Damian McNamara

SAN ANTONIO — The number of unintended subsequent teenage pregnancies might decrease with enhanced postpartum contraceptive counseling, particularly about side effects of birth control options, based on findings from a telephone survey of 40 young women.

The survey, conducted at 7 months to 1 year post partum, included women aged 21 years and younger who were delivered between April and September 2007 at Sinai Hospital in Baltimore, said Dr. Suzanne Elizabeth Jose and Dr. Julie Jacobstein.

“We see a lot of 15-year-old, 16-year-old girls coming in with their second or third babies,” Dr. Jose said in an interview. “Before they leave the hospital, we counsel them about birth control options.” The most common contraceptive choices were the birth control pill (13 patients) and injectable contraception (10 patients).

“But they come back. So we asked ourselves: What are we doing wrong?” Dr. Jose said at her poster during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

All of the surveyed patients reported receiving some counseling, but half had discontinued contraception. “Some had no reason—they just stopped.” Others cited adverse effects.

“We have to improve our counseling about side effects,” Dr. Jose said. Group contraception counseling is a possible strategy.

When talking to adolescents, “you have to be able to talk to them in language they understand,” and a planned study will explore age-appropriate dialogue, Dr. Jose said. The routine 6-week follow-up visit after vaginal deliveries might be a good time to reinforce contraceptive counseling, she added.

Of the 40 adolescent mothers, 11 (28%) reported a subsequent pregnancy—all unintended, Dr. Jose said. There were no miscarriages or ectopic pregnancies.

Although it did not occur in this study, some adolescents choose to get pregnant again, she said. Physicians can ask about such plans during contraceptive counseling and consider the duration of different options. For example, an intrauterine device that lasts 5 years may not be a good option for a teenager.

Next, Dr. Jose and her associates plan to study the effectiveness of postpartum contraceptive counseling in a prospective study.

Dr. Jose said she had no relevant financial disclosures.

The 6-week follow-up visit after vaginal deliveries might be a good time to reinforce counseling. DR. JOSE

SAN ANTONIO — The number of unintended subsequent teenage pregnancies might decrease with enhanced postpartum contraceptive counseling, particularly about side effects of birth control options, based on findings from a telephone survey of 40 young women.

The survey, conducted at 7 months to 1 year post partum, included women aged 21 years and younger who were delivered between April and September 2007 at Sinai Hospital in Baltimore, said Dr. Suzanne Elizabeth Jose and Dr. Julie Jacobstein.

“We see a lot of 15-year-old, 16-year-old girls coming in with their second or third babies,” Dr. Jose said in an interview. “Before they leave the hospital, we counsel them about birth control options.” The most common contraceptive choices were the birth control pill (13 patients) and injectable contraception (10 patients).

“But they come back. So we asked ourselves: What are we doing wrong?” Dr. Jose said at her poster during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

All of the surveyed patients reported receiving some counseling, but half had discontinued contraception. “Some had no reason—they just stopped.” Others cited adverse effects.

“We have to improve our counseling about side effects,” Dr. Jose said. Group contraception counseling is a possible strategy.

When talking to adolescents, “you have to be able to talk to them in language they understand,” and a planned study will explore age-appropriate dialogue, Dr. Jose said. The routine 6-week follow-up visit after vaginal deliveries might be a good time to reinforce contraceptive counseling, she added.

Of the 40 adolescent mothers, 11 (28%) reported a subsequent pregnancy—all unintended, Dr. Jose said. There were no miscarriages or ectopic pregnancies.

Although it did not occur in this study, some adolescents choose to get pregnant again, she said. Physicians can ask about such plans during contraceptive counseling and consider the duration of different options. For example, an intrauterine device that lasts 5 years may not be a good option for a teenager.

Next, Dr. Jose and her associates plan to study the effectiveness of postpartum contraceptive counseling in a prospective study.

Dr. Jose said she had no relevant financial disclosures.

The 6-week follow-up visit after vaginal deliveries might be a good time to reinforce counseling. DR. JOSE

SAN ANTONIO — The number of unintended subsequent teenage pregnancies might decrease with enhanced postpartum contraceptive counseling, particularly about side effects of birth control options, based on findings from a telephone survey of 40 young women.

The survey, conducted at 7 months to 1 year post partum, included women aged 21 years and younger who were delivered between April and September 2007 at Sinai Hospital in Baltimore, said Dr. Suzanne Elizabeth Jose and Dr. Julie Jacobstein.

“We see a lot of 15-year-old, 16-year-old girls coming in with their second or third babies,” Dr. Jose said in an interview. “Before they leave the hospital, we counsel them about birth control options.” The most common contraceptive choices were the birth control pill (13 patients) and injectable contraception (10 patients).

“But they come back. So we asked ourselves: What are we doing wrong?” Dr. Jose said at her poster during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

All of the surveyed patients reported receiving some counseling, but half had discontinued contraception. “Some had no reason—they just stopped.” Others cited adverse effects.

“We have to improve our counseling about side effects,” Dr. Jose said. Group contraception counseling is a possible strategy.

When talking to adolescents, “you have to be able to talk to them in language they understand,” and a planned study will explore age-appropriate dialogue, Dr. Jose said. The routine 6-week follow-up visit after vaginal deliveries might be a good time to reinforce contraceptive counseling, she added.

Of the 40 adolescent mothers, 11 (28%) reported a subsequent pregnancy—all unintended, Dr. Jose said. There were no miscarriages or ectopic pregnancies.

Although it did not occur in this study, some adolescents choose to get pregnant again, she said. Physicians can ask about such plans during contraceptive counseling and consider the duration of different options. For example, an intrauterine device that lasts 5 years may not be a good option for a teenager.

Next, Dr. Jose and her associates plan to study the effectiveness of postpartum contraceptive counseling in a prospective study.

Dr. Jose said she had no relevant financial disclosures.

The 6-week follow-up visit after vaginal deliveries might be a good time to reinforce counseling. DR. JOSE

MIAMI BEACH — Adoption of an electronic health record system is associated with a consistent but modest increase in quality of hospital care, according to a survey of more than 4,800 acute care hospitals in the United States.

Acute myocardial infarction care and infection prevention improved significantly with electronic health records (EHRs), but the differences were small overall, Catherine DesRoches, Ph.D., said at the annual meeting of the Society of General Internal Medicine.

Electronic clinical reminders also had a significant but “extremely modest” effect.

Most previous studies of specific EHR functionalities and quality have focused on a small set of pioneering hospitals, said Dr. DesRoches, a survey scientist at the Institute for Health Policy at Massachusetts General Hospital and an instructor in medicine at Harvard Medical School, both in Boston.

She and her colleagues surveyed all 4,840 acute care general medical and surgical hospitals as part of the American Hospital Association 2008 Annual Survey. They received answers from 3,049 hospital administrators, for a response rate of 63%.

The investigators asked administrators if they had an EHR, and if so, whether it was basic or comprehensive, based on 24 key clinical functionalities. Using data from the Hospital Quality Alliance and the Medicare Provider Analysis and Review, they linked EHR status to 30-day mortality and readmission for acute MI, heart failure, pneumonia, and prevention of surgical infections.

Hospitals with EHRs provided the right acute MI care 95.3% of the time, compared with 94.5% of the time for hospitals without a system. Also, acute MI mortality was modestly lower at EHR hospitals (14.9%) than at other institutions (15.8%). Mortality rates for heart failure and pneumonia were comparable between different hospital types, Dr. DesRoches said.

Similarly, hospitals with EHRs had modestly lower 30-day readmission rates for acute MI, heart failure, and pneumonia. The difference was significant only for patients with pneumonia (19.0% with EHRs versus 20.2% without).

“Our findings suggest EHR adoption is likely to be an important part of improving the efficiency and efficacy of our health care system, but just implementing [these] systems will not have a dramatic effect on care,” she said. “Finding ways to ensure effective use of these systems will be critical if we are to realize the potential of EHRs to improve the health and health care of all Americans.”

The $20 billion pledged by President Obama to improve health information technology “is a good start, and likely to get a good number of hospitals over the hump,” but will not help all institutions, especially those that are not currently ready for an EHR, said Dr. Ashish K. Jha, who presented survey results in a separate talk at the meeting.

Fewer than 10% of U.S. hospitals have EHRs, largely because of inadequate capital, he said.

Physician resistance, an insufficient information technology department, and ongoing costs also were impediments cited in the survey, according to Dr. Jha, an attending physician at Brigham and Women's Hospital in Boston who is also on the medicine faculty at Harvard Medical School.

Dr. Jha and his colleagues found 1.5% of hospitals had a comprehensive EHR system, defined as 24 key clinical functionalities across all major units of the hospital. Another 7.6% had a basic EHR system, defined as having 12 such features or having the 24 features adopted in fewer areas of the institution. Individual EHR functions varied, with 76% of institutions reporting they had widespread viewing of laboratory test results electronically, and only 12% saying they had fully implemented electronic physician notes.

MIAMI BEACH — Adoption of an electronic health record system is associated with a consistent but modest increase in quality of hospital care, according to a survey of more than 4,800 acute care hospitals in the United States.

Acute myocardial infarction care and infection prevention improved significantly with electronic health records (EHRs), but the differences were small overall, Catherine DesRoches, Ph.D., said at the annual meeting of the Society of General Internal Medicine.

Electronic clinical reminders also had a significant but “extremely modest” effect.

Most previous studies of specific EHR functionalities and quality have focused on a small set of pioneering hospitals, said Dr. DesRoches, a survey scientist at the Institute for Health Policy at Massachusetts General Hospital and an instructor in medicine at Harvard Medical School, both in Boston.

She and her colleagues surveyed all 4,840 acute care general medical and surgical hospitals as part of the American Hospital Association 2008 Annual Survey. They received answers from 3,049 hospital administrators, for a response rate of 63%.

The investigators asked administrators if they had an EHR, and if so, whether it was basic or comprehensive, based on 24 key clinical functionalities. Using data from the Hospital Quality Alliance and the Medicare Provider Analysis and Review, they linked EHR status to 30-day mortality and readmission for acute MI, heart failure, pneumonia, and prevention of surgical infections.

Hospitals with EHRs provided the right acute MI care 95.3% of the time, compared with 94.5% of the time for hospitals without a system. Also, acute MI mortality was modestly lower at EHR hospitals (14.9%) than at other institutions (15.8%). Mortality rates for heart failure and pneumonia were comparable between different hospital types, Dr. DesRoches said.

Similarly, hospitals with EHRs had modestly lower 30-day readmission rates for acute MI, heart failure, and pneumonia. The difference was significant only for patients with pneumonia (19.0% with EHRs versus 20.2% without).

