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Surgical Site Infection Monitoring and Reporting Vary Widely
Monitoring of rates of surgical site infection, as well as reporting of those rates to the public, vary dramatically from state to state, according to a study published online in the Journal for Healthcare Quality.
Monitoring and publicly reporting data on surgical site infections (SSIs) has been demonstrated to markedly improve patient outcomes, and the Centers for Medicare and Medicaid Services recently announced that hospitals must report such data (for certain procedures) and meet benchmarks to avoid financial penalties. Yet currently there is no standardized system for collecting or reporting SSI data, with each state addressing the issue through its own individual laws, regulations, or "plans," said Dr. Martin A. Makary, a laparoscopic and pancreatic surgeon at Johns Hopkins University, Baltimore, and his associates.
"It is critical to standardize the reporting process before SSIs are incorporated into the Medicare payment scheme," they noted.
Dr. Makary and his colleagues reviewed the legislation on SSI monitoring and reporting for all 50 states and the District of Columbia, then assessed each state’s actual reporting of such data for a single month – September 2010.
They found that only 21 states mandate the monitoring of SSI rates and only 20 require public reporting; the remaining states had no such laws. And despite these legal mandates, only 8 of the 21 states had SSI data available in an easily accessible manner.
These states were South Carolina, Missouri, Colorado, Massachusetts, New York, Ohio, Vermont, and Oregon.
Among these eight states, SSI reporting still varied widely, with each state tracking different procedures. Seven states reported on CABG, six on hip or knee replacements, four on hysterectomies, and two each on colon surgeries or herniorrphaphies. One state reported on breast surgeries, one on gallbladder procedures, one on cesarean sections, and one on spinal fusions.
"Interestingly, colon surgery, which has the highest rate of SSIs nationally, was only reported by two states. And gallbladder surgery, which is among the most common surgical procedures ... was only reported by one state," the investigators said (J. Healthc. Qual. 2012 [doi: 10.1111/j.1945-1474.2011.00176.x]).).
The data collection itself varied greatly by state. For example, some states monitored only in-hospital SSIs for colorectal surgery, while others monitored 30-day SSIs for the same procedure. This resulted in a nearly 40% discrepancy in colorectal SSIs between these states, since many of these infections don’t develop until after hospital discharge, the researchers said.
The lag time between collection of the information and its publication tended to be long, with some states failing to post their SSI data until 11 months after it was obtained.
"Without the same quality and type of data, it is difficult for consumers, payers, or regulators to compare infections within or across states, potentially making inaccurate inferences about the quality of care," Dr. Makary and his associates said.
"Our study highlights the need for the federal government to set the rules for how hospitals define, monitor, and report SSIs," they added.
No conflicts of interest were reported.
It is an interesting observation that simply measuring something tends to improve outcomes. Whether this is due to variations in reporting standards, self-reporting biases, or a real effect is unclear. What is surprising, and demonstrated by this report, is that we measure and record so little about outcomes following surgical procedures. Many of these outcomes have a major impact on the patient are therefore important.
| Dr. Cliff P. Shearman |
This report makes the very important point that a standardized reporting system needs to be used. This often tends to be the stumbling block to get reporting schemes up and running. Clinicians tend to use complex stratified schemes that make clinical sense but can be time consuming to collect and analyze. Commissioners of health care such as insurers and public bodies, however, usually want basic data such as crude infection rates, mortality and length of hospital stay.
In England and Wales such data are now published for a range of conditions (NHS Atlas of Variation). While many feel that this data is deeply flawed, it is now in the public domain and has had significant effects on health care providers. Perhaps the message is that clinicians need to be proactive in agreeing robust reporting standards and using them rather than waiting for regulatory bodies to impose less sensitive indicators of quality on them.
Collecting data needs resourcing and self-reported data has limitations. High quality data is expensive and collecting it will have an impact overall on the cost or procedures, something often overlooked by health care commissioners.
Dr. Cliff P. Shearman is a professor of vascular surgery at the University of Southampton, Southampton, United Kingdom. He is an associate medical editor for Vascular Specialist.
It is an interesting observation that simply measuring something tends to improve outcomes. Whether this is due to variations in reporting standards, self-reporting biases, or a real effect is unclear. What is surprising, and demonstrated by this report, is that we measure and record so little about outcomes following surgical procedures. Many of these outcomes have a major impact on the patient are therefore important.
| Dr. Cliff P. Shearman |
This report makes the very important point that a standardized reporting system needs to be used. This often tends to be the stumbling block to get reporting schemes up and running. Clinicians tend to use complex stratified schemes that make clinical sense but can be time consuming to collect and analyze. Commissioners of health care such as insurers and public bodies, however, usually want basic data such as crude infection rates, mortality and length of hospital stay.
In England and Wales such data are now published for a range of conditions (NHS Atlas of Variation). While many feel that this data is deeply flawed, it is now in the public domain and has had significant effects on health care providers. Perhaps the message is that clinicians need to be proactive in agreeing robust reporting standards and using them rather than waiting for regulatory bodies to impose less sensitive indicators of quality on them.
Collecting data needs resourcing and self-reported data has limitations. High quality data is expensive and collecting it will have an impact overall on the cost or procedures, something often overlooked by health care commissioners.
Dr. Cliff P. Shearman is a professor of vascular surgery at the University of Southampton, Southampton, United Kingdom. He is an associate medical editor for Vascular Specialist.
It is an interesting observation that simply measuring something tends to improve outcomes. Whether this is due to variations in reporting standards, self-reporting biases, or a real effect is unclear. What is surprising, and demonstrated by this report, is that we measure and record so little about outcomes following surgical procedures. Many of these outcomes have a major impact on the patient are therefore important.
| Dr. Cliff P. Shearman |
This report makes the very important point that a standardized reporting system needs to be used. This often tends to be the stumbling block to get reporting schemes up and running. Clinicians tend to use complex stratified schemes that make clinical sense but can be time consuming to collect and analyze. Commissioners of health care such as insurers and public bodies, however, usually want basic data such as crude infection rates, mortality and length of hospital stay.
In England and Wales such data are now published for a range of conditions (NHS Atlas of Variation). While many feel that this data is deeply flawed, it is now in the public domain and has had significant effects on health care providers. Perhaps the message is that clinicians need to be proactive in agreeing robust reporting standards and using them rather than waiting for regulatory bodies to impose less sensitive indicators of quality on them.
Collecting data needs resourcing and self-reported data has limitations. High quality data is expensive and collecting it will have an impact overall on the cost or procedures, something often overlooked by health care commissioners.
Dr. Cliff P. Shearman is a professor of vascular surgery at the University of Southampton, Southampton, United Kingdom. He is an associate medical editor for Vascular Specialist.
Monitoring of rates of surgical site infection, as well as reporting of those rates to the public, vary dramatically from state to state, according to a study published online in the Journal for Healthcare Quality.
Monitoring and publicly reporting data on surgical site infections (SSIs) has been demonstrated to markedly improve patient outcomes, and the Centers for Medicare and Medicaid Services recently announced that hospitals must report such data (for certain procedures) and meet benchmarks to avoid financial penalties. Yet currently there is no standardized system for collecting or reporting SSI data, with each state addressing the issue through its own individual laws, regulations, or "plans," said Dr. Martin A. Makary, a laparoscopic and pancreatic surgeon at Johns Hopkins University, Baltimore, and his associates.
"It is critical to standardize the reporting process before SSIs are incorporated into the Medicare payment scheme," they noted.
Dr. Makary and his colleagues reviewed the legislation on SSI monitoring and reporting for all 50 states and the District of Columbia, then assessed each state’s actual reporting of such data for a single month – September 2010.
They found that only 21 states mandate the monitoring of SSI rates and only 20 require public reporting; the remaining states had no such laws. And despite these legal mandates, only 8 of the 21 states had SSI data available in an easily accessible manner.
These states were South Carolina, Missouri, Colorado, Massachusetts, New York, Ohio, Vermont, and Oregon.
Among these eight states, SSI reporting still varied widely, with each state tracking different procedures. Seven states reported on CABG, six on hip or knee replacements, four on hysterectomies, and two each on colon surgeries or herniorrphaphies. One state reported on breast surgeries, one on gallbladder procedures, one on cesarean sections, and one on spinal fusions.
"Interestingly, colon surgery, which has the highest rate of SSIs nationally, was only reported by two states. And gallbladder surgery, which is among the most common surgical procedures ... was only reported by one state," the investigators said (J. Healthc. Qual. 2012 [doi: 10.1111/j.1945-1474.2011.00176.x]).).
The data collection itself varied greatly by state. For example, some states monitored only in-hospital SSIs for colorectal surgery, while others monitored 30-day SSIs for the same procedure. This resulted in a nearly 40% discrepancy in colorectal SSIs between these states, since many of these infections don’t develop until after hospital discharge, the researchers said.
The lag time between collection of the information and its publication tended to be long, with some states failing to post their SSI data until 11 months after it was obtained.
"Without the same quality and type of data, it is difficult for consumers, payers, or regulators to compare infections within or across states, potentially making inaccurate inferences about the quality of care," Dr. Makary and his associates said.
"Our study highlights the need for the federal government to set the rules for how hospitals define, monitor, and report SSIs," they added.
No conflicts of interest were reported.
Monitoring of rates of surgical site infection, as well as reporting of those rates to the public, vary dramatically from state to state, according to a study published online in the Journal for Healthcare Quality.
Monitoring and publicly reporting data on surgical site infections (SSIs) has been demonstrated to markedly improve patient outcomes, and the Centers for Medicare and Medicaid Services recently announced that hospitals must report such data (for certain procedures) and meet benchmarks to avoid financial penalties. Yet currently there is no standardized system for collecting or reporting SSI data, with each state addressing the issue through its own individual laws, regulations, or "plans," said Dr. Martin A. Makary, a laparoscopic and pancreatic surgeon at Johns Hopkins University, Baltimore, and his associates.
"It is critical to standardize the reporting process before SSIs are incorporated into the Medicare payment scheme," they noted.
Dr. Makary and his colleagues reviewed the legislation on SSI monitoring and reporting for all 50 states and the District of Columbia, then assessed each state’s actual reporting of such data for a single month – September 2010.
They found that only 21 states mandate the monitoring of SSI rates and only 20 require public reporting; the remaining states had no such laws. And despite these legal mandates, only 8 of the 21 states had SSI data available in an easily accessible manner.
These states were South Carolina, Missouri, Colorado, Massachusetts, New York, Ohio, Vermont, and Oregon.
Among these eight states, SSI reporting still varied widely, with each state tracking different procedures. Seven states reported on CABG, six on hip or knee replacements, four on hysterectomies, and two each on colon surgeries or herniorrphaphies. One state reported on breast surgeries, one on gallbladder procedures, one on cesarean sections, and one on spinal fusions.
"Interestingly, colon surgery, which has the highest rate of SSIs nationally, was only reported by two states. And gallbladder surgery, which is among the most common surgical procedures ... was only reported by one state," the investigators said (J. Healthc. Qual. 2012 [doi: 10.1111/j.1945-1474.2011.00176.x]).).
The data collection itself varied greatly by state. For example, some states monitored only in-hospital SSIs for colorectal surgery, while others monitored 30-day SSIs for the same procedure. This resulted in a nearly 40% discrepancy in colorectal SSIs between these states, since many of these infections don’t develop until after hospital discharge, the researchers said.
The lag time between collection of the information and its publication tended to be long, with some states failing to post their SSI data until 11 months after it was obtained.
"Without the same quality and type of data, it is difficult for consumers, payers, or regulators to compare infections within or across states, potentially making inaccurate inferences about the quality of care," Dr. Makary and his associates said.
"Our study highlights the need for the federal government to set the rules for how hospitals define, monitor, and report SSIs," they added.
No conflicts of interest were reported.
FROM THE JOURNAL FOR HEALTHCARE QUALITY
Major Finding: Only 21 states legally mandate the monitoring of surgical site infections, and in a given month, only 8 states made the data accessible to the public.
Data Source: This was a review of the laws, regulations, and plans regarding the monitoring and reporting of SSIs in all 50 states and the District of Columbia.
Disclosures: No conflicts of interest were reported.
Higher Spending Linked to Better Hospital Care
Higher spending intensity was associated with substantially better hospital care in Ontario, which has a universal health care system, according to a report in JAMA.
Patients with acute illness treated at hospitals with higher spending intensity had lower mortality, lower readmission rates, and fewer adverse events than did those treated at hospitals with lower spending intensity, said Therese A. Stukel, Ph.D., of the Institute for Clinical Evaluative Sciences, Toronto, and her associates.
