Naseem S. Miller

Enhanced cleaning of intensive care unit rooms did a better job of reducing the overall risk of acquiring methicillin-resistant S. aureus than it did of reducing the risk of acquiring vancomycin-resistant enterococci.

The findings from a retrospective cohort study, published March 28 in the Archives of Internal Medicine, showed that a cleaning intervention lowered MRSA acquisition by 49% and VRE acquisition by 29% for patients admitted to rooms previously occupied by carriers of either organism, in any of 10 ICUs in a 750-bed academic medical center.

The cleaning intervention consisted of frequently immersing cleaning cloths in buckets containing an ammonium agent. The adequacy of cleaning was measured by the presence of a tracking marker that was visible under UV light. Based on measures of the marker, staff were given targeted feedback designed to improve their cleaning technique.

The intervention paid off in reduced transmissions, but "the impact of this intervention depends on the prevalence of pathogens in hospitals," Rupak Datta, the lead author of the study (Arch. Intern. Med. 2011;171:491-4), said in an interview.

Further, "environmental contamination makes up a small fraction of overall transmission" of antibiotic-resistant organisms in hospitals, noted Mr. Datta of the University of California, Irvine. The majority of MRSA and VRE transmissions are the result of suboptimal handwashing by hospital staff, he said.

Mr. Datta and the research group had formerly shown that admission to rooms previously occupied by a MRSA-positive or a VRE-positive patient increased by 40% the odds of MRSA and VRE acquisition (Arch. Intern. Med. 2006;166:1945-51). Cleaning interventions were undertaken as a result of that finding. In addition, other investigators had reported that "increasing the volume of disinfectant applied to environmental surfaces, providing education for Environmental Services staff, and instituting feedback with a black-light marker improved cleaning and reduced the frequency of MRSA and VRE contamination" (Infect. Control Hosp. Epidemiol. 2008;29:593-9).

In the current study, the group evaluated the impact of the cleaning interventions on patient risk of acquiring MRSA or VRE from the prior room occupants.

The researchers compared hospital occupancy data during the 2 years when the enhanced cleaning intervention was implemented (Sept. 1, 2006, through April 30, 2008) with baseline data from the 2 years prior to the implementation (Sept. 1, 2003, through April 30, 2005).

For MRSA detection, there were 10,151 eligible room stays at baseline, and 11,849 at intervention. There were 10,349 eligible room stays for VRE detection at baseline, and 11,871 at intervention.

The MRSA acquisition rate decreased from 3% (305 of 10,151) at baseline to 1.5% (182 of 11,849) at intervention. The VRE acquisition rate fell from 3% (314 if 10,349) at baseline to 2.2% (256 of 11,871) at intervention.

Patients at baseline who were admitted to rooms previously occupied by MRSA carriers had a 3.9% risk of MRSA acquisition, compared with 2.9% for patients admitted to rooms previously occupied by MRSA-negative patients. After the cleaning intervention, the risk of MRSA acquisition was 1.5% for all patients, regardless of whether the previous room occupant had MRSA.

Patients admitted at baseline to rooms previously occupied by VRE carriers had a 4.5% risk of VRE acquisition, compared with a 2.8% risk when the previous room occupant was not a VRE carrier. After the intervention, the risk of acquiring VRE was 3.5% when the previous room occupant was a VRE carrier and 2% when the previous room occupant wasn’t a carrier.

"We were surprised" by the difference in the results between MRSA and VRE, said Mr. Datta.

The authors cited several explanations for this difference, including the "generally higher burden of VRE contamination and evidence that room contamination may be a major factor in VRE transmission." They added that "VRE contamination has been shown to persist through three standard room cleanings."

The study’s limitations include lack of data on antibiotic use, which is associated with increased VRE shedding and acquisition.

"Additional studies are needed to evaluate the differential effect of enhanced cleaning on MRSA vs. VRE. This may be particularly relevant for hospitals with high VRE prevalence, where the burden of VRE contamination may demand more rigorous cleaning methods," the authors wrote.

The authors reported no financial conflicts.

Enhanced cleaning of intensive care unit rooms did a better job of reducing the overall risk of acquiring methicillin-resistant S. aureus than it did of reducing the risk of acquiring vancomycin-resistant enterococci.

The findings from a retrospective cohort study, published March 28 in the Archives of Internal Medicine, showed that a cleaning intervention lowered MRSA acquisition by 49% and VRE acquisition by 29% for patients admitted to rooms previously occupied by carriers of either organism, in any of 10 ICUs in a 750-bed academic medical center.

The cleaning intervention consisted of frequently immersing cleaning cloths in buckets containing an ammonium agent. The adequacy of cleaning was measured by the presence of a tracking marker that was visible under UV light. Based on measures of the marker, staff were given targeted feedback designed to improve their cleaning technique.

The intervention paid off in reduced transmissions, but "the impact of this intervention depends on the prevalence of pathogens in hospitals," Rupak Datta, the lead author of the study (Arch. Intern. Med. 2011;171:491-4), said in an interview.

Further, "environmental contamination makes up a small fraction of overall transmission" of antibiotic-resistant organisms in hospitals, noted Mr. Datta of the University of California, Irvine. The majority of MRSA and VRE transmissions are the result of suboptimal handwashing by hospital staff, he said.

Mr. Datta and the research group had formerly shown that admission to rooms previously occupied by a MRSA-positive or a VRE-positive patient increased by 40% the odds of MRSA and VRE acquisition (Arch. Intern. Med. 2006;166:1945-51). Cleaning interventions were undertaken as a result of that finding. In addition, other investigators had reported that "increasing the volume of disinfectant applied to environmental surfaces, providing education for Environmental Services staff, and instituting feedback with a black-light marker improved cleaning and reduced the frequency of MRSA and VRE contamination" (Infect. Control Hosp. Epidemiol. 2008;29:593-9).

In the current study, the group evaluated the impact of the cleaning interventions on patient risk of acquiring MRSA or VRE from the prior room occupants.

The researchers compared hospital occupancy data during the 2 years when the enhanced cleaning intervention was implemented (Sept. 1, 2006, through April 30, 2008) with baseline data from the 2 years prior to the implementation (Sept. 1, 2003, through April 30, 2005).

For MRSA detection, there were 10,151 eligible room stays at baseline, and 11,849 at intervention. There were 10,349 eligible room stays for VRE detection at baseline, and 11,871 at intervention.

The MRSA acquisition rate decreased from 3% (305 of 10,151) at baseline to 1.5% (182 of 11,849) at intervention. The VRE acquisition rate fell from 3% (314 if 10,349) at baseline to 2.2% (256 of 11,871) at intervention.

Patients at baseline who were admitted to rooms previously occupied by MRSA carriers had a 3.9% risk of MRSA acquisition, compared with 2.9% for patients admitted to rooms previously occupied by MRSA-negative patients. After the cleaning intervention, the risk of MRSA acquisition was 1.5% for all patients, regardless of whether the previous room occupant had MRSA.

Patients admitted at baseline to rooms previously occupied by VRE carriers had a 4.5% risk of VRE acquisition, compared with a 2.8% risk when the previous room occupant was not a VRE carrier. After the intervention, the risk of acquiring VRE was 3.5% when the previous room occupant was a VRE carrier and 2% when the previous room occupant wasn’t a carrier.

"We were surprised" by the difference in the results between MRSA and VRE, said Mr. Datta.

The authors cited several explanations for this difference, including the "generally higher burden of VRE contamination and evidence that room contamination may be a major factor in VRE transmission." They added that "VRE contamination has been shown to persist through three standard room cleanings."

The study’s limitations include lack of data on antibiotic use, which is associated with increased VRE shedding and acquisition.

"Additional studies are needed to evaluate the differential effect of enhanced cleaning on MRSA vs. VRE. This may be particularly relevant for hospitals with high VRE prevalence, where the burden of VRE contamination may demand more rigorous cleaning methods," the authors wrote.

The authors reported no financial conflicts.

Enhanced cleaning of intensive care unit rooms did a better job of reducing the overall risk of acquiring methicillin-resistant S. aureus than it did of reducing the risk of acquiring vancomycin-resistant enterococci.

The findings from a retrospective cohort study, published March 28 in the Archives of Internal Medicine, showed that a cleaning intervention lowered MRSA acquisition by 49% and VRE acquisition by 29% for patients admitted to rooms previously occupied by carriers of either organism, in any of 10 ICUs in a 750-bed academic medical center.

The cleaning intervention consisted of frequently immersing cleaning cloths in buckets containing an ammonium agent. The adequacy of cleaning was measured by the presence of a tracking marker that was visible under UV light. Based on measures of the marker, staff were given targeted feedback designed to improve their cleaning technique.

The intervention paid off in reduced transmissions, but "the impact of this intervention depends on the prevalence of pathogens in hospitals," Rupak Datta, the lead author of the study (Arch. Intern. Med. 2011;171:491-4), said in an interview.