“Our findings suggest EHR adoption is likely to be an important part of improving the efficiency and efficacy of our health care system, but just implementing [these] systems will not have a dramatic effect on care,” she said. “Finding ways to ensure effective use of these systems will be critical if we are to realize the potential of EHRs to improve the health and health care of all Americans.”

The $20 billion pledged by President Obama to improve health information technology “is a good start, and likely to get a good number of hospitals over the hump,” but will not help all institutions, especially those that are not currently ready for an EHR, said Dr. Ashish K. Jha, who presented survey results in a separate talk at the meeting.

Fewer than 10% of U.S. hospitals have EHRs, largely because of inadequate capital, he said.

Physician resistance, an insufficient information technology department, and ongoing costs also were impediments cited in the survey, according to Dr. Jha, an attending physician at Brigham and Women's Hospital in Boston who is also on the medicine faculty at Harvard Medical School.

Dr. Jha and his colleagues found 1.5% of hospitals had a comprehensive EHR system, defined as 24 key clinical functionalities across all major units of the hospital. Another 7.6% had a basic EHR system, defined as having 12 such features or having the 24 features adopted in fewer areas of the institution. Individual EHR functions varied, with 76% of institutions reporting they had widespread viewing of laboratory test results electronically, and only 12% saying they had fully implemented electronic physician notes.

MIAMI BEACH — Adoption of an electronic health record system is associated with a consistent but modest increase in quality of hospital care, according to a survey of more than 4,800 acute care hospitals in the United States.

Acute myocardial infarction care and infection prevention improved significantly with electronic health records (EHRs), but the differences were small overall, Catherine DesRoches, Ph.D., said at the annual meeting of the Society of General Internal Medicine.

Electronic clinical reminders also had a significant but “extremely modest” effect.

Most previous studies of specific EHR functionalities and quality have focused on a small set of pioneering hospitals, said Dr. DesRoches, a survey scientist at the Institute for Health Policy at Massachusetts General Hospital and an instructor in medicine at Harvard Medical School, both in Boston.

She and her colleagues surveyed all 4,840 acute care general medical and surgical hospitals as part of the American Hospital Association 2008 Annual Survey. They received answers from 3,049 hospital administrators, for a response rate of 63%.

The investigators asked administrators if they had an EHR, and if so, whether it was basic or comprehensive, based on 24 key clinical functionalities. Using data from the Hospital Quality Alliance and the Medicare Provider Analysis and Review, they linked EHR status to 30-day mortality and readmission for acute MI, heart failure, pneumonia, and prevention of surgical infections.

Hospitals with EHRs provided the right acute MI care 95.3% of the time, compared with 94.5% of the time for hospitals without a system. Also, acute MI mortality was modestly lower at EHR hospitals (14.9%) than at other institutions (15.8%). Mortality rates for heart failure and pneumonia were comparable between different hospital types, Dr. DesRoches said.

Similarly, hospitals with EHRs had modestly lower 30-day readmission rates for acute MI, heart failure, and pneumonia. The difference was significant only for patients with pneumonia (19.0% with EHRs versus 20.2% without).

“Our findings suggest EHR adoption is likely to be an important part of improving the efficiency and efficacy of our health care system, but just implementing [these] systems will not have a dramatic effect on care,” she said. “Finding ways to ensure effective use of these systems will be critical if we are to realize the potential of EHRs to improve the health and health care of all Americans.”

The $20 billion pledged by President Obama to improve health information technology “is a good start, and likely to get a good number of hospitals over the hump,” but will not help all institutions, especially those that are not currently ready for an EHR, said Dr. Ashish K. Jha, who presented survey results in a separate talk at the meeting.

Fewer than 10% of U.S. hospitals have EHRs, largely because of inadequate capital, he said.

Physician resistance, an insufficient information technology department, and ongoing costs also were impediments cited in the survey, according to Dr. Jha, an attending physician at Brigham and Women's Hospital in Boston who is also on the medicine faculty at Harvard Medical School.

Dr. Jha and his colleagues found 1.5% of hospitals had a comprehensive EHR system, defined as 24 key clinical functionalities across all major units of the hospital. Another 7.6% had a basic EHR system, defined as having 12 such features or having the 24 features adopted in fewer areas of the institution. Individual EHR functions varied, with 76% of institutions reporting they had widespread viewing of laboratory test results electronically, and only 12% saying they had fully implemented electronic physician notes.

MIAMI BEACH — The use of colonoscopy to screen for colorectal cancer may cause net harm if continued beyond age 70, according to a clinical- and cost-effectiveness study. Fecal occult blood testing, on the other hand, remained both effective and cost-effective up until age 80 years.

Many guidelines recommend routine colorectal cancer screening for adults aged 50–75 years and individualized decisions in the elderly, including a 2008 recommendation statement from the U.S. Preventive Services Task Force (Ann. Intern. Med. 2008;149:627–37). But the effectiveness and incremental costs of continuing to routinely screen older people have not been well quantified in the literature, Dr. Sandeep Vijan said at the annual meeting of the Society for General Internal Medicine.

Colorectal cancer and polyps are clearly more common in the elderly, Dr. Vijan said. “However, potential benefits of screening are limited. If it takes a long time for a polyp to become cancer, you need a relatively long life expectancy to make polyp removal worthwhile,” Dr. Vijan said.

He and his colleagues developed a Markov decision model to assess the incremental cost-effectiveness of screening patients with a colonoscopy once each decade after age 50 and with fecal occult blood testing (FOBT) annually. “We assumed an adherence rate of 60%, which is in the ballpark, but may be a little optimistic,” said Dr. Vijan, who is on the internal medicine faculty at the University of Michigan, Ann Arbor. He is also an investigator at the Ann Arbor Veterans Affairs Center for Clinical Management Research.

“From 66 years to 85-plus the bleeding and perforation risks double,” according to Medicare data, Dr. Vijan said. For example, risk of bleeding was 0.49% for the 66- to 69-year-old cohort and increased to 1.15% among those 85 and older. Their model also incorporated polyp prevalence data from autopsy and screening colonoscopy studies, and colorectal cancer rates from the Surveillance, Epidemiology, and End Results (SEER) database.

If colonoscopy is stopped at age 60 years, life expectancy beyond age 50 is 17.1651 years and screening costs $1,554 in 2006 dollars. (All life expectancies are discounted from a value of about 27 years, based on economic present-value analysis.) If colonoscopy stops at age 70, life expectancy increases very slightly to 17.1670 years beyond age 50—“essentially a day”—and costs $1,623. But an additional colonoscopy at age 80 “actually causes harm,” Dr. Vijan said. The additional colonoscopy was associated with a decrease in life expectancy to 17.1668 years beyond age 50 and a cost of $1,648. Also, “if a patient has actually had a colonoscopy at ages 50 and 60, then even a third one at age 70 ends up being harmful,” he noted.

“This fits with the recent U.S. Preventive Services Task Force report to stop [screening] at age 75,” he said. “From a population perspective, stopping colonoscopy after age 70 seems appropriate.”

But the findings suggest that FOBT is cost-effective for screening up to about age 80. For example, at age 76, FOBT is associated with a life expectancy of 17.1485 years beyond age 50 and costs $1,336. Continuing annually to age 80 is associated with an added life expectancy of 17.1489 years and costs $1,355.

The findings do not apply to people with no prior screening, “so if someone is 80 and has never been screened, it might be effective.” Also, the study did not address screening of high-risk patients and did not assess complex strategies such as two colonoscopies followed by subsequent FOBT. Dr. Vijan said that alternative strategies, such as mixed testing approaches, should be evaluated in future research.

MIAMI BEACH — The use of colonoscopy to screen for colorectal cancer may cause net harm if continued beyond age 70, according to a clinical- and cost-effectiveness study. Fecal occult blood testing, on the other hand, remained both effective and cost-effective up until age 80 years.

Many guidelines recommend routine colorectal cancer screening for adults aged 50–75 years and individualized decisions in the elderly, including a 2008 recommendation statement from the U.S. Preventive Services Task Force (Ann. Intern. Med. 2008;149:627–37). But the effectiveness and incremental costs of continuing to routinely screen older people have not been well quantified in the literature, Dr. Sandeep Vijan said at the annual meeting of the Society for General Internal Medicine.

Colorectal cancer and polyps are clearly more common in the elderly, Dr. Vijan said. “However, potential benefits of screening are limited. If it takes a long time for a polyp to become cancer, you need a relatively long life expectancy to make polyp removal worthwhile,” Dr. Vijan said.

He and his colleagues developed a Markov decision model to assess the incremental cost-effectiveness of screening patients with a colonoscopy once each decade after age 50 and with fecal occult blood testing (FOBT) annually. “We assumed an adherence rate of 60%, which is in the ballpark, but may be a little optimistic,” said Dr. Vijan, who is on the internal medicine faculty at the University of Michigan, Ann Arbor. He is also an investigator at the Ann Arbor Veterans Affairs Center for Clinical Management Research.

“From 66 years to 85-plus the bleeding and perforation risks double,” according to Medicare data, Dr. Vijan said. For example, risk of bleeding was 0.49% for the 66- to 69-year-old cohort and increased to 1.15% among those 85 and older. Their model also incorporated polyp prevalence data from autopsy and screening colonoscopy studies, and colorectal cancer rates from the Surveillance, Epidemiology, and End Results (SEER) database.

If colonoscopy is stopped at age 60 years, life expectancy beyond age 50 is 17.1651 years and screening costs $1,554 in 2006 dollars. (All life expectancies are discounted from a value of about 27 years, based on economic present-value analysis.) If colonoscopy stops at age 70, life expectancy increases very slightly to 17.1670 years beyond age 50—“essentially a day”—and costs $1,623. But an additional colonoscopy at age 80 “actually causes harm,” Dr. Vijan said. The additional colonoscopy was associated with a decrease in life expectancy to 17.1668 years beyond age 50 and a cost of $1,648. Also, “if a patient has actually had a colonoscopy at ages 50 and 60, then even a third one at age 70 ends up being harmful,” he noted.

“This fits with the recent U.S. Preventive Services Task Force report to stop [screening] at age 75,” he said. “From a population perspective, stopping colonoscopy after age 70 seems appropriate.”

But the findings suggest that FOBT is cost-effective for screening up to about age 80. For example, at age 76, FOBT is associated with a life expectancy of 17.1485 years beyond age 50 and costs $1,336. Continuing annually to age 80 is associated with an added life expectancy of 17.1489 years and costs $1,355.

