General Surgery

SAN DIEGO  – Since the late 1990s, when the annual number of antireflux procedures performed in the United States peaked, the overall rate of complications has increased, operations have shifted to more complex procedures in sicker patients, and the largest gains in caseload have occurred at urban nonteaching hospitals.

Those are three key findings from a large analysis of National Inpatient Sample (NIS) data reported by Dr. Paul D. Colavita at the annual Digestive Disease Week.

"Around the same time that antireflux surgery surged in the late 1990s, the Leapfrog Group – a large consortium of public and private health care purchasers – emerged as leaders in the national call for regionalization of complex surgical procedures in 2000," said Dr. Colavita, of the general surgery department at Carolinas Medical Center, Charlotte, N.C. "The objective of our study was to measure the extent of regionalization from its peak in 1998-1999 with data from 2008-2009."

He and his associates examined NIS data from 1998-1999 and 2008-2009 for antireflux procedures performed on patients with a diagnosis of gastroesophageal reflux, esophagitis, esophageal ulcer, and hiatal hernia. They excluded cases of achalasia, gangrenous/incarcerated diaphragmatic hernia, and patients younger than 18 years.

To measure the effect of regionalization, the researchers used 1998-1999 annual hospital volume of antireflux operations stratified into one of three baseline terciles: low-volume centers, defined as 1-14 annual procedures; medium-volume centers (15-37 annual procedures); and high-volume centers (38 or more annual procedures). The researchers also compared complications and outcomes that occurred in 1998-99 (time period 1) with those that occurred in 2008-09 (time period 2).

Dr. Colavita reported that 11,803 procedures were performed in time period 1, compared with 8,855 in time period 2. The proportion of procedures performed at low-volume centers increased between time periods 1 and 2 (from 33.3% to 40.4%) and declined at high-volume centers (from 33.4% to 25.3%).

As has been found with other surgical procedures, outcomes improved in high-volume centers, he said. The researchers attribute the lack of regionalization, in part, to the increased number of surgeons trained to perform these procedures. "In the past decade, surgical residents have been trained to perform antireflux procedures," Dr. Colavita said. "These former residents are now general surgeons who are performing these procedures in a variety of hospitals in different locations, both urban and rural."

Certain baseline characteristics differed significantly between time periods 1 and 2, including age (a mean of 50 vs. 57 years, respectively), percentage of women (57% vs. 69%), percentage of white patients (91% vs. 85%), and those with a Charlson comorbidity index score of more than 1 (5% vs. 10%). All differences had a P value of less than .0001.

There was no difference in inpatient mortality between time periods 1 and 2 (0.41% vs. 0.34%, respectively; P = .433), but there were significant increases in the rate of complications (4% vs. 6%) and total charges ($16,000 vs. $40,000), while the frequency of routine discharge decreased (95% vs. 92%). All differences had a P value of less than .0001. The average length of stay increased by 0.15 days (P = .001).

Multivariate regression analysis revealed that between time periods 1 and 2, low-volume centers remained independently associated with increased complications (odds ratio 1.8 vs. 1.9, respectively), nonroutine discharge (OR 2.0 vs. 1.8), length of stay (0.82 vs. 0.94 days), and higher total charges ($2,700 vs. $3,200).

"Taking these findings into consideration, we as health care providers must decide whether or not to call for increased referrals to high-volume centers," Dr. Colavita said.

Multivariate regression revealed two significant predictors of antireflux procedures performed at low-volume centers during time periods 1 and 2: emergent admission (OR 3.7 vs. 3.0, respectively) and lack of private insurance (OR 1.3 in both). Nonwhite race was a significant predictor in time period 1 only (OR 1.8), while significant predictors in time period 2 only included residing in the poorest vs. wealthiest zip code (OR 1.2), decreasing age (OR 1.1), and female gender (OR 1.2).

Dr. Colavita also reported that rural hospitals had decreased surgical volume between time periods 1 and 2 (19% to 10%), while the volume increased at urban nonteaching hospitals (from 33% to 39%) and at urban teaching hospitals (from 48% to 51%).

"Urban teaching hospitals had the highest proportion of high-volume cases in both eras, while urban nonteaching hospitals had the highest proportion of low-volume cases in both eras," he said.

Dr. Colavita acknowledged certain limitations of the study, including the lack of opportunity for follow-up in the NIS database and the fact that there are no codes for redo fundoplications. Also, "higher volumes have a shorter length of stay," he said. "This is a smaller window to detect death, complications, and overall cost. We also lack operative details such as operative time."

Dr. Colavita said he had no relevant financial conflicts to disclose.

SAN DIEGO  – Since the late 1990s, when the annual number of antireflux procedures performed in the United States peaked, the overall rate of complications has increased, operations have shifted to more complex procedures in sicker patients, and the largest gains in caseload have occurred at urban nonteaching hospitals.

Those are three key findings from a large analysis of National Inpatient Sample (NIS) data reported by Dr. Paul D. Colavita at the annual Digestive Disease Week.

"Around the same time that antireflux surgery surged in the late 1990s, the Leapfrog Group – a large consortium of public and private health care purchasers – emerged as leaders in the national call for regionalization of complex surgical procedures in 2000," said Dr. Colavita, of the general surgery department at Carolinas Medical Center, Charlotte, N.C. "The objective of our study was to measure the extent of regionalization from its peak in 1998-1999 with data from 2008-2009."

He and his associates examined NIS data from 1998-1999 and 2008-2009 for antireflux procedures performed on patients with a diagnosis of gastroesophageal reflux, esophagitis, esophageal ulcer, and hiatal hernia. They excluded cases of achalasia, gangrenous/incarcerated diaphragmatic hernia, and patients younger than 18 years.

To measure the effect of regionalization, the researchers used 1998-1999 annual hospital volume of antireflux operations stratified into one of three baseline terciles: low-volume centers, defined as 1-14 annual procedures; medium-volume centers (15-37 annual procedures); and high-volume centers (38 or more annual procedures). The researchers also compared complications and outcomes that occurred in 1998-99 (time period 1) with those that occurred in 2008-09 (time period 2).

Dr. Colavita reported that 11,803 procedures were performed in time period 1, compared with 8,855 in time period 2. The proportion of procedures performed at low-volume centers increased between time periods 1 and 2 (from 33.3% to 40.4%) and declined at high-volume centers (from 33.4% to 25.3%).

As has been found with other surgical procedures, outcomes improved in high-volume centers, he said. The researchers attribute the lack of regionalization, in part, to the increased number of surgeons trained to perform these procedures. "In the past decade, surgical residents have been trained to perform antireflux procedures," Dr. Colavita said. "These former residents are now general surgeons who are performing these procedures in a variety of hospitals in different locations, both urban and rural."

Certain baseline characteristics differed significantly between time periods 1 and 2, including age (a mean of 50 vs. 57 years, respectively), percentage of women (57% vs. 69%), percentage of white patients (91% vs. 85%), and those with a Charlson comorbidity index score of more than 1 (5% vs. 10%). All differences had a P value of less than .0001.

There was no difference in inpatient mortality between time periods 1 and 2 (0.41% vs. 0.34%, respectively; P = .433), but there were significant increases in the rate of complications (4% vs. 6%) and total charges ($16,000 vs. $40,000), while the frequency of routine discharge decreased (95% vs. 92%). All differences had a P value of less than .0001. The average length of stay increased by 0.15 days (P = .001).

Multivariate regression analysis revealed that between time periods 1 and 2, low-volume centers remained independently associated with increased complications (odds ratio 1.8 vs. 1.9, respectively), nonroutine discharge (OR 2.0 vs. 1.8), length of stay (0.82 vs. 0.94 days), and higher total charges ($2,700 vs. $3,200).

"Taking these findings into consideration, we as health care providers must decide whether or not to call for increased referrals to high-volume centers," Dr. Colavita said.

Multivariate regression revealed two significant predictors of antireflux procedures performed at low-volume centers during time periods 1 and 2: emergent admission (OR 3.7 vs. 3.0, respectively) and lack of private insurance (OR 1.3 in both). Nonwhite race was a significant predictor in time period 1 only (OR 1.8), while significant predictors in time period 2 only included residing in the poorest vs. wealthiest zip code (OR 1.2), decreasing age (OR 1.1), and female gender (OR 1.2).

Dr. Colavita also reported that rural hospitals had decreased surgical volume between time periods 1 and 2 (19% to 10%), while the volume increased at urban nonteaching hospitals (from 33% to 39%) and at urban teaching hospitals (from 48% to 51%).

"Urban teaching hospitals had the highest proportion of high-volume cases in both eras, while urban nonteaching hospitals had the highest proportion of low-volume cases in both eras," he said.

Dr. Colavita acknowledged certain limitations of the study, including the lack of opportunity for follow-up in the NIS database and the fact that there are no codes for redo fundoplications. Also, "higher volumes have a shorter length of stay," he said. "This is a smaller window to detect death, complications, and overall cost. We also lack operative details such as operative time."

Dr. Colavita said he had no relevant financial conflicts to disclose.

SAN DIEGO  – Since the late 1990s, when the annual number of antireflux procedures performed in the United States peaked, the overall rate of complications has increased, operations have shifted to more complex procedures in sicker patients, and the largest gains in caseload have occurred at urban nonteaching hospitals.

Those are three key findings from a large analysis of National Inpatient Sample (NIS) data reported by Dr. Paul D. Colavita at the annual Digestive Disease Week.

"Around the same time that antireflux surgery surged in the late 1990s, the Leapfrog Group – a large consortium of public and private health care purchasers – emerged as leaders in the national call for regionalization of complex surgical procedures in 2000," said Dr. Colavita, of the general surgery department at Carolinas Medical Center, Charlotte, N.C. "The objective of our study was to measure the extent of regionalization from its peak in 1998-1999 with data from 2008-2009."

He and his associates examined NIS data from 1998-1999 and 2008-2009 for antireflux procedures performed on patients with a diagnosis of gastroesophageal reflux, esophagitis, esophageal ulcer, and hiatal hernia. They excluded cases of achalasia, gangrenous/incarcerated diaphragmatic hernia, and patients younger than 18 years.

To measure the effect of regionalization, the researchers used 1998-1999 annual hospital volume of antireflux operations stratified into one of three baseline terciles: low-volume centers, defined as 1-14 annual procedures; medium-volume centers (15-37 annual procedures); and high-volume centers (38 or more annual procedures). The researchers also compared complications and outcomes that occurred in 1998-99 (time period 1) with those that occurred in 2008-09 (time period 2).

Dr. Colavita reported that 11,803 procedures were performed in time period 1, compared with 8,855 in time period 2. The proportion of procedures performed at low-volume centers increased between time periods 1 and 2 (from 33.3% to 40.4%) and declined at high-volume centers (from 33.4% to 25.3%).

As has been found with other surgical procedures, outcomes improved in high-volume centers, he said. The researchers attribute the lack of regionalization, in part, to the increased number of surgeons trained to perform these procedures. "In the past decade, surgical residents have been trained to perform antireflux procedures," Dr. Colavita said. "These former residents are now general surgeons who are performing these procedures in a variety of hospitals in different locations, both urban and rural."

