and when a return on investment can be expected, which type of bariatric surgical procedure produces the greatest cost reduction, and whether cost reductions are sustained over time," Dr. Weiner and his colleagues said.

To clarify the issue, they analyzed health care costs in a large cohort of privately insured people covered by seven Blue Cross Blue Shield plans in seven states, of which 29,820 underwent a variety of bariatric procedures during a 6-year period. Each of these subjects was matched for age, sex, area of residence, and 33 markers of obesity with a control subject who did not have bariatric surgery.

Surgical trends shifted during the course of the study. At the beginning, 72% of the procedures were open gastric bypass operations; by the end, laparoscopic procedures were predominant.

Although laparoscopic operations were associated with lower costs in the short term than other procedures, this advantage lasted only for a brief period. So overall, health care costs were not significantly different by type of bariatric surgery.

In an unadjusted analysis of the data, the surgical group showed an approximately 30% decrease in pharmacy costs during the first 3 years after the procedure. The control group showed no such drop.

However, the surgical group had significantly more hospital admissions for GI-related diagnoses than the control group during all 6 years of follow-up, which were concentrated during the second and third years following the procedure. Most of these admissions likely were for surgery-related complications, the investigators said.

In an analysis that adjusted for multiple possible confounders, inpatient costs remained higher for the surgical group than the control group throughout follow-up, but particularly during year 2 and year 3 following the procedure. Pharmacy and office visit costs were significantly lower for the surgery group but did not offset the excess in inpatient costs, Dr. Weiner and his associates reported (JAMA Surg. 2013;148:555-61).

This study "adds substantially to the existing literature on cost of bariatric surgery" because the study population was the largest to date and was representative of a broad cross section of the commercially insured U.S. population. The study also boasts one of the longest follow-ups of bariatric surgery outcomes in the United States, since previous studies generally had follow-ups of only 6 months to 2 years, the researchers said.

In a Clinical Review & Education piece accompanying this report (JAMA Surg. 2013;310:742-3), Matthew L. Maciejewski, Ph.D., and Dr. David E. Arterburn said that bariatric surgery may still be cost-effective even if it is not cost-saving.

"Does bariatric surgery need to be cost-effective (i.e., more effective but more costly than usual care), or does it need to achieve the higher standard of cost savings (i.e., more effective and less costly than usual care) to justify broader insurance coverage?" they asked.

The procedures are so expensive that they are unlikely to meet the threshold of "cost saving" for most patients. Even if a patient’s total health care costs are cut by half after the surgery, "it may take up to 20 years to achieve cost neutrality," said Dr. Maciejewski of the Center for Health Services Research in Primary Care, Durham (N.C.) VA Medical Center, and Dr. Arterburn of the Group Health Research Institute, Seattle.

This lack of cost savings shouldn’t be surprising, given that Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are invasive procedures that carry high early complication rates. It is possible that newer procedures such as sleeve gastrectomy might eventually yield cost savings because of relatively low complication rates, but these operations haven’t yet undergone long-term economic evaluation, they added.

This study was supported in part by Ethicon Endo-Surgery (a division of Johnson & Johnson), Pfizer, and GlaxoSmithKline, as well as by the National BlueCross BlueShield Association and the seven local plans that participated. No other financial conflicts of interest were reported.

Bariatric surgery doesn’t reduce long-term health care costs, according to a report in the June issue of JAMA Surgery.

In a 6-year follow-up study comparing nearly 30,000 patients who underwent bariatric surgery against the same number of well-matched patients who did not have the surgery, the surgery group showed decreases in costs for office visits and prescriptions, but these were offset by their significant increases in inpatient costs, said Jonathan P. Weiner, Dr.P.H., of the department of health policy and management, Johns Hopkins Bloomberg School of Public Health, Baltimore, and his associates.

Health care costs for the bariatric surgery patients did fall off somewhat during the fourth, fifth, and sixth years following the operation, but not enough to outweigh the expenses incurred during the first 3 postoperative years, the investigators said.

Taken together with the results of two other recent studies of the total health care costs related to bariatric surgery, these findings indicate that "to assess the value of bariatric surgery, future studies should focus on the potential benefit of improved health and well-being of persons undergoing the procedure rather than on cost savings," they noted.

It seems intuitive that bariatric surgery, which produces considerable weight loss and alleviates or eliminates many obesity-related disorders such as hypertension and diabetes, would of course save future health care costs, at least in the long term. But studies of the impact of the procedure on such costs have shown mixed results.

"Many uncertainties remain about whether and when a return on investment can be expected, which type of bariatric surgical procedure produces the greatest cost reduction, and whether cost reductions are sustained over time," Dr. Weiner and his colleagues said.

To clarify the issue, they analyzed health care costs in a large cohort of privately insured people covered by seven Blue Cross Blue Shield plans in seven states, of which 29,820 underwent a variety of bariatric procedures during a 6-year period. Each of these subjects was matched for age, sex, area of residence, and 33 markers of obesity with a control subject who did not have bariatric surgery.

Surgical trends shifted during the course of the study. At the beginning, 72% of the procedures were open gastric bypass operations; by the end, laparoscopic procedures were predominant.

Although laparoscopic operations were associated with lower costs in the short term than other procedures, this advantage lasted only for a brief period. So overall, health care costs were not significantly different by type of bariatric surgery.

In an unadjusted analysis of the data, the surgical group showed an approximately 30% decrease in pharmacy costs during the first 3 years after the procedure. The control group showed no such drop.

However, the surgical group had significantly more hospital admissions for GI-related diagnoses than the control group during all 6 years of follow-up, which were concentrated during the second and third years following the procedure. Most of these admissions likely were for surgery-related complications, the investigators said.

In an analysis that adjusted for multiple possible confounders, inpatient costs remained higher for the surgical group than the control group throughout follow-up, but particularly during year 2 and year 3 following the procedure. Pharmacy and office visit costs were significantly lower for the surgery group but did not offset the excess in inpatient costs, Dr. Weiner and his associates reported (JAMA Surg. 2013;148:555-61).

This study "adds substantially to the existing literature on cost of bariatric surgery" because the study population was the largest to date and was representative of a broad cross section of the commercially insured U.S. population. The study also boasts one of the longest follow-ups of bariatric surgery outcomes in the United States, since previous studies generally had follow-ups of only 6 months to 2 years, the researchers said.

In a Clinical Review & Education piece accompanying this report (JAMA Surg. 2013;310:742-3), Matthew L. Maciejewski, Ph.D., and Dr. David E. Arterburn said that bariatric surgery may still be cost-effective even if it is not cost-saving.

"Does bariatric surgery need to be cost-effective (i.e., more effective but more costly than usual care), or does it need to achieve the higher standard of cost savings (i.e., more effective and less costly than usual care) to justify broader insurance coverage?" they asked.

The procedures are so expensive that they are unlikely to meet the threshold of "cost saving" for most patients. Even if a patient’s total health care costs are cut by half after the surgery, "it may take up to 20 years to achieve cost neutrality," said Dr. Maciejewski of the Center for Health Services Research in Primary Care, Durham (N.C.) VA Medical Center, and Dr. Arterburn of the Group Health Research Institute, Seattle.

This lack of cost savings shouldn’t be surprising, given that Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are invasive procedures that carry high early complication rates. It is possible that newer procedures such as sleeve gastrectomy might eventually yield cost savings because of relatively low complication rates, but these operations haven’t yet undergone long-term economic evaluation, they added.

This study was supported in part by Ethicon Endo-Surgery (a division of Johnson & Johnson), Pfizer, and GlaxoSmithKline, as well as by the National BlueCross BlueShield Association and the seven local plans that participated. No other financial conflicts of interest were reported.

An estimated 440,000 adult inpatients acquire one of the top five nosocomial infections in the United States every year, according to a report published online Sept. 2 in JAMA Internal Medicine.

The annual cost of these hospital-acquired infections is an estimated $9.8 billion. One-third of these costs are attributable to surgical site infections. One-fourth are due to ventilator-associated pneumonia, and another fourth are due to catheter-associated urinary tract infections, said Dr. Eyal Zimlichman of the Center for Patient Safety Research and Practice, Brigham and Women’s Hospital and Harvard Medical School, Boston.

CDC/D. Holdeman

Other studies have estimated that 55%-75% of hospital-acquired infections are preventable with currently available evidence-based interventions. If hospitals nationwide were to implement these existing interventions, an estimated $5.0-$5.5 billion would be saved annually, and the hospitals themselves would be able to tap into those savings.

"Thus, implementation of readily available strategies has the potential to produce significant bottom-line savings to hospitals," the investigators noted.

Dr. Zimlichman and his colleagues analyzed data from the Centers for Disease Control and Prevention’s National Healthcare Safety Network and from a systematic review of the medical literature to estimate the impact of hospital-acquired infections on the U.S. health care system. They focused on a single year (2009) and the five most common, most costly, most preventable, and most well-monitored infections among adult inpatients: surgical site infection, central line–associated bloodstream infection, catheter-associated urinary tract infection, ventilator-associated pneumonia, and Clostridium difficile infection.

