Patients who were admitted for emergency surgery on a weekend to treat left-sided diverticulitis experience more short-term complications and are markedly more likely to undergo a Hartmann procedure than are those admitted on weekdays, according to results from a large population-based study.

Longer hospital stays, significantly higher treatment costs, and higher rates of reoperations were also associated with weekend admission. However, no differences in mortality were observed between the patient groups.

Previous studies have shown worse outcomes for patients with gastrointestinal hemorrhage, kidney injury, myocardial infarction, pulmonary embolism, and intracerebral hemorrhage when they were admitted on weekends. Although the current study, led by Dr. Mathias Worni of Duke University Medical Center in Durham, N.C., and Bern (Switzerland) University Hospital, was not designed to isolate the cause of the "weekend effect" for left-sided diverticulitis patients, the authors noted that hospital staffing tends to be reduced on weekends – especially among specialists such as colorectal surgeons.

Dr. Worni and his colleagues looked at records from the Nationwide Inpatient Sample between January 2002 and December 2008. Of the 31,832 patients who were treated surgically for left-sided diverticulitis, 7,066 (22.2%) were admitted on weekends and 24,766 (77.8%) on weekdays. Patients’ mean age was 60.8 years, and more than half were women.

Among patients who were admitted on a Saturday or Sunday, a Hartmann procedure was performed on 64.8% (n = 4,580), compared with only 53.9% (n = 13,351) for those admitted on a weekday (Arch. Surg. 2012;147:649-55). The Hartmann procedure – which involves formation of a colostomy – has long been the standard surgery for people presenting with left-sided diverticulitis, but is associated with long-term complications and a low rate of reversals.

Primary anastomosis, in which colostomy is avoided, is increasingly preferred, but only 35.2% of patients who were admitted on weekends underwent primary anastomosis, compared with 46.1% of patients admitted on weekdays.

The investigators found that patients admitted on weekends had significantly higher risk for any postoperative complication (odds ratio, 1.10; P = .005), compared with patients admitted on weekdays. Risk of reoperation was also higher among weekend admissions (OR, 1.50; P less than .001).

Furthermore, median total hospital charges were $3,734 higher among patients treated on weekends, and the median length of hospital stay was 0.5 days longer (P less than .001). The authors observed that these findings should motivate improvements in the quality of weekend care.

"Physicians working on weekends are thought to be less experienced than teams working during the week," they wrote. Experienced and specialized colorectal surgeons have been shown to perform more primary anastomoses, compared with trainees or general surgeons (Arch. Surg. 2010;145:79-86; Dis. Colon Rectum 2003;46:1461-8).

Limitations of the study include the fact that it did not capture long-term outcomes or severity of disease at presentation. The latter could be of potential importance: "Some patients, especially those with milder symptoms, may prefer weekend or weekday admission and may time their admission accordingly," the investigators noted.

In an invited critique that accompanied the article, Dr. Juerg Metzger, a surgeon at Lucerne (Switzerland) Cantonal Hospital, wrote that a disparity in experience among weekday and weekend surgical staff likely accounted for the higher rate of Hartmann procedures and complications following weekend admissions.

"Work-hour restrictions do not seem to have a negative influence on mortality and morbidity in surgical patients," Dr. Metzger wrote. "However, reduced experience owing to restricted working hours may negatively influence the practical skills of younger surgeons, resulting in more limited surgery [for example, a Hartmann procedure being performed instead of a primary anastomosis] and an increase in complications related to that surgery."

In the end, Dr. Metzger wrote, "quality is expensive, and our society has to decide if it is desirable and necessary to have the best surgical quality available all the time, especially when considering that health care costs will dramatically increase. It would be relevant to analyze additional large databases, asking similar questions about the outcomes of other common diseases [for example, appendicitis, cholecystitis, and strangulated hernias] and studying the effect of weekend admission on these illnesses."

Dr. Worni’s and colleagues’ was funded by a grant from the Swiss National Science Foundation. None of the investigators declared conflicts of interest. Dr. Metzger declared that he had no conflicts of interest related to his critique.

Patients who were admitted for emergency surgery on a weekend to treat left-sided diverticulitis experience more short-term complications and are markedly more likely to undergo a Hartmann procedure than are those admitted on weekdays, according to results from a large population-based study.

Longer hospital stays, significantly higher treatment costs, and higher rates of reoperations were also associated with weekend admission. However, no differences in mortality were observed between the patient groups.

Previous studies have shown worse outcomes for patients with gastrointestinal hemorrhage, kidney injury, myocardial infarction, pulmonary embolism, and intracerebral hemorrhage when they were admitted on weekends. Although the current study, led by Dr. Mathias Worni of Duke University Medical Center in Durham, N.C., and Bern (Switzerland) University Hospital, was not designed to isolate the cause of the "weekend effect" for left-sided diverticulitis patients, the authors noted that hospital staffing tends to be reduced on weekends – especially among specialists such as colorectal surgeons.

Dr. Worni and his colleagues looked at records from the Nationwide Inpatient Sample between January 2002 and December 2008. Of the 31,832 patients who were treated surgically for left-sided diverticulitis, 7,066 (22.2%) were admitted on weekends and 24,766 (77.8%) on weekdays. Patients’ mean age was 60.8 years, and more than half were women.

Among patients who were admitted on a Saturday or Sunday, a Hartmann procedure was performed on 64.8% (n = 4,580), compared with only 53.9% (n = 13,351) for those admitted on a weekday (Arch. Surg. 2012;147:649-55). The Hartmann procedure – which involves formation of a colostomy – has long been the standard surgery for people presenting with left-sided diverticulitis, but is associated with long-term complications and a low rate of reversals.

Primary anastomosis, in which colostomy is avoided, is increasingly preferred, but only 35.2% of patients who were admitted on weekends underwent primary anastomosis, compared with 46.1% of patients admitted on weekdays.

The investigators found that patients admitted on weekends had significantly higher risk for any postoperative complication (odds ratio, 1.10; P = .005), compared with patients admitted on weekdays. Risk of reoperation was also higher among weekend admissions (OR, 1.50; P less than .001).

Furthermore, median total hospital charges were $3,734 higher among patients treated on weekends, and the median length of hospital stay was 0.5 days longer (P less than .001). The authors observed that these findings should motivate improvements in the quality of weekend care.

"Physicians working on weekends are thought to be less experienced than teams working during the week," they wrote. Experienced and specialized colorectal surgeons have been shown to perform more primary anastomoses, compared with trainees or general surgeons (Arch. Surg. 2010;145:79-86; Dis. Colon Rectum 2003;46:1461-8).

Limitations of the study include the fact that it did not capture long-term outcomes or severity of disease at presentation. The latter could be of potential importance: "Some patients, especially those with milder symptoms, may prefer weekend or weekday admission and may time their admission accordingly," the investigators noted.

In an invited critique that accompanied the article, Dr. Juerg Metzger, a surgeon at Lucerne (Switzerland) Cantonal Hospital, wrote that a disparity in experience among weekday and weekend surgical staff likely accounted for the higher rate of Hartmann procedures and complications following weekend admissions.

"Work-hour restrictions do not seem to have a negative influence on mortality and morbidity in surgical patients," Dr. Metzger wrote. "However, reduced experience owing to restricted working hours may negatively influence the practical skills of younger surgeons, resulting in more limited surgery [for example, a Hartmann procedure being performed instead of a primary anastomosis] and an increase in complications related to that surgery."

In the end, Dr. Metzger wrote, "quality is expensive, and our society has to decide if it is desirable and necessary to have the best surgical quality available all the time, especially when considering that health care costs will dramatically increase. It would be relevant to analyze additional large databases, asking similar questions about the outcomes of other common diseases [for example, appendicitis, cholecystitis, and strangulated hernias] and studying the effect of weekend admission on these illnesses."

Dr. Worni’s and colleagues’ was funded by a grant from the Swiss National Science Foundation. None of the investigators declared conflicts of interest. Dr. Metzger declared that he had no conflicts of interest related to his critique.

Patients who were admitted for emergency surgery on a weekend to treat left-sided diverticulitis experience more short-term complications and are markedly more likely to undergo a Hartmann procedure than are those admitted on weekdays, according to results from a large population-based study.

Longer hospital stays, significantly higher treatment costs, and higher rates of reoperations were also associated with weekend admission. However, no differences in mortality were observed between the patient groups.

Previous studies have shown worse outcomes for patients with gastrointestinal hemorrhage, kidney injury, myocardial infarction, pulmonary embolism, and intracerebral hemorrhage when they were admitted on weekends. Although the current study, led by Dr. Mathias Worni of Duke University Medical Center in Durham, N.C., and Bern (Switzerland) University Hospital, was not designed to isolate the cause of the "weekend effect" for left-sided diverticulitis patients, the authors noted that hospital staffing tends to be reduced on weekends – especially among specialists such as colorectal surgeons.

