Alicia Ault

Barriers to Care in New Orleans

Four years after Hurricane Katrina, children in New Orleans are still at risk for mental health problems and yet continue encountering barriers to care, according to a July report by the Government Accountability Office. The GAO estimated that some 187,000 children were living in the four parishes that make up the metro area, and that a “substantial number of these children may need referrals for mental health services.” Lack of providers and lack of funding continuity were cited as barriers to providing services, along with transportation problems, competing family priorities, and concerns about stigma. Federal grants have helped, but aren't enough, said GAO. Sen. Joseph Lieberman (I-Conn.) and Sen. Mary Landrieu (D-La.) requested the study.

Violence Against Women Is Focus

The Obama administration has named Lynn Rosenthal, a national expert on domestic violence policy, the first-ever White House adviser on violence against women. She will advise the president and vice president and will work with federal agencies on their domestic violence and sexual assault prevention programs. She also will consult advocacy groups and members of Congress to develop new policies. Ms. Rosenthal served most recently as the executive director of the New Mexico Coalition Against Domestic Violence. The White House announcement said she was a major advocate for reauthorizations of the Violence Against Women Act of 2000 and of 2005 and helped states and communities implement the legislation.

Malpractice Payments Are Down

Medical malpractice payments were at record low levels in 2008, according to an analysis by the consumer-advocacy group Public Citizen. For the third straight year, 2008 saw the lowest number of malpractice payments since the federal government's National Practitioner Data Bank began tracking such data in 1990, the group said. The data showed that 11,037 payments were made last year, which Public Citizen said was nearly one-third lower than the historical average. The monetary value of payments was either the lowest or second lowest since 1990, depending on how inflation was calculated, the group said. The total cost of all malpractice insurance premiums fell to much less than 1% of the total $2.1 trillion in annual health costs in 2006 (the most recent year for which full data were available). The cost of actual malpractice payments to patients fell to 0.2% of overall health costs, the group said. David Arkush, director of Public Citizen's Congress Watch division, said in a statement that the numbers indicate that many victims of medical malpractice receive no compensation for their injuries.

Early Schizophrenia to Be Studied

Funds provided to the National Institute of Mental Health by the American Recovery and Reinvestment Act are going to pay for a large-scale trial to determine whether early and aggressive treatment reduces the symptoms and prevents deterioration in functioning in people with chronic schizophrenia. The NIMH announced the launch of the Recovery After an Initial Schizophrenia Episode (RAISE) trial in late July to see whether early, diverse, and individually targeted treatment will help people return to work and school. The interventions “will be designed from the outset to be readily adopted in real-world health care settings and quickly put into practice,” said NIMH director Thomas R. Insel in a statement. The research will be led by Dr. John M. Kane at the Zucker Hillside Hospital in Manhasset, N.Y., and by Dr. Jeffrey Lieberman at the Research Foundation for Mental Hygiene in New York.

Many Young Adults Uninsured

About 5 million adults aged 19-23 years in the United States had no health insurance in 2006 for the entire year, and 30% of them said they didnot think it was worth the cost, according to the Agency for Healthcare Research and Quality. The AHRQ found that 46% of uninsured young adults worked full time and 26% worked part time. Only 19% of those who were uninsured throughout 2006 were full-time students, the agency said. In addition, 19- to 23-year-olds who were uninsured for the entire year were only about half as likely as those who had insurance part of the year to have a usual source of care, such as a family doctor–just 36% of the wholly uninsured reported a usual source of care.

FDA Seeks Tobacco Comments

The Food and Drug Administration wants public input on how to implement its new authority to regulate tobacco products. In a Federal Register notice, the agency said it would rely on public comments when implementing the new Family Smoking Prevention and Tobacco Control Act and when establishing the FDA Center for Tobacco Products. It said it is interested in suggestions for reducing tobacco use and protecting public health, but that remarks on any aspect of its new regulatory authority are welcome. Comments can be submitted at

regulations.gov

Barriers to Care in New Orleans

Four years after Hurricane Katrina, children in New Orleans are still at risk for mental health problems and yet continue encountering barriers to care, according to a July report by the Government Accountability Office. The GAO estimated that some 187,000 children were living in the four parishes that make up the metro area, and that a “substantial number of these children may need referrals for mental health services.” Lack of providers and lack of funding continuity were cited as barriers to providing services, along with transportation problems, competing family priorities, and concerns about stigma. Federal grants have helped, but aren't enough, said GAO. Sen. Joseph Lieberman (I-Conn.) and Sen. Mary Landrieu (D-La.) requested the study.

Violence Against Women Is Focus

The Obama administration has named Lynn Rosenthal, a national expert on domestic violence policy, the first-ever White House adviser on violence against women. She will advise the president and vice president and will work with federal agencies on their domestic violence and sexual assault prevention programs. She also will consult advocacy groups and members of Congress to develop new policies. Ms. Rosenthal served most recently as the executive director of the New Mexico Coalition Against Domestic Violence. The White House announcement said she was a major advocate for reauthorizations of the Violence Against Women Act of 2000 and of 2005 and helped states and communities implement the legislation.

Malpractice Payments Are Down

Medical malpractice payments were at record low levels in 2008, according to an analysis by the consumer-advocacy group Public Citizen. For the third straight year, 2008 saw the lowest number of malpractice payments since the federal government's National Practitioner Data Bank began tracking such data in 1990, the group said. The data showed that 11,037 payments were made last year, which Public Citizen said was nearly one-third lower than the historical average. The monetary value of payments was either the lowest or second lowest since 1990, depending on how inflation was calculated, the group said. The total cost of all malpractice insurance premiums fell to much less than 1% of the total $2.1 trillion in annual health costs in 2006 (the most recent year for which full data were available). The cost of actual malpractice payments to patients fell to 0.2% of overall health costs, the group said. David Arkush, director of Public Citizen's Congress Watch division, said in a statement that the numbers indicate that many victims of medical malpractice receive no compensation for their injuries.

Early Schizophrenia to Be Studied

Funds provided to the National Institute of Mental Health by the American Recovery and Reinvestment Act are going to pay for a large-scale trial to determine whether early and aggressive treatment reduces the symptoms and prevents deterioration in functioning in people with chronic schizophrenia. The NIMH announced the launch of the Recovery After an Initial Schizophrenia Episode (RAISE) trial in late July to see whether early, diverse, and individually targeted treatment will help people return to work and school. The interventions “will be designed from the outset to be readily adopted in real-world health care settings and quickly put into practice,” said NIMH director Thomas R. Insel in a statement. The research will be led by Dr. John M. Kane at the Zucker Hillside Hospital in Manhasset, N.Y., and by Dr. Jeffrey Lieberman at the Research Foundation for Mental Hygiene in New York.

Many Young Adults Uninsured

About 5 million adults aged 19-23 years in the United States had no health insurance in 2006 for the entire year, and 30% of them said they didnot think it was worth the cost, according to the Agency for Healthcare Research and Quality. The AHRQ found that 46% of uninsured young adults worked full time and 26% worked part time. Only 19% of those who were uninsured throughout 2006 were full-time students, the agency said. In addition, 19- to 23-year-olds who were uninsured for the entire year were only about half as likely as those who had insurance part of the year to have a usual source of care, such as a family doctor–just 36% of the wholly uninsured reported a usual source of care.

FDA Seeks Tobacco Comments

The Food and Drug Administration wants public input on how to implement its new authority to regulate tobacco products. In a Federal Register notice, the agency said it would rely on public comments when implementing the new Family Smoking Prevention and Tobacco Control Act and when establishing the FDA Center for Tobacco Products. It said it is interested in suggestions for reducing tobacco use and protecting public health, but that remarks on any aspect of its new regulatory authority are welcome. Comments can be submitted at

regulations.gov

Barriers to Care in New Orleans

Four years after Hurricane Katrina, children in New Orleans are still at risk for mental health problems and yet continue encountering barriers to care, according to a July report by the Government Accountability Office. The GAO estimated that some 187,000 children were living in the four parishes that make up the metro area, and that a “substantial number of these children may need referrals for mental health services.” Lack of providers and lack of funding continuity were cited as barriers to providing services, along with transportation problems, competing family priorities, and concerns about stigma. Federal grants have helped, but aren't enough, said GAO. Sen. Joseph Lieberman (I-Conn.) and Sen. Mary Landrieu (D-La.) requested the study.

Violence Against Women Is Focus

The Obama administration has named Lynn Rosenthal, a national expert on domestic violence policy, the first-ever White House adviser on violence against women. She will advise the president and vice president and will work with federal agencies on their domestic violence and sexual assault prevention programs. She also will consult advocacy groups and members of Congress to develop new policies. Ms. Rosenthal served most recently as the executive director of the New Mexico Coalition Against Domestic Violence. The White House announcement said she was a major advocate for reauthorizations of the Violence Against Women Act of 2000 and of 2005 and helped states and communities implement the legislation.

Malpractice Payments Are Down

Medical malpractice payments were at record low levels in 2008, according to an analysis by the consumer-advocacy group Public Citizen. For the third straight year, 2008 saw the lowest number of malpractice payments since the federal government's National Practitioner Data Bank began tracking such data in 1990, the group said. The data showed that 11,037 payments were made last year, which Public Citizen said was nearly one-third lower than the historical average. The monetary value of payments was either the lowest or second lowest since 1990, depending on how inflation was calculated, the group said. The total cost of all malpractice insurance premiums fell to much less than 1% of the total $2.1 trillion in annual health costs in 2006 (the most recent year for which full data were available). The cost of actual malpractice payments to patients fell to 0.2% of overall health costs, the group said. David Arkush, director of Public Citizen's Congress Watch division, said in a statement that the numbers indicate that many victims of medical malpractice receive no compensation for their injuries.

Early Schizophrenia to Be Studied

Funds provided to the National Institute of Mental Health by the American Recovery and Reinvestment Act are going to pay for a large-scale trial to determine whether early and aggressive treatment reduces the symptoms and prevents deterioration in functioning in people with chronic schizophrenia. The NIMH announced the launch of the Recovery After an Initial Schizophrenia Episode (RAISE) trial in late July to see whether early, diverse, and individually targeted treatment will help people return to work and school. The interventions “will be designed from the outset to be readily adopted in real-world health care settings and quickly put into practice,” said NIMH director Thomas R. Insel in a statement. The research will be led by Dr. John M. Kane at the Zucker Hillside Hospital in Manhasset, N.Y., and by Dr. Jeffrey Lieberman at the Research Foundation for Mental Hygiene in New York.