These infections occurred against a background of approximately 34.7 million adults receiving inpatient care in U.S. hospitals, for a total of 165.1 million patient-days. These patients underwent approximately 8 million surgical procedures and were treated with invasive medical devices for approximately 96.2 million days of care, which placed them at risk for hospital-acquired infections.

"On an annual basis, surgical site infections (158,639) and Clostridium difficile infections (133,657) were estimated to be the most frequent hospital-acquired infections nationwide," accounting for 36% and 30% of the total number. Catheter-associated UTIs accounted for another 17%, central line–associated bloodstream infection accounted for 9%, and ventilator-associated pneumonia accounted for 7%, Dr. Zimlichman and his associates wrote (JAMA Intern. Med. 2013 Sept. 2 [doi:10.1001/jamainternmed.2013.9763]).

Surgical site infections contributed the greatest portion (34%) to the $9.8 billion estimated total. Catheter-associated UTIs, while frequent, contributed less than 1% to the total expenditure. Ventilator-associated pneumonia contributed 32%, central line–associated bloodstream infection contributed 19%, and C. difficile contributed 15%.

"Since surgical site infections constitute the largest portion of hospital-acquired infection–related costs nationally, and since less progress has been made in preventing these infections than in other areas of care, research and quality improvement efforts are clearly needed in this area," noted Dr. Zimlichman and his associates.

Even though central line–associated bloodstream infections were relatively infrequent, accounting for less than 10% of the total number, these were the most costly infections on a case-by-case basis. Each case of this infection was estimated to cost $45,814. The subgroup of central line–associated bloodstream infections caused by methicillin-resistant Staphylococcus aureus was even more expensive, at $58,614 per case.

The study findings indicate that although much progress has been made in preventing hospital-acquired infections, "much more remains to be done."

"Our study provides updated, robust, and applicable estimates for resources attributable to the major hospital-acquired infections that continue to plague modern health care systems and create considerable harm to patients," they noted.

The investigators added that their findings underestimate the true health care costs of hospital-acquired infection because this study excluded "not only neonatal and pediatric patients but also patients in non–acute care facilities such as long-term care and dialysis centers."

This study was sponsored by the Texas Medical Institute of Technology in Austin. No financial conflicts of interest were reported.

An estimated 440,000 adult inpatients acquire one of the top five nosocomial infections in the United States every year, according to a report published online Sept. 2 in JAMA Internal Medicine.

The annual cost of these hospital-acquired infections is an estimated $9.8 billion. One-third of these costs are attributable to surgical site infections. One-fourth are due to ventilator-associated pneumonia, and another fourth are due to catheter-associated urinary tract infections, said Dr. Eyal Zimlichman of the Center for Patient Safety Research and Practice, Brigham and Women’s Hospital and Harvard Medical School, Boston.

CDC/D. Holdeman

Other studies have estimated that 55%-75% of hospital-acquired infections are preventable with currently available evidence-based interventions. If hospitals nationwide were to implement these existing interventions, an estimated $5.0-$5.5 billion would be saved annually, and the hospitals themselves would be able to tap into those savings.

"Thus, implementation of readily available strategies has the potential to produce significant bottom-line savings to hospitals," the investigators noted.

Dr. Zimlichman and his colleagues analyzed data from the Centers for Disease Control and Prevention’s National Healthcare Safety Network and from a systematic review of the medical literature to estimate the impact of hospital-acquired infections on the U.S. health care system. They focused on a single year (2009) and the five most common, most costly, most preventable, and most well-monitored infections among adult inpatients: surgical site infection, central line–associated bloodstream infection, catheter-associated urinary tract infection, ventilator-associated pneumonia, and Clostridium difficile infection.

These infections occurred against a background of approximately 34.7 million adults receiving inpatient care in U.S. hospitals, for a total of 165.1 million patient-days. These patients underwent approximately 8 million surgical procedures and were treated with invasive medical devices for approximately 96.2 million days of care, which placed them at risk for hospital-acquired infections.

"On an annual basis, surgical site infections (158,639) and Clostridium difficile infections (133,657) were estimated to be the most frequent hospital-acquired infections nationwide," accounting for 36% and 30% of the total number. Catheter-associated UTIs accounted for another 17%, central line–associated bloodstream infection accounted for 9%, and ventilator-associated pneumonia accounted for 7%, Dr. Zimlichman and his associates wrote (JAMA Intern. Med. 2013 Sept. 2 [doi:10.1001/jamainternmed.2013.9763]).

Surgical site infections contributed the greatest portion (34%) to the $9.8 billion estimated total. Catheter-associated UTIs, while frequent, contributed less than 1% to the total expenditure. Ventilator-associated pneumonia contributed 32%, central line–associated bloodstream infection contributed 19%, and C. difficile contributed 15%.

"Since surgical site infections constitute the largest portion of hospital-acquired infection–related costs nationally, and since less progress has been made in preventing these infections than in other areas of care, research and quality improvement efforts are clearly needed in this area," noted Dr. Zimlichman and his associates.

Even though central line–associated bloodstream infections were relatively infrequent, accounting for less than 10% of the total number, these were the most costly infections on a case-by-case basis. Each case of this infection was estimated to cost $45,814. The subgroup of central line–associated bloodstream infections caused by methicillin-resistant Staphylococcus aureus was even more expensive, at $58,614 per case.

The study findings indicate that although much progress has been made in preventing hospital-acquired infections, "much more remains to be done."

"Our study provides updated, robust, and applicable estimates for resources attributable to the major hospital-acquired infections that continue to plague modern health care systems and create considerable harm to patients," they noted.

The investigators added that their findings underestimate the true health care costs of hospital-acquired infection because this study excluded "not only neonatal and pediatric patients but also patients in non–acute care facilities such as long-term care and dialysis centers."

This study was sponsored by the Texas Medical Institute of Technology in Austin. No financial conflicts of interest were reported.

An estimated 440,000 adult inpatients acquire one of the top five nosocomial infections in the United States every year, according to a report published online Sept. 2 in JAMA Internal Medicine.

The annual cost of these hospital-acquired infections is an estimated $9.8 billion. One-third of these costs are attributable to surgical site infections. One-fourth are due to ventilator-associated pneumonia, and another fourth are due to catheter-associated urinary tract infections, said Dr. Eyal Zimlichman of the Center for Patient Safety Research and Practice, Brigham and Women’s Hospital and Harvard Medical School, Boston.

CDC/D. Holdeman

Other studies have estimated that 55%-75% of hospital-acquired infections are preventable with currently available evidence-based interventions. If hospitals nationwide were to implement these existing interventions, an estimated $5.0-$5.5 billion would be saved annually, and the hospitals themselves would be able to tap into those savings.

"Thus, implementation of readily available strategies has the potential to produce significant bottom-line savings to hospitals," the investigators noted.

Dr. Zimlichman and his colleagues analyzed data from the Centers for Disease Control and Prevention’s National Healthcare Safety Network and from a systematic review of the medical literature to estimate the impact of hospital-acquired infections on the U.S. health care system. They focused on a single year (2009) and the five most common, most costly, most preventable, and most well-monitored infections among adult inpatients: surgical site infection, central line–associated bloodstream infection, catheter-associated urinary tract infection, ventilator-associated pneumonia, and Clostridium difficile infection.

These infections occurred against a background of approximately 34.7 million adults receiving inpatient care in U.S. hospitals, for a total of 165.1 million patient-days. These patients underwent approximately 8 million surgical procedures and were treated with invasive medical devices for approximately 96.2 million days of care, which placed them at risk for hospital-acquired infections.

"On an annual basis, surgical site infections (158,639) and Clostridium difficile infections (133,657) were estimated to be the most frequent hospital-acquired infections nationwide," accounting for 36% and 30% of the total number. Catheter-associated UTIs accounted for another 17%, central line–associated bloodstream infection accounted for 9%, and ventilator-associated pneumonia accounted for 7%, Dr. Zimlichman and his associates wrote (JAMA Intern. Med. 2013 Sept. 2 [doi:10.1001/jamainternmed.2013.9763]).

Surgical site infections contributed the greatest portion (34%) to the $9.8 billion estimated total. Catheter-associated UTIs, while frequent, contributed less than 1% to the total expenditure. Ventilator-associated pneumonia contributed 32%, central line–associated bloodstream infection contributed 19%, and C. difficile contributed 15%.

"Since surgical site infections constitute the largest portion of hospital-acquired infection–related costs nationally, and since less progress has been made in preventing these infections than in other areas of care, research and quality improvement efforts are clearly needed in this area," noted Dr. Zimlichman and his associates.

Even though central line–associated bloodstream infections were relatively infrequent, accounting for less than 10% of the total number, these were the most costly infections on a case-by-case basis. Each case of this infection was estimated to cost $45,814. The subgroup of central line–associated bloodstream infections caused by methicillin-resistant Staphylococcus aureus was even more expensive, at $58,614 per case.