Dr. Worni and his colleagues looked at records from the Nationwide Inpatient Sample between January 2002 and December 2008. Of the 31,832 patients who were treated surgically for left-sided diverticulitis, 7,066 (22.2%) were admitted on weekends and 24,766 (77.8%) on weekdays. Patients’ mean age was 60.8 years, and more than half were women.

Among patients who were admitted on a Saturday or Sunday, a Hartmann procedure was performed on 64.8% (n = 4,580), compared with only 53.9% (n = 13,351) for those admitted on a weekday (Arch. Surg. 2012;147:649-55). The Hartmann procedure – which involves formation of a colostomy – has long been the standard surgery for people presenting with left-sided diverticulitis, but is associated with long-term complications and a low rate of reversals.

Primary anastomosis, in which colostomy is avoided, is increasingly preferred, but only 35.2% of patients who were admitted on weekends underwent primary anastomosis, compared with 46.1% of patients admitted on weekdays.

The investigators found that patients admitted on weekends had significantly higher risk for any postoperative complication (odds ratio, 1.10; P = .005), compared with patients admitted on weekdays. Risk of reoperation was also higher among weekend admissions (OR, 1.50; P less than .001).

Furthermore, median total hospital charges were $3,734 higher among patients treated on weekends, and the median length of hospital stay was 0.5 days longer (P less than .001). The authors observed that these findings should motivate improvements in the quality of weekend care.

"Physicians working on weekends are thought to be less experienced than teams working during the week," they wrote. Experienced and specialized colorectal surgeons have been shown to perform more primary anastomoses, compared with trainees or general surgeons (Arch. Surg. 2010;145:79-86; Dis. Colon Rectum 2003;46:1461-8).

Limitations of the study include the fact that it did not capture long-term outcomes or severity of disease at presentation. The latter could be of potential importance: "Some patients, especially those with milder symptoms, may prefer weekend or weekday admission and may time their admission accordingly," the investigators noted.

In an invited critique that accompanied the article, Dr. Juerg Metzger, a surgeon at Lucerne (Switzerland) Cantonal Hospital, wrote that a disparity in experience among weekday and weekend surgical staff likely accounted for the higher rate of Hartmann procedures and complications following weekend admissions.

"Work-hour restrictions do not seem to have a negative influence on mortality and morbidity in surgical patients," Dr. Metzger wrote. "However, reduced experience owing to restricted working hours may negatively influence the practical skills of younger surgeons, resulting in more limited surgery [for example, a Hartmann procedure being performed instead of a primary anastomosis] and an increase in complications related to that surgery."

In the end, Dr. Metzger wrote, "quality is expensive, and our society has to decide if it is desirable and necessary to have the best surgical quality available all the time, especially when considering that health care costs will dramatically increase. It would be relevant to analyze additional large databases, asking similar questions about the outcomes of other common diseases [for example, appendicitis, cholecystitis, and strangulated hernias] and studying the effect of weekend admission on these illnesses."

Dr. Worni’s and colleagues’ was funded by a grant from the Swiss National Science Foundation. None of the investigators declared conflicts of interest. Dr. Metzger declared that he had no conflicts of interest related to his critique.

Neurosurgeons can now follow a glowing road map that points the way to cancerous brain tissue, leading thereby to a more effective surgical excision.

Researchers at the Norris Cotton Cancer Center and the Thayer School of Engineering at Dartmouth College, Hanover, N.H., have developed a probe that uses protoporphyrin IX fluorescence, oxygen saturation, hemoglobin concentration, and cell morphology to differentiate cancerous tissue from normal.

The probe identified 94% of glioma tissue in a small pilot study (J. Biomed. Opt. 2012 May 4 [doi:10.1117/1.JBO.17.5.056008]).

Photo courtesy Keith Paulsen, PhD, and Norris Cotton Cancer Center.

Research in Germany 15 years ago suggested that such a tool would identify only highly metabolic primary tumors. But augmenting the fluorescence technique with a computer algorithm that added the other cellular features gave surgeons a "jaw-dropping" view of low-grade tumors.

"The tumor glowed like lava," said Keith Paulsen, Ph.D., a professor of biomedical engineering at the school of engineering and a member of the cancer imaging and radiobiology research program at Norris Cotton Cancer Center.

The team will next evaluate their technique on lung cancers, with investigations of other tumor types to follow.

Neurosurgeons can now follow a glowing road map that points the way to cancerous brain tissue, leading thereby to a more effective surgical excision.

Researchers at the Norris Cotton Cancer Center and the Thayer School of Engineering at Dartmouth College, Hanover, N.H., have developed a probe that uses protoporphyrin IX fluorescence, oxygen saturation, hemoglobin concentration, and cell morphology to differentiate cancerous tissue from normal.

The probe identified 94% of glioma tissue in a small pilot study (J. Biomed. Opt. 2012 May 4 [doi:10.1117/1.JBO.17.5.056008]).

Photo courtesy Keith Paulsen, PhD, and Norris Cotton Cancer Center.

Research in Germany 15 years ago suggested that such a tool would identify only highly metabolic primary tumors. But augmenting the fluorescence technique with a computer algorithm that added the other cellular features gave surgeons a "jaw-dropping" view of low-grade tumors.

"The tumor glowed like lava," said Keith Paulsen, Ph.D., a professor of biomedical engineering at the school of engineering and a member of the cancer imaging and radiobiology research program at Norris Cotton Cancer Center.

The team will next evaluate their technique on lung cancers, with investigations of other tumor types to follow.

Neurosurgeons can now follow a glowing road map that points the way to cancerous brain tissue, leading thereby to a more effective surgical excision.

Researchers at the Norris Cotton Cancer Center and the Thayer School of Engineering at Dartmouth College, Hanover, N.H., have developed a probe that uses protoporphyrin IX fluorescence, oxygen saturation, hemoglobin concentration, and cell morphology to differentiate cancerous tissue from normal.

The probe identified 94% of glioma tissue in a small pilot study (J. Biomed. Opt. 2012 May 4 [doi:10.1117/1.JBO.17.5.056008]).

Photo courtesy Keith Paulsen, PhD, and Norris Cotton Cancer Center.

Research in Germany 15 years ago suggested that such a tool would identify only highly metabolic primary tumors. But augmenting the fluorescence technique with a computer algorithm that added the other cellular features gave surgeons a "jaw-dropping" view of low-grade tumors.

"The tumor glowed like lava," said Keith Paulsen, Ph.D., a professor of biomedical engineering at the school of engineering and a member of the cancer imaging and radiobiology research program at Norris Cotton Cancer Center.

The team will next evaluate their technique on lung cancers, with investigations of other tumor types to follow.

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

They hailed from such places as Germany, Bermuda, and Brazil, yet they were searching for the same answers as their American counterparts. How do I improve our better discharge process? How can we work better with administrators or primary-care physicians (PCPs)? How can we recruit better clinicians or see more patients in a day?

Nearly 20 international hospitalists gathered to discuss ideas, exchange business cards, and report on the growth of the hospitalist model in their countries at a Special Interest Forum at HM12 in April in San Diego.

“I’m here to get together with hospitalists, colleagues in the same field. We have a new program, and I thought I could learn from meeting people already in the field,” said David McGowan, MD, a hospitalist at the only HM group in Bermuda.

Dr. McGowan, attending his first SHM annual meeting, focused his attention on practice management, leadership and quality-initiative (QI) topics. His four-doctor HM group is relatively new, and he planned to “take some stuff back to my group.”

Bermuda has one hospital, in the capital city of Hamilton, for the entire island of nearly 65,000 residents. Administration has been very supportive of the HM model, according to Dr. McGowan, although the group has faced challenges in the community.

“The system is new and people are used to their primary-care physicians being in the hospital,” he said. “We have been working on that through public relations, providing good care, and ramping up our communication with the primary-care physicians in the community.

“We set the standard for the island, and I think we are making progress. The quality of care is better. … I think the potential is there for things to be better, and outcomes are going to [get] better.”

Euro Development

Not so new to the HM model of care was Stefan Reinecke, MBA, chief of the division of general internal medicine at St. Mary’s Hospital in Stuttgart, Germany. HM12 marked the third time he’d traveled to the U.S. for an HM-focused meeting, and, as before, his areas of focus were on practice management and quality.

“I think there is a need for well-trained physicians in internal medicine, with a high knowledge of quality, methods of quality measurement, and outcome measurement,” said Dr. Reinecke, whose division has 35 inpatient physicians and 20 residents.

