Junior-level residents are getting less operative experience in some common general surgery procedures, a large case review study has found.

The rise in laparoscopic surgery and the decline of open procedures have been accompanied by a reduction in junior resident participation in what previously would have been considered junior-level cases, reported Matthew Mullen, MD, and his associates at the department of surgery, University of Virginia, Charlottesville (J Surg Educ. 2016 August. doi: 10.1016/j.jsurg.2016.02.010).

©Comstock/Thinkstock

“The general response from the surgical community has been that this issue would correct over time, and the distribution of cases to junior residents would normalize,” the investigators explained. In the present study, the investigators “sought to evaluate continuing trends in case distribution among junior and senior residents.”

A total of 185,335 surgical cases performed between 2005 and 2012, identified through a query of the Participant Use Data File, were analyzed. Junior residents were defined as PGY1-3. Of the surgical cases reviewed, 30.2% were appendectomies, 21.9% were inguinal herniorrhaphies, 14.2% were colectomies, and 33.8% were cholecystectomy.

Over the 8-year period, 66% of those procedures were laparoscopic, and each year the likelihood of surgery being performed laparoscopically increased steadily for appendectomy, inguinal herniorrhaphy, and colectomy but remained the same for cholecystectomies.

In the same 8-year period, the likelihood of junior resident participation across all of these procedures decreased by an average of 5.3% per year. This decrease was most drastic for laparoscopic cholecystectomy at 6.2% per year while participation did not change for laparoscopic inguinal herniorrhaphy and increased by 3.9% for partial colectomy.

Junior level participation in open surgeries over the 8 years also decreased by 9.4% for appendectomy, 10% for inguinal herniorrhaphy, 2.9% for partial colectomy, and 4.1% for cholecystectomy.

Among the limitations of the study, the data did not show whether the lack of operative experience among junior residents was compensated for in their senior year or if these patterns differed between academic and community training environments.

“The reason for diminishing junior resident case volume for the basic general surgery procedures we examined is not truly known. It is possible that these common and technically straightforward cases, traditionally the training ground for junior residents, now require advanced laparoscopic skills and therefore are no longer appropriate for junior-level residents,” Dr. Mullen and his associates wrote.

Nonetheless, the decline of junior resident participation in these procedures will have significant implications for general surgery resident education, the investigators concluded.

This study was funded by the National Institutes of Health. Author disclosures were not reported.

Junior-level residents are getting less operative experience in some common general surgery procedures, a large case review study has found.

The rise in laparoscopic surgery and the decline of open procedures have been accompanied by a reduction in junior resident participation in what previously would have been considered junior-level cases, reported Matthew Mullen, MD, and his associates at the department of surgery, University of Virginia, Charlottesville (J Surg Educ. 2016 August. doi: 10.1016/j.jsurg.2016.02.010).

©Comstock/Thinkstock

“The general response from the surgical community has been that this issue would correct over time, and the distribution of cases to junior residents would normalize,” the investigators explained. In the present study, the investigators “sought to evaluate continuing trends in case distribution among junior and senior residents.”

A total of 185,335 surgical cases performed between 2005 and 2012, identified through a query of the Participant Use Data File, were analyzed. Junior residents were defined as PGY1-3. Of the surgical cases reviewed, 30.2% were appendectomies, 21.9% were inguinal herniorrhaphies, 14.2% were colectomies, and 33.8% were cholecystectomy.

Over the 8-year period, 66% of those procedures were laparoscopic, and each year the likelihood of surgery being performed laparoscopically increased steadily for appendectomy, inguinal herniorrhaphy, and colectomy but remained the same for cholecystectomies.

In the same 8-year period, the likelihood of junior resident participation across all of these procedures decreased by an average of 5.3% per year. This decrease was most drastic for laparoscopic cholecystectomy at 6.2% per year while participation did not change for laparoscopic inguinal herniorrhaphy and increased by 3.9% for partial colectomy.

Junior level participation in open surgeries over the 8 years also decreased by 9.4% for appendectomy, 10% for inguinal herniorrhaphy, 2.9% for partial colectomy, and 4.1% for cholecystectomy.

Among the limitations of the study, the data did not show whether the lack of operative experience among junior residents was compensated for in their senior year or if these patterns differed between academic and community training environments.

“The reason for diminishing junior resident case volume for the basic general surgery procedures we examined is not truly known. It is possible that these common and technically straightforward cases, traditionally the training ground for junior residents, now require advanced laparoscopic skills and therefore are no longer appropriate for junior-level residents,” Dr. Mullen and his associates wrote.

Nonetheless, the decline of junior resident participation in these procedures will have significant implications for general surgery resident education, the investigators concluded.

This study was funded by the National Institutes of Health. Author disclosures were not reported.

Junior-level residents are getting less operative experience in some common general surgery procedures, a large case review study has found.

The rise in laparoscopic surgery and the decline of open procedures have been accompanied by a reduction in junior resident participation in what previously would have been considered junior-level cases, reported Matthew Mullen, MD, and his associates at the department of surgery, University of Virginia, Charlottesville (J Surg Educ. 2016 August. doi: 10.1016/j.jsurg.2016.02.010).

©Comstock/Thinkstock

“The general response from the surgical community has been that this issue would correct over time, and the distribution of cases to junior residents would normalize,” the investigators explained. In the present study, the investigators “sought to evaluate continuing trends in case distribution among junior and senior residents.”

A total of 185,335 surgical cases performed between 2005 and 2012, identified through a query of the Participant Use Data File, were analyzed. Junior residents were defined as PGY1-3. Of the surgical cases reviewed, 30.2% were appendectomies, 21.9% were inguinal herniorrhaphies, 14.2% were colectomies, and 33.8% were cholecystectomy.

Over the 8-year period, 66% of those procedures were laparoscopic, and each year the likelihood of surgery being performed laparoscopically increased steadily for appendectomy, inguinal herniorrhaphy, and colectomy but remained the same for cholecystectomies.

In the same 8-year period, the likelihood of junior resident participation across all of these procedures decreased by an average of 5.3% per year. This decrease was most drastic for laparoscopic cholecystectomy at 6.2% per year while participation did not change for laparoscopic inguinal herniorrhaphy and increased by 3.9% for partial colectomy.

Junior level participation in open surgeries over the 8 years also decreased by 9.4% for appendectomy, 10% for inguinal herniorrhaphy, 2.9% for partial colectomy, and 4.1% for cholecystectomy.

Among the limitations of the study, the data did not show whether the lack of operative experience among junior residents was compensated for in their senior year or if these patterns differed between academic and community training environments.

“The reason for diminishing junior resident case volume for the basic general surgery procedures we examined is not truly known. It is possible that these common and technically straightforward cases, traditionally the training ground for junior residents, now require advanced laparoscopic skills and therefore are no longer appropriate for junior-level residents,” Dr. Mullen and his associates wrote.

Nonetheless, the decline of junior resident participation in these procedures will have significant implications for general surgery resident education, the investigators concluded.

This study was funded by the National Institutes of Health. Author disclosures were not reported.

(This column is the first in a three-part series.)

Question: Which of the following statements about state medical boards is best?

A. They are made up exclusively of doctors.

B. Disciplinary actions are on the rise.

C. They investigate narrowly defined areas of clinical practice.

D. They usually end with physician suspension.

E. They are insufficiently vigilant, according to critics.

Answer: E. The 10th Amendment of the U.S. Constitution authorizes states to establish laws protecting the health, safety, and general welfare of their citizens.

All 50 states have enacted legislation under the Medical Practice Act authorizing medical boards to issue licenses and regulate physician conduct. The structure and authority of these boards vary from state to state, with some retaining all licensing and disciplinary powers, while others are more advisory in nature and report to the department of health.

Medical boards consist primarily of appointed volunteer physicians and may employ an administrative staff that includes an executive officer and support personnel.¹

State statutes, rules, and regulations govern the disciplinary function of medical boards, which receive, review, and investigate complaints directly from patients and other sources.

There are six main categories of complaints: substandard patient care, alcohol and substance abuse, fraud and other criminal conduct, dishonesty, sexual misconduct, and failure to meet CME requirements. Whether a board can sanction a physician for misconduct outside the realm of medical practice is frequently at issue.

In Maryland, for example, conduct that has merely a general or associative relationship to the physician in his or her capacity as a member of the medical profession is not sanctionable by the state board of physicians.

On the other hand, if it relates to the effective delivery of patient care, then the misconduct can be said to occur in the “practice of medicine,” even if there is no issue of the individual’s grasp of particular technical skills.

However, the term “practice of medicine” is liberally construed in most jurisdictions, and both boards and courts tend to take a dim view of physician dishonesty and lack of integrity.

For example, the California Court of Appeals in Windham v. Board of Medical Quality Assurance rejected a defendant’s position that his conviction for tax evasion was not the type of transgression that reflected on his professional standing.² Instead, the court held that such dishonesty necessarily involves moral turpitude, and is sufficiently related to the practice of medicine as to justify revocation of licensure.

The court stated that it was difficult to “compartmentalize dishonesty in such a way that a person who is willing to cheat his government out of $65,000 in taxes may yet be considered honest in his dealings with his patients.”

Likewise, the Washington Supreme Court in an older case upheld the suspension of a doctor’s license following his conviction for tax fraud.³ In taking a broad view of the requirement that improper conduct relates to the practice of medicine, the court held that conviction for tax fraud, which goes to the issue of trustworthiness, is a valid reason for taking disciplinary action against a physician.

The number of adverse actions taken by boards nationwide appears to be stabilizing. In 2009, they affected some 4,560 errant physicians. In some states, both the number of complaints and actions may even be subsiding.

For example, the 2014 report by the Texas Medical Board showed that the number of complaints had fallen 17% after reaching a peak in 2009. In 2012, the year with the latest published nationwide data, there were 9,219 total board actions affecting 4,479 physicians. However, only a minority – some 275 doctors – faced the most severe disciplinary sanction, i.e., license revocation. The others either saw their licenses denied (170) or suspended (739), or faced lesser sanctions such as reprimands, probations, restrictions, and fines.

Critics have labeled medical boards “a good old boys network” where any private admonition is never made public. A stinging report of medical licensing and discipline in the state of New York, using data from 1982 through 1989, concluded, “the structure and functioning of the process as they now exist are seriously deficient in these areas and that major reforms are urgently needed.”⁴

The consumer group Public Citizen has bemoaned the fact that most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner. Advocacy groups worry about insufficient vigilance, and cite the case of Dr. Farid Fata, an oncologist whose license was finally removed by the Michigan board in 2013 for giving chemotherapy to healthy patients. The board had received an earlier complaint from a nurse in 2010, but it took no action until federal authorities charged the doctor following a tip from a whistleblower.⁵

To be sure, there are troubling observations. For one thing, there is an inexplicably wide variability in the rates of disciplinary actions. During 2007-2009, for example, Minnesota had the lowest rate per 1,000 physicians (1.07), whereas Alaska had the highest rate of 7.89, some seven times higher. State rankings also change drastically from year to year without apparent good reason.

