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Safe Harbor for Docs  Who Follow Guidelines

Safe Harbor for Docs Who Follow Guidelines

Physician leaders are supporting a new proposed federal law that aims to reduce litigation against physicians, lower healthcare costs, and establish more fairness in the analyzing of malpractice claims. The new House bill, Saving Lives, Saving Costs Act, introduced by Congressmen Andy Barr (R-KY) and Ami Bera, MD, (D-CA) would create “safe harbor” – protection from liability – for physicians who follow best practice guidelines from malpractice suits. More than 75% of physicians face a malpractice claim over the course of their career—a liability climate that can drive patient care and encourage overutilization, adding billions of dollars in health costs each year. And patient outcomes don’t appear to improve as a result. If the physician being sued argues that he or she adhered to relevant, best practice guidelines, the case will be put in front of an independent medical review panel for investigation. If the panel determines that the clinician did comply to the guidelines or that the injury was not caused by failure to comply, the case will be dismissed. Personal injury lawyers are pushing back, one in particular claiming: “There is no evidence, however, that this safe harbor would actually promote patient safety. In fact, in Texas, where emergency room physicians have had immunity since 2003, patient safety has steadily decreased.” The Center for Justice and Democracy argues that clinical practice guidelines should not be used as a legal basis for determining negligence. The organization claims that there is already a general recognition that conflict of interest and specialty bias are ongoing problems in the development of clinical practice guidelines. Other concerns include the numerous, and sometimes contradictory, guidelines...

SCAI 2014: Gender Differences Following Angioplasty

The Particulars: Prior research suggests that women with ST-segment myocardial infarction (STEMI) are at greater risk for mortality following primary PCI (PPCI) when compared with men. However, published results have been inconclusive. Data Breakdown: Data on more than 1,200 patients with STEMI who underwent PPCI from 2001 to 2010 were reviewed to compare clinical and procedural characteristics and 30-day mortality between men and women for a study. Women were less likely to be smokers, but more likely to be diabetic and hypertensive. Women also had higher symptoms-to-balloon times, lower left ventricular ejection fractions, and lower left main disease. Women also had a significantly higher 30-day mortality rate than men. Take Home Pearl: Among patients undergoing PPCI, women appear to have more bleeding complications and higher 30-day mortality than...

SCAI 2014: Renal Artery Stenting Outcomes

The Particulars: Results from renal artery stenosis stenting trials have been inconclusive due to varying levels of patient selection criteria, stenosis severity, and trial site quality. A true assessment of the efficacy of renal artery stenting is needed. Data Breakdown: For a study, investigators conducted a meta-analysis of trials published from 1966 to 2013 comparing optimal medical therapy alone with optimal medical therapy plus renal artery stenting in patients with renal artery stenosis. Patients who received stents experienced a 10% risk reduction when compared with those who did not. Although blood pressure changes were similar in both populations, antihypertensive medication requirements were significantly lower in stented patients. Take Home Pearl: Among patients with renal artery stenosis, revascularization with stents appears to decrease the risk of clinical events and antihypertensive medication needs when compared with optimal medical therapy...

SCAI 2014: Radial Access PCI for STEMI

The Particulars: Radial access for PCI in patients with ST segment elevation myocardial infarction (STEMI) is associated with lower rates of bleeding and improved clinical outcomes when compared with femoral access PCI. However, data on the frequency and temporal trends in the use of transradial PCI for patients with STEMI in a real-world setting are lacking. Data Breakdown: Researchers in Michigan compared transradial access (TRA) with transfemoral access (TFA) for patients undergoing PCI for STEMI or for other indications from 2010 to 2013. Although TRA use increased substantially for all patients, this growth was significantly slower for STEMI patients. Lower bleeding and transfusion rates were observed with TRA use when compared with TFA use, but no significant difference was seen in in-hospital mortality. Take Home Pearls: Use of TRA for PCI in patients with STEMI appears to be increasing but at a slower pace than for patients with other indications. TRA appears to significantly reduce bleeding and transfusion rates in STEMI patient when compared with...
Study shows paying people to lose weight works. Or does it?

Study shows paying people to lose weight works. Or does it?