Certain baseline characteristics differed significantly between time periods 1 and 2, including age (a mean of 50 vs. 57 years, respectively), percentage of women (57% vs. 69%), percentage of white patients (91% vs. 85%), and those with a Charlson comorbidity index score of more than 1 (5% vs. 10%). All differences had a P value of less than .0001.

There was no difference in inpatient mortality between time periods 1 and 2 (0.41% vs. 0.34%, respectively; P = .433), but there were significant increases in the rate of complications (4% vs. 6%) and total charges ($16,000 vs. $40,000), while the frequency of routine discharge decreased (95% vs. 92%). All differences had a P value of less than .0001. The average length of stay increased by 0.15 days (P = .001).

Multivariate regression analysis revealed that between time periods 1 and 2, low-volume centers remained independently associated with increased complications (odds ratio 1.8 vs. 1.9, respectively), nonroutine discharge (OR 2.0 vs. 1.8), length of stay (0.82 vs. 0.94 days), and higher total charges ($2,700 vs. $3,200).

"Taking these findings into consideration, we as health care providers must decide whether or not to call for increased referrals to high-volume centers," Dr. Colavita said.

Multivariate regression revealed two significant predictors of antireflux procedures performed at low-volume centers during time periods 1 and 2: emergent admission (OR 3.7 vs. 3.0, respectively) and lack of private insurance (OR 1.3 in both). Nonwhite race was a significant predictor in time period 1 only (OR 1.8), while significant predictors in time period 2 only included residing in the poorest vs. wealthiest zip code (OR 1.2), decreasing age (OR 1.1), and female gender (OR 1.2).

Dr. Colavita also reported that rural hospitals had decreased surgical volume between time periods 1 and 2 (19% to 10%), while the volume increased at urban nonteaching hospitals (from 33% to 39%) and at urban teaching hospitals (from 48% to 51%).

"Urban teaching hospitals had the highest proportion of high-volume cases in both eras, while urban nonteaching hospitals had the highest proportion of low-volume cases in both eras," he said.

Dr. Colavita acknowledged certain limitations of the study, including the lack of opportunity for follow-up in the NIS database and the fact that there are no codes for redo fundoplications. Also, "higher volumes have a shorter length of stay," he said. "This is a smaller window to detect death, complications, and overall cost. We also lack operative details such as operative time."

Dr. Colavita said he had no relevant financial conflicts to disclose.

Patients with severe diabetes but only mild obesity see a dramatic benefit after gastric bypass surgery, a new study has found, with 88% experiencing durable disease remission within 6 months, along with major reductions in 10-year cardiovascular risk.

No mortality, major surgical complications, excessive weight loss, or malnutrition was seen among the 66 patients in the study, all of whom underwent laparoscopic Roux-en-Y gastric bypass (RYGB) surgery, according to the findings published in the July issue of Diabetes Care (2012;35:1420-8) and presented at the annual scientific sessions of the American Diabetes Association in Philadelphia.

Bariatric surgery is currently recommended by the National Institutes of Health only for people with a body mass index (BMI) of 40 kg/m² or higher, or above 35 for people with comorbidities such as severe diabetes. Very obese patients with diabetes have seen dramatic reductions in disease activity after RYGB surgery, with an estimated 80%-85% experiencing durable remission. There is increasing evidence that the procedure triggers hormonal and metabolic antidiabetes responses independent of weight loss (Annu. Rev. Med. 2010;61:393-411; Int. J. Obes. 2009;33:S33-S40; Endocrinology 2009;150:2518-25).

People with mild obesity and diabetes constitute a larger group than the very obese, yet they do not currently qualify for bariatric surgery.

Dr. Ricardo V. Cohen of Oswaldo Cruz Hospital and Marcia Maria Braido Hospital, both in São Paulo, Brazil, and his colleagues sought to investigate whether people with a lower BMI and poorly controlled diabetes also would see significant benefit. More than one-fourth of people in the United States with diabetes have class I obesity, or a BMI of 30-35 (Int. J. Clin. Pract. 2007;61:737-47).

For their research, Dr. Cohen and his colleagues recruited 40 men and 26 women. All were white and ranged in age from 31 to 63 years, and had a BMI of 30.0-34.9 and diabetes lasting 7 years or more at the time of surgery. The mean HbA_1c level was 9.7% at the time of surgery, despite the use of insulin and/or oral diabetes medications (n = 7 on insulin). Follow-up on the cohort was 100%, for a median 5 years.

Within 26 weeks after surgery, 88% of patients were able to discontinue their diabetes medications and maintain an HbA_1c level of less than 6.5% without resuming diabetes medications in the follow-up period.

Improvement without remission was seen in 11% of patients, who were able to withdraw insulin and/or reduce dosages of oral medications between 3 and 14 weeks after surgery. One patient showed no improvement in glycemic control, but was able to withdraw insulin and achieve diabetes control with oral medications 7 months post surgery.

Mean HbA_1c for the entire cohort fell progressively throughout the study, from 9.7% to 5.9% (P less than .001). Fasting plasma glucose (FPG) fell from 156 mg/dL to 97 mg/dL (P less than .001). Most of these changes occurred within the first 6 months.

All patients saw progressive reductions in waist circumference and total body weight, although the magnitude of weight loss was not seen as corresponding with decreases in either FPG or HbA_1c until after 5 years post surgery, when the investigators saw significant correlations between weight loss and decrease in FPG. No correlations were seen between weight loss and decrease in HbA_1c. Also, while the ratio of change in C-peptide to change in glucose increased significantly in the postoperative period, there was no correlation seen between the magnitude of the increase and weight lost. All these findings suggest that the surgery induces mechanisms of antidiabetes action independent of weight loss.

The predicted 10-year risk of cardiovascular disease fell after surgery in the cohort, with a 71% decrease in coronary heart disease (CHD, P = .001), 84% decrease in fatal CHD (P = .001), 50% decrease in stroke (P = .01), and 57% decrease in fatal stroke (P = .009). Hypertension and dyslipidemia were also seen to have improved, with hypertension resolving in 15 of the 26 (58%) patients who had it at baseline, hypercholesterolemia resolving in 21 of 33 (64%) patients, and hypertriglyceridemia resolving in 18 of 31 (58%), in the follow-up period.

Importantly, none of the subjects lost excessive weight or showed evidence of malnutrition. The lowest BMI observed in the follow-up period was 23.6.

The findings, Dr. Cohen and his colleagues wrote in their analysis, have broad implications for health policy, as they "indicate that RYGB is a safe, effective procedure to ameliorate type 2 diabetes and associated comorbidities, thereby reducing predicted cardiovascular disease risk, in patients with a BMI of 30–35 kg/m²."

While randomized controlled trial data are required to confirm that the procedure can be recommended in these patients, the investigators wrote, "our favorable findings from a relatively large, long-term study help justify such trials to clarify whether standard indications for RYGB should be broadened and whether this operation might be viewed primarily as ‘metabolic,’ rather than ‘bariatric,’ surgery."

Dr. Cohen and colleagues’ study was funded by the Municipal Health Authority and Marcia Maria Braido Hospital in São Paulo, Brazil. Dr. Cohen disclosed that he received previous study funding from Covidien, and one of his coauthors, Dr. David E. Cummings of the University of Washington, Seattle, disclosed receiving past funding from Ethicon Endo-Surgery. The other authors said they had no relevant financial disclosures.

Patients with severe diabetes but only mild obesity see a dramatic benefit after gastric bypass surgery, a new study has found, with 88% experiencing durable disease remission within 6 months, along with major reductions in 10-year cardiovascular risk.

No mortality, major surgical complications, excessive weight loss, or malnutrition was seen among the 66 patients in the study, all of whom underwent laparoscopic Roux-en-Y gastric bypass (RYGB) surgery, according to the findings published in the July issue of Diabetes Care (2012;35:1420-8) and presented at the annual scientific sessions of the American Diabetes Association in Philadelphia.

Bariatric surgery is currently recommended by the National Institutes of Health only for people with a body mass index (BMI) of 40 kg/m² or higher, or above 35 for people with comorbidities such as severe diabetes. Very obese patients with diabetes have seen dramatic reductions in disease activity after RYGB surgery, with an estimated 80%-85% experiencing durable remission. There is increasing evidence that the procedure triggers hormonal and metabolic antidiabetes responses independent of weight loss (Annu. Rev. Med. 2010;61:393-411; Int. J. Obes. 2009;33:S33-S40; Endocrinology 2009;150:2518-25).

People with mild obesity and diabetes constitute a larger group than the very obese, yet they do not currently qualify for bariatric surgery.

Dr. Ricardo V. Cohen of Oswaldo Cruz Hospital and Marcia Maria Braido Hospital, both in São Paulo, Brazil, and his colleagues sought to investigate whether people with a lower BMI and poorly controlled diabetes also would see significant benefit. More than one-fourth of people in the United States with diabetes have class I obesity, or a BMI of 30-35 (Int. J. Clin. Pract. 2007;61:737-47).

For their research, Dr. Cohen and his colleagues recruited 40 men and 26 women. All were white and ranged in age from 31 to 63 years, and had a BMI of 30.0-34.9 and diabetes lasting 7 years or more at the time of surgery. The mean HbA_1c level was 9.7% at the time of surgery, despite the use of insulin and/or oral diabetes medications (n = 7 on insulin). Follow-up on the cohort was 100%, for a median 5 years.

Within 26 weeks after surgery, 88% of patients were able to discontinue their diabetes medications and maintain an HbA_1c level of less than 6.5% without resuming diabetes medications in the follow-up period.

Improvement without remission was seen in 11% of patients, who were able to withdraw insulin and/or reduce dosages of oral medications between 3 and 14 weeks after surgery. One patient showed no improvement in glycemic control, but was able to withdraw insulin and achieve diabetes control with oral medications 7 months post surgery.

Mean HbA_1c for the entire cohort fell progressively throughout the study, from 9.7% to 5.9% (P less than .001). Fasting plasma glucose (FPG) fell from 156 mg/dL to 97 mg/dL (P less than .001). Most of these changes occurred within the first 6 months.

All patients saw progressive reductions in waist circumference and total body weight, although the magnitude of weight loss was not seen as corresponding with decreases in either FPG or HbA_1c until after 5 years post surgery, when the investigators saw significant correlations between weight loss and decrease in FPG. No correlations were seen between weight loss and decrease in HbA_1c. Also, while the ratio of change in C-peptide to change in glucose increased significantly in the postoperative period, there was no correlation seen between the magnitude of the increase and weight lost. All these findings suggest that the surgery induces mechanisms of antidiabetes action independent of weight loss.

