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Poll: Most voters oppose House and Senate health care bills
Voters in nearly every region of the United States are opposed to the health reform bills that have been proposed in the House and Senate, according to a poll by the American Medical Association.
Surveys conducted in Alaska, Arkansas, Colorado, Nevada, Ohio, Tennessee, and West Virginia showed that voters in each state had an overall low opinion of the House-passed American Health Care Act (AHCA), according to an AMA analysis released June 27.
When asked whether the reform bill was a “good idea” or a “bad idea,” the most common response in each state was “bad idea,” ranging from 40% in Arkansas to 58% in Colorado. The majority of respondents in Alaska, Arkansas, Colorado, Nevada, and Ohio replied that the Senate should not pass the House legislation and the ACA should remain in place.
The plurality of Tennessee voters said the Senate should make major changes to the AHCA and pass it, while voters in West Virginia were split on what should happen to the AHCA.
Voters were not asked their views on the Senate’s Better Care Reconciliation Act (BCRA), but they were asked about specific provisions of the proposal.
When asked if federal funding for Medicaid expansion should be eliminated or reduced – as both the House and Senate propose – the majority of respondents in each state were opposed, ranging from 54% to 63%.
Voters in each state also strongly opposed BCRA provisions that would allow insurers to offer low-cost health plans, referred to as “skinny plans,” that would limit coverage for prescription drugs, mental health care, and other areas. When asked if low-income people should be provided with federal assistance to purchase inexpensive plans that would cover expensive illnesses, but not include preventive health care, a plurality of respondents were opposed, ranging from 43% in Arkansas to 58% in Ohio.
Respondents were supportive of the ACA’s individual mandate. When asked whether the ACA’s individual mandate should be eliminated and replaced with allowing health insurance companies to charge people 30% higher premiums for a year if they have not had continuous coverage, the majority of voters surveyed in all seven states were strongly opposed.
However, most voters were supportive of changing the Medicaid program to a federal grant program. When asked whether the government should change Medicaid from an entitlement program to a federal grant program and allow states to decide how to best use federal dollars to cover their low-income population, most voters agreed, ranging from 45% in Ohio to 52% in West Virginia.
The survey was conducted by phone in Alaska, Arkansas, Colorado, Nevada, Ohio, and Tennessee June 13-20, 2017. Samples were drawn from the voter file proportional to the statewide registered voter population. Quotas were set by specific demographics such as region, age, gender, and ethnicity based on data from the U.S. Census and the voter file to ensure a representative sample. Polling in West Virginia was conducted June 19-22, 2017.
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On Twitter @legal_med
Voters in nearly every region of the United States are opposed to the health reform bills that have been proposed in the House and Senate, according to a poll by the American Medical Association.
Surveys conducted in Alaska, Arkansas, Colorado, Nevada, Ohio, Tennessee, and West Virginia showed that voters in each state had an overall low opinion of the House-passed American Health Care Act (AHCA), according to an AMA analysis released June 27.
When asked whether the reform bill was a “good idea” or a “bad idea,” the most common response in each state was “bad idea,” ranging from 40% in Arkansas to 58% in Colorado. The majority of respondents in Alaska, Arkansas, Colorado, Nevada, and Ohio replied that the Senate should not pass the House legislation and the ACA should remain in place.
The plurality of Tennessee voters said the Senate should make major changes to the AHCA and pass it, while voters in West Virginia were split on what should happen to the AHCA.
Voters were not asked their views on the Senate’s Better Care Reconciliation Act (BCRA), but they were asked about specific provisions of the proposal.
When asked if federal funding for Medicaid expansion should be eliminated or reduced – as both the House and Senate propose – the majority of respondents in each state were opposed, ranging from 54% to 63%.
Voters in each state also strongly opposed BCRA provisions that would allow insurers to offer low-cost health plans, referred to as “skinny plans,” that would limit coverage for prescription drugs, mental health care, and other areas. When asked if low-income people should be provided with federal assistance to purchase inexpensive plans that would cover expensive illnesses, but not include preventive health care, a plurality of respondents were opposed, ranging from 43% in Arkansas to 58% in Ohio.
Respondents were supportive of the ACA’s individual mandate. When asked whether the ACA’s individual mandate should be eliminated and replaced with allowing health insurance companies to charge people 30% higher premiums for a year if they have not had continuous coverage, the majority of voters surveyed in all seven states were strongly opposed.
However, most voters were supportive of changing the Medicaid program to a federal grant program. When asked whether the government should change Medicaid from an entitlement program to a federal grant program and allow states to decide how to best use federal dollars to cover their low-income population, most voters agreed, ranging from 45% in Ohio to 52% in West Virginia.
The survey was conducted by phone in Alaska, Arkansas, Colorado, Nevada, Ohio, and Tennessee June 13-20, 2017. Samples were drawn from the voter file proportional to the statewide registered voter population. Quotas were set by specific demographics such as region, age, gender, and ethnicity based on data from the U.S. Census and the voter file to ensure a representative sample. Polling in West Virginia was conducted June 19-22, 2017.
[email protected]
On Twitter @legal_med
Voters in nearly every region of the United States are opposed to the health reform bills that have been proposed in the House and Senate, according to a poll by the American Medical Association.
Surveys conducted in Alaska, Arkansas, Colorado, Nevada, Ohio, Tennessee, and West Virginia showed that voters in each state had an overall low opinion of the House-passed American Health Care Act (AHCA), according to an AMA analysis released June 27.
When asked whether the reform bill was a “good idea” or a “bad idea,” the most common response in each state was “bad idea,” ranging from 40% in Arkansas to 58% in Colorado. The majority of respondents in Alaska, Arkansas, Colorado, Nevada, and Ohio replied that the Senate should not pass the House legislation and the ACA should remain in place.
The plurality of Tennessee voters said the Senate should make major changes to the AHCA and pass it, while voters in West Virginia were split on what should happen to the AHCA.
Voters were not asked their views on the Senate’s Better Care Reconciliation Act (BCRA), but they were asked about specific provisions of the proposal.
When asked if federal funding for Medicaid expansion should be eliminated or reduced – as both the House and Senate propose – the majority of respondents in each state were opposed, ranging from 54% to 63%.
Voters in each state also strongly opposed BCRA provisions that would allow insurers to offer low-cost health plans, referred to as “skinny plans,” that would limit coverage for prescription drugs, mental health care, and other areas. When asked if low-income people should be provided with federal assistance to purchase inexpensive plans that would cover expensive illnesses, but not include preventive health care, a plurality of respondents were opposed, ranging from 43% in Arkansas to 58% in Ohio.
Respondents were supportive of the ACA’s individual mandate. When asked whether the ACA’s individual mandate should be eliminated and replaced with allowing health insurance companies to charge people 30% higher premiums for a year if they have not had continuous coverage, the majority of voters surveyed in all seven states were strongly opposed.
However, most voters were supportive of changing the Medicaid program to a federal grant program. When asked whether the government should change Medicaid from an entitlement program to a federal grant program and allow states to decide how to best use federal dollars to cover their low-income population, most voters agreed, ranging from 45% in Ohio to 52% in West Virginia.
The survey was conducted by phone in Alaska, Arkansas, Colorado, Nevada, Ohio, and Tennessee June 13-20, 2017. Samples were drawn from the voter file proportional to the statewide registered voter population. Quotas were set by specific demographics such as region, age, gender, and ethnicity based on data from the U.S. Census and the voter file to ensure a representative sample. Polling in West Virginia was conducted June 19-22, 2017.
[email protected]
On Twitter @legal_med
CBO: Senate health care proposal marginally better than House-passed bill
The Senate health care proposal is only marginally better in terms of the number of uninsured Americans, compared with the House-passed bill it aims to replace, but it still would leave 22 million more Americans without insurance coverage, according to a June 26 analysis by the Congressional Budget Office.
The analysis raised voices of opposition from the medical community.
BCRA would lower the federal deficit by $321 billion between 2017-2026, driven by the dramatic cuts in spending on Medicaid (estimated to be $772 billion), as well as $408 billion saved from reduced tax credits and other subsidies to help people afford health insurance.
The CBO’s estimate also addresses how the bill could impact access to health care.
Initially, patients can expect another short-term spike in insurance premiums, with average premiums in 2018 increasing by 20%, compared with current law, “mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up.” In 2019, premiums are predicted to be about 10% higher than under current law; however, by 2020, premiums for benchmark plans would be 30% lower than with current law.
However, as premiums come down, deductibles would continue to rise for plans that would offer lower levels of coverage, according to the CBO report. Additionally, “starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low income people. The deductible for a plan ... would be a significantly higher percentage of income – also making such a plan unattractive but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan.”
The report also notes that the Senate proposal would not necessarily reverse current concerns regarding consumer choice in the individual markets, stating that “a small fraction of the population resides in areas which – because of this legislation, for at least some of the years after 2019 – no insurers will participate in the nongroup market or insurance would be offered only with very high premiums.” Additionally, removing the employer mandate could result in employers forgoing offering health insurance to their employees.
The bill faces an uphill battle in the Senate as there seemingly are not enough votes to pass the bill at this time. The measure is using the budget reconciliation process, meaning it will need 50 of the 52 Senate Republicans to pass it (all 48 Democrats are expected to vote against it). At least six GOP senators have said they are not ready to start debate. Senate Majority Leader Mitch McConnell (R-Ky) will not present the bill to the chamber for consideration until after the July 4 recess in an effort to tweak the language to garner the 50 votes needed to pass.*
Medical societies are pushing back against the bill as well.
The American Medical Association, in a letter to Senate leaders, notes that the first principal that medical professionals operate under is to do no harm. “The draft legislation violates that standard on many levels,” according to the AMA letter.
The American Osteopathic Association reiterated its objections to BCRA in a statement, citing the CBO’s determination that 22 million would lose coverage.
“As patient advocates, we cannot accept that under [BCRA] patients in need will no longer have the coverage they require to access health care services,” the association said in a statement. “The BCRA does nothing to control health costs but instead focuses on reducing federal health care expenditures by cutting coverage of our nation’s most vulnerable individuals and eliminating policies that promote access to preventive care services that can actually drive down expenses while improving patient outcomes.”
