It is estimated that over 11,000 women will be diagnosed with cervical cancer and nearly 4000 women will die of cancer of the cervix this year. A high percentage of women will develop abnormal cervical pathology-a precursor to cervical cancer. Guidelines recommend Pap screening at least every 3 years for all women and annual screening for women greater than 30 years of age.
According to a study published in Clinical Gastroenterology and Hepatology, women with IBD like ulcerative colitis and Crohns disease have a high incidence of abnormal cervical cytology. However they are tested for cervical abnormalities at suboptimal rates.
Using the PharMetrics Patient-Centric Database (1996 to 2005), doctors identified cases of IBD and matched controls via a validated algorithm. With logistic regression, they compared utilization of cervical testing with IBD case status, patients' age, use of immunosuppressive medications, Medicaid insurance status and use of primary care services.
Although Cervical malignancy is largely preventable through proper screening half of all women –especially those with IBD who receive the diagnosis of cervical cancer have never been screened. This has to be changed through proper education. Quality improvement initiatives are needed to improve disease prevention services for women with IBD.
Clinical Gastroenterology and Hepatology; 2009: 7(5): 549-553
Friday, June 19, 2009
Thursday, June 18, 2009
CAN WE BELIEVE HOSPITAL STATISTICS?
Reporting of Mistakes by Hospitals Is Faulted
A.Hatocollis reports that at least in one city--New York City-- hospitals are the least reliable in the state at reporting preventable mistakes and adverse incidents for patients like heart attacks, blood clots, hospital infections and medication errors, according to a new report by the office of City Comptroller.
The comptroller also expressed concern that the New York City data on medication errors appear to run counter to the national trend, citing estimates by the Institute of Medicine of the National Academies that at least 400,000 hospital patients are harmed and 7,000 killed by medication errors annually. In contrast, the report said, from 2004 through 2007, city hospitals rarely reported medication errors: 37 that resulted in death, near death or permanent harm to patients, with 22 hospitals, including four very large ones, reporting none.
The lack of accurate reporting makes it virtually impossible for consumers to judge accurately the quality of a hospital or for the hospital to compare itself with its peers and make improvements, the comptroller’s office argues, saying the consequences include longer hospital stays and higher health-care costs. “Without the fullest possible reporting, hospitals cannot identify areas where systematic improvement may be needed,” reads the report. “Weak enforcement and flagging commitment to a broad-based effort has compromised the whole program.”
NewYork-Presbyterian/Weill Cornell Medical Center one of New York City’s major academic medical centers, reported only about 20 adverse incidents per 10,000 patient discharges, while a comparable institution outside the city, which was not named, reported about 166 incidents per 10,000, a rate more than eight times higher.
Within New York City’s 60-plus hospitals, there was great range: 17 reported no heart attacks unrelated to a cardiac procedure while one had more than 40; six hospitals reported 2 blood clots or acute pulmonary embolisms per 10,000 patient discharges while two others had more than 60 per 10,000; one major academic medical center reported 3.6 post-operative infections per 10,000 discharges and a similar hospital had 32 per 10,000. None of these hospitals were named in the report.
The report, which looks at data from 2004 through 2006, with some additional data from 2007, echoes a state Health Department study in 2001 that similarly concluded that New York City underreported adverse incidents, with 6 of the 11 city-run public hospitals among the 25 lowest reporters. The new analysis faulted the state for not being more aggressive in enforcing penalties such as fines against hospitals with lax reporting, and cited “enormous and inexplicable disparities among individual hospitals.”
A hospital’s size and the type of procedures it performs do not seem to explain the differences in reporting rates.
The report does not name individual hospitals, but the comptroller’s office separately released a list of the 12 lowest reporters in the city based on 2006 data. The top three — St. Vincent’s Midtown and Cabrini Medical Center in Manhattan, and Mary Immaculate in Jamaica, Queens — have all since closed.
The others include some of New York’s biggest and most prestigious hospitals: Lenox Hill, on the Upper East Side (No. 7); Bellevue, the flagship hospital of the city’s Health and Hospitals Corporation (10); Weill-Cornell (11); and Mount Sinai (12).
COMMENT:
It’s not difficult to believe that NYC is not an isolated city. I believe that hospital statistics reported from other cities will have to also be investigated—with severe sanctions applied to violaters.
A.Hatocollis reports that at least in one city--New York City-- hospitals are the least reliable in the state at reporting preventable mistakes and adverse incidents for patients like heart attacks, blood clots, hospital infections and medication errors, according to a new report by the office of City Comptroller.
The comptroller also expressed concern that the New York City data on medication errors appear to run counter to the national trend, citing estimates by the Institute of Medicine of the National Academies that at least 400,000 hospital patients are harmed and 7,000 killed by medication errors annually. In contrast, the report said, from 2004 through 2007, city hospitals rarely reported medication errors: 37 that resulted in death, near death or permanent harm to patients, with 22 hospitals, including four very large ones, reporting none.
The lack of accurate reporting makes it virtually impossible for consumers to judge accurately the quality of a hospital or for the hospital to compare itself with its peers and make improvements, the comptroller’s office argues, saying the consequences include longer hospital stays and higher health-care costs. “Without the fullest possible reporting, hospitals cannot identify areas where systematic improvement may be needed,” reads the report. “Weak enforcement and flagging commitment to a broad-based effort has compromised the whole program.”
NewYork-Presbyterian/Weill Cornell Medical Center one of New York City’s major academic medical centers, reported only about 20 adverse incidents per 10,000 patient discharges, while a comparable institution outside the city, which was not named, reported about 166 incidents per 10,000, a rate more than eight times higher.
Within New York City’s 60-plus hospitals, there was great range: 17 reported no heart attacks unrelated to a cardiac procedure while one had more than 40; six hospitals reported 2 blood clots or acute pulmonary embolisms per 10,000 patient discharges while two others had more than 60 per 10,000; one major academic medical center reported 3.6 post-operative infections per 10,000 discharges and a similar hospital had 32 per 10,000. None of these hospitals were named in the report.
The report, which looks at data from 2004 through 2006, with some additional data from 2007, echoes a state Health Department study in 2001 that similarly concluded that New York City underreported adverse incidents, with 6 of the 11 city-run public hospitals among the 25 lowest reporters. The new analysis faulted the state for not being more aggressive in enforcing penalties such as fines against hospitals with lax reporting, and cited “enormous and inexplicable disparities among individual hospitals.”
A hospital’s size and the type of procedures it performs do not seem to explain the differences in reporting rates.
The report does not name individual hospitals, but the comptroller’s office separately released a list of the 12 lowest reporters in the city based on 2006 data. The top three — St. Vincent’s Midtown and Cabrini Medical Center in Manhattan, and Mary Immaculate in Jamaica, Queens — have all since closed.
The others include some of New York’s biggest and most prestigious hospitals: Lenox Hill, on the Upper East Side (No. 7); Bellevue, the flagship hospital of the city’s Health and Hospitals Corporation (10); Weill-Cornell (11); and Mount Sinai (12).
COMMENT:
It’s not difficult to believe that NYC is not an isolated city. I believe that hospital statistics reported from other cities will have to also be investigated—with severe sanctions applied to violaters.
Wednesday, June 17, 2009
BOOKS TO READ ON THE BEACH
BOOKS TO READ ON THE BEACH SO YOU CAN SMARTLY CONVERSE AT LIBERAL DOCTOR HATING COCKTAIL PARTIES THIS FALL – OR READ THIS AND SAY YOU DID
Guy Clifton, a neurosurgery professor at the University of Texas Health Science Center in Houston, argues in his book Flatlined: Resuscitating American Medicine that there are two ways to control healthcare costs: price controls with rationing (used by most industrialized nations and abhorred in the U.S.) or increased efficiency. Clifton points out that the cost of healthcare is so high that it is affordable only if someone else is paying for it, such as government or employers. The "haves" consume the healthcare of the "have nots," to the detriment of both. An estimated 30,000 patients die each year from overtreatment. He estimates that 50 percent of healthcare is a waste, if you factor in excessive medical care and patient health behavior.
In The Great American Heart Hoax: Lifesaving Advice Your Doctor Should Tell You About Heart Disease Prevention (But Probably Never Will), cardiologist Michael Ozner claims that the annual 1.5 million U.S. angioplasties and coronary bypass surgeries, for which the price tag is $60 billion, neither save lives nor prevent heart attacks. He cites Harvard research that 70 to 90 percent of those procedures are unnecessary.
The U.S. is the only industrialized nation not to guarantee healthcare to its citizens. We spend more than twice as much per capita as any other country, yet if longevity is the criteria comparatively we do not live longer lives. Medical professor Nortin Hadler, author of Worried Sick: A Prescription for Health in an Overtreated America, says healthcare interventions rarely, if ever, improve longevity. He defines two types of medical malpractice. Type I malpractice: Doing something medically necessary unacceptably poorly. Type II malpractice: Doing something unnecessary very well.