For another, criminal convictions for insurance fraud and violation of controlled substances prescriptions frequently end up with only mild or modest discipline.

In 1999, Public Citizen began publishing yearly rankings that purportedly showed each board’s effectiveness, based on its number of “serious actions.” The rankings were based on yearly data released by the Federation of State Medical Boards (FSMB), a national nonprofit organization that represents the 70 medical and osteopathic boards of the United States and its territories.

The federation protested the way its data were being used, but the rankings apparently caused some board executives to lose their jobs. In 2012, the FSMB stopped reporting state actions, thus ending this type of public disclosure.

To be seen as unbiased guardians of the public trust, boards now have nonphysician members, some of whom are health care attorneys. The state governor who appoints the board members is answerable to the voters for any delay or decision that permits a rogue physician to keep on practicing.

Accordingly, Michigan has instituted a process that allows it to overrule a disciplinary decision by the board, which raises an issue of due process rights. Theoretically, physicians would clear themselves in a formal hearing and be officially exonerated by the board, only to see the decision overruled by an administrative department.

Some medical boards have been accused of going too far. In Rhode Island, state legislator Rep. Michael W. Chippendale (R) is heading a commission to look into its medical board. The controversy arose from an “outlandish” and “personal” accusation against a physician in a gastroenterology group, which was forced to stop work for a week.

All the facts have not been made public, but a civil suit against the complainant is apparently in the works. The accused physician reportedly had to undergo three board-ordered psychiatric evaluations, and a fourth is pending.

Elsewhere, Oklahoma state lawmaker Rep. Richard Morrissette (D) is said to be introducing legislation limiting the powers of Oklahoma’s medical board.⁶

These are probably isolated events, however, and may not necessarily signal the development of any backlash across the country.

References

1. U.S. Medical Regulatory Trends and Actions, May 2014.

2. Windham v. Board of Medical Quality Assurance, 104 Cal. App.3d 461 (1980).

3. In Re Kindschi, 52 Wn.2d 8 (1958).

4. Post, J. “Medical Discipline and Licensing in the State of New York: A Critical Review.” Bull NY Acad Med. 1991;67:66-98.

5. “One nurse’s gutsy effort to protect patients.” Detroit News, Feb. 6, 2015.

6. “The Black Cloud of a Medical Board Investigation.” Medscape, Dec. 23, 2015.

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

(This column is the first in a three-part series.)

Question: Which of the following statements about state medical boards is best?

A. They are made up exclusively of doctors.

B. Disciplinary actions are on the rise.

C. They investigate narrowly defined areas of clinical practice.

D. They usually end with physician suspension.

E. They are insufficiently vigilant, according to critics.

Answer: E. The 10th Amendment of the U.S. Constitution authorizes states to establish laws protecting the health, safety, and general welfare of their citizens.

All 50 states have enacted legislation under the Medical Practice Act authorizing medical boards to issue licenses and regulate physician conduct. The structure and authority of these boards vary from state to state, with some retaining all licensing and disciplinary powers, while others are more advisory in nature and report to the department of health.

Medical boards consist primarily of appointed volunteer physicians and may employ an administrative staff that includes an executive officer and support personnel.¹

State statutes, rules, and regulations govern the disciplinary function of medical boards, which receive, review, and investigate complaints directly from patients and other sources.

There are six main categories of complaints: substandard patient care, alcohol and substance abuse, fraud and other criminal conduct, dishonesty, sexual misconduct, and failure to meet CME requirements. Whether a board can sanction a physician for misconduct outside the realm of medical practice is frequently at issue.

In Maryland, for example, conduct that has merely a general or associative relationship to the physician in his or her capacity as a member of the medical profession is not sanctionable by the state board of physicians.

On the other hand, if it relates to the effective delivery of patient care, then the misconduct can be said to occur in the “practice of medicine,” even if there is no issue of the individual’s grasp of particular technical skills.

However, the term “practice of medicine” is liberally construed in most jurisdictions, and both boards and courts tend to take a dim view of physician dishonesty and lack of integrity.

For example, the California Court of Appeals in Windham v. Board of Medical Quality Assurance rejected a defendant’s position that his conviction for tax evasion was not the type of transgression that reflected on his professional standing.² Instead, the court held that such dishonesty necessarily involves moral turpitude, and is sufficiently related to the practice of medicine as to justify revocation of licensure.

The court stated that it was difficult to “compartmentalize dishonesty in such a way that a person who is willing to cheat his government out of $65,000 in taxes may yet be considered honest in his dealings with his patients.”

Likewise, the Washington Supreme Court in an older case upheld the suspension of a doctor’s license following his conviction for tax fraud.³ In taking a broad view of the requirement that improper conduct relates to the practice of medicine, the court held that conviction for tax fraud, which goes to the issue of trustworthiness, is a valid reason for taking disciplinary action against a physician.

The number of adverse actions taken by boards nationwide appears to be stabilizing. In 2009, they affected some 4,560 errant physicians. In some states, both the number of complaints and actions may even be subsiding.

For example, the 2014 report by the Texas Medical Board showed that the number of complaints had fallen 17% after reaching a peak in 2009. In 2012, the year with the latest published nationwide data, there were 9,219 total board actions affecting 4,479 physicians. However, only a minority – some 275 doctors – faced the most severe disciplinary sanction, i.e., license revocation. The others either saw their licenses denied (170) or suspended (739), or faced lesser sanctions such as reprimands, probations, restrictions, and fines.

Critics have labeled medical boards “a good old boys network” where any private admonition is never made public. A stinging report of medical licensing and discipline in the state of New York, using data from 1982 through 1989, concluded, “the structure and functioning of the process as they now exist are seriously deficient in these areas and that major reforms are urgently needed.”⁴

The consumer group Public Citizen has bemoaned the fact that most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner. Advocacy groups worry about insufficient vigilance, and cite the case of Dr. Farid Fata, an oncologist whose license was finally removed by the Michigan board in 2013 for giving chemotherapy to healthy patients. The board had received an earlier complaint from a nurse in 2010, but it took no action until federal authorities charged the doctor following a tip from a whistleblower.⁵

To be sure, there are troubling observations. For one thing, there is an inexplicably wide variability in the rates of disciplinary actions. During 2007-2009, for example, Minnesota had the lowest rate per 1,000 physicians (1.07), whereas Alaska had the highest rate of 7.89, some seven times higher. State rankings also change drastically from year to year without apparent good reason.

For another, criminal convictions for insurance fraud and violation of controlled substances prescriptions frequently end up with only mild or modest discipline.

In 1999, Public Citizen began publishing yearly rankings that purportedly showed each board’s effectiveness, based on its number of “serious actions.” The rankings were based on yearly data released by the Federation of State Medical Boards (FSMB), a national nonprofit organization that represents the 70 medical and osteopathic boards of the United States and its territories.

The federation protested the way its data were being used, but the rankings apparently caused some board executives to lose their jobs. In 2012, the FSMB stopped reporting state actions, thus ending this type of public disclosure.

To be seen as unbiased guardians of the public trust, boards now have nonphysician members, some of whom are health care attorneys. The state governor who appoints the board members is answerable to the voters for any delay or decision that permits a rogue physician to keep on practicing.

Accordingly, Michigan has instituted a process that allows it to overrule a disciplinary decision by the board, which raises an issue of due process rights. Theoretically, physicians would clear themselves in a formal hearing and be officially exonerated by the board, only to see the decision overruled by an administrative department.

Some medical boards have been accused of going too far. In Rhode Island, state legislator Rep. Michael W. Chippendale (R) is heading a commission to look into its medical board. The controversy arose from an “outlandish” and “personal” accusation against a physician in a gastroenterology group, which was forced to stop work for a week.

All the facts have not been made public, but a civil suit against the complainant is apparently in the works. The accused physician reportedly had to undergo three board-ordered psychiatric evaluations, and a fourth is pending.

Elsewhere, Oklahoma state lawmaker Rep. Richard Morrissette (D) is said to be introducing legislation limiting the powers of Oklahoma’s medical board.⁶

These are probably isolated events, however, and may not necessarily signal the development of any backlash across the country.

References

1. U.S. Medical Regulatory Trends and Actions, May 2014.

2. Windham v. Board of Medical Quality Assurance, 104 Cal. App.3d 461 (1980).

3. In Re Kindschi, 52 Wn.2d 8 (1958).

4. Post, J. “Medical Discipline and Licensing in the State of New York: A Critical Review.” Bull NY Acad Med. 1991;67:66-98.

5. “One nurse’s gutsy effort to protect patients.” Detroit News, Feb. 6, 2015.

6. “The Black Cloud of a Medical Board Investigation.” Medscape, Dec. 23, 2015.

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

(This column is the first in a three-part series.)

Question: Which of the following statements about state medical boards is best?

A. They are made up exclusively of doctors.

B. Disciplinary actions are on the rise.

C. They investigate narrowly defined areas of clinical practice.

D. They usually end with physician suspension.

E. They are insufficiently vigilant, according to critics.

Answer: E. The 10th Amendment of the U.S. Constitution authorizes states to establish laws protecting the health, safety, and general welfare of their citizens.

All 50 states have enacted legislation under the Medical Practice Act authorizing medical boards to issue licenses and regulate physician conduct. The structure and authority of these boards vary from state to state, with some retaining all licensing and disciplinary powers, while others are more advisory in nature and report to the department of health.

Medical boards consist primarily of appointed volunteer physicians and may employ an administrative staff that includes an executive officer and support personnel.¹

State statutes, rules, and regulations govern the disciplinary function of medical boards, which receive, review, and investigate complaints directly from patients and other sources.

There are six main categories of complaints: substandard patient care, alcohol and substance abuse, fraud and other criminal conduct, dishonesty, sexual misconduct, and failure to meet CME requirements. Whether a board can sanction a physician for misconduct outside the realm of medical practice is frequently at issue.

In Maryland, for example, conduct that has merely a general or associative relationship to the physician in his or her capacity as a member of the medical profession is not sanctionable by the state board of physicians.

On the other hand, if it relates to the effective delivery of patient care, then the misconduct can be said to occur in the “practice of medicine,” even if there is no issue of the individual’s grasp of particular technical skills.

However, the term “practice of medicine” is liberally construed in most jurisdictions, and both boards and courts tend to take a dim view of physician dishonesty and lack of integrity.

For example, the California Court of Appeals in Windham v. Board of Medical Quality Assurance rejected a defendant’s position that his conviction for tax evasion was not the type of transgression that reflected on his professional standing.² Instead, the court held that such dishonesty necessarily involves moral turpitude, and is sufficiently related to the practice of medicine as to justify revocation of licensure.

The court stated that it was difficult to “compartmentalize dishonesty in such a way that a person who is willing to cheat his government out of $65,000 in taxes may yet be considered honest in his dealings with his patients.”