The study findings indicate that although much progress has been made in preventing hospital-acquired infections, "much more remains to be done."

"Our study provides updated, robust, and applicable estimates for resources attributable to the major hospital-acquired infections that continue to plague modern health care systems and create considerable harm to patients," they noted.

The investigators added that their findings underestimate the true health care costs of hospital-acquired infection because this study excluded "not only neonatal and pediatric patients but also patients in non–acute care facilities such as long-term care and dialysis centers."

This study was sponsored by the Texas Medical Institute of Technology in Austin. No financial conflicts of interest were reported.

Endoscopic cystogastrostomy was as effective as surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial comparing the two approaches.

None of the 20 patients randomized to undergo endoscopic treatment, and 1 of 20 patients randomized to undergo surgery, experienced pseudocyst recurrence within 24 months of follow-up, Dr. Shyam Varadarajulu of the University of Alabama at Birmingham and his colleagues reported online May 31, ahead of print in Gastroenterology.

Source: American Gastroenterological Association

Moreover, those in the endoscopy group had a shorter hospital length of stay than did the patients in the surgery group (median of 2 vs. 6 days) and a lower mean cost of care ($7,011 vs. $15,052), the investigators reported (Gastroenterology 2013 May 31 [doi: 10.1053/j.gastro.2013.05.046]).

Patients included in the study were adults with intrapancreatic or extrapancreatic pseudocysts who were enrolled between Jan. 20 and Dec. 28, 2009, following evaluation by a gastroenterologist or surgeon in an outpatient clinic or inpatient setting.

The 20 patients in the endoscopy group underwent cystogastrostomy using endoscopic ultrasound guidance and fluoroscopy while they were under conscious sedation.

"Once the pseudocyst was identified, it was accessed using a 19-gauge needle, and the gastric wall was dilated up to 15 mm using a wire-guided balloon. Two plastic stents then were deployed to facilitate the drainage of pseudocyst contents into the stomach," the investigators explained, noting that endoscopy patients were discharged following the procedure.

No procedural complications occurred in any of the 20 patients. However, one patient presented to the hospital 13 days later with persistent abdominal pain; a computed tomography scan showed a residual 7-cm pseudocyst, which was successfully treated by deployment of additional stents. At 8-week follow-up, abdominal CT scans showed pseudocyst resolution in all 20 patients.

Endoscopic retrograde cholangiopancreatography (ERCP), which was performed in all of the endoscopy patients to assess and treat any pancreatic duct leaks, was successful in 18 of the 20 patients. Magnetic resonance cholangiopancreatography (MRCP), performed in those two patients, showed a normal pancreatic duct in one and a disconnected duct in the other, the investigators said.

The 20 patients in the surgery group were all treated by the same pancreatic surgeon, who used an endovascular stapler to create at least a 6-cm cystogastrostomy after obtaining entry to the pseudocyst.

"A nasogastric tube then was left in the stomach and passed into the pseudocyst cavity to allow for intermittent irrigation until postoperative day 1 ... the nasogastric tube was removed on postoperative day 1 and clear liquids were started on day 2," they said.

Patients were discharged once a soft diet was tolerated and pain adequately controlled.

One patient with ongoing alcohol consumption developed pseudocyst recurrence at 4 months and was managed by endoscopic cystogastrostomy.

Two surgery patients experienced complications, including a wound infection treated by local debridement and antibiotics in one patient, and a case of hematemesis in one patient who was on anticoagulation and who was readmitted 9 days after discharge. "At endoscopy, a visible clot was noted at the site of surgical anastomosis, and hemostasis was achieved by application of electrocautery," the investigators said.

Two other patients were not able to tolerate oral intake postoperatively; one of them was managed conservatively, and one required surgical placement of a temporary enteral feeding tube. In addition, one patient presented at 6 months with abdominal pain and was found on ERCP to have a stricture in the pancreatic tail that required management by distal pancreatectomy.

Overall, there were no differences in the rates of treatment success, treatment failure, complications, or reinterventions between the endoscopy and surgery groups.

However, in addition to the shorter hospital stay and lower costs in the endoscopy group, patients in that group had significantly greater improvement over time in physical and mental health component scores on the Medical Outcomes Study 36-Item Short-Form General Survey. Although the scores improved for both cohorts, they were 4.48 points and 4.41 points lower, respectively, in the surgery group than the endoscopy group, the investigators said.

The findings are of note because although endoscopic drainage of pancreatic pseudocysts is increasingly performed, surgical cystogastrostomy is still considered the gold standard for treatment, as randomized trials comparing the two approaches had not previously been performed.

"The clinical relevance of this study is substantial because it shows that endoscopically managed patients can be discharged home earlier with a better health-related quality of life, and treatment can be delivered at a lower cost," the investigators said.

The authors reported having no disclosures.

[email protected]

Endoscopic cystogastrostomy was as effective as surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial comparing the two approaches.

None of the 20 patients randomized to undergo endoscopic treatment, and 1 of 20 patients randomized to undergo surgery, experienced pseudocyst recurrence within 24 months of follow-up, Dr. Shyam Varadarajulu of the University of Alabama at Birmingham and his colleagues reported online May 31, ahead of print in Gastroenterology.

Source: American Gastroenterological Association

Moreover, those in the endoscopy group had a shorter hospital length of stay than did the patients in the surgery group (median of 2 vs. 6 days) and a lower mean cost of care ($7,011 vs. $15,052), the investigators reported (Gastroenterology 2013 May 31 [doi: 10.1053/j.gastro.2013.05.046]).

Patients included in the study were adults with intrapancreatic or extrapancreatic pseudocysts who were enrolled between Jan. 20 and Dec. 28, 2009, following evaluation by a gastroenterologist or surgeon in an outpatient clinic or inpatient setting.

The 20 patients in the endoscopy group underwent cystogastrostomy using endoscopic ultrasound guidance and fluoroscopy while they were under conscious sedation.

"Once the pseudocyst was identified, it was accessed using a 19-gauge needle, and the gastric wall was dilated up to 15 mm using a wire-guided balloon. Two plastic stents then were deployed to facilitate the drainage of pseudocyst contents into the stomach," the investigators explained, noting that endoscopy patients were discharged following the procedure.

No procedural complications occurred in any of the 20 patients. However, one patient presented to the hospital 13 days later with persistent abdominal pain; a computed tomography scan showed a residual 7-cm pseudocyst, which was successfully treated by deployment of additional stents. At 8-week follow-up, abdominal CT scans showed pseudocyst resolution in all 20 patients.

Endoscopic retrograde cholangiopancreatography (ERCP), which was performed in all of the endoscopy patients to assess and treat any pancreatic duct leaks, was successful in 18 of the 20 patients. Magnetic resonance cholangiopancreatography (MRCP), performed in those two patients, showed a normal pancreatic duct in one and a disconnected duct in the other, the investigators said.

The 20 patients in the surgery group were all treated by the same pancreatic surgeon, who used an endovascular stapler to create at least a 6-cm cystogastrostomy after obtaining entry to the pseudocyst.

"A nasogastric tube then was left in the stomach and passed into the pseudocyst cavity to allow for intermittent irrigation until postoperative day 1 ... the nasogastric tube was removed on postoperative day 1 and clear liquids were started on day 2," they said.

Patients were discharged once a soft diet was tolerated and pain adequately controlled.

One patient with ongoing alcohol consumption developed pseudocyst recurrence at 4 months and was managed by endoscopic cystogastrostomy.

Two surgery patients experienced complications, including a wound infection treated by local debridement and antibiotics in one patient, and a case of hematemesis in one patient who was on anticoagulation and who was readmitted 9 days after discharge. "At endoscopy, a visible clot was noted at the site of surgical anastomosis, and hemostasis was achieved by application of electrocautery," the investigators said.

Two other patients were not able to tolerate oral intake postoperatively; one of them was managed conservatively, and one required surgical placement of a temporary enteral feeding tube. In addition, one patient presented at 6 months with abdominal pain and was found on ERCP to have a stricture in the pancreatic tail that required management by distal pancreatectomy.

Overall, there were no differences in the rates of treatment success, treatment failure, complications, or reinterventions between the endoscopy and surgery groups.

However, in addition to the shorter hospital stay and lower costs in the endoscopy group, patients in that group had significantly greater improvement over time in physical and mental health component scores on the Medical Outcomes Study 36-Item Short-Form General Survey. Although the scores improved for both cohorts, they were 4.48 points and 4.41 points lower, respectively, in the surgery group than the endoscopy group, the investigators said.

The findings are of note because although endoscopic drainage of pancreatic pseudocysts is increasingly performed, surgical cystogastrostomy is still considered the gold standard for treatment, as randomized trials comparing the two approaches had not previously been performed.

"The clinical relevance of this study is substantial because it shows that endoscopically managed patients can be discharged home earlier with a better health-related quality of life, and treatment can be delivered at a lower cost," the investigators said.

The authors reported having no disclosures.