The American College of Cardiology noted that CBO analysis “makes it clear that the [BCRA] would lead to loss of coverage for millions of Americans and limit access to care for our most vulnerable populations. ... The ACC opposes the BCRA as it does not align with our Principles for Health Reform, which stress the need for patient access to meaningful insurance coverage and high-quality care.”
*This article was updated on June 27, 2017.
The Senate health care proposal is only marginally better in terms of the number of uninsured Americans, compared with the House-passed bill it aims to replace, but it still would leave 22 million more Americans without insurance coverage, according to a June 26 analysis by the Congressional Budget Office.
The analysis raised voices of opposition from the medical community.
BCRA would lower the federal deficit by $321 billion between 2017-2026, driven by the dramatic cuts in spending on Medicaid (estimated to be $772 billion), as well as $408 billion saved from reduced tax credits and other subsidies to help people afford health insurance.
The CBO’s estimate also addresses how the bill could impact access to health care.
Initially, patients can expect another short-term spike in insurance premiums, with average premiums in 2018 increasing by 20%, compared with current law, “mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up.” In 2019, premiums are predicted to be about 10% higher than under current law; however, by 2020, premiums for benchmark plans would be 30% lower than with current law.
However, as premiums come down, deductibles would continue to rise for plans that would offer lower levels of coverage, according to the CBO report. Additionally, “starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low income people. The deductible for a plan ... would be a significantly higher percentage of income – also making such a plan unattractive but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan.”
The report also notes that the Senate proposal would not necessarily reverse current concerns regarding consumer choice in the individual markets, stating that “a small fraction of the population resides in areas which – because of this legislation, for at least some of the years after 2019 – no insurers will participate in the nongroup market or insurance would be offered only with very high premiums.” Additionally, removing the employer mandate could result in employers forgoing offering health insurance to their employees.
The bill faces an uphill battle in the Senate as there seemingly are not enough votes to pass the bill at this time. The measure is using the budget reconciliation process, meaning it will need 50 of the 52 Senate Republicans to pass it (all 48 Democrats are expected to vote against it). At least six GOP senators have said they are not ready to start debate. Senate Majority Leader Mitch McConnell (R-Ky) will not present the bill to the chamber for consideration until after the July 4 recess in an effort to tweak the language to garner the 50 votes needed to pass.*
Medical societies are pushing back against the bill as well.
The American Medical Association, in a letter to Senate leaders, notes that the first principal that medical professionals operate under is to do no harm. “The draft legislation violates that standard on many levels,” according to the AMA letter.
The American Osteopathic Association reiterated its objections to BCRA in a statement, citing the CBO’s determination that 22 million would lose coverage.
“As patient advocates, we cannot accept that under [BCRA] patients in need will no longer have the coverage they require to access health care services,” the association said in a statement. “The BCRA does nothing to control health costs but instead focuses on reducing federal health care expenditures by cutting coverage of our nation’s most vulnerable individuals and eliminating policies that promote access to preventive care services that can actually drive down expenses while improving patient outcomes.”
The American College of Cardiology noted that CBO analysis “makes it clear that the [BCRA] would lead to loss of coverage for millions of Americans and limit access to care for our most vulnerable populations. ... The ACC opposes the BCRA as it does not align with our Principles for Health Reform, which stress the need for patient access to meaningful insurance coverage and high-quality care.”
*This article was updated on June 27, 2017.
The Senate health care proposal is only marginally better in terms of the number of uninsured Americans, compared with the House-passed bill it aims to replace, but it still would leave 22 million more Americans without insurance coverage, according to a June 26 analysis by the Congressional Budget Office.
The analysis raised voices of opposition from the medical community.
BCRA would lower the federal deficit by $321 billion between 2017-2026, driven by the dramatic cuts in spending on Medicaid (estimated to be $772 billion), as well as $408 billion saved from reduced tax credits and other subsidies to help people afford health insurance.
The CBO’s estimate also addresses how the bill could impact access to health care.
Initially, patients can expect another short-term spike in insurance premiums, with average premiums in 2018 increasing by 20%, compared with current law, “mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up.” In 2019, premiums are predicted to be about 10% higher than under current law; however, by 2020, premiums for benchmark plans would be 30% lower than with current law.
However, as premiums come down, deductibles would continue to rise for plans that would offer lower levels of coverage, according to the CBO report. Additionally, “starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low income people. The deductible for a plan ... would be a significantly higher percentage of income – also making such a plan unattractive but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan.”
The report also notes that the Senate proposal would not necessarily reverse current concerns regarding consumer choice in the individual markets, stating that “a small fraction of the population resides in areas which – because of this legislation, for at least some of the years after 2019 – no insurers will participate in the nongroup market or insurance would be offered only with very high premiums.” Additionally, removing the employer mandate could result in employers forgoing offering health insurance to their employees.
The bill faces an uphill battle in the Senate as there seemingly are not enough votes to pass the bill at this time. The measure is using the budget reconciliation process, meaning it will need 50 of the 52 Senate Republicans to pass it (all 48 Democrats are expected to vote against it). At least six GOP senators have said they are not ready to start debate. Senate Majority Leader Mitch McConnell (R-Ky) will not present the bill to the chamber for consideration until after the July 4 recess in an effort to tweak the language to garner the 50 votes needed to pass.*
Medical societies are pushing back against the bill as well.
The American Medical Association, in a letter to Senate leaders, notes that the first principal that medical professionals operate under is to do no harm. “The draft legislation violates that standard on many levels,” according to the AMA letter.
The American Osteopathic Association reiterated its objections to BCRA in a statement, citing the CBO’s determination that 22 million would lose coverage.
“As patient advocates, we cannot accept that under [BCRA] patients in need will no longer have the coverage they require to access health care services,” the association said in a statement. “The BCRA does nothing to control health costs but instead focuses on reducing federal health care expenditures by cutting coverage of our nation’s most vulnerable individuals and eliminating policies that promote access to preventive care services that can actually drive down expenses while improving patient outcomes.”
The American College of Cardiology noted that CBO analysis “makes it clear that the [BCRA] would lead to loss of coverage for millions of Americans and limit access to care for our most vulnerable populations. ... The ACC opposes the BCRA as it does not align with our Principles for Health Reform, which stress the need for patient access to meaningful insurance coverage and high-quality care.”
*This article was updated on June 27, 2017.
Very-low-volume vascular surgery practice linked to worse outcomes
The very-low-volume practice of surgeons performing no more than one open abdominal aortic aneurysm repair (OAR) or carotid endarterectomy (CEA) per year has persisted in New York State and was associated with worse postoperative outcomes and longer lengths of stay in a cohort study of statewide hospital data.
The study examined inpatient data on elective OARs and CEAs performed from 2000 to 2014 in every hospital in the state.
While the numbers and proportions of very-low-volume surgeons decreased (44.6%-23% for OAR and 35.2%-18.1% for CEA) and the number of procedures performed by these surgeons also decreased (QAR, 346-47; CEA, 395-90), the data are “concerning” and elucidate the “persistence” of very-low-volume practice in open vascular surgery, said Jialin Mao, MD, of Cornell University, New York, and associates (JAMA Surg. doi: 10:1001/jamasurg.2017.1100).
Very-low-volume surgeons were significantly less likely to be vascular surgeons, compared with higher-volume surgeons for both OAR (23.9% vs. 63.9%) and CEA (14.6% vs. 51.7%), they reported.
Compared with patients treated by higher-volume surgeons, those whose OAR was performed by very-low-volume surgeons had a twofold higher risk of postoperative death (6.7% vs. 3.5%) after adjusting for patient risk factors, surgeon specialty, and facility characteristics. Patients of very-low-volume surgeons also had significantly higher odds of sepsis or shock (odds ratio, 1.45), prolonged length of stay (OR, 1.37) and 30-day readmission (OR, 1.19), although the latter was not significant.
Similarly, patients whose CEA was performed by very-low-volume surgeons had a significant 1.8-fold higher odds of experiencing postoperative acute myocardial infarction (1.5% vs. 0.5%) and stroke (3.5% vs. 2.1%). They also were significantly more likely to have 30-day readmission (OR, 1.30).
With both procedures, patients treated by very-low-volume surgeons tended to be younger and healthier (less likely to have two or more comorbidities). They also were more likely to be nonwhite or insured by Medicaid.
“It is reasonable to speculate,” the researchers wrote, “that those treated by very-low-volume surgeons were more likely to be socioeconomically disadvantaged.”
Notably, 30% of the very-low-volume practice occurred in New York City, “where accessibility to high-volume practitioners should generally be higher,” they said.
The findings “indicate the need to eliminate this type of practice, to restrict the practice of these very-low-volume surgeons or to force referrals to higher-volume and specialized surgeons, and to improve disparity in access to high-quality care for all patients,” they said.
The study was funded in part by the U.S. Food and Drug Administration. The researchers reported having no relevant conflicts of interest.
The delineation of a threshold number of cases of OAR and CEA below which surgeons should not be credentialed remains unclear, despite much discussion of the volume-outcome relationship in vascular surgery.
In the current endovascular era, OAR in particular has become increasingly less frequent, with a dramatic effect on trainee experiences. It is often proposed that these cases be limited to high-volume surgeons. Some are concerned, however, that this action will leave rural surgeons unprepared to deal with ruptured abdominal aortic aneurysm and will force patients to travel long distances.
Sarah E. Deery, MD, and Marc L. Schermerhorn, MD, are in the division of vascular and endovascular surgery at Beth Israel Deaconess Medical Center in Boston. These remarks are adapted from an editorial accompanying the study. They reported having no disclosures.
The delineation of a threshold number of cases of OAR and CEA below which surgeons should not be credentialed remains unclear, despite much discussion of the volume-outcome relationship in vascular surgery.
In the current endovascular era, OAR in particular has become increasingly less frequent, with a dramatic effect on trainee experiences. It is often proposed that these cases be limited to high-volume surgeons. Some are concerned, however, that this action will leave rural surgeons unprepared to deal with ruptured abdominal aortic aneurysm and will force patients to travel long distances.
Sarah E. Deery, MD, and Marc L. Schermerhorn, MD, are in the division of vascular and endovascular surgery at Beth Israel Deaconess Medical Center in Boston. These remarks are adapted from an editorial accompanying the study. They reported having no disclosures.