Likewise, the Washington Supreme Court in an older case upheld the suspension of a doctor’s license following his conviction for tax fraud.³ In taking a broad view of the requirement that improper conduct relates to the practice of medicine, the court held that conviction for tax fraud, which goes to the issue of trustworthiness, is a valid reason for taking disciplinary action against a physician.

The number of adverse actions taken by boards nationwide appears to be stabilizing. In 2009, they affected some 4,560 errant physicians. In some states, both the number of complaints and actions may even be subsiding.

For example, the 2014 report by the Texas Medical Board showed that the number of complaints had fallen 17% after reaching a peak in 2009. In 2012, the year with the latest published nationwide data, there were 9,219 total board actions affecting 4,479 physicians. However, only a minority – some 275 doctors – faced the most severe disciplinary sanction, i.e., license revocation. The others either saw their licenses denied (170) or suspended (739), or faced lesser sanctions such as reprimands, probations, restrictions, and fines.

Critics have labeled medical boards “a good old boys network” where any private admonition is never made public. A stinging report of medical licensing and discipline in the state of New York, using data from 1982 through 1989, concluded, “the structure and functioning of the process as they now exist are seriously deficient in these areas and that major reforms are urgently needed.”⁴

The consumer group Public Citizen has bemoaned the fact that most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner. Advocacy groups worry about insufficient vigilance, and cite the case of Dr. Farid Fata, an oncologist whose license was finally removed by the Michigan board in 2013 for giving chemotherapy to healthy patients. The board had received an earlier complaint from a nurse in 2010, but it took no action until federal authorities charged the doctor following a tip from a whistleblower.⁵

To be sure, there are troubling observations. For one thing, there is an inexplicably wide variability in the rates of disciplinary actions. During 2007-2009, for example, Minnesota had the lowest rate per 1,000 physicians (1.07), whereas Alaska had the highest rate of 7.89, some seven times higher. State rankings also change drastically from year to year without apparent good reason.

For another, criminal convictions for insurance fraud and violation of controlled substances prescriptions frequently end up with only mild or modest discipline.

In 1999, Public Citizen began publishing yearly rankings that purportedly showed each board’s effectiveness, based on its number of “serious actions.” The rankings were based on yearly data released by the Federation of State Medical Boards (FSMB), a national nonprofit organization that represents the 70 medical and osteopathic boards of the United States and its territories.

The federation protested the way its data were being used, but the rankings apparently caused some board executives to lose their jobs. In 2012, the FSMB stopped reporting state actions, thus ending this type of public disclosure.

To be seen as unbiased guardians of the public trust, boards now have nonphysician members, some of whom are health care attorneys. The state governor who appoints the board members is answerable to the voters for any delay or decision that permits a rogue physician to keep on practicing.

Accordingly, Michigan has instituted a process that allows it to overrule a disciplinary decision by the board, which raises an issue of due process rights. Theoretically, physicians would clear themselves in a formal hearing and be officially exonerated by the board, only to see the decision overruled by an administrative department.

Some medical boards have been accused of going too far. In Rhode Island, state legislator Rep. Michael W. Chippendale (R) is heading a commission to look into its medical board. The controversy arose from an “outlandish” and “personal” accusation against a physician in a gastroenterology group, which was forced to stop work for a week.

All the facts have not been made public, but a civil suit against the complainant is apparently in the works. The accused physician reportedly had to undergo three board-ordered psychiatric evaluations, and a fourth is pending.

Elsewhere, Oklahoma state lawmaker Rep. Richard Morrissette (D) is said to be introducing legislation limiting the powers of Oklahoma’s medical board.⁶

These are probably isolated events, however, and may not necessarily signal the development of any backlash across the country.

References

1. U.S. Medical Regulatory Trends and Actions, May 2014.

2. Windham v. Board of Medical Quality Assurance, 104 Cal. App.3d 461 (1980).

3. In Re Kindschi, 52 Wn.2d 8 (1958).

4. Post, J. “Medical Discipline and Licensing in the State of New York: A Critical Review.” Bull NY Acad Med. 1991;67:66-98.

5. “One nurse’s gutsy effort to protect patients.” Detroit News, Feb. 6, 2015.

6. “The Black Cloud of a Medical Board Investigation.” Medscape, Dec. 23, 2015.

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

This month’s issue features coverage of a presentation by John Morton, MD, FACS, at the ACS National Surgical Quality Improvement Project annual meeting on the remarkable progress made over the past decade on bariatric surgery safety and patient satisfaction. The work in this area of quality improvement continues with the DROP project currently underway. See p

In this month’s From the Washington Office column, Patrick V. Bailey, MD, FACS, keeps the Fellows informed on the advocacy efforts to make sure the 2017 proposed Medicare Physician Fee Schedule does not impose unreasonable data collection burdens on surgeons. See p. 7

Meet our new co-Editors of ACS Surgery News, Karen E. Deveney, MD, FACS and Tyler G. Hughes, MD, FACS! These two surgeons are teaming up to oversee the content and direction of ACS Surgery News, replacing our esteemed former Editor-in-Chief, Layton F. Rikkers, MD, FACS. Dr. Rikkers is a tough act to follow, but our two new Editors are up to the challenge and I hope you will join me in welcoming them both. See p. 8

Use the mobile app to download or view as a pdf.

This month’s issue features coverage of a presentation by John Morton, MD, FACS, at the ACS National Surgical Quality Improvement Project annual meeting on the remarkable progress made over the past decade on bariatric surgery safety and patient satisfaction. The work in this area of quality improvement continues with the DROP project currently underway. See p

In this month’s From the Washington Office column, Patrick V. Bailey, MD, FACS, keeps the Fellows informed on the advocacy efforts to make sure the 2017 proposed Medicare Physician Fee Schedule does not impose unreasonable data collection burdens on surgeons. See p. 7

Meet our new co-Editors of ACS Surgery News, Karen E. Deveney, MD, FACS and Tyler G. Hughes, MD, FACS! These two surgeons are teaming up to oversee the content and direction of ACS Surgery News, replacing our esteemed former Editor-in-Chief, Layton F. Rikkers, MD, FACS. Dr. Rikkers is a tough act to follow, but our two new Editors are up to the challenge and I hope you will join me in welcoming them both. See p. 8

Use the mobile app to download or view as a pdf.

This month’s issue features coverage of a presentation by John Morton, MD, FACS, at the ACS National Surgical Quality Improvement Project annual meeting on the remarkable progress made over the past decade on bariatric surgery safety and patient satisfaction. The work in this area of quality improvement continues with the DROP project currently underway. See p

In this month’s From the Washington Office column, Patrick V. Bailey, MD, FACS, keeps the Fellows informed on the advocacy efforts to make sure the 2017 proposed Medicare Physician Fee Schedule does not impose unreasonable data collection burdens on surgeons. See p. 7

Meet our new co-Editors of ACS Surgery News, Karen E. Deveney, MD, FACS and Tyler G. Hughes, MD, FACS! These two surgeons are teaming up to oversee the content and direction of ACS Surgery News, replacing our esteemed former Editor-in-Chief, Layton F. Rikkers, MD, FACS. Dr. Rikkers is a tough act to follow, but our two new Editors are up to the challenge and I hope you will join me in welcoming them both. See p. 8

Use the mobile app to download or view as a pdf.

SAN DIEGO – A Food and Drug Administration official told diabetes educators that her agency is carefully monitoring the growth of an unusual development in diabetes care: the do-it-yourself artificial pancreas.

While the homemade insulin pumps are serving a need that has been unmet by manufacturers, the unregulated devices can be dangerous, according to Courtney Lias, PhD, director of the FDA’s Division of Chemistry and Toxicology Devices, who spoke at the annual meeting of the American Association of Diabetes Educators. “As they go toward a larger community, we see that the risk is raised.”

Still, “people are doing this because they feel this is the best way for them to help themselves or their children. We understand why people are doing it, but we want to make sure they do it safely,” Dr. Lias said.

At issue: The need for a “closed loop” artificial pancreas that needs little or no human intervention to measure blood sugar levels and deliver insulin as needed.

While current insulin pumps can deliver basal insulin continuously, users must program them to deliver an insulin bolus after meals or to address high blood sugar. Manufacturers are trying to develop a closed-loop artificial pancreas (also known as a bionic pancreas) that will simplify the process.

On their own, computer experts have been experimenting with jury-rigged homemade do-it-yourself (DIY) systems. “We recognize that for many PWDs [people with diabetes] the available help is not yet enough, so we are not waiting,” according to Dana Lewis and Scott Leibrand, two bloggers on a site called DIYPS.org.

In May 2016, The Wall Street Journal profiled a San Diego third-grader who uses a homemade “robotic pancreas” designed by his software engineer father. “More than 50 people have soldered, tinkered, and written software to make such devices for themselves or their children,” according to the Wall Street Journal report.

In her talk at the American Association of Diabetes Educators meeting, Dr. Lias noted that “there are a lot of questions about whether this is something that should be done.”

The algorithm behind a homemade device is one of area of concern, she said. “Who developed it and who’s responsible for having developed it? You may not understand how the algorithm is developed and what information is behind it. If something goes wrong, there’s no recourse.”

There are also questions about quality control, she noted: “Is there a responsible party for understanding things, for collecting information and making corrections?”

Dr. Lias said physicians should ask these questions if patients say they are using a DIY artificial pancreas: Do you understand exactly what algorithm is being used? Is it right for you? Have you checked the code to ensure it implements the algorithm correctly? Have you double-checked? When new, modified versions of code are shared, have you re-validated your entire system before implementing it?

It’s also important, she said, to note that these devices have not been determined to be safe and effective.

As the FDA monitors these DIY devices, Dr. Lias said, it’s also working to be ready to consider the work of manufacturers who are trying to develop the first commercial artificial pancreas device.

“Artificial pancreas devices do not have to be perfect with zero risk to be beneficial,” she says. “The approval decision is a benefit/risk decision. We make this decision in the context of the high risks that people with diabetes face every day.”

For now, she says, one focus is to make it easier for companies to work together to create the components of an artificial pancreas device.

The FDA is also concerned about what newly diagnosed people with diabetes will do if their devices break down, and they don’t know how to give themselves an insulin injection. “That’s a scenario that we will need to work out,” she said. “We’re talking with manufacturers about how they plan to work with that.”

SAN DIEGO – A Food and Drug Administration official told diabetes educators that her agency is carefully monitoring the growth of an unusual development in diabetes care: the do-it-yourself artificial pancreas.

While the homemade insulin pumps are serving a need that has been unmet by manufacturers, the unregulated devices can be dangerous, according to Courtney Lias, PhD, director of the FDA’s Division of Chemistry and Toxicology Devices, who spoke at the annual meeting of the American Association of Diabetes Educators. “As they go toward a larger community, we see that the risk is raised.”

Still, “people are doing this because they feel this is the best way for them to help themselves or their children. We understand why people are doing it, but we want to make sure they do it safely,” Dr. Lias said.

