Clinical question

What are the most effective strategies in improving patient safety?

Bottom line

This group of experts, commissioned by the Agency for Healthcare Research and Quality (AHRQ), outlined the top 10 strategies for improved patient safety. These strategies, which are "strongly encouraged" for adoption in all health care systems, consist primarily of interventions that help prevent health care-associated infections and avoid medical errors. LOE = 5

Reference

Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 2013;158(5 Pt 2):365-368.

Study design

Systematic review

Funding source

Government

Allocation

Uncertain

Setting

Various (guideline)

Synopsis

Previous publications by the Institute of Medicine and the AHRQ have highlighted the importance of patient safety practices. A group of researchers, supported by the AHRQ, evaluated the data on current strategies to improve patient safety. The group assessed the quality of existing systematic reviews on these topics and performed new literature searches when needed. The focus was on data that reported on implementation and adoption of these strategies, as well as on the context in which they have been used. Individual studies on safety interventions were examined for quality and risk of bias. The authors rated the strength of evidence of the effectiveness of each intervention, reported evidence on possible harmful consequences, assessed difficulty in implementation, and estimated costs. Of the 41 safety strategies that were evaluated, the following 10 were chosen as strategies that are "strongly encouraged" for adoption now: 1. Preoperative and anesthesia checklists to prevent perioperative events 2. Bundles that include checklists to prevent central line-associated bloodstream infections 3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders , or nurse-initiated removal protocols 4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia 5. Hand hygiene 6. The do-not-use list for hazardous abbreviations 7. Multicomponent interventions to reduce pressure ulcers 8. Barrier precautions to prevent health care-associated infections 9. Use of real-time ultrasonography for central line placement 10. Interventions to improve prophylaxis for venous thromboembolism.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

What are the most effective strategies in improving patient safety?

Bottom line

This group of experts, commissioned by the Agency for Healthcare Research and Quality (AHRQ), outlined the top 10 strategies for improved patient safety. These strategies, which are "strongly encouraged" for adoption in all health care systems, consist primarily of interventions that help prevent health care-associated infections and avoid medical errors. LOE = 5

Reference

Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 2013;158(5 Pt 2):365-368.

Study design

Systematic review

Funding source

Government

Allocation

Uncertain

Setting

Various (guideline)

Synopsis

Previous publications by the Institute of Medicine and the AHRQ have highlighted the importance of patient safety practices. A group of researchers, supported by the AHRQ, evaluated the data on current strategies to improve patient safety. The group assessed the quality of existing systematic reviews on these topics and performed new literature searches when needed. The focus was on data that reported on implementation and adoption of these strategies, as well as on the context in which they have been used. Individual studies on safety interventions were examined for quality and risk of bias. The authors rated the strength of evidence of the effectiveness of each intervention, reported evidence on possible harmful consequences, assessed difficulty in implementation, and estimated costs. Of the 41 safety strategies that were evaluated, the following 10 were chosen as strategies that are "strongly encouraged" for adoption now: 1. Preoperative and anesthesia checklists to prevent perioperative events 2. Bundles that include checklists to prevent central line-associated bloodstream infections 3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders , or nurse-initiated removal protocols 4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia 5. Hand hygiene 6. The do-not-use list for hazardous abbreviations 7. Multicomponent interventions to reduce pressure ulcers 8. Barrier precautions to prevent health care-associated infections 9. Use of real-time ultrasonography for central line placement 10. Interventions to improve prophylaxis for venous thromboembolism.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

What are the most effective strategies in improving patient safety?

Bottom line

This group of experts, commissioned by the Agency for Healthcare Research and Quality (AHRQ), outlined the top 10 strategies for improved patient safety. These strategies, which are "strongly encouraged" for adoption in all health care systems, consist primarily of interventions that help prevent health care-associated infections and avoid medical errors. LOE = 5

Reference

Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 2013;158(5 Pt 2):365-368.

Study design

Systematic review

Funding source

Government

Allocation

Uncertain

Setting

Various (guideline)

Synopsis

Previous publications by the Institute of Medicine and the AHRQ have highlighted the importance of patient safety practices. A group of researchers, supported by the AHRQ, evaluated the data on current strategies to improve patient safety. The group assessed the quality of existing systematic reviews on these topics and performed new literature searches when needed. The focus was on data that reported on implementation and adoption of these strategies, as well as on the context in which they have been used. Individual studies on safety interventions were examined for quality and risk of bias. The authors rated the strength of evidence of the effectiveness of each intervention, reported evidence on possible harmful consequences, assessed difficulty in implementation, and estimated costs. Of the 41 safety strategies that were evaluated, the following 10 were chosen as strategies that are "strongly encouraged" for adoption now: 1. Preoperative and anesthesia checklists to prevent perioperative events 2. Bundles that include checklists to prevent central line-associated bloodstream infections 3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders , or nurse-initiated removal protocols 4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia 5. Hand hygiene 6. The do-not-use list for hazardous abbreviations 7. Multicomponent interventions to reduce pressure ulcers 8. Barrier precautions to prevent health care-associated infections 9. Use of real-time ultrasonography for central line placement 10. Interventions to improve prophylaxis for venous thromboembolism.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does the addition of aliskiren, a direct renin inhibitor, to standard therapy decrease mortality and readmission in patients hospitalized for worsening heart failure?

Bottom line

The addition of aliskiren to standard therapy in patients hospitalized with heart failure (HF) does not reduce cardiovascular mortality or HF readmission rates. LOE = 1b

Reference

Gheorghiade M, Böhm M, Greene SJ, et al, for the ASTRONAUT Investigators and Coordinators. Effect of aliskiren on postdischarge mortality and heart failure readmissions among patients hospitalized for heart failure. JAMA 2013;309(11):1125-1135.

Study design

Randomized controlled trial (double-blinded)

Funding source

Industry

Allocation

Uncertain

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Despite current standard therapy, postdischarge mortality and rehospitalizations remain high for patients hospitalized for HF. To study the effect of direct renin inhibitors on these outcomes, investigators enrolled adults hospitalized for worsening HF with a left ventricular ejection fraction (LVEF) of 40% or less. Once these patients were clinically and hemodynamically stable, they were randomized to receive aliskiren 150 mg daily or placebo. Study patients were followed up at regular intervals and the aliskiren dose was increased to 300 mg daily as long as the initial dose was tolerated. Aliskiren, either 150 mg or 300 mg, was then continued up to a maximum follow-up time of 12 months. All patients also received standard HF therapy at the discretion of their treating physicians. The 2 groups had similar baseline characteristics. The patients' mean age was 65 years, mean LVEF was 28%, and the majority were New York Heart Association Class III-IV at randomization. For the primary end point of either cardiovascular death or HF rehospitalization at 6 months, there was no significant difference between the aliskiren and placebo groups. Events rates between the 2 groups were also similar at 12 months. The aliskiren group was more likely to experience hyperkalemia, hypotension, and renal impairment or renal failure. Additionally, a subgroup analysis showed that patients with diabetes fared worse with aliskiren, with a greater risk of all-cause mortality at 12 months, than those who took placebo.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does the addition of aliskiren, a direct renin inhibitor, to standard therapy decrease mortality and readmission in patients hospitalized for worsening heart failure?

Bottom line

The addition of aliskiren to standard therapy in patients hospitalized with heart failure (HF) does not reduce cardiovascular mortality or HF readmission rates. LOE = 1b

Reference

Gheorghiade M, Böhm M, Greene SJ, et al, for the ASTRONAUT Investigators and Coordinators. Effect of aliskiren on postdischarge mortality and heart failure readmissions among patients hospitalized for heart failure. JAMA 2013;309(11):1125-1135.