The findings do not apply to people with no prior screening, “so if someone is 80 and has never been screened, it might be effective.” Also, the study did not address screening of high-risk patients and did not assess complex strategies such as two colonoscopies followed by subsequent FOBT. Dr. Vijan said that alternative strategies, such as mixed testing approaches, should be evaluated in future research.

MIAMI BEACH — The use of colonoscopy to screen for colorectal cancer may cause net harm if continued beyond age 70, according to a clinical- and cost-effectiveness study. Fecal occult blood testing, on the other hand, remained both effective and cost-effective up until age 80 years.

Many guidelines recommend routine colorectal cancer screening for adults aged 50–75 years and individualized decisions in the elderly, including a 2008 recommendation statement from the U.S. Preventive Services Task Force (Ann. Intern. Med. 2008;149:627–37). But the effectiveness and incremental costs of continuing to routinely screen older people have not been well quantified in the literature, Dr. Sandeep Vijan said at the annual meeting of the Society for General Internal Medicine.

Colorectal cancer and polyps are clearly more common in the elderly, Dr. Vijan said. “However, potential benefits of screening are limited. If it takes a long time for a polyp to become cancer, you need a relatively long life expectancy to make polyp removal worthwhile,” Dr. Vijan said.

He and his colleagues developed a Markov decision model to assess the incremental cost-effectiveness of screening patients with a colonoscopy once each decade after age 50 and with fecal occult blood testing (FOBT) annually. “We assumed an adherence rate of 60%, which is in the ballpark, but may be a little optimistic,” said Dr. Vijan, who is on the internal medicine faculty at the University of Michigan, Ann Arbor. He is also an investigator at the Ann Arbor Veterans Affairs Center for Clinical Management Research.

“From 66 years to 85-plus the bleeding and perforation risks double,” according to Medicare data, Dr. Vijan said. For example, risk of bleeding was 0.49% for the 66- to 69-year-old cohort and increased to 1.15% among those 85 and older. Their model also incorporated polyp prevalence data from autopsy and screening colonoscopy studies, and colorectal cancer rates from the Surveillance, Epidemiology, and End Results (SEER) database.

If colonoscopy is stopped at age 60 years, life expectancy beyond age 50 is 17.1651 years and screening costs $1,554 in 2006 dollars. (All life expectancies are discounted from a value of about 27 years, based on economic present-value analysis.) If colonoscopy stops at age 70, life expectancy increases very slightly to 17.1670 years beyond age 50—“essentially a day”—and costs $1,623. But an additional colonoscopy at age 80 “actually causes harm,” Dr. Vijan said. The additional colonoscopy was associated with a decrease in life expectancy to 17.1668 years beyond age 50 and a cost of $1,648. Also, “if a patient has actually had a colonoscopy at ages 50 and 60, then even a third one at age 70 ends up being harmful,” he noted.

“This fits with the recent U.S. Preventive Services Task Force report to stop [screening] at age 75,” he said. “From a population perspective, stopping colonoscopy after age 70 seems appropriate.”

But the findings suggest that FOBT is cost-effective for screening up to about age 80. For example, at age 76, FOBT is associated with a life expectancy of 17.1485 years beyond age 50 and costs $1,336. Continuing annually to age 80 is associated with an added life expectancy of 17.1489 years and costs $1,355.

The findings do not apply to people with no prior screening, “so if someone is 80 and has never been screened, it might be effective.” Also, the study did not address screening of high-risk patients and did not assess complex strategies such as two colonoscopies followed by subsequent FOBT. Dr. Vijan said that alternative strategies, such as mixed testing approaches, should be evaluated in future research.

HOLLYWOOD, FLA. — Nearly 50% of patients diagnosed with colorectal cancer at two large tertiary-care hospitals in Michigan would fall outside recommendations that limit routine screening to patients who are 50–75 years of age.

Last year, the U.S. Preventive Services Task Force released a recommendation statement following two studies that assessed expected health outcomes and resource utilization from screening with fecal occult blood testing, sigmoidoscopy, and colonoscopy (Ann. Intern. Med. 2008;149:627–37).

This report recommends against routine screening of patients aged 76–85 years, but notes that screening may be warranted in some individuals outside of that age group. They also recommended against screening any adult older than 85 years.

Dr. Jason Shellnut and his associates launched a study to assess the appropriateness of these guidelines at William Beaumont Hospital System in Royal Oak, Mich. They identified 6,925 patients with colorectal cancer treated at one of their two referral hospitals with a total of 1,357 beds between January 1973 and December 2007. They divided patients into three groups by age at diagnosis—younger than 50 years, 50–75 years, or older than 75.

They also evaluated the 35 years' worth of data in 5-year increments to assess trends over time.

“Not screening those older than 75 and younger than 50 would miss 49% of our diagnosed patients in the last 5-year period [2003–2007],” said Dr. Shellnut, a colorectal surgery fellow at William Beaumont Hospital. This 49% is a significant increase, compared with 36% in the first 5 years (1973–1978) of the tumor registry data. Most of the increase is attributed to the older patient group.

The percentage of patients older than 75 years at diagnosis rose from 29% (1973–1978) to 40% (2003–2007). This includes a significant increase in patients older than 85 years, from 6% to 12%. In contrast, the percentage of patients younger than 50 did not change significantly from 1973 to 2007, staying within a 6%–8% range.

At the same time, the percentage of patients in the age range recommended for screening declined significantly. Specifically, patients who were in the age range of 50–75 years decreased from 64% (1973–1978) to 52% (2003–2007) of those diagnosed.

The researchers looked for any differences in pathologic stage and tumor location. “Pathologic stage data did not vary [significantly] across the years,” Dr. Shellnut said at the annual meeting of the American Society of Colon and Rectal Surgeons.

However, patients under 50 years old were significantly more likely to present with advanced disease: 51% were diagnosed with either stage III or IV colorectal cancer, compared with 41% of the 50- to 75-year-olds and 35% of patients older than 75.

Dr. Shellnut had no conflicts to disclose.

Patients under 50 years old were significantly more likely to present with advanced disease. DR. SHELLNUT

HOLLYWOOD, FLA. — Nearly 50% of patients diagnosed with colorectal cancer at two large tertiary-care hospitals in Michigan would fall outside recommendations that limit routine screening to patients who are 50–75 years of age.

Last year, the U.S. Preventive Services Task Force released a recommendation statement following two studies that assessed expected health outcomes and resource utilization from screening with fecal occult blood testing, sigmoidoscopy, and colonoscopy (Ann. Intern. Med. 2008;149:627–37).

This report recommends against routine screening of patients aged 76–85 years, but notes that screening may be warranted in some individuals outside of that age group. They also recommended against screening any adult older than 85 years.

Dr. Jason Shellnut and his associates launched a study to assess the appropriateness of these guidelines at William Beaumont Hospital System in Royal Oak, Mich. They identified 6,925 patients with colorectal cancer treated at one of their two referral hospitals with a total of 1,357 beds between January 1973 and December 2007. They divided patients into three groups by age at diagnosis—younger than 50 years, 50–75 years, or older than 75.

They also evaluated the 35 years' worth of data in 5-year increments to assess trends over time.

“Not screening those older than 75 and younger than 50 would miss 49% of our diagnosed patients in the last 5-year period [2003–2007],” said Dr. Shellnut, a colorectal surgery fellow at William Beaumont Hospital. This 49% is a significant increase, compared with 36% in the first 5 years (1973–1978) of the tumor registry data. Most of the increase is attributed to the older patient group.

The percentage of patients older than 75 years at diagnosis rose from 29% (1973–1978) to 40% (2003–2007). This includes a significant increase in patients older than 85 years, from 6% to 12%. In contrast, the percentage of patients younger than 50 did not change significantly from 1973 to 2007, staying within a 6%–8% range.

At the same time, the percentage of patients in the age range recommended for screening declined significantly. Specifically, patients who were in the age range of 50–75 years decreased from 64% (1973–1978) to 52% (2003–2007) of those diagnosed.

The researchers looked for any differences in pathologic stage and tumor location. “Pathologic stage data did not vary [significantly] across the years,” Dr. Shellnut said at the annual meeting of the American Society of Colon and Rectal Surgeons.

However, patients under 50 years old were significantly more likely to present with advanced disease: 51% were diagnosed with either stage III or IV colorectal cancer, compared with 41% of the 50- to 75-year-olds and 35% of patients older than 75.

Dr. Shellnut had no conflicts to disclose.

Patients under 50 years old were significantly more likely to present with advanced disease. DR. SHELLNUT

HOLLYWOOD, FLA. — Nearly 50% of patients diagnosed with colorectal cancer at two large tertiary-care hospitals in Michigan would fall outside recommendations that limit routine screening to patients who are 50–75 years of age.

Last year, the U.S. Preventive Services Task Force released a recommendation statement following two studies that assessed expected health outcomes and resource utilization from screening with fecal occult blood testing, sigmoidoscopy, and colonoscopy (Ann. Intern. Med. 2008;149:627–37).

This report recommends against routine screening of patients aged 76–85 years, but notes that screening may be warranted in some individuals outside of that age group. They also recommended against screening any adult older than 85 years.

Dr. Jason Shellnut and his associates launched a study to assess the appropriateness of these guidelines at William Beaumont Hospital System in Royal Oak, Mich. They identified 6,925 patients with colorectal cancer treated at one of their two referral hospitals with a total of 1,357 beds between January 1973 and December 2007. They divided patients into three groups by age at diagnosis—younger than 50 years, 50–75 years, or older than 75.

They also evaluated the 35 years' worth of data in 5-year increments to assess trends over time.

“Not screening those older than 75 and younger than 50 would miss 49% of our diagnosed patients in the last 5-year period [2003–2007],” said Dr. Shellnut, a colorectal surgery fellow at William Beaumont Hospital. This 49% is a significant increase, compared with 36% in the first 5 years (1973–1978) of the tumor registry data. Most of the increase is attributed to the older patient group.

The percentage of patients older than 75 years at diagnosis rose from 29% (1973–1978) to 40% (2003–2007). This includes a significant increase in patients older than 85 years, from 6% to 12%. In contrast, the percentage of patients younger than 50 did not change significantly from 1973 to 2007, staying within a 6%–8% range.

At the same time, the percentage of patients in the age range recommended for screening declined significantly. Specifically, patients who were in the age range of 50–75 years decreased from 64% (1973–1978) to 52% (2003–2007) of those diagnosed.

The researchers looked for any differences in pathologic stage and tumor location. “Pathologic stage data did not vary [significantly] across the years,” Dr. Shellnut said at the annual meeting of the American Society of Colon and Rectal Surgeons.

However, patients under 50 years old were significantly more likely to present with advanced disease: 51% were diagnosed with either stage III or IV colorectal cancer, compared with 41% of the 50- to 75-year-olds and 35% of patients older than 75.