The predicted 10-year risk of cardiovascular disease fell after surgery in the cohort, with a 71% decrease in coronary heart disease (CHD, P = .001), 84% decrease in fatal CHD (P = .001), 50% decrease in stroke (P = .01), and 57% decrease in fatal stroke (P = .009). Hypertension and dyslipidemia were also seen to have improved, with hypertension resolving in 15 of the 26 (58%) patients who had it at baseline, hypercholesterolemia resolving in 21 of 33 (64%) patients, and hypertriglyceridemia resolving in 18 of 31 (58%), in the follow-up period.

Importantly, none of the subjects lost excessive weight or showed evidence of malnutrition. The lowest BMI observed in the follow-up period was 23.6.

The findings, Dr. Cohen and his colleagues wrote in their analysis, have broad implications for health policy, as they "indicate that RYGB is a safe, effective procedure to ameliorate type 2 diabetes and associated comorbidities, thereby reducing predicted cardiovascular disease risk, in patients with a BMI of 30–35 kg/m²."

While randomized controlled trial data are required to confirm that the procedure can be recommended in these patients, the investigators wrote, "our favorable findings from a relatively large, long-term study help justify such trials to clarify whether standard indications for RYGB should be broadened and whether this operation might be viewed primarily as ‘metabolic,’ rather than ‘bariatric,’ surgery."

Dr. Cohen and colleagues’ study was funded by the Municipal Health Authority and Marcia Maria Braido Hospital in São Paulo, Brazil. Dr. Cohen disclosed that he received previous study funding from Covidien, and one of his coauthors, Dr. David E. Cummings of the University of Washington, Seattle, disclosed receiving past funding from Ethicon Endo-Surgery. The other authors said they had no relevant financial disclosures.

Patients with severe diabetes but only mild obesity see a dramatic benefit after gastric bypass surgery, a new study has found, with 88% experiencing durable disease remission within 6 months, along with major reductions in 10-year cardiovascular risk.

No mortality, major surgical complications, excessive weight loss, or malnutrition was seen among the 66 patients in the study, all of whom underwent laparoscopic Roux-en-Y gastric bypass (RYGB) surgery, according to the findings published in the July issue of Diabetes Care (2012;35:1420-8) and presented at the annual scientific sessions of the American Diabetes Association in Philadelphia.

Bariatric surgery is currently recommended by the National Institutes of Health only for people with a body mass index (BMI) of 40 kg/m² or higher, or above 35 for people with comorbidities such as severe diabetes. Very obese patients with diabetes have seen dramatic reductions in disease activity after RYGB surgery, with an estimated 80%-85% experiencing durable remission. There is increasing evidence that the procedure triggers hormonal and metabolic antidiabetes responses independent of weight loss (Annu. Rev. Med. 2010;61:393-411; Int. J. Obes. 2009;33:S33-S40; Endocrinology 2009;150:2518-25).

People with mild obesity and diabetes constitute a larger group than the very obese, yet they do not currently qualify for bariatric surgery.

Dr. Ricardo V. Cohen of Oswaldo Cruz Hospital and Marcia Maria Braido Hospital, both in São Paulo, Brazil, and his colleagues sought to investigate whether people with a lower BMI and poorly controlled diabetes also would see significant benefit. More than one-fourth of people in the United States with diabetes have class I obesity, or a BMI of 30-35 (Int. J. Clin. Pract. 2007;61:737-47).

For their research, Dr. Cohen and his colleagues recruited 40 men and 26 women. All were white and ranged in age from 31 to 63 years, and had a BMI of 30.0-34.9 and diabetes lasting 7 years or more at the time of surgery. The mean HbA_1c level was 9.7% at the time of surgery, despite the use of insulin and/or oral diabetes medications (n = 7 on insulin). Follow-up on the cohort was 100%, for a median 5 years.

Within 26 weeks after surgery, 88% of patients were able to discontinue their diabetes medications and maintain an HbA_1c level of less than 6.5% without resuming diabetes medications in the follow-up period.

Improvement without remission was seen in 11% of patients, who were able to withdraw insulin and/or reduce dosages of oral medications between 3 and 14 weeks after surgery. One patient showed no improvement in glycemic control, but was able to withdraw insulin and achieve diabetes control with oral medications 7 months post surgery.

Mean HbA_1c for the entire cohort fell progressively throughout the study, from 9.7% to 5.9% (P less than .001). Fasting plasma glucose (FPG) fell from 156 mg/dL to 97 mg/dL (P less than .001). Most of these changes occurred within the first 6 months.

All patients saw progressive reductions in waist circumference and total body weight, although the magnitude of weight loss was not seen as corresponding with decreases in either FPG or HbA_1c until after 5 years post surgery, when the investigators saw significant correlations between weight loss and decrease in FPG. No correlations were seen between weight loss and decrease in HbA_1c. Also, while the ratio of change in C-peptide to change in glucose increased significantly in the postoperative period, there was no correlation seen between the magnitude of the increase and weight lost. All these findings suggest that the surgery induces mechanisms of antidiabetes action independent of weight loss.

The predicted 10-year risk of cardiovascular disease fell after surgery in the cohort, with a 71% decrease in coronary heart disease (CHD, P = .001), 84% decrease in fatal CHD (P = .001), 50% decrease in stroke (P = .01), and 57% decrease in fatal stroke (P = .009). Hypertension and dyslipidemia were also seen to have improved, with hypertension resolving in 15 of the 26 (58%) patients who had it at baseline, hypercholesterolemia resolving in 21 of 33 (64%) patients, and hypertriglyceridemia resolving in 18 of 31 (58%), in the follow-up period.

Importantly, none of the subjects lost excessive weight or showed evidence of malnutrition. The lowest BMI observed in the follow-up period was 23.6.

The findings, Dr. Cohen and his colleagues wrote in their analysis, have broad implications for health policy, as they "indicate that RYGB is a safe, effective procedure to ameliorate type 2 diabetes and associated comorbidities, thereby reducing predicted cardiovascular disease risk, in patients with a BMI of 30–35 kg/m²."

While randomized controlled trial data are required to confirm that the procedure can be recommended in these patients, the investigators wrote, "our favorable findings from a relatively large, long-term study help justify such trials to clarify whether standard indications for RYGB should be broadened and whether this operation might be viewed primarily as ‘metabolic,’ rather than ‘bariatric,’ surgery."

Dr. Cohen and colleagues’ study was funded by the Municipal Health Authority and Marcia Maria Braido Hospital in São Paulo, Brazil. Dr. Cohen disclosed that he received previous study funding from Covidien, and one of his coauthors, Dr. David E. Cummings of the University of Washington, Seattle, disclosed receiving past funding from Ethicon Endo-Surgery. The other authors said they had no relevant financial disclosures.

SAN DIEGO – Nasal colonization of methicillin-resistant Staphylococcus aureus was linked to an increase in surgical site infections and longer hospital stays in patients undergoing major gastrointestinal surgery in a large retrospective study, a finding that surprised investigators who had hypothesized that nasal colonization of the organism, which is not routinely found or colonized in the GI tract, would have little impact on outcome measures.

"Gastrointestinal operations are different from other surgeries in that infectious pathogens are typically organisms found in the gut, not bacteria that colonize in the skin, which is why we didn’t expect to find a correlation," lead investigator Dr. Harry T. Papaconstantinou said during a teleconference reporting the results, which he presented on Sunday, May 20, at the annual Digestive Disease Week conference.

Courtesy U.S. National Institute of Allergy and Infectious Diseases

While it’s unlikely that nasal colonization of MRSA necessarily increases the risk of developing a surgical site infection following GI surgery, "it is possible that it might be an indicator of the type of organism that is involved in the infection." For example, in the current analysis, wound culture data were available for 92 patients. In patients who tested positive for MRSA, 70% of the wound infections stemmed from MRSA, compared with only 8.5% in of those who tested negative, he said.

To evaluate the relationship between MRSA nasal colonization and surgical site infection, wound cultures, hospital length of stay, and mortality, Dr. Papaconstantinou, chief of colorectal surgery at Scott and White Memorial Hospital in Temple, Tex., and his colleagues examined the records of patients who underwent major GI surgery at the hospital between December 2007 and August 2009. The patients, who also had nasal swab tests within 24-48 hours after admission, were divided into one of three categories: MRSA-swab positive, methicillin-sensitive Staphylococcus aureus (MSSA)–swab positive, or negative for both.

Of the 1,137 patients, mean age 59.5 years, 73 (6.4%) were MRSA-swab positive, 167 (14.7%) were MSSA-swab positive, and 897 (78.9%) were negative, Dr. Papaconstantinou reported. Surgical site infection was identified in 101 patients (8.9%), and the rate of infection was highest, at 14%, in the MRSA-swab positive patients, compared with 4% and 9%, respectively, in the MSSA-swab positive and negative patients, he said. "When we controlled for other confounding factors, we didn’t find nasal swab to be an independent predictor of surgical site infection, but what we did find was a strong relationship between MRSA-positive nasal colonization and type of organism involved [in the surgical site infection]."

Regarding mean hospital length of stay, the respective durations for the MRSA-swab positive, MSSA-swab positive, and the negative groups overall were 12.5 days, 7.6 days, and 8.8 days, representing a significant increase, said Dr. Papaconstantinou. "By multiregression analysis, we found a MRSA-positive swab to be an independent risk factor for extended length of stay." However, when looking specifically at patients with surgical site infections, the presence of which increased hospital length of stay significantly from 6.2 days to 15.7 days, "there was no between group differences based on nasal swab," he said. Similarly, the 45 deaths in the study population wee distributed evenly across the nasal swab groups.

Based on the findings, Dr. Papaconstantinou said in an interview, "we can conclude that a positive MRSA nasal swab test for colonization is a strong predictor that MRSA-associated surgical site infections will occur in patients undergoing major GI surgery." As such, "we propose the possibility that it might be beneficial to preoperatively screen and decolonize these patients in an effort to reduce the incidence of these infections and improve patient outcomes following surgery." Toward this end, he and his colleagues are anticipating performing such a study and plan on including a cost-benefit analysis to determine whether screening is economically beneficial, he said.

Dr. Papaconstantinou disclosed a financial relationship with Covidien.

SAN DIEGO – Nasal colonization of methicillin-resistant Staphylococcus aureus was linked to an increase in surgical site infections and longer hospital stays in patients undergoing major gastrointestinal surgery in a large retrospective study, a finding that surprised investigators who had hypothesized that nasal colonization of the organism, which is not routinely found or colonized in the GI tract, would have little impact on outcome measures.

"Gastrointestinal operations are different from other surgeries in that infectious pathogens are typically organisms found in the gut, not bacteria that colonize in the skin, which is why we didn’t expect to find a correlation," lead investigator Dr. Harry T. Papaconstantinou said during a teleconference reporting the results, which he presented on Sunday, May 20, at the annual Digestive Disease Week conference.

Courtesy U.S. National Institute of Allergy and Infectious Diseases

While it’s unlikely that nasal colonization of MRSA necessarily increases the risk of developing a surgical site infection following GI surgery, "it is possible that it might be an indicator of the type of organism that is involved in the infection." For example, in the current analysis, wound culture data were available for 92 patients. In patients who tested positive for MRSA, 70% of the wound infections stemmed from MRSA, compared with only 8.5% in of those who tested negative, he said.