Study design

Randomized controlled trial (double-blinded)

Funding source

Industry

Allocation

Uncertain

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Despite current standard therapy, postdischarge mortality and rehospitalizations remain high for patients hospitalized for HF. To study the effect of direct renin inhibitors on these outcomes, investigators enrolled adults hospitalized for worsening HF with a left ventricular ejection fraction (LVEF) of 40% or less. Once these patients were clinically and hemodynamically stable, they were randomized to receive aliskiren 150 mg daily or placebo. Study patients were followed up at regular intervals and the aliskiren dose was increased to 300 mg daily as long as the initial dose was tolerated. Aliskiren, either 150 mg or 300 mg, was then continued up to a maximum follow-up time of 12 months. All patients also received standard HF therapy at the discretion of their treating physicians. The 2 groups had similar baseline characteristics. The patients' mean age was 65 years, mean LVEF was 28%, and the majority were New York Heart Association Class III-IV at randomization. For the primary end point of either cardiovascular death or HF rehospitalization at 6 months, there was no significant difference between the aliskiren and placebo groups. Events rates between the 2 groups were also similar at 12 months. The aliskiren group was more likely to experience hyperkalemia, hypotension, and renal impairment or renal failure. Additionally, a subgroup analysis showed that patients with diabetes fared worse with aliskiren, with a greater risk of all-cause mortality at 12 months, than those who took placebo.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does the addition of aliskiren, a direct renin inhibitor, to standard therapy decrease mortality and readmission in patients hospitalized for worsening heart failure?

Bottom line

The addition of aliskiren to standard therapy in patients hospitalized with heart failure (HF) does not reduce cardiovascular mortality or HF readmission rates. LOE = 1b

Reference

Gheorghiade M, Böhm M, Greene SJ, et al, for the ASTRONAUT Investigators and Coordinators. Effect of aliskiren on postdischarge mortality and heart failure readmissions among patients hospitalized for heart failure. JAMA 2013;309(11):1125-1135.

Study design

Randomized controlled trial (double-blinded)

Funding source

Industry

Allocation

Uncertain

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Despite current standard therapy, postdischarge mortality and rehospitalizations remain high for patients hospitalized for HF. To study the effect of direct renin inhibitors on these outcomes, investigators enrolled adults hospitalized for worsening HF with a left ventricular ejection fraction (LVEF) of 40% or less. Once these patients were clinically and hemodynamically stable, they were randomized to receive aliskiren 150 mg daily or placebo. Study patients were followed up at regular intervals and the aliskiren dose was increased to 300 mg daily as long as the initial dose was tolerated. Aliskiren, either 150 mg or 300 mg, was then continued up to a maximum follow-up time of 12 months. All patients also received standard HF therapy at the discretion of their treating physicians. The 2 groups had similar baseline characteristics. The patients' mean age was 65 years, mean LVEF was 28%, and the majority were New York Heart Association Class III-IV at randomization. For the primary end point of either cardiovascular death or HF rehospitalization at 6 months, there was no significant difference between the aliskiren and placebo groups. Events rates between the 2 groups were also similar at 12 months. The aliskiren group was more likely to experience hyperkalemia, hypotension, and renal impairment or renal failure. Additionally, a subgroup analysis showed that patients with diabetes fared worse with aliskiren, with a greater risk of all-cause mortality at 12 months, than those who took placebo.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

The approval of the biologic drug golimumab has been expanded to include the treatment of adults with moderate to severe ulcerative colitis that is refractory to prior treatment or requires continuous steroid therapy, the Food and Drug Administration announced on May 15.

Golimumab (Simponi), a tumor necrosis factor–blocker, was approved in 2009 for treatment of moderate to severe active rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, all in adults. Simponi is marketed by Janssen Ortho Biotech.

The approval for ulcerative colitis was based on two studies of patients with moderate to severe ulcerative colitis, according to the FDA statement announcing the approval. In one study, which enrolled 513 patients who could not tolerate or had not responded to other treatments, "a greater proportion of Simponi-treated patients achieved clinical response, clinical remission and, as seen during endoscopy, had improved appearance of the colon after 6 weeks," compared with those on placebo, the statement said.

In a study of 310 patients who had responded to golimumab and were then randomized to continue treatment with golimumab or were switched to placebo, "a greater proportion of Simponi-treated patients maintained clinical response through week 54, had clinical remission at both weeks 30 and 54 and, as seen during endoscopy, had improved appearance of the colon at both weeks 30 and 54 compared with the placebo group," the FDA said. The most common adverse effects associated with golimumab are upper respiratory infection and redness at the injection site.

The risks of serious infections, invasive fungal infections, reactivation of hepatitis B infection, lymphoma, heart failure, nervous system disorders, and allergic reactions are increased with treatment.

Serious adverse events associated with golimumab should be reported to the FDA at 800-332-1088 or www.fda.gov/medwatch/.

[email protected]

The approval of the biologic drug golimumab has been expanded to include the treatment of adults with moderate to severe ulcerative colitis that is refractory to prior treatment or requires continuous steroid therapy, the Food and Drug Administration announced on May 15.

Golimumab (Simponi), a tumor necrosis factor–blocker, was approved in 2009 for treatment of moderate to severe active rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, all in adults. Simponi is marketed by Janssen Ortho Biotech.

The approval for ulcerative colitis was based on two studies of patients with moderate to severe ulcerative colitis, according to the FDA statement announcing the approval. In one study, which enrolled 513 patients who could not tolerate or had not responded to other treatments, "a greater proportion of Simponi-treated patients achieved clinical response, clinical remission and, as seen during endoscopy, had improved appearance of the colon after 6 weeks," compared with those on placebo, the statement said.

In a study of 310 patients who had responded to golimumab and were then randomized to continue treatment with golimumab or were switched to placebo, "a greater proportion of Simponi-treated patients maintained clinical response through week 54, had clinical remission at both weeks 30 and 54 and, as seen during endoscopy, had improved appearance of the colon at both weeks 30 and 54 compared with the placebo group," the FDA said. The most common adverse effects associated with golimumab are upper respiratory infection and redness at the injection site.

The risks of serious infections, invasive fungal infections, reactivation of hepatitis B infection, lymphoma, heart failure, nervous system disorders, and allergic reactions are increased with treatment.

Serious adverse events associated with golimumab should be reported to the FDA at 800-332-1088 or www.fda.gov/medwatch/.

[email protected]

The approval of the biologic drug golimumab has been expanded to include the treatment of adults with moderate to severe ulcerative colitis that is refractory to prior treatment or requires continuous steroid therapy, the Food and Drug Administration announced on May 15.

Golimumab (Simponi), a tumor necrosis factor–blocker, was approved in 2009 for treatment of moderate to severe active rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, all in adults. Simponi is marketed by Janssen Ortho Biotech.

The approval for ulcerative colitis was based on two studies of patients with moderate to severe ulcerative colitis, according to the FDA statement announcing the approval. In one study, which enrolled 513 patients who could not tolerate or had not responded to other treatments, "a greater proportion of Simponi-treated patients achieved clinical response, clinical remission and, as seen during endoscopy, had improved appearance of the colon after 6 weeks," compared with those on placebo, the statement said.