The delineation of a threshold number of cases of OAR and CEA below which surgeons should not be credentialed remains unclear, despite much discussion of the volume-outcome relationship in vascular surgery.
In the current endovascular era, OAR in particular has become increasingly less frequent, with a dramatic effect on trainee experiences. It is often proposed that these cases be limited to high-volume surgeons. Some are concerned, however, that this action will leave rural surgeons unprepared to deal with ruptured abdominal aortic aneurysm and will force patients to travel long distances.
Sarah E. Deery, MD, and Marc L. Schermerhorn, MD, are in the division of vascular and endovascular surgery at Beth Israel Deaconess Medical Center in Boston. These remarks are adapted from an editorial accompanying the study. They reported having no disclosures.
The very-low-volume practice of surgeons performing no more than one open abdominal aortic aneurysm repair (OAR) or carotid endarterectomy (CEA) per year has persisted in New York State and was associated with worse postoperative outcomes and longer lengths of stay in a cohort study of statewide hospital data.
The study examined inpatient data on elective OARs and CEAs performed from 2000 to 2014 in every hospital in the state.
While the numbers and proportions of very-low-volume surgeons decreased (44.6%-23% for OAR and 35.2%-18.1% for CEA) and the number of procedures performed by these surgeons also decreased (QAR, 346-47; CEA, 395-90), the data are “concerning” and elucidate the “persistence” of very-low-volume practice in open vascular surgery, said Jialin Mao, MD, of Cornell University, New York, and associates (JAMA Surg. doi: 10:1001/jamasurg.2017.1100).
Very-low-volume surgeons were significantly less likely to be vascular surgeons, compared with higher-volume surgeons for both OAR (23.9% vs. 63.9%) and CEA (14.6% vs. 51.7%), they reported.
Compared with patients treated by higher-volume surgeons, those whose OAR was performed by very-low-volume surgeons had a twofold higher risk of postoperative death (6.7% vs. 3.5%) after adjusting for patient risk factors, surgeon specialty, and facility characteristics. Patients of very-low-volume surgeons also had significantly higher odds of sepsis or shock (odds ratio, 1.45), prolonged length of stay (OR, 1.37) and 30-day readmission (OR, 1.19), although the latter was not significant.
Similarly, patients whose CEA was performed by very-low-volume surgeons had a significant 1.8-fold higher odds of experiencing postoperative acute myocardial infarction (1.5% vs. 0.5%) and stroke (3.5% vs. 2.1%). They also were significantly more likely to have 30-day readmission (OR, 1.30).
With both procedures, patients treated by very-low-volume surgeons tended to be younger and healthier (less likely to have two or more comorbidities). They also were more likely to be nonwhite or insured by Medicaid.
“It is reasonable to speculate,” the researchers wrote, “that those treated by very-low-volume surgeons were more likely to be socioeconomically disadvantaged.”
Notably, 30% of the very-low-volume practice occurred in New York City, “where accessibility to high-volume practitioners should generally be higher,” they said.
The findings “indicate the need to eliminate this type of practice, to restrict the practice of these very-low-volume surgeons or to force referrals to higher-volume and specialized surgeons, and to improve disparity in access to high-quality care for all patients,” they said.
The study was funded in part by the U.S. Food and Drug Administration. The researchers reported having no relevant conflicts of interest.
The very-low-volume practice of surgeons performing no more than one open abdominal aortic aneurysm repair (OAR) or carotid endarterectomy (CEA) per year has persisted in New York State and was associated with worse postoperative outcomes and longer lengths of stay in a cohort study of statewide hospital data.
The study examined inpatient data on elective OARs and CEAs performed from 2000 to 2014 in every hospital in the state.
While the numbers and proportions of very-low-volume surgeons decreased (44.6%-23% for OAR and 35.2%-18.1% for CEA) and the number of procedures performed by these surgeons also decreased (QAR, 346-47; CEA, 395-90), the data are “concerning” and elucidate the “persistence” of very-low-volume practice in open vascular surgery, said Jialin Mao, MD, of Cornell University, New York, and associates (JAMA Surg. doi: 10:1001/jamasurg.2017.1100).
Very-low-volume surgeons were significantly less likely to be vascular surgeons, compared with higher-volume surgeons for both OAR (23.9% vs. 63.9%) and CEA (14.6% vs. 51.7%), they reported.
Compared with patients treated by higher-volume surgeons, those whose OAR was performed by very-low-volume surgeons had a twofold higher risk of postoperative death (6.7% vs. 3.5%) after adjusting for patient risk factors, surgeon specialty, and facility characteristics. Patients of very-low-volume surgeons also had significantly higher odds of sepsis or shock (odds ratio, 1.45), prolonged length of stay (OR, 1.37) and 30-day readmission (OR, 1.19), although the latter was not significant.
Similarly, patients whose CEA was performed by very-low-volume surgeons had a significant 1.8-fold higher odds of experiencing postoperative acute myocardial infarction (1.5% vs. 0.5%) and stroke (3.5% vs. 2.1%). They also were significantly more likely to have 30-day readmission (OR, 1.30).
With both procedures, patients treated by very-low-volume surgeons tended to be younger and healthier (less likely to have two or more comorbidities). They also were more likely to be nonwhite or insured by Medicaid.
“It is reasonable to speculate,” the researchers wrote, “that those treated by very-low-volume surgeons were more likely to be socioeconomically disadvantaged.”
Notably, 30% of the very-low-volume practice occurred in New York City, “where accessibility to high-volume practitioners should generally be higher,” they said.
The findings “indicate the need to eliminate this type of practice, to restrict the practice of these very-low-volume surgeons or to force referrals to higher-volume and specialized surgeons, and to improve disparity in access to high-quality care for all patients,” they said.
The study was funded in part by the U.S. Food and Drug Administration. The researchers reported having no relevant conflicts of interest.
FROM JAMA SURGERY
Key clinical point: The very-low-volume practice of open abdominal aortic aneurysm repair and carotid endarterectomy (one or fewer annual procedures) is associated with worse postoperative outcomes and greater length of stay.
Major finding: Patients whose procedure was performed by very-low-volume surgeons had a twofold higher risk of postoperative death after OAR or 1.8-fold higher odds of experiencing postoperative acute myocardial infarction or stroke after CEA.
Data source: The study was funded in part by the U.S. Food and Drug Administration.
Disclosures: The researchers reported having no relevant conflicts of interest.
MV disease in children requires modified strategies
NEW YORK – Repairing mitral valves in pediatric patients must overcome two issues: the wide variability in their anatomy and their growth. Using strategies and techniques common in adult mitral surgery can accomplish good mitral valve function in children, but some techniques in children differ, like using combined resorbable material with autologous tissue or transferring native chords instead of placing artificial chords to a malfunctioning leaflet.
Pedro del Nido, MD, of Boston Children’s Hospital, said the spectrum of mitral valve pathology in children goes from congenital mitral stenosis with a thick annulus with leaflet immobility to leaflet hypermobility that involves anterior leaflet prolapse and can involve a cleft that causes regurgitation. Dr. del Nido explained his surgical approaches for mitral valve disease in children at the 2017 Mitral Conclave, sponsored by the American Association of Thoracic Surgery.
Accessing the mitral valve in children requires a different approach than in adults, Dr. del Nido said. “Going through the left atrium is generally difficult, so we often enter through a trans-septal incision,” he said. “The main reason for that is because the tricuspid valve is often associated with the mitral valve problem and this gives us the most direct exposure.”
Once the surgeon gains exposure, the surgical analysis for a diseased adult or child valve is almost identical, with the exception that adult disease is acquired whereas childhood disease tends to be congenital, Dr. del Nido said. “In the congenital patient, we often find fibroelastic tissue that the child is born with,” he said. “We see this in neonates and young infants. It thickens over time; it doesn’t often calcify, but it does often restrict the leaflets and it tends to fuse the chords, so in essence you have direct attachments of the leaflets to the papillaries.”
He explained that this pathology requires an approach similar to that for rheumatic mitral disease in adults. “Start splitting the commissures and start resecting the tissue off the chords creating fenestrations in order to improve the inflow.” Dr. del Nido added, “If you don’t do this, the child will always have a gradient, and if you think about an adult having problems and symptoms with a gradient, think about a 10-year-old running around trying to do athletics; it’s impossible.”
Dysfunctional chords also require a somewhat different approach in children than they require in adults. “We find elongation of the chords and the anterior support structure is abnormal; the secondary chords are totally intact,” Dr. del Nido said. When confronting a torn-edge chord, resection is often an option in adults, but is uncommon in children. “We don’t usually have very much leaflet tissue,” he said. Artificial chords do not accommodate growth.
“We tend to use native tissue,” said Dr. del Nido. “You can transfer the strut chord; you can transfer the secondary chord in order to achieve support for the edge of that prolapsed leaflet.”
Leaflet problems are probably the biggest single source of recurrence in children, Dr. del Nido said. A cleft on the anterior leaflet can be particularly vexing. For example, cleft edges attached to the septum can prevent the valve leaflet from coaptation with the posterior leaflet. “If you don’t recognize that on 3-D echocardiography, you’re going to have a problem; that leaflet will never create the coaptation surface that you want,” he said.
The solution may lie underneath the leaflet. Said Dr. del Nido, “We tend to want to close a cleft, and, yes, that will get you relief of regurgitation in the central portion, but if you end up with immobility of that leaflet, then look underneath. Most often there are very abnormal attachments to the edges of that cleft to the septum. You have to get rid of that; if you don’t resect all that, you’ll never have a leaflet that truly floats up to coapt against the posterior leaflet.”
Annular dilation in children can also challenge a cardiothoracic surgeon’s skill.
In rare cases, a suture commissuroplasty may correct the problem. Sometimes Dr. del Nido will use the DeVega suture annuloplasty – “even though it is very much user dependent; it’s very easy in pediatrics to create stenosis with the DeVega.” As an alternative, synthetic ring annuloplasties can confine valve growth and are rarely used.
Dr. del Nido’s preference is to use a hybrid approach of tissue and resorbable material. “The advantage of the resorbable material is that it will go away, but that’s also the problem with the resorbable material,” he said. “Once it does go away, there’s nothing there to support the annulus, so a combination of tissue and resorbable suture is probably the best answer.”
