OBG Management

As the population of patients with limited English proficiency increases throughout English-speaking countries, health care providers often need translator services. Medical translator smartphone applications (apps) are useful tools that can provide ad hoc translator services.

According to the US Census Bureau in 2015, more than 60 million individuals — about 19% of Americans — reported speaking a language other than English at home, and more than 25 million said that they speak English “less than very well.”^1,2 The top 5 non-English languages spoken at home were Spanish, French, Chinese, Tagalog, and Vietnamese, encompassing 72% of non-English speakers.

In the health care sector, translator services are essential for providing accurate and culturally competent care. Current options for translator services include face-to-face interpreters, phone-based translator services, and translator apps on mobile devices. In settings where face-to-face interpreters or phone-based translator services are not available, translator apps may provide reasonable alternatives. My colleagues, Dr. Amrin Khander and Dr. Sara Farag, and I identified and evaluated medical translator apps that are available from the Apple iTunes and Google Play stores to aid clinicians in using such apps during clinical encounters.³

Three types of translator apps

Preset medical phrase translator apps require the user to search for or find a question or statement in order to facilitate a conversation. With these types of apps, a health care provider can choose fully conjugated sentences, which then can be played or read back to the patient in the chosen translated language. Within this group of apps, Canopy Speak and Universal Doctor Speaker are highly accessible, since both apps are available from the Apple iTunes and Google Play stores and both are free.

Medical dictionary apps require the user to search for a medical term in one language to receive a translation in another language. These apps are less useful, but they can help providers find and define specific terms in a given language.

General language translator apps require the user to enter a term, statement, or question in one language and then provide a translation in another language. Google Translate and Vocre Translate are examples.

The top recommended translator apps are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁴ I hope the apps described here will help you enhance communication with your patients who have limited English proficiency.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

As the population of patients with limited English proficiency increases throughout English-speaking countries, health care providers often need translator services. Medical translator smartphone applications (apps) are useful tools that can provide ad hoc translator services.

According to the US Census Bureau in 2015, more than 60 million individuals — about 19% of Americans — reported speaking a language other than English at home, and more than 25 million said that they speak English “less than very well.”^1,2 The top 5 non-English languages spoken at home were Spanish, French, Chinese, Tagalog, and Vietnamese, encompassing 72% of non-English speakers.

In the health care sector, translator services are essential for providing accurate and culturally competent care. Current options for translator services include face-to-face interpreters, phone-based translator services, and translator apps on mobile devices. In settings where face-to-face interpreters or phone-based translator services are not available, translator apps may provide reasonable alternatives. My colleagues, Dr. Amrin Khander and Dr. Sara Farag, and I identified and evaluated medical translator apps that are available from the Apple iTunes and Google Play stores to aid clinicians in using such apps during clinical encounters.³

Three types of translator apps

Preset medical phrase translator apps require the user to search for or find a question or statement in order to facilitate a conversation. With these types of apps, a health care provider can choose fully conjugated sentences, which then can be played or read back to the patient in the chosen translated language. Within this group of apps, Canopy Speak and Universal Doctor Speaker are highly accessible, since both apps are available from the Apple iTunes and Google Play stores and both are free.

Medical dictionary apps require the user to search for a medical term in one language to receive a translation in another language. These apps are less useful, but they can help providers find and define specific terms in a given language.

General language translator apps require the user to enter a term, statement, or question in one language and then provide a translation in another language. Google Translate and Vocre Translate are examples.

The top recommended translator apps are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁴ I hope the apps described here will help you enhance communication with your patients who have limited English proficiency.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

As the population of patients with limited English proficiency increases throughout English-speaking countries, health care providers often need translator services. Medical translator smartphone applications (apps) are useful tools that can provide ad hoc translator services.

According to the US Census Bureau in 2015, more than 60 million individuals — about 19% of Americans — reported speaking a language other than English at home, and more than 25 million said that they speak English “less than very well.”^1,2 The top 5 non-English languages spoken at home were Spanish, French, Chinese, Tagalog, and Vietnamese, encompassing 72% of non-English speakers.

In the health care sector, translator services are essential for providing accurate and culturally competent care. Current options for translator services include face-to-face interpreters, phone-based translator services, and translator apps on mobile devices. In settings where face-to-face interpreters or phone-based translator services are not available, translator apps may provide reasonable alternatives. My colleagues, Dr. Amrin Khander and Dr. Sara Farag, and I identified and evaluated medical translator apps that are available from the Apple iTunes and Google Play stores to aid clinicians in using such apps during clinical encounters.³

Three types of translator apps

Preset medical phrase translator apps require the user to search for or find a question or statement in order to facilitate a conversation. With these types of apps, a health care provider can choose fully conjugated sentences, which then can be played or read back to the patient in the chosen translated language. Within this group of apps, Canopy Speak and Universal Doctor Speaker are highly accessible, since both apps are available from the Apple iTunes and Google Play stores and both are free.

Medical dictionary apps require the user to search for a medical term in one language to receive a translation in another language. These apps are less useful, but they can help providers find and define specific terms in a given language.

General language translator apps require the user to enter a term, statement, or question in one language and then provide a translation in another language. Google Translate and Vocre Translate are examples.

The top recommended translator apps are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁴ I hope the apps described here will help you enhance communication with your patients who have limited English proficiency.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

MY STORY: Prologue

My aunt received a breast cancer diagnosis at age 40, and she died at age 60, in 1970. Then, in 1975, my mother’s breast cancer was found at age 55, but only after she was examined for nipple retraction; on mammography, the cancer had been obscured by dense breast tissue. Mom had 2 metastatic nodes but participated in the earliest clinical trials of chemotherapy and lived free of breast cancer for another 41 years. Naturally I thought that, were I to develop this disease, I would want it found earlier. Ironically, it was, but only because I had spent my career trying to understand the optimal screening approaches for women with dense breasts—women like me.

Cancers are masked on mammography in dense breasts

For women, screening mammography is an important step in reducing the risk of dying from breast cancer. The greatest benefits are realized by those who start annual screening at age 40, or 45 at the latest.¹ As it takes 9 to 10 years to see a benefit from breast cancer screening at the population level, it is not logical to continue this testing when life expectancy is less than 10 years, as is the case with women age 85 or older, even those in the healthiest quartile.^2–4 However, despite recent advances, the development of 3D mammography (tomosynthesis) (FIGURE 1) in particular, cancers can still be masked by dense breast tissue. Both 2D and 3D mammograms are x-rays; both dense tissue and cancers absorb x-rays and appear white.

Breast density is determined on mammography and is categorized as fatty, scattered fibroglandular, heterogeneously dense, or extremely dense (FIGURE 2).⁵ Tissue in the heterogeneous and extreme categories is considered dense. More than half of women in their 40s have dense breasts; with some fatty involution occurring around menopause, the proportion drops to 25% for women in their 60s.⁶ About half of breast cancers have calcifications, which on mammography are usually easily visible even in dense breasts. The problem is with noncalcified invasive cancers that can be hidden by dense tissue (FIGURE 3).

3D mammography improves cancer detection but is of minimal benefit in extremely dense breasts

Although 3D mammography improves cancer detection in most women, any benefit is minimal in women with extremely dense breasts, as there is no inherent soft-tissue contrast.⁷ Masked cancers are often only discovered because of a lump after a normal screening mammogram, as so-called “interval cancers.” Compared with screen-detected cancers, interval cancers tend to be more biologically aggressive, to have spread to lymph nodes, and to have worse prognoses. However, even some small screen-detected cancers are biologically aggressive and can spread to lymph nodes quickly, and no screening test or combination of screening tests can prevent this occurrence completely, regardless of breast density.

Related article:
Get smart about dense breasts

ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT/COURTESY OF WENDIE A. BERG, MD, PHD

MRI provides early detection across all breast densities

In all tissue densities, contrast-enhanced magnetic resonance imaging (MRI) is far better than mammography in detecting breast cancer.⁸ Women at high risk for breast cancer caused by mutations in BRCA1, BRCA2, p53, and other genes have poor outcomes with screening mammography alone—up to 50% of cancers are interval cancers. Annual screening MRI reduces this percentage significantly, to 11% in women with pathogenic BRCA1 mutations and to 4% in women with BRCA2 mutations.⁹ Warner and colleagues found a decrease in late-stage cancers in high-risk women who underwent annual MRI screenings compared to high-risk women unable to have MRI.¹⁰

The use of MRI for screening is limited by availability, patient tolerance,¹¹ and high cost. Research is being conducted to further validate approaches using shortened screening MRI times (so-called “abbreviated” or “fast” MRI) and, thereby, improve access, tolerance, and reduce associated costs; several investigators already have reported promising results, and a few centers offer this modality directly to patients willing to pay $300 to $350 out of pocket.^12,13 Even in normal-risk women, MRI significantly increases detection of early breast cancer after a normal mammogram and ultrasound, and the cancer detection benefit of MRI is seen across all breast densities.¹⁴

Most health insurance plans cover screening MRI only for women who meet defined risk criteria, including women who have a known disease-causing mutation—or are suspected of having one, given a family history of breast cancer with higher than 20% to 25% lifetime risk by a model that predicts mutation carrier status—as well as women who had chest radiation therapy before age 30, typically for Hodgkin lymphoma, and at least 8 years earlier.¹⁵ In addition, MRI can be considered in women with atypical breast biopsy results or a personal history of lobular carcinoma in situ (LCIS).¹⁶

Screening MRI should start by age 25 in women with disease-causing mutations, or at the time of atypical or LCIS biopsy results, and should be performed annually unless the woman is pregnant or has a metallic implant, renal insufficiency, or another contraindication to MRI. MRI can be beneficial in women with a personal history of cancer, although annual mammography remains the standard of care.^17–19

MRI and mammography can be performed at the same time or on an alternating 6-month basis, with mammography usually starting only after age 30 because of the small risk that radiation poses for younger women. There are a few other impediments to having breast MRI: The woman must lie on her stomach within a confined space (tunnel), the contrast that is injected may not be well tolerated, and insurance does not cover the test for women who do not meet the defined risk criteria.¹¹

Read why mammography supplemented by US is best for women with dense breasts.

Ultrasonography supplements mammography

Mammography supplemented with ultrasonography (US) has been studied as a “Goldilocks” or best-fit solution for the screening of women with dense breasts, as detection of invasive cancers is improved with the 2 modalities over mammography alone, and US is less invasive, better tolerated, and lower in cost than the more sensitive MRI.

In women with dense breasts, US has been found to improve cancer detection over mammography alone, and early results suggest a larger cancer detection benefit from US than from 3D mammography, although research is ongoing.²⁰ Adding US reduces the interval cancer rate in women with dense breasts to less than 10% of all cancers found—similar to results for women with fatty breasts.^17,21,22

US can be performed by a trained technologist or a physician using a small transducer, which usually provides diagnostic images (so that most callbacks would be for a true finding), or a larger transducer and an automated system can be used to create more than a thousand images for radiologist review.^23,24 Use of a hybrid system, a small transducer with an automated arm, has been validated as well.²⁵ Screening US is not available universally, and with all these approaches optimal performance requires trained personnel. Supplemental screening US usually is covered by insurance but is nearly always subject to a deductible/copay.

Related article:
Educate patients about dense breasts and cancer risk

Reducing false-positives, callbacks, and additional testing

Mammography carries a risk of false-positives. On average, 11% to 12% of women are called back for additional testing after a screening mammogram, and in more than 95% of women brought back for extra testing, no cancer is found.²⁶ Women with dense breasts are more likely than those with less dense breasts to be called back.²⁷ US and MRI improve cancer detection and therefore yield additional positive, but also false-positive, findings. Notably, callbacks decrease after the first round of screening with any modality or combination of tests, as long as prior examinations are available for comparison.

One advantage of 3D over 2D mammography is a decrease in extra testing for areas of asymmetry, which are often recognizable on 3D mammography as representing normal superimposed tissue.^28–30 Architectural distortion, which is better seen on 3D mammography and usually represents either cancer or a benign radial scar, can lead to false-positive biopsies, although the average biopsy rate is no higher for 3D than for 2D alone.³¹ Typically, the 3D and 2D examinations are performed together (slightly more than doubling the radiation dose), or synthetic 2D images can be created from the 3D slices (resulting in a total radiation dose almost the same as standard 2D alone).

Most additional cancers seen on 3D mammography or US are lower-grade invasive cancers with good prognoses. Some aggressive high-grade breast cancers go undetected even when mammography is supplemented with US, either because they are too small to be seen or because they resemble common benign masses and may not be recognized. MRI is particularly effective in depicting high-grade cancers, even small ones.