In a study of 310 patients who had responded to golimumab and were then randomized to continue treatment with golimumab or were switched to placebo, "a greater proportion of Simponi-treated patients maintained clinical response through week 54, had clinical remission at both weeks 30 and 54 and, as seen during endoscopy, had improved appearance of the colon at both weeks 30 and 54 compared with the placebo group," the FDA said. The most common adverse effects associated with golimumab are upper respiratory infection and redness at the injection site.

The risks of serious infections, invasive fungal infections, reactivation of hepatitis B infection, lymphoma, heart failure, nervous system disorders, and allergic reactions are increased with treatment.

Serious adverse events associated with golimumab should be reported to the FDA at 800-332-1088 or www.fda.gov/medwatch/.

[email protected]

EDITOR'S NOTE: August 26, 2013: This article has been amended since it was first published to make it clear that Dr. Kelley Pagliai Redbord's description of the pulley stitch procedure was taken directly from an article published by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg.2011;37:1503-5). In her presentation, Dr. Redbord credited Dr. Yag-Howard and her article. However, this credit and attribution to Dr. Yag-Howard was not included in the article published.

WASHINGTON – The pulley stitch "is my go-to stitch for defects under tension," said Dr. Kelley Pagliai Redbord.

The pulley stitch allows for considerable reduction in the surface area of a large defect that can’t be closed by side-to-side stitches alone, making it an excellent choice for use on the scalp and legs, Dr. Redbord said at the Atlantic Dermatological Conference.

"When the tension across the wound is decreased, buried dermal sutures can be placed more easily and accurately," she said. "I use it a lot as an intraoperative tissue expander."

Dr. Redbord said that her description of the pulley stitch was taken from an article by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg. 2011; 37:1503-5).* 

The pulley stitch can serve as a temporary suture that can be left in place or removed, said Dr. Redbord, a dermatologist in group practice in Rockville, Md.

Courtesy of Dr. Kelley Pagliani Redbord

The technique follows a far-near-near-far pattern, starting the stitch 8 mm from the wound edge (far), then bringing it to the opposite side just 4 mm from the wound edge (near). Dr. Redbord then reenters the stitch 4 mm from the wound edge on the initial side (near), and makes another pass to the opposite side 8 mm from the wound edge (far).

Multiple passes through the tissue create resistance that keeps the suture from slipping. "The loops of the stitch are placed at an oblique angle so that the inner and outer loops are offset and do not override each other," she noted. This technique minimizes potential skin damage from pressure necrosis caused by overriding loop sutures. The pulley stitch has a 2:1 mechanical advantage over an interrupted suture, and the additional friction of a second loop prevents the knot from slipping.

A modification of the pulley stitch is to loop the suture through an external loop on the opposite side of the incision, and pull across. "This new loop functions as a pulley and directs the tension away from the other strands," she said.

Another stitch with excellent eversion, in which the pulley stitch plays a key role, is the subcutaneous inverted cross mattress stitch (SICM). The SCIM is entirely subcutaneous, and combines the buried vertical mattress stitch and the buried pulley stitch.

The SCIM "uses the buried vertical mattress’s ability to evert wound edges and combines it with the pulley stitch’s ability to decrease tension at the wound edge," she said.

The four-step process is as follows:

• 1. Insert the needle into the dermis 3-5 mm lateral to the wound edge. Advance the needle into the upper reticular dermis, and then curve down to exit through the lower reticular dermis.

• 2. Insert the needle into the opposite edge of the wound at the lower reticular dermis and advance into the upper reticular dermis, then curve down and exit intradermally.

• 3. Insert the needle across the defect using an intradermal approach 1-2 mm lateral to the initial needle insertion point. Then, create a second buried vertical mattress stitch.

• 4. Pull the two stitches to close, which "creates a pulley effect with minimal recoil, and tie off," Dr. Redbord said.

"The pulley system locks the wound edges so that a knot can be tied without slipping," she added.

Dr. Redbord said she had no relevant financial disclosures.

[email protected]

EDITOR'S NOTE: August 26, 2013: This article has been amended since it was first published to make it clear that Dr. Kelley Pagliai Redbord's description of the pulley stitch procedure was taken directly from an article published by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg.2011;37:1503-5). In her presentation, Dr. Redbord credited Dr. Yag-Howard and her article. However, this credit and attribution to Dr. Yag-Howard was not included in the article published.

WASHINGTON – The pulley stitch "is my go-to stitch for defects under tension," said Dr. Kelley Pagliai Redbord.

The pulley stitch allows for considerable reduction in the surface area of a large defect that can’t be closed by side-to-side stitches alone, making it an excellent choice for use on the scalp and legs, Dr. Redbord said at the Atlantic Dermatological Conference.

"When the tension across the wound is decreased, buried dermal sutures can be placed more easily and accurately," she said. "I use it a lot as an intraoperative tissue expander."

Dr. Redbord said that her description of the pulley stitch was taken from an article by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg. 2011; 37:1503-5).* 

The pulley stitch can serve as a temporary suture that can be left in place or removed, said Dr. Redbord, a dermatologist in group practice in Rockville, Md.

Courtesy of Dr. Kelley Pagliani Redbord

The technique follows a far-near-near-far pattern, starting the stitch 8 mm from the wound edge (far), then bringing it to the opposite side just 4 mm from the wound edge (near). Dr. Redbord then reenters the stitch 4 mm from the wound edge on the initial side (near), and makes another pass to the opposite side 8 mm from the wound edge (far).

Multiple passes through the tissue create resistance that keeps the suture from slipping. "The loops of the stitch are placed at an oblique angle so that the inner and outer loops are offset and do not override each other," she noted. This technique minimizes potential skin damage from pressure necrosis caused by overriding loop sutures. The pulley stitch has a 2:1 mechanical advantage over an interrupted suture, and the additional friction of a second loop prevents the knot from slipping.

A modification of the pulley stitch is to loop the suture through an external loop on the opposite side of the incision, and pull across. "This new loop functions as a pulley and directs the tension away from the other strands," she said.

Another stitch with excellent eversion, in which the pulley stitch plays a key role, is the subcutaneous inverted cross mattress stitch (SICM). The SCIM is entirely subcutaneous, and combines the buried vertical mattress stitch and the buried pulley stitch.

The SCIM "uses the buried vertical mattress’s ability to evert wound edges and combines it with the pulley stitch’s ability to decrease tension at the wound edge," she said.

The four-step process is as follows:

• 1. Insert the needle into the dermis 3-5 mm lateral to the wound edge. Advance the needle into the upper reticular dermis, and then curve down to exit through the lower reticular dermis.

• 2. Insert the needle into the opposite edge of the wound at the lower reticular dermis and advance into the upper reticular dermis, then curve down and exit intradermally.

• 3. Insert the needle across the defect using an intradermal approach 1-2 mm lateral to the initial needle insertion point. Then, create a second buried vertical mattress stitch.

• 4. Pull the two stitches to close, which "creates a pulley effect with minimal recoil, and tie off," Dr. Redbord said.

"The pulley system locks the wound edges so that a knot can be tied without slipping," she added.

Dr. Redbord said she had no relevant financial disclosures.

[email protected]

EDITOR'S NOTE: August 26, 2013: This article has been amended since it was first published to make it clear that Dr. Kelley Pagliai Redbord's description of the pulley stitch procedure was taken directly from an article published by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg.2011;37:1503-5). In her presentation, Dr. Redbord credited Dr. Yag-Howard and her article. However, this credit and attribution to Dr. Yag-Howard was not included in the article published.