As in the U.S., a hospitalist model requires upfront costs to the German healthcare system, and Dr. Reinecke said he and other group leaders are feeling “strong financial pressures” from administration. He said he hoped to build new quality- and systems-improvement structures into his division, and “to do it daily,” he said.

South America

One way to validate a hospitalist service is to demonstrate improvements in quality and cost of care. That’s exactly what Rafaela Komorowski Dal Molin’s group at Hospital Mae de Deus in Porto Alegre, Brazil, has done─and her chief medical officer noticed.

“Our HM service reduced length of stay,” she said, noting hospitals and payors in her country are “thinking more and more about costs of care.”

She also said administrators are learning why the HM model of care is important. “HM in USA proved we can reduce the costs, and proved we influence the length of stay,” she said. “That’s interesting to medical directors.”

Dr. Dal Molin’s six-hospitalist group began in 2009 and includes an intensivist and pulmonologist. Starting this summer, the group will begin training four residents in an HM-focused program.

Dr. Dal Molin admitted Brazil’s healthcare system is just learning about the HM model, and groups face myriad clinical, financial, and professional issues. “HM in Brazil is not recognized as a specialty yet,” she said. “We’re working on it. I’m thinking maybe in the next two years it will be recognized.”

As scientific director of the Brazilian Society of Hospital Medicine, Dr. Dal Molin was one of a small contingency of hospitalists from the Southern Hemisphere at HM12. The group is planning its second Brazilian Congress of HM Nov. 15-16 in Sao Paulo.

Richard Quinn is a freelance writer based in New Jersey.

They hailed from such places as Germany, Bermuda, and Brazil, yet they were searching for the same answers as their American counterparts. How do I improve our better discharge process? How can we work better with administrators or primary-care physicians (PCPs)? How can we recruit better clinicians or see more patients in a day?

Nearly 20 international hospitalists gathered to discuss ideas, exchange business cards, and report on the growth of the hospitalist model in their countries at a Special Interest Forum at HM12 in April in San Diego.

“I’m here to get together with hospitalists, colleagues in the same field. We have a new program, and I thought I could learn from meeting people already in the field,” said David McGowan, MD, a hospitalist at the only HM group in Bermuda.

Dr. McGowan, attending his first SHM annual meeting, focused his attention on practice management, leadership and quality-initiative (QI) topics. His four-doctor HM group is relatively new, and he planned to “take some stuff back to my group.”

Bermuda has one hospital, in the capital city of Hamilton, for the entire island of nearly 65,000 residents. Administration has been very supportive of the HM model, according to Dr. McGowan, although the group has faced challenges in the community.

“The system is new and people are used to their primary-care physicians being in the hospital,” he said. “We have been working on that through public relations, providing good care, and ramping up our communication with the primary-care physicians in the community.

“We set the standard for the island, and I think we are making progress. The quality of care is better. … I think the potential is there for things to be better, and outcomes are going to [get] better.”

Euro Development

Not so new to the HM model of care was Stefan Reinecke, MBA, chief of the division of general internal medicine at St. Mary’s Hospital in Stuttgart, Germany. HM12 marked the third time he’d traveled to the U.S. for an HM-focused meeting, and, as before, his areas of focus were on practice management and quality.

“I think there is a need for well-trained physicians in internal medicine, with a high knowledge of quality, methods of quality measurement, and outcome measurement,” said Dr. Reinecke, whose division has 35 inpatient physicians and 20 residents.

As in the U.S., a hospitalist model requires upfront costs to the German healthcare system, and Dr. Reinecke said he and other group leaders are feeling “strong financial pressures” from administration. He said he hoped to build new quality- and systems-improvement structures into his division, and “to do it daily,” he said.

South America

One way to validate a hospitalist service is to demonstrate improvements in quality and cost of care. That’s exactly what Rafaela Komorowski Dal Molin’s group at Hospital Mae de Deus in Porto Alegre, Brazil, has done─and her chief medical officer noticed.

“Our HM service reduced length of stay,” she said, noting hospitals and payors in her country are “thinking more and more about costs of care.”

She also said administrators are learning why the HM model of care is important. “HM in USA proved we can reduce the costs, and proved we influence the length of stay,” she said. “That’s interesting to medical directors.”

Dr. Dal Molin’s six-hospitalist group began in 2009 and includes an intensivist and pulmonologist. Starting this summer, the group will begin training four residents in an HM-focused program.

Dr. Dal Molin admitted Brazil’s healthcare system is just learning about the HM model, and groups face myriad clinical, financial, and professional issues. “HM in Brazil is not recognized as a specialty yet,” she said. “We’re working on it. I’m thinking maybe in the next two years it will be recognized.”

As scientific director of the Brazilian Society of Hospital Medicine, Dr. Dal Molin was one of a small contingency of hospitalists from the Southern Hemisphere at HM12. The group is planning its second Brazilian Congress of HM Nov. 15-16 in Sao Paulo.

Richard Quinn is a freelance writer based in New Jersey.

They hailed from such places as Germany, Bermuda, and Brazil, yet they were searching for the same answers as their American counterparts. How do I improve our better discharge process? How can we work better with administrators or primary-care physicians (PCPs)? How can we recruit better clinicians or see more patients in a day?

Nearly 20 international hospitalists gathered to discuss ideas, exchange business cards, and report on the growth of the hospitalist model in their countries at a Special Interest Forum at HM12 in April in San Diego.

“I’m here to get together with hospitalists, colleagues in the same field. We have a new program, and I thought I could learn from meeting people already in the field,” said David McGowan, MD, a hospitalist at the only HM group in Bermuda.

Dr. McGowan, attending his first SHM annual meeting, focused his attention on practice management, leadership and quality-initiative (QI) topics. His four-doctor HM group is relatively new, and he planned to “take some stuff back to my group.”

Bermuda has one hospital, in the capital city of Hamilton, for the entire island of nearly 65,000 residents. Administration has been very supportive of the HM model, according to Dr. McGowan, although the group has faced challenges in the community.

“The system is new and people are used to their primary-care physicians being in the hospital,” he said. “We have been working on that through public relations, providing good care, and ramping up our communication with the primary-care physicians in the community.

“We set the standard for the island, and I think we are making progress. The quality of care is better. … I think the potential is there for things to be better, and outcomes are going to [get] better.”

Euro Development

Not so new to the HM model of care was Stefan Reinecke, MBA, chief of the division of general internal medicine at St. Mary’s Hospital in Stuttgart, Germany. HM12 marked the third time he’d traveled to the U.S. for an HM-focused meeting, and, as before, his areas of focus were on practice management and quality.

“I think there is a need for well-trained physicians in internal medicine, with a high knowledge of quality, methods of quality measurement, and outcome measurement,” said Dr. Reinecke, whose division has 35 inpatient physicians and 20 residents.

As in the U.S., a hospitalist model requires upfront costs to the German healthcare system, and Dr. Reinecke said he and other group leaders are feeling “strong financial pressures” from administration. He said he hoped to build new quality- and systems-improvement structures into his division, and “to do it daily,” he said.

South America

One way to validate a hospitalist service is to demonstrate improvements in quality and cost of care. That’s exactly what Rafaela Komorowski Dal Molin’s group at Hospital Mae de Deus in Porto Alegre, Brazil, has done─and her chief medical officer noticed.

“Our HM service reduced length of stay,” she said, noting hospitals and payors in her country are “thinking more and more about costs of care.”

She also said administrators are learning why the HM model of care is important. “HM in USA proved we can reduce the costs, and proved we influence the length of stay,” she said. “That’s interesting to medical directors.”

Dr. Dal Molin’s six-hospitalist group began in 2009 and includes an intensivist and pulmonologist. Starting this summer, the group will begin training four residents in an HM-focused program.

Dr. Dal Molin admitted Brazil’s healthcare system is just learning about the HM model, and groups face myriad clinical, financial, and professional issues. “HM in Brazil is not recognized as a specialty yet,” she said. “We’re working on it. I’m thinking maybe in the next two years it will be recognized.”

As scientific director of the Brazilian Society of Hospital Medicine, Dr. Dal Molin was one of a small contingency of hospitalists from the Southern Hemisphere at HM12. The group is planning its second Brazilian Congress of HM Nov. 15-16 in Sao Paulo.

Richard Quinn is a freelance writer based in New Jersey.

Clinical question: Does supported self-management of patients with chronic obstructive pulmonary disease (COPD) decrease COPD-related hospital readmission or death?

Clinical background: Supported self-management has benefited patients with such chronic diseases as heart failure and asthma. Evidence to support such a strategy for patients with COPD is relatively lacking.

Study design: Randomized, controlled trial.