The TABLE summarizes the relative rates of cancer detection and additional testing by various breast screening tests or combinations of tests. Neither clinical breast examination by a physician or other health care professional nor routine breast self-examination reduces the number of deaths caused by breast cancer. Nevertheless, women should monitor any changes in their breasts and report these changes to their clinician. A new lump, skin or nipple retraction, or a spontaneous clear or bloody nipple discharge merits diagnostic breast imaging even if a recent screening mammogram was normal.

Read how to take advantage of today’s technology for breast density screening

MY STORY: Epilogue

My annual 3D mammograms were normal, even the year my cancer was present. In 2014, I entered my family history into the IBIS Breast Cancer Risk Evaluation Tool (Tyrer-Cuzick model of breast cancer risk) (http://www.ems-trials.org/riskevaluator/) and calculated my lifetime risk at 19.7%. That is when I decided to have a screening MRI. My invasive breast cancer was easily seen on MRI and then on US. The cancer was node-negative, easily confirmed with needle biopsy, and treated with lumpectomy and radiation. There was no need for chemotherapy.

My personal experience prompted me to join JoAnn Pushkin and Cindy Henke-Sarmento, RT(R)(M), BA, in developing a website, www.DenseBreast-info.org, to give women and their physicians easy access to information on making decisions about screening in dense breasts.

My colleagues and I are often asked what is the best way to order supplemental imaging for a patient who may have dense breasts. Even in cases in which a mammogram does not exist or is unavailable, the following prescription can be implemented easily at centers that offer US: “2D plus 3D mammogram if available; if dense, perform ultrasound as needed.”

Related article:
DenseBreast-info.org: What this resource can offer you, and your patients

Breast density screening: Take advantage of today’s technology

Breast screening and diagnostic imaging have improved significantly since the 1970s, when many of the randomized trials of mammography were conducted. Breast density is one of the most common and important risk factors for development of breast cancer and is now incorporated into the Breast Cancer Surveillance Consortium model (https://tools.bcsc-scc.org/BC5yearRisk/calculator.htm) and the Tyrer-Cuzick model (see also http://densebreast-info.org/explanation-of-dense-breast-risk-models.aspx).³² Although we continue to validate newer approaches, women should take advantage of the improved methods of early cancer detection, particularly if they have dense breasts or are at high risk for breast cancer.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

MY STORY: Prologue

My aunt received a breast cancer diagnosis at age 40, and she died at age 60, in 1970. Then, in 1975, my mother’s breast cancer was found at age 55, but only after she was examined for nipple retraction; on mammography, the cancer had been obscured by dense breast tissue. Mom had 2 metastatic nodes but participated in the earliest clinical trials of chemotherapy and lived free of breast cancer for another 41 years. Naturally I thought that, were I to develop this disease, I would want it found earlier. Ironically, it was, but only because I had spent my career trying to understand the optimal screening approaches for women with dense breasts—women like me.

Cancers are masked on mammography in dense breasts

For women, screening mammography is an important step in reducing the risk of dying from breast cancer. The greatest benefits are realized by those who start annual screening at age 40, or 45 at the latest.¹ As it takes 9 to 10 years to see a benefit from breast cancer screening at the population level, it is not logical to continue this testing when life expectancy is less than 10 years, as is the case with women age 85 or older, even those in the healthiest quartile.^2–4 However, despite recent advances, the development of 3D mammography (tomosynthesis) (FIGURE 1) in particular, cancers can still be masked by dense breast tissue. Both 2D and 3D mammograms are x-rays; both dense tissue and cancers absorb x-rays and appear white.

Breast density is determined on mammography and is categorized as fatty, scattered fibroglandular, heterogeneously dense, or extremely dense (FIGURE 2).⁵ Tissue in the heterogeneous and extreme categories is considered dense. More than half of women in their 40s have dense breasts; with some fatty involution occurring around menopause, the proportion drops to 25% for women in their 60s.⁶ About half of breast cancers have calcifications, which on mammography are usually easily visible even in dense breasts. The problem is with noncalcified invasive cancers that can be hidden by dense tissue (FIGURE 3).

3D mammography improves cancer detection but is of minimal benefit in extremely dense breasts

Although 3D mammography improves cancer detection in most women, any benefit is minimal in women with extremely dense breasts, as there is no inherent soft-tissue contrast.⁷ Masked cancers are often only discovered because of a lump after a normal screening mammogram, as so-called “interval cancers.” Compared with screen-detected cancers, interval cancers tend to be more biologically aggressive, to have spread to lymph nodes, and to have worse prognoses. However, even some small screen-detected cancers are biologically aggressive and can spread to lymph nodes quickly, and no screening test or combination of screening tests can prevent this occurrence completely, regardless of breast density.

Related article:
Get smart about dense breasts

ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT/COURTESY OF WENDIE A. BERG, MD, PHD

MRI provides early detection across all breast densities

In all tissue densities, contrast-enhanced magnetic resonance imaging (MRI) is far better than mammography in detecting breast cancer.⁸ Women at high risk for breast cancer caused by mutations in BRCA1, BRCA2, p53, and other genes have poor outcomes with screening mammography alone—up to 50% of cancers are interval cancers. Annual screening MRI reduces this percentage significantly, to 11% in women with pathogenic BRCA1 mutations and to 4% in women with BRCA2 mutations.⁹ Warner and colleagues found a decrease in late-stage cancers in high-risk women who underwent annual MRI screenings compared to high-risk women unable to have MRI.¹⁰

The use of MRI for screening is limited by availability, patient tolerance,¹¹ and high cost. Research is being conducted to further validate approaches using shortened screening MRI times (so-called “abbreviated” or “fast” MRI) and, thereby, improve access, tolerance, and reduce associated costs; several investigators already have reported promising results, and a few centers offer this modality directly to patients willing to pay $300 to $350 out of pocket.^12,13 Even in normal-risk women, MRI significantly increases detection of early breast cancer after a normal mammogram and ultrasound, and the cancer detection benefit of MRI is seen across all breast densities.¹⁴

Most health insurance plans cover screening MRI only for women who meet defined risk criteria, including women who have a known disease-causing mutation—or are suspected of having one, given a family history of breast cancer with higher than 20% to 25% lifetime risk by a model that predicts mutation carrier status—as well as women who had chest radiation therapy before age 30, typically for Hodgkin lymphoma, and at least 8 years earlier.¹⁵ In addition, MRI can be considered in women with atypical breast biopsy results or a personal history of lobular carcinoma in situ (LCIS).¹⁶

Screening MRI should start by age 25 in women with disease-causing mutations, or at the time of atypical or LCIS biopsy results, and should be performed annually unless the woman is pregnant or has a metallic implant, renal insufficiency, or another contraindication to MRI. MRI can be beneficial in women with a personal history of cancer, although annual mammography remains the standard of care.^17–19

MRI and mammography can be performed at the same time or on an alternating 6-month basis, with mammography usually starting only after age 30 because of the small risk that radiation poses for younger women. There are a few other impediments to having breast MRI: The woman must lie on her stomach within a confined space (tunnel), the contrast that is injected may not be well tolerated, and insurance does not cover the test for women who do not meet the defined risk criteria.¹¹

Read why mammography supplemented by US is best for women with dense breasts.

Ultrasonography supplements mammography

Mammography supplemented with ultrasonography (US) has been studied as a “Goldilocks” or best-fit solution for the screening of women with dense breasts, as detection of invasive cancers is improved with the 2 modalities over mammography alone, and US is less invasive, better tolerated, and lower in cost than the more sensitive MRI.

In women with dense breasts, US has been found to improve cancer detection over mammography alone, and early results suggest a larger cancer detection benefit from US than from 3D mammography, although research is ongoing.²⁰ Adding US reduces the interval cancer rate in women with dense breasts to less than 10% of all cancers found—similar to results for women with fatty breasts.^17,21,22

US can be performed by a trained technologist or a physician using a small transducer, which usually provides diagnostic images (so that most callbacks would be for a true finding), or a larger transducer and an automated system can be used to create more than a thousand images for radiologist review.^23,24 Use of a hybrid system, a small transducer with an automated arm, has been validated as well.²⁵ Screening US is not available universally, and with all these approaches optimal performance requires trained personnel. Supplemental screening US usually is covered by insurance but is nearly always subject to a deductible/copay.

Related article:
Educate patients about dense breasts and cancer risk

Reducing false-positives, callbacks, and additional testing

Mammography carries a risk of false-positives. On average, 11% to 12% of women are called back for additional testing after a screening mammogram, and in more than 95% of women brought back for extra testing, no cancer is found.²⁶ Women with dense breasts are more likely than those with less dense breasts to be called back.²⁷ US and MRI improve cancer detection and therefore yield additional positive, but also false-positive, findings. Notably, callbacks decrease after the first round of screening with any modality or combination of tests, as long as prior examinations are available for comparison.

One advantage of 3D over 2D mammography is a decrease in extra testing for areas of asymmetry, which are often recognizable on 3D mammography as representing normal superimposed tissue.^28–30 Architectural distortion, which is better seen on 3D mammography and usually represents either cancer or a benign radial scar, can lead to false-positive biopsies, although the average biopsy rate is no higher for 3D than for 2D alone.³¹ Typically, the 3D and 2D examinations are performed together (slightly more than doubling the radiation dose), or synthetic 2D images can be created from the 3D slices (resulting in a total radiation dose almost the same as standard 2D alone).

Most additional cancers seen on 3D mammography or US are lower-grade invasive cancers with good prognoses. Some aggressive high-grade breast cancers go undetected even when mammography is supplemented with US, either because they are too small to be seen or because they resemble common benign masses and may not be recognized. MRI is particularly effective in depicting high-grade cancers, even small ones.

The TABLE summarizes the relative rates of cancer detection and additional testing by various breast screening tests or combinations of tests. Neither clinical breast examination by a physician or other health care professional nor routine breast self-examination reduces the number of deaths caused by breast cancer. Nevertheless, women should monitor any changes in their breasts and report these changes to their clinician. A new lump, skin or nipple retraction, or a spontaneous clear or bloody nipple discharge merits diagnostic breast imaging even if a recent screening mammogram was normal.

Read how to take advantage of today’s technology for breast density screening

MY STORY: Epilogue

My annual 3D mammograms were normal, even the year my cancer was present. In 2014, I entered my family history into the IBIS Breast Cancer Risk Evaluation Tool (Tyrer-Cuzick model of breast cancer risk) (http://www.ems-trials.org/riskevaluator/) and calculated my lifetime risk at 19.7%. That is when I decided to have a screening MRI. My invasive breast cancer was easily seen on MRI and then on US. The cancer was node-negative, easily confirmed with needle biopsy, and treated with lumpectomy and radiation. There was no need for chemotherapy.

My personal experience prompted me to join JoAnn Pushkin and Cindy Henke-Sarmento, RT(R)(M), BA, in developing a website, www.DenseBreast-info.org, to give women and their physicians easy access to information on making decisions about screening in dense breasts.

My colleagues and I are often asked what is the best way to order supplemental imaging for a patient who may have dense breasts. Even in cases in which a mammogram does not exist or is unavailable, the following prescription can be implemented easily at centers that offer US: “2D plus 3D mammogram if available; if dense, perform ultrasound as needed.”

Related article:
DenseBreast-info.org: What this resource can offer you, and your patients

Breast density screening: Take advantage of today’s technology

Breast screening and diagnostic imaging have improved significantly since the 1970s, when many of the randomized trials of mammography were conducted. Breast density is one of the most common and important risk factors for development of breast cancer and is now incorporated into the Breast Cancer Surveillance Consortium model (https://tools.bcsc-scc.org/BC5yearRisk/calculator.htm) and the Tyrer-Cuzick model (see also http://densebreast-info.org/explanation-of-dense-breast-risk-models.aspx).³² Although we continue to validate newer approaches, women should take advantage of the improved methods of early cancer detection, particularly if they have dense breasts or are at high risk for breast cancer.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

MY STORY: Prologue

My aunt received a breast cancer diagnosis at age 40, and she died at age 60, in 1970. Then, in 1975, my mother’s breast cancer was found at age 55, but only after she was examined for nipple retraction; on mammography, the cancer had been obscured by dense breast tissue. Mom had 2 metastatic nodes but participated in the earliest clinical trials of chemotherapy and lived free of breast cancer for another 41 years. Naturally I thought that, were I to develop this disease, I would want it found earlier. Ironically, it was, but only because I had spent my career trying to understand the optimal screening approaches for women with dense breasts—women like me.

