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From the Washington Office: Medicare audit accountability
The Recovery Audit Contractor (RAC) program was launched in 2010 by the Centers for Medicare and Medicaid Services (CMS) with the intention of identifying and preventing improper payments to Medicare providers. Recovery Audit Contractors are paid on “contingency fee” basis, i.e. a commission on each claim that they deny. Some have thus likened their actions to those of ‘bounty hunters.” Though there is an appeals process, hospitals and physicians bear the cost of audits, denials, and appeals, regardless of the ultimate outcome of the appeals process.
Because of the lack of accountability in the RAC process, concern has been expressed about both the number of inaccurate findings as well as the high volume of appeals. As evidence, the American Hospital Association (AHA) reported that the Office of the Inspector General (OIG) found that 49% of hospital denials are appealed and 72% of the appeals brought before an Administrative Law Judge are overturned in favor of the hospital.
In response to these concerns, Rep. George Holding (R-NC) introduced the H.R. 2568, the Fair Medical Audits Act in May 2015. The bill was jointly referred to the Ways and Means and Energy and Commerce committees in the House of Representatives for further consideration. Currently, H.R. 2568 has 23 cosponsors.
H.R. 2568 addresses many of the concerns in the RAC program by:
• Enhancing transparency in the audit process to improve compliance.
• Improving the claims-review process by mandating that contractors meet appropriate knowledge and experience requirements.
• Promoting provider education while increasing RAC accountability for inaccurate audit findings.
• Ensuring accuracy of those overpayment amounts calculated by contractors using extrapolation methodology.
• Requiring contractors to reimburse certain documentation requests to reduce provider burdens.
• Delaying payment to RACs until after external appeal.
• Reducing the appeals backlog by shortening the “look-back” period.
On Dec. 3, 2015, the American College of Surgeons joined 10 other surgical associations in sending a letter of support to Representative Holding thanking him for introducing the Fair Medical Audits Act. In addition, an ACTION ALERT was posted on the SurgeonsVoice website to facilitate the efforts of Fellows in contacting their individual representatives urging they support the legislation. I would urge all Fellows to log onto www.surgeonsvoice.org, and then click on the “TAKE ACTION” tab on the right side of the screen. It takes only a few moments to send a message to your Member of Congress requesting their assistance in passing this sensible legislation increasing accountability in the Medicare Recovery Audit Contractor program.
Until next month …
Dr. Patrick V. Bailey is an ACS Fellow, a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
The Recovery Audit Contractor (RAC) program was launched in 2010 by the Centers for Medicare and Medicaid Services (CMS) with the intention of identifying and preventing improper payments to Medicare providers. Recovery Audit Contractors are paid on “contingency fee” basis, i.e. a commission on each claim that they deny. Some have thus likened their actions to those of ‘bounty hunters.” Though there is an appeals process, hospitals and physicians bear the cost of audits, denials, and appeals, regardless of the ultimate outcome of the appeals process.
Because of the lack of accountability in the RAC process, concern has been expressed about both the number of inaccurate findings as well as the high volume of appeals. As evidence, the American Hospital Association (AHA) reported that the Office of the Inspector General (OIG) found that 49% of hospital denials are appealed and 72% of the appeals brought before an Administrative Law Judge are overturned in favor of the hospital.
In response to these concerns, Rep. George Holding (R-NC) introduced the H.R. 2568, the Fair Medical Audits Act in May 2015. The bill was jointly referred to the Ways and Means and Energy and Commerce committees in the House of Representatives for further consideration. Currently, H.R. 2568 has 23 cosponsors.
H.R. 2568 addresses many of the concerns in the RAC program by:
• Enhancing transparency in the audit process to improve compliance.
• Improving the claims-review process by mandating that contractors meet appropriate knowledge and experience requirements.
• Promoting provider education while increasing RAC accountability for inaccurate audit findings.
• Ensuring accuracy of those overpayment amounts calculated by contractors using extrapolation methodology.
• Requiring contractors to reimburse certain documentation requests to reduce provider burdens.
• Delaying payment to RACs until after external appeal.
• Reducing the appeals backlog by shortening the “look-back” period.
On Dec. 3, 2015, the American College of Surgeons joined 10 other surgical associations in sending a letter of support to Representative Holding thanking him for introducing the Fair Medical Audits Act. In addition, an ACTION ALERT was posted on the SurgeonsVoice website to facilitate the efforts of Fellows in contacting their individual representatives urging they support the legislation. I would urge all Fellows to log onto www.surgeonsvoice.org, and then click on the “TAKE ACTION” tab on the right side of the screen. It takes only a few moments to send a message to your Member of Congress requesting their assistance in passing this sensible legislation increasing accountability in the Medicare Recovery Audit Contractor program.
Until next month …
Dr. Patrick V. Bailey is an ACS Fellow, a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
The Recovery Audit Contractor (RAC) program was launched in 2010 by the Centers for Medicare and Medicaid Services (CMS) with the intention of identifying and preventing improper payments to Medicare providers. Recovery Audit Contractors are paid on “contingency fee” basis, i.e. a commission on each claim that they deny. Some have thus likened their actions to those of ‘bounty hunters.” Though there is an appeals process, hospitals and physicians bear the cost of audits, denials, and appeals, regardless of the ultimate outcome of the appeals process.
Because of the lack of accountability in the RAC process, concern has been expressed about both the number of inaccurate findings as well as the high volume of appeals. As evidence, the American Hospital Association (AHA) reported that the Office of the Inspector General (OIG) found that 49% of hospital denials are appealed and 72% of the appeals brought before an Administrative Law Judge are overturned in favor of the hospital.
In response to these concerns, Rep. George Holding (R-NC) introduced the H.R. 2568, the Fair Medical Audits Act in May 2015. The bill was jointly referred to the Ways and Means and Energy and Commerce committees in the House of Representatives for further consideration. Currently, H.R. 2568 has 23 cosponsors.
H.R. 2568 addresses many of the concerns in the RAC program by:
• Enhancing transparency in the audit process to improve compliance.
• Improving the claims-review process by mandating that contractors meet appropriate knowledge and experience requirements.
• Promoting provider education while increasing RAC accountability for inaccurate audit findings.
• Ensuring accuracy of those overpayment amounts calculated by contractors using extrapolation methodology.
• Requiring contractors to reimburse certain documentation requests to reduce provider burdens.
• Delaying payment to RACs until after external appeal.
• Reducing the appeals backlog by shortening the “look-back” period.
On Dec. 3, 2015, the American College of Surgeons joined 10 other surgical associations in sending a letter of support to Representative Holding thanking him for introducing the Fair Medical Audits Act. In addition, an ACTION ALERT was posted on the SurgeonsVoice website to facilitate the efforts of Fellows in contacting their individual representatives urging they support the legislation. I would urge all Fellows to log onto www.surgeonsvoice.org, and then click on the “TAKE ACTION” tab on the right side of the screen. It takes only a few moments to send a message to your Member of Congress requesting their assistance in passing this sensible legislation increasing accountability in the Medicare Recovery Audit Contractor program.
Until next month …
Dr. Patrick V. Bailey is an ACS Fellow, a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
The American College of Surgeons: Challenges for the Second Century
As the American College of Surgeons enters its second century, the challenge before us is to uphold the traditions and values of the past while embracing the future with enthusiasm.
The ACS Board of Governors, which represents the broad constituencies of the College, uses the term “pillars” to define the College’s core activities. Although these areas of focus will likely change in time, I would like to offer some thoughts regarding the current pillars and likely future challenges for each.
Communications
The College leadership is sensitive and responsive to the concerns and desires of Fellows; however, some members maintain that the leadership isn’t aware of what they are experiencing in practice. To eliminate this disconnect, Fellows should take advantage of some of the communications vehicles that the College now offers to encourage interaction between the Fellows and the leadership.
We now have more than 100 online “Communities” that allow members to engage in real-time discussions issues of mutual interest. Embrace your specialty’s Community and become enmeshed in conversations about advocacy, rural surgery, international surgery, and so on. ACS leaders are active in these Communities and pay attention to the concerns raised in these forums.
Member services
At the 2015 ACS Leadership & Advocacy Summit, retired U.S. Army General Stanley McChrystal offered his perspective on leadership. One theme he articulated is that leaders should actively engage with the rank-and-file troops. Building on that viewpoint, I would opine that for the ACS to succeed, we need the active and sustained engagement of our surgeons in the field.
Indeed, it has been the College’s experience that these members are the innovators who move the organization forward. For example, the Advanced Trauma Life Support® program is one of the most successful programs in ACS history. This course wasn’t a pipe dream of a regent; rather it was developed by surgeons in Nebraska who saw a need and acted on it. Similarly, the women and men practicing in rural areas created an Advisory Council for Rural Surgery and the online Rural Surgery Community to address the concerns of individuals who practice in nonmetropolitan areas.
For young Fellows, local involvement may be an ideal starting point. Many ACS chapters are floundering and need the energy and creativity young Fellows bring to the table.
Quality
Setting the standards for the delivery of quality surgical care was a core objective of the College’s founders, and quality improvement (QI) remains a primary mission. Although most surgeons are committed to providing high-quality care, they are less likely to participate in QI programs at their institutions.
Quality, which will be increasingly data and outcomes driven, is the benchmark by which future surgeons will be judged. Surgeons must own quality. Its measurement must be local, personal, accurate, and risk adjusted.
Recognizing that if surgeons don’t take ownership of this space, someone else will, the ACS has invested millions of dollars in QI programs – including the ACS National Surgical Quality Improvement Program (ACS NSQIP®) and “QIPs” for trauma, cancer, and bariatric surgery. However, surgeons and their institutions must use them if they are to have a meaningful effect on patient care. If your hospital can’t afford to participate in ACS NSQIP, find a partner, build a consortium or cooperative, or create your own QI measurement tool. Specialty societies have registries that you can tap. One way or another, though, tomorrow’s surgeons will need a record of all cases and outcomes and a means to critically evaluate their performance.
Education
Since the first Clinical Congress more than 100 years ago, education has been the heart of all College efforts. The ACS now offers educational activities programs for surgeons at all levels, but mostly continuing education for practicing surgeons while other groups have assumed control over residency training. In my opinion, the greatest threat to the provision of quality surgical care in the future is the erosion of core surgical training.
I have spent 18 years as a general surgery residency program director; 7 years on the American Board of Surgery, including 1 as chair; and 7 years on the Residency Review Committee for Surgery, including 1 as vice-chair. These experiences have convinced me that future ACS leaders should demand radical changes in surgical training paradigms.
Undoubtedly, any attempt to fundamentally change training will be met with resistance from organizations currently in control. We should engage these bodies in a cooperative spirit; however, real solutions may require a surgical approach – a thoughtful, calculated plan that can be executed decisively.
Advocacy
The College entered the advocacy arena somewhat late but has become an influential force in the halls of Congress and the statehouses, at think tank meetings, with payers, and in discussions with other stakeholders.
Unfortunately, most surgeons have little understanding of how the work of our Division of Advocacy and Health Policy affects their daily practices, and have little time to devote to grassroots efforts. But as medicine becomes more regulated, it is imperative that all surgeons advocate for their profession and their patients.
Indeed, surgical practice is changing quickly. Approximately 80 percent of surgeons are now employees of health care networks or institutions rather than in private practice, and the number of surgeon employees will likely reach 100% soon. Problems have already surfaced for surgeons with contracts, including terminations without cause and other issues. Bundled care payments for all health care services, including hospital and physician services, may be on the horizon. These changes could have deleterious effect on patient care.
As corporate medicine continues to grow and consolidate, a new form of representation may be needed to protect the interest of surgeons and their patients. The College would be the ideal group to lead such an effort.
Your anchor
Although this piece has suggested challenges College Fellows may encounter in the future, in truth, I have no idea what obstacles lie ahead. When times get rough, and they likely will, be certain of your anchors: your family, your friends, your faith, and your profession. The ACS can be that professional anchor.
