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Posts Tagged ‘surgery’

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Choosing Where to have High-Risk Elective Surgery

Posted by medconsumers on November 1, 2005

You’re facing non-emergency surgery, so there is time to weigh and consider the choice of a surgeon and hospital. Ideally, the choice would be based on the surgeon and the hospital with the best records. An increasing number of state health departments, consumer advocacy groups, and coalitions of employers and insurers can help by providing what is called “performance data” on hospitals and surgeons.

But a new survey found that few elderly Americans who had recently undergone non-emergency surgery looked for performance data. Most relied on the opinions of their referring physician, family members and friends in choosing where to have surgery. The telephone survey was conducted in the U.S. and was published recently in the BMJ, the British medical journal. The 510 randomly chosen respondents had undergone high-risk elective procedures, such as heart valve replacement or cancer surgery involving the bladder, lung or stomach. All were Medicare beneficiaries, so a choice of hospital and surgeon was possible.

The survey’s authors led by Lisa M. Schwartz, MD, Dartmouth Medical School did not see their results as a sign of the ineffectiveness of public reporting of performance data. It was well known—before this survey—that public reporting of this type of information does not have seem to affect people’s choice of hospital or doctor. Instead, Schwartz and colleagues say that the problem lies in assuming that the public is the primary target for surgical performance data. They think that the target audience should be referring physicians and purchasers of health services.

A good example of the latter, say Schwartz and colleagues, is the Leapfrog Group, a coalition of employers and insurers that buy health care. The Group encourages its employer members to use the purchasing power of their health plans to reward doctors and hospitals for improving the quality, safety, and affordability of health care. (To see ratings of hospitals in your area, go to www.leapfroggroup.org and click “For Consumers.”)

Still, the referring physician’s opinions loomed large in this new survey. Schwartz and colleagues acknowledged the fact that more work has to be done to ensure that referring physicians appreciate the importance of performance data. The information must be easily understandable, and doctors may need help in finding the best ways to communicate performance data to their patients.

Maryann Napoli, Center for Medical Consumers ©
November 2005

Posted in hospitals, surgery | Tagged: , | Comments Off

Hospital-Acquired Infections

Posted by medconsumers on June 1, 2005

Protect Yourself

Citing evidence that safety problems in hospitals continue to be a significant threat to patients, two leading health-care quality “gurus” Lucian Leape, MD, Harvard School of Public Health, and Donald Berwick, MD, Institute for Health Care Improvement and Harvard Medical School, recently described the pace of safety improvements by physicians, hospitals and government as frustratingly slow. They argue that the lack of urgency to save lives will continue unless there is a sea change in the “beliefs, intentions, cultures and choices” of those who work in the health care system (JAMA, 5/23/05).

Leape and Berwick cite a 2004 Commonwealth Fund-Institute of Medicine meeting commemorating the fifth anniversary of the Institute’s report on medical errors, “To Err is Human.” They consider a list of concrete, technically achievable five-year goals for hospitals developed by the meeting participants as a good “starter set” of national patient safety goals. Those of us who attended that meeting felt strongly that 90% of all hospital-acquired infections could be eliminated by 2010—a move that could save as many as 90,000 lives annually.

An estimated 2,000,000 patients in U.S. hospitals suffer a hospital-acquired infection each year and more than 100,000 die as a result. Yet, hospitals are not currently held accountable for their infection track record. With a few exceptions, patients facing elective surgery cannot find out their odds of acquiring a serious infection in any given hospital; odds that may be considerably greater than being harmed by the surgery itself.

The Center for Disease Control and Prevention operates a national hospital-acquired infection reporting system. Despite the fact that it is paid for with taxpayer money, it cannot be accessed by the public. What’s more, it’s purely voluntary and less than 10% of all U.S. hospitals report to it. While more than 20 states require some sort of reporting, usually an infection-caused death, this information was kept from public view until recently.

But the veil of secrecy is slowly lifting. In the last year or so, Florida, Illinois, Missouri, Nebraska, Pennsylvania and Virginia have mandated public reporting. In New York, one of 13 states with pending legislation, I have been working with advocates, state legislators, and New York’s hospital trade associations, to pass a law requiring public reporting of hospital-acquired infection rates.