Setting: Community-based care following urban hospitalization in western Scotland.

Synopsis: From June 2007 to May 2009, and following hospitalization for COPD exacerbation, 464 patients were randomized to receive routine community-based care with or without 12 months of support and training to detect, and promptly treat, recurrent exacerbations. Independent of disease severity or demographics, investigators found no difference in combined readmission rates (48% vs. 47%, 95% confidence interval [CI] 0.80-1.38) or death (10% vs. 7%, 95% CI 0.71-2.61).

Based on review of appropriateness of self-management strategies used by the intervention group, unplanned exploratory subgroup analysis classified a minority of the intervention group as “successful” (42%) supported self-managers, and demonstrated decreased COPD readmissions and deaths (27% vs. 49%, 95% CI 0.25-0.76, P=0.003) vs. “unsuccessful” self-managers. This successful group was younger and tended to live with others. Further research to define characteristics of patients who benefit from self-management is needed.

Bottom line: Supported self-management of COPD does not reduce COPD-related readmissions or deaths in a large population.

Citation: Bucknall CE, Miller G, Lloyd SM, et al. Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial. BMJ. 2012;344:e1060.

Check out more physician reviews of HM-relevant research.

Clinical question: Does supported self-management of patients with chronic obstructive pulmonary disease (COPD) decrease COPD-related hospital readmission or death?

Clinical background: Supported self-management has benefited patients with such chronic diseases as heart failure and asthma. Evidence to support such a strategy for patients with COPD is relatively lacking.

Study design: Randomized, controlled trial.

Setting: Community-based care following urban hospitalization in western Scotland.

Synopsis: From June 2007 to May 2009, and following hospitalization for COPD exacerbation, 464 patients were randomized to receive routine community-based care with or without 12 months of support and training to detect, and promptly treat, recurrent exacerbations. Independent of disease severity or demographics, investigators found no difference in combined readmission rates (48% vs. 47%, 95% confidence interval [CI] 0.80-1.38) or death (10% vs. 7%, 95% CI 0.71-2.61).

Based on review of appropriateness of self-management strategies used by the intervention group, unplanned exploratory subgroup analysis classified a minority of the intervention group as “successful” (42%) supported self-managers, and demonstrated decreased COPD readmissions and deaths (27% vs. 49%, 95% CI 0.25-0.76, P=0.003) vs. “unsuccessful” self-managers. This successful group was younger and tended to live with others. Further research to define characteristics of patients who benefit from self-management is needed.

Bottom line: Supported self-management of COPD does not reduce COPD-related readmissions or deaths in a large population.

Citation: Bucknall CE, Miller G, Lloyd SM, et al. Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial. BMJ. 2012;344:e1060.

Check out more physician reviews of HM-relevant research.

Clinical question: Does supported self-management of patients with chronic obstructive pulmonary disease (COPD) decrease COPD-related hospital readmission or death?

Clinical background: Supported self-management has benefited patients with such chronic diseases as heart failure and asthma. Evidence to support such a strategy for patients with COPD is relatively lacking.

Study design: Randomized, controlled trial.

Setting: Community-based care following urban hospitalization in western Scotland.

Synopsis: From June 2007 to May 2009, and following hospitalization for COPD exacerbation, 464 patients were randomized to receive routine community-based care with or without 12 months of support and training to detect, and promptly treat, recurrent exacerbations. Independent of disease severity or demographics, investigators found no difference in combined readmission rates (48% vs. 47%, 95% confidence interval [CI] 0.80-1.38) or death (10% vs. 7%, 95% CI 0.71-2.61).

Based on review of appropriateness of self-management strategies used by the intervention group, unplanned exploratory subgroup analysis classified a minority of the intervention group as “successful” (42%) supported self-managers, and demonstrated decreased COPD readmissions and deaths (27% vs. 49%, 95% CI 0.25-0.76, P=0.003) vs. “unsuccessful” self-managers. This successful group was younger and tended to live with others. Further research to define characteristics of patients who benefit from self-management is needed.

Bottom line: Supported self-management of COPD does not reduce COPD-related readmissions or deaths in a large population.

Citation: Bucknall CE, Miller G, Lloyd SM, et al. Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial. BMJ. 2012;344:e1060.

Check out more physician reviews of HM-relevant research.

The FDA has announced accelerated approval of carfilzomib (Kyprolis) as treatment for relapsed or refractory multiple myeloma (MM).
 
The drug is indicated for MM patients who have received at least 2 prior therapies, including bortezomib and an immunomodulatory agent, and have demonstrated disease progression on or within 60 days of completing their last treatment.

Carfilzomib was approved under the FDA’s accelerated approval program, which allows the agency to approve a drug based on data suggesting a clinical benefit. The drug’s maker is required to submit additional information after the approval to confirm that benefit.

Carfilzomib’s approval was based on efficacy data from a trial of 266 patients and safety data from 526 patients who received the drug.

The 266 patients had relapsed MM and had received at least 2 prior therapies, including bortezomib and an immunomodulatory agent (either thalidomide or lenalidomide). Patients received carfilzomib intravenously over a period of 2 to 10 minutes on 2 consecutive days a week for 3 weeks, followed by a 12-day rest period.

Patients received 20 mg/m² at each dose in cycle 1 and 27 mg/m² in subsequent cycles. They continued to receive treatment until their disease progressed, they developed unacceptable toxicity, or they completed 12 cycles. 

Following treatment, the overall response rate was 22.9%. One patient achieved a complete response, 13 had very good partial responses, and 47 achieved partial responses. The median response duration was 7.8 months.

Researchers also evaluated carfilzomib’s safety in 526 patients with relapsed MM. Patients received a median of 4 treatment cycles and a median cumulative carfilzomib dose of 993.4 mg.

The most common adverse reactions—with an incidence of 30% or greater—were fatigue, anemia, nausea, thrombocytopenia, dyspnea, diarrhea, and pyrexia.

In addition, 45% of patients experienced serious adverse reactions. The most common were pneumonia, acute renal failure, pyrexia, and congestive heart failure.

Seven percent of patients (n=37) died on study. The most common causes of death, other than underlying disease, were cardiac (n=5), end-organ failure (n=4), and infection (n=4).

Carfilzomib will be marketed as Kyprolis by Onyx Pharmaceuticals. As a condition of the drug’s accelerated approval, Onyx is required to submit the complete analysis of an ongoing phase 3 trial comparing lenalidomide plus low-dose dexamethasone to lenalidomide, low-dose dexamethasone, and carfilzomib.

For more information on carfilzomib, consult the FDA website.

The FDA has announced accelerated approval of carfilzomib (Kyprolis) as treatment for relapsed or refractory multiple myeloma (MM).
 
The drug is indicated for MM patients who have received at least 2 prior therapies, including bortezomib and an immunomodulatory agent, and have demonstrated disease progression on or within 60 days of completing their last treatment.

Carfilzomib was approved under the FDA’s accelerated approval program, which allows the agency to approve a drug based on data suggesting a clinical benefit. The drug’s maker is required to submit additional information after the approval to confirm that benefit.

Carfilzomib’s approval was based on efficacy data from a trial of 266 patients and safety data from 526 patients who received the drug.

The 266 patients had relapsed MM and had received at least 2 prior therapies, including bortezomib and an immunomodulatory agent (either thalidomide or lenalidomide). Patients received carfilzomib intravenously over a period of 2 to 10 minutes on 2 consecutive days a week for 3 weeks, followed by a 12-day rest period.

Patients received 20 mg/m² at each dose in cycle 1 and 27 mg/m² in subsequent cycles. They continued to receive treatment until their disease progressed, they developed unacceptable toxicity, or they completed 12 cycles. 

Following treatment, the overall response rate was 22.9%. One patient achieved a complete response, 13 had very good partial responses, and 47 achieved partial responses. The median response duration was 7.8 months.

Researchers also evaluated carfilzomib’s safety in 526 patients with relapsed MM. Patients received a median of 4 treatment cycles and a median cumulative carfilzomib dose of 993.4 mg.

The most common adverse reactions—with an incidence of 30% or greater—were fatigue, anemia, nausea, thrombocytopenia, dyspnea, diarrhea, and pyrexia.

In addition, 45% of patients experienced serious adverse reactions. The most common were pneumonia, acute renal failure, pyrexia, and congestive heart failure.

Seven percent of patients (n=37) died on study. The most common causes of death, other than underlying disease, were cardiac (n=5), end-organ failure (n=4), and infection (n=4).

Carfilzomib will be marketed as Kyprolis by Onyx Pharmaceuticals. As a condition of the drug’s accelerated approval, Onyx is required to submit the complete analysis of an ongoing phase 3 trial comparing lenalidomide plus low-dose dexamethasone to lenalidomide, low-dose dexamethasone, and carfilzomib.

