M. Alexander Otto

HUNTINGTON BEACH, CALIF. - Underrecognized and undertreated obstructive sleep apnea is the most likely cause of unexplained deaths following bariatric surgery, according to results of a small pilot study.

Because of that, continuous positive airway pressure (CPAP) and continuous pulse oximetry monitoring – with alarms to alert nursing staff to hypoxic episodes and rouse oxygen-desaturated patients from sleep – should be included in postoperative care, said Dr. Scott Gallagher, a bariatric surgeon at the University of South Florida, Tampa, where the study was conducted.

In previous work, the researchers found that severe, prolonged, and frequent arterial hypoxemia is common in sleeping bariatric surgery patients. They sought to determine why such patients – who seemed to be doing well after surgery – died suddenly in their sleep, without pulmonary embolism or any other obvious cause. In 15 gastric bypass patients monitored for 24 hours after surgery, they found that the average episode of hypoxemia lasted 21 minutes, and the longest for hours. Blood oxygen saturation fell as low as 60% (J. Surg. Res. 2010;159:622-6).

Right-to-left shunt, diminished inspired oxygen partial pressure, and other textbook explanations did not provide a rationale for the hypoxemia. Such causes "didn’t exist in these patients," Dr. Gallagher said.

That left either postoperative, narcotic-induced hypoventilation or obstructive sleep apnea as the most likely explanation. Narcotic pain control is common after bariatric surgery, as is sleep apnea.

Dr. Gallagher and his team measured carbon dioxide partial pressures transcutaneously (PtcCO₂) to gauge hypoventilation in 20 patients (14 female) during the first 24 hours after Roux-en-Y gastric bypass. Patients also wore blood oxygen saturation (SpO₂) ear-clip sensors.

Their mean body mass index was 54 kg/m², and 15 were diagnosed with obstructive sleep apnea. All were on postoperative narcotics.

As in the previous study, all the patients had multiple episodes of prolonged hypoxemia, with a mean of 191 episodes per patient lasting a mean of 1 minute.

Mean SpO₂ was 94%, and mean minimum SpO2 was 60%. Patients spent about 5% of their time (75 minutes) with SpO2 below 88%; hypoxemia lasted longer than 5 minutes in three patients.

All patients also had mild hypercarbia, suggesting mild, chronic hypoventilation.

They had a mean PtcCO₂ of 44 mmHg and a mean maximum of 56 mm Hg. The maximum PtcCO₂ value recorded in any patient was 75 mm Hg. Heart rates temporarily dropped below 50 bpm in 14 patients.

However, "in no patient could hypoxemia be explained entirely by hypoventilation, and there was no obvious relationship between hypoxemic episodes and [hypoventilation]," said Dr. Krista Haines, a recent University of South Florida graduate now with the University of Nevada, Las Vegas, who presented the findings at the annual Academic Surgical Congress.

The mild hypoventilation by itself was "not clinically significant," leaving obstructive sleep apnea as the most likely cause of hypoxemia following bariatric surgery, Dr. Gallagher stated.

As far as the unexplained deaths go, Dr. Gallagher and his team believe that once patients desaturate, the mild narcotic-induced hypoventilation pushes a few of them over the edge, though no one died in the study.

Because sleep apnea is the likely root cause of such deaths, Dr. Gallagher recommends routine postoperative monitoring of bariatric surgery patients. "[Apneics] need to have their CPAP on" after surgery, especially when receiving narcotics, he said.

CPAP and postoperative monitoring are necessary until sleep apnea resolves, usually after a weight loss of 50-75 pounds. In his study, he noted that 14 patients had machines but still desaturated. Barring faulty gear or incorrect settings, that means the machines weren’t being used throughout the night.

He also pointed out the supplemental oxygen used in the study didn’t prevent hypercarbia or hypoxemia and seems to have no therapeutic role at this point.

In many places, sleep apnea screens, CPAP, and nighttime pulse oximetry are not the standard of care following bariatric surgery, Dr. Gallagher said.

Dr. Stefan Holubar, a colorectal surgeon and comoderator of the session, thinks that needs to change.

"The standard of care should include formal obstructive sleep apnea [screening] for all patients undergoing bariatric surgery, or they should all be empirically treated [with CPAP] regardless of whether or not they have the diagnosis," said Dr. Holubar of Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

"Although it’s a small pilot study, there are profound implications," he added.

The study "is a great start," said comoderator Dr. George Chang, a colorectal surgeon at that University of Texas at Houston. But the team needs to "demonstrate an association between unexplained deaths and these measures. You’d have to do a very large long-term study to see if those unexplained deaths go down."

Dr. Gallagher and his team are considering a randomized study to further investigate the issue, and they plan to include obese people having other kinds of operations.

Dr. Gallagher believes what the team has found thus far is "the tip of the iceberg."

Dr. Gallagher and Dr. Haines said they have no conflicts of interest. The study received no outside funding.

HUNTINGTON BEACH, CALIF. - Underrecognized and undertreated obstructive sleep apnea is the most likely cause of unexplained deaths following bariatric surgery, according to results of a small pilot study.

Because of that, continuous positive airway pressure (CPAP) and continuous pulse oximetry monitoring – with alarms to alert nursing staff to hypoxic episodes and rouse oxygen-desaturated patients from sleep – should be included in postoperative care, said Dr. Scott Gallagher, a bariatric surgeon at the University of South Florida, Tampa, where the study was conducted.

In previous work, the researchers found that severe, prolonged, and frequent arterial hypoxemia is common in sleeping bariatric surgery patients. They sought to determine why such patients – who seemed to be doing well after surgery – died suddenly in their sleep, without pulmonary embolism or any other obvious cause. In 15 gastric bypass patients monitored for 24 hours after surgery, they found that the average episode of hypoxemia lasted 21 minutes, and the longest for hours. Blood oxygen saturation fell as low as 60% (J. Surg. Res. 2010;159:622-6).

Right-to-left shunt, diminished inspired oxygen partial pressure, and other textbook explanations did not provide a rationale for the hypoxemia. Such causes "didn’t exist in these patients," Dr. Gallagher said.

That left either postoperative, narcotic-induced hypoventilation or obstructive sleep apnea as the most likely explanation. Narcotic pain control is common after bariatric surgery, as is sleep apnea.

Dr. Gallagher and his team measured carbon dioxide partial pressures transcutaneously (PtcCO₂) to gauge hypoventilation in 20 patients (14 female) during the first 24 hours after Roux-en-Y gastric bypass. Patients also wore blood oxygen saturation (SpO₂) ear-clip sensors.

Their mean body mass index was 54 kg/m², and 15 were diagnosed with obstructive sleep apnea. All were on postoperative narcotics.

As in the previous study, all the patients had multiple episodes of prolonged hypoxemia, with a mean of 191 episodes per patient lasting a mean of 1 minute.

Mean SpO₂ was 94%, and mean minimum SpO2 was 60%. Patients spent about 5% of their time (75 minutes) with SpO2 below 88%; hypoxemia lasted longer than 5 minutes in three patients.

All patients also had mild hypercarbia, suggesting mild, chronic hypoventilation.

They had a mean PtcCO₂ of 44 mmHg and a mean maximum of 56 mm Hg. The maximum PtcCO₂ value recorded in any patient was 75 mm Hg. Heart rates temporarily dropped below 50 bpm in 14 patients.

However, "in no patient could hypoxemia be explained entirely by hypoventilation, and there was no obvious relationship between hypoxemic episodes and [hypoventilation]," said Dr. Krista Haines, a recent University of South Florida graduate now with the University of Nevada, Las Vegas, who presented the findings at the annual Academic Surgical Congress.

The mild hypoventilation by itself was "not clinically significant," leaving obstructive sleep apnea as the most likely cause of hypoxemia following bariatric surgery, Dr. Gallagher stated.

As far as the unexplained deaths go, Dr. Gallagher and his team believe that once patients desaturate, the mild narcotic-induced hypoventilation pushes a few of them over the edge, though no one died in the study.

Because sleep apnea is the likely root cause of such deaths, Dr. Gallagher recommends routine postoperative monitoring of bariatric surgery patients. "[Apneics] need to have their CPAP on" after surgery, especially when receiving narcotics, he said.

CPAP and postoperative monitoring are necessary until sleep apnea resolves, usually after a weight loss of 50-75 pounds. In his study, he noted that 14 patients had machines but still desaturated. Barring faulty gear or incorrect settings, that means the machines weren’t being used throughout the night.

He also pointed out the supplemental oxygen used in the study didn’t prevent hypercarbia or hypoxemia and seems to have no therapeutic role at this point.

In many places, sleep apnea screens, CPAP, and nighttime pulse oximetry are not the standard of care following bariatric surgery, Dr. Gallagher said.

Dr. Stefan Holubar, a colorectal surgeon and comoderator of the session, thinks that needs to change.

"The standard of care should include formal obstructive sleep apnea [screening] for all patients undergoing bariatric surgery, or they should all be empirically treated [with CPAP] regardless of whether or not they have the diagnosis," said Dr. Holubar of Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

"Although it’s a small pilot study, there are profound implications," he added.

The study "is a great start," said comoderator Dr. George Chang, a colorectal surgeon at that University of Texas at Houston. But the team needs to "demonstrate an association between unexplained deaths and these measures. You’d have to do a very large long-term study to see if those unexplained deaths go down."

Dr. Gallagher and his team are considering a randomized study to further investigate the issue, and they plan to include obese people having other kinds of operations.

Dr. Gallagher believes what the team has found thus far is "the tip of the iceberg."

Dr. Gallagher and Dr. Haines said they have no conflicts of interest. The study received no outside funding.

HUNTINGTON BEACH, CALIF. - Underrecognized and undertreated obstructive sleep apnea is the most likely cause of unexplained deaths following bariatric surgery, according to results of a small pilot study.

Because of that, continuous positive airway pressure (CPAP) and continuous pulse oximetry monitoring – with alarms to alert nursing staff to hypoxic episodes and rouse oxygen-desaturated patients from sleep – should be included in postoperative care, said Dr. Scott Gallagher, a bariatric surgeon at the University of South Florida, Tampa, where the study was conducted.

In previous work, the researchers found that severe, prolonged, and frequent arterial hypoxemia is common in sleeping bariatric surgery patients. They sought to determine why such patients – who seemed to be doing well after surgery – died suddenly in their sleep, without pulmonary embolism or any other obvious cause. In 15 gastric bypass patients monitored for 24 hours after surgery, they found that the average episode of hypoxemia lasted 21 minutes, and the longest for hours. Blood oxygen saturation fell as low as 60% (J. Surg. Res. 2010;159:622-6).

Right-to-left shunt, diminished inspired oxygen partial pressure, and other textbook explanations did not provide a rationale for the hypoxemia. Such causes "didn’t exist in these patients," Dr. Gallagher said.

That left either postoperative, narcotic-induced hypoventilation or obstructive sleep apnea as the most likely explanation. Narcotic pain control is common after bariatric surgery, as is sleep apnea.

Dr. Gallagher and his team measured carbon dioxide partial pressures transcutaneously (PtcCO₂) to gauge hypoventilation in 20 patients (14 female) during the first 24 hours after Roux-en-Y gastric bypass. Patients also wore blood oxygen saturation (SpO₂) ear-clip sensors.

Their mean body mass index was 54 kg/m², and 15 were diagnosed with obstructive sleep apnea. All were on postoperative narcotics.

As in the previous study, all the patients had multiple episodes of prolonged hypoxemia, with a mean of 191 episodes per patient lasting a mean of 1 minute.

Mean SpO₂ was 94%, and mean minimum SpO2 was 60%. Patients spent about 5% of their time (75 minutes) with SpO2 below 88%; hypoxemia lasted longer than 5 minutes in three patients.

All patients also had mild hypercarbia, suggesting mild, chronic hypoventilation.

They had a mean PtcCO₂ of 44 mmHg and a mean maximum of 56 mm Hg. The maximum PtcCO₂ value recorded in any patient was 75 mm Hg. Heart rates temporarily dropped below 50 bpm in 14 patients.

However, "in no patient could hypoxemia be explained entirely by hypoventilation, and there was no obvious relationship between hypoxemic episodes and [hypoventilation]," said Dr. Krista Haines, a recent University of South Florida graduate now with the University of Nevada, Las Vegas, who presented the findings at the annual Academic Surgical Congress.

The mild hypoventilation by itself was "not clinically significant," leaving obstructive sleep apnea as the most likely cause of hypoxemia following bariatric surgery, Dr. Gallagher stated.

As far as the unexplained deaths go, Dr. Gallagher and his team believe that once patients desaturate, the mild narcotic-induced hypoventilation pushes a few of them over the edge, though no one died in the study.

Because sleep apnea is the likely root cause of such deaths, Dr. Gallagher recommends routine postoperative monitoring of bariatric surgery patients. "[Apneics] need to have their CPAP on" after surgery, especially when receiving narcotics, he said.

CPAP and postoperative monitoring are necessary until sleep apnea resolves, usually after a weight loss of 50-75 pounds. In his study, he noted that 14 patients had machines but still desaturated. Barring faulty gear or incorrect settings, that means the machines weren’t being used throughout the night.

He also pointed out the supplemental oxygen used in the study didn’t prevent hypercarbia or hypoxemia and seems to have no therapeutic role at this point.

In many places, sleep apnea screens, CPAP, and nighttime pulse oximetry are not the standard of care following bariatric surgery, Dr. Gallagher said.

Dr. Stefan Holubar, a colorectal surgeon and comoderator of the session, thinks that needs to change.

"The standard of care should include formal obstructive sleep apnea [screening] for all patients undergoing bariatric surgery, or they should all be empirically treated [with CPAP] regardless of whether or not they have the diagnosis," said Dr. Holubar of Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

"Although it’s a small pilot study, there are profound implications," he added.

The study "is a great start," said comoderator Dr. George Chang, a colorectal surgeon at that University of Texas at Houston. But the team needs to "demonstrate an association between unexplained deaths and these measures. You’d have to do a very large long-term study to see if those unexplained deaths go down."

Dr. Gallagher and his team are considering a randomized study to further investigate the issue, and they plan to include obese people having other kinds of operations.

Dr. Gallagher believes what the team has found thus far is "the tip of the iceberg."

Dr. Gallagher and Dr. Haines said they have no conflicts of interest. The study received no outside funding.

HUNTINGTON BEACH, CALIF. - Underrecognized and undertreated obstructive sleep apnea is the most likely cause of unexplained deaths following bariatric surgery, according to results of a small pilot study.