Dr. Shellnut had no conflicts to disclose.

Patients under 50 years old were significantly more likely to present with advanced disease. DR. SHELLNUT

HOLLYWOOD, FLA. — Nearly 50% of patients who were diagn with colorectal cancer at two large tertiary-care hospitals in Michigan would fall outside recommendations that favor limiting routine screening to patients who are 50–75 years of age.

Last year, the U.S. Preventive Services Task Force released a recommendation statement following two studies that assessed expected health outcomes and resource utilization from screening with fecal occult blood testing, sigmoidoscopy, and colonoscopy (Ann. Intern. Med. 2008;149:627–37). This report recommends against routine screening of patients aged 76–85 years, but notes that screening may be warranted in some individuals outside of that age group. They also recommended against screening any adult older than 85 years.

Dr. Jason Shellnut and his associates launched a study to assess the appropriateness of these guidelines at William Beaumont Hospital System in Royal Oak, Mich. They identified 6,925 patients with colorectal cancer treated at one of their two referral hospitals with a total of 1,357 beds between January 1973 and December 2007. They divided patients into three groups by age at diagnosis—younger than 50 years, 50–75 years, or older than 75.

They also evaluated the 35 years' worth of data in 5-year increments to assess trends over time.

“Not screening those older than 75 and younger than 50 would miss 49% of our diagnosed patients in the last 5-year period [2003–2007],” said Dr. Shellnut, a colorectal surgery fellow at William Beaumont Hospital. This 49% is a significant increase, compared with 36% in the first 5 years (1973–1978) of the tumor registry data. Most of the increase is attributed to the older patient group.

The percentage of patients who were older than 75 years at diagnosis rose from 29% (1973–1978) to 40% (2003–2007). This includes a significant increase in patients older than 85 years, from 6% to 12%. In contrast, the percentage of patients younger than 50 did not change significantly from 1973 to 2007, staying within a 6% to 8% range.

At the same time, the percentage of patients in the age range recommended for screening declined significantly. Specifically, patients in the age range of 50-75 years decreased from 64% (1973–1978) to 52% (2003–2007) of those diagnosed.

The researchers looked for any differences in pathologic stage and tumor location. “Pathologic stage data did not vary [significantly] across the years,” Dr. Shellnut reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

However, patients under 50 years old were significantly more likely to present with advanced disease. A total of 51% of these younger patients were diagnosed with either stage III or IV colorectal cancer, compared with 41% of the 50- to 75-year-olds and 35% of patients older than 75.

By age of diagnosis, there were significant differences in terms of rectal and left-sided cancer diagnoses. These tumors were most common in the younger age group, 68%, compared with 64% of the patients aged 50–75 years and 50% of the older group.

The retrospective design of the study is a potential limitation, Dr. Shellnut said, and applicability of the findings beyond their health system is unknown. In addition, the tumor registry data track only patients who underwent resection of their cancer.

Dr. Shellnut had no disclosures.

'Not screening those older than 75 and younger than 50 would miss 49% of our diagnosed patients.' DR. SHELLNUT

HOLLYWOOD, FLA. — Nearly 50% of patients who were diagn with colorectal cancer at two large tertiary-care hospitals in Michigan would fall outside recommendations that favor limiting routine screening to patients who are 50–75 years of age.

Last year, the U.S. Preventive Services Task Force released a recommendation statement following two studies that assessed expected health outcomes and resource utilization from screening with fecal occult blood testing, sigmoidoscopy, and colonoscopy (Ann. Intern. Med. 2008;149:627–37). This report recommends against routine screening of patients aged 76–85 years, but notes that screening may be warranted in some individuals outside of that age group. They also recommended against screening any adult older than 85 years.

Dr. Jason Shellnut and his associates launched a study to assess the appropriateness of these guidelines at William Beaumont Hospital System in Royal Oak, Mich. They identified 6,925 patients with colorectal cancer treated at one of their two referral hospitals with a total of 1,357 beds between January 1973 and December 2007. They divided patients into three groups by age at diagnosis—younger than 50 years, 50–75 years, or older than 75.

They also evaluated the 35 years' worth of data in 5-year increments to assess trends over time.

“Not screening those older than 75 and younger than 50 would miss 49% of our diagnosed patients in the last 5-year period [2003–2007],” said Dr. Shellnut, a colorectal surgery fellow at William Beaumont Hospital. This 49% is a significant increase, compared with 36% in the first 5 years (1973–1978) of the tumor registry data. Most of the increase is attributed to the older patient group.

The percentage of patients who were older than 75 years at diagnosis rose from 29% (1973–1978) to 40% (2003–2007). This includes a significant increase in patients older than 85 years, from 6% to 12%. In contrast, the percentage of patients younger than 50 did not change significantly from 1973 to 2007, staying within a 6% to 8% range.

At the same time, the percentage of patients in the age range recommended for screening declined significantly. Specifically, patients in the age range of 50-75 years decreased from 64% (1973–1978) to 52% (2003–2007) of those diagnosed.

The researchers looked for any differences in pathologic stage and tumor location. “Pathologic stage data did not vary [significantly] across the years,” Dr. Shellnut reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

However, patients under 50 years old were significantly more likely to present with advanced disease. A total of 51% of these younger patients were diagnosed with either stage III or IV colorectal cancer, compared with 41% of the 50- to 75-year-olds and 35% of patients older than 75.

By age of diagnosis, there were significant differences in terms of rectal and left-sided cancer diagnoses. These tumors were most common in the younger age group, 68%, compared with 64% of the patients aged 50–75 years and 50% of the older group.

The retrospective design of the study is a potential limitation, Dr. Shellnut said, and applicability of the findings beyond their health system is unknown. In addition, the tumor registry data track only patients who underwent resection of their cancer.

Dr. Shellnut had no disclosures.

'Not screening those older than 75 and younger than 50 would miss 49% of our diagnosed patients.' DR. SHELLNUT

HOLLYWOOD, FLA. — Nearly 50% of patients who were diagn with colorectal cancer at two large tertiary-care hospitals in Michigan would fall outside recommendations that favor limiting routine screening to patients who are 50–75 years of age.

Last year, the U.S. Preventive Services Task Force released a recommendation statement following two studies that assessed expected health outcomes and resource utilization from screening with fecal occult blood testing, sigmoidoscopy, and colonoscopy (Ann. Intern. Med. 2008;149:627–37). This report recommends against routine screening of patients aged 76–85 years, but notes that screening may be warranted in some individuals outside of that age group. They also recommended against screening any adult older than 85 years.

Dr. Jason Shellnut and his associates launched a study to assess the appropriateness of these guidelines at William Beaumont Hospital System in Royal Oak, Mich. They identified 6,925 patients with colorectal cancer treated at one of their two referral hospitals with a total of 1,357 beds between January 1973 and December 2007. They divided patients into three groups by age at diagnosis—younger than 50 years, 50–75 years, or older than 75.

They also evaluated the 35 years' worth of data in 5-year increments to assess trends over time.

“Not screening those older than 75 and younger than 50 would miss 49% of our diagnosed patients in the last 5-year period [2003–2007],” said Dr. Shellnut, a colorectal surgery fellow at William Beaumont Hospital. This 49% is a significant increase, compared with 36% in the first 5 years (1973–1978) of the tumor registry data. Most of the increase is attributed to the older patient group.

The percentage of patients who were older than 75 years at diagnosis rose from 29% (1973–1978) to 40% (2003–2007). This includes a significant increase in patients older than 85 years, from 6% to 12%. In contrast, the percentage of patients younger than 50 did not change significantly from 1973 to 2007, staying within a 6% to 8% range.

At the same time, the percentage of patients in the age range recommended for screening declined significantly. Specifically, patients in the age range of 50-75 years decreased from 64% (1973–1978) to 52% (2003–2007) of those diagnosed.

The researchers looked for any differences in pathologic stage and tumor location. “Pathologic stage data did not vary [significantly] across the years,” Dr. Shellnut reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

However, patients under 50 years old were significantly more likely to present with advanced disease. A total of 51% of these younger patients were diagnosed with either stage III or IV colorectal cancer, compared with 41% of the 50- to 75-year-olds and 35% of patients older than 75.

By age of diagnosis, there were significant differences in terms of rectal and left-sided cancer diagnoses. These tumors were most common in the younger age group, 68%, compared with 64% of the patients aged 50–75 years and 50% of the older group.

The retrospective design of the study is a potential limitation, Dr. Shellnut said, and applicability of the findings beyond their health system is unknown. In addition, the tumor registry data track only patients who underwent resection of their cancer.

Dr. Shellnut had no disclosures.

'Not screening those older than 75 and younger than 50 would miss 49% of our diagnosed patients.' DR. SHELLNUT

MIAMI BEACH — The use of colonoscopy to screen for colorectal cancer may cause net harm if continued beyond age 70, according to a clinical- and cost-effectiveness study. Fecal occult blood testing, on the other hand, remained both effective and cost-effective up until age 80 years.

Many guidelines recommend routine colorectal cancer screening for adults aged 50–75 years and individualized decisions in the elderly, including a 2008 recommendation statement from the U.S. Preventive Services Task Force (Ann. Intern. Med. 2008;149:627–37). But the effectiveness and incremental costs of continuing to routinely screen older people have not been well quantified in the literature, Dr. Sandeep Vijan said at the annual meeting of the Society for General Internal Medicine.

Colorectal cancer and polyps are clearly more common in the elderly, Dr. Vijan said. “However, potential benefits of screening are limited. If it takes a long time for a polyp to become cancer, you need a relatively long life expectancy to make polyp removal worthwhile,” Dr. Vijan said.

With that in mind, he and his colleagues developed a Markov decision model to assess the effectiveness and incremental cost-effectiveness of screening patients with a colonoscopy once each decade after age 50 and with fecal occult blood testing (FOBT) annually.

“We assumed an adherence rate of 60%, which is in the ballpark, but may be a little optimistic compared to general colonoscopy adherence,” said Dr. Vijan, who is on the internal medicine faculty at the University of Michigan, Ann Arbor. He is also an investigator at the Ann Arbor Veterans Affairs Center for Clinical Management Research.

“From 66 years to 85-plus the bleeding and perforation risks double,” according to Medicare data, Dr. Vijan said. For example, risk of bleeding was 0.49% for the 66- to 69-year-old cohort and increased to 1.15% among those 85 and older.

Their model also incorporated polyp prevalence data from autopsy and screening colonoscopy studies as well as rates of colorectal cancer from the Surveillance, Epidemiology, and End Results (SEER) database.