In posterior leaflet deficiency, a patch of pericardium posteriorly can augment the dysfunctional leaflet. You can also use pericardium as an annuloplasty ring. “You can use it circumferentially,” Dr. del Nido said. “It’s a soft ring; you can certainly use this material which is autologous; it does provide strength to the fibrous annulus; it does support that valve; and you do see growth.” He added that bovine pericardium is not ideal for this use.
Dr. del Nido reported no relevant financial relationships.
NEW YORK – Repairing mitral valves in pediatric patients must overcome two issues: the wide variability in their anatomy and their growth. Using strategies and techniques common in adult mitral surgery can accomplish good mitral valve function in children, but some techniques in children differ, like using combined resorbable material with autologous tissue or transferring native chords instead of placing artificial chords to a malfunctioning leaflet.
Pedro del Nido, MD, of Boston Children’s Hospital, said the spectrum of mitral valve pathology in children goes from congenital mitral stenosis with a thick annulus with leaflet immobility to leaflet hypermobility that involves anterior leaflet prolapse and can involve a cleft that causes regurgitation. Dr. del Nido explained his surgical approaches for mitral valve disease in children at the 2017 Mitral Conclave, sponsored by the American Association of Thoracic Surgery.
Accessing the mitral valve in children requires a different approach than in adults, Dr. del Nido said. “Going through the left atrium is generally difficult, so we often enter through a trans-septal incision,” he said. “The main reason for that is because the tricuspid valve is often associated with the mitral valve problem and this gives us the most direct exposure.”
Once the surgeon gains exposure, the surgical analysis for a diseased adult or child valve is almost identical, with the exception that adult disease is acquired whereas childhood disease tends to be congenital, Dr. del Nido said. “In the congenital patient, we often find fibroelastic tissue that the child is born with,” he said. “We see this in neonates and young infants. It thickens over time; it doesn’t often calcify, but it does often restrict the leaflets and it tends to fuse the chords, so in essence you have direct attachments of the leaflets to the papillaries.”
He explained that this pathology requires an approach similar to that for rheumatic mitral disease in adults. “Start splitting the commissures and start resecting the tissue off the chords creating fenestrations in order to improve the inflow.” Dr. del Nido added, “If you don’t do this, the child will always have a gradient, and if you think about an adult having problems and symptoms with a gradient, think about a 10-year-old running around trying to do athletics; it’s impossible.”
Dysfunctional chords also require a somewhat different approach in children than they require in adults. “We find elongation of the chords and the anterior support structure is abnormal; the secondary chords are totally intact,” Dr. del Nido said. When confronting a torn-edge chord, resection is often an option in adults, but is uncommon in children. “We don’t usually have very much leaflet tissue,” he said. Artificial chords do not accommodate growth.
“We tend to use native tissue,” said Dr. del Nido. “You can transfer the strut chord; you can transfer the secondary chord in order to achieve support for the edge of that prolapsed leaflet.”
Leaflet problems are probably the biggest single source of recurrence in children, Dr. del Nido said. A cleft on the anterior leaflet can be particularly vexing. For example, cleft edges attached to the septum can prevent the valve leaflet from coaptation with the posterior leaflet. “If you don’t recognize that on 3-D echocardiography, you’re going to have a problem; that leaflet will never create the coaptation surface that you want,” he said.
The solution may lie underneath the leaflet. Said Dr. del Nido, “We tend to want to close a cleft, and, yes, that will get you relief of regurgitation in the central portion, but if you end up with immobility of that leaflet, then look underneath. Most often there are very abnormal attachments to the edges of that cleft to the septum. You have to get rid of that; if you don’t resect all that, you’ll never have a leaflet that truly floats up to coapt against the posterior leaflet.”
Annular dilation in children can also challenge a cardiothoracic surgeon’s skill.
In rare cases, a suture commissuroplasty may correct the problem. Sometimes Dr. del Nido will use the DeVega suture annuloplasty – “even though it is very much user dependent; it’s very easy in pediatrics to create stenosis with the DeVega.” As an alternative, synthetic ring annuloplasties can confine valve growth and are rarely used.
Dr. del Nido’s preference is to use a hybrid approach of tissue and resorbable material. “The advantage of the resorbable material is that it will go away, but that’s also the problem with the resorbable material,” he said. “Once it does go away, there’s nothing there to support the annulus, so a combination of tissue and resorbable suture is probably the best answer.”
In posterior leaflet deficiency, a patch of pericardium posteriorly can augment the dysfunctional leaflet. You can also use pericardium as an annuloplasty ring. “You can use it circumferentially,” Dr. del Nido said. “It’s a soft ring; you can certainly use this material which is autologous; it does provide strength to the fibrous annulus; it does support that valve; and you do see growth.” He added that bovine pericardium is not ideal for this use.
Dr. del Nido reported no relevant financial relationships.
NEW YORK – Repairing mitral valves in pediatric patients must overcome two issues: the wide variability in their anatomy and their growth. Using strategies and techniques common in adult mitral surgery can accomplish good mitral valve function in children, but some techniques in children differ, like using combined resorbable material with autologous tissue or transferring native chords instead of placing artificial chords to a malfunctioning leaflet.
Pedro del Nido, MD, of Boston Children’s Hospital, said the spectrum of mitral valve pathology in children goes from congenital mitral stenosis with a thick annulus with leaflet immobility to leaflet hypermobility that involves anterior leaflet prolapse and can involve a cleft that causes regurgitation. Dr. del Nido explained his surgical approaches for mitral valve disease in children at the 2017 Mitral Conclave, sponsored by the American Association of Thoracic Surgery.
Accessing the mitral valve in children requires a different approach than in adults, Dr. del Nido said. “Going through the left atrium is generally difficult, so we often enter through a trans-septal incision,” he said. “The main reason for that is because the tricuspid valve is often associated with the mitral valve problem and this gives us the most direct exposure.”
Once the surgeon gains exposure, the surgical analysis for a diseased adult or child valve is almost identical, with the exception that adult disease is acquired whereas childhood disease tends to be congenital, Dr. del Nido said. “In the congenital patient, we often find fibroelastic tissue that the child is born with,” he said. “We see this in neonates and young infants. It thickens over time; it doesn’t often calcify, but it does often restrict the leaflets and it tends to fuse the chords, so in essence you have direct attachments of the leaflets to the papillaries.”
He explained that this pathology requires an approach similar to that for rheumatic mitral disease in adults. “Start splitting the commissures and start resecting the tissue off the chords creating fenestrations in order to improve the inflow.” Dr. del Nido added, “If you don’t do this, the child will always have a gradient, and if you think about an adult having problems and symptoms with a gradient, think about a 10-year-old running around trying to do athletics; it’s impossible.”
Dysfunctional chords also require a somewhat different approach in children than they require in adults. “We find elongation of the chords and the anterior support structure is abnormal; the secondary chords are totally intact,” Dr. del Nido said. When confronting a torn-edge chord, resection is often an option in adults, but is uncommon in children. “We don’t usually have very much leaflet tissue,” he said. Artificial chords do not accommodate growth.
“We tend to use native tissue,” said Dr. del Nido. “You can transfer the strut chord; you can transfer the secondary chord in order to achieve support for the edge of that prolapsed leaflet.”
Leaflet problems are probably the biggest single source of recurrence in children, Dr. del Nido said. A cleft on the anterior leaflet can be particularly vexing. For example, cleft edges attached to the septum can prevent the valve leaflet from coaptation with the posterior leaflet. “If you don’t recognize that on 3-D echocardiography, you’re going to have a problem; that leaflet will never create the coaptation surface that you want,” he said.
The solution may lie underneath the leaflet. Said Dr. del Nido, “We tend to want to close a cleft, and, yes, that will get you relief of regurgitation in the central portion, but if you end up with immobility of that leaflet, then look underneath. Most often there are very abnormal attachments to the edges of that cleft to the septum. You have to get rid of that; if you don’t resect all that, you’ll never have a leaflet that truly floats up to coapt against the posterior leaflet.”
Annular dilation in children can also challenge a cardiothoracic surgeon’s skill.
In rare cases, a suture commissuroplasty may correct the problem. Sometimes Dr. del Nido will use the DeVega suture annuloplasty – “even though it is very much user dependent; it’s very easy in pediatrics to create stenosis with the DeVega.” As an alternative, synthetic ring annuloplasties can confine valve growth and are rarely used.
Dr. del Nido’s preference is to use a hybrid approach of tissue and resorbable material. “The advantage of the resorbable material is that it will go away, but that’s also the problem with the resorbable material,” he said. “Once it does go away, there’s nothing there to support the annulus, so a combination of tissue and resorbable suture is probably the best answer.”
In posterior leaflet deficiency, a patch of pericardium posteriorly can augment the dysfunctional leaflet. You can also use pericardium as an annuloplasty ring. “You can use it circumferentially,” Dr. del Nido said. “It’s a soft ring; you can certainly use this material which is autologous; it does provide strength to the fibrous annulus; it does support that valve; and you do see growth.” He added that bovine pericardium is not ideal for this use.
Dr. del Nido reported no relevant financial relationships.
AT THE 2017 MITRAL VALVE CONCLAVE
Key clinical point: Operating on mitral valves in pediatric patients must overcome the wide variability in anatomy among young patients and accommodate growth.
Major finding: Strategies that involve a combination of resorbable material with autologous tissue can accomplish repair in most of these patients.
Data source: Review based on Dr. del Nido’s experience.
Disclosures: Dr. del Nido reported having no relevant financial disclosures.
Supreme Court allows partial travel ban to proceed
The U.S. Supreme Court has allowed a limited version of President Trump’s travel ban to move forward, prohibiting certain foreign nationals from six majority-Muslim countries from entering the country.
The justices’ June 26 order means that travelers from the affected countries who do not have a bona fide relationship with U.S. nationals or U.S. entities may not enter the United States. Conversely, it means that foreign physicians who have accepted a job at a U.S. institution or students who have been accepted to a U.S. medical school will be allowed to take those positions.
“In practical terms, this means that [the executive order] may not be enforced against foreign nationals who have a credible claim of a bona fide relationship with a person or entity in the United States,” justices wrote in their order. “All other foreign nationals are subject to the provisions. For individuals, a close familial relationship is required. A foreign national who wishes to enter the United States to live with or visit a family member ... clearly has such a relationship. As for entities, the relationship must be formal, documented, and formed in the ordinary course, rather than for the purpose of evading [the executive order].”
