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Feds charge 243 in huge Medicare fraud bust
A nationwide investigation by the federal Medicare Fraud Strike Force has led to health fraud charges against 243 people – including 46 medical providers – in the largest bust in strike force history.
The defendants are accused of various Medicare fraud schemes that involved $712 million in false billings to the Centers for Medicare & Medicaid Services, according to a joint announcement on June 18 by Health and Human Services Secretary Sylvia M. Burwell and Attorney General Loretta E. Lynch.
Among the allegations are that defendants submitted claims to Medicare and Medicaid for treatments that were medically unnecessary and often never provided. In many cases, patient recruiters, Medicare beneficiaries, and other coconspirators were allegedly paid cash kickbacks in return for supplying beneficiary information to providers so that physicians then could bill Medicare fraudulently, according to the announcement. The defendants include doctors, nurses, and other licensed professionals, along with lay individuals who participated in the alleged fraud. Several health professionals were also suspended from participating in federal government health care programs.
Accused defendants are from Los Angeles; Dallas, McAllen, and Houston, Tex.; Detroit; Brooklyn, N.Y.; Tampa and Miami; and New Orleans. Among the medical services involved in the alleged schemes are home health care, mental health services, pharmacy services, durable medical equipment, and physical and occupational therapy.
The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative between the Department of Justice and HHS to prevent and deter fraud and enforce antifraud laws. Since its inception in March 2007, Strike Force operations in nine locations have charged more than 2,300 defendants for allegedly falsely billing more than $7 billion to the Medicare program.
On Twitter @legal_med
A nationwide investigation by the federal Medicare Fraud Strike Force has led to health fraud charges against 243 people – including 46 medical providers – in the largest bust in strike force history.
The defendants are accused of various Medicare fraud schemes that involved $712 million in false billings to the Centers for Medicare & Medicaid Services, according to a joint announcement on June 18 by Health and Human Services Secretary Sylvia M. Burwell and Attorney General Loretta E. Lynch.
Among the allegations are that defendants submitted claims to Medicare and Medicaid for treatments that were medically unnecessary and often never provided. In many cases, patient recruiters, Medicare beneficiaries, and other coconspirators were allegedly paid cash kickbacks in return for supplying beneficiary information to providers so that physicians then could bill Medicare fraudulently, according to the announcement. The defendants include doctors, nurses, and other licensed professionals, along with lay individuals who participated in the alleged fraud. Several health professionals were also suspended from participating in federal government health care programs.
Accused defendants are from Los Angeles; Dallas, McAllen, and Houston, Tex.; Detroit; Brooklyn, N.Y.; Tampa and Miami; and New Orleans. Among the medical services involved in the alleged schemes are home health care, mental health services, pharmacy services, durable medical equipment, and physical and occupational therapy.
The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative between the Department of Justice and HHS to prevent and deter fraud and enforce antifraud laws. Since its inception in March 2007, Strike Force operations in nine locations have charged more than 2,300 defendants for allegedly falsely billing more than $7 billion to the Medicare program.
On Twitter @legal_med
A nationwide investigation by the federal Medicare Fraud Strike Force has led to health fraud charges against 243 people – including 46 medical providers – in the largest bust in strike force history.
The defendants are accused of various Medicare fraud schemes that involved $712 million in false billings to the Centers for Medicare & Medicaid Services, according to a joint announcement on June 18 by Health and Human Services Secretary Sylvia M. Burwell and Attorney General Loretta E. Lynch.
Among the allegations are that defendants submitted claims to Medicare and Medicaid for treatments that were medically unnecessary and often never provided. In many cases, patient recruiters, Medicare beneficiaries, and other coconspirators were allegedly paid cash kickbacks in return for supplying beneficiary information to providers so that physicians then could bill Medicare fraudulently, according to the announcement. The defendants include doctors, nurses, and other licensed professionals, along with lay individuals who participated in the alleged fraud. Several health professionals were also suspended from participating in federal government health care programs.
Accused defendants are from Los Angeles; Dallas, McAllen, and Houston, Tex.; Detroit; Brooklyn, N.Y.; Tampa and Miami; and New Orleans. Among the medical services involved in the alleged schemes are home health care, mental health services, pharmacy services, durable medical equipment, and physical and occupational therapy.
The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative between the Department of Justice and HHS to prevent and deter fraud and enforce antifraud laws. Since its inception in March 2007, Strike Force operations in nine locations have charged more than 2,300 defendants for allegedly falsely billing more than $7 billion to the Medicare program.
On Twitter @legal_med
VIDEO: How to avoid questionable physician compensation arrangements
CHICAGO – The U.S. Department of Health & Human Service’s Office of Inspector General (OIG) is warning doctors to be wary of improper physician arrangements that could violate the federal Anti-Kickback Statute.
The federal law prohibits doctors from receiving any form of payment in exchange for past or future patient referrals under the Medicare or Medicaid programs.
The OIG recently reached settlements with 12 individual physicians who entered into questionable medical directorship and office staff arrangements. The agency stated money paid to the doctors was improper because the payments took into account volume or value of referrals and did not reflect fair market value for services provided.
Physicians sometimes enter into questionable physicians arrangements, such as medical directorships, without fully understanding if they are proper, said attorney Adrienne Dresevic, who spoke at a recent conference held by the American Bar Association.
In a video interview during the conference, Ms. Dresevic discussed common physician compensation arrangements that come under government scrutiny and how well-intentioned doctors can fall prey to Anti-Kickback Statute allegations. Ms. Dresevic, who practices health law in Southfield, Mich., also spoke about how physicians can avoid risky physician compensation arrangements.
CHICAGO – The U.S. Department of Health & Human Service’s Office of Inspector General (OIG) is warning doctors to be wary of improper physician arrangements that could violate the federal Anti-Kickback Statute.
The federal law prohibits doctors from receiving any form of payment in exchange for past or future patient referrals under the Medicare or Medicaid programs.
The OIG recently reached settlements with 12 individual physicians who entered into questionable medical directorship and office staff arrangements. The agency stated money paid to the doctors was improper because the payments took into account volume or value of referrals and did not reflect fair market value for services provided.
Physicians sometimes enter into questionable physicians arrangements, such as medical directorships, without fully understanding if they are proper, said attorney Adrienne Dresevic, who spoke at a recent conference held by the American Bar Association.
In a video interview during the conference, Ms. Dresevic discussed common physician compensation arrangements that come under government scrutiny and how well-intentioned doctors can fall prey to Anti-Kickback Statute allegations. Ms. Dresevic, who practices health law in Southfield, Mich., also spoke about how physicians can avoid risky physician compensation arrangements.
CHICAGO – The U.S. Department of Health & Human Service’s Office of Inspector General (OIG) is warning doctors to be wary of improper physician arrangements that could violate the federal Anti-Kickback Statute.
The federal law prohibits doctors from receiving any form of payment in exchange for past or future patient referrals under the Medicare or Medicaid programs.
The OIG recently reached settlements with 12 individual physicians who entered into questionable medical directorship and office staff arrangements. The agency stated money paid to the doctors was improper because the payments took into account volume or value of referrals and did not reflect fair market value for services provided.
Physicians sometimes enter into questionable physicians arrangements, such as medical directorships, without fully understanding if they are proper, said attorney Adrienne Dresevic, who spoke at a recent conference held by the American Bar Association.
In a video interview during the conference, Ms. Dresevic discussed common physician compensation arrangements that come under government scrutiny and how well-intentioned doctors can fall prey to Anti-Kickback Statute allegations. Ms. Dresevic, who practices health law in Southfield, Mich., also spoke about how physicians can avoid risky physician compensation arrangements.
EXPERT ANALYSIS FROM THE PHYSICIANS LEGAL ISSUES CONFERENCE
Insurance, location, income drive breast cancer surgery choices
The rates of breast-conserving surgery have increased over the last 2 decades among women with early-stage breast cancers in the United States, but disparities persist, based on an analysis of data from the National Cancer Data Base.
The rate of breast-conserving surgery has risen from approximately 54% in 1998 to 60% in 2011, but this rate may have been affected by “technical advances and changes in societal norms [that] include genetic testing for BRCA1 and BRCA2 mutation, advances in reconstruction techniques, breast magnetic resonance imaging, and increased patient interest in contralateral prophylactic mastectomy,” Dr. Meeghan Lautner and her colleagues at University of Texas MD Anderson Cancer Care Center, Houston, wrote.
“Among the most encouraging findings from our analysis is the considerable improvement of disparities based on facility type and the options afforded to older populations … however, insurance, income, and travel distance to treatment facilities persist as key barriers to [breast-conserving therapy] use,” the researchers said.
Their analysis of a cohort of 727,927 women, published online June 17 in JAMA Surgery, showed that women with early breast cancer were less likely to receive breast-conserving surgery if they had a low educational level, public or no health insurance, and low income.
Women aged 52-61 years were 14% more likely to be treated with breast-conserving surgery, compared with younger women. White race, fewer comorbidities, and living closer to a treatment facility were all positively associated with being treated with breast-conserving surgery.
Those in southern regions of the United States were significantly less likely to receive breast-conserving surgery, compared with those in the Northeast. The researchers said their data suggest the lower rates are because of the greater travel distances to treatment facilities in the South.
Women with no insurance were 25% less likely than those with private insurance to have breast-conserving therapy (JAMA Surgery 2015 June 17 [doi:10.1001/jamasurg.2015.1102]).
The researchers declared no conflicts of interest.
Optimal breast-conserving surgery for most lumpectomy-eligible patients requires a commitment to whole-breast radiation, which also requires access to a radiation oncologist and specialized treatment facility. This is an often insurmountable barrier for patients who lack transportation, have job or family responsibilities, or who live a considerable distance from a radiation facility.