Cancers are masked on mammography in dense breasts

For women, screening mammography is an important step in reducing the risk of dying from breast cancer. The greatest benefits are realized by those who start annual screening at age 40, or 45 at the latest.¹ As it takes 9 to 10 years to see a benefit from breast cancer screening at the population level, it is not logical to continue this testing when life expectancy is less than 10 years, as is the case with women age 85 or older, even those in the healthiest quartile.^2–4 However, despite recent advances, the development of 3D mammography (tomosynthesis) (FIGURE 1) in particular, cancers can still be masked by dense breast tissue. Both 2D and 3D mammograms are x-rays; both dense tissue and cancers absorb x-rays and appear white.

Breast density is determined on mammography and is categorized as fatty, scattered fibroglandular, heterogeneously dense, or extremely dense (FIGURE 2).⁵ Tissue in the heterogeneous and extreme categories is considered dense. More than half of women in their 40s have dense breasts; with some fatty involution occurring around menopause, the proportion drops to 25% for women in their 60s.⁶ About half of breast cancers have calcifications, which on mammography are usually easily visible even in dense breasts. The problem is with noncalcified invasive cancers that can be hidden by dense tissue (FIGURE 3).

3D mammography improves cancer detection but is of minimal benefit in extremely dense breasts

Although 3D mammography improves cancer detection in most women, any benefit is minimal in women with extremely dense breasts, as there is no inherent soft-tissue contrast.⁷ Masked cancers are often only discovered because of a lump after a normal screening mammogram, as so-called “interval cancers.” Compared with screen-detected cancers, interval cancers tend to be more biologically aggressive, to have spread to lymph nodes, and to have worse prognoses. However, even some small screen-detected cancers are biologically aggressive and can spread to lymph nodes quickly, and no screening test or combination of screening tests can prevent this occurrence completely, regardless of breast density.

Related article:
Get smart about dense breasts

ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT/COURTESY OF WENDIE A. BERG, MD, PHD

MRI provides early detection across all breast densities

In all tissue densities, contrast-enhanced magnetic resonance imaging (MRI) is far better than mammography in detecting breast cancer.⁸ Women at high risk for breast cancer caused by mutations in BRCA1, BRCA2, p53, and other genes have poor outcomes with screening mammography alone—up to 50% of cancers are interval cancers. Annual screening MRI reduces this percentage significantly, to 11% in women with pathogenic BRCA1 mutations and to 4% in women with BRCA2 mutations.⁹ Warner and colleagues found a decrease in late-stage cancers in high-risk women who underwent annual MRI screenings compared to high-risk women unable to have MRI.¹⁰

The use of MRI for screening is limited by availability, patient tolerance,¹¹ and high cost. Research is being conducted to further validate approaches using shortened screening MRI times (so-called “abbreviated” or “fast” MRI) and, thereby, improve access, tolerance, and reduce associated costs; several investigators already have reported promising results, and a few centers offer this modality directly to patients willing to pay $300 to $350 out of pocket.^12,13 Even in normal-risk women, MRI significantly increases detection of early breast cancer after a normal mammogram and ultrasound, and the cancer detection benefit of MRI is seen across all breast densities.¹⁴

Most health insurance plans cover screening MRI only for women who meet defined risk criteria, including women who have a known disease-causing mutation—or are suspected of having one, given a family history of breast cancer with higher than 20% to 25% lifetime risk by a model that predicts mutation carrier status—as well as women who had chest radiation therapy before age 30, typically for Hodgkin lymphoma, and at least 8 years earlier.¹⁵ In addition, MRI can be considered in women with atypical breast biopsy results or a personal history of lobular carcinoma in situ (LCIS).¹⁶

Screening MRI should start by age 25 in women with disease-causing mutations, or at the time of atypical or LCIS biopsy results, and should be performed annually unless the woman is pregnant or has a metallic implant, renal insufficiency, or another contraindication to MRI. MRI can be beneficial in women with a personal history of cancer, although annual mammography remains the standard of care.^17–19

MRI and mammography can be performed at the same time or on an alternating 6-month basis, with mammography usually starting only after age 30 because of the small risk that radiation poses for younger women. There are a few other impediments to having breast MRI: The woman must lie on her stomach within a confined space (tunnel), the contrast that is injected may not be well tolerated, and insurance does not cover the test for women who do not meet the defined risk criteria.¹¹

Read why mammography supplemented by US is best for women with dense breasts.

Ultrasonography supplements mammography

Mammography supplemented with ultrasonography (US) has been studied as a “Goldilocks” or best-fit solution for the screening of women with dense breasts, as detection of invasive cancers is improved with the 2 modalities over mammography alone, and US is less invasive, better tolerated, and lower in cost than the more sensitive MRI.

In women with dense breasts, US has been found to improve cancer detection over mammography alone, and early results suggest a larger cancer detection benefit from US than from 3D mammography, although research is ongoing.²⁰ Adding US reduces the interval cancer rate in women with dense breasts to less than 10% of all cancers found—similar to results for women with fatty breasts.^17,21,22

US can be performed by a trained technologist or a physician using a small transducer, which usually provides diagnostic images (so that most callbacks would be for a true finding), or a larger transducer and an automated system can be used to create more than a thousand images for radiologist review.^23,24 Use of a hybrid system, a small transducer with an automated arm, has been validated as well.²⁵ Screening US is not available universally, and with all these approaches optimal performance requires trained personnel. Supplemental screening US usually is covered by insurance but is nearly always subject to a deductible/copay.

Related article:
Educate patients about dense breasts and cancer risk

Reducing false-positives, callbacks, and additional testing

Mammography carries a risk of false-positives. On average, 11% to 12% of women are called back for additional testing after a screening mammogram, and in more than 95% of women brought back for extra testing, no cancer is found.²⁶ Women with dense breasts are more likely than those with less dense breasts to be called back.²⁷ US and MRI improve cancer detection and therefore yield additional positive, but also false-positive, findings. Notably, callbacks decrease after the first round of screening with any modality or combination of tests, as long as prior examinations are available for comparison.

One advantage of 3D over 2D mammography is a decrease in extra testing for areas of asymmetry, which are often recognizable on 3D mammography as representing normal superimposed tissue.^28–30 Architectural distortion, which is better seen on 3D mammography and usually represents either cancer or a benign radial scar, can lead to false-positive biopsies, although the average biopsy rate is no higher for 3D than for 2D alone.³¹ Typically, the 3D and 2D examinations are performed together (slightly more than doubling the radiation dose), or synthetic 2D images can be created from the 3D slices (resulting in a total radiation dose almost the same as standard 2D alone).

Most additional cancers seen on 3D mammography or US are lower-grade invasive cancers with good prognoses. Some aggressive high-grade breast cancers go undetected even when mammography is supplemented with US, either because they are too small to be seen or because they resemble common benign masses and may not be recognized. MRI is particularly effective in depicting high-grade cancers, even small ones.

The TABLE summarizes the relative rates of cancer detection and additional testing by various breast screening tests or combinations of tests. Neither clinical breast examination by a physician or other health care professional nor routine breast self-examination reduces the number of deaths caused by breast cancer. Nevertheless, women should monitor any changes in their breasts and report these changes to their clinician. A new lump, skin or nipple retraction, or a spontaneous clear or bloody nipple discharge merits diagnostic breast imaging even if a recent screening mammogram was normal.

Read how to take advantage of today’s technology for breast density screening

MY STORY: Epilogue

My annual 3D mammograms were normal, even the year my cancer was present. In 2014, I entered my family history into the IBIS Breast Cancer Risk Evaluation Tool (Tyrer-Cuzick model of breast cancer risk) (http://www.ems-trials.org/riskevaluator/) and calculated my lifetime risk at 19.7%. That is when I decided to have a screening MRI. My invasive breast cancer was easily seen on MRI and then on US. The cancer was node-negative, easily confirmed with needle biopsy, and treated with lumpectomy and radiation. There was no need for chemotherapy.

My personal experience prompted me to join JoAnn Pushkin and Cindy Henke-Sarmento, RT(R)(M), BA, in developing a website, www.DenseBreast-info.org, to give women and their physicians easy access to information on making decisions about screening in dense breasts.

My colleagues and I are often asked what is the best way to order supplemental imaging for a patient who may have dense breasts. Even in cases in which a mammogram does not exist or is unavailable, the following prescription can be implemented easily at centers that offer US: “2D plus 3D mammogram if available; if dense, perform ultrasound as needed.”

Related article:
DenseBreast-info.org: What this resource can offer you, and your patients

Breast density screening: Take advantage of today’s technology

Breast screening and diagnostic imaging have improved significantly since the 1970s, when many of the randomized trials of mammography were conducted. Breast density is one of the most common and important risk factors for development of breast cancer and is now incorporated into the Breast Cancer Surveillance Consortium model (https://tools.bcsc-scc.org/BC5yearRisk/calculator.htm) and the Tyrer-Cuzick model (see also http://densebreast-info.org/explanation-of-dense-breast-risk-models.aspx).³² Although we continue to validate newer approaches, women should take advantage of the improved methods of early cancer detection, particularly if they have dense breasts or are at high risk for breast cancer.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Independent of the Affordable Care Act or any upcoming changes in health care, the focus of an ObGyn practice remains paramount: the patient comes first.

The “recipe” for creating patient satisfaction and service excellence is predicated upon the mission of your practice and creating a shared vision with your employees. An action plan that is created and “visited/revisited”on a regular basis will serve to keep all abreast of the latest information to enhance the quality of patient care. It goes without saying, the ObGyn must first “lead by example” and always strive for satisfied patients who will tell their friends about your practice.

Start with the right tools

To organize a practice well, you need the right tools, which ideally include mission and vision statements and an action plan with goals and objectives.

Mission statement

A mission statement can be developed by the ObGyn(s) in your office or in concert with your staff. It should include:

• the “here and now” focus on the current approach to patient care
• why the practice exists (Develop a brief description of your practice, including the desired patient population.)
• the products and services offered and why and how those services are provided.

Here is an example of a mission statement for an ObGyn practice: “Our mission is to provide excellent, exceptional, personalized care for women of all ages in a warm and friendly environment. We incorporate leading-edge technology in our practice and continue to be a leader in obstetrics and gynecology.”

Vision statement

A vision statement should be developed in concert with your staff. It should include:

• the “then and there” focus on the historic perspective of your practice
• the ObGyn(s) and staff vision of the future
• what the ObGyn(s) and staff want to create.

The vision statement should energize and excite your personnel, create a shared and meaningful purpose, inspire passion and interest, and convey the values you want to share in your practice.

Here is an example of a vision statement for an ObGyn practice: “We aim to become the premier obstetrics and gynecology pro-vider to residents of (location) community.”

Action plan: Setting goals

To succeed, an ObGyn practice needs to:

• develop targets and challenges reflecting periodic (quarterly) meetings with staff and new entity development in the practice
• establish benchmarks and measurable parameters (How do you compare with other local practices? Set criteria/metrics to assess your progress.)
• ensure that the objectives support the goals (Develop goals and objectives over a defined period of time.)
• revisit the goals (Have they have been met? Do they need revision?)

Goals and objectives are essential for the continued health of your practice. This is all predicated upon developing a competitive advantage and then maintaining it.

Read about how to make a positive first impression on a new patient.

Is the environment welcoming?

When we examine a practice from the patient’s point of view, a good starting place is with the front desk. Have you looked at your front desk “from the outside in?” In one sense, this is the showcase of your practice.

Related article:
Four pillars of a successful practice: 2. Attract new patients

The first impression: Appointment scheduling

The first impression a patient receives about your practice occurs when she attempts to set up an appointment. Perhaps you might ask someone to call in to schedule an appointment. Is the caller immediately put on hold? Are your personnel courteous on the phone? Can she be seen quickly if she has a problem? How long is the wait for an annual exam? A test run can be very revealing.

Walk in the front door

When a patient walks in the door, does the physical office space radiate a friendly, relaxed atmosphere? Walk through the waiting room, then consultation and exam rooms as if you are a patient seeing it for the first time. Have you created an environment in which patients sense a well-organized office and the esprit de corps of the personnel? Does it look and smell fresh and clean? This all sends a loud and clear positive message about your practice.^1–3

Here are some suggestions for making a waiting room more inviting:

• Provide a seating arrangement that is “patient centered.” For example, semi- circular arrangements allow easy viewing of any monitors in the waiting room.
• WiFi is a great addition. Post several signs with the user name and password.
• Offer computers for patients to use to complete registration
• Set up a fish tank. If well-maintained, it can be soothing to many people.
• Display medical information pamphlets, even if they are rarely taken.
• Provide a big screen television that offers information about your practice, including personnel and procedures.