[email protected]

Endoscopic cystogastrostomy was as effective as surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial comparing the two approaches.

None of the 20 patients randomized to undergo endoscopic treatment, and 1 of 20 patients randomized to undergo surgery, experienced pseudocyst recurrence within 24 months of follow-up, Dr. Shyam Varadarajulu of the University of Alabama at Birmingham and his colleagues reported online May 31, ahead of print in Gastroenterology.

Source: American Gastroenterological Association

Moreover, those in the endoscopy group had a shorter hospital length of stay than did the patients in the surgery group (median of 2 vs. 6 days) and a lower mean cost of care ($7,011 vs. $15,052), the investigators reported (Gastroenterology 2013 May 31 [doi: 10.1053/j.gastro.2013.05.046]).

Patients included in the study were adults with intrapancreatic or extrapancreatic pseudocysts who were enrolled between Jan. 20 and Dec. 28, 2009, following evaluation by a gastroenterologist or surgeon in an outpatient clinic or inpatient setting.

The 20 patients in the endoscopy group underwent cystogastrostomy using endoscopic ultrasound guidance and fluoroscopy while they were under conscious sedation.

"Once the pseudocyst was identified, it was accessed using a 19-gauge needle, and the gastric wall was dilated up to 15 mm using a wire-guided balloon. Two plastic stents then were deployed to facilitate the drainage of pseudocyst contents into the stomach," the investigators explained, noting that endoscopy patients were discharged following the procedure.

No procedural complications occurred in any of the 20 patients. However, one patient presented to the hospital 13 days later with persistent abdominal pain; a computed tomography scan showed a residual 7-cm pseudocyst, which was successfully treated by deployment of additional stents. At 8-week follow-up, abdominal CT scans showed pseudocyst resolution in all 20 patients.

Endoscopic retrograde cholangiopancreatography (ERCP), which was performed in all of the endoscopy patients to assess and treat any pancreatic duct leaks, was successful in 18 of the 20 patients. Magnetic resonance cholangiopancreatography (MRCP), performed in those two patients, showed a normal pancreatic duct in one and a disconnected duct in the other, the investigators said.

The 20 patients in the surgery group were all treated by the same pancreatic surgeon, who used an endovascular stapler to create at least a 6-cm cystogastrostomy after obtaining entry to the pseudocyst.

"A nasogastric tube then was left in the stomach and passed into the pseudocyst cavity to allow for intermittent irrigation until postoperative day 1 ... the nasogastric tube was removed on postoperative day 1 and clear liquids were started on day 2," they said.

Patients were discharged once a soft diet was tolerated and pain adequately controlled.

One patient with ongoing alcohol consumption developed pseudocyst recurrence at 4 months and was managed by endoscopic cystogastrostomy.

Two surgery patients experienced complications, including a wound infection treated by local debridement and antibiotics in one patient, and a case of hematemesis in one patient who was on anticoagulation and who was readmitted 9 days after discharge. "At endoscopy, a visible clot was noted at the site of surgical anastomosis, and hemostasis was achieved by application of electrocautery," the investigators said.

Two other patients were not able to tolerate oral intake postoperatively; one of them was managed conservatively, and one required surgical placement of a temporary enteral feeding tube. In addition, one patient presented at 6 months with abdominal pain and was found on ERCP to have a stricture in the pancreatic tail that required management by distal pancreatectomy.

Overall, there were no differences in the rates of treatment success, treatment failure, complications, or reinterventions between the endoscopy and surgery groups.

However, in addition to the shorter hospital stay and lower costs in the endoscopy group, patients in that group had significantly greater improvement over time in physical and mental health component scores on the Medical Outcomes Study 36-Item Short-Form General Survey. Although the scores improved for both cohorts, they were 4.48 points and 4.41 points lower, respectively, in the surgery group than the endoscopy group, the investigators said.

The findings are of note because although endoscopic drainage of pancreatic pseudocysts is increasingly performed, surgical cystogastrostomy is still considered the gold standard for treatment, as randomized trials comparing the two approaches had not previously been performed.

"The clinical relevance of this study is substantial because it shows that endoscopically managed patients can be discharged home earlier with a better health-related quality of life, and treatment can be delivered at a lower cost," the investigators said.

The authors reported having no disclosures.

[email protected]

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013

Early dual therapy with infliximab and an immunomodulator significantly decreased the 1-year risk of hospitalization and surgery in patients with inflammatory bowel disease, in a cohort study of almost 20,500 patients.

The improvements in hospitalization and surgery rates became apparent as quickly as 5 months after therapy initiation. By 9 months after dual therapy began, there was an 86% decrease in hospitalization and a 92% decrease in surgery compared with the rates in those who had not taken these medications.

The study shows that aggressive treatment of inflammatory bowel disease can reap robust results, Dr. Neena S. Abraham and colleagues reported in the Aug. 29 issue of Clinical Gastroenterology and Hepatology (doi:10.1016/j.cgh.2013.04.051).

The results probably underestimate the potential benefits of dual therapy, wrote Dr. Abraham of the Mayo Clinic, Scottsdale, Ariz., and associates. Only 11% of patients in the database took one of the studied treatment regimens, and of those, most (85%) got an immunomodulator only.

"Given the paucity prescribed dual therapy (8.5%), the dose-response data are even more impressive and suggest that if dual therapy had been initiated earlier, greater benefit may have been observed," the investigators wrote.

The study examined 1-year hospitalization and surgical rates in 20,474 patients with either ulcerative colitis or Crohn’s disease. The patients were all included in a database that covered 176 U.S. Department of Veteran Affairs facilities.

Three treatment protocols were examined: immunomodulator monotherapy, anti–tumor necrosis factor (TNF)-alpha monotherapy with infliximab, and dual therapy with an immunomodulator and infliximab.

Most of the patients (12,432) had ulcerative colitis (UC); the remainder had Crohn’s disease (CD). Most (94%) were male; the mean age was 72 years.

The most common strategy was the anti–TNF-alpha alone (8%). Among patients receiving infliximab, 63% had evidence of induction therapy preceding a maintenance regimen.

"Despite their clear therapeutic benefit, less than 15% of patients with inflammatory bowel disease receive anti-TNF monotherapy, and 40% of patients with active CD receive anti-TNF agents in combination with immunomodulator agents (thiopurines or methotrexate)," they commented.

Most patients (66%) were taking other drugs, including steroids (14%), nonsteroidal anti-inflammatory agents (39%), aspirin (21%), cyclosporine (0.21%), antimetabolites (0.67%), and antibiotics (29%).

A 50% relative reduction in hospitalization occurred at 7.7 months with dual therapy compared with 9 months with immunomodulator monotherapy and 8 months with anti–TNF-alpha therapy. All of these differences were statistically significant after the model was adjusted for diagnosis (UC or CD), smoking status, race/ethnicity, and other medications that could modify the treatment effect.

By 1 year, there was a 45% relative reduction in hospitalization for immunomodulator therapy and a 78% relative reduction with anti–TNF-alpha monotherapy. But patients taking dual therapy reached a similar reduction of 73% by 9 months.

"Results suggested that, if dual therapy had been initiated earlier, perhaps a greater response in the outcome may have been observed," the investigators wrote.

There was a similar beneficial effect on surgeries related to the disorders. In the first year of treatment, there were 276 procedures. By 9 months, there was a 28% risk reduction associated with immunomodulator monotherapy, a 90% reduction associated with anti–TNF-alpha monotherapy, and a 92% reduction associated with dual therapy.

This also suggests that a "greater response may have been observed with earlier initiation of dual therapy," the authors said.

Safety concerns may be one reason for the dearth of these treatment protocols, the authors noted. However, recent long-term safety data suggest that there is a very low risk of mortality associated with them.

"[Five-year] outcome data on infliximab use has failed to demonstrate increased risk of mortality, and, although increased risk of infection was observed, the presence of severe disease and use of prednisone or narcotics carried higher risks," they said, referring to a 2012 study (Am. J. Gastroenterol. 2012;107:1409-22).

A 2011 study also suggested that the benefits of dual therapy outweigh the risks of developing a serious infection or cancer (Clin. J. Gastroenterol. Hepatol. 2012;10:46-51).

Janssen Biotech funded the study. None of the authors reported having any relevant financial disclosures.

[email protected]

Early dual therapy with infliximab and an immunomodulator significantly decreased the 1-year risk of hospitalization and surgery in patients with inflammatory bowel disease, in a cohort study of almost 20,500 patients.

The improvements in hospitalization and surgery rates became apparent as quickly as 5 months after therapy initiation. By 9 months after dual therapy began, there was an 86% decrease in hospitalization and a 92% decrease in surgery compared with the rates in those who had not taken these medications.

The study shows that aggressive treatment of inflammatory bowel disease can reap robust results, Dr. Neena S. Abraham and colleagues reported in the Aug. 29 issue of Clinical Gastroenterology and Hepatology (doi:10.1016/j.cgh.2013.04.051).