Many Young Adults Uninsured

About 5 million adults aged 19-23 years in the United States had no health insurance in 2006 for the entire year, and 30% of them said they didnot think it was worth the cost, according to the Agency for Healthcare Research and Quality. The AHRQ found that 46% of uninsured young adults worked full time and 26% worked part time. Only 19% of those who were uninsured throughout 2006 were full-time students, the agency said. In addition, 19- to 23-year-olds who were uninsured for the entire year were only about half as likely as those who had insurance part of the year to have a usual source of care, such as a family doctor–just 36% of the wholly uninsured reported a usual source of care.

FDA Seeks Tobacco Comments

The Food and Drug Administration wants public input on how to implement its new authority to regulate tobacco products. In a Federal Register notice, the agency said it would rely on public comments when implementing the new Family Smoking Prevention and Tobacco Control Act and when establishing the FDA Center for Tobacco Products. It said it is interested in suggestions for reducing tobacco use and protecting public health, but that remarks on any aspect of its new regulatory authority are welcome. Comments can be submitted at

regulations.gov

ASMS Opposes Subcertification

The American Society for Mohs Surgery is coming out in opposition to the American Board of Dermatology's proposal for a subcertification in procedural dermatology. Such a certification would be redundant, said ASMS President Stephen Spencer, in a statement. The proposal, if passed, "will divide the house of dermatology between medical and surgical, lead to economic credentialing, and may lead to increased litigation if a new standard of care is perceived," said Dr. Spencer. The American Board of Medical Specialties Committee on Certification, Subcertification and Recertification was due to meet in early August.

Texas Gets Tough on Tanning

Gov. Rick Perry (R) has signed Texas House Bill 1310, which, beginning in January 2010, prohibits anyone under the age of 161/2 from using a tanning bed. It also requires in-person parental consent for anyone between that age and 18. Tanning salons are also required to keep records of visits for 3 years after a patron's last session. The American Academy of Dermatology said that Texas is the first state to prohibit use of tanning beds for children under 161/2. "Texas's leadership on this issue will serve as a model for other states to improve their laws and regulations," Dr. Evan Farmer, AAD vice president, said in a statement.

Florida Boosts ABD Certification

When Florida Gov. Charlie Crist (R) signed Senate Bill 720 in mid-June, the Florida Society of Dermatology and Dermatologic Surgery celebrated a "victory" for dermatology and patients. In an online letter, FSDDS President Albert J. Nemeth advised members to read "between the lines" of the law's wording: "A physician may not hold himself or herself out as a board-certified specialist in dermatology unless the recognizing agency, whether authorized in statute or by rule, is triennially reviewed and reauthorized by the Board of Medicine." That means, wrote Dr. Nemeth, that it will be much harder for dermatologists certified through the American Association of Plastic Surgeons or the American Board of Plastic Surgery to stay credentialed in Florida unless they also pursue certification through the American Board of Dermatology.

Clinics Expand Into Dermatology

A wholly owned subsidiary of Walgreens is expanding into a few dermatology services. Take Care Clinics will now offer wart removal by cryotherapy, skin tag removal, closure of minor cuts with Dermabond, treatment of skin irritations, and expanded skin evaluation and treatment for skin infections, injuries, and rashes. The clinics are open 7 days a week and have evening hours. According to Walgreens, there are 345 Take Care Clinics in stores in 19 states, and they're staffed by nurse practitioners and physician assistants.

Generic Biologics Get a Boost

Creating a process at the Food and Drug Administration for approving generic versions of biologic drugs, called follow-on biologics (FOBs), could bring down the cost of biologics, the Federal Trade Commission said in a report, but the 12- to 14-year exclusivity period sought by biologics manufacturers is too long. FOBs wouldn't tread deep into innovative products' turf—those drugs would retain 70%-90% of their market shares and continue making substantial profits—according to the FTC. Rep. Henry A. Waxman (D-Calif.), who has introduced legislation to create a regulatory pathway for FOBs, praised the report, but the Biotechnology Industry Organization said it was based on a "lack of true understanding of the necessary conditions to drive future biomedical breakthroughs."

Vermont Bans Most Pharma Gifts

Vermont Gov. Jim Douglas (R) has signed into law a bill that prohibits manufacturers of drugs, medical devices, and biologics from providing free gifts, including meals and travel, to physicians and other health care providers. The toughest of its kind in the nation, the legislation also requires disclosure of any allowed gifts or payments, regardless of their value. Under the stronger law, manufacturers can give physicians only gifts such as samples intended for patients, "reasonable quantities" of medical device evaluation or demonstration units, and copies of peer-reviewed articles.

FTC Wants 'Pay-for-Delay' Outlawed

A new law to eliminate deals in which pharmaceutical companies agree with their competitors to keep low-cost generic drugs off the market could save consumers and the federal government $3.5 billion a year over the next decade, according to Federal Trade Commission Chairman Jon Leibowitz. In a speech, Mr. Leibowitz said that stopping these "pay-for-delay" deals is one of the FTC's top priorities, although a series of recent court rulings has allowed some of the arrangements to continue. For instance, the U.S. Supreme Court recently declined to hear a case brought by consumers and health plans challenging a $398 million payment by drug maker Bayer AG to Barr Laboratories Inc. to settle the companies' patent dispute over a generic version of the antibiotic Cipro (ciprofloxacin).

ASMS Opposes Subcertification

The American Society for Mohs Surgery is coming out in opposition to the American Board of Dermatology's proposal for a subcertification in procedural dermatology. Such a certification would be redundant, said ASMS President Stephen Spencer, in a statement. The proposal, if passed, "will divide the house of dermatology between medical and surgical, lead to economic credentialing, and may lead to increased litigation if a new standard of care is perceived," said Dr. Spencer. The American Board of Medical Specialties Committee on Certification, Subcertification and Recertification was due to meet in early August.

Texas Gets Tough on Tanning

Gov. Rick Perry (R) has signed Texas House Bill 1310, which, beginning in January 2010, prohibits anyone under the age of 161/2 from using a tanning bed. It also requires in-person parental consent for anyone between that age and 18. Tanning salons are also required to keep records of visits for 3 years after a patron's last session. The American Academy of Dermatology said that Texas is the first state to prohibit use of tanning beds for children under 161/2. "Texas's leadership on this issue will serve as a model for other states to improve their laws and regulations," Dr. Evan Farmer, AAD vice president, said in a statement.

Florida Boosts ABD Certification

When Florida Gov. Charlie Crist (R) signed Senate Bill 720 in mid-June, the Florida Society of Dermatology and Dermatologic Surgery celebrated a "victory" for dermatology and patients. In an online letter, FSDDS President Albert J. Nemeth advised members to read "between the lines" of the law's wording: "A physician may not hold himself or herself out as a board-certified specialist in dermatology unless the recognizing agency, whether authorized in statute or by rule, is triennially reviewed and reauthorized by the Board of Medicine." That means, wrote Dr. Nemeth, that it will be much harder for dermatologists certified through the American Association of Plastic Surgeons or the American Board of Plastic Surgery to stay credentialed in Florida unless they also pursue certification through the American Board of Dermatology.

Clinics Expand Into Dermatology

A wholly owned subsidiary of Walgreens is expanding into a few dermatology services. Take Care Clinics will now offer wart removal by cryotherapy, skin tag removal, closure of minor cuts with Dermabond, treatment of skin irritations, and expanded skin evaluation and treatment for skin infections, injuries, and rashes. The clinics are open 7 days a week and have evening hours. According to Walgreens, there are 345 Take Care Clinics in stores in 19 states, and they're staffed by nurse practitioners and physician assistants.

Generic Biologics Get a Boost

Creating a process at the Food and Drug Administration for approving generic versions of biologic drugs, called follow-on biologics (FOBs), could bring down the cost of biologics, the Federal Trade Commission said in a report, but the 12- to 14-year exclusivity period sought by biologics manufacturers is too long. FOBs wouldn't tread deep into innovative products' turf—those drugs would retain 70%-90% of their market shares and continue making substantial profits—according to the FTC. Rep. Henry A. Waxman (D-Calif.), who has introduced legislation to create a regulatory pathway for FOBs, praised the report, but the Biotechnology Industry Organization said it was based on a "lack of true understanding of the necessary conditions to drive future biomedical breakthroughs."

Vermont Bans Most Pharma Gifts

Vermont Gov. Jim Douglas (R) has signed into law a bill that prohibits manufacturers of drugs, medical devices, and biologics from providing free gifts, including meals and travel, to physicians and other health care providers. The toughest of its kind in the nation, the legislation also requires disclosure of any allowed gifts or payments, regardless of their value. Under the stronger law, manufacturers can give physicians only gifts such as samples intended for patients, "reasonable quantities" of medical device evaluation or demonstration units, and copies of peer-reviewed articles.

FTC Wants 'Pay-for-Delay' Outlawed

A new law to eliminate deals in which pharmaceutical companies agree with their competitors to keep low-cost generic drugs off the market could save consumers and the federal government $3.5 billion a year over the next decade, according to Federal Trade Commission Chairman Jon Leibowitz. In a speech, Mr. Leibowitz said that stopping these "pay-for-delay" deals is one of the FTC's top priorities, although a series of recent court rulings has allowed some of the arrangements to continue. For instance, the U.S. Supreme Court recently declined to hear a case brought by consumers and health plans challenging a $398 million payment by drug maker Bayer AG to Barr Laboratories Inc. to settle the companies' patent dispute over a generic version of the antibiotic Cipro (ciprofloxacin).

ASMS Opposes Subcertification

The American Society for Mohs Surgery is coming out in opposition to the American Board of Dermatology's proposal for a subcertification in procedural dermatology. Such a certification would be redundant, said ASMS President Stephen Spencer, in a statement. The proposal, if passed, "will divide the house of dermatology between medical and surgical, lead to economic credentialing, and may lead to increased litigation if a new standard of care is perceived," said Dr. Spencer. The American Board of Medical Specialties Committee on Certification, Subcertification and Recertification was due to meet in early August.

Texas Gets Tough on Tanning

Gov. Rick Perry (R) has signed Texas House Bill 1310, which, beginning in January 2010, prohibits anyone under the age of 161/2 from using a tanning bed. It also requires in-person parental consent for anyone between that age and 18. Tanning salons are also required to keep records of visits for 3 years after a patron's last session. The American Academy of Dermatology said that Texas is the first state to prohibit use of tanning beds for children under 161/2. "Texas's leadership on this issue will serve as a model for other states to improve their laws and regulations," Dr. Evan Farmer, AAD vice president, said in a statement.

Florida Boosts ABD Certification

When Florida Gov. Charlie Crist (R) signed Senate Bill 720 in mid-June, the Florida Society of Dermatology and Dermatologic Surgery celebrated a "victory" for dermatology and patients. In an online letter, FSDDS President Albert J. Nemeth advised members to read "between the lines" of the law's wording: "A physician may not hold himself or herself out as a board-certified specialist in dermatology unless the recognizing agency, whether authorized in statute or by rule, is triennially reviewed and reauthorized by the Board of Medicine." That means, wrote Dr. Nemeth, that it will be much harder for dermatologists certified through the American Association of Plastic Surgeons or the American Board of Plastic Surgery to stay credentialed in Florida unless they also pursue certification through the American Board of Dermatology.

