Category Archives: Transplant Medicine and Surgery

Bundled Dialysis Payments May Leave Some Shortchanged

It’s difficult not to equate the Centers for Medicare and Medicaid Services’ bundled payment system for outpatient hemodialysis with, say, handing a 12-year-old boy a $10 bill to buy lunch and telling him to keep the change.

That the 12 year old might decide to forego the healthful $9.95 veggie wrap with a side of fruit in favor of the $1 Snickers bar so he can pocket the $9 profit is well within the realm of possibility. In the same vein, should we really be surprised to learn that hemodialysis facilities might not be optimizing patient care when they are being paid a flat fee vs. separate payments for each service —  if not to make a buck, to avoid losing one? A study reported during Kidney Week 2011, the annual meeting of the American Society of Nephrology, hints at just such a scenario.

Image courtesy of Image Courtesy Wikimedia Commons/Elembis/Creative Commons

Using data from the nationally representative Dialysis Outcomes and Practice Patterns Study (DOPPS) practice monitor, investigators with the Ann Arbor Research Collaborative for Health in Michigan determined that uncontrolled secondary hyperparathyroidism has been on the rise among black hemodialysis patients since the implementation in January 2011 of the CMS’s prospective payment system for dialysis services. The system bundles payments for dialysis treatments, supplies, drugs, and lab tests. It rewards facilities for meeting or exceeding quality measures in the Medicare fee-for-service system.

Although the revised payment system is intended to “improve patient outcomes and promote efficient delivery of health care services,” in the words of CMS administrator Donald Berwick, the Ann Arbor investigators hypothesized that the increased financial constraints may lead to less use of intravenous vitamin D analogs, and thus poorer control of secondary hyperparathyroidism (SHPT). Black patients would be left especially vulnerable because they require higher vitamin D doses on average than other patients, according to lead investigator Dr. Francesca Tentori.

To test the hypothesis, the investigators examined trends in parathyroid hormone (PTH) values and SHPT in dialysis patients from July 2010-February 2011 and observed a notable increase in PTH levels overall and in severe, uncontrolled SHPT (defined as a PTH level greater than 600 pg/ml) among black patients.

Specifically, the median PTH value rose among blacks from 296 to 379 pg/ml and from 244 to 283 among non-blacks, and the prevalence of SHPT rose significantly from 16-25% among blacks and slightly, from 9-11% among nonblacks,  Dr. Tentori reported.

Based on preliminary analysis, “these changes don’t appear to be related to decreased overall use of [SHPT] treatments, as the percentage of prescribed intravenous vitamin D rose slightly in both groups, or to changes in serum calcium or phosphorous,” Dr. Tentori said. The findings warrant further evaluation to tease out the cause of the trend, particularly because untreated SHPT has been linked to increased mortality risk in dialysis patients, she stressed.

Dr. Tentori disclosed financial relationships with Amgen, Genzyme, KHK, Abbott, and Baxter.

—Diana Mahoney

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Whose Rights Are at Stake?

The Supreme Court heard arguments Tuesday in support of the 2007 Vermont statute limiting the release of the information detailing which drugs doctors prescribe. This information is maintained by pharmacies, which sell it to data-mining agencies, that in turn sell it to drug companies, for marketing purposes. Patient information is excluded from the data, doctor’s information is not.

Under the Vermont law, this information can be released only with the consent of the doctor. However, once data collection firms like IMS Health and interested parties like Pharmaceutical Research Manufacturers of America, challenged the statute, the issue became a question of free speech.

In the case of Sorrell v. IMS Health Inc., data-mining firms claim they have First Amendment rights to buy and sell the information for their marketing use.

However, the state’s attorney’s office likened the release of the confidential information to disclosing a doctor’s tax returns, patient files, or a competitor’s business information, arguing that First Amendment rights in the case apply to protecting doctor’s information. But since the information is given away to parties including insurance companies, journalists, and law enforcement, the court wasn’t too convinced.