A recent study looked at the effect of paying people to lose weight. The authors randomized 100 people with BMIs ranging from 30 to 39.9 into four groups. Two groups received weight-loss education, one group with and one without payment. The other two groups received education plus behavior modification with, again, one group receiving financial incentives and the other not. To remain in the study, they were all supposed to have lost 4 pounds per month. Patients in the two financial incentive groups received $20 per month if they met their goal, and those not meeting the goal had to pay $20 per month, which was pooled for a lottery among the participants at the end of the study. A significantly larger percentage of those receiving remuneration completed the study. At the study’s endpoint—12 months, the average weight loss for those in the paid groups was about 9 pounds compared to just over 2 pounds for the two unpaid groups. Using a two-way ANOVA, the incentives were estimated to have led to a weight loss of 6.5 pounds, which was statistically significant with a p value < 0.001. The authors concluded, “Sustained weight loss may be achieved with financial incentives.” The paper was presented at the American College of Cardiology meeting last March and is available only in abstract form. It raises some questions. The paid groups lost less than 1 lb per month. If the subjects were to have lost 4 lbs per month as stated in the protocol, why didn’t they lose a minimum of 48 lbs, which would be 4 lbs x 12 months? How durable...
Managing Critically Ill Surgery Patients

Managing Critically Ill Surgery Patients

Staff shortages for sur­geons and intensivists can make it challenging for hospitals to optimize the care of critically ill and injured surgical patients. “Although critical care and surgery have made tremendous advances during the past 50 years, these advances have led to greater subspecialization,” says Samuel A. Tisherman, MD. “This has discouraged many surgeons from including critical care as a principal component of their practice.” Broadening Training In a white paper published in JAMA Surgery, Dr. Tisherman and colleagues presented recommendations for broadening multidisciplinary training and practice opportunities in surgical critical care for intensivists. The article also offered guidance for maintaining a 24/7 intensivist model. In this model, all intensivists—regardless of their base specialty—must be appropriately trained, credentialed, and dedicated to critical care and give undivided attention to critically ill patients. Dr. Tisherman and colleagues encouraged several approaches to assure adequate staffing in order to provide intensivist coverage of critically ill or injured surgical patients: – Mechanisms should be in place for physicians from multiple disciplines to be educated in surgical critical care, to enroll in accredited surgical critical care fellowship programs, and to receive full certification. – Organizational support is needed to develop common critical care training programs and credentialing with other specialties that offer these certifications. – Hospitals and surgical departments should recognize that intensivists whose primary specialty is not surgery are necessary to provide patients with high-level surgical critical care. – All intensivists should dedicate time to the ICU without other concurrent obligations. The amount of time devoted to surgical critical care within training programs should not be shortened or diluted. Critical care coverage must be...
ASCO 2014

ASCO 2014

New research is being presented at ASCO 2014, the American Society of Clinical Oncology’s annual meeting, from May 30 to June 3 in Chicago. Meeting Highlights Improving Prostate Cancer Screening Pillars4Life Online Intervention Improves QOL in Cancer Patients Discussing Clinical Trials With Lung & Colorectal Cancer Patients Perceptions on Novel Prostate Cancer Technology Assessing Mobile Apps in Oncology Assessing Prostate Cancer Incidence Rates Patients’ Actual Vs Preferred Decision-Making Roles Tobacco Cessation in Cancer Patients Second Malignancies After Prostate Cancer Treatment Discussing Costs of Cancer Care Under the ACA Practice Changing: Drug Preserves Fertility During Chemo Low-Dose Radiation Okay in Some HPV-positive Head and Neck Cancers Breast Cancer With Bone Mets: Less Zoledronic Acid Is Fine Palliative Care: It’s for Caregivers Too, Says Study Ramucirumab Hailed for Marginal Benefit in Lung Cancer New Targeted Drug Highly Effective in Advanced Thyroid Cancer Practice-Changing Results for Metastatic Prostate Cancer ASCO Sounds Alarm on Declining Federally Funded Research Bevacizumab, Cetuximab Have Similar Survival Benefits in CRC Two Major Trials: AIs Work in Premenopausal Breast Cancer Too Targeted Drug Combo Improves Outcomes in Ovarian Cancer   News From the Meeting A ‘Home Run’ in Prostate Cancer Tx Biologic Agents Plus Chemo Equal in Colon Ca Aromasin Better for Young Breast Ca Survivors Time to Change Lung Ca Surrogate Endpoint? Lenvatinib Slows Resistant Thyroid Ca Cyramza Boosts Survival in NSCLC Ibrutinib Proves Its Mettle in CLL OK to Cut Back on Bone Mets Therapy Early Palliation in Ca Patients Eases Caregiver Burden Drug Helps Save Fertility in Breast Ca OK to Stop Statins in Terminal Illness Myeloma Studies Presented at ASCO 50 Years of Progress,...
Patient-Provider Dialogue With HIV Drugs

