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Mixed results for rheumatologists on Medicare quality measures
SAN DIEGO – As quality measures are poised to become crucial to U.S. physician incomes in 2019, an analysis of a nationwide registry sample finds that rheumatologists overall have decent scores on several fronts. But they still need to boost their record on preventive measures that are not geared specifically to their specialty.
“Rheumatologists are performing well, so far, on aspects of care coordination, such as communication with the health care team post osteoporotic fracture and on several patient safety measures, such as avoiding high-risk drugs in the elderly,” said Jinoos Yazdany, MD, of the University of California, San Francisco. However, “in some preventive care measures, such as tobacco screening, there is room for improvement compared to benchmarks that the Centers for Medicare & Medicaid Services has set across providers.”
The ACR created the registry “to help rheumatology harness the power of electronic health record data to advance our understanding of the natural history, treatment, and outcomes of rheumatic disease,” Dr. Yazdany said. “Another important goal was to harness the power of a national registry to measure and improve quality of care and outcomes. Practices can use RISE to see where they are performing well and where there is room for improvement.”
Since 2016, the registry has passively collected data on 2.5 million patients and 13.7 million encounters.
“The quality measures in RISE serve several purposes,” Dr. Yazdany said. “First, they fulfill reporting requirements to CMS through the Merit-Based Incentive Payment System [MIPS]. Second, the measures provide information to practices that can be used to track quality improvement and population health management. Finally, the measures create unprecedented opportunities to learn from practices that are excelling and to adapt successful work flows to improve care for our patients.”
These measures matter. In 2019, payments for many physicians under Medicare Part B will be adjusted based on their performance in these areas in previous years. Most rheumatologists will take part, Dr. Yazdany said.
“Rather than focusing on a single measure, the key number in 2017 for the MIPS program is 70 points across the three domains of Quality, Advancing Care Information, and Improvement Activities,” she said. “Above that threshold, rheumatologists will qualify for an ‘exceptional performance bonus.’ That means they will get a minimum of an additional 0.5% on their Medicare billing.”
She added that “there is no reason that most rheumatologists should not cross the 70-point threshold. Proactively monitoring their progress in RISE will help them succeed.”
The ACR session focused on a registry sample of 225 practices and 750 rheumatologists. The analysis measured their performance from January to September 2017 in the Quality, Advancing Care Information, and Improvement Activities areas.
In terms of meeting benchmarks, the rheumatologists in the sample performed especially well in several areas.
On the drug safety front, across elderly patients, an average of just 3.6% were prescribed one or more high-risk medications, and 0.2% were prescribed two or more.
On rheumatoid arthritis measures, 52% of patients had documentation of tuberculosis screening before biologics, and 46.3% underwent functional status assessments. And in the care coordination and documentation measure, 92.9% documented current medications in the EHR.
Rheumatologists lagged in terms of preventive care, compared with other physicians nationally: The average performance across patients was 77.2% for tobacco screening and counseling, 42.7% for body mass index screening and counseling, and 60.2% for blood pressure management.
Why are these preventive care measures being tracked in rheumatology instead of more rheumatology-specific measures? “CMS requires that physicians submit an outcome measure. Unfortunately, we don’t have validated outcome measures in rheumatology, so we had to adopt outcome measures like controlling blood pressure,” Dr. Yazdany said. “Also, many preventive care measures are designated ‘high priority,’ which enables physicians to get bonus points. We wanted rheumatologists to have access to these extra points and therefore included these measures in RISE.”
The ACR is working on developing outcome measures, she said, “and hopefully we’ll have outcomes to put in the registry in coming years.”
What are the chances that rheumatologists will do well? “Our analyses show that most rheumatologists participating in RISE are well positioned to succeed. If they complete their improvement activities (15% of MIPS), and advancing care information (25% of MIPS) modules, that gets them to 40 points. That means they only need 30 additional points in the quality domain to get to the exceptional performance threshold and qualify for a bonus,” she said. “All 15 of the rheumatologists who have completed all three MIPS categories have reached 70 points, and we anticipate that many others will by the end of the year.”
Even just participating in RISE will boost points, she said. “It is clear that CMS is encouraging the large-scale development of quality improvement registries like RISE.”
In the big picture, she said, “the key point is that rheumatologists should be proactive. They need to understand their performance on measures, pick areas to focus on, including areas where they can easily improve their scores.”
Dr. Yazdany reported no relevant disclosures. The study was funded by ACR.
SAN DIEGO – As quality measures are poised to become crucial to U.S. physician incomes in 2019, an analysis of a nationwide registry sample finds that rheumatologists overall have decent scores on several fronts. But they still need to boost their record on preventive measures that are not geared specifically to their specialty.
“Rheumatologists are performing well, so far, on aspects of care coordination, such as communication with the health care team post osteoporotic fracture and on several patient safety measures, such as avoiding high-risk drugs in the elderly,” said Jinoos Yazdany, MD, of the University of California, San Francisco. However, “in some preventive care measures, such as tobacco screening, there is room for improvement compared to benchmarks that the Centers for Medicare & Medicaid Services has set across providers.”
The ACR created the registry “to help rheumatology harness the power of electronic health record data to advance our understanding of the natural history, treatment, and outcomes of rheumatic disease,” Dr. Yazdany said. “Another important goal was to harness the power of a national registry to measure and improve quality of care and outcomes. Practices can use RISE to see where they are performing well and where there is room for improvement.”
Since 2016, the registry has passively collected data on 2.5 million patients and 13.7 million encounters.
“The quality measures in RISE serve several purposes,” Dr. Yazdany said. “First, they fulfill reporting requirements to CMS through the Merit-Based Incentive Payment System [MIPS]. Second, the measures provide information to practices that can be used to track quality improvement and population health management. Finally, the measures create unprecedented opportunities to learn from practices that are excelling and to adapt successful work flows to improve care for our patients.”
These measures matter. In 2019, payments for many physicians under Medicare Part B will be adjusted based on their performance in these areas in previous years. Most rheumatologists will take part, Dr. Yazdany said.
“Rather than focusing on a single measure, the key number in 2017 for the MIPS program is 70 points across the three domains of Quality, Advancing Care Information, and Improvement Activities,” she said. “Above that threshold, rheumatologists will qualify for an ‘exceptional performance bonus.’ That means they will get a minimum of an additional 0.5% on their Medicare billing.”
She added that “there is no reason that most rheumatologists should not cross the 70-point threshold. Proactively monitoring their progress in RISE will help them succeed.”
The ACR session focused on a registry sample of 225 practices and 750 rheumatologists. The analysis measured their performance from January to September 2017 in the Quality, Advancing Care Information, and Improvement Activities areas.
In terms of meeting benchmarks, the rheumatologists in the sample performed especially well in several areas.
On the drug safety front, across elderly patients, an average of just 3.6% were prescribed one or more high-risk medications, and 0.2% were prescribed two or more.
On rheumatoid arthritis measures, 52% of patients had documentation of tuberculosis screening before biologics, and 46.3% underwent functional status assessments. And in the care coordination and documentation measure, 92.9% documented current medications in the EHR.
Rheumatologists lagged in terms of preventive care, compared with other physicians nationally: The average performance across patients was 77.2% for tobacco screening and counseling, 42.7% for body mass index screening and counseling, and 60.2% for blood pressure management.
Why are these preventive care measures being tracked in rheumatology instead of more rheumatology-specific measures? “CMS requires that physicians submit an outcome measure. Unfortunately, we don’t have validated outcome measures in rheumatology, so we had to adopt outcome measures like controlling blood pressure,” Dr. Yazdany said. “Also, many preventive care measures are designated ‘high priority,’ which enables physicians to get bonus points. We wanted rheumatologists to have access to these extra points and therefore included these measures in RISE.”
The ACR is working on developing outcome measures, she said, “and hopefully we’ll have outcomes to put in the registry in coming years.”
What are the chances that rheumatologists will do well? “Our analyses show that most rheumatologists participating in RISE are well positioned to succeed. If they complete their improvement activities (15% of MIPS), and advancing care information (25% of MIPS) modules, that gets them to 40 points. That means they only need 30 additional points in the quality domain to get to the exceptional performance threshold and qualify for a bonus,” she said. “All 15 of the rheumatologists who have completed all three MIPS categories have reached 70 points, and we anticipate that many others will by the end of the year.”
Even just participating in RISE will boost points, she said. “It is clear that CMS is encouraging the large-scale development of quality improvement registries like RISE.”
In the big picture, she said, “the key point is that rheumatologists should be proactive. They need to understand their performance on measures, pick areas to focus on, including areas where they can easily improve their scores.”
Dr. Yazdany reported no relevant disclosures. The study was funded by ACR.
SAN DIEGO – As quality measures are poised to become crucial to U.S. physician incomes in 2019, an analysis of a nationwide registry sample finds that rheumatologists overall have decent scores on several fronts. But they still need to boost their record on preventive measures that are not geared specifically to their specialty.
“Rheumatologists are performing well, so far, on aspects of care coordination, such as communication with the health care team post osteoporotic fracture and on several patient safety measures, such as avoiding high-risk drugs in the elderly,” said Jinoos Yazdany, MD, of the University of California, San Francisco. However, “in some preventive care measures, such as tobacco screening, there is room for improvement compared to benchmarks that the Centers for Medicare & Medicaid Services has set across providers.”
The ACR created the registry “to help rheumatology harness the power of electronic health record data to advance our understanding of the natural history, treatment, and outcomes of rheumatic disease,” Dr. Yazdany said. “Another important goal was to harness the power of a national registry to measure and improve quality of care and outcomes. Practices can use RISE to see where they are performing well and where there is room for improvement.”