To evaluate the relationship between MRSA nasal colonization and surgical site infection, wound cultures, hospital length of stay, and mortality, Dr. Papaconstantinou, chief of colorectal surgery at Scott and White Memorial Hospital in Temple, Tex., and his colleagues examined the records of patients who underwent major GI surgery at the hospital between December 2007 and August 2009. The patients, who also had nasal swab tests within 24-48 hours after admission, were divided into one of three categories: MRSA-swab positive, methicillin-sensitive Staphylococcus aureus (MSSA)–swab positive, or negative for both.

Of the 1,137 patients, mean age 59.5 years, 73 (6.4%) were MRSA-swab positive, 167 (14.7%) were MSSA-swab positive, and 897 (78.9%) were negative, Dr. Papaconstantinou reported. Surgical site infection was identified in 101 patients (8.9%), and the rate of infection was highest, at 14%, in the MRSA-swab positive patients, compared with 4% and 9%, respectively, in the MSSA-swab positive and negative patients, he said. "When we controlled for other confounding factors, we didn’t find nasal swab to be an independent predictor of surgical site infection, but what we did find was a strong relationship between MRSA-positive nasal colonization and type of organism involved [in the surgical site infection]."

Regarding mean hospital length of stay, the respective durations for the MRSA-swab positive, MSSA-swab positive, and the negative groups overall were 12.5 days, 7.6 days, and 8.8 days, representing a significant increase, said Dr. Papaconstantinou. "By multiregression analysis, we found a MRSA-positive swab to be an independent risk factor for extended length of stay." However, when looking specifically at patients with surgical site infections, the presence of which increased hospital length of stay significantly from 6.2 days to 15.7 days, "there was no between group differences based on nasal swab," he said. Similarly, the 45 deaths in the study population wee distributed evenly across the nasal swab groups.

Based on the findings, Dr. Papaconstantinou said in an interview, "we can conclude that a positive MRSA nasal swab test for colonization is a strong predictor that MRSA-associated surgical site infections will occur in patients undergoing major GI surgery." As such, "we propose the possibility that it might be beneficial to preoperatively screen and decolonize these patients in an effort to reduce the incidence of these infections and improve patient outcomes following surgery." Toward this end, he and his colleagues are anticipating performing such a study and plan on including a cost-benefit analysis to determine whether screening is economically beneficial, he said.

Dr. Papaconstantinou disclosed a financial relationship with Covidien.

SAN DIEGO – Nasal colonization of methicillin-resistant Staphylococcus aureus was linked to an increase in surgical site infections and longer hospital stays in patients undergoing major gastrointestinal surgery in a large retrospective study, a finding that surprised investigators who had hypothesized that nasal colonization of the organism, which is not routinely found or colonized in the GI tract, would have little impact on outcome measures.

"Gastrointestinal operations are different from other surgeries in that infectious pathogens are typically organisms found in the gut, not bacteria that colonize in the skin, which is why we didn’t expect to find a correlation," lead investigator Dr. Harry T. Papaconstantinou said during a teleconference reporting the results, which he presented on Sunday, May 20, at the annual Digestive Disease Week conference.

Courtesy U.S. National Institute of Allergy and Infectious Diseases

While it’s unlikely that nasal colonization of MRSA necessarily increases the risk of developing a surgical site infection following GI surgery, "it is possible that it might be an indicator of the type of organism that is involved in the infection." For example, in the current analysis, wound culture data were available for 92 patients. In patients who tested positive for MRSA, 70% of the wound infections stemmed from MRSA, compared with only 8.5% in of those who tested negative, he said.

To evaluate the relationship between MRSA nasal colonization and surgical site infection, wound cultures, hospital length of stay, and mortality, Dr. Papaconstantinou, chief of colorectal surgery at Scott and White Memorial Hospital in Temple, Tex., and his colleagues examined the records of patients who underwent major GI surgery at the hospital between December 2007 and August 2009. The patients, who also had nasal swab tests within 24-48 hours after admission, were divided into one of three categories: MRSA-swab positive, methicillin-sensitive Staphylococcus aureus (MSSA)–swab positive, or negative for both.

Of the 1,137 patients, mean age 59.5 years, 73 (6.4%) were MRSA-swab positive, 167 (14.7%) were MSSA-swab positive, and 897 (78.9%) were negative, Dr. Papaconstantinou reported. Surgical site infection was identified in 101 patients (8.9%), and the rate of infection was highest, at 14%, in the MRSA-swab positive patients, compared with 4% and 9%, respectively, in the MSSA-swab positive and negative patients, he said. "When we controlled for other confounding factors, we didn’t find nasal swab to be an independent predictor of surgical site infection, but what we did find was a strong relationship between MRSA-positive nasal colonization and type of organism involved [in the surgical site infection]."

Regarding mean hospital length of stay, the respective durations for the MRSA-swab positive, MSSA-swab positive, and the negative groups overall were 12.5 days, 7.6 days, and 8.8 days, representing a significant increase, said Dr. Papaconstantinou. "By multiregression analysis, we found a MRSA-positive swab to be an independent risk factor for extended length of stay." However, when looking specifically at patients with surgical site infections, the presence of which increased hospital length of stay significantly from 6.2 days to 15.7 days, "there was no between group differences based on nasal swab," he said. Similarly, the 45 deaths in the study population wee distributed evenly across the nasal swab groups.

Based on the findings, Dr. Papaconstantinou said in an interview, "we can conclude that a positive MRSA nasal swab test for colonization is a strong predictor that MRSA-associated surgical site infections will occur in patients undergoing major GI surgery." As such, "we propose the possibility that it might be beneficial to preoperatively screen and decolonize these patients in an effort to reduce the incidence of these infections and improve patient outcomes following surgery." Toward this end, he and his colleagues are anticipating performing such a study and plan on including a cost-benefit analysis to determine whether screening is economically beneficial, he said.

Dr. Papaconstantinou disclosed a financial relationship with Covidien.

MIAMI BEACH – "Green suit hypertension" can result in cancellation of procedures on the scheduled day of surgery, according to researchers who retrospectively studied 9,543 preoperative patients at the VA Nebraska – Western Iowa Health System.

And about half of these cases of preoperative hypertension result from withholding or missing antihypertensive medications on the morning of surgery, Dr. Joleen Fixley said at a meeting on perioperative medicine sponsored by the University of Miami.

Dr. Fixley and her colleagues found that 2,947 – or 31% of the total cohort of presurgical patients seen between 2004 and 2009 – had significant increases in blood pressure readings (blood pressure over 140 mmHg/90 mmHg) on the day of their procedure. This so-called green suit hypertension has been attributed to patients seeing their surgeons in green scrubs on the day of their operation. The group included 1,389 patients with previously controlled hypertension.

Those with green suit hypertension had a statistically significant average increase of 16 mmHg systolic and 23 mmHg diastolic over their baseline blood pressure measures as compared with other patients at the VA Nebraska – Western Iowa Health System, where Dr. Fixley is an attending in the department of internal medicine and medical director of the preoperative clinic.

Preoperative hypertension resulted in surgical cancellations for 73 patients overall, including 38 patients with green suit hypertension. These 38 patients had an average blood pressure increase from baseline of 47 mmHg systolic and 27 mmHg diastolic just before surgery.

"Holding or missing antihypertensive medications on the morning of surgery was responsible for almost half [45%] of our cancellations due to preoperative hypertension," Dr. Fixley said. This included 22% who skipped their diuretics, 15% who skipped their ACE inhibitors, and 8% who skipped both.

"Patient adherence to antihypertensive medication regimen is a factor in the perioperative period. The controversial practice of holding diuretics and ACE-inhibitors should cease," Dr. Fixley said.

Use of baseline blood pressure readings taken anywhere within their institution within 90 days of surgery was a potential limitation of the study, Dr. Fixley said. In addition, the study included a predominantly male population (94% were men; the average age was 63 years).

Future trials that assess intraoperative beta blockade therapy could include a cohort of patients with green suit hypertension to determine any beneficial effect, Dr. Fixley said.

Dr. Fixley said that she had no relevant financial disclosures.

MIAMI BEACH – "Green suit hypertension" can result in cancellation of procedures on the scheduled day of surgery, according to researchers who retrospectively studied 9,543 preoperative patients at the VA Nebraska – Western Iowa Health System.

And about half of these cases of preoperative hypertension result from withholding or missing antihypertensive medications on the morning of surgery, Dr. Joleen Fixley said at a meeting on perioperative medicine sponsored by the University of Miami.

Dr. Fixley and her colleagues found that 2,947 – or 31% of the total cohort of presurgical patients seen between 2004 and 2009 – had significant increases in blood pressure readings (blood pressure over 140 mmHg/90 mmHg) on the day of their procedure. This so-called green suit hypertension has been attributed to patients seeing their surgeons in green scrubs on the day of their operation. The group included 1,389 patients with previously controlled hypertension.

Those with green suit hypertension had a statistically significant average increase of 16 mmHg systolic and 23 mmHg diastolic over their baseline blood pressure measures as compared with other patients at the VA Nebraska – Western Iowa Health System, where Dr. Fixley is an attending in the department of internal medicine and medical director of the preoperative clinic.

Preoperative hypertension resulted in surgical cancellations for 73 patients overall, including 38 patients with green suit hypertension. These 38 patients had an average blood pressure increase from baseline of 47 mmHg systolic and 27 mmHg diastolic just before surgery.

"Holding or missing antihypertensive medications on the morning of surgery was responsible for almost half [45%] of our cancellations due to preoperative hypertension," Dr. Fixley said. This included 22% who skipped their diuretics, 15% who skipped their ACE inhibitors, and 8% who skipped both.

"Patient adherence to antihypertensive medication regimen is a factor in the perioperative period. The controversial practice of holding diuretics and ACE-inhibitors should cease," Dr. Fixley said.

Use of baseline blood pressure readings taken anywhere within their institution within 90 days of surgery was a potential limitation of the study, Dr. Fixley said. In addition, the study included a predominantly male population (94% were men; the average age was 63 years).

Future trials that assess intraoperative beta blockade therapy could include a cohort of patients with green suit hypertension to determine any beneficial effect, Dr. Fixley said.

Dr. Fixley said that she had no relevant financial disclosures.

MIAMI BEACH – "Green suit hypertension" can result in cancellation of procedures on the scheduled day of surgery, according to researchers who retrospectively studied 9,543 preoperative patients at the VA Nebraska – Western Iowa Health System.

And about half of these cases of preoperative hypertension result from withholding or missing antihypertensive medications on the morning of surgery, Dr. Joleen Fixley said at a meeting on perioperative medicine sponsored by the University of Miami.