In the meantime, what can be done to prevent infection? Here are a few critically important steps that patients should insist be followed. First, make sure that doctors and hospital staff members wash their hands prior to close contact with you and your immediate surroundings. Unfortunately, research continues to find this simple, highly effective step is omitted more often than not. Recent studies have shown that alcohol-based hand rubs are a more effective preventative than washing with antimicrobial soaps. Sterile gloves not discarded after contact with a previous patient or hospital equipment can spread infection, so make sure staff members put on new gloves after hand washing and before touching you.

Second, if you’re having an operation, most likely a preventative dose of antibiotics will be given prior to surgery. Studies show that getting the antibiotic within one hour of the surgery maximizes protection against a postoperative infection. Unfortunately, nurses can forget to give the antibiotic within the one hour window and you may need to remind them, or have them explain why you don’t need it. The days of having the skin shaved in preparation for surgery should be over. Shaving causes minute nicks in the skin which can allow bacteria to enter the body. Hair clippers are now the preferred way of preparing a surgical site.

Patients and visitors can bring dangerous infections into the hospital. Consequently, some hospitals with aggressive infection control policies screen patients for infection prior to admission, and some limit contact with visitors.

To find out the status of hospital infection public reporting legislation in your state and how to help pass a reporting law, Consumers Union maintains an informative web site: www.consumersunion.org/campaigns Click on “Stop Hospital Infections.”

Arthur A. Levin, MPH, © Center for Medical Consumers, June 2005

Posted in Advocacy, hospital-acquired infection, hospitals | Tagged: , , , | Comments Off

Antibiotics Before Dental Procedures

Posted by medconsumers on April 1, 2005

Should People with Heart Valve Problems Take Antibiotics Before Invasive Dental Procedures?

People with heart valve problems are told to take antibiotics before certain dental procedures in order to prevent bacterial endocarditis. This disease can be triggered by bacteria disrupted by tooth scaling, dental implantation, and other invasive procedures. The bacteria goes into the bloodstream and become lodged in the innermost layers of the damaged heart valves. It is potentially fatal and can be well underway before symptoms ever appear. To treat after the fact might very well be too late. But antibiotic therapy in itself can cause harm. And some researchers have questioned the universal preventive antibiotics recommendation because bacterial endocarditis is an uncommon disease.

For a 2004 Cochrane* review entitled, “Penicillins for the prophylaxis of bacterial endocarditis in dentistry,” R. Oliver and colleagues searched the published medical literature to find studies that proved the benefits of preventive antibiotics outweigh the harm for high-risk people facing an invasive dental procedure. All that could be found was one case-control study conducted in The Netherlands, and its results are inconclusive.

The Cochrane reviewers also found a population study published in 2000 in the American cardiac journal, Circulation that quantified the risk of bacterial endocarditis and the risk of taking antibiotics. It estimated that people taking penicillin were five times more likely to die from an allergic reaction to this antibiotic than from endocarditis.

The Cochrane authors concluded: “There is no evidence about whether penicillin prophylaxis is effective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. There is a lack of evidence to support published guidelines in this area. It is not clear whether potential harms and costs of penicillin administration outweigh any beneficial effect. Ethically practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.”

*The abstracts from all Cochrane reviews are available at www.thecochranelibrary.com . See “Penicillins for the prophylaxis of bacterial endocarditis in dentistry”.

Maryann Napoli, Center for Medical Consumers ©
April 2005

Posted in Drugs, Heart | Tagged: , , , | Comments Off

Surgery For Early Prostate Cancer

Posted by medconsumers on October 1, 2002

Surgery for Early Prostate Cancer
By Maryann Napoli

When a man is diagnosed with early prostate cancer, he faces several options but no clear answer to the most crucial of all questions: Is treatment better than no treatment at all? A new Swedish study showed that surgical removal of the prostate does, in fact, reduce a man’s odds of dying of prostate cancer, but worsens his quality of life.

Unfortunately, the finding has little relevance to most American men because prostate cancer screening has become so popular in this country that the majority are diagnosed before they have any signs or symptoms of the disease. This was not true of the majority of the Swedish men who participated in the study published last month in The New England Journal of Medicine (9/12/02).