Clinics Expand Into Dermatology

A wholly owned subsidiary of Walgreens is expanding into a few dermatology services. Take Care Clinics will now offer wart removal by cryotherapy, skin tag removal, closure of minor cuts with Dermabond, treatment of skin irritations, and expanded skin evaluation and treatment for skin infections, injuries, and rashes. The clinics are open 7 days a week and have evening hours. According to Walgreens, there are 345 Take Care Clinics in stores in 19 states, and they're staffed by nurse practitioners and physician assistants.

Generic Biologics Get a Boost

Creating a process at the Food and Drug Administration for approving generic versions of biologic drugs, called follow-on biologics (FOBs), could bring down the cost of biologics, the Federal Trade Commission said in a report, but the 12- to 14-year exclusivity period sought by biologics manufacturers is too long. FOBs wouldn't tread deep into innovative products' turf—those drugs would retain 70%-90% of their market shares and continue making substantial profits—according to the FTC. Rep. Henry A. Waxman (D-Calif.), who has introduced legislation to create a regulatory pathway for FOBs, praised the report, but the Biotechnology Industry Organization said it was based on a "lack of true understanding of the necessary conditions to drive future biomedical breakthroughs."

Vermont Bans Most Pharma Gifts

Vermont Gov. Jim Douglas (R) has signed into law a bill that prohibits manufacturers of drugs, medical devices, and biologics from providing free gifts, including meals and travel, to physicians and other health care providers. The toughest of its kind in the nation, the legislation also requires disclosure of any allowed gifts or payments, regardless of their value. Under the stronger law, manufacturers can give physicians only gifts such as samples intended for patients, "reasonable quantities" of medical device evaluation or demonstration units, and copies of peer-reviewed articles.

FTC Wants 'Pay-for-Delay' Outlawed

A new law to eliminate deals in which pharmaceutical companies agree with their competitors to keep low-cost generic drugs off the market could save consumers and the federal government $3.5 billion a year over the next decade, according to Federal Trade Commission Chairman Jon Leibowitz. In a speech, Mr. Leibowitz said that stopping these "pay-for-delay" deals is one of the FTC's top priorities, although a series of recent court rulings has allowed some of the arrangements to continue. For instance, the U.S. Supreme Court recently declined to hear a case brought by consumers and health plans challenging a $398 million payment by drug maker Bayer AG to Barr Laboratories Inc. to settle the companies' patent dispute over a generic version of the antibiotic Cipro (ciprofloxacin).

AUSTIN, TEX. — Adding cosmetic dermatology to a Mohs practice is a natural transition, according to Dr. Christopher B. Zachary and Dr. Ronald L Moy.

However, do not expect such a practice to be lucrative, especially not immediately, Dr. Zachary said at the meeting of the American College of Mohs Surgery. "If you want to make a lot of money, I'd stick with cancer because that actually pays the bills."

Although the public might not perceive Mohs surgeons as "real" plastic surgeons, "we are facial plastic surgeons … we are dermatologic surgeons," Dr. Moy, president-elect of the American Academy of Dermatology, said in a panel presentation.

He said he would not be ashamed to have a Mohs defect patient sitting next to a Botox (botulinum toxin type A) candidate because it would demonstrate that he performed "real" surgery. Dr. Zachary, however, cautioned against mixing the cancer patients with the cosmetic clients.

Another reason to add cosmetic procedures is "there are a lot more new things going on in cosmetic surgery than in Mohs," said Dr. Moy, a dermatologist in Los Angeles. "I get more excited about new procedures."

Dr. Zachary agreed, "The newness is quite interesting." But, he added, "My Mohs day is my best day—the day I enjoy the most because the patients are the most appreciative and you get to do really good things."

Another plus: Many of the cosmetic techniques can be applied to Mohs patients, such as using fractionated lasers to improve scar appearance, said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.

When Dr. Moy decided to add cosmetic services, he spent $5,000 on a consultant and closed the practice for 2 days of meetings, personality tests, and management quizzes.

Both dermatologists suggested starting out slowly so as to minimize initial capital outlays. Dr. Zachary said intense pulsed light devices were a good beginning purchase, and noted that some older techniques such as chemical peels were still extremely useful. "Nobody in private practice can afford to have all the devices we have in a big university environment," he said.

Dr. Moy said his practice started out by renting lasers. Now, the practice owns 20.

Also important: marketing. Older practices do not need to do as much marketing because "the best patients you have are your existing patients," Dr. Moy said. Pamphlets on face-lifts placed in the waiting room are effective because they could be seen by someone who has had reconstruction, for instance. His practice also plays DVDs on available procedures in the waiting room. "Most patients I see are existing patients," he said.

Dr. Zachary agreed that marketing is necessary, but lamented the unsavory aspect of many advertisements. "You almost have to prostitute yourself," he said. He suggested creating a good Web site that is easily accessible, and that registers near the top of various search engines.

It also pays to have staff trained specifically for the cosmetic services. Dr. Zachary said a call center is important because it is the patient's first contact. Nurse practitioners and aestheticians might be needed.

Dr. Moy said that he does not use staff for initial interviews. He also tries to spend as much time as possible with the patient, pre- and postoperatively. This helps reduce misunderstandings and malpractice, he said.

Dr. Moy made no disclosures. Dr. Zachary disclosed that he is a speaker for Solta Medical Inc. and Cutera Inc. and is on the advisory board for Primaeva Medical Inc.

'There are a lot more new [exciting] things going on in cosmetic surgery than in Mohs.'

Source DR. MOY

AUSTIN, TEX. — Adding cosmetic dermatology to a Mohs practice is a natural transition, according to Dr. Christopher B. Zachary and Dr. Ronald L Moy.

However, do not expect such a practice to be lucrative, especially not immediately, Dr. Zachary said at the meeting of the American College of Mohs Surgery. "If you want to make a lot of money, I'd stick with cancer because that actually pays the bills."

Although the public might not perceive Mohs surgeons as "real" plastic surgeons, "we are facial plastic surgeons … we are dermatologic surgeons," Dr. Moy, president-elect of the American Academy of Dermatology, said in a panel presentation.

He said he would not be ashamed to have a Mohs defect patient sitting next to a Botox (botulinum toxin type A) candidate because it would demonstrate that he performed "real" surgery. Dr. Zachary, however, cautioned against mixing the cancer patients with the cosmetic clients.

Another reason to add cosmetic procedures is "there are a lot more new things going on in cosmetic surgery than in Mohs," said Dr. Moy, a dermatologist in Los Angeles. "I get more excited about new procedures."

Dr. Zachary agreed, "The newness is quite interesting." But, he added, "My Mohs day is my best day—the day I enjoy the most because the patients are the most appreciative and you get to do really good things."

Another plus: Many of the cosmetic techniques can be applied to Mohs patients, such as using fractionated lasers to improve scar appearance, said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.

When Dr. Moy decided to add cosmetic services, he spent $5,000 on a consultant and closed the practice for 2 days of meetings, personality tests, and management quizzes.

Both dermatologists suggested starting out slowly so as to minimize initial capital outlays. Dr. Zachary said intense pulsed light devices were a good beginning purchase, and noted that some older techniques such as chemical peels were still extremely useful. "Nobody in private practice can afford to have all the devices we have in a big university environment," he said.

Dr. Moy said his practice started out by renting lasers. Now, the practice owns 20.

Also important: marketing. Older practices do not need to do as much marketing because "the best patients you have are your existing patients," Dr. Moy said. Pamphlets on face-lifts placed in the waiting room are effective because they could be seen by someone who has had reconstruction, for instance. His practice also plays DVDs on available procedures in the waiting room. "Most patients I see are existing patients," he said.

Dr. Zachary agreed that marketing is necessary, but lamented the unsavory aspect of many advertisements. "You almost have to prostitute yourself," he said. He suggested creating a good Web site that is easily accessible, and that registers near the top of various search engines.

It also pays to have staff trained specifically for the cosmetic services. Dr. Zachary said a call center is important because it is the patient's first contact. Nurse practitioners and aestheticians might be needed.

Dr. Moy said that he does not use staff for initial interviews. He also tries to spend as much time as possible with the patient, pre- and postoperatively. This helps reduce misunderstandings and malpractice, he said.

Dr. Moy made no disclosures. Dr. Zachary disclosed that he is a speaker for Solta Medical Inc. and Cutera Inc. and is on the advisory board for Primaeva Medical Inc.

'There are a lot more new [exciting] things going on in cosmetic surgery than in Mohs.'

Source DR. MOY

AUSTIN, TEX. — Adding cosmetic dermatology to a Mohs practice is a natural transition, according to Dr. Christopher B. Zachary and Dr. Ronald L Moy.

However, do not expect such a practice to be lucrative, especially not immediately, Dr. Zachary said at the meeting of the American College of Mohs Surgery. "If you want to make a lot of money, I'd stick with cancer because that actually pays the bills."

Although the public might not perceive Mohs surgeons as "real" plastic surgeons, "we are facial plastic surgeons … we are dermatologic surgeons," Dr. Moy, president-elect of the American Academy of Dermatology, said in a panel presentation.

He said he would not be ashamed to have a Mohs defect patient sitting next to a Botox (botulinum toxin type A) candidate because it would demonstrate that he performed "real" surgery. Dr. Zachary, however, cautioned against mixing the cancer patients with the cosmetic clients.

Another reason to add cosmetic procedures is "there are a lot more new things going on in cosmetic surgery than in Mohs," said Dr. Moy, a dermatologist in Los Angeles. "I get more excited about new procedures."

Dr. Zachary agreed, "The newness is quite interesting." But, he added, "My Mohs day is my best day—the day I enjoy the most because the patients are the most appreciative and you get to do really good things."

Another plus: Many of the cosmetic techniques can be applied to Mohs patients, such as using fractionated lasers to improve scar appearance, said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.

When Dr. Moy decided to add cosmetic services, he spent $5,000 on a consultant and closed the practice for 2 days of meetings, personality tests, and management quizzes.

Both dermatologists suggested starting out slowly so as to minimize initial capital outlays. Dr. Zachary said intense pulsed light devices were a good beginning purchase, and noted that some older techniques such as chemical peels were still extremely useful. "Nobody in private practice can afford to have all the devices we have in a big university environment," he said.

Dr. Moy said his practice started out by renting lasers. Now, the practice owns 20.

Also important: marketing. Older practices do not need to do as much marketing because "the best patients you have are your existing patients," Dr. Moy said. Pamphlets on face-lifts placed in the waiting room are effective because they could be seen by someone who has had reconstruction, for instance. His practice also plays DVDs on available procedures in the waiting room. "Most patients I see are existing patients," he said.