Dr. Richardson is professor of surgery and vice-chairman, department of surgery, University of Louisville (Ky.) School of Medicine, and President of the American College of Surgeons.
As the American College of Surgeons enters its second century, the challenge before us is to uphold the traditions and values of the past while embracing the future with enthusiasm.
The ACS Board of Governors, which represents the broad constituencies of the College, uses the term “pillars” to define the College’s core activities. Although these areas of focus will likely change in time, I would like to offer some thoughts regarding the current pillars and likely future challenges for each.
Communications
The College leadership is sensitive and responsive to the concerns and desires of Fellows; however, some members maintain that the leadership isn’t aware of what they are experiencing in practice. To eliminate this disconnect, Fellows should take advantage of some of the communications vehicles that the College now offers to encourage interaction between the Fellows and the leadership.
We now have more than 100 online “Communities” that allow members to engage in real-time discussions issues of mutual interest. Embrace your specialty’s Community and become enmeshed in conversations about advocacy, rural surgery, international surgery, and so on. ACS leaders are active in these Communities and pay attention to the concerns raised in these forums.
Member services
At the 2015 ACS Leadership & Advocacy Summit, retired U.S. Army General Stanley McChrystal offered his perspective on leadership. One theme he articulated is that leaders should actively engage with the rank-and-file troops. Building on that viewpoint, I would opine that for the ACS to succeed, we need the active and sustained engagement of our surgeons in the field.
Indeed, it has been the College’s experience that these members are the innovators who move the organization forward. For example, the Advanced Trauma Life Support® program is one of the most successful programs in ACS history. This course wasn’t a pipe dream of a regent; rather it was developed by surgeons in Nebraska who saw a need and acted on it. Similarly, the women and men practicing in rural areas created an Advisory Council for Rural Surgery and the online Rural Surgery Community to address the concerns of individuals who practice in nonmetropolitan areas.
For young Fellows, local involvement may be an ideal starting point. Many ACS chapters are floundering and need the energy and creativity young Fellows bring to the table.
Quality
Setting the standards for the delivery of quality surgical care was a core objective of the College’s founders, and quality improvement (QI) remains a primary mission. Although most surgeons are committed to providing high-quality care, they are less likely to participate in QI programs at their institutions.
Quality, which will be increasingly data and outcomes driven, is the benchmark by which future surgeons will be judged. Surgeons must own quality. Its measurement must be local, personal, accurate, and risk adjusted.
Recognizing that if surgeons don’t take ownership of this space, someone else will, the ACS has invested millions of dollars in QI programs – including the ACS National Surgical Quality Improvement Program (ACS NSQIP®) and “QIPs” for trauma, cancer, and bariatric surgery. However, surgeons and their institutions must use them if they are to have a meaningful effect on patient care. If your hospital can’t afford to participate in ACS NSQIP, find a partner, build a consortium or cooperative, or create your own QI measurement tool. Specialty societies have registries that you can tap. One way or another, though, tomorrow’s surgeons will need a record of all cases and outcomes and a means to critically evaluate their performance.
Education
Since the first Clinical Congress more than 100 years ago, education has been the heart of all College efforts. The ACS now offers educational activities programs for surgeons at all levels, but mostly continuing education for practicing surgeons while other groups have assumed control over residency training. In my opinion, the greatest threat to the provision of quality surgical care in the future is the erosion of core surgical training.
I have spent 18 years as a general surgery residency program director; 7 years on the American Board of Surgery, including 1 as chair; and 7 years on the Residency Review Committee for Surgery, including 1 as vice-chair. These experiences have convinced me that future ACS leaders should demand radical changes in surgical training paradigms.
Undoubtedly, any attempt to fundamentally change training will be met with resistance from organizations currently in control. We should engage these bodies in a cooperative spirit; however, real solutions may require a surgical approach – a thoughtful, calculated plan that can be executed decisively.
Advocacy
The College entered the advocacy arena somewhat late but has become an influential force in the halls of Congress and the statehouses, at think tank meetings, with payers, and in discussions with other stakeholders.
Unfortunately, most surgeons have little understanding of how the work of our Division of Advocacy and Health Policy affects their daily practices, and have little time to devote to grassroots efforts. But as medicine becomes more regulated, it is imperative that all surgeons advocate for their profession and their patients.
Indeed, surgical practice is changing quickly. Approximately 80 percent of surgeons are now employees of health care networks or institutions rather than in private practice, and the number of surgeon employees will likely reach 100% soon. Problems have already surfaced for surgeons with contracts, including terminations without cause and other issues. Bundled care payments for all health care services, including hospital and physician services, may be on the horizon. These changes could have deleterious effect on patient care.
As corporate medicine continues to grow and consolidate, a new form of representation may be needed to protect the interest of surgeons and their patients. The College would be the ideal group to lead such an effort.
Your anchor
Although this piece has suggested challenges College Fellows may encounter in the future, in truth, I have no idea what obstacles lie ahead. When times get rough, and they likely will, be certain of your anchors: your family, your friends, your faith, and your profession. The ACS can be that professional anchor.
Dr. Richardson is professor of surgery and vice-chairman, department of surgery, University of Louisville (Ky.) School of Medicine, and President of the American College of Surgeons.
As the American College of Surgeons enters its second century, the challenge before us is to uphold the traditions and values of the past while embracing the future with enthusiasm.
The ACS Board of Governors, which represents the broad constituencies of the College, uses the term “pillars” to define the College’s core activities. Although these areas of focus will likely change in time, I would like to offer some thoughts regarding the current pillars and likely future challenges for each.
Communications
The College leadership is sensitive and responsive to the concerns and desires of Fellows; however, some members maintain that the leadership isn’t aware of what they are experiencing in practice. To eliminate this disconnect, Fellows should take advantage of some of the communications vehicles that the College now offers to encourage interaction between the Fellows and the leadership.
We now have more than 100 online “Communities” that allow members to engage in real-time discussions issues of mutual interest. Embrace your specialty’s Community and become enmeshed in conversations about advocacy, rural surgery, international surgery, and so on. ACS leaders are active in these Communities and pay attention to the concerns raised in these forums.
Member services
At the 2015 ACS Leadership & Advocacy Summit, retired U.S. Army General Stanley McChrystal offered his perspective on leadership. One theme he articulated is that leaders should actively engage with the rank-and-file troops. Building on that viewpoint, I would opine that for the ACS to succeed, we need the active and sustained engagement of our surgeons in the field.
Indeed, it has been the College’s experience that these members are the innovators who move the organization forward. For example, the Advanced Trauma Life Support® program is one of the most successful programs in ACS history. This course wasn’t a pipe dream of a regent; rather it was developed by surgeons in Nebraska who saw a need and acted on it. Similarly, the women and men practicing in rural areas created an Advisory Council for Rural Surgery and the online Rural Surgery Community to address the concerns of individuals who practice in nonmetropolitan areas.
For young Fellows, local involvement may be an ideal starting point. Many ACS chapters are floundering and need the energy and creativity young Fellows bring to the table.
Quality
Setting the standards for the delivery of quality surgical care was a core objective of the College’s founders, and quality improvement (QI) remains a primary mission. Although most surgeons are committed to providing high-quality care, they are less likely to participate in QI programs at their institutions.
Quality, which will be increasingly data and outcomes driven, is the benchmark by which future surgeons will be judged. Surgeons must own quality. Its measurement must be local, personal, accurate, and risk adjusted.
Recognizing that if surgeons don’t take ownership of this space, someone else will, the ACS has invested millions of dollars in QI programs – including the ACS National Surgical Quality Improvement Program (ACS NSQIP®) and “QIPs” for trauma, cancer, and bariatric surgery. However, surgeons and their institutions must use them if they are to have a meaningful effect on patient care. If your hospital can’t afford to participate in ACS NSQIP, find a partner, build a consortium or cooperative, or create your own QI measurement tool. Specialty societies have registries that you can tap. One way or another, though, tomorrow’s surgeons will need a record of all cases and outcomes and a means to critically evaluate their performance.
Education
Since the first Clinical Congress more than 100 years ago, education has been the heart of all College efforts. The ACS now offers educational activities programs for surgeons at all levels, but mostly continuing education for practicing surgeons while other groups have assumed control over residency training. In my opinion, the greatest threat to the provision of quality surgical care in the future is the erosion of core surgical training.
I have spent 18 years as a general surgery residency program director; 7 years on the American Board of Surgery, including 1 as chair; and 7 years on the Residency Review Committee for Surgery, including 1 as vice-chair. These experiences have convinced me that future ACS leaders should demand radical changes in surgical training paradigms.
Undoubtedly, any attempt to fundamentally change training will be met with resistance from organizations currently in control. We should engage these bodies in a cooperative spirit; however, real solutions may require a surgical approach – a thoughtful, calculated plan that can be executed decisively.
Advocacy
The College entered the advocacy arena somewhat late but has become an influential force in the halls of Congress and the statehouses, at think tank meetings, with payers, and in discussions with other stakeholders.
Unfortunately, most surgeons have little understanding of how the work of our Division of Advocacy and Health Policy affects their daily practices, and have little time to devote to grassroots efforts. But as medicine becomes more regulated, it is imperative that all surgeons advocate for their profession and their patients.
Indeed, surgical practice is changing quickly. Approximately 80 percent of surgeons are now employees of health care networks or institutions rather than in private practice, and the number of surgeon employees will likely reach 100% soon. Problems have already surfaced for surgeons with contracts, including terminations without cause and other issues. Bundled care payments for all health care services, including hospital and physician services, may be on the horizon. These changes could have deleterious effect on patient care.
As corporate medicine continues to grow and consolidate, a new form of representation may be needed to protect the interest of surgeons and their patients. The College would be the ideal group to lead such an effort.
Your anchor
Although this piece has suggested challenges College Fellows may encounter in the future, in truth, I have no idea what obstacles lie ahead. When times get rough, and they likely will, be certain of your anchors: your family, your friends, your faith, and your profession. The ACS can be that professional anchor.
Dr. Richardson is professor of surgery and vice-chairman, department of surgery, University of Louisville (Ky.) School of Medicine, and President of the American College of Surgeons.
General surgery’s place in the world
I heard the expression, “This is the age of specialization” the other day and I winced. As a general surgeon, I understood the implicit corollary that I was not a specialist. I disagree, by the way. As a person interested in the public good, I winced because subspecialization is an oft-repeated mantra as a solution to all the surgical world’s problems. That just isn’t so, any more than that generalism is the solution. As my father used to say, “All generalizations are false – including this one.”
We have more than one issue in surgery today. Simply creating more and more subspecialists who do less and less of an area of surgery on the premise that high-volume repetitive practice creates the best public good is too narrow a view, because there is more to success in surgery than the simple performance of the procedure itself. Further, the definition of an outcome is becoming far too quantitative at the expense of an overall qualitative reality from the patient’s point of view.
The Lancet Global Surgery Commission reports that 1.5 billion people in the world have no access to surgical care when they need it and that 5 billion have no access to timely surgical care. As the Australians (presented at the Royal Australasian College of Surgeons) have found, the local conditions that result in delay in diagnosis (as well as treatment) play the major role in poor outcomes. We tend to think of the Lancet numbers as applying to underdeveloped countries, but even in the United States there are underserved areas. Successful solutions in developed countries may well mean templates for solutions in those less developed countries.
The point of this is to state that in our rush to improve the quantitative measurable results such as 30-day mortality, we find answers that lead us away from the qualitative results patients want and deserve. In relentlessly pursuing these results, we risk creating situations of inequality and unmet needs far greater than the risks to an individual patient vis à vis arbitrary definitions of outcome.
The specialty of general surgery can be described in this country as in decline. Over the past 50 years several core components of what a general surgeon did have been excised. Some of this has come through obvious advances, some through economics, and some through abdication of our surgical roles. In aggregate, this trend is leading to a further crisis that was no doubt unintended by those who made the individual decisions and changes.