Because of that, continuous positive airway pressure (CPAP) and continuous pulse oximetry monitoring – with alarms to alert nursing staff to hypoxic episodes and rouse oxygen-desaturated patients from sleep – should be included in postoperative care, said Dr. Scott Gallagher, a bariatric surgeon at the University of South Florida, Tampa, where the study was conducted.

In previous work, the researchers found that severe, prolonged, and frequent arterial hypoxemia is common in sleeping bariatric surgery patients. They sought to determine why such patients – who seemed to be doing well after surgery – died suddenly in their sleep, without pulmonary embolism or any other obvious cause. In 15 gastric bypass patients monitored for 24 hours after surgery, they found that the average episode of hypoxemia lasted 21 minutes, and the longest for hours. Blood oxygen saturation fell as low as 60% (J. Surg. Res. 2010;159:622-6).

Right-to-left shunt, diminished inspired oxygen partial pressure, and other textbook explanations did not provide a rationale for the hypoxemia. Such causes "didn’t exist in these patients," Dr. Gallagher said.

That left either postoperative, narcotic-induced hypoventilation or obstructive sleep apnea as the most likely explanation. Narcotic pain control is common after bariatric surgery, as is sleep apnea.

Dr. Gallagher and his team measured carbon dioxide partial pressures transcutaneously (PtcCO₂) to gauge hypoventilation in 20 patients (14 female) during the first 24 hours after Roux-en-Y gastric bypass. Patients also wore blood oxygen saturation (SpO₂) ear-clip sensors.

Their mean body mass index was 54 kg/m², and 15 were diagnosed with obstructive sleep apnea. All were on postoperative narcotics.

As in the previous study, all the patients had multiple episodes of prolonged hypoxemia, with a mean of 191 episodes per patient lasting a mean of 1 minute.

Mean SpO₂ was 94%, and mean minimum SpO2 was 60%. Patients spent about 5% of their time (75 minutes) with SpO2 below 88%; hypoxemia lasted longer than 5 minutes in three patients.

All patients also had mild hypercarbia, suggesting mild, chronic hypoventilation.

They had a mean PtcCO₂ of 44 mmHg and a mean maximum of 56 mm Hg. The maximum PtcCO₂ value recorded in any patient was 75 mm Hg. Heart rates temporarily dropped below 50 bpm in 14 patients.

However, "in no patient could hypoxemia be explained entirely by hypoventilation, and there was no obvious relationship between hypoxemic episodes and [hypoventilation]," said Dr. Krista Haines, a recent University of South Florida graduate now with the University of Nevada, Las Vegas, who presented the findings at the annual Academic Surgical Congress.

The mild hypoventilation by itself was "not clinically significant," leaving obstructive sleep apnea as the most likely cause of hypoxemia following bariatric surgery, Dr. Gallagher stated.

As far as the unexplained deaths go, Dr. Gallagher and his team believe that once patients desaturate, the mild narcotic-induced hypoventilation pushes a few of them over the edge, though no one died in the study.

Because sleep apnea is the likely root cause of such deaths, Dr. Gallagher recommends routine postoperative monitoring of bariatric surgery patients. "[Apneics] need to have their CPAP on" after surgery, especially when receiving narcotics, he said.

CPAP and postoperative monitoring are necessary until sleep apnea resolves, usually after a weight loss of 50-75 pounds. In his study, he noted that 14 patients had machines but still desaturated. Barring faulty gear or incorrect settings, that means the machines weren’t being used throughout the night.

He also pointed out the supplemental oxygen used in the study didn’t prevent hypercarbia or hypoxemia and seems to have no therapeutic role at this point.

In many places, sleep apnea screens, CPAP, and nighttime pulse oximetry are not the standard of care following bariatric surgery, Dr. Gallagher said.

Dr. Stefan Holubar, a colorectal surgeon and comoderator of the session, thinks that needs to change.

"The standard of care should include formal obstructive sleep apnea [screening] for all patients undergoing bariatric surgery, or they should all be empirically treated [with CPAP] regardless of whether or not they have the diagnosis," said Dr. Holubar of Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

"Although it’s a small pilot study, there are profound implications," he added.

The study "is a great start," said comoderator Dr. George Chang, a colorectal surgeon at that University of Texas at Houston. But the team needs to "demonstrate an association between unexplained deaths and these measures. You’d have to do a very large long-term study to see if those unexplained deaths go down."

Dr. Gallagher and his team are considering a randomized study to further investigate the issue, and they plan to include obese people having other kinds of operations.

Dr. Gallagher believes what the team has found thus far is "the tip of the iceberg."

Dr. Gallagher and Dr. Haines said they have no conflicts of interest. The study received no outside funding.

HUNTINGTON BEACH, CALIF. - Underrecognized and undertreated obstructive sleep apnea is the most likely cause of unexplained deaths following bariatric surgery, according to results of a small pilot study.

Because of that, continuous positive airway pressure (CPAP) and continuous pulse oximetry monitoring – with alarms to alert nursing staff to hypoxic episodes and rouse oxygen-desaturated patients from sleep – should be included in postoperative care, said Dr. Scott Gallagher, a bariatric surgeon at the University of South Florida, Tampa, where the study was conducted.

In previous work, the researchers found that severe, prolonged, and frequent arterial hypoxemia is common in sleeping bariatric surgery patients. They sought to determine why such patients – who seemed to be doing well after surgery – died suddenly in their sleep, without pulmonary embolism or any other obvious cause. In 15 gastric bypass patients monitored for 24 hours after surgery, they found that the average episode of hypoxemia lasted 21 minutes, and the longest for hours. Blood oxygen saturation fell as low as 60% (J. Surg. Res. 2010;159:622-6).

Right-to-left shunt, diminished inspired oxygen partial pressure, and other textbook explanations did not provide a rationale for the hypoxemia. Such causes "didn’t exist in these patients," Dr. Gallagher said.

That left either postoperative, narcotic-induced hypoventilation or obstructive sleep apnea as the most likely explanation. Narcotic pain control is common after bariatric surgery, as is sleep apnea.

Dr. Gallagher and his team measured carbon dioxide partial pressures transcutaneously (PtcCO₂) to gauge hypoventilation in 20 patients (14 female) during the first 24 hours after Roux-en-Y gastric bypass. Patients also wore blood oxygen saturation (SpO₂) ear-clip sensors.

Their mean body mass index was 54 kg/m², and 15 were diagnosed with obstructive sleep apnea. All were on postoperative narcotics.

As in the previous study, all the patients had multiple episodes of prolonged hypoxemia, with a mean of 191 episodes per patient lasting a mean of 1 minute.

Mean SpO₂ was 94%, and mean minimum SpO2 was 60%. Patients spent about 5% of their time (75 minutes) with SpO2 below 88%; hypoxemia lasted longer than 5 minutes in three patients.

All patients also had mild hypercarbia, suggesting mild, chronic hypoventilation.

They had a mean PtcCO₂ of 44 mmHg and a mean maximum of 56 mm Hg. The maximum PtcCO₂ value recorded in any patient was 75 mm Hg. Heart rates temporarily dropped below 50 bpm in 14 patients.

However, "in no patient could hypoxemia be explained entirely by hypoventilation, and there was no obvious relationship between hypoxemic episodes and [hypoventilation]," said Dr. Krista Haines, a recent University of South Florida graduate now with the University of Nevada, Las Vegas, who presented the findings at the annual Academic Surgical Congress.

The mild hypoventilation by itself was "not clinically significant," leaving obstructive sleep apnea as the most likely cause of hypoxemia following bariatric surgery, Dr. Gallagher stated.

As far as the unexplained deaths go, Dr. Gallagher and his team believe that once patients desaturate, the mild narcotic-induced hypoventilation pushes a few of them over the edge, though no one died in the study.

Because sleep apnea is the likely root cause of such deaths, Dr. Gallagher recommends routine postoperative monitoring of bariatric surgery patients. "[Apneics] need to have their CPAP on" after surgery, especially when receiving narcotics, he said.

CPAP and postoperative monitoring are necessary until sleep apnea resolves, usually after a weight loss of 50-75 pounds. In his study, he noted that 14 patients had machines but still desaturated. Barring faulty gear or incorrect settings, that means the machines weren’t being used throughout the night.

He also pointed out the supplemental oxygen used in the study didn’t prevent hypercarbia or hypoxemia and seems to have no therapeutic role at this point.

In many places, sleep apnea screens, CPAP, and nighttime pulse oximetry are not the standard of care following bariatric surgery, Dr. Gallagher said.

Dr. Stefan Holubar, a colorectal surgeon and comoderator of the session, thinks that needs to change.

"The standard of care should include formal obstructive sleep apnea [screening] for all patients undergoing bariatric surgery, or they should all be empirically treated [with CPAP] regardless of whether or not they have the diagnosis," said Dr. Holubar of Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

"Although it’s a small pilot study, there are profound implications," he added.

The study "is a great start," said comoderator Dr. George Chang, a colorectal surgeon at that University of Texas at Houston. But the team needs to "demonstrate an association between unexplained deaths and these measures. You’d have to do a very large long-term study to see if those unexplained deaths go down."

Dr. Gallagher and his team are considering a randomized study to further investigate the issue, and they plan to include obese people having other kinds of operations.

Dr. Gallagher believes what the team has found thus far is "the tip of the iceberg."

Dr. Gallagher and Dr. Haines said they have no conflicts of interest. The study received no outside funding.

HUNTINGTON BEACH, CALIF. - Underrecognized and undertreated obstructive sleep apnea is the most likely cause of unexplained deaths following bariatric surgery, according to results of a small pilot study.

Because of that, continuous positive airway pressure (CPAP) and continuous pulse oximetry monitoring – with alarms to alert nursing staff to hypoxic episodes and rouse oxygen-desaturated patients from sleep – should be included in postoperative care, said Dr. Scott Gallagher, a bariatric surgeon at the University of South Florida, Tampa, where the study was conducted.

In previous work, the researchers found that severe, prolonged, and frequent arterial hypoxemia is common in sleeping bariatric surgery patients. They sought to determine why such patients – who seemed to be doing well after surgery – died suddenly in their sleep, without pulmonary embolism or any other obvious cause. In 15 gastric bypass patients monitored for 24 hours after surgery, they found that the average episode of hypoxemia lasted 21 minutes, and the longest for hours. Blood oxygen saturation fell as low as 60% (J. Surg. Res. 2010;159:622-6).

Right-to-left shunt, diminished inspired oxygen partial pressure, and other textbook explanations did not provide a rationale for the hypoxemia. Such causes "didn’t exist in these patients," Dr. Gallagher said.

That left either postoperative, narcotic-induced hypoventilation or obstructive sleep apnea as the most likely explanation. Narcotic pain control is common after bariatric surgery, as is sleep apnea.

Dr. Gallagher and his team measured carbon dioxide partial pressures transcutaneously (PtcCO₂) to gauge hypoventilation in 20 patients (14 female) during the first 24 hours after Roux-en-Y gastric bypass. Patients also wore blood oxygen saturation (SpO₂) ear-clip sensors.

Their mean body mass index was 54 kg/m², and 15 were diagnosed with obstructive sleep apnea. All were on postoperative narcotics.

As in the previous study, all the patients had multiple episodes of prolonged hypoxemia, with a mean of 191 episodes per patient lasting a mean of 1 minute.

Mean SpO₂ was 94%, and mean minimum SpO2 was 60%. Patients spent about 5% of their time (75 minutes) with SpO2 below 88%; hypoxemia lasted longer than 5 minutes in three patients.

All patients also had mild hypercarbia, suggesting mild, chronic hypoventilation.

They had a mean PtcCO₂ of 44 mmHg and a mean maximum of 56 mm Hg. The maximum PtcCO₂ value recorded in any patient was 75 mm Hg. Heart rates temporarily dropped below 50 bpm in 14 patients.

However, "in no patient could hypoxemia be explained entirely by hypoventilation, and there was no obvious relationship between hypoxemic episodes and [hypoventilation]," said Dr. Krista Haines, a recent University of South Florida graduate now with the University of Nevada, Las Vegas, who presented the findings at the annual Academic Surgical Congress.

The mild hypoventilation by itself was "not clinically significant," leaving obstructive sleep apnea as the most likely cause of hypoxemia following bariatric surgery, Dr. Gallagher stated.

As far as the unexplained deaths go, Dr. Gallagher and his team believe that once patients desaturate, the mild narcotic-induced hypoventilation pushes a few of them over the edge, though no one died in the study.

Because sleep apnea is the likely root cause of such deaths, Dr. Gallagher recommends routine postoperative monitoring of bariatric surgery patients. "[Apneics] need to have their CPAP on" after surgery, especially when receiving narcotics, he said.

CPAP and postoperative monitoring are necessary until sleep apnea resolves, usually after a weight loss of 50-75 pounds. In his study, he noted that 14 patients had machines but still desaturated. Barring faulty gear or incorrect settings, that means the machines weren’t being used throughout the night.

He also pointed out the supplemental oxygen used in the study didn’t prevent hypercarbia or hypoxemia and seems to have no therapeutic role at this point.

In many places, sleep apnea screens, CPAP, and nighttime pulse oximetry are not the standard of care following bariatric surgery, Dr. Gallagher said.

Dr. Stefan Holubar, a colorectal surgeon and comoderator of the session, thinks that needs to change.

"The standard of care should include formal obstructive sleep apnea [screening] for all patients undergoing bariatric surgery, or they should all be empirically treated [with CPAP] regardless of whether or not they have the diagnosis," said Dr. Holubar of Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

"Although it’s a small pilot study, there are profound implications," he added.

The study "is a great start," said comoderator Dr. George Chang, a colorectal surgeon at that University of Texas at Houston. But the team needs to "demonstrate an association between unexplained deaths and these measures. You’d have to do a very large long-term study to see if those unexplained deaths go down."

Dr. Gallagher and his team are considering a randomized study to further investigate the issue, and they plan to include obese people having other kinds of operations.

Dr. Gallagher believes what the team has found thus far is "the tip of the iceberg."

Dr. Gallagher and Dr. Haines said they have no conflicts of interest. The study received no outside funding.

HUNTINGTON BEACH, CALIF. - Underrecognized and undertreated obstructive sleep apnea is the most likely cause of unexplained deaths following bariatric surgery, according to results of a small pilot study.

Because of that, continuous positive airway pressure (CPAP) and continuous pulse oximetry monitoring – with alarms to alert nursing staff to hypoxic episodes and rouse oxygen-desaturated patients from sleep – should be included in postoperative care, said Dr. Scott Gallagher, a bariatric surgeon at the University of South Florida, Tampa, where the study was conducted.