Journalist Shannon Brownlee, author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, gives partial credit of overtreatment to Americans’ blind faith in technology and science. About 34 percent agreed with the statement in a Harvard survey that modern medicine can cure almost any illness with the right technology. However, Brownlee points out that 25 to 40 percent of autopsies show that patients were being treated for the wrong diagnosis, which is virtually unchanged from 1910.
Physician Dennis Gottfried, who wrote Too Much Medicine: A Doctor’s Prescription for Better and More Affordable Health Care, wants to ban direct-to-consumer advertising for medications and aggressive promotion of pharmaceuticals to physicians because both result in prescription of more expensive, less effective drugs. About 31 percent of patients who see these advertisements ask about the drug, and a significant portion of them want it even though they are clueless to its effects. Unfortunately, he says,a significant percentage of doctors comply because they do not want to lose a fully insured patient.
Guy Clifton, a neurosurgery professor at the University of Texas Health Science Center in Houston, argues in his book Flatlined: Resuscitating American Medicine that there are two ways to control healthcare costs: price controls with rationing (used by most industrialized nations and abhorred in the U.S.) or increased efficiency. Clifton points out that the cost of healthcare is so high that it is affordable only if someone else is paying for it, such as government or employers. The "haves" consume the healthcare of the "have nots," to the detriment of both. An estimated 30,000 patients die each year from overtreatment. He estimates that 50 percent of healthcare is a waste, if you factor in excessive medical care and patient health behavior.
In The Great American Heart Hoax: Lifesaving Advice Your Doctor Should Tell You About Heart Disease Prevention (But Probably Never Will), cardiologist Michael Ozner claims that the annual 1.5 million U.S. angioplasties and coronary bypass surgeries, for which the price tag is $60 billion, neither save lives nor prevent heart attacks. He cites Harvard research that 70 to 90 percent of those procedures are unnecessary.
The U.S. is the only industrialized nation not to guarantee healthcare to its citizens. We spend more than twice as much per capita as any other country, yet if longevity is the criteria comparatively we do not live longer lives. Medical professor Nortin Hadler, author of Worried Sick: A Prescription for Health in an Overtreated America, says healthcare interventions rarely, if ever, improve longevity. He defines two types of medical malpractice. Type I malpractice: Doing something medically necessary unacceptably poorly. Type II malpractice: Doing something unnecessary very well.
Journalist Shannon Brownlee, author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, gives partial credit of overtreatment to Americans’ blind faith in technology and science. About 34 percent agreed with the statement in a Harvard survey that modern medicine can cure almost any illness with the right technology. However, Brownlee points out that 25 to 40 percent of autopsies show that patients were being treated for the wrong diagnosis, which is virtually unchanged from 1910.
Physician Dennis Gottfried, who wrote Too Much Medicine: A Doctor’s Prescription for Better and More Affordable Health Care, wants to ban direct-to-consumer advertising for medications and aggressive promotion of pharmaceuticals to physicians because both result in prescription of more expensive, less effective drugs. About 31 percent of patients who see these advertisements ask about the drug, and a significant portion of them want it even though they are clueless to its effects. Unfortunately, he says,a significant percentage of doctors comply because they do not want to lose a fully insured patient.
Tuesday, June 16, 2009
June 8, 2009 Radio Interview with Sybil Tonkonogy on the subject of C.difficile infections
June 8, 2009 Radio Interview with Sybil Tonkonogy on the subject of C.difficile infections.:
This is Sybil Tonkonogy with a little laryngitis this morning. I do not know where it came from and wish it would go back to wherever it came from, but anyway, we are going to continue and you, I hope that you remember that I had a very pleasant voice, but here this morning, very, very laryngitisy. So, maybe it will just go away. I would like to present our guest this morning who is Dr. Perry Hookman, who is an Associate Professor of Medicine at the University of Miami - Miller School of Medicine. What we are going to be talking about this morning is a thing called C. difficile and if I said it wrong, Dr. Hookman, please correct me. Hello?
Dr. Perry Hookman: You got it right. You got it right. It is called C. difficile infection.
Sybil Tonkonogy: Difficile.
Dr. Perry Hookman: Or C. difficile, it does not matter.
Sybil Tonkonogy: Difficile, we will call it. Tell us what it is.
Dr. Perry Hookman: Well, C. difficile infection is a very vicious type of infection, which attacks people when they are most vulnerable and that is in the hospital. It is a hospital-acquired infection and it is starting to make a tremendous impact. We know that there is a total of over a 12-year period, there has been a total of two million hospital discharges, which has doubled from a similar period in 2001 to 2005. Before that, the rate was 301,000 and we know now that there is 100% increase in the past four years of this infection. This infection gives patients with a very vicious type of diarrhea in which in many if it is hit by a virulent drug means that their colon has to come out. Basically, it is called C. difficile diarrhea and it is the technical name for pseudomembranous colitis.
Sybil Tonkonogy: Now, perhaps we can talk about it. This is particularly from antibiotics.
Dr. Perry Hookman: Well, that is right. What happens is that the bugs are evolving over a period of time as antibiotics evolve. So, every time we use a stronger antibiotic or different antibiotic and use it on a mass basis, the drugs go through an evolutionary process in which the Darwinian selection takes place and the fetus of the bacteria, or the strongest of the bacteria, able to survive in that environment of the new antibiotic takes hold. The more sensitive ones to the antibiotic die off, but those bacteria that develop through their genes, a different type of gene, which makes it more resistant to that antibiotic take over. This most vicious virulent type of C. difficile we are seeing now is called NAP1, B1, 027, which is the full name for it, talking about the way we type it in the gel-field electrophoresis and endonucleus analysis and a polymerase chain reaction, 027. So, technically, all technical terms aside, we will call this a NAP1 virulent epidemic type of C. difficile, which has evolved on the basis of an antibiotic resistance to the fluoroquinolones like Cipro and other type of antibiotics, which because they are being used more frequently and some would say for unnecessary reasons are making these bacteria much stronger.
Sybil Tonkonogy: Now, are we as doctors, and I am not one, but eye doctors and nurses and medical people in hospitals, using more antibiotics, and let us say they did, in the 1900s?
Dr. Perry Hookman: They certainly are using more antibiotics and up until a short time ago, before committees are formed in the hospitals, they realized that these massive use of antibiotics, some of which may be unnecessary, have to be curtailed and controlled. There are many hospital committees now, which watch what the doctors are prescribing and are trying to prevent the most egregious of these practices from taking place.
Sybil Tonkonogy: As you said before, there are definitely special kinds of antibiotics that have caused this.
Dr. Perry Hookman: Yeah. Actually, all antibiotics will cause the evolution of the more fit bacteria. So, for example, if you use penicillin a lot, we now know that you can get penicillin-resistant bacteria. When we use methicillin a lot, we now know that we can get methicillin-resistant bacteria. Those are called MRSA infections. These MRSA infections are merciless in that there are very few ways to handle them and some of them we may call them flesh-eating bacteria because when they get involved into the human skin and flesh, they can actually cause a tremendous amount of necrosis. So, it is not just one antibiotic, but all antibiotics when used extensively will cause the bacteria to evolve into a more fitter bacteria, which can actually surmount the antibiotic defenses, which we can mount. So, it is a race between the bacteria, which are becoming stronger and more virulent and the bacteria which we try to keep making stronger and stronger so that it could kill the bacteria that are already becoming selected to survive through the bacterial crises that they face.
Sybil Tonkonogy: Now, how about if you are not in a hospital and you are taking an antibiotic? Could this happen in a home?
Dr. Perry Hookman: Yes. Actually, now we are beginning to see these bacterial resistant organisms, which used to be seen mostly in hospitals and not only hospitals, but long-term care centers have these problems. For example, there are certain populations that increase risk for C. difficile. The patients who are taking, of course, drugs, antibiotics, even patients who are taking proton pump inhibitors, you know, these are pills, which will cut down acid in people with heartburn who take the strong PPIs like the purple pill Nexium or the other type of heartburn pills, they also are susceptible to getting these infections. Patients who have IBD, which include Crohn's disease and ulcerative colitis have a tendency to get these infections even outside the hospitals as do patients who have serious underlying illnesses or what we call co-morbidities, that is, being sick with more than one disease. We are seeing patients who have had even outpatient surgery get more tendencies to have this disease. Elderly patients have increased tendency for this disease. We are seeing these in immune-compromised conditions, people in whom their immune system are compromised either by disease or by medications they are taking like cortisone. We are even seeing these in the peripartum patient, the people who are pregnant both during the pregnancy and after the pregnancy, but chiefly, we are seeing this healthcare settings, in patients who have prolonged stays in these hospitals and in the long-term care facilities, but in answer to your question are people outside the hospitals getting it, the answer is a definite yes.