WASHINGTON – The pulley stitch "is my go-to stitch for defects under tension," said Dr. Kelley Pagliai Redbord.

The pulley stitch allows for considerable reduction in the surface area of a large defect that can’t be closed by side-to-side stitches alone, making it an excellent choice for use on the scalp and legs, Dr. Redbord said at the Atlantic Dermatological Conference.

"When the tension across the wound is decreased, buried dermal sutures can be placed more easily and accurately," she said. "I use it a lot as an intraoperative tissue expander."

Dr. Redbord said that her description of the pulley stitch was taken from an article by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg. 2011; 37:1503-5).* 

The pulley stitch can serve as a temporary suture that can be left in place or removed, said Dr. Redbord, a dermatologist in group practice in Rockville, Md.

Courtesy of Dr. Kelley Pagliani Redbord

The technique follows a far-near-near-far pattern, starting the stitch 8 mm from the wound edge (far), then bringing it to the opposite side just 4 mm from the wound edge (near). Dr. Redbord then reenters the stitch 4 mm from the wound edge on the initial side (near), and makes another pass to the opposite side 8 mm from the wound edge (far).

Multiple passes through the tissue create resistance that keeps the suture from slipping. "The loops of the stitch are placed at an oblique angle so that the inner and outer loops are offset and do not override each other," she noted. This technique minimizes potential skin damage from pressure necrosis caused by overriding loop sutures. The pulley stitch has a 2:1 mechanical advantage over an interrupted suture, and the additional friction of a second loop prevents the knot from slipping.

A modification of the pulley stitch is to loop the suture through an external loop on the opposite side of the incision, and pull across. "This new loop functions as a pulley and directs the tension away from the other strands," she said.

Another stitch with excellent eversion, in which the pulley stitch plays a key role, is the subcutaneous inverted cross mattress stitch (SICM). The SCIM is entirely subcutaneous, and combines the buried vertical mattress stitch and the buried pulley stitch.

The SCIM "uses the buried vertical mattress’s ability to evert wound edges and combines it with the pulley stitch’s ability to decrease tension at the wound edge," she said.

The four-step process is as follows:

• 1. Insert the needle into the dermis 3-5 mm lateral to the wound edge. Advance the needle into the upper reticular dermis, and then curve down to exit through the lower reticular dermis.

• 2. Insert the needle into the opposite edge of the wound at the lower reticular dermis and advance into the upper reticular dermis, then curve down and exit intradermally.

• 3. Insert the needle across the defect using an intradermal approach 1-2 mm lateral to the initial needle insertion point. Then, create a second buried vertical mattress stitch.

• 4. Pull the two stitches to close, which "creates a pulley effect with minimal recoil, and tie off," Dr. Redbord said.

"The pulley system locks the wound edges so that a knot can be tied without slipping," she added.

Dr. Redbord said she had no relevant financial disclosures.

[email protected]

You’ve heard it before: Social media is the new marketing. Chances are good that you’re already using social media to market your practice. The question is: Are you using it effectively?

Traditional marketing – buying ads through newspapers, magazines, radio, et cetera – is still alive. But more and more, companies, including medical practices, are turning to social media marketing or "media marketing." Why? Social marketing costs less, helps build your brand, is interactive, is less obtrusive, provides real-time results, and can be adjusted or tailored quickly to meet your current needs.

As health care providers, we know that the best form of advertising is positive word of mouth. Turns out the same is true online. A 2012 Nielsen Global Trust in Advertising report found that of 28,000 Internet respondents in 56 countries, 92% of consumers said they trusted earned media (media recommended by family and friends) above all other forms of advertising.

The same is true with health care. Health care consumers want more, not fewer, online reviews of doctors and medical centers because they trust word of mouth. According to a May 2011 report from the Pew Research Center, 16% of Internet users, or 12% of adults, have consulted online rankings or reviews of doctors or other health care providers. These numbers will only rise as more patients post reviews.

Despite its benefits, social marketing won’t work for your practice if you don’t use it correctly. Unlike traditional marketing, which relies on a one-way message from the company (you) to the consumer (your current and prospective patients), social marketing is a two-way message. You are connecting with and sharing information with others on different social media platforms on a regular basis.

Successful marketing is a multistep process. It’s not good enough to simply attract. You also need to convert. The online world is full of clutter, so to attract people’s attention, you need to provide value. You do this by creating compelling, credible content that can be easily shared on many social platforms, such as Twitter, Facebook, and Pinterest. The hub of your social media marketing content should be your website/blog.

Your practice website should include a blog that is continually updated with fresh, original material that can be shared on social platforms. That way, when people find you on Facebook or Twitter, they can click through to your practice website where conversion takes place. Keep in mind it often takes more than one visit to convert.

For social marketing to be effective, you need a strong brand and message. Are you the acne expert? The technologically tricked-out Mohs surgeon? The bilingual pediatrician?

Let’s look at an example: You’re a pediatric dermatologist who specializes in eczema. You write engaging, useful, medically accurate blog posts that you share on different social media platforms. A mom of a child with eczema finds a link to one of your posts on natural remedies for eczema. She clicks through to your practice website, where she posts a comment on the blog and shares the post on Pinterest.

Here’s what she should find while she’s on your practice’s website:

• A clean, updated site with information about you and your practice.

• More blog posts for visitors to read and comment on.

• An RSS feed to subscribe to your blog.

• The ability to sign up for your newsletter or do one-click shopping (if applicable).

• The ability to make an appointment by phone or by using an online booking service (such as ZocDoc.com).

• Links to your other social media platforms (Facebook page, twitter feed).

• Any details that make your practice stand out, such as when and whether you offer night or weekend appointments, descriptions of your latest technology, or the presence of multilingual staff.

She will likely start consuming your information. She might comment on a blog post, begin following you on Twitter, or sign up for your RSS feed that will provide her with updates every time you post new content. Over time, she will come to value your brand and see you as a trusted source of information. She may eventually schedule an appointment, refer you to a friend, or buy one of your products. Likely, she’ll share her positive experiences online, helping to spread the good word about you.

If you’ve tried social media marketing in the past and didn’t find it successful, then ask yourself these questions: Did you misuse your social media platforms by constantly promoting yourself or criticizing others? Did you spam people with unwanted ads or add people to your e-mail list without their permission? Ignore questions and comments? Forget to make it about them, not you?

Today, there is no successful marketing without successful social media. By following these steps, not only will you attract new clients, you will also convert them, leading to more satisfied patients and a more satisfied you.

Dr. Benabio is in private practice in San Diego. Visit his consumer health blog at http://thedermblog.com; connect with him on Twitter @Dermdoc, and on Facebook (DermDoc).

You’ve heard it before: Social media is the new marketing. Chances are good that you’re already using social media to market your practice. The question is: Are you using it effectively?

Traditional marketing – buying ads through newspapers, magazines, radio, et cetera – is still alive. But more and more, companies, including medical practices, are turning to social media marketing or "media marketing." Why? Social marketing costs less, helps build your brand, is interactive, is less obtrusive, provides real-time results, and can be adjusted or tailored quickly to meet your current needs.

As health care providers, we know that the best form of advertising is positive word of mouth. Turns out the same is true online. A 2012 Nielsen Global Trust in Advertising report found that of 28,000 Internet respondents in 56 countries, 92% of consumers said they trusted earned media (media recommended by family and friends) above all other forms of advertising.