For more information on carfilzomib, consult the FDA website.

The FDA has announced accelerated approval of carfilzomib (Kyprolis) as treatment for relapsed or refractory multiple myeloma (MM).
 
The drug is indicated for MM patients who have received at least 2 prior therapies, including bortezomib and an immunomodulatory agent, and have demonstrated disease progression on or within 60 days of completing their last treatment.

Carfilzomib was approved under the FDA’s accelerated approval program, which allows the agency to approve a drug based on data suggesting a clinical benefit. The drug’s maker is required to submit additional information after the approval to confirm that benefit.

Carfilzomib’s approval was based on efficacy data from a trial of 266 patients and safety data from 526 patients who received the drug.

The 266 patients had relapsed MM and had received at least 2 prior therapies, including bortezomib and an immunomodulatory agent (either thalidomide or lenalidomide). Patients received carfilzomib intravenously over a period of 2 to 10 minutes on 2 consecutive days a week for 3 weeks, followed by a 12-day rest period.

Patients received 20 mg/m² at each dose in cycle 1 and 27 mg/m² in subsequent cycles. They continued to receive treatment until their disease progressed, they developed unacceptable toxicity, or they completed 12 cycles. 

Following treatment, the overall response rate was 22.9%. One patient achieved a complete response, 13 had very good partial responses, and 47 achieved partial responses. The median response duration was 7.8 months.

Researchers also evaluated carfilzomib’s safety in 526 patients with relapsed MM. Patients received a median of 4 treatment cycles and a median cumulative carfilzomib dose of 993.4 mg.

The most common adverse reactions—with an incidence of 30% or greater—were fatigue, anemia, nausea, thrombocytopenia, dyspnea, diarrhea, and pyrexia.

In addition, 45% of patients experienced serious adverse reactions. The most common were pneumonia, acute renal failure, pyrexia, and congestive heart failure.

Seven percent of patients (n=37) died on study. The most common causes of death, other than underlying disease, were cardiac (n=5), end-organ failure (n=4), and infection (n=4).

Carfilzomib will be marketed as Kyprolis by Onyx Pharmaceuticals. As a condition of the drug’s accelerated approval, Onyx is required to submit the complete analysis of an ongoing phase 3 trial comparing lenalidomide plus low-dose dexamethasone to lenalidomide, low-dose dexamethasone, and carfilzomib.

For more information on carfilzomib, consult the FDA website.

ORLANDO – Treatment centers and surgeons tend to play to their strengths when choosing therapy for patients with well-compensated cirrhosis of the liver and early hepatocellular carcinoma, investigators reported at a symposium sponsored by the Society of Surgical Oncology.

Therapy for early HCC with well-compensated cirrhosis is controversial; there is little agreement on when resection, transplantation, or radiofrequency ablation becomes the best approach. Choice of therapy for early HCC often depends on the surgeon’s repertoire of techniques and the therapeutic services the hospital offers, based on the findings of a web-based survey of centers that had at least five HCC cases per year.

"This study demonstrates that nonclinical factors have an important effect of therapy for early HCC, and in particular the choice of therapy depends in part on the surgeon’s portfolio of techniques, as well as the availability of transplantation services," said Dr. Hari Nathan of the department of surgery at Johns Hopkins Hospital in Baltimore.

In a previous analysis of the data from their web-based survey, Dr. Nathan and colleagues found that surgeon specialty was more important than certain patient-specific factors when determining treatment choice (J. Clin. Oncol. 2011;29:619-25).

"Differences in choice of therapy for nontransplant and transplant surgeons were not the result of an across-the-board preference for one therapy vs. another. Rather, some clinical factors impacted surgeons differently, depending on their specialty," he said.

In the new analysis, the authors used the survey data to assess the effect of surgeon and hospital factors on the choice of therapy for early, well-compensated HCC, and the effect of regional liver transplantation services on the surgeon’s choice of therapy.

They defined early HCC according to the Milan criteria as a single tumor less than 5 cm in its largest dimension, or two to three tumors less than 3 cm. Cirrhosis was considered to be well compensated if it was Child-Pugh class A, with no varices, ascites, or encephalopathy.

They presented respondents with case scenarios factoring in age, tumor number and size, type of resection required, etiology of cirrhosis (hepatitis B or C, or alcoholic), biological MELD (Model for End-Stage Liver Disease) score, platelet count, and anticipated transplantation waiting time.

Of the 1,032 invitations they extended, 336 surgeons (33%) responded. Of the respondents, 284 (85%) were in academic practices and 52 (15%) were in community practices for a median of 10 years (range, 4-17 years). About two-thirds (65%) were trained in liver transplantation. Procedures performed for HCC included transplantation and radiofrequency ablation (41% of responders), transplantation alone (14%), or liver resection but not transplantation (45%). Asked which procedures were available at their primary hospital (regardless of whether the respondent performed them personally), 100% said that resections were available, and 99% said that ablations were available. In contrast, transplantations were available at 71% of respondents’ hospitals.

The authors found that neither years in practice, surgical oncology training, nor liver transplantation training had a significant effect on treatment choice. Similarly, regional transplantation variables – such as number of procedures, percentage of transplant recipients with HCC, 30th percentile of liver transplantation wait time, and severity of illness by median MELD score – did not significantly predict treatment choice.

There was, however, significant variation in therapeutic choice based on practice type, adjusted for case presentation, with surgeons in academic practices favoring transplantation 57% of the time, compared with 47% for those in community practice. Community-based surgeons were more likely to favor liver resection (45% vs. 38% for academic surgeons), and radiofrequency ablation (9% vs. 4%).

In regression analysis that controlled for clinical factors, they found that surgeons in academic setting were significantly less likely than community-based surgeons to recommend ablation over liver transplantation (relative risk ratio [RRR], 0.41; P = .01). When they looked at the effect of practice types’ controlling for surgeons’ specialties, however, the significance of the practice type on treatment choice disappeared.

Regression analysis also showed that "higher volume surgeons prefer transplantation over resection more strongly than lower-volume surgeons," Dr. Nathan said.

High-volume surgeons (defined as those performing 30 or more cases annually) were overwhelmingly transplantation surgeons; when the authors adjusted for whether the surgeon performed transplantations, the preference for transplantation disappeared.

Additionally, nontransplantation surgeons who worked at hospitals where transplantations were available were more likely to recommend transplantation over ablation, compared with surgeons working at nontransplantation hospitals.

"Interestingly, they also favored resection over radiofrequency ablation more strongly. This appeared to be a separate phenomenon than the one that we observed for the portfolio – that’s personally performed by each surgeon – and in regression analyses these effects were independent," he said.

Coauthor John F.P. Bridges, Ph.D., provided financial and administrative support for the study. Dr. Nathan reported no relevant financial disclosures.

ORLANDO – Treatment centers and surgeons tend to play to their strengths when choosing therapy for patients with well-compensated cirrhosis of the liver and early hepatocellular carcinoma, investigators reported at a symposium sponsored by the Society of Surgical Oncology.

Therapy for early HCC with well-compensated cirrhosis is controversial; there is little agreement on when resection, transplantation, or radiofrequency ablation becomes the best approach. Choice of therapy for early HCC often depends on the surgeon’s repertoire of techniques and the therapeutic services the hospital offers, based on the findings of a web-based survey of centers that had at least five HCC cases per year.

"This study demonstrates that nonclinical factors have an important effect of therapy for early HCC, and in particular the choice of therapy depends in part on the surgeon’s portfolio of techniques, as well as the availability of transplantation services," said Dr. Hari Nathan of the department of surgery at Johns Hopkins Hospital in Baltimore.

In a previous analysis of the data from their web-based survey, Dr. Nathan and colleagues found that surgeon specialty was more important than certain patient-specific factors when determining treatment choice (J. Clin. Oncol. 2011;29:619-25).

"Differences in choice of therapy for nontransplant and transplant surgeons were not the result of an across-the-board preference for one therapy vs. another. Rather, some clinical factors impacted surgeons differently, depending on their specialty," he said.

In the new analysis, the authors used the survey data to assess the effect of surgeon and hospital factors on the choice of therapy for early, well-compensated HCC, and the effect of regional liver transplantation services on the surgeon’s choice of therapy.

They defined early HCC according to the Milan criteria as a single tumor less than 5 cm in its largest dimension, or two to three tumors less than 3 cm. Cirrhosis was considered to be well compensated if it was Child-Pugh class A, with no varices, ascites, or encephalopathy.

They presented respondents with case scenarios factoring in age, tumor number and size, type of resection required, etiology of cirrhosis (hepatitis B or C, or alcoholic), biological MELD (Model for End-Stage Liver Disease) score, platelet count, and anticipated transplantation waiting time.