Patient-Provider Dialogue With HIV Drugs

Research has shown that race and ethnicity may be associated with differences in how healthcare providers communicate with patients. “In HIV, a key component to outcomes is adherence to antiretroviral therapy (ART),” says Michael Barton Laws, PhD, MA. “Investigators have hypothesized that clinical communication may be a factor in how well or poorly HIV patients adhere to ART regimens.” Examining Themes In a study published in AIDS and Behavior, Dr. Laws and colleagues reviewed more than 400 routine outpatient visits by people with HIV. Three themes emerged from the analysis of patient–provider conversations, depending on patients’ race and ethnicity: 1) Speech patterns: African Americans spoke less to their providers than Caucasians or Hispanics. Hence, there was greater provider verbal dominance in their discussions. They also less frequently expressed their goals or values. Healthcare providers asked Hispanics fewer open-ended questions. 2) ART adherence: Visits with African-American and Hispanic patients included more dialogue about adherence than visits with Caucasian patients. This difference occurred regardless of how adherent patients reported being to their ART regimens or whether laboratory tests showed that HIV was under control. 3) Problem solving: The more extensive dialogue about ART adherence between patients and healthcare providers was directive rather than problem solving. “There was more discussion about ART adherence with African Americans and Hispanics,” adds Dr. Laws, “but no more discussion about strategies to improve adherence.”   Possible Interpretations Dr. Laws says that several factors may influence why healthcare providers talked more with minority patients than with Caucasians about adherence. “It’s possible that healthcare providers are trying to compensate for what they’ve seen in studies about lower adherence...

ATS 2014: Gender Differences in COPD

The Particulars: Researchers have speculated that COPD may manifest differently in men than in women. However, few studies have assessed gender differences among this population. Data Breakdown: A study of patients with mild to severe COPD found that women had fewer pack-years smoking history than men. No differences were observed between genders in degree of obstruction or emphysema. However, women had lower BMIs, shorter 6-minute walk distances, and worse quality of life measures than men. They also had more exacerbations requiring healthcare use and treatment with antibiotics or steroids. Take Home Pearls: Women appear to exhibit more severe symptoms of COPD and suffer more exacerbations when compared with...
The New Bionics That Let Us Run, Climb, and Dance

The New Bionics That Let Us Run, Climb, and Dance

Hugh Herr is building the next generation of bionic limbs, robotic prosthetics inspired by nature’s own designs. Herr lost both legs in a climbing accident 30 years ago; now, as the head of the MIT Media Lab’s Biomechatronics group, he shows his incredible technology in a talk that’s both technical and deeply personal — with the help of ballroom dancer Adrianne Haslet-Davis, who lost her left leg in the 2013 Boston Marathon bombing, and performs again for the first time on the TED stage. Source:...
The Contenders

The Contenders

Biologists spent ten years trying to map the structure of the elusive Mason Pfizer Monkey Virus, a problem that could unlock the cure for AIDS. The Contenders solved it in three weeks. Using the online puzzle game Fold It, scientists are enlisting video gamers to solve real- world problems. Source: GE Focus...
Immune System

Immune System

“I’m afraid neither your insurance nor your immune system will cover...

ATS 2014: Patients Miss Signs of Severe Asthma

The Particulars: Physicians often rely on asthma patients to help them make accurate assessments of disease severity and to individualize treatment. However, little is known about patient self-perceptions of asthma severity, impairment, and risk. Data Breakdown: A national survey of adults with asthma found that the majority of those who identified themselves as having moderate asthma also reported several impairments and risks that were potentially indicative of more severe asthma. Specifically, 78% reported at least one emergency room or urgent care visit in the past year and 62% reported two or more asthma attacks requiring oral systemic corticosteroids. Nearly 60% reported missing work or school and 17% used their quick-relief inhalers at least once daily. Take Home Pearls: Many patients who identify themselves as having moderate asthma report having indicators of more severe disease and fail to recognize their condition as being severe. Greater patient education may be...
SCAI 2014