Within very major training centers, the need for the general surgeon is eclipsed by the plethora of subspecialists available. Many of my academic friends at such institutions admit there really isn’t a job for the broad-based surgeon except for covering call (the acute care surgeon). The problem is that the model of a wonderful fully resourced major center doesn’t translate to suburbia, exurbias, and rural settings where most of the U.S. population resides.
We need a new definition and era of general surgery both for the United States and the rest of the world. Without it, I fear we will drift into a fragmented, patient-unfriendly, bankrupting system that treats late-diagnosed patients who travel at great personal pain to overloaded centers.
The new general surgeon I envision will not proudly proclaim that there is no operation he or she can’t do. That attitude is as outdated as resident work hours equal to the number of hours in the week, banning women from surgical careers, paying residents in room and board, or firing residents for getting married. The general surgery community must accept that times and science have changed for highly complex operations, but that the performance of “standard” and moderately complex operations must remain in the arsenal of the general surgeon. At the same time, subspecialists need to recognize that they must keep a “hands off” attitude toward these core general surgery cases and respect the obvious need throughout the world for the well-trained generalist.
Patients want a doctor they know who is close to home and who has surgical cognition of a wide nature with multiple skills to solve their problems. This local surgeon they know and trust needs to be part of a system that supports the local surgeon’s decision to send the patient to the “center” with neither economic penalty nor the implied message that the local surgeon isn’t quite up to the task.
To know everything about everything is as hard as knowing a lot about a relatively small body of knowledge, perhaps harder. To the patient, they want both – knowledgeable and dependable surgeons locally who can meet perhaps 80% of their surgical needs but also the subspecialist who can stop their heart for an hour, repair their liver or heart problem, and then reboot them. Ask yourself as a surgeon, isn’t that what you want as well for yourself? Would you really prefer to have your gall bladder out 70, 100, 400 miles away or 20 minutes from your home with equally good results?
The generalization I propose is that we need a more sensible approach than the big center vs. small center fight we have now. The Kansas City Royals shouldn’t ever win a World Series. They are a small-market team with a constrained budget, but they formed a mass of generalists and some spectacularly good specialists. That’s how they won in 2015 against the common wisdom of baseball and statistics.
I ask all to support the efforts of the American College of Surgeons, American Board of Surgery, Residency Review Committee, the Association of Program Directors in Surgery, the Accreditation Council of Graduate Medical Education, and the various subspecialty societies in supporting the growing effort to redesign general surgery education and establish its place in this century for the good of all those patients far and wide who cannot, will not, and should not be forced into an uncoordinated system of surgical care.
Dr. Hughes is an ACS Fellow with the department of general surgery, McPherson Hospital, McPherson, Kan., and is the Editor in Chief of ACS Communities. He is also Associate Editor for ACS Surgery News.
I heard the expression, “This is the age of specialization” the other day and I winced. As a general surgeon, I understood the implicit corollary that I was not a specialist. I disagree, by the way. As a person interested in the public good, I winced because subspecialization is an oft-repeated mantra as a solution to all the surgical world’s problems. That just isn’t so, any more than that generalism is the solution. As my father used to say, “All generalizations are false – including this one.”
We have more than one issue in surgery today. Simply creating more and more subspecialists who do less and less of an area of surgery on the premise that high-volume repetitive practice creates the best public good is too narrow a view, because there is more to success in surgery than the simple performance of the procedure itself. Further, the definition of an outcome is becoming far too quantitative at the expense of an overall qualitative reality from the patient’s point of view.
The Lancet Global Surgery Commission reports that 1.5 billion people in the world have no access to surgical care when they need it and that 5 billion have no access to timely surgical care. As the Australians (presented at the Royal Australasian College of Surgeons) have found, the local conditions that result in delay in diagnosis (as well as treatment) play the major role in poor outcomes. We tend to think of the Lancet numbers as applying to underdeveloped countries, but even in the United States there are underserved areas. Successful solutions in developed countries may well mean templates for solutions in those less developed countries.
The point of this is to state that in our rush to improve the quantitative measurable results such as 30-day mortality, we find answers that lead us away from the qualitative results patients want and deserve. In relentlessly pursuing these results, we risk creating situations of inequality and unmet needs far greater than the risks to an individual patient vis à vis arbitrary definitions of outcome.
The specialty of general surgery can be described in this country as in decline. Over the past 50 years several core components of what a general surgeon did have been excised. Some of this has come through obvious advances, some through economics, and some through abdication of our surgical roles. In aggregate, this trend is leading to a further crisis that was no doubt unintended by those who made the individual decisions and changes.
Within very major training centers, the need for the general surgeon is eclipsed by the plethora of subspecialists available. Many of my academic friends at such institutions admit there really isn’t a job for the broad-based surgeon except for covering call (the acute care surgeon). The problem is that the model of a wonderful fully resourced major center doesn’t translate to suburbia, exurbias, and rural settings where most of the U.S. population resides.
We need a new definition and era of general surgery both for the United States and the rest of the world. Without it, I fear we will drift into a fragmented, patient-unfriendly, bankrupting system that treats late-diagnosed patients who travel at great personal pain to overloaded centers.
The new general surgeon I envision will not proudly proclaim that there is no operation he or she can’t do. That attitude is as outdated as resident work hours equal to the number of hours in the week, banning women from surgical careers, paying residents in room and board, or firing residents for getting married. The general surgery community must accept that times and science have changed for highly complex operations, but that the performance of “standard” and moderately complex operations must remain in the arsenal of the general surgeon. At the same time, subspecialists need to recognize that they must keep a “hands off” attitude toward these core general surgery cases and respect the obvious need throughout the world for the well-trained generalist.
Patients want a doctor they know who is close to home and who has surgical cognition of a wide nature with multiple skills to solve their problems. This local surgeon they know and trust needs to be part of a system that supports the local surgeon’s decision to send the patient to the “center” with neither economic penalty nor the implied message that the local surgeon isn’t quite up to the task.
To know everything about everything is as hard as knowing a lot about a relatively small body of knowledge, perhaps harder. To the patient, they want both – knowledgeable and dependable surgeons locally who can meet perhaps 80% of their surgical needs but also the subspecialist who can stop their heart for an hour, repair their liver or heart problem, and then reboot them. Ask yourself as a surgeon, isn’t that what you want as well for yourself? Would you really prefer to have your gall bladder out 70, 100, 400 miles away or 20 minutes from your home with equally good results?
The generalization I propose is that we need a more sensible approach than the big center vs. small center fight we have now. The Kansas City Royals shouldn’t ever win a World Series. They are a small-market team with a constrained budget, but they formed a mass of generalists and some spectacularly good specialists. That’s how they won in 2015 against the common wisdom of baseball and statistics.
I ask all to support the efforts of the American College of Surgeons, American Board of Surgery, Residency Review Committee, the Association of Program Directors in Surgery, the Accreditation Council of Graduate Medical Education, and the various subspecialty societies in supporting the growing effort to redesign general surgery education and establish its place in this century for the good of all those patients far and wide who cannot, will not, and should not be forced into an uncoordinated system of surgical care.
Dr. Hughes is an ACS Fellow with the department of general surgery, McPherson Hospital, McPherson, Kan., and is the Editor in Chief of ACS Communities. He is also Associate Editor for ACS Surgery News.
I heard the expression, “This is the age of specialization” the other day and I winced. As a general surgeon, I understood the implicit corollary that I was not a specialist. I disagree, by the way. As a person interested in the public good, I winced because subspecialization is an oft-repeated mantra as a solution to all the surgical world’s problems. That just isn’t so, any more than that generalism is the solution. As my father used to say, “All generalizations are false – including this one.”
We have more than one issue in surgery today. Simply creating more and more subspecialists who do less and less of an area of surgery on the premise that high-volume repetitive practice creates the best public good is too narrow a view, because there is more to success in surgery than the simple performance of the procedure itself. Further, the definition of an outcome is becoming far too quantitative at the expense of an overall qualitative reality from the patient’s point of view.
The Lancet Global Surgery Commission reports that 1.5 billion people in the world have no access to surgical care when they need it and that 5 billion have no access to timely surgical care. As the Australians (presented at the Royal Australasian College of Surgeons) have found, the local conditions that result in delay in diagnosis (as well as treatment) play the major role in poor outcomes. We tend to think of the Lancet numbers as applying to underdeveloped countries, but even in the United States there are underserved areas. Successful solutions in developed countries may well mean templates for solutions in those less developed countries.
The point of this is to state that in our rush to improve the quantitative measurable results such as 30-day mortality, we find answers that lead us away from the qualitative results patients want and deserve. In relentlessly pursuing these results, we risk creating situations of inequality and unmet needs far greater than the risks to an individual patient vis à vis arbitrary definitions of outcome.
The specialty of general surgery can be described in this country as in decline. Over the past 50 years several core components of what a general surgeon did have been excised. Some of this has come through obvious advances, some through economics, and some through abdication of our surgical roles. In aggregate, this trend is leading to a further crisis that was no doubt unintended by those who made the individual decisions and changes.
Within very major training centers, the need for the general surgeon is eclipsed by the plethora of subspecialists available. Many of my academic friends at such institutions admit there really isn’t a job for the broad-based surgeon except for covering call (the acute care surgeon). The problem is that the model of a wonderful fully resourced major center doesn’t translate to suburbia, exurbias, and rural settings where most of the U.S. population resides.
We need a new definition and era of general surgery both for the United States and the rest of the world. Without it, I fear we will drift into a fragmented, patient-unfriendly, bankrupting system that treats late-diagnosed patients who travel at great personal pain to overloaded centers.
The new general surgeon I envision will not proudly proclaim that there is no operation he or she can’t do. That attitude is as outdated as resident work hours equal to the number of hours in the week, banning women from surgical careers, paying residents in room and board, or firing residents for getting married. The general surgery community must accept that times and science have changed for highly complex operations, but that the performance of “standard” and moderately complex operations must remain in the arsenal of the general surgeon. At the same time, subspecialists need to recognize that they must keep a “hands off” attitude toward these core general surgery cases and respect the obvious need throughout the world for the well-trained generalist.
Patients want a doctor they know who is close to home and who has surgical cognition of a wide nature with multiple skills to solve their problems. This local surgeon they know and trust needs to be part of a system that supports the local surgeon’s decision to send the patient to the “center” with neither economic penalty nor the implied message that the local surgeon isn’t quite up to the task.
To know everything about everything is as hard as knowing a lot about a relatively small body of knowledge, perhaps harder. To the patient, they want both – knowledgeable and dependable surgeons locally who can meet perhaps 80% of their surgical needs but also the subspecialist who can stop their heart for an hour, repair their liver or heart problem, and then reboot them. Ask yourself as a surgeon, isn’t that what you want as well for yourself? Would you really prefer to have your gall bladder out 70, 100, 400 miles away or 20 minutes from your home with equally good results?
The generalization I propose is that we need a more sensible approach than the big center vs. small center fight we have now. The Kansas City Royals shouldn’t ever win a World Series. They are a small-market team with a constrained budget, but they formed a mass of generalists and some spectacularly good specialists. That’s how they won in 2015 against the common wisdom of baseball and statistics.
I ask all to support the efforts of the American College of Surgeons, American Board of Surgery, Residency Review Committee, the Association of Program Directors in Surgery, the Accreditation Council of Graduate Medical Education, and the various subspecialty societies in supporting the growing effort to redesign general surgery education and establish its place in this century for the good of all those patients far and wide who cannot, will not, and should not be forced into an uncoordinated system of surgical care.
Dr. Hughes is an ACS Fellow with the department of general surgery, McPherson Hospital, McPherson, Kan., and is the Editor in Chief of ACS Communities. He is also Associate Editor for ACS Surgery News.