The results probably underestimate the potential benefits of dual therapy, wrote Dr. Abraham of the Mayo Clinic, Scottsdale, Ariz., and associates. Only 11% of patients in the database took one of the studied treatment regimens, and of those, most (85%) got an immunomodulator only.

"Given the paucity prescribed dual therapy (8.5%), the dose-response data are even more impressive and suggest that if dual therapy had been initiated earlier, greater benefit may have been observed," the investigators wrote.

The study examined 1-year hospitalization and surgical rates in 20,474 patients with either ulcerative colitis or Crohn’s disease. The patients were all included in a database that covered 176 U.S. Department of Veteran Affairs facilities.

Three treatment protocols were examined: immunomodulator monotherapy, anti–tumor necrosis factor (TNF)-alpha monotherapy with infliximab, and dual therapy with an immunomodulator and infliximab.

Most of the patients (12,432) had ulcerative colitis (UC); the remainder had Crohn’s disease (CD). Most (94%) were male; the mean age was 72 years.

The most common strategy was the anti–TNF-alpha alone (8%). Among patients receiving infliximab, 63% had evidence of induction therapy preceding a maintenance regimen.

"Despite their clear therapeutic benefit, less than 15% of patients with inflammatory bowel disease receive anti-TNF monotherapy, and 40% of patients with active CD receive anti-TNF agents in combination with immunomodulator agents (thiopurines or methotrexate)," they commented.

Most patients (66%) were taking other drugs, including steroids (14%), nonsteroidal anti-inflammatory agents (39%), aspirin (21%), cyclosporine (0.21%), antimetabolites (0.67%), and antibiotics (29%).

A 50% relative reduction in hospitalization occurred at 7.7 months with dual therapy compared with 9 months with immunomodulator monotherapy and 8 months with anti–TNF-alpha therapy. All of these differences were statistically significant after the model was adjusted for diagnosis (UC or CD), smoking status, race/ethnicity, and other medications that could modify the treatment effect.

By 1 year, there was a 45% relative reduction in hospitalization for immunomodulator therapy and a 78% relative reduction with anti–TNF-alpha monotherapy. But patients taking dual therapy reached a similar reduction of 73% by 9 months.

"Results suggested that, if dual therapy had been initiated earlier, perhaps a greater response in the outcome may have been observed," the investigators wrote.

There was a similar beneficial effect on surgeries related to the disorders. In the first year of treatment, there were 276 procedures. By 9 months, there was a 28% risk reduction associated with immunomodulator monotherapy, a 90% reduction associated with anti–TNF-alpha monotherapy, and a 92% reduction associated with dual therapy.

This also suggests that a "greater response may have been observed with earlier initiation of dual therapy," the authors said.

Safety concerns may be one reason for the dearth of these treatment protocols, the authors noted. However, recent long-term safety data suggest that there is a very low risk of mortality associated with them.

"[Five-year] outcome data on infliximab use has failed to demonstrate increased risk of mortality, and, although increased risk of infection was observed, the presence of severe disease and use of prednisone or narcotics carried higher risks," they said, referring to a 2012 study (Am. J. Gastroenterol. 2012;107:1409-22).

A 2011 study also suggested that the benefits of dual therapy outweigh the risks of developing a serious infection or cancer (Clin. J. Gastroenterol. Hepatol. 2012;10:46-51).

Janssen Biotech funded the study. None of the authors reported having any relevant financial disclosures.

[email protected]

Early dual therapy with infliximab and an immunomodulator significantly decreased the 1-year risk of hospitalization and surgery in patients with inflammatory bowel disease, in a cohort study of almost 20,500 patients.

The improvements in hospitalization and surgery rates became apparent as quickly as 5 months after therapy initiation. By 9 months after dual therapy began, there was an 86% decrease in hospitalization and a 92% decrease in surgery compared with the rates in those who had not taken these medications.

The study shows that aggressive treatment of inflammatory bowel disease can reap robust results, Dr. Neena S. Abraham and colleagues reported in the Aug. 29 issue of Clinical Gastroenterology and Hepatology (doi:10.1016/j.cgh.2013.04.051).

The results probably underestimate the potential benefits of dual therapy, wrote Dr. Abraham of the Mayo Clinic, Scottsdale, Ariz., and associates. Only 11% of patients in the database took one of the studied treatment regimens, and of those, most (85%) got an immunomodulator only.

"Given the paucity prescribed dual therapy (8.5%), the dose-response data are even more impressive and suggest that if dual therapy had been initiated earlier, greater benefit may have been observed," the investigators wrote.

The study examined 1-year hospitalization and surgical rates in 20,474 patients with either ulcerative colitis or Crohn’s disease. The patients were all included in a database that covered 176 U.S. Department of Veteran Affairs facilities.

Three treatment protocols were examined: immunomodulator monotherapy, anti–tumor necrosis factor (TNF)-alpha monotherapy with infliximab, and dual therapy with an immunomodulator and infliximab.

Most of the patients (12,432) had ulcerative colitis (UC); the remainder had Crohn’s disease (CD). Most (94%) were male; the mean age was 72 years.

The most common strategy was the anti–TNF-alpha alone (8%). Among patients receiving infliximab, 63% had evidence of induction therapy preceding a maintenance regimen.

"Despite their clear therapeutic benefit, less than 15% of patients with inflammatory bowel disease receive anti-TNF monotherapy, and 40% of patients with active CD receive anti-TNF agents in combination with immunomodulator agents (thiopurines or methotrexate)," they commented.

Most patients (66%) were taking other drugs, including steroids (14%), nonsteroidal anti-inflammatory agents (39%), aspirin (21%), cyclosporine (0.21%), antimetabolites (0.67%), and antibiotics (29%).

A 50% relative reduction in hospitalization occurred at 7.7 months with dual therapy compared with 9 months with immunomodulator monotherapy and 8 months with anti–TNF-alpha therapy. All of these differences were statistically significant after the model was adjusted for diagnosis (UC or CD), smoking status, race/ethnicity, and other medications that could modify the treatment effect.

By 1 year, there was a 45% relative reduction in hospitalization for immunomodulator therapy and a 78% relative reduction with anti–TNF-alpha monotherapy. But patients taking dual therapy reached a similar reduction of 73% by 9 months.

"Results suggested that, if dual therapy had been initiated earlier, perhaps a greater response in the outcome may have been observed," the investigators wrote.

There was a similar beneficial effect on surgeries related to the disorders. In the first year of treatment, there were 276 procedures. By 9 months, there was a 28% risk reduction associated with immunomodulator monotherapy, a 90% reduction associated with anti–TNF-alpha monotherapy, and a 92% reduction associated with dual therapy.

This also suggests that a "greater response may have been observed with earlier initiation of dual therapy," the authors said.

Safety concerns may be one reason for the dearth of these treatment protocols, the authors noted. However, recent long-term safety data suggest that there is a very low risk of mortality associated with them.

"[Five-year] outcome data on infliximab use has failed to demonstrate increased risk of mortality, and, although increased risk of infection was observed, the presence of severe disease and use of prednisone or narcotics carried higher risks," they said, referring to a 2012 study (Am. J. Gastroenterol. 2012;107:1409-22).

A 2011 study also suggested that the benefits of dual therapy outweigh the risks of developing a serious infection or cancer (Clin. J. Gastroenterol. Hepatol. 2012;10:46-51).

Janssen Biotech funded the study. None of the authors reported having any relevant financial disclosures.

[email protected]

More than 1 in 4 patients who died from all causes after noncardiac surgery may have survived if they were not treated with perioperative beta-blockers as specified by joint American College of Cardiology Foundation/American Heart Association and separate European Society of Cardiology guidelines.

These guidelines recommend perioperative beta-blockers in all patients undergoing vascular or intermediate-risk surgery with coronary artery disease, or with more than one risk factor for CAD, or with preexisting beta-blockade. These are all iatrogenic deaths, according to a meta-analysis of secure studies, which excluded data from the now discredited Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) family of trials.

©Jan Mika/iStockphoto.com

"Refraining from this ESC [European Society of Cardiology] guideline would therefore be expected to prevent up to 10,000 iatrogenic deaths each year in the U.K.," according to Dr. Sonia Bouri and her coauthors at the National Heart and Lung Institute, Imperial College London.

The researchers analyzed nine secure randomized trials totaling 10,529 patients who met the guideline criteria, 291 of whom died. They found that initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in mortality.

In the secure trials, use of perioperative beta-blockers decreased nonfatal myocardial infarction significantly (RR, 0.73; P = .001), but increased stroke (RR, 1.73; P =.05) and hypotension (RR, 1.51; P less than .00001), according to the authors, who presented their data in Heart (2013 July 31 [doi: 10.1136/heartjnl-2013-304262]).

Of the 291 deaths recorded in the secure trials, 162 deaths (3.21%) occurred in 5,264 patients randomized to beta-blockers, and 129 deaths (2.45%) occurred in the 5,265 patients randomized to placebo.