Sybil Tonkonogy: Now, you mentioned something like Nexium and, of course, I immediately jumped on that one because I have been taking it for years. I have been taking Nexium so that I am not having heartburn and is the longer I take it, does that have anything to do with it?
Dr. Perry Hookman: Well, we do not know that. We do know that among all people taking Nexium or other such drugs, PPIs, or proton pump inhibitors, which cut down acid in the stomach, we know that an increased percentage of these people are more susceptible to this disease. Now, there are a lot of speculations as to why. People will speculate that the acid in the stomach is a natural barrier to bacteria and C. difficile and if you take a drug to decrease the acid, you are decreasing the natural barrier to the bacteria and, therefore, are more susceptible. We do not know exactly why yet, but we do know that people taking PPIs are increasingly susceptible.
Sybil Tonkonogy: Even advise people not to take that particular type of medication?
Dr. Perry Hookman: Well, no. You cannot advise people not to take a medication that is useful for them, but as with all medications, even aspirin, it is your doctor that has to weigh the risks between the benefits derived from the medicine and the dangers that the medicines cause. So, what I am saying is you should not just buy PPI over-the-counter without a doctor knowing about it and simply buy the drug either in Costco or it is now over-the-counter in many places and in drugstores. You do not buy it for yourself as with any medication until you talk with the doctor and let him help you weigh the risks or, what we say in medicine, do a risk-benefit analysis. Each patient is different and some patients, you have to take it and have to suffer the risk of increasing susceptibility.
Sybil Tonkonogy: Okay. We are going to take a message break at this point to listen to our sponsor. We will be right back with Dr. Hookman in just one moment, so do not go away because we are going to continue our discussion.
[Break]
Sybil Tonkonogy: Welcome back to 1550 Today. This is Sybil Tonkonogy and on the line with us is Dr. Perry Hookman who have had over 30 years experience of internal medicine and gastroenterology, is a Voluntary Associate Professor of Medicine at the University of Miami - Miller School of Medicine, and on the teaching staff of Mount Sinai Hospital in Miami, Florida, and we are talking about a disease called C. difficile and we are talking about how it has developed more and more over the several past years. Dr. Hookman, perhaps you could tell me, is more C. difficile happening because we are using more medications?
Dr. Perry Hookman: Well, in a way, yes. We are using antibiotics on a greater scale than we ever have and because of this, there is an evolution of so-called resistant bugs, we just call them bugs. The bugs become resistant to the antibiotics, not because they look up a book and find out what they can do to become resistant to the antibiotic and develop a technology, but because of evolution. What happens is that the antibiotic designed to kill the bugs do kill the bugs, but some bugs develop a genetic mutation and the ones with the genetic mutation that provides the bug with survival skills in the face of that antibiotic begins to survive more than the bugs that are being killed, which are sensitive to the antibiotic and after a while, the resistant bugs are the ones that populate the human intestinal track. So, for example, if you have a C. difficile sensitive to a common antibiotic, the common antibiotic will kill it, but if you have a resistant bug and you get resistant bugs simply by touching the walls or touching a bed or touching the toilet of a previous patient who has been a carrier of C. difficile, then you have problems. So, the bugs evolve and become much more resistant to the very drugs that we try to kill them with.
Sybil Tonkonogy: Now, doesn't the hospitals when a person has this particular disease, don't they clean it up and sterilize everything that they touched in the hospital?
Dr. Perry Hookman: Yes, they do try and as we are learning more and more about these bugs, if you remember, if you have looked at the review article we wrote for the World Journal of Gastroenterology, which by the way anybody can download on the Internet, just go to the World Journal of Gastroenterology, and this is the April 7, 2009 article, it will tell you most everything you want to know about C. difficile and the way you get and the way it is treated. But yes, the hospitals do know, but it is a very difficult, very difficult organism to eliminate. For example, C. difficile can remain dormant in a hospital room for many weeks and it does so by becoming a spore. A spore is an organism that circles itself in a protective round body and the spore formation of these C. difficiles will go on skin and on doctors' ties and on doctors' shoes and on patients' clothes and anybody who touches these patients, of course, can spread the disease and we are learning that it is very difficult, not even alcohol wipes will take care and eliminate these spores of C. difficile. The important point to remember is that only mechanically getting them off your hands like washing your hands thoroughly with soap and water multiple times will do this, will get of these spores. Only by cleaning the walls and the bathrooms of these patients and any patient, of course, may have it in their room, especially those with diarrhea, previously been there with diarrhea, the wall should be cleaned with a Clorox-type bleach, which is the only thing we find now that can do this. I, for one, advise patients who go into a hospital as a patient to actually initiate the conversation with the nurse to find out whether the walls and the bathrooms have been cleaned by housekeeping with Clorox bleach. That is really the only way that you can be sure that there are no more C. difficile spores lying around the room.
Sybil Tonkonogy: Is it accumulation of let us say how long you take these medications?
Dr. Perry Hookman: Actually, one day or one week or one month of taking the medication has shown the same result. You can see C. difficile infections coming even after one day of taking antibiotics. Everybody is different. Everybody has a different sensitivity. What the antibiotics appear to do is to kill off the good bacteria in the colon, and everybody has very good bacteria, and the bad bacteria take over. When that happens, that is when the C. difficile infection occurs. The C. difficile infection produces huge amounts of toxin and the toxin is what changes the pattern in the disease to make the patient have a lot more diarrhea and a lot more intestinal necrosis. Just to give you an example, before 2002, the average C. difficile bug produced just very low amounts of toxins. We call them toxin A and B and also now, there is another one, a third one, but since then the bug has evolved so the ones especially that are resistant to fluoroquinolones have developed higher degrees of producing the toxins and caused much more damage than they used to.
Sybil Tonkonogy: Is there any way of telling what patient is going to have a reaction? I mean is there any way of telling before the patient takes the medication that maybe that type of [unintelligible]?
Dr. Perry Hookman: Yes. The risk factors are the ones that I mentioned, the patients with those special risk factors. The risk factors for relapses occur in those who have prolonged antibiotic usage and those with prolonged hospitalization and those over age 65 and those who have diverticulosis and in those who have co-morbid medical conditions, that is, a lot of other medical conditions than just one, for example, diabetes and coronary disease and hypertension and various other type of diseases. Now, it is very important that doctors understand that severe C. difficile disease occurs in certain patients with certain characteristics, so you would want to measure and protect these patients with tremendous care and those are older patients, greater than 65 years old; again, the presence of co-morbid conditions; immune-compromising conditions; an organ failure of any type, kidney, lung, or shock; people who have increased white blood counts; renal failure; those that have low serum albumin, that is a certain protein; and various complications of the disease like ileus and toxic megacolon. In patients that develop those kinds of severe disease, the standard of care now is to not wait too long for surgery. Surgery and colectomy is probably the only way to go now rather than to wait around trying to find out if the medications we have will work.
Sybil Tonkonogy: If people who take medications like antibiotics, etc., who are not hospitalized, is there any difference in how they can catch it or is there any lesser frequency of it?
Dr. Perry Hookman: Well, the only difference between being hospitalized now and not being hospitalized is the extent of the disease in terms of populations. In other words, more people will get the disease in the hospitals, or as before 2001, these diseases were very rare outside the hospital, now they are becoming more common. So, you can get this disease both inside the hospital and outside the hospital.
Sybil Tonkonogy: Is there a great deal of study being done on what can be done eventually?
Dr. Perry Hookman: In what way?
Sybil Tonkonogy: How we can somehow lower the levels of C. difficile?
Dr. Perry Hookman: I think the main way to do this is to cut down on the amount of antibiotics being given. That is crucial, especially cut down on the amount of antibiotics being used in hospitals and now every good hospital has a committee in which all the antibiotics that is being given are being studied and trying to eliminate unnecessary administration of antibiotics and at least the unnecessary administration of the fluoroquinolones, which are the antibiotics that have shown to cause increasing resistance of C. difficile infections.
Sybil Tonkonogy: Well, Dr. Hookman, I want to thank you so very much for joining us. I think this has been most interesting and I think at least these people are aware of it. They can take some of the suggestions that you have given them and really think about them and hopefully wash their hands and that seems to be the cure for many, many things and I really believe it. So, I thank you so very much for joining us and it is very important for us to bring this type of information to people.
Dr. Perry Hookman: You are welcome.
Sybil Tonkonogy: Thank you and everybody else, you have a nice day. Be good to yourself. Be good to each other. Drive carefully and I will talk to you next time. Bye-bye.