Of the 1,032 invitations they extended, 336 surgeons (33%) responded. Of the respondents, 284 (85%) were in academic practices and 52 (15%) were in community practices for a median of 10 years (range, 4-17 years). About two-thirds (65%) were trained in liver transplantation. Procedures performed for HCC included transplantation and radiofrequency ablation (41% of responders), transplantation alone (14%), or liver resection but not transplantation (45%). Asked which procedures were available at their primary hospital (regardless of whether the respondent performed them personally), 100% said that resections were available, and 99% said that ablations were available. In contrast, transplantations were available at 71% of respondents’ hospitals.

The authors found that neither years in practice, surgical oncology training, nor liver transplantation training had a significant effect on treatment choice. Similarly, regional transplantation variables – such as number of procedures, percentage of transplant recipients with HCC, 30th percentile of liver transplantation wait time, and severity of illness by median MELD score – did not significantly predict treatment choice.

There was, however, significant variation in therapeutic choice based on practice type, adjusted for case presentation, with surgeons in academic practices favoring transplantation 57% of the time, compared with 47% for those in community practice. Community-based surgeons were more likely to favor liver resection (45% vs. 38% for academic surgeons), and radiofrequency ablation (9% vs. 4%).

In regression analysis that controlled for clinical factors, they found that surgeons in academic setting were significantly less likely than community-based surgeons to recommend ablation over liver transplantation (relative risk ratio [RRR], 0.41; P = .01). When they looked at the effect of practice types’ controlling for surgeons’ specialties, however, the significance of the practice type on treatment choice disappeared.

Regression analysis also showed that "higher volume surgeons prefer transplantation over resection more strongly than lower-volume surgeons," Dr. Nathan said.

High-volume surgeons (defined as those performing 30 or more cases annually) were overwhelmingly transplantation surgeons; when the authors adjusted for whether the surgeon performed transplantations, the preference for transplantation disappeared.

Additionally, nontransplantation surgeons who worked at hospitals where transplantations were available were more likely to recommend transplantation over ablation, compared with surgeons working at nontransplantation hospitals.

"Interestingly, they also favored resection over radiofrequency ablation more strongly. This appeared to be a separate phenomenon than the one that we observed for the portfolio – that’s personally performed by each surgeon – and in regression analyses these effects were independent," he said.

Coauthor John F.P. Bridges, Ph.D., provided financial and administrative support for the study. Dr. Nathan reported no relevant financial disclosures.

ORLANDO – Treatment centers and surgeons tend to play to their strengths when choosing therapy for patients with well-compensated cirrhosis of the liver and early hepatocellular carcinoma, investigators reported at a symposium sponsored by the Society of Surgical Oncology.

Therapy for early HCC with well-compensated cirrhosis is controversial; there is little agreement on when resection, transplantation, or radiofrequency ablation becomes the best approach. Choice of therapy for early HCC often depends on the surgeon’s repertoire of techniques and the therapeutic services the hospital offers, based on the findings of a web-based survey of centers that had at least five HCC cases per year.

"This study demonstrates that nonclinical factors have an important effect of therapy for early HCC, and in particular the choice of therapy depends in part on the surgeon’s portfolio of techniques, as well as the availability of transplantation services," said Dr. Hari Nathan of the department of surgery at Johns Hopkins Hospital in Baltimore.

In a previous analysis of the data from their web-based survey, Dr. Nathan and colleagues found that surgeon specialty was more important than certain patient-specific factors when determining treatment choice (J. Clin. Oncol. 2011;29:619-25).

"Differences in choice of therapy for nontransplant and transplant surgeons were not the result of an across-the-board preference for one therapy vs. another. Rather, some clinical factors impacted surgeons differently, depending on their specialty," he said.

In the new analysis, the authors used the survey data to assess the effect of surgeon and hospital factors on the choice of therapy for early, well-compensated HCC, and the effect of regional liver transplantation services on the surgeon’s choice of therapy.

They defined early HCC according to the Milan criteria as a single tumor less than 5 cm in its largest dimension, or two to three tumors less than 3 cm. Cirrhosis was considered to be well compensated if it was Child-Pugh class A, with no varices, ascites, or encephalopathy.

They presented respondents with case scenarios factoring in age, tumor number and size, type of resection required, etiology of cirrhosis (hepatitis B or C, or alcoholic), biological MELD (Model for End-Stage Liver Disease) score, platelet count, and anticipated transplantation waiting time.

Of the 1,032 invitations they extended, 336 surgeons (33%) responded. Of the respondents, 284 (85%) were in academic practices and 52 (15%) were in community practices for a median of 10 years (range, 4-17 years). About two-thirds (65%) were trained in liver transplantation. Procedures performed for HCC included transplantation and radiofrequency ablation (41% of responders), transplantation alone (14%), or liver resection but not transplantation (45%). Asked which procedures were available at their primary hospital (regardless of whether the respondent performed them personally), 100% said that resections were available, and 99% said that ablations were available. In contrast, transplantations were available at 71% of respondents’ hospitals.

The authors found that neither years in practice, surgical oncology training, nor liver transplantation training had a significant effect on treatment choice. Similarly, regional transplantation variables – such as number of procedures, percentage of transplant recipients with HCC, 30th percentile of liver transplantation wait time, and severity of illness by median MELD score – did not significantly predict treatment choice.

There was, however, significant variation in therapeutic choice based on practice type, adjusted for case presentation, with surgeons in academic practices favoring transplantation 57% of the time, compared with 47% for those in community practice. Community-based surgeons were more likely to favor liver resection (45% vs. 38% for academic surgeons), and radiofrequency ablation (9% vs. 4%).

In regression analysis that controlled for clinical factors, they found that surgeons in academic setting were significantly less likely than community-based surgeons to recommend ablation over liver transplantation (relative risk ratio [RRR], 0.41; P = .01). When they looked at the effect of practice types’ controlling for surgeons’ specialties, however, the significance of the practice type on treatment choice disappeared.

Regression analysis also showed that "higher volume surgeons prefer transplantation over resection more strongly than lower-volume surgeons," Dr. Nathan said.

High-volume surgeons (defined as those performing 30 or more cases annually) were overwhelmingly transplantation surgeons; when the authors adjusted for whether the surgeon performed transplantations, the preference for transplantation disappeared.

Additionally, nontransplantation surgeons who worked at hospitals where transplantations were available were more likely to recommend transplantation over ablation, compared with surgeons working at nontransplantation hospitals.

"Interestingly, they also favored resection over radiofrequency ablation more strongly. This appeared to be a separate phenomenon than the one that we observed for the portfolio – that’s personally performed by each surgeon – and in regression analyses these effects were independent," he said.

Coauthor John F.P. Bridges, Ph.D., provided financial and administrative support for the study. Dr. Nathan reported no relevant financial disclosures.

There was a piece in last Sunday’s New York Times written by an oncology nurse with an injunction to avoid getting sick in July. She wrote about her experience with a fresh resident who would not give her dying patient enough pain medications. She proceeded to remind readers that in July, when the academic year starts, the people taking care of sick patients in the hospital are fresh graduates who know nothing about the art of doctoring.

We’ve all heard this before. And, frankly, it is annoying.

In the article she wrote: "Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because ... the first-year residents are calling the plays, but they have little real knowledge of the game."

I would like to counter that any new medical trainees who have worked in a teaching hospital are likely to have found July an especially difficult month, because on top of being concerned with patient well-being, they are also being constantly reminded by nurses that they don’t know what they are doing.

The truth is medical school in the United States is structured such that a medical student spends most of his 3rd year and all of his 4th year of medical school in clinical work. So when July comes around, the "brand-new intern" in fact is not "brand new." He has spent the last 2 years of his life in hospitals. He may not have as much experience as nurses that have worked the floors for years, but he is no greenhorn either.

In addition, there are the years of medical education. There has been so much focus on clinical skills – talking with patients, listening, sleuthing around for clues, even prettifying the narrative – that we forget that in order for any of these skills even to be useful, there is a basic knowledge set upon which these clinical skills are built. That knowledge base is what we earn from 2-3 years of didactic work, which is qualitatively different from clinical work, to be sure, but indispensable. The ability to combine clinical skills with sound medical knowledge is part of what makes a good physician good.

New graduates offer a fresh look at habits that have grown petrified. I remember an ICU intern being asked by a family if she could turn the ventilator off but keep tube feeds going. Being young and deferential, the intern asked the nurse about this. The nurse looked at the intern as if she had two heads. "Do they think palliative care can be à la carte?" When I heard the story I was shocked by the strong negative reaction to a request that I thought was reasonable. The patient is dying. Why can’t it be à la carte?