In previous work, the researchers found that severe, prolonged, and frequent arterial hypoxemia is common in sleeping bariatric surgery patients. They sought to determine why such patients – who seemed to be doing well after surgery – died suddenly in their sleep, without pulmonary embolism or any other obvious cause. In 15 gastric bypass patients monitored for 24 hours after surgery, they found that the average episode of hypoxemia lasted 21 minutes, and the longest for hours. Blood oxygen saturation fell as low as 60% (J. Surg. Res. 2010;159:622-6).

Right-to-left shunt, diminished inspired oxygen partial pressure, and other textbook explanations did not provide a rationale for the hypoxemia. Such causes "didn’t exist in these patients," Dr. Gallagher said.

That left either postoperative, narcotic-induced hypoventilation or obstructive sleep apnea as the most likely explanation. Narcotic pain control is common after bariatric surgery, as is sleep apnea.

Dr. Gallagher and his team measured carbon dioxide partial pressures transcutaneously (PtcCO₂) to gauge hypoventilation in 20 patients (14 female) during the first 24 hours after Roux-en-Y gastric bypass. Patients also wore blood oxygen saturation (SpO₂) ear-clip sensors.

Their mean body mass index was 54 kg/m², and 15 were diagnosed with obstructive sleep apnea. All were on postoperative narcotics.

As in the previous study, all the patients had multiple episodes of prolonged hypoxemia, with a mean of 191 episodes per patient lasting a mean of 1 minute.

Mean SpO₂ was 94%, and mean minimum SpO2 was 60%. Patients spent about 5% of their time (75 minutes) with SpO2 below 88%; hypoxemia lasted longer than 5 minutes in three patients.

All patients also had mild hypercarbia, suggesting mild, chronic hypoventilation.

They had a mean PtcCO₂ of 44 mmHg and a mean maximum of 56 mm Hg. The maximum PtcCO₂ value recorded in any patient was 75 mm Hg. Heart rates temporarily dropped below 50 bpm in 14 patients.

However, "in no patient could hypoxemia be explained entirely by hypoventilation, and there was no obvious relationship between hypoxemic episodes and [hypoventilation]," said Dr. Krista Haines, a recent University of South Florida graduate now with the University of Nevada, Las Vegas, who presented the findings at the annual Academic Surgical Congress.

The mild hypoventilation by itself was "not clinically significant," leaving obstructive sleep apnea as the most likely cause of hypoxemia following bariatric surgery, Dr. Gallagher stated.

As far as the unexplained deaths go, Dr. Gallagher and his team believe that once patients desaturate, the mild narcotic-induced hypoventilation pushes a few of them over the edge, though no one died in the study.

Because sleep apnea is the likely root cause of such deaths, Dr. Gallagher recommends routine postoperative monitoring of bariatric surgery patients. "[Apneics] need to have their CPAP on" after surgery, especially when receiving narcotics, he said.

CPAP and postoperative monitoring are necessary until sleep apnea resolves, usually after a weight loss of 50-75 pounds. In his study, he noted that 14 patients had machines but still desaturated. Barring faulty gear or incorrect settings, that means the machines weren’t being used throughout the night.

He also pointed out the supplemental oxygen used in the study didn’t prevent hypercarbia or hypoxemia and seems to have no therapeutic role at this point.

In many places, sleep apnea screens, CPAP, and nighttime pulse oximetry are not the standard of care following bariatric surgery, Dr. Gallagher said.

Dr. Stefan Holubar, a colorectal surgeon and comoderator of the session, thinks that needs to change.

"The standard of care should include formal obstructive sleep apnea [screening] for all patients undergoing bariatric surgery, or they should all be empirically treated [with CPAP] regardless of whether or not they have the diagnosis," said Dr. Holubar of Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

"Although it’s a small pilot study, there are profound implications," he added.

The study "is a great start," said comoderator Dr. George Chang, a colorectal surgeon at that University of Texas at Houston. But the team needs to "demonstrate an association between unexplained deaths and these measures. You’d have to do a very large long-term study to see if those unexplained deaths go down."

Dr. Gallagher and his team are considering a randomized study to further investigate the issue, and they plan to include obese people having other kinds of operations.

Dr. Gallagher believes what the team has found thus far is "the tip of the iceberg."

Dr. Gallagher and Dr. Haines said they have no conflicts of interest. The study received no outside funding.

HUNTINGTON BEACH, CALIF. - Underrecognized and undertreated obstructive sleep apnea is the most likely cause of unexplained deaths following bariatric surgery, according to results of a small pilot study.

Because of that, continuous positive airway pressure (CPAP) and continuous pulse oximetry monitoring – with alarms to alert nursing staff to hypoxic episodes and rouse oxygen-desaturated patients from sleep – should be included in postoperative care, said Dr. Scott Gallagher, a bariatric surgeon at the University of South Florida, Tampa, where the study was conducted.

In previous work, the researchers found that severe, prolonged, and frequent arterial hypoxemia is common in sleeping bariatric surgery patients. They sought to determine why such patients – who seemed to be doing well after surgery – died suddenly in their sleep, without pulmonary embolism or any other obvious cause. In 15 gastric bypass patients monitored for 24 hours after surgery, they found that the average episode of hypoxemia lasted 21 minutes, and the longest for hours. Blood oxygen saturation fell as low as 60% (J. Surg. Res. 2010;159:622-6).

Right-to-left shunt, diminished inspired oxygen partial pressure, and other textbook explanations did not provide a rationale for the hypoxemia. Such causes "didn’t exist in these patients," Dr. Gallagher said.

That left either postoperative, narcotic-induced hypoventilation or obstructive sleep apnea as the most likely explanation. Narcotic pain control is common after bariatric surgery, as is sleep apnea.

Dr. Gallagher and his team measured carbon dioxide partial pressures transcutaneously (PtcCO₂) to gauge hypoventilation in 20 patients (14 female) during the first 24 hours after Roux-en-Y gastric bypass. Patients also wore blood oxygen saturation (SpO₂) ear-clip sensors.

Their mean body mass index was 54 kg/m², and 15 were diagnosed with obstructive sleep apnea. All were on postoperative narcotics.

As in the previous study, all the patients had multiple episodes of prolonged hypoxemia, with a mean of 191 episodes per patient lasting a mean of 1 minute.

Mean SpO₂ was 94%, and mean minimum SpO2 was 60%. Patients spent about 5% of their time (75 minutes) with SpO2 below 88%; hypoxemia lasted longer than 5 minutes in three patients.

All patients also had mild hypercarbia, suggesting mild, chronic hypoventilation.

They had a mean PtcCO₂ of 44 mmHg and a mean maximum of 56 mm Hg. The maximum PtcCO₂ value recorded in any patient was 75 mm Hg. Heart rates temporarily dropped below 50 bpm in 14 patients.

However, "in no patient could hypoxemia be explained entirely by hypoventilation, and there was no obvious relationship between hypoxemic episodes and [hypoventilation]," said Dr. Krista Haines, a recent University of South Florida graduate now with the University of Nevada, Las Vegas, who presented the findings at the annual Academic Surgical Congress.

The mild hypoventilation by itself was "not clinically significant," leaving obstructive sleep apnea as the most likely cause of hypoxemia following bariatric surgery, Dr. Gallagher stated.

As far as the unexplained deaths go, Dr. Gallagher and his team believe that once patients desaturate, the mild narcotic-induced hypoventilation pushes a few of them over the edge, though no one died in the study.

Because sleep apnea is the likely root cause of such deaths, Dr. Gallagher recommends routine postoperative monitoring of bariatric surgery patients. "[Apneics] need to have their CPAP on" after surgery, especially when receiving narcotics, he said.

CPAP and postoperative monitoring are necessary until sleep apnea resolves, usually after a weight loss of 50-75 pounds. In his study, he noted that 14 patients had machines but still desaturated. Barring faulty gear or incorrect settings, that means the machines weren’t being used throughout the night.

He also pointed out the supplemental oxygen used in the study didn’t prevent hypercarbia or hypoxemia and seems to have no therapeutic role at this point.

In many places, sleep apnea screens, CPAP, and nighttime pulse oximetry are not the standard of care following bariatric surgery, Dr. Gallagher said.

Dr. Stefan Holubar, a colorectal surgeon and comoderator of the session, thinks that needs to change.

"The standard of care should include formal obstructive sleep apnea [screening] for all patients undergoing bariatric surgery, or they should all be empirically treated [with CPAP] regardless of whether or not they have the diagnosis," said Dr. Holubar of Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

"Although it’s a small pilot study, there are profound implications," he added.

The study "is a great start," said comoderator Dr. George Chang, a colorectal surgeon at that University of Texas at Houston. But the team needs to "demonstrate an association between unexplained deaths and these measures. You’d have to do a very large long-term study to see if those unexplained deaths go down."

Dr. Gallagher and his team are considering a randomized study to further investigate the issue, and they plan to include obese people having other kinds of operations.

Dr. Gallagher believes what the team has found thus far is "the tip of the iceberg."

Dr. Gallagher and Dr. Haines said they have no conflicts of interest. The study received no outside funding.

HUNTINGTON BEACH, CALIF. - Underrecognized and undertreated obstructive sleep apnea is the most likely cause of unexplained deaths following bariatric surgery, according to results of a small pilot study.

Because of that, continuous positive airway pressure (CPAP) and continuous pulse oximetry monitoring – with alarms to alert nursing staff to hypoxic episodes and rouse oxygen-desaturated patients from sleep – should be included in postoperative care, said Dr. Scott Gallagher, a bariatric surgeon at the University of South Florida, Tampa, where the study was conducted.

In previous work, the researchers found that severe, prolonged, and frequent arterial hypoxemia is common in sleeping bariatric surgery patients. They sought to determine why such patients – who seemed to be doing well after surgery – died suddenly in their sleep, without pulmonary embolism or any other obvious cause. In 15 gastric bypass patients monitored for 24 hours after surgery, they found that the average episode of hypoxemia lasted 21 minutes, and the longest for hours. Blood oxygen saturation fell as low as 60% (J. Surg. Res. 2010;159:622-6).

Right-to-left shunt, diminished inspired oxygen partial pressure, and other textbook explanations did not provide a rationale for the hypoxemia. Such causes "didn’t exist in these patients," Dr. Gallagher said.

That left either postoperative, narcotic-induced hypoventilation or obstructive sleep apnea as the most likely explanation. Narcotic pain control is common after bariatric surgery, as is sleep apnea.

Dr. Gallagher and his team measured carbon dioxide partial pressures transcutaneously (PtcCO₂) to gauge hypoventilation in 20 patients (14 female) during the first 24 hours after Roux-en-Y gastric bypass. Patients also wore blood oxygen saturation (SpO₂) ear-clip sensors.

Their mean body mass index was 54 kg/m², and 15 were diagnosed with obstructive sleep apnea. All were on postoperative narcotics.

As in the previous study, all the patients had multiple episodes of prolonged hypoxemia, with a mean of 191 episodes per patient lasting a mean of 1 minute.

Mean SpO₂ was 94%, and mean minimum SpO2 was 60%. Patients spent about 5% of their time (75 minutes) with SpO2 below 88%; hypoxemia lasted longer than 5 minutes in three patients.

All patients also had mild hypercarbia, suggesting mild, chronic hypoventilation.

They had a mean PtcCO₂ of 44 mmHg and a mean maximum of 56 mm Hg. The maximum PtcCO₂ value recorded in any patient was 75 mm Hg. Heart rates temporarily dropped below 50 bpm in 14 patients.

However, "in no patient could hypoxemia be explained entirely by hypoventilation, and there was no obvious relationship between hypoxemic episodes and [hypoventilation]," said Dr. Krista Haines, a recent University of South Florida graduate now with the University of Nevada, Las Vegas, who presented the findings at the annual Academic Surgical Congress.

The mild hypoventilation by itself was "not clinically significant," leaving obstructive sleep apnea as the most likely cause of hypoxemia following bariatric surgery, Dr. Gallagher stated.

As far as the unexplained deaths go, Dr. Gallagher and his team believe that once patients desaturate, the mild narcotic-induced hypoventilation pushes a few of them over the edge, though no one died in the study.

Because sleep apnea is the likely root cause of such deaths, Dr. Gallagher recommends routine postoperative monitoring of bariatric surgery patients. "[Apneics] need to have their CPAP on" after surgery, especially when receiving narcotics, he said.

CPAP and postoperative monitoring are necessary until sleep apnea resolves, usually after a weight loss of 50-75 pounds. In his study, he noted that 14 patients had machines but still desaturated. Barring faulty gear or incorrect settings, that means the machines weren’t being used throughout the night.

He also pointed out the supplemental oxygen used in the study didn’t prevent hypercarbia or hypoxemia and seems to have no therapeutic role at this point.

In many places, sleep apnea screens, CPAP, and nighttime pulse oximetry are not the standard of care following bariatric surgery, Dr. Gallagher said.

Dr. Stefan Holubar, a colorectal surgeon and comoderator of the session, thinks that needs to change.

"The standard of care should include formal obstructive sleep apnea [screening] for all patients undergoing bariatric surgery, or they should all be empirically treated [with CPAP] regardless of whether or not they have the diagnosis," said Dr. Holubar of Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

"Although it’s a small pilot study, there are profound implications," he added.

The study "is a great start," said comoderator Dr. George Chang, a colorectal surgeon at that University of Texas at Houston. But the team needs to "demonstrate an association between unexplained deaths and these measures. You’d have to do a very large long-term study to see if those unexplained deaths go down."

Dr. Gallagher and his team are considering a randomized study to further investigate the issue, and they plan to include obese people having other kinds of operations.

Dr. Gallagher believes what the team has found thus far is "the tip of the iceberg."

Dr. Gallagher and Dr. Haines said they have no conflicts of interest. The study received no outside funding.

SEATTLE – After 2 years, a pilot medical home project in a Seattle suburb cut emergency department visits by 29% and hospitalizations by 6%, recouping $1.50 for every $1.00 invested.

“We thought it would take years to see savings,” but after 1 year, the pilot was “so successful that we've spread the model to all of our 26 primary care sites,” said Dr. Claire Trescott, primary care medical director at Group Health Cooperative, a nonprofit, Seattle-based health system.

Patients involved in the pilot reported better doctor interactions, better care, and increased access to care, compared with those at other Group Health clinics, Dr. Trescott reported at the symposium

Work-life improved for physicians, too. Compared with colleagues at other clinics, those in the pilot had lower mean emotional exhaustion and depersonalization scores on the Maslach Burnout Inventory.

This “experience demonstrates that primary care investments in the form of the medical home can improve patients' experiences … and providers' work environment, and at the same time save money,” said Dr. Robert Reid, an investigator with the Group Health Research Institute and lead author on a review of the project (Health Affairs 2010 May [doi: 10.1377/hlthaff.2010.0158]).