Document
|
Dr. Lisa A. Newman |
Socioeconomically disadvantaged patients are typically the ones who face these obstacles, and these burdens of financial deprivation are disproportionately faced by minority racial/ethnic groups and rural communities.
Tragically, disadvantage will continue to breed more disadvantage.
Dr. Lisa A. Newman is director of the Breast Care Center at the University of Michigan Comprehensive Cancer Care Center, Ann Arbor, Mich. These comments are taken from an accompanying editorial (JAMA Surgery 2015 June 17 [doi:10.1001/jamasurg.2015.1114]). Dr. Newman declared no conflicts of interest.
Optimal breast-conserving surgery for most lumpectomy-eligible patients requires a commitment to whole-breast radiation, which also requires access to a radiation oncologist and specialized treatment facility. This is an often insurmountable barrier for patients who lack transportation, have job or family responsibilities, or who live a considerable distance from a radiation facility.
Document
|
Dr. Lisa A. Newman |
Socioeconomically disadvantaged patients are typically the ones who face these obstacles, and these burdens of financial deprivation are disproportionately faced by minority racial/ethnic groups and rural communities.
Tragically, disadvantage will continue to breed more disadvantage.
Dr. Lisa A. Newman is director of the Breast Care Center at the University of Michigan Comprehensive Cancer Care Center, Ann Arbor, Mich. These comments are taken from an accompanying editorial (JAMA Surgery 2015 June 17 [doi:10.1001/jamasurg.2015.1114]). Dr. Newman declared no conflicts of interest.
Optimal breast-conserving surgery for most lumpectomy-eligible patients requires a commitment to whole-breast radiation, which also requires access to a radiation oncologist and specialized treatment facility. This is an often insurmountable barrier for patients who lack transportation, have job or family responsibilities, or who live a considerable distance from a radiation facility.
Document
|
Dr. Lisa A. Newman |
Socioeconomically disadvantaged patients are typically the ones who face these obstacles, and these burdens of financial deprivation are disproportionately faced by minority racial/ethnic groups and rural communities.
Tragically, disadvantage will continue to breed more disadvantage.
Dr. Lisa A. Newman is director of the Breast Care Center at the University of Michigan Comprehensive Cancer Care Center, Ann Arbor, Mich. These comments are taken from an accompanying editorial (JAMA Surgery 2015 June 17 [doi:10.1001/jamasurg.2015.1114]). Dr. Newman declared no conflicts of interest.
The rates of breast-conserving surgery have increased over the last 2 decades among women with early-stage breast cancers in the United States, but disparities persist, based on an analysis of data from the National Cancer Data Base.
The rate of breast-conserving surgery has risen from approximately 54% in 1998 to 60% in 2011, but this rate may have been affected by “technical advances and changes in societal norms [that] include genetic testing for BRCA1 and BRCA2 mutation, advances in reconstruction techniques, breast magnetic resonance imaging, and increased patient interest in contralateral prophylactic mastectomy,” Dr. Meeghan Lautner and her colleagues at University of Texas MD Anderson Cancer Care Center, Houston, wrote.
“Among the most encouraging findings from our analysis is the considerable improvement of disparities based on facility type and the options afforded to older populations … however, insurance, income, and travel distance to treatment facilities persist as key barriers to [breast-conserving therapy] use,” the researchers said.
Their analysis of a cohort of 727,927 women, published online June 17 in JAMA Surgery, showed that women with early breast cancer were less likely to receive breast-conserving surgery if they had a low educational level, public or no health insurance, and low income.
Women aged 52-61 years were 14% more likely to be treated with breast-conserving surgery, compared with younger women. White race, fewer comorbidities, and living closer to a treatment facility were all positively associated with being treated with breast-conserving surgery.
Those in southern regions of the United States were significantly less likely to receive breast-conserving surgery, compared with those in the Northeast. The researchers said their data suggest the lower rates are because of the greater travel distances to treatment facilities in the South.
Women with no insurance were 25% less likely than those with private insurance to have breast-conserving therapy (JAMA Surgery 2015 June 17 [doi:10.1001/jamasurg.2015.1102]).
The researchers declared no conflicts of interest.
The rates of breast-conserving surgery have increased over the last 2 decades among women with early-stage breast cancers in the United States, but disparities persist, based on an analysis of data from the National Cancer Data Base.
The rate of breast-conserving surgery has risen from approximately 54% in 1998 to 60% in 2011, but this rate may have been affected by “technical advances and changes in societal norms [that] include genetic testing for BRCA1 and BRCA2 mutation, advances in reconstruction techniques, breast magnetic resonance imaging, and increased patient interest in contralateral prophylactic mastectomy,” Dr. Meeghan Lautner and her colleagues at University of Texas MD Anderson Cancer Care Center, Houston, wrote.
“Among the most encouraging findings from our analysis is the considerable improvement of disparities based on facility type and the options afforded to older populations … however, insurance, income, and travel distance to treatment facilities persist as key barriers to [breast-conserving therapy] use,” the researchers said.
Their analysis of a cohort of 727,927 women, published online June 17 in JAMA Surgery, showed that women with early breast cancer were less likely to receive breast-conserving surgery if they had a low educational level, public or no health insurance, and low income.
Women aged 52-61 years were 14% more likely to be treated with breast-conserving surgery, compared with younger women. White race, fewer comorbidities, and living closer to a treatment facility were all positively associated with being treated with breast-conserving surgery.
Those in southern regions of the United States were significantly less likely to receive breast-conserving surgery, compared with those in the Northeast. The researchers said their data suggest the lower rates are because of the greater travel distances to treatment facilities in the South.
Women with no insurance were 25% less likely than those with private insurance to have breast-conserving therapy (JAMA Surgery 2015 June 17 [doi:10.1001/jamasurg.2015.1102]).
The researchers declared no conflicts of interest.
FROM JAMA SURGERY
Key clinical point: Insurance status, income, and travel distance to treatment facilities are associated with the likelihood of having breast-conserving surgery.
Major finding: Women with no health insurance were 25% less likely than those with private insurance to receive breast-conserving surgery.
Data source: Analysis of data from 727,927 women in the National Cancer Data Base.
Disclosures: The researchers declared no conflicts of interest.
VIDEO: The most pressing health law risks for physicians
CHICAGO – From Stark law to HIPAA violations to whistle-blower claims, physicians face a litany of legal land mines in today’s practice landscape.
Not only that, but rules and regulations are constantly changing, and the government continues to increase its scope in some areas, said Michael E. Clark, chair of the American Bar Association Health Law Section.
Physicians should be mindful of the new – and old – laws that impact them and take steps to prevent legal scrutiny, Mr. Clark advised during a conference held by the American Bar Association.
In a video interview at the conference, Mr. Clark discussed the most pressing health law issues for doctors and ways in which physicians can avoid such risks. Mr. Clark, who practices health law in Houston, also shared his perspectives on what the future holds for upcoming legal dangers.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
CHICAGO – From Stark law to HIPAA violations to whistle-blower claims, physicians face a litany of legal land mines in today’s practice landscape.
Not only that, but rules and regulations are constantly changing, and the government continues to increase its scope in some areas, said Michael E. Clark, chair of the American Bar Association Health Law Section.
Physicians should be mindful of the new – and old – laws that impact them and take steps to prevent legal scrutiny, Mr. Clark advised during a conference held by the American Bar Association.
In a video interview at the conference, Mr. Clark discussed the most pressing health law issues for doctors and ways in which physicians can avoid such risks. Mr. Clark, who practices health law in Houston, also shared his perspectives on what the future holds for upcoming legal dangers.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
CHICAGO – From Stark law to HIPAA violations to whistle-blower claims, physicians face a litany of legal land mines in today’s practice landscape.
Not only that, but rules and regulations are constantly changing, and the government continues to increase its scope in some areas, said Michael E. Clark, chair of the American Bar Association Health Law Section.
Physicians should be mindful of the new – and old – laws that impact them and take steps to prevent legal scrutiny, Mr. Clark advised during a conference held by the American Bar Association.
In a video interview at the conference, Mr. Clark discussed the most pressing health law issues for doctors and ways in which physicians can avoid such risks. Mr. Clark, who practices health law in Houston, also shared his perspectives on what the future holds for upcoming legal dangers.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
EXPERT ANALYSIS FROM THE PHYSICIANS LEGAL ISSUES CONFERENCE
FDA database provides information on drug risks
The Food and Drug Administration has launched an online resource with a centralized, easily-navigable layout for approved Risk Evaluation and Mitigation Strategies (REMS), required by the FDA to help ensure that health care providers have information on risks and treatment strategies associated with certain drugs.
The database will have information about currently approved individual and shared system REMS – as well as historical and released REMS – providing health care providers and the general public with necessary information for managing a known or potential serious risk associated with a drug.
A provision of the Food and Drug Administration Amendments Act, enacted in 2007, gave the FDA the authority to require a REMS from manufacturers if the drug has potential risks associated with its use.
To access the database, go to this FDA website.
The Food and Drug Administration has launched an online resource with a centralized, easily-navigable layout for approved Risk Evaluation and Mitigation Strategies (REMS), required by the FDA to help ensure that health care providers have information on risks and treatment strategies associated with certain drugs.
The database will have information about currently approved individual and shared system REMS – as well as historical and released REMS – providing health care providers and the general public with necessary information for managing a known or potential serious risk associated with a drug.
A provision of the Food and Drug Administration Amendments Act, enacted in 2007, gave the FDA the authority to require a REMS from manufacturers if the drug has potential risks associated with its use.
To access the database, go to this FDA website.
The Food and Drug Administration has launched an online resource with a centralized, easily-navigable layout for approved Risk Evaluation and Mitigation Strategies (REMS), required by the FDA to help ensure that health care providers have information on risks and treatment strategies associated with certain drugs.