The same is true with health care. Health care consumers want more, not fewer, online reviews of doctors and medical centers because they trust word of mouth. According to a May 2011 report from the Pew Research Center, 16% of Internet users, or 12% of adults, have consulted online rankings or reviews of doctors or other health care providers. These numbers will only rise as more patients post reviews.

Despite its benefits, social marketing won’t work for your practice if you don’t use it correctly. Unlike traditional marketing, which relies on a one-way message from the company (you) to the consumer (your current and prospective patients), social marketing is a two-way message. You are connecting with and sharing information with others on different social media platforms on a regular basis.

Successful marketing is a multistep process. It’s not good enough to simply attract. You also need to convert. The online world is full of clutter, so to attract people’s attention, you need to provide value. You do this by creating compelling, credible content that can be easily shared on many social platforms, such as Twitter, Facebook, and Pinterest. The hub of your social media marketing content should be your website/blog.

Your practice website should include a blog that is continually updated with fresh, original material that can be shared on social platforms. That way, when people find you on Facebook or Twitter, they can click through to your practice website where conversion takes place. Keep in mind it often takes more than one visit to convert.

For social marketing to be effective, you need a strong brand and message. Are you the acne expert? The technologically tricked-out Mohs surgeon? The bilingual pediatrician?

Let’s look at an example: You’re a pediatric dermatologist who specializes in eczema. You write engaging, useful, medically accurate blog posts that you share on different social media platforms. A mom of a child with eczema finds a link to one of your posts on natural remedies for eczema. She clicks through to your practice website, where she posts a comment on the blog and shares the post on Pinterest.

Here’s what she should find while she’s on your practice’s website:

• A clean, updated site with information about you and your practice.

• More blog posts for visitors to read and comment on.

• An RSS feed to subscribe to your blog.

• The ability to sign up for your newsletter or do one-click shopping (if applicable).

• The ability to make an appointment by phone or by using an online booking service (such as ZocDoc.com).

• Links to your other social media platforms (Facebook page, twitter feed).

• Any details that make your practice stand out, such as when and whether you offer night or weekend appointments, descriptions of your latest technology, or the presence of multilingual staff.

She will likely start consuming your information. She might comment on a blog post, begin following you on Twitter, or sign up for your RSS feed that will provide her with updates every time you post new content. Over time, she will come to value your brand and see you as a trusted source of information. She may eventually schedule an appointment, refer you to a friend, or buy one of your products. Likely, she’ll share her positive experiences online, helping to spread the good word about you.

If you’ve tried social media marketing in the past and didn’t find it successful, then ask yourself these questions: Did you misuse your social media platforms by constantly promoting yourself or criticizing others? Did you spam people with unwanted ads or add people to your e-mail list without their permission? Ignore questions and comments? Forget to make it about them, not you?

Today, there is no successful marketing without successful social media. By following these steps, not only will you attract new clients, you will also convert them, leading to more satisfied patients and a more satisfied you.

Dr. Benabio is in private practice in San Diego. Visit his consumer health blog at http://thedermblog.com; connect with him on Twitter @Dermdoc, and on Facebook (DermDoc).

You’ve heard it before: Social media is the new marketing. Chances are good that you’re already using social media to market your practice. The question is: Are you using it effectively?

Traditional marketing – buying ads through newspapers, magazines, radio, et cetera – is still alive. But more and more, companies, including medical practices, are turning to social media marketing or "media marketing." Why? Social marketing costs less, helps build your brand, is interactive, is less obtrusive, provides real-time results, and can be adjusted or tailored quickly to meet your current needs.

As health care providers, we know that the best form of advertising is positive word of mouth. Turns out the same is true online. A 2012 Nielsen Global Trust in Advertising report found that of 28,000 Internet respondents in 56 countries, 92% of consumers said they trusted earned media (media recommended by family and friends) above all other forms of advertising.

The same is true with health care. Health care consumers want more, not fewer, online reviews of doctors and medical centers because they trust word of mouth. According to a May 2011 report from the Pew Research Center, 16% of Internet users, or 12% of adults, have consulted online rankings or reviews of doctors or other health care providers. These numbers will only rise as more patients post reviews.

Despite its benefits, social marketing won’t work for your practice if you don’t use it correctly. Unlike traditional marketing, which relies on a one-way message from the company (you) to the consumer (your current and prospective patients), social marketing is a two-way message. You are connecting with and sharing information with others on different social media platforms on a regular basis.

Successful marketing is a multistep process. It’s not good enough to simply attract. You also need to convert. The online world is full of clutter, so to attract people’s attention, you need to provide value. You do this by creating compelling, credible content that can be easily shared on many social platforms, such as Twitter, Facebook, and Pinterest. The hub of your social media marketing content should be your website/blog.

Your practice website should include a blog that is continually updated with fresh, original material that can be shared on social platforms. That way, when people find you on Facebook or Twitter, they can click through to your practice website where conversion takes place. Keep in mind it often takes more than one visit to convert.

For social marketing to be effective, you need a strong brand and message. Are you the acne expert? The technologically tricked-out Mohs surgeon? The bilingual pediatrician?

Let’s look at an example: You’re a pediatric dermatologist who specializes in eczema. You write engaging, useful, medically accurate blog posts that you share on different social media platforms. A mom of a child with eczema finds a link to one of your posts on natural remedies for eczema. She clicks through to your practice website, where she posts a comment on the blog and shares the post on Pinterest.

Here’s what she should find while she’s on your practice’s website:

• A clean, updated site with information about you and your practice.

• More blog posts for visitors to read and comment on.

• An RSS feed to subscribe to your blog.

• The ability to sign up for your newsletter or do one-click shopping (if applicable).

• The ability to make an appointment by phone or by using an online booking service (such as ZocDoc.com).

• Links to your other social media platforms (Facebook page, twitter feed).

• Any details that make your practice stand out, such as when and whether you offer night or weekend appointments, descriptions of your latest technology, or the presence of multilingual staff.

She will likely start consuming your information. She might comment on a blog post, begin following you on Twitter, or sign up for your RSS feed that will provide her with updates every time you post new content. Over time, she will come to value your brand and see you as a trusted source of information. She may eventually schedule an appointment, refer you to a friend, or buy one of your products. Likely, she’ll share her positive experiences online, helping to spread the good word about you.

If you’ve tried social media marketing in the past and didn’t find it successful, then ask yourself these questions: Did you misuse your social media platforms by constantly promoting yourself or criticizing others? Did you spam people with unwanted ads or add people to your e-mail list without their permission? Ignore questions and comments? Forget to make it about them, not you?

Today, there is no successful marketing without successful social media. By following these steps, not only will you attract new clients, you will also convert them, leading to more satisfied patients and a more satisfied you.

Dr. Benabio is in private practice in San Diego. Visit his consumer health blog at http://thedermblog.com; connect with him on Twitter @Dermdoc, and on Facebook (DermDoc).

For most physicians, the resolution of patients’ complaints ranks second only to firing an employee on the Least Favorite Tasks List. With so many potential problems, and so many ways patients can react to them, it seems impossible to construct any sort of template for consistent, mutually satisfactory resolutions.

But it can be done, and it’s not as complex as it appears, once you realize that the vast majority of complaints have the same basic root: The patient’s expectations have not been met. Sometimes it’s your fault, sometimes the patient’s, and often a bit of both, but either way, the result is the same: You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple, three-part strategy:

• Discover which expectations went unmet and why.

• Agree on a solution.