In a dissenting statement, Associate Justice Clarence Thomas wrote that the full ban should have gone into effect. Associate Justice Samuel Alito and Associate Justice Neil Gorsuch joined the dissent.
“I agree with the court’s implicit conclusion that the government has made a strong showing that it is likely to succeed on the merits – that is, that the [lower] judgments will be reversed,”Associate Justice Thomas wrote. “The government has also established that failure to stay the injunctions will cause irreparable harm by interfering with its compelling need to provide for the nation’s security. Finally, weighing the government’s interest in preserving national security against the hardships caused to respondents by temporary denials of entry into the country, the balance of the equities favors the government. I would thus grant the government’s applications for a stay in their entirety.”
President Trump’s revised executive order, signed March 6, bars citizens of Iran, Libya, Somalia, Sudan, Syria, and Yemen from obtaining visas for 90 days and blocks refugees from the affected countries from entering the U.S. for 120 days. The executive measure superseded President Trump’s original Jan. 27 travel ban. The revised order clarified that citizens of the six countries who are legal permanent U.S. residents or who have current visas to enter the country are exempt from the travel prohibition. Federal judges in Hawaii and Maryland ruled that the revised order was discriminatory and blocked the order from taking effect, a decision upheld by the 9th U.S. Circuit Court of Appeals.
Justices will hear oral arguments in the case this fall.
[email protected]
On Twitter @legal_med
The U.S. Supreme Court has allowed a limited version of President Trump’s travel ban to move forward, prohibiting certain foreign nationals from six majority-Muslim countries from entering the country.
The justices’ June 26 order means that travelers from the affected countries who do not have a bona fide relationship with U.S. nationals or U.S. entities may not enter the United States. Conversely, it means that foreign physicians who have accepted a job at a U.S. institution or students who have been accepted to a U.S. medical school will be allowed to take those positions.
“In practical terms, this means that [the executive order] may not be enforced against foreign nationals who have a credible claim of a bona fide relationship with a person or entity in the United States,” justices wrote in their order. “All other foreign nationals are subject to the provisions. For individuals, a close familial relationship is required. A foreign national who wishes to enter the United States to live with or visit a family member ... clearly has such a relationship. As for entities, the relationship must be formal, documented, and formed in the ordinary course, rather than for the purpose of evading [the executive order].”
In a dissenting statement, Associate Justice Clarence Thomas wrote that the full ban should have gone into effect. Associate Justice Samuel Alito and Associate Justice Neil Gorsuch joined the dissent.
“I agree with the court’s implicit conclusion that the government has made a strong showing that it is likely to succeed on the merits – that is, that the [lower] judgments will be reversed,”Associate Justice Thomas wrote. “The government has also established that failure to stay the injunctions will cause irreparable harm by interfering with its compelling need to provide for the nation’s security. Finally, weighing the government’s interest in preserving national security against the hardships caused to respondents by temporary denials of entry into the country, the balance of the equities favors the government. I would thus grant the government’s applications for a stay in their entirety.”
President Trump’s revised executive order, signed March 6, bars citizens of Iran, Libya, Somalia, Sudan, Syria, and Yemen from obtaining visas for 90 days and blocks refugees from the affected countries from entering the U.S. for 120 days. The executive measure superseded President Trump’s original Jan. 27 travel ban. The revised order clarified that citizens of the six countries who are legal permanent U.S. residents or who have current visas to enter the country are exempt from the travel prohibition. Federal judges in Hawaii and Maryland ruled that the revised order was discriminatory and blocked the order from taking effect, a decision upheld by the 9th U.S. Circuit Court of Appeals.
Justices will hear oral arguments in the case this fall.
[email protected]
On Twitter @legal_med
The U.S. Supreme Court has allowed a limited version of President Trump’s travel ban to move forward, prohibiting certain foreign nationals from six majority-Muslim countries from entering the country.
The justices’ June 26 order means that travelers from the affected countries who do not have a bona fide relationship with U.S. nationals or U.S. entities may not enter the United States. Conversely, it means that foreign physicians who have accepted a job at a U.S. institution or students who have been accepted to a U.S. medical school will be allowed to take those positions.
“In practical terms, this means that [the executive order] may not be enforced against foreign nationals who have a credible claim of a bona fide relationship with a person or entity in the United States,” justices wrote in their order. “All other foreign nationals are subject to the provisions. For individuals, a close familial relationship is required. A foreign national who wishes to enter the United States to live with or visit a family member ... clearly has such a relationship. As for entities, the relationship must be formal, documented, and formed in the ordinary course, rather than for the purpose of evading [the executive order].”
In a dissenting statement, Associate Justice Clarence Thomas wrote that the full ban should have gone into effect. Associate Justice Samuel Alito and Associate Justice Neil Gorsuch joined the dissent.
“I agree with the court’s implicit conclusion that the government has made a strong showing that it is likely to succeed on the merits – that is, that the [lower] judgments will be reversed,”Associate Justice Thomas wrote. “The government has also established that failure to stay the injunctions will cause irreparable harm by interfering with its compelling need to provide for the nation’s security. Finally, weighing the government’s interest in preserving national security against the hardships caused to respondents by temporary denials of entry into the country, the balance of the equities favors the government. I would thus grant the government’s applications for a stay in their entirety.”
President Trump’s revised executive order, signed March 6, bars citizens of Iran, Libya, Somalia, Sudan, Syria, and Yemen from obtaining visas for 90 days and blocks refugees from the affected countries from entering the U.S. for 120 days. The executive measure superseded President Trump’s original Jan. 27 travel ban. The revised order clarified that citizens of the six countries who are legal permanent U.S. residents or who have current visas to enter the country are exempt from the travel prohibition. Federal judges in Hawaii and Maryland ruled that the revised order was discriminatory and blocked the order from taking effect, a decision upheld by the 9th U.S. Circuit Court of Appeals.
Justices will hear oral arguments in the case this fall.
[email protected]
On Twitter @legal_med
Dr. Turner concludes term as SBAS president teaser
Patricia L. Turner, MD, FACS, Director, American College of Surgeons (ACS) Division of Member Services, recently concluded her term (2016–2017) as president of the Society of Black Academic Surgeons (SBAS). She is the first woman to have served in that role.
Dr. Turner addressed attendees during the April 27–29 SBAS annual meeting, cohosted with the University of Chicago Medicine and Department of Surgery, IL, which is chaired by Jeffrey B. Matthews, MD, FACS, Dallas B. Phemister Professor of Surgery. In her presidential address, The Enduring Influence of Surgical Societies, she described the first time she attended an SBAS meeting as a medical student and expressed her gratitude for being able to lead the meeting as its 22nd president. “I am also grateful to SBAS for the privilege of serving as its first female president,” she said. (Watch a video from the meeting on the Women of SBAS, including Dr. Turner, at www.sbas.net/media/surgeon-spotlight.aspx?id=13).
In her address, Dr. Turner highlighted historical elements of surgery and the activities of surgical societies. She challenged SBAS to continue to expand diversity in all contexts, including age, specialty, gender, and representative institutional members. She urged the organization to extend its influence by amplifying existing relationships with other organizations, such as the ACS, National Institutes of Health, and the Association of American Medical Colleges, while developing new partnerships with other societies and institutions. She also noted that mentorship and excellence in the surgical sciences continue to be the hallmarks of SBAS.
“SBAS has become a formidable scientific forum for surgeons of all backgrounds interested in quality and excellence,” Dr. Turner said. “[Our membership is] small in number, but the power invested in our members and leaders is substantial; we are influential.”
Anthony Stallion, MD, FACS, chief of pediatric surgery, Carolinas HealthCare System, Charlotte, NC, was installed as Dr. Turner’s successor.
Patricia L. Turner, MD, FACS, Director, American College of Surgeons (ACS) Division of Member Services, recently concluded her term (2016–2017) as president of the Society of Black Academic Surgeons (SBAS). She is the first woman to have served in that role.
Dr. Turner addressed attendees during the April 27–29 SBAS annual meeting, cohosted with the University of Chicago Medicine and Department of Surgery, IL, which is chaired by Jeffrey B. Matthews, MD, FACS, Dallas B. Phemister Professor of Surgery. In her presidential address, The Enduring Influence of Surgical Societies, she described the first time she attended an SBAS meeting as a medical student and expressed her gratitude for being able to lead the meeting as its 22nd president. “I am also grateful to SBAS for the privilege of serving as its first female president,” she said. (Watch a video from the meeting on the Women of SBAS, including Dr. Turner, at www.sbas.net/media/surgeon-spotlight.aspx?id=13).
In her address, Dr. Turner highlighted historical elements of surgery and the activities of surgical societies. She challenged SBAS to continue to expand diversity in all contexts, including age, specialty, gender, and representative institutional members. She urged the organization to extend its influence by amplifying existing relationships with other organizations, such as the ACS, National Institutes of Health, and the Association of American Medical Colleges, while developing new partnerships with other societies and institutions. She also noted that mentorship and excellence in the surgical sciences continue to be the hallmarks of SBAS.
“SBAS has become a formidable scientific forum for surgeons of all backgrounds interested in quality and excellence,” Dr. Turner said. “[Our membership is] small in number, but the power invested in our members and leaders is substantial; we are influential.”
Anthony Stallion, MD, FACS, chief of pediatric surgery, Carolinas HealthCare System, Charlotte, NC, was installed as Dr. Turner’s successor.
Patricia L. Turner, MD, FACS, Director, American College of Surgeons (ACS) Division of Member Services, recently concluded her term (2016–2017) as president of the Society of Black Academic Surgeons (SBAS). She is the first woman to have served in that role.
Dr. Turner addressed attendees during the April 27–29 SBAS annual meeting, cohosted with the University of Chicago Medicine and Department of Surgery, IL, which is chaired by Jeffrey B. Matthews, MD, FACS, Dallas B. Phemister Professor of Surgery. In her presidential address, The Enduring Influence of Surgical Societies, she described the first time she attended an SBAS meeting as a medical student and expressed her gratitude for being able to lead the meeting as its 22nd president. “I am also grateful to SBAS for the privilege of serving as its first female president,” she said. (Watch a video from the meeting on the Women of SBAS, including Dr. Turner, at www.sbas.net/media/surgeon-spotlight.aspx?id=13).