Further, "environmental contamination makes up a small fraction of overall transmission" of antibiotic-resistant organisms in hospitals, noted Mr. Datta of the University of California, Irvine. The majority of MRSA and VRE transmissions are the result of suboptimal handwashing by hospital staff, he said.

Mr. Datta and the research group had formerly shown that admission to rooms previously occupied by a MRSA-positive or a VRE-positive patient increased by 40% the odds of MRSA and VRE acquisition (Arch. Intern. Med. 2006;166:1945-51). Cleaning interventions were undertaken as a result of that finding. In addition, other investigators had reported that "increasing the volume of disinfectant applied to environmental surfaces, providing education for Environmental Services staff, and instituting feedback with a black-light marker improved cleaning and reduced the frequency of MRSA and VRE contamination" (Infect. Control Hosp. Epidemiol. 2008;29:593-9).

In the current study, the group evaluated the impact of the cleaning interventions on patient risk of acquiring MRSA or VRE from the prior room occupants.

The researchers compared hospital occupancy data during the 2 years when the enhanced cleaning intervention was implemented (Sept. 1, 2006, through April 30, 2008) with baseline data from the 2 years prior to the implementation (Sept. 1, 2003, through April 30, 2005).

For MRSA detection, there were 10,151 eligible room stays at baseline, and 11,849 at intervention. There were 10,349 eligible room stays for VRE detection at baseline, and 11,871 at intervention.

The MRSA acquisition rate decreased from 3% (305 of 10,151) at baseline to 1.5% (182 of 11,849) at intervention. The VRE acquisition rate fell from 3% (314 if 10,349) at baseline to 2.2% (256 of 11,871) at intervention.

Patients at baseline who were admitted to rooms previously occupied by MRSA carriers had a 3.9% risk of MRSA acquisition, compared with 2.9% for patients admitted to rooms previously occupied by MRSA-negative patients. After the cleaning intervention, the risk of MRSA acquisition was 1.5% for all patients, regardless of whether the previous room occupant had MRSA.

Patients admitted at baseline to rooms previously occupied by VRE carriers had a 4.5% risk of VRE acquisition, compared with a 2.8% risk when the previous room occupant was not a VRE carrier. After the intervention, the risk of acquiring VRE was 3.5% when the previous room occupant was a VRE carrier and 2% when the previous room occupant wasn’t a carrier.

"We were surprised" by the difference in the results between MRSA and VRE, said Mr. Datta.

The authors cited several explanations for this difference, including the "generally higher burden of VRE contamination and evidence that room contamination may be a major factor in VRE transmission." They added that "VRE contamination has been shown to persist through three standard room cleanings."

The study’s limitations include lack of data on antibiotic use, which is associated with increased VRE shedding and acquisition.

"Additional studies are needed to evaluate the differential effect of enhanced cleaning on MRSA vs. VRE. This may be particularly relevant for hospitals with high VRE prevalence, where the burden of VRE contamination may demand more rigorous cleaning methods," the authors wrote.

The authors reported no financial conflicts.

Enhanced cleaning of intensive care unit rooms did a better job of reducing the overall risk of acquiring methicillin-resistant S. aureus than it did of reducing the risk of acquiring vancomycin-resistant enterococci.

The findings from a retrospective cohort study, published March 28 in the Archives of Internal Medicine, showed that a cleaning intervention lowered MRSA acquisition by 49% and VRE acquisition by 29% for patients admitted to rooms previously occupied by carriers of either organism, in any of 10 ICUs in a 750-bed academic medical center.

The cleaning intervention consisted of frequently immersing cleaning cloths in buckets containing an ammonium agent. The adequacy of cleaning was measured by the presence of a tracking marker that was visible under UV light. Based on measures of the marker, staff were given targeted feedback designed to improve their cleaning technique.

The intervention paid off in reduced transmissions, but "the impact of this intervention depends on the prevalence of pathogens in hospitals," Rupak Datta, the lead author of the study (Arch. Intern. Med. 2011;171:491-4), said in an interview.

Further, "environmental contamination makes up a small fraction of overall transmission" of antibiotic-resistant organisms in hospitals, noted Mr. Datta of the University of California, Irvine. The majority of MRSA and VRE transmissions are the result of suboptimal handwashing by hospital staff, he said.

Mr. Datta and the research group had formerly shown that admission to rooms previously occupied by a MRSA-positive or a VRE-positive patient increased by 40% the odds of MRSA and VRE acquisition (Arch. Intern. Med. 2006;166:1945-51).

Cleaning interventions were undertaken as a result of that finding. In addition, other investigators had reported that "increasing the volume of disinfectant applied to environmental surfaces, providing education for Environmental Services staff, and instituting feedback with a black-light marker improved cleaning and reduced the frequency of MRSA and VRE contamination" (Infect. Control Hosp. Epidemiol. 2008;29:593-9).

In the current study, the group evaluated the impact of the cleaning interventions on patient risk of acquiring MRSA or VRE from the prior room occupants.

The researchers compared hospital occupancy data during the 2 years when the enhanced cleaning intervention was implemented (Sept. 1, 2006, through April 30, 2008) with baseline data from the 2 years prior to the implementation (Sept. 1, 2003, through April 30, 2005).

For MRSA detection, there were 10,151 eligible room stays at baseline, and 11,849 at intervention. There were 10,349 eligible room stays for VRE detection at baseline, and 11,871 at intervention.

The MRSA acquisition rate decreased from 3% (305 of 10,151) at baseline to 1.5% (182 of 11,849) at intervention. The VRE acquisition rate fell from 3% (314 if 10,349) at baseline to 2.2% (256 of 11,871) at intervention.

Patients at baseline who were admitted to rooms previously occupied by MRSA carriers had a 3.9% risk of MRSA acquisition, compared with 2.9% for patients admitted to rooms previously occupied by MRSA-negative patients. After the cleaning intervention, the risk of MRSA acquisition was 1.5% for all patients, regardless of whether the previous room occupant had MRSA.

Patients admitted at baseline to rooms previously occupied by VRE carriers had a 4.5% risk of VRE acquisition, compared with a 2.8% risk when the previous room occupant was not a VRE carrier. After the intervention, the risk of acquiring VRE was 3.5% when the previous room occupant was a VRE carrier and 2% when the previous room occupant wasn't a carrier.

"We were surprised" by the difference in the results between MRSA and VRE, said Mr. Datta.

The authors cited several explanations for this difference, including the "generally higher burden of VRE contamination and evidence that room contamination may be a major factor in VRE transmission." They added that "VRE contamination has been shown to persist through three standard room cleanings."

The study's limitations include lack of data on antibiotic use, which is associated with increased VRE shedding and acquisition.

"Additional studies are needed to evaluate the differential effect of enhanced cleaning on MRSA vs. VRE. This may be particularly relevant for hospitals with high VRE prevalence, where the burden of VRE contamination may demand more rigorous cleaning methods," the authors wrote.

The authors reported no financial conflicts.

Enhanced cleaning of intensive care unit rooms did a better job of reducing the overall risk of acquiring methicillin-resistant S. aureus than it did of reducing the risk of acquiring vancomycin-resistant enterococci.

The findings from a retrospective cohort study, published March 28 in the Archives of Internal Medicine, showed that a cleaning intervention lowered MRSA acquisition by 49% and VRE acquisition by 29% for patients admitted to rooms previously occupied by carriers of either organism, in any of 10 ICUs in a 750-bed academic medical center.

The cleaning intervention consisted of frequently immersing cleaning cloths in buckets containing an ammonium agent. The adequacy of cleaning was measured by the presence of a tracking marker that was visible under UV light. Based on measures of the marker, staff were given targeted feedback designed to improve their cleaning technique.

The intervention paid off in reduced transmissions, but "the impact of this intervention depends on the prevalence of pathogens in hospitals," Rupak Datta, the lead author of the study (Arch. Intern. Med. 2011;171:491-4), said in an interview.

Further, "environmental contamination makes up a small fraction of overall transmission" of antibiotic-resistant organisms in hospitals, noted Mr. Datta of the University of California, Irvine. The majority of MRSA and VRE transmissions are the result of suboptimal handwashing by hospital staff, he said.

Mr. Datta and the research group had formerly shown that admission to rooms previously occupied by a MRSA-positive or a VRE-positive patient increased by 40% the odds of MRSA and VRE acquisition (Arch. Intern. Med. 2006;166:1945-51).

Cleaning interventions were undertaken as a result of that finding. In addition, other investigators had reported that "increasing the volume of disinfectant applied to environmental surfaces, providing education for Environmental Services staff, and instituting feedback with a black-light marker improved cleaning and reduced the frequency of MRSA and VRE contamination" (Infect. Control Hosp. Epidemiol. 2008;29:593-9).

In the current study, the group evaluated the impact of the cleaning interventions on patient risk of acquiring MRSA or VRE from the prior room occupants.