Streaming ads for physician offices are available. One platform, Outcome Health (https://www.outcomehealth.com), provides flat-screen TVs and tablets that show patient education videos.⁴ Another vendor, Patient Point (http://patientpoint.com), offers waiting room networks, editorials, and other communications designed to support “the goals of improving healthcare.”⁵ Other available media include channel news and music programming to relax patients.⁶

Wait times. A patient’s perceived wait time and the actual wait time are often quite different. How long she waits to see the ObGyn is “numero uno” with regard to patient satisfaction and can be a key source of annoyance, irritability, stress, and anger.

Does someone inform waiting patients that the ObGyn is running late? Does staff at the front desk or perhaps your medical assistant inquire, “Can I get you anything? The doctor is running late,” or “Dr. Jones has just finished delivering a baby. He’ll be here in 10 minutes. He’ll see you first.”

Consultation and exam rooms

Suggestions to develop a relaxing environment in your consultation and exam rooms are⁷:

• decorate the walls with soft, pastel colors
• use “spa aesthetics” to create a colorful atmosphere with appropriate lighting, artwork, and modern furnishings
• present a few magazines neatly and update them periodically
• stock and appropriately maintain the patients rooms with medical supplies
• remember, “Subjects perceive people more positively in beautiful rooms than in ugly rooms.”⁵

Read about how to keep your patients satisfied and your business stable.

Set the lead example

The need for open and supportive communication between you and your office staff cannot be overly emphasized. An ideal office staff member understands and shares in the vision, is aware of stated goals and objectives, is responsive to patient needs, and wants to create a win-win environment.

Frequently discuss your expectations with your staff. Expect them to be responsive, courteous, competent, have good communication skills, and be influenced by the appearance of the physical environ-ment. Provide support and educational tools to help them successfully perform their work.

Related article:
Four pillars of a successful practice: 1. Keep your current patients happy

Discover your patients’ vision of customer service

Formal measurement of patient satisfaction began with Professor Irwin Press at the University of Notre Dame. Rod Ganey, a sociologist and statistician, then developed the Press Ganey Patient Satisfaction Survey. These points earlier conveyed by Maslow and Mintz⁸ addressed the “effects of esthetic surroundings.” Color and art proved to be preferences in an esthetically pleasing environment. Additional historical information has been provided by Siegrist, who addressed “the patient experience.”⁹ He cites the myth that patients do not fill out satisfaction surveys. Indeed they do. Patient satisfaction is not a personality contest but rather a reflection of the health care provider’s investment of time and effort to offer patient-centered care. Siegrist also notes that the patient’s family plays a key role in how a patient perceives her experience with her health care professional.⁹

The federal government has been actively involved in assessing patient satisfaction in the hospital setting since 2002. This is reflected in the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. The HCAHPS is a 27-question survey randomly administered to adult inpatients after discharge.^10–12

The following metrics are often included in patient satisfaction surveys^9,10:

• rating of hospital care from 0 (lowest) to 10 (highest)
• percentage of patients who would recommend a practice to family and friends
• number of patients who say their health care providers always communicate well
• the number of patients who report that the office is always clean and friendly.

Use of search engines focused on health care patient surveys can provide a number of options for clinicians to use in their practice.

Tips on patient satisfaction

Several interesting tips from the busi-ness world can be applied to an ObGyn’s practice¹⁴:

• You will only hear from 4% of unhappy customers.
• One dissatisfied customer tells 9.
• 95% of customers with resolved issues will do business with you again.
• If a problem is not addressed, that patient will tell 10 others.
• Resolve the problem and 5 people will know about it.
• It costs 5 times as much effort to gain 1 new customer.
• Loyal customers in 1 area of service are good prospects for other (new) services.

Related article:
Using the Internet in your practice. Part 2: Generating new patients using social media

Tell stories about good, satisfied patients

Sharing the stories of satisfied patients motivates others to consider coming to your practice. To develop these stories, offer a “suggestion box” where patients can leave compliments or comments about their experiences. Ask patients to record their positive reviews (be sure to obtain written consent before recording and publishing). Show the videos on the big-screen TVs in your waiting room and include patient reviews (written, audio, and video) on your website.¹⁵

Related article:
Four pillars of a successful practice: 4. Motivate your staff

Reevaluate periodically

Encouraging team spirit makes good business sense. Offer staff members bonuses for coming up with improved processes. Provide educational programs for staff on patient care, technology, etc. If a difficult experience occurs, discuss it openly with staff members without accusing, asking them for suggestions to improve the situation.¹⁶

Talking cents: Assessing your practice

---

To assess the monetary value of your practice, you need to know what contributes to your profit margin and overhead. What investments are the most profitable? Then monitor each segment of the office practice.

Should you proceed with a purchase? Should you take on a new hire? Let's look at one excellent model from the Boston Consulting Group (FIGURE) that provides insight into "low and high performance" aspects of business or practice.¹

In the matrix, Stars use large amounts of cash and are leaders in cash generation. Stars lead to development of a Cash Cow, which are entities that generate profits and cash with low investment prerequisites. Dogs are segments of product and service line(s) that should be carefully reevaluated. A decision must be made to liquidate if the problem cannot be corrected. Question Marks have the worst cash characteristics of all and are associated with high demands and low profit margin(s).¹

SWOT analysis
A SWOT analysis is most helpful when assessing a practice in real time. The basic tenets are²:  
Strengths:  

• prestigious reputation
• technological expertise

Weaknesses:  

• antiquated computer system
• lack of experience in specific areas

Opportunities:

• growing market demand for a specific product or procedure
• provision of unique services

Threats:

• changing demographics
• competitive practices
• changes in health care third-party payers.

The American College of Obstetricians and Gynecologists (ACOG) has developed an "ACOG Medical Home Toolkit" to allow ObGyns to assess how significant the changes regarding payers will be to their practice. Sections include the patient/practice partnership support; clinical care information; community resources; care delivery management; performance measurement and improvement; and payment and finance.³ The toolkit is available for download from the ACOG website.

References

1. Morrison A, Wensley R. Boxing up or boxed in? A short history of the Boston Consulting Group Share/Growth Matrix. J Market Manag. 1993;7(2):105-129. http://www.tandfonline.com/doi/abs/10.1080/0267257X.1991.9964145.
2. Klasko SK, Toub DB. It's not a plan without a business plan. In: Sanfilippo JS, Nolan TE, Whiteside BH, eds. MBA Handbook for Healthcare Professionals. New York, NY: Parthenon Publishing Group; 2002:36-37.
3. American Congress of Obstetricians and Gynecologists. ACOG Medical Home Toolkit. https://www.acog.org/About-ACOG/ACOG-Departments/Practice-Management-and-Managed-Care/ACOG-Medical-Home-Toolkit. Accessed August 14, 2017.

Bottom line

Ensuring that your patients have an outstanding experience is a smart business strategy. A unified approach that includes team members’ involvement to create a patient-centered environment will provide a quality experience and encourage patients to recommend your ObGyn practice to others.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Independent of the Affordable Care Act or any upcoming changes in health care, the focus of an ObGyn practice remains paramount: the patient comes first.

The “recipe” for creating patient satisfaction and service excellence is predicated upon the mission of your practice and creating a shared vision with your employees. An action plan that is created and “visited/revisited”on a regular basis will serve to keep all abreast of the latest information to enhance the quality of patient care. It goes without saying, the ObGyn must first “lead by example” and always strive for satisfied patients who will tell their friends about your practice.

Start with the right tools

To organize a practice well, you need the right tools, which ideally include mission and vision statements and an action plan with goals and objectives.

Mission statement

A mission statement can be developed by the ObGyn(s) in your office or in concert with your staff. It should include:

• the “here and now” focus on the current approach to patient care
• why the practice exists (Develop a brief description of your practice, including the desired patient population.)
• the products and services offered and why and how those services are provided.

Here is an example of a mission statement for an ObGyn practice: “Our mission is to provide excellent, exceptional, personalized care for women of all ages in a warm and friendly environment. We incorporate leading-edge technology in our practice and continue to be a leader in obstetrics and gynecology.”

Vision statement

A vision statement should be developed in concert with your staff. It should include:

• the “then and there” focus on the historic perspective of your practice
• the ObGyn(s) and staff vision of the future
• what the ObGyn(s) and staff want to create.

The vision statement should energize and excite your personnel, create a shared and meaningful purpose, inspire passion and interest, and convey the values you want to share in your practice.

Here is an example of a vision statement for an ObGyn practice: “We aim to become the premier obstetrics and gynecology pro-vider to residents of (location) community.”

Action plan: Setting goals

To succeed, an ObGyn practice needs to:

• develop targets and challenges reflecting periodic (quarterly) meetings with staff and new entity development in the practice
• establish benchmarks and measurable parameters (How do you compare with other local practices? Set criteria/metrics to assess your progress.)
• ensure that the objectives support the goals (Develop goals and objectives over a defined period of time.)
• revisit the goals (Have they have been met? Do they need revision?)

Goals and objectives are essential for the continued health of your practice. This is all predicated upon developing a competitive advantage and then maintaining it.

Read about how to make a positive first impression on a new patient.

Is the environment welcoming?

When we examine a practice from the patient’s point of view, a good starting place is with the front desk. Have you looked at your front desk “from the outside in?” In one sense, this is the showcase of your practice.

Related article:
Four pillars of a successful practice: 2. Attract new patients

The first impression: Appointment scheduling

The first impression a patient receives about your practice occurs when she attempts to set up an appointment. Perhaps you might ask someone to call in to schedule an appointment. Is the caller immediately put on hold? Are your personnel courteous on the phone? Can she be seen quickly if she has a problem? How long is the wait for an annual exam? A test run can be very revealing.

Walk in the front door

When a patient walks in the door, does the physical office space radiate a friendly, relaxed atmosphere? Walk through the waiting room, then consultation and exam rooms as if you are a patient seeing it for the first time. Have you created an environment in which patients sense a well-organized office and the esprit de corps of the personnel? Does it look and smell fresh and clean? This all sends a loud and clear positive message about your practice.^1–3

Here are some suggestions for making a waiting room more inviting:

• Provide a seating arrangement that is “patient centered.” For example, semi- circular arrangements allow easy viewing of any monitors in the waiting room.
• WiFi is a great addition. Post several signs with the user name and password.
• Offer computers for patients to use to complete registration
• Set up a fish tank. If well-maintained, it can be soothing to many people.
• Display medical information pamphlets, even if they are rarely taken.
• Provide a big screen television that offers information about your practice, including personnel and procedures.

Streaming ads for physician offices are available. One platform, Outcome Health (https://www.outcomehealth.com), provides flat-screen TVs and tablets that show patient education videos.⁴ Another vendor, Patient Point (http://patientpoint.com), offers waiting room networks, editorials, and other communications designed to support “the goals of improving healthcare.”⁵ Other available media include channel news and music programming to relax patients.⁶

Wait times. A patient’s perceived wait time and the actual wait time are often quite different. How long she waits to see the ObGyn is “numero uno” with regard to patient satisfaction and can be a key source of annoyance, irritability, stress, and anger.

Does someone inform waiting patients that the ObGyn is running late? Does staff at the front desk or perhaps your medical assistant inquire, “Can I get you anything? The doctor is running late,” or “Dr. Jones has just finished delivering a baby. He’ll be here in 10 minutes. He’ll see you first.”

Consultation and exam rooms

Suggestions to develop a relaxing environment in your consultation and exam rooms are⁷:

• decorate the walls with soft, pastel colors
• use “spa aesthetics” to create a colorful atmosphere with appropriate lighting, artwork, and modern furnishings
• present a few magazines neatly and update them periodically
• stock and appropriately maintain the patients rooms with medical supplies
• remember, “Subjects perceive people more positively in beautiful rooms than in ugly rooms.”⁵

Read about how to keep your patients satisfied and your business stable.

Set the lead example

The need for open and supportive communication between you and your office staff cannot be overly emphasized. An ideal office staff member understands and shares in the vision, is aware of stated goals and objectives, is responsive to patient needs, and wants to create a win-win environment.

Frequently discuss your expectations with your staff. Expect them to be responsive, courteous, competent, have good communication skills, and be influenced by the appearance of the physical environ-ment. Provide support and educational tools to help them successfully perform their work.