However, it would be "facile" to conclude that more spending necessarily leads to better patient outcomes, and that providing more money to lower-spending facilities would necessarily improve their patient outcomes. "Higher-spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive," the investigators noted.
Many studies have examined whether higher health care spending produces better patient outcomes, but until now, none have assessed the issue in an area with universal access to health care but a lower supply of specialists and of medical technology than in the United States. "Our objective was to assess whether acute care patients admitted to Canadian hospitals that treat patients more intensively (and at higher cost) have lower mortality and readmissions and higher quality of care," Dr. Stukel and her colleagues said.
They analyzed the medical records of adults with an index admission to one of 129 acute care hospitals in Ontario in 1998-2008 for any of four common conditions for which treatment follows relatively standard protocols: acute myocardial infarction (179,139 patients), heart failure (92,377 patients), hip fracture (90,046 patients), or surgical resection of colon cancer (26,195 patients). The study subjects were followed for 1 year after the index admission.
Several quality-of-care measures were assessed: whether patients received preoperative visits from a surgeon and an anesthetist, whether surgery took place within 2 days of admission, whether patients received in-hospital rehabilitation, whether MI patients underwent same-day percutaneous coronary intervention, and the number of visits from medical specialists during the hospital stay.
Higher-spending hospitals tended to be high-volume centers in urban areas. They tended to be affiliated with regional cancer centers and to have on-site CT, MRI, cardiac catheterization, and cardiac surgery capabilities. They also tended to employ critical care response teams, as well as attending physicians who were specialists. And they provided 30% more inpatient nursing hours per patient-day and per bed than did lower-spending hospitals.
At higher-spending hospitals, 30-day mortality was 12.7% (vs 12.8%) for acute MI, 10.2% (vs. 12.4%) for CHF, 7.7% (vs. 9.7%) for hip fracture, and 3.3% (vs 3.9%) for colon cancer. The 30-day major cardiac event rate was 17.4% (vs.18.7%) for acute MI and 15.0% (vs. 17.6%) for CHF. And the 30-day readmission rate was 23.1% (vs. 25.8%) for hip fracture and 10.3% (vs 13.1%) for colon cancer.
After the data were adjusted fully to account for patient age, sex, illness severity, and other variables, mortality and readmission rates remained significantly lower in high-spending hospitals for every study subgroup, Dr. Stukel and her colleagues said (JAMA 2012;307:1037-45).
Compared with patients at lower-spending hospitals, those at higher-spending hospitals were more likely to see a medical specialist during their stay. Cardiac patients at higher-spending hospitals were more likely to receive the indicated cardiac interventions and evidence-based medications, to attend ambulatory care within 1 month, and to visit a cardiologist within 1 year.
CHF patients at higher-spending hospitals were less likely than were those at lower-spending hospitals to receive contraindicated medications. Those with hip fracture were more likely to begin rehabilitation during their inpatient stay. And those with colon cancer were more likely to have a preoperative consultation with a surgeon and an anesthetist, and to undergo CT for preoperative staging, compared with colon cancer patients at lower-spending hospitals.
The study findings "suggest that it is critical to understand not simply how much money is spent but whether it is spent on effective procedures and services," the researchers noted.
This study was supported by the Canadian Institute of Health Research, the U.S. National Institute on Aging, the Institute for Clinical Evaluative Sciences, and the Ontario Ministry of Health and Long-Term Care. No relevant financial conflicts of interest were reported.
"The notion that payments to hospitals can be reduced while maintaining or improving the quality of care delivered at these hospitals has become so ingrained in policy circles as to be a given," said Dr. Karen E. Joynt and Dr. Ashish K. Jha in remarks were taken from their editorial accompanying Dr. Stukel’s report (JAMA 2012;307:1082-3).
"Although paying hospitals less may appear to be a good strategy to save money, the findings reported by Stukel et al. serve as a timely reminder that this approach is likely to have negative consequences for patients," they noted.
So-called "expensive" hospitals are likely spending that money directly on nurses, specialists, and technology – in other words, on care that improves the outcomes of acutely ill patients, Dr. Joynt and Dr. Jha said.
Dr. Joynt and Dr. Jha are in the department of health policy and management at Harvard School of Public Health, Boston. Dr. Joynt is also in the cardiovascular division and Dr. Jha is in the division of general internal medicine at Brigham and Women’s Hospital, Boston. They reported no relevant financial conflicts of interest.
This study is both interesting and provocative. Reading this from the UK where we are currently making health care savings of £20 billion ($32 billion) while trying to improve outcomes and meet increased need there are some resonances particularly in the drive to reduce rates of hospital admission and length of stay.
| Dr. Cliff P. Shearman |
While the authors point out it would be foolish just to imagine that spending more will give better results there are some important messages. Not following best evidence treatment pathways and providing important supplementary treatments such as rehabilitation are obvious issues which need addressing. Increasingly many of these aspects of care are provided outside of the hospital setting and it would be interesting to know how many of the low spending institutions have had aspects of care sub-contracted to other providers. The financial health of an institution is probably a good indicator of leadership and staff morale and it would be useful to explore these areas more. Not having a pre-operative consultation with a surgeon and anesthetist and CT staging prior to colonic surgery seems indicative of something other than financial constraints.
There is little doubt that for the next decade the Western World will see an increasing demand for health care from a burgeoning elderly population faced with a relatively smaller health care budget. Increased spending will not be an option and smarter ways of delivering health care, particularly in hospitals will have to be found. Perhaps behind the headline message of this study lie clues as to what makes a high quality, efficient health care organization work; it is likely to be more than money.
Dr. Cliff P. Shearman is a professor of vascular surgery at the University of Southampton, Southampton, United Kingdom. He is an associate medical editor for Vascular Specialist.
This study is both interesting and provocative. Reading this from the UK where we are currently making health care savings of £20 billion ($32 billion) while trying to improve outcomes and meet increased need there are some resonances particularly in the drive to reduce rates of hospital admission and length of stay.
| Dr. Cliff P. Shearman |
While the authors point out it would be foolish just to imagine that spending more will give better results there are some important messages. Not following best evidence treatment pathways and providing important supplementary treatments such as rehabilitation are obvious issues which need addressing. Increasingly many of these aspects of care are provided outside of the hospital setting and it would be interesting to know how many of the low spending institutions have had aspects of care sub-contracted to other providers. The financial health of an institution is probably a good indicator of leadership and staff morale and it would be useful to explore these areas more. Not having a pre-operative consultation with a surgeon and anesthetist and CT staging prior to colonic surgery seems indicative of something other than financial constraints.
There is little doubt that for the next decade the Western World will see an increasing demand for health care from a burgeoning elderly population faced with a relatively smaller health care budget. Increased spending will not be an option and smarter ways of delivering health care, particularly in hospitals will have to be found. Perhaps behind the headline message of this study lie clues as to what makes a high quality, efficient health care organization work; it is likely to be more than money.
Dr. Cliff P. Shearman is a professor of vascular surgery at the University of Southampton, Southampton, United Kingdom. He is an associate medical editor for Vascular Specialist.
This study is both interesting and provocative. Reading this from the UK where we are currently making health care savings of £20 billion ($32 billion) while trying to improve outcomes and meet increased need there are some resonances particularly in the drive to reduce rates of hospital admission and length of stay.
| Dr. Cliff P. Shearman |
While the authors point out it would be foolish just to imagine that spending more will give better results there are some important messages. Not following best evidence treatment pathways and providing important supplementary treatments such as rehabilitation are obvious issues which need addressing. Increasingly many of these aspects of care are provided outside of the hospital setting and it would be interesting to know how many of the low spending institutions have had aspects of care sub-contracted to other providers. The financial health of an institution is probably a good indicator of leadership and staff morale and it would be useful to explore these areas more. Not having a pre-operative consultation with a surgeon and anesthetist and CT staging prior to colonic surgery seems indicative of something other than financial constraints.
There is little doubt that for the next decade the Western World will see an increasing demand for health care from a burgeoning elderly population faced with a relatively smaller health care budget. Increased spending will not be an option and smarter ways of delivering health care, particularly in hospitals will have to be found. Perhaps behind the headline message of this study lie clues as to what makes a high quality, efficient health care organization work; it is likely to be more than money.
Dr. Cliff P. Shearman is a professor of vascular surgery at the University of Southampton, Southampton, United Kingdom. He is an associate medical editor for Vascular Specialist.
Higher spending intensity was associated with substantially better hospital care in Ontario, which has a universal health care system, according to a report in JAMA.
Patients with acute illness treated at hospitals with higher spending intensity had lower mortality, lower readmission rates, and fewer adverse events than did those treated at hospitals with lower spending intensity, said Therese A. Stukel, Ph.D., of the Institute for Clinical Evaluative Sciences, Toronto, and her associates.
However, it would be "facile" to conclude that more spending necessarily leads to better patient outcomes, and that providing more money to lower-spending facilities would necessarily improve their patient outcomes. "Higher-spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive," the investigators noted.
Many studies have examined whether higher health care spending produces better patient outcomes, but until now, none have assessed the issue in an area with universal access to health care but a lower supply of specialists and of medical technology than in the United States. "Our objective was to assess whether acute care patients admitted to Canadian hospitals that treat patients more intensively (and at higher cost) have lower mortality and readmissions and higher quality of care," Dr. Stukel and her colleagues said.
They analyzed the medical records of adults with an index admission to one of 129 acute care hospitals in Ontario in 1998-2008 for any of four common conditions for which treatment follows relatively standard protocols: acute myocardial infarction (179,139 patients), heart failure (92,377 patients), hip fracture (90,046 patients), or surgical resection of colon cancer (26,195 patients). The study subjects were followed for 1 year after the index admission.
Several quality-of-care measures were assessed: whether patients received preoperative visits from a surgeon and an anesthetist, whether surgery took place within 2 days of admission, whether patients received in-hospital rehabilitation, whether MI patients underwent same-day percutaneous coronary intervention, and the number of visits from medical specialists during the hospital stay.
Higher-spending hospitals tended to be high-volume centers in urban areas. They tended to be affiliated with regional cancer centers and to have on-site CT, MRI, cardiac catheterization, and cardiac surgery capabilities. They also tended to employ critical care response teams, as well as attending physicians who were specialists. And they provided 30% more inpatient nursing hours per patient-day and per bed than did lower-spending hospitals.
At higher-spending hospitals, 30-day mortality was 12.7% (vs 12.8%) for acute MI, 10.2% (vs. 12.4%) for CHF, 7.7% (vs. 9.7%) for hip fracture, and 3.3% (vs 3.9%) for colon cancer. The 30-day major cardiac event rate was 17.4% (vs.18.7%) for acute MI and 15.0% (vs. 17.6%) for CHF. And the 30-day readmission rate was 23.1% (vs. 25.8%) for hip fracture and 10.3% (vs 13.1%) for colon cancer.
After the data were adjusted fully to account for patient age, sex, illness severity, and other variables, mortality and readmission rates remained significantly lower in high-spending hospitals for every study subgroup, Dr. Stukel and her colleagues said (JAMA 2012;307:1037-45).
Compared with patients at lower-spending hospitals, those at higher-spending hospitals were more likely to see a medical specialist during their stay. Cardiac patients at higher-spending hospitals were more likely to receive the indicated cardiac interventions and evidence-based medications, to attend ambulatory care within 1 month, and to visit a cardiologist within 1 year.
CHF patients at higher-spending hospitals were less likely than were those at lower-spending hospitals to receive contraindicated medications. Those with hip fracture were more likely to begin rehabilitation during their inpatient stay. And those with colon cancer were more likely to have a preoperative consultation with a surgeon and an anesthetist, and to undergo CT for preoperative staging, compared with colon cancer patients at lower-spending hospitals.
The study findings "suggest that it is critical to understand not simply how much money is spent but whether it is spent on effective procedures and services," the researchers noted.
This study was supported by the Canadian Institute of Health Research, the U.S. National Institute on Aging, the Institute for Clinical Evaluative Sciences, and the Ontario Ministry of Health and Long-Term Care. No relevant financial conflicts of interest were reported.
"The notion that payments to hospitals can be reduced while maintaining or improving the quality of care delivered at these hospitals has become so ingrained in policy circles as to be a given," said Dr. Karen E. Joynt and Dr. Ashish K. Jha in remarks were taken from their editorial accompanying Dr. Stukel’s report (JAMA 2012;307:1082-3).
"Although paying hospitals less may appear to be a good strategy to save money, the findings reported by Stukel et al. serve as a timely reminder that this approach is likely to have negative consequences for patients," they noted.
So-called "expensive" hospitals are likely spending that money directly on nurses, specialists, and technology – in other words, on care that improves the outcomes of acutely ill patients, Dr. Joynt and Dr. Jha said.