Since 2016, the registry has passively collected data on 2.5 million patients and 13.7 million encounters.
“The quality measures in RISE serve several purposes,” Dr. Yazdany said. “First, they fulfill reporting requirements to CMS through the Merit-Based Incentive Payment System [MIPS]. Second, the measures provide information to practices that can be used to track quality improvement and population health management. Finally, the measures create unprecedented opportunities to learn from practices that are excelling and to adapt successful work flows to improve care for our patients.”
These measures matter. In 2019, payments for many physicians under Medicare Part B will be adjusted based on their performance in these areas in previous years. Most rheumatologists will take part, Dr. Yazdany said.
“Rather than focusing on a single measure, the key number in 2017 for the MIPS program is 70 points across the three domains of Quality, Advancing Care Information, and Improvement Activities,” she said. “Above that threshold, rheumatologists will qualify for an ‘exceptional performance bonus.’ That means they will get a minimum of an additional 0.5% on their Medicare billing.”
She added that “there is no reason that most rheumatologists should not cross the 70-point threshold. Proactively monitoring their progress in RISE will help them succeed.”
The ACR session focused on a registry sample of 225 practices and 750 rheumatologists. The analysis measured their performance from January to September 2017 in the Quality, Advancing Care Information, and Improvement Activities areas.
In terms of meeting benchmarks, the rheumatologists in the sample performed especially well in several areas.
On the drug safety front, across elderly patients, an average of just 3.6% were prescribed one or more high-risk medications, and 0.2% were prescribed two or more.
On rheumatoid arthritis measures, 52% of patients had documentation of tuberculosis screening before biologics, and 46.3% underwent functional status assessments. And in the care coordination and documentation measure, 92.9% documented current medications in the EHR.
Rheumatologists lagged in terms of preventive care, compared with other physicians nationally: The average performance across patients was 77.2% for tobacco screening and counseling, 42.7% for body mass index screening and counseling, and 60.2% for blood pressure management.
Why are these preventive care measures being tracked in rheumatology instead of more rheumatology-specific measures? “CMS requires that physicians submit an outcome measure. Unfortunately, we don’t have validated outcome measures in rheumatology, so we had to adopt outcome measures like controlling blood pressure,” Dr. Yazdany said. “Also, many preventive care measures are designated ‘high priority,’ which enables physicians to get bonus points. We wanted rheumatologists to have access to these extra points and therefore included these measures in RISE.”
The ACR is working on developing outcome measures, she said, “and hopefully we’ll have outcomes to put in the registry in coming years.”
What are the chances that rheumatologists will do well? “Our analyses show that most rheumatologists participating in RISE are well positioned to succeed. If they complete their improvement activities (15% of MIPS), and advancing care information (25% of MIPS) modules, that gets them to 40 points. That means they only need 30 additional points in the quality domain to get to the exceptional performance threshold and qualify for a bonus,” she said. “All 15 of the rheumatologists who have completed all three MIPS categories have reached 70 points, and we anticipate that many others will by the end of the year.”
Even just participating in RISE will boost points, she said. “It is clear that CMS is encouraging the large-scale development of quality improvement registries like RISE.”
In the big picture, she said, “the key point is that rheumatologists should be proactive. They need to understand their performance on measures, pick areas to focus on, including areas where they can easily improve their scores.”
Dr. Yazdany reported no relevant disclosures. The study was funded by ACR.
AT ACR 2017
Here’s what’s trending at SHM – Nov. 2017
Recognizing American Diabetes Month, COPD Awareness Month, and CDC’s Get Smart Week with QI Solutions
- There’s no better time than during American Diabetes Month to learn more about SHM’s Glycemic Control programs. Find out how your institution can submit point-of-care data to SHM’s Data Center, generate monthly reports and be included in the national glucometrics benchmark report. Hospital systems are also encouraged to subscribe to track and compare their individual as well as overall performance. Be one of the 100-plus hospitals nationwide that are supported by SHM’s respected Glycemic Control Programs. Contact Sara Platt for a free demo at splatt@hospitalmedicine.org or by phone at 267-702-2672. For additional information, visit hospitalmedicine.org/gc.
- November marks Chronic Obstructive Pulmonary Disease (COPD) Month, and it is critical that hospitals begin to direct QI resources to improving care for COPD patients. SHM developed a free guide to help you make changes to COPD care at both the individual patient and the institutional levels. Whether you are a clinician, medical director, VP of quality or chief medical officer, these resources can help you. Visit hospitalmedicine.org/COPD to download the guide.
- And, in conjunction with the Centers for Disease Control & Prevention’s (CDC’s) Get Smart Week, SHM is committed to promoting improved antibiotic prescribing behaviors among U.S. hospitalists. Through the Fight the Resistance campaign, SHM has developed many antimicrobial stewardship resources, including an implementation guide, four educational modules, and posters to hang in your hospital. Learn more at hospitalmedicine.org/abx.
Present your abstract in front of a national audience at HM18
SHM is accepting submissions for the Research, Innovations, and Clinical Vignettes (RIV) Competition at Hospital Medicine 2018 (HM18). Based on past experience, the RIV Competition is likely to be one of the most popular events at HM18, enabling hospitalists from across the country to discuss emerging science and clinical cases, share feedback, and make valuable professional connections.
Many of the cutting-edge abstracts that are first presented at SHM’s RIV sessions go on to be published in highly respected medical journals. The competition also includes a special Trainee Award category for resident and student authors.
SHM is excited to launch the Resident Travel Grant for 10 residents to receive funding to help cover the costs of travel and accommodations to attend SHM’s annual conference. See full details on how to apply and the selection process at shmannualconference.org/riv.
The submission deadline is Sunday, Dec. 3, 2017.
Distinguish yourself as a Class of 2018 Fellow in Hospital Medicine
SHM’s Fellows designation is a prestigious way to differentiate yourself in the rapidly growing profession of hospital medicine. There are currently over 2,000 hospitalists who have earned the Fellow in Hospital Medicine (FHM) or Senior Fellow in Hospital Medicine (SFHM) designation by demonstrating the core values of leadership, teamwork, and quality improvement.
Apply now and learn how you can join this prestigious group of hospitalists at hospitalmedicine.org/fellows. Applications officially close on Nov. 30, 2017.
The hospital observation care problem: Perspectives and solutions from SHM
Hospitalists provide the majority of observation care to Medicare beneficiaries and are often the primary points of contact for patients as they navigate the impact of inpatient and observation care determinations during and after their hospitalizations.
In 2017, SHM re-surveyed members to understand the state of hospital observation care after several legislative and regulatory changes. Through this new survey, hospitalists reported on their experience with the two-midnight rule and the impact of the recent Notification of Observation Treatment and Implication of Care Eligibility (NOTICE) Act, which requires hospitals to inform patients through the Medicare Outpatient Observation Notice (MOON) form that they are hospitalized under observation. Read the white paper to get perspectives and solutions from SHM at hospitalmedicine.org/advocacy.
Introducing ‘Ultrasonography: Essentials in Critical Care’
Brought to you by SHM and CHEST®, the Ultrasonography: Essentials in Critical Care course will be held Dec. 1-3, 2017, at the CHEST Innovation, Simulation, and Training Center in Glenview, Ill.
Enhance your point-of-care ultrasonography skills through hands-on training by experts in the field. Discover key elements of critical care ultrasonography and practice image acquisition with human models using high-quality ultrasound machines in this intensive 3-day course. Participants will earn 20.50 AMA PRA Category 1 Credits™ and MOC points.
Topics include:
- Vascular Access
- Vascular Diagnostic
- Echocardiography: Techniques and Standard Views
- Basic Critical Care and Echocardiography Overview
- Common Clinical Application of Ultrasonography to Guide Management of the Critically Ill
Learn more and register at livelearning.chestnet.org/ultrasonography.
Not a member? Join the movement today
Over 15,000 members have joined SHM to show their commitment to transforming health care and revolutionizing patient care. As an SHM member you will be connected to a wealth of opportunities designed to help you grow professionally, network with colleagues nationwide, and shape the practice of hospital medicine. See a full list of SHM member benefits or become a member today by visiting hospitalmedicine.org/join.
Mr. Radler is marketing communications manager at the Society of Hospital Medicine.
Recognizing American Diabetes Month, COPD Awareness Month, and CDC’s Get Smart Week with QI Solutions
- There’s no better time than during American Diabetes Month to learn more about SHM’s Glycemic Control programs. Find out how your institution can submit point-of-care data to SHM’s Data Center, generate monthly reports and be included in the national glucometrics benchmark report. Hospital systems are also encouraged to subscribe to track and compare their individual as well as overall performance. Be one of the 100-plus hospitals nationwide that are supported by SHM’s respected Glycemic Control Programs. Contact Sara Platt for a free demo at splatt@hospitalmedicine.org or by phone at 267-702-2672. For additional information, visit hospitalmedicine.org/gc.
- November marks Chronic Obstructive Pulmonary Disease (COPD) Month, and it is critical that hospitals begin to direct QI resources to improving care for COPD patients. SHM developed a free guide to help you make changes to COPD care at both the individual patient and the institutional levels. Whether you are a clinician, medical director, VP of quality or chief medical officer, these resources can help you. Visit hospitalmedicine.org/COPD to download the guide.
- And, in conjunction with the Centers for Disease Control & Prevention’s (CDC’s) Get Smart Week, SHM is committed to promoting improved antibiotic prescribing behaviors among U.S. hospitalists. Through the Fight the Resistance campaign, SHM has developed many antimicrobial stewardship resources, including an implementation guide, four educational modules, and posters to hang in your hospital. Learn more at hospitalmedicine.org/abx.