” … just don’t tell me that the purpose is to protect their privacy,” said Justice Antonin Scalia. “[A doctor's] privacy isn’t protected by saying you can’t sell it but you can give it away.”

Justice John Roberts said Vermont is trying to reduce health care costs by “censoring” information doctors hear about brand-name drugs, with the intent that they will prescribe more generics, a measure Justice Scalia added was a restriction on free speech.

Vermont Assistant Attorney General Bridget Asay responded that “the purpose of the statute is to let doctors decide whether sales representatives will have access to this inside information” on the prescribing habits of physicians.

Attorneys general of several states, the federal government, AARP, medical associations, privacy groups, and the New England Journal of Medicine have filed briefs in support of the Vermont statute, according to a brief by Cornell (N.Y.) University Law SchoolThe National Association of Chain Drug Stores, the Association of National Advertisers, the Associated Press, and Bloomberg have filed in support of the data mining firms.

In an age in which personal data can mined through social networks and search engines, this case could set the precedent concerning how much personal information can be used for marketing. A decision is expected by June.

 Tell us what you think. 

–Frances Correa (@FMCReporting on Twitter)

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Surgeons Sound, Heed Call to Serve

As president of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dr. Jo Buyske has made it her mission to develop a “more humanitarian SAGES,” she said at the organization’s annual meeting last week in San Antonio, Texas.

Dr. Jo Buyske challenged her SAGES colleagues to share their gifts with those in need. Photo by Diana Mahoney

Toward this end, the University of Pennsylvania adjunct professor and associate executive director of the American Board of Surgery spearheaded a series of initiatives that debuted at the conference. On Thursday, a group of meeting attendees boarded a bus to a Habitat for Humanity construction site where they swapped their surgical scrubs and scalpels for hard hats and hammers to help build a new home for a low-income family. The following day, SAGES sponsored an on-site donor blood bank and a bone marrow testing station at the convention center – both of which were well utilized between sessions – and a number of SAGES surgeons offered to mentor local high school students with an interest in medicine who had been invited to the meeting for the day.

Throughout the week, attendees dropped off used medical text books for medical schools in China and old medical instruments and supplies that for shipment (via Medwish) to the Albert Schweitzer Hospital in Haiti. During the course of the week, SAGES members also gathered information about international volunteerism from the several medical volunteers’ desks located near the SAGES membership booth and Dr. Buyske announced the formation of a SAGES humanitarian task force, charged with identifying new service opportunities and resources for its SAGES members.

Dr. Buyske volunteering with Aloha Medical Missions in Bohol, Philippines. Image courtesy of SAGES.

The very vocal call to arms is more than just lip service for Dr. Buyske. In her presidential address, aptly titled, “To Whom Much is Given, Much is Required” [Luke 12:48], she described her own humbling experiences as a surgical volunteer in remote villages of Chiapas, Mexico; Bohol, Phillipines; and in the Republic of Mozambique, where access to sufficient water and electricity was erratic, at best, and where all of the niceties of surgery in this country, such as having assistants to help scrub, glove, and gown, as well as prepare and handle instruments, were non-existent. “I was not prepared for things as simple as having to pick up and unwrap my own instruments and choosing which sutures to use and which size needle. I was used to having everything handed right to me. It takes a different part of you brain to think about these things.”

Despite at various times having to pull anesthesia tubing from the trash to reuse it, having such poor lighting that she had to wait until the afternoon sun was just right in to perform cesarean sections, and having to use water from the local stream to scrub, Dr. Buyske said that each of the volunteer experiences made her a better person, and a better surgeon,. “You begin to think hard about what you use and why; you become more flexible; and you become more frugal. You revisit surgery in a way you might not have since medical school or residency. And though you’ll be exhausted, you will also be refreshed.”

