Category Archives: Surgery

Whoa! Before you give the kid the keys to the car . . .

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You’ve been protecting your kids their whole lives. So don’t just hand them the keys to a two-ton machine with no rules… Talk it out. Tell your teenagers they have to agree to 5 rules to drive:

  1. No cell phones,
  2. No extra passengers,
  3. No speeding,
  4. No alcohol, and
  5. Buckle-up.

Set the rules before they hit the road.

Learn more here.

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Pressure from providers leads some women to have C-sections, inductions

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Blue Pregnant BellyBy Christen Brownlee
Health Behavior News Service

Pregnant women who felt pressured to have a labor induction or cesarean section by their obstetrical care providers were significantly more likely to have these procedures, even if there was no medical need for them, suggests a new study in the journal Health Services Research.

Both cesarean deliveries and labor inductions continue to rise, accounting for about a third of births in the U.S.

While both procedures can be life saving for mothers and babies, previous studies have found that they can also increase the risk of poor health outcomes, such as respiratory problems for newborns and infections and death for mothers, as well as significantly increasing health care costs. Continue reading

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A new look at why surgical rates vary

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surgeons performing surgery in operating roomBy Michael Ollove
Stateline

Several years ago, a California study showed that a half-dozen elective surgeries were being performed far more often in Humboldt County than they were in the rest of the state.

The procedures included hip and knee replacements, hysterectomies and carotid endarterectomies, a surgery to remove plaque buildup in the carotid arteries.

Geographical variation in the delivery of health care can harm patients and increase costs. That is especially true when it comes to surgery, which is usually more expensive and riskier than less invasive treatments.

Medicaid makes up a huge portion of state budgets, so the issue of health care variation is a pressing one for states looking to hold down costs.

In Humboldt County, doctors, hospitals, and others involved in health care wondered why surgeons in their area operated so often, and if they could do anything to get closer to the state norms.

To find out, they launched the Humboldt County Surgical Rate Project, which brought together doctors, health-care advocates, community organizations, unions, colleges and small employers.

As it turned out, a large part of “what was actually happening out there” was surprisingly simple . . .

“We weren’t trying to identify anyone as a ‘bad guy,’” said Betsy Stapleton, a retired nurse practitioner who is the co-director of the Humboldt County Surgical Rate Project. “The idea was to identify what was actually happening out there and to figure out ways to address it. It led to really fascinating conversations.”

As it turned out, a large part of “what was actually happening out there” was surprisingly simple: Patients in Humboldt County weren’t playing a big enough part in their own health care decisions. Continue reading

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Seeking cheaper care, patients take online bids from doctors

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This KHN story also ran in wapo.

Francisco Velazco couldn’t wait any longer. For several years, the 35-year-old Seattle handyman had searched for an orthopedic surgeon who would reconstruct the torn ligament in his knee for a price he could afford.

Out of work because of the pain and unable to scrape together $15,000 – the cheapest option he could find in Seattle – Velazco turned to an unconventional and controversial option: an online medical auction site called Medibid, which largely operates outside the confines of traditional health insurance.

The four-year-old online service links patients seeking non-emergency care with doctors and facilities that offer it, much the way Priceline unites travelers and hotels. Continue reading

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Women’s Health – Week 36: Pelvic Floor Disorders

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tacuin womenFrom the Office of Research on Women’s Health

The term pelvic floor refers to the group of muscles and connective tissue that form a sling or hammock across the opening of a woman’s pelvis.

These muscles and tissues keep all of your pelvic organs in place so that the organs can function correctly.

A pelvic floor disorder occurs when your pelvic muscles and connective tissue in the pelvis is weak due to factors such as genetics, injury, or aging. Continue reading

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Republicans say no to CDC gun violence research

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Giving the Centers for Disease Control and Prevention money for gun violence research is a “request to fund propaganda,” a Georgia congressman says.

GunBy Lois Beckett
ProPublica, April 21, 2014

After the Sandy Hook school shooting, Rep. Jack Kingston (R-GA) was one of a few congressional Republicans who expressed a willingness to reconsider the need for gun control laws.

“Putgunson thetable, also put video games on thetable, put mental health on the table,” he said less than a week after the Newtown shootings.

He told a local TV station that he wanted to see more research done to understand mass shootings. “Let’s let the data lead rather than our political opinions.”