Finally, interns are not unsupervised. Beside the fact that they are not "brand new" and indeed have already had some experience working the floors, they also do not go around without oversight. Interns are accountable to their medical residents, and medical residents are accountable to their attending physicians. Nothing happens without the knowledge of the senior house staff.

Telling the general public that hospitals are not a safe place in July sends a dangerous and irresponsible message. The article is, as with most anecdotes (mine included!), hyperbolic. There is little evidence that medical errors are committed in excess in July, compared with the rest of the year.

We are in training because we want to become doctors, good doctors. Starting a new job is intimidating enough as it is without nurses telling us that we don’t know what we’re doing. What we need, more than being undermined, is guidance. It’s infinitely more productive and makes July a much less harrowing place in time.

 Dr. Chan is in practice in Pawtucket, R.I. 

There was a piece in last Sunday’s New York Times written by an oncology nurse with an injunction to avoid getting sick in July. She wrote about her experience with a fresh resident who would not give her dying patient enough pain medications. She proceeded to remind readers that in July, when the academic year starts, the people taking care of sick patients in the hospital are fresh graduates who know nothing about the art of doctoring.

We’ve all heard this before. And, frankly, it is annoying.

In the article she wrote: "Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because ... the first-year residents are calling the plays, but they have little real knowledge of the game."

I would like to counter that any new medical trainees who have worked in a teaching hospital are likely to have found July an especially difficult month, because on top of being concerned with patient well-being, they are also being constantly reminded by nurses that they don’t know what they are doing.

The truth is medical school in the United States is structured such that a medical student spends most of his 3rd year and all of his 4th year of medical school in clinical work. So when July comes around, the "brand-new intern" in fact is not "brand new." He has spent the last 2 years of his life in hospitals. He may not have as much experience as nurses that have worked the floors for years, but he is no greenhorn either.

In addition, there are the years of medical education. There has been so much focus on clinical skills – talking with patients, listening, sleuthing around for clues, even prettifying the narrative – that we forget that in order for any of these skills even to be useful, there is a basic knowledge set upon which these clinical skills are built. That knowledge base is what we earn from 2-3 years of didactic work, which is qualitatively different from clinical work, to be sure, but indispensable. The ability to combine clinical skills with sound medical knowledge is part of what makes a good physician good.

New graduates offer a fresh look at habits that have grown petrified. I remember an ICU intern being asked by a family if she could turn the ventilator off but keep tube feeds going. Being young and deferential, the intern asked the nurse about this. The nurse looked at the intern as if she had two heads. "Do they think palliative care can be à la carte?" When I heard the story I was shocked by the strong negative reaction to a request that I thought was reasonable. The patient is dying. Why can’t it be à la carte?

Finally, interns are not unsupervised. Beside the fact that they are not "brand new" and indeed have already had some experience working the floors, they also do not go around without oversight. Interns are accountable to their medical residents, and medical residents are accountable to their attending physicians. Nothing happens without the knowledge of the senior house staff.

Telling the general public that hospitals are not a safe place in July sends a dangerous and irresponsible message. The article is, as with most anecdotes (mine included!), hyperbolic. There is little evidence that medical errors are committed in excess in July, compared with the rest of the year.

We are in training because we want to become doctors, good doctors. Starting a new job is intimidating enough as it is without nurses telling us that we don’t know what we’re doing. What we need, more than being undermined, is guidance. It’s infinitely more productive and makes July a much less harrowing place in time.

 Dr. Chan is in practice in Pawtucket, R.I. 

There was a piece in last Sunday’s New York Times written by an oncology nurse with an injunction to avoid getting sick in July. She wrote about her experience with a fresh resident who would not give her dying patient enough pain medications. She proceeded to remind readers that in July, when the academic year starts, the people taking care of sick patients in the hospital are fresh graduates who know nothing about the art of doctoring.

We’ve all heard this before. And, frankly, it is annoying.

In the article she wrote: "Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because ... the first-year residents are calling the plays, but they have little real knowledge of the game."

I would like to counter that any new medical trainees who have worked in a teaching hospital are likely to have found July an especially difficult month, because on top of being concerned with patient well-being, they are also being constantly reminded by nurses that they don’t know what they are doing.

The truth is medical school in the United States is structured such that a medical student spends most of his 3rd year and all of his 4th year of medical school in clinical work. So when July comes around, the "brand-new intern" in fact is not "brand new." He has spent the last 2 years of his life in hospitals. He may not have as much experience as nurses that have worked the floors for years, but he is no greenhorn either.

In addition, there are the years of medical education. There has been so much focus on clinical skills – talking with patients, listening, sleuthing around for clues, even prettifying the narrative – that we forget that in order for any of these skills even to be useful, there is a basic knowledge set upon which these clinical skills are built. That knowledge base is what we earn from 2-3 years of didactic work, which is qualitatively different from clinical work, to be sure, but indispensable. The ability to combine clinical skills with sound medical knowledge is part of what makes a good physician good.

New graduates offer a fresh look at habits that have grown petrified. I remember an ICU intern being asked by a family if she could turn the ventilator off but keep tube feeds going. Being young and deferential, the intern asked the nurse about this. The nurse looked at the intern as if she had two heads. "Do they think palliative care can be à la carte?" When I heard the story I was shocked by the strong negative reaction to a request that I thought was reasonable. The patient is dying. Why can’t it be à la carte?

Finally, interns are not unsupervised. Beside the fact that they are not "brand new" and indeed have already had some experience working the floors, they also do not go around without oversight. Interns are accountable to their medical residents, and medical residents are accountable to their attending physicians. Nothing happens without the knowledge of the senior house staff.

Telling the general public that hospitals are not a safe place in July sends a dangerous and irresponsible message. The article is, as with most anecdotes (mine included!), hyperbolic. There is little evidence that medical errors are committed in excess in July, compared with the rest of the year.

We are in training because we want to become doctors, good doctors. Starting a new job is intimidating enough as it is without nurses telling us that we don’t know what we’re doing. What we need, more than being undermined, is guidance. It’s infinitely more productive and makes July a much less harrowing place in time.

 Dr. Chan is in practice in Pawtucket, R.I. 

Vascular surgery is an exciting field. It also faces enormous challenges. These include a difficult economic climate and intense competition from other specialties, both interventional and surgical. Vascular surgery has certain assets, such as its commitment only to the management of vascular disease and its ability to provide medical, open surgical and interventional treatments, depending on which is best for the patient. However, these assets are balanced by liabilities, such as impaired access to interventional suites, the public perception that other specialties can provide better less invasive treatments, and weak influence or power within institutions or departments.

These liabilities are real and impact on both individual vascular surgeons and the specialty as a whole. It is because of these liabilities that vascular surgery has only maintained a degree of stability despite the enormous growth in the number of vascular patients and the introduction of exciting new means of treating these patients less invasively, more safely and more effectively.

How can we overcome these liabilities and make our specialty survive and prosper? The answer is creativity. If we develop new and better ways to manage and treat vascular patients and let the world know we are the innovators, our specialty will grow and prosper. Patients will seek out those that developed the new and better treatments and come to them. Having more patients needing treatment will increase the influence and power of vascular surgeons within institutions and departments.

Let’s look at some examples. I have had experience with three. The first was so-called limb salvage surgery. In the 1960s and 1970s, no one was interested in patients with toe and foot gangrene. However, as techniques were developed to improve the limb circulation in such patients, they flocked to those who could provide these treatments, even though many physicians and surgeons expressed doubts and skepticism about their value.

Later, when less invasive interventional treatments were also developed for improving the circulation, again patients sought out the centers that could provide them. Sure, the open and endovascular treatments for these ischemic problems were difficult to perform. They required skill and commitment. But when they worked, patients found out about them and requested them. The skeptics were eventually proven wrong, and creativity was rewarded.

However, even today skeptics exist with regard to some newer endovascular treatments below the inguinal ligament. I suspect they will again be proven wrong as the treatments improve and indications for use are crystalized.

A second example was endovascular grafts and EVAR. In the beginning, after Juan Parodi’s first demonstration of feasibility, these procedures were regarded with enormous skepticism and even derision. Complications and failures were highlighted by many. But as the techniques and devices were made better, results improved. Innovating vascular surgeons and centers gained in stature, and their patient loads increased. Creativity in developing new and better treatments reaped its rewards for individual surgeons, institutions, and our specialty.

A third example is the newer endovenous treatments to ablate the greater saphenous and other veins less invasively. These treatments work, and because of their less invasive nature, patients seek out those who perform them. This has opened up a new treatment area of opportunity for vascular surgeons. It now comprises a large portion of many vascular surgeons’ practices.