Group Health launched its medical home in 2007 at its Factoria, Wash., clinic. Managers “wanted to see if there really were savings and quality improvements from better primary care,” Dr. Reid said in an interview.

They also wanted to see if it would make the clinic a better place to work. The situation there had not been “favorable in terms of recruiting and sustaining the workforce,” Dr. Reid said.

Better staffing was the key change at Factoria. Managers hired additional physicians and nurses. They also hired more pharmacists, medical assistants, and licensed practical nurses, and increased their involvement in direct patient care. As a result, physician panels at Factoria dropped from 2,300 to 1,800 patients per doctor.

To deemphasize rapid patient turnover, Group Health eliminated productivity incentives for Factoria physicians.

Patients in the pilot were assigned to care teams; nurses, pharmacists, and other staff helped them manage their conditions with personalized care plans, medication monitoring, test result updates, chronic illness workshops, and other measures. When patients called the clinic, they were connected directly with their team, instead of having to struggle through a phone tree.

Daily, short, all-team meetings helped to coordinate the efforts, distribute tasks, and troubleshoot problems. To help with the planning, medical assistants called patients before each appointment to learn the reason for their visit.

The changes led to a drop in patient visits during the pilot, but visit duration went from a mean of 20 minutes up to 30.

There were also 80% more e-mail exchanges between patients and providers, and 5% more telephone encounters, compared with other those at Group Health sites.

To assess the results, Dr. Reid and his colleagues compared the utilization and cost numbers for Factoria's 7,018 continuously enrolled adults with those of the 200,970 adults enrolled at Group Health's other clinics.

Primary care cost $1.60 more per member per month in Factoria, and specialty care there approximately $5.80 more per member per month.

But Factoria patients visited emergency departments and urgent care clinics less often, saving $4 per member per month, and had fewer inpatient admissions, saving $14.18 per member per month. Balanced against increased staffing and other costs, Factoria saved an estimated $10.30 per member per month.

The pilot and review were both conducted by Group Health Cooperative. The investigators are employees and shareholders of Group Health Permanente, the physician group affiliated with the Group Health Cooperative.

SEATTLE – After 2 years, a pilot medical home project in a Seattle suburb cut emergency department visits by 29% and hospitalizations by 6%, recouping $1.50 for every $1.00 invested.

“We thought it would take years to see savings,” but after 1 year, the pilot was “so successful that we've spread the model to all of our 26 primary care sites,” said Dr. Claire Trescott, primary care medical director at Group Health Cooperative, a nonprofit, Seattle-based health system.

Patients involved in the pilot reported better doctor interactions, better care, and increased access to care, compared with those at other Group Health clinics, Dr. Trescott reported at the symposium

Work-life improved for physicians, too. Compared with colleagues at other clinics, those in the pilot had lower mean emotional exhaustion and depersonalization scores on the Maslach Burnout Inventory.

This “experience demonstrates that primary care investments in the form of the medical home can improve patients' experiences … and providers' work environment, and at the same time save money,” said Dr. Robert Reid, an investigator with the Group Health Research Institute and lead author on a review of the project (Health Affairs 2010 May [doi: 10.1377/hlthaff.2010.0158]).

Group Health launched its medical home in 2007 at its Factoria, Wash., clinic. Managers “wanted to see if there really were savings and quality improvements from better primary care,” Dr. Reid said in an interview.

They also wanted to see if it would make the clinic a better place to work. The situation there had not been “favorable in terms of recruiting and sustaining the workforce,” Dr. Reid said.

Better staffing was the key change at Factoria. Managers hired additional physicians and nurses. They also hired more pharmacists, medical assistants, and licensed practical nurses, and increased their involvement in direct patient care. As a result, physician panels at Factoria dropped from 2,300 to 1,800 patients per doctor.

To deemphasize rapid patient turnover, Group Health eliminated productivity incentives for Factoria physicians.

Patients in the pilot were assigned to care teams; nurses, pharmacists, and other staff helped them manage their conditions with personalized care plans, medication monitoring, test result updates, chronic illness workshops, and other measures. When patients called the clinic, they were connected directly with their team, instead of having to struggle through a phone tree.

Daily, short, all-team meetings helped to coordinate the efforts, distribute tasks, and troubleshoot problems. To help with the planning, medical assistants called patients before each appointment to learn the reason for their visit.

The changes led to a drop in patient visits during the pilot, but visit duration went from a mean of 20 minutes up to 30.

There were also 80% more e-mail exchanges between patients and providers, and 5% more telephone encounters, compared with other those at Group Health sites.

To assess the results, Dr. Reid and his colleagues compared the utilization and cost numbers for Factoria's 7,018 continuously enrolled adults with those of the 200,970 adults enrolled at Group Health's other clinics.

Primary care cost $1.60 more per member per month in Factoria, and specialty care there approximately $5.80 more per member per month.

But Factoria patients visited emergency departments and urgent care clinics less often, saving $4 per member per month, and had fewer inpatient admissions, saving $14.18 per member per month. Balanced against increased staffing and other costs, Factoria saved an estimated $10.30 per member per month.

The pilot and review were both conducted by Group Health Cooperative. The investigators are employees and shareholders of Group Health Permanente, the physician group affiliated with the Group Health Cooperative.

SEATTLE – After 2 years, a pilot medical home project in a Seattle suburb cut emergency department visits by 29% and hospitalizations by 6%, recouping $1.50 for every $1.00 invested.

“We thought it would take years to see savings,” but after 1 year, the pilot was “so successful that we've spread the model to all of our 26 primary care sites,” said Dr. Claire Trescott, primary care medical director at Group Health Cooperative, a nonprofit, Seattle-based health system.

Patients involved in the pilot reported better doctor interactions, better care, and increased access to care, compared with those at other Group Health clinics, Dr. Trescott reported at the symposium

Work-life improved for physicians, too. Compared with colleagues at other clinics, those in the pilot had lower mean emotional exhaustion and depersonalization scores on the Maslach Burnout Inventory.

This “experience demonstrates that primary care investments in the form of the medical home can improve patients' experiences … and providers' work environment, and at the same time save money,” said Dr. Robert Reid, an investigator with the Group Health Research Institute and lead author on a review of the project (Health Affairs 2010 May [doi: 10.1377/hlthaff.2010.0158]).

Group Health launched its medical home in 2007 at its Factoria, Wash., clinic. Managers “wanted to see if there really were savings and quality improvements from better primary care,” Dr. Reid said in an interview.

They also wanted to see if it would make the clinic a better place to work. The situation there had not been “favorable in terms of recruiting and sustaining the workforce,” Dr. Reid said.

Better staffing was the key change at Factoria. Managers hired additional physicians and nurses. They also hired more pharmacists, medical assistants, and licensed practical nurses, and increased their involvement in direct patient care. As a result, physician panels at Factoria dropped from 2,300 to 1,800 patients per doctor.

To deemphasize rapid patient turnover, Group Health eliminated productivity incentives for Factoria physicians.

Patients in the pilot were assigned to care teams; nurses, pharmacists, and other staff helped them manage their conditions with personalized care plans, medication monitoring, test result updates, chronic illness workshops, and other measures. When patients called the clinic, they were connected directly with their team, instead of having to struggle through a phone tree.

Daily, short, all-team meetings helped to coordinate the efforts, distribute tasks, and troubleshoot problems. To help with the planning, medical assistants called patients before each appointment to learn the reason for their visit.

The changes led to a drop in patient visits during the pilot, but visit duration went from a mean of 20 minutes up to 30.

There were also 80% more e-mail exchanges between patients and providers, and 5% more telephone encounters, compared with other those at Group Health sites.

To assess the results, Dr. Reid and his colleagues compared the utilization and cost numbers for Factoria's 7,018 continuously enrolled adults with those of the 200,970 adults enrolled at Group Health's other clinics.

Primary care cost $1.60 more per member per month in Factoria, and specialty care there approximately $5.80 more per member per month.

But Factoria patients visited emergency departments and urgent care clinics less often, saving $4 per member per month, and had fewer inpatient admissions, saving $14.18 per member per month. Balanced against increased staffing and other costs, Factoria saved an estimated $10.30 per member per month.

The pilot and review were both conducted by Group Health Cooperative. The investigators are employees and shareholders of Group Health Permanente, the physician group affiliated with the Group Health Cooperative.

SEATTLE – Home health care will increasingly replace hospital care, panelists said in a discussion of the phenomenon at the symposium.

They weren't just talking about lower-intensity care.

Panelist Dr. Bruce Leff and his colleagues at Johns Hopkins University in Baltimore are among those developing – and disseminating – the Hospital at Home care model.

It's about “true acute care,” he said, “taking someone from the emergency department [where a] physician has said 'this person needs to be admitted' ” for pneumonia, heart failure, chronic obstructive pulmonary disease, cellulitis, deep vein thrombosis, “and other things that people end up in the hospital for,” and treating that person at home.

The “best way this works is when the Hospital at Home is thought of as a virtual unit of the acute hospital. Recently, we've been partnering with proto-ACOs [accountable care organizations] that are very interested in this model,” said Dr. Leff, a Hopkins geriatrician and professor of medicine.

Several things are driving the trend, he and other panelists said. Payers want to cut costs by cutting hospital admissions. Hospital executives want to empty beds of patients on whom they lose money; patients generally prefer treatment at home; elderly patients usually do better there; and technology increasingly enables hospital-level home care, panelists said.

Hospitals are being built with fewer beds than they might have had a decade ago. A $1-billion high-tech tower being built at Johns Hopkins won't add any more beds to the campus, Dr. Leff noted.

Given the trend, if hospitals aren't thinking about how to focus on high-margin patients and effectively treat others in lower-cost settings, “they're dead; they're gone,” he said.

The trend toward home care has been embraced by one of the nation's largest health care companies, Louisville, Ky.–based Kindred Healthcare Inc., according to CEO Paul Diaz, also a panelist. “We are increasingly investing in home care because 40% of our discharges are going to home care” already. “That's where we see an opportunity for our patients and our shareholders,” he said.

He and others said they think technology will further the trend.

Panelist Diane Cook, Ph.D., a professor of electrical engineering, said she and her colleagues at Washington State University, Pullman, have rigged an apartment on campus with sensors (motion detectors, for instance, and stove-burner monitors) to see if the feedback accurately indicates how well patients – especially the elderly – perform day-to-day tasks, and if they need intervention. If the technology proves itself, it could reduce unnecessary home-health visits, saving providers time and money. Dr. Cook and her colleagues envision “a lightweight, simple package caregivers can purchase from Home Depot or Lowe's” that would be capable of remote, hospital-level monitoring. The idea is to empower patients to “do as much as they can at home and avoid leaving their personal space to get care,” she said.

Dr. Leff and his colleagues plan to pilot an adhesive strip–like sensor that could be used in the home. It “gives you everything you get in the ICU now, with 14 different probes and needles,” he said.

Hospital at Home is “a pretty intense intervention” that can include IV medications; oxygen and respiratory therapy; and x-rays, ultrasounds, and diagnostic labs, Dr. Leff said. Nursing assistants (“a relatively cheap” addition) can help with daily activities, he said.

“A hospital [will be] where you will go for brief, ultraspecialized, high-tech care,” he said.

Dr. Leff said he has no conflicts of interest. His research is supported in part by fees paid to Johns Hopkins for his consulting services. Dr. Cook said she did not have any disclosures.

For more information about Hospital at Home, visit www.hospitalathome.org/DGM/hah

SEATTLE – Home health care will increasingly replace hospital care, panelists said in a discussion of the phenomenon at the symposium.

They weren't just talking about lower-intensity care.

Panelist Dr. Bruce Leff and his colleagues at Johns Hopkins University in Baltimore are among those developing – and disseminating – the Hospital at Home care model.

It's about “true acute care,” he said, “taking someone from the emergency department [where a] physician has said 'this person needs to be admitted' ” for pneumonia, heart failure, chronic obstructive pulmonary disease, cellulitis, deep vein thrombosis, “and other things that people end up in the hospital for,” and treating that person at home.

The “best way this works is when the Hospital at Home is thought of as a virtual unit of the acute hospital. Recently, we've been partnering with proto-ACOs [accountable care organizations] that are very interested in this model,” said Dr. Leff, a Hopkins geriatrician and professor of medicine.

Several things are driving the trend, he and other panelists said. Payers want to cut costs by cutting hospital admissions. Hospital executives want to empty beds of patients on whom they lose money; patients generally prefer treatment at home; elderly patients usually do better there; and technology increasingly enables hospital-level home care, panelists said.

Hospitals are being built with fewer beds than they might have had a decade ago. A $1-billion high-tech tower being built at Johns Hopkins won't add any more beds to the campus, Dr. Leff noted.

Given the trend, if hospitals aren't thinking about how to focus on high-margin patients and effectively treat others in lower-cost settings, “they're dead; they're gone,” he said.

The trend toward home care has been embraced by one of the nation's largest health care companies, Louisville, Ky.–based Kindred Healthcare Inc., according to CEO Paul Diaz, also a panelist. “We are increasingly investing in home care because 40% of our discharges are going to home care” already. “That's where we see an opportunity for our patients and our shareholders,” he said.

He and others said they think technology will further the trend.

Panelist Diane Cook, Ph.D., a professor of electrical engineering, said she and her colleagues at Washington State University, Pullman, have rigged an apartment on campus with sensors (motion detectors, for instance, and stove-burner monitors) to see if the feedback accurately indicates how well patients – especially the elderly – perform day-to-day tasks, and if they need intervention. If the technology proves itself, it could reduce unnecessary home-health visits, saving providers time and money. Dr. Cook and her colleagues envision “a lightweight, simple package caregivers can purchase from Home Depot or Lowe's” that would be capable of remote, hospital-level monitoring. The idea is to empower patients to “do as much as they can at home and avoid leaving their personal space to get care,” she said.

Dr. Leff and his colleagues plan to pilot an adhesive strip–like sensor that could be used in the home. It “gives you everything you get in the ICU now, with 14 different probes and needles,” he said.

Hospital at Home is “a pretty intense intervention” that can include IV medications; oxygen and respiratory therapy; and x-rays, ultrasounds, and diagnostic labs, Dr. Leff said. Nursing assistants (“a relatively cheap” addition) can help with daily activities, he said.

“A hospital [will be] where you will go for brief, ultraspecialized, high-tech care,” he said.

Dr. Leff said he has no conflicts of interest. His research is supported in part by fees paid to Johns Hopkins for his consulting services. Dr. Cook said she did not have any disclosures.

For more information about Hospital at Home, visit www.hospitalathome.org/DGM/hah

SEATTLE – Home health care will increasingly replace hospital care, panelists said in a discussion of the phenomenon at the symposium.