For nearly 20 years, Congress has pushed the Centers for Disease Control and Prevention (CDC) to steer clear of firearms violence research. Continue reading

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Why hospitals are failing civilians who get PTSD

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Gunby Lois Beckett
ProPublica, March 4, 2014

More than 20 percent of civilians with traumatic injuries may develop PTSD. Trauma surgeons explain why many hospitals aren’t doing anything about it.

Undiagnosed post-traumatic stress disorder is having a major impact on injured civilians, particularly those with violent injuries, as Propublica detailed last month.

One national study of patients with traumatic injuries found that more than 20 percent of them developed PTSD.

But many hospitals still have no systematic approach to identifying patients with PTSD or helping them get treatment.

We surveyed 21 top-level trauma centers in cities with high rates of violence. The results show that trauma surgeons across the country see PTSD as a serious problem.  Continue reading

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Insurance, not Injuries, may determine who goes to trauma centers

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Sign for an emergency room.By Sarah Varney
KHN Staff Writer

FEB 20, 2014

It’s called “patient dumping” – when hospitals transfer patients without insurance to public hospitals.

But a new study from Stanford University has turned dumping on its head.

It finds that hospitals are less likely to transfer critically injured patients to trauma centers if they have health insurance.  Continue reading

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When a university hospital backs a surgical robot, controversy ensues

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DaVinci ad1By Charles Ornstein
ProPublica, Feb. 14, 2014

Flipping through the New York Times magazine a few Sundays ago, former hospital executive Paul Levy was taken aback by a full-page ad for the da Vinci robot.

It wasn’t that Levy hadn’t seen advertising before for the robot, which is used for minimally invasive surgeries. It was that the ad prominently featured a dozen members of the surgery team at the University of Illinois Hospital and Health Sciences System. “We believe in da Vinci surgery because our patients benefit,” read the ad’s headline.

“While I have become accustomed to the many da Vinci ads, I was struck by the idea that a major university health system had apparently made a business judgment that it was worthwhile to advertise outside of its territory, in a national ad in the New York Times,” Levy, former chief executive of the prestigious Beth Israel Deaconess Medical Center in Boston, told me by email.  Continue reading

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Over-the-counter pills left out of FDA acetaminophen limits

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By Jeff Gerth and T. Christian Miller
ProPublica

January 16, 2014 – Earlier this week, the U.S. Food and Drug Administration urged health care providers to stop writing prescriptions for pain relievers containing more than 325 milligrams of acetaminophen, the active ingredient in Tylenol.

The agency’s announcement was aimed primarily at popular prescription medicines that combine acetaminophen with a more powerful opioid such as hydrocodone.

Agency officials said they had determined that “there are no available data” to show that the benefits of having more than 325 milligrams of acetaminophen in a single pill outweighed the risks from taking too much of the drug. Continue reading

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Does knowing medical prices save money? California experiment says yes

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Hip replacement  - thumbBy Ankita Rao

The fact that the cost of a hip replacement can ring up as $15,000 or $100,000 — depending on the hospital — makes a lot of people uncomfortable. But that’s only if they know about the wide price tag variations.

In an effort to raise awareness and rein in what can seem like the Wild West of health care, the California Public Employees’ Retirement System (CalPERS), the second largest benefits program in the country, and Anthem Blue Cross started a “reference pricing” initiative in 2011.

The initiative involved a system to guide their enrollees to choose facilities where routine hip and knee replacement procedures cost less than $30,000.

Here’s how it works: The CalPERS program designated certain hospitals that met this cost threshold, and enrollees who chose among these facilities pay only the plan’s typical deductible and coinsurance up to the out-of-pocket maximum.

Patients who opted for other in-network hospitals were responsible for regular cost sharing and “all allowed amounts exceeding the $30,000 threshold, which are not subject to an out-of-pocket maximum,” noted the report.

The results tallied savings of $2.8 million for CalPERS, and $300,000 in patients’ cost sharing, according to research released Thursday by the Center for Studying Health System Change for the non-profit group National Institute for Health Care Reform.

Researchers found that patients who received “intensive communication” from CalPERS were supportive of the efforts and recognized lack of price transparency in the system. The report also said enrollees were satisfied with the level of care they received when choosing facilities that met their cost threshold.

But that information has yet to reach the larger population of health consumers, said Alwyn Casill, the director of public relations for the Center for Studying Health System Change.

“There is a tremendous need to increase public awareness of this problem,” she said. “It should matter to you as someone who is paying for health care, not just for you, but for everybody.”