The researchers compared hospital occupancy data during the 2 years when the enhanced cleaning intervention was implemented (Sept. 1, 2006, through April 30, 2008) with baseline data from the 2 years prior to the implementation (Sept. 1, 2003, through April 30, 2005).

For MRSA detection, there were 10,151 eligible room stays at baseline, and 11,849 at intervention. There were 10,349 eligible room stays for VRE detection at baseline, and 11,871 at intervention.

The MRSA acquisition rate decreased from 3% (305 of 10,151) at baseline to 1.5% (182 of 11,849) at intervention. The VRE acquisition rate fell from 3% (314 if 10,349) at baseline to 2.2% (256 of 11,871) at intervention.

Patients at baseline who were admitted to rooms previously occupied by MRSA carriers had a 3.9% risk of MRSA acquisition, compared with 2.9% for patients admitted to rooms previously occupied by MRSA-negative patients. After the cleaning intervention, the risk of MRSA acquisition was 1.5% for all patients, regardless of whether the previous room occupant had MRSA.

Patients admitted at baseline to rooms previously occupied by VRE carriers had a 4.5% risk of VRE acquisition, compared with a 2.8% risk when the previous room occupant was not a VRE carrier. After the intervention, the risk of acquiring VRE was 3.5% when the previous room occupant was a VRE carrier and 2% when the previous room occupant wasn't a carrier.

"We were surprised" by the difference in the results between MRSA and VRE, said Mr. Datta.

The authors cited several explanations for this difference, including the "generally higher burden of VRE contamination and evidence that room contamination may be a major factor in VRE transmission." They added that "VRE contamination has been shown to persist through three standard room cleanings."

The study's limitations include lack of data on antibiotic use, which is associated with increased VRE shedding and acquisition.

"Additional studies are needed to evaluate the differential effect of enhanced cleaning on MRSA vs. VRE. This may be particularly relevant for hospitals with high VRE prevalence, where the burden of VRE contamination may demand more rigorous cleaning methods," the authors wrote.

The authors reported no financial conflicts.

Enhanced cleaning of intensive care unit rooms did a better job of reducing the overall risk of acquiring methicillin-resistant S. aureus than it did of reducing the risk of acquiring vancomycin-resistant enterococci.

The findings from a retrospective cohort study, published March 28 in the Archives of Internal Medicine, showed that a cleaning intervention lowered MRSA acquisition by 49% and VRE acquisition by 29% for patients admitted to rooms previously occupied by carriers of either organism, in any of 10 ICUs in a 750-bed academic medical center.

The cleaning intervention consisted of frequently immersing cleaning cloths in buckets containing an ammonium agent. The adequacy of cleaning was measured by the presence of a tracking marker that was visible under UV light. Based on measures of the marker, staff were given targeted feedback designed to improve their cleaning technique.

The intervention paid off in reduced transmissions, but "the impact of this intervention depends on the prevalence of pathogens in hospitals," Rupak Datta, the lead author of the study (Arch. Intern. Med. 2011;171:491-4), said in an interview.

Further, "environmental contamination makes up a small fraction of overall transmission" of antibiotic-resistant organisms in hospitals, noted Mr. Datta of the University of California, Irvine. The majority of MRSA and VRE transmissions are the result of suboptimal handwashing by hospital staff, he said.

Mr. Datta and the research group had formerly shown that admission to rooms previously occupied by a MRSA-positive or a VRE-positive patient increased by 40% the odds of MRSA and VRE acquisition (Arch. Intern. Med. 2006;166:1945-51).

Cleaning interventions were undertaken as a result of that finding. In addition, other investigators had reported that "increasing the volume of disinfectant applied to environmental surfaces, providing education for Environmental Services staff, and instituting feedback with a black-light marker improved cleaning and reduced the frequency of MRSA and VRE contamination" (Infect. Control Hosp. Epidemiol. 2008;29:593-9).

In the current study, the group evaluated the impact of the cleaning interventions on patient risk of acquiring MRSA or VRE from the prior room occupants.

The researchers compared hospital occupancy data during the 2 years when the enhanced cleaning intervention was implemented (Sept. 1, 2006, through April 30, 2008) with baseline data from the 2 years prior to the implementation (Sept. 1, 2003, through April 30, 2005).

For MRSA detection, there were 10,151 eligible room stays at baseline, and 11,849 at intervention. There were 10,349 eligible room stays for VRE detection at baseline, and 11,871 at intervention.

The MRSA acquisition rate decreased from 3% (305 of 10,151) at baseline to 1.5% (182 of 11,849) at intervention. The VRE acquisition rate fell from 3% (314 if 10,349) at baseline to 2.2% (256 of 11,871) at intervention.

Patients at baseline who were admitted to rooms previously occupied by MRSA carriers had a 3.9% risk of MRSA acquisition, compared with 2.9% for patients admitted to rooms previously occupied by MRSA-negative patients. After the cleaning intervention, the risk of MRSA acquisition was 1.5% for all patients, regardless of whether the previous room occupant had MRSA.

Patients admitted at baseline to rooms previously occupied by VRE carriers had a 4.5% risk of VRE acquisition, compared with a 2.8% risk when the previous room occupant was not a VRE carrier. After the intervention, the risk of acquiring VRE was 3.5% when the previous room occupant was a VRE carrier and 2% when the previous room occupant wasn't a carrier.

"We were surprised" by the difference in the results between MRSA and VRE, said Mr. Datta.

The authors cited several explanations for this difference, including the "generally higher burden of VRE contamination and evidence that room contamination may be a major factor in VRE transmission." They added that "VRE contamination has been shown to persist through three standard room cleanings."

The study's limitations include lack of data on antibiotic use, which is associated with increased VRE shedding and acquisition.

"Additional studies are needed to evaluate the differential effect of enhanced cleaning on MRSA vs. VRE. This may be particularly relevant for hospitals with high VRE prevalence, where the burden of VRE contamination may demand more rigorous cleaning methods," the authors wrote.

The authors reported no financial conflicts.

Chondroitin sulfate slows the progression of knee osteoarthritis, according to findings from a pilot study that used magnetic resonance imaging to assess joint structural changes.

"It’s reassuring to see that the four major x-rays studies are now confirmed by high technology in the assessment of disease progression," said the study’s lead author Dr. Jean-Pierre Pelletier, in an interview. (Osteoarthr. Cartil. 1998;6:39-46), (Osteoarthr. Cartil. 2004;12:269-76), (Arthritis Rheum. 2005;52:779-86), (Arthritis Rheum. 2009;60:524-33).

The randomized, double-blind, placebo-controlled study showed that chondroitin sulfate reduced the cartilage loss volume in 69 patients with knee OA in as early as 6 months. (Ann. Rheum. Dis. 2011 March 1)

The findings show that "[MRI] is a good quantitative technique to find answers in shorter period of time with smaller number of patients," said Dr. Roy D. Altman, professor of medicine at the University of California, Los Angeles, who is not involved with the study.

The effect of disease-modifying drug chondroitin sulfate on cartilage volume loss, bone marrow lesions (BML), and disease symptoms has been controversial (BMJ 2010;341:c4675). However, the authors of this study said that the MRI findings provided additional evidence on the joint structure protective effect of chondroitin sulfate.

Several studies have also shown that MRI can quantitatively and reliably assess the volume and cartilage thickness in addition to joint structural changes in subchondral bone, menisci, and synovium, the authors reported.

"MRI provides you with direct visualization of the cartilage," said Dr. Pelletier, director of the osteoarthritis research unit at the University of Montreal Hospital Research Centre. "And the beauty of MRI is that it not only it provides assessment of progression of change in cartilage, but also in many other tissues of the joint, like the subchondral bone and the synovium.

"In addition, the pronounced reduction in OA cartilage loss found in patients treated with chondroitin sulfate was also associated with a reduction in the size of BML. This finding is most interesting as BML are believed to be associated with the progression of OA cartilage lesions," according to a number of studies, said Dr. Pelletier.

The study also showed that patients who were being treated with NSAIDs in addition to chondroitin sulfate showed a significant reduction in synovial membrane thickness (1.3 plus or minus 0.3 mm in 6 months vs. 1.6 plus or minus 0.3 mm placebo) and a lower incidence of joint swelling, compared with the placebo group (0% in chondroitin sulfate vs. 11.4% in placebo). The finding "is interesting with practical clinical impact, and definitely needs future exploration," the authors wrote.

Researchers recruited 69 patients of both sexes between 40 and 80 years of age from rheumatology clinics in Quebec province. All patients had clinical signs of synovitis.

The study had two phases. For the double-blind phase, the patients were randomly assigned to once-daily placebo or 800 mg of chondroitin sulfate for 6 months. During the following 6 months, or the open-label phase, both groups received 800 mg of chondroitin sulfate daily.

Cartilage volume and BML were assessed by MRI at baseline, 6 months, and 12 months. Synovial membrane thickness was assessed at baseline and 6 months.