As surgeons, “we have the great good fortune of doing work that allows us to go to bed every night knowing that just by doing our jobs, by our livelihoods, we have taken care of people; we have improved lives; we have done good. We should pause for a minute and savor the great good fortune, the luck, the wisdom, the hard work that went into a profession that is so fulfilling. but we should also be good stewards of our skills and our good fortune and take advantage of opportunities to be of service,” Dr. Buyske stressed. “As our Japanese friends and colleagues can tell us, our fortune and status can’t be taken for granted. There is no guarantee that it will be with us, even tomorrow.”

Thoracic surgeon Dr. Cameron Wright is a Colonel in the Medical Corps of the US Army Reserve. Image courtesy of MGH.

Dr. Buyske’s pledge to service was echoed by Dr. Cameron Wright, during the meeting’s Gerald Marks Lecture. A respected thoracic surgeon at Boston’s Massachusetts General Hospital, Dr. Wright is also a colonel in the Medical Corps of the US Army reserve, which he joined in 2007, “for many reasons,” including the obvious need for qualified surgeons to deal with the many casualties of the wars in Iraq and Afghanistan, and the opportunity to experience war surgery, he said. The most important reason, however, was the fact that his son, a heavy weapons specialist in the US Marine Corps “had skin in the game, and I decided I should put my skin in the game as well.”

In a moving slide presentation, Dr. Wright told his story through dramatic pictures, both of the soldiers with whom he served with and those to whom he ministered. Evident in all of the pictures are the camaraderie and sense of shared purpose that pervades military deployments, but also the human destruction that begs for the hands of a skilled surgeon.

— Diana Mahoney

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Going Postal

 What’s delivered by the U.S. Postal Service, but can’t fit into a letter or package?

The untold hope that a bone marrow match can bring to patients with leukemia, lymphoma and other life-threatening blood diseases.

Since holding its first drive in Baltimore in 1997, the Postal Service has become the largest contributor to the National Marrow Donor Program’s Be The Match Registry, adding more than 40,000 potential donors to the nonprofit registry.

Postal workers comprise the second largest civilian workforce in the country, and perhaps more importantly, one of its most diverse. Offering free tissue type-testing to its employees, their spouses and dependents is one way of harnessing that diversity and leveling the playing field for patients with blood diseases.

About 70% of patients do not have a donor in their family, and only 7% of potential donors on the national registry are African American, according to the NMDP.

In hopes of improving awareness, the NMDP has tapped larger-than-life basketball star Shaquille O’Neal , while its fundraising arm gave the Postal Service its first-ever “Rod Carew Award for Leadership” in recognition of saving more lives – 80 – than any other business organization in the country.

Not bad for a group of workers that have been the butt of jokes for years and frequently endure our ire this time of year.

Anyone interested in becoming a potential bone marrow or cord blood donor can contact the registry at: www.marrow.org.

Patrice Wendling (on Twitter @pwendl)

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Dismiss the Dogma and Close Mohs Surgery the Day After?

If you perform a lot of Mohs micrographic surgery in your dermatology practice, you probably close the majority of surgical wounds on the same day. 

Why? “It’s always done that way,” Dr. Andrew Weinstein said. This dogma exists, he said, because physicians who start and complete Mohs surgery on the same day are thought to be more efficient. Also, some dermatologists believe a surgical site left open overnight increases the risk for bleeding, pain, and infection.  

But these beliefs are not necessarily true, Dr. Weinstein said. 

Dr. Andrew Weinstein (photo by D. McNamara)

The serious infection rate is no different with delayed closure, Dr. Weinstein said. He reported nine infections in a series of 1,000 of his patients (0.9% rate). Eight occurred with delayed closure, but each was an uncomplicated infection. The only major infection arose in a patient closed on the same day. 

Benefits for the dermatologist include not feeling as rushed or tired after a full day of surgery. “Ease of repair is an advantage. You have a night to collect your thoughts and you can change your repair approach,” Dr. Weinstein said at the annual meeting of the Florida Society of Dermatologic Surgeons

Delayed closure and staggered scheduling allow Dr. Weinstein to perform 20% more Mohs surgeries each day. “It’s increased my efficiency.” His Mohs technician is more efficient as well, returning slides in as little as 10 minutes.

