And those most affected are African Americans, poor, uninsured and rural residents.

Researchers from the University of California, San Francisco examined changes in driving time to trauma centers, which have increasingly been shuttered in recent years. They found that by 2007, 69 million Americans — nearly one in four — had to travel farther to the nearest trauma center than they traveled in 2001.

“Trauma centers aren’t just for ‘certain’ people — if you sustain a serious injury from a car accident or fall off your roof, you need a trauma center,’’ said lead author Dr. Renee Y. Hsia, an assistant professor of emergency medicine at UCSF. She is also an attending physician in the emergency department at San Francisco General Hospital & Trauma Center and a Robert Wood Johnson Foundation Physician Faculty Scholar.

“We found evidence that vulnerable communities have less geographic access to trauma care, adding to their health disparities,’’ Hsia said in a news release. “This study will help us better understand how trauma center closures are affecting people.’’

Hsia’s research centers on illustrating inequalities in accessing trauma care as well as the decline of emergency care in the United States. She has documented that tens of millions of Americans do not have ready access to a certified trauma center, and that nearly a third of urban and suburban emergency rooms have closed in the last two decades.

Trauma services are not, as commonly believed, available in all hospitals. They are hospitals with emergency departments that provide specialty care for injured patients, regardless of ability to pay. As a result, trauma centers face greater financial jeopardy depending on the surrounding patient population.

For their new study, the researchers analyzed 31,475 ZIP codes in the United States, covering some 283 million people, nearly the entire nation.

Overall, nearly three-quarters of the U.S. lives within 10 miles of a trauma center. Of the remainder, 14 percent live more than 30 miles from a trauma center.

Communities with a higher number of residents under the federal poverty level, black residents, uninsured residents and rural residents faced longer drives compared to communities with a low share of these vulnerable populations.

For nearly 16 million people, the extra driving time amounts to about 30 minutes — a critical period for people facing life-threatening injuries such as stroke and gunshot wounds.

In 1990 there were 1,125 trauma centers in the United States; by 2005, about 30 percent of them had closed primarily because of the high costs and fewer patients able to pay the bills. The majority of closures took place in urban areas but rural communities have also been affected.

The authors recommend policy makers should subsidize trauma centers that treat a large number of African American, uninsured or poor people. In rural areas, they recommend that hospitals establish agreements with nearby trauma centers to ease transfers of seriously injured patients.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

Although most patients would allow residents and medical students to be involved in their operation, researchers say the rates of consent vary depending on the type of surgery and the trainee’s level of participation

Dr. Christopher R. Porta and colleagues from Madigan Army Health System, Tacoma, Wash., conducted an anonymous questionnaire at a tertiary-level U.S. Army hospital and referral center, to evaluate patient perceptions and willingness to participate in surgical resident education and training programs.

“Currently, no widely accepted guidelines or policies exist for providing information regarding the role of surgical trainees to the patient during the informed consent process,” the authors write. “The accepted standard is to provide information that ‘a reasonable patient’ would want and would need to know to make an informed decision, but this counseling may vary widely by health care professional, setting, and type of surgical procedure.”

The authors distributed 500 surveys, 316 (63.2 percent) of which were returned and included in the study. Most patients indicated no preference for a private hospital versus a teaching hospital, however of those who did, more preferred a teaching hospital to a private facility for overall care (24.9 percent vs. 8.8 percent) and minor surgical procedures (28.2 percent vs. 12 percent), but hospital preference for major surgical procedures was similar (24.7 percent vs. 26.6 percent).

Additionally, 91.2 percent of those patients who indicated a facility preference reported that their care in a teaching hospital would be equivalent to or better than that of a private hospital.

Patients also indicated they overwhelmingly preferred to be informed of resident participation in their surgical procedure, regardless of whether it was a major procedure (95.7 percent) or a minor surgery (87.5 percent).

A total of 94 percent of respondents indicated they would consent to involvement of a surgical resident, however this decreased to 85 percent for a surgical intern and 79.9 percent for medical student involvement.

When provided with specific scenarios involving trainee participation, 57.6 percent of patients consented to having a junior resident act as the first assistant, 25.6 percent consented to the resident acting as the operation surgeon with direct staff observation, and 18.2 percent consented to resident participation without direct staff observation.