Dr. Joynt and Dr. Jha are in the department of health policy and management at Harvard School of Public Health, Boston. Dr. Joynt is also in the cardiovascular division and Dr. Jha is in the division of general internal medicine at Brigham and Women’s Hospital, Boston. They reported no relevant financial conflicts of interest.
Higher spending intensity was associated with substantially better hospital care in Ontario, which has a universal health care system, according to a report in JAMA.
Patients with acute illness treated at hospitals with higher spending intensity had lower mortality, lower readmission rates, and fewer adverse events than did those treated at hospitals with lower spending intensity, said Therese A. Stukel, Ph.D., of the Institute for Clinical Evaluative Sciences, Toronto, and her associates.
However, it would be "facile" to conclude that more spending necessarily leads to better patient outcomes, and that providing more money to lower-spending facilities would necessarily improve their patient outcomes. "Higher-spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive," the investigators noted.
Many studies have examined whether higher health care spending produces better patient outcomes, but until now, none have assessed the issue in an area with universal access to health care but a lower supply of specialists and of medical technology than in the United States. "Our objective was to assess whether acute care patients admitted to Canadian hospitals that treat patients more intensively (and at higher cost) have lower mortality and readmissions and higher quality of care," Dr. Stukel and her colleagues said.
They analyzed the medical records of adults with an index admission to one of 129 acute care hospitals in Ontario in 1998-2008 for any of four common conditions for which treatment follows relatively standard protocols: acute myocardial infarction (179,139 patients), heart failure (92,377 patients), hip fracture (90,046 patients), or surgical resection of colon cancer (26,195 patients). The study subjects were followed for 1 year after the index admission.
Several quality-of-care measures were assessed: whether patients received preoperative visits from a surgeon and an anesthetist, whether surgery took place within 2 days of admission, whether patients received in-hospital rehabilitation, whether MI patients underwent same-day percutaneous coronary intervention, and the number of visits from medical specialists during the hospital stay.
Higher-spending hospitals tended to be high-volume centers in urban areas. They tended to be affiliated with regional cancer centers and to have on-site CT, MRI, cardiac catheterization, and cardiac surgery capabilities. They also tended to employ critical care response teams, as well as attending physicians who were specialists. And they provided 30% more inpatient nursing hours per patient-day and per bed than did lower-spending hospitals.
At higher-spending hospitals, 30-day mortality was 12.7% (vs 12.8%) for acute MI, 10.2% (vs. 12.4%) for CHF, 7.7% (vs. 9.7%) for hip fracture, and 3.3% (vs 3.9%) for colon cancer. The 30-day major cardiac event rate was 17.4% (vs.18.7%) for acute MI and 15.0% (vs. 17.6%) for CHF. And the 30-day readmission rate was 23.1% (vs. 25.8%) for hip fracture and 10.3% (vs 13.1%) for colon cancer.
After the data were adjusted fully to account for patient age, sex, illness severity, and other variables, mortality and readmission rates remained significantly lower in high-spending hospitals for every study subgroup, Dr. Stukel and her colleagues said (JAMA 2012;307:1037-45).
Compared with patients at lower-spending hospitals, those at higher-spending hospitals were more likely to see a medical specialist during their stay. Cardiac patients at higher-spending hospitals were more likely to receive the indicated cardiac interventions and evidence-based medications, to attend ambulatory care within 1 month, and to visit a cardiologist within 1 year.
CHF patients at higher-spending hospitals were less likely than were those at lower-spending hospitals to receive contraindicated medications. Those with hip fracture were more likely to begin rehabilitation during their inpatient stay. And those with colon cancer were more likely to have a preoperative consultation with a surgeon and an anesthetist, and to undergo CT for preoperative staging, compared with colon cancer patients at lower-spending hospitals.
The study findings "suggest that it is critical to understand not simply how much money is spent but whether it is spent on effective procedures and services," the researchers noted.
This study was supported by the Canadian Institute of Health Research, the U.S. National Institute on Aging, the Institute for Clinical Evaluative Sciences, and the Ontario Ministry of Health and Long-Term Care. No relevant financial conflicts of interest were reported.
"The notion that payments to hospitals can be reduced while maintaining or improving the quality of care delivered at these hospitals has become so ingrained in policy circles as to be a given," said Dr. Karen E. Joynt and Dr. Ashish K. Jha in remarks were taken from their editorial accompanying Dr. Stukel’s report (JAMA 2012;307:1082-3).
"Although paying hospitals less may appear to be a good strategy to save money, the findings reported by Stukel et al. serve as a timely reminder that this approach is likely to have negative consequences for patients," they noted.
So-called "expensive" hospitals are likely spending that money directly on nurses, specialists, and technology – in other words, on care that improves the outcomes of acutely ill patients, Dr. Joynt and Dr. Jha said.
Dr. Joynt and Dr. Jha are in the department of health policy and management at Harvard School of Public Health, Boston. Dr. Joynt is also in the cardiovascular division and Dr. Jha is in the division of general internal medicine at Brigham and Women’s Hospital, Boston. They reported no relevant financial conflicts of interest.
FROM JAMA
Major Finding: Thirty-day and 1-year rates of mortality and readmission were consistently lower in patients treated at hospitals with higher spending intensity than in those treated at hospitals with lower spending intensity.
Data Source: A longitudinal cohort study involving 179,139 men and women with acute MI, 92,377 with CHF, 90,046 with hip fracture, and 26,195 with colon cancer requiring surgical resection, all of whom were hospitalized at 129 Ontario medical centers in 1998-2008 and followed for 1 year.
Disclosures: This study was supported by the Canadian Institute of Health Research, the U.S. National Institute on Aging, the Institute for Clinical Evaluative Sciences, and the Ontario Ministry of Health and Long-Term Care. No relevant financial conflicts of interest were reported.
Penalties Loom for Lagging on E-Health Initiatives
The incentives offered for early adopters of the various electronic health initiatives promulgated by the Centers for Medicare and Medicaid Services are expected to transition into penalties within the next 2-3 years.
Currently, the Electronic Prescribing, or eRx, program offers both incentives and penalties. However, the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) programs, which still offer incentives for participating, will transition to penalties by 2015.
The EHR incentive program authorized up to $27 billion for incentive payments to hospitals and physicians for "meaningful use" of a qualified electronic health record. Surgeons and other physicians qualifying for the first time last year and this year could receive up to $18,000 in the first year and annual payments through 2016 totaling $44,000.
During 2013 and 2014, there will be a reduced incentive for initial qualification, and beginning in 2015, failure to demonstrate meaningful use will lead to a penalty of 1% in Medicare reimbursement. That penalty increases to 2% in 2016 and to 3% for 2017 and beyond.
Dr. Margaret Tracci, a vascular surgeon at the University of Virginia Health System who has analyzed these programs and their potential effects on surgeons, projects that penalties for surgeons who don't meet the requirements for any of the programs could reach 5.5% in 2018.
The overall emphasis on primary care in the initial program rollouts may have made surgeons less attuned to the concept of electronic reporting and record-keeping, according to Dr. Don Detmer, medical director of the American College of Surgeons (ACS) Division of Advocacy and Health Policy. "It let some surgeons think they could put it off," he said in an interview. "We started out with some carrots, but the carrots are becoming sticks. Still, it's not like this hasn't been known from the beginning."
Ways to Participate
The ACS doesn't have a good sense of how many surgeons and which types of practices aren't prepared for these programs to transition to penalties. Nonetheless, EHR adoption may have outpaced adoption of the PQRS and eRx, because many surgeons are using some form of electronic health record, according to Dr. Tracci. There's less participation in electronic prescribing programs or in PQRS as of yet, she said.
PQRS, which began in 2007 as an incentive program for voluntary reporting of quality measures, will transition into penalties for nonparticipants beginning in 2015. Surgeons who don't report data for PQRS will be hit by a 1.5% Medicare reimbursement penalty in 2015 and a 2% penalty in 2016. Conversely, there's a 0.5% incentive available for Maintenance of Certification (MOC) for those who participate in PQRS through a qualified entity.
Surgeons and other "individual eligible professionals" may report selected measures by several mechanisms, including claims-based, registry-based, or EHR-based mechanisms. There's also a group practice reporting option, although the deadline already has passed for groups to select this option.
For PQRS, "there are three registries surgeons can use to participate now [but] we really are on our own collecting and submitting data," Dr. Tracci said. Several hundred institutions nationwide have formed their own registries, she added.
A 2009 CMS report indicated that surgeons are far more likely to report PQRS data when they participate in their own group's registry. However, there are no recent data indicating just how many surgeons are participating, according to the ACS.
The electronic prescribing, or eRx, incentive program provides an incentive to use a qualifying electronic health record to generate and transmit eligible prescriptions for Medicare beneficiaries. This program begins transitioning to its penalty phase this year.
To avoid penalties, individuals and groups must generate a set amount of e-prescriptions. "In practice, it has been much harder for surgeons to meet the requirements than primary care physicians," said Dr. Tracci.
Pay Now or Pay Later
EHR programs are admittedly expensive to implement, but the penalties for failing to do so can add up into the millions over the life of the program for a physician group of several hundred surgeons and other doctors, Dr. Tracci noted.
While her group at the University of Virginia is "in a position to do this" and maintains an EHR system that meets meaningful use requirements, she said, most practicing surgeons are in smaller groups, and will have a tougher time implementing EHR. And some practices have invested in EHR, only to find that the product they've chosen doesn't suit them and they need to switch. "That is incredibly costly, and also costly in terms of productivity," Dr. Tracci said.
Many enterprise-wide EHR products "are not well suited for subspecialty data requirements," noted Dr. Detmer. "When you get right down to it, when you put in an EHR, it's not about electronics, it's about changing the way you work. Once you make the transition -- and it usually takes a couple of months -- most folks would rather not go back."
The ACS is getting more engaged in an effort to help surgeons cope with the deadlines, he added. Surgeons who haven't started on any of these programs first should carefully analyze the reporting periods for all of the incentives and penalties when prioritizing which program to begin first, according to information provided by the ACS health policy division. "For example, this is the last year you can begin the stage 1 of the EHR incentive program to be eligible to receive the full incentive bonus of $44,000. The first 6 months of the year is also one of the reporting periods to avoid getting the 2013 eRx payment penalty," according to the ACS.
The time and money involved also should play a role in decision making. Keep in mind that the eRx and PQRS programs both have relatively low start-up costs, and do not take a long time to begin.
More Information
The ACS provides information focused on each quality program -- eRx, HER, and PQRS -- where surgeons can find resources such as flow charts and step-by-step guides to help lead them through the process of implementation:
-- ACS Division of Advocacy and Health Policy: www.facs.org/ahp/index.html
-- EHR: www.facs.org/ahp/ehr/index.html
-- eRx: www.facs.org/ahp/erx.html; www.facs.org/ahp/erx-exemption.pdf
-- PQRS: www.facs.org/ahp/pqri/index.html
However, "if you get into this, you will need to have someone in your group really spend some time with it," Dr. Detmer cautioned. In addition, he noted that there can be long waits for installation of popular products, which surgeons need to keep in mind while considering when the EHRs need to be operational to avoid CMS penalties.
In general, institutions are much further ahead on EHRs than are surgeons practicing solo or in small groups, Dr. Detmer said. "Most people who are in an institution or large system are typically well into this at this point," he said. "If they haven't made the move to [electronic] order entry, they're doing it right now."
In institution-wide efforts involving multiple specialties, "surgeons don't necessarily have to lead, but surgeons will need a champion as part of the process," he added.
With the new subspecialty certification in medical informatics now available, "there really is a need for some young surgeons to decide they need to be part surgeon, part informatician," Dr. Detmer said. "We have some good surgeons involved in this, but not the numbers we need."
The incentives offered for early adopters of the various electronic health initiatives promulgated by the Centers for Medicare and Medicaid Services are expected to transition into penalties within the next 2-3 years.
Currently, the Electronic Prescribing, or eRx, program offers both incentives and penalties. However, the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) programs, which still offer incentives for participating, will transition to penalties by 2015.
The EHR incentive program authorized up to $27 billion for incentive payments to hospitals and physicians for "meaningful use" of a qualified electronic health record. Surgeons and other physicians qualifying for the first time last year and this year could receive up to $18,000 in the first year and annual payments through 2016 totaling $44,000.
During 2013 and 2014, there will be a reduced incentive for initial qualification, and beginning in 2015, failure to demonstrate meaningful use will lead to a penalty of 1% in Medicare reimbursement. That penalty increases to 2% in 2016 and to 3% for 2017 and beyond.
