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.

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“The good news is that over the last ten years hospital palliative care teams have more than doubled,” said Dr. Diane E. Meier, director of the Center and co-author of the study, in a news release. “The bad news is that despite its enormous benefits to patients and care givers, millions of seriously ill Americans still do not have access to palliative care. Given the will of Congress to assure patients receive high quality care while reducing costs, it seems that palliative care should be a natural part of that prescription.”

Palliative care is a medical specialty that helps people facing serious and chronic illness more comfortable by alleviating pain, treating a host of other symptoms and focusing on their quality of life. It is appropriate at any age and any stage of a serious illness and can be provided along with curative treatment.

Approximately 90 million Americans are living with serious and chronic illnesses, such as cancer, heart disease, diabetes, Parkinson’s, stroke, and Alzheimer’s.

The Report Card demonstrates considerable improvement in the growth of palliative care. (Out of a total of 2,489 hospitals nationwide who participated in this survey, about 1,500 provide palliative care services.) This number is expected to grow significantly over the next five years, but barriers continue to exist in three key areas: Workforce, Research and Access.

Of course, you can’t get palliative care from a hospital that does not offer it.
Meier and colleagues graded states on the percentage of hospitals that have palliative care teams. They counted only hospitals with 50 or more beds, as palliative care savings may not offset costs for very small hospitals.

States got an A for having palliative care teams in 83 percent or more of their hospitals, a B for 61 to 80 percent of hospitals, a C for 42 to 60 percent of hospitals, a D for 28 to 38 percent of hospitals, and an F for 0 to 20 percent of hospitals.

The report gives seven states plus the District of Columbia an A: Maryland, Minnesota, Nebraska, Oregon, Rhode Island, Vermont and Washington. Only three states, Vermont, Montana and New Hampshire, received an A in 2008.

More than half of the fifty states received a grade of B, including Florida. Seven states improved from a D to a C (Georgia, Kentucky, New Mexico, Texas, South Carolina, Louisiana and Wyoming).

Nevada saw dramatic gains, rising from a D to a B grade. Only two states – Delaware and Mississippi – got an F. Oklahoma, Alabama and Arkansas improved from an F in the last report card to a D in 2011.

Findings from a separate 2011 Public Opinion Strategies survey found that most Americans believe palliative care should be made available at all hospitals. Once informed about it, 92 percent of respondents said they would consider it for a seriously ill loved one.

“America’s hospitals have a strong history of caring for patients and families during the most difficult of times,” said Rich Umbdenstock, President and CEO of the American Hospital Association. “Hospitals and other health care organizations are taking the lead in ensuring health care is patient-centered, reflecting patient’s desires including palliative care assistance.”

“Studies suggest that in states with more hospital-based palliative care programs, patients are less likely to die in the hospital, are likely to spend fewer days in the ICU, have better pain management and higher satisfaction with their healthcare,” said Dr. Sean Morrison, director of the National Palliative Care Research Center and the study’s lead author. “Some studies have reported that palliative care may also prolong life. And beyond patient benefits, the overall cost savings to hospitals have been well documented.”

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An analysis of Medicare data showed a higher death risk if the stent was inserted by a doctor who performed less than six procedures a year, or if the procedure was conducted early in the physician’s career.

Carotid stenting is increasingly being used to treat severe carotid atherosclerosis, an important cause of ischemic stroke. Since approval of the first carotid stent system by the U.S. Food and Drug Administration in 2004, use of carotid stenting has more than doubled in Medicare beneficiaries.

Despite the promise of this procedure, its increasing use has raised potential concerns.

“Carotid stenting is a technically demanding procedure and earlier studies have demonstrated a substantial learning curve with it,” says lead study author Dr. Brahmajee K. Nallamothu, cardiologist at the University of Michigan Cardiovascular Center, in a news release. “The total number of operators currently performing carotid stenting in routine clinical practice and their overall experiences and outcomes with the procedure remain largely unknown.

Nallamothu and colleagues at the U-M Health System, Mayo Clinic, Dartmouth-Hitchcock Medical Center, and Yale University School of Medicine conducted a study to examine recent patterns of utilization and outcomes for carotid stenting in the U.S. among elderly patients.

The researchers used administrative data from fee-for-service Medicare beneficiaries ages 65 years or older who underwent carotid stenting between 2005 and 2007. Among the outcomes the researchers measured were 30-day mortality and treatment early vs. late during an operator’s experience.

Analysis of the data identified 24,701 patients who underwent carotid stenting by 2,339 operators. Average age of the patients in the study was 76.2 years.