Dr. Fixley and her colleagues found that 2,947 – or 31% of the total cohort of presurgical patients seen between 2004 and 2009 – had significant increases in blood pressure readings (blood pressure over 140 mmHg/90 mmHg) on the day of their procedure. This so-called green suit hypertension has been attributed to patients seeing their surgeons in green scrubs on the day of their operation. The group included 1,389 patients with previously controlled hypertension.

Those with green suit hypertension had a statistically significant average increase of 16 mmHg systolic and 23 mmHg diastolic over their baseline blood pressure measures as compared with other patients at the VA Nebraska – Western Iowa Health System, where Dr. Fixley is an attending in the department of internal medicine and medical director of the preoperative clinic.

Preoperative hypertension resulted in surgical cancellations for 73 patients overall, including 38 patients with green suit hypertension. These 38 patients had an average blood pressure increase from baseline of 47 mmHg systolic and 27 mmHg diastolic just before surgery.

"Holding or missing antihypertensive medications on the morning of surgery was responsible for almost half [45%] of our cancellations due to preoperative hypertension," Dr. Fixley said. This included 22% who skipped their diuretics, 15% who skipped their ACE inhibitors, and 8% who skipped both.

"Patient adherence to antihypertensive medication regimen is a factor in the perioperative period. The controversial practice of holding diuretics and ACE-inhibitors should cease," Dr. Fixley said.

Use of baseline blood pressure readings taken anywhere within their institution within 90 days of surgery was a potential limitation of the study, Dr. Fixley said. In addition, the study included a predominantly male population (94% were men; the average age was 63 years).

Future trials that assess intraoperative beta blockade therapy could include a cohort of patients with green suit hypertension to determine any beneficial effect, Dr. Fixley said.

Dr. Fixley said that she had no relevant financial disclosures.

LONDON – Being obese increased the risk of surgical site infection nearly fourfold among patients who underwent operations in the United Kingdom from 2006 through 2010.

The findings pose questions such as whether preoperative dosing of antibiotics might be adjusted upward or whether preoperative weight loss should be advocated, said Dr. Simon Thelwall of the Health Protection Agency, London.

The analysis was done using nationwide data from the UK’s Health Protection Agency (HPA) Surgical Site Infection Surveillance Service, comprising data submitted from all 212 of the National Health Service hospitals in England on a cumulative total of 326,880 adult patients who underwent one of five operations: abdominal hysterectomy, coronary artery bypass graft (CABG), hip replacement, knee replacement, and large bowel surgery.

Of those, surgical site infections (SSIs) were detected in inpatients and at readmission for 4,453, and body mass index (BMI) data were available for 43%. Of these 112,048 (79.3%) were overweight or obese, said Dr. Thelwall.

The rates of SSIs didn’t differ among those with and without available body mass index data except among CABG patients, for whom the rate of SSIs was double among those with and without BMI data (5.17% vs. 2.71%). The CABG patients with BMI data were also significantly more likely to have received implants (85% vs. 61%), to have undergone emergency operations (1.29% vs. 0.76%), and to have had significantly longer operations (205 vs. 220 minutes).

Thus, "CABG patients with BMI data are more likely to have risk factors predisposing them to SSI," Dr. Thelwall noted.

Obesity significantly increased the risk for SSI in all surgical groups except for abdominal hysterectomy, with risk ratios ranging from 1.62 for knee replacement to 1.87 for large bowel surgery. Obesity still increased the SSI risk among abdominal hysterectomy patients with a risk ratio of 1.81, but that did not reach statistical significance, he said.

Overall, the SSI risk increased with increasing BMI. In multivariate analysis adjusting for a variety of potential confounders including age, trauma, category of surgery, implant, and emergency surgery, the odds ratios for SSI increased from 1.44 among the overweight patients to 1.89 for those with BMIs of 30-34.99 kg/m², to 2.94 for BMIs of 35-39.99 kg/m², and to 3.73 for BMIs greater than 40 kg/m². In the highest BMI category, even the SSI rate for abdominal hysterectomy became significantly greater, compared with that of patients of normal weight (risk ratio, 3.90), Dr. Thelwall said.

Among the morbidly obese (BMI greater than 40 kg/m²), between 65% and 78% of the risk for SSI was attributable to being very obese. And in that group of morbidly obese patients, the risk of SSI among abdominal hysterectomy patients became significantly elevated three- to fivefold, compared with that of women of normal weight, he noted.

Dr. Thelwall declared that he had no disclosures.

LONDON – Being obese increased the risk of surgical site infection nearly fourfold among patients who underwent operations in the United Kingdom from 2006 through 2010.

The findings pose questions such as whether preoperative dosing of antibiotics might be adjusted upward or whether preoperative weight loss should be advocated, said Dr. Simon Thelwall of the Health Protection Agency, London.

The analysis was done using nationwide data from the UK’s Health Protection Agency (HPA) Surgical Site Infection Surveillance Service, comprising data submitted from all 212 of the National Health Service hospitals in England on a cumulative total of 326,880 adult patients who underwent one of five operations: abdominal hysterectomy, coronary artery bypass graft (CABG), hip replacement, knee replacement, and large bowel surgery.

Of those, surgical site infections (SSIs) were detected in inpatients and at readmission for 4,453, and body mass index (BMI) data were available for 43%. Of these 112,048 (79.3%) were overweight or obese, said Dr. Thelwall.

The rates of SSIs didn’t differ among those with and without available body mass index data except among CABG patients, for whom the rate of SSIs was double among those with and without BMI data (5.17% vs. 2.71%). The CABG patients with BMI data were also significantly more likely to have received implants (85% vs. 61%), to have undergone emergency operations (1.29% vs. 0.76%), and to have had significantly longer operations (205 vs. 220 minutes).

Thus, "CABG patients with BMI data are more likely to have risk factors predisposing them to SSI," Dr. Thelwall noted.

Obesity significantly increased the risk for SSI in all surgical groups except for abdominal hysterectomy, with risk ratios ranging from 1.62 for knee replacement to 1.87 for large bowel surgery. Obesity still increased the SSI risk among abdominal hysterectomy patients with a risk ratio of 1.81, but that did not reach statistical significance, he said.

Overall, the SSI risk increased with increasing BMI. In multivariate analysis adjusting for a variety of potential confounders including age, trauma, category of surgery, implant, and emergency surgery, the odds ratios for SSI increased from 1.44 among the overweight patients to 1.89 for those with BMIs of 30-34.99 kg/m², to 2.94 for BMIs of 35-39.99 kg/m², and to 3.73 for BMIs greater than 40 kg/m². In the highest BMI category, even the SSI rate for abdominal hysterectomy became significantly greater, compared with that of patients of normal weight (risk ratio, 3.90), Dr. Thelwall said.

Among the morbidly obese (BMI greater than 40 kg/m²), between 65% and 78% of the risk for SSI was attributable to being very obese. And in that group of morbidly obese patients, the risk of SSI among abdominal hysterectomy patients became significantly elevated three- to fivefold, compared with that of women of normal weight, he noted.

Dr. Thelwall declared that he had no disclosures.

LONDON – Being obese increased the risk of surgical site infection nearly fourfold among patients who underwent operations in the United Kingdom from 2006 through 2010.

The findings pose questions such as whether preoperative dosing of antibiotics might be adjusted upward or whether preoperative weight loss should be advocated, said Dr. Simon Thelwall of the Health Protection Agency, London.

The analysis was done using nationwide data from the UK’s Health Protection Agency (HPA) Surgical Site Infection Surveillance Service, comprising data submitted from all 212 of the National Health Service hospitals in England on a cumulative total of 326,880 adult patients who underwent one of five operations: abdominal hysterectomy, coronary artery bypass graft (CABG), hip replacement, knee replacement, and large bowel surgery.

Of those, surgical site infections (SSIs) were detected in inpatients and at readmission for 4,453, and body mass index (BMI) data were available for 43%. Of these 112,048 (79.3%) were overweight or obese, said Dr. Thelwall.

The rates of SSIs didn’t differ among those with and without available body mass index data except among CABG patients, for whom the rate of SSIs was double among those with and without BMI data (5.17% vs. 2.71%). The CABG patients with BMI data were also significantly more likely to have received implants (85% vs. 61%), to have undergone emergency operations (1.29% vs. 0.76%), and to have had significantly longer operations (205 vs. 220 minutes).

Thus, "CABG patients with BMI data are more likely to have risk factors predisposing them to SSI," Dr. Thelwall noted.

Obesity significantly increased the risk for SSI in all surgical groups except for abdominal hysterectomy, with risk ratios ranging from 1.62 for knee replacement to 1.87 for large bowel surgery. Obesity still increased the SSI risk among abdominal hysterectomy patients with a risk ratio of 1.81, but that did not reach statistical significance, he said.

Overall, the SSI risk increased with increasing BMI. In multivariate analysis adjusting for a variety of potential confounders including age, trauma, category of surgery, implant, and emergency surgery, the odds ratios for SSI increased from 1.44 among the overweight patients to 1.89 for those with BMIs of 30-34.99 kg/m², to 2.94 for BMIs of 35-39.99 kg/m², and to 3.73 for BMIs greater than 40 kg/m². In the highest BMI category, even the SSI rate for abdominal hysterectomy became significantly greater, compared with that of patients of normal weight (risk ratio, 3.90), Dr. Thelwall said.

Among the morbidly obese (BMI greater than 40 kg/m²), between 65% and 78% of the risk for SSI was attributable to being very obese. And in that group of morbidly obese patients, the risk of SSI among abdominal hysterectomy patients became significantly elevated three- to fivefold, compared with that of women of normal weight, he noted.

Dr. Thelwall declared that he had no disclosures.

In California, the median cost of treating patients hospitalized for uncomplicated appendicitis ranged from $1,529 to a whopping $182,955, a finding that surprised investigators led by Dr. Renee Y. Hsia, of the emergency medicine department at the University of California, San Francisco.

"Given estimates that 60% of bankruptcies in the United States involve catastrophic medical expenses, these data should alarm those making decisions about our society’s ability to obtain medical care without financial catastrophe," Dr. Hsia and her associates wrote online April 23 in the Archives of Internal Medicine.

Courtesy UCSF News Center

The investigators used demographic and financial data from the 2009 Discharge Database of California’s Office of Statewide Health Planning and Development to review 19,368 cases of routine appendicitis treated at 289 hospitals and medical centers throughout California. They limited the analysis to patients 18-59 years who were admitted for 3 or fewer days (Arch. Intern. Med. 2012 April 23 [doi:10.1001/archinternmed.2012.1173]). The main outcome of interest was total charges per visit.

"It has been well described that the actual cost of care and charges billed to the patient are not necessarily the same," the investigators wrote. "But for the uninsured or underinsured, these charges are what the patient ultimately sees and therefore represent the perceived cost of their care."

Dr. Hsia and her associates found that the median hospital charge among all patients was $33,611; the lowest observed charge was $1,529 and highest was $182,955. Factors associated with higher median charges included being on Medicaid, being insured, and being treated at a for-profit hospital.