Related article:
Four pillars of a successful practice: 1. Keep your current patients happy

Discover your patients’ vision of customer service

Formal measurement of patient satisfaction began with Professor Irwin Press at the University of Notre Dame. Rod Ganey, a sociologist and statistician, then developed the Press Ganey Patient Satisfaction Survey. These points earlier conveyed by Maslow and Mintz⁸ addressed the “effects of esthetic surroundings.” Color and art proved to be preferences in an esthetically pleasing environment. Additional historical information has been provided by Siegrist, who addressed “the patient experience.”⁹ He cites the myth that patients do not fill out satisfaction surveys. Indeed they do. Patient satisfaction is not a personality contest but rather a reflection of the health care provider’s investment of time and effort to offer patient-centered care. Siegrist also notes that the patient’s family plays a key role in how a patient perceives her experience with her health care professional.⁹

The federal government has been actively involved in assessing patient satisfaction in the hospital setting since 2002. This is reflected in the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. The HCAHPS is a 27-question survey randomly administered to adult inpatients after discharge.^10–12

The following metrics are often included in patient satisfaction surveys^9,10:

• rating of hospital care from 0 (lowest) to 10 (highest)
• percentage of patients who would recommend a practice to family and friends
• number of patients who say their health care providers always communicate well
• the number of patients who report that the office is always clean and friendly.

Use of search engines focused on health care patient surveys can provide a number of options for clinicians to use in their practice.

Tips on patient satisfaction

Several interesting tips from the busi-ness world can be applied to an ObGyn’s practice¹⁴:

• You will only hear from 4% of unhappy customers.
• One dissatisfied customer tells 9.
• 95% of customers with resolved issues will do business with you again.
• If a problem is not addressed, that patient will tell 10 others.
• Resolve the problem and 5 people will know about it.
• It costs 5 times as much effort to gain 1 new customer.
• Loyal customers in 1 area of service are good prospects for other (new) services.

Related article:
Using the Internet in your practice. Part 2: Generating new patients using social media

Tell stories about good, satisfied patients

Sharing the stories of satisfied patients motivates others to consider coming to your practice. To develop these stories, offer a “suggestion box” where patients can leave compliments or comments about their experiences. Ask patients to record their positive reviews (be sure to obtain written consent before recording and publishing). Show the videos on the big-screen TVs in your waiting room and include patient reviews (written, audio, and video) on your website.¹⁵

Related article:
Four pillars of a successful practice: 4. Motivate your staff

Reevaluate periodically

Encouraging team spirit makes good business sense. Offer staff members bonuses for coming up with improved processes. Provide educational programs for staff on patient care, technology, etc. If a difficult experience occurs, discuss it openly with staff members without accusing, asking them for suggestions to improve the situation.¹⁶

Talking cents: Assessing your practice

---

To assess the monetary value of your practice, you need to know what contributes to your profit margin and overhead. What investments are the most profitable? Then monitor each segment of the office practice.

Should you proceed with a purchase? Should you take on a new hire? Let's look at one excellent model from the Boston Consulting Group (FIGURE) that provides insight into "low and high performance" aspects of business or practice.¹

In the matrix, Stars use large amounts of cash and are leaders in cash generation. Stars lead to development of a Cash Cow, which are entities that generate profits and cash with low investment prerequisites. Dogs are segments of product and service line(s) that should be carefully reevaluated. A decision must be made to liquidate if the problem cannot be corrected. Question Marks have the worst cash characteristics of all and are associated with high demands and low profit margin(s).¹

SWOT analysis
A SWOT analysis is most helpful when assessing a practice in real time. The basic tenets are²:  
Strengths:  

• prestigious reputation
• technological expertise

Weaknesses:  

• antiquated computer system
• lack of experience in specific areas

Opportunities:

• growing market demand for a specific product or procedure
• provision of unique services

Threats:

• changing demographics
• competitive practices
• changes in health care third-party payers.

The American College of Obstetricians and Gynecologists (ACOG) has developed an "ACOG Medical Home Toolkit" to allow ObGyns to assess how significant the changes regarding payers will be to their practice. Sections include the patient/practice partnership support; clinical care information; community resources; care delivery management; performance measurement and improvement; and payment and finance.³ The toolkit is available for download from the ACOG website.

References

1. Morrison A, Wensley R. Boxing up or boxed in? A short history of the Boston Consulting Group Share/Growth Matrix. J Market Manag. 1993;7(2):105-129. http://www.tandfonline.com/doi/abs/10.1080/0267257X.1991.9964145.
2. Klasko SK, Toub DB. It's not a plan without a business plan. In: Sanfilippo JS, Nolan TE, Whiteside BH, eds. MBA Handbook for Healthcare Professionals. New York, NY: Parthenon Publishing Group; 2002:36-37.
3. American Congress of Obstetricians and Gynecologists. ACOG Medical Home Toolkit. https://www.acog.org/About-ACOG/ACOG-Departments/Practice-Management-and-Managed-Care/ACOG-Medical-Home-Toolkit. Accessed August 14, 2017.

Bottom line

Ensuring that your patients have an outstanding experience is a smart business strategy. A unified approach that includes team members’ involvement to create a patient-centered environment will provide a quality experience and encourage patients to recommend your ObGyn practice to others.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Independent of the Affordable Care Act or any upcoming changes in health care, the focus of an ObGyn practice remains paramount: the patient comes first.

The “recipe” for creating patient satisfaction and service excellence is predicated upon the mission of your practice and creating a shared vision with your employees. An action plan that is created and “visited/revisited”on a regular basis will serve to keep all abreast of the latest information to enhance the quality of patient care. It goes without saying, the ObGyn must first “lead by example” and always strive for satisfied patients who will tell their friends about your practice.

Start with the right tools

To organize a practice well, you need the right tools, which ideally include mission and vision statements and an action plan with goals and objectives.

Mission statement

A mission statement can be developed by the ObGyn(s) in your office or in concert with your staff. It should include:

• the “here and now” focus on the current approach to patient care
• why the practice exists (Develop a brief description of your practice, including the desired patient population.)
• the products and services offered and why and how those services are provided.

Here is an example of a mission statement for an ObGyn practice: “Our mission is to provide excellent, exceptional, personalized care for women of all ages in a warm and friendly environment. We incorporate leading-edge technology in our practice and continue to be a leader in obstetrics and gynecology.”

Vision statement

A vision statement should be developed in concert with your staff. It should include:

• the “then and there” focus on the historic perspective of your practice
• the ObGyn(s) and staff vision of the future
• what the ObGyn(s) and staff want to create.

The vision statement should energize and excite your personnel, create a shared and meaningful purpose, inspire passion and interest, and convey the values you want to share in your practice.

Here is an example of a vision statement for an ObGyn practice: “We aim to become the premier obstetrics and gynecology pro-vider to residents of (location) community.”

Action plan: Setting goals

To succeed, an ObGyn practice needs to:

• develop targets and challenges reflecting periodic (quarterly) meetings with staff and new entity development in the practice
• establish benchmarks and measurable parameters (How do you compare with other local practices? Set criteria/metrics to assess your progress.)
• ensure that the objectives support the goals (Develop goals and objectives over a defined period of time.)
• revisit the goals (Have they have been met? Do they need revision?)

Goals and objectives are essential for the continued health of your practice. This is all predicated upon developing a competitive advantage and then maintaining it.

Read about how to make a positive first impression on a new patient.

Is the environment welcoming?

When we examine a practice from the patient’s point of view, a good starting place is with the front desk. Have you looked at your front desk “from the outside in?” In one sense, this is the showcase of your practice.

Related article:
Four pillars of a successful practice: 2. Attract new patients

The first impression: Appointment scheduling

The first impression a patient receives about your practice occurs when she attempts to set up an appointment. Perhaps you might ask someone to call in to schedule an appointment. Is the caller immediately put on hold? Are your personnel courteous on the phone? Can she be seen quickly if she has a problem? How long is the wait for an annual exam? A test run can be very revealing.

Walk in the front door

When a patient walks in the door, does the physical office space radiate a friendly, relaxed atmosphere? Walk through the waiting room, then consultation and exam rooms as if you are a patient seeing it for the first time. Have you created an environment in which patients sense a well-organized office and the esprit de corps of the personnel? Does it look and smell fresh and clean? This all sends a loud and clear positive message about your practice.^1–3

Here are some suggestions for making a waiting room more inviting:

• Provide a seating arrangement that is “patient centered.” For example, semi- circular arrangements allow easy viewing of any monitors in the waiting room.
• WiFi is a great addition. Post several signs with the user name and password.
• Offer computers for patients to use to complete registration
• Set up a fish tank. If well-maintained, it can be soothing to many people.
• Display medical information pamphlets, even if they are rarely taken.
• Provide a big screen television that offers information about your practice, including personnel and procedures.

Streaming ads for physician offices are available. One platform, Outcome Health (https://www.outcomehealth.com), provides flat-screen TVs and tablets that show patient education videos.⁴ Another vendor, Patient Point (http://patientpoint.com), offers waiting room networks, editorials, and other communications designed to support “the goals of improving healthcare.”⁵ Other available media include channel news and music programming to relax patients.⁶

Wait times. A patient’s perceived wait time and the actual wait time are often quite different. How long she waits to see the ObGyn is “numero uno” with regard to patient satisfaction and can be a key source of annoyance, irritability, stress, and anger.

Does someone inform waiting patients that the ObGyn is running late? Does staff at the front desk or perhaps your medical assistant inquire, “Can I get you anything? The doctor is running late,” or “Dr. Jones has just finished delivering a baby. He’ll be here in 10 minutes. He’ll see you first.”

Consultation and exam rooms

Suggestions to develop a relaxing environment in your consultation and exam rooms are⁷:

• decorate the walls with soft, pastel colors
• use “spa aesthetics” to create a colorful atmosphere with appropriate lighting, artwork, and modern furnishings
• present a few magazines neatly and update them periodically
• stock and appropriately maintain the patients rooms with medical supplies
• remember, “Subjects perceive people more positively in beautiful rooms than in ugly rooms.”⁵

Read about how to keep your patients satisfied and your business stable.

Set the lead example

The need for open and supportive communication between you and your office staff cannot be overly emphasized. An ideal office staff member understands and shares in the vision, is aware of stated goals and objectives, is responsive to patient needs, and wants to create a win-win environment.

Frequently discuss your expectations with your staff. Expect them to be responsive, courteous, competent, have good communication skills, and be influenced by the appearance of the physical environ-ment. Provide support and educational tools to help them successfully perform their work.

Related article:
Four pillars of a successful practice: 1. Keep your current patients happy

Discover your patients’ vision of customer service

Formal measurement of patient satisfaction began with Professor Irwin Press at the University of Notre Dame. Rod Ganey, a sociologist and statistician, then developed the Press Ganey Patient Satisfaction Survey. These points earlier conveyed by Maslow and Mintz⁸ addressed the “effects of esthetic surroundings.” Color and art proved to be preferences in an esthetically pleasing environment. Additional historical information has been provided by Siegrist, who addressed “the patient experience.”⁹ He cites the myth that patients do not fill out satisfaction surveys. Indeed they do. Patient satisfaction is not a personality contest but rather a reflection of the health care provider’s investment of time and effort to offer patient-centered care. Siegrist also notes that the patient’s family plays a key role in how a patient perceives her experience with her health care professional.⁹

The federal government has been actively involved in assessing patient satisfaction in the hospital setting since 2002. This is reflected in the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. The HCAHPS is a 27-question survey randomly administered to adult inpatients after discharge.^10–12

The following metrics are often included in patient satisfaction surveys^9,10:

• rating of hospital care from 0 (lowest) to 10 (highest)
• percentage of patients who would recommend a practice to family and friends
• number of patients who say their health care providers always communicate well
• the number of patients who report that the office is always clean and friendly.

Use of search engines focused on health care patient surveys can provide a number of options for clinicians to use in their practice.

Tips on patient satisfaction

Several interesting tips from the busi-ness world can be applied to an ObGyn’s practice¹⁴:

• You will only hear from 4% of unhappy customers.
• One dissatisfied customer tells 9.
• 95% of customers with resolved issues will do business with you again.
• If a problem is not addressed, that patient will tell 10 others.
• Resolve the problem and 5 people will know about it.
• It costs 5 times as much effort to gain 1 new customer.
• Loyal customers in 1 area of service are good prospects for other (new) services.

Related article:
Using the Internet in your practice. Part 2: Generating new patients using social media

Tell stories about good, satisfied patients

Sharing the stories of satisfied patients motivates others to consider coming to your practice. To develop these stories, offer a “suggestion box” where patients can leave compliments or comments about their experiences. Ask patients to record their positive reviews (be sure to obtain written consent before recording and publishing). Show the videos on the big-screen TVs in your waiting room and include patient reviews (written, audio, and video) on your website.¹⁵

Related article:
Four pillars of a successful practice: 4. Motivate your staff

Reevaluate periodically

Encouraging team spirit makes good business sense. Offer staff members bonuses for coming up with improved processes. Provide educational programs for staff on patient care, technology, etc. If a difficult experience occurs, discuss it openly with staff members without accusing, asking them for suggestions to improve the situation.¹⁶

Talking cents: Assessing your practice

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To assess the monetary value of your practice, you need to know what contributes to your profit margin and overhead. What investments are the most profitable? Then monitor each segment of the office practice.