Dr. Zachary agreed that marketing is necessary, but lamented the unsavory aspect of many advertisements. "You almost have to prostitute yourself," he said. He suggested creating a good Web site that is easily accessible, and that registers near the top of various search engines.

It also pays to have staff trained specifically for the cosmetic services. Dr. Zachary said a call center is important because it is the patient's first contact. Nurse practitioners and aestheticians might be needed.

Dr. Moy said that he does not use staff for initial interviews. He also tries to spend as much time as possible with the patient, pre- and postoperatively. This helps reduce misunderstandings and malpractice, he said.

Dr. Moy made no disclosures. Dr. Zachary disclosed that he is a speaker for Solta Medical Inc. and Cutera Inc. and is on the advisory board for Primaeva Medical Inc.

'There are a lot more new [exciting] things going on in cosmetic surgery than in Mohs.'

Source DR. MOY

AUSTIN, TEX. — Getting good, consistent pre- and postoperative photos of Mohs procedures is crucial to documenting a reconstructive procedure and sharing those procedures and outcomes with colleagues.

Dr. Juan-Carlos Martinez of the Mayo Clinic in Jacksonville, Fla., shared tips on getting the best pictures at the annual meeting of the American College of Mohs Surgery. "Mohs surgeons make a living out of striving for perfection," he said, adding that "photographs can and should reflect those same qualities," including being meticulous, thoughtful, and consistent.

Consistency, especially, is key. Ideally, the only difference between the preoperative and postoperative photos should be the surgical intervention, said Dr. Martinez.

The standard for photography is to have a dedicated studio, but this is an expensive undertaking. Although photographs might not turn out as well without such a studio, the advent of digital photography has simplified image acquisition and management, making it much easier to obtain high-quality, reproducible photographs, he said. There are some simple tools that can make this task easier: a felt-covered foam board for a background and a digital camera with at least 7 megapixels of resolution. The felt board can be purchased online or made from materials obtained at a local hardware store. The camera can be a digital single lens reflex (SLR) or a point-and-shoot model.

The same camera should always be used. It's also important to always use flash to maintain consistent lighting.

To frame the photos and keep up the consistency, use anatomic landmarks. The patient should always be sitting upright, in front of the felt board, looking straight ahead. A neutral expression is best, since smiles are hard to reproduce on a consistent basis. Gently closed eyes can help avoid the distraction of inconsistent sideways glances, said Dr. Martinez.

Some cameras have a viewfinder grid, which allows better framing. Dr. Martinez uses a horizontal line across the pupils to ensure there is symmetric framing for the frontal, oblique, and base views. For an oblique view, he uses the same horizontal line across the pupils and another across the peak of the nasal tip. This locks the head in the transverse and sagittal planes. For a lateral image, he employs a single horizontal line from the lateral canthus to the top of the auricular helix and a vertical line from the brow to the chin. The goal is to ensure that no aspect of the contralateral brow is in view.

The base view is preferred by professional photographers, said Dr. Martinez, noting that it's nicknamed the "view of shame" because it will highlight the slightest tip or alar distortion resulting from a reconstruction. It is useful for any tumor on or near the nose. Any nasal reconstructive paper or presentation should include this view.

Dr. Martinez reported no conflicts.

AUSTIN, TEX. — Getting good, consistent pre- and postoperative photos of Mohs procedures is crucial to documenting a reconstructive procedure and sharing those procedures and outcomes with colleagues.

Dr. Juan-Carlos Martinez of the Mayo Clinic in Jacksonville, Fla., shared tips on getting the best pictures at the annual meeting of the American College of Mohs Surgery. "Mohs surgeons make a living out of striving for perfection," he said, adding that "photographs can and should reflect those same qualities," including being meticulous, thoughtful, and consistent.

Consistency, especially, is key. Ideally, the only difference between the preoperative and postoperative photos should be the surgical intervention, said Dr. Martinez.

The standard for photography is to have a dedicated studio, but this is an expensive undertaking. Although photographs might not turn out as well without such a studio, the advent of digital photography has simplified image acquisition and management, making it much easier to obtain high-quality, reproducible photographs, he said. There are some simple tools that can make this task easier: a felt-covered foam board for a background and a digital camera with at least 7 megapixels of resolution. The felt board can be purchased online or made from materials obtained at a local hardware store. The camera can be a digital single lens reflex (SLR) or a point-and-shoot model.

The same camera should always be used. It's also important to always use flash to maintain consistent lighting.

To frame the photos and keep up the consistency, use anatomic landmarks. The patient should always be sitting upright, in front of the felt board, looking straight ahead. A neutral expression is best, since smiles are hard to reproduce on a consistent basis. Gently closed eyes can help avoid the distraction of inconsistent sideways glances, said Dr. Martinez.

Some cameras have a viewfinder grid, which allows better framing. Dr. Martinez uses a horizontal line across the pupils to ensure there is symmetric framing for the frontal, oblique, and base views. For an oblique view, he uses the same horizontal line across the pupils and another across the peak of the nasal tip. This locks the head in the transverse and sagittal planes. For a lateral image, he employs a single horizontal line from the lateral canthus to the top of the auricular helix and a vertical line from the brow to the chin. The goal is to ensure that no aspect of the contralateral brow is in view.

The base view is preferred by professional photographers, said Dr. Martinez, noting that it's nicknamed the "view of shame" because it will highlight the slightest tip or alar distortion resulting from a reconstruction. It is useful for any tumor on or near the nose. Any nasal reconstructive paper or presentation should include this view.

Dr. Martinez reported no conflicts.

AUSTIN, TEX. — Getting good, consistent pre- and postoperative photos of Mohs procedures is crucial to documenting a reconstructive procedure and sharing those procedures and outcomes with colleagues.

Dr. Juan-Carlos Martinez of the Mayo Clinic in Jacksonville, Fla., shared tips on getting the best pictures at the annual meeting of the American College of Mohs Surgery. "Mohs surgeons make a living out of striving for perfection," he said, adding that "photographs can and should reflect those same qualities," including being meticulous, thoughtful, and consistent.

Consistency, especially, is key. Ideally, the only difference between the preoperative and postoperative photos should be the surgical intervention, said Dr. Martinez.

The standard for photography is to have a dedicated studio, but this is an expensive undertaking. Although photographs might not turn out as well without such a studio, the advent of digital photography has simplified image acquisition and management, making it much easier to obtain high-quality, reproducible photographs, he said. There are some simple tools that can make this task easier: a felt-covered foam board for a background and a digital camera with at least 7 megapixels of resolution. The felt board can be purchased online or made from materials obtained at a local hardware store. The camera can be a digital single lens reflex (SLR) or a point-and-shoot model.

The same camera should always be used. It's also important to always use flash to maintain consistent lighting.

To frame the photos and keep up the consistency, use anatomic landmarks. The patient should always be sitting upright, in front of the felt board, looking straight ahead. A neutral expression is best, since smiles are hard to reproduce on a consistent basis. Gently closed eyes can help avoid the distraction of inconsistent sideways glances, said Dr. Martinez.

Some cameras have a viewfinder grid, which allows better framing. Dr. Martinez uses a horizontal line across the pupils to ensure there is symmetric framing for the frontal, oblique, and base views. For an oblique view, he uses the same horizontal line across the pupils and another across the peak of the nasal tip. This locks the head in the transverse and sagittal planes. For a lateral image, he employs a single horizontal line from the lateral canthus to the top of the auricular helix and a vertical line from the brow to the chin. The goal is to ensure that no aspect of the contralateral brow is in view.

The base view is preferred by professional photographers, said Dr. Martinez, noting that it's nicknamed the "view of shame" because it will highlight the slightest tip or alar distortion resulting from a reconstruction. It is useful for any tumor on or near the nose. Any nasal reconstructive paper or presentation should include this view.

Dr. Martinez reported no conflicts.

CHICAGO — The duodenal switch procedure resolved comorbidities in “super-obese” patients more effectively than does Roux-en-Y gastric bypass, according to ongoing follow-up of a single-institution case series presented at the annual Digestive Disease Week.

Dr. Vivek N. Prachand of the University of Chicago presented data on 350 patients with a BMI of more than 50 kg/m

The super-obese category—those with a BMI of more than 50 and who are at least 200 pounds above ideal body weight—is the fastest-growing obesity group, said Dr. Prachand in a press briefing. Roux-en-Y gastric bypass is performed more often in this group, but in an earlier study of this same patient cohort, Dr. Prachand and his colleagues showed that gastric bypass does not always achieve the greatest weight loss.

Duodenal switch accounts for less than 10% of procedures in the super-obese group, he said, noting that it is technically more difficult and generally results in a greater degree of malabsorption.

In this study, 198 patients underwent duodenal switch and 152 had gastric bypass. At baseline, the incidence and severity of hypertension, dyslipidemia, and gastroesophageal reflux disease (GERD) were similar in the two groups. Diabetes was less common but more severe in the duodenal switch group, affecting 24% (47 patients), compared with 35% (53 patients) in the gastric bypass group.

At 36 months after surgery, all of the duodenal switch patients had a resolution of diabetes, which meant they were no longer using insulin and their blood sugar had returned to normal levels, compared with 91 patients (60%) of the bypass group.

A total of 70% (138) of the duodenal switch group had a resolution of hypertension, compared with only 39% (59) of the gastric bypass arm. Lipid levels returned to normal for 72% (142) of the duodenal switch patients, compared with only 26% (39) of the gastric bypass group.

GERD resolved in a greater proportion of the bypass group, which makes sense anatomically, said Dr. Prachand. The percentage with resolution of GERD was 77% (117) in the gastric bypass group, versus 49% (97) of the duodenal switch group.

The amount of weight lost did not seem to be correlated with the resolution of comorbidities, said Dr. Prachand. “It raises some very interesting avenues for investigation in terms of trying to understand the mechanisms of these underlying diseases as well as how these diseases improve with these operations,” he said.

It's still not clear which procedure is of greatest benefit to which obesity patients, said Dr. Prachand. When choosing a procedure for his patients, he considers three factors: the severity of the obesity; the associated medical problems, as some procedures might be better than others for resolving metabolic issues; and patient preference, because the procedures require motivation and follow-up, he said.

Dr. Prachand reported no conflicts of interest.

CHICAGO — The duodenal switch procedure resolved comorbidities in “super-obese” patients more effectively than does Roux-en-Y gastric bypass, according to ongoing follow-up of a single-institution case series presented at the annual Digestive Disease Week.

Dr. Vivek N. Prachand of the University of Chicago presented data on 350 patients with a BMI of more than 50 kg/m

The super-obese category—those with a BMI of more than 50 and who are at least 200 pounds above ideal body weight—is the fastest-growing obesity group, said Dr. Prachand in a press briefing. Roux-en-Y gastric bypass is performed more often in this group, but in an earlier study of this same patient cohort, Dr. Prachand and his colleagues showed that gastric bypass does not always achieve the greatest weight loss.