The database will have information about currently approved individual and shared system REMS – as well as historical and released REMS – providing health care providers and the general public with necessary information for managing a known or potential serious risk associated with a drug.
A provision of the Food and Drug Administration Amendments Act, enacted in 2007, gave the FDA the authority to require a REMS from manufacturers if the drug has potential risks associated with its use.
To access the database, go to this FDA website.
Arthroscopic knee surgery offers no lasting pain benefit
Arthroscopic knee surgery in middle-aged or older patients with knee pain is associated with greater harm than good, according to a meta-analysis.
The analysis of nine randomized, controlled trials in 1,270 patients of arthroscopic surgery involving partial meniscectomy, debridement, or both showed a small but statistically significant benefit from the procedure – comparable to the pain-relieving effects of paracetamol – but which falls below significance after 12 months.
However, there were no significant improvements in knee function, and there were significant increases in the risk of deep vein thrombosis (4.13 events per 1,000 procedures) as well as infection, pulmonary embolism, and death, according to the paper published online June 16 in BMJ.
“Thus, middle-aged patients with knee pain and meniscal tears should be considered as having early-stage osteoarthritis and be treated according to clinical guidelines for knee osteoarthritis, starting with information, exercise, and often weight loss,” wrote Dr. Jonas B. Thorlund of the University of Southern Denmark, Odense, and coauthors (BMJ 2015, June 16 [doi:10.1136/bmj.h2747]).
The study was supported by the Swedish Research Council. One author declared personal fees from several pharmaceutical and medical companies and relevant journal editorship, while another declared fees from lectureships and books.
While randomized trials, uncontrolled observational studies, and surgeons’ own observations suggest that patients improve after arthroscopy, robust and bias-free trials that use placebo controls show that active treatment works no better than control treatment.
We may be close to a tipping point where the weight of evidence against arthroscopic knee surgery for pain is enough to overcome concerns about the quality of the studies, confirmation bias, and vested interests. When that point is reached, we should anticipate a swift reversal of established practice.
Dr. Andy Carr is from the Oxford University Institute of Musculoskeletal Sciences at the NIHR Oxford Musculoskeletal Biomedical Research Unit, Oxford, England. These comments are taken from an accompanying editorial (BMJ 2015, June 16 [doi:10.1136/bmj.h2983]). He declared research grants from NIHR and Arthritis Research UK.
While randomized trials, uncontrolled observational studies, and surgeons’ own observations suggest that patients improve after arthroscopy, robust and bias-free trials that use placebo controls show that active treatment works no better than control treatment.
We may be close to a tipping point where the weight of evidence against arthroscopic knee surgery for pain is enough to overcome concerns about the quality of the studies, confirmation bias, and vested interests. When that point is reached, we should anticipate a swift reversal of established practice.
Dr. Andy Carr is from the Oxford University Institute of Musculoskeletal Sciences at the NIHR Oxford Musculoskeletal Biomedical Research Unit, Oxford, England. These comments are taken from an accompanying editorial (BMJ 2015, June 16 [doi:10.1136/bmj.h2983]). He declared research grants from NIHR and Arthritis Research UK.
While randomized trials, uncontrolled observational studies, and surgeons’ own observations suggest that patients improve after arthroscopy, robust and bias-free trials that use placebo controls show that active treatment works no better than control treatment.
We may be close to a tipping point where the weight of evidence against arthroscopic knee surgery for pain is enough to overcome concerns about the quality of the studies, confirmation bias, and vested interests. When that point is reached, we should anticipate a swift reversal of established practice.
Dr. Andy Carr is from the Oxford University Institute of Musculoskeletal Sciences at the NIHR Oxford Musculoskeletal Biomedical Research Unit, Oxford, England. These comments are taken from an accompanying editorial (BMJ 2015, June 16 [doi:10.1136/bmj.h2983]). He declared research grants from NIHR and Arthritis Research UK.
Arthroscopic knee surgery in middle-aged or older patients with knee pain is associated with greater harm than good, according to a meta-analysis.
The analysis of nine randomized, controlled trials in 1,270 patients of arthroscopic surgery involving partial meniscectomy, debridement, or both showed a small but statistically significant benefit from the procedure – comparable to the pain-relieving effects of paracetamol – but which falls below significance after 12 months.
However, there were no significant improvements in knee function, and there were significant increases in the risk of deep vein thrombosis (4.13 events per 1,000 procedures) as well as infection, pulmonary embolism, and death, according to the paper published online June 16 in BMJ.
“Thus, middle-aged patients with knee pain and meniscal tears should be considered as having early-stage osteoarthritis and be treated according to clinical guidelines for knee osteoarthritis, starting with information, exercise, and often weight loss,” wrote Dr. Jonas B. Thorlund of the University of Southern Denmark, Odense, and coauthors (BMJ 2015, June 16 [doi:10.1136/bmj.h2747]).
The study was supported by the Swedish Research Council. One author declared personal fees from several pharmaceutical and medical companies and relevant journal editorship, while another declared fees from lectureships and books.
Arthroscopic knee surgery in middle-aged or older patients with knee pain is associated with greater harm than good, according to a meta-analysis.
The analysis of nine randomized, controlled trials in 1,270 patients of arthroscopic surgery involving partial meniscectomy, debridement, or both showed a small but statistically significant benefit from the procedure – comparable to the pain-relieving effects of paracetamol – but which falls below significance after 12 months.
However, there were no significant improvements in knee function, and there were significant increases in the risk of deep vein thrombosis (4.13 events per 1,000 procedures) as well as infection, pulmonary embolism, and death, according to the paper published online June 16 in BMJ.
“Thus, middle-aged patients with knee pain and meniscal tears should be considered as having early-stage osteoarthritis and be treated according to clinical guidelines for knee osteoarthritis, starting with information, exercise, and often weight loss,” wrote Dr. Jonas B. Thorlund of the University of Southern Denmark, Odense, and coauthors (BMJ 2015, June 16 [doi:10.1136/bmj.h2747]).
The study was supported by the Swedish Research Council. One author declared personal fees from several pharmaceutical and medical companies and relevant journal editorship, while another declared fees from lectureships and books.
FROM BMJ
Key clinical point: The potential harms of arthroscopic knee surgery in middle-aged or older patients with knee pain outweigh the benefits.
Major finding: Arthroscopic knee surgery is associated with a small but significant improvement in symptoms that disappears after 12 months.
Data source: Meta-analysis of nine randomized, controlled trials in 1,270 patients.
Disclosures: The study was supported by the Swedish Research Council. One author declared personal fees from several pharmaceutical and medical companies and relevant journal editorship, while another declared fees from lectureships and books.
ICOO: Opioids blurring criminal activity and malpractice
BOSTON – There may be no area of clinical medicine in which strict adherence to medical standards is more important than in the prescription of opioids.
Rather than malpractice, the consequence of deviations from accepted standards is often criminal prosecution, Dr. Carol A. Warfield said at the International Conference on Opioids.
Some physicians, believing they have acted in the best interests of the patient, have been sent to jail, said Dr. Warfield, professor of anesthesiology at Harvard Medical School, Boston. “Juries don’t seem to understand the difference between malpractice and criminal activity.”
The distinctions are large, she said. In the case of opioids, criminal practice occurs when prescriptions are dispensed without a legitimate medical purpose. Inappropriate prescription of opioids, however, may be malpractice but it is not criminal, particularly if the underlying intent was to relieve patient suffering.
But that distinction is not necessarily recognized in the courtroom. Dr. Warfield recounted numerous criminal cases involving opioids in which the intent of the physician was to relieve pain. Prosecutors in those cases pointed to incomplete records or the lack of a physical examination to convince juries that a crime had been committed.
Often, a criminal prosecution begins with an opioid overdose. Charges may ensue with a review of the medical records that leads prosecutors to believe that standard practices were not followed. But bad outcomes are not essential to trigger an investigation.
Other cases start with an insurance company review, Dr. Warfield cautioned. “High utilization and increased costs push [insurers] to investigate doctors with peer review, and many criminal cases start with an insurance company that thought the clinician was prescribing too much of an expensive drug.”
What can physicians do to protect themselves from these accusations? Ensure that opioids are prescribed within the acceptable standards of practice, which includes first creating a clear physician-patient relationship, Dr. Warfield advised. Opioids should not be prescribed without a physical and history that provides a basis for the diagnosis. And provide clear documentation for each step of care, she emphasized.
Dr. Warfield acknowledged that she “is not a big advocate of using opioids for chronic pain” in her own practice. However, “I am a big advocate of a doctor’s right to do so.”
The risks of malpractice suits and criminal prosecution have already produced some defensive behaviors, inducing a growing number of physicians to abandon opioids altogether, she said. Others will give opioid injections, but will not prescribe opioids in any other form. Still others insist on lengthy consent forms that outline opioid risks.
Dr. Steven J. Bennett, director of pain services at Greenwich (Conn.) Hospital said that he is concerned about the current climate.
“I am very careful in my practice. I document everything,” Dr. Bennett said. However, “opioids are useful in my practice. They can help the right patient, so I am going to keep using them. I just plan to be very careful.”
BOSTON – There may be no area of clinical medicine in which strict adherence to medical standards is more important than in the prescription of opioids.
Rather than malpractice, the consequence of deviations from accepted standards is often criminal prosecution, Dr. Carol A. Warfield said at the International Conference on Opioids.
Some physicians, believing they have acted in the best interests of the patient, have been sent to jail, said Dr. Warfield, professor of anesthesiology at Harvard Medical School, Boston. “Juries don’t seem to understand the difference between malpractice and criminal activity.”
The distinctions are large, she said. In the case of opioids, criminal practice occurs when prescriptions are dispensed without a legitimate medical purpose. Inappropriate prescription of opioids, however, may be malpractice but it is not criminal, particularly if the underlying intent was to relieve patient suffering.