“Although most patients express an overall willingness to participate in surgical education, wide variations can be observed in the actual consent rates for specific training situations, “ the authors said. “This decreased willingness to consent and the potential effect on training programs must be considered when discussing policy initiatives aimed at improving informed consent.”

For more on medical safety issues, see the library of  articles by Daytona Beach medical malpractice attorney.

A new report from Consumer Reports features advice on this very topic.

“Americans are overwhelmed by health costs and many people simply can’t pay their bills, can’t afford their medications,” says Dr. John Santa, director of the Consumer Reports Health Ratings Center, in a news release. “The last thing most patients want to do is haggle with their doctors, but a little bit of negotiating can go a long way.

“It’s also important to know that there are tremendous variations in health care costs —knowing this can help a consumer get a hand up and politely insist on the fairest possible price.”

Consumer Reports offers this advice for three possible scenarios:

You’re healthy. The optimal time for patients to talk with their healthcare providers about costs is before any have been incurred. While doctors have a professional obligation to take a patient’s financial resources into account, patients should raise the issue with their doctors to let them know that costs are important to them.

“For a variety of reasons, doctors are likely to suggest the most expensive options first. But you might be surprised by your doctor’s willingness to change course, for example prescribing fewer expensive brand name drugs or choosing watchful waiting over a costly diagnostic test,”  Santa said.

The unexpected occurs. A patient lands in the hospital without the benefit of any planning and gets slammed with a huge bill, say $15,000 for a coronary angiogram, and insurance ends up covering only a fraction of the bill.

These approaches are recommended to get the greatest reduction to their bill:

• Sit down with the doctor who ordered or performed the hospital services to find out how the hospital costs ran so high. Were all the services needed and reasonably priced? Consumers can judge for themselves by checking www.healthcarebluebook.com which lists the going rates for many medical services for free. Closely examine each bill to identify errors, which are common.
• Consumers should not assume the price on their bill is set in stone. Providers often discount rates substantially to insurers and others, so why shouldn’t a consumer ask for the same rate reduction? Consumers should dispute any charges they think their insurance company ought to cover.
• Patients should not pay their bill until they have exhausted all of their options, but they should make clear to the hospital’s billing department that reaching a resolution is important to them. They might consider making a discounted offer they think would be manageable within a set time period. Consumers can consult one of the reputable groups that, for a fee, can help reduce the size of medical bills, such as INSNET (www.myinsnet.com) or Medical Cost Advocate (www.medicalcostadvocate.com).

You’re having an elective surgery. This situation allows for more planning and research into the best procedure, doctor, hospital, drug or other option. As you do research, keep in mind this advice:

• Consumers should shop around, talk to different providers, and bargain for what they think is a fair price.
• Consumers shouldn’t hesitate to ask for the price upfront and get it in writing. Request an itemized list of all potential charges.
• As with any purchase, consumers should beware of any offer that sounds too good to be true. If a provider suggests a shortcut, be wary and ask a lot of questions, and check out providers that are unfamiliar.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

According to Australian researchers who collected data from studies of incentive programs in the U.S., the UK and Germany, it’s not even  clear if the incentives always do more good than harm.

“Despite the popularity of these schemes, there is currently little rigorous evidence of their success in improving the quality of primary health care, or of whether such an approach is cost-effective relative to other ways to improve the quality of care,” the authors write.

Seven studies were included in this review. Three of the studies evaluated single-threshold target payments, one examined a fixed fee per patient achieving a specified outcome, one study evaluated payments based on the relative ranking of medical groups’ performance (tournament-based pay), one study examined a mix of tournament-based pay and threshold payments, and one study evaluated changing from a blended payments scheme to salaried payment.

Researchers looked at randomized controlled trials (RCT) for smoking cessation, controlled before and after studies (CBA) for cervical screening and mammography screening, and a series of interrupted time series analyses (ITS), one focused on four outcomes in diabetes and one examined cervical screening, childhood immunizations, chlamydia screening and appropriate asthma medication. Quality of care was defined as patient reported outcome measures, clinical behaviors, and intermediate clinical and physiological measures.

Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures, but not all. One study found no effect on quality of care.