Duodenal switch accounts for less than 10% of procedures in the super-obese group, he said, noting that it is technically more difficult and generally results in a greater degree of malabsorption.

In this study, 198 patients underwent duodenal switch and 152 had gastric bypass. At baseline, the incidence and severity of hypertension, dyslipidemia, and gastroesophageal reflux disease (GERD) were similar in the two groups. Diabetes was less common but more severe in the duodenal switch group, affecting 24% (47 patients), compared with 35% (53 patients) in the gastric bypass group.

At 36 months after surgery, all of the duodenal switch patients had a resolution of diabetes, which meant they were no longer using insulin and their blood sugar had returned to normal levels, compared with 91 patients (60%) of the bypass group.

A total of 70% (138) of the duodenal switch group had a resolution of hypertension, compared with only 39% (59) of the gastric bypass arm. Lipid levels returned to normal for 72% (142) of the duodenal switch patients, compared with only 26% (39) of the gastric bypass group.

GERD resolved in a greater proportion of the bypass group, which makes sense anatomically, said Dr. Prachand. The percentage with resolution of GERD was 77% (117) in the gastric bypass group, versus 49% (97) of the duodenal switch group.

The amount of weight lost did not seem to be correlated with the resolution of comorbidities, said Dr. Prachand. “It raises some very interesting avenues for investigation in terms of trying to understand the mechanisms of these underlying diseases as well as how these diseases improve with these operations,” he said.

It's still not clear which procedure is of greatest benefit to which obesity patients, said Dr. Prachand. When choosing a procedure for his patients, he considers three factors: the severity of the obesity; the associated medical problems, as some procedures might be better than others for resolving metabolic issues; and patient preference, because the procedures require motivation and follow-up, he said.

Dr. Prachand reported no conflicts of interest.

CHICAGO — The duodenal switch procedure resolved comorbidities in “super-obese” patients more effectively than does Roux-en-Y gastric bypass, according to ongoing follow-up of a single-institution case series presented at the annual Digestive Disease Week.

Dr. Vivek N. Prachand of the University of Chicago presented data on 350 patients with a BMI of more than 50 kg/m

The super-obese category—those with a BMI of more than 50 and who are at least 200 pounds above ideal body weight—is the fastest-growing obesity group, said Dr. Prachand in a press briefing. Roux-en-Y gastric bypass is performed more often in this group, but in an earlier study of this same patient cohort, Dr. Prachand and his colleagues showed that gastric bypass does not always achieve the greatest weight loss.

Duodenal switch accounts for less than 10% of procedures in the super-obese group, he said, noting that it is technically more difficult and generally results in a greater degree of malabsorption.

In this study, 198 patients underwent duodenal switch and 152 had gastric bypass. At baseline, the incidence and severity of hypertension, dyslipidemia, and gastroesophageal reflux disease (GERD) were similar in the two groups. Diabetes was less common but more severe in the duodenal switch group, affecting 24% (47 patients), compared with 35% (53 patients) in the gastric bypass group.

At 36 months after surgery, all of the duodenal switch patients had a resolution of diabetes, which meant they were no longer using insulin and their blood sugar had returned to normal levels, compared with 91 patients (60%) of the bypass group.

A total of 70% (138) of the duodenal switch group had a resolution of hypertension, compared with only 39% (59) of the gastric bypass arm. Lipid levels returned to normal for 72% (142) of the duodenal switch patients, compared with only 26% (39) of the gastric bypass group.

GERD resolved in a greater proportion of the bypass group, which makes sense anatomically, said Dr. Prachand. The percentage with resolution of GERD was 77% (117) in the gastric bypass group, versus 49% (97) of the duodenal switch group.

The amount of weight lost did not seem to be correlated with the resolution of comorbidities, said Dr. Prachand. “It raises some very interesting avenues for investigation in terms of trying to understand the mechanisms of these underlying diseases as well as how these diseases improve with these operations,” he said.

It's still not clear which procedure is of greatest benefit to which obesity patients, said Dr. Prachand. When choosing a procedure for his patients, he considers three factors: the severity of the obesity; the associated medical problems, as some procedures might be better than others for resolving metabolic issues; and patient preference, because the procedures require motivation and follow-up, he said.

Dr. Prachand reported no conflicts of interest.

NEW ORLEANS — The incidence of neuropathy after gynecologic surgery appears to be fairly low, based on a prospective cohort study of more than 600 patients.

Dr. Justin C. Bohrer, an ob.gyn. at the Cleveland Clinic Lerner College of Medicine, presented data on his study at the annual meeting of the Society of Gynecologic Surgeons.

The authors enrolled 642 patients who underwent gynecologic surgery. The most common procedures were midurethral slings (26%, 166 patients); followed by vaginal prolapse surgery (25%, 160); abdominal hysterectomy (21%, 134); and hysteroscopy (16%, 102). Twenty-one percent of the procedures were conducted laparoscopically.

Of the total 642 enrolled, 611 subjects had a preoperative physical exam and neurologic history, asking about preexisting injuries and pain. Patients also were given a post-op neurologic exam within 24 hours of the procedure. Overall, 616 received that examination. Of the 616 patients, 12 (1.9%) were found to have a preexisting lower-extremity neuropathy. There were 14 new-onset peripheral nerve injuries in 11 patients, for an incidence of 1.8%, said Dr. Bohrer. Four of the neuropathies occurred in patients in boot stirrups and seven in those who were in candy cane stirrups.

The injuries were observed in the following nerves: lateral femoral cutaneous (five injuries), femoral (five), common fibular (one), ilioinguinal/iliohypogastric (one), saphenous (one), and genitofemoral (one). Bilateral femoral neuropathy was seen in three patients. Bilateral lateral femoral cutaneous neuropathy was seen in one patient. The injuries were mostly sensory, except for one of the bilateral femoral nerve injuries, which had motor and sensory components, said Dr. Bohrer, who reported no disclosures. No sacral nerve injuries were observed.

Looking at all the baseline characteristics, which included age, body mass index, race, tobacco use, and comorbidities such as diabetes, Dr. Bohrer found no significant differences between the groups.

The study had aimed to determine risk factors for neuropathy, but it was underpowered. It also did not fully account for patients who had a neuropathy more than 24 hours after surgery, he said. And because no nerve conduction studies were performed, the results were limited to only clinically significant injuries. Dr. Bohrer concluded that neuropathies are relatively rare in patients undergoing gynecologic surgery (at 1.9%), and that there is also a low incidence of injuries (1.8%).

Dr. Marc Toglia, a urogynecologist practicing in Philadelphia, commented that the study “does add significantly to our understanding of the topic.” He added that it is also “extremely timely” as Medicare is instituting new payment policies that hold hospitals and surgeons accountable for hospital-acquired injuries.

Dr. Bohrer's study 'does add significantly to our understanding of the topic.' DR. TOGLIA

NEW ORLEANS — The incidence of neuropathy after gynecologic surgery appears to be fairly low, based on a prospective cohort study of more than 600 patients.

Dr. Justin C. Bohrer, an ob.gyn. at the Cleveland Clinic Lerner College of Medicine, presented data on his study at the annual meeting of the Society of Gynecologic Surgeons.

The authors enrolled 642 patients who underwent gynecologic surgery. The most common procedures were midurethral slings (26%, 166 patients); followed by vaginal prolapse surgery (25%, 160); abdominal hysterectomy (21%, 134); and hysteroscopy (16%, 102). Twenty-one percent of the procedures were conducted laparoscopically.

Of the total 642 enrolled, 611 subjects had a preoperative physical exam and neurologic history, asking about preexisting injuries and pain. Patients also were given a post-op neurologic exam within 24 hours of the procedure. Overall, 616 received that examination. Of the 616 patients, 12 (1.9%) were found to have a preexisting lower-extremity neuropathy. There were 14 new-onset peripheral nerve injuries in 11 patients, for an incidence of 1.8%, said Dr. Bohrer. Four of the neuropathies occurred in patients in boot stirrups and seven in those who were in candy cane stirrups.

The injuries were observed in the following nerves: lateral femoral cutaneous (five injuries), femoral (five), common fibular (one), ilioinguinal/iliohypogastric (one), saphenous (one), and genitofemoral (one). Bilateral femoral neuropathy was seen in three patients. Bilateral lateral femoral cutaneous neuropathy was seen in one patient. The injuries were mostly sensory, except for one of the bilateral femoral nerve injuries, which had motor and sensory components, said Dr. Bohrer, who reported no disclosures. No sacral nerve injuries were observed.

Looking at all the baseline characteristics, which included age, body mass index, race, tobacco use, and comorbidities such as diabetes, Dr. Bohrer found no significant differences between the groups.

The study had aimed to determine risk factors for neuropathy, but it was underpowered. It also did not fully account for patients who had a neuropathy more than 24 hours after surgery, he said. And because no nerve conduction studies were performed, the results were limited to only clinically significant injuries. Dr. Bohrer concluded that neuropathies are relatively rare in patients undergoing gynecologic surgery (at 1.9%), and that there is also a low incidence of injuries (1.8%).

Dr. Marc Toglia, a urogynecologist practicing in Philadelphia, commented that the study “does add significantly to our understanding of the topic.” He added that it is also “extremely timely” as Medicare is instituting new payment policies that hold hospitals and surgeons accountable for hospital-acquired injuries.

Dr. Bohrer's study 'does add significantly to our understanding of the topic.' DR. TOGLIA

NEW ORLEANS — The incidence of neuropathy after gynecologic surgery appears to be fairly low, based on a prospective cohort study of more than 600 patients.

Dr. Justin C. Bohrer, an ob.gyn. at the Cleveland Clinic Lerner College of Medicine, presented data on his study at the annual meeting of the Society of Gynecologic Surgeons.

The authors enrolled 642 patients who underwent gynecologic surgery. The most common procedures were midurethral slings (26%, 166 patients); followed by vaginal prolapse surgery (25%, 160); abdominal hysterectomy (21%, 134); and hysteroscopy (16%, 102). Twenty-one percent of the procedures were conducted laparoscopically.

Of the total 642 enrolled, 611 subjects had a preoperative physical exam and neurologic history, asking about preexisting injuries and pain. Patients also were given a post-op neurologic exam within 24 hours of the procedure. Overall, 616 received that examination. Of the 616 patients, 12 (1.9%) were found to have a preexisting lower-extremity neuropathy. There were 14 new-onset peripheral nerve injuries in 11 patients, for an incidence of 1.8%, said Dr. Bohrer. Four of the neuropathies occurred in patients in boot stirrups and seven in those who were in candy cane stirrups.