Patients who took a daily oral dose of chondroitin sulfate had a significant reduction in cartilage volume loss at 6 months (–2.87%) and 12 months (–3.71%) in the global knee compared to the placebo group (–4.67% at 6 months and -6.12% at 12 months).

There were no differences in BML during the first 6 months. But, at 12 months reduction in BML were observed in the chondroitin sulfate group (–0.57%), especially in the lateral compartment (–0.13%) and the lateral condyle (–0.43). The additional 6-months needed to see the change could suggest that "BML are consequential to cartilage degradation and thus reducing cartilage lesions could lead to fewer BML. Alternatively, BML were shown to be involved in an inflammatory/catabolic process on which chondroitin sulfate could act directly, leading to structural repair," according to the study.

No significant difference in disease symptoms were measured by visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires. "The main aim of the study was not the symptoms. The main goal was to find out whether chondroitin sulfate can reduce progression of knee OA," said Dr. Pelletier.

The study had limitations, including a small sample size. In addition, the system used did not allow the detection of the cartilage in the patella, researchers reported. They added that long-term studies are needed to find the impact of CS in disease symptoms.

Whether the quantitive MRI technique will eventually replace X-ray technology in such studies is unclear, said Dr. Pelletier. "That’s for regulatory bodies to decide," he said. "But it’s quite clear that MRI is the technology of the future. It’s very helpful, because you can truly speed up drug development in the field of OA and with less expense, using smaller number of patients and in a shorter period of time."

Dr. Jean-Pierre Pelletier and Dr. Johanne Martel-Pelletier are consultants for and shareholders in ArthroLab Inc. and ArthroVision Inc. Jean-Pierre Raynauld is a consultant for ArthroVision. Dr. André Beaulieu, Dr. Louis Bassette, and Dr. Frédéric Morin received honoraria from ArthroLab. François Abram is an employee of ArthroVision. Marc Dorais is a consultant for ArthroVision. Dr. Altman had no relevant financial conflicts of interest.

Chondroitin sulfate slows the progression of knee osteoarthritis, according to findings from a pilot study that used magnetic resonance imaging to assess joint structural changes.

"It’s reassuring to see that the four major x-rays studies are now confirmed by high technology in the assessment of disease progression," said the study’s lead author Dr. Jean-Pierre Pelletier, in an interview. (Osteoarthr. Cartil. 1998;6:39-46), (Osteoarthr. Cartil. 2004;12:269-76), (Arthritis Rheum. 2005;52:779-86), (Arthritis Rheum. 2009;60:524-33).

The randomized, double-blind, placebo-controlled study showed that chondroitin sulfate reduced the cartilage loss volume in 69 patients with knee OA in as early as 6 months. (Ann. Rheum. Dis. 2011 March 1)

The findings show that "[MRI] is a good quantitative technique to find answers in shorter period of time with smaller number of patients," said Dr. Roy D. Altman, professor of medicine at the University of California, Los Angeles, who is not involved with the study.

The effect of disease-modifying drug chondroitin sulfate on cartilage volume loss, bone marrow lesions (BML), and disease symptoms has been controversial (BMJ 2010;341:c4675). However, the authors of this study said that the MRI findings provided additional evidence on the joint structure protective effect of chondroitin sulfate.

Several studies have also shown that MRI can quantitatively and reliably assess the volume and cartilage thickness in addition to joint structural changes in subchondral bone, menisci, and synovium, the authors reported.

"MRI provides you with direct visualization of the cartilage," said Dr. Pelletier, director of the osteoarthritis research unit at the University of Montreal Hospital Research Centre. "And the beauty of MRI is that it not only it provides assessment of progression of change in cartilage, but also in many other tissues of the joint, like the subchondral bone and the synovium.

"In addition, the pronounced reduction in OA cartilage loss found in patients treated with chondroitin sulfate was also associated with a reduction in the size of BML. This finding is most interesting as BML are believed to be associated with the progression of OA cartilage lesions," according to a number of studies, said Dr. Pelletier.

The study also showed that patients who were being treated with NSAIDs in addition to chondroitin sulfate showed a significant reduction in synovial membrane thickness (1.3 plus or minus 0.3 mm in 6 months vs. 1.6 plus or minus 0.3 mm placebo) and a lower incidence of joint swelling, compared with the placebo group (0% in chondroitin sulfate vs. 11.4% in placebo). The finding "is interesting with practical clinical impact, and definitely needs future exploration," the authors wrote.

Researchers recruited 69 patients of both sexes between 40 and 80 years of age from rheumatology clinics in Quebec province. All patients had clinical signs of synovitis.

The study had two phases. For the double-blind phase, the patients were randomly assigned to once-daily placebo or 800 mg of chondroitin sulfate for 6 months. During the following 6 months, or the open-label phase, both groups received 800 mg of chondroitin sulfate daily.

Cartilage volume and BML were assessed by MRI at baseline, 6 months, and 12 months. Synovial membrane thickness was assessed at baseline and 6 months.

Patients who took a daily oral dose of chondroitin sulfate had a significant reduction in cartilage volume loss at 6 months (–2.87%) and 12 months (–3.71%) in the global knee compared to the placebo group (–4.67% at 6 months and -6.12% at 12 months).

There were no differences in BML during the first 6 months. But, at 12 months reduction in BML were observed in the chondroitin sulfate group (–0.57%), especially in the lateral compartment (–0.13%) and the lateral condyle (–0.43). The additional 6-months needed to see the change could suggest that "BML are consequential to cartilage degradation and thus reducing cartilage lesions could lead to fewer BML. Alternatively, BML were shown to be involved in an inflammatory/catabolic process on which chondroitin sulfate could act directly, leading to structural repair," according to the study.

No significant difference in disease symptoms were measured by visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires. "The main aim of the study was not the symptoms. The main goal was to find out whether chondroitin sulfate can reduce progression of knee OA," said Dr. Pelletier.

The study had limitations, including a small sample size. In addition, the system used did not allow the detection of the cartilage in the patella, researchers reported. They added that long-term studies are needed to find the impact of CS in disease symptoms.

Whether the quantitive MRI technique will eventually replace X-ray technology in such studies is unclear, said Dr. Pelletier. "That’s for regulatory bodies to decide," he said. "But it’s quite clear that MRI is the technology of the future. It’s very helpful, because you can truly speed up drug development in the field of OA and with less expense, using smaller number of patients and in a shorter period of time."

Dr. Jean-Pierre Pelletier and Dr. Johanne Martel-Pelletier are consultants for and shareholders in ArthroLab Inc. and ArthroVision Inc. Jean-Pierre Raynauld is a consultant for ArthroVision. Dr. André Beaulieu, Dr. Louis Bassette, and Dr. Frédéric Morin received honoraria from ArthroLab. François Abram is an employee of ArthroVision. Marc Dorais is a consultant for ArthroVision. Dr. Altman had no relevant financial conflicts of interest.

Chondroitin sulfate slows the progression of knee osteoarthritis, according to findings from a pilot study that used magnetic resonance imaging to assess joint structural changes.

"It’s reassuring to see that the four major x-rays studies are now confirmed by high technology in the assessment of disease progression," said the study’s lead author Dr. Jean-Pierre Pelletier, in an interview. (Osteoarthr. Cartil. 1998;6:39-46), (Osteoarthr. Cartil. 2004;12:269-76), (Arthritis Rheum. 2005;52:779-86), (Arthritis Rheum. 2009;60:524-33).

The randomized, double-blind, placebo-controlled study showed that chondroitin sulfate reduced the cartilage loss volume in 69 patients with knee OA in as early as 6 months. (Ann. Rheum. Dis. 2011 March 1)

The findings show that "[MRI] is a good quantitative technique to find answers in shorter period of time with smaller number of patients," said Dr. Roy D. Altman, professor of medicine at the University of California, Los Angeles, who is not involved with the study.

The effect of disease-modifying drug chondroitin sulfate on cartilage volume loss, bone marrow lesions (BML), and disease symptoms has been controversial (BMJ 2010;341:c4675). However, the authors of this study said that the MRI findings provided additional evidence on the joint structure protective effect of chondroitin sulfate.

Several studies have also shown that MRI can quantitatively and reliably assess the volume and cartilage thickness in addition to joint structural changes in subchondral bone, menisci, and synovium, the authors reported.

"MRI provides you with direct visualization of the cartilage," said Dr. Pelletier, director of the osteoarthritis research unit at the University of Montreal Hospital Research Centre. "And the beauty of MRI is that it not only it provides assessment of progression of change in cartilage, but also in many other tissues of the joint, like the subchondral bone and the synovium.

"In addition, the pronounced reduction in OA cartilage loss found in patients treated with chondroitin sulfate was also associated with a reduction in the size of BML. This finding is most interesting as BML are believed to be associated with the progression of OA cartilage lesions," according to a number of studies, said Dr. Pelletier.