Compared with patients treated by operators performing 24 or more procedures per year, those treated by operators performing less than six procedures per year were nearly twice as likely to die within 30 days of the stent placement, the study showed.

The authors found higher 30-day mortality in patients treated early vs. late during a new operator’s experience (2.3 percent vs. 1.4 percent, respectively). Compared with patients who were their operator’s 12th procedure or higher, those who were among their operator’s first 11 procedures had a 1.7 times higher odds of dying within 30 days of the procedure.

“In conclusion, many physicians have begun performing carotid stenting in Medicare beneficiaries during recent years, although most operators appear to have developed limited experience with the procedure over time, “ study authors write. “This finding is important since adjusted outcomes following the procedure are worse among very low-volume operators and early during an operator’s experience. Given limitations of these data, caution should be exerted when using our findings to set specific targets for operator experience.”

Collecting more detailed data about operator experience during the early dissemination of new procedures, like carotid stenting, may help optimize outcomes, according to the researchers.

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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.”

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“Our data demonstrate that obesity is a major risk factor for complications following certain kinds of elective surgery,” said Dr. Marty Makary, an associate professor of surgery at the Johns Hopkins University School of Medicine and leader of the study.

Not only are these findings relevant to physicians due to potential surgical site infections in heavier patients but also to policymakers whose metrics for surgical quality and reimbursement do not account for the higher risk of worse outcomes in the obese.

“With the government and other insurers penalizing doctors whose patients get infections or are readmitted to the hospital — and with obese patients more likely to have those problems — policymakers need to make sure they aren’t giving physicians financial incentives to discriminate on the basis of weight,” Makary said in a news release.

In the study, Makary and his colleagues examined insurance claims data from seven Blue Cross and Blue Shield plans and identified patients who underwent elective breast procedures covered by insurance between 2002 and 2006. There were 2,403 patients in the obese group and 5,597 patients in the normal weight control group. The most common procedure, by far, was breast reduction, followed by breast reconstruction, augmentation and breast lift.

Within 30 days of surgery, 18.3 percent of the obese group experienced at least once complication, compared to 2.2 percent of patients in the control group. The differences between the two groups were most pronounced in complications, such as inflammation (with obese patients 22 times more likely to suffer a complication), infection (13 times) and pain (11 times).

Thirty-four percent of adults in the United States are now estimated to be obese, up from just 15 percent a decade ago. Meanwhile, the number of people nationwide having elective plastic surgery has also increased in recent years — with annual plastic surgery volume up 725 percent between 1992 and 2005.

Surgical outcomes are increasingly judged using standardized measures to evaluate quality and to inform the public and insurance companies. These metrics also are used more and more to penalize hospitals with higher complication rates. But, Makary says, they do not take into account that obese patients may suffer more complications, as this new research finds.

Operations on obese patients are more taxing, says Makary, a surgeon himself. These surgeries usually take longer, the operating fields are deeper, the spaces in which an infection can set in are often greater and blood flow in fat tissue is less than in other types of tissue, which results in slower healing, he says.

“But payments are based on the complexity of the procedure and are not adjusted for the complexity of the patient,” he said.

“There are definitely incentives there for surgeons and institutions to select healthier patients,” he said. “They’re getting reimbursed less per unit of work for obese patients.”

According to Makary, more research needs to be done on the role of obesity in surgical complications covering a wider variety of surgeries so that new metrics can be developed to account for any differences due to obesity.

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

The survey found that 59 percent of physicians acknowledged having less empathy for so-called frequent users than other patients, and 77 percent held bias for frequent users. Physicians defined frequent users in the survey as patients who visit the ED at least 10 times a year.

Other highlights of the survey include:

• 91 percent of physicians say frequent users pose challenges for the ED.
• 71 percent of physicians believe a program to manage frequent users is necessary.
• 82 percent of physicians say they feel some level of burnout.
• Experience did not shield physicians from burnout.

Physicians who responded to the survey comprised seasoned professionals, up-and-coming residents and alumni whose experience ranged from one year to 30 years. They represented every state, except Alaska.

While frequent users long have been linked with provoking negative attitudes in the ED, the survey’s findings are believed to be the first time physicians’ opinions have been measured. The findings were presented at the annual meeting of the Society for Academic Emergency Medicine June 1-5 in Boston.

“Our findings should be a wake-up call for hospital administrators to look at ways to manage these types of patients,” said Dr. Jennifer Peltzer-Jones, a clinical psychologist at Henry Ford’s Department of Emergency Medicine who led the survey, in a press release.  In 2004, the hospital created the Community Resources for Emergency Department Overuse (CREDO) in response to increased frequent users in its ED.