If colonoscopy is stopped at age 60 years, life expectancy beyond age 50 is 17.1651 years and screening costs $1,554 in 2006 dollars. (All life expectancies are discounted from a value of about 27 years, based on economic present-value analysis.) If colonoscopy stops at age 70, life expectancy increases very slightly to 17.1670 years beyond age 50—“essentially a day”—and costs $1,623. But an additional colonoscopy at age 80 “actually causes harm,” Dr. Vijan said. The additional colonoscopy was associated with a decrease in life expectancy beyond age 50 to 17.1668 years and a cost of $1,648.

Also, he noted, “if a patient has actually had a colonoscopy at ages 50 and 60, then even a third one at age 70 ends up being harmful.

“This fits with the recent U.S. Preventive Services Task Force report to stop [screening] at age 75,” he said. “From a population perspective, stopping colonoscopy after age 70 seems appropriate. But this does not apply equally to fecal occult blood testing.”

The study findings suggest that FOBT is effective and cost-effective for screening up to about age 80. For example, at age 76, FOBT is associated with a life expectancy of 17.1485 years beyond age 50 and costs $1,336. Continuing annually to age 80 is associated with an added life expectancy of 17.1489 years and a cost of $1,355.

Although the researchers found that FOBT screening does not cause harm, it costs more than $100,000 per life-year to continue screening beyond age 80.

The findings do not apply to people with no prior screening, “so if someone is 80 and has never been screened, it might be effective.” Also, the study did not address screening of high-risk patients and did not assess complex strategies such as two colonoscopies followed by subsequent FOBT. Dr. Vijan said that alternative strategies, such as mixed testing approaches, should be evaluated in future research.

MIAMI BEACH — The use of colonoscopy to screen for colorectal cancer may cause net harm if continued beyond age 70, according to a clinical- and cost-effectiveness study. Fecal occult blood testing, on the other hand, remained both effective and cost-effective up until age 80 years.

Many guidelines recommend routine colorectal cancer screening for adults aged 50–75 years and individualized decisions in the elderly, including a 2008 recommendation statement from the U.S. Preventive Services Task Force (Ann. Intern. Med. 2008;149:627–37). But the effectiveness and incremental costs of continuing to routinely screen older people have not been well quantified in the literature, Dr. Sandeep Vijan said at the annual meeting of the Society for General Internal Medicine.

Colorectal cancer and polyps are clearly more common in the elderly, Dr. Vijan said. “However, potential benefits of screening are limited. If it takes a long time for a polyp to become cancer, you need a relatively long life expectancy to make polyp removal worthwhile,” Dr. Vijan said.

With that in mind, he and his colleagues developed a Markov decision model to assess the effectiveness and incremental cost-effectiveness of screening patients with a colonoscopy once each decade after age 50 and with fecal occult blood testing (FOBT) annually.

“We assumed an adherence rate of 60%, which is in the ballpark, but may be a little optimistic compared to general colonoscopy adherence,” said Dr. Vijan, who is on the internal medicine faculty at the University of Michigan, Ann Arbor. He is also an investigator at the Ann Arbor Veterans Affairs Center for Clinical Management Research.

“From 66 years to 85-plus the bleeding and perforation risks double,” according to Medicare data, Dr. Vijan said. For example, risk of bleeding was 0.49% for the 66- to 69-year-old cohort and increased to 1.15% among those 85 and older.

Their model also incorporated polyp prevalence data from autopsy and screening colonoscopy studies as well as rates of colorectal cancer from the Surveillance, Epidemiology, and End Results (SEER) database.

If colonoscopy is stopped at age 60 years, life expectancy beyond age 50 is 17.1651 years and screening costs $1,554 in 2006 dollars. (All life expectancies are discounted from a value of about 27 years, based on economic present-value analysis.) If colonoscopy stops at age 70, life expectancy increases very slightly to 17.1670 years beyond age 50—“essentially a day”—and costs $1,623. But an additional colonoscopy at age 80 “actually causes harm,” Dr. Vijan said. The additional colonoscopy was associated with a decrease in life expectancy beyond age 50 to 17.1668 years and a cost of $1,648.

Also, he noted, “if a patient has actually had a colonoscopy at ages 50 and 60, then even a third one at age 70 ends up being harmful.

“This fits with the recent U.S. Preventive Services Task Force report to stop [screening] at age 75,” he said. “From a population perspective, stopping colonoscopy after age 70 seems appropriate. But this does not apply equally to fecal occult blood testing.”

The study findings suggest that FOBT is effective and cost-effective for screening up to about age 80. For example, at age 76, FOBT is associated with a life expectancy of 17.1485 years beyond age 50 and costs $1,336. Continuing annually to age 80 is associated with an added life expectancy of 17.1489 years and a cost of $1,355.

Although the researchers found that FOBT screening does not cause harm, it costs more than $100,000 per life-year to continue screening beyond age 80.

The findings do not apply to people with no prior screening, “so if someone is 80 and has never been screened, it might be effective.” Also, the study did not address screening of high-risk patients and did not assess complex strategies such as two colonoscopies followed by subsequent FOBT. Dr. Vijan said that alternative strategies, such as mixed testing approaches, should be evaluated in future research.

MIAMI BEACH — The use of colonoscopy to screen for colorectal cancer may cause net harm if continued beyond age 70, according to a clinical- and cost-effectiveness study. Fecal occult blood testing, on the other hand, remained both effective and cost-effective up until age 80 years.

Many guidelines recommend routine colorectal cancer screening for adults aged 50–75 years and individualized decisions in the elderly, including a 2008 recommendation statement from the U.S. Preventive Services Task Force (Ann. Intern. Med. 2008;149:627–37). But the effectiveness and incremental costs of continuing to routinely screen older people have not been well quantified in the literature, Dr. Sandeep Vijan said at the annual meeting of the Society for General Internal Medicine.

Colorectal cancer and polyps are clearly more common in the elderly, Dr. Vijan said. “However, potential benefits of screening are limited. If it takes a long time for a polyp to become cancer, you need a relatively long life expectancy to make polyp removal worthwhile,” Dr. Vijan said.

With that in mind, he and his colleagues developed a Markov decision model to assess the effectiveness and incremental cost-effectiveness of screening patients with a colonoscopy once each decade after age 50 and with fecal occult blood testing (FOBT) annually.

“We assumed an adherence rate of 60%, which is in the ballpark, but may be a little optimistic compared to general colonoscopy adherence,” said Dr. Vijan, who is on the internal medicine faculty at the University of Michigan, Ann Arbor. He is also an investigator at the Ann Arbor Veterans Affairs Center for Clinical Management Research.

“From 66 years to 85-plus the bleeding and perforation risks double,” according to Medicare data, Dr. Vijan said. For example, risk of bleeding was 0.49% for the 66- to 69-year-old cohort and increased to 1.15% among those 85 and older.

Their model also incorporated polyp prevalence data from autopsy and screening colonoscopy studies as well as rates of colorectal cancer from the Surveillance, Epidemiology, and End Results (SEER) database.

If colonoscopy is stopped at age 60 years, life expectancy beyond age 50 is 17.1651 years and screening costs $1,554 in 2006 dollars. (All life expectancies are discounted from a value of about 27 years, based on economic present-value analysis.) If colonoscopy stops at age 70, life expectancy increases very slightly to 17.1670 years beyond age 50—“essentially a day”—and costs $1,623. But an additional colonoscopy at age 80 “actually causes harm,” Dr. Vijan said. The additional colonoscopy was associated with a decrease in life expectancy beyond age 50 to 17.1668 years and a cost of $1,648.

Also, he noted, “if a patient has actually had a colonoscopy at ages 50 and 60, then even a third one at age 70 ends up being harmful.

“This fits with the recent U.S. Preventive Services Task Force report to stop [screening] at age 75,” he said. “From a population perspective, stopping colonoscopy after age 70 seems appropriate. But this does not apply equally to fecal occult blood testing.”

The study findings suggest that FOBT is effective and cost-effective for screening up to about age 80. For example, at age 76, FOBT is associated with a life expectancy of 17.1485 years beyond age 50 and costs $1,336. Continuing annually to age 80 is associated with an added life expectancy of 17.1489 years and a cost of $1,355.

Although the researchers found that FOBT screening does not cause harm, it costs more than $100,000 per life-year to continue screening beyond age 80.

The findings do not apply to people with no prior screening, “so if someone is 80 and has never been screened, it might be effective.” Also, the study did not address screening of high-risk patients and did not assess complex strategies such as two colonoscopies followed by subsequent FOBT. Dr. Vijan said that alternative strategies, such as mixed testing approaches, should be evaluated in future research.

SAN ANTONIO — Despite the controversy surrounding bariatric surgery for very obese adolescents, appropriate candidates often experience better psychosocial quality of life and improve or reverse obesity-related comorbidities, according to preliminary results of a study at Texas Children's Hospital, Houston.

“This has been one of the most profoundly gratifying things in my career,” said Dr. Mary L. Brandt, director of the hospital's adolescent bariatric surgery program. “They get their lives back.”

Dr. Brandt reported results for 44 severely obese adolescents in an ongoing surgery study. Excess weight loss is 58% at 1 year and 60% at 2 years, she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The average age of the 32 girls and 12 boys is 16 years, and average body mass index is 60 kg/m

Surgery improved many of the preoperative comorbidities. For example, 70% of the 44 teenagers had preoperative insulin resistance (and there was an 82% resolution rate) and 91% had sleep apnea (45% resolution rate).

In preliminary results from the National Institutes of Health-funded Teen LABS study, Dr. Brandt and her associates found that type 2 diabetes resolved after surgery for 10 of 11 severely obese adolescents (Pediatrics 2009;123:214–22). Participants had a mean BMI of 50. Surgery was associated with a 34% decrease in BMI, a 41% decrease in fasting blood glucose levels, and an 81% decrease in fasting insulin concentrations.

In the Texas Children's Hospital series, 12 of the 44 patients experienced complications. Two patients had anastomotic bleeding, two had thiamine deficiency, and two had marginal ulcers. One patient each had a retained nasogastric tube, coagulopathy, pulmonary embolism, anastomotic leak, urethral injury, and a Peterson hernia. The complications resolved and there have been no deaths, said Dr. Brandt, professor and vice chair of surgery at Baylor College of Medicine, Houston.

“We are also participating in a second study called TeenView to look at the psychological component—eating disorders and depression especially,” Dr. Brandt said.

“The psychosocial cost of [severe obesity] is not measurable,” she said. Greater depressive symptoms, decreasing competence and self-esteem, and greater poverty are associated with adolescent obesity (Pediatrics 2000;105:e15; N. Engl. J. Med. 1993;329:1036–7).