The study also showed that patients who were being treated with NSAIDs in addition to chondroitin sulfate showed a significant reduction in synovial membrane thickness (1.3 plus or minus 0.3 mm in 6 months vs. 1.6 plus or minus 0.3 mm placebo) and a lower incidence of joint swelling, compared with the placebo group (0% in chondroitin sulfate vs. 11.4% in placebo). The finding "is interesting with practical clinical impact, and definitely needs future exploration," the authors wrote.

Researchers recruited 69 patients of both sexes between 40 and 80 years of age from rheumatology clinics in Quebec province. All patients had clinical signs of synovitis.

The study had two phases. For the double-blind phase, the patients were randomly assigned to once-daily placebo or 800 mg of chondroitin sulfate for 6 months. During the following 6 months, or the open-label phase, both groups received 800 mg of chondroitin sulfate daily.

Cartilage volume and BML were assessed by MRI at baseline, 6 months, and 12 months. Synovial membrane thickness was assessed at baseline and 6 months.

Patients who took a daily oral dose of chondroitin sulfate had a significant reduction in cartilage volume loss at 6 months (–2.87%) and 12 months (–3.71%) in the global knee compared to the placebo group (–4.67% at 6 months and -6.12% at 12 months).

There were no differences in BML during the first 6 months. But, at 12 months reduction in BML were observed in the chondroitin sulfate group (–0.57%), especially in the lateral compartment (–0.13%) and the lateral condyle (–0.43). The additional 6-months needed to see the change could suggest that "BML are consequential to cartilage degradation and thus reducing cartilage lesions could lead to fewer BML. Alternatively, BML were shown to be involved in an inflammatory/catabolic process on which chondroitin sulfate could act directly, leading to structural repair," according to the study.

No significant difference in disease symptoms were measured by visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires. "The main aim of the study was not the symptoms. The main goal was to find out whether chondroitin sulfate can reduce progression of knee OA," said Dr. Pelletier.

The study had limitations, including a small sample size. In addition, the system used did not allow the detection of the cartilage in the patella, researchers reported. They added that long-term studies are needed to find the impact of CS in disease symptoms.

Whether the quantitive MRI technique will eventually replace X-ray technology in such studies is unclear, said Dr. Pelletier. "That’s for regulatory bodies to decide," he said. "But it’s quite clear that MRI is the technology of the future. It’s very helpful, because you can truly speed up drug development in the field of OA and with less expense, using smaller number of patients and in a shorter period of time."

Dr. Jean-Pierre Pelletier and Dr. Johanne Martel-Pelletier are consultants for and shareholders in ArthroLab Inc. and ArthroVision Inc. Jean-Pierre Raynauld is a consultant for ArthroVision. Dr. André Beaulieu, Dr. Louis Bassette, and Dr. Frédéric Morin received honoraria from ArthroLab. François Abram is an employee of ArthroVision. Marc Dorais is a consultant for ArthroVision. Dr. Altman had no relevant financial conflicts of interest.

Chondroitin sulfate slows the progression of knee osteoarthritis, according to findings from a pilot study that used magnetic resonance imaging to assess joint structural changes.

"It’s reassuring to see that the four major x-rays studies are now confirmed by high technology in the assessment of disease progression," said the study’s lead author Dr. Jean-Pierre Pelletier, in an interview. (Osteoarthr. Cartil. 1998;6:39-46), (Osteoarthr. Cartil. 2004;12:269-76), (Arthritis Rheum. 2005;52:779-86), (Arthritis Rheum. 2009;60:524-33).

The randomized, double-blind, placebo-controlled study showed that chondroitin sulfate reduced the cartilage loss volume in 69 patients with knee OA in as early as 6 months. (Ann. Rheum. Dis. 2011 March 1)

The findings show that "[MRI] is a good quantitative technique to find answers in shorter period of time with smaller number of patients," said Dr. Roy D. Altman, professor of medicine at the University of California, Los Angeles, who is not involved with the study.

The effect of disease-modifying drug chondroitin sulfate on cartilage volume loss, bone marrow lesions (BML), and disease symptoms has been controversial (BMJ 2010;341:c4675). However, the authors of this study said that the MRI findings provided additional evidence on the joint structure protective effect of chondroitin sulfate.

Several studies have also shown that MRI can quantitatively and reliably assess the volume and cartilage thickness in addition to joint structural changes in subchondral bone, menisci, and synovium, the authors reported.

"MRI provides you with direct visualization of the cartilage," said Dr. Pelletier, director of the osteoarthritis research unit at the University of Montreal Hospital Research Centre. "And the beauty of MRI is that it not only it provides assessment of progression of change in cartilage, but also in many other tissues of the joint, like the subchondral bone and the synovium.

"In addition, the pronounced reduction in OA cartilage loss found in patients treated with chondroitin sulfate was also associated with a reduction in the size of BML. This finding is most interesting as BML are believed to be associated with the progression of OA cartilage lesions," according to a number of studies, said Dr. Pelletier.

The study also showed that patients who were being treated with NSAIDs in addition to chondroitin sulfate showed a significant reduction in synovial membrane thickness (1.3 plus or minus 0.3 mm in 6 months vs. 1.6 plus or minus 0.3 mm placebo) and a lower incidence of joint swelling, compared with the placebo group (0% in chondroitin sulfate vs. 11.4% in placebo). The finding "is interesting with practical clinical impact, and definitely needs future exploration," the authors wrote.

Researchers recruited 69 patients of both sexes between 40 and 80 years of age from rheumatology clinics in Quebec province. All patients had clinical signs of synovitis.

The study had two phases. For the double-blind phase, the patients were randomly assigned to once-daily placebo or 800 mg of chondroitin sulfate for 6 months. During the following 6 months, or the open-label phase, both groups received 800 mg of chondroitin sulfate daily.

Cartilage volume and BML were assessed by MRI at baseline, 6 months, and 12 months. Synovial membrane thickness was assessed at baseline and 6 months.

Patients who took a daily oral dose of chondroitin sulfate had a significant reduction in cartilage volume loss at 6 months (–2.87%) and 12 months (–3.71%) in the global knee compared to the placebo group (–4.67% at 6 months and -6.12% at 12 months).

There were no differences in BML during the first 6 months. But, at 12 months reduction in BML were observed in the chondroitin sulfate group (–0.57%), especially in the lateral compartment (–0.13%) and the lateral condyle (–0.43). The additional 6-months needed to see the change could suggest that "BML are consequential to cartilage degradation and thus reducing cartilage lesions could lead to fewer BML. Alternatively, BML were shown to be involved in an inflammatory/catabolic process on which chondroitin sulfate could act directly, leading to structural repair," according to the study.

No significant difference in disease symptoms were measured by visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires. "The main aim of the study was not the symptoms. The main goal was to find out whether chondroitin sulfate can reduce progression of knee OA," said Dr. Pelletier.

The study had limitations, including a small sample size. In addition, the system used did not allow the detection of the cartilage in the patella, researchers reported. They added that long-term studies are needed to find the impact of CS in disease symptoms.

Whether the quantitive MRI technique will eventually replace X-ray technology in such studies is unclear, said Dr. Pelletier. "That’s for regulatory bodies to decide," he said. "But it’s quite clear that MRI is the technology of the future. It’s very helpful, because you can truly speed up drug development in the field of OA and with less expense, using smaller number of patients and in a shorter period of time."

Dr. Jean-Pierre Pelletier and Dr. Johanne Martel-Pelletier are consultants for and shareholders in ArthroLab Inc. and ArthroVision Inc. Jean-Pierre Raynauld is a consultant for ArthroVision. Dr. André Beaulieu, Dr. Louis Bassette, and Dr. Frédéric Morin received honoraria from ArthroLab. François Abram is an employee of ArthroVision. Marc Dorais is a consultant for ArthroVision. Dr. Altman had no relevant financial conflicts of interest.

Chondroitin sulfate slows the progression of knee osteoarthritis, according to findings from a pilot study that used magnetic resonance imaging to assess joint structural changes.

"It’s reassuring to see that the four major x-rays studies are now confirmed by high technology in the assessment of disease progression," said the study’s lead author Dr. Jean-Pierre Pelletier, in an interview. (Osteoarthr. Cartil. 1998;6:39-46), (Osteoarthr. Cartil. 2004;12:269-76), (Arthritis Rheum. 2005;52:779-86), (Arthritis Rheum. 2009;60:524-33).

The randomized, double-blind, placebo-controlled study showed that chondroitin sulfate reduced the cartilage loss volume in 69 patients with knee OA in as early as 6 months. (Ann. Rheum. Dis. 2011 March 1)

The findings show that "[MRI] is a good quantitative technique to find answers in shorter period of time with smaller number of patients," said Dr. Roy D. Altman, professor of medicine at the University of California, Los Angeles, who is not involved with the study.

The effect of disease-modifying drug chondroitin sulfate on cartilage volume loss, bone marrow lesions (BML), and disease symptoms has been controversial (BMJ 2010;341:c4675). However, the authors of this study said that the MRI findings provided additional evidence on the joint structure protective effect of chondroitin sulfate.