Poor study design led to substantial risk of bias in most studies. In particular, none of the studies addressed issues of selection bias as a result of the ability of primary care physicians to select into or out of the incentive scheme or health plan.

The study authors concluded there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care.

“Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation,“ the authors write. “More rigorous study designs need to be used to account for the selection of physicians into incentive schemes.”

Researchers say future studies should more consistently describe:

• The type of payment scheme at baseline or in the control group
• How payments to medical groups were used and distributed within the groups
• The size of the new payments as a percentage of total revenue.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

Researchers analyzed data from the Nationwide Inpatient Sample — a national database of hospital discharge records — from 1993-2008 and found a significant increase in infections related to cardiac electrophysiological devices or CIED.

Their analysis found that the annual incidence of CIED-related infection increased by 210 percent over the 16-year period studied. 

Further analysis showed a jump in infections after 2004, directly correlating with an increase in four major comorbidities or other medical conditions: renal failure, respiratory failure, heart failure and diabetes.

“We believe the growing number of clinical comorbidities in this patient population plays a large role in the increase in infections associated with CIEDs,” said Dr. Arnold J. Greenspon, professor of medicine at Jefferson Medical College of Thomas Jefferson University, director of Cardiac Electrophysiology at Thomas Jefferson University Hospital, and lead author of the study. “The patients are sicker, which may place them at higher risk for infection.”

Pacemakers and implantable cardioverter-defibrillators or ICDs are important in regulating the electrical signaling to the heart. Pacemakers help to speed up a slow heart rhythm (bradycardia) whereas ICDs help to slow down rapid heart rhythm (tachycardia), a potentially life-threatening condition.

The study showed a 96 percent increase in CIED implantation, mostly due to a marked increase in the use of ICDs.

“The expanding indications for ICD implantation may have contributed to the rise in infections since many of these patients have multiple medical co-morbidities,” said Dr. Greenspon. The highest infection rates occurred in white males over 65.

“The number of Americans receiving pacemakers and defibrillators has dramatically increased. This analysis shows that the infection risk associated with these devices has, unfortunately, increased as well,” said Greenspon. “A better understanding of the risk factors for infection will improve patient care and, hopefully, reduce the prolonged hospital stays that often result.”

Rising CIED infection rates also have economic implications for hospitals, as these patients require prolonged hospital stays which are associated with increased costs.

Researchers say further investigation into the risk factors that predict CIED infection or therapies to mitigate this issue is warranted.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

There are many different types of Staphylococci bacteria, which cause skin infections, pneumonia, food and blood infections (blood poisoning). Staphylococcus aureus or “Staph” is a very common germ that about 1 out of every 3 people have on their skin or in their nose. This germ does not cause any problems for most people who have it on their skin. But sometimes it can cause serious infections such as skin or wound infections, pneumonia, or infections of the blood.

While some S.aureus infections are treated easily with antibiotics, others are resistant (MRSA) to commonly prescribed antibiotics such as penicillin and amoxicillin.

The KeyPath MRSA/MSSA Blood Culture Test determines whether bacteria growing in a patient’s positive blood culture sample are MRSA or MSSA within about five hours after any bacterial growth is first detected in the sample. Aside from blood culture equipment, the test does not require any specific instruments to get results, which makes it useful in any laboratory.

“Clearing this test gives health care professionals a test that can confirm S.aureus and then identify whether the bacteria is MRSA or MSSA,” said Alberto Gutierrez, Ph.D., director of the Office of In Vitro Diagnostics Device Evaluation and Safety in the FDA’s Center for Devices and Radiological Health, in a news release.

MRSA infections can occur anywhere; however, infections appearing in health care settings are usually more severe and potentially life-threatening given patients being treated in those facilities may have weakened immune systems and frequently undergo procedures such as surgery, which allows an easier spread of bacteria directly into the body.

It is estimated that in 2005, the staph bug caused severe infections in nearly 95,000 Americans and killed more than 18,500 of them. However, in 2010 results from a CDC study showed that invasive (life-threatening) MRSA infections that began in hospitals declined 28% from 2005 through 2008. The study also showed a 17 percent drop in invasive MRSA infections that were diagnosed before hospital admissions (community onset) in people with recent exposures to healthcare settings.