"A patient with severe abdominal pain is in a poor position to determine whether his or her physician is ordering the appropriate blood work, imaging, or surgical procedure," the investigators commented. "Price shopping is improbable, if not impossible, because the services are complex, urgently needed, and no definitive diagnosis has yet been made. In our study, even if patients did have the luxury of time and clinical knowledge to ‘shop around,’ we found that California hospitals charge patients inconsistently for what should be similar services as defined by our relatively strict definition of uncomplicated appendicitis."

The study was funded by grant KL2 RR024130 and the Robert Wood Johnson Foundation Physician Faculty Scholars. The investigators stated that they had no relevant financial conflicts to disclose.

In California, the median cost of treating patients hospitalized for uncomplicated appendicitis ranged from $1,529 to a whopping $182,955, a finding that surprised investigators led by Dr. Renee Y. Hsia, of the emergency medicine department at the University of California, San Francisco.

"Given estimates that 60% of bankruptcies in the United States involve catastrophic medical expenses, these data should alarm those making decisions about our society’s ability to obtain medical care without financial catastrophe," Dr. Hsia and her associates wrote online April 23 in the Archives of Internal Medicine.

Courtesy UCSF News Center

The investigators used demographic and financial data from the 2009 Discharge Database of California’s Office of Statewide Health Planning and Development to review 19,368 cases of routine appendicitis treated at 289 hospitals and medical centers throughout California. They limited the analysis to patients 18-59 years who were admitted for 3 or fewer days (Arch. Intern. Med. 2012 April 23 [doi:10.1001/archinternmed.2012.1173]). The main outcome of interest was total charges per visit.

"It has been well described that the actual cost of care and charges billed to the patient are not necessarily the same," the investigators wrote. "But for the uninsured or underinsured, these charges are what the patient ultimately sees and therefore represent the perceived cost of their care."

Dr. Hsia and her associates found that the median hospital charge among all patients was $33,611; the lowest observed charge was $1,529 and highest was $182,955. Factors associated with higher median charges included being on Medicaid, being insured, and being treated at a for-profit hospital.

"A patient with severe abdominal pain is in a poor position to determine whether his or her physician is ordering the appropriate blood work, imaging, or surgical procedure," the investigators commented. "Price shopping is improbable, if not impossible, because the services are complex, urgently needed, and no definitive diagnosis has yet been made. In our study, even if patients did have the luxury of time and clinical knowledge to ‘shop around,’ we found that California hospitals charge patients inconsistently for what should be similar services as defined by our relatively strict definition of uncomplicated appendicitis."

The study was funded by grant KL2 RR024130 and the Robert Wood Johnson Foundation Physician Faculty Scholars. The investigators stated that they had no relevant financial conflicts to disclose.

In California, the median cost of treating patients hospitalized for uncomplicated appendicitis ranged from $1,529 to a whopping $182,955, a finding that surprised investigators led by Dr. Renee Y. Hsia, of the emergency medicine department at the University of California, San Francisco.

"Given estimates that 60% of bankruptcies in the United States involve catastrophic medical expenses, these data should alarm those making decisions about our society’s ability to obtain medical care without financial catastrophe," Dr. Hsia and her associates wrote online April 23 in the Archives of Internal Medicine.

Courtesy UCSF News Center

The investigators used demographic and financial data from the 2009 Discharge Database of California’s Office of Statewide Health Planning and Development to review 19,368 cases of routine appendicitis treated at 289 hospitals and medical centers throughout California. They limited the analysis to patients 18-59 years who were admitted for 3 or fewer days (Arch. Intern. Med. 2012 April 23 [doi:10.1001/archinternmed.2012.1173]). The main outcome of interest was total charges per visit.

"It has been well described that the actual cost of care and charges billed to the patient are not necessarily the same," the investigators wrote. "But for the uninsured or underinsured, these charges are what the patient ultimately sees and therefore represent the perceived cost of their care."

Dr. Hsia and her associates found that the median hospital charge among all patients was $33,611; the lowest observed charge was $1,529 and highest was $182,955. Factors associated with higher median charges included being on Medicaid, being insured, and being treated at a for-profit hospital.

"A patient with severe abdominal pain is in a poor position to determine whether his or her physician is ordering the appropriate blood work, imaging, or surgical procedure," the investigators commented. "Price shopping is improbable, if not impossible, because the services are complex, urgently needed, and no definitive diagnosis has yet been made. In our study, even if patients did have the luxury of time and clinical knowledge to ‘shop around,’ we found that California hospitals charge patients inconsistently for what should be similar services as defined by our relatively strict definition of uncomplicated appendicitis."

The study was funded by grant KL2 RR024130 and the Robert Wood Johnson Foundation Physician Faculty Scholars. The investigators stated that they had no relevant financial conflicts to disclose.

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.

NEW ORLEANS – Because of problems inherent in the "expert medical testimony" system for medical liability cases, some form of extrajudicial oversight is probably needed, according to Dr. Steve Waxman.

Dr. Waxman, a urologist and a lawyer who is an expert in medicolegal issues, spoke at the annual conference of the American College of Legal Medicine.

Medical experts play a crucial role in determining causation, whether a physician has met the standard of care, and whether a case should move forward. While they used to be given great deference by the court and enjoyed near-immunity, problems with expert testimony are now being acknowledged, Dr. Waxman said.

These include, in particular, the varying levels of expertise and the questionable impartiality of some medical experts and the fact that scientific support for testimony is often lacking. "Their opinions on causation are not always supported by facts," he observed. And while expert witnesses should see themselves as "educators," they often become "advocates," depending upon who is paying their fee, he said, noting they could be swayed by financial gain.

"There is a big difference in level 1 evidence and expert opinion, but to a jury those distinguishing characteristics are not so clear, especially when presented by a smooth-talking expert witness," he continued.

Medical experts should determine the standard of care based on several factors: scientific basis, method and testability; peer-reviewed literature; clinical practice guidelines; and majority or respected minority opinion. The standard of care upon which a physician defendant is judged "should not just be personal opinion or experience," he emphasized.

Such concerns raise the question of whether "extrajudicial oversight" is necessary. "If a judge, jury, or attorney cannot recognize and therefore challenge false or misleading testimony, can it or should it be challenged outside of the courtroom?" Dr. Waxman asked.

A Need for Extrajudicial Review of Experts?

There are Federal Rules of Evidence that give trial judges oversight of expert witness testimony, although the court is not inclined to impose punitive measures against experts who testify falsely, according to Dr. Waxman. "The view of the medical community is that the judicial oversight of medical expert testimony is incomplete," he said.

Extrajudicial oversight, therefore, has been advocated by a number of entities, including medical specialty organizations, state medical boards, and national and state medical associations. A number have instituted some means of peer review, evaluating medical experts with regard to ethics and bylaws violations, unprofessional behavior, and the "practice of medicine."

Some of the medical specialty organizations providing extrajudicial oversight include the American Association of Neurological Surgeons (Professional Conduct Committee and Procedural Guidelines), Society of Thoracic Surgeons (Expert Registry), American Academy of Emergency Medicine (Remarkable Testimony), and the American Urological Association (Judicial and Ethics Committee). The Society of Hospital Medicine does not have a policy statement on the issue.

The American Urological Association, of which Dr. Waxman is a member, lays out qualifications that must be met by medical. Members pay their dues and sign an affirmation statement agreeing to the guidelines. Members who violate this agreement can be disciplined.

But such extrajudicial oversight is not welcomed by the plaintiff bar, he said. The American Association for Justice maintains that cross-examination should uncover the truth; that peer-review programs may be "facially neutral," but their real purpose is suspect; that the threat of extrajudicial review will reduce the pool of available medical experts for plaintiffs; and that medical associations have a conflict of interest in participating (they want to protect their members).

Emerging Alternatives

Some specialty societies are developing their own expert registries, which are aimed at improving the availability of qualified medical expert witnesses for the plaintiff, to raise the bar for testimony, and to weed out frivolous suits and encourage settlement of meritorious suits. "The defense bar likes this idea, but the plaintiff bar is not very interested," Dr. Waxman said. "They have a stable of experts whose responses are predictable. If they use the registry, they may not like the answers they get. This is not a case of ‘if you build it, they will come,’ in terms of the plaintiff bar."

Physician panels are another emerging alternative and are in place in Indiana and Louisiana. These panels review all cases to determine merit, but plaintiff attorneys can proceed in spite of the outcome.

Dr. Waxman concluded that "the current system is working, most of the time," and that problematic medical experts are being weeded out of the system, though there is room for improvement. Peer oversight is "probably appropriate and necessary," he maintained, "because it usually takes a physician to spot a physician giving false or misleading testimony."

"Because of the esoteric nature of many specialties, judges and juries are not able to spot irresponsible, misleading, or even fraudulent testimony. Physicians are best suited to review the quality of medical expert testimony, but the current judicial system does not adequately allow for a critical objective review of this form of testimony," he said.

"My view is that physician panels or physician review of medical expert testimony, early on in the litigation process, is preferable to extrajudicial review by medical societies, associations, or boards after the fact. If there is a three-to-zero decision by the panel, and the plaintiff still wants to bring in the expert, this expert is on notice that he or she has three of their own who disagree. The expert better be able to back the testimony up with science."

American Urological Association Qualifications for Expert Witness Testimony

• Active in the practice of clinical urology with a current valid and unrestricted license at the time of the alleged occurrence.

• Current certification in urology from the American Board of Urology.

• At least 5 years of clinical practice after satisfactorily completing residency/fellowship training.

• Expertise with texts, journals, guidelines, and other sources of information that establish the applicable standard of care at the time of the alleged occurrence.

• Perform a complete and thorough review of all available medical and legal information, including other medical depositions, before rendering any opinion regarding the case.

• Identify personal opinions as such, particularly where these deviate from other urologic viewpoints.

• Proficiency and experience in the area of clinical practice that is the subject of the case.

• Willingness to serve for either defendant or plaintiff in a fair and impartial manner; refusal to be manipulated by an attorney into becoming an advocate or partisan for one side.

• Willingness to declare and document the particulars related to the expert witness practice, inclusive of the number of cases for the defense or plaintiff, percentage of time spent in expert witness testimony, fees and compensation; refusal to accept contingency fees.

• Willingness to sign the AUA Expert Witness Affirmation Statement.

NEW ORLEANS – Because of problems inherent in the "expert medical testimony" system for medical liability cases, some form of extrajudicial oversight is probably needed, according to Dr. Steve Waxman.

Dr. Waxman, a urologist and a lawyer who is an expert in medicolegal issues, spoke at the annual conference of the American College of Legal Medicine.

Medical experts play a crucial role in determining causation, whether a physician has met the standard of care, and whether a case should move forward. While they used to be given great deference by the court and enjoyed near-immunity, problems with expert testimony are now being acknowledged, Dr. Waxman said.

These include, in particular, the varying levels of expertise and the questionable impartiality of some medical experts and the fact that scientific support for testimony is often lacking. "Their opinions on causation are not always supported by facts," he observed. And while expert witnesses should see themselves as "educators," they often become "advocates," depending upon who is paying their fee, he said, noting they could be swayed by financial gain.