Present your abstract in front of a national audience at HM18
SHM is accepting submissions for the Research, Innovations, and Clinical Vignettes (RIV) Competition at Hospital Medicine 2018 (HM18). Based on past experience, the RIV Competition is likely to be one of the most popular events at HM18, enabling hospitalists from across the country to discuss emerging science and clinical cases, share feedback, and make valuable professional connections.
Many of the cutting-edge abstracts that are first presented at SHM’s RIV sessions go on to be published in highly respected medical journals. The competition also includes a special Trainee Award category for resident and student authors.
SHM is excited to launch the Resident Travel Grant for 10 residents to receive funding to help cover the costs of travel and accommodations to attend SHM’s annual conference. See full details on how to apply and the selection process at shmannualconference.org/riv.
The submission deadline is Sunday, Dec. 3, 2017.
Distinguish yourself as a Class of 2018 Fellow in Hospital Medicine
SHM’s Fellows designation is a prestigious way to differentiate yourself in the rapidly growing profession of hospital medicine. There are currently over 2,000 hospitalists who have earned the Fellow in Hospital Medicine (FHM) or Senior Fellow in Hospital Medicine (SFHM) designation by demonstrating the core values of leadership, teamwork, and quality improvement.
Apply now and learn how you can join this prestigious group of hospitalists at hospitalmedicine.org/fellows. Applications officially close on Nov. 30, 2017.
The hospital observation care problem: Perspectives and solutions from SHM
Hospitalists provide the majority of observation care to Medicare beneficiaries and are often the primary points of contact for patients as they navigate the impact of inpatient and observation care determinations during and after their hospitalizations.
In 2017, SHM re-surveyed members to understand the state of hospital observation care after several legislative and regulatory changes. Through this new survey, hospitalists reported on their experience with the two-midnight rule and the impact of the recent Notification of Observation Treatment and Implication of Care Eligibility (NOTICE) Act, which requires hospitals to inform patients through the Medicare Outpatient Observation Notice (MOON) form that they are hospitalized under observation. Read the white paper to get perspectives and solutions from SHM at hospitalmedicine.org/advocacy.
Introducing ‘Ultrasonography: Essentials in Critical Care’
Brought to you by SHM and CHEST®, the Ultrasonography: Essentials in Critical Care course will be held Dec. 1-3, 2017, at the CHEST Innovation, Simulation, and Training Center in Glenview, Ill.
Enhance your point-of-care ultrasonography skills through hands-on training by experts in the field. Discover key elements of critical care ultrasonography and practice image acquisition with human models using high-quality ultrasound machines in this intensive 3-day course. Participants will earn 20.50 AMA PRA Category 1 Credits™ and MOC points.
Topics include:
- Vascular Access
- Vascular Diagnostic
- Echocardiography: Techniques and Standard Views
- Basic Critical Care and Echocardiography Overview
- Common Clinical Application of Ultrasonography to Guide Management of the Critically Ill
Learn more and register at livelearning.chestnet.org/ultrasonography.
Not a member? Join the movement today
Over 15,000 members have joined SHM to show their commitment to transforming health care and revolutionizing patient care. As an SHM member you will be connected to a wealth of opportunities designed to help you grow professionally, network with colleagues nationwide, and shape the practice of hospital medicine. See a full list of SHM member benefits or become a member today by visiting hospitalmedicine.org/join.
Mr. Radler is marketing communications manager at the Society of Hospital Medicine.
Recognizing American Diabetes Month, COPD Awareness Month, and CDC’s Get Smart Week with QI Solutions
- There’s no better time than during American Diabetes Month to learn more about SHM’s Glycemic Control programs. Find out how your institution can submit point-of-care data to SHM’s Data Center, generate monthly reports and be included in the national glucometrics benchmark report. Hospital systems are also encouraged to subscribe to track and compare their individual as well as overall performance. Be one of the 100-plus hospitals nationwide that are supported by SHM’s respected Glycemic Control Programs. Contact Sara Platt for a free demo at splatt@hospitalmedicine.org or by phone at 267-702-2672. For additional information, visit hospitalmedicine.org/gc.
- November marks Chronic Obstructive Pulmonary Disease (COPD) Month, and it is critical that hospitals begin to direct QI resources to improving care for COPD patients. SHM developed a free guide to help you make changes to COPD care at both the individual patient and the institutional levels. Whether you are a clinician, medical director, VP of quality or chief medical officer, these resources can help you. Visit hospitalmedicine.org/COPD to download the guide.
- And, in conjunction with the Centers for Disease Control & Prevention’s (CDC’s) Get Smart Week, SHM is committed to promoting improved antibiotic prescribing behaviors among U.S. hospitalists. Through the Fight the Resistance campaign, SHM has developed many antimicrobial stewardship resources, including an implementation guide, four educational modules, and posters to hang in your hospital. Learn more at hospitalmedicine.org/abx.
Present your abstract in front of a national audience at HM18
SHM is accepting submissions for the Research, Innovations, and Clinical Vignettes (RIV) Competition at Hospital Medicine 2018 (HM18). Based on past experience, the RIV Competition is likely to be one of the most popular events at HM18, enabling hospitalists from across the country to discuss emerging science and clinical cases, share feedback, and make valuable professional connections.
Many of the cutting-edge abstracts that are first presented at SHM’s RIV sessions go on to be published in highly respected medical journals. The competition also includes a special Trainee Award category for resident and student authors.
SHM is excited to launch the Resident Travel Grant for 10 residents to receive funding to help cover the costs of travel and accommodations to attend SHM’s annual conference. See full details on how to apply and the selection process at shmannualconference.org/riv.
The submission deadline is Sunday, Dec. 3, 2017.
Distinguish yourself as a Class of 2018 Fellow in Hospital Medicine
SHM’s Fellows designation is a prestigious way to differentiate yourself in the rapidly growing profession of hospital medicine. There are currently over 2,000 hospitalists who have earned the Fellow in Hospital Medicine (FHM) or Senior Fellow in Hospital Medicine (SFHM) designation by demonstrating the core values of leadership, teamwork, and quality improvement.
Apply now and learn how you can join this prestigious group of hospitalists at hospitalmedicine.org/fellows. Applications officially close on Nov. 30, 2017.
The hospital observation care problem: Perspectives and solutions from SHM
Hospitalists provide the majority of observation care to Medicare beneficiaries and are often the primary points of contact for patients as they navigate the impact of inpatient and observation care determinations during and after their hospitalizations.
In 2017, SHM re-surveyed members to understand the state of hospital observation care after several legislative and regulatory changes. Through this new survey, hospitalists reported on their experience with the two-midnight rule and the impact of the recent Notification of Observation Treatment and Implication of Care Eligibility (NOTICE) Act, which requires hospitals to inform patients through the Medicare Outpatient Observation Notice (MOON) form that they are hospitalized under observation. Read the white paper to get perspectives and solutions from SHM at hospitalmedicine.org/advocacy.
Introducing ‘Ultrasonography: Essentials in Critical Care’
Brought to you by SHM and CHEST®, the Ultrasonography: Essentials in Critical Care course will be held Dec. 1-3, 2017, at the CHEST Innovation, Simulation, and Training Center in Glenview, Ill.
Enhance your point-of-care ultrasonography skills through hands-on training by experts in the field. Discover key elements of critical care ultrasonography and practice image acquisition with human models using high-quality ultrasound machines in this intensive 3-day course. Participants will earn 20.50 AMA PRA Category 1 Credits™ and MOC points.
Topics include:
- Vascular Access
- Vascular Diagnostic
- Echocardiography: Techniques and Standard Views
- Basic Critical Care and Echocardiography Overview
- Common Clinical Application of Ultrasonography to Guide Management of the Critically Ill
Learn more and register at livelearning.chestnet.org/ultrasonography.
Not a member? Join the movement today
Over 15,000 members have joined SHM to show their commitment to transforming health care and revolutionizing patient care. As an SHM member you will be connected to a wealth of opportunities designed to help you grow professionally, network with colleagues nationwide, and shape the practice of hospital medicine. See a full list of SHM member benefits or become a member today by visiting hospitalmedicine.org/join.
Mr. Radler is marketing communications manager at the Society of Hospital Medicine.
Technique for apical suspension at the time of total laparoscopic hysterectomy
Visit the Society of Gynecologic Surgeons online: sgsonline.org
Additional videos from SGS are available here, including these recent offerings:
Visit the Society of Gynecologic Surgeons online: sgsonline.org
Additional videos from SGS are available here, including these recent offerings:
Visit the Society of Gynecologic Surgeons online: sgsonline.org
Additional videos from SGS are available here, including these recent offerings:
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Schizophrenia’s silent epidemic: Iatrogenic sexual dysfunction
PARIS – Many psychiatrists have no inkling of how often the antipsychotic agents they prescribe cause hyperprolactinemia-related sexual dysfunction, or the serious negative consequences these common side effects have on quality of life and treatment adherence, Ángel L. Montejo, MD, PhD, declared at the annual congress of the European College of Neuropsychopharmacology.
Psychiatrists are largely uninformed about these matters, because for the most part, they avoid talking with their schizophrenia patients about their sexual activity or inquiring about sexual dysfunction. And they don’t perform the physical examinations that might reveal tell-tale stigmatizing gynecomastia or galactorrhea, according to Dr. Montejo, professor of psychiatry at the University of Salamanca (Spain).
The consensus report includes recommendations for the detection and management of the full range of manifestations of iatrogenic hyperprolactinemia, including osteoporosis and hip fracture, hypogonadism, premature menopause, cardiovascular disease, breast and endometrial cancer, and immunologic disorders.