In her address, Dr. Turner highlighted historical elements of surgery and the activities of surgical societies. She challenged SBAS to continue to expand diversity in all contexts, including age, specialty, gender, and representative institutional members. She urged the organization to extend its influence by amplifying existing relationships with other organizations, such as the ACS, National Institutes of Health, and the Association of American Medical Colleges, while developing new partnerships with other societies and institutions. She also noted that mentorship and excellence in the surgical sciences continue to be the hallmarks of SBAS.
“SBAS has become a formidable scientific forum for surgeons of all backgrounds interested in quality and excellence,” Dr. Turner said. “[Our membership is] small in number, but the power invested in our members and leaders is substantial; we are influential.”
Anthony Stallion, MD, FACS, chief of pediatric surgery, Carolinas HealthCare System, Charlotte, NC, was installed as Dr. Turner’s successor.
NSAIDs remain a concern in colorectal ERAS protocols
SEATTLE – Nonselective NSAIDs increase the risk of anastomotic leaks after colorectal surgery, according to a meta-analysis from the University of Sydney, Australia.
After combing results from six randomized, controlled trials and seven retrospective studies involving a total of 23,508 patients, investigators found that postop nonselective NSAIDs (odds ratio, 0.54; 95% CI, 0.43-0.67; P less than .00001), and especially diclofenac (OR, 0.39; 95% CI, 0.28-0.55; P less than .00001), were both associated with an increased risk of leakage.
There was an increased risk with all NSAIDs compared to patients who did not receive them after surgery, but the risk was statistically significant only for nonselective options like diclofenac on subgroup analysis. There was a trend for increased leakage with the nonselective agent ketorolac, as well, but it was not significant (OR, 0.71; 95% CI, 0.35-1.43; P = .34).
“I’m not going to say we need to wait for more studies; there’s something here. We have to be aware there could be a high risk of leakage with nonsteroidals, and we have to be mindful of that with our ERAS [Enhanced Recovery after Surgery] protocols. I don’t think you should be using nonsteroidals unless you are using them in a trial” and collecting data, “because of the uncertainty,” lead investigator and colorectal surgeon Christopher Young, MD, a clinical associate professor of surgery at the University of Sydney, said at the American Society of Colon and Rectal Surgeons annual meeting.
NSAIDS are a routine part of colorectal ERAS protocols in some places to limit opioid use and hasten recovery and hospital discharge, but there’s been concern for some time that they might also increase the risk of anastomotic leakage. The new Australian findings fit in with previous investigations that raised concerns.
A 2016 review, for instance, found that among 856 patients undergoing an elective colon or rectal resection for cancer, the anastomotic leakage rate was significantly higher in the group that received nonsteroidal anti-inflammatory drugs compared to patients who did not (9.2% versus 5.3%). The higher rate was only seen in patients receiving diclofenac. “The use of diclofenac in colorectal surgery can no longer be recommended. Alternatives for postoperative analgesia need to be explored within an enhanced recovery program,” the investigators concluded (J Gastrointest Surg. 2016 Apr;20[4]:776-82. doi: 10.1007/s11605-015-3010-1).
A review of 13,082 bariatric and colorectal surgery patients in Washington State found that NSAIDs beginning within 24 hours after surgery were associated with a 70% increased risk of anastomotic leaks in nonelective colorectal surgery, with a leak rate of 12.3% in the NSAID group and 8.3% in the non-NSAID group (OR, 1.70; 95% CI, 1.11–2.68; P = .01). Although it was unclear which nonsteroidals patients received, intravenous ketorolac or ibuprofen were likely the most common (JAMA Surg. 2015 Mar 1;150[3]: 223–8).
It’s unknown why, exactly, NSAIDs impair healing and anastomotic strength, but it’s thought to be related to effects on prostaglandin synthesis, Dr. Young noted.
Dr. Young had no disclosures.
SEATTLE – Nonselective NSAIDs increase the risk of anastomotic leaks after colorectal surgery, according to a meta-analysis from the University of Sydney, Australia.
After combing results from six randomized, controlled trials and seven retrospective studies involving a total of 23,508 patients, investigators found that postop nonselective NSAIDs (odds ratio, 0.54; 95% CI, 0.43-0.67; P less than .00001), and especially diclofenac (OR, 0.39; 95% CI, 0.28-0.55; P less than .00001), were both associated with an increased risk of leakage.
There was an increased risk with all NSAIDs compared to patients who did not receive them after surgery, but the risk was statistically significant only for nonselective options like diclofenac on subgroup analysis. There was a trend for increased leakage with the nonselective agent ketorolac, as well, but it was not significant (OR, 0.71; 95% CI, 0.35-1.43; P = .34).
“I’m not going to say we need to wait for more studies; there’s something here. We have to be aware there could be a high risk of leakage with nonsteroidals, and we have to be mindful of that with our ERAS [Enhanced Recovery after Surgery] protocols. I don’t think you should be using nonsteroidals unless you are using them in a trial” and collecting data, “because of the uncertainty,” lead investigator and colorectal surgeon Christopher Young, MD, a clinical associate professor of surgery at the University of Sydney, said at the American Society of Colon and Rectal Surgeons annual meeting.
NSAIDS are a routine part of colorectal ERAS protocols in some places to limit opioid use and hasten recovery and hospital discharge, but there’s been concern for some time that they might also increase the risk of anastomotic leakage. The new Australian findings fit in with previous investigations that raised concerns.
A 2016 review, for instance, found that among 856 patients undergoing an elective colon or rectal resection for cancer, the anastomotic leakage rate was significantly higher in the group that received nonsteroidal anti-inflammatory drugs compared to patients who did not (9.2% versus 5.3%). The higher rate was only seen in patients receiving diclofenac. “The use of diclofenac in colorectal surgery can no longer be recommended. Alternatives for postoperative analgesia need to be explored within an enhanced recovery program,” the investigators concluded (J Gastrointest Surg. 2016 Apr;20[4]:776-82. doi: 10.1007/s11605-015-3010-1).
A review of 13,082 bariatric and colorectal surgery patients in Washington State found that NSAIDs beginning within 24 hours after surgery were associated with a 70% increased risk of anastomotic leaks in nonelective colorectal surgery, with a leak rate of 12.3% in the NSAID group and 8.3% in the non-NSAID group (OR, 1.70; 95% CI, 1.11–2.68; P = .01). Although it was unclear which nonsteroidals patients received, intravenous ketorolac or ibuprofen were likely the most common (JAMA Surg. 2015 Mar 1;150[3]: 223–8).
It’s unknown why, exactly, NSAIDs impair healing and anastomotic strength, but it’s thought to be related to effects on prostaglandin synthesis, Dr. Young noted.
Dr. Young had no disclosures.
SEATTLE – Nonselective NSAIDs increase the risk of anastomotic leaks after colorectal surgery, according to a meta-analysis from the University of Sydney, Australia.
After combing results from six randomized, controlled trials and seven retrospective studies involving a total of 23,508 patients, investigators found that postop nonselective NSAIDs (odds ratio, 0.54; 95% CI, 0.43-0.67; P less than .00001), and especially diclofenac (OR, 0.39; 95% CI, 0.28-0.55; P less than .00001), were both associated with an increased risk of leakage.
There was an increased risk with all NSAIDs compared to patients who did not receive them after surgery, but the risk was statistically significant only for nonselective options like diclofenac on subgroup analysis. There was a trend for increased leakage with the nonselective agent ketorolac, as well, but it was not significant (OR, 0.71; 95% CI, 0.35-1.43; P = .34).
“I’m not going to say we need to wait for more studies; there’s something here. We have to be aware there could be a high risk of leakage with nonsteroidals, and we have to be mindful of that with our ERAS [Enhanced Recovery after Surgery] protocols. I don’t think you should be using nonsteroidals unless you are using them in a trial” and collecting data, “because of the uncertainty,” lead investigator and colorectal surgeon Christopher Young, MD, a clinical associate professor of surgery at the University of Sydney, said at the American Society of Colon and Rectal Surgeons annual meeting.
NSAIDS are a routine part of colorectal ERAS protocols in some places to limit opioid use and hasten recovery and hospital discharge, but there’s been concern for some time that they might also increase the risk of anastomotic leakage. The new Australian findings fit in with previous investigations that raised concerns.
A 2016 review, for instance, found that among 856 patients undergoing an elective colon or rectal resection for cancer, the anastomotic leakage rate was significantly higher in the group that received nonsteroidal anti-inflammatory drugs compared to patients who did not (9.2% versus 5.3%). The higher rate was only seen in patients receiving diclofenac. “The use of diclofenac in colorectal surgery can no longer be recommended. Alternatives for postoperative analgesia need to be explored within an enhanced recovery program,” the investigators concluded (J Gastrointest Surg. 2016 Apr;20[4]:776-82. doi: 10.1007/s11605-015-3010-1).
A review of 13,082 bariatric and colorectal surgery patients in Washington State found that NSAIDs beginning within 24 hours after surgery were associated with a 70% increased risk of anastomotic leaks in nonelective colorectal surgery, with a leak rate of 12.3% in the NSAID group and 8.3% in the non-NSAID group (OR, 1.70; 95% CI, 1.11–2.68; P = .01). Although it was unclear which nonsteroidals patients received, intravenous ketorolac or ibuprofen were likely the most common (JAMA Surg. 2015 Mar 1;150[3]: 223–8).
It’s unknown why, exactly, NSAIDs impair healing and anastomotic strength, but it’s thought to be related to effects on prostaglandin synthesis, Dr. Young noted.
Dr. Young had no disclosures.
AT ASCRS 2017
Key clinical point:
Major finding: Postop nonselective NSAIDs (OR, 0.54; 95% CI, 0.43-0.67; P less than .00001), and especially diclofenac (OR, 0.39; 95% CI, 0.28-0.55; P less than .00001), were both associated with an increased risk of leakage.
Data source: Meta-analysis involving 23,508 patients
Disclosures: The presenter had no disclosures.