"There is a big difference in level 1 evidence and expert opinion, but to a jury those distinguishing characteristics are not so clear, especially when presented by a smooth-talking expert witness," he continued.

Medical experts should determine the standard of care based on several factors: scientific basis, method and testability; peer-reviewed literature; clinical practice guidelines; and majority or respected minority opinion. The standard of care upon which a physician defendant is judged "should not just be personal opinion or experience," he emphasized.

Such concerns raise the question of whether "extrajudicial oversight" is necessary. "If a judge, jury, or attorney cannot recognize and therefore challenge false or misleading testimony, can it or should it be challenged outside of the courtroom?" Dr. Waxman asked.

A Need for Extrajudicial Review of Experts?

There are Federal Rules of Evidence that give trial judges oversight of expert witness testimony, although the court is not inclined to impose punitive measures against experts who testify falsely, according to Dr. Waxman. "The view of the medical community is that the judicial oversight of medical expert testimony is incomplete," he said.

Extrajudicial oversight, therefore, has been advocated by a number of entities, including medical specialty organizations, state medical boards, and national and state medical associations. A number have instituted some means of peer review, evaluating medical experts with regard to ethics and bylaws violations, unprofessional behavior, and the "practice of medicine."

Some of the medical specialty organizations providing extrajudicial oversight include the American Association of Neurological Surgeons (Professional Conduct Committee and Procedural Guidelines), Society of Thoracic Surgeons (Expert Registry), American Academy of Emergency Medicine (Remarkable Testimony), and the American Urological Association (Judicial and Ethics Committee). The Society of Hospital Medicine does not have a policy statement on the issue.

The American Urological Association, of which Dr. Waxman is a member, lays out qualifications that must be met by medical. Members pay their dues and sign an affirmation statement agreeing to the guidelines. Members who violate this agreement can be disciplined.

But such extrajudicial oversight is not welcomed by the plaintiff bar, he said. The American Association for Justice maintains that cross-examination should uncover the truth; that peer-review programs may be "facially neutral," but their real purpose is suspect; that the threat of extrajudicial review will reduce the pool of available medical experts for plaintiffs; and that medical associations have a conflict of interest in participating (they want to protect their members).

Emerging Alternatives

Some specialty societies are developing their own expert registries, which are aimed at improving the availability of qualified medical expert witnesses for the plaintiff, to raise the bar for testimony, and to weed out frivolous suits and encourage settlement of meritorious suits. "The defense bar likes this idea, but the plaintiff bar is not very interested," Dr. Waxman said. "They have a stable of experts whose responses are predictable. If they use the registry, they may not like the answers they get. This is not a case of ‘if you build it, they will come,’ in terms of the plaintiff bar."

Physician panels are another emerging alternative and are in place in Indiana and Louisiana. These panels review all cases to determine merit, but plaintiff attorneys can proceed in spite of the outcome.

Dr. Waxman concluded that "the current system is working, most of the time," and that problematic medical experts are being weeded out of the system, though there is room for improvement. Peer oversight is "probably appropriate and necessary," he maintained, "because it usually takes a physician to spot a physician giving false or misleading testimony."

"Because of the esoteric nature of many specialties, judges and juries are not able to spot irresponsible, misleading, or even fraudulent testimony. Physicians are best suited to review the quality of medical expert testimony, but the current judicial system does not adequately allow for a critical objective review of this form of testimony," he said.

"My view is that physician panels or physician review of medical expert testimony, early on in the litigation process, is preferable to extrajudicial review by medical societies, associations, or boards after the fact. If there is a three-to-zero decision by the panel, and the plaintiff still wants to bring in the expert, this expert is on notice that he or she has three of their own who disagree. The expert better be able to back the testimony up with science."

American Urological Association Qualifications for Expert Witness Testimony

• Active in the practice of clinical urology with a current valid and unrestricted license at the time of the alleged occurrence.

• Current certification in urology from the American Board of Urology.

• At least 5 years of clinical practice after satisfactorily completing residency/fellowship training.

• Expertise with texts, journals, guidelines, and other sources of information that establish the applicable standard of care at the time of the alleged occurrence.

• Perform a complete and thorough review of all available medical and legal information, including other medical depositions, before rendering any opinion regarding the case.

• Identify personal opinions as such, particularly where these deviate from other urologic viewpoints.

• Proficiency and experience in the area of clinical practice that is the subject of the case.

• Willingness to serve for either defendant or plaintiff in a fair and impartial manner; refusal to be manipulated by an attorney into becoming an advocate or partisan for one side.

• Willingness to declare and document the particulars related to the expert witness practice, inclusive of the number of cases for the defense or plaintiff, percentage of time spent in expert witness testimony, fees and compensation; refusal to accept contingency fees.

• Willingness to sign the AUA Expert Witness Affirmation Statement.

NEW ORLEANS – Because of problems inherent in the "expert medical testimony" system for medical liability cases, some form of extrajudicial oversight is probably needed, according to Dr. Steve Waxman.

Dr. Waxman, a urologist and a lawyer who is an expert in medicolegal issues, spoke at the annual conference of the American College of Legal Medicine.

Medical experts play a crucial role in determining causation, whether a physician has met the standard of care, and whether a case should move forward. While they used to be given great deference by the court and enjoyed near-immunity, problems with expert testimony are now being acknowledged, Dr. Waxman said.

These include, in particular, the varying levels of expertise and the questionable impartiality of some medical experts and the fact that scientific support for testimony is often lacking. "Their opinions on causation are not always supported by facts," he observed. And while expert witnesses should see themselves as "educators," they often become "advocates," depending upon who is paying their fee, he said, noting they could be swayed by financial gain.

"There is a big difference in level 1 evidence and expert opinion, but to a jury those distinguishing characteristics are not so clear, especially when presented by a smooth-talking expert witness," he continued.

Medical experts should determine the standard of care based on several factors: scientific basis, method and testability; peer-reviewed literature; clinical practice guidelines; and majority or respected minority opinion. The standard of care upon which a physician defendant is judged "should not just be personal opinion or experience," he emphasized.

Such concerns raise the question of whether "extrajudicial oversight" is necessary. "If a judge, jury, or attorney cannot recognize and therefore challenge false or misleading testimony, can it or should it be challenged outside of the courtroom?" Dr. Waxman asked.

A Need for Extrajudicial Review of Experts?

There are Federal Rules of Evidence that give trial judges oversight of expert witness testimony, although the court is not inclined to impose punitive measures against experts who testify falsely, according to Dr. Waxman. "The view of the medical community is that the judicial oversight of medical expert testimony is incomplete," he said.

Extrajudicial oversight, therefore, has been advocated by a number of entities, including medical specialty organizations, state medical boards, and national and state medical associations. A number have instituted some means of peer review, evaluating medical experts with regard to ethics and bylaws violations, unprofessional behavior, and the "practice of medicine."

Some of the medical specialty organizations providing extrajudicial oversight include the American Association of Neurological Surgeons (Professional Conduct Committee and Procedural Guidelines), Society of Thoracic Surgeons (Expert Registry), American Academy of Emergency Medicine (Remarkable Testimony), and the American Urological Association (Judicial and Ethics Committee). The Society of Hospital Medicine does not have a policy statement on the issue.

The American Urological Association, of which Dr. Waxman is a member, lays out qualifications that must be met by medical. Members pay their dues and sign an affirmation statement agreeing to the guidelines. Members who violate this agreement can be disciplined.

But such extrajudicial oversight is not welcomed by the plaintiff bar, he said. The American Association for Justice maintains that cross-examination should uncover the truth; that peer-review programs may be "facially neutral," but their real purpose is suspect; that the threat of extrajudicial review will reduce the pool of available medical experts for plaintiffs; and that medical associations have a conflict of interest in participating (they want to protect their members).

Emerging Alternatives

Some specialty societies are developing their own expert registries, which are aimed at improving the availability of qualified medical expert witnesses for the plaintiff, to raise the bar for testimony, and to weed out frivolous suits and encourage settlement of meritorious suits. "The defense bar likes this idea, but the plaintiff bar is not very interested," Dr. Waxman said. "They have a stable of experts whose responses are predictable. If they use the registry, they may not like the answers they get. This is not a case of ‘if you build it, they will come,’ in terms of the plaintiff bar."

Physician panels are another emerging alternative and are in place in Indiana and Louisiana. These panels review all cases to determine merit, but plaintiff attorneys can proceed in spite of the outcome.

Dr. Waxman concluded that "the current system is working, most of the time," and that problematic medical experts are being weeded out of the system, though there is room for improvement. Peer oversight is "probably appropriate and necessary," he maintained, "because it usually takes a physician to spot a physician giving false or misleading testimony."

"Because of the esoteric nature of many specialties, judges and juries are not able to spot irresponsible, misleading, or even fraudulent testimony. Physicians are best suited to review the quality of medical expert testimony, but the current judicial system does not adequately allow for a critical objective review of this form of testimony," he said.

"My view is that physician panels or physician review of medical expert testimony, early on in the litigation process, is preferable to extrajudicial review by medical societies, associations, or boards after the fact. If there is a three-to-zero decision by the panel, and the plaintiff still wants to bring in the expert, this expert is on notice that he or she has three of their own who disagree. The expert better be able to back the testimony up with science."

American Urological Association Qualifications for Expert Witness Testimony

• Active in the practice of clinical urology with a current valid and unrestricted license at the time of the alleged occurrence.

• Current certification in urology from the American Board of Urology.

• At least 5 years of clinical practice after satisfactorily completing residency/fellowship training.

• Expertise with texts, journals, guidelines, and other sources of information that establish the applicable standard of care at the time of the alleged occurrence.

• Perform a complete and thorough review of all available medical and legal information, including other medical depositions, before rendering any opinion regarding the case.

• Identify personal opinions as such, particularly where these deviate from other urologic viewpoints.

• Proficiency and experience in the area of clinical practice that is the subject of the case.

• Willingness to serve for either defendant or plaintiff in a fair and impartial manner; refusal to be manipulated by an attorney into becoming an advocate or partisan for one side.

• Willingness to declare and document the particulars related to the expert witness practice, inclusive of the number of cases for the defense or plaintiff, percentage of time spent in expert witness testimony, fees and compensation; refusal to accept contingency fees.

• Willingness to sign the AUA Expert Witness Affirmation Statement.

MIAMI BEACH – You get along with most of your colleagues in the hospital, but there is that one physician who doesn’t follow the rules, disrupts everyone’s workday, and ramps up the tension when they walk onto the ward.

Advice on which strategies work best to change disruptive and other problematic physician behavior comes from an anesthesiologist who oversees a South Florida health system of more than 1,400 doctors.

Focusing on changing behavior "is primarily what I do now more than anything else. ... It is about getting people to all pull in one direction," said Dr. David Lubarsky, who in September 2011 became CEO of UHealth Physician Practice and associate vice president for UHealth Practice administration at the University of Miami.