This is Sybil Tonkonogy with a little laryngitis this morning. I do not know where it came from and wish it would go back to wherever it came from, but anyway, we are going to continue and you, I hope that you remember that I had a very pleasant voice, but here this morning, very, very laryngitisy. So, maybe it will just go away. I would like to present our guest this morning who is Dr. Perry Hookman, who is an Associate Professor of Medicine at the University of Miami - Miller School of Medicine. What we are going to be talking about this morning is a thing called C. difficile and if I said it wrong, Dr. Hookman, please correct me. Hello?
Dr. Perry Hookman: You got it right. You got it right. It is called C. difficile infection.
Sybil Tonkonogy: Difficile.
Dr. Perry Hookman: Or C. difficile, it does not matter.
Sybil Tonkonogy: Difficile, we will call it. Tell us what it is.
Dr. Perry Hookman: Well, C. difficile infection is a very vicious type of infection, which attacks people when they are most vulnerable and that is in the hospital. It is a hospital-acquired infection and it is starting to make a tremendous impact. We know that there is a total of over a 12-year period, there has been a total of two million hospital discharges, which has doubled from a similar period in 2001 to 2005. Before that, the rate was 301,000 and we know now that there is 100% increase in the past four years of this infection. This infection gives patients with a very vicious type of diarrhea in which in many if it is hit by a virulent drug means that their colon has to come out. Basically, it is called C. difficile diarrhea and it is the technical name for pseudomembranous colitis.
Sybil Tonkonogy: Now, perhaps we can talk about it. This is particularly from antibiotics.
Dr. Perry Hookman: Well, that is right. What happens is that the bugs are evolving over a period of time as antibiotics evolve. So, every time we use a stronger antibiotic or different antibiotic and use it on a mass basis, the drugs go through an evolutionary process in which the Darwinian selection takes place and the fetus of the bacteria, or the strongest of the bacteria, able to survive in that environment of the new antibiotic takes hold. The more sensitive ones to the antibiotic die off, but those bacteria that develop through their genes, a different type of gene, which makes it more resistant to that antibiotic take over. This most vicious virulent type of C. difficile we are seeing now is called NAP1, B1, 027, which is the full name for it, talking about the way we type it in the gel-field electrophoresis and endonucleus analysis and a polymerase chain reaction, 027. So, technically, all technical terms aside, we will call this a NAP1 virulent epidemic type of C. difficile, which has evolved on the basis of an antibiotic resistance to the fluoroquinolones like Cipro and other type of antibiotics, which because they are being used more frequently and some would say for unnecessary reasons are making these bacteria much stronger.
Sybil Tonkonogy: Now, are we as doctors, and I am not one, but eye doctors and nurses and medical people in hospitals, using more antibiotics, and let us say they did, in the 1900s?
Dr. Perry Hookman: They certainly are using more antibiotics and up until a short time ago, before committees are formed in the hospitals, they realized that these massive use of antibiotics, some of which may be unnecessary, have to be curtailed and controlled. There are many hospital committees now, which watch what the doctors are prescribing and are trying to prevent the most egregious of these practices from taking place.
Sybil Tonkonogy: As you said before, there are definitely special kinds of antibiotics that have caused this.
Dr. Perry Hookman: Yeah. Actually, all antibiotics will cause the evolution of the more fit bacteria. So, for example, if you use penicillin a lot, we now know that you can get penicillin-resistant bacteria. When we use methicillin a lot, we now know that we can get methicillin-resistant bacteria. Those are called MRSA infections. These MRSA infections are merciless in that there are very few ways to handle them and some of them we may call them flesh-eating bacteria because when they get involved into the human skin and flesh, they can actually cause a tremendous amount of necrosis. So, it is not just one antibiotic, but all antibiotics when used extensively will cause the bacteria to evolve into a more fitter bacteria, which can actually surmount the antibiotic defenses, which we can mount. So, it is a race between the bacteria, which are becoming stronger and more virulent and the bacteria which we try to keep making stronger and stronger so that it could kill the bacteria that are already becoming selected to survive through the bacterial crises that they face.
Sybil Tonkonogy: Now, how about if you are not in a hospital and you are taking an antibiotic? Could this happen in a home?
Dr. Perry Hookman: Yes. Actually, now we are beginning to see these bacterial resistant organisms, which used to be seen mostly in hospitals and not only hospitals, but long-term care centers have these problems. For example, there are certain populations that increase risk for C. difficile. The patients who are taking, of course, drugs, antibiotics, even patients who are taking proton pump inhibitors, you know, these are pills, which will cut down acid in people with heartburn who take the strong PPIs like the purple pill Nexium or the other type of heartburn pills, they also are susceptible to getting these infections. Patients who have IBD, which include Crohn's disease and ulcerative colitis have a tendency to get these infections even outside the hospitals as do patients who have serious underlying illnesses or what we call co-morbidities, that is, being sick with more than one disease. We are seeing patients who have had even outpatient surgery get more tendencies to have this disease. Elderly patients have increased tendency for this disease. We are seeing these in immune-compromised conditions, people in whom their immune system are compromised either by disease or by medications they are taking like cortisone. We are even seeing these in the peripartum patient, the people who are pregnant both during the pregnancy and after the pregnancy, but chiefly, we are seeing this healthcare settings, in patients who have prolonged stays in these hospitals and in the long-term care facilities, but in answer to your question are people outside the hospitals getting it, the answer is a definite yes.
Sybil Tonkonogy: Now, you mentioned something like Nexium and, of course, I immediately jumped on that one because I have been taking it for years. I have been taking Nexium so that I am not having heartburn and is the longer I take it, does that have anything to do with it?
Dr. Perry Hookman: Well, we do not know that. We do know that among all people taking Nexium or other such drugs, PPIs, or proton pump inhibitors, which cut down acid in the stomach, we know that an increased percentage of these people are more susceptible to this disease. Now, there are a lot of speculations as to why. People will speculate that the acid in the stomach is a natural barrier to bacteria and C. difficile and if you take a drug to decrease the acid, you are decreasing the natural barrier to the bacteria and, therefore, are more susceptible. We do not know exactly why yet, but we do know that people taking PPIs are increasingly susceptible.
Sybil Tonkonogy: Even advise people not to take that particular type of medication?
Dr. Perry Hookman: Well, no. You cannot advise people not to take a medication that is useful for them, but as with all medications, even aspirin, it is your doctor that has to weigh the risks between the benefits derived from the medicine and the dangers that the medicines cause. So, what I am saying is you should not just buy PPI over-the-counter without a doctor knowing about it and simply buy the drug either in Costco or it is now over-the-counter in many places and in drugstores. You do not buy it for yourself as with any medication until you talk with the doctor and let him help you weigh the risks or, what we say in medicine, do a risk-benefit analysis. Each patient is different and some patients, you have to take it and have to suffer the risk of increasing susceptibility.
Sybil Tonkonogy: Okay. We are going to take a message break at this point to listen to our sponsor. We will be right back with Dr. Hookman in just one moment, so do not go away because we are going to continue our discussion.
[Break]
Sybil Tonkonogy: Welcome back to 1550 Today. This is Sybil Tonkonogy and on the line with us is Dr. Perry Hookman who have had over 30 years experience of internal medicine and gastroenterology, is a Voluntary Associate Professor of Medicine at the University of Miami - Miller School of Medicine, and on the teaching staff of Mount Sinai Hospital in Miami, Florida, and we are talking about a disease called C. difficile and we are talking about how it has developed more and more over the several past years. Dr. Hookman, perhaps you could tell me, is more C. difficile happening because we are using more medications?
Dr. Perry Hookman: Well, in a way, yes. We are using antibiotics on a greater scale than we ever have and because of this, there is an evolution of so-called resistant bugs, we just call them bugs. The bugs become resistant to the antibiotics, not because they look up a book and find out what they can do to become resistant to the antibiotic and develop a technology, but because of evolution. What happens is that the antibiotic designed to kill the bugs do kill the bugs, but some bugs develop a genetic mutation and the ones with the genetic mutation that provides the bug with survival skills in the face of that antibiotic begins to survive more than the bugs that are being killed, which are sensitive to the antibiotic and after a while, the resistant bugs are the ones that populate the human intestinal track. So, for example, if you have a C. difficile sensitive to a common antibiotic, the common antibiotic will kill it, but if you have a resistant bug and you get resistant bugs simply by touching the walls or touching a bed or touching the toilet of a previous patient who has been a carrier of C. difficile, then you have problems. So, the bugs evolve and become much more resistant to the very drugs that we try to kill them with.
Sybil Tonkonogy: Now, doesn't the hospitals when a person has this particular disease, don't they clean it up and sterilize everything that they touched in the hospital?