But that distinction is not necessarily recognized in the courtroom. Dr. Warfield recounted numerous criminal cases involving opioids in which the intent of the physician was to relieve pain. Prosecutors in those cases pointed to incomplete records or the lack of a physical examination to convince juries that a crime had been committed.
Often, a criminal prosecution begins with an opioid overdose. Charges may ensue with a review of the medical records that leads prosecutors to believe that standard practices were not followed. But bad outcomes are not essential to trigger an investigation.
Other cases start with an insurance company review, Dr. Warfield cautioned. “High utilization and increased costs push [insurers] to investigate doctors with peer review, and many criminal cases start with an insurance company that thought the clinician was prescribing too much of an expensive drug.”
What can physicians do to protect themselves from these accusations? Ensure that opioids are prescribed within the acceptable standards of practice, which includes first creating a clear physician-patient relationship, Dr. Warfield advised. Opioids should not be prescribed without a physical and history that provides a basis for the diagnosis. And provide clear documentation for each step of care, she emphasized.
Dr. Warfield acknowledged that she “is not a big advocate of using opioids for chronic pain” in her own practice. However, “I am a big advocate of a doctor’s right to do so.”
The risks of malpractice suits and criminal prosecution have already produced some defensive behaviors, inducing a growing number of physicians to abandon opioids altogether, she said. Others will give opioid injections, but will not prescribe opioids in any other form. Still others insist on lengthy consent forms that outline opioid risks.
Dr. Steven J. Bennett, director of pain services at Greenwich (Conn.) Hospital said that he is concerned about the current climate.
“I am very careful in my practice. I document everything,” Dr. Bennett said. However, “opioids are useful in my practice. They can help the right patient, so I am going to keep using them. I just plan to be very careful.”
BOSTON – There may be no area of clinical medicine in which strict adherence to medical standards is more important than in the prescription of opioids.
Rather than malpractice, the consequence of deviations from accepted standards is often criminal prosecution, Dr. Carol A. Warfield said at the International Conference on Opioids.
Some physicians, believing they have acted in the best interests of the patient, have been sent to jail, said Dr. Warfield, professor of anesthesiology at Harvard Medical School, Boston. “Juries don’t seem to understand the difference between malpractice and criminal activity.”
The distinctions are large, she said. In the case of opioids, criminal practice occurs when prescriptions are dispensed without a legitimate medical purpose. Inappropriate prescription of opioids, however, may be malpractice but it is not criminal, particularly if the underlying intent was to relieve patient suffering.
But that distinction is not necessarily recognized in the courtroom. Dr. Warfield recounted numerous criminal cases involving opioids in which the intent of the physician was to relieve pain. Prosecutors in those cases pointed to incomplete records or the lack of a physical examination to convince juries that a crime had been committed.
Often, a criminal prosecution begins with an opioid overdose. Charges may ensue with a review of the medical records that leads prosecutors to believe that standard practices were not followed. But bad outcomes are not essential to trigger an investigation.
Other cases start with an insurance company review, Dr. Warfield cautioned. “High utilization and increased costs push [insurers] to investigate doctors with peer review, and many criminal cases start with an insurance company that thought the clinician was prescribing too much of an expensive drug.”
What can physicians do to protect themselves from these accusations? Ensure that opioids are prescribed within the acceptable standards of practice, which includes first creating a clear physician-patient relationship, Dr. Warfield advised. Opioids should not be prescribed without a physical and history that provides a basis for the diagnosis. And provide clear documentation for each step of care, she emphasized.
Dr. Warfield acknowledged that she “is not a big advocate of using opioids for chronic pain” in her own practice. However, “I am a big advocate of a doctor’s right to do so.”
The risks of malpractice suits and criminal prosecution have already produced some defensive behaviors, inducing a growing number of physicians to abandon opioids altogether, she said. Others will give opioid injections, but will not prescribe opioids in any other form. Still others insist on lengthy consent forms that outline opioid risks.
Dr. Steven J. Bennett, director of pain services at Greenwich (Conn.) Hospital said that he is concerned about the current climate.
“I am very careful in my practice. I document everything,” Dr. Bennett said. However, “opioids are useful in my practice. They can help the right patient, so I am going to keep using them. I just plan to be very careful.”
EXPERT ANALYSIS FROM ICOO2015
Antibiotic therapy an option for acute appendicitis
Antibiotic therapy failed to be shown as noninferior to surgery in a study of adults with uncomplicated acute appendicitis, but it did resolve the problem and avert surgery with no adverse effects in 73% of patients, according to a report published online June 15 in JAMA.
Moreover, patients who did require surgery after initial antibiotic treatment did not develop significant complications and arguably were no worse off than were those who were operated on immediately. In fact, the overall complication rate was 2.8% among patients assigned to antibiotics and 7% among those assigned to antibiotics who eventually underwent appendectomy, compared with a 20.5% complication rate among patients assigned to surgery, said Dr. Paulina Salminen of the division of digestive surgery and urology, Turku (Finland) University Hospital, and her associates.
Their findings indicate that acute uncomplicated appendicitis need no longer be considered a surgical emergency, and that delaying the operation while trying a course of antibiotics “has few consequences,” they noted.
The few previous studies that have compared the two approaches had many limitations, including small study populations.
For their study, the Appendicitis Acuta (AAPAC) trial, Dr. Salminen and her associates included 530 patients aged 18-60 years who presented to six Finnish hospitals with suspected appendicitis during a 2-year period and were followed for 1 year. Appendicitis was confirmed via computed tomography (CT). Patients who had an appendicolith, perforation, abscess, or tumor were excluded from the study.
A total of 273 patients were randomly assigned to undergo immediate open appendectomy (with preoperative prophylactic antibiotics) and the remaining 257 were assigned to a 3-day course of IV ertapenem followed by 7 days of oral levofloxacin and metronidazole. If progressive infection, perforation, or peritonitis was suspected, appendectomy was performed.
Previous studies of uncomplicated appendicitis treated with antibiotics found a 70%-80% success rate, so the researchers prespecified criteria for noninferiority to surgery at 75% for the study group.
The primary endpoint for the antibiotic group – resolution of acute appendicitis with no recurrences for a full year – occurred in 73%. The remaining 27% of patients in this group underwent appendectomy during follow-up, at a median of 102 days after initial presentation. None of these patients developed abscesses or serious infections, “suggesting that the decision to delay appendectomy ... can be made with a low likelihood of major complications,” the investigators said (JAMA 2015 June 15 [doi:10.1001/jama.2015.6154]). Nevertheless, antibiotic treatment did not qualify as noninferior to immediate surgery according to the study’s preset definitions, they said.
This study was supported by a government research grant from the EVO Foundation to Turku University Hospital. Dr. Salminen reported receiving lecture fees from Merck and Roche; there were no other financial disclosures.
This trial technically had a negative result because antibiotic therapy failed to meet the boundary for noninferiority, but in practical terms the findings fully justify a new approach to uncomplicated acute appendicitis.
The study findings dispel the notion that appendectomy is always an emergency and suggest instead that, given our current precise diagnostic capabilities and effective wide-spectrum antibiotics, a trial of antibiotic therapy is reasonable. However, it’s important to note that children, adolescents, pregnant women, and patients with complications were excluded from this trial so the findings do not apply to those patient groups.
Edward Livingston, M.D., is deputy editor of JAMA. Corrine Vons, M.D., Ph.D., is in the digestive surgery department at Jean-Verdier Hospital, Bondy, France. They reported having no financial conflicts of interest. Dr. Livingston and Dr. Vons made these remarks in an editorial accompanying Dr. Salminen’s report (JAMA 2015;313:2327-8).
This trial technically had a negative result because antibiotic therapy failed to meet the boundary for noninferiority, but in practical terms the findings fully justify a new approach to uncomplicated acute appendicitis.
The study findings dispel the notion that appendectomy is always an emergency and suggest instead that, given our current precise diagnostic capabilities and effective wide-spectrum antibiotics, a trial of antibiotic therapy is reasonable. However, it’s important to note that children, adolescents, pregnant women, and patients with complications were excluded from this trial so the findings do not apply to those patient groups.
Edward Livingston, M.D., is deputy editor of JAMA. Corrine Vons, M.D., Ph.D., is in the digestive surgery department at Jean-Verdier Hospital, Bondy, France. They reported having no financial conflicts of interest. Dr. Livingston and Dr. Vons made these remarks in an editorial accompanying Dr. Salminen’s report (JAMA 2015;313:2327-8).
This trial technically had a negative result because antibiotic therapy failed to meet the boundary for noninferiority, but in practical terms the findings fully justify a new approach to uncomplicated acute appendicitis.
The study findings dispel the notion that appendectomy is always an emergency and suggest instead that, given our current precise diagnostic capabilities and effective wide-spectrum antibiotics, a trial of antibiotic therapy is reasonable. However, it’s important to note that children, adolescents, pregnant women, and patients with complications were excluded from this trial so the findings do not apply to those patient groups.
Edward Livingston, M.D., is deputy editor of JAMA. Corrine Vons, M.D., Ph.D., is in the digestive surgery department at Jean-Verdier Hospital, Bondy, France. They reported having no financial conflicts of interest. Dr. Livingston and Dr. Vons made these remarks in an editorial accompanying Dr. Salminen’s report (JAMA 2015;313:2327-8).
Antibiotic therapy failed to be shown as noninferior to surgery in a study of adults with uncomplicated acute appendicitis, but it did resolve the problem and avert surgery with no adverse effects in 73% of patients, according to a report published online June 15 in JAMA.
Moreover, patients who did require surgery after initial antibiotic treatment did not develop significant complications and arguably were no worse off than were those who were operated on immediately. In fact, the overall complication rate was 2.8% among patients assigned to antibiotics and 7% among those assigned to antibiotics who eventually underwent appendectomy, compared with a 20.5% complication rate among patients assigned to surgery, said Dr. Paulina Salminen of the division of digestive surgery and urology, Turku (Finland) University Hospital, and her associates.