On a typical day in his private practice in Boynton Beach, Fla., Dr. Weinstein sees four patients at 1 p.m., three more at 2 p.m., and another three at 2:30 p.m. Results of the Mohs excisions for the first group are read before the second wave of patients arrive. The 1 p.m. patients with negative results go home immediately, typically within 45 minutes, he said. Patients with positive margins remain. “Then I [excise] the first stage of the second group and anything left over from first group.” The process is repeated once the third group of patients arrives as well.  

Dr. Weinstein places retention sutures postop and schedules most of his Mohs patients to return the next morning for complete wound closure. (There are still exceptions ; he closes some the same day if it is indicated.)

Although less convenient for patients, they end up waiting less time overall, Dr. Weinstein said. He has received “generally good reviews from patients,” including previous Mohs patients and new ones. 

Patients are scheduled for wound closure in 15 minute appointments the next morning. The suturing is generally done by 11:15 AM.  

Another dermatologist at the meeting asked Dr. Weinstein if his next-day approach was motivated in part by additional insurance payment. He started doing delayed closures before changes to insurance allowed him to collect more money for seeing the patient again the next day, he replied. “The reimbursement is not the reason for what I presented here today.” 

–Damian McNamara, @MedReporter on twitter

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Risk Threshold for Living Donor Death in Liver Transplantation

Should living donor death be a “zero event” in liver transplantation surgery?

Image via Flickr user beth821 by Creative Commons License

This was one of the questions posed by Dr. Michael M. Abecassis, chief of the division of organ transplantation at Chicago’s Northwestern Memorial Hospital, during his Thomas E. Starzl Transplant Surgery State-of-the-Art lecture in Boston over the weekend at the annual meeting of the American Association for the Study of Liver Diseases.

“If we truly believe that living donor death should be a zero event, we should not be doing living donor transplants, because it will never be a zero event,” Dr. Abecassis said. Zero events are defined as things “that should never, ever happen, such as operating on the wrong side of a patient,” he said. “In living donor transplantation there are factors much beyond our control that can result in a donor death.” Two recent living donor deaths—one death occurred in late May at the Lahey Clinic in Burlington, Mass., and the other occurred in early August at the University of Colorado Hospital in Aurora—are a testament to this statement.

“Clearly, we just have to accept that donor death will never be a zero event, whether it’s kidney donor or liver donor, and we have to make a decision about what is the right risk threshold,” Dr. Abecassis stated.

In your opinion, what is an acceptable risk threshold?

–Diana Mahoney (on twitter @DMPM1)

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And a Woman Will Show Them the Way

Henry VIII and the Barber Surgeons image from Wikimedia Commons

From the annual meeting of the American Surgical Association

 Lifestyle and generational priorities are often cited as fostering the high attrition rate for both male and female surgical trainees.

 According to the first prospective, national survey, one in five general surgery residents resigns before completing their training, Yale University surgical resident Dr. Heather Yeo reported at the ASA’s annual meeting. That number is based on 2007-2008 data in 6,303 general surgery residents, but is fairly constant despite earlier implementation of the ACGME work rules limiting residents to an 80-hour work week, which many at the meeting said they hoped would help reduce attrition.

Slightly more women than men resigned (2.1% vs. 1.9%). Singles  were also more likely than married residents to resign (2.1% vs. 2%).

In multivariate analysis however, only postgraduate year level was a significant predictor of resignation, with most resignations occurring in PGY-1.

These data are both disturbing and strangely reassuring given the brain drain in general surgery and the well-known paucity of women in the field. Indeed, only a dozen or so women were in the audience, except for when the wives were allowed in for special sessions. And of the 39 new ASA fellows inducted at the meeting, only three were women.

Dr. Rachel Kelz stood out, both as one of the few women in that room and for her efforts to stop the bleeding.