While the report doesn’t completely detail CalPERS’ approach to reference pricing, Casill said there is optimism that it will be a model for other insurance plans and medical systems.

But that is further limited by the narrow focus of this initiative on just two kinds of procedures — others, like MRIs and CAT scans, are also vulnerable to wide pricing disparities.

Some experts say any real success on streamlining health care costs will include the ability for consumers to understand the issue and call for change.

“The numbers are dramatic,” said Julie Schoenman, director of research and quality at the National Institute For Health Care Management Foundation, a non-profit educational organization unaffiliated with the report. “I think you really do need to have good quality measures, good transparency. And a lot of patient education.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Robot

As robot-assisted surgery expands, are patients and providers getting enough information?

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RobotBy Marissa Evans
KHN Staff Writer

The use of robotic surgical systems is expanding rapidly, but hospitals, patients and regulators may not be getting enough information to determine whether the high tech approach is worth its cost.

Problems resulting from surgery using robotic equipment—including deaths—have been reported late, inaccurately or not at all to the Food and Drug Administration, according to one study.

The study, published in the Journal for Healthcare Quality earlier this year, focused on incidents involving Intuitive Surgical’s da Vinci Robotic Surgical System over nearly 12 years, scrubbing through several data bases to find troubled outcomes.

Researchers found 245 incidents reported to the FDA, including 71 deaths and 174 nonfatal injuries. But they also found eight cases in which reporting fell short, including five cases in which no FDA report was filed at all.

The FDA assesses and approves products based on reported device-related complications. If a medical device malfunctions, hospitals are required to report the incident to the manufacturer, which then reports it to the agency. The FDA, in turn, creates a report for its Manufacturer and User Facility Device Experience database.

The use of surgical robots has grown rapidly since it was first approved for laparoscopic surgery (a type of surgery that uses smaller incisions than in traditional surgery) by the FDA in 2000. Between 2007 and 2011 the number of da Vinci systems installed increased by 75 percent in the United States from 800 to 1,400, according to the study.

Noting that robotic surgery has promising benefits, the study also called it “essential that device related complications be uniformly captured, reported and evaluated,” so the medical community fully understands “the safety of the new technology.”

Intuitive Surgical, the makers of the da Vinci device, released a statement last monthtaking issue with the study’s findings.

“The Journal for Healthcare Quality article gives the misleading impression that Intuitive Surgical has systematically failed in its obligation to timely report known adverse events to the FDA,” the statement said. “Intuitive Surgical can only report adverse events after it becomes aware of them. We take this requirement very seriously and make every effort to account for all reportable events—even those from several years prior.”

The company said it agreed regarding the “need for a more robust and standardized system for reporting adverse events” but also encouraged the study’s authors “to conduct a comparable study that assesses the under reporting of both open and laparoscopic surgical events and would welcome a comparison with robotic-assisted surgery.”

Health care professionals say benefits to robotic surgery compared with traditional open surgery include smaller incisions, shorter hospital stays and less pain after the operation.

Dr. Martin A. Makary, an associate professor of surgery and health policy and management at John Hopkins University and one of the study’s authors,  said that, while the future for robotic surgery is promising, there is a gray area when it comes to assessing the difference between doctor and device error. And benefits from the use of the device may be inconsistent, he said.

Robotic surgery has shown benefits when it comes to head and neck surgery, he said, but there’s not necessarily a stark difference between a conventional laparoscopic or robotic-assisted surgery when it comes to gall bladder removal.

Comparing patient outcomes from conventional and robotic surgeries is important for determining which is best for patients and insurers and whether it is worth the extra cost. A study in the Journal of the American Medical Association compared robotically assisted hysterectomies with traditional laparoscopic surgeries over a three year period and found the former added an average of $2,000 in costs per procedure—nearly a third higher—with no significant clinical advantages.

Noting that information, the American Congress of Obstetricians and Gynecologists released a statement in March, advising patients that “robotic hysterectomy is best used for unusual and complex clinical conditions in which improved outcomes over standard minimally invasive approaches have been demonstrated.”

The ACOG statement noted that “if robotic surgery is used for all hysterectomies each year,” it would add an estimated $960 million to $1.9 billion to the annual cost of hysterectomy surgeries.

Even if better data were available through the FDA, that information might not make it to the patient.