• Learn from the experience, to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It’s what you would want if you were the complainant, and it’s often too important to trust to a subordinate.

At this point, you may be asking, "Why should I care?" Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, but a dissatisfied one will frighten away 20 or more. Besides, if the complaint is significant and you don’t resolve it, the patient is likely to find someone who will; and chances are you won’t like their choice, or the eventual resolution.

Of course, the easiest way to deal with complaints is to prevent as many as possible in the first place. Try to nip unrealistic expectations in the bud. Take the time in advance to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation is like garlic: There is no such thing as too much of it.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill in that set is the one most people – especially physicians – do poorly: Listening to the complaint. Before you can resolve a problem, you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

So listen to the entire complaint without interrupting, defending, or justifying. Angry patients don’t care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: "So, if I understand you correctly, you expected "X" to happen, but "Y" happened instead." If I’m wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind – additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. Consider it.

If the patient’s solution is reasonable, by all means, agree to it; if it is unreasonable, try to offer a reasonable alternative. The temptation is to think more about protecting yourself than about making the patient happy, but that often leads to bigger problems. Don’t be defensive. Remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) will interpret a refund as a tacit admission of guilt, so I generally try to avoid them. However, cancelling a small fee for an angry patient can be very prudent, and in my opinion that looks exactly like what it is: an honest effort to rectify the situation. But in general, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, again, document everything, but consider reserving a "private" chart area for such documentation (unless it is a bona fide clinical issue) so that it won’t go out to referrers and other third parties with copies of your clinical notes. Also, consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in a similar future situation.

Above all, don’t take complaints personally – even when they are personal. It’s always worth remembering that no matter how hard you try, you can never please everyone.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

For most physicians, the resolution of patients’ complaints ranks second only to firing an employee on the Least Favorite Tasks List. With so many potential problems, and so many ways patients can react to them, it seems impossible to construct any sort of template for consistent, mutually satisfactory resolutions.

But it can be done, and it’s not as complex as it appears, once you realize that the vast majority of complaints have the same basic root: The patient’s expectations have not been met. Sometimes it’s your fault, sometimes the patient’s, and often a bit of both, but either way, the result is the same: You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple, three-part strategy:

• Discover which expectations went unmet and why.

• Agree on a solution.

• Learn from the experience, to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It’s what you would want if you were the complainant, and it’s often too important to trust to a subordinate.

At this point, you may be asking, "Why should I care?" Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, but a dissatisfied one will frighten away 20 or more. Besides, if the complaint is significant and you don’t resolve it, the patient is likely to find someone who will; and chances are you won’t like their choice, or the eventual resolution.

Of course, the easiest way to deal with complaints is to prevent as many as possible in the first place. Try to nip unrealistic expectations in the bud. Take the time in advance to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation is like garlic: There is no such thing as too much of it.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill in that set is the one most people – especially physicians – do poorly: Listening to the complaint. Before you can resolve a problem, you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

So listen to the entire complaint without interrupting, defending, or justifying. Angry patients don’t care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: "So, if I understand you correctly, you expected "X" to happen, but "Y" happened instead." If I’m wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind – additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. Consider it.

If the patient’s solution is reasonable, by all means, agree to it; if it is unreasonable, try to offer a reasonable alternative. The temptation is to think more about protecting yourself than about making the patient happy, but that often leads to bigger problems. Don’t be defensive. Remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) will interpret a refund as a tacit admission of guilt, so I generally try to avoid them. However, cancelling a small fee for an angry patient can be very prudent, and in my opinion that looks exactly like what it is: an honest effort to rectify the situation. But in general, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, again, document everything, but consider reserving a "private" chart area for such documentation (unless it is a bona fide clinical issue) so that it won’t go out to referrers and other third parties with copies of your clinical notes. Also, consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in a similar future situation.

Above all, don’t take complaints personally – even when they are personal. It’s always worth remembering that no matter how hard you try, you can never please everyone.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

For most physicians, the resolution of patients’ complaints ranks second only to firing an employee on the Least Favorite Tasks List. With so many potential problems, and so many ways patients can react to them, it seems impossible to construct any sort of template for consistent, mutually satisfactory resolutions.

But it can be done, and it’s not as complex as it appears, once you realize that the vast majority of complaints have the same basic root: The patient’s expectations have not been met. Sometimes it’s your fault, sometimes the patient’s, and often a bit of both, but either way, the result is the same: You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple, three-part strategy:

• Discover which expectations went unmet and why.

• Agree on a solution.

• Learn from the experience, to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It’s what you would want if you were the complainant, and it’s often too important to trust to a subordinate.

At this point, you may be asking, "Why should I care?" Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, but a dissatisfied one will frighten away 20 or more. Besides, if the complaint is significant and you don’t resolve it, the patient is likely to find someone who will; and chances are you won’t like their choice, or the eventual resolution.

Of course, the easiest way to deal with complaints is to prevent as many as possible in the first place. Try to nip unrealistic expectations in the bud. Take the time in advance to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation is like garlic: There is no such thing as too much of it.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill in that set is the one most people – especially physicians – do poorly: Listening to the complaint. Before you can resolve a problem, you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

So listen to the entire complaint without interrupting, defending, or justifying. Angry patients don’t care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: "So, if I understand you correctly, you expected "X" to happen, but "Y" happened instead." If I’m wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind – additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. Consider it.

If the patient’s solution is reasonable, by all means, agree to it; if it is unreasonable, try to offer a reasonable alternative. The temptation is to think more about protecting yourself than about making the patient happy, but that often leads to bigger problems. Don’t be defensive. Remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) will interpret a refund as a tacit admission of guilt, so I generally try to avoid them. However, cancelling a small fee for an angry patient can be very prudent, and in my opinion that looks exactly like what it is: an honest effort to rectify the situation. But in general, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, again, document everything, but consider reserving a "private" chart area for such documentation (unless it is a bona fide clinical issue) so that it won’t go out to referrers and other third parties with copies of your clinical notes. Also, consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in a similar future situation.

Above all, don’t take complaints personally – even when they are personal. It’s always worth remembering that no matter how hard you try, you can never please everyone.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Who knew?

I was almost speechless when the federal government released data that show striking variation across America, and even within individual communities, in what hospitals charge patients. The 100 most frequently billed discharges of 2011 are represented in the data, and the associated DRGs represent close to 7 million discharges.

President Obama promised more transparency in and by government, and this headline from the Washington Post about CMS’s data-sharing move makes it crystal clear for all to see: "One hospital charges $8,000 – another, $38,000." Yes, for the same service. But that is just the tip of the iceberg. The article goes on to note that, according to hospitals’ once-secret "chargemaster" lists, the cost of joint replacements ranged from $5,304 in Ada, Okla., to a whopping $223,373 in Monterey, Calif. And, while a case of uncomplicated pneumonia may cost only $5,093 in Water Valley, Miss., you better hope you are not visiting Philadelphia when you get sick, or you can plan to tack on additional $119,000 to that bill. Surely, it is not the cost of the medications that accounts for this vast difference. National guidelines for treating pneumonia apply to all 50 states, so the care should be comparable. So what accounts for the extremes in hospital charges?

Okay, there’s the cost-of-living factor, and thus the hospitals’ overhead is undoubtedly drastically different in small-town U.S.A. vs. a popular metropolis, but it is shocking that this gap is so huge. While I have always known that there were differences in charges for medical services based on where you go, I never imagined such a stark contrast in the price tag for the same service in the same country – and sometimes even in the same city. As if the medical profession were not already struggling with its reputation eyes of the public. These data really paint of negative picture of the medical community.