SCAI 2014

New research is being presented at SCAI 2014, the Society for Cardiovascular Angiography and Intervetions annual scientific sessions, from May 28 to 31 in Las Vegas. Meeting Highlights Radial Access PCI for STEMI Renal Artery Stenting Outcomes Gender Differences Following Angioplasty    News From the Meeting Comparison of Lesion Level Decision Making in the Cath Lab Using Hyperemic and Non-Hyperemic Pressure Wire Derived Indices of Stenosis Severity: The VERIFY-2 Study Effect of a Real Time Radiation Monitoring Device on Radiation Exposure During Cardiac Catheterization: The Radiation Reduction during Cardiac Catheterization Using Real Time Monitoring (RadiCure) Study Diamondback 360° Coronary Orbital Atherectomy System for Treating De Novo, Severely Calcified Lesions: ORBIT II 1-Year Results and Cost Comparison to a Sample of Medicare Hospital Claims 3-Dimensional Quantitative Coronary Angiography Using Coronary Catheters as Objective Markers Reliably Unmasks Severe Occult Stenosis in Diffusely Diseased Vessels: New Results from the IQ-CATEGORIZE Lesions Study SCAI 2014 Scientific Sessions Hildner Lecture Tackles Looming Shortage of Interventional Cardiologists Dr. Charles Chambers Inducted as 38th SCAI President SCAI 2014 Lecture Highlights Why Tiny Hearts Need Big Innovations SCAI 2014 Scientific Sessions Founders’ Lectureto Emphasize the Next Phase of Innovation in Interventional Cardiology Pediatric and Congenital Interventional Cardiologists Should Complete One Year of Additional Training New SCAI Toolkit Guides Pediatric Cath Lab Quality Improvement SCAI Publishes New Treatment Recommendations for Common Form of Peripheral Artery Disease Online AUC App Is Fast, Easy Source of Real-Time Quality Data in Cath Lab Smart Technology Plays Useful Role in Pediatric Interventional Cardiology Smoking Makes Arterial Plaques More Vulnerable to Rupture Studies Add Insight Into Heparin-Bivalirudin Controversy in PCI New Study Supports...

AUA 2014: Antibiotic Prophylaxis in Urologic Surgery

The Particulars: According to prior analyses, there appears to be considerable variation in the duration and class of antibiotics administered by urologists. This is occurring despite the release of best practice recommendations from the American Urological Association (AUA) for antimicrobial prophylaxis during urologic surgeries. More research is needed to assess compliance with the AUA guidelines for antibiotic class and duration among index urologic procedures. Data Breakdown: For a study, antibiotic class and duration were obtained from the billing data of patients who underwent one of several types of urologic procedures. The surgeries included radical prostatectomy, radical cystectomy (RC), partial or radical nephrectomy, ureteroscopy or shock wave lithotripsy, transurethral resection of the prostate, percutaneous nephrostolithotomy, transvaginal surgery, penile prosthesis, brachytherapy, or transurethral resection of bladder tumors. Using recommendations from the AUA guidelines, the correct antibiotic class was ordered in 67% of cases, and the correct duration was used in 78% of cases. The average length of antibiotic prophylaxis ranged from 1.1 days after brachytherapy to 10.3 days after RC. Overall compliance with AUA guidelines was 53.4%, but increased over time, rising from 46.2% in 2007 to 58.9% in 2012. Take Home Pearls: Antibiotic prophylaxis administration in urologic surgeries varies considerably. Although compliance appears to have increased in recent years, efforts are needed to increase the standardization of antibiotic administration for common urologic surgical...

AUA 2014: Predicting Post-Nephrectomy Readmissions

The Particulars: Previous research suggests that readmissions are common following major abdominal surgery for cancer. Other studies, however, indicate that surgical readmissions account for only about 22% of total readmissions. Little is known about urologic readmission rates for kidney cancer patients. Data Breakdown: Investigators in North Carolina reviewed national data on patients who underwent nephrectomy for kidney cancer in 2011 in order to evaluate predictors of readmissions. Readmission rates were 8.0% for open radical nephrectomy and 3.9% for laparoscopic radical nephrectomy. Preoperative dialysis (odds ratio [OR], 9.8), using an open surgical approach (OR, 0.31), and high American Society of Anesthesiologists (ASA) scores (OR, 4.9) were significant predictors of readmission. Readmission rates were about 4.5% for patients who underwent open or laparoscopic partial nephrectomy. Take Home Pearls: Regardless of the surgical approach that is used, readmission rates following partial nephrectomy appear to be low. However, readmission rates with radical nephrectomy appear to be higher, particularly when an open approach is used, among patients on dialysis before surgery, and in those with high ASA...