Several studies have also shown that MRI can quantitatively and reliably assess the volume and cartilage thickness in addition to joint structural changes in subchondral bone, menisci, and synovium, the authors reported.

"MRI provides you with direct visualization of the cartilage," said Dr. Pelletier, director of the osteoarthritis research unit at the University of Montreal Hospital Research Centre. "And the beauty of MRI is that it not only it provides assessment of progression of change in cartilage, but also in many other tissues of the joint, like the subchondral bone and the synovium.

"In addition, the pronounced reduction in OA cartilage loss found in patients treated with chondroitin sulfate was also associated with a reduction in the size of BML. This finding is most interesting as BML are believed to be associated with the progression of OA cartilage lesions," according to a number of studies, said Dr. Pelletier.

The study also showed that patients who were being treated with NSAIDs in addition to chondroitin sulfate showed a significant reduction in synovial membrane thickness (1.3 plus or minus 0.3 mm in 6 months vs. 1.6 plus or minus 0.3 mm placebo) and a lower incidence of joint swelling, compared with the placebo group (0% in chondroitin sulfate vs. 11.4% in placebo). The finding "is interesting with practical clinical impact, and definitely needs future exploration," the authors wrote.

Researchers recruited 69 patients of both sexes between 40 and 80 years of age from rheumatology clinics in Quebec province. All patients had clinical signs of synovitis.

The study had two phases. For the double-blind phase, the patients were randomly assigned to once-daily placebo or 800 mg of chondroitin sulfate for 6 months. During the following 6 months, or the open-label phase, both groups received 800 mg of chondroitin sulfate daily.

Cartilage volume and BML were assessed by MRI at baseline, 6 months, and 12 months. Synovial membrane thickness was assessed at baseline and 6 months.

Patients who took a daily oral dose of chondroitin sulfate had a significant reduction in cartilage volume loss at 6 months (–2.87%) and 12 months (–3.71%) in the global knee compared to the placebo group (–4.67% at 6 months and -6.12% at 12 months).

There were no differences in BML during the first 6 months. But, at 12 months reduction in BML were observed in the chondroitin sulfate group (–0.57%), especially in the lateral compartment (–0.13%) and the lateral condyle (–0.43). The additional 6-months needed to see the change could suggest that "BML are consequential to cartilage degradation and thus reducing cartilage lesions could lead to fewer BML. Alternatively, BML were shown to be involved in an inflammatory/catabolic process on which chondroitin sulfate could act directly, leading to structural repair," according to the study.

No significant difference in disease symptoms were measured by visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires. "The main aim of the study was not the symptoms. The main goal was to find out whether chondroitin sulfate can reduce progression of knee OA," said Dr. Pelletier.

The study had limitations, including a small sample size. In addition, the system used did not allow the detection of the cartilage in the patella, researchers reported. They added that long-term studies are needed to find the impact of CS in disease symptoms.

Whether the quantitive MRI technique will eventually replace X-ray technology in such studies is unclear, said Dr. Pelletier. "That’s for regulatory bodies to decide," he said. "But it’s quite clear that MRI is the technology of the future. It’s very helpful, because you can truly speed up drug development in the field of OA and with less expense, using smaller number of patients and in a shorter period of time."

Dr. Jean-Pierre Pelletier and Dr. Johanne Martel-Pelletier are consultants for and shareholders in ArthroLab Inc. and ArthroVision Inc. Jean-Pierre Raynauld is a consultant for ArthroVision. Dr. André Beaulieu, Dr. Louis Bassette, and Dr. Frédéric Morin received honoraria from ArthroLab. François Abram is an employee of ArthroVision. Marc Dorais is a consultant for ArthroVision. Dr. Altman had no relevant financial conflicts of interest.

Chondroitin sulfate slows the progression of knee osteoarthritis, according to findings from a pilot study that used magnetic resonance imaging to assess joint structural changes.

"It’s reassuring to see that the four major x-rays studies are now confirmed by high technology in the assessment of disease progression," said the study’s lead author Dr. Jean-Pierre Pelletier, in an interview. (Osteoarthr. Cartil. 1998;6:39-46), (Osteoarthr. Cartil. 2004;12:269-76), (Arthritis Rheum. 2005;52:779-86), (Arthritis Rheum. 2009;60:524-33).

The randomized, double-blind, placebo-controlled study showed that chondroitin sulfate reduced the cartilage loss volume in 69 patients with knee OA in as early as 6 months. (Ann. Rheum. Dis. 2011 March 1)

The findings show that "[MRI] is a good quantitative technique to find answers in shorter period of time with smaller number of patients," said Dr. Roy D. Altman, professor of medicine at the University of California, Los Angeles, who is not involved with the study.

The effect of disease-modifying drug chondroitin sulfate on cartilage volume loss, bone marrow lesions (BML), and disease symptoms has been controversial (BMJ 2010;341:c4675). However, the authors of this study said that the MRI findings provided additional evidence on the joint structure protective effect of chondroitin sulfate.

Several studies have also shown that MRI can quantitatively and reliably assess the volume and cartilage thickness in addition to joint structural changes in subchondral bone, menisci, and synovium, the authors reported.

"MRI provides you with direct visualization of the cartilage," said Dr. Pelletier, director of the osteoarthritis research unit at the University of Montreal Hospital Research Centre. "And the beauty of MRI is that it not only it provides assessment of progression of change in cartilage, but also in many other tissues of the joint, like the subchondral bone and the synovium.

"In addition, the pronounced reduction in OA cartilage loss found in patients treated with chondroitin sulfate was also associated with a reduction in the size of BML. This finding is most interesting as BML are believed to be associated with the progression of OA cartilage lesions," according to a number of studies, said Dr. Pelletier.

The study also showed that patients who were being treated with NSAIDs in addition to chondroitin sulfate showed a significant reduction in synovial membrane thickness (1.3 plus or minus 0.3 mm in 6 months vs. 1.6 plus or minus 0.3 mm placebo) and a lower incidence of joint swelling, compared with the placebo group (0% in chondroitin sulfate vs. 11.4% in placebo). The finding "is interesting with practical clinical impact, and definitely needs future exploration," the authors wrote.

Researchers recruited 69 patients of both sexes between 40 and 80 years of age from rheumatology clinics in Quebec province. All patients had clinical signs of synovitis.

The study had two phases. For the double-blind phase, the patients were randomly assigned to once-daily placebo or 800 mg of chondroitin sulfate for 6 months. During the following 6 months, or the open-label phase, both groups received 800 mg of chondroitin sulfate daily.

Cartilage volume and BML were assessed by MRI at baseline, 6 months, and 12 months. Synovial membrane thickness was assessed at baseline and 6 months.

Patients who took a daily oral dose of chondroitin sulfate had a significant reduction in cartilage volume loss at 6 months (–2.87%) and 12 months (–3.71%) in the global knee compared to the placebo group (–4.67% at 6 months and -6.12% at 12 months).

There were no differences in BML during the first 6 months. But, at 12 months reduction in BML were observed in the chondroitin sulfate group (–0.57%), especially in the lateral compartment (–0.13%) and the lateral condyle (–0.43). The additional 6-months needed to see the change could suggest that "BML are consequential to cartilage degradation and thus reducing cartilage lesions could lead to fewer BML. Alternatively, BML were shown to be involved in an inflammatory/catabolic process on which chondroitin sulfate could act directly, leading to structural repair," according to the study.

No significant difference in disease symptoms were measured by visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires. "The main aim of the study was not the symptoms. The main goal was to find out whether chondroitin sulfate can reduce progression of knee OA," said Dr. Pelletier.

The study had limitations, including a small sample size. In addition, the system used did not allow the detection of the cartilage in the patella, researchers reported. They added that long-term studies are needed to find the impact of CS in disease symptoms.

Whether the quantitive MRI technique will eventually replace X-ray technology in such studies is unclear, said Dr. Pelletier. "That’s for regulatory bodies to decide," he said. "But it’s quite clear that MRI is the technology of the future. It’s very helpful, because you can truly speed up drug development in the field of OA and with less expense, using smaller number of patients and in a shorter period of time."

Dr. Jean-Pierre Pelletier and Dr. Johanne Martel-Pelletier are consultants for and shareholders in ArthroLab Inc. and ArthroVision Inc. Jean-Pierre Raynauld is a consultant for ArthroVision. Dr. André Beaulieu, Dr. Louis Bassette, and Dr. Frédéric Morin received honoraria from ArthroLab. François Abram is an employee of ArthroVision. Marc Dorais is a consultant for ArthroVision. Dr. Altman had no relevant financial conflicts of interest.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress (pdf).

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress (pdf).

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress (pdf).

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress (pdf).

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress (pdf).

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress (pdf).

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress (pdf).

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress (pdf).

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress (pdf).

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress.

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress.

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress.

"For a long time, I’ve been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare’s physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we’re going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission’s goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress.