At issue: The need for a “closed loop” artificial pancreas that needs little or no human intervention to measure blood sugar levels and deliver insulin as needed.

While current insulin pumps can deliver basal insulin continuously, users must program them to deliver an insulin bolus after meals or to address high blood sugar. Manufacturers are trying to develop a closed-loop artificial pancreas (also known as a bionic pancreas) that will simplify the process.

On their own, computer experts have been experimenting with jury-rigged homemade do-it-yourself (DIY) systems. “We recognize that for many PWDs [people with diabetes] the available help is not yet enough, so we are not waiting,” according to Dana Lewis and Scott Leibrand, two bloggers on a site called DIYPS.org.

In May 2016, The Wall Street Journal profiled a San Diego third-grader who uses a homemade “robotic pancreas” designed by his software engineer father. “More than 50 people have soldered, tinkered, and written software to make such devices for themselves or their children,” according to the Wall Street Journal report.

In her talk at the American Association of Diabetes Educators meeting, Dr. Lias noted that “there are a lot of questions about whether this is something that should be done.”

The algorithm behind a homemade device is one of area of concern, she said. “Who developed it and who’s responsible for having developed it? You may not understand how the algorithm is developed and what information is behind it. If something goes wrong, there’s no recourse.”

There are also questions about quality control, she noted: “Is there a responsible party for understanding things, for collecting information and making corrections?”

Dr. Lias said physicians should ask these questions if patients say they are using a DIY artificial pancreas: Do you understand exactly what algorithm is being used? Is it right for you? Have you checked the code to ensure it implements the algorithm correctly? Have you double-checked? When new, modified versions of code are shared, have you re-validated your entire system before implementing it?

It’s also important, she said, to note that these devices have not been determined to be safe and effective.

As the FDA monitors these DIY devices, Dr. Lias said, it’s also working to be ready to consider the work of manufacturers who are trying to develop the first commercial artificial pancreas device.

“Artificial pancreas devices do not have to be perfect with zero risk to be beneficial,” she says. “The approval decision is a benefit/risk decision. We make this decision in the context of the high risks that people with diabetes face every day.”

For now, she says, one focus is to make it easier for companies to work together to create the components of an artificial pancreas device.

The FDA is also concerned about what newly diagnosed people with diabetes will do if their devices break down, and they don’t know how to give themselves an insulin injection. “That’s a scenario that we will need to work out,” she said. “We’re talking with manufacturers about how they plan to work with that.”

SAN DIEGO – A Food and Drug Administration official told diabetes educators that her agency is carefully monitoring the growth of an unusual development in diabetes care: the do-it-yourself artificial pancreas.

While the homemade insulin pumps are serving a need that has been unmet by manufacturers, the unregulated devices can be dangerous, according to Courtney Lias, PhD, director of the FDA’s Division of Chemistry and Toxicology Devices, who spoke at the annual meeting of the American Association of Diabetes Educators. “As they go toward a larger community, we see that the risk is raised.”

Still, “people are doing this because they feel this is the best way for them to help themselves or their children. We understand why people are doing it, but we want to make sure they do it safely,” Dr. Lias said.

At issue: The need for a “closed loop” artificial pancreas that needs little or no human intervention to measure blood sugar levels and deliver insulin as needed.

While current insulin pumps can deliver basal insulin continuously, users must program them to deliver an insulin bolus after meals or to address high blood sugar. Manufacturers are trying to develop a closed-loop artificial pancreas (also known as a bionic pancreas) that will simplify the process.

On their own, computer experts have been experimenting with jury-rigged homemade do-it-yourself (DIY) systems. “We recognize that for many PWDs [people with diabetes] the available help is not yet enough, so we are not waiting,” according to Dana Lewis and Scott Leibrand, two bloggers on a site called DIYPS.org.

In May 2016, The Wall Street Journal profiled a San Diego third-grader who uses a homemade “robotic pancreas” designed by his software engineer father. “More than 50 people have soldered, tinkered, and written software to make such devices for themselves or their children,” according to the Wall Street Journal report.

In her talk at the American Association of Diabetes Educators meeting, Dr. Lias noted that “there are a lot of questions about whether this is something that should be done.”

The algorithm behind a homemade device is one of area of concern, she said. “Who developed it and who’s responsible for having developed it? You may not understand how the algorithm is developed and what information is behind it. If something goes wrong, there’s no recourse.”

There are also questions about quality control, she noted: “Is there a responsible party for understanding things, for collecting information and making corrections?”

Dr. Lias said physicians should ask these questions if patients say they are using a DIY artificial pancreas: Do you understand exactly what algorithm is being used? Is it right for you? Have you checked the code to ensure it implements the algorithm correctly? Have you double-checked? When new, modified versions of code are shared, have you re-validated your entire system before implementing it?

It’s also important, she said, to note that these devices have not been determined to be safe and effective.

As the FDA monitors these DIY devices, Dr. Lias said, it’s also working to be ready to consider the work of manufacturers who are trying to develop the first commercial artificial pancreas device.

“Artificial pancreas devices do not have to be perfect with zero risk to be beneficial,” she says. “The approval decision is a benefit/risk decision. We make this decision in the context of the high risks that people with diabetes face every day.”

For now, she says, one focus is to make it easier for companies to work together to create the components of an artificial pancreas device.

The FDA is also concerned about what newly diagnosed people with diabetes will do if their devices break down, and they don’t know how to give themselves an insulin injection. “That’s a scenario that we will need to work out,” she said. “We’re talking with manufacturers about how they plan to work with that.”

April 29 – May 3, 2017
Boston Hynes Convention Center
Boston, MA

President & Annual Meeting Chair
Thoralf M. Sundt, III

Annual Meeting Co-Chairs
Robert D. Jaquiss
Bryan F. Meyers

Reflecting on the Past. Building Our Future. Always Learning.

Please join us in Boston to celebrate the AATS Centennial.

Attendees will commemorate the first 100 years of the AATS and cardiothoracic surgery by enjoying activities and events, as well as viewing historical artifacts and memorabilia.

Celebrate How Far We Have Come: The Centennial officially begins with the Welcome Reception in the Exhibit Hall.

Celebrate Our Leadership: “In the Words of the Presidents” — a commemorative text containing personal reminiscences from most recent AATS past presidents — will be provided to all professional attendees.

Celebrate Our Specialty: The once-in-a-lifetime Centennial Gala will be held at the famed Wang Theatre in the heart of Boston. This black tie affair will include a cocktail reception, sit-down dinner on the stage, and performances from local musicians from prestigious Boston institutes.

Celebrate Our History: “In the Beginning” is a documentary film providing an in-depth look at the formative years of and challenges faced by cardiothoracic surgery. The film includes interviews with past presidents and members of the Centennial Committee.

April 29 – May 3, 2017
Boston Hynes Convention Center
Boston, MA

President & Annual Meeting Chair
Thoralf M. Sundt, III

Annual Meeting Co-Chairs
Robert D. Jaquiss
Bryan F. Meyers

Reflecting on the Past. Building Our Future. Always Learning.

Please join us in Boston to celebrate the AATS Centennial.

Attendees will commemorate the first 100 years of the AATS and cardiothoracic surgery by enjoying activities and events, as well as viewing historical artifacts and memorabilia.

Celebrate How Far We Have Come: The Centennial officially begins with the Welcome Reception in the Exhibit Hall.

Celebrate Our Leadership: “In the Words of the Presidents” — a commemorative text containing personal reminiscences from most recent AATS past presidents — will be provided to all professional attendees.

Celebrate Our Specialty: The once-in-a-lifetime Centennial Gala will be held at the famed Wang Theatre in the heart of Boston. This black tie affair will include a cocktail reception, sit-down dinner on the stage, and performances from local musicians from prestigious Boston institutes.

Celebrate Our History: “In the Beginning” is a documentary film providing an in-depth look at the formative years of and challenges faced by cardiothoracic surgery. The film includes interviews with past presidents and members of the Centennial Committee.

April 29 – May 3, 2017
Boston Hynes Convention Center
Boston, MA

President & Annual Meeting Chair
Thoralf M. Sundt, III

Annual Meeting Co-Chairs
Robert D. Jaquiss
Bryan F. Meyers

Reflecting on the Past. Building Our Future. Always Learning.

Please join us in Boston to celebrate the AATS Centennial.

Attendees will commemorate the first 100 years of the AATS and cardiothoracic surgery by enjoying activities and events, as well as viewing historical artifacts and memorabilia.

Celebrate How Far We Have Come: The Centennial officially begins with the Welcome Reception in the Exhibit Hall.

Celebrate Our Leadership: “In the Words of the Presidents” — a commemorative text containing personal reminiscences from most recent AATS past presidents — will be provided to all professional attendees.

Celebrate Our Specialty: The once-in-a-lifetime Centennial Gala will be held at the famed Wang Theatre in the heart of Boston. This black tie affair will include a cocktail reception, sit-down dinner on the stage, and performances from local musicians from prestigious Boston institutes.

Celebrate Our History: “In the Beginning” is a documentary film providing an in-depth look at the formative years of and challenges faced by cardiothoracic surgery. The film includes interviews with past presidents and members of the Centennial Committee.

Some of the Affordable Care Act’s insurance marketplaces are in turmoil as the fourth open enrollment season approaches this fall, but what’s ahead for consumers very much depends on where they live.

Competition on these exchanges will be diminished next year when three of the nation’s largest health insurers – Aetna, UnitedHealthcare and Humana – will sell individual plans in many fewer markets. So too will several Blue Cross and Blue Shield plans in various states. That’s on top of the 16 nonprofit co-ops that have closed since January 2015.

The announcements, however, apply generally only to the individual market. The much larger market of employer-sponsored insurance is not part of the health law exchanges.

Aetna’s exit announcement Aug. 15 that blamed financial losses on its marketplace plans gave Obamacare opponents who have from the start predicted the ACA’s failure a fresh chance to proclaim “I told you so.”

That story line got more complicated Aug. 17 after the Huffington Post reported that Aetna CEO Mark Bertolini sent a letter to the Department of Justice (DOJ) on July 5 threatening to withdraw from the Obamacare marketplaces if the DOJ sued to block his company’s planned merger with Humana. The DOJ did just that a couple weeks later.

But most marketplace consumers won’t see any ill effects from insurers’ withdrawals, according to ACA advocates and independent experts.

“The effect on consumers is going to be mixed around the country,” said Katherine Hempstead, PhD, a senior adviser at the nonpartisan Robert Wood Johnson Foundation. “Most of these marketplaces are not dependent on” the large national carriers.

Many major metropolitan areas, such as those in California, New York, and Texas, will still have several insurers for individual health insurance consumers to choose from. In Texas, all major metro areas – including Austin, Dallas, Houston, and San Antonio – will have at least three insurers after Aetna and UnitedHealthcare exit.

That’s true also for most urban exchange customers living in the Northwest, the Midwest, and New England.

Most hurt will be marketplace consumers in Arizona, North and South Carolina, Georgia, and parts of Florida, where only one or two insurers will be left when open enrollment season begins Nov. 15.