They weren't just talking about lower-intensity care.

Panelist Dr. Bruce Leff and his colleagues at Johns Hopkins University in Baltimore are among those developing – and disseminating – the Hospital at Home care model.

It's about “true acute care,” he said, “taking someone from the emergency department [where a] physician has said 'this person needs to be admitted' ” for pneumonia, heart failure, chronic obstructive pulmonary disease, cellulitis, deep vein thrombosis, “and other things that people end up in the hospital for,” and treating that person at home.

The “best way this works is when the Hospital at Home is thought of as a virtual unit of the acute hospital. Recently, we've been partnering with proto-ACOs [accountable care organizations] that are very interested in this model,” said Dr. Leff, a Hopkins geriatrician and professor of medicine.

Several things are driving the trend, he and other panelists said. Payers want to cut costs by cutting hospital admissions. Hospital executives want to empty beds of patients on whom they lose money; patients generally prefer treatment at home; elderly patients usually do better there; and technology increasingly enables hospital-level home care, panelists said.

Hospitals are being built with fewer beds than they might have had a decade ago. A $1-billion high-tech tower being built at Johns Hopkins won't add any more beds to the campus, Dr. Leff noted.

Given the trend, if hospitals aren't thinking about how to focus on high-margin patients and effectively treat others in lower-cost settings, “they're dead; they're gone,” he said.

The trend toward home care has been embraced by one of the nation's largest health care companies, Louisville, Ky.–based Kindred Healthcare Inc., according to CEO Paul Diaz, also a panelist. “We are increasingly investing in home care because 40% of our discharges are going to home care” already. “That's where we see an opportunity for our patients and our shareholders,” he said.

He and others said they think technology will further the trend.

Panelist Diane Cook, Ph.D., a professor of electrical engineering, said she and her colleagues at Washington State University, Pullman, have rigged an apartment on campus with sensors (motion detectors, for instance, and stove-burner monitors) to see if the feedback accurately indicates how well patients – especially the elderly – perform day-to-day tasks, and if they need intervention. If the technology proves itself, it could reduce unnecessary home-health visits, saving providers time and money. Dr. Cook and her colleagues envision “a lightweight, simple package caregivers can purchase from Home Depot or Lowe's” that would be capable of remote, hospital-level monitoring. The idea is to empower patients to “do as much as they can at home and avoid leaving their personal space to get care,” she said.

Dr. Leff and his colleagues plan to pilot an adhesive strip–like sensor that could be used in the home. It “gives you everything you get in the ICU now, with 14 different probes and needles,” he said.

Hospital at Home is “a pretty intense intervention” that can include IV medications; oxygen and respiratory therapy; and x-rays, ultrasounds, and diagnostic labs, Dr. Leff said. Nursing assistants (“a relatively cheap” addition) can help with daily activities, he said.

“A hospital [will be] where you will go for brief, ultraspecialized, high-tech care,” he said.

Dr. Leff said he has no conflicts of interest. His research is supported in part by fees paid to Johns Hopkins for his consulting services. Dr. Cook said she did not have any disclosures.

For more information about Hospital at Home, visit www.hospitalathome.org/DGM/hah

LOS ANGELES – It's reasonable to consider the anticonvulsant valproate as a last option for women with bipolar disorder, given the drug's associations with the risk of developing isolated features of polycystic ovary syndrome, according to Dr. Harold Carlson.

“I don't have any problem with that,” he said, when an audience member suggested it and also noted the drug's teratogenicity.

Women under age 25, and particularly adolescents in their midteens, are most at risk for valproate-induced PCOS, usually within the first year of treatment, said Dr. Carlson, professor of endocrinology at Stony Brook (N.Y.) University.

In one study, 9 of 86 women with bipolar disorder (10.5%) treated with valproate developed PCOS; 2 of 144 women with bipolar disorder (1.4%) developed PCOS when treated with other mood stabilizers (Biol. Psychiatry 2006;59:1078-86).

Valproate seems to pose a particular risk for the condition driven by something more than the weight gain caused by the drug.

After all, “the folks [who] gain all that weight on olanzapine don't get PCOS,” Dr. Carlson noted.

Valproate appears to act directly on the ovaries, altering their hormone production. Cultured ovarian cells produce more testosterone in its presence. The excess testosterone shuts off menstruation, and causes acne and hirsutism. Obesity, insulin resistance, and dyslipidemia are problems in PCOS, as well.

When valproate cannot be switched out for a mood stabilizer, prescribing birth control pills at the start of therapy might be a smart move, Dr. Carlson said at the meeting, sponsored by the American Academy of Child and Adolescent Psychiatry. That appeared to help prevent PCOS in valproate-treated women in one study (Seizure 2003;12:323-9).

Baseline pelvic ultrasounds might seem like a good idea, too, but they're “not worth doing,” he said. The reason is that 10%–15% of healthy women have cysts on their ovaries without having PCOS, and ovarian cysts aren't always present in PCOS.

When women are started on the drug, ask them “every time you see them about their menstrual function. Look at them and see if they are getting acne and hirsutism. Ask them about it. Provide some counseling on diet and exercise to avoid the excessive weight gain, which only makes it worse,” Dr. Carlson said.

Should PCOS develop, Metformin is the first-line symptom treatment. Clomiphene can induce ovulation if pregnancy is the goal. Endocrinology, urology, or gynecology referrals also are in order to help with symptoms, he said.

Dr. Carlson said he is a consultant to Eli Lilly & Co., and has received research funding from GlaxoSmithKline.

Ask patients on valproate about their menstrual function. Look to see if they are getting acne and hirsutism.

Source DR. CARLSON

LOS ANGELES – It's reasonable to consider the anticonvulsant valproate as a last option for women with bipolar disorder, given the drug's associations with the risk of developing isolated features of polycystic ovary syndrome, according to Dr. Harold Carlson.

“I don't have any problem with that,” he said, when an audience member suggested it and also noted the drug's teratogenicity.

Women under age 25, and particularly adolescents in their midteens, are most at risk for valproate-induced PCOS, usually within the first year of treatment, said Dr. Carlson, professor of endocrinology at Stony Brook (N.Y.) University.

In one study, 9 of 86 women with bipolar disorder (10.5%) treated with valproate developed PCOS; 2 of 144 women with bipolar disorder (1.4%) developed PCOS when treated with other mood stabilizers (Biol. Psychiatry 2006;59:1078-86).

Valproate seems to pose a particular risk for the condition driven by something more than the weight gain caused by the drug.

After all, “the folks [who] gain all that weight on olanzapine don't get PCOS,” Dr. Carlson noted.

Valproate appears to act directly on the ovaries, altering their hormone production. Cultured ovarian cells produce more testosterone in its presence. The excess testosterone shuts off menstruation, and causes acne and hirsutism. Obesity, insulin resistance, and dyslipidemia are problems in PCOS, as well.

When valproate cannot be switched out for a mood stabilizer, prescribing birth control pills at the start of therapy might be a smart move, Dr. Carlson said at the meeting, sponsored by the American Academy of Child and Adolescent Psychiatry. That appeared to help prevent PCOS in valproate-treated women in one study (Seizure 2003;12:323-9).

Baseline pelvic ultrasounds might seem like a good idea, too, but they're “not worth doing,” he said. The reason is that 10%–15% of healthy women have cysts on their ovaries without having PCOS, and ovarian cysts aren't always present in PCOS.

When women are started on the drug, ask them “every time you see them about their menstrual function. Look at them and see if they are getting acne and hirsutism. Ask them about it. Provide some counseling on diet and exercise to avoid the excessive weight gain, which only makes it worse,” Dr. Carlson said.

Should PCOS develop, Metformin is the first-line symptom treatment. Clomiphene can induce ovulation if pregnancy is the goal. Endocrinology, urology, or gynecology referrals also are in order to help with symptoms, he said.

Dr. Carlson said he is a consultant to Eli Lilly & Co., and has received research funding from GlaxoSmithKline.

Ask patients on valproate about their menstrual function. Look to see if they are getting acne and hirsutism.

Source DR. CARLSON

LOS ANGELES – It's reasonable to consider the anticonvulsant valproate as a last option for women with bipolar disorder, given the drug's associations with the risk of developing isolated features of polycystic ovary syndrome, according to Dr. Harold Carlson.

“I don't have any problem with that,” he said, when an audience member suggested it and also noted the drug's teratogenicity.

Women under age 25, and particularly adolescents in their midteens, are most at risk for valproate-induced PCOS, usually within the first year of treatment, said Dr. Carlson, professor of endocrinology at Stony Brook (N.Y.) University.

In one study, 9 of 86 women with bipolar disorder (10.5%) treated with valproate developed PCOS; 2 of 144 women with bipolar disorder (1.4%) developed PCOS when treated with other mood stabilizers (Biol. Psychiatry 2006;59:1078-86).

Valproate seems to pose a particular risk for the condition driven by something more than the weight gain caused by the drug.

After all, “the folks [who] gain all that weight on olanzapine don't get PCOS,” Dr. Carlson noted.

Valproate appears to act directly on the ovaries, altering their hormone production. Cultured ovarian cells produce more testosterone in its presence. The excess testosterone shuts off menstruation, and causes acne and hirsutism. Obesity, insulin resistance, and dyslipidemia are problems in PCOS, as well.

When valproate cannot be switched out for a mood stabilizer, prescribing birth control pills at the start of therapy might be a smart move, Dr. Carlson said at the meeting, sponsored by the American Academy of Child and Adolescent Psychiatry. That appeared to help prevent PCOS in valproate-treated women in one study (Seizure 2003;12:323-9).

Baseline pelvic ultrasounds might seem like a good idea, too, but they're “not worth doing,” he said. The reason is that 10%–15% of healthy women have cysts on their ovaries without having PCOS, and ovarian cysts aren't always present in PCOS.

When women are started on the drug, ask them “every time you see them about their menstrual function. Look at them and see if they are getting acne and hirsutism. Ask them about it. Provide some counseling on diet and exercise to avoid the excessive weight gain, which only makes it worse,” Dr. Carlson said.

Should PCOS develop, Metformin is the first-line symptom treatment. Clomiphene can induce ovulation if pregnancy is the goal. Endocrinology, urology, or gynecology referrals also are in order to help with symptoms, he said.

Dr. Carlson said he is a consultant to Eli Lilly & Co., and has received research funding from GlaxoSmithKline.

Ask patients on valproate about their menstrual function. Look to see if they are getting acne and hirsutism.

Source DR. CARLSON

SEATTLE – Home health care will increasingly replace hospital care, panelists said during a discussion of the phenomenon at the symposium.

They weren't just talking about lower-intensity care, either. Consider the work of panelist Dr. Bruce Leff and his colleagues at Johns Hopkins University in Baltimore, who are among those developing and disseminating the “Hospital at Home” care model. It's about “true acute care,” he said, “taking someone from the emergency department [where a] physician has said 'this person needs to be admitted' ” and treating that person at home. The “best way this works is when the 'Hospital at Home' is thought of as a virtual unit of the acute hospital. Recently, we've been partnering with proto-ACOs [accountable care organizations] that are very interested in this model,” said Dr. Leff, a Hopkins geriatrician.

Several things are driving the trend. First, payers are looking to cut costs by cutting hospital admissions. Also, hospital executives want to empty their beds of patients on whom they lose money; patients generally prefer treatment at home; elderly patients usually do better there; and technology increasingly enables hospital-level home care, panelists said. Hospitals are already being built with fewer beds than they might have had a decade ago. A $1 billion high-tech tower being built at Johns Hopkins won't add any more beds to the campus, Dr. Leff noted.

Given the trend, if hospitals aren't thinking about how to focus on high-margin patients and effectively treat others in lower-cost settings, “they're dead; they're gone,” he said.

The trend toward home care has been embraced by one of the nation's largest health care companies, Louisville, Ky.–based Kindred Healthcare Inc., according to CEO Paul Diaz, also a panelist. “We are increasingly investing in home care because 40% of our discharges are going to home care” already.

He and others said they think technology will further the trend. Diane Cook, Ph.D., a professor of electrical engineering who was also a panelist, gave an example of what could be coming soon. She and her colleagues at Washington State University, Pullman, have rigged an apartment on campus with sensors (motion detectors, for instance, and stove-burner monitors) to see if the feedback accurately indicates how well patients – especially the elderly – perform day-to-day tasks, and if they need intervention. If the technology proves itself, it could reduce unnecessary home-health visits, saving providers time and money.

Dr. Cook and her colleagues ultimately envision “a lightweight, simple package caregivers can purchase from Home Depot or Lowe's” that would be capable of remote, hospital-level monitoring. The idea is to empower patients to “do as much as they can at home,” she said.

Meanwhile, Dr. Leff and his colleagues are planning to pilot an adhesive strip–like sensor that could be used in the home. It “gives you everything you get in the ICU now, with 14 different probes and needles,” he said. “Hospital at Home” is already “a pretty intense intervention” that can include IV medications; oxygen and respiratory therapy; and x-rays, ultrasounds, and diagnostic labs, among other things, Dr. Leff said.

Dr. Leff said he has no personal conflicts of interest. His research is supported in part by fees paid to Johns Hopkins for his consulting services. Dr. Cook said she did not currently have any disclosures.

For more information about “Hospital at Home,” visit www.hospitalathome.org/DGM/hah

The 'Hospital at Home' works best when it's thought of as a virtual unit of the acute hospital.

Source DR. LEFF

SEATTLE – Home health care will increasingly replace hospital care, panelists said during a discussion of the phenomenon at the symposium.

They weren't just talking about lower-intensity care, either. Consider the work of panelist Dr. Bruce Leff and his colleagues at Johns Hopkins University in Baltimore, who are among those developing and disseminating the “Hospital at Home” care model. It's about “true acute care,” he said, “taking someone from the emergency department [where a] physician has said 'this person needs to be admitted' ” and treating that person at home. The “best way this works is when the 'Hospital at Home' is thought of as a virtual unit of the acute hospital. Recently, we've been partnering with proto-ACOs [accountable care organizations] that are very interested in this model,” said Dr. Leff, a Hopkins geriatrician.

Several things are driving the trend. First, payers are looking to cut costs by cutting hospital admissions. Also, hospital executives want to empty their beds of patients on whom they lose money; patients generally prefer treatment at home; elderly patients usually do better there; and technology increasingly enables hospital-level home care, panelists said. Hospitals are already being built with fewer beds than they might have had a decade ago. A $1 billion high-tech tower being built at Johns Hopkins won't add any more beds to the campus, Dr. Leff noted.

Given the trend, if hospitals aren't thinking about how to focus on high-margin patients and effectively treat others in lower-cost settings, “they're dead; they're gone,” he said.