Dr. Brandt said quality of life for obese adolescents is similar to levels reported by people with cancer during chemotherapy (JAMA 2003:289:1813–9).

She said that bariatric surgery should be considered only for morbidly obese adolescents who meet specific criteria (Pediatrics 2004;114:217–23). It should be limited to children with comorbidities and a BMI greater than 40, according to the recommendations. Candidates are those who have failed to lose weight after at least 6 months of organized attempts, are Tanner stage IV or V, and have supportive families.

Bariatric surgery improved many of the preoperative comorbidities. There was an 82% resolution rate for insulin resistance and a 45% resolution rate for sleep apnea. ©Tina Lorien/

SAN ANTONIO — Despite the controversy surrounding bariatric surgery for very obese adolescents, appropriate candidates often experience better psychosocial quality of life and improve or reverse obesity-related comorbidities, according to preliminary results of a study at Texas Children's Hospital, Houston.

“This has been one of the most profoundly gratifying things in my career,” said Dr. Mary L. Brandt, director of the hospital's adolescent bariatric surgery program. “They get their lives back.”

Dr. Brandt reported results for 44 severely obese adolescents in an ongoing surgery study. Excess weight loss is 58% at 1 year and 60% at 2 years, she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The average age of the 32 girls and 12 boys is 16 years, and average body mass index is 60 kg/m

Surgery improved many of the preoperative comorbidities. For example, 70% of the 44 teenagers had preoperative insulin resistance (and there was an 82% resolution rate) and 91% had sleep apnea (45% resolution rate).

In preliminary results from the National Institutes of Health-funded Teen LABS study, Dr. Brandt and her associates found that type 2 diabetes resolved after surgery for 10 of 11 severely obese adolescents (Pediatrics 2009;123:214–22). Participants had a mean BMI of 50. Surgery was associated with a 34% decrease in BMI, a 41% decrease in fasting blood glucose levels, and an 81% decrease in fasting insulin concentrations.

In the Texas Children's Hospital series, 12 of the 44 patients experienced complications. Two patients had anastomotic bleeding, two had thiamine deficiency, and two had marginal ulcers. One patient each had a retained nasogastric tube, coagulopathy, pulmonary embolism, anastomotic leak, urethral injury, and a Peterson hernia. The complications resolved and there have been no deaths, said Dr. Brandt, professor and vice chair of surgery at Baylor College of Medicine, Houston.

“We are also participating in a second study called TeenView to look at the psychological component—eating disorders and depression especially,” Dr. Brandt said.

“The psychosocial cost of [severe obesity] is not measurable,” she said. Greater depressive symptoms, decreasing competence and self-esteem, and greater poverty are associated with adolescent obesity (Pediatrics 2000;105:e15; N. Engl. J. Med. 1993;329:1036–7).

Dr. Brandt said quality of life for obese adolescents is similar to levels reported by people with cancer during chemotherapy (JAMA 2003:289:1813–9).

She said that bariatric surgery should be considered only for morbidly obese adolescents who meet specific criteria (Pediatrics 2004;114:217–23). It should be limited to children with comorbidities and a BMI greater than 40, according to the recommendations. Candidates are those who have failed to lose weight after at least 6 months of organized attempts, are Tanner stage IV or V, and have supportive families.

Bariatric surgery improved many of the preoperative comorbidities. There was an 82% resolution rate for insulin resistance and a 45% resolution rate for sleep apnea. ©Tina Lorien/

SAN ANTONIO — Despite the controversy surrounding bariatric surgery for very obese adolescents, appropriate candidates often experience better psychosocial quality of life and improve or reverse obesity-related comorbidities, according to preliminary results of a study at Texas Children's Hospital, Houston.

“This has been one of the most profoundly gratifying things in my career,” said Dr. Mary L. Brandt, director of the hospital's adolescent bariatric surgery program. “They get their lives back.”

Dr. Brandt reported results for 44 severely obese adolescents in an ongoing surgery study. Excess weight loss is 58% at 1 year and 60% at 2 years, she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The average age of the 32 girls and 12 boys is 16 years, and average body mass index is 60 kg/m

Surgery improved many of the preoperative comorbidities. For example, 70% of the 44 teenagers had preoperative insulin resistance (and there was an 82% resolution rate) and 91% had sleep apnea (45% resolution rate).

In preliminary results from the National Institutes of Health-funded Teen LABS study, Dr. Brandt and her associates found that type 2 diabetes resolved after surgery for 10 of 11 severely obese adolescents (Pediatrics 2009;123:214–22). Participants had a mean BMI of 50. Surgery was associated with a 34% decrease in BMI, a 41% decrease in fasting blood glucose levels, and an 81% decrease in fasting insulin concentrations.

In the Texas Children's Hospital series, 12 of the 44 patients experienced complications. Two patients had anastomotic bleeding, two had thiamine deficiency, and two had marginal ulcers. One patient each had a retained nasogastric tube, coagulopathy, pulmonary embolism, anastomotic leak, urethral injury, and a Peterson hernia. The complications resolved and there have been no deaths, said Dr. Brandt, professor and vice chair of surgery at Baylor College of Medicine, Houston.

“We are also participating in a second study called TeenView to look at the psychological component—eating disorders and depression especially,” Dr. Brandt said.

“The psychosocial cost of [severe obesity] is not measurable,” she said. Greater depressive symptoms, decreasing competence and self-esteem, and greater poverty are associated with adolescent obesity (Pediatrics 2000;105:e15; N. Engl. J. Med. 1993;329:1036–7).

Dr. Brandt said quality of life for obese adolescents is similar to levels reported by people with cancer during chemotherapy (JAMA 2003:289:1813–9).

She said that bariatric surgery should be considered only for morbidly obese adolescents who meet specific criteria (Pediatrics 2004;114:217–23). It should be limited to children with comorbidities and a BMI greater than 40, according to the recommendations. Candidates are those who have failed to lose weight after at least 6 months of organized attempts, are Tanner stage IV or V, and have supportive families.

Bariatric surgery improved many of the preoperative comorbidities. There was an 82% resolution rate for insulin resistance and a 45% resolution rate for sleep apnea. ©Tina Lorien/

SAN ANTONIO — Increased endometrial thickness on ultrasound is a strong risk factor for endometrial hyperplasia in adolescent and young women with prolonged, irregular menstrual bleeding.

“There are very scarce data on adolescent women,” Dr. Mee Hwa Lee said. So she and her colleagues retrospectively studied 54 patients (aged 13–20 years) with irregular menstrual bleeding. They each had an endometrial biopsy between 1999 and 2007.

A total of 16 patients (30%) had endometrial hyperplasia (EH) based on endometrial sampling. “Endometrial hyperplasia is not an uncommon condition in adolescent girl patients with irregular menstrual bleeding,” Dr. Lee said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Another 30 patients had normal endometrium and 8 had a polyp detected.

Dr. Lee and her associates found three risk factors associated with a significantly higher risk of EH in this population: endometrial thickness of 12 mm or greater (odds ratio, 37.3) and endometrial thickness of 14 mm or greater (OR, 35.0) on ultrasound, and prolonged vaginal bleeding (OR, 4.33).

“Ultrasonography seems to be an effective test,” Dr. Lee said.

An endometrial thickness of 12 mm or greater was the most sensitive risk factor (sensitivity of 94%, specificity of 84%, positive predictive value of 71%, and negative predictive value of 97%).

A combination of this feature with an abnormal ultrasound endometrial appearance increased the specificity to 97% (but sensitivity is 44%, positive predictive value is 87%, and negative predictive value is 80%).

“The thickness cutoff value of 12 mm is the most reliable for adolescent endometrial hyperplasia,” said Dr. Lee of the department of obstetrics and gynecology, Pundang CHA General Hospital, Pochon CHA University, Gyeonggi do, Korea.

“Endometrial hyperplasia could be ruled out if the endometrial thickness is less than 10 mm,” she added.

In contrast, body mass index of 25 kg/m

The researchers also looked for clinical risk factors significantly associated with EH. A univariate analysis identified prolonged vaginal bleeding (OR, 4.3), but the significance disappeared on multivariate analysis, Dr. Lee said. “No clinical risk factor assessed in this study showed significance in predicting EH in adolescent patients with irregular menstrual bleeding.”

Physicians recommend an endometrial biopsy for most but not all patients with irregular menstrual bleeding at her institution, Dr. Lee said in response to a question from an attendee. This study supports examination with less invasive ultrasound—it is “not about doing an endometrial biopsy in all patients, but [about] the high proportion of endometrial hyperplasia in this age group,” she noted.

One limitation of the study was its retrospective design, Dr. Lee said. For example, the incidence of EH might be different in a prospective, randomized trial, she said.

Endometrial hyperplasia is not uncommon in adolescent girls with irregular menstrual bleeding. DR. LEE

SAN ANTONIO — Increased endometrial thickness on ultrasound is a strong risk factor for endometrial hyperplasia in adolescent and young women with prolonged, irregular menstrual bleeding.

“There are very scarce data on adolescent women,” Dr. Mee Hwa Lee said. So she and her colleagues retrospectively studied 54 patients (aged 13–20 years) with irregular menstrual bleeding. They each had an endometrial biopsy between 1999 and 2007.

A total of 16 patients (30%) had endometrial hyperplasia (EH) based on endometrial sampling. “Endometrial hyperplasia is not an uncommon condition in adolescent girl patients with irregular menstrual bleeding,” Dr. Lee said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Another 30 patients had normal endometrium and 8 had a polyp detected.

Dr. Lee and her associates found three risk factors associated with a significantly higher risk of EH in this population: endometrial thickness of 12 mm or greater (odds ratio, 37.3) and endometrial thickness of 14 mm or greater (OR, 35.0) on ultrasound, and prolonged vaginal bleeding (OR, 4.33).

“Ultrasonography seems to be an effective test,” Dr. Lee said.

An endometrial thickness of 12 mm or greater was the most sensitive risk factor (sensitivity of 94%, specificity of 84%, positive predictive value of 71%, and negative predictive value of 97%).

A combination of this feature with an abnormal ultrasound endometrial appearance increased the specificity to 97% (but sensitivity is 44%, positive predictive value is 87%, and negative predictive value is 80%).

“The thickness cutoff value of 12 mm is the most reliable for adolescent endometrial hyperplasia,” said Dr. Lee of the department of obstetrics and gynecology, Pundang CHA General Hospital, Pochon CHA University, Gyeonggi do, Korea.

“Endometrial hyperplasia could be ruled out if the endometrial thickness is less than 10 mm,” she added.