Dr. Margaret Tracci, a vascular surgeon at the University of Virginia Health System who has analyzed these programs and their potential effects on surgeons, projects that penalties for surgeons who don't meet the requirements for any of the programs could reach 5.5% in 2018.
The overall emphasis on primary care in the initial program rollouts may have made surgeons less attuned to the concept of electronic reporting and record-keeping, according to Dr. Don Detmer, medical director of the American College of Surgeons (ACS) Division of Advocacy and Health Policy. "It let some surgeons think they could put it off," he said in an interview. "We started out with some carrots, but the carrots are becoming sticks. Still, it's not like this hasn't been known from the beginning."
Ways to Participate
The ACS doesn't have a good sense of how many surgeons and which types of practices aren't prepared for these programs to transition to penalties. Nonetheless, EHR adoption may have outpaced adoption of the PQRS and eRx, because many surgeons are using some form of electronic health record, according to Dr. Tracci. There's less participation in electronic prescribing programs or in PQRS as of yet, she said.
PQRS, which began in 2007 as an incentive program for voluntary reporting of quality measures, will transition into penalties for nonparticipants beginning in 2015. Surgeons who don't report data for PQRS will be hit by a 1.5% Medicare reimbursement penalty in 2015 and a 2% penalty in 2016. Conversely, there's a 0.5% incentive available for Maintenance of Certification (MOC) for those who participate in PQRS through a qualified entity.
Surgeons and other "individual eligible professionals" may report selected measures by several mechanisms, including claims-based, registry-based, or EHR-based mechanisms. There's also a group practice reporting option, although the deadline already has passed for groups to select this option.
For PQRS, "there are three registries surgeons can use to participate now [but] we really are on our own collecting and submitting data," Dr. Tracci said. Several hundred institutions nationwide have formed their own registries, she added.
A 2009 CMS report indicated that surgeons are far more likely to report PQRS data when they participate in their own group's registry. However, there are no recent data indicating just how many surgeons are participating, according to the ACS.
The electronic prescribing, or eRx, incentive program provides an incentive to use a qualifying electronic health record to generate and transmit eligible prescriptions for Medicare beneficiaries. This program begins transitioning to its penalty phase this year.
To avoid penalties, individuals and groups must generate a set amount of e-prescriptions. "In practice, it has been much harder for surgeons to meet the requirements than primary care physicians," said Dr. Tracci.
Pay Now or Pay Later
EHR programs are admittedly expensive to implement, but the penalties for failing to do so can add up into the millions over the life of the program for a physician group of several hundred surgeons and other doctors, Dr. Tracci noted.
While her group at the University of Virginia is "in a position to do this" and maintains an EHR system that meets meaningful use requirements, she said, most practicing surgeons are in smaller groups, and will have a tougher time implementing EHR. And some practices have invested in EHR, only to find that the product they've chosen doesn't suit them and they need to switch. "That is incredibly costly, and also costly in terms of productivity," Dr. Tracci said.
Many enterprise-wide EHR products "are not well suited for subspecialty data requirements," noted Dr. Detmer. "When you get right down to it, when you put in an EHR, it's not about electronics, it's about changing the way you work. Once you make the transition -- and it usually takes a couple of months -- most folks would rather not go back."
The ACS is getting more engaged in an effort to help surgeons cope with the deadlines, he added. Surgeons who haven't started on any of these programs first should carefully analyze the reporting periods for all of the incentives and penalties when prioritizing which program to begin first, according to information provided by the ACS health policy division. "For example, this is the last year you can begin the stage 1 of the EHR incentive program to be eligible to receive the full incentive bonus of $44,000. The first 6 months of the year is also one of the reporting periods to avoid getting the 2013 eRx payment penalty," according to the ACS.
The time and money involved also should play a role in decision making. Keep in mind that the eRx and PQRS programs both have relatively low start-up costs, and do not take a long time to begin.
More Information
The ACS provides information focused on each quality program -- eRx, HER, and PQRS -- where surgeons can find resources such as flow charts and step-by-step guides to help lead them through the process of implementation:
-- ACS Division of Advocacy and Health Policy: www.facs.org/ahp/index.html
-- EHR: www.facs.org/ahp/ehr/index.html
-- eRx: www.facs.org/ahp/erx.html; www.facs.org/ahp/erx-exemption.pdf
-- PQRS: www.facs.org/ahp/pqri/index.html
However, "if you get into this, you will need to have someone in your group really spend some time with it," Dr. Detmer cautioned. In addition, he noted that there can be long waits for installation of popular products, which surgeons need to keep in mind while considering when the EHRs need to be operational to avoid CMS penalties.
In general, institutions are much further ahead on EHRs than are surgeons practicing solo or in small groups, Dr. Detmer said. "Most people who are in an institution or large system are typically well into this at this point," he said. "If they haven't made the move to [electronic] order entry, they're doing it right now."
In institution-wide efforts involving multiple specialties, "surgeons don't necessarily have to lead, but surgeons will need a champion as part of the process," he added.
With the new subspecialty certification in medical informatics now available, "there really is a need for some young surgeons to decide they need to be part surgeon, part informatician," Dr. Detmer said. "We have some good surgeons involved in this, but not the numbers we need."
The incentives offered for early adopters of the various electronic health initiatives promulgated by the Centers for Medicare and Medicaid Services are expected to transition into penalties within the next 2-3 years.
Currently, the Electronic Prescribing, or eRx, program offers both incentives and penalties. However, the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) programs, which still offer incentives for participating, will transition to penalties by 2015.
The EHR incentive program authorized up to $27 billion for incentive payments to hospitals and physicians for "meaningful use" of a qualified electronic health record. Surgeons and other physicians qualifying for the first time last year and this year could receive up to $18,000 in the first year and annual payments through 2016 totaling $44,000.
During 2013 and 2014, there will be a reduced incentive for initial qualification, and beginning in 2015, failure to demonstrate meaningful use will lead to a penalty of 1% in Medicare reimbursement. That penalty increases to 2% in 2016 and to 3% for 2017 and beyond.
Dr. Margaret Tracci, a vascular surgeon at the University of Virginia Health System who has analyzed these programs and their potential effects on surgeons, projects that penalties for surgeons who don't meet the requirements for any of the programs could reach 5.5% in 2018.
The overall emphasis on primary care in the initial program rollouts may have made surgeons less attuned to the concept of electronic reporting and record-keeping, according to Dr. Don Detmer, medical director of the American College of Surgeons (ACS) Division of Advocacy and Health Policy. "It let some surgeons think they could put it off," he said in an interview. "We started out with some carrots, but the carrots are becoming sticks. Still, it's not like this hasn't been known from the beginning."
Ways to Participate
The ACS doesn't have a good sense of how many surgeons and which types of practices aren't prepared for these programs to transition to penalties. Nonetheless, EHR adoption may have outpaced adoption of the PQRS and eRx, because many surgeons are using some form of electronic health record, according to Dr. Tracci. There's less participation in electronic prescribing programs or in PQRS as of yet, she said.
PQRS, which began in 2007 as an incentive program for voluntary reporting of quality measures, will transition into penalties for nonparticipants beginning in 2015. Surgeons who don't report data for PQRS will be hit by a 1.5% Medicare reimbursement penalty in 2015 and a 2% penalty in 2016. Conversely, there's a 0.5% incentive available for Maintenance of Certification (MOC) for those who participate in PQRS through a qualified entity.
Surgeons and other "individual eligible professionals" may report selected measures by several mechanisms, including claims-based, registry-based, or EHR-based mechanisms. There's also a group practice reporting option, although the deadline already has passed for groups to select this option.
For PQRS, "there are three registries surgeons can use to participate now [but] we really are on our own collecting and submitting data," Dr. Tracci said. Several hundred institutions nationwide have formed their own registries, she added.
A 2009 CMS report indicated that surgeons are far more likely to report PQRS data when they participate in their own group's registry. However, there are no recent data indicating just how many surgeons are participating, according to the ACS.
The electronic prescribing, or eRx, incentive program provides an incentive to use a qualifying electronic health record to generate and transmit eligible prescriptions for Medicare beneficiaries. This program begins transitioning to its penalty phase this year.
To avoid penalties, individuals and groups must generate a set amount of e-prescriptions. "In practice, it has been much harder for surgeons to meet the requirements than primary care physicians," said Dr. Tracci.
Pay Now or Pay Later
EHR programs are admittedly expensive to implement, but the penalties for failing to do so can add up into the millions over the life of the program for a physician group of several hundred surgeons and other doctors, Dr. Tracci noted.
While her group at the University of Virginia is "in a position to do this" and maintains an EHR system that meets meaningful use requirements, she said, most practicing surgeons are in smaller groups, and will have a tougher time implementing EHR. And some practices have invested in EHR, only to find that the product they've chosen doesn't suit them and they need to switch. "That is incredibly costly, and also costly in terms of productivity," Dr. Tracci said.
Many enterprise-wide EHR products "are not well suited for subspecialty data requirements," noted Dr. Detmer. "When you get right down to it, when you put in an EHR, it's not about electronics, it's about changing the way you work. Once you make the transition -- and it usually takes a couple of months -- most folks would rather not go back."
The ACS is getting more engaged in an effort to help surgeons cope with the deadlines, he added. Surgeons who haven't started on any of these programs first should carefully analyze the reporting periods for all of the incentives and penalties when prioritizing which program to begin first, according to information provided by the ACS health policy division. "For example, this is the last year you can begin the stage 1 of the EHR incentive program to be eligible to receive the full incentive bonus of $44,000. The first 6 months of the year is also one of the reporting periods to avoid getting the 2013 eRx payment penalty," according to the ACS.
The time and money involved also should play a role in decision making. Keep in mind that the eRx and PQRS programs both have relatively low start-up costs, and do not take a long time to begin.
More Information
The ACS provides information focused on each quality program -- eRx, HER, and PQRS -- where surgeons can find resources such as flow charts and step-by-step guides to help lead them through the process of implementation:
-- ACS Division of Advocacy and Health Policy: www.facs.org/ahp/index.html
-- EHR: www.facs.org/ahp/ehr/index.html
-- eRx: www.facs.org/ahp/erx.html; www.facs.org/ahp/erx-exemption.pdf
-- PQRS: www.facs.org/ahp/pqri/index.html
However, "if you get into this, you will need to have someone in your group really spend some time with it," Dr. Detmer cautioned. In addition, he noted that there can be long waits for installation of popular products, which surgeons need to keep in mind while considering when the EHRs need to be operational to avoid CMS penalties.
In general, institutions are much further ahead on EHRs than are surgeons practicing solo or in small groups, Dr. Detmer said. "Most people who are in an institution or large system are typically well into this at this point," he said. "If they haven't made the move to [electronic] order entry, they're doing it right now."
In institution-wide efforts involving multiple specialties, "surgeons don't necessarily have to lead, but surgeons will need a champion as part of the process," he added.
With the new subspecialty certification in medical informatics now available, "there really is a need for some young surgeons to decide they need to be part surgeon, part informatician," Dr. Detmer said. "We have some good surgeons involved in this, but not the numbers we need."
Early Returns: ACOs Improve Management of Patient Populations, Offer Short-Term Savings
Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.
When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”
By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.
Keys to Success
In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.
—David Arredondo, MD, executive medical director, Presbyterian Medical Group, Albuquerque, N.M.
All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.
“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”
Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.
“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.
If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”
Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.
“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.
—Greg Sheff, MD, president, chief medical officer, Seton Health Alliance, Austin, Texas
“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)
No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.
“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”
Bryn Nelson is a freelance medical writer in Seattle.
Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.
When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”
By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.
Keys to Success
In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.
—David Arredondo, MD, executive medical director, Presbyterian Medical Group, Albuquerque, N.M.
All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.
“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”
Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.
“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.
If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”
Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.
“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.
—Greg Sheff, MD, president, chief medical officer, Seton Health Alliance, Austin, Texas
“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)
No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.
“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”
Bryn Nelson is a freelance medical writer in Seattle.
Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.
When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”
By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.
Keys to Success
In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.
—David Arredondo, MD, executive medical director, Presbyterian Medical Group, Albuquerque, N.M.
All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.
“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”
Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.
“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.
If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”
Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.
“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.
—Greg Sheff, MD, president, chief medical officer, Seton Health Alliance, Austin, Texas
“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)
No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.
“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”
Bryn Nelson is a freelance medical writer in Seattle.
CMS Releases TAVR Coverage Decision
Medicare will cover transcatheter aortic valve replacement, or TAVR, under certain conditions, including the presence of a heart team during the procedure and evaluation of the patient by two cardiac surgeons, according to an official document released on May 1.
The Centers for Medicare and Medicaid Services’ (CMS) final national coverage decision for TAVR arrives as planned, nearly 3 months after the agency released its coverage proposal.