Should you proceed with a purchase? Should you take on a new hire? Let's look at one excellent model from the Boston Consulting Group (FIGURE) that provides insight into "low and high performance" aspects of business or practice.¹

In the matrix, Stars use large amounts of cash and are leaders in cash generation. Stars lead to development of a Cash Cow, which are entities that generate profits and cash with low investment prerequisites. Dogs are segments of product and service line(s) that should be carefully reevaluated. A decision must be made to liquidate if the problem cannot be corrected. Question Marks have the worst cash characteristics of all and are associated with high demands and low profit margin(s).¹

SWOT analysis
A SWOT analysis is most helpful when assessing a practice in real time. The basic tenets are²:  
Strengths:  

• prestigious reputation
• technological expertise

Weaknesses:  

• antiquated computer system
• lack of experience in specific areas

Opportunities:

• growing market demand for a specific product or procedure
• provision of unique services

Threats:

• changing demographics
• competitive practices
• changes in health care third-party payers.

The American College of Obstetricians and Gynecologists (ACOG) has developed an "ACOG Medical Home Toolkit" to allow ObGyns to assess how significant the changes regarding payers will be to their practice. Sections include the patient/practice partnership support; clinical care information; community resources; care delivery management; performance measurement and improvement; and payment and finance.³ The toolkit is available for download from the ACOG website.

References

1. Morrison A, Wensley R. Boxing up or boxed in? A short history of the Boston Consulting Group Share/Growth Matrix. J Market Manag. 1993;7(2):105-129. http://www.tandfonline.com/doi/abs/10.1080/0267257X.1991.9964145.
2. Klasko SK, Toub DB. It's not a plan without a business plan. In: Sanfilippo JS, Nolan TE, Whiteside BH, eds. MBA Handbook for Healthcare Professionals. New York, NY: Parthenon Publishing Group; 2002:36-37.
3. American Congress of Obstetricians and Gynecologists. ACOG Medical Home Toolkit. https://www.acog.org/About-ACOG/ACOG-Departments/Practice-Management-and-Managed-Care/ACOG-Medical-Home-Toolkit. Accessed August 14, 2017.

Bottom line

Ensuring that your patients have an outstanding experience is a smart business strategy. A unified approach that includes team members’ involvement to create a patient-centered environment will provide a quality experience and encourage patients to recommend your ObGyn practice to others.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Woman dies following cervical cone biopsy: $4.25M award  

A 46-year-old woman underwent a cervical cone biopsy at a Veterans Administration (VA) hospital on July 18. Following the test, significant bleeding occurred. The gynecologic surgeon attempted to control the hemorrhage by injecting ferric subsulfate (Monsel’s) solution into the patient’s vagina. The bleeding abated, but the patient went into hypovolemic shock. During emergency laparotomy, a uterine perforation and injuries to both uterine arteries were detected. A hysterectomy was performed to stop the hemorrhage. The patient improved at first, but developed sepsis, small-bowel necrosis, and other complications. A bowel resection procedure was performed on July 26. She died on September 5.

ESTATE'S CLAIM:
The surgeon’s actions were negligent. She removed too much tissue during the biopsy, injured the vaginal and uterine walls, and failed to timely diagnose and appropriately treat the injuries. The ferric subsulfate solution entered the abdominal cavity via the perforation, causing peritonitis and bowel injuries. A pathology report from the bowel resection surgery informed the surgeon that the bowel was not properly reconnected after the damaged portion was removed, but this condition was neither detected intraoperatively nor treated postoperatively.

DEFENDANTS' DEFENSE:
The surgeon moved for summary judgment, countering that, as a federal employee, she was exempt from personal liability for the services performed as an employee of the VA. That motion was denied. She then argued that injury to the vaginal/uterine wall is a known complication of the biopsy procedure.

VERDICT:
A $4.25 million Illinois verdict was returned in federal court.

Related article:
Reducing maternal mortality in the United States—Let’s get organized!

Needle stick not reported to patient

A woman delivered a baby assisted by an on-call ObGyn. When the baby developed fetal tachycardia, the ObGyn recommended expediting delivery and discussed various options and the risks of each option. The mother chose a vaginal forceps delivery. During the procedure, the mother experienced a 3rd-degree perineal laceration and a few minor lacerations, which were repaired. The mother was in pain, so the ObGyn performed a revision repair. During the procedure, the ObGyn accidentally stuck himself with a clean needle. He replaced the needle and changed his glove. The mother reported instant pain relief following revision and was discharged. After the needle incident, the ObGyn’s thumb became red and swollen, so he took antibiotics.

Two days after discharge, the patient reported to the ObGyn’s office with fever, pain, and a foul odor emanating from the surgery site. She was given the diagnosis of pelvic incisional cellulitis and was taken to the operating room for exploration and debridement. The patient developed septic shock and necrotizing fasciitis. She was placed on a ventilator and underwent 13 surgeries.

PATIENTS' CLAIM:
The ObGyn was negligent. The patient claimed breach of duty: the ObGyn did not disclose that his thumb was swollen and that he took antibiotics.

PHYSICIANS' DEFENSE:
There was no breach of duty. He did not feel the need to concern the patient about an injury to himself that did not affect her.

VERDICT:
A Kansas defense verdict was returned.

Related article:
2017 Update on infectious disease

Catheter removal, air embolism: $3.5M settlement

A 44-year-old woman underwent gynecologic surgery on April 22. She developed a rectovaginal fistula and other complications. Intravenous antibiotics were required and parenteral nutrition was delivered through a central venous catheter. On May 22, after a hospital nurse removed the catheter, an air embolism developed, causing a brain injury. The patient has a mental disability and residual leg tremors.

PATIENTS' CLAIM:
Because of the surgeon’s negligence during surgery, a fistula developed. The nurse negligently removed the catheter, causing the embolism.

DEFENDANTS' DEFENSE:
The case settled during the trial.

VERDICT:
A $3.5 million Illinois settlement was reached, including payments of $1 million from the surgeon and $2.5 million from the hospital.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Woman dies following cervical cone biopsy: $4.25M award  

A 46-year-old woman underwent a cervical cone biopsy at a Veterans Administration (VA) hospital on July 18. Following the test, significant bleeding occurred. The gynecologic surgeon attempted to control the hemorrhage by injecting ferric subsulfate (Monsel’s) solution into the patient’s vagina. The bleeding abated, but the patient went into hypovolemic shock. During emergency laparotomy, a uterine perforation and injuries to both uterine arteries were detected. A hysterectomy was performed to stop the hemorrhage. The patient improved at first, but developed sepsis, small-bowel necrosis, and other complications. A bowel resection procedure was performed on July 26. She died on September 5.

ESTATE'S CLAIM:
The surgeon’s actions were negligent. She removed too much tissue during the biopsy, injured the vaginal and uterine walls, and failed to timely diagnose and appropriately treat the injuries. The ferric subsulfate solution entered the abdominal cavity via the perforation, causing peritonitis and bowel injuries. A pathology report from the bowel resection surgery informed the surgeon that the bowel was not properly reconnected after the damaged portion was removed, but this condition was neither detected intraoperatively nor treated postoperatively.

DEFENDANTS' DEFENSE:
The surgeon moved for summary judgment, countering that, as a federal employee, she was exempt from personal liability for the services performed as an employee of the VA. That motion was denied. She then argued that injury to the vaginal/uterine wall is a known complication of the biopsy procedure.

VERDICT:
A $4.25 million Illinois verdict was returned in federal court.

Related article:
Reducing maternal mortality in the United States—Let’s get organized!

Needle stick not reported to patient

A woman delivered a baby assisted by an on-call ObGyn. When the baby developed fetal tachycardia, the ObGyn recommended expediting delivery and discussed various options and the risks of each option. The mother chose a vaginal forceps delivery. During the procedure, the mother experienced a 3rd-degree perineal laceration and a few minor lacerations, which were repaired. The mother was in pain, so the ObGyn performed a revision repair. During the procedure, the ObGyn accidentally stuck himself with a clean needle. He replaced the needle and changed his glove. The mother reported instant pain relief following revision and was discharged. After the needle incident, the ObGyn’s thumb became red and swollen, so he took antibiotics.

Two days after discharge, the patient reported to the ObGyn’s office with fever, pain, and a foul odor emanating from the surgery site. She was given the diagnosis of pelvic incisional cellulitis and was taken to the operating room for exploration and debridement. The patient developed septic shock and necrotizing fasciitis. She was placed on a ventilator and underwent 13 surgeries.

PATIENTS' CLAIM:
The ObGyn was negligent. The patient claimed breach of duty: the ObGyn did not disclose that his thumb was swollen and that he took antibiotics.

PHYSICIANS' DEFENSE:
There was no breach of duty. He did not feel the need to concern the patient about an injury to himself that did not affect her.

VERDICT:
A Kansas defense verdict was returned.

Related article:
2017 Update on infectious disease

Catheter removal, air embolism: $3.5M settlement

A 44-year-old woman underwent gynecologic surgery on April 22. She developed a rectovaginal fistula and other complications. Intravenous antibiotics were required and parenteral nutrition was delivered through a central venous catheter. On May 22, after a hospital nurse removed the catheter, an air embolism developed, causing a brain injury. The patient has a mental disability and residual leg tremors.

PATIENTS' CLAIM:
Because of the surgeon’s negligence during surgery, a fistula developed. The nurse negligently removed the catheter, causing the embolism.

DEFENDANTS' DEFENSE:
The case settled during the trial.

VERDICT:
A $3.5 million Illinois settlement was reached, including payments of $1 million from the surgeon and $2.5 million from the hospital.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Woman dies following cervical cone biopsy: $4.25M award  

A 46-year-old woman underwent a cervical cone biopsy at a Veterans Administration (VA) hospital on July 18. Following the test, significant bleeding occurred. The gynecologic surgeon attempted to control the hemorrhage by injecting ferric subsulfate (Monsel’s) solution into the patient’s vagina. The bleeding abated, but the patient went into hypovolemic shock. During emergency laparotomy, a uterine perforation and injuries to both uterine arteries were detected. A hysterectomy was performed to stop the hemorrhage. The patient improved at first, but developed sepsis, small-bowel necrosis, and other complications. A bowel resection procedure was performed on July 26. She died on September 5.

ESTATE'S CLAIM:
The surgeon’s actions were negligent. She removed too much tissue during the biopsy, injured the vaginal and uterine walls, and failed to timely diagnose and appropriately treat the injuries. The ferric subsulfate solution entered the abdominal cavity via the perforation, causing peritonitis and bowel injuries. A pathology report from the bowel resection surgery informed the surgeon that the bowel was not properly reconnected after the damaged portion was removed, but this condition was neither detected intraoperatively nor treated postoperatively.

DEFENDANTS' DEFENSE:
The surgeon moved for summary judgment, countering that, as a federal employee, she was exempt from personal liability for the services performed as an employee of the VA. That motion was denied. She then argued that injury to the vaginal/uterine wall is a known complication of the biopsy procedure.

VERDICT:
A $4.25 million Illinois verdict was returned in federal court.

Related article:
Reducing maternal mortality in the United States—Let’s get organized!

Needle stick not reported to patient

A woman delivered a baby assisted by an on-call ObGyn. When the baby developed fetal tachycardia, the ObGyn recommended expediting delivery and discussed various options and the risks of each option. The mother chose a vaginal forceps delivery. During the procedure, the mother experienced a 3rd-degree perineal laceration and a few minor lacerations, which were repaired. The mother was in pain, so the ObGyn performed a revision repair. During the procedure, the ObGyn accidentally stuck himself with a clean needle. He replaced the needle and changed his glove. The mother reported instant pain relief following revision and was discharged. After the needle incident, the ObGyn’s thumb became red and swollen, so he took antibiotics.

Two days after discharge, the patient reported to the ObGyn’s office with fever, pain, and a foul odor emanating from the surgery site. She was given the diagnosis of pelvic incisional cellulitis and was taken to the operating room for exploration and debridement. The patient developed septic shock and necrotizing fasciitis. She was placed on a ventilator and underwent 13 surgeries.

PATIENTS' CLAIM:
The ObGyn was negligent. The patient claimed breach of duty: the ObGyn did not disclose that his thumb was swollen and that he took antibiotics.

PHYSICIANS' DEFENSE:
There was no breach of duty. He did not feel the need to concern the patient about an injury to himself that did not affect her.