“Only 31 percent of the physicians surveyed said they had a program to help manage patients who are frequent users. Hospital administrators have to realize that these patients are invoking burnout and staff want and need additional resources,” Dr. Peltzer-Jones says.

Findings were compiled from an 18-question, anonymous survey randomly sent to 1,500 physicians nationally between July-October 2010. Of the 1,500 surveys sent, 418 physicians responded.

“People go to the Emergency Department because it’s accessible 24/7,” Dr. Peltzer-Jones says. “However, the ED is meant for emergent care, not primary care. ED physicians are not equipped to be primary care providers and case managers.”

Dr. Peltzer-Jones says many social factors contribute to patients frequently using the ED: lack of access to primary and specialty care, homelessness, lack of transportation for appointments, substance abuse, psychiatric disorders and chronic medical conditions.

Contrary to popular belief, many frequent users do have some type of medical insurance, she says.

“Physicians are feeling frustrated because they want to assist their patients who have emergent care issues. But they find they are managing chronic medical and social problems with very little resources ,” Dr. Peltzer-Jones said in the release. “The Emergency Department is supposed to be the last, not first, resource for patient care. That’s not the case with the frequent user population.”

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Average hospital stays after total hip arthroplasty (replacement) has gone from 9 days in 1991 to 3.5 days in 2008, according to analysis of data from Medicare beneficiaries who underwent hip replacement or subsequent follow-up corrective surgery between 1991 and 2008.

That’s both good and bad news for hip replacement patients.

“The good news is you don’t have to stay in the hospital to recover,” said Dr. Peter Cram,  of the University of Iowa’s Roy J. and Lucille A. Carver College of Medicine and lead researcher on the study, in a press release. “The bad news is that you’re not in the hospital while you’re recovering.”

Total hip arthroplasty is a safe and effective therapy for patients with advanced degenerative joint disease. In recent years, there has been a dramatic increase in performance of this procedure both in the United States and abroad.

There is a general assumption that increasing experience with total hip arthroplasty has resulted in improvements in patient outcomes, as has been observed in other procedures, but rigorous empirical data documenting such improvement are limited. This lack of data are striking given that an estimated 280,000 total hip arthroplasty procedures are performed annually at a cost of more than $12 billion, according to background information in the article.

Cram and Yue Li, associate professor of internal medicine at the UI Carver College of Medicine, evaluated the long-term trends in the outcomes of Medicare beneficiaries undergoing primary hip replacement and follow-up corrective surgery and to explore whether reductions in hospital length of stay (LOS) might be associated with increased discharge of patients to postacute care settings, increased readmission rates, or a combination of both outcomes.

The study included data from between 1991 and 2008 on 1,453,493 Medicare Part A beneficiaries who underwent primary total hip arthroplasty and 348,596 who underwent revision total hip arthroplasty.

“In an analysis of 1991-2008 Medicare administrative data, 3 trends were identified. First, we found that despite increasing patient complexity, both unadjusted and adjusted mortality for primary total hip arthroplasty showed substantial improvement over time,” the authors note in the study. “Conversely, our second finding was that for revision total hip arthroplasty, unadjusted mortality appeared to increase modestly but this increase was largely explained by increasing patient complexity. Third and most importantly, marked declines in hospital LOS for both primary and revision total hip arthroplasty seemed to correspond with an increase in the proportion of patients who were discharged to postacute care and an increase in patient readmissions.”

For primary total hip arthroplasty, average hospital LOS decreased from 9.1 days to 3.7 days. After adjustment for patient characteristics, risk-adjusted 30-day mortality over the study period decreased from 0.7 percent to 0.3 percent and 90-day mortality decreased from 1.3 percent to 0.7 percent.

“What we found is that patients are staying in the hospital a much shorter amount of time, patient mortality is increasingly low, but an increasing number of patients are requiring readmission 30 to 90 days after their initial surgery,” Cram said.

The researchers also found that the proportion of primary total hip arthroplasty patients discharged to home decreased from 68 percent in 1991-1992 to 48.2 percent in 2007-2008, while the proportion of patients discharged to skilled or intermediate care increased from 17.8 percent to 34.3 percent. The 30-day all-cause readmission rate decreased from 5.9 percent in 1991-1992 to 4.6 percent in 2001-2002, before increasing to 8.5 percent in 2007-2008. Results were similar for 90-day readmission rates.

“For revision total hip arthroplasty, similar trends were observed in hospital LOS, in-hospital mortality, discharge disposition, and hospital readmission rates,” the authors write.

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

The inability to close the eye can be a devastating result of facial paralysis.