The trend toward home care has been embraced by one of the nation's largest health care companies, Louisville, Ky.–based Kindred Healthcare Inc., according to CEO Paul Diaz, also a panelist. “We are increasingly investing in home care because 40% of our discharges are going to home care” already.

He and others said they think technology will further the trend. Diane Cook, Ph.D., a professor of electrical engineering who was also a panelist, gave an example of what could be coming soon. She and her colleagues at Washington State University, Pullman, have rigged an apartment on campus with sensors (motion detectors, for instance, and stove-burner monitors) to see if the feedback accurately indicates how well patients – especially the elderly – perform day-to-day tasks, and if they need intervention. If the technology proves itself, it could reduce unnecessary home-health visits, saving providers time and money.

Dr. Cook and her colleagues ultimately envision “a lightweight, simple package caregivers can purchase from Home Depot or Lowe's” that would be capable of remote, hospital-level monitoring. The idea is to empower patients to “do as much as they can at home,” she said.

Meanwhile, Dr. Leff and his colleagues are planning to pilot an adhesive strip–like sensor that could be used in the home. It “gives you everything you get in the ICU now, with 14 different probes and needles,” he said. “Hospital at Home” is already “a pretty intense intervention” that can include IV medications; oxygen and respiratory therapy; and x-rays, ultrasounds, and diagnostic labs, among other things, Dr. Leff said.

Dr. Leff said he has no personal conflicts of interest. His research is supported in part by fees paid to Johns Hopkins for his consulting services. Dr. Cook said she did not currently have any disclosures.

For more information about “Hospital at Home,” visit www.hospitalathome.org/DGM/hah

The 'Hospital at Home' works best when it's thought of as a virtual unit of the acute hospital.

Source DR. LEFF

SEATTLE – Home health care will increasingly replace hospital care, panelists said during a discussion of the phenomenon at the symposium.

They weren't just talking about lower-intensity care, either. Consider the work of panelist Dr. Bruce Leff and his colleagues at Johns Hopkins University in Baltimore, who are among those developing and disseminating the “Hospital at Home” care model. It's about “true acute care,” he said, “taking someone from the emergency department [where a] physician has said 'this person needs to be admitted' ” and treating that person at home. The “best way this works is when the 'Hospital at Home' is thought of as a virtual unit of the acute hospital. Recently, we've been partnering with proto-ACOs [accountable care organizations] that are very interested in this model,” said Dr. Leff, a Hopkins geriatrician.

Several things are driving the trend. First, payers are looking to cut costs by cutting hospital admissions. Also, hospital executives want to empty their beds of patients on whom they lose money; patients generally prefer treatment at home; elderly patients usually do better there; and technology increasingly enables hospital-level home care, panelists said. Hospitals are already being built with fewer beds than they might have had a decade ago. A $1 billion high-tech tower being built at Johns Hopkins won't add any more beds to the campus, Dr. Leff noted.

Given the trend, if hospitals aren't thinking about how to focus on high-margin patients and effectively treat others in lower-cost settings, “they're dead; they're gone,” he said.

The trend toward home care has been embraced by one of the nation's largest health care companies, Louisville, Ky.–based Kindred Healthcare Inc., according to CEO Paul Diaz, also a panelist. “We are increasingly investing in home care because 40% of our discharges are going to home care” already.

He and others said they think technology will further the trend. Diane Cook, Ph.D., a professor of electrical engineering who was also a panelist, gave an example of what could be coming soon. She and her colleagues at Washington State University, Pullman, have rigged an apartment on campus with sensors (motion detectors, for instance, and stove-burner monitors) to see if the feedback accurately indicates how well patients – especially the elderly – perform day-to-day tasks, and if they need intervention. If the technology proves itself, it could reduce unnecessary home-health visits, saving providers time and money.

Dr. Cook and her colleagues ultimately envision “a lightweight, simple package caregivers can purchase from Home Depot or Lowe's” that would be capable of remote, hospital-level monitoring. The idea is to empower patients to “do as much as they can at home,” she said.

Meanwhile, Dr. Leff and his colleagues are planning to pilot an adhesive strip–like sensor that could be used in the home. It “gives you everything you get in the ICU now, with 14 different probes and needles,” he said. “Hospital at Home” is already “a pretty intense intervention” that can include IV medications; oxygen and respiratory therapy; and x-rays, ultrasounds, and diagnostic labs, among other things, Dr. Leff said.

Dr. Leff said he has no personal conflicts of interest. His research is supported in part by fees paid to Johns Hopkins for his consulting services. Dr. Cook said she did not currently have any disclosures.

For more information about “Hospital at Home,” visit www.hospitalathome.org/DGM/hah

The 'Hospital at Home' works best when it's thought of as a virtual unit of the acute hospital.

Source DR. LEFF

HUNTINGTON BEACH, CALIF. – Three things have been found to be strong predictors of whether a patient will develop post-traumatic stress disorder following physical trauma, Medical College of Wisconsin, Milwaukee, researchers reported.

Patients are more likely to develop PTSD if they were victims of violence; if they perceive they were grievously injured, regardless of their injury severity score; and if they think they were almost killed, whether that’s true or not.

The researchers used surveys to determine what factors predict PTSD in trauma patients, fourth-year medical student Jessica Anderson said when she presented the findings at the Academic Surgical Conference, which was sponsored by the Association for Academic Surgery and the Society of University Surgeons.

Within about 72 hours of admission, 403 trauma patients completed the 17-question Post-Traumatic Stress Disorder checklist (pdf) and the Short Form-36 – a quality of life survey that assesses mental and physical function; 129 filled out the forms when requested to do so 6 months later.

A previous study found severe PTSD symptoms in 22.5% of patients admitted to the trauma service; in the new study, 18.6% of the 6-month respondents had checklist scores above 44, indicating PTSD.

Victims of violence – shootings, stabbings, or assaults – had mean 6-month checklist scores of 45.79; mean score for accident victims was 32.27 (P = .005).

Higher PTSD scores correlated with lower quality-of-life scores. Assault victims also scored lower on mental functioning at 6 months (P = .001).

"The variables that were statistically significant in predicting PTSD severity at 6 months included assaultive type of mechanism, scene heart rate, perceived injury severity score, and perceived life threat," Ms. Anderson said.

Age and gender were not predictive. On multiple regression analysis, scene heart rate was no longer significant.

Such studies of PTSD in trauma patients are relatively new, said Dr. Karen Brasel, a surgery professor at the college and a trauma surgeon at its associated Froedtert Memorial Lutheran Hospital, also in Milwaukee.

These three factors have been identified before among military personnel and domestic violence victims, but they appear to apply to other trauma victims, as well, she said.

"People don’t really think about PTSD in relation to garden-variety car crashes or getting stabbed in a gang fight," said Dr. Brasel, who is helping to lead efforts at the hospital to address PTSD in trauma patients.

Although nothing can be done about the injury mechanism, the other two contributing factors – the perceptions about injury severity and death risk – may be amenable to cognitive-behavioral therapy (CBT).

Patients admitted to the hospital’s level 1 trauma center are screened as soon as possible for PTSD symptoms with the civilian version of the PTSD Checklist.

Those who score above 44, indicating severe PTSD symptoms, are referred to psychologist Terri deRoon Cassini, Ph.D., who begins to work with them to mitigate PTSD symptoms, and continues to do so after they are discharged.

Since joining the trauma team in September 2008, Dr. deRoon Cassini has used CBT to halt possible PTSD for several hundred assault victims and survivors of car crashes and other accidents. The CBT approach involves disengaging the memory of the event from the autonomic response to it, as it’s the hyperactivated fight-or-flight response that creates and maintains the panic attacks, nightmares, flashbacks, and other PTSD symptoms that make return to a normal quality of life difficult.

Patients tell Dr. deRoon Cassini their stories over and over again; with each retelling, the autonomic response fades. Eventually, the trauma becomes just another memory, not something the body relives 24 hours a day.

"A lot of times people will say, ‘I’m having flashbacks, I’m having nightmares, I’m going crazy. I keep seeing the car flipping over and over and over again. I keep hearing the gun go off,’ " she said.

After the conditioned response is broken through CBT, she helps patients "process what happened and restructure their cognitive perceptions," she said. Eventually they realize "that was really scary, but it’s over," said Dr. deRoon Cassini.

A randomized trial is planned to measure the success of that approach, Dr. Brasel said. In the planned trial, half of newly admitted high scorers on the PTSD checklist will be randomized to CBT, half to no treatment.

They’ll be followed to assess rates of PTSD development, a diagnosis that requires symptoms be present at least 1 month, with the goal of finding out if early intervention helps.

The trial will include salivary cortisol measurements and possibly functional MRI, Dr. Brasel said.

Dr. Brasel, Dr. deRoon Cassini, and Ms. Anderson said they have no conflicts of interest.

The PTSD risk factor study was funded in part by a Centers for Disease Control and Prevention grant to the college’s Injury Research Center. The study was done not only to figure out how to best help patients after physical trauma, but also "to provide evidence to the funding agencies that this is truly an important thing to investigate," Dr. Brasel said.

The researchers said they had no conflicts of interest.

HUNTINGTON BEACH, CALIF. – Three things have been found to be strong predictors of whether a patient will develop post-traumatic stress disorder following physical trauma, Medical College of Wisconsin, Milwaukee, researchers reported.

Patients are more likely to develop PTSD if they were victims of violence; if they perceive they were grievously injured, regardless of their injury severity score; and if they think they were almost killed, whether that’s true or not.

The researchers used surveys to determine what factors predict PTSD in trauma patients, fourth-year medical student Jessica Anderson said when she presented the findings at the Academic Surgical Conference, which was sponsored by the Association for Academic Surgery and the Society of University Surgeons.

Within about 72 hours of admission, 403 trauma patients completed the 17-question Post-Traumatic Stress Disorder checklist (pdf) and the Short Form-36 – a quality of life survey that assesses mental and physical function; 129 filled out the forms when requested to do so 6 months later.

A previous study found severe PTSD symptoms in 22.5% of patients admitted to the trauma service; in the new study, 18.6% of the 6-month respondents had checklist scores above 44, indicating PTSD.

Victims of violence – shootings, stabbings, or assaults – had mean 6-month checklist scores of 45.79; mean score for accident victims was 32.27 (P = .005).

Higher PTSD scores correlated with lower quality-of-life scores. Assault victims also scored lower on mental functioning at 6 months (P = .001).

"The variables that were statistically significant in predicting PTSD severity at 6 months included assaultive type of mechanism, scene heart rate, perceived injury severity score, and perceived life threat," Ms. Anderson said.

Age and gender were not predictive. On multiple regression analysis, scene heart rate was no longer significant.

Such studies of PTSD in trauma patients are relatively new, said Dr. Karen Brasel, a surgery professor at the college and a trauma surgeon at its associated Froedtert Memorial Lutheran Hospital, also in Milwaukee.

These three factors have been identified before among military personnel and domestic violence victims, but they appear to apply to other trauma victims, as well, she said.

"People don’t really think about PTSD in relation to garden-variety car crashes or getting stabbed in a gang fight," said Dr. Brasel, who is helping to lead efforts at the hospital to address PTSD in trauma patients.

Although nothing can be done about the injury mechanism, the other two contributing factors – the perceptions about injury severity and death risk – may be amenable to cognitive-behavioral therapy (CBT).

Patients admitted to the hospital’s level 1 trauma center are screened as soon as possible for PTSD symptoms with the civilian version of the PTSD Checklist.

Those who score above 44, indicating severe PTSD symptoms, are referred to psychologist Terri deRoon Cassini, Ph.D., who begins to work with them to mitigate PTSD symptoms, and continues to do so after they are discharged.

Since joining the trauma team in September 2008, Dr. deRoon Cassini has used CBT to halt possible PTSD for several hundred assault victims and survivors of car crashes and other accidents. The CBT approach involves disengaging the memory of the event from the autonomic response to it, as it’s the hyperactivated fight-or-flight response that creates and maintains the panic attacks, nightmares, flashbacks, and other PTSD symptoms that make return to a normal quality of life difficult.

Patients tell Dr. deRoon Cassini their stories over and over again; with each retelling, the autonomic response fades. Eventually, the trauma becomes just another memory, not something the body relives 24 hours a day.

"A lot of times people will say, ‘I’m having flashbacks, I’m having nightmares, I’m going crazy. I keep seeing the car flipping over and over and over again. I keep hearing the gun go off,’ " she said.

After the conditioned response is broken through CBT, she helps patients "process what happened and restructure their cognitive perceptions," she said. Eventually they realize "that was really scary, but it’s over," said Dr. deRoon Cassini.

A randomized trial is planned to measure the success of that approach, Dr. Brasel said. In the planned trial, half of newly admitted high scorers on the PTSD checklist will be randomized to CBT, half to no treatment.

They’ll be followed to assess rates of PTSD development, a diagnosis that requires symptoms be present at least 1 month, with the goal of finding out if early intervention helps.

The trial will include salivary cortisol measurements and possibly functional MRI, Dr. Brasel said.

Dr. Brasel, Dr. deRoon Cassini, and Ms. Anderson said they have no conflicts of interest.

The PTSD risk factor study was funded in part by a Centers for Disease Control and Prevention grant to the college’s Injury Research Center. The study was done not only to figure out how to best help patients after physical trauma, but also "to provide evidence to the funding agencies that this is truly an important thing to investigate," Dr. Brasel said.

The researchers said they had no conflicts of interest.

HUNTINGTON BEACH, CALIF. – Three things have been found to be strong predictors of whether a patient will develop post-traumatic stress disorder following physical trauma, Medical College of Wisconsin, Milwaukee, researchers reported.

Patients are more likely to develop PTSD if they were victims of violence; if they perceive they were grievously injured, regardless of their injury severity score; and if they think they were almost killed, whether that’s true or not.

The researchers used surveys to determine what factors predict PTSD in trauma patients, fourth-year medical student Jessica Anderson said when she presented the findings at the Academic Surgical Conference, which was sponsored by the Association for Academic Surgery and the Society of University Surgeons.

Within about 72 hours of admission, 403 trauma patients completed the 17-question Post-Traumatic Stress Disorder checklist (pdf) and the Short Form-36 – a quality of life survey that assesses mental and physical function; 129 filled out the forms when requested to do so 6 months later.

A previous study found severe PTSD symptoms in 22.5% of patients admitted to the trauma service; in the new study, 18.6% of the 6-month respondents had checklist scores above 44, indicating PTSD.

Victims of violence – shootings, stabbings, or assaults – had mean 6-month checklist scores of 45.79; mean score for accident victims was 32.27 (P = .005).