In contrast, body mass index of 25 kg/m

The researchers also looked for clinical risk factors significantly associated with EH. A univariate analysis identified prolonged vaginal bleeding (OR, 4.3), but the significance disappeared on multivariate analysis, Dr. Lee said. “No clinical risk factor assessed in this study showed significance in predicting EH in adolescent patients with irregular menstrual bleeding.”

Physicians recommend an endometrial biopsy for most but not all patients with irregular menstrual bleeding at her institution, Dr. Lee said in response to a question from an attendee. This study supports examination with less invasive ultrasound—it is “not about doing an endometrial biopsy in all patients, but [about] the high proportion of endometrial hyperplasia in this age group,” she noted.

One limitation of the study was its retrospective design, Dr. Lee said. For example, the incidence of EH might be different in a prospective, randomized trial, she said.

Endometrial hyperplasia is not uncommon in adolescent girls with irregular menstrual bleeding. DR. LEE

SAN ANTONIO — Increased endometrial thickness on ultrasound is a strong risk factor for endometrial hyperplasia in adolescent and young women with prolonged, irregular menstrual bleeding.

“There are very scarce data on adolescent women,” Dr. Mee Hwa Lee said. So she and her colleagues retrospectively studied 54 patients (aged 13–20 years) with irregular menstrual bleeding. They each had an endometrial biopsy between 1999 and 2007.

A total of 16 patients (30%) had endometrial hyperplasia (EH) based on endometrial sampling. “Endometrial hyperplasia is not an uncommon condition in adolescent girl patients with irregular menstrual bleeding,” Dr. Lee said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Another 30 patients had normal endometrium and 8 had a polyp detected.

Dr. Lee and her associates found three risk factors associated with a significantly higher risk of EH in this population: endometrial thickness of 12 mm or greater (odds ratio, 37.3) and endometrial thickness of 14 mm or greater (OR, 35.0) on ultrasound, and prolonged vaginal bleeding (OR, 4.33).

“Ultrasonography seems to be an effective test,” Dr. Lee said.

An endometrial thickness of 12 mm or greater was the most sensitive risk factor (sensitivity of 94%, specificity of 84%, positive predictive value of 71%, and negative predictive value of 97%).

A combination of this feature with an abnormal ultrasound endometrial appearance increased the specificity to 97% (but sensitivity is 44%, positive predictive value is 87%, and negative predictive value is 80%).

“The thickness cutoff value of 12 mm is the most reliable for adolescent endometrial hyperplasia,” said Dr. Lee of the department of obstetrics and gynecology, Pundang CHA General Hospital, Pochon CHA University, Gyeonggi do, Korea.

“Endometrial hyperplasia could be ruled out if the endometrial thickness is less than 10 mm,” she added.

In contrast, body mass index of 25 kg/m

The researchers also looked for clinical risk factors significantly associated with EH. A univariate analysis identified prolonged vaginal bleeding (OR, 4.3), but the significance disappeared on multivariate analysis, Dr. Lee said. “No clinical risk factor assessed in this study showed significance in predicting EH in adolescent patients with irregular menstrual bleeding.”

Physicians recommend an endometrial biopsy for most but not all patients with irregular menstrual bleeding at her institution, Dr. Lee said in response to a question from an attendee. This study supports examination with less invasive ultrasound—it is “not about doing an endometrial biopsy in all patients, but [about] the high proportion of endometrial hyperplasia in this age group,” she noted.

One limitation of the study was its retrospective design, Dr. Lee said. For example, the incidence of EH might be different in a prospective, randomized trial, she said.

Endometrial hyperplasia is not uncommon in adolescent girls with irregular menstrual bleeding. DR. LEE

MIAMI BEACH — When performing a preoperative assessment of the patient with liver disease, consider specific risk factors during the history and physical examination, said Dr. Paul Martin at a meeting on perioperative medicine sponsored by the University of Miami.

Also assess the likelihood of renal insufficiency and portal hypertension, two of the most concerning perioperative developments.

“Assessing liver patients for surgery is one of the most common consults we get in the hospital,” said Dr. Martin, professor of medicine and chief of hepatology at the University of Miami.

Taking a careful history is essential. “You really want to know if the patient has ever had variceal hemorrhage, ascites, encephalopathy, or jaundice,” Dr. Martin said. Also, if the patient has a relevant surgical history, ask: What did the surgeon say your liver looked like? Did you have any bleeding problems afterward? Correct any coagulopathy before surgery, he added. “Coagulopathy and thrombocytopenia are really the important clues of underlying liver disease.”

Exclude patients with acute hepatitis from surgery. “If patients really had a compelling reason for surgery, I would wait until the liver enzymes are trending downward.”

A patient with cirrhosis is at increased risk for renal insufficiency and/or portal hypertension during surgery. Advise the surgeon and anesthesiologist to watch for onset of renal insufficiency, “because it's a marker of markedly reduced survival,” Dr. Martin said.

Although evidence of renal insufficiency “is what concerns us most” during the perioperative period, avoiding perioperative hypotension also is important, he noted. “Patients with hypotension are poorly tolerant of any drop in blood pressure.”

What has changed in assessment of liver disease is the Model for End-Stage Liver Disease (MELD) score (visit www.unos.org/resources

Operative risk can also be predicted using the Child-Turcotte-Pugh (CTP) classification, which assigns points based on values for bilirubin, albumin, prolonged prothrombin time/INR, ascites, and encephalopathy stage. The classification system correlates with mortality among patients with liver cirrhosis (Hepatogastroenterology 2008;55:1034–40).

A patient with a CTP-A classification generally has no limitations for surgery, Dr. Martin said. Perioperative mortality increases for someone classified as CTP-B, and major hepatic surgery should be avoided. A CTP-C patient is not a candidate for any major elective surgery, and instead should be considered for liver transplantation, he said.

A meeting attendee asked for advice about a common patient type: “I get asked a lot to assess a class Child's B cirrhotic plus, approaching a C, with hip fracture.” Dr. Martin replied: “That patient should not have a general anesthetic, if possible. Use a spinal. There is a substantial risk [of complications], as high as 50%.” He added, “If there is a nonoperative option, that would be the best option, but often, we don't have that luxury.”

Also, cirrhotic patients who experience intraoperative hypotension, who have a respiratory procedure (such as thoracotomy) or who have biliary and liver procedures, are more likely to run into problems after surgery, he said.

MIAMI BEACH — When performing a preoperative assessment of the patient with liver disease, consider specific risk factors during the history and physical examination, said Dr. Paul Martin at a meeting on perioperative medicine sponsored by the University of Miami.

Also assess the likelihood of renal insufficiency and portal hypertension, two of the most concerning perioperative developments.

“Assessing liver patients for surgery is one of the most common consults we get in the hospital,” said Dr. Martin, professor of medicine and chief of hepatology at the University of Miami.

Taking a careful history is essential. “You really want to know if the patient has ever had variceal hemorrhage, ascites, encephalopathy, or jaundice,” Dr. Martin said. Also, if the patient has a relevant surgical history, ask: What did the surgeon say your liver looked like? Did you have any bleeding problems afterward? Correct any coagulopathy before surgery, he added. “Coagulopathy and thrombocytopenia are really the important clues of underlying liver disease.”

Exclude patients with acute hepatitis from surgery. “If patients really had a compelling reason for surgery, I would wait until the liver enzymes are trending downward.”

A patient with cirrhosis is at increased risk for renal insufficiency and/or portal hypertension during surgery. Advise the surgeon and anesthesiologist to watch for onset of renal insufficiency, “because it's a marker of markedly reduced survival,” Dr. Martin said.

Although evidence of renal insufficiency “is what concerns us most” during the perioperative period, avoiding perioperative hypotension also is important, he noted. “Patients with hypotension are poorly tolerant of any drop in blood pressure.”

What has changed in assessment of liver disease is the Model for End-Stage Liver Disease (MELD) score (visit www.unos.org/resources

Operative risk can also be predicted using the Child-Turcotte-Pugh (CTP) classification, which assigns points based on values for bilirubin, albumin, prolonged prothrombin time/INR, ascites, and encephalopathy stage. The classification system correlates with mortality among patients with liver cirrhosis (Hepatogastroenterology 2008;55:1034–40).

A patient with a CTP-A classification generally has no limitations for surgery, Dr. Martin said. Perioperative mortality increases for someone classified as CTP-B, and major hepatic surgery should be avoided. A CTP-C patient is not a candidate for any major elective surgery, and instead should be considered for liver transplantation, he said.

A meeting attendee asked for advice about a common patient type: “I get asked a lot to assess a class Child's B cirrhotic plus, approaching a C, with hip fracture.” Dr. Martin replied: “That patient should not have a general anesthetic, if possible. Use a spinal. There is a substantial risk [of complications], as high as 50%.” He added, “If there is a nonoperative option, that would be the best option, but often, we don't have that luxury.”

Also, cirrhotic patients who experience intraoperative hypotension, who have a respiratory procedure (such as thoracotomy) or who have biliary and liver procedures, are more likely to run into problems after surgery, he said.

MIAMI BEACH — When performing a preoperative assessment of the patient with liver disease, consider specific risk factors during the history and physical examination, said Dr. Paul Martin at a meeting on perioperative medicine sponsored by the University of Miami.

Also assess the likelihood of renal insufficiency and portal hypertension, two of the most concerning perioperative developments.

“Assessing liver patients for surgery is one of the most common consults we get in the hospital,” said Dr. Martin, professor of medicine and chief of hepatology at the University of Miami.

Taking a careful history is essential. “You really want to know if the patient has ever had variceal hemorrhage, ascites, encephalopathy, or jaundice,” Dr. Martin said. Also, if the patient has a relevant surgical history, ask: What did the surgeon say your liver looked like? Did you have any bleeding problems afterward? Correct any coagulopathy before surgery, he added. “Coagulopathy and thrombocytopenia are really the important clues of underlying liver disease.”

Exclude patients with acute hepatitis from surgery. “If patients really had a compelling reason for surgery, I would wait until the liver enzymes are trending downward.”

A patient with cirrhosis is at increased risk for renal insufficiency and/or portal hypertension during surgery. Advise the surgeon and anesthesiologist to watch for onset of renal insufficiency, “because it's a marker of markedly reduced survival,” Dr. Martin said.

Although evidence of renal insufficiency “is what concerns us most” during the perioperative period, avoiding perioperative hypotension also is important, he noted. “Patients with hypotension are poorly tolerant of any drop in blood pressure.”

What has changed in assessment of liver disease is the Model for End-Stage Liver Disease (MELD) score (visit www.unos.org/resources

Operative risk can also be predicted using the Child-Turcotte-Pugh (CTP) classification, which assigns points based on values for bilirubin, albumin, prolonged prothrombin time/INR, ascites, and encephalopathy stage. The classification system correlates with mortality among patients with liver cirrhosis (Hepatogastroenterology 2008;55:1034–40).