Why so many pertussis outbreaks despite acellular pertussis vaccine? A call to action
There has been a justified re-examination of acellular pertussis vaccine (aP)1,2 in light of the multiple large outbreaks of pertussis since 2000, particularly the two large California outbreaks in 2010 and 2014.
Lessons learned: aP protection is less durable than originally thought, and much pertussis is not in infants, but in the school-age and adolescent populations.
aP appears to produce reasonable protection (approximately 84% overall) for infants and preschool children, plus a much improved adverse effect profile, compared with whole cell pertussis vaccine (WCP), which provided approximately 94% protection.1 This 10% difference in aP versus WCP, however, means that herd immunity is more difficult to attain. The accepted pertussis immunization rate needed to provide herd immunity is 92%-94%. Because our current tools (DTaP and Tdap) provide only 84% protection at least in infants and preschoolers, even 100% uptake may leave us 6% to 8% short of the threshold for complete herd immunity.
The California outbreak data from school-age and teenage populations show protection rates drop each year post aP booster. That means that by the fourth year after the last dose, protection is less than 10%. So despite a Tdap dose at 11- to 12-years-of-age, protection gaps occur in 8-to 10-year-olds and 14- to 18-year-olds. These vulnerable periods in older children add to aP’s 84% vs. WCP’s 94% protection for those greater than 3 years of age, explaining more frequent pertussis outbreaks as the pool of WCP-immunized children among older populations decreased.
But before we place all blame on switching to aP, consider that we can now confirm more pertussis infections with molecular assays than was possible with culture and fluorescent assay testing in the WCP era. So improved testing sensitivity means more reports of minimally symptomatic cases that may have been missed before. So WCP, if still used today, might not show 94% protection either.
Additionally, aPs rely heavily on pertactin as a target antigen,3 likely less than WCP, given that WCP contained all pertussis antigens rather than just the 3-5 purified antigens in aPs. So the emergence of pertactin-altered pertussis strains could disproportionately affect protection from aP, compared with WCP.
There seem to be no quick fixes to preventing outbreaks using aPs as our vaccine. One suggestion by the authors of the California outbreak report is to use aP mostly to terminate outbreaks rather than routinely in late childhood. My concern is that if we do not continue routine use in 4-to 6-year-olds, 10-to 11-year-olds, and in early adulthood, the vulnerable proportion of the population during outbreaks would be larger, making outbreaks more difficult to terminate. So continuing to produce some protection, albeit short-lived, with current schedules of aP vaccines seems important.
Also remember that T cells, particularly TH 17 pertussis-specific cells, may be as important as pertussis antibody. Therefore, crafting pertussis vaccines that yield improved antibody plus T cell responses is the current goal. Disease and WCP seem to elicit more T-17 response than aP. One method to craft a better vaccine is to use antigen blends that differ from those in the current vaccines, such as antigens derived from circulating pertussis strains instead of the standard laboratory strain. Another option is to use current antigens but with more potent adjuvants. Such vaccines are likely 5 years away.
But we need to have reasonable expectations for pertussis vaccines. Pertussis infection begins in respiratory epithelium. Many of the most obvious signs and symptoms are due to destruction of ciliated respiratory epithelium plus increased tenacity/volume of secretions. Can a parenterally administered vaccine that induces mostly serum antibody protect against infection of epithelium where antibody concentrations are likely 10% or less than in serum? The short answer is – likely not. We should expect neither aP nor WCP to consistently protect against pertussis infection, but it does seem reasonable to expect aP to reduce disease severity. Preventing infections awaits a vaccine that induces surface IgA. Mucosally administered vaccines produce surface IgA – for example, rotavirus vaccine – but no mucosal pertussis vaccine appears imminent.
A key question is whether our most vulnerable populations, young children, have increased morbidity and mortality. Data from the California suggest an increase but mostly in infants under 6 months of age, the group not old enough to benefit from even the most effective of infant vaccines. Protecting young infants depends on vaccine administered prenatally to mothers. The over-representation of the Hispanic infants among fatalities shows a population on which to focus with maternal immunization. Hopefully, the recent universal TdaP recommendation in pregnancy will help when maternal immunization is higher than current approximately 50% rates.4
Despite the problems, it seems clear that we must continue to use current aP vaccines according to the current schedules, attempting to get as close to 100% uptake as possible. While the current, nearly 10% unimmunized rates add to the likelihood that we are losing complete herd immunity, partial herd immunity is better than no herd immunity.
Expectations: There will be ongoing outbreaks. Continue to be alert for signs of pertussis. They are often less obvious in older patients, and may be as subtle as more than 2 weeks of persistent cough. During outbreaks, we may be called upon to give aP doses at intervals shorter than the usual schedule.
Our responsibility: Do not become discouraged or lose enthusiasm for aP, but explain to parents that because aP is less reactogenic, it produces less protection and is less durable, particularly in school-age children. But please emphasize that modest protection is best in the youngest and modest protection of older children is better than none. Emphasize that the adverse effect profile of current aPs puts the harm/benefit balance heavily in favor of aP.
Bottom line: We can hopefully do better than the current 88% to 92% rate of aP vaccine uptake. We need to get as close to 100% uptake as possible until new vaccines or new strategies become available.
1. Clin Infect Dis. 2016 Feb 7; doi: 10.1093/cid/ciw051.
2. Pediatrics. 2016 Feb 5; doi: 10.1542/peds.2015-3326.
3. Expert Rev Vaccines. 2007 Feb;6(1):47-56.
4. Vaccine. 2016 Feb 10;34(7):968-73.
Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He disclosed that his institution received grant support for a study on hexavalent infant vaccine containing pertussis from GlaxoSmithKline, and he was the local primary investigator.*
*Correction, 2/17/2016: An earlier version of this article incompletely stated Dr. Harrison's disclosure information.
There has been a justified re-examination of acellular pertussis vaccine (aP)1,2 in light of the multiple large outbreaks of pertussis since 2000, particularly the two large California outbreaks in 2010 and 2014.
Lessons learned: aP protection is less durable than originally thought, and much pertussis is not in infants, but in the school-age and adolescent populations.
aP appears to produce reasonable protection (approximately 84% overall) for infants and preschool children, plus a much improved adverse effect profile, compared with whole cell pertussis vaccine (WCP), which provided approximately 94% protection.1 This 10% difference in aP versus WCP, however, means that herd immunity is more difficult to attain. The accepted pertussis immunization rate needed to provide herd immunity is 92%-94%. Because our current tools (DTaP and Tdap) provide only 84% protection at least in infants and preschoolers, even 100% uptake may leave us 6% to 8% short of the threshold for complete herd immunity.
The California outbreak data from school-age and teenage populations show protection rates drop each year post aP booster. That means that by the fourth year after the last dose, protection is less than 10%. So despite a Tdap dose at 11- to 12-years-of-age, protection gaps occur in 8-to 10-year-olds and 14- to 18-year-olds. These vulnerable periods in older children add to aP’s 84% vs. WCP’s 94% protection for those greater than 3 years of age, explaining more frequent pertussis outbreaks as the pool of WCP-immunized children among older populations decreased.
But before we place all blame on switching to aP, consider that we can now confirm more pertussis infections with molecular assays than was possible with culture and fluorescent assay testing in the WCP era. So improved testing sensitivity means more reports of minimally symptomatic cases that may have been missed before. So WCP, if still used today, might not show 94% protection either.
Additionally, aPs rely heavily on pertactin as a target antigen,3 likely less than WCP, given that WCP contained all pertussis antigens rather than just the 3-5 purified antigens in aPs. So the emergence of pertactin-altered pertussis strains could disproportionately affect protection from aP, compared with WCP.
There seem to be no quick fixes to preventing outbreaks using aPs as our vaccine. One suggestion by the authors of the California outbreak report is to use aP mostly to terminate outbreaks rather than routinely in late childhood. My concern is that if we do not continue routine use in 4-to 6-year-olds, 10-to 11-year-olds, and in early adulthood, the vulnerable proportion of the population during outbreaks would be larger, making outbreaks more difficult to terminate. So continuing to produce some protection, albeit short-lived, with current schedules of aP vaccines seems important.
Also remember that T cells, particularly TH 17 pertussis-specific cells, may be as important as pertussis antibody. Therefore, crafting pertussis vaccines that yield improved antibody plus T cell responses is the current goal. Disease and WCP seem to elicit more T-17 response than aP. One method to craft a better vaccine is to use antigen blends that differ from those in the current vaccines, such as antigens derived from circulating pertussis strains instead of the standard laboratory strain. Another option is to use current antigens but with more potent adjuvants. Such vaccines are likely 5 years away.
But we need to have reasonable expectations for pertussis vaccines. Pertussis infection begins in respiratory epithelium. Many of the most obvious signs and symptoms are due to destruction of ciliated respiratory epithelium plus increased tenacity/volume of secretions. Can a parenterally administered vaccine that induces mostly serum antibody protect against infection of epithelium where antibody concentrations are likely 10% or less than in serum? The short answer is – likely not. We should expect neither aP nor WCP to consistently protect against pertussis infection, but it does seem reasonable to expect aP to reduce disease severity. Preventing infections awaits a vaccine that induces surface IgA. Mucosally administered vaccines produce surface IgA – for example, rotavirus vaccine – but no mucosal pertussis vaccine appears imminent.
A key question is whether our most vulnerable populations, young children, have increased morbidity and mortality. Data from the California suggest an increase but mostly in infants under 6 months of age, the group not old enough to benefit from even the most effective of infant vaccines. Protecting young infants depends on vaccine administered prenatally to mothers. The over-representation of the Hispanic infants among fatalities shows a population on which to focus with maternal immunization. Hopefully, the recent universal TdaP recommendation in pregnancy will help when maternal immunization is higher than current approximately 50% rates.4
Despite the problems, it seems clear that we must continue to use current aP vaccines according to the current schedules, attempting to get as close to 100% uptake as possible. While the current, nearly 10% unimmunized rates add to the likelihood that we are losing complete herd immunity, partial herd immunity is better than no herd immunity.
Expectations: There will be ongoing outbreaks. Continue to be alert for signs of pertussis. They are often less obvious in older patients, and may be as subtle as more than 2 weeks of persistent cough. During outbreaks, we may be called upon to give aP doses at intervals shorter than the usual schedule.
Our responsibility: Do not become discouraged or lose enthusiasm for aP, but explain to parents that because aP is less reactogenic, it produces less protection and is less durable, particularly in school-age children. But please emphasize that modest protection is best in the youngest and modest protection of older children is better than none. Emphasize that the adverse effect profile of current aPs puts the harm/benefit balance heavily in favor of aP.
Bottom line: We can hopefully do better than the current 88% to 92% rate of aP vaccine uptake. We need to get as close to 100% uptake as possible until new vaccines or new strategies become available.
1. Clin Infect Dis. 2016 Feb 7; doi: 10.1093/cid/ciw051.
2. Pediatrics. 2016 Feb 5; doi: 10.1542/peds.2015-3326.
3. Expert Rev Vaccines. 2007 Feb;6(1):47-56.
4. Vaccine. 2016 Feb 10;34(7):968-73.
Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He disclosed that his institution received grant support for a study on hexavalent infant vaccine containing pertussis from GlaxoSmithKline, and he was the local primary investigator.*
*Correction, 2/17/2016: An earlier version of this article incompletely stated Dr. Harrison's disclosure information.
There has been a justified re-examination of acellular pertussis vaccine (aP)1,2 in light of the multiple large outbreaks of pertussis since 2000, particularly the two large California outbreaks in 2010 and 2014.
Lessons learned: aP protection is less durable than originally thought, and much pertussis is not in infants, but in the school-age and adolescent populations.
aP appears to produce reasonable protection (approximately 84% overall) for infants and preschool children, plus a much improved adverse effect profile, compared with whole cell pertussis vaccine (WCP), which provided approximately 94% protection.1 This 10% difference in aP versus WCP, however, means that herd immunity is more difficult to attain. The accepted pertussis immunization rate needed to provide herd immunity is 92%-94%. Because our current tools (DTaP and Tdap) provide only 84% protection at least in infants and preschoolers, even 100% uptake may leave us 6% to 8% short of the threshold for complete herd immunity.