Americans Diagnosed Earlier

The term early means that the cancer has not spread beyond the prostate gland. But there are degrees of “early.” The majority of the Swedish participants had tumors that could be felt by a digital rectal examination, and many had symptoms, such as difficulty urinating. Whereas 75% of American men with prostate cancer do not have a tumor that can be felt, nor do they have symptoms. They are diagnosed after a biopsy performed as a result of a PSA screening test. The Prostate-Specific Antigen (PSA) test identifies a protein in the blood that can indicate the presence of a cancer too small to be felt. Originally intended as a follow-up test for men who had been treated for prostate cancer, the PSA test has been promoted to symptomless men for over a decade.

The relatively small group of newly diagnosed American men who fit the profile of the 695 participants in the Swedish Study should take note: The results of this study are a wash. At six years, the men who had a prostatectomy (surgical removal of the prostate) had a lower death rate from prostate cancer, but it was canceled out by a higher death rate from other causes. If the aim is solely to reduce the odds of dying of prostate cancer within the next six years, then surgery is the way to go. Only 4.6% of the men died of prostate cancer after undergoing a radical prostatectomy; where 8.9% of the untreated men died of the disease.

If, however, the goal is to lower the odds of dying from any cause, then no treatment may be the way to go. The overall death rate in both groups was exactly the same. It is possible that the surgically treated men died of treatment-related causes, such as an infection. In that case, their deaths would not be counted as prostate cancer deaths. All the men were under the age of 75, with an average age of 64 years.

By counting the overall death rate-that is, the deaths from all causes-the authors of this study are following an important new trend in research. They are stepping back and looking at the big picture, as opposed to looking solely at the question of whether X medical treatment lowers the death rate from Y disease. Too often, the treatment itself will cause deaths, but they go uncounted by most researchers. Here is the conclusion of the Swedish study: “…there was no significant difference between surgery or watchful waiting in terms of overall survival,” wrote Lars Holmberg, MD, and colleagues at the Scandinavian Prostatic Cancer Group Study.

The Swedish research team noted that there were 37 deaths from other causes in the surgically treated group and 31 in the untreated group. “This difference could be due to chance or to long-term but hitherto unknown adverse effects of prostatectomy.”

While it is unusual for researchers to address the overall death rate in the conclusion of their study, the finding itself is not. There are already several examples of medical interventions that reduced the death rate from cancer but failed to lower the overall death rate. For example, several randomized controlled trials showed that screening tests for colon cancer reduce the rate of deaths from this disease, but inexplicably increase the death rate from heart disease. More recently, a review of all the best mammography clinical trials came to a similar conclusion about the overall death rate.

Symptoms Worsen After Surgery

Now for the question of quality of life. It’s certainly possible that a prostatectomy could improve a man’s life without prolonging it. Consequently, the Swedish research team sent questionnaires to the 326 men who had symptoms at the start of the study to see how they fared four years later. The percentage of men suffering the following symptoms was consistently higher among the surgically treated, as compared to the untreated: impotence (80% vs 45%), “distress from compromised sexuality” (55% vs 40%), urinary leakage (49% vs 21%), “distress from all urinary symptoms” (27% vs 18%).

The clinical trial with the most relevance to American men is currently in progress, and results will not be available until 2008. It is sponsored by the Department of Veterans Affairs, the National Cancer Institute and the U.S. Agency for Health Research and Quality. The 731 participants had cancer that was confined to the prostate, and most were diagnosed initially with a PSA test. The men were randomly assigned to have their prostates removed or to remain untreated. The lead researcher, Timothy J. Wilt of the Minneapolis VA Medical Center, recently told The New York Times that five years into the study, no survival advantage has been shown for either group.

Although there are other treatment options for men with localized prostate cancer, such as radiation therapy and radiation seed implants, no head-to-head comparison study has ever been done.