The injuries were observed in the following nerves: lateral femoral cutaneous (five injuries), femoral (five), common fibular (one), ilioinguinal/iliohypogastric (one), saphenous (one), and genitofemoral (one). Bilateral femoral neuropathy was seen in three patients. Bilateral lateral femoral cutaneous neuropathy was seen in one patient. The injuries were mostly sensory, except for one of the bilateral femoral nerve injuries, which had motor and sensory components, said Dr. Bohrer, who reported no disclosures. No sacral nerve injuries were observed.

Looking at all the baseline characteristics, which included age, body mass index, race, tobacco use, and comorbidities such as diabetes, Dr. Bohrer found no significant differences between the groups.

The study had aimed to determine risk factors for neuropathy, but it was underpowered. It also did not fully account for patients who had a neuropathy more than 24 hours after surgery, he said. And because no nerve conduction studies were performed, the results were limited to only clinically significant injuries. Dr. Bohrer concluded that neuropathies are relatively rare in patients undergoing gynecologic surgery (at 1.9%), and that there is also a low incidence of injuries (1.8%).

Dr. Marc Toglia, a urogynecologist practicing in Philadelphia, commented that the study “does add significantly to our understanding of the topic.” He added that it is also “extremely timely” as Medicare is instituting new payment policies that hold hospitals and surgeons accountable for hospital-acquired injuries.

Dr. Bohrer's study 'does add significantly to our understanding of the topic.' DR. TOGLIA

NEW ORLEANS — A polypropylene mesh was found effective for repair of anterior vaginal prolapse, a 12-month, single-arm multicenter study showed.

In initial data from the ongoing prospective trial, 96 women with stage II or greater anterior vaginal wall prolapse who underwent placement of the mesh had stage I or less prolapse at 12 months' follow-up.

During placement of the mesh, the cystocele was not reduced or repaired. If additional reconstructive or incontinence repair was needed, it was completed at that time. Women with a history of anterior wall graft or concomitant hysterectomy were excluded, Dr. R.D. Moore, a gynecologic surgeon in private practice in Alpharetta, Ga., reported at the annual meeting of the Society of Gynecologic Surgeons.

The trial was funded by American Medical Systems of Minnetonka, Minn., maker of the Perigee system with IntePro mesh used in the study. All of the surgeons already had experience with using this macroporous type I soft polypropylene mesh.

Dr. Moore presented 12-month data on 96 of the 114 patients studied. Twenty-three percent (22) had prior cystocele repair, 87% (83) were postmenopausal, and 54% (52) had a prior hysterectomy. With the Perigee only, the procedure took about 29 minutes. If there was a concomitant repair, overall operative time averaged 87 minutes. Sixty-four percent (61) had a concomitant vault suspension, 70% (67) had an incontinence procedure, and 65% (62) had a rectocele repair.

Thirty-seven patients were discharged on the same day and 33 on day 1.

Follow-up was conducted at 6 weeks, 3 months, 6 months, 12 months, and 24 months. The mean follow-up was 18 months. Eleven patients (11%) had a mesh extrusion into the vagina, a mean of 133 days after surgery. Dr. Moore said this extrusion rate was consistent with findings in the literature for this type of material. Nine (9%) of the extrusion cases required surgical intervention; two (2%) healed with conservative treatment, including trimming of exposed mesh in the office. Not a single mesh system was removed to try to resolve an extrusion, said Dr. Moore.

Five (5%) patients had postoperative pain. Almost 3% of women reported de novo urge with incontinence and dyspareunia, but those cases all resolved. One patient had a reoperation for a device system failure.

The researchers looked to see whether use of vaginal estrogen postoperatively had any protective effect, and found that it did not change the extrusion rate, said Dr. Moore.

There was a significant improvement in all the quality of life scales used. And there was a decrease in dyspareunia, from 46% (44) to 31% (29) at the 12-month mark. Sexual activity remained consistent, with 52% (50) of women reporting they were active.

Despite its limitation as a single-arm study, the trial did show consistent and good anatomic results and minimum morbidity, said Dr. Moore. He said he expected to report data soon on the 2-year follow-up.

Dr. Moore disclosed that he received honoraria, and speaking and teaching fees from American Medical Systems. He also is on some AMS advisory committees.

In discussing the paper, Dr. Charles R. Rardin of Brown University, Providence, R.I., lauded the study for its relatively large numbers, but said the lack of a comparison group hindered its conclusions. Also, he said there were no data on women who were implanted but excluded from follow-up, and he was also concerned that results for women who had concomitant apical suspension might be confounding. He questioned whether the results were generalizable, given that the procedures in the trial were conducted by experienced surgeons.

Dr. Rardin made no disclosures.

Dr. Moore replied that the results were not likely to be reproducible in the general surgeon population, and suggested it was up to the Society of Gynecologic Surgeons and other professional groups to determine whether there should be minimum qualifications for conducting mesh procedures.

NEW ORLEANS — A polypropylene mesh was found effective for repair of anterior vaginal prolapse, a 12-month, single-arm multicenter study showed.

In initial data from the ongoing prospective trial, 96 women with stage II or greater anterior vaginal wall prolapse who underwent placement of the mesh had stage I or less prolapse at 12 months' follow-up.

During placement of the mesh, the cystocele was not reduced or repaired. If additional reconstructive or incontinence repair was needed, it was completed at that time. Women with a history of anterior wall graft or concomitant hysterectomy were excluded, Dr. R.D. Moore, a gynecologic surgeon in private practice in Alpharetta, Ga., reported at the annual meeting of the Society of Gynecologic Surgeons.

The trial was funded by American Medical Systems of Minnetonka, Minn., maker of the Perigee system with IntePro mesh used in the study. All of the surgeons already had experience with using this macroporous type I soft polypropylene mesh.

Dr. Moore presented 12-month data on 96 of the 114 patients studied. Twenty-three percent (22) had prior cystocele repair, 87% (83) were postmenopausal, and 54% (52) had a prior hysterectomy. With the Perigee only, the procedure took about 29 minutes. If there was a concomitant repair, overall operative time averaged 87 minutes. Sixty-four percent (61) had a concomitant vault suspension, 70% (67) had an incontinence procedure, and 65% (62) had a rectocele repair.

Thirty-seven patients were discharged on the same day and 33 on day 1.

Follow-up was conducted at 6 weeks, 3 months, 6 months, 12 months, and 24 months. The mean follow-up was 18 months. Eleven patients (11%) had a mesh extrusion into the vagina, a mean of 133 days after surgery. Dr. Moore said this extrusion rate was consistent with findings in the literature for this type of material. Nine (9%) of the extrusion cases required surgical intervention; two (2%) healed with conservative treatment, including trimming of exposed mesh in the office. Not a single mesh system was removed to try to resolve an extrusion, said Dr. Moore.

Five (5%) patients had postoperative pain. Almost 3% of women reported de novo urge with incontinence and dyspareunia, but those cases all resolved. One patient had a reoperation for a device system failure.

The researchers looked to see whether use of vaginal estrogen postoperatively had any protective effect, and found that it did not change the extrusion rate, said Dr. Moore.

There was a significant improvement in all the quality of life scales used. And there was a decrease in dyspareunia, from 46% (44) to 31% (29) at the 12-month mark. Sexual activity remained consistent, with 52% (50) of women reporting they were active.

Despite its limitation as a single-arm study, the trial did show consistent and good anatomic results and minimum morbidity, said Dr. Moore. He said he expected to report data soon on the 2-year follow-up.

Dr. Moore disclosed that he received honoraria, and speaking and teaching fees from American Medical Systems. He also is on some AMS advisory committees.

In discussing the paper, Dr. Charles R. Rardin of Brown University, Providence, R.I., lauded the study for its relatively large numbers, but said the lack of a comparison group hindered its conclusions. Also, he said there were no data on women who were implanted but excluded from follow-up, and he was also concerned that results for women who had concomitant apical suspension might be confounding. He questioned whether the results were generalizable, given that the procedures in the trial were conducted by experienced surgeons.

Dr. Rardin made no disclosures.

Dr. Moore replied that the results were not likely to be reproducible in the general surgeon population, and suggested it was up to the Society of Gynecologic Surgeons and other professional groups to determine whether there should be minimum qualifications for conducting mesh procedures.

NEW ORLEANS — A polypropylene mesh was found effective for repair of anterior vaginal prolapse, a 12-month, single-arm multicenter study showed.

In initial data from the ongoing prospective trial, 96 women with stage II or greater anterior vaginal wall prolapse who underwent placement of the mesh had stage I or less prolapse at 12 months' follow-up.

During placement of the mesh, the cystocele was not reduced or repaired. If additional reconstructive or incontinence repair was needed, it was completed at that time. Women with a history of anterior wall graft or concomitant hysterectomy were excluded, Dr. R.D. Moore, a gynecologic surgeon in private practice in Alpharetta, Ga., reported at the annual meeting of the Society of Gynecologic Surgeons.

The trial was funded by American Medical Systems of Minnetonka, Minn., maker of the Perigee system with IntePro mesh used in the study. All of the surgeons already had experience with using this macroporous type I soft polypropylene mesh.

Dr. Moore presented 12-month data on 96 of the 114 patients studied. Twenty-three percent (22) had prior cystocele repair, 87% (83) were postmenopausal, and 54% (52) had a prior hysterectomy. With the Perigee only, the procedure took about 29 minutes. If there was a concomitant repair, overall operative time averaged 87 minutes. Sixty-four percent (61) had a concomitant vault suspension, 70% (67) had an incontinence procedure, and 65% (62) had a rectocele repair.

Thirty-seven patients were discharged on the same day and 33 on day 1.

Follow-up was conducted at 6 weeks, 3 months, 6 months, 12 months, and 24 months. The mean follow-up was 18 months. Eleven patients (11%) had a mesh extrusion into the vagina, a mean of 133 days after surgery. Dr. Moore said this extrusion rate was consistent with findings in the literature for this type of material. Nine (9%) of the extrusion cases required surgical intervention; two (2%) healed with conservative treatment, including trimming of exposed mesh in the office. Not a single mesh system was removed to try to resolve an extrusion, said Dr. Moore.

Five (5%) patients had postoperative pain. Almost 3% of women reported de novo urge with incontinence and dyspareunia, but those cases all resolved. One patient had a reoperation for a device system failure.

The researchers looked to see whether use of vaginal estrogen postoperatively had any protective effect, and found that it did not change the extrusion rate, said Dr. Moore.

There was a significant improvement in all the quality of life scales used. And there was a decrease in dyspareunia, from 46% (44) to 31% (29) at the 12-month mark. Sexual activity remained consistent, with 52% (50) of women reporting they were active.

Despite its limitation as a single-arm study, the trial did show consistent and good anatomic results and minimum morbidity, said Dr. Moore. He said he expected to report data soon on the 2-year follow-up.