However, the most common expression of antipsychotic-related hyperprolactinemia is sexual dysfunction, and that’s what Dr. Montejo focused on. This is an issue that directly relates to clinical outcomes. The literature shows that roughly 36% of male and 19% of female schizophrenia patients either stop taking their medication because of its sexual side effects, which include decreased libido, erectile difficulty, vaginal dryness, and anorgasmia, or are thinking about doing so. At least two in three schizophrenia patients engage in some sort of sexual activity. Sixty percent of patients say that having a sexual life is important to them. Yet 73% of psychiatrists in one survey indicated that they don’t interview their patients about their sexual relations.
“If sexual activity is good for you, why isn’t it good for your patients? We’re talking about love, about human relationships. Having a sexual and emotional life can help patients get the best outcomes,” said Dr. Montejo.
“If you don’t ask about sexual dysfunction, your patients won’t tell. Therefore, you may not see it, but your patients will experience it. They know the difference between their sexual life before treatment and during treatment,” he continued.
The incidence of sexual dysfunction in patients on antipsychotic therapy is a function of the agent they are on. Iatrogenic hyperprolactinemia is a consequence of intense blockade of dopamine D2 receptors. The most potent antipsychotic dopamine D2 receptor antagonists are risperidone and paliperidone, followed by haloperidol and most other first-generation antipsychotics.
A normal prolactin level is less than 25 ng/mL in women and less than 20 ng/mL in men. Endocrinologists divide hyperprolactinemia into three categories: mild hyperprolactinemia is a level of 25-50 ng/mL, moderate is 51-100 ng/mL, and severe is anything over 100 ng/mL.
In one study, 44% of patients on oral risperidone at a mean dose of 4.9 mg/day had moderate and 23% had severe hyperprolactinemia; in patients on the injectable long-acting formulation of the drug at a mean dose of 46.2 mg/month, 23% of patients had moderate and 31% had severe hyperprolactinemia. Patients on oral paliperidone at a mean dose of 8.5 mg/day had a 45% prevalence of moderate and an 18% rate of severe hyperprolactinemia, while 40% of those on long-acting injectable paliperidone at a mean of 104 mg/month had moderate and another 40% had severe hyperprolactinemia.
Sixty to 80% of patients on risperidone or paliperidone experience hyperprolactinemia-induced sexual dysfunction. At the other end of the spectrum is the prolactin-sparing antipsychotic aripiprazole, which is associated with sexual dysfunction in about 5% of treated patients. In a meta-analysis, the other prolactin-sparing antipsychotics included ziprasidone, with a 10% rate, quetiapine at 12%, and olanzapine with a 20% rate.
Screening tests for sexual dysfunction
Psychiatrists who are uncomfortable asking patients about sexual dysfunction or don’t want to take the time to do so have other good options. Four easy-to-use, validated instruments are available for free online: the four-question Arizona Sexual Experiences Scale; the Change in Sexual Function Questionnaire, or CSFQ; the Sex Effects Scale, or SexFX; and the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ-SALSEX).
Managing antipsychotic-induced hyperprolactinemia
The Spanish consensus panel recommended that before psychiatrists prescribe an antipsychotic, they should always explain to patients their risk of antipsychotic-related hyperprolactinemia and make an assessment of personal and family history of risk factors for its possible downstream consequences, including osteoporosis and cancer. And Dr. Montejo stressed that clinicians must “always, always, always” get a baseline serum prolactin measurement, to be repeated after increasing the drug dosage, changing antipsychotics, or upon development of symptoms of hyperprolactinemia.
When a patient’s prolactin level climbs above 50 ng/mL or symptoms of hyperprolactinemia arise, the preferred strategy is to switch to a prolactin-sparing antipsychotic. Most of the alternative options are unsatisfactory. For example, waiting for a sexual side effect to pass is pointless, because it won’t happen spontaneously. A drug holiday undermines compliance. Reducing the antipsychotic dose increases the risk of relapse.
And as for prescribing adjunctive dopamine agonist therapy, well: “Adding a dopamine agonist is not the first step. It should be one of the last steps, because it greatly increases the odds of worsening psychosis,” Dr. Montejo said.
If switching to a different antipsychotic is not possible, the expert panel recommended add-on aripiprazole, accompanied if possible by a downward dose adjustment of the offending antipsychotic. This is an effective way to lower elevated serum prolactin levels.
It’s appropriate to order a lumbar spine and proximal femur bone mineral density measurement in patients on antipsychotic agents if they are older than age 65, have had amenorrhea for at least 6 months, experienced menopause before age 35, have a body mass index below 19 kg/m2, or are experiencing any symptoms of hyperprolactinemia, including sexual dysfunction, according to the Spanish consensus algorithm.
Dr. Montejo reported receiving research grants from and/or serving as a consultant to more than half a dozen pharmaceutical companies.
PARIS – Many psychiatrists have no inkling of how often the antipsychotic agents they prescribe cause hyperprolactinemia-related sexual dysfunction, or the serious negative consequences these common side effects have on quality of life and treatment adherence, Ángel L. Montejo, MD, PhD, declared at the annual congress of the European College of Neuropsychopharmacology.
Psychiatrists are largely uninformed about these matters, because for the most part, they avoid talking with their schizophrenia patients about their sexual activity or inquiring about sexual dysfunction. And they don’t perform the physical examinations that might reveal tell-tale stigmatizing gynecomastia or galactorrhea, according to Dr. Montejo, professor of psychiatry at the University of Salamanca (Spain).
The consensus report includes recommendations for the detection and management of the full range of manifestations of iatrogenic hyperprolactinemia, including osteoporosis and hip fracture, hypogonadism, premature menopause, cardiovascular disease, breast and endometrial cancer, and immunologic disorders.
However, the most common expression of antipsychotic-related hyperprolactinemia is sexual dysfunction, and that’s what Dr. Montejo focused on. This is an issue that directly relates to clinical outcomes. The literature shows that roughly 36% of male and 19% of female schizophrenia patients either stop taking their medication because of its sexual side effects, which include decreased libido, erectile difficulty, vaginal dryness, and anorgasmia, or are thinking about doing so. At least two in three schizophrenia patients engage in some sort of sexual activity. Sixty percent of patients say that having a sexual life is important to them. Yet 73% of psychiatrists in one survey indicated that they don’t interview their patients about their sexual relations.
“If sexual activity is good for you, why isn’t it good for your patients? We’re talking about love, about human relationships. Having a sexual and emotional life can help patients get the best outcomes,” said Dr. Montejo.
“If you don’t ask about sexual dysfunction, your patients won’t tell. Therefore, you may not see it, but your patients will experience it. They know the difference between their sexual life before treatment and during treatment,” he continued.
The incidence of sexual dysfunction in patients on antipsychotic therapy is a function of the agent they are on. Iatrogenic hyperprolactinemia is a consequence of intense blockade of dopamine D2 receptors. The most potent antipsychotic dopamine D2 receptor antagonists are risperidone and paliperidone, followed by haloperidol and most other first-generation antipsychotics.
A normal prolactin level is less than 25 ng/mL in women and less than 20 ng/mL in men. Endocrinologists divide hyperprolactinemia into three categories: mild hyperprolactinemia is a level of 25-50 ng/mL, moderate is 51-100 ng/mL, and severe is anything over 100 ng/mL.
In one study, 44% of patients on oral risperidone at a mean dose of 4.9 mg/day had moderate and 23% had severe hyperprolactinemia; in patients on the injectable long-acting formulation of the drug at a mean dose of 46.2 mg/month, 23% of patients had moderate and 31% had severe hyperprolactinemia. Patients on oral paliperidone at a mean dose of 8.5 mg/day had a 45% prevalence of moderate and an 18% rate of severe hyperprolactinemia, while 40% of those on long-acting injectable paliperidone at a mean of 104 mg/month had moderate and another 40% had severe hyperprolactinemia.
Sixty to 80% of patients on risperidone or paliperidone experience hyperprolactinemia-induced sexual dysfunction. At the other end of the spectrum is the prolactin-sparing antipsychotic aripiprazole, which is associated with sexual dysfunction in about 5% of treated patients. In a meta-analysis, the other prolactin-sparing antipsychotics included ziprasidone, with a 10% rate, quetiapine at 12%, and olanzapine with a 20% rate.
Screening tests for sexual dysfunction
Psychiatrists who are uncomfortable asking patients about sexual dysfunction or don’t want to take the time to do so have other good options. Four easy-to-use, validated instruments are available for free online: the four-question Arizona Sexual Experiences Scale; the Change in Sexual Function Questionnaire, or CSFQ; the Sex Effects Scale, or SexFX; and the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ-SALSEX).
Managing antipsychotic-induced hyperprolactinemia
The Spanish consensus panel recommended that before psychiatrists prescribe an antipsychotic, they should always explain to patients their risk of antipsychotic-related hyperprolactinemia and make an assessment of personal and family history of risk factors for its possible downstream consequences, including osteoporosis and cancer. And Dr. Montejo stressed that clinicians must “always, always, always” get a baseline serum prolactin measurement, to be repeated after increasing the drug dosage, changing antipsychotics, or upon development of symptoms of hyperprolactinemia.
When a patient’s prolactin level climbs above 50 ng/mL or symptoms of hyperprolactinemia arise, the preferred strategy is to switch to a prolactin-sparing antipsychotic. Most of the alternative options are unsatisfactory. For example, waiting for a sexual side effect to pass is pointless, because it won’t happen spontaneously. A drug holiday undermines compliance. Reducing the antipsychotic dose increases the risk of relapse.
And as for prescribing adjunctive dopamine agonist therapy, well: “Adding a dopamine agonist is not the first step. It should be one of the last steps, because it greatly increases the odds of worsening psychosis,” Dr. Montejo said.