(October 2002)

Posted in Cancer, Men's Health, surgery | Tagged: , , , | Comments Off

Mental Deficits After Surgery

Posted by medconsumers on April 1, 2002

Mental Defecits After Major Surgery: The Search For Explanations
by Maryann Napoli

It took about ten years for the rumors to surface after coronary-artery bypass surgery was first introduced in the late 1960s. Some people had mental deficits that persisted long after they had been discharged from the hospital. The initial recipients of bypass surgery were primarily men in early middle age, so it should have been difficult for surgeons to dismiss the reports as unrelated to the operation. But dismiss they did, and the researchers would not take on the subject for another 10 years. Now there is mounting evidence that cognitive decline can occur at any age, not only as a result of coronary-artery bypass surgery but other major operations as well. Those most likely to be afflicted, however, seem to be elderly people who undergo an operation of long duration.

Had coronary-artery bypass surgery not rapidly become one of the most common major operations in the U.S., we might never have learned about its adverse cognitive effects that include memory problems and difficulties processing information. But, in time, the research could not be ignored. By the 1990s, several studies with long-term follow-ups found the incidence of cognitive decline to be highest right after the operation, but decreasing over time. At discharge, 50-80% of the people showed cognitive dysfunction, 20-50% at six weeks, and 10-30% at six months. These studies were conducted at a time when the age of a person undergoing coronary-artery bypass surgery had been slowly rising to the current average of 66 years.

Last year, a study conducted at Duke University Medical Center provided even longer follow-up information on 172 people (mostly male with an average age of 61 years) with much more sobering results. Five years after surgery, 42% still showed cognitive dysfunction (New England Journal of Medicine, 2/8/01).

These adverse effects had long been attributed to the use of the machine that takes over the function of the heart during all major chest operations. The heart-lung machine not only cools the heart, but also temporarily paralyzes it so that the surgeons can operate. The patient’s blood is diverted to the heart-lung machine, where oxygen is introduced and carbon dioxide removed, before the blood is returned to the body. Tiny air bubbles obstructing the blood flow to the brain were identified as a suspected main cause of cognitive deficits. Consequently, some surgeons have been experimenting with what they call the off-pump version of coronary-artery bypass surgery, now used in 20% of all such operations performed in the U.S.

Last month, the largest randomized clinical trial to compare both techniques published discouraging results in the Journal of the American Medical Association. The 420 participants (mean age 61 years) were facing their first coronary-artery bypass surgery. All had been randomly assigned to either on-pump (the standard procedure) or off-pump surgery. Psychologists had tested the participants before and after the operation.

The off-pump group did better at three months, but by one year after surgery, the rate of cognitive dysfunction was about the same for both groups (32%). The trial’s authors speculate that the off-pump technique itself might be just another source of cognitive deficits. Or, factors other than the heart-lung machine could be the cause of cognitive decline. And general anesthesia had already been identified as a possible explanation for the delirium, confusion, and cognitive dysfunction commonly observed in elderly people immediately after undergoing any form of major surgery. Research dating back to the 1950s showed that these symptoms may persist in some elderly people for months and even years after major surgery.

To fill a large information gap about cognitive decline in the elderly after non-cardiac major surgery, an international team of researchers looked at a range of possible causes-not just general anesthesia. Among them were low blood pressure and postoperative infection. The 1,218 study participants, aged 60 years and older, were given neuropsychological tests pre- and postoperatively.

“We confirmed unequivocally that anesthesia and surgery cause long-term postoperative cognitive decline in the elderly and that the risk increases with age,” concluded the authors of this study that was published in the Lancet (3/21/98). Of the 10% whose cognitive dysfunction continued three-months after surgery, advanced age was the only relevant factor. The authors noted that their findings could actually understate the problem because the participants were not especially ill, physically or mentally, before surgery. They also believe that more research must be conducted to determine whether postoperative cognitive dysfunction is a permanent disorder.

What you can do

-Make sure the operation is necessary by getting a second opinion. Coronary-artery bypass surgery, for example, is notoriously overdone. No major operation has been subjected to so many large-scale clinical trials, often comparing it to drug therapy. Results consistently show that a huge percentage of people who undergo this operation can be just as effectively—and more safely—treated with drug therapy. For a second opinion consultation, consider a trip to the Lown Cardiovascular Center in Brookline, Massachusetts (617/ 732-1318).