Makary and his co-authors noted an earlier finding that “among the 37 percent of U.S. hospitals that describe robotic surgery on their hospital website, none mentioned any potential risks or complications.

“We rely on a haphazard reporting system that uses immature data and only the best experiences make it into the data,” Makary said. “We introduce things but we don’t evaluate them very well. If we’re relying on the FDA about what (products) are superior, then we need a new process…you can’t make conclusions on the safety profile of a device based on a shoddy reporting system.”

The study noted that one patient’s injury and death occurred in 2009, but no such incident was found in the FDA’s database for that year.  The authors found ”a very late report matching his case in 2010,” received by the FDA two weeks after the Wall Street Journal ran a story citing the case.

The agency issues warning letters to manufacturers who fail to meet their reporting obligations. If manufacturers still fail to report incidents, the FDA can exercise enforcement and compliance options, including product seizures or injunctions.

But the agency admits that its reporting system has limitations.

“Complaints or adverse event reports do not necessarily directly indicate a faulty or defective medical device, and adverse event reports alone cannot be used to establish or compare rates of event occurrence,” said FDA spokeswoman Synim Rivers in an email. “For these reasons, the FDA also evaluates other information to make decisions about a device’s safety and effectiveness once a device is on the market.”

James F. Blumstein, director of the Vanderbilt Health Policy Center and Professor of Constitutional  Law and Health Law & Policy, said with robotic surgery, for patients it’s not necessarily about knowing which procedure would be best but being fully informed of their options. He said that if there are known injuries and routine problems, health care providers need to disclose that information to patients.

“If you as a patient are going to a doctor, and they’re using a robot, it’s a question of who’s in charge,” Blumstein said. “If it’s a mechanical malfunction, would the professional standard of care apply to a robot?”

If problems occur during robotic surgery and subsequent litigation, a question might arise about whether the doctor, the hospital or the manufacturer was responsible, introducing the potential issue of product liability. But there may be protection for doctors performing robotic surgery in disclosing the risks, Blumstein said.

“If a doctor discloses to a patient there’s a comparative risk (between regular surgery and robotic surgery) and that disclosed risk materializes, I would have a hard time thinking the doctor would be considered negligent,” he said.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Jerral Hancock and Stacie Tscherny Portrait

Finally home, injured vets face new lives as VA faces costs

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By Jessica Wilde, News21

This report is part of a project on post-9/11 veterans in America produced by the Carnegie-Knight News21 program.

Jerral Hancock wakes up every night in Lancaster, Calif., around 1 a.m. dreaming he is trapped in a burning tank. He opens his eyes, but he can’t move, he can’t get out of bed and he can’t get a drink of water.

Stacie Tscherny dropped everything to take care of her son, U.S. Army veteran Jerral Hancock, when he came home from Iraq without an arm. She helps take care of his two children now as well. (Photo by Jessica Wilde/News21)

Hancock, 27, joined the Army in 2004 and went to Iraq, where he drove a tank. On Memorial Day 2007 — one month after the birth of his second child — Hancock drove over an IED. Just 21, he lost his arm and the use of both legs, and now suffers from post-traumatic stress disorder.

The Department of Veterans Affairs pays him $10,000 every month for his disability, his caretakers, health care, medications and equipment for his new life.

Jerral Hancock and Stacie Tscherny Portrait

Stacie Tscherny dropped everything to take care of her son, U.S. Army veteran Jerral Hancock, when he came home from Iraq without an arm. She helps take care of his two children now as well. (Photo by Jessica Wilde/News21)

No government agency has calculated fully the lifetime cost of health care for the large number of post-9/11 veterans of the wars in Iraq and Afghanistan with life-lasting wounds.

But it is certain to be high, with the veterans’ higher survival rates, longer tours of duty and multiple injuries, plus the anticipated cost to the VA of reducing the wait times for medical appointments and reaching veterans in rural areas.

“Medical costs peak decades later,” said Linda Bilmes, a professor in the Kennedy School of Government at Harvard University and coauthor of “The Three Trillion Dollar War: The True Cost of the Iraq Conflict.”

As veterans age, their injuries worsen over time, she said. The same long-term costs seen in previous wars are likely to be repeated to a much larger extent.

Post-9/11 veterans in 2012 cost the VA $2.8 billion of its $50.9 billion health budget for all of its annual costs, records show. And that number is expected to increase by $510 million in 2013, according to the VA budget.