Dr. Moore disclosed that he received honoraria, and speaking and teaching fees from American Medical Systems. He also is on some AMS advisory committees.

In discussing the paper, Dr. Charles R. Rardin of Brown University, Providence, R.I., lauded the study for its relatively large numbers, but said the lack of a comparison group hindered its conclusions. Also, he said there were no data on women who were implanted but excluded from follow-up, and he was also concerned that results for women who had concomitant apical suspension might be confounding. He questioned whether the results were generalizable, given that the procedures in the trial were conducted by experienced surgeons.

Dr. Rardin made no disclosures.

Dr. Moore replied that the results were not likely to be reproducible in the general surgeon population, and suggested it was up to the Society of Gynecologic Surgeons and other professional groups to determine whether there should be minimum qualifications for conducting mesh procedures.

NEW ORLEANS — Robotic-assisted laparoscopy appears to be a safe and effective, minimally invasive alternative to traditional laparotomy for treating and staging endometrial cancer, according to a small retrospective study from one institution.

Dr. John P. Judd of the Ochsner Medical Center in New Orleans and his colleagues compared patients who had robotic-assisted laparoscopic hysterectomy (RALH) with staging to those who had traditional laparotomy with staging.

The laparoscopic approach has many benefits, but it also means a limited range of motion, a significant learning curve, and the ability to see in two dimensions only, said Dr. Judd, who presented his results at the annual meeting of the Society of Gynecologic Surgeons. Robotic surgery offers three-dimensional views, enhanced knot tying and suturing, and the potential for a shorter learning curve.

In the Ochsner study, there were 14 patients in the robotic group and 50 in the traditional laparotomy group. They underwent exploratory laparotomy from July 2005 to February 2008. Patients in the robotic group had significantly less blood loss than those undergoing the traditional exploratory method—148 mL vs. 300 mL. And the total operating room time also was significantly less for the robotic procedure, at 192 minutes, compared with 314 minutes.

There was a shorter total procedure time, and the average postoperative stay was only 1.8 days for the robotic groups, compared with 3.5 days for the traditional approach.

Although robotic surgery conferred the same or better benefits than traditional laparotomy, it was significantly more expensive. The total charge for robotic surgery was $40,298, compared with $27,320 for traditional surgery, he said.

Dr. Judd concluded that the benefits outweighed the costs of the robotic surgery. However, he noted, prospective trials with more patients are needed to confirm the benefits.

Dr. Judd reported no disclosures.

NEW ORLEANS — Robotic-assisted laparoscopy appears to be a safe and effective, minimally invasive alternative to traditional laparotomy for treating and staging endometrial cancer, according to a small retrospective study from one institution.

Dr. John P. Judd of the Ochsner Medical Center in New Orleans and his colleagues compared patients who had robotic-assisted laparoscopic hysterectomy (RALH) with staging to those who had traditional laparotomy with staging.

The laparoscopic approach has many benefits, but it also means a limited range of motion, a significant learning curve, and the ability to see in two dimensions only, said Dr. Judd, who presented his results at the annual meeting of the Society of Gynecologic Surgeons. Robotic surgery offers three-dimensional views, enhanced knot tying and suturing, and the potential for a shorter learning curve.

In the Ochsner study, there were 14 patients in the robotic group and 50 in the traditional laparotomy group. They underwent exploratory laparotomy from July 2005 to February 2008. Patients in the robotic group had significantly less blood loss than those undergoing the traditional exploratory method—148 mL vs. 300 mL. And the total operating room time also was significantly less for the robotic procedure, at 192 minutes, compared with 314 minutes.

There was a shorter total procedure time, and the average postoperative stay was only 1.8 days for the robotic groups, compared with 3.5 days for the traditional approach.

Although robotic surgery conferred the same or better benefits than traditional laparotomy, it was significantly more expensive. The total charge for robotic surgery was $40,298, compared with $27,320 for traditional surgery, he said.

Dr. Judd concluded that the benefits outweighed the costs of the robotic surgery. However, he noted, prospective trials with more patients are needed to confirm the benefits.

Dr. Judd reported no disclosures.

NEW ORLEANS — Robotic-assisted laparoscopy appears to be a safe and effective, minimally invasive alternative to traditional laparotomy for treating and staging endometrial cancer, according to a small retrospective study from one institution.

Dr. John P. Judd of the Ochsner Medical Center in New Orleans and his colleagues compared patients who had robotic-assisted laparoscopic hysterectomy (RALH) with staging to those who had traditional laparotomy with staging.

The laparoscopic approach has many benefits, but it also means a limited range of motion, a significant learning curve, and the ability to see in two dimensions only, said Dr. Judd, who presented his results at the annual meeting of the Society of Gynecologic Surgeons. Robotic surgery offers three-dimensional views, enhanced knot tying and suturing, and the potential for a shorter learning curve.

In the Ochsner study, there were 14 patients in the robotic group and 50 in the traditional laparotomy group. They underwent exploratory laparotomy from July 2005 to February 2008. Patients in the robotic group had significantly less blood loss than those undergoing the traditional exploratory method—148 mL vs. 300 mL. And the total operating room time also was significantly less for the robotic procedure, at 192 minutes, compared with 314 minutes.

There was a shorter total procedure time, and the average postoperative stay was only 1.8 days for the robotic groups, compared with 3.5 days for the traditional approach.

Although robotic surgery conferred the same or better benefits than traditional laparotomy, it was significantly more expensive. The total charge for robotic surgery was $40,298, compared with $27,320 for traditional surgery, he said.

Dr. Judd concluded that the benefits outweighed the costs of the robotic surgery. However, he noted, prospective trials with more patients are needed to confirm the benefits.

Dr. Judd reported no disclosures.

Vermont Bans Most Pharma Gifts

Vermont Gov. Jim Douglas (R) has signed into law a bill that prohibits manufacturers of drugs, medical devices, and biologics from providing free gifts, including meals and travel, to physicians and other health care providers. The legislation, which is the toughest of its kind in the nation, also requires disclosure of any allowed gifts or payments, regardless of their value. In 2002, a Vermont law required disclosure of gifts or payments of $25 or more. Under the stronger law, manufacturers can give physicians only gifts such as samples intended for patients, “reasonable quantities” of medical device evaluation or demonstration units, and copies of peer-reviewed articles. The companies still can provide scholarships or other support for medical students, residents, and fellows to attend educational events held by professional associations, as long as the association selects the scholarship recipient.

Obama: Give MedPAC More Clout

President Obama's administration wants to give the Medicare Payment Advisory Commission greater influence. In a June 2 letter to Sen. Ted Kennedy (D-Mass.) and Sen. Max Baucus (D-Mont.), President Obama said he supported giving each MedPAC recommendation the force of law unless it is opposed by a joint resolution of Congress. This appeared to embrace the approach in the MedPAC Reform Act of 2009, which Sen. Jay Rockefeller (D-W.Va.) introduced in May. Currently, MedPAC advises Congress, which then decides whether to act on the recommendations. At a Brookings Institution conference in mid-June, White House Office of Management and Budget Director Peter Orszag reiterated support for giving MedPAC more teeth. Mr. Orszag said the administration wanted to “take the MedPAC recommendations and, rather than having them sit on a shelf somewhere, have them protected in a fast track procedure, voted up or down as a package, and considered within a limited period of time so they become much more relevant.”

ED Overcrowding Continues

The emergency department wait time to see a physician for emergent patients—those who should be seen in 1-14 minutes—averaged 37 minutes in 2006. Half of such patients waited longer than recommended, the Government Accountability Office said in a report. In addition, patients who should have been seen immediately waited an average of 28 minutes, and about three-fourths had to wait to be seen. Hospitals performed better with urgent cases: Those patients, who should be seen in 15-60 minutes, waited an average of 50 minutes, and about 20% waited longer than recommended, the report indicated. Lack of inpatient beds continues to be the main driver of emergency department overcrowding. ED boarding of patients who are waiting for an inpatient bed continues to be a problem, the GAO noted. The American College of Emergency Physicians warned that overcrowding and wait times will only get worse as the population ages. “People age 65 and older represent the fastest growing segment of the population and the group whose visits to the emergency department are increasing the fastest,” Dr. Nicholas Jouriles, president of ACEP, indicated in a statement.

Crossover Claims Investigated

Reports that crossover claims from Medicare to Medicaid are not being automatically filed in several states are being examined by the Physicians Regulatory Issues Team. The PRIT works with health care providers to address Medicare payment issues. According to Dr. William Rogers, director, the Healthcare Billing and Management Association and the Medical Group Management Association have been receiving complaints from members alleging that crossover claims from Medicare to Medicaid are not automatically being completed, as they should be. And “if you have to handle any paperwork to bill Medicaid for the copay, you've already burned up any revenue you might have generated” from the Medicaid claim, said Dr. Rogers. The states under investigation include New York, North Carolina, Louisiana, Nevada, South Carolina, Georgia, Kentucky, and Texas. Dr. Rogers said that physicians who believe their state Medicaid program is not accepting automatic crossover claims from Medicare should contact the Medical Group Management Association or Healthcare Billing and Management Asssociation, or e-mail Dr. Rogers at

wrogers@cms.hhs.gov

Vermont Bans Most Pharma Gifts

Vermont Gov. Jim Douglas (R) has signed into law a bill that prohibits manufacturers of drugs, medical devices, and biologics from providing free gifts, including meals and travel, to physicians and other health care providers. The legislation, which is the toughest of its kind in the nation, also requires disclosure of any allowed gifts or payments, regardless of their value. In 2002, a Vermont law required disclosure of gifts or payments of $25 or more. Under the stronger law, manufacturers can give physicians only gifts such as samples intended for patients, “reasonable quantities” of medical device evaluation or demonstration units, and copies of peer-reviewed articles. The companies still can provide scholarships or other support for medical students, residents, and fellows to attend educational events held by professional associations, as long as the association selects the scholarship recipient.

Obama: Give MedPAC More Clout

President Obama's administration wants to give the Medicare Payment Advisory Commission greater influence. In a June 2 letter to Sen. Ted Kennedy (D-Mass.) and Sen. Max Baucus (D-Mont.), President Obama said he supported giving each MedPAC recommendation the force of law unless it is opposed by a joint resolution of Congress. This appeared to embrace the approach in the MedPAC Reform Act of 2009, which Sen. Jay Rockefeller (D-W.Va.) introduced in May. Currently, MedPAC advises Congress, which then decides whether to act on the recommendations. At a Brookings Institution conference in mid-June, White House Office of Management and Budget Director Peter Orszag reiterated support for giving MedPAC more teeth. Mr. Orszag said the administration wanted to “take the MedPAC recommendations and, rather than having them sit on a shelf somewhere, have them protected in a fast track procedure, voted up or down as a package, and considered within a limited period of time so they become much more relevant.”