If switching to a different antipsychotic is not possible, the expert panel recommended add-on aripiprazole, accompanied if possible by a downward dose adjustment of the offending antipsychotic. This is an effective way to lower elevated serum prolactin levels.
It’s appropriate to order a lumbar spine and proximal femur bone mineral density measurement in patients on antipsychotic agents if they are older than age 65, have had amenorrhea for at least 6 months, experienced menopause before age 35, have a body mass index below 19 kg/m2, or are experiencing any symptoms of hyperprolactinemia, including sexual dysfunction, according to the Spanish consensus algorithm.
Dr. Montejo reported receiving research grants from and/or serving as a consultant to more than half a dozen pharmaceutical companies.
PARIS – Many psychiatrists have no inkling of how often the antipsychotic agents they prescribe cause hyperprolactinemia-related sexual dysfunction, or the serious negative consequences these common side effects have on quality of life and treatment adherence, Ángel L. Montejo, MD, PhD, declared at the annual congress of the European College of Neuropsychopharmacology.
Psychiatrists are largely uninformed about these matters, because for the most part, they avoid talking with their schizophrenia patients about their sexual activity or inquiring about sexual dysfunction. And they don’t perform the physical examinations that might reveal tell-tale stigmatizing gynecomastia or galactorrhea, according to Dr. Montejo, professor of psychiatry at the University of Salamanca (Spain).
The consensus report includes recommendations for the detection and management of the full range of manifestations of iatrogenic hyperprolactinemia, including osteoporosis and hip fracture, hypogonadism, premature menopause, cardiovascular disease, breast and endometrial cancer, and immunologic disorders.
However, the most common expression of antipsychotic-related hyperprolactinemia is sexual dysfunction, and that’s what Dr. Montejo focused on. This is an issue that directly relates to clinical outcomes. The literature shows that roughly 36% of male and 19% of female schizophrenia patients either stop taking their medication because of its sexual side effects, which include decreased libido, erectile difficulty, vaginal dryness, and anorgasmia, or are thinking about doing so. At least two in three schizophrenia patients engage in some sort of sexual activity. Sixty percent of patients say that having a sexual life is important to them. Yet 73% of psychiatrists in one survey indicated that they don’t interview their patients about their sexual relations.
“If sexual activity is good for you, why isn’t it good for your patients? We’re talking about love, about human relationships. Having a sexual and emotional life can help patients get the best outcomes,” said Dr. Montejo.
“If you don’t ask about sexual dysfunction, your patients won’t tell. Therefore, you may not see it, but your patients will experience it. They know the difference between their sexual life before treatment and during treatment,” he continued.
The incidence of sexual dysfunction in patients on antipsychotic therapy is a function of the agent they are on. Iatrogenic hyperprolactinemia is a consequence of intense blockade of dopamine D2 receptors. The most potent antipsychotic dopamine D2 receptor antagonists are risperidone and paliperidone, followed by haloperidol and most other first-generation antipsychotics.
A normal prolactin level is less than 25 ng/mL in women and less than 20 ng/mL in men. Endocrinologists divide hyperprolactinemia into three categories: mild hyperprolactinemia is a level of 25-50 ng/mL, moderate is 51-100 ng/mL, and severe is anything over 100 ng/mL.
In one study, 44% of patients on oral risperidone at a mean dose of 4.9 mg/day had moderate and 23% had severe hyperprolactinemia; in patients on the injectable long-acting formulation of the drug at a mean dose of 46.2 mg/month, 23% of patients had moderate and 31% had severe hyperprolactinemia. Patients on oral paliperidone at a mean dose of 8.5 mg/day had a 45% prevalence of moderate and an 18% rate of severe hyperprolactinemia, while 40% of those on long-acting injectable paliperidone at a mean of 104 mg/month had moderate and another 40% had severe hyperprolactinemia.
Sixty to 80% of patients on risperidone or paliperidone experience hyperprolactinemia-induced sexual dysfunction. At the other end of the spectrum is the prolactin-sparing antipsychotic aripiprazole, which is associated with sexual dysfunction in about 5% of treated patients. In a meta-analysis, the other prolactin-sparing antipsychotics included ziprasidone, with a 10% rate, quetiapine at 12%, and olanzapine with a 20% rate.
Screening tests for sexual dysfunction
Psychiatrists who are uncomfortable asking patients about sexual dysfunction or don’t want to take the time to do so have other good options. Four easy-to-use, validated instruments are available for free online: the four-question Arizona Sexual Experiences Scale; the Change in Sexual Function Questionnaire, or CSFQ; the Sex Effects Scale, or SexFX; and the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ-SALSEX).
Managing antipsychotic-induced hyperprolactinemia
The Spanish consensus panel recommended that before psychiatrists prescribe an antipsychotic, they should always explain to patients their risk of antipsychotic-related hyperprolactinemia and make an assessment of personal and family history of risk factors for its possible downstream consequences, including osteoporosis and cancer. And Dr. Montejo stressed that clinicians must “always, always, always” get a baseline serum prolactin measurement, to be repeated after increasing the drug dosage, changing antipsychotics, or upon development of symptoms of hyperprolactinemia.
When a patient’s prolactin level climbs above 50 ng/mL or symptoms of hyperprolactinemia arise, the preferred strategy is to switch to a prolactin-sparing antipsychotic. Most of the alternative options are unsatisfactory. For example, waiting for a sexual side effect to pass is pointless, because it won’t happen spontaneously. A drug holiday undermines compliance. Reducing the antipsychotic dose increases the risk of relapse.
And as for prescribing adjunctive dopamine agonist therapy, well: “Adding a dopamine agonist is not the first step. It should be one of the last steps, because it greatly increases the odds of worsening psychosis,” Dr. Montejo said.
If switching to a different antipsychotic is not possible, the expert panel recommended add-on aripiprazole, accompanied if possible by a downward dose adjustment of the offending antipsychotic. This is an effective way to lower elevated serum prolactin levels.
It’s appropriate to order a lumbar spine and proximal femur bone mineral density measurement in patients on antipsychotic agents if they are older than age 65, have had amenorrhea for at least 6 months, experienced menopause before age 35, have a body mass index below 19 kg/m2, or are experiencing any symptoms of hyperprolactinemia, including sexual dysfunction, according to the Spanish consensus algorithm.
Dr. Montejo reported receiving research grants from and/or serving as a consultant to more than half a dozen pharmaceutical companies.
EXPERT ANALYSIS FROM THE ECNP CONGRESS
VIDEO: Dr. Charles E. Miller’s AAGL highlights
NATIONAL HARBOR, MD. – The biggest theme of the 2017 AAGL Global Congress was the importance of understanding anatomy, Charles E. Miller, MD, a minimally invasive gynecologic surgeon in Naperville, Ill., and past president of the AAGL, said at the meeting.
“It’s about doing surgery in the right place, in the right space,” he said.
One of the advantages of this year’s Congress is a greater emphasis on cadaveric dissections, Dr. Miller said during an interview. “Understanding how the nerves are placed, how the vessels are in place, the muscles and the different spaces, and how that all relates to our most complex dissections.”
In a presentation on neuropelveology, Michael Hibner, MD, and Mario Castellanos, MD, of St. Joseph’s Hospital and Medical Center, Phoenix, performed a live cadaveric dissection showing how to deal with a trapped pudendal nerve, working over the gluteus maximus and dissecting down.
In a video session, surgeons demonstrated a needleless robotic-assisted transabdominal cerclage. The nonneedle procedure used a unique, posterior placement of the cerclage knot, a technique which Dr. Miller said he plans to use in his own practice.
The incorporation of colleagues from around the country, and around the world, was another strength of this year’s Congress, said Dr. Miller, particularly a presentation from a Chinese ob.gyn. association on isthmoceles. “To be able to see that this transcends miles upon miles upon miles, but yet we’re seeing the same type of problems, is quite interesting,” he said.
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
NATIONAL HARBOR, MD. – The biggest theme of the 2017 AAGL Global Congress was the importance of understanding anatomy, Charles E. Miller, MD, a minimally invasive gynecologic surgeon in Naperville, Ill., and past president of the AAGL, said at the meeting.
“It’s about doing surgery in the right place, in the right space,” he said.
One of the advantages of this year’s Congress is a greater emphasis on cadaveric dissections, Dr. Miller said during an interview. “Understanding how the nerves are placed, how the vessels are in place, the muscles and the different spaces, and how that all relates to our most complex dissections.”
In a presentation on neuropelveology, Michael Hibner, MD, and Mario Castellanos, MD, of St. Joseph’s Hospital and Medical Center, Phoenix, performed a live cadaveric dissection showing how to deal with a trapped pudendal nerve, working over the gluteus maximus and dissecting down.
In a video session, surgeons demonstrated a needleless robotic-assisted transabdominal cerclage. The nonneedle procedure used a unique, posterior placement of the cerclage knot, a technique which Dr. Miller said he plans to use in his own practice.
The incorporation of colleagues from around the country, and around the world, was another strength of this year’s Congress, said Dr. Miller, particularly a presentation from a Chinese ob.gyn. association on isthmoceles. “To be able to see that this transcends miles upon miles upon miles, but yet we’re seeing the same type of problems, is quite interesting,” he said.
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
NATIONAL HARBOR, MD. – The biggest theme of the 2017 AAGL Global Congress was the importance of understanding anatomy, Charles E. Miller, MD, a minimally invasive gynecologic surgeon in Naperville, Ill., and past president of the AAGL, said at the meeting.
“It’s about doing surgery in the right place, in the right space,” he said.