Most staph skin infections, including MRSA, appear as a bump or infected area on the skin that may be:

• Red
• Swollen
• Painful
• Warm to the touch
• Full of pus or other drainage
• Accompanied by a fever

The FDA based its clearance on a clinical study of 1,116 blood samples evaluated at four major U.S. hospital centers. Within the organisms determined to be S.aureus, the MRSA determination was 98.9 percent accurate (178/180) and the MSSA determination was 99.4 percent accurate (153/154).

“This not only saves time in diagnosing potentially life-threatening infections but also allows health care professionals to optimize treatment and start appropriate contact precautions to prevent the spread of the organism,” Gutierrez said.

For more on medical issues, see the library of articles by Daytona Beach nursing home injury attorney.

According to researchers, thyroidectomy is a common operation, but it can be associated with serious complications: paralysis of the recurrent laryngeal nerve (RLN, a nerve that transmits motor function and sensation to the larynx, or voice box) and hypoparathyroidism (caused by injury to the parathyroid glands, which make a hormone that controls calcium levels).

Unintentional damage to the RLN by this surgery is reported to cause nerve paralysis in one percent to two percent of cases. Extensive searching for the RLN during thyroid surgery may cause temporary or permanent hypoparathyroidism.

The authors note two methods of identifying the RLN: one approach locates the nerve where it enters the larynx (superior-inferior direction), and the other approach locates the nerve in the trachea-esophageal groove, and traces it in the superior direction (inferior-superior direction).

Dr. Bayram Veyseller, from Bezmialem Vakif University, Istanbul, Turkey, and colleagues conducted a study to compare both techniques. They studied patients undergoing partial or total thyroidectomy between January 2006 and August 2009.

In 67 patients, the superior-inferior RLN identification technique was used, and in 128 patients, the inferior-superior method was used, according to the attending surgeon’s preference.

Researchers evaluated patients’ vocal cord function and blood calcium levels on the first day after the surgery. Follow-up was conducted every three months until patients’ calcium levels improved, for an average of 26 months.

If at the one-year mark blood calcium levels were still low (a sign of hypoparathyroidism) or RLN paralysis did not improve, the conditions were considered permanent.

Permanent paralysis of the RLN occurred in two patients in the inferior-superior group, and none in the other group. Hypoparathyroidism among the superior-inferior group patients was temporary in four and permanent in none; among the inferior-superior group patients, 14 experienced temporary hyperthyroidism and four experienced permanent hypoparathyroidism.

Overall, significantly fewer complications were found in terms of RLN paralysis and hypoparathyroidism in the superior-inferior group, which is when surgeons locate the nerve where it enters the larynx.

“Significantly lower rates of RLN paralysis and hypoparathyroidism were observed in thyroidectomies using a superior-inferior approach,” the authors concluded. They added that more studies should be conducted to corroborate these results.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

The term Sepsis Belt might be a new one, though. Sepsis, a severe illness in which the bloodstream is overwhelmed by bacteria, also appears to have a belt of its own.

According to University of Alabama at Birmingham emergency physician Henry Wang, M.D., the death rate for sepsis is much higher in one geographic region of the United States — the same region in which stroke is most prevalent. The Stroke Belt spans 11 states from Louisiana to Virginia, but does not include Florida.

“In 2010, we examined death rates from sepsis across the United States,” said Wang, associate professor and vice chair for research in the UAB Department of Emergency Medicine, in a news release. “Laying it out on a map, we saw that the states with highest sepsis mortality formed a cluster in the Southeast United States, closely mirroring the appearance of the Stroke Belt.”

Wang says sepsis is responsible for 750,000 hospitalizations and some 200,000 deaths in the United States each year, about the same as for heart attack and breast cancer. Sepsis is triggered by infections such as meningitis or bacterial pneumonia, and can lead to shock, organ failure and death.

“There are a host of possible causes for this geographic cluster,” said Wang. “Possibilities include pre-existing medical conditions, health behaviors, diet, genetics and even the environment and air pollution.”

Wang will use data from REGARDS (Reasons for Geographic and Racial Differences in Stroke) study, a large, long-term study of the Stroke Belt, funded by the federal government and based at UAB.