So, what is the real significance of the discrepancy in these charges? For many with good insurance, nothing. Insurance companies decide what they are willing to pay for a given billing code and, typically, the rest is written off. Patients are not liable for the difference. Not quite true if you are uninsured.

Though the American Hospital Association states that centers often provide assistance to patients with meager finances, those who are most vulnerable and least able to pay for medical care may end up with the entire bill, frequently a bill that they will never be able to pay. That bill may eventually cause them to file for bankruptcy, which will adversely affect their lives and their children’s lives for many years to come – all because they became sick and assumed that the quality of care and the price for services rendered would be reasonable and comparable across all institutions.

While some may cringe at the revelation of the price discrepancy, I am glad this information came to light. Now consumers will be able to compare hospitals’ pricing as well as their quality measures and make better decisions about which hospital is best for them.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS. This blog, "Teachable Moments," appears regularly in Hospitalist News.

Who knew?

I was almost speechless when the federal government released data that show striking variation across America, and even within individual communities, in what hospitals charge patients. The 100 most frequently billed discharges of 2011 are represented in the data, and the associated DRGs represent close to 7 million discharges.

President Obama promised more transparency in and by government, and this headline from the Washington Post about CMS’s data-sharing move makes it crystal clear for all to see: "One hospital charges $8,000 – another, $38,000." Yes, for the same service. But that is just the tip of the iceberg. The article goes on to note that, according to hospitals’ once-secret "chargemaster" lists, the cost of joint replacements ranged from $5,304 in Ada, Okla., to a whopping $223,373 in Monterey, Calif. And, while a case of uncomplicated pneumonia may cost only $5,093 in Water Valley, Miss., you better hope you are not visiting Philadelphia when you get sick, or you can plan to tack on additional $119,000 to that bill. Surely, it is not the cost of the medications that accounts for this vast difference. National guidelines for treating pneumonia apply to all 50 states, so the care should be comparable. So what accounts for the extremes in hospital charges?

Okay, there’s the cost-of-living factor, and thus the hospitals’ overhead is undoubtedly drastically different in small-town U.S.A. vs. a popular metropolis, but it is shocking that this gap is so huge. While I have always known that there were differences in charges for medical services based on where you go, I never imagined such a stark contrast in the price tag for the same service in the same country – and sometimes even in the same city. As if the medical profession were not already struggling with its reputation eyes of the public. These data really paint of negative picture of the medical community.

So, what is the real significance of the discrepancy in these charges? For many with good insurance, nothing. Insurance companies decide what they are willing to pay for a given billing code and, typically, the rest is written off. Patients are not liable for the difference. Not quite true if you are uninsured.

Though the American Hospital Association states that centers often provide assistance to patients with meager finances, those who are most vulnerable and least able to pay for medical care may end up with the entire bill, frequently a bill that they will never be able to pay. That bill may eventually cause them to file for bankruptcy, which will adversely affect their lives and their children’s lives for many years to come – all because they became sick and assumed that the quality of care and the price for services rendered would be reasonable and comparable across all institutions.

While some may cringe at the revelation of the price discrepancy, I am glad this information came to light. Now consumers will be able to compare hospitals’ pricing as well as their quality measures and make better decisions about which hospital is best for them.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS. This blog, "Teachable Moments," appears regularly in Hospitalist News.

Who knew?

I was almost speechless when the federal government released data that show striking variation across America, and even within individual communities, in what hospitals charge patients. The 100 most frequently billed discharges of 2011 are represented in the data, and the associated DRGs represent close to 7 million discharges.

President Obama promised more transparency in and by government, and this headline from the Washington Post about CMS’s data-sharing move makes it crystal clear for all to see: "One hospital charges $8,000 – another, $38,000." Yes, for the same service. But that is just the tip of the iceberg. The article goes on to note that, according to hospitals’ once-secret "chargemaster" lists, the cost of joint replacements ranged from $5,304 in Ada, Okla., to a whopping $223,373 in Monterey, Calif. And, while a case of uncomplicated pneumonia may cost only $5,093 in Water Valley, Miss., you better hope you are not visiting Philadelphia when you get sick, or you can plan to tack on additional $119,000 to that bill. Surely, it is not the cost of the medications that accounts for this vast difference. National guidelines for treating pneumonia apply to all 50 states, so the care should be comparable. So what accounts for the extremes in hospital charges?

Okay, there’s the cost-of-living factor, and thus the hospitals’ overhead is undoubtedly drastically different in small-town U.S.A. vs. a popular metropolis, but it is shocking that this gap is so huge. While I have always known that there were differences in charges for medical services based on where you go, I never imagined such a stark contrast in the price tag for the same service in the same country – and sometimes even in the same city. As if the medical profession were not already struggling with its reputation eyes of the public. These data really paint of negative picture of the medical community.

So, what is the real significance of the discrepancy in these charges? For many with good insurance, nothing. Insurance companies decide what they are willing to pay for a given billing code and, typically, the rest is written off. Patients are not liable for the difference. Not quite true if you are uninsured.

Though the American Hospital Association states that centers often provide assistance to patients with meager finances, those who are most vulnerable and least able to pay for medical care may end up with the entire bill, frequently a bill that they will never be able to pay. That bill may eventually cause them to file for bankruptcy, which will adversely affect their lives and their children’s lives for many years to come – all because they became sick and assumed that the quality of care and the price for services rendered would be reasonable and comparable across all institutions.

While some may cringe at the revelation of the price discrepancy, I am glad this information came to light. Now consumers will be able to compare hospitals’ pricing as well as their quality measures and make better decisions about which hospital is best for them.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS. This blog, "Teachable Moments," appears regularly in Hospitalist News.

INDIANAPOLIS – Patients requiring surgery for adhesive small bowel obstruction have markedly lower major morbidity and mortality rates if they’re operated on within 24 hours of hospital admission, according to an analysis of a large national database.

This finding is at odds with the conventional wisdom.

Both the World Society of Emergency Surgery and the Eastern Association for the Surgery of Trauma recommend in published guidelines an initial 3-5 days of nonoperative management to give the obstruction a chance to resolve on its own, Dr. Pedro G. Teixeira noted in presenting the study findings at the annual meeting of the American Surgical Association.

Courtesy Wikimedia Commons/James Heilman, MD/Creative Commons License

He and his coinvestigators identified 4,163 patients in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for 2005-2010 who underwent emergency laparotomy for adhesive bowel obstruction. Thirty-day mortality was 3% in those operated upon within 24 hours of hospital admission. It rose in stepwise fashion thereafter: 4% mortality with surgery at 24-48 hours, 7% with surgery at 48-72 hours, and 9% a threefold increase – when surgery was delayed beyond 72 hours, according to Dr. Teixeira of the University of Southern California, Los Angeles.

Similarly, the incidence of systemic infectious complications, including pneumonia, urinary tract infections, and sepsis, climbed from 12% with early operation to 17% when surgery occurred at 24-48 hours, 21% at 48-72 hours, and 24% thereafter.

In a multivariate analysis adjusted for baseline comorbidities and other potential confounding variables, surgery delayed for 24 hours or more after admission was associated with a highly significant 58% increased risk of mortality, a 33% increase in surgical site infections, a 36% greater risk of pneumonia, and a 47% increased risk of septic shock, he continued.