The California outbreak data from school-age and teenage populations show protection rates drop each year post aP booster. That means that by the fourth year after the last dose, protection is less than 10%. So despite a Tdap dose at 11- to 12-years-of-age, protection gaps occur in 8-to 10-year-olds and 14- to 18-year-olds. These vulnerable periods in older children add to aP’s 84% vs. WCP’s 94% protection for those greater than 3 years of age, explaining more frequent pertussis outbreaks as the pool of WCP-immunized children among older populations decreased.
But before we place all blame on switching to aP, consider that we can now confirm more pertussis infections with molecular assays than was possible with culture and fluorescent assay testing in the WCP era. So improved testing sensitivity means more reports of minimally symptomatic cases that may have been missed before. So WCP, if still used today, might not show 94% protection either.
Additionally, aPs rely heavily on pertactin as a target antigen,3 likely less than WCP, given that WCP contained all pertussis antigens rather than just the 3-5 purified antigens in aPs. So the emergence of pertactin-altered pertussis strains could disproportionately affect protection from aP, compared with WCP.
There seem to be no quick fixes to preventing outbreaks using aPs as our vaccine. One suggestion by the authors of the California outbreak report is to use aP mostly to terminate outbreaks rather than routinely in late childhood. My concern is that if we do not continue routine use in 4-to 6-year-olds, 10-to 11-year-olds, and in early adulthood, the vulnerable proportion of the population during outbreaks would be larger, making outbreaks more difficult to terminate. So continuing to produce some protection, albeit short-lived, with current schedules of aP vaccines seems important.
Also remember that T cells, particularly TH 17 pertussis-specific cells, may be as important as pertussis antibody. Therefore, crafting pertussis vaccines that yield improved antibody plus T cell responses is the current goal. Disease and WCP seem to elicit more T-17 response than aP. One method to craft a better vaccine is to use antigen blends that differ from those in the current vaccines, such as antigens derived from circulating pertussis strains instead of the standard laboratory strain. Another option is to use current antigens but with more potent adjuvants. Such vaccines are likely 5 years away.
But we need to have reasonable expectations for pertussis vaccines. Pertussis infection begins in respiratory epithelium. Many of the most obvious signs and symptoms are due to destruction of ciliated respiratory epithelium plus increased tenacity/volume of secretions. Can a parenterally administered vaccine that induces mostly serum antibody protect against infection of epithelium where antibody concentrations are likely 10% or less than in serum? The short answer is – likely not. We should expect neither aP nor WCP to consistently protect against pertussis infection, but it does seem reasonable to expect aP to reduce disease severity. Preventing infections awaits a vaccine that induces surface IgA. Mucosally administered vaccines produce surface IgA – for example, rotavirus vaccine – but no mucosal pertussis vaccine appears imminent.
A key question is whether our most vulnerable populations, young children, have increased morbidity and mortality. Data from the California suggest an increase but mostly in infants under 6 months of age, the group not old enough to benefit from even the most effective of infant vaccines. Protecting young infants depends on vaccine administered prenatally to mothers. The over-representation of the Hispanic infants among fatalities shows a population on which to focus with maternal immunization. Hopefully, the recent universal TdaP recommendation in pregnancy will help when maternal immunization is higher than current approximately 50% rates.4
Despite the problems, it seems clear that we must continue to use current aP vaccines according to the current schedules, attempting to get as close to 100% uptake as possible. While the current, nearly 10% unimmunized rates add to the likelihood that we are losing complete herd immunity, partial herd immunity is better than no herd immunity.
Expectations: There will be ongoing outbreaks. Continue to be alert for signs of pertussis. They are often less obvious in older patients, and may be as subtle as more than 2 weeks of persistent cough. During outbreaks, we may be called upon to give aP doses at intervals shorter than the usual schedule.
Our responsibility: Do not become discouraged or lose enthusiasm for aP, but explain to parents that because aP is less reactogenic, it produces less protection and is less durable, particularly in school-age children. But please emphasize that modest protection is best in the youngest and modest protection of older children is better than none. Emphasize that the adverse effect profile of current aPs puts the harm/benefit balance heavily in favor of aP.
Bottom line: We can hopefully do better than the current 88% to 92% rate of aP vaccine uptake. We need to get as close to 100% uptake as possible until new vaccines or new strategies become available.
1. Clin Infect Dis. 2016 Feb 7; doi: 10.1093/cid/ciw051.
2. Pediatrics. 2016 Feb 5; doi: 10.1542/peds.2015-3326.
3. Expert Rev Vaccines. 2007 Feb;6(1):47-56.
4. Vaccine. 2016 Feb 10;34(7):968-73.
Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He disclosed that his institution received grant support for a study on hexavalent infant vaccine containing pertussis from GlaxoSmithKline, and he was the local primary investigator.*
*Correction, 2/17/2016: An earlier version of this article incompletely stated Dr. Harrison's disclosure information.
HIPAA enforcement in 2016: Is your practice ready?
Two reports from the Office of the Inspector General (OIG) have attracted a lot of attention in recent weeks: The Office for Civil Rights (OCR), OIG said, needs to improve and expand its enforcement of the Health Insurance Portability and Accountability Act (HIPAA). In response, the OCR announced that it plans to identify a pool of potential audit targets and launch a permanent audit program this year. That, combined with the substantial fine levied against a dermatology group last year for violating one of the new rules, signals the importance of reviewing your practice’s HIPAA compliance as soon as possible.
You can compare your office’s compliance status against the recommendations listed on the OCR website, but pay particular attention to your agreements with Business Associates (BAs). Those are the individuals or businesses, other than your employees, who perform “functions or activities” on behalf of your practice that involve “creating, receiving, maintaining, or transmitting” personal health information.
First, make sure that all individuals and enterprises fitting that definition have a signed agreement in place. Typical BAs include answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records. Practice management consultants, attorneys, specialty pharmacies, and record storage, microfilming, and shredding services are BAs if they must have direct access to confidential information in order to do their job.
The revised rules place additional onus on physicians for confidentiality breaches committed by their BAs. It’s not enough to simply have a BA contract; you are expected to use “reasonable diligence” in monitoring their work. BAs and their subcontractors are directly responsible for their own actions, but the primary responsibility is yours. Furthermore, you must now assume the worst-case scenario: Previously, when protected health information (PHI) was compromised, you would have to notify only affected patients (and the government) if there was a “significant risk of financial or reputational harm,” but now, any incident involving patient records is assumed to be a breach, and must be reported.
Failure to do so could subject your practice, as well as the contractor, to significant fines. That is where the Massachusetts dermatology group ran into trouble: It lost a thumb drive containing unencrypted patient records, and was forced to pay a $150,000 fine, even though there was no evidence that the information was found or exploited.
Had the lost drive been encrypted, the incident would not have been considered a breach, according to the Centers for Medicare & Medicaid Services, because its contents would not have been viewable by the finder. The biggest vulnerability in most practices is probably mobile devices carrying patient data. There is no longer any excuse for not encrypting HIPAA-protected information; encryption software is cheap, readily available, and easy to use.
Patients have new rights under the new rules as well; they may now restrict any PHI shared with third-party insurers and health plans, if they pay for the services themselves. They also have the right to request copies of their electronic health records (EHRs). You can bill the costs of responding to such requests. If you have EHRs, work out a system for doing this, because the response time has been decreased from 90 days to 30 days – even shorter in some states.
If you haven’t yet revised your Notice of Privacy Practices (NPP) to explain your relationships with BAs, and their status under the new rules, do it now. (You should have done it last year.) You need to explain the breach notification process too, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there, but you need not mail a copy to every patient.
You also should examine every part of your office where patient information is handled to identify potential violations. Examples include computer screens in your reception area that are visible to patients; laptops not locked up after hours; unencrypted emails or texts that might reveal confidential information; and documents designated for shredding that sit, unshredded, in the “to shred” bin for days.
And make sure you correct any problems you find before the OCR auditors come calling.
To view the recommendations at the OCR website so you can check your office’s compliance status, go to: www.hhs.gov/hipaa/index.html.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.
Two reports from the Office of the Inspector General (OIG) have attracted a lot of attention in recent weeks: The Office for Civil Rights (OCR), OIG said, needs to improve and expand its enforcement of the Health Insurance Portability and Accountability Act (HIPAA). In response, the OCR announced that it plans to identify a pool of potential audit targets and launch a permanent audit program this year. That, combined with the substantial fine levied against a dermatology group last year for violating one of the new rules, signals the importance of reviewing your practice’s HIPAA compliance as soon as possible.
You can compare your office’s compliance status against the recommendations listed on the OCR website, but pay particular attention to your agreements with Business Associates (BAs). Those are the individuals or businesses, other than your employees, who perform “functions or activities” on behalf of your practice that involve “creating, receiving, maintaining, or transmitting” personal health information.
First, make sure that all individuals and enterprises fitting that definition have a signed agreement in place. Typical BAs include answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records. Practice management consultants, attorneys, specialty pharmacies, and record storage, microfilming, and shredding services are BAs if they must have direct access to confidential information in order to do their job.
The revised rules place additional onus on physicians for confidentiality breaches committed by their BAs. It’s not enough to simply have a BA contract; you are expected to use “reasonable diligence” in monitoring their work. BAs and their subcontractors are directly responsible for their own actions, but the primary responsibility is yours. Furthermore, you must now assume the worst-case scenario: Previously, when protected health information (PHI) was compromised, you would have to notify only affected patients (and the government) if there was a “significant risk of financial or reputational harm,” but now, any incident involving patient records is assumed to be a breach, and must be reported.
Failure to do so could subject your practice, as well as the contractor, to significant fines. That is where the Massachusetts dermatology group ran into trouble: It lost a thumb drive containing unencrypted patient records, and was forced to pay a $150,000 fine, even though there was no evidence that the information was found or exploited.
Had the lost drive been encrypted, the incident would not have been considered a breach, according to the Centers for Medicare & Medicaid Services, because its contents would not have been viewable by the finder. The biggest vulnerability in most practices is probably mobile devices carrying patient data. There is no longer any excuse for not encrypting HIPAA-protected information; encryption software is cheap, readily available, and easy to use.
Patients have new rights under the new rules as well; they may now restrict any PHI shared with third-party insurers and health plans, if they pay for the services themselves. They also have the right to request copies of their electronic health records (EHRs). You can bill the costs of responding to such requests. If you have EHRs, work out a system for doing this, because the response time has been decreased from 90 days to 30 days – even shorter in some states.
If you haven’t yet revised your Notice of Privacy Practices (NPP) to explain your relationships with BAs, and their status under the new rules, do it now. (You should have done it last year.) You need to explain the breach notification process too, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there, but you need not mail a copy to every patient.
You also should examine every part of your office where patient information is handled to identify potential violations. Examples include computer screens in your reception area that are visible to patients; laptops not locked up after hours; unencrypted emails or texts that might reveal confidential information; and documents designated for shredding that sit, unshredded, in the “to shred” bin for days.
And make sure you correct any problems you find before the OCR auditors come calling.
To view the recommendations at the OCR website so you can check your office’s compliance status, go to: www.hhs.gov/hipaa/index.html.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.
Two reports from the Office of the Inspector General (OIG) have attracted a lot of attention in recent weeks: The Office for Civil Rights (OCR), OIG said, needs to improve and expand its enforcement of the Health Insurance Portability and Accountability Act (HIPAA). In response, the OCR announced that it plans to identify a pool of potential audit targets and launch a permanent audit program this year. That, combined with the substantial fine levied against a dermatology group last year for violating one of the new rules, signals the importance of reviewing your practice’s HIPAA compliance as soon as possible.