Disruptive or above-the-law behavior may garner the most attention, but behaviors related to low productivity, poor resource utilization, or poor patient satisfaction scores also need to change in this era of heightened accountability, Dr. Lubarsky said at a meeting on perioperative medicine sponsored by the University of Miami.

Sometimes there is a significant disconnect between how a disruptive physician perceives their own behavior compared with the impressions of clinicians around them. In such instances, a program such as Physicians Universal Leadership Skills Survey Enhancement (P.U.L.S.E.) 360 can help. "I have referred physicians for this," Dr. Lubarsky said. Essentially, the doctor in question first rates their own workplace behavior, and then the multidisciplinary team around them also completes surveys. Next, the doctor receives very specific feedback on both positive and negative behaviors.

"When they are confronted with this and told specifically what they are doing that isn’t really working, and given alternatives about how to approach a situation – and they see their scores getting better – they get better, they feel better. The whole team operates better. It’s a very positive experience."

Another tip: Don’t expend energy getting physicians to change their behavior when a technologic solution can achieve the same result, said Dr. Lubarsky, who retains his title as Emanuel M. Papper Professor and Chair, Department of Anesthesiology, Perioperative Medicine, and Pain Management, at the University of Miami.

A computerized prompt to administer preoperative antibiotics on time is an example. If this does not happen, other preparations for surgery automatically stop. Another successful intervention addresses incomplete chart documentation. This used to be an issue at the University of Miami when support staff had to "chase down a doctor for a signature," Dr. Lubarsky said. Now, if an attending forgets their documentation, they receive a page. "Incomplete chart documentation is now close to zero."

"You have to make it easy for everyone to do the right thing," he said.

Providing incentives can improve behaviors as well, but some ideas work better than others. Find out what the physicians value to devise meaningful incentives, Dr. Lubarsky said.

Increased commitment and motivation often ensue when physicians and others participate in setting specific, measurable goals. Difficult but achievable goals generate better performance than easy or impossible ones, Dr. Lubarsky noted. "The doctor must believe the goal is within reach."

Keep the plan simple. "Three to five goals are preferable to six or more goals," he said. Avoid complex incentive plans that assign two points for writing a paper, one point for attending a conference, and one point for staying late at work because "nobody understands this."

This era of tracking benchmark data for individual providers raises the question: Why is changing how people deliver care so difficult?

Part of it stems from physician experience and attitude, Dr. Lubarsky said. "After 4 years of college, 4 years of medical school, an average 4 years of training, and an average $150,000 of debt ... you paid for the right to call yourself a physician." Professional autonomy is deeply valued by physicians, he added.

However, "benchmarking, or use of external data, is very common now and it’s very powerful," Dr. Lubarsky said.

Physicians often balk when presented with their numbers, Dr. Lubarsky said. "I have not met a doctor yet who believes they are average or below average. I hear all this time: ‘The numbers are wrong. You have to get the right data.’ " Other reactions include, "So what?" or "My numbers are worse because my patients are sicker." Or there are physicians who dismiss what they perceive as a cookbook approach to medicine: "Are you planning to really make us do all you say and not individualize it for each patient?"

Benchmarking also relates to resource utilization. Physician attitude and behaviors are important because doctors dictate about 85% of the money spent in the hospital, he said.

Dr. Lubarsky said that he had no relevant financial disclosures.

MIAMI BEACH – You get along with most of your colleagues in the hospital, but there is that one physician who doesn’t follow the rules, disrupts everyone’s workday, and ramps up the tension when they walk onto the ward.

Advice on which strategies work best to change disruptive and other problematic physician behavior comes from an anesthesiologist who oversees a South Florida health system of more than 1,400 doctors.

Focusing on changing behavior "is primarily what I do now more than anything else. ... It is about getting people to all pull in one direction," said Dr. David Lubarsky, who in September 2011 became CEO of UHealth Physician Practice and associate vice president for UHealth Practice administration at the University of Miami.

Disruptive or above-the-law behavior may garner the most attention, but behaviors related to low productivity, poor resource utilization, or poor patient satisfaction scores also need to change in this era of heightened accountability, Dr. Lubarsky said at a meeting on perioperative medicine sponsored by the University of Miami.

Sometimes there is a significant disconnect between how a disruptive physician perceives their own behavior compared with the impressions of clinicians around them. In such instances, a program such as Physicians Universal Leadership Skills Survey Enhancement (P.U.L.S.E.) 360 can help. "I have referred physicians for this," Dr. Lubarsky said. Essentially, the doctor in question first rates their own workplace behavior, and then the multidisciplinary team around them also completes surveys. Next, the doctor receives very specific feedback on both positive and negative behaviors.

"When they are confronted with this and told specifically what they are doing that isn’t really working, and given alternatives about how to approach a situation – and they see their scores getting better – they get better, they feel better. The whole team operates better. It’s a very positive experience."

Another tip: Don’t expend energy getting physicians to change their behavior when a technologic solution can achieve the same result, said Dr. Lubarsky, who retains his title as Emanuel M. Papper Professor and Chair, Department of Anesthesiology, Perioperative Medicine, and Pain Management, at the University of Miami.

A computerized prompt to administer preoperative antibiotics on time is an example. If this does not happen, other preparations for surgery automatically stop. Another successful intervention addresses incomplete chart documentation. This used to be an issue at the University of Miami when support staff had to "chase down a doctor for a signature," Dr. Lubarsky said. Now, if an attending forgets their documentation, they receive a page. "Incomplete chart documentation is now close to zero."

"You have to make it easy for everyone to do the right thing," he said.

Providing incentives can improve behaviors as well, but some ideas work better than others. Find out what the physicians value to devise meaningful incentives, Dr. Lubarsky said.

Increased commitment and motivation often ensue when physicians and others participate in setting specific, measurable goals. Difficult but achievable goals generate better performance than easy or impossible ones, Dr. Lubarsky noted. "The doctor must believe the goal is within reach."

Keep the plan simple. "Three to five goals are preferable to six or more goals," he said. Avoid complex incentive plans that assign two points for writing a paper, one point for attending a conference, and one point for staying late at work because "nobody understands this."

This era of tracking benchmark data for individual providers raises the question: Why is changing how people deliver care so difficult?

Part of it stems from physician experience and attitude, Dr. Lubarsky said. "After 4 years of college, 4 years of medical school, an average 4 years of training, and an average $150,000 of debt ... you paid for the right to call yourself a physician." Professional autonomy is deeply valued by physicians, he added.

However, "benchmarking, or use of external data, is very common now and it’s very powerful," Dr. Lubarsky said.

Physicians often balk when presented with their numbers, Dr. Lubarsky said. "I have not met a doctor yet who believes they are average or below average. I hear all this time: ‘The numbers are wrong. You have to get the right data.’ " Other reactions include, "So what?" or "My numbers are worse because my patients are sicker." Or there are physicians who dismiss what they perceive as a cookbook approach to medicine: "Are you planning to really make us do all you say and not individualize it for each patient?"

Benchmarking also relates to resource utilization. Physician attitude and behaviors are important because doctors dictate about 85% of the money spent in the hospital, he said.

Dr. Lubarsky said that he had no relevant financial disclosures.

MIAMI BEACH – You get along with most of your colleagues in the hospital, but there is that one physician who doesn’t follow the rules, disrupts everyone’s workday, and ramps up the tension when they walk onto the ward.

Advice on which strategies work best to change disruptive and other problematic physician behavior comes from an anesthesiologist who oversees a South Florida health system of more than 1,400 doctors.

Focusing on changing behavior "is primarily what I do now more than anything else. ... It is about getting people to all pull in one direction," said Dr. David Lubarsky, who in September 2011 became CEO of UHealth Physician Practice and associate vice president for UHealth Practice administration at the University of Miami.

Disruptive or above-the-law behavior may garner the most attention, but behaviors related to low productivity, poor resource utilization, or poor patient satisfaction scores also need to change in this era of heightened accountability, Dr. Lubarsky said at a meeting on perioperative medicine sponsored by the University of Miami.

Sometimes there is a significant disconnect between how a disruptive physician perceives their own behavior compared with the impressions of clinicians around them. In such instances, a program such as Physicians Universal Leadership Skills Survey Enhancement (P.U.L.S.E.) 360 can help. "I have referred physicians for this," Dr. Lubarsky said. Essentially, the doctor in question first rates their own workplace behavior, and then the multidisciplinary team around them also completes surveys. Next, the doctor receives very specific feedback on both positive and negative behaviors.

"When they are confronted with this and told specifically what they are doing that isn’t really working, and given alternatives about how to approach a situation – and they see their scores getting better – they get better, they feel better. The whole team operates better. It’s a very positive experience."

Another tip: Don’t expend energy getting physicians to change their behavior when a technologic solution can achieve the same result, said Dr. Lubarsky, who retains his title as Emanuel M. Papper Professor and Chair, Department of Anesthesiology, Perioperative Medicine, and Pain Management, at the University of Miami.

A computerized prompt to administer preoperative antibiotics on time is an example. If this does not happen, other preparations for surgery automatically stop. Another successful intervention addresses incomplete chart documentation. This used to be an issue at the University of Miami when support staff had to "chase down a doctor for a signature," Dr. Lubarsky said. Now, if an attending forgets their documentation, they receive a page. "Incomplete chart documentation is now close to zero."

"You have to make it easy for everyone to do the right thing," he said.

Providing incentives can improve behaviors as well, but some ideas work better than others. Find out what the physicians value to devise meaningful incentives, Dr. Lubarsky said.

Increased commitment and motivation often ensue when physicians and others participate in setting specific, measurable goals. Difficult but achievable goals generate better performance than easy or impossible ones, Dr. Lubarsky noted. "The doctor must believe the goal is within reach."

Keep the plan simple. "Three to five goals are preferable to six or more goals," he said. Avoid complex incentive plans that assign two points for writing a paper, one point for attending a conference, and one point for staying late at work because "nobody understands this."

This era of tracking benchmark data for individual providers raises the question: Why is changing how people deliver care so difficult?

Part of it stems from physician experience and attitude, Dr. Lubarsky said. "After 4 years of college, 4 years of medical school, an average 4 years of training, and an average $150,000 of debt ... you paid for the right to call yourself a physician." Professional autonomy is deeply valued by physicians, he added.

However, "benchmarking, or use of external data, is very common now and it’s very powerful," Dr. Lubarsky said.

Physicians often balk when presented with their numbers, Dr. Lubarsky said. "I have not met a doctor yet who believes they are average or below average. I hear all this time: ‘The numbers are wrong. You have to get the right data.’ " Other reactions include, "So what?" or "My numbers are worse because my patients are sicker." Or there are physicians who dismiss what they perceive as a cookbook approach to medicine: "Are you planning to really make us do all you say and not individualize it for each patient?"

Benchmarking also relates to resource utilization. Physician attitude and behaviors are important because doctors dictate about 85% of the money spent in the hospital, he said.

Dr. Lubarsky said that he had no relevant financial disclosures.