Study shows that 20% of inpatients given antibiotics develop adverse reactions
Twenty percent of hospitalized adults given antibiotics develop adverse drug events, including GI, nephrotoxic, hematologic, cardiac, and neurotoxic effects, according to a report in JAMA Internal Medicine.
This high frequency of adverse reactions “may not be recognized by clinicians because [these events] have varied manifestations, clinicians may be unaware of the risks associated with specific antibiotic agents, or because they occur after patients are discharged from the hospital,” said Pranita D. Tamma, MD, of the division of pediatric infectious diseases, Johns Hopkins University, Baltimore, and her associates.
They assessed antibiotic-associated adverse drug events in all 1,488 adults admitted to four general medicine services at a single medical center during a 9-month period and given at least 24 hours of any antibiotic therapy. The most common indications for antibiotics were urinary tract infections (12%), skin and soft-tissue infections (8%), and community-acquired pneumonia (7%).
Perhaps as important, the researchers noted, 19% of these adverse drug events were attributed to unnecessary antibiotics – drugs given for conditions for which they were not clinically indicated according to the hospital’s own antibiotic guidelines. These included asymptomatic bacteriuria, aspiration pneumonitis, and heart failure (JAMA Intern. Med. 2017 June 12. doi: 10.1001/jamainternmed.2017.1938).
The most common adverse reactions that developed within 30 days were GI, renal, and hematologic abnormalities. Neurotoxic effects included encephalopathy and seizures; cardiotoxic effects included QTc prolongation. Less frequent adverse events included anaphylaxis, daptomycin-associated myositis, trimethoprim/sulfamethoxazole-associated pancreatitis, linezolid-associated neuropathy, and ciprofloxacin-related tendinitis. The most common adverse reactions that developed within 90 days were C. difficile infections and infections involving multidrug-resistant organisms.
“Our findings underscore the importance of avoiding unnecessary antibiotic prescribing to reduce the harm that can result from antibiotic-associated adverse drug events,” Dr. Tamma and her associates said.
Twenty percent of hospitalized adults given antibiotics develop adverse drug events, including GI, nephrotoxic, hematologic, cardiac, and neurotoxic effects, according to a report in JAMA Internal Medicine.
This high frequency of adverse reactions “may not be recognized by clinicians because [these events] have varied manifestations, clinicians may be unaware of the risks associated with specific antibiotic agents, or because they occur after patients are discharged from the hospital,” said Pranita D. Tamma, MD, of the division of pediatric infectious diseases, Johns Hopkins University, Baltimore, and her associates.
They assessed antibiotic-associated adverse drug events in all 1,488 adults admitted to four general medicine services at a single medical center during a 9-month period and given at least 24 hours of any antibiotic therapy. The most common indications for antibiotics were urinary tract infections (12%), skin and soft-tissue infections (8%), and community-acquired pneumonia (7%).
Perhaps as important, the researchers noted, 19% of these adverse drug events were attributed to unnecessary antibiotics – drugs given for conditions for which they were not clinically indicated according to the hospital’s own antibiotic guidelines. These included asymptomatic bacteriuria, aspiration pneumonitis, and heart failure (JAMA Intern. Med. 2017 June 12. doi: 10.1001/jamainternmed.2017.1938).
The most common adverse reactions that developed within 30 days were GI, renal, and hematologic abnormalities. Neurotoxic effects included encephalopathy and seizures; cardiotoxic effects included QTc prolongation. Less frequent adverse events included anaphylaxis, daptomycin-associated myositis, trimethoprim/sulfamethoxazole-associated pancreatitis, linezolid-associated neuropathy, and ciprofloxacin-related tendinitis. The most common adverse reactions that developed within 90 days were C. difficile infections and infections involving multidrug-resistant organisms.
“Our findings underscore the importance of avoiding unnecessary antibiotic prescribing to reduce the harm that can result from antibiotic-associated adverse drug events,” Dr. Tamma and her associates said.
Twenty percent of hospitalized adults given antibiotics develop adverse drug events, including GI, nephrotoxic, hematologic, cardiac, and neurotoxic effects, according to a report in JAMA Internal Medicine.
This high frequency of adverse reactions “may not be recognized by clinicians because [these events] have varied manifestations, clinicians may be unaware of the risks associated with specific antibiotic agents, or because they occur after patients are discharged from the hospital,” said Pranita D. Tamma, MD, of the division of pediatric infectious diseases, Johns Hopkins University, Baltimore, and her associates.
They assessed antibiotic-associated adverse drug events in all 1,488 adults admitted to four general medicine services at a single medical center during a 9-month period and given at least 24 hours of any antibiotic therapy. The most common indications for antibiotics were urinary tract infections (12%), skin and soft-tissue infections (8%), and community-acquired pneumonia (7%).
Perhaps as important, the researchers noted, 19% of these adverse drug events were attributed to unnecessary antibiotics – drugs given for conditions for which they were not clinically indicated according to the hospital’s own antibiotic guidelines. These included asymptomatic bacteriuria, aspiration pneumonitis, and heart failure (JAMA Intern. Med. 2017 June 12. doi: 10.1001/jamainternmed.2017.1938).
The most common adverse reactions that developed within 30 days were GI, renal, and hematologic abnormalities. Neurotoxic effects included encephalopathy and seizures; cardiotoxic effects included QTc prolongation. Less frequent adverse events included anaphylaxis, daptomycin-associated myositis, trimethoprim/sulfamethoxazole-associated pancreatitis, linezolid-associated neuropathy, and ciprofloxacin-related tendinitis. The most common adverse reactions that developed within 90 days were C. difficile infections and infections involving multidrug-resistant organisms.
“Our findings underscore the importance of avoiding unnecessary antibiotic prescribing to reduce the harm that can result from antibiotic-associated adverse drug events,” Dr. Tamma and her associates said.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Among hospitalized adults given antibiotics, 20% develop adverse reactions, including GI, nephrotoxic, hematologic, cardiac, and neurotoxic effects.
Major finding: Among 1,488 patients, 298 (20%) developed 324 adverse reactions to antibiotics – 73% during hospitalization and 27% after discharge – requiring prolonged hospitalization; a subsequent hospitalization; an ED visit; or additional lab tests, ECGs, or imaging studies.
Data source: A single-center retrospective cohort study involving all 1,488 general medicine inpatients admitted during a 9-month period who received any antibiotic for at least 24 hours.
Disclosures: This study was supported by Pfizer Independent Grants for Learning and Change and the Joint Commission. Dr. Tamma and her associates reported having no relevant financial disclosures.
Consider intraperitoneal ropivacaine for colectomy ERAS
SEATTLE – Intraperitoneal ropivacaine decreases postoperative pain and improves functional recovery after laparoscopic colectomy, according to randomized, blinded trial from the Royal Adelaide (Australia) Hospital.
“We recommend routine inclusion of IPLA [intraperitoneal local anesthetic] in the multimodal analgesia component of ERAS [enhanced-recovery-after-surgery] programs for laparoscopic colectomy,” the investigators concluded.
Recovery was smoother in the ropivacaine group. On a 90-point surgical recovery scale assessing fatigue, mental function, and the ability to do normal daily activities, ropivacaine patients were a few points ahead on days 1 and 3; the gap widened to about 10 points on days 7, 30, and 45. Ropivacaine might have helped reduced inflammation, accounting for the extended benefit, Dr. Lewis said.
Pain control was better with ropivacaine, as well. Ropivacaine patients were about 15-20 points lower on 50-point scales assessing both visceral and abdominal pain at postop hours 3 and 24, and day 7. The findings were statistically significant.
Several trends also favored ropivacaine. Ropivacaine patients had their first bowel movement at around 70 hours postop, versus about 82 hours in the control group. They were also discharged almost a day sooner, and had less postop vomiting. Just one patient in the ropivacaine group was diagnosed with ileus, versus four in the control arm.
There was also a trend for less opioid use in the ropivacaine group, which Dr. Lewis suspected would have been statistically significant if the trial had more patients.
Ropivacaine patients were a mean of 67 years old, versus 62 years old in the control group. There were slightly more men than women in each arm. The mean body mass index in the ropivacaine group was 28.5 kg/m2, and in the control group 26.4 kg/m2. Ropivacaine was discontinued in two patients due to possible toxicity.
An audience member noted that intravenous lidocaine has shown similar benefits in abdominal surgery.
The investigators had no disclosures.
SEATTLE – Intraperitoneal ropivacaine decreases postoperative pain and improves functional recovery after laparoscopic colectomy, according to randomized, blinded trial from the Royal Adelaide (Australia) Hospital.
“We recommend routine inclusion of IPLA [intraperitoneal local anesthetic] in the multimodal analgesia component of ERAS [enhanced-recovery-after-surgery] programs for laparoscopic colectomy,” the investigators concluded.
Recovery was smoother in the ropivacaine group. On a 90-point surgical recovery scale assessing fatigue, mental function, and the ability to do normal daily activities, ropivacaine patients were a few points ahead on days 1 and 3; the gap widened to about 10 points on days 7, 30, and 45. Ropivacaine might have helped reduced inflammation, accounting for the extended benefit, Dr. Lewis said.
Pain control was better with ropivacaine, as well. Ropivacaine patients were about 15-20 points lower on 50-point scales assessing both visceral and abdominal pain at postop hours 3 and 24, and day 7. The findings were statistically significant.
Several trends also favored ropivacaine. Ropivacaine patients had their first bowel movement at around 70 hours postop, versus about 82 hours in the control group. They were also discharged almost a day sooner, and had less postop vomiting. Just one patient in the ropivacaine group was diagnosed with ileus, versus four in the control arm.
There was also a trend for less opioid use in the ropivacaine group, which Dr. Lewis suspected would have been statistically significant if the trial had more patients.
Ropivacaine patients were a mean of 67 years old, versus 62 years old in the control group. There were slightly more men than women in each arm. The mean body mass index in the ropivacaine group was 28.5 kg/m2, and in the control group 26.4 kg/m2. Ropivacaine was discontinued in two patients due to possible toxicity.
An audience member noted that intravenous lidocaine has shown similar benefits in abdominal surgery.
The investigators had no disclosures.
SEATTLE – Intraperitoneal ropivacaine decreases postoperative pain and improves functional recovery after laparoscopic colectomy, according to randomized, blinded trial from the Royal Adelaide (Australia) Hospital.