Dr. Kelz and her surgical colleagues at the University of Pennsylvania modified the resident selection process to make it more extended, personalized and structured.

Their intervention, which required among other things that candidates write a 500-word essay related to stress management, organizational skills and future aspirations, dramatically decreased the overall 5-year attrition rate from 27% to 3% and attrition among women from 50% to 9%.

A smashing start considering that 63% of residents who left the program were women, 75% of exiting residents cited lifestyle issues as a reason for departing, and 38% of residents were flagged as having organizational/time management problems.

Other suggestions from the audience were for surgical programs to intentionally match additional residents to factor in attrition, and for medical schools to offer a more “robust” exposure to surgery so wannabe surgeons would have a better understanding of their residency and a surgeon’s lifestyle.

A quick peek at the old boy’s club could also motivate surgical residents to set their sights on  the ASA, “the nation’s oldest and most prestigious surgical organization.”

— Patrice Wendling (on Twitter @pwendl)

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Hospitals Moving “Moo” Off the Menus

(Courtesy NASA Goddard Space Flight Center)

Here’s a happy Earth Day item: Four hospitals in the San Francisco Bay Area reduced their meat purchasing for menus by 28% in a pilot study, thereby avoiding significant amounts of associated greenhouse gas emissions and saving hundreds of thousands of dollars in costs.

Most of the drop in greenhouse gases came from reduced purchases of beef, which is a notorious producer of gases that contribute to global warming.

The study is the first attempt to evaluate the “Balanced Menus” program, which was created by the San Francisco Bay chapter of Physicians for Social Responsibility and has been rolled out to 32 hospitals across the United States by the nonprofit organization Health Care Without Harm. The Johns Hopkins Center for a Livable Future partnered with Health Care Without Harm to conduct the study.

A hospital meal (not in one of the study hospitals) by flickr user VirtualErn (Creative Commons).

Two hospitals reduced meat (beef, pork and chicken) in its cafeterias or cafes, one hospital reduced meat in inpatient menus/meal services, and one hospital did both. The Balanced Menu program also had them try to replace the remaining meat on their menus with purchases from sustainable and grass-fed meat producers instead of industrialized meat sources.

The study estimated that in a year’s time, the reduced meat purchases would avoid a total of 1,004 tons of carbon dioxide-equivalent greenhouse gas emissions. That’s roughly equivalent to not using 102,454 gallons of gasoline, or growing 23,354 tree seedlings for 10 years. Although the study did not account for greenhouse gases associated with whatever food replaced that meat, no food makes gas like beef, so there’s no doubt the planet came out ahead.

They also calculated that the less-meat, better-meat program saved the four hospitals $21,080 per month in costs even after including increased purchases of fish and vegetable sources of protein. My calculator suggests that’s $252,960 per year.

What about the patients? No complaints there, only anecdotal reports of compliments. Plus changing the meat-heavy U.S. diet could help combat rising rates of diabetes, obesity, and some cancers. According to Department of Agriculture statistics, the U.S. food supply contains 58% more red meat and chicken (8.7 ounces per person per day) than is called for in dietary guidelines that cover meat, poultry, nuts, beans, and eggs (5.5 ounces per person per day).

One of the lessons learned in the pilot study, the investigators noted, is that hospitals should involve clinicians early in the process of menu development. If you’re a clinician who is looking for one small, achievable Earth Day action that could make a big difference, consider showing this study to your hospital team. They (and the planet) may thank you.

–Sherry Boschert (@sherryboschert on Twitter)
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A Lifeline for Acute Liver Failure?

Photo by P. Wendling

From the annual meeting of the American Surgical Association in Chicago

Scientists may be able to offer a lifeline to the roughly 2,000 Americans diagnosed each year with acute liver failure, due largely to acetaminophen overdose or acute viral hepatitis.

Neupogen and Mozobil, two drugs that mobilize human stem cells and are already approved for use in cancer patients, were found to significantly improve mortality in mice with acute liver failure.