"For a long time, I've been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare's physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we're going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission's goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress.

"For a long time, I've been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare's physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we're going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission's goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Medicare physician fees should be increased by 1% in 2012, and an alternative must be found for the Sustainable Growth Rate formula, according to recommendations in the Medicare Payment Advisory Commission annual March report to Congress.

"For a long time, I've been able to sit before this subcommittee and say that SGR is a problem but we don’t see an imminent threat to access," Medicare Payment Advisory Commission (MedPAC) Chairman Glenn Hackbarth testified before the Health Subcommittee of the House Ways and Means Committee. But "we think we’re getting closer to that tipping point" when that is no longer the case.

In 2009, fee-for-service Medicare spent about $64 billion on physician and other health professional services, accounting for 13% of total Medicare spending, according to the 2011 MedPAC report, which noted that "among the 1 million clinicians in Medicare’s registry, about half are physicians who actively bill Medicare."

In addressing the SGR, the report notes that "a main flaw of the SGR is its blunt approach.

"In setting across-the-board updates to Medicare's physician fee schedule, the system neither rewards individual providers who restrain unnecessary volume growth nor penalizes those who contribute most to volume increases. Also, the SGR does little to counter the volume incentives that are inherent in [fee-for-service] payments. In fact, volume growth is one of the major factors that has caused cumulative spending to exceed the SGR’s cumulative target," according to the report.

In the absence of congressional action, the SGR requires physician payments to be cut by approximately 30% in 2012, according to MedPAC calculations.

Every year since 2002, Medicare spending has exceeded SGR targets, causing physician pay, by law, to be reduced. However, pretty much every year, and more recently, two or three times a year, Congress has stepped in to legislate a way to avoid those cuts. Cumulatively, the avoided cuts are becoming an ever-growing debt being carried on the federal ledger.

The White House, in its fiscal 2012 budget proposal, is proposing to reduce that debt over the next 10 years, at a cost of $370 billion.

But the administration has figured out only how to pay for that fix for the first 2 years.

Mr. Hackbarth told the subcommittee that MedPAC will look into options for a new payment system, but he added that any new payment system will have a budget score attached to it. The question for Congress is "whether we're going to spend more by making last-minute adjustments piling more money into the existing payment system, or whether we’re going to spend more strategically to achieve important goals for the Medicare program. We think the latter course is the wiser course," he said.

He added that the commission's goal is to develop a package with a budget cost, which will also achieve certain goals for Medicare reform; such a plan could be ready later this year.

MedPAC is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June.

Multiple studies paint a picture of the continuing and projected shortage of general surgeons in the United States, especially in rural areas.

The number of general surgeons per 100,000 population dropped by 3.6% between 2004 and 2008, according to a 2010 study by the American College of Surgeons (ACS) Health Policy Research Institute. Projections by the federal Health Resources and Services Administration show that the number of general surgeons will drop by 3% between 2000 and 2020 from 33,980 to 31,880.

Additionally, the surgeon population overall is aging and retiring at a faster pace than new surgeons are entering practice, according to an analysis done by the ACS Health Policy Research Institute. Approximately one-third of all surgeons are older than age 55 years; the median age for rural surgeons is higher than for those who practice in urban areas.

Dr. Phil Caropreso, age 64, has been practicing in two small area hospitals in Keokuk, Iowa, for the past 13 years. Keokuk, a town of about 11,000 in the southeastern corner of the state, appeals to outdoors enthusiasts who enjoy hunting, fishing, golfing, and boating.

The only other general surgeon there retired, and Dr. Caropreso is now on call 24 hours a day, 7 days a week, for the two hospitals.

"Recruiting has almost been impossible," said Dr. Caropreso. "We’ve been advertising for the last 7 years in both [hospitals]." They have had recruitment services, placed ads in journals, talked with the residency director at University of Iowa, Iowa City, he said. Only a few people came to be interviewed. A couple of surgeons accepted the job, but left shortly thereafter.

"Surgeons today seem to prefer more urban areas; they want a different kind of work ethic. They’re trained differently. They now go into subspecialty surgery, and they don’t want to come here," he said.

Along with primary care physicians, general surgeons are a crucial component of the rural health care team, and they are essential to maintaining the financial health of the rural hospital, according to the Mithoefer Center for Rural Surgery in Cooperstown, N.Y. The center was established in 2004 to develop solutions aimed at benefiting rural citizens, rural surgeons, and rural hospitals.

"There’s a lot of information that shows that [rural surgeons are the] economic engine that maintains small rural hospitals," said Dr. David C. Borgstrom, the center’s codirector. "They’re the primary endoscopist for the community. They do a wide range of surgeries; they do obstetrics services, a bit of orthopedics," and other procedures, he added.

But many of today’s general surgeons are not as broadly trained as their colleagues were a decade or so ago, some surgeons say. Experienced rural general surgeons who can perform a wide range of procedures such as obstetrical, urological, and orthopedic procedures are becoming rare.

"I was trained in the ’70s and ’80s at [the then-Cook County Hospital, Chicago] where we were trained to do just about everything," said Dr. Arnold Serota, who until recently practiced general surgery in Kauai, Hawaii.

"The general surgery training back then was much different than it is now. In addition to routine general surgery – laparoscopic and open cases – I was doing trauma, critical care, placing pacemakers, esophagogastroduodenoscopies and colonoscopies, vascular surgery, and more," he said in an interview. "Now that I have left Kauai, there is no one person who can provide the services that I did." The scope of what more recently trained surgeons do is much more limited, he explained.

The economic and lifestyle preferences of the newer generation of medical school graduates also play into the rural surgeon shortage. According to a study by the Robert Graham Center, the policy arm of the American Academy of Family Physicians, "Growing physician income disparities are a major driver of student behavior. This income disparity explains much of the difficulty in achieving the balance in specialty and geographic physician distribution and will continue to inhibit achieving the workforce needed for better quality, efficiency, and equity."

The study adds that rural birth, interest in serving underserved or minority populations, and rural or inner-city training experience increase the likelihood of students choosing primary care or practice in rural and underserved areas.

This has been the case with Dr. Steve Olson, age 55, who grew up in rural Cooperstown, N.Y., where his father was a surgeon at the local hospital. "I’ve always liked practicing in rural environments and bringing new things to the rural areas," he said.

A resident of Bridgton, Maine, Dr. Olson does not maintain a private practice; instead, he is an employee of nearby Bridgton Hospital. Although he earns less than he would practicing in an urban area, that’s fine with him, he said in an interview. But with only one other surgeon in the area, Dr. Olson is on call every other night during week, and every other weekend. 

"If we had four surgeons, we’d have a really nice lifestyle," he said. "Nobody would be overburdened with calls."

There are programs that encourage and train young surgeons for rural practice, and the ACS continues to raise awareness about the shortage.

"Estimates show that there’s an increasing need to care for rural America, because of retiring rural surgeons. We are trying to fill those needs and to show why being a rural surgeon is a good thing," Dr. Borgstrom said in an interview.

But addressing the shortage of rural surgeons, given the lack of interest among young surgeons and the aging population of the existing ones, is multifaceted.

"It’s clear that our system doesn’t provide an easy way for surgical patients to access the appropriate level of care," said Dr. Olson, chair of the Rural Surgery Subcommittee and vice chair of the advisory council for general surgery for the ACS. "Solutions won’t come until major groups work together. Congress has to pass some laws on how health care is delivered, and physicians and health care organizations in rural areas need to really stand up and be part of that discussion. If we can establish a model on rural health care, we can make a difference."

Meanwhile, rural surgeons such as Dr. Caropreso continue their advocacy – and their search for colleagues.

Multiple studies paint a picture of the continuing and projected shortage of general surgeons in the United States, especially in rural areas.

The number of general surgeons per 100,000 population dropped by 3.6% between 2004 and 2008, according to a 2010 study by the American College of Surgeons (ACS) Health Policy Research Institute. Projections by the federal Health Resources and Services Administration show that the number of general surgeons will drop by 3% between 2000 and 2020 from 33,980 to 31,880.

Additionally, the surgeon population overall is aging and retiring at a faster pace than new surgeons are entering practice, according to an analysis done by the ACS Health Policy Research Institute. Approximately one-third of all surgeons are older than age 55 years; the median age for rural surgeons is higher than for those who practice in urban areas.

Dr. Phil Caropreso, age 64, has been practicing in two small area hospitals in Keokuk, Iowa, for the past 13 years. Keokuk, a town of about 11,000 in the southeastern corner of the state, appeals to outdoors enthusiasts who enjoy hunting, fishing, golfing, and boating.

The only other general surgeon there retired, and Dr. Caropreso is now on call 24 hours a day, 7 days a week, for the two hospitals.

"Recruiting has almost been impossible," said Dr. Caropreso. "We’ve been advertising for the last 7 years in both [hospitals]." They have had recruitment services, placed ads in journals, talked with the residency director at University of Iowa, Iowa City, he said. Only a few people came to be interviewed. A couple of surgeons accepted the job, but left shortly thereafter.