VERDICT:
A Kansas defense verdict was returned.

Related article:
2017 Update on infectious disease

Catheter removal, air embolism: $3.5M settlement

A 44-year-old woman underwent gynecologic surgery on April 22. She developed a rectovaginal fistula and other complications. Intravenous antibiotics were required and parenteral nutrition was delivered through a central venous catheter. On May 22, after a hospital nurse removed the catheter, an air embolism developed, causing a brain injury. The patient has a mental disability and residual leg tremors.

PATIENTS' CLAIM:
Because of the surgeon’s negligence during surgery, a fistula developed. The nurse negligently removed the catheter, causing the embolism.

DEFENDANTS' DEFENSE:
The case settled during the trial.

VERDICT:
A $3.5 million Illinois settlement was reached, including payments of $1 million from the surgeon and $2.5 million from the hospital.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

The relationship between procedure volume and outcomes has long been recognized: studies have concluded that patients operated on by high-volume surgeons at high-volume hospitals have improved outcomes.^1,2 This paradigm is also associated with ovarian cancer outcomes. But what affect does adherence to evidence-based guidelines have on these statistics?

Jason D. Wright, MD, and colleagues at the Columbia University College of Physicians and Surgeons, in New York City, sought to determine whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and ovarian cancer survival.³

Details of the study

Using the National Cancer Database (NCD), the research team identified 100,725 patients at 1,268 hospitals who were treated for invasive epithelial ovarian cancer between 2004 and 2013. Hospitals were stratified by annual case volume into quintiles: low-volume (≤2 cases; n = 299 [23.6%]), low-intermediate–volume (2.01–5 cases; n = 465 [36.7%]), intermediate-volume (5.01–9 cases; n = 157 [12.4%]), high-intermediate–volume (9.01–19.9 cases; n = 194 [15.3%]), and high-volume (≥20 cases; n = 153 [12.1%]).³

To measure quality, the authors defined hospital-level rates of 5 metrics based on clinical guidelines³:

1. lymph node dissection performed for patients with stage I–IIIB tumors
2. performance of omentectomy or cytoreduction for patients with advanced stage tumors
3. use of chemotherapy among patients with early-stage, high-risk tumors
4. omission of chemotherapy for women with early-stage, low-risk tumors
5. use of chemotherapy (either neoadjuvant or adjuvant) for women with advanced-stage disease.

For each metric, the authors determined the rate of hospital-level compliance for all study-eligible patients. Then a composite variable of overall quality was derived using all 5 metrics. Based on the overall quality metric, hospitals were stratified into quartiles: low-quality, medium-low–quality, medium-high–quality, and high-quality.³

Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to quality metrics.³

Related article:
2017 Update on ovarian cancer

Trends and conclusions

Researchers found that compliance with quality metrics generally increased with hospital volume. Trends of increased compliance were observed with lymph node dissection for early-stage tumors, cytoreduction for advanced-stage tumors, and use of chemotherapy for advanced-stage tumors. No trends were evident for use of chemotherapy for high-risk, early-stage tumors. By contrast, a trend for higher-volume hospitals to administer chemotherapy for low-risk, early-stage tumors was discovered. Adherence with the composite overall quality metric was noted in 64.2% of low-volume centers and increased with each volume category to 82.2% at the highest-volume hospitals.³

Study results indicated that survival increased with increasing hospital volume and with adherence to the quality metrics. The association between volume and quality was then examined. For each volume category, survival increased with increasing adherence to the quality metrics. In the highest-volume group, 2-year adjusted survival rose from 75.5% (95% confidence interval [CI], 73.2%–77.8%) at the lowest-quality hospitals, to 78.6% (95% CI, 78.0%–79.1%) at the highest-quality hospitals. Similar trends were found for intermediate-volume hospitals and for 5-year survival. However, the relationship between adherence to quality metrics and survival was less consistent for the low-, low-intermediate–, and high-intermediate–volume hospitals.³

The authors concluded that both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer. Even though survival rates are improved at low-volume hospitals that are highly adherent to quality metrics, their survival rates are still lower than high-volume hospitals.

Read about the pros and cons of regionalization for high-risk ovarian cancer surgery.

Study limitations

The authors cite several limitations to this study:

• chosen quality metrics focused on care during initial treatment. Women with ovarian cancer are often treated for many years.
• the NCD lacks information on aspects like hospital infrastructure and staffing; there are probably other confounders that influence treatment and outcomes
• although NCD data have been validated, misclassification of a small number of patients may exist. Also, some hospitals did not treat patients who might be eligible for a quality metric and therefore were not included in this analysis.
• some study participants (13.7%) received treatment at multiple hospitals
• the volume cutpoints chosen by the research team were based on prior studies; there could be outcome variation within a volume strata.

Should high-risk surgeries be regionalized?

The association between higher surgical volume and improved outcomes has led to efforts to regionalize the care for high-risk operations to high-volume centers, say the authors. They conclude that this may be a reasonable strategy for some procedures. However, they suggest that regionalization presents practical difficulties:

1. patients prefer to receive local care and are often unwilling to or cannot travel
2. regionalization can worsen inequalities in access to care and may adversely affect low-volume hospitals
3. high-volume centers do not exist in some areas of the country. A recent report suggested that 9% of the US female population had geographic barriers to receiving care from a gynecologic oncologist.⁴

Can low-volume facilities attain the same outcomes as high-volume centers?

The authors pose an important question: Can lower-volume facilities that deliver high-quality care achieve the same outcomes as higher-volume centers? With the difficulties associated with regionalization, many advocates seek strategies to raise the quality of care at low-volume centers, they say. The authors note that, “although outcomes improve at low-volume centers that are highly compliant with the quality metrics examined, survival at these centers is still lower than at high-volume centers.”³ The authors suggest that there are factors other than adherence to guidelines that play a role in how hospital volume affects ovarian cancer outcomes.³

Practice considerations

“Because the best outcomes appear to be achieved at high-volume hospitals, efforts to promote volume-based referral for women with ovarian cancer are reasonable,” the authors conclude.³ However, in practicality, many women will not be able to receive care at high-volume centers, they concede. “For low-volume centers, targeted quality improvement efforts and strict adherence to quality guidelines may help to optimize outcomes for women with ovarian cancer.”³

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

The relationship between procedure volume and outcomes has long been recognized: studies have concluded that patients operated on by high-volume surgeons at high-volume hospitals have improved outcomes.^1,2 This paradigm is also associated with ovarian cancer outcomes. But what affect does adherence to evidence-based guidelines have on these statistics?

Jason D. Wright, MD, and colleagues at the Columbia University College of Physicians and Surgeons, in New York City, sought to determine whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and ovarian cancer survival.³

Details of the study

Using the National Cancer Database (NCD), the research team identified 100,725 patients at 1,268 hospitals who were treated for invasive epithelial ovarian cancer between 2004 and 2013. Hospitals were stratified by annual case volume into quintiles: low-volume (≤2 cases; n = 299 [23.6%]), low-intermediate–volume (2.01–5 cases; n = 465 [36.7%]), intermediate-volume (5.01–9 cases; n = 157 [12.4%]), high-intermediate–volume (9.01–19.9 cases; n = 194 [15.3%]), and high-volume (≥20 cases; n = 153 [12.1%]).³

To measure quality, the authors defined hospital-level rates of 5 metrics based on clinical guidelines³:

1. lymph node dissection performed for patients with stage I–IIIB tumors
2. performance of omentectomy or cytoreduction for patients with advanced stage tumors
3. use of chemotherapy among patients with early-stage, high-risk tumors
4. omission of chemotherapy for women with early-stage, low-risk tumors
5. use of chemotherapy (either neoadjuvant or adjuvant) for women with advanced-stage disease.

For each metric, the authors determined the rate of hospital-level compliance for all study-eligible patients. Then a composite variable of overall quality was derived using all 5 metrics. Based on the overall quality metric, hospitals were stratified into quartiles: low-quality, medium-low–quality, medium-high–quality, and high-quality.³

Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to quality metrics.³

Related article:
2017 Update on ovarian cancer

Trends and conclusions

Researchers found that compliance with quality metrics generally increased with hospital volume. Trends of increased compliance were observed with lymph node dissection for early-stage tumors, cytoreduction for advanced-stage tumors, and use of chemotherapy for advanced-stage tumors. No trends were evident for use of chemotherapy for high-risk, early-stage tumors. By contrast, a trend for higher-volume hospitals to administer chemotherapy for low-risk, early-stage tumors was discovered. Adherence with the composite overall quality metric was noted in 64.2% of low-volume centers and increased with each volume category to 82.2% at the highest-volume hospitals.³

Study results indicated that survival increased with increasing hospital volume and with adherence to the quality metrics. The association between volume and quality was then examined. For each volume category, survival increased with increasing adherence to the quality metrics. In the highest-volume group, 2-year adjusted survival rose from 75.5% (95% confidence interval [CI], 73.2%–77.8%) at the lowest-quality hospitals, to 78.6% (95% CI, 78.0%–79.1%) at the highest-quality hospitals. Similar trends were found for intermediate-volume hospitals and for 5-year survival. However, the relationship between adherence to quality metrics and survival was less consistent for the low-, low-intermediate–, and high-intermediate–volume hospitals.³

The authors concluded that both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer. Even though survival rates are improved at low-volume hospitals that are highly adherent to quality metrics, their survival rates are still lower than high-volume hospitals.

Read about the pros and cons of regionalization for high-risk ovarian cancer surgery.

Study limitations

The authors cite several limitations to this study:

• chosen quality metrics focused on care during initial treatment. Women with ovarian cancer are often treated for many years.
• the NCD lacks information on aspects like hospital infrastructure and staffing; there are probably other confounders that influence treatment and outcomes
• although NCD data have been validated, misclassification of a small number of patients may exist. Also, some hospitals did not treat patients who might be eligible for a quality metric and therefore were not included in this analysis.
• some study participants (13.7%) received treatment at multiple hospitals
• the volume cutpoints chosen by the research team were based on prior studies; there could be outcome variation within a volume strata.

Should high-risk surgeries be regionalized?

The association between higher surgical volume and improved outcomes has led to efforts to regionalize the care for high-risk operations to high-volume centers, say the authors. They conclude that this may be a reasonable strategy for some procedures. However, they suggest that regionalization presents practical difficulties:

1. patients prefer to receive local care and are often unwilling to or cannot travel
2. regionalization can worsen inequalities in access to care and may adversely affect low-volume hospitals
3. high-volume centers do not exist in some areas of the country. A recent report suggested that 9% of the US female population had geographic barriers to receiving care from a gynecologic oncologist.⁴

Can low-volume facilities attain the same outcomes as high-volume centers?

The authors pose an important question: Can lower-volume facilities that deliver high-quality care achieve the same outcomes as higher-volume centers? With the difficulties associated with regionalization, many advocates seek strategies to raise the quality of care at low-volume centers, they say. The authors note that, “although outcomes improve at low-volume centers that are highly compliant with the quality metrics examined, survival at these centers is still lower than at high-volume centers.”³ The authors suggest that there are factors other than adherence to guidelines that play a role in how hospital volume affects ovarian cancer outcomes.³

Practice considerations

“Because the best outcomes appear to be achieved at high-volume hospitals, efforts to promote volume-based referral for women with ovarian cancer are reasonable,” the authors conclude.³ However, in practicality, many women will not be able to receive care at high-volume centers, they concede. “For low-volume centers, targeted quality improvement efforts and strict adherence to quality guidelines may help to optimize outcomes for women with ovarian cancer.”³

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

The relationship between procedure volume and outcomes has long been recognized: studies have concluded that patients operated on by high-volume surgeons at high-volume hospitals have improved outcomes.^1,2 This paradigm is also associated with ovarian cancer outcomes. But what affect does adherence to evidence-based guidelines have on these statistics?

Jason D. Wright, MD, and colleagues at the Columbia University College of Physicians and Surgeons, in New York City, sought to determine whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and ovarian cancer survival.³

Details of the study

Using the National Cancer Database (NCD), the research team identified 100,725 patients at 1,268 hospitals who were treated for invasive epithelial ovarian cancer between 2004 and 2013. Hospitals were stratified by annual case volume into quintiles: low-volume (≤2 cases; n = 299 [23.6%]), low-intermediate–volume (2.01–5 cases; n = 465 [36.7%]), intermediate-volume (5.01–9 cases; n = 157 [12.4%]), high-intermediate–volume (9.01–19.9 cases; n = 194 [15.3%]), and high-volume (≥20 cases; n = 153 [12.1%]).³

To measure quality, the authors defined hospital-level rates of 5 metrics based on clinical guidelines³:

1. lymph node dissection performed for patients with stage I–IIIB tumors
2. performance of omentectomy or cytoreduction for patients with advanced stage tumors
3. use of chemotherapy among patients with early-stage, high-risk tumors
4. omission of chemotherapy for women with early-stage, low-risk tumors
5. use of chemotherapy (either neoadjuvant or adjuvant) for women with advanced-stage disease.