Remaining insurers might raise their monthly premiums as a result, but more than eight in 10 consumers on the marketplaces who get government subsidies would be insulated. Subsidies increase as premiums rise.

Still, health experts worry that with less competition, insurers may tighten their provider networks and give these consumers fewer choices of hospitals and doctors. That trend started several years ago, and some states have responded with regulations requiring insurers to provide customers with reasonable access to doctors and hospitals in each county where they sell plans.

Nearly 13 million people signed up for Obamacare marketplace policies for 2016. Aetna, UnitedHealthcare, and Humana have 2 million members in total, but their exit from certain states is predicted to affect between 1 million and 1.5 million people who will have to choose new carriers.

While changing plans can force people to find new doctors, it’s also the best way for consumers get the best deals on coverage.

Aetna will exit 11 of 15 states where it sells plans on the exchanges. UnitedHealthcare has said it will quit 22 of 34 states, and Humana will leave 4 of the 15 states where it operates.

In late May, the Kaiser Family Foundation estimated the number of rural counties at risk of having one insurer on the exchanges would triple in 2017. That was before Humana and Aetna detailed their plans. (KHN is an editorially independent project of the foundation.)

Now, “we could be looking at about one in four counties in the U.S. with just one exchange insurer next year, though this could change between now and open enrollment in November,” said Cynthia Cox, associate director for the Kaiser Family Foundation Program for the Study of Health Reform and Private Insurance.

Overshadowed by the big insurers’ withdrawals is the prospect that other carriers will enter markets the three giants are leaving. Smaller insurers Molina and Centene have said they’re doing fine on the exchanges. And Cigna, a larger insurer, has said it will move into some North Carolina counties for 2017.

North Carolina will be left with just one or two plans in most of the state after it loses UnitedHealthcare and Aetna plans. Health insurance experts say three insurers are needed for a healthy competitive market.

“We’ve had a very robust enrollment under the ACA and hope consumers will still see benefits of having coverage even if they have fewer options,” said Ciara Zachary, health policy analyst for the North Carolina Justice Center’s Health Access Coalition.

Rural Americans had few health insurers to choose from even before Obamacare, but some suburban and urban parts of the Southeast will be in the same fix next year. In southeast Florida, consumers in counties near Naples and Fort Myers will have only one marketplace insurer – Florida Blue – next year, unless other insurers step in.

“There are some headwinds, but it’s not a question of whether the market will stabilize but how quickly and how well,” said Dr. Hempstead.

Strong winds are already blowing toward Arizona’s Pinal County, southeast of Phoenix, health care advocates say. Nearly 10,000 people enrolled in Obamacare marketplace policies this year and about 85% received a federal subsidy.

In 2017, Pinal stands to lose its only two insurers – UnitedHealthcare and Blue Cross and Blue Shield of Arizona.

“Clearly this is a big concern for consumers,” said Allen Gjersvig, director of navigator and enrollment services for the Arizona Alliance for Community Health Centers. He said he is hopeful, but not confident, that another insurer will step in.

Neighboring Maricopa County, which includes Phoenix, is expected to have just two relatively small insurers left on its marketplace next year. Mr. Gjersvig said that he questions whether those two – Cigna and Phoenix Health Plan – will have enough doctors and hospitals under contract to handle their new members after larger rival Blue Cross and Blue Shield of Arizona gives up its 40,000 customers.

At least a dozen other counties in Arizona will be left with just one health insurer, he said.

Arizona had eight insurers operating in various parts of the state this year, but four are leaving entirely – Aetna, UnitedHealthcare, Humana, and Health Choice. Two more, Blue Cross Blue Shield and Health Net, are scaling back their participation.

Despite the problems with the marketplaces, Mr. Gjersvig said thousands of people have gained coverage through them and he is confident they will survive.

“We do not see this as a death knell for the marketplace,” he said.

Tammie King, an insurance agent in Columbia, S.C., is less sure how insurer departures will affect consumers in the Palmetto State. Pullouts by UnitedHealthcare and Aetna mean only one carrier in the state in 2017 – Blue Cross and Blue Shield of South Carolina.

That’s a concern in Columbia, S.C., because the Blue Cross plan does not include one of the biggest hospitals, Lexington Medical Center, and its affiliated physicians, she said.

“People will be left unable to see the doctors they are now using,” she added.

Ms. King said she worried the Blue Cross plan will use its monopoly power to further reduce the number of doctors and hospitals in its network and limit its choice of prescription drugs. “You can’t blame them because … they have to do something to control costs,” she said.

This story appears courtesy of Kaiser Health News, a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Some of the Affordable Care Act’s insurance marketplaces are in turmoil as the fourth open enrollment season approaches this fall, but what’s ahead for consumers very much depends on where they live.

Competition on these exchanges will be diminished next year when three of the nation’s largest health insurers – Aetna, UnitedHealthcare and Humana – will sell individual plans in many fewer markets. So too will several Blue Cross and Blue Shield plans in various states. That’s on top of the 16 nonprofit co-ops that have closed since January 2015.

The announcements, however, apply generally only to the individual market. The much larger market of employer-sponsored insurance is not part of the health law exchanges.

Aetna’s exit announcement Aug. 15 that blamed financial losses on its marketplace plans gave Obamacare opponents who have from the start predicted the ACA’s failure a fresh chance to proclaim “I told you so.”

That story line got more complicated Aug. 17 after the Huffington Post reported that Aetna CEO Mark Bertolini sent a letter to the Department of Justice (DOJ) on July 5 threatening to withdraw from the Obamacare marketplaces if the DOJ sued to block his company’s planned merger with Humana. The DOJ did just that a couple weeks later.

But most marketplace consumers won’t see any ill effects from insurers’ withdrawals, according to ACA advocates and independent experts.

“The effect on consumers is going to be mixed around the country,” said Katherine Hempstead, PhD, a senior adviser at the nonpartisan Robert Wood Johnson Foundation. “Most of these marketplaces are not dependent on” the large national carriers.

Many major metropolitan areas, such as those in California, New York, and Texas, will still have several insurers for individual health insurance consumers to choose from. In Texas, all major metro areas – including Austin, Dallas, Houston, and San Antonio – will have at least three insurers after Aetna and UnitedHealthcare exit.

That’s true also for most urban exchange customers living in the Northwest, the Midwest, and New England.

Most hurt will be marketplace consumers in Arizona, North and South Carolina, Georgia, and parts of Florida, where only one or two insurers will be left when open enrollment season begins Nov. 15.

Remaining insurers might raise their monthly premiums as a result, but more than eight in 10 consumers on the marketplaces who get government subsidies would be insulated. Subsidies increase as premiums rise.

Still, health experts worry that with less competition, insurers may tighten their provider networks and give these consumers fewer choices of hospitals and doctors. That trend started several years ago, and some states have responded with regulations requiring insurers to provide customers with reasonable access to doctors and hospitals in each county where they sell plans.

Nearly 13 million people signed up for Obamacare marketplace policies for 2016. Aetna, UnitedHealthcare, and Humana have 2 million members in total, but their exit from certain states is predicted to affect between 1 million and 1.5 million people who will have to choose new carriers.

While changing plans can force people to find new doctors, it’s also the best way for consumers get the best deals on coverage.

Aetna will exit 11 of 15 states where it sells plans on the exchanges. UnitedHealthcare has said it will quit 22 of 34 states, and Humana will leave 4 of the 15 states where it operates.

In late May, the Kaiser Family Foundation estimated the number of rural counties at risk of having one insurer on the exchanges would triple in 2017. That was before Humana and Aetna detailed their plans. (KHN is an editorially independent project of the foundation.)

Now, “we could be looking at about one in four counties in the U.S. with just one exchange insurer next year, though this could change between now and open enrollment in November,” said Cynthia Cox, associate director for the Kaiser Family Foundation Program for the Study of Health Reform and Private Insurance.

Overshadowed by the big insurers’ withdrawals is the prospect that other carriers will enter markets the three giants are leaving. Smaller insurers Molina and Centene have said they’re doing fine on the exchanges. And Cigna, a larger insurer, has said it will move into some North Carolina counties for 2017.

North Carolina will be left with just one or two plans in most of the state after it loses UnitedHealthcare and Aetna plans. Health insurance experts say three insurers are needed for a healthy competitive market.

“We’ve had a very robust enrollment under the ACA and hope consumers will still see benefits of having coverage even if they have fewer options,” said Ciara Zachary, health policy analyst for the North Carolina Justice Center’s Health Access Coalition.

Rural Americans had few health insurers to choose from even before Obamacare, but some suburban and urban parts of the Southeast will be in the same fix next year. In southeast Florida, consumers in counties near Naples and Fort Myers will have only one marketplace insurer – Florida Blue – next year, unless other insurers step in.

“There are some headwinds, but it’s not a question of whether the market will stabilize but how quickly and how well,” said Dr. Hempstead.

Strong winds are already blowing toward Arizona’s Pinal County, southeast of Phoenix, health care advocates say. Nearly 10,000 people enrolled in Obamacare marketplace policies this year and about 85% received a federal subsidy.

In 2017, Pinal stands to lose its only two insurers – UnitedHealthcare and Blue Cross and Blue Shield of Arizona.

“Clearly this is a big concern for consumers,” said Allen Gjersvig, director of navigator and enrollment services for the Arizona Alliance for Community Health Centers. He said he is hopeful, but not confident, that another insurer will step in.

Neighboring Maricopa County, which includes Phoenix, is expected to have just two relatively small insurers left on its marketplace next year. Mr. Gjersvig said that he questions whether those two – Cigna and Phoenix Health Plan – will have enough doctors and hospitals under contract to handle their new members after larger rival Blue Cross and Blue Shield of Arizona gives up its 40,000 customers.

At least a dozen other counties in Arizona will be left with just one health insurer, he said.

Arizona had eight insurers operating in various parts of the state this year, but four are leaving entirely – Aetna, UnitedHealthcare, Humana, and Health Choice. Two more, Blue Cross Blue Shield and Health Net, are scaling back their participation.

Despite the problems with the marketplaces, Mr. Gjersvig said thousands of people have gained coverage through them and he is confident they will survive.

“We do not see this as a death knell for the marketplace,” he said.

Tammie King, an insurance agent in Columbia, S.C., is less sure how insurer departures will affect consumers in the Palmetto State. Pullouts by UnitedHealthcare and Aetna mean only one carrier in the state in 2017 – Blue Cross and Blue Shield of South Carolina.

That’s a concern in Columbia, S.C., because the Blue Cross plan does not include one of the biggest hospitals, Lexington Medical Center, and its affiliated physicians, she said.

“People will be left unable to see the doctors they are now using,” she added.

Ms. King said she worried the Blue Cross plan will use its monopoly power to further reduce the number of doctors and hospitals in its network and limit its choice of prescription drugs. “You can’t blame them because … they have to do something to control costs,” she said.