Dr. Perry Hookman: Yes, they do try and as we are learning more and more about these bugs, if you remember, if you have looked at the review article we wrote for the World Journal of Gastroenterology, which by the way anybody can download on the Internet, just go to the World Journal of Gastroenterology, and this is the April 7, 2009 article, it will tell you most everything you want to know about C. difficile and the way you get and the way it is treated. But yes, the hospitals do know, but it is a very difficult, very difficult organism to eliminate. For example, C. difficile can remain dormant in a hospital room for many weeks and it does so by becoming a spore. A spore is an organism that circles itself in a protective round body and the spore formation of these C. difficiles will go on skin and on doctors' ties and on doctors' shoes and on patients' clothes and anybody who touches these patients, of course, can spread the disease and we are learning that it is very difficult, not even alcohol wipes will take care and eliminate these spores of C. difficile. The important point to remember is that only mechanically getting them off your hands like washing your hands thoroughly with soap and water multiple times will do this, will get of these spores. Only by cleaning the walls and the bathrooms of these patients and any patient, of course, may have it in their room, especially those with diarrhea, previously been there with diarrhea, the wall should be cleaned with a Clorox-type bleach, which is the only thing we find now that can do this. I, for one, advise patients who go into a hospital as a patient to actually initiate the conversation with the nurse to find out whether the walls and the bathrooms have been cleaned by housekeeping with Clorox bleach. That is really the only way that you can be sure that there are no more C. difficile spores lying around the room.
Sybil Tonkonogy: Is it accumulation of let us say how long you take these medications?
Dr. Perry Hookman: Actually, one day or one week or one month of taking the medication has shown the same result. You can see C. difficile infections coming even after one day of taking antibiotics. Everybody is different. Everybody has a different sensitivity. What the antibiotics appear to do is to kill off the good bacteria in the colon, and everybody has very good bacteria, and the bad bacteria take over. When that happens, that is when the C. difficile infection occurs. The C. difficile infection produces huge amounts of toxin and the toxin is what changes the pattern in the disease to make the patient have a lot more diarrhea and a lot more intestinal necrosis. Just to give you an example, before 2002, the average C. difficile bug produced just very low amounts of toxins. We call them toxin A and B and also now, there is another one, a third one, but since then the bug has evolved so the ones especially that are resistant to fluoroquinolones have developed higher degrees of producing the toxins and caused much more damage than they used to.
Sybil Tonkonogy: Is there any way of telling what patient is going to have a reaction? I mean is there any way of telling before the patient takes the medication that maybe that type of [unintelligible]?
Dr. Perry Hookman: Yes. The risk factors are the ones that I mentioned, the patients with those special risk factors. The risk factors for relapses occur in those who have prolonged antibiotic usage and those with prolonged hospitalization and those over age 65 and those who have diverticulosis and in those who have co-morbid medical conditions, that is, a lot of other medical conditions than just one, for example, diabetes and coronary disease and hypertension and various other type of diseases. Now, it is very important that doctors understand that severe C. difficile disease occurs in certain patients with certain characteristics, so you would want to measure and protect these patients with tremendous care and those are older patients, greater than 65 years old; again, the presence of co-morbid conditions; immune-compromising conditions; an organ failure of any type, kidney, lung, or shock; people who have increased white blood counts; renal failure; those that have low serum albumin, that is a certain protein; and various complications of the disease like ileus and toxic megacolon. In patients that develop those kinds of severe disease, the standard of care now is to not wait too long for surgery. Surgery and colectomy is probably the only way to go now rather than to wait around trying to find out if the medications we have will work.
Sybil Tonkonogy: If people who take medications like antibiotics, etc., who are not hospitalized, is there any difference in how they can catch it or is there any lesser frequency of it?
Dr. Perry Hookman: Well, the only difference between being hospitalized now and not being hospitalized is the extent of the disease in terms of populations. In other words, more people will get the disease in the hospitals, or as before 2001, these diseases were very rare outside the hospital, now they are becoming more common. So, you can get this disease both inside the hospital and outside the hospital.
Sybil Tonkonogy: Is there a great deal of study being done on what can be done eventually?
Dr. Perry Hookman: In what way?
Sybil Tonkonogy: How we can somehow lower the levels of C. difficile?
Dr. Perry Hookman: I think the main way to do this is to cut down on the amount of antibiotics being given. That is crucial, especially cut down on the amount of antibiotics being used in hospitals and now every good hospital has a committee in which all the antibiotics that is being given are being studied and trying to eliminate unnecessary administration of antibiotics and at least the unnecessary administration of the fluoroquinolones, which are the antibiotics that have shown to cause increasing resistance of C. difficile infections.
Sybil Tonkonogy: Well, Dr. Hookman, I want to thank you so very much for joining us. I think this has been most interesting and I think at least these people are aware of it. They can take some of the suggestions that you have given them and really think about them and hopefully wash their hands and that seems to be the cure for many, many things and I really believe it. So, I thank you so very much for joining us and it is very important for us to bring this type of information to people.
Dr. Perry Hookman: You are welcome.
Sybil Tonkonogy: Thank you and everybody else, you have a nice day. Be good to yourself. Be good to each other. Drive carefully and I will talk to you next time. Bye-bye.
Monday, June 15, 2009
PART II OF II. The Key to Reducing Medical Malpractice in the U.S.
Stopping Repeat Offenders: Five Percent Of The Doctors In The United States Are Responsible For Half The Malpractice Claims.
In reality, states a report in Public Citizen only a small percentage of doctors are responsible for the bulk of malpractice in the United States. Public Citizen’s analysis of the National Practitioner Data Bank, which covers malpractice judgments and settlements since September 1990, found that about five percent of the doctors in the United States are responsible for half the malpractice.
Specifically, 4.8 percent of doctors (40,118) have paid two or more malpractice awards to patients. These doctors are responsible for 51 percent of all the reports made to the Data Bank, and have paid out nearly $21 billion in damages, more than 53 percent of the total damages paid. In addition, 14,293 doctors, representing 1.7 percent of the doctors in the U.S., have made three or more payments, totaling $11 billion. These doctors are thus responsible for 27.5 percent of all malpractice awards.
This distribution very much resembles the pattern of drunk driving recidivism says Public Citizen. There are over 6,000 doctors in the U.S. who have paid four or more malpractice claims, amounting to more than $6 billion.
Number of Medical Malpractice Payments and Amounts Paid by Doctors
Number of Payment Reports Number of Doctors Percent/Total Doctors in US Total Number of Payments Total Amount of Payments Percent of Total Number of
Payments
All 147,378 17.6% 219,272 $38,993,664,850 100%
1 107,260 12.8% 107,260 $18,131,973,750 48.9%
2 or more 40,118 4.8% 112,012 $20,861,691,100 51.1%
3 or more 14,293 1.7% 60,362 $11,084,300,850 27.5%
4 or more 6,193 0.7% 36,063 $6,481,629,350 16.5%
5 or more 3,071 0.4% 23,576 $4,073,749,100 10.8%
Redacted records from the National Practitioner Data Bank demonstrate the following examples.
• Physician Number 94358, licensed in New Jersey, settled or lost 33 medical malpractice suits involving improper diagnosis or treatment between 1988 and 1993, inflicting over $400,000 in disability costs to his patients.
• Physician Number 64625, licensed in Pennsylvania, paid 24 medical malpractice claims involving improper performance of surgery between 1989 and 2001. Damages to this doctor’s patients exceeded $370,000.
• Physician Number 125457, while licensed in Nevada, paid 5 malpractice claims involving improper performance of surgery between 1995 and 1997, with damages totalling $2.3 million. Recent news accounts have reported that doctors are fleeing from Las Vegas to other states to avoid high malpractice insurance premiums. Physician 125457 was ahead of the curve in moving his practice to California. There he paid another 8 malpractice claims with damages exceeding $7.5 million.
• Physician Number 37949, licensed in Texas, settled or lost 13 medical malpractice suits involving improper treatment or improper performance of surgery between 1990 and 1997. Two of the suits involved the same allegation—a foreign body left in the patient during surgery. Damages to this doctor’s patients exceeded $2 million.
How about these stories?
• Surgeon Hits Double Digits in Medical Malpractice Complaints is a headline in an Illinois paper-A surgeon had a 15th medical malpractice complaint filed against him after international exposure for allegedly leaving a Russian teen brain dead. This last complaint was filed in civil court and the attorney was mum to details. Among the complaints, the surgeon is a defendant in a litigation involving “wrongful death.”