One of the advantages of this year’s Congress is a greater emphasis on cadaveric dissections, Dr. Miller said during an interview. “Understanding how the nerves are placed, how the vessels are in place, the muscles and the different spaces, and how that all relates to our most complex dissections.”
In a presentation on neuropelveology, Michael Hibner, MD, and Mario Castellanos, MD, of St. Joseph’s Hospital and Medical Center, Phoenix, performed a live cadaveric dissection showing how to deal with a trapped pudendal nerve, working over the gluteus maximus and dissecting down.
In a video session, surgeons demonstrated a needleless robotic-assisted transabdominal cerclage. The nonneedle procedure used a unique, posterior placement of the cerclage knot, a technique which Dr. Miller said he plans to use in his own practice.
The incorporation of colleagues from around the country, and around the world, was another strength of this year’s Congress, said Dr. Miller, particularly a presentation from a Chinese ob.gyn. association on isthmoceles. “To be able to see that this transcends miles upon miles upon miles, but yet we’re seeing the same type of problems, is quite interesting,” he said.
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
AT AAGL 2017
In bariatric surgery, leak test may backfire
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
AT WSA 2017
Key clinical point: Use of endoscopy to perform the provocative test may reduce the incidence of anastomotic leaks.
Major finding: The rate of leaks was 0.8% in patients who had the provocative test, compared with 0.4% in patients who didn’t have the test.
Data source: A retrospective analysis of 133,478 procedures.
Disclosures: The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
Dedicated sickle cell center offers roadmap for care
CONCORD, N.C. – A care center for acute sickle cell pain management, which includes a dedicated emergency room and a daytime management unit in the hospital, decreased health system costs and the frequency of acute care visits by sickle cell patients, James Eckman, MD, reported at Sickle Cell Disease Symposium held by Carolinas Health Care System.
“In the first 5 years of the center, acute care visits dropped from 16 per patient per year to 10, and admissions per active patient per year dropped from 2.1 to less than one,” said Dr. Eckman, former medical director of the Georgia Comprehensive Sickle Cell Center at Grady Health System in Atlanta.
By 2011, those numbers had dropped further, falling to less than four acute care visits per patient per year and less than 0.5 admissions per patient per year.
The results Dr. Eckman reported are based on 37 years of his experience at Grady Health System, which included setting up an emergency room dedicated to patients with sickle cell disease (SCD) and the launch of a tertiary care clinic in 1985. The Grady SCD database includes more than 4,500 patients, with about 1,000 adults active at any given time.
It’s , according to Emory University.
“We really developed a model that was very cost effective for the management of this disease,” said Dr. Eckman, professor emeritus in hematology and medical oncology at Emory University. “We actually consistently turned a profit in our budget.”
Previously, SCD patients went to the regular emergency department for their acute pain crises, and they would often wait for hours without treatment. “You need to initiate treatment rapidly in these patients,” Dr. Eckman said. “It’s really unacceptable now what’s happening in our emergency rooms, where they have to wait 3, 4, or more hours to get treated while they’re in intolerable pain.”
In 2014, an expert panel issued guidelines for pain management in SCD calling for the initiation of pain treatment for acute crisis within 30 minutes of the patient’s arrival in the emergency department (JAMA. 2014 Sep 10;312[10]:1033-48). “Our goal is 20 minutes to have a complete assessment, get a laboratory draw, and have them on therapy,” he said. “And we were relatively successful in being able to do that.”
Each patient at the center was enrolled in a care management program consisting of 35 assessment and intervention elements. Assessment includes a complete medical evaluation, along with social and psychological evaluations. Intervention entails developing a detailed problem list – including medical, social, and psychological issues – a detailed management plan, and a social support plan. The initial assessment can take 4-8 hours.
For the first decade, the program tracked acute care visits and admissions in 166 continuing patients and saw dramatic declines in both. “The data only go through 1995, but they actually look exactly the same after 1995 all the way up to 2015,” Dr. Eckman said. “This sustained a really marked decrease in health care utilization.”
The program also identified a small group of patients – fewer than 75 out of a base of 1,000 – who accounted for 90% of visits, he said.
Although the Georgia experience is based on a dedicated care center for SCD, the results can be replicated without that type of dedicated infrastructure, Dr. Eckman said. “It is not the 24-hour acute care center,” he said. “It’s the carefully thought out and implemented comprehensive care plan by a multidisciplinary care team dedicated to care of the individuals with sickle cell disease that makes the difference.”
Dr. Eckman reported having no financial disclosures.
CONCORD, N.C. – A care center for acute sickle cell pain management, which includes a dedicated emergency room and a daytime management unit in the hospital, decreased health system costs and the frequency of acute care visits by sickle cell patients, James Eckman, MD, reported at Sickle Cell Disease Symposium held by Carolinas Health Care System.
“In the first 5 years of the center, acute care visits dropped from 16 per patient per year to 10, and admissions per active patient per year dropped from 2.1 to less than one,” said Dr. Eckman, former medical director of the Georgia Comprehensive Sickle Cell Center at Grady Health System in Atlanta.
By 2011, those numbers had dropped further, falling to less than four acute care visits per patient per year and less than 0.5 admissions per patient per year.
The results Dr. Eckman reported are based on 37 years of his experience at Grady Health System, which included setting up an emergency room dedicated to patients with sickle cell disease (SCD) and the launch of a tertiary care clinic in 1985. The Grady SCD database includes more than 4,500 patients, with about 1,000 adults active at any given time.
It’s , according to Emory University.
“We really developed a model that was very cost effective for the management of this disease,” said Dr. Eckman, professor emeritus in hematology and medical oncology at Emory University. “We actually consistently turned a profit in our budget.”
Previously, SCD patients went to the regular emergency department for their acute pain crises, and they would often wait for hours without treatment. “You need to initiate treatment rapidly in these patients,” Dr. Eckman said. “It’s really unacceptable now what’s happening in our emergency rooms, where they have to wait 3, 4, or more hours to get treated while they’re in intolerable pain.”
In 2014, an expert panel issued guidelines for pain management in SCD calling for the initiation of pain treatment for acute crisis within 30 minutes of the patient’s arrival in the emergency department (JAMA. 2014 Sep 10;312[10]:1033-48). “Our goal is 20 minutes to have a complete assessment, get a laboratory draw, and have them on therapy,” he said. “And we were relatively successful in being able to do that.”
Each patient at the center was enrolled in a care management program consisting of 35 assessment and intervention elements. Assessment includes a complete medical evaluation, along with social and psychological evaluations. Intervention entails developing a detailed problem list – including medical, social, and psychological issues – a detailed management plan, and a social support plan. The initial assessment can take 4-8 hours.
For the first decade, the program tracked acute care visits and admissions in 166 continuing patients and saw dramatic declines in both. “The data only go through 1995, but they actually look exactly the same after 1995 all the way up to 2015,” Dr. Eckman said. “This sustained a really marked decrease in health care utilization.”
The program also identified a small group of patients – fewer than 75 out of a base of 1,000 – who accounted for 90% of visits, he said.
Although the Georgia experience is based on a dedicated care center for SCD, the results can be replicated without that type of dedicated infrastructure, Dr. Eckman said. “It is not the 24-hour acute care center,” he said. “It’s the carefully thought out and implemented comprehensive care plan by a multidisciplinary care team dedicated to care of the individuals with sickle cell disease that makes the difference.”
Dr. Eckman reported having no financial disclosures.
CONCORD, N.C. – A care center for acute sickle cell pain management, which includes a dedicated emergency room and a daytime management unit in the hospital, decreased health system costs and the frequency of acute care visits by sickle cell patients, James Eckman, MD, reported at Sickle Cell Disease Symposium held by Carolinas Health Care System.
“In the first 5 years of the center, acute care visits dropped from 16 per patient per year to 10, and admissions per active patient per year dropped from 2.1 to less than one,” said Dr. Eckman, former medical director of the Georgia Comprehensive Sickle Cell Center at Grady Health System in Atlanta.
By 2011, those numbers had dropped further, falling to less than four acute care visits per patient per year and less than 0.5 admissions per patient per year.
The results Dr. Eckman reported are based on 37 years of his experience at Grady Health System, which included setting up an emergency room dedicated to patients with sickle cell disease (SCD) and the launch of a tertiary care clinic in 1985. The Grady SCD database includes more than 4,500 patients, with about 1,000 adults active at any given time.
It’s , according to Emory University.
“We really developed a model that was very cost effective for the management of this disease,” said Dr. Eckman, professor emeritus in hematology and medical oncology at Emory University. “We actually consistently turned a profit in our budget.”
Previously, SCD patients went to the regular emergency department for their acute pain crises, and they would often wait for hours without treatment. “You need to initiate treatment rapidly in these patients,” Dr. Eckman said. “It’s really unacceptable now what’s happening in our emergency rooms, where they have to wait 3, 4, or more hours to get treated while they’re in intolerable pain.”
In 2014, an expert panel issued guidelines for pain management in SCD calling for the initiation of pain treatment for acute crisis within 30 minutes of the patient’s arrival in the emergency department (JAMA. 2014 Sep 10;312[10]:1033-48). “Our goal is 20 minutes to have a complete assessment, get a laboratory draw, and have them on therapy,” he said. “And we were relatively successful in being able to do that.”
Each patient at the center was enrolled in a care management program consisting of 35 assessment and intervention elements. Assessment includes a complete medical evaluation, along with social and psychological evaluations. Intervention entails developing a detailed problem list – including medical, social, and psychological issues – a detailed management plan, and a social support plan. The initial assessment can take 4-8 hours.
For the first decade, the program tracked acute care visits and admissions in 166 continuing patients and saw dramatic declines in both. “The data only go through 1995, but they actually look exactly the same after 1995 all the way up to 2015,” Dr. Eckman said. “This sustained a really marked decrease in health care utilization.”