Like Hancock, many veterans returning from Iraq and Afghanistan have survived multiple combat injuries because of military medicine’s highly advanced care. Doctors at Brooke Army Medical Center in San Antonio repaired Hancock’s body with skin grafts and sent him to spinal-cord doctors for the shrapnel that ultimately left him paralyzed. He still has his right arm, but he can only move the thumb on his right hand.

Injuries like Hancock’s likely will lead to other medical issues, ranging from heart disease to diabetes, for example, as post-9/11 veterans age.

“So we have the same phenomenon but to a much greater extent,” Bilmes said. “And that drives a lot of the long-term costs of the war, which we’re not looking at the moment, but which will hit in 30, 40, 50 years from now.”

Veterans like Hancock with polytraumatic injuries will require decades of costly rehabilitation, according to a 2012 Military Medicine report that analyzed the medical costs of war through 2035. More than half of Iraq and Afghanistan veterans are between the ages of 18 and 32, according to 2011 American Community Survey data. They are expected to live 50 more years, the Institute of Medicine reports.

About 25 percent of post-9/11 veterans suffer from post-traumatic stress disorder, and 7 percent have traumatic brain injury (TBI), according to Congressional Budget Office analyses of VA data. The average cost to treat them is about four to six times greater than those without these injuries, CBO reported. And polytrauma patients cost an additional 10 times more than that.

Post-9/11 veterans use the VA more than other veterans and their numbers are growing at the fastest rate. Fifty-six percent of Iraq and Afghanistan veterans use the VA now, and their numbers are expected to grow by 9.6 percent this year and another 7.2 percent next year, according to a VA report from March 2013.

Jerral Hancock Drinking Water

Hancock drove over an IED in Iraq in 2007. Hancock’s stepfather, Dirrick Benjamin, helps him take his medication. He and Hancock’s mother take care of him full time, helping him with everyday tasks like getting dressed and drinking water. (Photo by Jessica Wilde/News21)

 

In response to multiple injuries suffered by Iraq and Afghanistan veterans, the VA established its polytrauma care system in 2005, creating centers around the country where veterans are treated for multiple injuries, ranging from TBI and PTSD to amputations, hearing loss, visual impairments, spinal-cord injuries, fractures and burns.

Post-9/11 veterans make up around 90 percent of polytrauma patients, said Susan Lucht, program manager of the polytrauma center at the Southern Arizona VA Health Care System in Tucson.

Each polytrauma patient costs the VA on average $136,000 a year, according to a CBO report, using VA data from 2004 through 2009. And many of their medical issues will never go away.

One TBI patient at the Tucson center, Erik Castillo, has received speech, physical, occupational, psychological and recreational therapies for all of the paralysis, cognition and memory issues associated with injuries he received in a bomb blast in Baghdad.

But Castillo’s treatment is exactly what medical professionals and economists say could potentially be cost-saving as well as life-saving.

If the VA treats primary injuries early on and creates a community and family support system, it might be able to lower costs later, said Dr. James Geiling, Dr. Joseph Rosen and Ryan Edwards, an economist, in their 2012 Military Medicine report.

“And those are the costs that we’re trying to reduce by giving the care that we do,” said Dr. G. Alex Hishaw, a staff neurologist at the Tucson center.

Castillo has been living with TBI for nine years, and he still goes to the VA three times a week for therapy. “I’ll utilize the VA for the rest of my life,” he said.

The shrapnel that entered Castillo’s brain from a bomb in Baghdad in 2004 burned a portion of his frontal lobe, which had to be removed. Doctors told his parents that he wouldn’t survive and that if he did, he would need care for the rest of his life.

Slowly, Castillo started to re-create himself. He learned to talk again, to eat again, to move his left arm and leg. Now, he is going to college.

“We want them to graduate,” Lucht said. “But they always know that this is their foundation. This space is here. And their needs will change as they age.”

As Hancock and other post-9/11 veterans age, they will need increased medical care and will become more expensive for the VA. The injuries they have now will likely lead to more complicated and expensive medical issues. TBI, for example, may lead to greater risk of Alzheimer’s disease, psychological, physical and functional problems, and alcohol-abuse disorders.

Doctors and economists argue that today’s conversation should not only be about the primary wounds of war, but about the medical issues that are often associated with them. PTSD, for example, is often associated with smoking, substance abuse, depression, anxiety, heart disease, obesity and diabetes. Amputations are associated with obesity, cardiovascular disease, osteoarthritis, back pain and phantom limb pain.