• A negligent surgeon barred in another state linked to deaths in a VA hospital. A patient hemorrhaged after routine surgery at a VA Hospital The surgeon, was barred from practicing in another state because he had previously been accused of causing life-threatening complications and deaths by providing "grossly substandard care" and making repeated errors in a series of inpatient surgeries shortly associated with post-surgical deaths. The hospital was responsible for a mortality rate over four times the normal amount. The barred surgeon was involved in all of them. The same surgeon had been linked to deaths all over the country.
• A Pennsylvania doctor with 27 malpractice suits no longer has operating privileges in any hospital which fortunately has prevented him from performing further surgeries. He said in December 2008 that he would be on “medical administrative leave" for "several months" but would return to his practice.” Yet despite his record of 27 malpractice lawsuits and settlements, the Pennsylvania Board of Medicine renewed this doctor’s license to practice in December 2008 which is valid through the end of 2010.
RECOMMENDATIONS
Good Ideas:
1. Institute experience rating.
Doctors should be rated on performance for malpractice premiums. Doctors with numerous malpractice claims must be reviewed and higher premiums imposed so that they are discouraged from practicing and competent doctors do not subsidize them.
2. Empower Patients with More Information
Public Citizen has long sought greater consumer access to information about doctors, and there have been recent improvements in making that information available. Most state medical boards now provide some physician information on the Internet, but the information about disciplinary actions varies greatly, is often inadequate and can be difficult for people to access. To read Public Citizen’s survey of state medical board Web sites, go to: http://www.citizen.org/publications/release.cfm?ID=7168
3. Legislate More Information Out to the Public
One state bill that would allow residents to have full access to a physician’s history was approved. The bill was named after a patient who died at age 25 due to when he underwent unnecessary brain surgery after a misdiagnosis of a brain cyst. His neurosurgeon had many previous medical malpractice lawsuits in multiple states. The bill requires the state Board of Medical Examiners to collect information on physicians’ history of disciplinary action, malpractice and license probation, their criminal records, limits on their hospital privileges and their ownership and employment affiliation. This information would then be made public.
Bad Idea
4. Open the National Practitioner Data Bank. Information about doctor discipline, including state sanctions, hospital disciplinary actions and medical malpractice awards is now contained in the National Practitioner Data Bank. HMOs, hospitals and medical boards can look at the National Practitioner Data Bank. The names of physicians in the database are kept secret from the public. Public citizen wants Congress should allow people to get the information they need from this source on the Internet.
This is a bad idea because it will lead to vital information going underground and out of reach of any agencies. It will also weaken those agencies now delegated to deal with these problems in an orderly manner and with due process instead of with a populist witch hunt.
It will make matters worse, because it will force underground what should be reported to the National Data bank-although some critics say it can’t get much worse than this.
A May 27, 2009 Report suggests hospitals not reporting discipline against physicians.
More than a third of Michigan hospitals have never reported a single doctor disciplinary action against a physician in 17 years of a national database, according to the report by a Washington, D.C., health watchdog organization and "nearly half of all hospitals" in the US "failed to report actions against doctors to the National Practitioner Data Bank between Sept. 1, 1990, when the database began, through December 2007." Although "federal law requires hospitals to report physicians who have had their admitting privileges revoked or restricted for more than 30 days," the group "charged that hospitals use loopholes in the law, avoiding filing requirements by putting doctors on leave, or disciplining them for less than 30 days." Public Citizen "sent a letter and recommendations on the issue to HHS secretary including a proposal to "tie a hospital's Medicare reimbursement with its participation in the data bank."
Even doctors with more than two disciplinary actions weren’t reported to the database.
In all, U.S. hospitals filed 11,221 reports to the data bank in its first 17 years, significantly less than the 10,000 a year expected by industry leaders and 5,000 a year the government estimated before beginning the system.It is run by the Health Resources and Services Administration, part of the U.S. Department of Health and Human Services
The report and recommendations are at www.citizen.org.
REFERENCES:
Sloan et al, "Medical Malpractice Experience of Physicians: Predictable or Haphazard?" 262 JAMA 3291 (1989)
www.questionabledoctors.org
http://www.injuryboard.com/national-news/bad-doctors-going undisciplined.aspx?googleid=261504
Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com
Book II –“Medical Expert Testimony: Advanced Syllabus for Physicians and Medical Professionals”
(Hardcover) by Perry Hookman MD (Author) 32 chapters; 936 pages. Proj.Pub date Spring 2009. Publisher: Potomac Press-CRC; ; Language: English ISBN: 978-0-9817570-0-1; ISBN:10:0-9817570-0-6 - Barcode (9780981757001.eps) Dimensions: 10.1 x 7.1 x 2.1 inches; Shipping Weight: 3.0 pounds; Price $289.95; includes CD-ROM. For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com
In reality, states a report in Public Citizen only a small percentage of doctors are responsible for the bulk of malpractice in the United States. Public Citizen’s analysis of the National Practitioner Data Bank, which covers malpractice judgments and settlements since September 1990, found that about five percent of the doctors in the United States are responsible for half the malpractice.
Specifically, 4.8 percent of doctors (40,118) have paid two or more malpractice awards to patients. These doctors are responsible for 51 percent of all the reports made to the Data Bank, and have paid out nearly $21 billion in damages, more than 53 percent of the total damages paid. In addition, 14,293 doctors, representing 1.7 percent of the doctors in the U.S., have made three or more payments, totaling $11 billion. These doctors are thus responsible for 27.5 percent of all malpractice awards.
This distribution very much resembles the pattern of drunk driving recidivism says Public Citizen. There are over 6,000 doctors in the U.S. who have paid four or more malpractice claims, amounting to more than $6 billion.
Number of Medical Malpractice Payments and Amounts Paid by Doctors
Number of Payment Reports Number of Doctors Percent/Total Doctors in US Total Number of Payments Total Amount of Payments Percent of Total Number of
Payments
All 147,378 17.6% 219,272 $38,993,664,850 100%
1 107,260 12.8% 107,260 $18,131,973,750 48.9%
2 or more 40,118 4.8% 112,012 $20,861,691,100 51.1%
3 or more 14,293 1.7% 60,362 $11,084,300,850 27.5%
4 or more 6,193 0.7% 36,063 $6,481,629,350 16.5%
5 or more 3,071 0.4% 23,576 $4,073,749,100 10.8%
Redacted records from the National Practitioner Data Bank demonstrate the following examples.
• Physician Number 94358, licensed in New Jersey, settled or lost 33 medical malpractice suits involving improper diagnosis or treatment between 1988 and 1993, inflicting over $400,000 in disability costs to his patients.
• Physician Number 64625, licensed in Pennsylvania, paid 24 medical malpractice claims involving improper performance of surgery between 1989 and 2001. Damages to this doctor’s patients exceeded $370,000.
• Physician Number 125457, while licensed in Nevada, paid 5 malpractice claims involving improper performance of surgery between 1995 and 1997, with damages totalling $2.3 million. Recent news accounts have reported that doctors are fleeing from Las Vegas to other states to avoid high malpractice insurance premiums. Physician 125457 was ahead of the curve in moving his practice to California. There he paid another 8 malpractice claims with damages exceeding $7.5 million.
• Physician Number 37949, licensed in Texas, settled or lost 13 medical malpractice suits involving improper treatment or improper performance of surgery between 1990 and 1997. Two of the suits involved the same allegation—a foreign body left in the patient during surgery. Damages to this doctor’s patients exceeded $2 million.
How about these stories?
• Surgeon Hits Double Digits in Medical Malpractice Complaints is a headline in an Illinois paper-A surgeon had a 15th medical malpractice complaint filed against him after international exposure for allegedly leaving a Russian teen brain dead. This last complaint was filed in civil court and the attorney was mum to details. Among the complaints, the surgeon is a defendant in a litigation involving “wrongful death.”
• A negligent surgeon barred in another state linked to deaths in a VA hospital. A patient hemorrhaged after routine surgery at a VA Hospital The surgeon, was barred from practicing in another state because he had previously been accused of causing life-threatening complications and deaths by providing "grossly substandard care" and making repeated errors in a series of inpatient surgeries shortly associated with post-surgical deaths. The hospital was responsible for a mortality rate over four times the normal amount. The barred surgeon was involved in all of them. The same surgeon had been linked to deaths all over the country.
• A Pennsylvania doctor with 27 malpractice suits no longer has operating privileges in any hospital which fortunately has prevented him from performing further surgeries. He said in December 2008 that he would be on “medical administrative leave" for "several months" but would return to his practice.” Yet despite his record of 27 malpractice lawsuits and settlements, the Pennsylvania Board of Medicine renewed this doctor’s license to practice in December 2008 which is valid through the end of 2010.
RECOMMENDATIONS
Good Ideas:
1. Institute experience rating.
Doctors should be rated on performance for malpractice premiums. Doctors with numerous malpractice claims must be reviewed and higher premiums imposed so that they are discouraged from practicing and competent doctors do not subsidize them.