Their findings indicate that acute uncomplicated appendicitis need no longer be considered a surgical emergency, and that delaying the operation while trying a course of antibiotics “has few consequences,” they noted.
The few previous studies that have compared the two approaches had many limitations, including small study populations.
For their study, the Appendicitis Acuta (AAPAC) trial, Dr. Salminen and her associates included 530 patients aged 18-60 years who presented to six Finnish hospitals with suspected appendicitis during a 2-year period and were followed for 1 year. Appendicitis was confirmed via computed tomography (CT). Patients who had an appendicolith, perforation, abscess, or tumor were excluded from the study.
A total of 273 patients were randomly assigned to undergo immediate open appendectomy (with preoperative prophylactic antibiotics) and the remaining 257 were assigned to a 3-day course of IV ertapenem followed by 7 days of oral levofloxacin and metronidazole. If progressive infection, perforation, or peritonitis was suspected, appendectomy was performed.
Previous studies of uncomplicated appendicitis treated with antibiotics found a 70%-80% success rate, so the researchers prespecified criteria for noninferiority to surgery at 75% for the study group.
The primary endpoint for the antibiotic group – resolution of acute appendicitis with no recurrences for a full year – occurred in 73%. The remaining 27% of patients in this group underwent appendectomy during follow-up, at a median of 102 days after initial presentation. None of these patients developed abscesses or serious infections, “suggesting that the decision to delay appendectomy ... can be made with a low likelihood of major complications,” the investigators said (JAMA 2015 June 15 [doi:10.1001/jama.2015.6154]). Nevertheless, antibiotic treatment did not qualify as noninferior to immediate surgery according to the study’s preset definitions, they said.
This study was supported by a government research grant from the EVO Foundation to Turku University Hospital. Dr. Salminen reported receiving lecture fees from Merck and Roche; there were no other financial disclosures.
Antibiotic therapy failed to be shown as noninferior to surgery in a study of adults with uncomplicated acute appendicitis, but it did resolve the problem and avert surgery with no adverse effects in 73% of patients, according to a report published online June 15 in JAMA.
Moreover, patients who did require surgery after initial antibiotic treatment did not develop significant complications and arguably were no worse off than were those who were operated on immediately. In fact, the overall complication rate was 2.8% among patients assigned to antibiotics and 7% among those assigned to antibiotics who eventually underwent appendectomy, compared with a 20.5% complication rate among patients assigned to surgery, said Dr. Paulina Salminen of the division of digestive surgery and urology, Turku (Finland) University Hospital, and her associates.
Their findings indicate that acute uncomplicated appendicitis need no longer be considered a surgical emergency, and that delaying the operation while trying a course of antibiotics “has few consequences,” they noted.
The few previous studies that have compared the two approaches had many limitations, including small study populations.
For their study, the Appendicitis Acuta (AAPAC) trial, Dr. Salminen and her associates included 530 patients aged 18-60 years who presented to six Finnish hospitals with suspected appendicitis during a 2-year period and were followed for 1 year. Appendicitis was confirmed via computed tomography (CT). Patients who had an appendicolith, perforation, abscess, or tumor were excluded from the study.
A total of 273 patients were randomly assigned to undergo immediate open appendectomy (with preoperative prophylactic antibiotics) and the remaining 257 were assigned to a 3-day course of IV ertapenem followed by 7 days of oral levofloxacin and metronidazole. If progressive infection, perforation, or peritonitis was suspected, appendectomy was performed.
Previous studies of uncomplicated appendicitis treated with antibiotics found a 70%-80% success rate, so the researchers prespecified criteria for noninferiority to surgery at 75% for the study group.
The primary endpoint for the antibiotic group – resolution of acute appendicitis with no recurrences for a full year – occurred in 73%. The remaining 27% of patients in this group underwent appendectomy during follow-up, at a median of 102 days after initial presentation. None of these patients developed abscesses or serious infections, “suggesting that the decision to delay appendectomy ... can be made with a low likelihood of major complications,” the investigators said (JAMA 2015 June 15 [doi:10.1001/jama.2015.6154]). Nevertheless, antibiotic treatment did not qualify as noninferior to immediate surgery according to the study’s preset definitions, they said.
This study was supported by a government research grant from the EVO Foundation to Turku University Hospital. Dr. Salminen reported receiving lecture fees from Merck and Roche; there were no other financial disclosures.
FROM JAMA
Key clinical point: Antibiotic therapy was not noninferior to surgery for uncomplicated acute appendicitis, but it averted surgery in a clear majority without any adverse effects.
Major finding: The primary endpoint for the antibiotic group – resolution of acute appendicitis with no recurrences for a full year – occurred in 73% of patients.
Data source: An open-label randomized noninferiority trial involving 530 adults treated at six Finnish hospitals during a 2-year period.
Disclosures: This study was supported by a government research grant from the EVO Foundation to Turku University Hospital. Dr. Salminen reported receiving lecture fees from Merck and Roche; there were no other financial disclosures.
For doctors who take a break from practice, coming back can be tough
After taking a 10-year break from practicing medicine to raise four sons, Dr. Kate Gibson was ready to go back to work.
The family physician had been reading about a shortage of primary care doctors and knew she could help. But when Dr. Gibson, 51, applied to work at her former hospital near Los Angeles, she was turned away. She’d been out of clinical practice too long.
“I really thought it was not going to be that hard,” she said.
Like many professionals, physicians take time off to raise children, care for sick family members, or recover from their own illnesses. Some want to return from retirement or switch from nonclinical jobs back to seeing patients. But picking up where they left off is more difficult in medicine than in most careers.
In medicine, change occurs quickly. Drugs, devices, and surgical techniques that were standard a decade ago may now be obsolete. Or a returning doctor’s skills may simply be rusty.
“My hands feel like those of an intern,” said Dr. Molly Carey, 36, an Ivy League–educated doctor who recently enrolled in a Texas retraining program after 4 years away from patients.
After extended leaves, doctors must convince medical boards to reissue their licenses, hospitals to grant admitting privileges, and malpractice insurers to provide coverage. Only a handful of programs around the country are set up to help physicians brush up on their skills, and they can cost doctors thousands of dollars.
“Medical schools do a fantastic job graduating brand new medical students,” said Dr. Humayun J. Chaudhry, president of the Federation of State Medical Boards. “But what about people who have already graduated and need to get some retraining? There is clearly a dearth of those kind of training programs.”
Policy makers and professional organizations are pushing to make the process less burdensome and costly – in part because it may help ease shortages of primary care doctors.
Getting experienced doctors to dust off their white coats is cheaper than starting from scratch, said Dr. Robert Steele, director of KSTAR physician programs at Texas A&M Health Science Center, College Station. He oversees a miniresidency program at the University of Texas Medical Branch, Galveston, in which returning doctors divide their time between seeing patients and attending classes. The 3-month training includes the latest on medications, procedures, disease management, and treatment.
“[Returning doctors] just need polishing up to practice safely and competently,” Dr. Steele said.
Patient safety advocates argue that minimum standards should be set to ensure that doctors coming back after a hiatus are providing the best care possible. As it stands, no nationwide standards or requirements exist, and states have different requirements.
“Patients would like to think that any doctor who is seeing them or doing procedures on them is at the height of their career,” said Joe Kiani, founder of the Patient Safety Movement Foundation. “If a doctor has been out for a while, they are not.”
Dr. Carey had a great education, graduating from medical school at the University of Pennsylvania and completing a residency in 2011 in obstetrics and gynecology at Brown University and a Providence hospital. But after taking just 4 years off to care for a sick grandmother and another relative, she felt she needed to freshen her clinical skills. So she moved from Rhode Island to Texas to take part in the KSTAR program, hoping to gain more confidence as a surgeon and become more marketable.
Setting standards and removing obstacles
Reliable numbers of how many doctors suspend their practices aren’t available, but the American Medical Association estimated in 2011 that 10,000 doctors could reenter practice each year.
The Federation of State Medical Boards wants states to create a standard process for physicians to show they have the skills to return to medicine. It is asking licensing agencies to track whether doctors are still practicing and whether they are doing so in their area of training.
The American Academy of Pediatrics and the AMA also are trying to remove obstacles for doctors who want to return to work after taking time off. And Rep. John Sarbanes (D-Md.) has proposed legislation to help expand reentry programs for primary care doctors and help cover physicians’ costs if they agree to practice in high-need areas.
After hitting a wall with her former employer and others, Dr. Gibson enrolled in an online retraining program in San Diego, which cost her $7,000. She spent 4 months completing the courses last year and a week shadowing a family physician. Then she took a written exam and was evaluated during mock visits with “patients” played by actors.
In the end, she received two certificates – one from the program and one from the University of California, San Diego, for 180 hours of continuing medical education.
“I definitely felt more confident,” Dr. Gibson said. But she still wanted more hands-on clinical training. So she recently started a paid family medicine fellowship at the University of Southern California, seeing patients under the oversight of other doctors.
Former medical school professor Dr. Leonard Glass created the San Diego program, called the Physician Retraining and Reentry Program, in 2013. Besides retraining primary care doctors, the online program has attracted specialists who wanted to switch to primary care, as well as some restless retirees.
“Some are simply tired of being retired,” he said. “It’s sort of an itch to go back to taking care of people.”
‘Expensive and time consuming’
Several retraining programs are run by hospitals, including Cedars-Sinai Medical Center in Los Angeles. There, participants spend between 6 weeks and 3 months seeing patients under the supervision of other physicians, then discuss their cases in an exit interview to demonstrate what they learned. They leave with a letter that can be submitted to employers or hospitals.