Thus, the initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in all-cause mortality, Dr. Bouri and her coauthors stated. "Any remaining [perioperative beta-blocker] enthusiasts might best channel their energy into a further randomized trial, which should be designed carefully and honestly," they added.

The results from the DECREASE family of trials substantially contradicted the meta-analysis of the secure trials on the effect on mortality (P = .05 for divergence).

"All studies investigated in the DECREASE family for which data had not been lost were found to be insecure because of serious flaws. In one case, it was clear that the entire study database had been fabricated. DECREASE I, published in 1999, escaped investigation as the terms of the investigation only reached back 10 years," the researchers reported.

When the ESC and American College of Cardiology Foundation/American Heart Association guidelines were formulated, "the inclusion of insecure data caused them to reach the conclusion that beta-blockade had a neutral effect on mortality and allowed them to focus on the reduction of non-fatal MI as a surrogate endpoint," the authors explained.

The DECREASE family of studies was discredited almost 2 years ago and subsequently underwent lengthy internal investigation, the results of which have been public for some time, according to the authors. "Nevertheless, neither the European Society of Cardiology nor the AHA guidelines have been retracted," they said.

"Patient safety being paramount, guidelines for perioperative beta-blockers should be retracted without further delay. Future guidelines should be accompanied by a commitment from named individuals to retract them immediately if the advice given is later revealed to be harmful," the authors concluded.

The authors reported that they had no conflicts of interest.

[email protected]

More than 1 in 4 patients who died from all causes after noncardiac surgery may have survived if they were not treated with perioperative beta-blockers as specified by joint American College of Cardiology Foundation/American Heart Association and separate European Society of Cardiology guidelines.

These guidelines recommend perioperative beta-blockers in all patients undergoing vascular or intermediate-risk surgery with coronary artery disease, or with more than one risk factor for CAD, or with preexisting beta-blockade. These are all iatrogenic deaths, according to a meta-analysis of secure studies, which excluded data from the now discredited Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) family of trials.

©Jan Mika/iStockphoto.com

"Refraining from this ESC [European Society of Cardiology] guideline would therefore be expected to prevent up to 10,000 iatrogenic deaths each year in the U.K.," according to Dr. Sonia Bouri and her coauthors at the National Heart and Lung Institute, Imperial College London.

The researchers analyzed nine secure randomized trials totaling 10,529 patients who met the guideline criteria, 291 of whom died. They found that initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in mortality.

In the secure trials, use of perioperative beta-blockers decreased nonfatal myocardial infarction significantly (RR, 0.73; P = .001), but increased stroke (RR, 1.73; P =.05) and hypotension (RR, 1.51; P less than .00001), according to the authors, who presented their data in Heart (2013 July 31 [doi: 10.1136/heartjnl-2013-304262]).

Of the 291 deaths recorded in the secure trials, 162 deaths (3.21%) occurred in 5,264 patients randomized to beta-blockers, and 129 deaths (2.45%) occurred in the 5,265 patients randomized to placebo.

Thus, the initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in all-cause mortality, Dr. Bouri and her coauthors stated. "Any remaining [perioperative beta-blocker] enthusiasts might best channel their energy into a further randomized trial, which should be designed carefully and honestly," they added.

The results from the DECREASE family of trials substantially contradicted the meta-analysis of the secure trials on the effect on mortality (P = .05 for divergence).

"All studies investigated in the DECREASE family for which data had not been lost were found to be insecure because of serious flaws. In one case, it was clear that the entire study database had been fabricated. DECREASE I, published in 1999, escaped investigation as the terms of the investigation only reached back 10 years," the researchers reported.

When the ESC and American College of Cardiology Foundation/American Heart Association guidelines were formulated, "the inclusion of insecure data caused them to reach the conclusion that beta-blockade had a neutral effect on mortality and allowed them to focus on the reduction of non-fatal MI as a surrogate endpoint," the authors explained.

The DECREASE family of studies was discredited almost 2 years ago and subsequently underwent lengthy internal investigation, the results of which have been public for some time, according to the authors. "Nevertheless, neither the European Society of Cardiology nor the AHA guidelines have been retracted," they said.

"Patient safety being paramount, guidelines for perioperative beta-blockers should be retracted without further delay. Future guidelines should be accompanied by a commitment from named individuals to retract them immediately if the advice given is later revealed to be harmful," the authors concluded.

The authors reported that they had no conflicts of interest.

[email protected]

More than 1 in 4 patients who died from all causes after noncardiac surgery may have survived if they were not treated with perioperative beta-blockers as specified by joint American College of Cardiology Foundation/American Heart Association and separate European Society of Cardiology guidelines.

These guidelines recommend perioperative beta-blockers in all patients undergoing vascular or intermediate-risk surgery with coronary artery disease, or with more than one risk factor for CAD, or with preexisting beta-blockade. These are all iatrogenic deaths, according to a meta-analysis of secure studies, which excluded data from the now discredited Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) family of trials.

©Jan Mika/iStockphoto.com

"Refraining from this ESC [European Society of Cardiology] guideline would therefore be expected to prevent up to 10,000 iatrogenic deaths each year in the U.K.," according to Dr. Sonia Bouri and her coauthors at the National Heart and Lung Institute, Imperial College London.

The researchers analyzed nine secure randomized trials totaling 10,529 patients who met the guideline criteria, 291 of whom died. They found that initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in mortality.

In the secure trials, use of perioperative beta-blockers decreased nonfatal myocardial infarction significantly (RR, 0.73; P = .001), but increased stroke (RR, 1.73; P =.05) and hypotension (RR, 1.51; P less than .00001), according to the authors, who presented their data in Heart (2013 July 31 [doi: 10.1136/heartjnl-2013-304262]).

Of the 291 deaths recorded in the secure trials, 162 deaths (3.21%) occurred in 5,264 patients randomized to beta-blockers, and 129 deaths (2.45%) occurred in the 5,265 patients randomized to placebo.

Thus, the initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in all-cause mortality, Dr. Bouri and her coauthors stated. "Any remaining [perioperative beta-blocker] enthusiasts might best channel their energy into a further randomized trial, which should be designed carefully and honestly," they added.

The results from the DECREASE family of trials substantially contradicted the meta-analysis of the secure trials on the effect on mortality (P = .05 for divergence).

"All studies investigated in the DECREASE family for which data had not been lost were found to be insecure because of serious flaws. In one case, it was clear that the entire study database had been fabricated. DECREASE I, published in 1999, escaped investigation as the terms of the investigation only reached back 10 years," the researchers reported.

When the ESC and American College of Cardiology Foundation/American Heart Association guidelines were formulated, "the inclusion of insecure data caused them to reach the conclusion that beta-blockade had a neutral effect on mortality and allowed them to focus on the reduction of non-fatal MI as a surrogate endpoint," the authors explained.

The DECREASE family of studies was discredited almost 2 years ago and subsequently underwent lengthy internal investigation, the results of which have been public for some time, according to the authors. "Nevertheless, neither the European Society of Cardiology nor the AHA guidelines have been retracted," they said.

"Patient safety being paramount, guidelines for perioperative beta-blockers should be retracted without further delay. Future guidelines should be accompanied by a commitment from named individuals to retract them immediately if the advice given is later revealed to be harmful," the authors concluded.

The authors reported that they had no conflicts of interest.

[email protected]

Implementing the requirements of an accountable care organization for one group of patients may lower costs and improve care for every patient seen in a physician’s practice, according to a study published online Aug. 27 in JAMA.

Dr. J. Michael McWilliams of Harvard Medical School, Boston, and his colleagues looked at whether the Blue Cross Blue Shield of Massachusetts’ Alternative Quality Contract (ACQ), a successful ACO started in 2009, was associated with changes in spending or quality of care for Medicare beneficiaries who were not part of the ACO.

In the AQC, physicians and other providers assumed financial risk if they spent more than a global budget, but shared savings with the insurer if spending was under budget. Physicians could also receive bonuses for meeting quality targets.

©sndr/istockphoto.com

The investigators compared total quarterly medical spending per beneficiary between two groups: beneficiaries who received care through the AQC in 2009 or 2010 (1.7 million person-years) and controls who received care from other providers (JAMA 2013;310:829-836).

Quarterly spending per beneficiary in 2007 and 2008 (prior to the AQC contracts) was $150 higher for the AQC group than the control group. Two years after the ACQ contracts went into effect, the difference was $51 per quarter. The biggest reduction in spending was for beneficiaries with five or more conditions, and in spending on outpatient care. Spending was significantly reduced for office visits, emergency department visits, minor procedures, imaging, and lab tests.

Some improvement was seen on quality measures. The number of beneficiaries tested for low-density lipoprotein levels increased. Prior to the AQC, LDL testing rates for diabetic beneficiaries in the AQC group were 2.2% higher than for controls. By the second year, the testing rate was 5.2% higher for those in the AQC. LDL testing rates also improved for cardiovascular disease patients in the AQC.