"This decision is particularly important as it highlights cooperative efforts among CMS, the Food and Drug Administration (FDA), the Agency for Healthcare Research and Quality, medical societies, and the medical device industry," said CMS Acting Administrator Marilyn Tavenner in a statement.
Because TAVR is relatively new, the final decision uses "coverage with evidence development," meaning certain criteria must be met as a condition of coverage, according to the statement.
The criteria outlined by CMS include:
• Two cardiac surgeons independently examine the patient face-to-face and evaluate the patient’s suitability for open valve replacement surgery.
• Before and after the surgery, the patient is under the care of a heart team, which is "a cohesive, multidisciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care," according to the decision document. The document breaks down these criteria by centers with or without previous TAVR clinical trial experience.
• The heart team’s interventional cardiologist(s) and cardiac surgeon(s) must work together on the intraoperative technical aspects of TAVR.
• The heart team and hospital are also participating in a prospective, national, audited registry.
The agency will cover the procedure in clinical trials that follow criteria listed in the decision memo.
Meanwhile, Medicare patients whose comorbidities would prevent them from benefiting from the procedure will not be covered.
CMS also responded to comments, making some changes.
For instance, 23 commenters had disagreed with the requirement that unlabeled uses of TAVR be covered in clinical studies that have superiority designs. Eight had requested that CMS remove the requirement, according to CMS’s final decision memo.
Among those commenters was Edwards Lifesciences, the maker of the Sapien valve.
"CMS’s proposed requirement limiting coverage for unlabeled uses to ‘superiority trials’ undermines the agency’s efforts to promote continued U.S.-based clinical investigations in Medicare beneficiaries aimed at better understanding key determinants of health and quality of life outcomes," according to Edwards’ comments.
"Noninferiority and other clinical trial designs play an important role in the advancement of medical technology," the company added, saying that if the proposed conditions aren’t revised, important, yet relatively small, patient populations may not be able to receive treatment.
Removing the requirement, CMS explained in its final decision memo that "while we believe superiority trial designs provide important advantages that are not completely addressed by non-inferiority design, we recognize that non-inferiority trials have a place in the conduct of medical device regulatory trials.
"Therefore, we believe a broad non-coverage of non-inferiority trials may have unintended consequences for certain important studies."
CMS opened the national coverage determination analysis in September 2011, before the Edwards Lifesciences Sapien valve was approved, in response to a request from the Society of Thoracic Surgeons and the American College of Cardiology to establish the criteria for national Medicare coverage of the minimally invasive valve procedure.
In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011 for use in inoperable patients with severe aortic stenosis.
The FDA’s Circulatory System Devices Panel will be meeting in order to evaluate the Sapien valve’s performance in severe aortic stenosis patients who are at high surgical risk for use in this application on June 13. Medtronic’s CoreValve is also in being studied in large U.S. trials.
Medicare will cover transcatheter aortic valve replacement, or TAVR, under certain conditions, including the presence of a heart team during the procedure and evaluation of the patient by two cardiac surgeons, according to an official document released on May 1.
The Centers for Medicare and Medicaid Services’ (CMS) final national coverage decision for TAVR arrives as planned, nearly 3 months after the agency released its coverage proposal.
"This decision is particularly important as it highlights cooperative efforts among CMS, the Food and Drug Administration (FDA), the Agency for Healthcare Research and Quality, medical societies, and the medical device industry," said CMS Acting Administrator Marilyn Tavenner in a statement.
Because TAVR is relatively new, the final decision uses "coverage with evidence development," meaning certain criteria must be met as a condition of coverage, according to the statement.
The criteria outlined by CMS include:
• Two cardiac surgeons independently examine the patient face-to-face and evaluate the patient’s suitability for open valve replacement surgery.
• Before and after the surgery, the patient is under the care of a heart team, which is "a cohesive, multidisciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care," according to the decision document. The document breaks down these criteria by centers with or without previous TAVR clinical trial experience.
• The heart team’s interventional cardiologist(s) and cardiac surgeon(s) must work together on the intraoperative technical aspects of TAVR.
• The heart team and hospital are also participating in a prospective, national, audited registry.
The agency will cover the procedure in clinical trials that follow criteria listed in the decision memo.
Meanwhile, Medicare patients whose comorbidities would prevent them from benefiting from the procedure will not be covered.
CMS also responded to comments, making some changes.
For instance, 23 commenters had disagreed with the requirement that unlabeled uses of TAVR be covered in clinical studies that have superiority designs. Eight had requested that CMS remove the requirement, according to CMS’s final decision memo.
Among those commenters was Edwards Lifesciences, the maker of the Sapien valve.
"CMS’s proposed requirement limiting coverage for unlabeled uses to ‘superiority trials’ undermines the agency’s efforts to promote continued U.S.-based clinical investigations in Medicare beneficiaries aimed at better understanding key determinants of health and quality of life outcomes," according to Edwards’ comments.
"Noninferiority and other clinical trial designs play an important role in the advancement of medical technology," the company added, saying that if the proposed conditions aren’t revised, important, yet relatively small, patient populations may not be able to receive treatment.
Removing the requirement, CMS explained in its final decision memo that "while we believe superiority trial designs provide important advantages that are not completely addressed by non-inferiority design, we recognize that non-inferiority trials have a place in the conduct of medical device regulatory trials.
"Therefore, we believe a broad non-coverage of non-inferiority trials may have unintended consequences for certain important studies."
CMS opened the national coverage determination analysis in September 2011, before the Edwards Lifesciences Sapien valve was approved, in response to a request from the Society of Thoracic Surgeons and the American College of Cardiology to establish the criteria for national Medicare coverage of the minimally invasive valve procedure.
In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011 for use in inoperable patients with severe aortic stenosis.
The FDA’s Circulatory System Devices Panel will be meeting in order to evaluate the Sapien valve’s performance in severe aortic stenosis patients who are at high surgical risk for use in this application on June 13. Medtronic’s CoreValve is also in being studied in large U.S. trials.
Medicare will cover transcatheter aortic valve replacement, or TAVR, under certain conditions, including the presence of a heart team during the procedure and evaluation of the patient by two cardiac surgeons, according to an official document released on May 1.
The Centers for Medicare and Medicaid Services’ (CMS) final national coverage decision for TAVR arrives as planned, nearly 3 months after the agency released its coverage proposal.
"This decision is particularly important as it highlights cooperative efforts among CMS, the Food and Drug Administration (FDA), the Agency for Healthcare Research and Quality, medical societies, and the medical device industry," said CMS Acting Administrator Marilyn Tavenner in a statement.
Because TAVR is relatively new, the final decision uses "coverage with evidence development," meaning certain criteria must be met as a condition of coverage, according to the statement.
The criteria outlined by CMS include:
• Two cardiac surgeons independently examine the patient face-to-face and evaluate the patient’s suitability for open valve replacement surgery.
• Before and after the surgery, the patient is under the care of a heart team, which is "a cohesive, multidisciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care," according to the decision document. The document breaks down these criteria by centers with or without previous TAVR clinical trial experience.
• The heart team’s interventional cardiologist(s) and cardiac surgeon(s) must work together on the intraoperative technical aspects of TAVR.
• The heart team and hospital are also participating in a prospective, national, audited registry.
The agency will cover the procedure in clinical trials that follow criteria listed in the decision memo.
Meanwhile, Medicare patients whose comorbidities would prevent them from benefiting from the procedure will not be covered.
CMS also responded to comments, making some changes.
For instance, 23 commenters had disagreed with the requirement that unlabeled uses of TAVR be covered in clinical studies that have superiority designs. Eight had requested that CMS remove the requirement, according to CMS’s final decision memo.
Among those commenters was Edwards Lifesciences, the maker of the Sapien valve.
"CMS’s proposed requirement limiting coverage for unlabeled uses to ‘superiority trials’ undermines the agency’s efforts to promote continued U.S.-based clinical investigations in Medicare beneficiaries aimed at better understanding key determinants of health and quality of life outcomes," according to Edwards’ comments.
"Noninferiority and other clinical trial designs play an important role in the advancement of medical technology," the company added, saying that if the proposed conditions aren’t revised, important, yet relatively small, patient populations may not be able to receive treatment.
Removing the requirement, CMS explained in its final decision memo that "while we believe superiority trial designs provide important advantages that are not completely addressed by non-inferiority design, we recognize that non-inferiority trials have a place in the conduct of medical device regulatory trials.
"Therefore, we believe a broad non-coverage of non-inferiority trials may have unintended consequences for certain important studies."
CMS opened the national coverage determination analysis in September 2011, before the Edwards Lifesciences Sapien valve was approved, in response to a request from the Society of Thoracic Surgeons and the American College of Cardiology to establish the criteria for national Medicare coverage of the minimally invasive valve procedure.
In the United States, the first valve to be used for TAVR (the Edwards Lifesciences Sapien valve) was approved in November 2011 for use in inoperable patients with severe aortic stenosis.
The FDA’s Circulatory System Devices Panel will be meeting in order to evaluate the Sapien valve’s performance in severe aortic stenosis patients who are at high surgical risk for use in this application on June 13. Medtronic’s CoreValve is also in being studied in large U.S. trials.
States Adopt Health Reform
Two years into the Affordable Care Act, almost every state in the union has implemented at least one item from the law’s early market reforms, the Patient’s Bill of Rights, an analysis from the Commonwealth Fund has found. Of the 49 states that have taken some action, 23 (and the District of Columbia) passed legislation or enacted regulations addressing at least one of the reforms. Twelve states addressed all reforms. An additional 15 issued guidance for insurers, and 11 states took no action but reported that regulators were reviewing insurers’ policy forms for compliance with reforms. Only Arizona has done nothing to enact ACA reforms
"The vast majority of states have been very busy on health reform, at least on these early market reforms,"said Katie Keith, lead author of the analysis in an interview.
As the law currently stands, if states don’t implement the Patient’s Bill of Rights by Jan. 1, 2014, the federal government will do it for them. States that have not acted on these ACA reforms already may have stronger patient protections or their laws already may allow ACA enforcement.
–Frances Correa
Two years into the Affordable Care Act, almost every state in the union has implemented at least one item from the law’s early market reforms, the Patient’s Bill of Rights, an analysis from the Commonwealth Fund has found. Of the 49 states that have taken some action, 23 (and the District of Columbia) passed legislation or enacted regulations addressing at least one of the reforms. Twelve states addressed all reforms. An additional 15 issued guidance for insurers, and 11 states took no action but reported that regulators were reviewing insurers’ policy forms for compliance with reforms. Only Arizona has done nothing to enact ACA reforms
"The vast majority of states have been very busy on health reform, at least on these early market reforms,"said Katie Keith, lead author of the analysis in an interview.
As the law currently stands, if states don’t implement the Patient’s Bill of Rights by Jan. 1, 2014, the federal government will do it for them. States that have not acted on these ACA reforms already may have stronger patient protections or their laws already may allow ACA enforcement.
–Frances Correa
Two years into the Affordable Care Act, almost every state in the union has implemented at least one item from the law’s early market reforms, the Patient’s Bill of Rights, an analysis from the Commonwealth Fund has found. Of the 49 states that have taken some action, 23 (and the District of Columbia) passed legislation or enacted regulations addressing at least one of the reforms. Twelve states addressed all reforms. An additional 15 issued guidance for insurers, and 11 states took no action but reported that regulators were reviewing insurers’ policy forms for compliance with reforms. Only Arizona has done nothing to enact ACA reforms
"The vast majority of states have been very busy on health reform, at least on these early market reforms,"said Katie Keith, lead author of the analysis in an interview.
As the law currently stands, if states don’t implement the Patient’s Bill of Rights by Jan. 1, 2014, the federal government will do it for them. States that have not acted on these ACA reforms already may have stronger patient protections or their laws already may allow ACA enforcement.
–Frances Correa
Establish a Social Media Policy
Physicians who opt out of social media risk losing control of their reputations to a certain extent, according to Dr. Danielle S. Walsh.
"People are creating accounts and information about you whether you do it or not. Google your name and I promise you will find something there. You can either contribute to this and police what’s said about you and add to that information, or you can let everyone else do it for you," Dr. Walsh said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.
If you choose to become a social media player, one of the best ways to protect yourself from a legal standpoint is to establish a social media policy, said Dr. Walsh, an ACS Fellow in the division of pediatric surgery at the Brody School of Medicine at East Carolina University, Greenville, N.C. "You want to ensure that you can place accurate information on there and correct any inaccuracies that are posted to your site. You also want to give guidance to employees who already use or want to use social media appropriately," she explained.
Templates of social media policies can be found at www.SocialMediaGovernance.com, and the American Medical Association’s guidelines for professionalism in the use of social media can be seen at www.ama-assn.org/ama/pubmeeting/professionalism-social- media.html.