“We should help an amputee to reduce his cholesterol and maintain his weight at age 30 to 40, rather than treating his coronary artery disease or diabetes at age 50,” Geiling, Rosen and Edwards wrote.

“Society is not yet considering the medical costs of caring for today’s veterans in 2035 — a time when they will be middle-aged, with health issues like those now seen in aging Vietnam veterans, exacerbated by comorbidities of post-traumatic stress disorder, traumatic brain injury and polytrauma,” they wrote.

Polytrauma centers have expanded across the country. But that doesn’t mean that all veterans live close enough to access them. In many parts of country, health care is hampered by distance because veterans who use the VA live far away from their closest VA hospital.

For Army Spc. Terence “Bo” Jones, it is more important that he live near his family.

U.S. Army Spc. Terence “Bo” Jones stepped on an IED in Afghanistan in 2012, and lost both of his legs. Now an outpatient at the VA polytrauma center in San Antonio, Texas, Jones is learning to walk on prostheses and drive an adapted car with only his hands. (Photo by Jessica Wilde/News21)

Jones lost both of his legs to an improvised explosive device blast in Afghanistan in 2012. Like Hancock, Jones woke up at Brooke Army Medical Center with his family by his side.

He was 21 when he stepped on the IED. It shot him 10 feet into the air and he landed in a nearby well. He doesn’t remember it, but his friends told him he was conscious and trying to climb out.

Now an outpatient at the VA polytrauma center in San Antonio, Jones is learning to walk on prosthetic legs, provided to him by the VA. The VA also provides adaptive driving equipment for his car, and he is taking driver education to learn how to drive with only his hands. One day, he hopes to get a service dog, and the VA will pay for veterinary care and equipment for the dog to help its owner.

“We can get them anything that they need,” Lucht said.

The VA provides other assistive accommodations for injured veterans — from grab bars and walk-in showers to wheelchairs and specialized seating. And a lot of veterans wear out their prosthetic limbs because they’re active, Lucht said.

When Jones finishes rehab, he plans to move home to Idaho, go to college and open his own shop doing custom cars and motorcycles. But in Idaho, Jones won’t be near a polytrauma center anymore.

One of the most rural veteran populations in the country is served by the Reno, Nev., VA hospital, said Darin Farr, the hospital’s public affairs officer. “We’re actually considered frontier,” he said.

The hospital’s patients come from as far away as 280 miles. More than 29,000 veterans are enrolled in the Reno hospital, staffed by 1,200 employees, only 40 to 50 percent of whom actually provide medical care.

Many VA hospitals fall behind in entering data from private health records or following up with patients, especially mental health patients for whom follow-up care is particularly important, according to VA Office of Inspector General reports.

The VA doesn’t always provide timely mental health evaluations for first-time patients, and existing patients often wait more than the recommended 14 days for their appointments, the OIG reported last year.

Veterans have complained for many years about long wait times to schedule appointments. “Long wait times and inadequate scheduling processes at VA medical centers have been long-standing problems that persist today,” the U.S. Government Accountability Office reported in February. Inconsistent scheduling policies, staffing, phone access and an outdated scheduling system make the problem worse.

Meanwhile, both the GAO and OIG have reported that VA’s data on wait times for medical appointments is unreliable, and some schedulers entered incorrect dates or changed them to meet performance standards.

Farr says the Reno hospital faces unique challenges that might contribute to wait times. The hospital competes with other hospitals for employees who might pay more than the government does.

“We don’t have a lot of space,” he added. The hospital schedules more than 373,000 outpatient visits and 4,200 inpatient visits every year. But it only has 64 hospital beds — 14 psychiatric, 12 ICU and only 38 for general use.

When Terence Jones finishes rehab at the polytrauma center in San Antonio, he hopes adaptive equipment will help him return to a normal life. Jerral Hancock, on the other hand, knows that he never will.

Hancock misses the adrenaline rush of life before his injury. He longs for a wheelchair that will go faster than 5 mph. He described the time he fell out of his hospital bed as exhilarating. He busted his cheek open, but he loved it.

With the $100,000 the Defense Department gave Hancock for his injuries when he was discharged, he bought two mobile homes outside Los Angeles, one for him and his two children, ages 9 and 6, and one for his mother and stepfather, who take care of him full time. Hancock supports all of them with his monthly disability check from the VA.