No improvement was seen on other quality measures, including hospitalization for an ambulatory care–sensitive condition related to cardiovascular disease or diabetes; readmission within 30 days of discharge; screening mammography for women aged 65-69 years; LDL testing for beneficiaries with a history of ischemic heart disease, myocardial infarction, or stroke; and hemoglobin A_1c testing and retinal exams for beneficiaries with diabetes.

"These findings suggest that global payment incentives in the AQC elicited responses from participating organizations that extended beyond targeted case management of BCBS enrollees," the authors wrote.

Overall, the study "suggests that organizations in Massachusetts willing to assume greater financial risk were capable of achieving modest reductions in spending for Medicare beneficiaries without compromising quality of care," wrote Dr. McWilliams and his colleagues.

The study also showed that physicians and provider organizations who see spillover effects from one ACO contract might be willing "to enter similar contracts with additional insurers."

But there is a potential downside to the spillover effect, according to the authors: Because cost and quality may be improved overall, "competing insurers with similar provider networks could offer lower premiums without incurring the costs of managing an ACO."

The study was supported by grants from the National Institute on Aging, the American Federation for Aging Research, the Doris Duke Charitable Foundation, and the Commonwealth Fund. The investigators reported no relevant conflicts of interest.

[email protected]

On Twitter @aliciaault

Implementing the requirements of an accountable care organization for one group of patients may lower costs and improve care for every patient seen in a physician’s practice, according to a study published online Aug. 27 in JAMA.

Dr. J. Michael McWilliams of Harvard Medical School, Boston, and his colleagues looked at whether the Blue Cross Blue Shield of Massachusetts’ Alternative Quality Contract (ACQ), a successful ACO started in 2009, was associated with changes in spending or quality of care for Medicare beneficiaries who were not part of the ACO.

In the AQC, physicians and other providers assumed financial risk if they spent more than a global budget, but shared savings with the insurer if spending was under budget. Physicians could also receive bonuses for meeting quality targets.

©sndr/istockphoto.com

The investigators compared total quarterly medical spending per beneficiary between two groups: beneficiaries who received care through the AQC in 2009 or 2010 (1.7 million person-years) and controls who received care from other providers (JAMA 2013;310:829-836).

Quarterly spending per beneficiary in 2007 and 2008 (prior to the AQC contracts) was $150 higher for the AQC group than the control group. Two years after the ACQ contracts went into effect, the difference was $51 per quarter. The biggest reduction in spending was for beneficiaries with five or more conditions, and in spending on outpatient care. Spending was significantly reduced for office visits, emergency department visits, minor procedures, imaging, and lab tests.

Some improvement was seen on quality measures. The number of beneficiaries tested for low-density lipoprotein levels increased. Prior to the AQC, LDL testing rates for diabetic beneficiaries in the AQC group were 2.2% higher than for controls. By the second year, the testing rate was 5.2% higher for those in the AQC. LDL testing rates also improved for cardiovascular disease patients in the AQC.

No improvement was seen on other quality measures, including hospitalization for an ambulatory care–sensitive condition related to cardiovascular disease or diabetes; readmission within 30 days of discharge; screening mammography for women aged 65-69 years; LDL testing for beneficiaries with a history of ischemic heart disease, myocardial infarction, or stroke; and hemoglobin A_1c testing and retinal exams for beneficiaries with diabetes.

"These findings suggest that global payment incentives in the AQC elicited responses from participating organizations that extended beyond targeted case management of BCBS enrollees," the authors wrote.

Overall, the study "suggests that organizations in Massachusetts willing to assume greater financial risk were capable of achieving modest reductions in spending for Medicare beneficiaries without compromising quality of care," wrote Dr. McWilliams and his colleagues.

The study also showed that physicians and provider organizations who see spillover effects from one ACO contract might be willing "to enter similar contracts with additional insurers."

But there is a potential downside to the spillover effect, according to the authors: Because cost and quality may be improved overall, "competing insurers with similar provider networks could offer lower premiums without incurring the costs of managing an ACO."

The study was supported by grants from the National Institute on Aging, the American Federation for Aging Research, the Doris Duke Charitable Foundation, and the Commonwealth Fund. The investigators reported no relevant conflicts of interest.

[email protected]

On Twitter @aliciaault

Implementing the requirements of an accountable care organization for one group of patients may lower costs and improve care for every patient seen in a physician’s practice, according to a study published online Aug. 27 in JAMA.

Dr. J. Michael McWilliams of Harvard Medical School, Boston, and his colleagues looked at whether the Blue Cross Blue Shield of Massachusetts’ Alternative Quality Contract (ACQ), a successful ACO started in 2009, was associated with changes in spending or quality of care for Medicare beneficiaries who were not part of the ACO.

In the AQC, physicians and other providers assumed financial risk if they spent more than a global budget, but shared savings with the insurer if spending was under budget. Physicians could also receive bonuses for meeting quality targets.

©sndr/istockphoto.com

The investigators compared total quarterly medical spending per beneficiary between two groups: beneficiaries who received care through the AQC in 2009 or 2010 (1.7 million person-years) and controls who received care from other providers (JAMA 2013;310:829-836).

Quarterly spending per beneficiary in 2007 and 2008 (prior to the AQC contracts) was $150 higher for the AQC group than the control group. Two years after the ACQ contracts went into effect, the difference was $51 per quarter. The biggest reduction in spending was for beneficiaries with five or more conditions, and in spending on outpatient care. Spending was significantly reduced for office visits, emergency department visits, minor procedures, imaging, and lab tests.

Some improvement was seen on quality measures. The number of beneficiaries tested for low-density lipoprotein levels increased. Prior to the AQC, LDL testing rates for diabetic beneficiaries in the AQC group were 2.2% higher than for controls. By the second year, the testing rate was 5.2% higher for those in the AQC. LDL testing rates also improved for cardiovascular disease patients in the AQC.

No improvement was seen on other quality measures, including hospitalization for an ambulatory care–sensitive condition related to cardiovascular disease or diabetes; readmission within 30 days of discharge; screening mammography for women aged 65-69 years; LDL testing for beneficiaries with a history of ischemic heart disease, myocardial infarction, or stroke; and hemoglobin A_1c testing and retinal exams for beneficiaries with diabetes.

"These findings suggest that global payment incentives in the AQC elicited responses from participating organizations that extended beyond targeted case management of BCBS enrollees," the authors wrote.

Overall, the study "suggests that organizations in Massachusetts willing to assume greater financial risk were capable of achieving modest reductions in spending for Medicare beneficiaries without compromising quality of care," wrote Dr. McWilliams and his colleagues.

The study also showed that physicians and provider organizations who see spillover effects from one ACO contract might be willing "to enter similar contracts with additional insurers."

But there is a potential downside to the spillover effect, according to the authors: Because cost and quality may be improved overall, "competing insurers with similar provider networks could offer lower premiums without incurring the costs of managing an ACO."

The study was supported by grants from the National Institute on Aging, the American Federation for Aging Research, the Doris Duke Charitable Foundation, and the Commonwealth Fund. The investigators reported no relevant conflicts of interest.

[email protected]

On Twitter @aliciaault

Nearly 90% of physicians accept new Medicare patients, a percentage that has held steady for the last several years, according to an analysis released by the Department of Health and Human Services.

In 2012, 90.7% of physicians were accepting new Medicare patients, compared with 87.9% in 2005. The HHS report, released Aug. 22, relies on data from the National Ambulatory Medical Care Survey, a nationally representative survey of office-based medical doctors and osteopaths. It excludes radiologists, anesthesiologists, and pathologists. As of 2011, about 650,000 physicians were participating in the Medicare program.

©moodboard/Fotolia.com

The figures reported by the HHS are similar to the percentage of physicians who were accepting private health insurance between 2005 and 2012. However, preliminary data from the National Ambulatory Medical Care Survey suggests that between 2011 and 2012, the percentage of doctors seeing new Medicare patients was slightly higher than the percentage accepting new privately-insured patients.

Medicare officials said the report confirms that physician participation in the Medicare program remains strong despite reports that a growing number of physicians are choosing to opt out. As a percentage of the total physicians participating in Medicare, those opting out represent only about 1% each year and are greatly outpaced by physicians choosing to participate in the program, according to the Centers for Medicare and Medicaid Services.

[email protected]

On Twitter @MaryEllenNY

Nearly 90% of physicians accept new Medicare patients, a percentage that has held steady for the last several years, according to an analysis released by the Department of Health and Human Services.

In 2012, 90.7% of physicians were accepting new Medicare patients, compared with 87.9% in 2005. The HHS report, released Aug. 22, relies on data from the National Ambulatory Medical Care Survey, a nationally representative survey of office-based medical doctors and osteopaths. It excludes radiologists, anesthesiologists, and pathologists. As of 2011, about 650,000 physicians were participating in the Medicare program.

©moodboard/Fotolia.com

The figures reported by the HHS are similar to the percentage of physicians who were accepting private health insurance between 2005 and 2012. However, preliminary data from the National Ambulatory Medical Care Survey suggests that between 2011 and 2012, the percentage of doctors seeing new Medicare patients was slightly higher than the percentage accepting new privately-insured patients.