"Surgeons today seem to prefer more urban areas; they want a different kind of work ethic. They’re trained differently. They now go into subspecialty surgery, and they don’t want to come here," he said.

Along with primary care physicians, general surgeons are a crucial component of the rural health care team, and they are essential to maintaining the financial health of the rural hospital, according to the Mithoefer Center for Rural Surgery in Cooperstown, N.Y. The center was established in 2004 to develop solutions aimed at benefiting rural citizens, rural surgeons, and rural hospitals.

"There’s a lot of information that shows that [rural surgeons are the] economic engine that maintains small rural hospitals," said Dr. David C. Borgstrom, the center’s codirector. "They’re the primary endoscopist for the community. They do a wide range of surgeries; they do obstetrics services, a bit of orthopedics," and other procedures, he added.

But many of today’s general surgeons are not as broadly trained as their colleagues were a decade or so ago, some surgeons say. Experienced rural general surgeons who can perform a wide range of procedures such as obstetrical, urological, and orthopedic procedures are becoming rare.

"I was trained in the ’70s and ’80s at [the then-Cook County Hospital, Chicago] where we were trained to do just about everything," said Dr. Arnold Serota, who until recently practiced general surgery in Kauai, Hawaii.

"The general surgery training back then was much different than it is now. In addition to routine general surgery – laparoscopic and open cases – I was doing trauma, critical care, placing pacemakers, esophagogastroduodenoscopies and colonoscopies, vascular surgery, and more," he said in an interview. "Now that I have left Kauai, there is no one person who can provide the services that I did." The scope of what more recently trained surgeons do is much more limited, he explained.

The economic and lifestyle preferences of the newer generation of medical school graduates also play into the rural surgeon shortage. According to a study by the Robert Graham Center, the policy arm of the American Academy of Family Physicians, "Growing physician income disparities are a major driver of student behavior. This income disparity explains much of the difficulty in achieving the balance in specialty and geographic physician distribution and will continue to inhibit achieving the workforce needed for better quality, efficiency, and equity."

The study adds that rural birth, interest in serving underserved or minority populations, and rural or inner-city training experience increase the likelihood of students choosing primary care or practice in rural and underserved areas.

This has been the case with Dr. Steve Olson, age 55, who grew up in rural Cooperstown, N.Y., where his father was a surgeon at the local hospital. "I’ve always liked practicing in rural environments and bringing new things to the rural areas," he said.

A resident of Bridgton, Maine, Dr. Olson does not maintain a private practice; instead, he is an employee of nearby Bridgton Hospital. Although he earns less than he would practicing in an urban area, that’s fine with him, he said in an interview. But with only one other surgeon in the area, Dr. Olson is on call every other night during week, and every other weekend. 

"If we had four surgeons, we’d have a really nice lifestyle," he said. "Nobody would be overburdened with calls."

There are programs that encourage and train young surgeons for rural practice, and the ACS continues to raise awareness about the shortage.

"Estimates show that there’s an increasing need to care for rural America, because of retiring rural surgeons. We are trying to fill those needs and to show why being a rural surgeon is a good thing," Dr. Borgstrom said in an interview.

But addressing the shortage of rural surgeons, given the lack of interest among young surgeons and the aging population of the existing ones, is multifaceted.

"It’s clear that our system doesn’t provide an easy way for surgical patients to access the appropriate level of care," said Dr. Olson, chair of the Rural Surgery Subcommittee and vice chair of the advisory council for general surgery for the ACS. "Solutions won’t come until major groups work together. Congress has to pass some laws on how health care is delivered, and physicians and health care organizations in rural areas need to really stand up and be part of that discussion. If we can establish a model on rural health care, we can make a difference."

Meanwhile, rural surgeons such as Dr. Caropreso continue their advocacy – and their search for colleagues.

Multiple studies paint a picture of the continuing and projected shortage of general surgeons in the United States, especially in rural areas.

The number of general surgeons per 100,000 population dropped by 3.6% between 2004 and 2008, according to a 2010 study by the American College of Surgeons (ACS) Health Policy Research Institute. Projections by the federal Health Resources and Services Administration show that the number of general surgeons will drop by 3% between 2000 and 2020 from 33,980 to 31,880.

Additionally, the surgeon population overall is aging and retiring at a faster pace than new surgeons are entering practice, according to an analysis done by the ACS Health Policy Research Institute. Approximately one-third of all surgeons are older than age 55 years; the median age for rural surgeons is higher than for those who practice in urban areas.

Dr. Phil Caropreso, age 64, has been practicing in two small area hospitals in Keokuk, Iowa, for the past 13 years. Keokuk, a town of about 11,000 in the southeastern corner of the state, appeals to outdoors enthusiasts who enjoy hunting, fishing, golfing, and boating.

The only other general surgeon there retired, and Dr. Caropreso is now on call 24 hours a day, 7 days a week, for the two hospitals.

"Recruiting has almost been impossible," said Dr. Caropreso. "We’ve been advertising for the last 7 years in both [hospitals]." They have had recruitment services, placed ads in journals, talked with the residency director at University of Iowa, Iowa City, he said. Only a few people came to be interviewed. A couple of surgeons accepted the job, but left shortly thereafter.

"Surgeons today seem to prefer more urban areas; they want a different kind of work ethic. They’re trained differently. They now go into subspecialty surgery, and they don’t want to come here," he said.

Along with primary care physicians, general surgeons are a crucial component of the rural health care team, and they are essential to maintaining the financial health of the rural hospital, according to the Mithoefer Center for Rural Surgery in Cooperstown, N.Y. The center was established in 2004 to develop solutions aimed at benefiting rural citizens, rural surgeons, and rural hospitals.

"There’s a lot of information that shows that [rural surgeons are the] economic engine that maintains small rural hospitals," said Dr. David C. Borgstrom, the center’s codirector. "They’re the primary endoscopist for the community. They do a wide range of surgeries; they do obstetrics services, a bit of orthopedics," and other procedures, he added.

But many of today’s general surgeons are not as broadly trained as their colleagues were a decade or so ago, some surgeons say. Experienced rural general surgeons who can perform a wide range of procedures such as obstetrical, urological, and orthopedic procedures are becoming rare.

"I was trained in the ’70s and ’80s at [the then-Cook County Hospital, Chicago] where we were trained to do just about everything," said Dr. Arnold Serota, who until recently practiced general surgery in Kauai, Hawaii.

"The general surgery training back then was much different than it is now. In addition to routine general surgery – laparoscopic and open cases – I was doing trauma, critical care, placing pacemakers, esophagogastroduodenoscopies and colonoscopies, vascular surgery, and more," he said in an interview. "Now that I have left Kauai, there is no one person who can provide the services that I did." The scope of what more recently trained surgeons do is much more limited, he explained.

The economic and lifestyle preferences of the newer generation of medical school graduates also play into the rural surgeon shortage. According to a study by the Robert Graham Center, the policy arm of the American Academy of Family Physicians, "Growing physician income disparities are a major driver of student behavior. This income disparity explains much of the difficulty in achieving the balance in specialty and geographic physician distribution and will continue to inhibit achieving the workforce needed for better quality, efficiency, and equity."

The study adds that rural birth, interest in serving underserved or minority populations, and rural or inner-city training experience increase the likelihood of students choosing primary care or practice in rural and underserved areas.

This has been the case with Dr. Steve Olson, age 55, who grew up in rural Cooperstown, N.Y., where his father was a surgeon at the local hospital. "I’ve always liked practicing in rural environments and bringing new things to the rural areas," he said.

A resident of Bridgton, Maine, Dr. Olson does not maintain a private practice; instead, he is an employee of nearby Bridgton Hospital. Although he earns less than he would practicing in an urban area, that’s fine with him, he said in an interview. But with only one other surgeon in the area, Dr. Olson is on call every other night during week, and every other weekend. 

"If we had four surgeons, we’d have a really nice lifestyle," he said. "Nobody would be overburdened with calls."

There are programs that encourage and train young surgeons for rural practice, and the ACS continues to raise awareness about the shortage.

"Estimates show that there’s an increasing need to care for rural America, because of retiring rural surgeons. We are trying to fill those needs and to show why being a rural surgeon is a good thing," Dr. Borgstrom said in an interview.

But addressing the shortage of rural surgeons, given the lack of interest among young surgeons and the aging population of the existing ones, is multifaceted.

"It’s clear that our system doesn’t provide an easy way for surgical patients to access the appropriate level of care," said Dr. Olson, chair of the Rural Surgery Subcommittee and vice chair of the advisory council for general surgery for the ACS. "Solutions won’t come until major groups work together. Congress has to pass some laws on how health care is delivered, and physicians and health care organizations in rural areas need to really stand up and be part of that discussion. If we can establish a model on rural health care, we can make a difference."

Meanwhile, rural surgeons such as Dr. Caropreso continue their advocacy – and their search for colleagues.