Higher PTSD scores correlated with lower quality-of-life scores. Assault victims also scored lower on mental functioning at 6 months (P = .001).

"The variables that were statistically significant in predicting PTSD severity at 6 months included assaultive type of mechanism, scene heart rate, perceived injury severity score, and perceived life threat," Ms. Anderson said.

Age and gender were not predictive. On multiple regression analysis, scene heart rate was no longer significant.

Such studies of PTSD in trauma patients are relatively new, said Dr. Karen Brasel, a surgery professor at the college and a trauma surgeon at its associated Froedtert Memorial Lutheran Hospital, also in Milwaukee.

These three factors have been identified before among military personnel and domestic violence victims, but they appear to apply to other trauma victims, as well, she said.

"People don’t really think about PTSD in relation to garden-variety car crashes or getting stabbed in a gang fight," said Dr. Brasel, who is helping to lead efforts at the hospital to address PTSD in trauma patients.

Although nothing can be done about the injury mechanism, the other two contributing factors – the perceptions about injury severity and death risk – may be amenable to cognitive-behavioral therapy (CBT).

Patients admitted to the hospital’s level 1 trauma center are screened as soon as possible for PTSD symptoms with the civilian version of the PTSD Checklist.

Those who score above 44, indicating severe PTSD symptoms, are referred to psychologist Terri deRoon Cassini, Ph.D., who begins to work with them to mitigate PTSD symptoms, and continues to do so after they are discharged.

Since joining the trauma team in September 2008, Dr. deRoon Cassini has used CBT to halt possible PTSD for several hundred assault victims and survivors of car crashes and other accidents. The CBT approach involves disengaging the memory of the event from the autonomic response to it, as it’s the hyperactivated fight-or-flight response that creates and maintains the panic attacks, nightmares, flashbacks, and other PTSD symptoms that make return to a normal quality of life difficult.

Patients tell Dr. deRoon Cassini their stories over and over again; with each retelling, the autonomic response fades. Eventually, the trauma becomes just another memory, not something the body relives 24 hours a day.

"A lot of times people will say, ‘I’m having flashbacks, I’m having nightmares, I’m going crazy. I keep seeing the car flipping over and over and over again. I keep hearing the gun go off,’ " she said.

After the conditioned response is broken through CBT, she helps patients "process what happened and restructure their cognitive perceptions," she said. Eventually they realize "that was really scary, but it’s over," said Dr. deRoon Cassini.

A randomized trial is planned to measure the success of that approach, Dr. Brasel said. In the planned trial, half of newly admitted high scorers on the PTSD checklist will be randomized to CBT, half to no treatment.

They’ll be followed to assess rates of PTSD development, a diagnosis that requires symptoms be present at least 1 month, with the goal of finding out if early intervention helps.

The trial will include salivary cortisol measurements and possibly functional MRI, Dr. Brasel said.

Dr. Brasel, Dr. deRoon Cassini, and Ms. Anderson said they have no conflicts of interest.

The PTSD risk factor study was funded in part by a Centers for Disease Control and Prevention grant to the college’s Injury Research Center. The study was done not only to figure out how to best help patients after physical trauma, but also "to provide evidence to the funding agencies that this is truly an important thing to investigate," Dr. Brasel said.

The researchers said they had no conflicts of interest.

HUNTINGTON BEACH, CALIF. – Three things have been found to be strong predictors of whether a patient will develop post-traumatic stress disorder following physical trauma, Medical College of Wisconsin, Milwaukee, researchers reported.

Patients are more likely to develop PTSD if they were victims of violence; if they perceive they were grievously injured, regardless of their injury severity score; and if they think they were almost killed, whether that’s true or not.

The researchers used surveys to determine what factors predict PTSD in trauma patients, fourth-year medical student Jessica Anderson said when she presented the findings at the Academic Surgical Conference, which was sponsored by the Association for Academic Surgery and the Society of University Surgeons.

Within about 72 hours of admission, 403 trauma patients completed the 17-question Post-Traumatic Stress Disorder checklist (pdf) and the Short Form-36 – a quality of life survey that assesses mental and physical function; 129 filled out the forms when requested to do so 6 months later.

A previous study found severe PTSD symptoms in 22.5% of patients admitted to the trauma service; in the new study, 18.6% of the 6-month respondents had checklist scores above 44, indicating PTSD.

Victims of violence – shootings, stabbings, or assaults – had mean 6-month checklist scores of 45.79; mean score for accident victims was 32.27 (P = .005).

Higher PTSD scores correlated with lower quality-of-life scores. Assault victims also scored lower on mental functioning at 6 months (P = .001).

"The variables that were statistically significant in predicting PTSD severity at 6 months included assaultive type of mechanism, scene heart rate, perceived injury severity score, and perceived life threat," Ms. Anderson said.

Age and gender were not predictive. On multiple regression analysis, scene heart rate was no longer significant.

Such studies of PTSD in trauma patients are relatively new, said Dr. Karen Brasel, a surgery professor at the college and a trauma surgeon at its associated Froedtert Memorial Lutheran Hospital, also in Milwaukee.

These three factors have been identified before among military personnel and domestic violence victims, but they appear to apply to other trauma victims, as well, she said.

"People don’t really think about PTSD in relation to garden-variety car crashes or getting stabbed in a gang fight," said Dr. Brasel, who is helping to lead efforts at the hospital to address PTSD in trauma patients.

Although nothing can be done about the injury mechanism, the other two contributing factors – the perceptions about injury severity and death risk – may be amenable to cognitive-behavioral therapy (CBT).

Patients admitted to the hospital’s level 1 trauma center are screened as soon as possible for PTSD symptoms with the civilian version of the PTSD Checklist.

Those who score above 44, indicating severe PTSD symptoms, are referred to psychologist Terri deRoon Cassini, Ph.D., who begins to work with them to mitigate PTSD symptoms, and continues to do so after they are discharged.

Since joining the trauma team in September 2008, Dr. deRoon Cassini has used CBT to halt possible PTSD for several hundred assault victims and survivors of car crashes and other accidents. The CBT approach involves disengaging the memory of the event from the autonomic response to it, as it’s the hyperactivated fight-or-flight response that creates and maintains the panic attacks, nightmares, flashbacks, and other PTSD symptoms that make return to a normal quality of life difficult.

Patients tell Dr. deRoon Cassini their stories over and over again; with each retelling, the autonomic response fades. Eventually, the trauma becomes just another memory, not something the body relives 24 hours a day.

"A lot of times people will say, ‘I’m having flashbacks, I’m having nightmares, I’m going crazy. I keep seeing the car flipping over and over and over again. I keep hearing the gun go off,’ " she said.

After the conditioned response is broken through CBT, she helps patients "process what happened and restructure their cognitive perceptions," she said. Eventually they realize "that was really scary, but it’s over," said Dr. deRoon Cassini.

A randomized trial is planned to measure the success of that approach, Dr. Brasel said. In the planned trial, half of newly admitted high scorers on the PTSD checklist will be randomized to CBT, half to no treatment.

They’ll be followed to assess rates of PTSD development, a diagnosis that requires symptoms be present at least 1 month, with the goal of finding out if early intervention helps.

The trial will include salivary cortisol measurements and possibly functional MRI, Dr. Brasel said.

Dr. Brasel, Dr. deRoon Cassini, and Ms. Anderson said they have no conflicts of interest.

The PTSD risk factor study was funded in part by a Centers for Disease Control and Prevention grant to the college’s Injury Research Center. The study was done not only to figure out how to best help patients after physical trauma, but also "to provide evidence to the funding agencies that this is truly an important thing to investigate," Dr. Brasel said.

The researchers said they had no conflicts of interest.

HUNTINGTON BEACH, CALIF. – Three things have been found to be strong predictors of whether a patient will develop post-traumatic stress disorder following physical trauma, Medical College of Wisconsin, Milwaukee, researchers reported.

Patients are more likely to develop PTSD if they were victims of violence; if they perceive they were grievously injured, regardless of their injury severity score; and if they think they were almost killed, whether that’s true or not.

The researchers used surveys to determine what factors predict PTSD in trauma patients, fourth-year medical student Jessica Anderson said when she presented the findings at the Academic Surgical Conference, which was sponsored by the Association for Academic Surgery and the Society of University Surgeons.

Within about 72 hours of admission, 403 trauma patients completed the 17-question Post-Traumatic Stress Disorder checklist (pdf) and the Short Form-36 – a quality of life survey that assesses mental and physical function; 129 filled out the forms when requested to do so 6 months later.

A previous study found severe PTSD symptoms in 22.5% of patients admitted to the trauma service; in the new study, 18.6% of the 6-month respondents had checklist scores above 44, indicating PTSD.

Victims of violence – shootings, stabbings, or assaults – had mean 6-month checklist scores of 45.79; mean score for accident victims was 32.27 (P = .005).

Higher PTSD scores correlated with lower quality-of-life scores. Assault victims also scored lower on mental functioning at 6 months (P = .001).

"The variables that were statistically significant in predicting PTSD severity at 6 months included assaultive type of mechanism, scene heart rate, perceived injury severity score, and perceived life threat," Ms. Anderson said.

Age and gender were not predictive. On multiple regression analysis, scene heart rate was no longer significant.

Such studies of PTSD in trauma patients are relatively new, said Dr. Karen Brasel, a surgery professor at the college and a trauma surgeon at its associated Froedtert Memorial Lutheran Hospital, also in Milwaukee.

These three factors have been identified before among military personnel and domestic violence victims, but they appear to apply to other trauma victims, as well, she said.

"People don’t really think about PTSD in relation to garden-variety car crashes or getting stabbed in a gang fight," said Dr. Brasel, who is helping to lead efforts at the hospital to address PTSD in trauma patients.

Although nothing can be done about the injury mechanism, the other two contributing factors – the perceptions about injury severity and death risk – may be amenable to cognitive-behavioral therapy (CBT).

Patients admitted to the hospital’s level 1 trauma center are screened as soon as possible for PTSD symptoms with the civilian version of the PTSD Checklist.

Those who score above 44, indicating severe PTSD symptoms, are referred to psychologist Terri deRoon Cassini, Ph.D., who begins to work with them to mitigate PTSD symptoms, and continues to do so after they are discharged.

Since joining the trauma team in September 2008, Dr. deRoon Cassini has used CBT to halt possible PTSD for several hundred assault victims and survivors of car crashes and other accidents. The CBT approach involves disengaging the memory of the event from the autonomic response to it, as it’s the hyperactivated fight-or-flight response that creates and maintains the panic attacks, nightmares, flashbacks, and other PTSD symptoms that make return to a normal quality of life difficult.

Patients tell Dr. deRoon Cassini their stories over and over again; with each retelling, the autonomic response fades. Eventually, the trauma becomes just another memory, not something the body relives 24 hours a day.

"A lot of times people will say, ‘I’m having flashbacks, I’m having nightmares, I’m going crazy. I keep seeing the car flipping over and over and over again. I keep hearing the gun go off,’ " she said.

After the conditioned response is broken through CBT, she helps patients "process what happened and restructure their cognitive perceptions," she said. Eventually they realize "that was really scary, but it’s over," said Dr. deRoon Cassini.

A randomized trial is planned to measure the success of that approach, Dr. Brasel said. In the planned trial, half of newly admitted high scorers on the PTSD checklist will be randomized to CBT, half to no treatment.

They’ll be followed to assess rates of PTSD development, a diagnosis that requires symptoms be present at least 1 month, with the goal of finding out if early intervention helps.

The trial will include salivary cortisol measurements and possibly functional MRI, Dr. Brasel said.

Dr. Brasel, Dr. deRoon Cassini, and Ms. Anderson said they have no conflicts of interest.

The PTSD risk factor study was funded in part by a Centers for Disease Control and Prevention grant to the college’s Injury Research Center. The study was done not only to figure out how to best help patients after physical trauma, but also "to provide evidence to the funding agencies that this is truly an important thing to investigate," Dr. Brasel said.

The researchers said they had no conflicts of interest.

HUNTINGTON BEACH, CALIF. – Three things have been found to be strong predictors of whether a patient will develop post-traumatic stress disorder following physical trauma, Medical College of Wisconsin, Milwaukee, researchers reported.

Patients are more likely to develop PTSD if they were victims of violence; if they perceive they were grievously injured, regardless of their injury severity score; and if they think they were almost killed, whether that’s true or not.

The researchers used surveys to determine what factors predict PTSD in trauma patients, fourth-year medical student Jessica Anderson said when she presented the findings at the Academic Surgical Conference, which was sponsored by the Association for Academic Surgery and the Society of University Surgeons.

Within about 72 hours of admission, 403 trauma patients completed the 17-question Post-Traumatic Stress Disorder checklist (pdf) and the Short Form-36 – a quality of life survey that assesses mental and physical function; 129 filled out the forms when requested to do so 6 months later.

A previous study found severe PTSD symptoms in 22.5% of patients admitted to the trauma service; in the new study, 18.6% of the 6-month respondents had checklist scores above 44, indicating PTSD.

Victims of violence – shootings, stabbings, or assaults – had mean 6-month checklist scores of 45.79; mean score for accident victims was 32.27 (P = .005).

Higher PTSD scores correlated with lower quality-of-life scores. Assault victims also scored lower on mental functioning at 6 months (P = .001).

"The variables that were statistically significant in predicting PTSD severity at 6 months included assaultive type of mechanism, scene heart rate, perceived injury severity score, and perceived life threat," Ms. Anderson said.

Age and gender were not predictive. On multiple regression analysis, scene heart rate was no longer significant.

Such studies of PTSD in trauma patients are relatively new, said Dr. Karen Brasel, a surgery professor at the college and a trauma surgeon at its associated Froedtert Memorial Lutheran Hospital, also in Milwaukee.

These three factors have been identified before among military personnel and domestic violence victims, but they appear to apply to other trauma victims, as well, she said.

"People don’t really think about PTSD in relation to garden-variety car crashes or getting stabbed in a gang fight," said Dr. Brasel, who is helping to lead efforts at the hospital to address PTSD in trauma patients.

Although nothing can be done about the injury mechanism, the other two contributing factors – the perceptions about injury severity and death risk – may be amenable to cognitive-behavioral therapy (CBT).

Patients admitted to the hospital’s level 1 trauma center are screened as soon as possible for PTSD symptoms with the civilian version of the PTSD Checklist.

Those who score above 44, indicating severe PTSD symptoms, are referred to psychologist Terri deRoon Cassini, Ph.D., who begins to work with them to mitigate PTSD symptoms, and continues to do so after they are discharged.