This story appears courtesy of Kaiser Health News, a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Some of the Affordable Care Act’s insurance marketplaces are in turmoil as the fourth open enrollment season approaches this fall, but what’s ahead for consumers very much depends on where they live.

Competition on these exchanges will be diminished next year when three of the nation’s largest health insurers – Aetna, UnitedHealthcare and Humana – will sell individual plans in many fewer markets. So too will several Blue Cross and Blue Shield plans in various states. That’s on top of the 16 nonprofit co-ops that have closed since January 2015.

The announcements, however, apply generally only to the individual market. The much larger market of employer-sponsored insurance is not part of the health law exchanges.

Aetna’s exit announcement Aug. 15 that blamed financial losses on its marketplace plans gave Obamacare opponents who have from the start predicted the ACA’s failure a fresh chance to proclaim “I told you so.”

That story line got more complicated Aug. 17 after the Huffington Post reported that Aetna CEO Mark Bertolini sent a letter to the Department of Justice (DOJ) on July 5 threatening to withdraw from the Obamacare marketplaces if the DOJ sued to block his company’s planned merger with Humana. The DOJ did just that a couple weeks later.

But most marketplace consumers won’t see any ill effects from insurers’ withdrawals, according to ACA advocates and independent experts.

“The effect on consumers is going to be mixed around the country,” said Katherine Hempstead, PhD, a senior adviser at the nonpartisan Robert Wood Johnson Foundation. “Most of these marketplaces are not dependent on” the large national carriers.

Many major metropolitan areas, such as those in California, New York, and Texas, will still have several insurers for individual health insurance consumers to choose from. In Texas, all major metro areas – including Austin, Dallas, Houston, and San Antonio – will have at least three insurers after Aetna and UnitedHealthcare exit.

That’s true also for most urban exchange customers living in the Northwest, the Midwest, and New England.

Most hurt will be marketplace consumers in Arizona, North and South Carolina, Georgia, and parts of Florida, where only one or two insurers will be left when open enrollment season begins Nov. 15.

Remaining insurers might raise their monthly premiums as a result, but more than eight in 10 consumers on the marketplaces who get government subsidies would be insulated. Subsidies increase as premiums rise.

Still, health experts worry that with less competition, insurers may tighten their provider networks and give these consumers fewer choices of hospitals and doctors. That trend started several years ago, and some states have responded with regulations requiring insurers to provide customers with reasonable access to doctors and hospitals in each county where they sell plans.

Nearly 13 million people signed up for Obamacare marketplace policies for 2016. Aetna, UnitedHealthcare, and Humana have 2 million members in total, but their exit from certain states is predicted to affect between 1 million and 1.5 million people who will have to choose new carriers.

While changing plans can force people to find new doctors, it’s also the best way for consumers get the best deals on coverage.

Aetna will exit 11 of 15 states where it sells plans on the exchanges. UnitedHealthcare has said it will quit 22 of 34 states, and Humana will leave 4 of the 15 states where it operates.

In late May, the Kaiser Family Foundation estimated the number of rural counties at risk of having one insurer on the exchanges would triple in 2017. That was before Humana and Aetna detailed their plans. (KHN is an editorially independent project of the foundation.)

Now, “we could be looking at about one in four counties in the U.S. with just one exchange insurer next year, though this could change between now and open enrollment in November,” said Cynthia Cox, associate director for the Kaiser Family Foundation Program for the Study of Health Reform and Private Insurance.

Overshadowed by the big insurers’ withdrawals is the prospect that other carriers will enter markets the three giants are leaving. Smaller insurers Molina and Centene have said they’re doing fine on the exchanges. And Cigna, a larger insurer, has said it will move into some North Carolina counties for 2017.

North Carolina will be left with just one or two plans in most of the state after it loses UnitedHealthcare and Aetna plans. Health insurance experts say three insurers are needed for a healthy competitive market.

“We’ve had a very robust enrollment under the ACA and hope consumers will still see benefits of having coverage even if they have fewer options,” said Ciara Zachary, health policy analyst for the North Carolina Justice Center’s Health Access Coalition.

Rural Americans had few health insurers to choose from even before Obamacare, but some suburban and urban parts of the Southeast will be in the same fix next year. In southeast Florida, consumers in counties near Naples and Fort Myers will have only one marketplace insurer – Florida Blue – next year, unless other insurers step in.

“There are some headwinds, but it’s not a question of whether the market will stabilize but how quickly and how well,” said Dr. Hempstead.

Strong winds are already blowing toward Arizona’s Pinal County, southeast of Phoenix, health care advocates say. Nearly 10,000 people enrolled in Obamacare marketplace policies this year and about 85% received a federal subsidy.

In 2017, Pinal stands to lose its only two insurers – UnitedHealthcare and Blue Cross and Blue Shield of Arizona.

“Clearly this is a big concern for consumers,” said Allen Gjersvig, director of navigator and enrollment services for the Arizona Alliance for Community Health Centers. He said he is hopeful, but not confident, that another insurer will step in.

Neighboring Maricopa County, which includes Phoenix, is expected to have just two relatively small insurers left on its marketplace next year. Mr. Gjersvig said that he questions whether those two – Cigna and Phoenix Health Plan – will have enough doctors and hospitals under contract to handle their new members after larger rival Blue Cross and Blue Shield of Arizona gives up its 40,000 customers.

At least a dozen other counties in Arizona will be left with just one health insurer, he said.

Arizona had eight insurers operating in various parts of the state this year, but four are leaving entirely – Aetna, UnitedHealthcare, Humana, and Health Choice. Two more, Blue Cross Blue Shield and Health Net, are scaling back their participation.

Despite the problems with the marketplaces, Mr. Gjersvig said thousands of people have gained coverage through them and he is confident they will survive.

“We do not see this as a death knell for the marketplace,” he said.

Tammie King, an insurance agent in Columbia, S.C., is less sure how insurer departures will affect consumers in the Palmetto State. Pullouts by UnitedHealthcare and Aetna mean only one carrier in the state in 2017 – Blue Cross and Blue Shield of South Carolina.

That’s a concern in Columbia, S.C., because the Blue Cross plan does not include one of the biggest hospitals, Lexington Medical Center, and its affiliated physicians, she said.

“People will be left unable to see the doctors they are now using,” she added.

Ms. King said she worried the Blue Cross plan will use its monopoly power to further reduce the number of doctors and hospitals in its network and limit its choice of prescription drugs. “You can’t blame them because … they have to do something to control costs,” she said.

This story appears courtesy of Kaiser Health News, a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Compared to other healthcare-associated infections, catheter-associated urinary tract infections (CAUTIs) cause relatively low rates of mortality and morbidity, but their prevalence nevertheless leads to a considerable cumulative burden.

Hospitalists can impact CAUTI rates by using a simple bundle of interventions. This idea was recently demonstrated by a quality improvement project addressing high CAUTI rates in the hospital setting. The project was summarized in a paper published in The Joint Commission Journal on Quality and Patient Safety.

The project identified a bundle of primary interventions to reduce CAUTI, which consisted of six elements: the “6 Cs” of CAUTI reduction. These include “consider alternatives,” “culture urine only when indication is clear,” and “connect with a securement device.” The interventions were implemented on one ICU with excellent results and subsequently diffused throughout the healthcare facility using multimedia tools. CAUTI rates decreased by 70%.

“The first steps in CAUTI prevention are to ensure that catheters are placed only when necessary, aseptic technique used for placement, and that they are removed when no longer essential,” says lead author Priya Sampathkumar, MD, Mayo Clinic associate professor of medicine. “Once this has been achieved, if CAUTI rates are still high, a secondary bundle of CAUTI prevention can help to reduce CAUTI further.”

About one in four hospitalized patients have a urinary catheter in place.2 “Hospitalists, therefore, can have a significant impact on CAUTI by being mindful about catheter use and catheter management.” Dr. Sampathkumar says.

References

1. Sampathkumar P, Barth JW, Johnson M, et al. Mayo Clinic reduces catheter-associated urinary tract infections. Jt Comm J Qual Patient Saf. 2016;42(6):254-265.
2. Catheter-associated urinary tract infections (CAUTI). Centers for Disease Control and Prevention website. Accessed August 8, 2016.

Compared to other healthcare-associated infections, catheter-associated urinary tract infections (CAUTIs) cause relatively low rates of mortality and morbidity, but their prevalence nevertheless leads to a considerable cumulative burden.

Hospitalists can impact CAUTI rates by using a simple bundle of interventions. This idea was recently demonstrated by a quality improvement project addressing high CAUTI rates in the hospital setting. The project was summarized in a paper published in The Joint Commission Journal on Quality and Patient Safety.

The project identified a bundle of primary interventions to reduce CAUTI, which consisted of six elements: the “6 Cs” of CAUTI reduction. These include “consider alternatives,” “culture urine only when indication is clear,” and “connect with a securement device.” The interventions were implemented on one ICU with excellent results and subsequently diffused throughout the healthcare facility using multimedia tools. CAUTI rates decreased by 70%.

“The first steps in CAUTI prevention are to ensure that catheters are placed only when necessary, aseptic technique used for placement, and that they are removed when no longer essential,” says lead author Priya Sampathkumar, MD, Mayo Clinic associate professor of medicine. “Once this has been achieved, if CAUTI rates are still high, a secondary bundle of CAUTI prevention can help to reduce CAUTI further.”

About one in four hospitalized patients have a urinary catheter in place.2 “Hospitalists, therefore, can have a significant impact on CAUTI by being mindful about catheter use and catheter management.” Dr. Sampathkumar says.

References

1. Sampathkumar P, Barth JW, Johnson M, et al. Mayo Clinic reduces catheter-associated urinary tract infections. Jt Comm J Qual Patient Saf. 2016;42(6):254-265.
2. Catheter-associated urinary tract infections (CAUTI). Centers for Disease Control and Prevention website. Accessed August 8, 2016.

Compared to other healthcare-associated infections, catheter-associated urinary tract infections (CAUTIs) cause relatively low rates of mortality and morbidity, but their prevalence nevertheless leads to a considerable cumulative burden.

Hospitalists can impact CAUTI rates by using a simple bundle of interventions. This idea was recently demonstrated by a quality improvement project addressing high CAUTI rates in the hospital setting. The project was summarized in a paper published in The Joint Commission Journal on Quality and Patient Safety.

The project identified a bundle of primary interventions to reduce CAUTI, which consisted of six elements: the “6 Cs” of CAUTI reduction. These include “consider alternatives,” “culture urine only when indication is clear,” and “connect with a securement device.” The interventions were implemented on one ICU with excellent results and subsequently diffused throughout the healthcare facility using multimedia tools. CAUTI rates decreased by 70%.

“The first steps in CAUTI prevention are to ensure that catheters are placed only when necessary, aseptic technique used for placement, and that they are removed when no longer essential,” says lead author Priya Sampathkumar, MD, Mayo Clinic associate professor of medicine. “Once this has been achieved, if CAUTI rates are still high, a secondary bundle of CAUTI prevention can help to reduce CAUTI further.”