Discussant Gregory J. Jurkovich commented that this study challenges current dogma and harkens back to a century-old adage that has since been cast aside, namely, "Never let the sun set on a bowel obstruction."

The trouble is, however, that having a low threshold for surgery within 24 hours would subject a massive number of patients to an unnecessary operation.

An analysis of Nationwide Inpatient Sample data for 2009 by other investigators concluded that bowel obstruction resolved on its own within 3 days in 60% of patients and within 5 days in 80%. Fewer than 20% of the patients who presented with adhesive small bowel obstruction without evidence of ischemia underwent surgery, noted Dr. Jurkovich, director of surgery at Denver Health Medical Center and professor of trauma surgery and vice chairman of the department of surgery at the University of Colorado at Denver.

Dr. Teixeira concurred that bowel obstruction will resolve on its own in most patients. The challenge for surgeons in light of his study findings, he stressed, is to expedite the identification of those patients who will fail the period of nonoperative management. The best tool for that, in his view, is a CT scan of the abdomen and pelvis with water-soluble contrast.

At the University of Southern California, he explained, a patient who presents with adhesive bowel obstruction without evidence of ischemia undergoes the CT scan and is admitted to the surgical observation unit for close monitoring.

"At our institution, failure to demonstrate contrast progression through the colon within 24 hours would be a very strong indication for surgical exploration," according to Dr. Teixeira.

He reported having no financial conflicts.

[email protected]

INDIANAPOLIS – Patients requiring surgery for adhesive small bowel obstruction have markedly lower major morbidity and mortality rates if they’re operated on within 24 hours of hospital admission, according to an analysis of a large national database.

This finding is at odds with the conventional wisdom.

Both the World Society of Emergency Surgery and the Eastern Association for the Surgery of Trauma recommend in published guidelines an initial 3-5 days of nonoperative management to give the obstruction a chance to resolve on its own, Dr. Pedro G. Teixeira noted in presenting the study findings at the annual meeting of the American Surgical Association.

Courtesy Wikimedia Commons/James Heilman, MD/Creative Commons License

He and his coinvestigators identified 4,163 patients in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for 2005-2010 who underwent emergency laparotomy for adhesive bowel obstruction. Thirty-day mortality was 3% in those operated upon within 24 hours of hospital admission. It rose in stepwise fashion thereafter: 4% mortality with surgery at 24-48 hours, 7% with surgery at 48-72 hours, and 9% a threefold increase – when surgery was delayed beyond 72 hours, according to Dr. Teixeira of the University of Southern California, Los Angeles.

Similarly, the incidence of systemic infectious complications, including pneumonia, urinary tract infections, and sepsis, climbed from 12% with early operation to 17% when surgery occurred at 24-48 hours, 21% at 48-72 hours, and 24% thereafter.

In a multivariate analysis adjusted for baseline comorbidities and other potential confounding variables, surgery delayed for 24 hours or more after admission was associated with a highly significant 58% increased risk of mortality, a 33% increase in surgical site infections, a 36% greater risk of pneumonia, and a 47% increased risk of septic shock, he continued.

Discussant Gregory J. Jurkovich commented that this study challenges current dogma and harkens back to a century-old adage that has since been cast aside, namely, "Never let the sun set on a bowel obstruction."

The trouble is, however, that having a low threshold for surgery within 24 hours would subject a massive number of patients to an unnecessary operation.

An analysis of Nationwide Inpatient Sample data for 2009 by other investigators concluded that bowel obstruction resolved on its own within 3 days in 60% of patients and within 5 days in 80%. Fewer than 20% of the patients who presented with adhesive small bowel obstruction without evidence of ischemia underwent surgery, noted Dr. Jurkovich, director of surgery at Denver Health Medical Center and professor of trauma surgery and vice chairman of the department of surgery at the University of Colorado at Denver.

Dr. Teixeira concurred that bowel obstruction will resolve on its own in most patients. The challenge for surgeons in light of his study findings, he stressed, is to expedite the identification of those patients who will fail the period of nonoperative management. The best tool for that, in his view, is a CT scan of the abdomen and pelvis with water-soluble contrast.

At the University of Southern California, he explained, a patient who presents with adhesive bowel obstruction without evidence of ischemia undergoes the CT scan and is admitted to the surgical observation unit for close monitoring.

"At our institution, failure to demonstrate contrast progression through the colon within 24 hours would be a very strong indication for surgical exploration," according to Dr. Teixeira.

He reported having no financial conflicts.

[email protected]

INDIANAPOLIS – Patients requiring surgery for adhesive small bowel obstruction have markedly lower major morbidity and mortality rates if they’re operated on within 24 hours of hospital admission, according to an analysis of a large national database.

This finding is at odds with the conventional wisdom.

Both the World Society of Emergency Surgery and the Eastern Association for the Surgery of Trauma recommend in published guidelines an initial 3-5 days of nonoperative management to give the obstruction a chance to resolve on its own, Dr. Pedro G. Teixeira noted in presenting the study findings at the annual meeting of the American Surgical Association.

Courtesy Wikimedia Commons/James Heilman, MD/Creative Commons License

He and his coinvestigators identified 4,163 patients in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for 2005-2010 who underwent emergency laparotomy for adhesive bowel obstruction. Thirty-day mortality was 3% in those operated upon within 24 hours of hospital admission. It rose in stepwise fashion thereafter: 4% mortality with surgery at 24-48 hours, 7% with surgery at 48-72 hours, and 9% a threefold increase – when surgery was delayed beyond 72 hours, according to Dr. Teixeira of the University of Southern California, Los Angeles.

Similarly, the incidence of systemic infectious complications, including pneumonia, urinary tract infections, and sepsis, climbed from 12% with early operation to 17% when surgery occurred at 24-48 hours, 21% at 48-72 hours, and 24% thereafter.

In a multivariate analysis adjusted for baseline comorbidities and other potential confounding variables, surgery delayed for 24 hours or more after admission was associated with a highly significant 58% increased risk of mortality, a 33% increase in surgical site infections, a 36% greater risk of pneumonia, and a 47% increased risk of septic shock, he continued.

Discussant Gregory J. Jurkovich commented that this study challenges current dogma and harkens back to a century-old adage that has since been cast aside, namely, "Never let the sun set on a bowel obstruction."

The trouble is, however, that having a low threshold for surgery within 24 hours would subject a massive number of patients to an unnecessary operation.

An analysis of Nationwide Inpatient Sample data for 2009 by other investigators concluded that bowel obstruction resolved on its own within 3 days in 60% of patients and within 5 days in 80%. Fewer than 20% of the patients who presented with adhesive small bowel obstruction without evidence of ischemia underwent surgery, noted Dr. Jurkovich, director of surgery at Denver Health Medical Center and professor of trauma surgery and vice chairman of the department of surgery at the University of Colorado at Denver.

Dr. Teixeira concurred that bowel obstruction will resolve on its own in most patients. The challenge for surgeons in light of his study findings, he stressed, is to expedite the identification of those patients who will fail the period of nonoperative management. The best tool for that, in his view, is a CT scan of the abdomen and pelvis with water-soluble contrast.

At the University of Southern California, he explained, a patient who presents with adhesive bowel obstruction without evidence of ischemia undergoes the CT scan and is admitted to the surgical observation unit for close monitoring.

"At our institution, failure to demonstrate contrast progression through the colon within 24 hours would be a very strong indication for surgical exploration," according to Dr. Teixeira.

He reported having no financial conflicts.

[email protected]