The program also identified a small group of patients – fewer than 75 out of a base of 1,000 – who accounted for 90% of visits, he said.
Although the Georgia experience is based on a dedicated care center for SCD, the results can be replicated without that type of dedicated infrastructure, Dr. Eckman said. “It is not the 24-hour acute care center,” he said. “It’s the carefully thought out and implemented comprehensive care plan by a multidisciplinary care team dedicated to care of the individuals with sickle cell disease that makes the difference.”
Dr. Eckman reported having no financial disclosures.
EXPERT ANALYSIS FROM A MEETING ON SICKLE CELL DISEASE
Living liver donation safety supported in single-center study
SCOTTSDALE, ARIZ. – A single-center analysis of complications following living liver donation found a low rate of severe complications, and a high quality of life among donors. The results are similar to what has been seen in a previous multicenter study in the United States, and the authors hope that the results can help inform potential donors and their physicians.
There is a significant shortage of deceased liver donors, leading to the death of about 3,500 liver transplant hopefuls in 2016, compared with about 2,900 who received a transplant. Living donor transplant was developed and first attempted in 1996 as an attempt to counter this shortage, and for a brief period it was popular, peaking at 500 donor surgeries in 2001. But that year the death of a donor occurred in New York and received widespread publicity.
Overall, though, the study showed relatively few complications, and that donors reported good quality of life. “There was a slight dip in health-related quality of life at 5 years and 10 years, but at all times the donors had significantly better quality of life compared to the standard population,” said Dr. Chinnakotla, clinical director of pediatric transplantation at the University of Minnesota, Minneapolis.
The researchers examined long-term complications and quality of life among 176 liver donors who underwent surgery between 1997 and 2016 at the University of Minnesota. At total of 140 donors underwent a right-lobe hepatectomy without middle hepatic vein, 14 underwent right lobe with middle hepatic vein, 4 underwent left lobe, and 18 underwent left lateral segmentectomy.
The researchers then analyzed complications graded by the Clavien scale. They found that 59.1% of right-lobe donors experienced no complications at all; 5.8% had Clavien scale 1 complications, meaning something abnormal occurred but required no intervention; and 27.3% had a Clavien 2 complication, requiring pharmaceutical treatment, a blood transfusion, or parenteral nutrition. Clavien 3a complications, which required an intervention without general anesthesia, occurred in 1.9% of cases, and Clavien 3b complications, which required anesthesia, occurred in 5.8%.
A total of 81.8% of left-lobe donors experienced no complications, 4.5% had a Clavien 1 complication, and 13.6% a Clavien 2. There were no Clavien 3 or 4 complications in left-lobe donors.
Overall, the incidence of Clavien grade 3 or higher complications was 7%, there were no complications involving organ failure, and there were no deaths.
Quality of life, as measured by the 36-item Short Form Health Survey and an internally designed donor-specific survey, was higher among recipients than in the general population at all time points. The primary long-term complaints were incisional discomfort, which ranged from about 23% to 38% in frequency, and intolerance to fatty meals, which had a frequency of 20%-30%, and is likely attributable to accompanying cholecystectomy, according to Dr. Chinnakotla.
“The overall results appear to have been excellent,” said William C. Chapman, MD, who was invited by the meeting organizers to review and comment on the study. Dr. Chapman is surgical director of transplant surgery at Washington University in St. Louis.
Dr. Chapman also noted that some studies in Asia have looked at reducing complications in donors, while avoiding a small-for-size graft, by using two left-lobe grafts from separate living donors (Liver Transpl 2015;21[11]1438-48). “We haven’t been brave enough to do that in the United States, but I think that is a strategy we can look forward to in the future,” said Dr. Chinnakotla.
No funding source was disclosed.
SCOTTSDALE, ARIZ. – A single-center analysis of complications following living liver donation found a low rate of severe complications, and a high quality of life among donors. The results are similar to what has been seen in a previous multicenter study in the United States, and the authors hope that the results can help inform potential donors and their physicians.
There is a significant shortage of deceased liver donors, leading to the death of about 3,500 liver transplant hopefuls in 2016, compared with about 2,900 who received a transplant. Living donor transplant was developed and first attempted in 1996 as an attempt to counter this shortage, and for a brief period it was popular, peaking at 500 donor surgeries in 2001. But that year the death of a donor occurred in New York and received widespread publicity.
Overall, though, the study showed relatively few complications, and that donors reported good quality of life. “There was a slight dip in health-related quality of life at 5 years and 10 years, but at all times the donors had significantly better quality of life compared to the standard population,” said Dr. Chinnakotla, clinical director of pediatric transplantation at the University of Minnesota, Minneapolis.
The researchers examined long-term complications and quality of life among 176 liver donors who underwent surgery between 1997 and 2016 at the University of Minnesota. At total of 140 donors underwent a right-lobe hepatectomy without middle hepatic vein, 14 underwent right lobe with middle hepatic vein, 4 underwent left lobe, and 18 underwent left lateral segmentectomy.
The researchers then analyzed complications graded by the Clavien scale. They found that 59.1% of right-lobe donors experienced no complications at all; 5.8% had Clavien scale 1 complications, meaning something abnormal occurred but required no intervention; and 27.3% had a Clavien 2 complication, requiring pharmaceutical treatment, a blood transfusion, or parenteral nutrition. Clavien 3a complications, which required an intervention without general anesthesia, occurred in 1.9% of cases, and Clavien 3b complications, which required anesthesia, occurred in 5.8%.
A total of 81.8% of left-lobe donors experienced no complications, 4.5% had a Clavien 1 complication, and 13.6% a Clavien 2. There were no Clavien 3 or 4 complications in left-lobe donors.
Overall, the incidence of Clavien grade 3 or higher complications was 7%, there were no complications involving organ failure, and there were no deaths.
Quality of life, as measured by the 36-item Short Form Health Survey and an internally designed donor-specific survey, was higher among recipients than in the general population at all time points. The primary long-term complaints were incisional discomfort, which ranged from about 23% to 38% in frequency, and intolerance to fatty meals, which had a frequency of 20%-30%, and is likely attributable to accompanying cholecystectomy, according to Dr. Chinnakotla.
“The overall results appear to have been excellent,” said William C. Chapman, MD, who was invited by the meeting organizers to review and comment on the study. Dr. Chapman is surgical director of transplant surgery at Washington University in St. Louis.
Dr. Chapman also noted that some studies in Asia have looked at reducing complications in donors, while avoiding a small-for-size graft, by using two left-lobe grafts from separate living donors (Liver Transpl 2015;21[11]1438-48). “We haven’t been brave enough to do that in the United States, but I think that is a strategy we can look forward to in the future,” said Dr. Chinnakotla.
No funding source was disclosed.
SCOTTSDALE, ARIZ. – A single-center analysis of complications following living liver donation found a low rate of severe complications, and a high quality of life among donors. The results are similar to what has been seen in a previous multicenter study in the United States, and the authors hope that the results can help inform potential donors and their physicians.
There is a significant shortage of deceased liver donors, leading to the death of about 3,500 liver transplant hopefuls in 2016, compared with about 2,900 who received a transplant. Living donor transplant was developed and first attempted in 1996 as an attempt to counter this shortage, and for a brief period it was popular, peaking at 500 donor surgeries in 2001. But that year the death of a donor occurred in New York and received widespread publicity.
Overall, though, the study showed relatively few complications, and that donors reported good quality of life. “There was a slight dip in health-related quality of life at 5 years and 10 years, but at all times the donors had significantly better quality of life compared to the standard population,” said Dr. Chinnakotla, clinical director of pediatric transplantation at the University of Minnesota, Minneapolis.
The researchers examined long-term complications and quality of life among 176 liver donors who underwent surgery between 1997 and 2016 at the University of Minnesota. At total of 140 donors underwent a right-lobe hepatectomy without middle hepatic vein, 14 underwent right lobe with middle hepatic vein, 4 underwent left lobe, and 18 underwent left lateral segmentectomy.
The researchers then analyzed complications graded by the Clavien scale. They found that 59.1% of right-lobe donors experienced no complications at all; 5.8% had Clavien scale 1 complications, meaning something abnormal occurred but required no intervention; and 27.3% had a Clavien 2 complication, requiring pharmaceutical treatment, a blood transfusion, or parenteral nutrition. Clavien 3a complications, which required an intervention without general anesthesia, occurred in 1.9% of cases, and Clavien 3b complications, which required anesthesia, occurred in 5.8%.
A total of 81.8% of left-lobe donors experienced no complications, 4.5% had a Clavien 1 complication, and 13.6% a Clavien 2. There were no Clavien 3 or 4 complications in left-lobe donors.
Overall, the incidence of Clavien grade 3 or higher complications was 7%, there were no complications involving organ failure, and there were no deaths.
Quality of life, as measured by the 36-item Short Form Health Survey and an internally designed donor-specific survey, was higher among recipients than in the general population at all time points. The primary long-term complaints were incisional discomfort, which ranged from about 23% to 38% in frequency, and intolerance to fatty meals, which had a frequency of 20%-30%, and is likely attributable to accompanying cholecystectomy, according to Dr. Chinnakotla.
“The overall results appear to have been excellent,” said William C. Chapman, MD, who was invited by the meeting organizers to review and comment on the study. Dr. Chapman is surgical director of transplant surgery at Washington University in St. Louis.
Dr. Chapman also noted that some studies in Asia have looked at reducing complications in donors, while avoiding a small-for-size graft, by using two left-lobe grafts from separate living donors (Liver Transpl 2015;21[11]1438-48). “We haven’t been brave enough to do that in the United States, but I think that is a strategy we can look forward to in the future,” said Dr. Chinnakotla.