About one in four hospitalized patients have a urinary catheter in place.2 “Hospitalists, therefore, can have a significant impact on CAUTI by being mindful about catheter use and catheter management.” Dr. Sampathkumar says.

References

1. Sampathkumar P, Barth JW, Johnson M, et al. Mayo Clinic reduces catheter-associated urinary tract infections. Jt Comm J Qual Patient Saf. 2016;42(6):254-265.
2. Catheter-associated urinary tract infections (CAUTI). Centers for Disease Control and Prevention website. Accessed August 8, 2016.

Plasmodium sporozoite

Image courtesy of Ute

Frevert and Margaret Shear

A synthetic version of the protein PD-L2 can treat malaria in mice and protect them from re-infection, according to researchers.

The team’s experiments indicated that PD-L2 determines the severity of malaria infection and is essential for CD4+ T-cell immunity against malaria.

When the researchers administered soluble multimeric PD-L2 to mice, the animals were cured of severe malaria and protected from re-infection months later.

Michelle Wykes, DPhil, of QIMR Berghofer Medical Research Institute in Herston, Queensland, Australia, and her colleagues reported these results in Immunity.

The researchers noted that Plasmodium parasites exploit the interaction between PD-1 and PD-L1 to prevent T cells from fighting malaria, but the role of PD-L2 has not been clear.

With this study, the team found that PD-L2 regulates the PD-1—PD-L1 interaction and might therefore be used to treat malaria.

“We found that, when humans and mice are infected with severe malaria, levels of PD-L2 decrease, and so the T cells aren’t being told to keep fighting the parasites,” Dr Wykes explained.

“We don’t know how malaria manages to block the production of PD-L2. But once we knew how important this protein was for fighting the disease, we developed a synthetic version of it in the laboratory.”

The researchers gave 3 doses of this synthetic PD-L2 to mice that had been infected with a lethal dose of malaria.

“All of these mice were cured of the malaria,” Dr Wykes said. “About 5 months later, we re-infected the same mice with malaria parasites, but, this time, we didn’t give them any more of the synthetic protein. All of the mice were completely protected and didn’t become infected.”

Dr Wykes said these findings could form the basis for new ways to treat malaria in the future.

“[I]f this approach is successful, it should treat all species of malaria parasite,” she noted. “This would be a completely new way of treating malaria—by stimulating a person’s own immune system to destroy the parasites.”

Plasmodium sporozoite

Image courtesy of Ute

Frevert and Margaret Shear

A synthetic version of the protein PD-L2 can treat malaria in mice and protect them from re-infection, according to researchers.

The team’s experiments indicated that PD-L2 determines the severity of malaria infection and is essential for CD4+ T-cell immunity against malaria.

When the researchers administered soluble multimeric PD-L2 to mice, the animals were cured of severe malaria and protected from re-infection months later.

Michelle Wykes, DPhil, of QIMR Berghofer Medical Research Institute in Herston, Queensland, Australia, and her colleagues reported these results in Immunity.

The researchers noted that Plasmodium parasites exploit the interaction between PD-1 and PD-L1 to prevent T cells from fighting malaria, but the role of PD-L2 has not been clear.

With this study, the team found that PD-L2 regulates the PD-1—PD-L1 interaction and might therefore be used to treat malaria.

“We found that, when humans and mice are infected with severe malaria, levels of PD-L2 decrease, and so the T cells aren’t being told to keep fighting the parasites,” Dr Wykes explained.

“We don’t know how malaria manages to block the production of PD-L2. But once we knew how important this protein was for fighting the disease, we developed a synthetic version of it in the laboratory.”

The researchers gave 3 doses of this synthetic PD-L2 to mice that had been infected with a lethal dose of malaria.

“All of these mice were cured of the malaria,” Dr Wykes said. “About 5 months later, we re-infected the same mice with malaria parasites, but, this time, we didn’t give them any more of the synthetic protein. All of the mice were completely protected and didn’t become infected.”

Dr Wykes said these findings could form the basis for new ways to treat malaria in the future.

“[I]f this approach is successful, it should treat all species of malaria parasite,” she noted. “This would be a completely new way of treating malaria—by stimulating a person’s own immune system to destroy the parasites.”

Plasmodium sporozoite

Image courtesy of Ute

Frevert and Margaret Shear

A synthetic version of the protein PD-L2 can treat malaria in mice and protect them from re-infection, according to researchers.

The team’s experiments indicated that PD-L2 determines the severity of malaria infection and is essential for CD4+ T-cell immunity against malaria.

When the researchers administered soluble multimeric PD-L2 to mice, the animals were cured of severe malaria and protected from re-infection months later.

Michelle Wykes, DPhil, of QIMR Berghofer Medical Research Institute in Herston, Queensland, Australia, and her colleagues reported these results in Immunity.

The researchers noted that Plasmodium parasites exploit the interaction between PD-1 and PD-L1 to prevent T cells from fighting malaria, but the role of PD-L2 has not been clear.

With this study, the team found that PD-L2 regulates the PD-1—PD-L1 interaction and might therefore be used to treat malaria.

“We found that, when humans and mice are infected with severe malaria, levels of PD-L2 decrease, and so the T cells aren’t being told to keep fighting the parasites,” Dr Wykes explained.

“We don’t know how malaria manages to block the production of PD-L2. But once we knew how important this protein was for fighting the disease, we developed a synthetic version of it in the laboratory.”

The researchers gave 3 doses of this synthetic PD-L2 to mice that had been infected with a lethal dose of malaria.

“All of these mice were cured of the malaria,” Dr Wykes said. “About 5 months later, we re-infected the same mice with malaria parasites, but, this time, we didn’t give them any more of the synthetic protein. All of the mice were completely protected and didn’t become infected.”

Dr Wykes said these findings could form the basis for new ways to treat malaria in the future.

“[I]f this approach is successful, it should treat all species of malaria parasite,” she noted. “This would be a completely new way of treating malaria—by stimulating a person’s own immune system to destroy the parasites.”

Cancer patient

receiving treatment

Photo by Rhoda Baer

A new study suggests cancer survivors and the general population have comparable sex lives, although cancer survivors don’t realize it.

According to a survey of more than 6500 people, cancer survivors over the age of 49 have just as much sex and similar levels of sexual function as individuals of the same age who never had cancer.

However, the cancer survivors were more likely to report being dissatisfied with their sex lives.

“We hope our findings will put cancer survivors’ concerns to rest—showing that they are just as sexually active and function just as well as others their age,” said Sarah Jackson, PhD, of University College London in the UK.

“The next stage of our research will look at why cancer patients feel less satisfied with their sex lives.”

Dr Jackson and her colleagues reported their current findings in Cancer.

The researchers set out to explore differences in sexual activity and function, as well as concerns about sex, between cancer survivors and cancer-free controls in a population-based study.

The team surveyed 3708 women (341 cancer survivors and 3367 controls) and 2982 men (220 cancer survivors and 2762 controls) aged 50 and older. Male and female cancer survivors were significantly older than controls (P<0.001 for both) and reported more comorbidities (P=0.003 for both).

Frequency

There were no significant differences in levels of sexual activity between cancer survivors and controls of either sex.

Among women, 58.2% of cancer survivors and 55.5% of controls reported having any sexual activity in the last year. Among men, the rates were 76.0% and 78.5%, respectively.

Overall, about half of the people surveyed reported having “frequent” sexual intercourse, which was defined as 2 to 3 times a month or more.

This included 49.1% of female cancer survivors, 50.1% of female controls, 49% of male cancer survivors, and 48% of male controls.

Function

The incidence of sexual problems was similar in cancer survivors and controls—both male and female.

For example, around a third of the women said they had problems becoming aroused (31.4% of cancer survivors and 31.8% of controls), and about 40% of the men had erectile dysfunction (40.3% of cancer survivors and 39.3% of controls).

Satisfaction

Despite similar levels of sexual activity and function, cancer survivors were more likely than controls to report feeling dissatisfied with their sex lives.

Among the women, 18.2% of cancer survivors and 11.8% of controls reported dissatisfaction (P=0.034). Among the men, the rates were 30.9% and 19.8%, respectively (P=0.023).

In addition, female cancer survivors were more likely to be concerned about their libido than female controls—10.2% and 7.1%, respectively (P=0.006). But there was no significant difference for the men.

Time from cancer diagnosis

The researchers also found the amount of time from cancer diagnosis was a factor affecting sexual function and concern among women but not men.

Females diagnosed with cancer less than 5 years from the time they were surveyed were more likely than female controls to report difficulty becoming aroused (55.4% and 31.8%, respectively, P=0.016) and achieving orgasm (60.6% and 28.3%, respectively, P<0.001).

The recently diagnosed females were also more likely than controls to be concerned about sexual desire (14.8% and 7.1%, respectively, P=0.007) and orgasmic experience (17.6% and 7.1%, respectively, P=0.042).

“Although some cancer treatments are known to impact on sexual function, this study suggests that the majority of cancer patients have similar sexual function and activity as the general population,” said Martin Ledwick, of Cancer Research UK, which sponsored this study.

“However, cancer patients in the study were more likely to be dissatisfied with their sex lives . . . . This highlights the need for health professionals to make sure they talk about sex with all patients—not just the ones whose sexual function is likely to be affected by their cancer or its treatment.”

Cancer patient

receiving treatment

Photo by Rhoda Baer

A new study suggests cancer survivors and the general population have comparable sex lives, although cancer survivors don’t realize it.

According to a survey of more than 6500 people, cancer survivors over the age of 49 have just as much sex and similar levels of sexual function as individuals of the same age who never had cancer.

However, the cancer survivors were more likely to report being dissatisfied with their sex lives.

“We hope our findings will put cancer survivors’ concerns to rest—showing that they are just as sexually active and function just as well as others their age,” said Sarah Jackson, PhD, of University College London in the UK.

“The next stage of our research will look at why cancer patients feel less satisfied with their sex lives.”

Dr Jackson and her colleagues reported their current findings in Cancer.

The researchers set out to explore differences in sexual activity and function, as well as concerns about sex, between cancer survivors and cancer-free controls in a population-based study.

The team surveyed 3708 women (341 cancer survivors and 3367 controls) and 2982 men (220 cancer survivors and 2762 controls) aged 50 and older. Male and female cancer survivors were significantly older than controls (P<0.001 for both) and reported more comorbidities (P=0.003 for both).

Frequency

There were no significant differences in levels of sexual activity between cancer survivors and controls of either sex.

Among women, 58.2% of cancer survivors and 55.5% of controls reported having any sexual activity in the last year. Among men, the rates were 76.0% and 78.5%, respectively.

Overall, about half of the people surveyed reported having “frequent” sexual intercourse, which was defined as 2 to 3 times a month or more.

This included 49.1% of female cancer survivors, 50.1% of female controls, 49% of male cancer survivors, and 48% of male controls.

Function

The incidence of sexual problems was similar in cancer survivors and controls—both male and female.