As you devise a policy, identify all of the involved parties, including your information technology department if you have one, the risk management team of your employer or your hospital, and the legal department and administrative leaders of your institution. "Make sure they all have an opportunity to review what you’re about to do, why you’re doing it; and get their feedback," she advised. Next, decide who will have ultimate ownership and oversight of the social media sites you plan to launch. She offered five "Ws" to include:
• Who it applies to and who manages the content.
• What types of information/statements are covered by the policy, including legal issues.
• Where it applies, that is, whether it applies to computers used at home, in the workplace, or both.
• When to bring information to top-level managers (e.g., in cases of threats of harm to office staff or patients, complaints about the practice, or privacy violations).
• Why it’s important: Your guidelines should be designed to keep you out of legal trouble.
She emphasized the importance of protecting patient privacy online and noted that physicians’ identities can be traced through posts referring to patients, even if physicians omit their names. "If they know where you work and you describe a patient scenario, or if you post a photograph, and a story about that person eventually hits the media, they can go back and put the pieces together and identify you," she said. If a patient posts a complaint about you or your practice, a carefully worded response can offset negativity, Dr. Walsh said, by showing that you care and that you are responding in a proactive way.
Dr. Walsh said that she had no relevant financial disclosures.
–Doug Brunk
Physicians who opt out of social media risk losing control of their reputations to a certain extent, according to Dr. Danielle S. Walsh.
"People are creating accounts and information about you whether you do it or not. Google your name and I promise you will find something there. You can either contribute to this and police what’s said about you and add to that information, or you can let everyone else do it for you," Dr. Walsh said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.
If you choose to become a social media player, one of the best ways to protect yourself from a legal standpoint is to establish a social media policy, said Dr. Walsh, an ACS Fellow in the division of pediatric surgery at the Brody School of Medicine at East Carolina University, Greenville, N.C. "You want to ensure that you can place accurate information on there and correct any inaccuracies that are posted to your site. You also want to give guidance to employees who already use or want to use social media appropriately," she explained.
Templates of social media policies can be found at www.SocialMediaGovernance.com, and the American Medical Association’s guidelines for professionalism in the use of social media can be seen at www.ama-assn.org/ama/pubmeeting/professionalism-social- media.html.
As you devise a policy, identify all of the involved parties, including your information technology department if you have one, the risk management team of your employer or your hospital, and the legal department and administrative leaders of your institution. "Make sure they all have an opportunity to review what you’re about to do, why you’re doing it; and get their feedback," she advised. Next, decide who will have ultimate ownership and oversight of the social media sites you plan to launch. She offered five "Ws" to include:
• Who it applies to and who manages the content.
• What types of information/statements are covered by the policy, including legal issues.
• Where it applies, that is, whether it applies to computers used at home, in the workplace, or both.
• When to bring information to top-level managers (e.g., in cases of threats of harm to office staff or patients, complaints about the practice, or privacy violations).
• Why it’s important: Your guidelines should be designed to keep you out of legal trouble.
She emphasized the importance of protecting patient privacy online and noted that physicians’ identities can be traced through posts referring to patients, even if physicians omit their names. "If they know where you work and you describe a patient scenario, or if you post a photograph, and a story about that person eventually hits the media, they can go back and put the pieces together and identify you," she said. If a patient posts a complaint about you or your practice, a carefully worded response can offset negativity, Dr. Walsh said, by showing that you care and that you are responding in a proactive way.
Dr. Walsh said that she had no relevant financial disclosures.
–Doug Brunk
Physicians who opt out of social media risk losing control of their reputations to a certain extent, according to Dr. Danielle S. Walsh.
"People are creating accounts and information about you whether you do it or not. Google your name and I promise you will find something there. You can either contribute to this and police what’s said about you and add to that information, or you can let everyone else do it for you," Dr. Walsh said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.
If you choose to become a social media player, one of the best ways to protect yourself from a legal standpoint is to establish a social media policy, said Dr. Walsh, an ACS Fellow in the division of pediatric surgery at the Brody School of Medicine at East Carolina University, Greenville, N.C. "You want to ensure that you can place accurate information on there and correct any inaccuracies that are posted to your site. You also want to give guidance to employees who already use or want to use social media appropriately," she explained.
Templates of social media policies can be found at www.SocialMediaGovernance.com, and the American Medical Association’s guidelines for professionalism in the use of social media can be seen at www.ama-assn.org/ama/pubmeeting/professionalism-social- media.html.
As you devise a policy, identify all of the involved parties, including your information technology department if you have one, the risk management team of your employer or your hospital, and the legal department and administrative leaders of your institution. "Make sure they all have an opportunity to review what you’re about to do, why you’re doing it; and get their feedback," she advised. Next, decide who will have ultimate ownership and oversight of the social media sites you plan to launch. She offered five "Ws" to include:
• Who it applies to and who manages the content.
• What types of information/statements are covered by the policy, including legal issues.
• Where it applies, that is, whether it applies to computers used at home, in the workplace, or both.
• When to bring information to top-level managers (e.g., in cases of threats of harm to office staff or patients, complaints about the practice, or privacy violations).
• Why it’s important: Your guidelines should be designed to keep you out of legal trouble.
She emphasized the importance of protecting patient privacy online and noted that physicians’ identities can be traced through posts referring to patients, even if physicians omit their names. "If they know where you work and you describe a patient scenario, or if you post a photograph, and a story about that person eventually hits the media, they can go back and put the pieces together and identify you," she said. If a patient posts a complaint about you or your practice, a carefully worded response can offset negativity, Dr. Walsh said, by showing that you care and that you are responding in a proactive way.
Dr. Walsh said that she had no relevant financial disclosures.
–Doug Brunk
Want to Participate in Social Media? #GOFORIT
SAN DIEGO – Facebook, Twitter, and other social media have their rightful place in surgeons’ busy schedules, according to several surgeons who participated in a social media symposium at the annual meeting. of the Society of American Gastrointestinal and Endoscopic Surgeons.
In fact, these media just might help you land your dream job, raise money, screen applicants to your fellowship program, enhance communication with your peers, or strengthen relationships with your patients.
Dr. Gretchen Purcell Jackson noted that 61% of adults in the United States look online for health information. In addition, 41% of patients have read a commentary or shared experiences about health or medical issues in an online news group, website, or blog; 24% of online patients have consulted rankings or reviews of physicians, providers, and hospitals; 60% of active online patients report that using the Web affected a medical decision; and more than 700 hospitals currently use social networking tools.
"People seek and give advice about their health care concerns, they seek and share information about medical problems, and they share stories about their health care experiences. Some people use social media to raise money for health-related causes. Patients are using social media in a wide variety of ways, and they might be talking about you," said Dr. Jackson, assistant professor of surgery at Vanderbilt University, Nashville, Tenn.
Facebook has 845 million active users making over 1 billion posts per day, while Twitter has more than 465 million accounts, growing by 11 accounts per second. Facebook is used by 64% of surgeons, compared with 42% of the general population in the United States, according to Dr. Kiran K. Turaga.
"As usual, we surgeons are ahead of the curve, but Facebook has unique characteristics that can affect every single aspect of our lives," said Dr. Turaga, assistant professor of surgery at the Medical College of Wisconsin, Milwaukee.
"In terms of trainees, it can affect medical student and resident education, and it can affect recruitment. For patients, you can use this for fund-raising, marketing, forming support groups, increasing awareness [about an aspect of health], recruiting for clinical trials, and monitoring for diseases."
More than 95% of U.S. medical schools have a Facebook presence, Dr. Turaga said, and 71% of these have active student group accounts. In addition, 70% of medical students have active individual Facebook accounts. However, 60% of medical schools have reported incidents of students posting unprofessional content, including profanity (in 52% of cases), breach of patient confidentiality (in 13% of cases), or photos of themselves in a state of intoxication (in 39% of cases) (JAMA 2009;302:1309-15).
Through a sister organization known as Causes (www.causes.com), Facebook has 170 million users who have generated $40 million for 27,000 not-for-profit groups, including hospitals. This makes Facebook "a remarkable tool for fund-raising," Dr. Turaga said. "This could be as simple as raising $1,000 for a new east wing in your hospital."
Furthermore, he said, creating an ad on Facebook allows you to reach 19 million people with an interest in cancer, 600,000 people with an interest in surgery, and 5,000 people with an interest in laparoscopy.
Facebook also offers physicians unique opportunities for peer-to-peer interaction by providing a platform for online consultations, virtual tumor boards, journals and summaries of medical news and blogs, and discussions of health care reform and other topics of interest. There are currently 757 Facebook health groups with 300,000 members, he said.
Dr. Turaga warned that posting recognizable patient information on Facebook or other social media channels can violate the Health Insurance Portability and Accountability Act, state criminal laws regarding patient health information, state licensure laws, state professional misconduct laws, and standards set by the Joint Commission.
"If you are considering posting any information that is patient specific, make sure you have exclusive consent of the patient," he said.
"The other thing to consider is unnecessary patient-provider interaction, which would mean that you start engaging in a relationship with a patient in which you start giving advice. Then you become liable for that advice, so there can be medical-legal consequences."
Before you start using Facebook or other social media, he recommends considering the acronym POST, which stands for people (whom do you want to target with your social media?), objectives (why do you want to target them?), strategy (how are you going to target them?), and technology (which social media will you use to do so?).
Twitter, a microblogging site that allows communication by posts of no more than 140 characters in length, is an open platform of communication rather than a closed platform, explained Dr. Niraj J. Gusani.
"This adds a level of complexity – and possibly risk – that may make this medium less ideal for health care professional use. Anything that you post can be seen by anyone in the world at any time. There’s no filter. On the other hand, Twitter has a wide reach, and it’s easy for people to find you," said Dr. Gusani, assistant professor of surgery, medicine, and public health sciences at Pennsylvania State University, Hershey.
A recent survey of 315 members of the American College of Surgeons found that 79% never use Twitter, while 6% use it daily and 3% use it weekly (Bull. Am. Coll. Surg. 2011;96:46-8). In Dr. Gusani’s opinion, surgeons can use Twitter to update the public about the latest news, events, and research highlights; respond to other tweets related to their field, area of research, or organization; participate in tweet chats or Q&A sessions; and tweet highlights from professional events and meetings.
While some clinicians use Twitter for patient contact and marketing, Dr. Gusani cautioned that it’s important to be wary of violating patient confidentiality. A review of 260 physician Twitter accounts revealed that 144 of 5,156 tweets (3%) were categorized as unprofessional (JAMA 2011;305:566-8).
Of these, 38 (0.7%) represented potential patient privacy violations and 33 (0.6%) contained profanity.
Dr. Gusani said that he uses Twitter to "push information, studies, and observations related mainly to oncology and surgical oncology patient education. I post perspectives about medical news and occasional retweets."
Twitter-based resources and chats recommended by Dr. Gusani include #twitJP, a journal club; #hcsm, a global health care chat that takes place at 9 p.m. ET every Sunday; #CMEchat, which takes place every Wednesday at 11 a.m. ET; and #Meded chat, which takes place every Thursday at 4 p.m. and 9 p.m. ET.
Dr. Seung S. Gwon spoke about the potential benefits of LinkedIn, a professional networking site that allows users to strengthen and expand their network of contacts. It currently has more than 15 million members in more than 200 countries and territories, including 44 million-plus members in the United States alone.
"The best part about LinkedIn is that it only takes a few minutes to set up your online profile, where you might list your experience, education, and accomplishments," said Dr. Gwon, a surgeon at El Centro (Calif.) Regional Medical Center.
The overall purpose is to connect to other users and build a network of trusted contacts, including personal e-mail contacts, professional colleagues, coworkers, and former classmates.
"There’s some discussion as to whether or not you should allow your Facebook contacts to be a part of LinkedIn," she said. "If you have separate business and personal Facebook accounts, that would be all right, but they highly discourage you from allowing your social contacts onto a professional network." Active participation on the site typically involves joining groups such as your alma mater or the medical institution you work for, participating in discussion boards, and writing and soliciting recommendations.
Dr. Gwon said that physicians have been slow to join LinkedIn because it doesn’t allow them to directly connect with their patients. "However, it does provide you with a digital footprint, so if patients want to look, they can," she said.
"Also, a lot of people feel there is no value to networking if they’re already employed. If you like your job and you like where you are, there’s no reason to set up a big profile, primarily because most physicians work in a narrowly defined geography and we don’t really see the need to sell ourselves.
"We rely on word-of-mouth, the reputations that we create in our communities, [and] physicians who refer patients to us." Even so, she advises physicians to consider joining LinkedIn because it improves Google search rankings, and is a cost-effective, efficient means to maintain professional relationships.