-It is not known how many people are informed that mental deficits are a possible risk of major surgery, or how many people are given an option of other forms of anesthesia when possible. The subject is worth a pre-surgical conversation with the surgeon and the anesthesiologist.

(April 2002)

Posted in Heart, surgery | Tagged: , , , , , , , , , | Comments Off

Links: Cancer

Posted by medconsumers on January 1, 2000

Adjuvant therapy decision aid for breast cancer patients.
Read our take on this free service   PREDICT

www.BrainMetsBC.org
Fills an enormous gap in treatment information needed by women whose breast cancer has spread (metastasized) to the brain.

Annie Appleseed Project
Information about complimentary, alternative, natural therapies for people with cancer.

Breast Cancer Action
A critical take on breast cancer treatment and policy decisions.

Cancer Treament
For summaries of the latest treatments for cancer complied by the National Cancer Institute. this Web Site also has a wide variety of other information, such as a registry of cancer-related trials and a directory of physicians, geneticists and genetic counselors.

Mammography Pamphlet for Informed Decision-Making
Excellent 2009 pamphlet from the Nordic Cochrane Centre is the first to provide women with balanced information about mammography screening.

YourmesotheliomaWeb
Mesothelioma Web
Two comprehensive sites on asbestos and mesothelioma, providing information and support to those who have been exposed to asbestos.

National Breast Cancer Coalition
A coalition of grassroots advocacy groups working to eradicate breast cancer. See advocacy training conferences, legislative accomplishments, free breast cancer information, and position statements.

PleuralMesothelioma.com
Pleural mesothelioma is a rare cancer that develops in the lungs. It is almost solely caused by exposure to asbestos, which was used in everything in children’s toys, house-hold insulation, and naval carriers. This Web site has information about symptoms, treatment options, and steps to take after a diagnosis.

www.susanlovemd.com
Susan Love, MD, American women’s favorite breast surgeon, provides a wealth of information about breast cancer.

Posted in Cancer, Links, Women's Health | Tagged: , , , , , | Comments Off

Links: Consumer Guides & Rights

Posted by medconsumers on January 1, 2000

Campaign for Safe Cosmetics
Learn which everyday products, including those marked “natural” and “organic,” contain toxins.

Foundation for Health Coverage Education
Helps low-income people get to free or low-cost government-sponsored health insurance coverage. Answer the five-question quiz on the home page to see whether you qualify. Or call 24-hour hotline 1(800) 234-1317.

New York Issues Office-Based Surgery Guidelines
The New York State Department of Health(NYSDOH) has released guidelines for office-based surgery to improve patient safety and the quality of care. Consumers considering a surgical procedure in a doctor’s office may want to refer to the guidelines which can be accessed at the NYSDOH Web site. Consumers should use the guidelines to check whether a doctor’s office is doing everything possible to maximize patient safety.

Medical Records in New York State
If you’re a resident of New York State and want to access your medical records, this Web site will give you the information you need to know. (For residents of other States, please contact your Department of Health to find out what your State’s laws are regarding medical records).

Nursing Homes and Long-term Care in New York State
This Web site from the NYS Department of Health provides tips on finding a qualified nursing home facility and information on financing for long-term care in NYS.

U.S. Consumer Product Safety Commission
Read about and report unsafe products at this site.

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Links: Hospital Care

Posted by medconsumers on January 1, 2000

Centers for Medicare & Medicaid
See how your local hospitals perform according to quality care standards.

Committee to Reduce Infection Deaths
Read the 15 steps that hospital patients can take to reduce the chance of hospital-acquired infection.

Compare Hospitals
Using Medicare study results from Dartmouth Medical School researchers, Consumer Reports helps you compare hospitals in your area in terms of cost, number of doctor visits, and the number of days spent in the hospital. Read the explanation for why aggressive care does not improve outcomes, even for life-threatening conditions, and can sometimes shorten life.

Coronary Artery Bypass Surgery Rates in New York State
Maintained by the New York State Department of Health, this Web site contains data of surgeon and hospital volumes as well as mortality rates for Coronary Artery Bypass Surgery.

The Leapfrog Group
Provides ratings of 1,300 U.S. hospitals on information about infection prevention measures.

Posted in Heart, Links | Tagged: , , | Comments Off

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