The Cedars-Sinai program costs $5,000 a month. Dr. Leo A. Gordon, who runs it, said some doctors who call to inquire are angry about having to spend the time and money when they already have so much education and experience. But he said others are simply appreciative that “there is a way to get back in the game.”
One Cedars-Sinai graduate, Dr. Maria DiMeglio decided she wanted to return to practice as an ob.gyn. after taking off almost 6 years to care for her children and her ill mother.
“I thought I was retiring, Dr. DiMeglio said, “but I kept my options open.” She had retained her medical license and kept up with continuing education courses. But she needed to persuade her old hospital, Cedars-Sinai, to give her privileges so she could perform surgeries. The Cedars-Sinai retraining program, she said, “wasn’t difficult, but it was expensive and time consuming. Not everyone can do that.”
Hospitals set their own requirements for doctors to get credentials and privileges, but doctors who have been out of practice for more than 2 years generally must show that they are competent to see patients. Having a certificate from a reentry program helps, said Dr. David Perrott, senior vice president and chief medical officer of the California Hospital Association.
Dr. Jeff Petrozzino, a 50-year old doctor who trained in pediatrics and neonatology, knows all about that. He ran into difficulty returning to clinical practice after spending several years doing health economics research.
“I was a double board–certified physician licensed in several states,” he said. “You would think I would be able to get a job.”
When he finally did get an offer at a medical center in New Jersey, he said both the position and the state medical license were contingent on him getting retrained. He completed a 2-month program at Drexel University in 2013, where he was surprised to discover many other doctors in a similar situation.
Dr. Petrozzino said he was grateful for the program – but given the hassles of reentry, he would advise doctors to plan carefully before taking a break from practice.
“Careers are interrupted or derailed for various reasons,” he said. “The system does not readily allow for reentry.”
Kaiser Health News (KHN) is a nonprofit national health policy news service. Blue Shield of California Foundation helps fund KHN coverage in California.
After taking a 10-year break from practicing medicine to raise four sons, Dr. Kate Gibson was ready to go back to work.
The family physician had been reading about a shortage of primary care doctors and knew she could help. But when Dr. Gibson, 51, applied to work at her former hospital near Los Angeles, she was turned away. She’d been out of clinical practice too long.
“I really thought it was not going to be that hard,” she said.
Like many professionals, physicians take time off to raise children, care for sick family members, or recover from their own illnesses. Some want to return from retirement or switch from nonclinical jobs back to seeing patients. But picking up where they left off is more difficult in medicine than in most careers.
In medicine, change occurs quickly. Drugs, devices, and surgical techniques that were standard a decade ago may now be obsolete. Or a returning doctor’s skills may simply be rusty.
“My hands feel like those of an intern,” said Dr. Molly Carey, 36, an Ivy League–educated doctor who recently enrolled in a Texas retraining program after 4 years away from patients.
After extended leaves, doctors must convince medical boards to reissue their licenses, hospitals to grant admitting privileges, and malpractice insurers to provide coverage. Only a handful of programs around the country are set up to help physicians brush up on their skills, and they can cost doctors thousands of dollars.
“Medical schools do a fantastic job graduating brand new medical students,” said Dr. Humayun J. Chaudhry, president of the Federation of State Medical Boards. “But what about people who have already graduated and need to get some retraining? There is clearly a dearth of those kind of training programs.”
Policy makers and professional organizations are pushing to make the process less burdensome and costly – in part because it may help ease shortages of primary care doctors.
Getting experienced doctors to dust off their white coats is cheaper than starting from scratch, said Dr. Robert Steele, director of KSTAR physician programs at Texas A&M Health Science Center, College Station. He oversees a miniresidency program at the University of Texas Medical Branch, Galveston, in which returning doctors divide their time between seeing patients and attending classes. The 3-month training includes the latest on medications, procedures, disease management, and treatment.
“[Returning doctors] just need polishing up to practice safely and competently,” Dr. Steele said.
Patient safety advocates argue that minimum standards should be set to ensure that doctors coming back after a hiatus are providing the best care possible. As it stands, no nationwide standards or requirements exist, and states have different requirements.
“Patients would like to think that any doctor who is seeing them or doing procedures on them is at the height of their career,” said Joe Kiani, founder of the Patient Safety Movement Foundation. “If a doctor has been out for a while, they are not.”
Dr. Carey had a great education, graduating from medical school at the University of Pennsylvania and completing a residency in 2011 in obstetrics and gynecology at Brown University and a Providence hospital. But after taking just 4 years off to care for a sick grandmother and another relative, she felt she needed to freshen her clinical skills. So she moved from Rhode Island to Texas to take part in the KSTAR program, hoping to gain more confidence as a surgeon and become more marketable.
Setting standards and removing obstacles
Reliable numbers of how many doctors suspend their practices aren’t available, but the American Medical Association estimated in 2011 that 10,000 doctors could reenter practice each year.
The Federation of State Medical Boards wants states to create a standard process for physicians to show they have the skills to return to medicine. It is asking licensing agencies to track whether doctors are still practicing and whether they are doing so in their area of training.
The American Academy of Pediatrics and the AMA also are trying to remove obstacles for doctors who want to return to work after taking time off. And Rep. John Sarbanes (D-Md.) has proposed legislation to help expand reentry programs for primary care doctors and help cover physicians’ costs if they agree to practice in high-need areas.
After hitting a wall with her former employer and others, Dr. Gibson enrolled in an online retraining program in San Diego, which cost her $7,000. She spent 4 months completing the courses last year and a week shadowing a family physician. Then she took a written exam and was evaluated during mock visits with “patients” played by actors.
In the end, she received two certificates – one from the program and one from the University of California, San Diego, for 180 hours of continuing medical education.
“I definitely felt more confident,” Dr. Gibson said. But she still wanted more hands-on clinical training. So she recently started a paid family medicine fellowship at the University of Southern California, seeing patients under the oversight of other doctors.
Former medical school professor Dr. Leonard Glass created the San Diego program, called the Physician Retraining and Reentry Program, in 2013. Besides retraining primary care doctors, the online program has attracted specialists who wanted to switch to primary care, as well as some restless retirees.
“Some are simply tired of being retired,” he said. “It’s sort of an itch to go back to taking care of people.”
‘Expensive and time consuming’
Several retraining programs are run by hospitals, including Cedars-Sinai Medical Center in Los Angeles. There, participants spend between 6 weeks and 3 months seeing patients under the supervision of other physicians, then discuss their cases in an exit interview to demonstrate what they learned. They leave with a letter that can be submitted to employers or hospitals.
The Cedars-Sinai program costs $5,000 a month. Dr. Leo A. Gordon, who runs it, said some doctors who call to inquire are angry about having to spend the time and money when they already have so much education and experience. But he said others are simply appreciative that “there is a way to get back in the game.”
One Cedars-Sinai graduate, Dr. Maria DiMeglio decided she wanted to return to practice as an ob.gyn. after taking off almost 6 years to care for her children and her ill mother.
“I thought I was retiring, Dr. DiMeglio said, “but I kept my options open.” She had retained her medical license and kept up with continuing education courses. But she needed to persuade her old hospital, Cedars-Sinai, to give her privileges so she could perform surgeries. The Cedars-Sinai retraining program, she said, “wasn’t difficult, but it was expensive and time consuming. Not everyone can do that.”
Hospitals set their own requirements for doctors to get credentials and privileges, but doctors who have been out of practice for more than 2 years generally must show that they are competent to see patients. Having a certificate from a reentry program helps, said Dr. David Perrott, senior vice president and chief medical officer of the California Hospital Association.
Dr. Jeff Petrozzino, a 50-year old doctor who trained in pediatrics and neonatology, knows all about that. He ran into difficulty returning to clinical practice after spending several years doing health economics research.
“I was a double board–certified physician licensed in several states,” he said. “You would think I would be able to get a job.”
When he finally did get an offer at a medical center in New Jersey, he said both the position and the state medical license were contingent on him getting retrained. He completed a 2-month program at Drexel University in 2013, where he was surprised to discover many other doctors in a similar situation.
Dr. Petrozzino said he was grateful for the program – but given the hassles of reentry, he would advise doctors to plan carefully before taking a break from practice.
“Careers are interrupted or derailed for various reasons,” he said. “The system does not readily allow for reentry.”
Kaiser Health News (KHN) is a nonprofit national health policy news service. Blue Shield of California Foundation helps fund KHN coverage in California.
After taking a 10-year break from practicing medicine to raise four sons, Dr. Kate Gibson was ready to go back to work.
The family physician had been reading about a shortage of primary care doctors and knew she could help. But when Dr. Gibson, 51, applied to work at her former hospital near Los Angeles, she was turned away. She’d been out of clinical practice too long.
“I really thought it was not going to be that hard,” she said.
Like many professionals, physicians take time off to raise children, care for sick family members, or recover from their own illnesses. Some want to return from retirement or switch from nonclinical jobs back to seeing patients. But picking up where they left off is more difficult in medicine than in most careers.
In medicine, change occurs quickly. Drugs, devices, and surgical techniques that were standard a decade ago may now be obsolete. Or a returning doctor’s skills may simply be rusty.
“My hands feel like those of an intern,” said Dr. Molly Carey, 36, an Ivy League–educated doctor who recently enrolled in a Texas retraining program after 4 years away from patients.
After extended leaves, doctors must convince medical boards to reissue their licenses, hospitals to grant admitting privileges, and malpractice insurers to provide coverage. Only a handful of programs around the country are set up to help physicians brush up on their skills, and they can cost doctors thousands of dollars.
“Medical schools do a fantastic job graduating brand new medical students,” said Dr. Humayun J. Chaudhry, president of the Federation of State Medical Boards. “But what about people who have already graduated and need to get some retraining? There is clearly a dearth of those kind of training programs.”