“The resulting loss of corneal protection can lead to exposure keratitis [inflammation of the cornea], corneal ulceration, and potentially permanently vision loss,” said Dr. Douglas K. Henstrom, of Harvard Medical School, Massachusetts Eye and Ear Infirmary, in a press release. “Eyelid weight placement, lower eyelid suspension, and brow ptosis [drooping or sagging of the eyelid] correction are frequently performed to protect the eye.”

Henstrom and colleagues measured and reported the change in quality of life (QOL) after surgery.

The researchers used the Facial Clinimetric Evaluation (FaCE) scale — a patient-based system that measures impairment and disability in facial paralysis and represents a valuable adjunct to traditional physician-graded scales for evaluating QOL issues in patients affected by facial paralysis.

From March 2009 to May 2010, 49 patients with paralytic inability to completely close the eye were treated at the Facial Nerve Center at Massachusetts Eye and Ear Infirmary, Boston. Thirty-seven of the patients completed preoperative and postoperative FaCE surveys.

“Overall QOL, measured by the FaCE instrument, significantly improved following static periocular treatment,” the authors report. “Mean FaCE scores increased from 44.1 to 52.7.”

“Patients also reported a significant decrease in the amount of time their eye felt dry, irritated, or scratchy,” the authors write in the study, published in the March issue of Archives of Facial Plastic Surgery.

Two patients experienced localized cellulitis (a bacterial infection of the skin and tissues beneath the skin) in reaction to the eyelid weight. There was one eyelid weight extrusion.

“In the overall treatment paradigm for patients with facial paralysis, treating the eye using this modality is simple, and not only improves corneal protection but also yields a significant subjective benefit,” the authors conclude.

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“Open surgical biopsy is not accounting for 10 percent or 5 percent of initial breast biopsies, which is what’s recommended,” said Dr. Luke Gutwein, a surgical resident in the University of Florida’s department of surgery, in a press release. “It’s accounting for 30 percent of initial breast biopsies, so open biopsy is incredibly over-utilized.”

Gutwein and six other UF researchers analyzed state public health data for the years 2003 to 2008 and found that about 30 percent of breast biopsies were performed through open surgery. The study, published online by  the American Journal of Surgery, reflects conditions outside Florida, too, said Dr. David P. Winchester, a professor of surgery at NorthShore University HealthSystem in Evanston, Ill., and a
former chairman of the National Accreditation Program for Breast Centers.

“This is an important message and should be generalizable to other parts of the country, in terms of the desirability of using minimally invasive biopsy techniques,” he said.

Needle biopsies are usually more appropriate when the suspicious area can be seen clearly through imaging techniques, according to reports written by panels of breast health specialists. The procedure, typically performed by radiologists, requires inserting a needle through a tiny incision into the suspicious area and extracting tissue samples through the needle. The radiologist monitors the procedure via ultrasound or mammography as it takes place.

A needle biopsy leaves only a tiny dot of a scar and carries significantly less risk of infection than an open surgical biopsy. In addition, it is less painful and does not require any recovery time.  Most breast biopsies show the area in question to be benign.

The latest report, published in the Journal of the American College of Surgery in 2009, stated that open breast biopsies, which require a full surgical procedure and general anesthesia, should be used to initially diagnose a lesion in less than 5 percent to 10 percent of cases.

Though use of needle biopsies increased significantly during the five years studied, the researchers found that overuse of open breast biopsies in Florida leads to $37.2 million in charges each year. The study did not take providers’ charges into account, meaning the actual amount wasted is much greater. The researchers did not analyze possible reasons for over-utilization of open breast biopsies.

“The article has clearly defined the problems with doing an open biopsy,” Winchester said. “The most compelling reason is that this may be a benign lesion. If it’s benign and needle biopsy confirms that, then surgery isn’t necessary.”

Some patients, such as those with very small breasts or whose lesions are located close to the chest wall or an implant, are not candidates for a needle biopsy.

In cases where a needle biopsy reveals cancer, physicians can begin treatment before surgery and can plan better for removal of the cancer, increasing the likelihood of extracting it entirely in a single surgery.

But Dr. Stephen Grobmyer, an associate professor of surgery, a member of the UF Shands Cancer Center and medical director of the UF Breast Center, said he regularly sees patients who have undergone an open breast biopsy when a needle biopsy would have sufficed. He said this can make multidisciplinary therapy and additional surgeries more
difficult to plan and administer.

“It makes determining how big a lesion is, or if there’s any residual cancer, difficult,” Grobmyer said. “It often makes the surgery that is required more extensive. It often will mean that patients, where they could have had one operation, end up with more than one operation.”

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