The three examples I have mentioned are now accepted areas of treatment in vascular surgery – all introduced largely by vascular surgeons. All three have also been adopted by other specialists, and there is nothing wrong with that. However, what are we to do about the uncertain future?

We vascular surgeons must continue to be creative. We must devise newer and better techniques for treating vascular disease. We must publicize and document the fact that these innovations have been made by vascular surgeons. This requires not only scientific publication but also an effective public relations campaign on all levels.

For vascular surgeons these new or better techniques can be medical, interventional or open surgical. Examples of medical treatment are those that slow the growth of aneurysms or the development and progression of atherosclerotic lesions.

Patients will seek out these creative improvements and come to the practitioners or centers that provide them. When they do, they will also return when they need a subsequent intervention or open surgical treatment. Our success as vascular surgeons will be enhanced.

The same is true for innovative, safer or better endovascular or open surgical procedures. When properly documented in the scientific peer-reviewed literature and appropriately publicized in the lay media, this creativity will enhance the stature and importance of Vascular Surgery.

Even though we exist in a highly competitive and difficult environment, this creativity more than anything else will help individual vascular surgeons and vascular surgery in general to survive and prosper.n

Dr. Frank J. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or publisher.

Vascular surgery is an exciting field. It also faces enormous challenges. These include a difficult economic climate and intense competition from other specialties, both interventional and surgical. Vascular surgery has certain assets, such as its commitment only to the management of vascular disease and its ability to provide medical, open surgical and interventional treatments, depending on which is best for the patient. However, these assets are balanced by liabilities, such as impaired access to interventional suites, the public perception that other specialties can provide better less invasive treatments, and weak influence or power within institutions or departments.

These liabilities are real and impact on both individual vascular surgeons and the specialty as a whole. It is because of these liabilities that vascular surgery has only maintained a degree of stability despite the enormous growth in the number of vascular patients and the introduction of exciting new means of treating these patients less invasively, more safely and more effectively.

How can we overcome these liabilities and make our specialty survive and prosper? The answer is creativity. If we develop new and better ways to manage and treat vascular patients and let the world know we are the innovators, our specialty will grow and prosper. Patients will seek out those that developed the new and better treatments and come to them. Having more patients needing treatment will increase the influence and power of vascular surgeons within institutions and departments.

Let’s look at some examples. I have had experience with three. The first was so-called limb salvage surgery. In the 1960s and 1970s, no one was interested in patients with toe and foot gangrene. However, as techniques were developed to improve the limb circulation in such patients, they flocked to those who could provide these treatments, even though many physicians and surgeons expressed doubts and skepticism about their value.

Later, when less invasive interventional treatments were also developed for improving the circulation, again patients sought out the centers that could provide them. Sure, the open and endovascular treatments for these ischemic problems were difficult to perform. They required skill and commitment. But when they worked, patients found out about them and requested them. The skeptics were eventually proven wrong, and creativity was rewarded.

However, even today skeptics exist with regard to some newer endovascular treatments below the inguinal ligament. I suspect they will again be proven wrong as the treatments improve and indications for use are crystalized.

A second example was endovascular grafts and EVAR. In the beginning, after Juan Parodi’s first demonstration of feasibility, these procedures were regarded with enormous skepticism and even derision. Complications and failures were highlighted by many. But as the techniques and devices were made better, results improved. Innovating vascular surgeons and centers gained in stature, and their patient loads increased. Creativity in developing new and better treatments reaped its rewards for individual surgeons, institutions, and our specialty.

A third example is the newer endovenous treatments to ablate the greater saphenous and other veins less invasively. These treatments work, and because of their less invasive nature, patients seek out those who perform them. This has opened up a new treatment area of opportunity for vascular surgeons. It now comprises a large portion of many vascular surgeons’ practices.

The three examples I have mentioned are now accepted areas of treatment in vascular surgery – all introduced largely by vascular surgeons. All three have also been adopted by other specialists, and there is nothing wrong with that. However, what are we to do about the uncertain future?

We vascular surgeons must continue to be creative. We must devise newer and better techniques for treating vascular disease. We must publicize and document the fact that these innovations have been made by vascular surgeons. This requires not only scientific publication but also an effective public relations campaign on all levels.

For vascular surgeons these new or better techniques can be medical, interventional or open surgical. Examples of medical treatment are those that slow the growth of aneurysms or the development and progression of atherosclerotic lesions.

Patients will seek out these creative improvements and come to the practitioners or centers that provide them. When they do, they will also return when they need a subsequent intervention or open surgical treatment. Our success as vascular surgeons will be enhanced.

The same is true for innovative, safer or better endovascular or open surgical procedures. When properly documented in the scientific peer-reviewed literature and appropriately publicized in the lay media, this creativity will enhance the stature and importance of Vascular Surgery.

Even though we exist in a highly competitive and difficult environment, this creativity more than anything else will help individual vascular surgeons and vascular surgery in general to survive and prosper.n

Dr. Frank J. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or publisher.

Vascular surgery is an exciting field. It also faces enormous challenges. These include a difficult economic climate and intense competition from other specialties, both interventional and surgical. Vascular surgery has certain assets, such as its commitment only to the management of vascular disease and its ability to provide medical, open surgical and interventional treatments, depending on which is best for the patient. However, these assets are balanced by liabilities, such as impaired access to interventional suites, the public perception that other specialties can provide better less invasive treatments, and weak influence or power within institutions or departments.

These liabilities are real and impact on both individual vascular surgeons and the specialty as a whole. It is because of these liabilities that vascular surgery has only maintained a degree of stability despite the enormous growth in the number of vascular patients and the introduction of exciting new means of treating these patients less invasively, more safely and more effectively.

How can we overcome these liabilities and make our specialty survive and prosper? The answer is creativity. If we develop new and better ways to manage and treat vascular patients and let the world know we are the innovators, our specialty will grow and prosper. Patients will seek out those that developed the new and better treatments and come to them. Having more patients needing treatment will increase the influence and power of vascular surgeons within institutions and departments.

Let’s look at some examples. I have had experience with three. The first was so-called limb salvage surgery. In the 1960s and 1970s, no one was interested in patients with toe and foot gangrene. However, as techniques were developed to improve the limb circulation in such patients, they flocked to those who could provide these treatments, even though many physicians and surgeons expressed doubts and skepticism about their value.

Later, when less invasive interventional treatments were also developed for improving the circulation, again patients sought out the centers that could provide them. Sure, the open and endovascular treatments for these ischemic problems were difficult to perform. They required skill and commitment. But when they worked, patients found out about them and requested them. The skeptics were eventually proven wrong, and creativity was rewarded.

However, even today skeptics exist with regard to some newer endovascular treatments below the inguinal ligament. I suspect they will again be proven wrong as the treatments improve and indications for use are crystalized.

A second example was endovascular grafts and EVAR. In the beginning, after Juan Parodi’s first demonstration of feasibility, these procedures were regarded with enormous skepticism and even derision. Complications and failures were highlighted by many. But as the techniques and devices were made better, results improved. Innovating vascular surgeons and centers gained in stature, and their patient loads increased. Creativity in developing new and better treatments reaped its rewards for individual surgeons, institutions, and our specialty.

A third example is the newer endovenous treatments to ablate the greater saphenous and other veins less invasively. These treatments work, and because of their less invasive nature, patients seek out those who perform them. This has opened up a new treatment area of opportunity for vascular surgeons. It now comprises a large portion of many vascular surgeons’ practices.

The three examples I have mentioned are now accepted areas of treatment in vascular surgery – all introduced largely by vascular surgeons. All three have also been adopted by other specialists, and there is nothing wrong with that. However, what are we to do about the uncertain future?

We vascular surgeons must continue to be creative. We must devise newer and better techniques for treating vascular disease. We must publicize and document the fact that these innovations have been made by vascular surgeons. This requires not only scientific publication but also an effective public relations campaign on all levels.

For vascular surgeons these new or better techniques can be medical, interventional or open surgical. Examples of medical treatment are those that slow the growth of aneurysms or the development and progression of atherosclerotic lesions.

Patients will seek out these creative improvements and come to the practitioners or centers that provide them. When they do, they will also return when they need a subsequent intervention or open surgical treatment. Our success as vascular surgeons will be enhanced.

The same is true for innovative, safer or better endovascular or open surgical procedures. When properly documented in the scientific peer-reviewed literature and appropriately publicized in the lay media, this creativity will enhance the stature and importance of Vascular Surgery.

Even though we exist in a highly competitive and difficult environment, this creativity more than anything else will help individual vascular surgeons and vascular surgery in general to survive and prosper.n

Dr. Frank J. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or publisher.