AUA 2014: Urinary Incontinence Improves After Bariatric Surgery

The Particulars: Few studies have assessed changes in the prevalence of urinary incontinence (UI) following bariatric surgery among obese women and men. Data Breakdown: For a study, nearly 2,000 severely obese patients completed a UI questionnaire before and after bariatric surgery. They also filled out a questionnaire during at least one follow-up assessment over a 3-year period. The prevalence of total, stress, and urgency UI for women and the prevalence of total and urgency UI for men decreased at each follow-up visit. At 1 year follow-up, the UI remission rates were about 70% for both men and women. The frequency of UI episodes of any type decreased after surgery for all patients, although there was a slight increase seen in women after year 1. Take Home Pearl: Severely obese men and women who undergo bariatric surgery appear to experience a substantial improvement in UI prevalence and UI episodic frequency after their...

AUA 2014: Comparing the Efficacy of Prostatectomy Approaches

The Particulars: Prior studies have not definitively shown that robotic-assisted radical prostatectomy (RARP) helps improve cancer control and patient outcomes. Conducting a comparative effectiveness analysis of RARP with open radical prostatectomy (ORP) may help address this research need by establishing the role of surgical margin status and the use of additional cancer therapies. Data Breakdown: For a study, researchers reviewed data on more than 13,000 men with non-metastatic prostate cancer who underwent RARP or ORP from 2004 to 2009. The incidence of positive surgical margins was significantly lower among men who underwent RARP (13.7%) when compared with those who underwent ORP (18.4%). This difference was driven by variations in intermediate- and high-risk disease. At 6, 12, and 24 months follow-up, RARP was associated with a lower need for using additional cancer therapies. Take Home Pearls: Among men with intermediate and high-risk, non-metastatic prostate cancer, RARP appears to be associated with an improved surgical margin status when compared with ORP. RARP recipients also required fewer additional cancer therapies after their...

AUA 2014: Analyzing BPH Surgery Outcomes

The Particulars: As the population ages, it is important to understand which patients are at risk for postoperative complications and who might be better treated with conservative management when caring for lower urinary tract symptoms. However, data are lacking on predictors of morbidity following surgical treatment of benign prostatic hyperplasia (BPH). Data Breakdown: Study investigators examined morbidity and mortality associated with transurethral resection of the prostate (TURP), laser vaporization of the prostate (LVP), and laser enucleation of the prostate (LEP) using a large national database. Overall, no significant differences in complications or perioperative mortality were observed between the three surgical groups. However, LVP was associated with decreased need for blood transfusions, risk of prolonged lengths of stay (LOS), and re-intervention rates. LEP was also associated with a decreased risk of prolonged LOS. Advanced age at surgery, non-Caucasian race, and smoking increased patients’ risk of morbidity and mortality. Conversely, normal preoperative albumin levels and higher preoperative hematocrit levels were predictors of fewer complications overall and lower perioperative mortality. Take Home Pearls: TURP, LVP, and LEP all appear to be safe for the treatment of BPH. Age, race, and smoking status appear to help predict the types of outcomes following these BPH...

ATS 2014: Counseling Patients About Tobacco Use

The Particulars: Previous research indicates that as many as 60% of active smokers are not counseled about smoking cessation. This rate is high despite cessation being a strategy to prevent morbidity and mortality. Data Breakdown: For a study, researchers compared patient charts of active tobacco users with those treated before and after implementation of a program designed to enhance smoking cessation. For the intervention, residents received teaching slides about documenting tobacco cessation counseling. Point-of-care reminders were also implemented. The documentation of smoking history improved from 49% to 66% after the intervention was implemented. After the intervention, the rate of smoking cessation medications prescribed increased from 11% to 16%, and the percentage of smokers who  were counseled rose from 32% to 59%. Take Home Pearl: Residents appear to document smoking history and use tobacco cessation counseling more often if they are given a brief lecture about documentation and are provided point-of-care...
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