No funding source was disclosed.
AT WSA 2017
Interprofessional communication demystified with hands-on EHR training
MONTREAL – A hands-on training program designed to improve communication between physicians and allied health professionals, such as physical therapists, produced gains in comfort and confidence to medical students who completed the training.
After completing the training, which involved both a didactic and a hands-on component, 92.58% of third-year medical students agreed or strongly agreed that they had the skills needed for effective interprofessional communication in the EHR, up from 43.86% before the training.
The idea for the training began when Zaiba Jetpuri, DO, and her physician colleagues at the University of Texas Southwestern Medical Center, Dallas, noticed that medical students and residents often were unsure how best to communicate with nurses, pharmacists, physical therapists, and other members of the healthcare team via the EHR.
Knowing who has what role in an interdisciplinary setting is far from obvious, and knowing how to strike the right tone in EHR communications was a challenge for trainees, Dr. Jetpuri said in an interview during her poster presentation at annual meeting of the North American Primary Care Research Groups.
To address such uncertainties, which can impact both quality and continuity of care, Dr. Jetpuri and her colleagues devised an intervention aimed at third-year medical students who were doing family medicine clerkships. The intervention has been given to about 360 students thus far.
The intervention consisted of two components. The first, a didactic module, delivered information about the importance of professionalism and teamwork and also defined interprofessional roles.
The second phase of the training had students using the “sandbox” of Epic, UT Southwestern’s EHR, to practice responding to hypothetical messages from a patient, a nurse, a pharmacist, and a physical therapist. One message would arrive in the medical student’s EHR inbox each week, and the student would have the week to craft a response.
Dr. Jetpuri said that she and her colleagues worked hard to make the scenarios as realistic as possible: The lengthy patient email included several questions about the safety of taking supplements or herbal remedies. They also tried to make sure that the nuts and bolts of interprofessional communication were covered so that, for example, medical students would end a module knowing what should be included when writing orders for physical therapy and how to place the order correctly.
The responses then went through peer evaluation according to a rubric constructed by the investigators. The training and evaluation were designed to make sure that students acquired a better understanding of the mechanics of EHR interprofessional communication and of the soft skills needed for collegial and professional communication.
Dr. Jetpuri said that she and her colleagues would like to extend this realistic educational tool through the clerkship year for better continuity. They also are working on some technical aspects of the EHR to make communication easier for medical students. Furthermore, they are in the process of validating the peer evaluation process by having instructors use the rubric to duplicate the students’ evaluation. She said, though, that both trainees and faculty see the value in early, realistic experience using the electronic record in a multidisciplinary team.
“Simulated EHR experiences are an important tool to utilize in a medical school curriculum to better train and prepare our students for the postgraduate stage,” wrote Dr. Jetpuri and her colleagues.
Dr. Jetpuri reported that she has no conflicts of interest.
koakes@frontlinemedcom.com
On Twitter @karioakes
MONTREAL – A hands-on training program designed to improve communication between physicians and allied health professionals, such as physical therapists, produced gains in comfort and confidence to medical students who completed the training.
After completing the training, which involved both a didactic and a hands-on component, 92.58% of third-year medical students agreed or strongly agreed that they had the skills needed for effective interprofessional communication in the EHR, up from 43.86% before the training.
The idea for the training began when Zaiba Jetpuri, DO, and her physician colleagues at the University of Texas Southwestern Medical Center, Dallas, noticed that medical students and residents often were unsure how best to communicate with nurses, pharmacists, physical therapists, and other members of the healthcare team via the EHR.
Knowing who has what role in an interdisciplinary setting is far from obvious, and knowing how to strike the right tone in EHR communications was a challenge for trainees, Dr. Jetpuri said in an interview during her poster presentation at annual meeting of the North American Primary Care Research Groups.
To address such uncertainties, which can impact both quality and continuity of care, Dr. Jetpuri and her colleagues devised an intervention aimed at third-year medical students who were doing family medicine clerkships. The intervention has been given to about 360 students thus far.
The intervention consisted of two components. The first, a didactic module, delivered information about the importance of professionalism and teamwork and also defined interprofessional roles.
The second phase of the training had students using the “sandbox” of Epic, UT Southwestern’s EHR, to practice responding to hypothetical messages from a patient, a nurse, a pharmacist, and a physical therapist. One message would arrive in the medical student’s EHR inbox each week, and the student would have the week to craft a response.
Dr. Jetpuri said that she and her colleagues worked hard to make the scenarios as realistic as possible: The lengthy patient email included several questions about the safety of taking supplements or herbal remedies. They also tried to make sure that the nuts and bolts of interprofessional communication were covered so that, for example, medical students would end a module knowing what should be included when writing orders for physical therapy and how to place the order correctly.
The responses then went through peer evaluation according to a rubric constructed by the investigators. The training and evaluation were designed to make sure that students acquired a better understanding of the mechanics of EHR interprofessional communication and of the soft skills needed for collegial and professional communication.
Dr. Jetpuri said that she and her colleagues would like to extend this realistic educational tool through the clerkship year for better continuity. They also are working on some technical aspects of the EHR to make communication easier for medical students. Furthermore, they are in the process of validating the peer evaluation process by having instructors use the rubric to duplicate the students’ evaluation. She said, though, that both trainees and faculty see the value in early, realistic experience using the electronic record in a multidisciplinary team.
“Simulated EHR experiences are an important tool to utilize in a medical school curriculum to better train and prepare our students for the postgraduate stage,” wrote Dr. Jetpuri and her colleagues.
Dr. Jetpuri reported that she has no conflicts of interest.
koakes@frontlinemedcom.com
On Twitter @karioakes
MONTREAL – A hands-on training program designed to improve communication between physicians and allied health professionals, such as physical therapists, produced gains in comfort and confidence to medical students who completed the training.
After completing the training, which involved both a didactic and a hands-on component, 92.58% of third-year medical students agreed or strongly agreed that they had the skills needed for effective interprofessional communication in the EHR, up from 43.86% before the training.
The idea for the training began when Zaiba Jetpuri, DO, and her physician colleagues at the University of Texas Southwestern Medical Center, Dallas, noticed that medical students and residents often were unsure how best to communicate with nurses, pharmacists, physical therapists, and other members of the healthcare team via the EHR.
Knowing who has what role in an interdisciplinary setting is far from obvious, and knowing how to strike the right tone in EHR communications was a challenge for trainees, Dr. Jetpuri said in an interview during her poster presentation at annual meeting of the North American Primary Care Research Groups.
To address such uncertainties, which can impact both quality and continuity of care, Dr. Jetpuri and her colleagues devised an intervention aimed at third-year medical students who were doing family medicine clerkships. The intervention has been given to about 360 students thus far.
The intervention consisted of two components. The first, a didactic module, delivered information about the importance of professionalism and teamwork and also defined interprofessional roles.
The second phase of the training had students using the “sandbox” of Epic, UT Southwestern’s EHR, to practice responding to hypothetical messages from a patient, a nurse, a pharmacist, and a physical therapist. One message would arrive in the medical student’s EHR inbox each week, and the student would have the week to craft a response.
Dr. Jetpuri said that she and her colleagues worked hard to make the scenarios as realistic as possible: The lengthy patient email included several questions about the safety of taking supplements or herbal remedies. They also tried to make sure that the nuts and bolts of interprofessional communication were covered so that, for example, medical students would end a module knowing what should be included when writing orders for physical therapy and how to place the order correctly.
The responses then went through peer evaluation according to a rubric constructed by the investigators. The training and evaluation were designed to make sure that students acquired a better understanding of the mechanics of EHR interprofessional communication and of the soft skills needed for collegial and professional communication.
Dr. Jetpuri said that she and her colleagues would like to extend this realistic educational tool through the clerkship year for better continuity. They also are working on some technical aspects of the EHR to make communication easier for medical students. Furthermore, they are in the process of validating the peer evaluation process by having instructors use the rubric to duplicate the students’ evaluation. She said, though, that both trainees and faculty see the value in early, realistic experience using the electronic record in a multidisciplinary team.
“Simulated EHR experiences are an important tool to utilize in a medical school curriculum to better train and prepare our students for the postgraduate stage,” wrote Dr. Jetpuri and her colleagues.
Dr. Jetpuri reported that she has no conflicts of interest.
koakes@frontlinemedcom.com
On Twitter @karioakes
AT NAPCRG 2017
Key clinical point:
Major finding: After the training, 93% of students felt they had the skills needed for effective interprofessional communication via the EHR.
Data source: Summary data from pilot involving about 360 third-year medical students completing family medicine clerkships.
Disclosures: Dr. Jetpuri reported no outside sources of funding and had no relevant disclosures.
Large database analysis suggests safety of bariatric surgery in seniors
NATIONAL HARBOR, MD. – despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.
There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.
Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.
Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”
Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.
Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.
However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.
The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.
Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.
Dr. Zeni reports no relevant financial relationships.
NATIONAL HARBOR, MD. – despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.
There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.
Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.
Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”
Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.
Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.
However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.
The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.
Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.
Dr. Zeni reports no relevant financial relationships.
NATIONAL HARBOR, MD. – despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.
There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.
Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.
Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”
Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.
Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.
However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.
The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.
Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.
Dr. Zeni reports no relevant financial relationships.
AT OBESITY WEEK 2017
Key clinical point: Based on mortality and morbidity rates, bariatric surgery is acceptably safe in patients older than 60 years of age.
Major finding: Compared with patients younger than 60 years, older patients had only modestly increased rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%).
Data source: A retrospective database analysis.
Disclosures: Dr. Zeni reports no relevant financial relationships.