The VA bought him a wheelchair and put a lift into his front porch. They widened the doors in his mobile home so his wheelchair could fit in and out. They will pay for his medications and all of his medical care for the rest of his life.

When Hancock arrived at his new mobile home, he couldn’t fit his wheelchair in the front door. So he kept one wheelchair inside, and his stepdad carried him through the door and down the steps to a second wheelchair that he paid for himself. It took eight months for the VA to pay him $1,000 for the second wheelchair, and four months to put a lift into his front porch.

“I was stuck in the house for six months over this fight,” Hancock said. “I had a wheelchair upstairs and I had a wheelchair downstairs. And my caretaker carried me up and down the stairs from wheelchair to wheelchair. It was ridiculous.”

The VA also bought Hancock an $85,000 arm that he could attach to his shoulder to use. But he can’t seem to get it to work.

The VA gave Hancock $11,000 toward a car, but his mother said that doesn’t come close to the cost of a handicap-equipped vehicle. Instead, he bought a seven-passenger bus with a lift for his wheelchair.

Even with all of the money that the VA spends on Hancock’s medical and family care, he still lives in a mobile home, and his bedroom has little extra space with a hospital bed and a wheelchair in it. He can’t fit into his kids’ bedrooms. He can’t drink a glass of water on his own. And his air conditioning hardly works, even though he can’t be in the heat for too long because his burns prevent him from sweating.

Hancock’s children also have had to adjust.

“My son watched me walk off — he was going on 3 — and I jumped on a bus with a couple hundred pounds of gear,” he said. “The next time he saw me, I lost 100 pounds … I looked like a skeleton and I had tubes coming out everywhere … My daughter, this is all she knows.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Illustration of the lungs in blue

GOP lawmakers press Sebelius to help child awaiting lung transplant

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sebelius100px

Sebelius

By Mary Agnes Carey

A child in desperate need of a lung transplant clinging to life. Long waiting lists of patients who need organs and too few donors to meet the demand.  Rules that govern who gets what life-saving organs – and when.

Department of Health and Human Services Secretary Kathleen Sebelius had to confront all those issues on Tuesday when Republican lawmakers asked her repeatedly why she would not use her authority to make sure a 10-year-old Pennsylvania girl gets a lung transplant that could save her life.

Sarah Murnaghan, who is suffering from end-stage cystic fibrosis, needs a lung transplant or will die in two to three weeks.

Current organ donation rules make her ineligible for an adult lung and there are fewer children’s lungs that come available.  She has been on a waiting list since 2011, according to published reports.

The Organ Procurement and Transplantation Network, whose duties include collecting and managing scientific data about organ donation, says that nearly 1,700 people nationwide are waiting for lung transplants.

Price

Price

Rep. Tom Price, R-Ga., drilled Sebelius about the situation during a Capitol Hill hearing on the HHS budget Tuesday. Murnaghan cannot get the transplant she needs “because of an arbitrary rule that if you’re not 12 years old, you’re not eligible to receive an adult lung,” said Price, who is a physician.  “Madam Secretary, I would urge you this week to let that lung transplant move forward … It simply takes your signature.”

Sebelius said she has spoken with the girl’s mother and “can’t imagine anything more agonizing” than what the family is going through.

Sebelius said about 40 very seriously ill people in Pennsylvania over the age of 12 also are waiting for a lung transplant, as are three other extremely sick children in the same Philadelphia hospital as Murnaghan.

“I would suggest that the rules that are in place and are reviewed on a regular basis are there because the worst of all worlds, in my mind, would be to have some individual picks who lives and who dies,” she said. “I think you’d want a process guided by medical science and medical experts.”

That answer didn’t satisify Rep. Lou Barletta, R-Pa.

“Why do we have such bullcrap around this place and we have the chance to save someone’s life. … Why wouldn’t we do this?” he asked.

While Sebelius has ordered a review of transplant rules to analyze their fairness, “a study will take over a year [and] this young lady will be dead,” Price said at the House Education and the Workforce Committee hearing.

After the hearing, Sebelius told reporters that HHS lawyers “very much disagree that there is any ability for an individual to reach in” and change the current organ rules.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Questions arise about robotic surgery’s cost, effectiveness

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© 2009 Intuitive Surgical, Inc.

© 2009 Intuitive Surgical, Inc.

By Michelle Andrews

In the dozen years since the Da Vinci robot has been approved for surgeries in the United States, it’s been embraced by health care providers and patients alike.