A patient with a CTP-A classification generally has no limitations for surgery, Dr. Martin said. Perioperative mortality increases for someone classified as CTP-B, and major hepatic surgery should be avoided. A CTP-C patient is not a candidate for any major elective surgery, and instead should be considered for liver transplantation, he said.

A meeting attendee asked for advice about a common patient type: “I get asked a lot to assess a class Child's B cirrhotic plus, approaching a C, with hip fracture.” Dr. Martin replied: “That patient should not have a general anesthetic, if possible. Use a spinal. There is a substantial risk [of complications], as high as 50%.” He added, “If there is a nonoperative option, that would be the best option, but often, we don't have that luxury.”

Also, cirrhotic patients who experience intraoperative hypotension, who have a respiratory procedure (such as thoracotomy) or who have biliary and liver procedures, are more likely to run into problems after surgery, he said.

MIAMI BEACH — With the aging of the U.S. population, hospitalists increasingly act as perioperative geriatricians and manage the unique challenges of this population, including increased cognitive dysfunction and delirium.

“Acute hospital care is becoming acute geriatric care,” Dr. Robert M. Palmer said. People aged 65 years and older accounted for 13% of the U.S. population and 38% of hospital discharges in 2005, according to a report based on data from the National Hospital Discharge Survey (Vital Health Stat. 13. 2007;165:1–209).

“There is something very different about these elderly perioperative patients,” said Dr. Palmer, clinical director of the division of geriatric medicine and gerontology, University of Pittsburgh.

Cognitive dysfunction is more common than delirium among elderly patients, but the two conditions are part of the same spectrum, Dr. Palmer said at a meeting on perioperative medicine sponsored by the University of Miami.

In a study of patients undergoing major noncardiac surgery, postoperative cognitive dysfunction occurred in 41% of patients aged 60 years and older, 37% of patients aged 18-39 years, and 30% of those aged 40–59 (Anesthesiology 2008;108:18–30).

For example, an 82-year-old woman who has been independent in all activities of daily living prior to a hip fracture “is at high risk, greater than 40%, of postoperative cognitive dysfunction” after hip surgery, Dr. Palmer said. “We don't totally understand the etiology.”

A meeting attendee asked about quick assessment of cognitive function. “Ask [the patients] about activities of daily living—have they been able to pay bills, do finances, and take medication without assistance?” Dr. Palmer said. Also ask patients or family members about history of memory loss. Also consider a bedside digit span test. “Ask them to repeat a random string of numbers. Give them the numbers 1 second apart in a monotone,” he said. “Someone with delirium can only repeat three or fewer numbers.”

Cognitive dysfunction can be long-lasting in some patients. “Even at months after surgery, 13% [of those aged 60 and older] had signs of postoperative cognitive dysfunction versus none in an age-matched control group,” he said. None of the younger or middle-aged patients had cognitive dysfunction at 3 months.

In contrast, postoperative delirium is more likely to last only 24–72 hours after surgery (Anesthesiology 2007;106:622–8). This disorder of attention and cognition also can exist preoperatively and/or emerge in the recovery room.

Predictors of delirium following elective surgery include age 70 or older, alcohol abuse, baseline cognitive impairment, severe physical impairment, abnormal preoperative electrolyte or glucose levels, abdominal aortic aneurysm surgery, and noncardiac thoracic surgery (JAMA 1994;271:134–9). Risk was 2% in patients with none of these predictors, 11% among those with one or two risk factors, and 50% in patients with three or more risk factors.

Anticholinergics, benzodiazepines, and meperidine can increase the risk of postoperative delirium, according to consensus data (Arch. Intern. Med. 2003;163:2716–24). “These agents, generally speaking, should be avoided in all elderly patients,” Dr. Palmer said.

In addition to cessation of any high-risk medication, the use of supplemental oxygen, adequate nutritional intake, and ambulation on postoperative day 1 can reduce the risk of postoperative delirium. It is also important to treat any severe pain, he said. “Patients who are in pain cannot participate in physical therapy, so you need to address pain before you do everything else.

'There is something very different about [the responses of] these elderly perioperative patients.' DR. PALMER

MIAMI BEACH — With the aging of the U.S. population, hospitalists increasingly act as perioperative geriatricians and manage the unique challenges of this population, including increased cognitive dysfunction and delirium.

“Acute hospital care is becoming acute geriatric care,” Dr. Robert M. Palmer said. People aged 65 years and older accounted for 13% of the U.S. population and 38% of hospital discharges in 2005, according to a report based on data from the National Hospital Discharge Survey (Vital Health Stat. 13. 2007;165:1–209).

“There is something very different about these elderly perioperative patients,” said Dr. Palmer, clinical director of the division of geriatric medicine and gerontology, University of Pittsburgh.

Cognitive dysfunction is more common than delirium among elderly patients, but the two conditions are part of the same spectrum, Dr. Palmer said at a meeting on perioperative medicine sponsored by the University of Miami.

In a study of patients undergoing major noncardiac surgery, postoperative cognitive dysfunction occurred in 41% of patients aged 60 years and older, 37% of patients aged 18-39 years, and 30% of those aged 40–59 (Anesthesiology 2008;108:18–30).

For example, an 82-year-old woman who has been independent in all activities of daily living prior to a hip fracture “is at high risk, greater than 40%, of postoperative cognitive dysfunction” after hip surgery, Dr. Palmer said. “We don't totally understand the etiology.”

A meeting attendee asked about quick assessment of cognitive function. “Ask [the patients] about activities of daily living—have they been able to pay bills, do finances, and take medication without assistance?” Dr. Palmer said. Also ask patients or family members about history of memory loss. Also consider a bedside digit span test. “Ask them to repeat a random string of numbers. Give them the numbers 1 second apart in a monotone,” he said. “Someone with delirium can only repeat three or fewer numbers.”

Cognitive dysfunction can be long-lasting in some patients. “Even at months after surgery, 13% [of those aged 60 and older] had signs of postoperative cognitive dysfunction versus none in an age-matched control group,” he said. None of the younger or middle-aged patients had cognitive dysfunction at 3 months.

In contrast, postoperative delirium is more likely to last only 24–72 hours after surgery (Anesthesiology 2007;106:622–8). This disorder of attention and cognition also can exist preoperatively and/or emerge in the recovery room.

Predictors of delirium following elective surgery include age 70 or older, alcohol abuse, baseline cognitive impairment, severe physical impairment, abnormal preoperative electrolyte or glucose levels, abdominal aortic aneurysm surgery, and noncardiac thoracic surgery (JAMA 1994;271:134–9). Risk was 2% in patients with none of these predictors, 11% among those with one or two risk factors, and 50% in patients with three or more risk factors.

Anticholinergics, benzodiazepines, and meperidine can increase the risk of postoperative delirium, according to consensus data (Arch. Intern. Med. 2003;163:2716–24). “These agents, generally speaking, should be avoided in all elderly patients,” Dr. Palmer said.

In addition to cessation of any high-risk medication, the use of supplemental oxygen, adequate nutritional intake, and ambulation on postoperative day 1 can reduce the risk of postoperative delirium. It is also important to treat any severe pain, he said. “Patients who are in pain cannot participate in physical therapy, so you need to address pain before you do everything else.

'There is something very different about [the responses of] these elderly perioperative patients.' DR. PALMER

MIAMI BEACH — With the aging of the U.S. population, hospitalists increasingly act as perioperative geriatricians and manage the unique challenges of this population, including increased cognitive dysfunction and delirium.

“Acute hospital care is becoming acute geriatric care,” Dr. Robert M. Palmer said. People aged 65 years and older accounted for 13% of the U.S. population and 38% of hospital discharges in 2005, according to a report based on data from the National Hospital Discharge Survey (Vital Health Stat. 13. 2007;165:1–209).

“There is something very different about these elderly perioperative patients,” said Dr. Palmer, clinical director of the division of geriatric medicine and gerontology, University of Pittsburgh.

Cognitive dysfunction is more common than delirium among elderly patients, but the two conditions are part of the same spectrum, Dr. Palmer said at a meeting on perioperative medicine sponsored by the University of Miami.

In a study of patients undergoing major noncardiac surgery, postoperative cognitive dysfunction occurred in 41% of patients aged 60 years and older, 37% of patients aged 18-39 years, and 30% of those aged 40–59 (Anesthesiology 2008;108:18–30).

For example, an 82-year-old woman who has been independent in all activities of daily living prior to a hip fracture “is at high risk, greater than 40%, of postoperative cognitive dysfunction” after hip surgery, Dr. Palmer said. “We don't totally understand the etiology.”

A meeting attendee asked about quick assessment of cognitive function. “Ask [the patients] about activities of daily living—have they been able to pay bills, do finances, and take medication without assistance?” Dr. Palmer said. Also ask patients or family members about history of memory loss. Also consider a bedside digit span test. “Ask them to repeat a random string of numbers. Give them the numbers 1 second apart in a monotone,” he said. “Someone with delirium can only repeat three or fewer numbers.”

Cognitive dysfunction can be long-lasting in some patients. “Even at months after surgery, 13% [of those aged 60 and older] had signs of postoperative cognitive dysfunction versus none in an age-matched control group,” he said. None of the younger or middle-aged patients had cognitive dysfunction at 3 months.

In contrast, postoperative delirium is more likely to last only 24–72 hours after surgery (Anesthesiology 2007;106:622–8). This disorder of attention and cognition also can exist preoperatively and/or emerge in the recovery room.

Predictors of delirium following elective surgery include age 70 or older, alcohol abuse, baseline cognitive impairment, severe physical impairment, abnormal preoperative electrolyte or glucose levels, abdominal aortic aneurysm surgery, and noncardiac thoracic surgery (JAMA 1994;271:134–9). Risk was 2% in patients with none of these predictors, 11% among those with one or two risk factors, and 50% in patients with three or more risk factors.

Anticholinergics, benzodiazepines, and meperidine can increase the risk of postoperative delirium, according to consensus data (Arch. Intern. Med. 2003;163:2716–24). “These agents, generally speaking, should be avoided in all elderly patients,” Dr. Palmer said.

In addition to cessation of any high-risk medication, the use of supplemental oxygen, adequate nutritional intake, and ambulation on postoperative day 1 can reduce the risk of postoperative delirium. It is also important to treat any severe pain, he said. “Patients who are in pain cannot participate in physical therapy, so you need to address pain before you do everything else.

'There is something very different about [the responses of] these elderly perioperative patients.' DR. PALMER