Medicare officials said the report confirms that physician participation in the Medicare program remains strong despite reports that a growing number of physicians are choosing to opt out. As a percentage of the total physicians participating in Medicare, those opting out represent only about 1% each year and are greatly outpaced by physicians choosing to participate in the program, according to the Centers for Medicare and Medicaid Services.

[email protected]

On Twitter @MaryEllenNY

Nearly 90% of physicians accept new Medicare patients, a percentage that has held steady for the last several years, according to an analysis released by the Department of Health and Human Services.

In 2012, 90.7% of physicians were accepting new Medicare patients, compared with 87.9% in 2005. The HHS report, released Aug. 22, relies on data from the National Ambulatory Medical Care Survey, a nationally representative survey of office-based medical doctors and osteopaths. It excludes radiologists, anesthesiologists, and pathologists. As of 2011, about 650,000 physicians were participating in the Medicare program.

©moodboard/Fotolia.com

The figures reported by the HHS are similar to the percentage of physicians who were accepting private health insurance between 2005 and 2012. However, preliminary data from the National Ambulatory Medical Care Survey suggests that between 2011 and 2012, the percentage of doctors seeing new Medicare patients was slightly higher than the percentage accepting new privately-insured patients.

Medicare officials said the report confirms that physician participation in the Medicare program remains strong despite reports that a growing number of physicians are choosing to opt out. As a percentage of the total physicians participating in Medicare, those opting out represent only about 1% each year and are greatly outpaced by physicians choosing to participate in the program, according to the Centers for Medicare and Medicaid Services.

[email protected]

On Twitter @MaryEllenNY

WASHINGTON – Congress appears to be on the brink of reforming the Medicare Sustainable Growth Rate formula after many years of temporary payment updates that physicians say undermine the stability of their practices and of the federal health program, as well.

Dr. Ardis Dee Hoven, president of the American Medical Association, discusses why Congress is so much closer to solving the Medicare physician payment puzzle this year. She also weighs in on prospects for action in the House and Senate when lawmakers return from their summer recess in September and what the practice world might look like after the SGR disappears.

[email protected]

On Twitter @aliciaault

WASHINGTON – Congress appears to be on the brink of reforming the Medicare Sustainable Growth Rate formula after many years of temporary payment updates that physicians say undermine the stability of their practices and of the federal health program, as well.

Dr. Ardis Dee Hoven, president of the American Medical Association, discusses why Congress is so much closer to solving the Medicare physician payment puzzle this year. She also weighs in on prospects for action in the House and Senate when lawmakers return from their summer recess in September and what the practice world might look like after the SGR disappears.

[email protected]

On Twitter @aliciaault

WASHINGTON – Congress appears to be on the brink of reforming the Medicare Sustainable Growth Rate formula after many years of temporary payment updates that physicians say undermine the stability of their practices and of the federal health program, as well.

Dr. Ardis Dee Hoven, president of the American Medical Association, discusses why Congress is so much closer to solving the Medicare physician payment puzzle this year. She also weighs in on prospects for action in the House and Senate when lawmakers return from their summer recess in September and what the practice world might look like after the SGR disappears.

[email protected]

On Twitter @aliciaault

The Medical Group Management Association wants an indefinite hold on penalties to be levied on physicians who cannot move on to the next stage of meaningful use of electronic health records.

In an Aug. 21 letter to the Health and Human Services (HHS) department, Dr. Susan Turney, MGMA president and chief executive officer, said that physicians who have already met requirements for stage 1 meaningful use should not be penalized if they can’t meet the requirements for stage 2.

Physicians have been receiving incentive payments to become meaningful users of EHRs under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. Those payments continue through 2014. But stage 2 starts in 2014, and physicians will be penalized in 2015 if they can’t meet the goals.

Dr. Turney noted that while there are 2,200 products and 1,400 complete EHRs that are certified by the government for stage 1, so far, there are only 75 products and 21 complete EHRs that are certified for stage 2.

That dearth of certified technology does not give physicians enough time to upgrade their systems or acquire new technology to allow them to be ready to participate in stage 2, Dr. Turney said.

Physicians not only are waiting on vendors to upgrade their products, but have to consider whether they can afford to invest in new technology. And, if they do, staff will have to be trained, which can take a year or more, she noted.

In addition to indefinitely delaying penalties on physicians who have achieved stage 1 but not stage 2, the MGMA recommended that HHS also extend the reporting period for stage 2 for at least a year. "This extra year would provide additional time for vendors to upgrade their software, certify for the stage 2 criteria, and install the products," Dr. Turney wrote.

HHS also should extend the reporting period for stage 1 so that providers who have attested for stage 1 and whose EHR has not been recertified by January 2015 can continue to report on stage 1 during 2014.

The MGMA is also concerned about the stage 2 criteria that would require physicians to give at least 5% of their patients the ability to view, download, and transmit their health information online within 4 days of it being posted. That requirement should be closely monitored and potentially adjusted, according to the MGMA letter.

The MGMA represents 22,500 leaders at 13,200 organizations that in turn employ or are affiliated with 280,000 physicians.

[email protected]

On Twitter @aliciaault

The Medical Group Management Association wants an indefinite hold on penalties to be levied on physicians who cannot move on to the next stage of meaningful use of electronic health records.

In an Aug. 21 letter to the Health and Human Services (HHS) department, Dr. Susan Turney, MGMA president and chief executive officer, said that physicians who have already met requirements for stage 1 meaningful use should not be penalized if they can’t meet the requirements for stage 2.

Physicians have been receiving incentive payments to become meaningful users of EHRs under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. Those payments continue through 2014. But stage 2 starts in 2014, and physicians will be penalized in 2015 if they can’t meet the goals.

Dr. Turney noted that while there are 2,200 products and 1,400 complete EHRs that are certified by the government for stage 1, so far, there are only 75 products and 21 complete EHRs that are certified for stage 2.

That dearth of certified technology does not give physicians enough time to upgrade their systems or acquire new technology to allow them to be ready to participate in stage 2, Dr. Turney said.

Physicians not only are waiting on vendors to upgrade their products, but have to consider whether they can afford to invest in new technology. And, if they do, staff will have to be trained, which can take a year or more, she noted.

In addition to indefinitely delaying penalties on physicians who have achieved stage 1 but not stage 2, the MGMA recommended that HHS also extend the reporting period for stage 2 for at least a year. "This extra year would provide additional time for vendors to upgrade their software, certify for the stage 2 criteria, and install the products," Dr. Turney wrote.

HHS also should extend the reporting period for stage 1 so that providers who have attested for stage 1 and whose EHR has not been recertified by January 2015 can continue to report on stage 1 during 2014.

The MGMA is also concerned about the stage 2 criteria that would require physicians to give at least 5% of their patients the ability to view, download, and transmit their health information online within 4 days of it being posted. That requirement should be closely monitored and potentially adjusted, according to the MGMA letter.

The MGMA represents 22,500 leaders at 13,200 organizations that in turn employ or are affiliated with 280,000 physicians.

[email protected]

On Twitter @aliciaault

The Medical Group Management Association wants an indefinite hold on penalties to be levied on physicians who cannot move on to the next stage of meaningful use of electronic health records.

In an Aug. 21 letter to the Health and Human Services (HHS) department, Dr. Susan Turney, MGMA president and chief executive officer, said that physicians who have already met requirements for stage 1 meaningful use should not be penalized if they can’t meet the requirements for stage 2.

Physicians have been receiving incentive payments to become meaningful users of EHRs under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. Those payments continue through 2014. But stage 2 starts in 2014, and physicians will be penalized in 2015 if they can’t meet the goals.

Dr. Turney noted that while there are 2,200 products and 1,400 complete EHRs that are certified by the government for stage 1, so far, there are only 75 products and 21 complete EHRs that are certified for stage 2.

That dearth of certified technology does not give physicians enough time to upgrade their systems or acquire new technology to allow them to be ready to participate in stage 2, Dr. Turney said.

Physicians not only are waiting on vendors to upgrade their products, but have to consider whether they can afford to invest in new technology. And, if they do, staff will have to be trained, which can take a year or more, she noted.

In addition to indefinitely delaying penalties on physicians who have achieved stage 1 but not stage 2, the MGMA recommended that HHS also extend the reporting period for stage 2 for at least a year. "This extra year would provide additional time for vendors to upgrade their software, certify for the stage 2 criteria, and install the products," Dr. Turney wrote.

HHS also should extend the reporting period for stage 1 so that providers who have attested for stage 1 and whose EHR has not been recertified by January 2015 can continue to report on stage 1 during 2014.

The MGMA is also concerned about the stage 2 criteria that would require physicians to give at least 5% of their patients the ability to view, download, and transmit their health information online within 4 days of it being posted. That requirement should be closely monitored and potentially adjusted, according to the MGMA letter.

The MGMA represents 22,500 leaders at 13,200 organizations that in turn employ or are affiliated with 280,000 physicians.

[email protected]

On Twitter @aliciaault