For example, around a third of the women said they had problems becoming aroused (31.4% of cancer survivors and 31.8% of controls), and about 40% of the men had erectile dysfunction (40.3% of cancer survivors and 39.3% of controls).

Satisfaction

Despite similar levels of sexual activity and function, cancer survivors were more likely than controls to report feeling dissatisfied with their sex lives.

Among the women, 18.2% of cancer survivors and 11.8% of controls reported dissatisfaction (P=0.034). Among the men, the rates were 30.9% and 19.8%, respectively (P=0.023).

In addition, female cancer survivors were more likely to be concerned about their libido than female controls—10.2% and 7.1%, respectively (P=0.006). But there was no significant difference for the men.

Time from cancer diagnosis

The researchers also found the amount of time from cancer diagnosis was a factor affecting sexual function and concern among women but not men.

Females diagnosed with cancer less than 5 years from the time they were surveyed were more likely than female controls to report difficulty becoming aroused (55.4% and 31.8%, respectively, P=0.016) and achieving orgasm (60.6% and 28.3%, respectively, P<0.001).

The recently diagnosed females were also more likely than controls to be concerned about sexual desire (14.8% and 7.1%, respectively, P=0.007) and orgasmic experience (17.6% and 7.1%, respectively, P=0.042).

“Although some cancer treatments are known to impact on sexual function, this study suggests that the majority of cancer patients have similar sexual function and activity as the general population,” said Martin Ledwick, of Cancer Research UK, which sponsored this study.

“However, cancer patients in the study were more likely to be dissatisfied with their sex lives . . . . This highlights the need for health professionals to make sure they talk about sex with all patients—not just the ones whose sexual function is likely to be affected by their cancer or its treatment.”

Cancer patient

receiving treatment

Photo by Rhoda Baer

A new study suggests cancer survivors and the general population have comparable sex lives, although cancer survivors don’t realize it.

According to a survey of more than 6500 people, cancer survivors over the age of 49 have just as much sex and similar levels of sexual function as individuals of the same age who never had cancer.

However, the cancer survivors were more likely to report being dissatisfied with their sex lives.

“We hope our findings will put cancer survivors’ concerns to rest—showing that they are just as sexually active and function just as well as others their age,” said Sarah Jackson, PhD, of University College London in the UK.

“The next stage of our research will look at why cancer patients feel less satisfied with their sex lives.”

Dr Jackson and her colleagues reported their current findings in Cancer.

The researchers set out to explore differences in sexual activity and function, as well as concerns about sex, between cancer survivors and cancer-free controls in a population-based study.

The team surveyed 3708 women (341 cancer survivors and 3367 controls) and 2982 men (220 cancer survivors and 2762 controls) aged 50 and older. Male and female cancer survivors were significantly older than controls (P<0.001 for both) and reported more comorbidities (P=0.003 for both).

Frequency

There were no significant differences in levels of sexual activity between cancer survivors and controls of either sex.

Among women, 58.2% of cancer survivors and 55.5% of controls reported having any sexual activity in the last year. Among men, the rates were 76.0% and 78.5%, respectively.

Overall, about half of the people surveyed reported having “frequent” sexual intercourse, which was defined as 2 to 3 times a month or more.

This included 49.1% of female cancer survivors, 50.1% of female controls, 49% of male cancer survivors, and 48% of male controls.

Function

The incidence of sexual problems was similar in cancer survivors and controls—both male and female.

For example, around a third of the women said they had problems becoming aroused (31.4% of cancer survivors and 31.8% of controls), and about 40% of the men had erectile dysfunction (40.3% of cancer survivors and 39.3% of controls).

Satisfaction

Despite similar levels of sexual activity and function, cancer survivors were more likely than controls to report feeling dissatisfied with their sex lives.

Among the women, 18.2% of cancer survivors and 11.8% of controls reported dissatisfaction (P=0.034). Among the men, the rates were 30.9% and 19.8%, respectively (P=0.023).

In addition, female cancer survivors were more likely to be concerned about their libido than female controls—10.2% and 7.1%, respectively (P=0.006). But there was no significant difference for the men.

Time from cancer diagnosis

The researchers also found the amount of time from cancer diagnosis was a factor affecting sexual function and concern among women but not men.

Females diagnosed with cancer less than 5 years from the time they were surveyed were more likely than female controls to report difficulty becoming aroused (55.4% and 31.8%, respectively, P=0.016) and achieving orgasm (60.6% and 28.3%, respectively, P<0.001).

The recently diagnosed females were also more likely than controls to be concerned about sexual desire (14.8% and 7.1%, respectively, P=0.007) and orgasmic experience (17.6% and 7.1%, respectively, P=0.042).

“Although some cancer treatments are known to impact on sexual function, this study suggests that the majority of cancer patients have similar sexual function and activity as the general population,” said Martin Ledwick, of Cancer Research UK, which sponsored this study.

“However, cancer patients in the study were more likely to be dissatisfied with their sex lives . . . . This highlights the need for health professionals to make sure they talk about sex with all patients—not just the ones whose sexual function is likely to be affected by their cancer or its treatment.”

Red blood cells

Anemia may increase the risk of death in older adults who have had a stroke, according to research published in the Journal of the American Heart Association.

An initial analysis of more than 8000 patients showed that anemia was associated with a higher risk of death for up to 1 year following ischemic or hemorrhagic stroke.

A second analysis of nearly 30,000 patients suggested the risk of dying from ischemic stroke is about 2 times higher in patients with anemia than those without it, and the risk of death from hemorrhagic stroke is about 1.5 times higher in anemic patients.

“So there’s the potential for a much poorer outcome if somebody comes in with stroke and they’re also anemic,” said study author Phyo Myint, MD, of the University of Aberdeen in Scotland.

Dr Myint and his colleagues first examined data from the UK Regional Stroke Register. This included 8013 patients with an average age of 78 who were admitted to the hospital with acute stroke between 2003 and 2015.

The team assessed the impact of anemia and hemoglobin levels at admission on death at different time points—inpatient, 7 days, 14 days, 1 month, 3 months, 6 months, and 1 year after stroke.

Anemia was associated with higher odds of death at most of the time points examined. And elevated hemoglobin was associated with a higher risk of death, mainly within the first month.

In addition to analyzing data from the UK Regional Stroke Registry, the researchers systematically reviewed relevant literature published to date. They compiled data from 20 previous studies, increasing the study population to 29,943 stroke patients.

In analyzing these patients, the researchers found that anemia on admission was associated with an increased risk of mortality in both ischemic stroke and hemorrhagic stroke. The odds ratios were 1.97 and 1.46, respectively.

The researchers believe this study emphasizes the impact of anemia on stroke outcomes and the need for increased awareness and interventions for stroke patients with anemia.

“One example of an intervention might be treating the underlying causes of anemia, such as iron deficiency, which is common in this age group,” said study author Raphae Barlas, a medical student at the University of Aberdeen.

“As the study has convincingly demonstrated, anemia does worsen the outcome of stroke, so it is very important that we identify at-risk patients and optimize the management.”

Red blood cells

Anemia may increase the risk of death in older adults who have had a stroke, according to research published in the Journal of the American Heart Association.

An initial analysis of more than 8000 patients showed that anemia was associated with a higher risk of death for up to 1 year following ischemic or hemorrhagic stroke.

A second analysis of nearly 30,000 patients suggested the risk of dying from ischemic stroke is about 2 times higher in patients with anemia than those without it, and the risk of death from hemorrhagic stroke is about 1.5 times higher in anemic patients.

“So there’s the potential for a much poorer outcome if somebody comes in with stroke and they’re also anemic,” said study author Phyo Myint, MD, of the University of Aberdeen in Scotland.

Dr Myint and his colleagues first examined data from the UK Regional Stroke Register. This included 8013 patients with an average age of 78 who were admitted to the hospital with acute stroke between 2003 and 2015.

The team assessed the impact of anemia and hemoglobin levels at admission on death at different time points—inpatient, 7 days, 14 days, 1 month, 3 months, 6 months, and 1 year after stroke.

Anemia was associated with higher odds of death at most of the time points examined. And elevated hemoglobin was associated with a higher risk of death, mainly within the first month.

In addition to analyzing data from the UK Regional Stroke Registry, the researchers systematically reviewed relevant literature published to date. They compiled data from 20 previous studies, increasing the study population to 29,943 stroke patients.

In analyzing these patients, the researchers found that anemia on admission was associated with an increased risk of mortality in both ischemic stroke and hemorrhagic stroke. The odds ratios were 1.97 and 1.46, respectively.

The researchers believe this study emphasizes the impact of anemia on stroke outcomes and the need for increased awareness and interventions for stroke patients with anemia.

“One example of an intervention might be treating the underlying causes of anemia, such as iron deficiency, which is common in this age group,” said study author Raphae Barlas, a medical student at the University of Aberdeen.

“As the study has convincingly demonstrated, anemia does worsen the outcome of stroke, so it is very important that we identify at-risk patients and optimize the management.”

Red blood cells

Anemia may increase the risk of death in older adults who have had a stroke, according to research published in the Journal of the American Heart Association.

An initial analysis of more than 8000 patients showed that anemia was associated with a higher risk of death for up to 1 year following ischemic or hemorrhagic stroke.

A second analysis of nearly 30,000 patients suggested the risk of dying from ischemic stroke is about 2 times higher in patients with anemia than those without it, and the risk of death from hemorrhagic stroke is about 1.5 times higher in anemic patients.

“So there’s the potential for a much poorer outcome if somebody comes in with stroke and they’re also anemic,” said study author Phyo Myint, MD, of the University of Aberdeen in Scotland.

Dr Myint and his colleagues first examined data from the UK Regional Stroke Register. This included 8013 patients with an average age of 78 who were admitted to the hospital with acute stroke between 2003 and 2015.

The team assessed the impact of anemia and hemoglobin levels at admission on death at different time points—inpatient, 7 days, 14 days, 1 month, 3 months, 6 months, and 1 year after stroke.

Anemia was associated with higher odds of death at most of the time points examined. And elevated hemoglobin was associated with a higher risk of death, mainly within the first month.

In addition to analyzing data from the UK Regional Stroke Registry, the researchers systematically reviewed relevant literature published to date. They compiled data from 20 previous studies, increasing the study population to 29,943 stroke patients.

In analyzing these patients, the researchers found that anemia on admission was associated with an increased risk of mortality in both ischemic stroke and hemorrhagic stroke. The odds ratios were 1.97 and 1.46, respectively.

The researchers believe this study emphasizes the impact of anemia on stroke outcomes and the need for increased awareness and interventions for stroke patients with anemia.

“One example of an intervention might be treating the underlying causes of anemia, such as iron deficiency, which is common in this age group,” said study author Raphae Barlas, a medical student at the University of Aberdeen.

“As the study has convincingly demonstrated, anemia does worsen the outcome of stroke, so it is very important that we identify at-risk patients and optimize the management.”