“We recommend routine inclusion of IPLA [intraperitoneal local anesthetic] in the multimodal analgesia component of ERAS [enhanced-recovery-after-surgery] programs for laparoscopic colectomy,” the investigators concluded.
Recovery was smoother in the ropivacaine group. On a 90-point surgical recovery scale assessing fatigue, mental function, and the ability to do normal daily activities, ropivacaine patients were a few points ahead on days 1 and 3; the gap widened to about 10 points on days 7, 30, and 45. Ropivacaine might have helped reduced inflammation, accounting for the extended benefit, Dr. Lewis said.
Pain control was better with ropivacaine, as well. Ropivacaine patients were about 15-20 points lower on 50-point scales assessing both visceral and abdominal pain at postop hours 3 and 24, and day 7. The findings were statistically significant.
Several trends also favored ropivacaine. Ropivacaine patients had their first bowel movement at around 70 hours postop, versus about 82 hours in the control group. They were also discharged almost a day sooner, and had less postop vomiting. Just one patient in the ropivacaine group was diagnosed with ileus, versus four in the control arm.
There was also a trend for less opioid use in the ropivacaine group, which Dr. Lewis suspected would have been statistically significant if the trial had more patients.
Ropivacaine patients were a mean of 67 years old, versus 62 years old in the control group. There were slightly more men than women in each arm. The mean body mass index in the ropivacaine group was 28.5 kg/m2, and in the control group 26.4 kg/m2. Ropivacaine was discontinued in two patients due to possible toxicity.
An audience member noted that intravenous lidocaine has shown similar benefits in abdominal surgery.
The investigators had no disclosures.
AT ASCRS 2017
Key clinical point:
Major finding: On a 90-point surgical recovery scale assessing fatigue, mental function, and the ability to do normal daily activities, ropivacaine patients were a few points ahead of saline controls on postop days 1 and 3; the gap widened to about 10 points on days 7, 30, and 45.
Data source: Randomized, blinded trial with 51 patients
Disclosures: The investigators had no disclosures.
Major bleeding deaths may outweigh VTE risk in older cancer patients
MADRID – Look before you leap into anticoagulation therapy for older cancer patients, results from a Canadian cohort study suggest.
Among patients 65 and older with cancer and a venous thromboembolic event (VTE) within 6 months of the cancer diagnosis, the 7-day mortality rate from VTE was 0.5%, compared with an 11% rate of death from a major bleeding episode, reported Alejandro Lazo-Langner MD, MSc from Western University in London, Canada.
If their findings are confirmed in further studies, “it would actually change what we do in terms of the treatment of thrombosis,” he said.
Risks for both VTE and for bleeding are known to be higher among patients with cancer than in the general population. Although a previously published systematic review suggested that mortality rates from recurrent VTE and major bleeding events were similar in the first 6 months of anticoagulation therapy, those results were limited by the heterogeneity of designs in the various studies included in the review, and by differences in outcome measures and the types of populations included, Dr. Lazo-Langner said.
To get a better idea of the case fatality rates of VTE recurrence and major bleeding and the case fatality rate ratio for each, the authors conducted a retrospective population-based cohort study in the Province of Ontario using de-identified linked administrative health care databases.
They assembled a cohort of patients 65 years of age and older who had a VTE event within 6 months of an initial cancer diagnosis. Recurrent VTE and major bleeding events were assessed within 180 days of the index date.
They found that from 2004 through 2014 there were 6,967 VTEs in cancer patients over 65 years of age (mean age 75) that were treated with an anticoagulant, either low-molecular-weight heparin (LMWH), LMWH plus warfarin, warfarin alone, or rivaroxaban (Xarelto).
Six months after the index VTE events, 235 patients (3%) had experienced a major bleeding event, and 1,184 (17%) had a recurrent VTE.
Within 7 days of the outcome event the mortality rate due to major bleeding was 11%, compared with 0.5% for recurrent VTEs. This translated into a mortality rate ratio for major bleeding vs. VTE of 21.8
Elizabeth Macintyre, MD, from the Hôpital Necker-Enfants Malades and University of Paris, France, who was not involved in the study, said in an interview that the results indicate that clinicians should not automatically assume that anticoagulation is a good idea for every older cancer patient.
“We now need to consider whether we should be reducing the time of anticoagulation, but that obviously depends on all sorts of other risk factors, so it has to be an individual patient decision. But the message is clearly don’t just anticoagulate to avoid the risk of thrombosis, and do in bear in mind that the other side of the coin could be just as serious,” she said.
The study was supported by the Institute for Clinical Evaluative Sciences, funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Dr. Lazo-Langner and Dr. Macintyre reported having no conflicts of interest to disclose.
MADRID – Look before you leap into anticoagulation therapy for older cancer patients, results from a Canadian cohort study suggest.
Among patients 65 and older with cancer and a venous thromboembolic event (VTE) within 6 months of the cancer diagnosis, the 7-day mortality rate from VTE was 0.5%, compared with an 11% rate of death from a major bleeding episode, reported Alejandro Lazo-Langner MD, MSc from Western University in London, Canada.
If their findings are confirmed in further studies, “it would actually change what we do in terms of the treatment of thrombosis,” he said.
Risks for both VTE and for bleeding are known to be higher among patients with cancer than in the general population. Although a previously published systematic review suggested that mortality rates from recurrent VTE and major bleeding events were similar in the first 6 months of anticoagulation therapy, those results were limited by the heterogeneity of designs in the various studies included in the review, and by differences in outcome measures and the types of populations included, Dr. Lazo-Langner said.
To get a better idea of the case fatality rates of VTE recurrence and major bleeding and the case fatality rate ratio for each, the authors conducted a retrospective population-based cohort study in the Province of Ontario using de-identified linked administrative health care databases.
They assembled a cohort of patients 65 years of age and older who had a VTE event within 6 months of an initial cancer diagnosis. Recurrent VTE and major bleeding events were assessed within 180 days of the index date.
They found that from 2004 through 2014 there were 6,967 VTEs in cancer patients over 65 years of age (mean age 75) that were treated with an anticoagulant, either low-molecular-weight heparin (LMWH), LMWH plus warfarin, warfarin alone, or rivaroxaban (Xarelto).
Six months after the index VTE events, 235 patients (3%) had experienced a major bleeding event, and 1,184 (17%) had a recurrent VTE.
Within 7 days of the outcome event the mortality rate due to major bleeding was 11%, compared with 0.5% for recurrent VTEs. This translated into a mortality rate ratio for major bleeding vs. VTE of 21.8
Elizabeth Macintyre, MD, from the Hôpital Necker-Enfants Malades and University of Paris, France, who was not involved in the study, said in an interview that the results indicate that clinicians should not automatically assume that anticoagulation is a good idea for every older cancer patient.
“We now need to consider whether we should be reducing the time of anticoagulation, but that obviously depends on all sorts of other risk factors, so it has to be an individual patient decision. But the message is clearly don’t just anticoagulate to avoid the risk of thrombosis, and do in bear in mind that the other side of the coin could be just as serious,” she said.
The study was supported by the Institute for Clinical Evaluative Sciences, funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Dr. Lazo-Langner and Dr. Macintyre reported having no conflicts of interest to disclose.
MADRID – Look before you leap into anticoagulation therapy for older cancer patients, results from a Canadian cohort study suggest.
Among patients 65 and older with cancer and a venous thromboembolic event (VTE) within 6 months of the cancer diagnosis, the 7-day mortality rate from VTE was 0.5%, compared with an 11% rate of death from a major bleeding episode, reported Alejandro Lazo-Langner MD, MSc from Western University in London, Canada.
If their findings are confirmed in further studies, “it would actually change what we do in terms of the treatment of thrombosis,” he said.
Risks for both VTE and for bleeding are known to be higher among patients with cancer than in the general population. Although a previously published systematic review suggested that mortality rates from recurrent VTE and major bleeding events were similar in the first 6 months of anticoagulation therapy, those results were limited by the heterogeneity of designs in the various studies included in the review, and by differences in outcome measures and the types of populations included, Dr. Lazo-Langner said.
To get a better idea of the case fatality rates of VTE recurrence and major bleeding and the case fatality rate ratio for each, the authors conducted a retrospective population-based cohort study in the Province of Ontario using de-identified linked administrative health care databases.
They assembled a cohort of patients 65 years of age and older who had a VTE event within 6 months of an initial cancer diagnosis. Recurrent VTE and major bleeding events were assessed within 180 days of the index date.
They found that from 2004 through 2014 there were 6,967 VTEs in cancer patients over 65 years of age (mean age 75) that were treated with an anticoagulant, either low-molecular-weight heparin (LMWH), LMWH plus warfarin, warfarin alone, or rivaroxaban (Xarelto).
Six months after the index VTE events, 235 patients (3%) had experienced a major bleeding event, and 1,184 (17%) had a recurrent VTE.
Within 7 days of the outcome event the mortality rate due to major bleeding was 11%, compared with 0.5% for recurrent VTEs. This translated into a mortality rate ratio for major bleeding vs. VTE of 21.8
Elizabeth Macintyre, MD, from the Hôpital Necker-Enfants Malades and University of Paris, France, who was not involved in the study, said in an interview that the results indicate that clinicians should not automatically assume that anticoagulation is a good idea for every older cancer patient.
“We now need to consider whether we should be reducing the time of anticoagulation, but that obviously depends on all sorts of other risk factors, so it has to be an individual patient decision. But the message is clearly don’t just anticoagulate to avoid the risk of thrombosis, and do in bear in mind that the other side of the coin could be just as serious,” she said.
The study was supported by the Institute for Clinical Evaluative Sciences, funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Dr. Lazo-Langner and Dr. Macintyre reported having no conflicts of interest to disclose.
AT EHA 2017
Key clinical point: In cancer patients older than 65, the risk of major bleeding from anticoagulants may outweigh the risk of venous thromboembolism.
Major finding: 7-day mortality rates were 11% for major bleeding vs 0.5% for recurrent VTE.
Data source: Retrospective cohort study of 6,967 cancer patients age 65 and older from Ontario, Canada.
Disclosures: The study was supported by the Institute for Clinical Evaluative Sciences, funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Dr. Lazo-Langner and Dr. Macintyre reported having no conflicts of interest to disclose.