You can compare your office’s compliance status against the recommendations listed on the OCR website, but pay particular attention to your agreements with Business Associates (BAs). Those are the individuals or businesses, other than your employees, who perform “functions or activities” on behalf of your practice that involve “creating, receiving, maintaining, or transmitting” personal health information.
First, make sure that all individuals and enterprises fitting that definition have a signed agreement in place. Typical BAs include answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records. Practice management consultants, attorneys, specialty pharmacies, and record storage, microfilming, and shredding services are BAs if they must have direct access to confidential information in order to do their job.
The revised rules place additional onus on physicians for confidentiality breaches committed by their BAs. It’s not enough to simply have a BA contract; you are expected to use “reasonable diligence” in monitoring their work. BAs and their subcontractors are directly responsible for their own actions, but the primary responsibility is yours. Furthermore, you must now assume the worst-case scenario: Previously, when protected health information (PHI) was compromised, you would have to notify only affected patients (and the government) if there was a “significant risk of financial or reputational harm,” but now, any incident involving patient records is assumed to be a breach, and must be reported.
Failure to do so could subject your practice, as well as the contractor, to significant fines. That is where the Massachusetts dermatology group ran into trouble: It lost a thumb drive containing unencrypted patient records, and was forced to pay a $150,000 fine, even though there was no evidence that the information was found or exploited.
Had the lost drive been encrypted, the incident would not have been considered a breach, according to the Centers for Medicare & Medicaid Services, because its contents would not have been viewable by the finder. The biggest vulnerability in most practices is probably mobile devices carrying patient data. There is no longer any excuse for not encrypting HIPAA-protected information; encryption software is cheap, readily available, and easy to use.
Patients have new rights under the new rules as well; they may now restrict any PHI shared with third-party insurers and health plans, if they pay for the services themselves. They also have the right to request copies of their electronic health records (EHRs). You can bill the costs of responding to such requests. If you have EHRs, work out a system for doing this, because the response time has been decreased from 90 days to 30 days – even shorter in some states.
If you haven’t yet revised your Notice of Privacy Practices (NPP) to explain your relationships with BAs, and their status under the new rules, do it now. (You should have done it last year.) You need to explain the breach notification process too, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there, but you need not mail a copy to every patient.
You also should examine every part of your office where patient information is handled to identify potential violations. Examples include computer screens in your reception area that are visible to patients; laptops not locked up after hours; unencrypted emails or texts that might reveal confidential information; and documents designated for shredding that sit, unshredded, in the “to shred” bin for days.
And make sure you correct any problems you find before the OCR auditors come calling.
To view the recommendations at the OCR website so you can check your office’s compliance status, go to: www.hhs.gov/hipaa/index.html.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.
Binge drinking in adolescents
Binge drinking is a common problem in adolescents as well as adults. In a 2013 survey, 60 million Americans, representing 22% of the population, 12 years of age and older engaged in binge drinking in the previous month. Among those 12-20 years of age, 14%, or one in seven, reported binge drinking. Depending on the survey, between one-third and one-half of all high school students currently drink alcohol. Among young people who drink, a higher proportion drink heavily than among adult drinkers. For teenagers who drink, 28%-60% report binge drinking. Among high school seniors, 1 in 10 report drinking more than 10 drinks in a row. The predominant liquor consumed by 13- to 20-year-olds is vodka (44% ), whereas beer is consumed by less than one-third of respondents. Underage drinkers typically get alcohol from adults of legal drinking age, and frequently drink in their own home or that of a friend. Clearly, this is an important, underappreciated problem that warrants clinical attention.
Background
Binge drinking is defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as the pattern of drinking required to bring the blood alcohol concentration (BAC) to 0.08% or greater. For adolescents, the required amount of alcohol to achieve the same BAC is thought to be less than the amount required for adults. Binge drinking for adults has traditionally been defined as more than five drinks over a 2-hour period for men or more than four drinks over 2 hours for women. Different cutoffs have been suggested for youth in several studies but were not clearly defined for this analysis.
Implications
Alcohol consumption in adolescents is associated with adverse events, and this is only exacerbated by binge drinking. These events include, but are not limited to, engaging in higher-risk behaviors, such as impaired driving or being the passenger in a vehicle with an impaired driver; an increased risk of suicide or attempted suicide; and an increased risk of nonautomobile accidents that can lead to severe injury or drowning. Adolescents who start drinking before the age of 15 years are four times as likely to develop alcohol dependence as people who start drinking after 20 years of age. In addition, adolescents who engage in binge drinking have an increased rate of high-risk sexual activity, which may result in a sexually transmitted infection as well as an unplanned pregnancy. Adolescents who continue to imbibe during pregnancy risk the development of fetal alcohol spectrum disorder. Finally, adolescent binge drinkers are subject to the immediate effects of alcohol, including hangover, blackout, and alcohol poisoning.
Guidance for the provider
The AAP recommends screening every adolescent for substance abuse, but if time constraints exist, alcohol abuse only (Pediatrics. 2015;136[3]:e718-26). The AAP has set up specific screening questions that are based upon the age group of the patient:
For elementary school students (ages 9-11) the following questions are appropriate:
• Do you have any friends who drank beer, wine, or any alcoholic drink in the past year?
• How about you? Have you ever had more than a few sips of beer, wine, or any drink with alcohol?
For patients in middle school (ages 11-14):
• Do you have any friends who drank beer, wine, or any alcohol-containing drink in the past year?
• How about you? Over the past year, how many days have you had where you’ve had more than a few sips of beer, wine, or any other alcohol?
For patients in high school (ages 14-18):
• Over the past year, how many days have you had where you’ve had more than a few sips of beer, wine, or any other alcohol?
• If your friends drink, how many drinks do they usually drink on an occasion?
The above questions help to risk stratify patients into three groups: low, moderate, and high risk. The guidelines do not make a recommendation on how to use these questions to risk stratify the patients. Low-risk patients receive brief counseling. Moderate-risk patients receive more intensive counseling as well as motivational interviewing. Motivational interviewing delivered over the course of one or more sessions has been found to be effective in reducing consumption of alcohol. Lastly, the high-risk group is given motivational interviewing, as well as possible referral.
The bottom line
Alcohol abuse in adolescents can have significant detrimental effects, both short and long term. The AAP recommends screening every adolescent for alcohol abuse and, if time permits, for other drug abuse as well, in order to prevent the morbidity and mortality associated with these substances. Interventions can range from brief counseling to motivational interviewing of adolescents at risk and finally referral to substance abuse specialists in the highest-risk groups
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Kiriakov is a second-year resident in the Abington-Jefferson Family Medicine Residency Program in Abington.
Binge drinking is a common problem in adolescents as well as adults. In a 2013 survey, 60 million Americans, representing 22% of the population, 12 years of age and older engaged in binge drinking in the previous month. Among those 12-20 years of age, 14%, or one in seven, reported binge drinking. Depending on the survey, between one-third and one-half of all high school students currently drink alcohol. Among young people who drink, a higher proportion drink heavily than among adult drinkers. For teenagers who drink, 28%-60% report binge drinking. Among high school seniors, 1 in 10 report drinking more than 10 drinks in a row. The predominant liquor consumed by 13- to 20-year-olds is vodka (44% ), whereas beer is consumed by less than one-third of respondents. Underage drinkers typically get alcohol from adults of legal drinking age, and frequently drink in their own home or that of a friend. Clearly, this is an important, underappreciated problem that warrants clinical attention.
Background
Binge drinking is defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as the pattern of drinking required to bring the blood alcohol concentration (BAC) to 0.08% or greater. For adolescents, the required amount of alcohol to achieve the same BAC is thought to be less than the amount required for adults. Binge drinking for adults has traditionally been defined as more than five drinks over a 2-hour period for men or more than four drinks over 2 hours for women. Different cutoffs have been suggested for youth in several studies but were not clearly defined for this analysis.
Implications
Alcohol consumption in adolescents is associated with adverse events, and this is only exacerbated by binge drinking. These events include, but are not limited to, engaging in higher-risk behaviors, such as impaired driving or being the passenger in a vehicle with an impaired driver; an increased risk of suicide or attempted suicide; and an increased risk of nonautomobile accidents that can lead to severe injury or drowning. Adolescents who start drinking before the age of 15 years are four times as likely to develop alcohol dependence as people who start drinking after 20 years of age. In addition, adolescents who engage in binge drinking have an increased rate of high-risk sexual activity, which may result in a sexually transmitted infection as well as an unplanned pregnancy. Adolescents who continue to imbibe during pregnancy risk the development of fetal alcohol spectrum disorder. Finally, adolescent binge drinkers are subject to the immediate effects of alcohol, including hangover, blackout, and alcohol poisoning.
Guidance for the provider
The AAP recommends screening every adolescent for substance abuse, but if time constraints exist, alcohol abuse only (Pediatrics. 2015;136[3]:e718-26). The AAP has set up specific screening questions that are based upon the age group of the patient:
For elementary school students (ages 9-11) the following questions are appropriate:
• Do you have any friends who drank beer, wine, or any alcoholic drink in the past year?
• How about you? Have you ever had more than a few sips of beer, wine, or any drink with alcohol?
For patients in middle school (ages 11-14):
• Do you have any friends who drank beer, wine, or any alcohol-containing drink in the past year?
• How about you? Over the past year, how many days have you had where you’ve had more than a few sips of beer, wine, or any other alcohol?
For patients in high school (ages 14-18):
• Over the past year, how many days have you had where you’ve had more than a few sips of beer, wine, or any other alcohol?
• If your friends drink, how many drinks do they usually drink on an occasion?
The above questions help to risk stratify patients into three groups: low, moderate, and high risk. The guidelines do not make a recommendation on how to use these questions to risk stratify the patients. Low-risk patients receive brief counseling. Moderate-risk patients receive more intensive counseling as well as motivational interviewing. Motivational interviewing delivered over the course of one or more sessions has been found to be effective in reducing consumption of alcohol. Lastly, the high-risk group is given motivational interviewing, as well as possible referral.
The bottom line
Alcohol abuse in adolescents can have significant detrimental effects, both short and long term. The AAP recommends screening every adolescent for alcohol abuse and, if time permits, for other drug abuse as well, in order to prevent the morbidity and mortality associated with these substances. Interventions can range from brief counseling to motivational interviewing of adolescents at risk and finally referral to substance abuse specialists in the highest-risk groups
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Kiriakov is a second-year resident in the Abington-Jefferson Family Medicine Residency Program in Abington.
Binge drinking is a common problem in adolescents as well as adults. In a 2013 survey, 60 million Americans, representing 22% of the population, 12 years of age and older engaged in binge drinking in the previous month. Among those 12-20 years of age, 14%, or one in seven, reported binge drinking. Depending on the survey, between one-third and one-half of all high school students currently drink alcohol. Among young people who drink, a higher proportion drink heavily than among adult drinkers. For teenagers who drink, 28%-60% report binge drinking. Among high school seniors, 1 in 10 report drinking more than 10 drinks in a row. The predominant liquor consumed by 13- to 20-year-olds is vodka (44% ), whereas beer is consumed by less than one-third of respondents. Underage drinkers typically get alcohol from adults of legal drinking age, and frequently drink in their own home or that of a friend. Clearly, this is an important, underappreciated problem that warrants clinical attention.
Background
Binge drinking is defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as the pattern of drinking required to bring the blood alcohol concentration (BAC) to 0.08% or greater. For adolescents, the required amount of alcohol to achieve the same BAC is thought to be less than the amount required for adults. Binge drinking for adults has traditionally been defined as more than five drinks over a 2-hour period for men or more than four drinks over 2 hours for women. Different cutoffs have been suggested for youth in several studies but were not clearly defined for this analysis.