Since joining the trauma team in September 2008, Dr. deRoon Cassini has used CBT to halt possible PTSD for several hundred assault victims and survivors of car crashes and other accidents. The CBT approach involves disengaging the memory of the event from the autonomic response to it, as it’s the hyperactivated fight-or-flight response that creates and maintains the panic attacks, nightmares, flashbacks, and other PTSD symptoms that make return to a normal quality of life difficult.

Patients tell Dr. deRoon Cassini their stories over and over again; with each retelling, the autonomic response fades. Eventually, the trauma becomes just another memory, not something the body relives 24 hours a day.

"A lot of times people will say, ‘I’m having flashbacks, I’m having nightmares, I’m going crazy. I keep seeing the car flipping over and over and over again. I keep hearing the gun go off,’ " she said.

After the conditioned response is broken through CBT, she helps patients "process what happened and restructure their cognitive perceptions," she said. Eventually they realize "that was really scary, but it’s over," said Dr. deRoon Cassini.

A randomized trial is planned to measure the success of that approach, Dr. Brasel said. In the planned trial, half of newly admitted high scorers on the PTSD checklist will be randomized to CBT, half to no treatment.

They’ll be followed to assess rates of PTSD development, a diagnosis that requires symptoms be present at least 1 month, with the goal of finding out if early intervention helps.

The trial will include salivary cortisol measurements and possibly functional MRI, Dr. Brasel said.

Dr. Brasel, Dr. deRoon Cassini, and Ms. Anderson said they have no conflicts of interest.

The PTSD risk factor study was funded in part by a Centers for Disease Control and Prevention grant to the college’s Injury Research Center. The study was done not only to figure out how to best help patients after physical trauma, but also "to provide evidence to the funding agencies that this is truly an important thing to investigate," Dr. Brasel said.

The researchers said they had no conflicts of interest.

HUNTINGTON BEACH, CALIF. – Fewer herniations and gastroesophageal reflux complications were seen in children undergoing minimal-dissection laparoscopic fundoplication than in those undergoing a more conventional procedure in a randomized trial of 177 patients.

Photo credit: Courtesy Dr. Shawn St. Peter

In recent years, surgeons have debated whether it’s best during pediatric fundoplication to free the esophagus from the phrenoesophageal membrane or leave it embedded in that anatomical anchor.

The conventional approach allows the surgeon to pull a bit of the esophagus into the abdomen so that it can be wrapped with the gastric fundus, as is done in adults. The second approach leaves the esophagus and its attachments in place; the top of the stomach is simply wrapped around the gastroesophageal junction.

Photo credit: Courtesy Dr. Shawn St. Peter

Not only does minimal-dissection laparoscopic fundoplication control reflux at least as well as the conventional approach does, it also greatly reduces the likelihood that the fundal wrap and stomach will herniate into the chest cavity, said Dr. Shawn St. Peter at the annual Academic Surgical Congress.

The trial randomized 87 children to laparoscopic fundoplication with circumferential division of the phrenoesophageal attachments; 90 children were randomized to laparoscopic fundoplication with minimal esophageal mobilization and no violation of the phrenoesophageal membrane.

The groups had no statistically significant differences in preoperative reflux symptoms, weight, neurologic impairment, or other parameters. The mean age in both groups was about 2 years; slightly more than half were male.

Dr. St. Peter, a pediatric surgeon at the Children’s Mercy Hospital in Kansas City, Mo., and five other surgeons each performed roughly equal numbers of both procedures.

At 1-year follow-up, the herniation rate by contrast study was 30% in children who had their phrenoesophageal membrane taken down, and 7.8% when it was left alone (P = .002).

Similarly, 18.4% of children in the take-down group needed at least one surgery to reduce a herniation; the redo rate in the minimal-dissection group was 3.3% (P = .006).

The minimal-dissection group also had fewer postop gastroesophageal reflux complications – weight loss, pneumonia, and acute life-threatening events – although the trend was not statistically significant (J. Pediatr. Surg. 2011;46:163-8).

"The results are very, very clear, and show that going forward we should be doing the minimal-dissection approach. This study should significantly change practice," said Dr. R. Lawrence Moss, surgeon-in-chief at Nationwide Children’s Hospital in Columbus, Ohio.

"This is one of the most significant studies in [pediatric] surgery for a long time, and it sets a standard that technique questions can be answered in a scientific manner. It really raises the bar for all of us," said Dr. Moss, who did not participate in the trial but was familiar with its results.

The most satisfying outcome of the trial was the reduction in hernias, Dr. St. Peter said in an interview following his presentation.

Adults aren’t typically at risk for fundal wrap herniation; the adult diaphragm is strong enough to hold the wrap in place. In children, however, simple inhalation – because of negative chest pressure – can sometimes pop the wrap and stomach into the chest, where they get stuck on top of the diaphragm.

"Anybody who does fundos [in children] has at least one patient who has had that problem. It’s a nightmare," Dr. St. Peter said. Postoperative retching, vomiting, and gagging may occur, and attempts to reduce the hernia sometimes fail. If multiple attempts fail, the stomach may no longer empty properly, leaving children with chronic gastric pain and other long-term complications.

During minimal-dissection laparoscopic fundoplication, Dr. St. Peter takes down the gastrohepatic ligament up toward diaphragm, without touching the phrenoesophageal membrane. He then bluntly creates an opening into the abdomen directly behind the esophagus, preserving all the anterolateral attachments.

Without membrane dissection, the operation goes a bit faster. But surgeons must be careful: "Even gentle manipulation can be enough to free up the diaphragm from the esophagus in a baby," he said.

Dr. St. Peter and his colleagues are investigating whether esophagocrural sutures – which were placed in all trial subjects – are needed when the phrenoesophageal membrane is left intact.

Those sutures are important when it’s taken down, but "if you never open the door, putting four sutures in the seam of the door seems silly," Dr. St. Peter said.

Thus far, they have enrolled 35 patients in a randomized trial aiming for a total enrollment of 120 patients. Half will get the sutures; the other half will not. But all the children will leave the OR with their esophageal attachments intact.

"The second we closed the study, that was the last time we took down a membrane," Dr. St. Peter said.

He and Dr. Moss said they have no conflicts of interest. The trial received no outside funding.

HUNTINGTON BEACH, CALIF. – Fewer herniations and gastroesophageal reflux complications were seen in children undergoing minimal-dissection laparoscopic fundoplication than in those undergoing a more conventional procedure in a randomized trial of 177 patients.

Photo credit: Courtesy Dr. Shawn St. Peter

In recent years, surgeons have debated whether it’s best during pediatric fundoplication to free the esophagus from the phrenoesophageal membrane or leave it embedded in that anatomical anchor.

The conventional approach allows the surgeon to pull a bit of the esophagus into the abdomen so that it can be wrapped with the gastric fundus, as is done in adults. The second approach leaves the esophagus and its attachments in place; the top of the stomach is simply wrapped around the gastroesophageal junction.

Photo credit: Courtesy Dr. Shawn St. Peter

Not only does minimal-dissection laparoscopic fundoplication control reflux at least as well as the conventional approach does, it also greatly reduces the likelihood that the fundal wrap and stomach will herniate into the chest cavity, said Dr. Shawn St. Peter at the annual Academic Surgical Congress.

The trial randomized 87 children to laparoscopic fundoplication with circumferential division of the phrenoesophageal attachments; 90 children were randomized to laparoscopic fundoplication with minimal esophageal mobilization and no violation of the phrenoesophageal membrane.

The groups had no statistically significant differences in preoperative reflux symptoms, weight, neurologic impairment, or other parameters. The mean age in both groups was about 2 years; slightly more than half were male.

Dr. St. Peter, a pediatric surgeon at the Children’s Mercy Hospital in Kansas City, Mo., and five other surgeons each performed roughly equal numbers of both procedures.

At 1-year follow-up, the herniation rate by contrast study was 30% in children who had their phrenoesophageal membrane taken down, and 7.8% when it was left alone (P = .002).

Similarly, 18.4% of children in the take-down group needed at least one surgery to reduce a herniation; the redo rate in the minimal-dissection group was 3.3% (P = .006).

The minimal-dissection group also had fewer postop gastroesophageal reflux complications – weight loss, pneumonia, and acute life-threatening events – although the trend was not statistically significant (J. Pediatr. Surg. 2011;46:163-8).

"The results are very, very clear, and show that going forward we should be doing the minimal-dissection approach. This study should significantly change practice," said Dr. R. Lawrence Moss, surgeon-in-chief at Nationwide Children’s Hospital in Columbus, Ohio.

"This is one of the most significant studies in [pediatric] surgery for a long time, and it sets a standard that technique questions can be answered in a scientific manner. It really raises the bar for all of us," said Dr. Moss, who did not participate in the trial but was familiar with its results.

The most satisfying outcome of the trial was the reduction in hernias, Dr. St. Peter said in an interview following his presentation.

Adults aren’t typically at risk for fundal wrap herniation; the adult diaphragm is strong enough to hold the wrap in place. In children, however, simple inhalation – because of negative chest pressure – can sometimes pop the wrap and stomach into the chest, where they get stuck on top of the diaphragm.

"Anybody who does fundos [in children] has at least one patient who has had that problem. It’s a nightmare," Dr. St. Peter said. Postoperative retching, vomiting, and gagging may occur, and attempts to reduce the hernia sometimes fail. If multiple attempts fail, the stomach may no longer empty properly, leaving children with chronic gastric pain and other long-term complications.

During minimal-dissection laparoscopic fundoplication, Dr. St. Peter takes down the gastrohepatic ligament up toward diaphragm, without touching the phrenoesophageal membrane. He then bluntly creates an opening into the abdomen directly behind the esophagus, preserving all the anterolateral attachments.

Without membrane dissection, the operation goes a bit faster. But surgeons must be careful: "Even gentle manipulation can be enough to free up the diaphragm from the esophagus in a baby," he said.

Dr. St. Peter and his colleagues are investigating whether esophagocrural sutures – which were placed in all trial subjects – are needed when the phrenoesophageal membrane is left intact.

Those sutures are important when it’s taken down, but "if you never open the door, putting four sutures in the seam of the door seems silly," Dr. St. Peter said.

Thus far, they have enrolled 35 patients in a randomized trial aiming for a total enrollment of 120 patients. Half will get the sutures; the other half will not. But all the children will leave the OR with their esophageal attachments intact.

"The second we closed the study, that was the last time we took down a membrane," Dr. St. Peter said.

He and Dr. Moss said they have no conflicts of interest. The trial received no outside funding.

HUNTINGTON BEACH, CALIF. – Fewer herniations and gastroesophageal reflux complications were seen in children undergoing minimal-dissection laparoscopic fundoplication than in those undergoing a more conventional procedure in a randomized trial of 177 patients.

Photo credit: Courtesy Dr. Shawn St. Peter

In recent years, surgeons have debated whether it’s best during pediatric fundoplication to free the esophagus from the phrenoesophageal membrane or leave it embedded in that anatomical anchor.

The conventional approach allows the surgeon to pull a bit of the esophagus into the abdomen so that it can be wrapped with the gastric fundus, as is done in adults. The second approach leaves the esophagus and its attachments in place; the top of the stomach is simply wrapped around the gastroesophageal junction.

Photo credit: Courtesy Dr. Shawn St. Peter

Not only does minimal-dissection laparoscopic fundoplication control reflux at least as well as the conventional approach does, it also greatly reduces the likelihood that the fundal wrap and stomach will herniate into the chest cavity, said Dr. Shawn St. Peter at the annual Academic Surgical Congress.

The trial randomized 87 children to laparoscopic fundoplication with circumferential division of the phrenoesophageal attachments; 90 children were randomized to laparoscopic fundoplication with minimal esophageal mobilization and no violation of the phrenoesophageal membrane.

The groups had no statistically significant differences in preoperative reflux symptoms, weight, neurologic impairment, or other parameters. The mean age in both groups was about 2 years; slightly more than half were male.

Dr. St. Peter, a pediatric surgeon at the Children’s Mercy Hospital in Kansas City, Mo., and five other surgeons each performed roughly equal numbers of both procedures.

At 1-year follow-up, the herniation rate by contrast study was 30% in children who had their phrenoesophageal membrane taken down, and 7.8% when it was left alone (P = .002).

Similarly, 18.4% of children in the take-down group needed at least one surgery to reduce a herniation; the redo rate in the minimal-dissection group was 3.3% (P = .006).

The minimal-dissection group also had fewer postop gastroesophageal reflux complications – weight loss, pneumonia, and acute life-threatening events – although the trend was not statistically significant (J. Pediatr. Surg. 2011;46:163-8).

"The results are very, very clear, and show that going forward we should be doing the minimal-dissection approach. This study should significantly change practice," said Dr. R. Lawrence Moss, surgeon-in-chief at Nationwide Children’s Hospital in Columbus, Ohio.

"This is one of the most significant studies in [pediatric] surgery for a long time, and it sets a standard that technique questions can be answered in a scientific manner. It really raises the bar for all of us," said Dr. Moss, who did not participate in the trial but was familiar with its results.

The most satisfying outcome of the trial was the reduction in hernias, Dr. St. Peter said in an interview following his presentation.

Adults aren’t typically at risk for fundal wrap herniation; the adult diaphragm is strong enough to hold the wrap in place. In children, however, simple inhalation – because of negative chest pressure – can sometimes pop the wrap and stomach into the chest, where they get stuck on top of the diaphragm.

"Anybody who does fundos [in children] has at least one patient who has had that problem. It’s a nightmare," Dr. St. Peter said. Postoperative retching, vomiting, and gagging may occur, and attempts to reduce the hernia sometimes fail. If multiple attempts fail, the stomach may no longer empty properly, leaving children with chronic gastric pain and other long-term complications.

During minimal-dissection laparoscopic fundoplication, Dr. St. Peter takes down the gastrohepatic ligament up toward diaphragm, without touching the phrenoesophageal membrane. He then bluntly creates an opening into the abdomen directly behind the esophagus, preserving all the anterolateral attachments.

Without membrane dissection, the operation goes a bit faster. But surgeons must be careful: "Even gentle manipulation can be enough to free up the diaphragm from the esophagus in a baby," he said.

Dr. St. Peter and his colleagues are investigating whether esophagocrural sutures – which were placed in all trial subjects – are needed when the phrenoesophageal membrane is left intact.

Those sutures are important when it’s taken down, but "if you never open the door, putting four sutures in the seam of the door seems silly," Dr. St. Peter said.

Thus far, they have enrolled 35 patients in a randomized trial aiming for a total enrollment of 120 patients. Half will get the sutures; the other half will not. But all the children will leave the OR with their esophageal attachments intact.

"The second we closed the study, that was the last time we took down a membrane," Dr. St. Peter said.

He and Dr. Moss said they have no conflicts of interest. The trial received no outside funding.