“We’ll be able to make extensive use of the REGARDS infrastructure, with access to information from the more than 30,000 people enrolled in that project,” said Wang. “With that wealth of information, we will be able to identify the characteristics of persons most likely to be hospitalized for sepsis. This information will may lead to strategies to prevent its onset.”

“Sepsis treatment is complex, dealing with disruption of blood flow, organs shutting down and shock,” he said. “Our current best course of action is to prevent sepsis from occurring in the first place. We hope our new research endeavor will lead to novel ways to prevent this disease and its effects.”

For more on medical issues, see the library  of articles by Daytona Beach medical malpractice attorney.

Xarelto (rivaroxaban) is a pill taken once daily. Those undergoing a knee replacement should take the medication for 12 days and patients undergoing a hip replacement procedure should take Xarelto for 35 days.

The safety and effectiveness of Xarelto was evaluated in patients undergoing hip replacement surgery and patients undergoing knee replacement surgery. Clinical studies were designed to identify occurrence of venous thromboembolic events (VTE), deep vein thrombosis (DVT), pulmonary embolism (PE) or death in patients treated. Treatment with Xarelto was compared to treatment with enoxaparin, a drug that prevents DVTs or blood clotting.

“Xarelto represents a new oral treatment option to help prevent blood clotting in patients receiving a hip or knee replacement,” said Dr. Richard Pazdur, director of the Office of Oncology Drug Products in the FDA’s Center for Drug Evaluation and Research, in a news release. Xarelto was reviewed by the Division of Hematology Products within the Office of Oncology Drug Products.

More than 6,000 patients undergoing hip or knee replacement surgery received Xarelto in clinical studies. Among patients undergoing knee replacement surgery, 9.7 percent of those treated with Xarelto had VTE compared with 18.8 percent of patients who received enoxaparin.

In a study involving hip replacement surgery, 1.1 percent of patients who received Xarelto had VTE compared with 3.9 percent of those who received enoxaparin. In another study of hip replacement patients, 2.0 percent of those treated with Xarelto had VTE compared with 8.4 percent of those who received enoxaparin.

The most common side effect observed in patients treated with Xarelto was bleeding.
Other FDA approved drugs to prevent blood clotting include Lovenox (enoxaparin), generic versions of enoxaparin, Arixtra (fondaparinux), Fragmin (dalteparin) for hip replacement surgery only, Coumadin (warfarin) and heparin.

For more on senior medical issues, see the library of articles by Daytona Beach nursing home injury attorney.

Researchers reviewed the VA National Center for Patient Safety database, looking for surgical adverse events and close calls that occurred between July 2006 and December 2009. The authors suggest possible reasons for the decline in adverse events, such as a greater emphasis on safety, team training and communication.

Julia Neily, R.N., from the VHA in White River Junction, Vt., and colleagues coded cases into categories (type of event, body segment, etc.) and root causes, and then reached consensus.

The data were analyzed in the context of the VHA’s Medical Team Training program, implemented across the country between 2006 and 2009, which aims to decrease the number of incorrect surgeries that occur in VHA medical center operating rooms.

Of the 237 reports that the researchers identified, 101 were adverse events and 136 were close calls. Roughly half of the adverse events took place in the operating room, but their severity, on average, decreased. A significant decrease in the number of adverse events per month was reported (2.4 in this study, vs. 3.21 in the previous study), whereas close calls increased from 1.97 reports per month to 3.24.

Researchers also found that reports of surgeons operating on the wrong body part ranged between 0.09 per 10,000 patients in some locations to 4.5 per 10,000 patients — a 50-fold difference.

“This 50-fold range in the estimated incidence reflects the variety of results reported in various settings and different methods for defining adverse events in this area,” explain the authors. Their article represents a follow-up report to research on surgical adverse events in the VHA system from 2001 to mid-2006, and also includes information about recent systemwide interventions.

The authors determined that 204 root causes contributed to the adverse events, the most common one being lack of standardization of clinical processes. The rate of “highest harm” adverse events decreased by 14 percent annually.

“Despite the overall decrease in patient harm, opportunities exist to further decrease the number of incorrect surgical and invasive procedures,” they write. “We must continue to improve.”

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.