Policy makers and professional organizations are pushing to make the process less burdensome and costly – in part because it may help ease shortages of primary care doctors.
Getting experienced doctors to dust off their white coats is cheaper than starting from scratch, said Dr. Robert Steele, director of KSTAR physician programs at Texas A&M Health Science Center, College Station. He oversees a miniresidency program at the University of Texas Medical Branch, Galveston, in which returning doctors divide their time between seeing patients and attending classes. The 3-month training includes the latest on medications, procedures, disease management, and treatment.
“[Returning doctors] just need polishing up to practice safely and competently,” Dr. Steele said.
Patient safety advocates argue that minimum standards should be set to ensure that doctors coming back after a hiatus are providing the best care possible. As it stands, no nationwide standards or requirements exist, and states have different requirements.
“Patients would like to think that any doctor who is seeing them or doing procedures on them is at the height of their career,” said Joe Kiani, founder of the Patient Safety Movement Foundation. “If a doctor has been out for a while, they are not.”
Dr. Carey had a great education, graduating from medical school at the University of Pennsylvania and completing a residency in 2011 in obstetrics and gynecology at Brown University and a Providence hospital. But after taking just 4 years off to care for a sick grandmother and another relative, she felt she needed to freshen her clinical skills. So she moved from Rhode Island to Texas to take part in the KSTAR program, hoping to gain more confidence as a surgeon and become more marketable.
Setting standards and removing obstacles
Reliable numbers of how many doctors suspend their practices aren’t available, but the American Medical Association estimated in 2011 that 10,000 doctors could reenter practice each year.
The Federation of State Medical Boards wants states to create a standard process for physicians to show they have the skills to return to medicine. It is asking licensing agencies to track whether doctors are still practicing and whether they are doing so in their area of training.
The American Academy of Pediatrics and the AMA also are trying to remove obstacles for doctors who want to return to work after taking time off. And Rep. John Sarbanes (D-Md.) has proposed legislation to help expand reentry programs for primary care doctors and help cover physicians’ costs if they agree to practice in high-need areas.
After hitting a wall with her former employer and others, Dr. Gibson enrolled in an online retraining program in San Diego, which cost her $7,000. She spent 4 months completing the courses last year and a week shadowing a family physician. Then she took a written exam and was evaluated during mock visits with “patients” played by actors.
In the end, she received two certificates – one from the program and one from the University of California, San Diego, for 180 hours of continuing medical education.
“I definitely felt more confident,” Dr. Gibson said. But she still wanted more hands-on clinical training. So she recently started a paid family medicine fellowship at the University of Southern California, seeing patients under the oversight of other doctors.
Former medical school professor Dr. Leonard Glass created the San Diego program, called the Physician Retraining and Reentry Program, in 2013. Besides retraining primary care doctors, the online program has attracted specialists who wanted to switch to primary care, as well as some restless retirees.
“Some are simply tired of being retired,” he said. “It’s sort of an itch to go back to taking care of people.”
‘Expensive and time consuming’
Several retraining programs are run by hospitals, including Cedars-Sinai Medical Center in Los Angeles. There, participants spend between 6 weeks and 3 months seeing patients under the supervision of other physicians, then discuss their cases in an exit interview to demonstrate what they learned. They leave with a letter that can be submitted to employers or hospitals.
The Cedars-Sinai program costs $5,000 a month. Dr. Leo A. Gordon, who runs it, said some doctors who call to inquire are angry about having to spend the time and money when they already have so much education and experience. But he said others are simply appreciative that “there is a way to get back in the game.”
One Cedars-Sinai graduate, Dr. Maria DiMeglio decided she wanted to return to practice as an ob.gyn. after taking off almost 6 years to care for her children and her ill mother.
“I thought I was retiring, Dr. DiMeglio said, “but I kept my options open.” She had retained her medical license and kept up with continuing education courses. But she needed to persuade her old hospital, Cedars-Sinai, to give her privileges so she could perform surgeries. The Cedars-Sinai retraining program, she said, “wasn’t difficult, but it was expensive and time consuming. Not everyone can do that.”
Hospitals set their own requirements for doctors to get credentials and privileges, but doctors who have been out of practice for more than 2 years generally must show that they are competent to see patients. Having a certificate from a reentry program helps, said Dr. David Perrott, senior vice president and chief medical officer of the California Hospital Association.
Dr. Jeff Petrozzino, a 50-year old doctor who trained in pediatrics and neonatology, knows all about that. He ran into difficulty returning to clinical practice after spending several years doing health economics research.
“I was a double board–certified physician licensed in several states,” he said. “You would think I would be able to get a job.”
When he finally did get an offer at a medical center in New Jersey, he said both the position and the state medical license were contingent on him getting retrained. He completed a 2-month program at Drexel University in 2013, where he was surprised to discover many other doctors in a similar situation.
Dr. Petrozzino said he was grateful for the program – but given the hassles of reentry, he would advise doctors to plan carefully before taking a break from practice.
“Careers are interrupted or derailed for various reasons,” he said. “The system does not readily allow for reentry.”
Kaiser Health News (KHN) is a nonprofit national health policy news service. Blue Shield of California Foundation helps fund KHN coverage in California.
Decompressive brain surgery carries high complication risk
VIENNA – Decompressive hemicraniectomy for malignant middle cerebral artery infarction was associated with high rates of in-hospital and late complications in a clinical practice setting, according to research reported at the annual European Stroke Conference.
The retrospective findings showed that 88.1% of the 48 patients who underwent the surgery experienced complications such as intracranial hemorrhage (ICH) or symptomatic epilepsy while hospitalized, and 89.5% experienced complications in the later months of their recovery.
While these complication rates are higher than those seen in the randomized controlled clinical studies, the operation still proved life saving for many, with in-hospital and overall mortality rates of 12.5% and 14.6%, respectively, which is similar to the mortality rate seen in the DESTINY trial (Stroke 2007;38:2518-25) after 6 months.
“Patients who underwent [decompressive hemicraniectomy] are a complication-prone collective”, said Dr. Hans-Werner Pledl, resident physician at the department of neurology, UniversitätsMedizin Mannheim, University of Heidelberg (Germany). “Especially in the elderly, recovery stays limited in relevant factors such as ambulation and conversation for self-sufficiency,” he added.
To date, four clinical trials – DECIMAL (Stroke 2007;38:2506-17), HAMLET (Lancet Neurol 2009;8:326-33) and DESTINY and DESTINY II (Int J Stroke 2011;6:79-86) – have looked at the efficacy and safety of DHC in small numbers of patients with life-threatening middle cerebral artery (MCA) infarction. Of these, only DESTINY II included patients over 60 years of age so while there was evidence that the pressure-relieving surgery reduced mortality if performed early, albeit with an increase in functional disability, experience in older patients was less clear. To look at the complication rates in a real-world practice setting, Dr. Pledl of University Hospital Mannheim’s stroke unit, examined the medical records of 48 patients with MCA infarction who underwent DHC between 2008 and 2014. At the time of admission, the 21 male and 27 female patients were aged 28 to 70 years, with the mean age being 57 years. Dr. Pledl noted that two out of every five (41.7%) patients was over the age of 60 years.
On average, patients were referred to the stroke unit within 3 hours and 44 minutes of the incident event, but some were seen within 30 minutes and others within 5 days. A total of 43.8% of patients had an MCA infarction involving the dominant hemisphere and just under 60% received thrombolytic therapy with rtPA. The median time to surgery was 1.3 days, with just over one-fifth (21.7%) of patients undergoing DHC more than 48 hours after their stroke.
The median National Institutes of Health Stroke Scale scores at admission and discharge were 19 and 18, respectively, while the modified Rankin Scale (mRS) score was 5 at both time points. The Barthel Index was 0 at admission, signifying that the patient was heavily dependent on a carer to perform basic living activities, and 7.5 at discharge, indicating some only marginal improvement in patients’ independence.
The majority (75%) of patients achieved reasonable recovery with early (phase B) rehabilitation, 44% with continued poststroke (phase C) rehabilitation, and 6% were able to become self-sufficient and some even returning to work (phase D). “Remarkably, nearly half (48.9%) of patients return home after rehabilitation and do not stay in a clinical or institutional care facility,” Dr. Pledl said.
In-hospital neurological or psychiatric complications included ICH (seven patients), symptomatic epilepsy (six patients), and delirium (five patients). Perioperative complications included meningitis (three patients), wound healing disorders (three patients), and two patients had epidural hemorrhage (EDH). Common infections included pneumonia (13 patients) and urinary tract infections (UTI, eight patients), and other complications included anemia (14 patients) and cardiac complications (nine patients).
During the recovery phase, the most common neurological or psychiatric complications were central pain syndrome and symptomatic epilepsy, affecting nine patients each. Patients again experienced EDH (five patients), with some cases of hydrocephalus (four patients) and wound-healing problems (three patients). UTIs were the most common type of infection, seen in 14 patients. Other late complications included dysphagia (41.7%) and tracheostomy (35.4%), and post-rehab depression (54.2%).
Dr. Pledl suggested that the findings could be used to help better inform patients and their carers so they can have “realistic expectations” of the procedure’s likely outcomes and decide whether or not to have the surgery performed. These “real world” data could also help physicians to be more aware of the likely complications and perhaps address them in some way so that they have minimal impact on patients’ quality of life.
Although patients who experienced complications in this study were not asked if they regretted the decision to undergo the surgery, there is evidence to show that patients and carers can accept a significant level of disability without having significantly impaired quality of life. Nevertheless, the decision on whether DHC should be performed should be made on an individual case basis, especially in older patients, Dr. Pledl concluded.
The next step is to see if there are any subgroups of patients who might fare better or worse after DHC and hopefully identify some predictive imaging markers that could help the decision-making process.
Dr. Pledl reported no conflicts.