2. Empower Patients with More Information
Public Citizen has long sought greater consumer access to information about doctors, and there have been recent improvements in making that information available. Most state medical boards now provide some physician information on the Internet, but the information about disciplinary actions varies greatly, is often inadequate and can be difficult for people to access. To read Public Citizen’s survey of state medical board Web sites, go to: http://www.citizen.org/publications/release.cfm?ID=7168
3. Legislate More Information Out to the Public
One state bill that would allow residents to have full access to a physician’s history was approved. The bill was named after a patient who died at age 25 due to when he underwent unnecessary brain surgery after a misdiagnosis of a brain cyst. His neurosurgeon had many previous medical malpractice lawsuits in multiple states. The bill requires the state Board of Medical Examiners to collect information on physicians’ history of disciplinary action, malpractice and license probation, their criminal records, limits on their hospital privileges and their ownership and employment affiliation. This information would then be made public.
Bad Idea
4. Open the National Practitioner Data Bank. Information about doctor discipline, including state sanctions, hospital disciplinary actions and medical malpractice awards is now contained in the National Practitioner Data Bank. HMOs, hospitals and medical boards can look at the National Practitioner Data Bank. The names of physicians in the database are kept secret from the public. Public citizen wants Congress should allow people to get the information they need from this source on the Internet.
This is a bad idea because it will lead to vital information going underground and out of reach of any agencies. It will also weaken those agencies now delegated to deal with these problems in an orderly manner and with due process instead of with a populist witch hunt.
It will make matters worse, because it will force underground what should be reported to the National Data bank-although some critics say it can’t get much worse than this.
A May 27, 2009 Report suggests hospitals not reporting discipline against physicians.
More than a third of Michigan hospitals have never reported a single doctor disciplinary action against a physician in 17 years of a national database, according to the report by a Washington, D.C., health watchdog organization and "nearly half of all hospitals" in the US "failed to report actions against doctors to the National Practitioner Data Bank between Sept. 1, 1990, when the database began, through December 2007." Although "federal law requires hospitals to report physicians who have had their admitting privileges revoked or restricted for more than 30 days," the group "charged that hospitals use loopholes in the law, avoiding filing requirements by putting doctors on leave, or disciplining them for less than 30 days." Public Citizen "sent a letter and recommendations on the issue to HHS secretary including a proposal to "tie a hospital's Medicare reimbursement with its participation in the data bank."
Even doctors with more than two disciplinary actions weren’t reported to the database.
In all, U.S. hospitals filed 11,221 reports to the data bank in its first 17 years, significantly less than the 10,000 a year expected by industry leaders and 5,000 a year the government estimated before beginning the system.It is run by the Health Resources and Services Administration, part of the U.S. Department of Health and Human Services
The report and recommendations are at www.citizen.org.
REFERENCES:
Sloan et al, "Medical Malpractice Experience of Physicians: Predictable or Haphazard?" 262 JAMA 3291 (1989)
www.questionabledoctors.org
http://www.injuryboard.com/national-news/bad-doctors-going undisciplined.aspx?googleid=261504
Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com
Book II –“Medical Expert Testimony: Advanced Syllabus for Physicians and Medical Professionals”
(Hardcover) by Perry Hookman MD (Author) 32 chapters; 936 pages. Proj.Pub date Spring 2009. Publisher: Potomac Press-CRC; ; Language: English ISBN: 978-0-9817570-0-1; ISBN:10:0-9817570-0-6 - Barcode (9780981757001.eps) Dimensions: 10.1 x 7.1 x 2.1 inches; Shipping Weight: 3.0 pounds; Price $289.95; includes CD-ROM. For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com
Sunday, June 14, 2009
PART I OF II. What is Medical malpractice?
Medical malpractice claims and lawsuits can arise when people are injured by acts of a doctor, nurse, psychiatrist, dentist, chiropractor, podiatrist, hospital, or other healthcare provider which was a “deviation of the standard of medical care.” In legal theory when one’s actions cause an injury to another person (but the actions do not rise to the level of a crime), they are said to be a "tort," or civil wrong, which can provide the basis for a lawsuit. When someone is determined to be legally responsible for injuring someone else, they are liable for the injury, and may be made to pay the injured person compensatory damages.
Terms definition:
Compensatory damages attempt to put an injured person back in the position he or she was in before being injured. In some cases, punitive damages are also awarded in these lawsuits.
Punitive damages are intended to punish wrongdoers and prevent them from harming others.
Specifically medical negligence & malpractice can include
• Missed diagnosis; Mis-diagnosis ; Delayed diagnosis
• Lack of informed consent
• Other Doctor, hospital & healthcare provider deviations in the standard of medical care.
• HMO misconduct
• Adverse drug reactions and their mis-handling
• Improperly prescribed, dispensed or filled medication
The common denominator in all the above is a deviation from the medical standard of care.
This is usually interpreted to be a deviation from what a prudent physician or other healthcare professional of similar training would do or not do in similar circumstances.
It is because of that definition that a medical expert of the same training is called upon to testify on his opinion whether or not the standard of medical care had been met or not.
What is Wrongful Death?
Wrongful death as a legal term is a death that has been caused by the fault of another person. For example, deaths caused by drunk driving, the manufacture of a defective or dangerous product, the construction of an unsound structure or building, or failing to diagnose a fatal disease may be considered under the law as "wrongful deaths".
• Wrongful death lawsuits or claims are generally filed by family members or beneficiaries of the decedent. In some instances, these claims are filed in order to obtain monetary damages to cover the earnings the deceased person would have provided.
Preventable Adverse Events
The National Quality Forum created a list of adverse malpractice issues.
This list contains serious medical malpractice events with dire consequences. They should not happen because they are so easily preventable.
These listed issues are:
• Switching donor eggs or sperm, resulting in paternity mixups
• Leaving of sponges or instruments inside a surgery patient.
• Disappearance of a patient from a facility.
• Medication errors (wrong drug, wrong patient, wrong dose, etc.)
• Giving wrong blood type.
• Electric shock to a patient.
• Fall of a patient.
• Surgery performed on the wrong body side or organ or on the wrong patient.
• Death during or after surgery on a healthy patient under anesthesia.
• Contaminated drugs or medical devices.
• Medical device malfunction or improper use.
• Air embolisms.
• Babies discharged to wrong parents.
• Patient suicide.
• Death or injury to a mother during low-risk pregnancy.
• patient developing hypoglycemia.
• Failing to identify high bilirubin in infants leading to death.
• Advanced pressure sores.
• Death or injury in spine manipulative therapy.
• Oxygen or other gas lines being switched or contaminated.
• Burn of a patient.
• Injury or death from restraints.
• Impersonation of a health care worker.
• Kidnapping of a patient.
• Assault of a patient or Assault or battery between staffers.
How successful are plaintiffs in medical malpractice litigation?
Using North Carolina data, Neil Vidmar, Russell M. Robinson II Professor of Law at Duke University Law School, and author of Medical Malpractice and the American Jury: Confronting the Myths About Jury Incompetence, Deep Pockets and Outrageous Damage Awards (1995), concludes that most claims grow from serious injuries. Minor or emotional injuries accounted for less than 5 percent of claims. Most claims are based on disability, or death. Just 17 out of 895 cases got anything at all. Among the 895 North Carolina cases Vidmar examined, just eighty-four reached the stage of trial by jury. Plaintiffs prevailed on the issue of liability in seventeen of the cases. There were three awards of at least $1 million, along with one for $750,000 and two for $300,000.
The remainder of the trials, though, resulted in much more modest sums, down to $4,000. "The most striking impression from these verdict statistics is that plaintiffs did not do well with juries," writes Vidmar. "They won less than one case in five. When they did receive an award, the amount was usually low."
REFERENCES:
Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com
Book II –“Medical Expert Testimony: Advanced Syllabus for Physicians and Medical Professionals”
(Hardcover) by Perry Hookman MD (Author) 32 chapters; 936 pages. Proj.Pub date Spring 2009. Publisher: Potomac Press-CRC; ; Language: English ISBN: 978-0-9817570-0-1; ISBN:10:0-9817570-0-6 - Barcode (9780981757001.eps) Dimensions: 10.1 x 7.1 x 2.1 inches; Shipping Weight: 3.0 pounds; Price $289.95; includes CD-ROM. For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com
Terms definition:
Compensatory damages attempt to put an injured person back in the position he or she was in before being injured. In some cases, punitive damages are also awarded in these lawsuits.
Punitive damages are intended to punish wrongdoers and prevent them from harming others.