ED Overcrowding Continues

The emergency department wait time to see a physician for emergent patients—those who should be seen in 1-14 minutes—averaged 37 minutes in 2006. Half of such patients waited longer than recommended, the Government Accountability Office said in a report. In addition, patients who should have been seen immediately waited an average of 28 minutes, and about three-fourths had to wait to be seen. Hospitals performed better with urgent cases: Those patients, who should be seen in 15-60 minutes, waited an average of 50 minutes, and about 20% waited longer than recommended, the report indicated. Lack of inpatient beds continues to be the main driver of emergency department overcrowding. ED boarding of patients who are waiting for an inpatient bed continues to be a problem, the GAO noted. The American College of Emergency Physicians warned that overcrowding and wait times will only get worse as the population ages. “People age 65 and older represent the fastest growing segment of the population and the group whose visits to the emergency department are increasing the fastest,” Dr. Nicholas Jouriles, president of ACEP, indicated in a statement.

Crossover Claims Investigated

Reports that crossover claims from Medicare to Medicaid are not being automatically filed in several states are being examined by the Physicians Regulatory Issues Team. The PRIT works with health care providers to address Medicare payment issues. According to Dr. William Rogers, director, the Healthcare Billing and Management Association and the Medical Group Management Association have been receiving complaints from members alleging that crossover claims from Medicare to Medicaid are not automatically being completed, as they should be. And “if you have to handle any paperwork to bill Medicaid for the copay, you've already burned up any revenue you might have generated” from the Medicaid claim, said Dr. Rogers. The states under investigation include New York, North Carolina, Louisiana, Nevada, South Carolina, Georgia, Kentucky, and Texas. Dr. Rogers said that physicians who believe their state Medicaid program is not accepting automatic crossover claims from Medicare should contact the Medical Group Management Association or Healthcare Billing and Management Asssociation, or e-mail Dr. Rogers at

wrogers@cms.hhs.gov

Vermont Bans Most Pharma Gifts

Vermont Gov. Jim Douglas (R) has signed into law a bill that prohibits manufacturers of drugs, medical devices, and biologics from providing free gifts, including meals and travel, to physicians and other health care providers. The legislation, which is the toughest of its kind in the nation, also requires disclosure of any allowed gifts or payments, regardless of their value. In 2002, a Vermont law required disclosure of gifts or payments of $25 or more. Under the stronger law, manufacturers can give physicians only gifts such as samples intended for patients, “reasonable quantities” of medical device evaluation or demonstration units, and copies of peer-reviewed articles. The companies still can provide scholarships or other support for medical students, residents, and fellows to attend educational events held by professional associations, as long as the association selects the scholarship recipient.

Obama: Give MedPAC More Clout

President Obama's administration wants to give the Medicare Payment Advisory Commission greater influence. In a June 2 letter to Sen. Ted Kennedy (D-Mass.) and Sen. Max Baucus (D-Mont.), President Obama said he supported giving each MedPAC recommendation the force of law unless it is opposed by a joint resolution of Congress. This appeared to embrace the approach in the MedPAC Reform Act of 2009, which Sen. Jay Rockefeller (D-W.Va.) introduced in May. Currently, MedPAC advises Congress, which then decides whether to act on the recommendations. At a Brookings Institution conference in mid-June, White House Office of Management and Budget Director Peter Orszag reiterated support for giving MedPAC more teeth. Mr. Orszag said the administration wanted to “take the MedPAC recommendations and, rather than having them sit on a shelf somewhere, have them protected in a fast track procedure, voted up or down as a package, and considered within a limited period of time so they become much more relevant.”

ED Overcrowding Continues

The emergency department wait time to see a physician for emergent patients—those who should be seen in 1-14 minutes—averaged 37 minutes in 2006. Half of such patients waited longer than recommended, the Government Accountability Office said in a report. In addition, patients who should have been seen immediately waited an average of 28 minutes, and about three-fourths had to wait to be seen. Hospitals performed better with urgent cases: Those patients, who should be seen in 15-60 minutes, waited an average of 50 minutes, and about 20% waited longer than recommended, the report indicated. Lack of inpatient beds continues to be the main driver of emergency department overcrowding. ED boarding of patients who are waiting for an inpatient bed continues to be a problem, the GAO noted. The American College of Emergency Physicians warned that overcrowding and wait times will only get worse as the population ages. “People age 65 and older represent the fastest growing segment of the population and the group whose visits to the emergency department are increasing the fastest,” Dr. Nicholas Jouriles, president of ACEP, indicated in a statement.

Crossover Claims Investigated

Reports that crossover claims from Medicare to Medicaid are not being automatically filed in several states are being examined by the Physicians Regulatory Issues Team. The PRIT works with health care providers to address Medicare payment issues. According to Dr. William Rogers, director, the Healthcare Billing and Management Association and the Medical Group Management Association have been receiving complaints from members alleging that crossover claims from Medicare to Medicaid are not automatically being completed, as they should be. And “if you have to handle any paperwork to bill Medicaid for the copay, you've already burned up any revenue you might have generated” from the Medicaid claim, said Dr. Rogers. The states under investigation include New York, North Carolina, Louisiana, Nevada, South Carolina, Georgia, Kentucky, and Texas. Dr. Rogers said that physicians who believe their state Medicaid program is not accepting automatic crossover claims from Medicare should contact the Medical Group Management Association or Healthcare Billing and Management Asssociation, or e-mail Dr. Rogers at

wrogers@cms.hhs.gov

There is not enough evidence to support coverage of pharmacogenomic testing that predicts a patient's response to warfarin, the Centers for Medicare and Medicaid Services announced in May.

The testing can be covered if it is part of a prospective, randomized trial that meets certain criteria proposed by the agency, said the CMS, which opened a 30-day comment period on the proposal.

In particular, the study should determine whether the test can predict the frequency and severity of major and minor hemorrhage, thromboembolism related to the primary indication for anticoagulation, other thromboembolic events, and mortality, the agency noted. In addition, any such trial should determine whether the results are generalizable to the Medicare population.

There are a number of lab tests already approved by the Food and Drug Administration, and many labs offer so-called “home-brew” tests.

Although there is evidence to indicate that these tests accurately identify people with certain gene variants that might heighten their responsiveness to warfarin, there is not any direct evidence of any improvement in health as a result, the agency indicated in its proposed decision.

The CMS proposal is not much of a surprise. In February, a Medicare Evidence Development and Coverage Advisory Committee determined that there were not enough data to support national coverage of the testing. The panel suggested that the data be compiled from a Coverage with Evidence Development study, which the CMS suggested in its proposed decision.

In comments to the CMS, there was a split of opinion among various professional societies.

The American Association for Clinical Chemistry and the College of American Pathologists supported coverage.

The American Society of Hematology, American College of Chest Physicians, and American College of Medical Genetics said there was not sufficient evidence at the moment.

The agency said it is possible that trials will show genetic testing to be of benefit.

“The ability to more effectively treat or prevent blood thrombosis and avoid the risk of hemorrhage due to overanticoagulation by guiding warfarin dosing based on genetic testing results would be a worthwhile potential benefit for the numerous Medicare beneficiaries, perhaps exceeding one million annually, who are initiating anticoagulant therapy,” the agency noted in its decision.

There is not enough evidence to support coverage of pharmacogenomic testing that predicts a patient's response to warfarin, the Centers for Medicare and Medicaid Services announced in May.

The testing can be covered if it is part of a prospective, randomized trial that meets certain criteria proposed by the agency, said the CMS, which opened a 30-day comment period on the proposal.

In particular, the study should determine whether the test can predict the frequency and severity of major and minor hemorrhage, thromboembolism related to the primary indication for anticoagulation, other thromboembolic events, and mortality, the agency noted. In addition, any such trial should determine whether the results are generalizable to the Medicare population.

There are a number of lab tests already approved by the Food and Drug Administration, and many labs offer so-called “home-brew” tests.

Although there is evidence to indicate that these tests accurately identify people with certain gene variants that might heighten their responsiveness to warfarin, there is not any direct evidence of any improvement in health as a result, the agency indicated in its proposed decision.

The CMS proposal is not much of a surprise. In February, a Medicare Evidence Development and Coverage Advisory Committee determined that there were not enough data to support national coverage of the testing. The panel suggested that the data be compiled from a Coverage with Evidence Development study, which the CMS suggested in its proposed decision.

In comments to the CMS, there was a split of opinion among various professional societies.

The American Association for Clinical Chemistry and the College of American Pathologists supported coverage.

The American Society of Hematology, American College of Chest Physicians, and American College of Medical Genetics said there was not sufficient evidence at the moment.

The agency said it is possible that trials will show genetic testing to be of benefit.

“The ability to more effectively treat or prevent blood thrombosis and avoid the risk of hemorrhage due to overanticoagulation by guiding warfarin dosing based on genetic testing results would be a worthwhile potential benefit for the numerous Medicare beneficiaries, perhaps exceeding one million annually, who are initiating anticoagulant therapy,” the agency noted in its decision.

There is not enough evidence to support coverage of pharmacogenomic testing that predicts a patient's response to warfarin, the Centers for Medicare and Medicaid Services announced in May.

The testing can be covered if it is part of a prospective, randomized trial that meets certain criteria proposed by the agency, said the CMS, which opened a 30-day comment period on the proposal.

In particular, the study should determine whether the test can predict the frequency and severity of major and minor hemorrhage, thromboembolism related to the primary indication for anticoagulation, other thromboembolic events, and mortality, the agency noted. In addition, any such trial should determine whether the results are generalizable to the Medicare population.

There are a number of lab tests already approved by the Food and Drug Administration, and many labs offer so-called “home-brew” tests.

Although there is evidence to indicate that these tests accurately identify people with certain gene variants that might heighten their responsiveness to warfarin, there is not any direct evidence of any improvement in health as a result, the agency indicated in its proposed decision.

The CMS proposal is not much of a surprise. In February, a Medicare Evidence Development and Coverage Advisory Committee determined that there were not enough data to support national coverage of the testing. The panel suggested that the data be compiled from a Coverage with Evidence Development study, which the CMS suggested in its proposed decision.

In comments to the CMS, there was a split of opinion among various professional societies.

The American Association for Clinical Chemistry and the College of American Pathologists supported coverage.

The American Society of Hematology, American College of Chest Physicians, and American College of Medical Genetics said there was not sufficient evidence at the moment.

The agency said it is possible that trials will show genetic testing to be of benefit.

“The ability to more effectively treat or prevent blood thrombosis and avoid the risk of hemorrhage due to overanticoagulation by guiding warfarin dosing based on genetic testing results would be a worthwhile potential benefit for the numerous Medicare beneficiaries, perhaps exceeding one million annually, who are initiating anticoagulant therapy,” the agency noted in its decision.