VIENNA – Decompressive hemicraniectomy for malignant middle cerebral artery infarction was associated with high rates of in-hospital and late complications in a clinical practice setting, according to research reported at the annual European Stroke Conference.
The retrospective findings showed that 88.1% of the 48 patients who underwent the surgery experienced complications such as intracranial hemorrhage (ICH) or symptomatic epilepsy while hospitalized, and 89.5% experienced complications in the later months of their recovery.
While these complication rates are higher than those seen in the randomized controlled clinical studies, the operation still proved life saving for many, with in-hospital and overall mortality rates of 12.5% and 14.6%, respectively, which is similar to the mortality rate seen in the DESTINY trial (Stroke 2007;38:2518-25) after 6 months.
“Patients who underwent [decompressive hemicraniectomy] are a complication-prone collective”, said Dr. Hans-Werner Pledl, resident physician at the department of neurology, UniversitätsMedizin Mannheim, University of Heidelberg (Germany). “Especially in the elderly, recovery stays limited in relevant factors such as ambulation and conversation for self-sufficiency,” he added.
To date, four clinical trials – DECIMAL (Stroke 2007;38:2506-17), HAMLET (Lancet Neurol 2009;8:326-33) and DESTINY and DESTINY II (Int J Stroke 2011;6:79-86) – have looked at the efficacy and safety of DHC in small numbers of patients with life-threatening middle cerebral artery (MCA) infarction. Of these, only DESTINY II included patients over 60 years of age so while there was evidence that the pressure-relieving surgery reduced mortality if performed early, albeit with an increase in functional disability, experience in older patients was less clear. To look at the complication rates in a real-world practice setting, Dr. Pledl of University Hospital Mannheim’s stroke unit, examined the medical records of 48 patients with MCA infarction who underwent DHC between 2008 and 2014. At the time of admission, the 21 male and 27 female patients were aged 28 to 70 years, with the mean age being 57 years. Dr. Pledl noted that two out of every five (41.7%) patients was over the age of 60 years.
On average, patients were referred to the stroke unit within 3 hours and 44 minutes of the incident event, but some were seen within 30 minutes and others within 5 days. A total of 43.8% of patients had an MCA infarction involving the dominant hemisphere and just under 60% received thrombolytic therapy with rtPA. The median time to surgery was 1.3 days, with just over one-fifth (21.7%) of patients undergoing DHC more than 48 hours after their stroke.
The median National Institutes of Health Stroke Scale scores at admission and discharge were 19 and 18, respectively, while the modified Rankin Scale (mRS) score was 5 at both time points. The Barthel Index was 0 at admission, signifying that the patient was heavily dependent on a carer to perform basic living activities, and 7.5 at discharge, indicating some only marginal improvement in patients’ independence.
The majority (75%) of patients achieved reasonable recovery with early (phase B) rehabilitation, 44% with continued poststroke (phase C) rehabilitation, and 6% were able to become self-sufficient and some even returning to work (phase D). “Remarkably, nearly half (48.9%) of patients return home after rehabilitation and do not stay in a clinical or institutional care facility,” Dr. Pledl said.
In-hospital neurological or psychiatric complications included ICH (seven patients), symptomatic epilepsy (six patients), and delirium (five patients). Perioperative complications included meningitis (three patients), wound healing disorders (three patients), and two patients had epidural hemorrhage (EDH). Common infections included pneumonia (13 patients) and urinary tract infections (UTI, eight patients), and other complications included anemia (14 patients) and cardiac complications (nine patients).
During the recovery phase, the most common neurological or psychiatric complications were central pain syndrome and symptomatic epilepsy, affecting nine patients each. Patients again experienced EDH (five patients), with some cases of hydrocephalus (four patients) and wound-healing problems (three patients). UTIs were the most common type of infection, seen in 14 patients. Other late complications included dysphagia (41.7%) and tracheostomy (35.4%), and post-rehab depression (54.2%).
Dr. Pledl suggested that the findings could be used to help better inform patients and their carers so they can have “realistic expectations” of the procedure’s likely outcomes and decide whether or not to have the surgery performed. These “real world” data could also help physicians to be more aware of the likely complications and perhaps address them in some way so that they have minimal impact on patients’ quality of life.
Although patients who experienced complications in this study were not asked if they regretted the decision to undergo the surgery, there is evidence to show that patients and carers can accept a significant level of disability without having significantly impaired quality of life. Nevertheless, the decision on whether DHC should be performed should be made on an individual case basis, especially in older patients, Dr. Pledl concluded.
The next step is to see if there are any subgroups of patients who might fare better or worse after DHC and hopefully identify some predictive imaging markers that could help the decision-making process.
Dr. Pledl reported no conflicts.
VIENNA – Decompressive hemicraniectomy for malignant middle cerebral artery infarction was associated with high rates of in-hospital and late complications in a clinical practice setting, according to research reported at the annual European Stroke Conference.
The retrospective findings showed that 88.1% of the 48 patients who underwent the surgery experienced complications such as intracranial hemorrhage (ICH) or symptomatic epilepsy while hospitalized, and 89.5% experienced complications in the later months of their recovery.
While these complication rates are higher than those seen in the randomized controlled clinical studies, the operation still proved life saving for many, with in-hospital and overall mortality rates of 12.5% and 14.6%, respectively, which is similar to the mortality rate seen in the DESTINY trial (Stroke 2007;38:2518-25) after 6 months.
“Patients who underwent [decompressive hemicraniectomy] are a complication-prone collective”, said Dr. Hans-Werner Pledl, resident physician at the department of neurology, UniversitätsMedizin Mannheim, University of Heidelberg (Germany). “Especially in the elderly, recovery stays limited in relevant factors such as ambulation and conversation for self-sufficiency,” he added.
To date, four clinical trials – DECIMAL (Stroke 2007;38:2506-17), HAMLET (Lancet Neurol 2009;8:326-33) and DESTINY and DESTINY II (Int J Stroke 2011;6:79-86) – have looked at the efficacy and safety of DHC in small numbers of patients with life-threatening middle cerebral artery (MCA) infarction. Of these, only DESTINY II included patients over 60 years of age so while there was evidence that the pressure-relieving surgery reduced mortality if performed early, albeit with an increase in functional disability, experience in older patients was less clear. To look at the complication rates in a real-world practice setting, Dr. Pledl of University Hospital Mannheim’s stroke unit, examined the medical records of 48 patients with MCA infarction who underwent DHC between 2008 and 2014. At the time of admission, the 21 male and 27 female patients were aged 28 to 70 years, with the mean age being 57 years. Dr. Pledl noted that two out of every five (41.7%) patients was over the age of 60 years.
On average, patients were referred to the stroke unit within 3 hours and 44 minutes of the incident event, but some were seen within 30 minutes and others within 5 days. A total of 43.8% of patients had an MCA infarction involving the dominant hemisphere and just under 60% received thrombolytic therapy with rtPA. The median time to surgery was 1.3 days, with just over one-fifth (21.7%) of patients undergoing DHC more than 48 hours after their stroke.
The median National Institutes of Health Stroke Scale scores at admission and discharge were 19 and 18, respectively, while the modified Rankin Scale (mRS) score was 5 at both time points. The Barthel Index was 0 at admission, signifying that the patient was heavily dependent on a carer to perform basic living activities, and 7.5 at discharge, indicating some only marginal improvement in patients’ independence.
The majority (75%) of patients achieved reasonable recovery with early (phase B) rehabilitation, 44% with continued poststroke (phase C) rehabilitation, and 6% were able to become self-sufficient and some even returning to work (phase D). “Remarkably, nearly half (48.9%) of patients return home after rehabilitation and do not stay in a clinical or institutional care facility,” Dr. Pledl said.
In-hospital neurological or psychiatric complications included ICH (seven patients), symptomatic epilepsy (six patients), and delirium (five patients). Perioperative complications included meningitis (three patients), wound healing disorders (three patients), and two patients had epidural hemorrhage (EDH). Common infections included pneumonia (13 patients) and urinary tract infections (UTI, eight patients), and other complications included anemia (14 patients) and cardiac complications (nine patients).
During the recovery phase, the most common neurological or psychiatric complications were central pain syndrome and symptomatic epilepsy, affecting nine patients each. Patients again experienced EDH (five patients), with some cases of hydrocephalus (four patients) and wound-healing problems (three patients). UTIs were the most common type of infection, seen in 14 patients. Other late complications included dysphagia (41.7%) and tracheostomy (35.4%), and post-rehab depression (54.2%).
Dr. Pledl suggested that the findings could be used to help better inform patients and their carers so they can have “realistic expectations” of the procedure’s likely outcomes and decide whether or not to have the surgery performed. These “real world” data could also help physicians to be more aware of the likely complications and perhaps address them in some way so that they have minimal impact on patients’ quality of life.
Although patients who experienced complications in this study were not asked if they regretted the decision to undergo the surgery, there is evidence to show that patients and carers can accept a significant level of disability without having significantly impaired quality of life. Nevertheless, the decision on whether DHC should be performed should be made on an individual case basis, especially in older patients, Dr. Pledl concluded.
The next step is to see if there are any subgroups of patients who might fare better or worse after DHC and hopefully identify some predictive imaging markers that could help the decision-making process.
Dr. Pledl reported no conflicts.
AT THE EUROPEAN STROKE CONFERENCE
Key clinical point: The high risk of complications associated with decompressive hemicraniectomy for malignant middle cerebral artery infarction warrants appropriate counseling and individualized therapeutic decision-making.
Major finding: The in-hospital and late complication rates associated with decompressive hemicraniectomy for malignant middle cerebral artery infarction were 88.1% and 89.5%, respectively.
Data source: Retrospective, observational, single-center study of 48 patients who underwent decompressive hemicrainiectomy between 2008 and 2014.
Disclosures: Dr. Pledl reported no conflicts.