Implications
Alcohol consumption in adolescents is associated with adverse events, and this is only exacerbated by binge drinking. These events include, but are not limited to, engaging in higher-risk behaviors, such as impaired driving or being the passenger in a vehicle with an impaired driver; an increased risk of suicide or attempted suicide; and an increased risk of nonautomobile accidents that can lead to severe injury or drowning. Adolescents who start drinking before the age of 15 years are four times as likely to develop alcohol dependence as people who start drinking after 20 years of age. In addition, adolescents who engage in binge drinking have an increased rate of high-risk sexual activity, which may result in a sexually transmitted infection as well as an unplanned pregnancy. Adolescents who continue to imbibe during pregnancy risk the development of fetal alcohol spectrum disorder. Finally, adolescent binge drinkers are subject to the immediate effects of alcohol, including hangover, blackout, and alcohol poisoning.
Guidance for the provider
The AAP recommends screening every adolescent for substance abuse, but if time constraints exist, alcohol abuse only (Pediatrics. 2015;136[3]:e718-26). The AAP has set up specific screening questions that are based upon the age group of the patient:
For elementary school students (ages 9-11) the following questions are appropriate:
• Do you have any friends who drank beer, wine, or any alcoholic drink in the past year?
• How about you? Have you ever had more than a few sips of beer, wine, or any drink with alcohol?
For patients in middle school (ages 11-14):
• Do you have any friends who drank beer, wine, or any alcohol-containing drink in the past year?
• How about you? Over the past year, how many days have you had where you’ve had more than a few sips of beer, wine, or any other alcohol?
For patients in high school (ages 14-18):
• Over the past year, how many days have you had where you’ve had more than a few sips of beer, wine, or any other alcohol?
• If your friends drink, how many drinks do they usually drink on an occasion?
The above questions help to risk stratify patients into three groups: low, moderate, and high risk. The guidelines do not make a recommendation on how to use these questions to risk stratify the patients. Low-risk patients receive brief counseling. Moderate-risk patients receive more intensive counseling as well as motivational interviewing. Motivational interviewing delivered over the course of one or more sessions has been found to be effective in reducing consumption of alcohol. Lastly, the high-risk group is given motivational interviewing, as well as possible referral.
The bottom line
Alcohol abuse in adolescents can have significant detrimental effects, both short and long term. The AAP recommends screening every adolescent for alcohol abuse and, if time permits, for other drug abuse as well, in order to prevent the morbidity and mortality associated with these substances. Interventions can range from brief counseling to motivational interviewing of adolescents at risk and finally referral to substance abuse specialists in the highest-risk groups
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Kiriakov is a second-year resident in the Abington-Jefferson Family Medicine Residency Program in Abington.
Obesity
Emily is a 15-year-old girl who was referred by her pediatrician because of cutting behavior and conflict with her parents. Her parents reported that she has had a high body weight in the obese range since early in life. She had tried various diets without success, and her parents were frustrated with the pediatrician’s emphasis on weight over the years.
Mood problems had begun when she was in the sixth grade when she began to be severely bullied about her weight. Emily said this time was so difficult that she did not have clear memories of it. She described feeling numb. She began experiencing intense anxiety about school, and she was sometimes reluctant to attend and started cutting herself as a means of managing her emotions. In middle school, she began to fight back and associated herself with a group of “mean girls” who drank. She began having increasing conflict with her parents over the drinking and the cutting.
Discussion
Obesity is an extremely complex issue without simple answers. Severe obesity is correlated with numerous health risks including not only cardiovascular disease, type 2 diabetes, hypertension, and cancer, but also psychiatric problems such as depression, anxiety, body dissatisfaction, eating disorders, and unhealthy weight control behaviors. While some of these issues relate directly to the weight itself, many of the psychiatric concerns stem from society’s extremely harsh response to obesity.
We are all aware that the percentage of overweight and obese children, teens, and adults has increased in the past 50 years, although with some recent stabilization.1 The rise in obesity is related to societal factors – the prevalence and advertising of nutrient-poor/high-calorie processed foods in the marketplace, the rise of technologies that have decreased the need for movement, increases in portion sizes in restaurants, especially fast food settings, as well as the subsidizing of unhealthy foods, limited access to and greater cost of more nutritious foods, and limited access to exercise opportunities in poorer areas. This is the “obesogenic environment.” As in numerous aspects of health, weight is also influenced by genetics. Those who are genetically more likely to gain weight are the ones who suffer most from these social changes.
The problem is that, except for bariatric surgery, the interventions prescribed for individuals with obesity don’t work for the vast majority of people in the long run. There is an assumption that if the obese would just eat and exercise the way a thin person does, then they would be thin. While there is evidence that lifestyle strategies that induce a negative energy balance through cutting calories (often by 500-1,000) and “programmed exercise” can help some people lose weight over the course of 6 months to a year, longer-term follow-up suggests that most people regain this weight in the long run, at 5 years out. Even the most optimistic estimates suggest that only about one out of five people can maintain weight losses of 10% in the long term with current standard lifestyle interventions.2
There is evidence that someone attaining a particular body mass index (BMI) through dieting is not able to consume as many calories as another person who has always been at that BMI, requiring constant dietary restraint and a very high level of exercise to maintain the weight loss.3 The great majority of people who are unable to lose the weight, or briefly succeed and then gain the weight back or more, are seen as failing by society, by many medical professionals, and by themselves. There is clearly a need to focus more of our efforts on making changes on a societal level.
There also are alternative individual approaches that take the emphasis away from dieting and weight loss and instead focus on body acceptance and self-care. These interventions go by several names including mindful eating, intuitive eating, weight neutral, and “Health at Every Size.” This approach acknowledges the environmental and genetic factors beyond personal control and discusses how society pressures people to be thin. Instead of emphasizing repeated restrictive dieting, these programs stress maximizing health through making sustainable changes to increase activity and nutrition. These programs encourage people to care for themselves now rather than focusing on dieting toward a future weight where one can start enjoying life. Enjoyment of food, taking time to savor food, and being aware of when one is hungry and when not are central. For physical activity, the emphasis is on discovering something that is pleasurable and sustainable, rather than an onerous duty, as a means to an end of weight loss.4
Management
For Emily, struggling on the individual level, there is not a neat resolution. Psychotherapy to address anxiety, trauma, and substance abuse is indicated. Psychotherapy also should address Emily’s relationship with her body, as this is at the heart of many of these issues. Acknowledging the powerful stigma that society places on the obese while tolerating and even promoting an obesogenic environment, and the reality that weight loss is in fact extremely difficult, would open the door to a discussion with Emily and her family about what she wants and all her options to find the healthiest and most enjoyable way for her to live her life.
1. Pediatr Clin North Am. 2015 Oct;62(5):1241-61.
2. Annu Rev Nutr. 2001;21:323-41.
3. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.
4. Tylka TL, Annunziato RA, Burgard D, et al. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” J Obes. 2014;2014:983495. doi: 10.1155/2014/983495.
Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington.
Emily is a 15-year-old girl who was referred by her pediatrician because of cutting behavior and conflict with her parents. Her parents reported that she has had a high body weight in the obese range since early in life. She had tried various diets without success, and her parents were frustrated with the pediatrician’s emphasis on weight over the years.
Mood problems had begun when she was in the sixth grade when she began to be severely bullied about her weight. Emily said this time was so difficult that she did not have clear memories of it. She described feeling numb. She began experiencing intense anxiety about school, and she was sometimes reluctant to attend and started cutting herself as a means of managing her emotions. In middle school, she began to fight back and associated herself with a group of “mean girls” who drank. She began having increasing conflict with her parents over the drinking and the cutting.
Discussion
Obesity is an extremely complex issue without simple answers. Severe obesity is correlated with numerous health risks including not only cardiovascular disease, type 2 diabetes, hypertension, and cancer, but also psychiatric problems such as depression, anxiety, body dissatisfaction, eating disorders, and unhealthy weight control behaviors. While some of these issues relate directly to the weight itself, many of the psychiatric concerns stem from society’s extremely harsh response to obesity.
We are all aware that the percentage of overweight and obese children, teens, and adults has increased in the past 50 years, although with some recent stabilization.1 The rise in obesity is related to societal factors – the prevalence and advertising of nutrient-poor/high-calorie processed foods in the marketplace, the rise of technologies that have decreased the need for movement, increases in portion sizes in restaurants, especially fast food settings, as well as the subsidizing of unhealthy foods, limited access to and greater cost of more nutritious foods, and limited access to exercise opportunities in poorer areas. This is the “obesogenic environment.” As in numerous aspects of health, weight is also influenced by genetics. Those who are genetically more likely to gain weight are the ones who suffer most from these social changes.
The problem is that, except for bariatric surgery, the interventions prescribed for individuals with obesity don’t work for the vast majority of people in the long run. There is an assumption that if the obese would just eat and exercise the way a thin person does, then they would be thin. While there is evidence that lifestyle strategies that induce a negative energy balance through cutting calories (often by 500-1,000) and “programmed exercise” can help some people lose weight over the course of 6 months to a year, longer-term follow-up suggests that most people regain this weight in the long run, at 5 years out. Even the most optimistic estimates suggest that only about one out of five people can maintain weight losses of 10% in the long term with current standard lifestyle interventions.2
There is evidence that someone attaining a particular body mass index (BMI) through dieting is not able to consume as many calories as another person who has always been at that BMI, requiring constant dietary restraint and a very high level of exercise to maintain the weight loss.3 The great majority of people who are unable to lose the weight, or briefly succeed and then gain the weight back or more, are seen as failing by society, by many medical professionals, and by themselves. There is clearly a need to focus more of our efforts on making changes on a societal level.
There also are alternative individual approaches that take the emphasis away from dieting and weight loss and instead focus on body acceptance and self-care. These interventions go by several names including mindful eating, intuitive eating, weight neutral, and “Health at Every Size.” This approach acknowledges the environmental and genetic factors beyond personal control and discusses how society pressures people to be thin. Instead of emphasizing repeated restrictive dieting, these programs stress maximizing health through making sustainable changes to increase activity and nutrition. These programs encourage people to care for themselves now rather than focusing on dieting toward a future weight where one can start enjoying life. Enjoyment of food, taking time to savor food, and being aware of when one is hungry and when not are central. For physical activity, the emphasis is on discovering something that is pleasurable and sustainable, rather than an onerous duty, as a means to an end of weight loss.4
Management
For Emily, struggling on the individual level, there is not a neat resolution. Psychotherapy to address anxiety, trauma, and substance abuse is indicated. Psychotherapy also should address Emily’s relationship with her body, as this is at the heart of many of these issues. Acknowledging the powerful stigma that society places on the obese while tolerating and even promoting an obesogenic environment, and the reality that weight loss is in fact extremely difficult, would open the door to a discussion with Emily and her family about what she wants and all her options to find the healthiest and most enjoyable way for her to live her life.
1. Pediatr Clin North Am. 2015 Oct;62(5):1241-61.
2. Annu Rev Nutr. 2001;21:323-41.
3. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.
4. Tylka TL, Annunziato RA, Burgard D, et al. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” J Obes. 2014;2014:983495. doi: 10.1155/2014/983495.
Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington.
Emily is a 15-year-old girl who was referred by her pediatrician because of cutting behavior and conflict with her parents. Her parents reported that she has had a high body weight in the obese range since early in life. She had tried various diets without success, and her parents were frustrated with the pediatrician’s emphasis on weight over the years.
Mood problems had begun when she was in the sixth grade when she began to be severely bullied about her weight. Emily said this time was so difficult that she did not have clear memories of it. She described feeling numb. She began experiencing intense anxiety about school, and she was sometimes reluctant to attend and started cutting herself as a means of managing her emotions. In middle school, she began to fight back and associated herself with a group of “mean girls” who drank. She began having increasing conflict with her parents over the drinking and the cutting.