Surgeons routinely use the multi-armed metal assistant to remove cancerous prostate glands and uteruses, repair heart valves and perform gastric bypass operations, among many other procedures.

Lately a key study and reports of reports of problems have raised questions about robotic surgery’s safety and cost-effectiveness, leading to a review of the Da Vinci system by the Food and Drug Administration and causing some experts to wonder whether the benefits of undergoing robot-assisted surgery may have been overstated.

At this time, health insurers generally pay for robotic surgery just as they would any other surgical procedure, and patient out-of-pocket costs are typically no different either.

That could change, some say, as more comprehensive data become available that clarifies when robotic-assisted surgery helps improve patient outcomes—and when it doesn’t.

Robotic surgery is similar to conventional laparascopic surgery, in which surgical instruments are inserted into small incisions in a patient’s torso and manipulated by the surgeon.

In robotic surgery, however, the surgeon sits at a console in the operating room and uses hand and foot controls to manipulate surgical tools attached to a robot’s arms.

Both types of surgery may result in quicker recovery times, less blood loss and pain for patients compared with traditional “open” surgeries performed through a larger incision.

Robot-assisted surgeries are generally more expensive than other methods, however, and don’t necessarily improve patient outcomes long-term.

study published in February in the Journal of the American Medical Association of more than 260,000 hysterectomy patients found that the median hospital cost for robot-assisted surgery was $8,868, compared with $6,679 for a laparascopic hysterectomy.

The study found that although patients who got robotic hysterectomies were less likely than laparscopic patients to be hospitalized for more than two days, there was no significant difference between the two groups on other measures, such as complications and blood transfusion rates.

In March, the American Congress of Obstetricians and Gynecologists released a statement that said in part, “There is no good data proving that robotic hysterectomy is even as good as—let alone better—than existing, and far less costly, minimally invasive alternatives.”

The statement said that conventional laparascopic hysterectomy and a procedure performed through an opening at the top of the vagina have proven track records and were generally preferable to robotic hysterectomy. That statement, however, was assailed by other physicians who use the robot.

“Our study and the ACOG statement raise awareness that we really need to be critical. Robotic hysterectomy may not be the best procedure from a patient’s perspective,” says Jason Wright, an assistant professor of women’s health at Columbia University College of Physicians and Surgeons and the lead author of the study.

“Patients need factual information about all of their treatment options, and the evidence supports that robotic surgery has dramatically decreased the number of open hysterectomies in the U.S.,” says Angela Wonson, a spokesperson for Intuitive Surgical, the manufacturer of the Da Vinci system. “Robotic surgery is a technological advance that is enabling more women to receive minimally invasive surgery.”

A 2010 New England Journal of Medicine analysis of studies that examined 20 robot-assisted procedures found that using a robot added about 13 percent, or $3,200, to the average cost of a procedure in 2007.

The authors noted that there were no large-scale randomized trials of robot-assisted surgery and that the limited data available failed to show that robot-assisted surgery was superior to other procedures.

The lack of hard data hasn’t stopped patients, their doctors and hospitals from enthusiastically adopting robotic surgery. Nearly a quarter of hospitals offered robotic surgery in 2011, according to the American Hospital Association.

Last year, 367,000 robotic procedures were performed in the United States using da Vinci robots, according to Intuitive Surgical, a 26 percent increase over the 292,000 procedures performed the previous year.

John Bello, 48, had his cancerous prostate gland removed robotically two years ago by a surgeon at MedStar Washington Hospital Center in the District.

The Annapolis resident couldn’t be happier with the results of the surgery, which was covered without a hitch by his Blue Cross Blue Shield plan. Although many patients struggle with impotence or incontinence following prostate cancer surgery, Bello says he has not had any serious side effects from the surgery. He’s cancer free.

“Unless I see the scars … I don’t even think about it,” he says.

To date, hospitals, eager to attract patients with the technology du jour, have generally been willing to absorb the higher costs associated with robotic surgery.

But health care overhaul provisions that encourage payments to providers based on “episodes of care” rather than individual services may begin to change these practices, say experts.

“As we move away from the fee-for-service model, we’re going to discourage [procedures] that are no better than the higher priced one,” says A. Mark Fendrick, director of the Center for Value-Based Insurance Design at the University of Michigan.

“Health plans will try to incentivize the appropriate surgery, and that is especially true with the evolving payment models that reward quality outcomes,” says Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade group.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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