Specifically medical negligence & malpractice can include
• Missed diagnosis; Mis-diagnosis ; Delayed diagnosis
• Lack of informed consent
• Other Doctor, hospital & healthcare provider deviations in the standard of medical care.
• HMO misconduct
• Adverse drug reactions and their mis-handling
• Improperly prescribed, dispensed or filled medication
The common denominator in all the above is a deviation from the medical standard of care.
This is usually interpreted to be a deviation from what a prudent physician or other healthcare professional of similar training would do or not do in similar circumstances.
It is because of that definition that a medical expert of the same training is called upon to testify on his opinion whether or not the standard of medical care had been met or not.
What is Wrongful Death?
Wrongful death as a legal term is a death that has been caused by the fault of another person. For example, deaths caused by drunk driving, the manufacture of a defective or dangerous product, the construction of an unsound structure or building, or failing to diagnose a fatal disease may be considered under the law as "wrongful deaths".
• Wrongful death lawsuits or claims are generally filed by family members or beneficiaries of the decedent. In some instances, these claims are filed in order to obtain monetary damages to cover the earnings the deceased person would have provided.
Preventable Adverse Events
The National Quality Forum created a list of adverse malpractice issues.
This list contains serious medical malpractice events with dire consequences. They should not happen because they are so easily preventable.
These listed issues are:
• Switching donor eggs or sperm, resulting in paternity mixups
• Leaving of sponges or instruments inside a surgery patient.
• Disappearance of a patient from a facility.
• Medication errors (wrong drug, wrong patient, wrong dose, etc.)
• Giving wrong blood type.
• Electric shock to a patient.
• Fall of a patient.
• Surgery performed on the wrong body side or organ or on the wrong patient.
• Death during or after surgery on a healthy patient under anesthesia.
• Contaminated drugs or medical devices.
• Medical device malfunction or improper use.
• Air embolisms.
• Babies discharged to wrong parents.
• Patient suicide.
• Death or injury to a mother during low-risk pregnancy.
• patient developing hypoglycemia.
• Failing to identify high bilirubin in infants leading to death.
• Advanced pressure sores.
• Death or injury in spine manipulative therapy.
• Oxygen or other gas lines being switched or contaminated.
• Burn of a patient.
• Injury or death from restraints.
• Impersonation of a health care worker.
• Kidnapping of a patient.
• Assault of a patient or Assault or battery between staffers.
How successful are plaintiffs in medical malpractice litigation?
Using North Carolina data, Neil Vidmar, Russell M. Robinson II Professor of Law at Duke University Law School, and author of Medical Malpractice and the American Jury: Confronting the Myths About Jury Incompetence, Deep Pockets and Outrageous Damage Awards (1995), concludes that most claims grow from serious injuries. Minor or emotional injuries accounted for less than 5 percent of claims. Most claims are based on disability, or death. Just 17 out of 895 cases got anything at all. Among the 895 North Carolina cases Vidmar examined, just eighty-four reached the stage of trial by jury. Plaintiffs prevailed on the issue of liability in seventeen of the cases. There were three awards of at least $1 million, along with one for $750,000 and two for $300,000.
The remainder of the trials, though, resulted in much more modest sums, down to $4,000. "The most striking impression from these verdict statistics is that plaintiffs did not do well with juries," writes Vidmar. "They won less than one case in five. When they did receive an award, the amount was usually low."
REFERENCES:
Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com
Book II –“Medical Expert Testimony: Advanced Syllabus for Physicians and Medical Professionals”
(Hardcover) by Perry Hookman MD (Author) 32 chapters; 936 pages. Proj.Pub date Spring 2009. Publisher: Potomac Press-CRC; ; Language: English ISBN: 978-0-9817570-0-1; ISBN:10:0-9817570-0-6 - Barcode (9780981757001.eps) Dimensions: 10.1 x 7.1 x 2.1 inches; Shipping Weight: 3.0 pounds; Price $289.95; includes CD-ROM. For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com
Saturday, June 13, 2009
ADRENAL INCIDENTALOMAS
In medicine, an incidentaloma is a tumor (-oma) found by coincidence (incidental) without clinical symptoms or suspicion. It is a common problem with the current rate of imaging and is the name given to a lesion found by accident when doing x-rays or other imaging procedures for something else. These lesions or masses are found on the adrenal gland which sits on top of the kidney.
Up to 7% of all patients over 60 may harbor a benign growth, often of the adrenal gland, which is detected when diagnostic imaging is used for the analysis of unrelated symptoms. With the increase of "whole-body CT scanning" as part of health screening programs, the chance of finding incidentalomas is expected to increase. 37% of patients receiving whole-body CT scan may have abnormal findings that need further evaluation.
When faced with an unexpected finding on diagnostic imaging, the clinician faces the challenge to prove that the lesion is indeed harmless. Other tests are required to determine the exact nature of an incidentaloma.
What are the facts about adrenal masses discovered during imaging for non-adrenal related causes?
• It is the commonest adrenal 'disorder'
• Found during 1-5% of abdominal CT scans
• 5-10% patients have non-functioning adrenal masses found at postmortem examination
• Male to female ratio is equal
• Most incidentalomas are benign and hormonally inactive
• Few patients require adrenalectomy
• Diagnostic assessment needs to evaluate:
o Is the lesion hormonally active
o Is the lesion malignant
Tom Cawood states that evaluation of adrenal incidentalomas is costly, has high false positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant and it’s time for a re-think of the whole matter. Cawood suggests that we-re-assess the performance of current clinical recommendations for the evaluation of an adrenal incidentaloma.
Cawood performed a literature review of electronic databases (Pubmed, Ovid and citation searches from key articles) from 1980 to 2008. Eligible studies were those deemed most applicable to the clinical scenario of a patient referred to an endocrinologist for assessment of an incidentally detected adrenal mass. Surgical series, histopathological series and oncological series were reviewed and most were excluded.
Results:
• The prevalence of functional and malignant lesions presenting as adrenal incidentaloma was similar to that quoted in most reviews, other than a lower incidence of adrenal carcinoma (1.9% vs 4.7%) and metastases (0.7% vs 2.3%).
• The development of functionality or malignancy during follow-up was rare (<1% style="font-weight: bold;">Bottom Line:
This argues for a review of current guidelines.
Current recommendations for evaluation of adrenal incidentaloma are likely to result in significant cost, both financial and emotional, due to high false-positive rates.
The dose of radiation involved in currently recommended CT scan follow-up confers a risk of fatal cancer that is similar to the risk of the adrenal becoming malignant.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
Up to 7% of all patients over 60 may harbor a benign growth, often of the adrenal gland, which is detected when diagnostic imaging is used for the analysis of unrelated symptoms. With the increase of "whole-body CT scanning" as part of health screening programs, the chance of finding incidentalomas is expected to increase. 37% of patients receiving whole-body CT scan may have abnormal findings that need further evaluation.
When faced with an unexpected finding on diagnostic imaging, the clinician faces the challenge to prove that the lesion is indeed harmless. Other tests are required to determine the exact nature of an incidentaloma.
What are the facts about adrenal masses discovered during imaging for non-adrenal related causes?
• It is the commonest adrenal 'disorder'
• Found during 1-5% of abdominal CT scans
• 5-10% patients have non-functioning adrenal masses found at postmortem examination
• Male to female ratio is equal
• Most incidentalomas are benign and hormonally inactive
• Few patients require adrenalectomy
• Diagnostic assessment needs to evaluate:
o Is the lesion hormonally active
o Is the lesion malignant
Tom Cawood states that evaluation of adrenal incidentalomas is costly, has high false positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant and it’s time for a re-think of the whole matter. Cawood suggests that we-re-assess the performance of current clinical recommendations for the evaluation of an adrenal incidentaloma.
Cawood performed a literature review of electronic databases (Pubmed, Ovid and citation searches from key articles) from 1980 to 2008. Eligible studies were those deemed most applicable to the clinical scenario of a patient referred to an endocrinologist for assessment of an incidentally detected adrenal mass. Surgical series, histopathological series and oncological series were reviewed and most were excluded.
Results:
• The prevalence of functional and malignant lesions presenting as adrenal incidentaloma was similar to that quoted in most reviews, other than a lower incidence of adrenal carcinoma (1.9% vs 4.7%) and metastases (0.7% vs 2.3%).
• The development of functionality or malignancy during follow-up was rare (<1% style="font-weight: bold;">Bottom Line:
This argues for a review of current guidelines.
Current recommendations for evaluation of adrenal incidentaloma are likely to result in significant cost, both financial and emotional, due to high false-positive rates.
The dose of radiation involved in currently recommended CT scan follow-up confers a risk of fatal cancer that is similar to the risk of the adrenal becoming malignant.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
Subscribe to:
Posts (Atom)
Posts