The symposium was supported by an educational grant from Stryker Endoscopy. None of the speakers had relevant financial conflicts to disclose.
SAN DIEGO – Facebook, Twitter, and other social media have their rightful place in surgeons’ busy schedules, according to several surgeons who participated in a social media symposium at the annual meeting. of the Society of American Gastrointestinal and Endoscopic Surgeons.
In fact, these media just might help you land your dream job, raise money, screen applicants to your fellowship program, enhance communication with your peers, or strengthen relationships with your patients.
Dr. Gretchen Purcell Jackson noted that 61% of adults in the United States look online for health information. In addition, 41% of patients have read a commentary or shared experiences about health or medical issues in an online news group, website, or blog; 24% of online patients have consulted rankings or reviews of physicians, providers, and hospitals; 60% of active online patients report that using the Web affected a medical decision; and more than 700 hospitals currently use social networking tools.
"People seek and give advice about their health care concerns, they seek and share information about medical problems, and they share stories about their health care experiences. Some people use social media to raise money for health-related causes. Patients are using social media in a wide variety of ways, and they might be talking about you," said Dr. Jackson, assistant professor of surgery at Vanderbilt University, Nashville, Tenn.
Facebook has 845 million active users making over 1 billion posts per day, while Twitter has more than 465 million accounts, growing by 11 accounts per second. Facebook is used by 64% of surgeons, compared with 42% of the general population in the United States, according to Dr. Kiran K. Turaga.
"As usual, we surgeons are ahead of the curve, but Facebook has unique characteristics that can affect every single aspect of our lives," said Dr. Turaga, assistant professor of surgery at the Medical College of Wisconsin, Milwaukee.
"In terms of trainees, it can affect medical student and resident education, and it can affect recruitment. For patients, you can use this for fund-raising, marketing, forming support groups, increasing awareness [about an aspect of health], recruiting for clinical trials, and monitoring for diseases."
More than 95% of U.S. medical schools have a Facebook presence, Dr. Turaga said, and 71% of these have active student group accounts. In addition, 70% of medical students have active individual Facebook accounts. However, 60% of medical schools have reported incidents of students posting unprofessional content, including profanity (in 52% of cases), breach of patient confidentiality (in 13% of cases), or photos of themselves in a state of intoxication (in 39% of cases) (JAMA 2009;302:1309-15).
Through a sister organization known as Causes (www.causes.com), Facebook has 170 million users who have generated $40 million for 27,000 not-for-profit groups, including hospitals. This makes Facebook "a remarkable tool for fund-raising," Dr. Turaga said. "This could be as simple as raising $1,000 for a new east wing in your hospital."
Furthermore, he said, creating an ad on Facebook allows you to reach 19 million people with an interest in cancer, 600,000 people with an interest in surgery, and 5,000 people with an interest in laparoscopy.
Facebook also offers physicians unique opportunities for peer-to-peer interaction by providing a platform for online consultations, virtual tumor boards, journals and summaries of medical news and blogs, and discussions of health care reform and other topics of interest. There are currently 757 Facebook health groups with 300,000 members, he said.
Dr. Turaga warned that posting recognizable patient information on Facebook or other social media channels can violate the Health Insurance Portability and Accountability Act, state criminal laws regarding patient health information, state licensure laws, state professional misconduct laws, and standards set by the Joint Commission.
"If you are considering posting any information that is patient specific, make sure you have exclusive consent of the patient," he said.
"The other thing to consider is unnecessary patient-provider interaction, which would mean that you start engaging in a relationship with a patient in which you start giving advice. Then you become liable for that advice, so there can be medical-legal consequences."
Before you start using Facebook or other social media, he recommends considering the acronym POST, which stands for people (whom do you want to target with your social media?), objectives (why do you want to target them?), strategy (how are you going to target them?), and technology (which social media will you use to do so?).
Twitter, a microblogging site that allows communication by posts of no more than 140 characters in length, is an open platform of communication rather than a closed platform, explained Dr. Niraj J. Gusani.
"This adds a level of complexity – and possibly risk – that may make this medium less ideal for health care professional use. Anything that you post can be seen by anyone in the world at any time. There’s no filter. On the other hand, Twitter has a wide reach, and it’s easy for people to find you," said Dr. Gusani, assistant professor of surgery, medicine, and public health sciences at Pennsylvania State University, Hershey.
A recent survey of 315 members of the American College of Surgeons found that 79% never use Twitter, while 6% use it daily and 3% use it weekly (Bull. Am. Coll. Surg. 2011;96:46-8). In Dr. Gusani’s opinion, surgeons can use Twitter to update the public about the latest news, events, and research highlights; respond to other tweets related to their field, area of research, or organization; participate in tweet chats or Q&A sessions; and tweet highlights from professional events and meetings.
While some clinicians use Twitter for patient contact and marketing, Dr. Gusani cautioned that it’s important to be wary of violating patient confidentiality. A review of 260 physician Twitter accounts revealed that 144 of 5,156 tweets (3%) were categorized as unprofessional (JAMA 2011;305:566-8).
Of these, 38 (0.7%) represented potential patient privacy violations and 33 (0.6%) contained profanity.
Dr. Gusani said that he uses Twitter to "push information, studies, and observations related mainly to oncology and surgical oncology patient education. I post perspectives about medical news and occasional retweets."
Twitter-based resources and chats recommended by Dr. Gusani include #twitJP, a journal club; #hcsm, a global health care chat that takes place at 9 p.m. ET every Sunday; #CMEchat, which takes place every Wednesday at 11 a.m. ET; and #Meded chat, which takes place every Thursday at 4 p.m. and 9 p.m. ET.
Dr. Seung S. Gwon spoke about the potential benefits of LinkedIn, a professional networking site that allows users to strengthen and expand their network of contacts. It currently has more than 15 million members in more than 200 countries and territories, including 44 million-plus members in the United States alone.
"The best part about LinkedIn is that it only takes a few minutes to set up your online profile, where you might list your experience, education, and accomplishments," said Dr. Gwon, a surgeon at El Centro (Calif.) Regional Medical Center.
The overall purpose is to connect to other users and build a network of trusted contacts, including personal e-mail contacts, professional colleagues, coworkers, and former classmates.
"There’s some discussion as to whether or not you should allow your Facebook contacts to be a part of LinkedIn," she said. "If you have separate business and personal Facebook accounts, that would be all right, but they highly discourage you from allowing your social contacts onto a professional network." Active participation on the site typically involves joining groups such as your alma mater or the medical institution you work for, participating in discussion boards, and writing and soliciting recommendations.
Dr. Gwon said that physicians have been slow to join LinkedIn because it doesn’t allow them to directly connect with their patients. "However, it does provide you with a digital footprint, so if patients want to look, they can," she said.
"Also, a lot of people feel there is no value to networking if they’re already employed. If you like your job and you like where you are, there’s no reason to set up a big profile, primarily because most physicians work in a narrowly defined geography and we don’t really see the need to sell ourselves.
"We rely on word-of-mouth, the reputations that we create in our communities, [and] physicians who refer patients to us." Even so, she advises physicians to consider joining LinkedIn because it improves Google search rankings, and is a cost-effective, efficient means to maintain professional relationships.
The symposium was supported by an educational grant from Stryker Endoscopy. None of the speakers had relevant financial conflicts to disclose.
SAN DIEGO – Facebook, Twitter, and other social media have their rightful place in surgeons’ busy schedules, according to several surgeons who participated in a social media symposium at the annual meeting. of the Society of American Gastrointestinal and Endoscopic Surgeons.
In fact, these media just might help you land your dream job, raise money, screen applicants to your fellowship program, enhance communication with your peers, or strengthen relationships with your patients.
Dr. Gretchen Purcell Jackson noted that 61% of adults in the United States look online for health information. In addition, 41% of patients have read a commentary or shared experiences about health or medical issues in an online news group, website, or blog; 24% of online patients have consulted rankings or reviews of physicians, providers, and hospitals; 60% of active online patients report that using the Web affected a medical decision; and more than 700 hospitals currently use social networking tools.
"People seek and give advice about their health care concerns, they seek and share information about medical problems, and they share stories about their health care experiences. Some people use social media to raise money for health-related causes. Patients are using social media in a wide variety of ways, and they might be talking about you," said Dr. Jackson, assistant professor of surgery at Vanderbilt University, Nashville, Tenn.
Facebook has 845 million active users making over 1 billion posts per day, while Twitter has more than 465 million accounts, growing by 11 accounts per second. Facebook is used by 64% of surgeons, compared with 42% of the general population in the United States, according to Dr. Kiran K. Turaga.
"As usual, we surgeons are ahead of the curve, but Facebook has unique characteristics that can affect every single aspect of our lives," said Dr. Turaga, assistant professor of surgery at the Medical College of Wisconsin, Milwaukee.
"In terms of trainees, it can affect medical student and resident education, and it can affect recruitment. For patients, you can use this for fund-raising, marketing, forming support groups, increasing awareness [about an aspect of health], recruiting for clinical trials, and monitoring for diseases."
More than 95% of U.S. medical schools have a Facebook presence, Dr. Turaga said, and 71% of these have active student group accounts. In addition, 70% of medical students have active individual Facebook accounts. However, 60% of medical schools have reported incidents of students posting unprofessional content, including profanity (in 52% of cases), breach of patient confidentiality (in 13% of cases), or photos of themselves in a state of intoxication (in 39% of cases) (JAMA 2009;302:1309-15).
Through a sister organization known as Causes (www.causes.com), Facebook has 170 million users who have generated $40 million for 27,000 not-for-profit groups, including hospitals. This makes Facebook "a remarkable tool for fund-raising," Dr. Turaga said. "This could be as simple as raising $1,000 for a new east wing in your hospital."
Furthermore, he said, creating an ad on Facebook allows you to reach 19 million people with an interest in cancer, 600,000 people with an interest in surgery, and 5,000 people with an interest in laparoscopy.
Facebook also offers physicians unique opportunities for peer-to-peer interaction by providing a platform for online consultations, virtual tumor boards, journals and summaries of medical news and blogs, and discussions of health care reform and other topics of interest. There are currently 757 Facebook health groups with 300,000 members, he said.
Dr. Turaga warned that posting recognizable patient information on Facebook or other social media channels can violate the Health Insurance Portability and Accountability Act, state criminal laws regarding patient health information, state licensure laws, state professional misconduct laws, and standards set by the Joint Commission.
"If you are considering posting any information that is patient specific, make sure you have exclusive consent of the patient," he said.
"The other thing to consider is unnecessary patient-provider interaction, which would mean that you start engaging in a relationship with a patient in which you start giving advice. Then you become liable for that advice, so there can be medical-legal consequences."
Before you start using Facebook or other social media, he recommends considering the acronym POST, which stands for people (whom do you want to target with your social media?), objectives (why do you want to target them?), strategy (how are you going to target them?), and technology (which social media will you use to do so?).
Twitter, a microblogging site that allows communication by posts of no more than 140 characters in length, is an open platform of communication rather than a closed platform, explained Dr. Niraj J. Gusani.
"This adds a level of complexity – and possibly risk – that may make this medium less ideal for health care professional use. Anything that you post can be seen by anyone in the world at any time. There’s no filter. On the other hand, Twitter has a wide reach, and it’s easy for people to find you," said Dr. Gusani, assistant professor of surgery, medicine, and public health sciences at Pennsylvania State University, Hershey.
A recent survey of 315 members of the American College of Surgeons found that 79% never use Twitter, while 6% use it daily and 3% use it weekly (Bull. Am. Coll. Surg. 2011;96:46-8). In Dr. Gusani’s opinion, surgeons can use Twitter to update the public about the latest news, events, and research highlights; respond to other tweets related to their field, area of research, or organization; participate in tweet chats or Q&A sessions; and tweet highlights from professional events and meetings.
While some clinicians use Twitter for patient contact and marketing, Dr. Gusani cautioned that it’s important to be wary of violating patient confidentiality. A review of 260 physician Twitter accounts revealed that 144 of 5,156 tweets (3%) were categorized as unprofessional (JAMA 2011;305:566-8).
Of these, 38 (0.7%) represented potential patient privacy violations and 33 (0.6%) contained profanity.
Dr. Gusani said that he uses Twitter to "push information, studies, and observations related mainly to oncology and surgical oncology patient education. I post perspectives about medical news and occasional retweets."
Twitter-based resources and chats recommended by Dr. Gusani include #twitJP, a journal club; #hcsm, a global health care chat that takes place at 9 p.m. ET every Sunday; #CMEchat, which takes place every Wednesday at 11 a.m. ET; and #Meded chat, which takes place every Thursday at 4 p.m. and 9 p.m. ET.