It is thought that the drugs may help the liver recover or lower the extent of injury that incurs. The theory has merit since stem cell mobilizing agents have been shown to be beneficial in animals with acute kidney injury and to improve heart function in humans after a heart attack.

Although the data are still very preliminary, the power of the animal work is that the drugs are patient-ready and would be used in a population with no good options, said lead researcher Dr. Andrew Cameron, surgical director of liver transplantation at Johns Hopkins University.

“These patients choose between liver transplant and death,” he said.

Forty percent of ALF patients spontaneously recover, but 60% require an urgent liver transplant and must compete with the 20,000 patients with chronic liver disease already on the transplant waiting list. Roughly 30% of patients die before they get an organ, while outcomes are suboptimal for those fortunate enough to get an organ.

In one of the largest published series on liver transplant for ALF, researchers at UCLA reported that 76% of 204 patients were comatose before liver transplant. One- and five-year survival rates were 73% and 67% . The median age of the patients was just 20 years.

—Patrice Wendling (on Twitter @pwendl)
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It’s Not Easy Being Clean

Photo courtesy of Flickr Creative Commons user Moria

Some of the rules seem simple. To prevent health care–associated (formerly called “nosocomial”) infections, hospital staff should wash their hands, use gloves and gowns, and disinfect the patients’ physical environment. But as I learned last week in Atlanta at the Fifth Decennial International Conference on Healthcare-Associated Infections, it takes far more than that.

About 1 in 20 patients in U.S. hospitals develop a health care–associated infection (HAI), leading to 99,000 deaths at a cost of up to $33 billion annually, numbers that Dr. Thomas R. Frieden, chief of the Centers for Disease Control and Prevention, deemed “unacceptable” in his opening remarks at the conference.

Dr. Frieden outlined the U.S. Health and Human Services’ Action Plan, launched in June 2009, which establishes measurable national goals for reducing HAIs. Five-year targets range from 25% reductions in methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and surgical site infections to 50% reduction in all bloodstream infections to 100% adherence to central-line insertion practices.

“What is acceptable? Changing the norm so HAIs are viewed as preventable events,” he said.

The trick is finding exactly what works and successfully implementing those measures. A big debate in the field is whether universal MRSA screening and surveillance of hospital patients is necessary to prevent that organism’s spread. The practice is common in Europe and has been mandated in at least one U.S. state, Illinois.

However, in a study conducted at Virginia Commonwealth University, Richmond, “conventional” infection control measures including hand hygiene, chlorhexidine bathing of ICU patients, and use of central line and “ventilator bundles” resulted in significant reductions in device-related MRSA rates without the need for screening. But other studies suggest universal screening may be necessary to meet infection control targets.

Meantime, as many efforts to reduce MRSA have been successful over the last decade, a study of 28 community hospitals in the Southeastern United States found that Clostridium difficile has now surpassed MRSA in prevalence.

Another seemingly simple infection control measure—vaccinating all hospital employees against influenza—evidently requires a mandate to actually happen. Two studies presented at the conference—one from Nashville-based Hospital Corporation of America, the other from Children’s Mercy Hospital of Kansas City—found that nearly 100% compliance could be achieved only after requiring employees to receive flu vaccine with very limited opportunity for exemption.

I asked renowned infectious disease expert Dr. William Schaffner of Vanderbilt University, Nashville, Tenn., whether he believes that HAIs can ever be reduced to zero. Realistically, he said, they will never be completely eliminated because patients today are more frail and immunocompromised and because current treatments are “more elaborate, invasive, and compromising of the immune system.”

But, he does believe HAIs can be dramatically reduced: “The adoption of checklists and many of the research findings presented at the Decennial meeting will enable us to cut the frequency of [HAIs] at least in half over the next decade. In addition, we will collaborate with our partners around the globe to extend those benefits worldwide.”

–Miriam E. Tucker (@MiriamETucker on Twitter)

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