For each metric, the authors determined the rate of hospital-level compliance for all study-eligible patients. Then a composite variable of overall quality was derived using all 5 metrics. Based on the overall quality metric, hospitals were stratified into quartiles: low-quality, medium-low–quality, medium-high–quality, and high-quality.³

Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to quality metrics.³

Related article:
2017 Update on ovarian cancer

Trends and conclusions

Researchers found that compliance with quality metrics generally increased with hospital volume. Trends of increased compliance were observed with lymph node dissection for early-stage tumors, cytoreduction for advanced-stage tumors, and use of chemotherapy for advanced-stage tumors. No trends were evident for use of chemotherapy for high-risk, early-stage tumors. By contrast, a trend for higher-volume hospitals to administer chemotherapy for low-risk, early-stage tumors was discovered. Adherence with the composite overall quality metric was noted in 64.2% of low-volume centers and increased with each volume category to 82.2% at the highest-volume hospitals.³

Study results indicated that survival increased with increasing hospital volume and with adherence to the quality metrics. The association between volume and quality was then examined. For each volume category, survival increased with increasing adherence to the quality metrics. In the highest-volume group, 2-year adjusted survival rose from 75.5% (95% confidence interval [CI], 73.2%–77.8%) at the lowest-quality hospitals, to 78.6% (95% CI, 78.0%–79.1%) at the highest-quality hospitals. Similar trends were found for intermediate-volume hospitals and for 5-year survival. However, the relationship between adherence to quality metrics and survival was less consistent for the low-, low-intermediate–, and high-intermediate–volume hospitals.³

The authors concluded that both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer. Even though survival rates are improved at low-volume hospitals that are highly adherent to quality metrics, their survival rates are still lower than high-volume hospitals.

Read about the pros and cons of regionalization for high-risk ovarian cancer surgery.

Study limitations

The authors cite several limitations to this study:

• chosen quality metrics focused on care during initial treatment. Women with ovarian cancer are often treated for many years.
• the NCD lacks information on aspects like hospital infrastructure and staffing; there are probably other confounders that influence treatment and outcomes
• although NCD data have been validated, misclassification of a small number of patients may exist. Also, some hospitals did not treat patients who might be eligible for a quality metric and therefore were not included in this analysis.
• some study participants (13.7%) received treatment at multiple hospitals
• the volume cutpoints chosen by the research team were based on prior studies; there could be outcome variation within a volume strata.

Should high-risk surgeries be regionalized?

The association between higher surgical volume and improved outcomes has led to efforts to regionalize the care for high-risk operations to high-volume centers, say the authors. They conclude that this may be a reasonable strategy for some procedures. However, they suggest that regionalization presents practical difficulties:

1. patients prefer to receive local care and are often unwilling to or cannot travel
2. regionalization can worsen inequalities in access to care and may adversely affect low-volume hospitals
3. high-volume centers do not exist in some areas of the country. A recent report suggested that 9% of the US female population had geographic barriers to receiving care from a gynecologic oncologist.⁴

Can low-volume facilities attain the same outcomes as high-volume centers?

The authors pose an important question: Can lower-volume facilities that deliver high-quality care achieve the same outcomes as higher-volume centers? With the difficulties associated with regionalization, many advocates seek strategies to raise the quality of care at low-volume centers, they say. The authors note that, “although outcomes improve at low-volume centers that are highly compliant with the quality metrics examined, survival at these centers is still lower than at high-volume centers.”³ The authors suggest that there are factors other than adherence to guidelines that play a role in how hospital volume affects ovarian cancer outcomes.³

Practice considerations

“Because the best outcomes appear to be achieved at high-volume hospitals, efforts to promote volume-based referral for women with ovarian cancer are reasonable,” the authors conclude.³ However, in practicality, many women will not be able to receive care at high-volume centers, they concede. “For low-volume centers, targeted quality improvement efforts and strict adherence to quality guidelines may help to optimize outcomes for women with ovarian cancer.”³

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

The list of new and revised International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes has been published, with changes becoming effective on October 1, 2017. This year, you can look forward to minimal code changes for gynecologic conditions. The biggest change in this category is the addition of codes that describe a lump in the breast according to which breast and the location on the breast, as well as the addition of a code for prophylactic removal of the fallopian tubes. The codes related to obstetrics will have more extensive changes. You will find revisions to the codes for ectopic pregnancy, a new set of codes for addressing an abnormal fetal heart rate during the antepartum period, and, most welcome of all, an expansion of the single code for antenatal testing to 17 very specific codes.

Gynecologic code changes

The single code N63, Unspecified lump in breast, has been expanded to include codes for both the right and the left breast. Code N63 therefore will be considered invalid after October 1, 2018. Expanded codes include:

• N63.0, Unspecified lump in unspecified breast
• N63.1, Unspecified lump in the right breast
  • N63.10, Unspecified lump in the right breast, unspecified quadrant
  • N63.11, Unspecified lump in the right breast, upper outer quadrant
  • N63.12, Unspecified lump in the right breast, upper inner quadrant
  • N63.13, Unspecified lump in the right breast, lower outer quadrant
  • N63.14, Unspecified lump in the right breast, lower inner quadrant
• N63.2, Unspecified lump in the left breast
  • N63.20, Unspecified lump in the left breast, unspecified quadrant
  • N63.21, Unspecified lump in the left breast, upper outer quadrant
  • N63.22, Unspecified lump in the left breast, upper inner quadrant
  • N63.23, Unspecified lump in the left breast, lower outer quadrant
  • N63.24, Unspecified lump in the left breast, lower inner quadrant
• N63.3, Unspecified lump in axillary tail
  • N63.31, Unspecified lump in axillary tail of the right breast
  • N63.32, Unspecified lump in axillary tail of the left breast
• N63.4, Unspecified lump in breast, subareolar
  • N63.41, Unspecified lump in right breast, subareolar
  • N63.42, Unspecified lump in left breast, subareolar

Other changes to gynecologic codes

There has been a minor change to the description for code Z31.5, Encounter for genetic counseling. It now is described as "Encounter for procreative genetic counseling."

The code Z40.02, Encounter for prophylactic removal of ovary(s), now refers to one or more ovaries without distinction of right or left, and a new code has been added for removal of the fallopian tube(s), Z40.03, Encounter for prophylactic removal of fallopian tube(s).

The inclusion term "endometriosis of the thorax" has been added to code N80.8, Other endometriosis.

The inclusion term "premenstrual dysphoric disorder" has been deleted from code N94.3, Premenstrual tension syndrome. If the patient has been diagnosed with this condition, the code F32.81, Premenstrual dysphoric disorder, should be reported, as this is considered a mental health issue.

The "excludes 1" note under code Z87.41, Personal history of dysplasia of the female genital tract, has been revised. The codes for personal history of intraepithelial neoplasia III that may not be reported with this code are Z86.001 and Z86.008.

Obstetric code changes

The ectopic pregnancy codes have been revised to include references to the right or left structure affected, which means the codes change from 5 digits to 6 digits in length, and the codes O00.10, O00.11, O00.20, and O00.21 will no longer be valid.

• O00.1, Tubal pregnancy
  • O00.10, Tubal pregnancy without intrauterine pregnancy
    • O00.101, Right tubal pregnancy without intrauterine pregnancy
    • O00.102, Left tubal pregnancy without intrauterine pregnancy
    • O00.109, Unspecified tubal pregnancy without intrauterine pregnancy
  • O00.11, Tubal pregnancy with intrauterine pregnancy
    • O00.111, Right tubal pregnancy with intrauterine pregnancy
    • O00.112, Left tubal pregnancy with intrauterine pregnancy
    • O00.119, Unspecified tubal pregnancy with intrauterine pregnancy
• O00.2, Ovarian pregnancy
  • O00.20, Ovarian pregnancy without intrauterine pregnancy
    • O00.201, Right ovarian pregnancy without intrauterine pregnancy
    • O00.202, Left ovarian pregnancy without intrauterine pregnancy
    • O00.209, Unspecified ovarian pregnancy without intrauterine pregnancy
  • O00.21, Ovarian pregnancy with intrauterine pregnancy
    • O00.211, Right ovarian pregnancy with intrauterine pregnancy
    • O00.212, Left ovarian pregnancy with intrauterine pregnancy
    • O00.219, Unspecified ovarian pregnancy with intrauterine pregnancy

New codes for fetal heart rate abnormalities

New codes have been added to report a fetal heart rate or rhythm abnormality during the antepartum period. Until now, there only has been a code that addresses this issue during labor and delivery, O76, Abnormality in fetal heart rate and rhythm complicating labor and delivery. 

• O36.83, Maternal care for abnormalities of the fetal heart rate or rhythm
  • O36.831, Maternal care for abnormalities of the fetal heart rate or rhythm, first trimester
  • O36.832, Maternal care for abnormalities of the fetal heart rate or rhythm, second trimester
  • O36.833, Maternal care for abnormalities of the fetal heart rate or rhythm, third trimester
  • O36.839, Maternal care for abnormalities of the fetal heart rate or rhythm, unspecified trimester

Several codes redefined

ICD-10 has corrected an "excludes" note error for the code O99.1, Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, childbirth, and the puerperium. In 2017, any hemorrhage with coagulation defects defined in code category O45.- or codes O46.0-, O67.0, or O72.3 could be reported with O99.1. This set of codes has now been redefined as an "excludes 1" note, which means that they may not be reported with O99.1 since they are considered inclusive.

More specific codes added for antenatal screening

Great news for those awaiting a more specific code for antenatal screening: The code Z36 has been expanded to more closely match the codes that were available in ICD-9-CM, but it goes beyond the basic list in that codes have been added for things like nonvisualization of anatomic structures on a previous scan and screening for cervical length and fetal lung maturity. Be sure to pay attention to the excludes notes and other inclusive terms.

• Z36, Encounter for antenatal screening of mother (Screening is the testing for disease or disease precursors in asymptomatic individuals so that early detection and treatment can be provided for those who test positive for the disease.)
  
  Includes: Encounter for placental sample (taken vaginally)
  
  Excludes 2: O28.-, Abnormal findings on antenatal screening of mother
   
  • Z36.5, Encounter for antenatal screening for isoimmunization
  • Z36.4, Encounter for antenatal screening for fetal growth retardation
    Intrauterine growth restriction (IUGR)/small-for-dates
  • Z36.3, Encounter for antenatal screening for malformations
    Screening for a suspected anomaly
  • Z36.2, Encounter for other antenatal screening follow-up
    Nonvisualized anatomy on a previous scan
  • Z36.1, Encounter for antenatal screening for raised alpha-fetoprotein level
    Encounter for antenatal screening for elevated maternal serum alpha-fetoprotein level  
  • Z36.0, Encounter for antenatal screening for chromosomal anomalies
• Z36.81, Encounter for antenatal screening for hydrops fetalis
  • Z36.8A, Encounter for antenatal screening for other genetic defects
  • Z36.89, Encounter for other specified antenatal screening
  • Z36.88, Encounter for antenatal screening for fetal macrosomia
    Screening for large-for-dates
  • Z36.87, Encounter for antenatal screening for uncertain dates
  • Z36.86, Encounter for antenatal screening for cervical length
    Screening for risk of preterm labor
  • Z36.85, Encounter for antenatal screening for Streptococcus B
  • Z36.84, Encounter for antenatal screening for fetal lung maturity
  • Z36.83, Encounter for fetal screening for congenital cardiac abnormalities
  • Z36.82, Encounter for antenatal screening for nuchal translucency
  • Z36.81, Encounter for antenatal screening for hydrops fetalis
• Z36.9, Encounter for antenatal screening, unspecified  

Code changes for abortion and complications

The code range for use with Z3A, weeks of gestation, has changed from O00-O9A to O09-O9A to reflect the guideline change last year to remove the requirement to use this code with any code that describes pregnancy with an abortive outcome (codes O00-O08).

In addition, if a patient has retained products of conception (POC) after either a spontaneous or elective abortion, report the "without complication" code for the retained POC (O03.4, Incomplete spontaneous abortion without complication, or O07.4, Failed attempted termination of pregnancy without complication). If any other complication occurred in addition to the retained POC, use the code for that particular complication and not O03.4 or O07.4.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.