Dr. Seung S. Gwon spoke about the potential benefits of LinkedIn, a professional networking site that allows users to strengthen and expand their network of contacts. It currently has more than 15 million members in more than 200 countries and territories, including 44 million-plus members in the United States alone.
"The best part about LinkedIn is that it only takes a few minutes to set up your online profile, where you might list your experience, education, and accomplishments," said Dr. Gwon, a surgeon at El Centro (Calif.) Regional Medical Center.
The overall purpose is to connect to other users and build a network of trusted contacts, including personal e-mail contacts, professional colleagues, coworkers, and former classmates.
"There’s some discussion as to whether or not you should allow your Facebook contacts to be a part of LinkedIn," she said. "If you have separate business and personal Facebook accounts, that would be all right, but they highly discourage you from allowing your social contacts onto a professional network." Active participation on the site typically involves joining groups such as your alma mater or the medical institution you work for, participating in discussion boards, and writing and soliciting recommendations.
Dr. Gwon said that physicians have been slow to join LinkedIn because it doesn’t allow them to directly connect with their patients. "However, it does provide you with a digital footprint, so if patients want to look, they can," she said.
"Also, a lot of people feel there is no value to networking if they’re already employed. If you like your job and you like where you are, there’s no reason to set up a big profile, primarily because most physicians work in a narrowly defined geography and we don’t really see the need to sell ourselves.
"We rely on word-of-mouth, the reputations that we create in our communities, [and] physicians who refer patients to us." Even so, she advises physicians to consider joining LinkedIn because it improves Google search rankings, and is a cost-effective, efficient means to maintain professional relationships.
The symposium was supported by an educational grant from Stryker Endoscopy. None of the speakers had relevant financial conflicts to disclose.
Surgeons Wary of Advance Directives
Nearly half of U.S. surgeons who routinely perform high-risk operations do not regularly ask patients about their advance directives – also known as living wills – before proceeding with a high-risk procedure, results of a survey indicate. Perhaps more importantly, more than half of survey respondents said they would not operate if they were aware of a restrictive directive.
The findings were derived from a survey mailed to 2,100 randomly selected vascular, neurological, and cardiothoracic surgeons in 2010. Of these, 912 eligible responses were entered into analysis, with the three types of surgeons responding at about the same rate: 56% for vascular surgeons and neurosurgeons and 54% for cardiothoracic surgeons (Ann. Surg. 2012;255:418-23).
A majority of respondents (81%), however, reported having conversations about patients’ preferences for limiting the use of life-sustaining procedures postoperatively. The surgeons said they tend to view factors such as a patient’s predicted postoperative quality of life, age, comorbidities, and mental readiness as vastly more important in determining whether to operate than the existence of an advance directive, which 48% said they do not routinely confirm, according to the study’s authors, led by Dr. Margaret L. Schwarze of the University of Wisconsin, Madison.
Because most information about advance directives and the surgical decision-making process thus far has been anecdotal, she and her colleagues investigated how conversations about formal directives actually proceed in a surgical setting and their role in decision making.
A total of 54% of all surgeons who responded said that they would not operate if they knew a patient had an advance directive that might limit the postoperative options. Among cardiothoracic surgeons, who routinely rely on ventilator support as part of postoperative care, 63% said they would not operate with prior knowledge of a restrictive advance directive. Multivariate analysis showed that cardiac surgeons were almost twice as likely to operate compared with their neurosurgeon counterparts (odds ratio, 1.96) and somewhat more likely than were vascular surgeons (OR, 1.35).
Younger surgeons – those with 20 or less years of experience – were less likely to discuss advance directives regularly (44%) than were those with more than 20 years of experience (69%).
Several of the survey results strongly suggest that surgeons view advance directives as "an impediment to the goals of surgical therapy" and that they interpret them as "a signal that patients with advance directives are not truly committed to the operation and the invasive postoperative therapy the operation necessarily entails," wrote the investigators. Furthermore, surgeons "often find it difficult to shift goals when surgery does not go as planned – the result of a surgical ethos which discourages moving from a curative model to a palliative mode of care."
Dr. Schwarze and her colleagues noted that their findings raise the question of whether it is ethical for surgeons to deny a patient a procedure because of a restrictive advance directive.
However, directives are not generally designed with high-risk surgical procedures in mind. They may be vague, and can potentially create confusion in a postoperative context. Thus, the investigators concluded that communication prior to surgery is urgently needed to "clarify patient preferences with respect to the surgical endeavor and the patient’s advance directive," and that such communication should be documented.
The investigators had no relevant disclosures.
Formal written advance directives may only express the patient’s wishes in a general way. In elective circumstances, the formal directive sets the stage for deeper detailed conversation during preparations for surgery focused on the specifics of the situation the patient is facing. Many of the issues discussed by the majority of surgeons who responded to the survey reflect appropriate, thorough consideration of the goals of surgery and the risk of unexpected complications which might activate a shift in goals.
| Dr. Donaldson |
These discussions occur within the context of the surgeon and the patient and family getting to know one another well before surgery and result in informed consent to proceed. It was therefore surprising that over half of respondents said they might not have proceeded with surgery if they knew about an advance directive and that others regarded such directives as impediments. These findings may suggest that some surgeons may need to spend more time discussing the key issues with their patients who have multiple risk factors in play.
Dr. Magruder C. Donaldson is Chairman of Surgery at Metrowest Medical Center in Framingham, Mass., and an associate medical editor for Vascular Specialist.
Formal written advance directives may only express the patient’s wishes in a general way. In elective circumstances, the formal directive sets the stage for deeper detailed conversation during preparations for surgery focused on the specifics of the situation the patient is facing. Many of the issues discussed by the majority of surgeons who responded to the survey reflect appropriate, thorough consideration of the goals of surgery and the risk of unexpected complications which might activate a shift in goals.
| Dr. Donaldson |
These discussions occur within the context of the surgeon and the patient and family getting to know one another well before surgery and result in informed consent to proceed. It was therefore surprising that over half of respondents said they might not have proceeded with surgery if they knew about an advance directive and that others regarded such directives as impediments. These findings may suggest that some surgeons may need to spend more time discussing the key issues with their patients who have multiple risk factors in play.
Dr. Magruder C. Donaldson is Chairman of Surgery at Metrowest Medical Center in Framingham, Mass., and an associate medical editor for Vascular Specialist.
Formal written advance directives may only express the patient’s wishes in a general way. In elective circumstances, the formal directive sets the stage for deeper detailed conversation during preparations for surgery focused on the specifics of the situation the patient is facing. Many of the issues discussed by the majority of surgeons who responded to the survey reflect appropriate, thorough consideration of the goals of surgery and the risk of unexpected complications which might activate a shift in goals.
| Dr. Donaldson |
These discussions occur within the context of the surgeon and the patient and family getting to know one another well before surgery and result in informed consent to proceed. It was therefore surprising that over half of respondents said they might not have proceeded with surgery if they knew about an advance directive and that others regarded such directives as impediments. These findings may suggest that some surgeons may need to spend more time discussing the key issues with their patients who have multiple risk factors in play.
Dr. Magruder C. Donaldson is Chairman of Surgery at Metrowest Medical Center in Framingham, Mass., and an associate medical editor for Vascular Specialist.
Nearly half of U.S. surgeons who routinely perform high-risk operations do not regularly ask patients about their advance directives – also known as living wills – before proceeding with a high-risk procedure, results of a survey indicate. Perhaps more importantly, more than half of survey respondents said they would not operate if they were aware of a restrictive directive.
The findings were derived from a survey mailed to 2,100 randomly selected vascular, neurological, and cardiothoracic surgeons in 2010. Of these, 912 eligible responses were entered into analysis, with the three types of surgeons responding at about the same rate: 56% for vascular surgeons and neurosurgeons and 54% for cardiothoracic surgeons (Ann. Surg. 2012;255:418-23).
A majority of respondents (81%), however, reported having conversations about patients’ preferences for limiting the use of life-sustaining procedures postoperatively. The surgeons said they tend to view factors such as a patient’s predicted postoperative quality of life, age, comorbidities, and mental readiness as vastly more important in determining whether to operate than the existence of an advance directive, which 48% said they do not routinely confirm, according to the study’s authors, led by Dr. Margaret L. Schwarze of the University of Wisconsin, Madison.
Because most information about advance directives and the surgical decision-making process thus far has been anecdotal, she and her colleagues investigated how conversations about formal directives actually proceed in a surgical setting and their role in decision making.
A total of 54% of all surgeons who responded said that they would not operate if they knew a patient had an advance directive that might limit the postoperative options. Among cardiothoracic surgeons, who routinely rely on ventilator support as part of postoperative care, 63% said they would not operate with prior knowledge of a restrictive advance directive. Multivariate analysis showed that cardiac surgeons were almost twice as likely to operate compared with their neurosurgeon counterparts (odds ratio, 1.96) and somewhat more likely than were vascular surgeons (OR, 1.35).
Younger surgeons – those with 20 or less years of experience – were less likely to discuss advance directives regularly (44%) than were those with more than 20 years of experience (69%).
Several of the survey results strongly suggest that surgeons view advance directives as "an impediment to the goals of surgical therapy" and that they interpret them as "a signal that patients with advance directives are not truly committed to the operation and the invasive postoperative therapy the operation necessarily entails," wrote the investigators. Furthermore, surgeons "often find it difficult to shift goals when surgery does not go as planned – the result of a surgical ethos which discourages moving from a curative model to a palliative mode of care."
Dr. Schwarze and her colleagues noted that their findings raise the question of whether it is ethical for surgeons to deny a patient a procedure because of a restrictive advance directive.
However, directives are not generally designed with high-risk surgical procedures in mind. They may be vague, and can potentially create confusion in a postoperative context. Thus, the investigators concluded that communication prior to surgery is urgently needed to "clarify patient preferences with respect to the surgical endeavor and the patient’s advance directive," and that such communication should be documented.
The investigators had no relevant disclosures.
Nearly half of U.S. surgeons who routinely perform high-risk operations do not regularly ask patients about their advance directives – also known as living wills – before proceeding with a high-risk procedure, results of a survey indicate. Perhaps more importantly, more than half of survey respondents said they would not operate if they were aware of a restrictive directive.
The findings were derived from a survey mailed to 2,100 randomly selected vascular, neurological, and cardiothoracic surgeons in 2010. Of these, 912 eligible responses were entered into analysis, with the three types of surgeons responding at about the same rate: 56% for vascular surgeons and neurosurgeons and 54% for cardiothoracic surgeons (Ann. Surg. 2012;255:418-23).
A majority of respondents (81%), however, reported having conversations about patients’ preferences for limiting the use of life-sustaining procedures postoperatively. The surgeons said they tend to view factors such as a patient’s predicted postoperative quality of life, age, comorbidities, and mental readiness as vastly more important in determining whether to operate than the existence of an advance directive, which 48% said they do not routinely confirm, according to the study’s authors, led by Dr. Margaret L. Schwarze of the University of Wisconsin, Madison.
Because most information about advance directives and the surgical decision-making process thus far has been anecdotal, she and her colleagues investigated how conversations about formal directives actually proceed in a surgical setting and their role in decision making.
A total of 54% of all surgeons who responded said that they would not operate if they knew a patient had an advance directive that might limit the postoperative options. Among cardiothoracic surgeons, who routinely rely on ventilator support as part of postoperative care, 63% said they would not operate with prior knowledge of a restrictive advance directive. Multivariate analysis showed that cardiac surgeons were almost twice as likely to operate compared with their neurosurgeon counterparts (odds ratio, 1.96) and somewhat more likely than were vascular surgeons (OR, 1.35).
Younger surgeons – those with 20 or less years of experience – were less likely to discuss advance directives regularly (44%) than were those with more than 20 years of experience (69%).
Several of the survey results strongly suggest that surgeons view advance directives as "an impediment to the goals of surgical therapy" and that they interpret them as "a signal that patients with advance directives are not truly committed to the operation and the invasive postoperative therapy the operation necessarily entails," wrote the investigators. Furthermore, surgeons "often find it difficult to shift goals when surgery does not go as planned – the result of a surgical ethos which discourages moving from a curative model to a palliative mode of care."
Dr. Schwarze and her colleagues noted that their findings raise the question of whether it is ethical for surgeons to deny a patient a procedure because of a restrictive advance directive.
However, directives are not generally designed with high-risk surgical procedures in mind. They may be vague, and can potentially create confusion in a postoperative context. Thus, the investigators concluded that communication prior to surgery is urgently needed to "clarify patient preferences with respect to the surgical endeavor and the patient’s advance directive," and that such communication should be documented.
The investigators had no relevant disclosures.