Discussion
Obesity is an extremely complex issue without simple answers. Severe obesity is correlated with numerous health risks including not only cardiovascular disease, type 2 diabetes, hypertension, and cancer, but also psychiatric problems such as depression, anxiety, body dissatisfaction, eating disorders, and unhealthy weight control behaviors. While some of these issues relate directly to the weight itself, many of the psychiatric concerns stem from society’s extremely harsh response to obesity.
We are all aware that the percentage of overweight and obese children, teens, and adults has increased in the past 50 years, although with some recent stabilization.1 The rise in obesity is related to societal factors – the prevalence and advertising of nutrient-poor/high-calorie processed foods in the marketplace, the rise of technologies that have decreased the need for movement, increases in portion sizes in restaurants, especially fast food settings, as well as the subsidizing of unhealthy foods, limited access to and greater cost of more nutritious foods, and limited access to exercise opportunities in poorer areas. This is the “obesogenic environment.” As in numerous aspects of health, weight is also influenced by genetics. Those who are genetically more likely to gain weight are the ones who suffer most from these social changes.
The problem is that, except for bariatric surgery, the interventions prescribed for individuals with obesity don’t work for the vast majority of people in the long run. There is an assumption that if the obese would just eat and exercise the way a thin person does, then they would be thin. While there is evidence that lifestyle strategies that induce a negative energy balance through cutting calories (often by 500-1,000) and “programmed exercise” can help some people lose weight over the course of 6 months to a year, longer-term follow-up suggests that most people regain this weight in the long run, at 5 years out. Even the most optimistic estimates suggest that only about one out of five people can maintain weight losses of 10% in the long term with current standard lifestyle interventions.2
There is evidence that someone attaining a particular body mass index (BMI) through dieting is not able to consume as many calories as another person who has always been at that BMI, requiring constant dietary restraint and a very high level of exercise to maintain the weight loss.3 The great majority of people who are unable to lose the weight, or briefly succeed and then gain the weight back or more, are seen as failing by society, by many medical professionals, and by themselves. There is clearly a need to focus more of our efforts on making changes on a societal level.
There also are alternative individual approaches that take the emphasis away from dieting and weight loss and instead focus on body acceptance and self-care. These interventions go by several names including mindful eating, intuitive eating, weight neutral, and “Health at Every Size.” This approach acknowledges the environmental and genetic factors beyond personal control and discusses how society pressures people to be thin. Instead of emphasizing repeated restrictive dieting, these programs stress maximizing health through making sustainable changes to increase activity and nutrition. These programs encourage people to care for themselves now rather than focusing on dieting toward a future weight where one can start enjoying life. Enjoyment of food, taking time to savor food, and being aware of when one is hungry and when not are central. For physical activity, the emphasis is on discovering something that is pleasurable and sustainable, rather than an onerous duty, as a means to an end of weight loss.4
Management
For Emily, struggling on the individual level, there is not a neat resolution. Psychotherapy to address anxiety, trauma, and substance abuse is indicated. Psychotherapy also should address Emily’s relationship with her body, as this is at the heart of many of these issues. Acknowledging the powerful stigma that society places on the obese while tolerating and even promoting an obesogenic environment, and the reality that weight loss is in fact extremely difficult, would open the door to a discussion with Emily and her family about what she wants and all her options to find the healthiest and most enjoyable way for her to live her life.
1. Pediatr Clin North Am. 2015 Oct;62(5):1241-61.
2. Annu Rev Nutr. 2001;21:323-41.
3. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.
4. Tylka TL, Annunziato RA, Burgard D, et al. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” J Obes. 2014;2014:983495. doi: 10.1155/2014/983495.
Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington.
Make Room on Your Shelves
As orthopedic surgeons, we’ve made a commitment to lifelong learning. I can’t think of a single surgery that I perform the same way I did when I was in training. With rapidly evolving technology, continuously advancing procedures, and ever-increasing documentation requirements, it’s hard to stay on top of it all. We know your time is precious and that you have less of it than ever before. What little time you have that is not dedicated to work is reserved for your family or your hobbies. There’s no time to read every orthopedic journal, many filled with articles that have no practical value to your practice. That’s why we’ve created the new AJO. Our goal, as an editorial staff, is to provide a journal where every article, column, and feature contains information that directly benefits your practice, your patients, or your bottom line, and keeps you informed of the latest techniques, procedures, and products. We will help surgeons “work smarter, not harder,” implement new technologies into their practices, and find creative revenue streams that are both legal and compliant.
We’ve assembled a team of talented editors to accomplish this task, and will introduce them throughout the coming year. In this issue, you will meet our Deputy Editors-in-Chief and some of our new Associate Editors who’ve collaborated to bring you the “new AJO”.
At this year’s Academy, the AJO launched an extensive rebranding. We have a new look, a new logo, and a new creative directive. The journal will now feature new columns, invited articles, and innovative surgical techniques. We will publish 5 issues for the remainder of 2016. Our March/April issue is a special edition dedicated to baseball. In time for Spring Training/Opening Day, this issue includes articles from Major League Baseball’s physicians and trainers, a “Codes to Know” segment, “Tips of the Trade,” and a “Tools of the Trade” feature. “The Baseball Issue” will set the tone for what readers can expect from the “new AJO”.
Our first feature article, written by Jed Kuhn, takes a philosophical look at the evolution of the throwing shoulder, and invites the reader to help unlock some of the great shoulder anatomy mysteries by viewing them from a time when throwing was an activity of daily living. In ancient times, if you couldn’t throw, you couldn’t eat. We know that children who play baseball remodel their shoulder to allow for increased external rotation. Read Dr. Kuhn’s article and imagine when a shoulder optimized for throwing was a competitive advantage for survival.
Our second feature article is written by Stan Conte, a legend of the game and longtime trainer for the Los Angeles Dodgers. Dr. Conte studied injury trends in baseball over the past 18 seasons and provides an analysis of the staggering cost of placing players on the disabled list.
A baseball issue could not be complete without an article on Tommy John surgery. In this issue, AJO shares a revolutionary new technique for treating players with MUCL tears by author Jeffrey Dugas. Named the “Internal Brace”, Dr. Dugas shares his technique for augmenting the injured MUCL and we are proud to bring it to you first.
A recurring feature in the new AJO will be a section we refer to as “Codes to Know.” In partnership with Karen Zupko, AJO will present little-known coding secrets and proper coding techniques to help you get reimbursed appropriately for your work. This month, in the first article of a 3-part series, Alan Hirahara teaches us how to properly code for a diagnostic ultrasound examination of the shoulder. The article includes templates available for download to assist you with proper documentation. Parts 2 and 3 will provide a tutorial on the proper technique for examinations and injections.
While shoulder and elbow injuries get more attention, Major League Baseball’s Injury Panel has produced a look at the staggering amount of knee injuries over the 2011-2014 seasons, inspiring us to feature the knee in our 2 “Trade” Columns.
The “Tips of the Trade” column will continue, featuring this month a guide to identifying and treating meniscal root tears. A new segment, referred to as “Tools of the Trade,” reviews the latest products for all-inside meniscal repair. Our “Tools” section will feature announcements and reviews of the hottest new products, with a buying guide and surgical pearls from the surgeons who know them best.
While we are discussing the lower extremity, we should point out that we plan to do the “leg work” for you. Each AJO issue will have handouts that can be downloaded from our website and utilized in your practice. Read Robin West’s article entitled “Interval Throwing and Hitting Programs in Baseball: Biomechanics and Rehabilitation,” and download Return to Throwing and Hitting programs your patients and therapists can use.
Finally, I’d like to thank our previous Editor-in-Chief Dr. Peter McCann for his stewardship the last 10 years and recognize him for his dedication to the journal.
Thank you for reading AJO and for continuing to do so in the future. I know that collectively, we can turn AJO into a product worthy of its title. We know our past reputation. We are no longer that journal. Spend some time to get to know the “new AJO”, and make some room on your shelves, because the information between the covers will provide a template to implement new technologies and revenue streams into your practice and help fulfill your commitment to learning.
As orthopedic surgeons, we’ve made a commitment to lifelong learning. I can’t think of a single surgery that I perform the same way I did when I was in training. With rapidly evolving technology, continuously advancing procedures, and ever-increasing documentation requirements, it’s hard to stay on top of it all. We know your time is precious and that you have less of it than ever before. What little time you have that is not dedicated to work is reserved for your family or your hobbies. There’s no time to read every orthopedic journal, many filled with articles that have no practical value to your practice. That’s why we’ve created the new AJO. Our goal, as an editorial staff, is to provide a journal where every article, column, and feature contains information that directly benefits your practice, your patients, or your bottom line, and keeps you informed of the latest techniques, procedures, and products. We will help surgeons “work smarter, not harder,” implement new technologies into their practices, and find creative revenue streams that are both legal and compliant.
We’ve assembled a team of talented editors to accomplish this task, and will introduce them throughout the coming year. In this issue, you will meet our Deputy Editors-in-Chief and some of our new Associate Editors who’ve collaborated to bring you the “new AJO”.
At this year’s Academy, the AJO launched an extensive rebranding. We have a new look, a new logo, and a new creative directive. The journal will now feature new columns, invited articles, and innovative surgical techniques. We will publish 5 issues for the remainder of 2016. Our March/April issue is a special edition dedicated to baseball. In time for Spring Training/Opening Day, this issue includes articles from Major League Baseball’s physicians and trainers, a “Codes to Know” segment, “Tips of the Trade,” and a “Tools of the Trade” feature. “The Baseball Issue” will set the tone for what readers can expect from the “new AJO”.
Our first feature article, written by Jed Kuhn, takes a philosophical look at the evolution of the throwing shoulder, and invites the reader to help unlock some of the great shoulder anatomy mysteries by viewing them from a time when throwing was an activity of daily living. In ancient times, if you couldn’t throw, you couldn’t eat. We know that children who play baseball remodel their shoulder to allow for increased external rotation. Read Dr. Kuhn’s article and imagine when a shoulder optimized for throwing was a competitive advantage for survival.
Our second feature article is written by Stan Conte, a legend of the game and longtime trainer for the Los Angeles Dodgers. Dr. Conte studied injury trends in baseball over the past 18 seasons and provides an analysis of the staggering cost of placing players on the disabled list.
A baseball issue could not be complete without an article on Tommy John surgery. In this issue, AJO shares a revolutionary new technique for treating players with MUCL tears by author Jeffrey Dugas. Named the “Internal Brace”, Dr. Dugas shares his technique for augmenting the injured MUCL and we are proud to bring it to you first.
A recurring feature in the new AJO will be a section we refer to as “Codes to Know.” In partnership with Karen Zupko, AJO will present little-known coding secrets and proper coding techniques to help you get reimbursed appropriately for your work. This month, in the first article of a 3-part series, Alan Hirahara teaches us how to properly code for a diagnostic ultrasound examination of the shoulder. The article includes templates available for download to assist you with proper documentation. Parts 2 and 3 will provide a tutorial on the proper technique for examinations and injections.
While shoulder and elbow injuries get more attention, Major League Baseball’s Injury Panel has produced a look at the staggering amount of knee injuries over the 2011-2014 seasons, inspiring us to feature the knee in our 2 “Trade” Columns.
The “Tips of the Trade” column will continue, featuring this month a guide to identifying and treating meniscal root tears. A new segment, referred to as “Tools of the Trade,” reviews the latest products for all-inside meniscal repair. Our “Tools” section will feature announcements and reviews of the hottest new products, with a buying guide and surgical pearls from the surgeons who know them best.
While we are discussing the lower extremity, we should point out that we plan to do the “leg work” for you. Each AJO issue will have handouts that can be downloaded from our website and utilized in your practice. Read Robin West’s article entitled “Interval Throwing and Hitting Programs in Baseball: Biomechanics and Rehabilitation,” and download Return to Throwing and Hitting programs your patients and therapists can use.
Finally, I’d like to thank our previous Editor-in-Chief Dr. Peter McCann for his stewardship the last 10 years and recognize him for his dedication to the journal.
Thank you for reading AJO and for continuing to do so in the future. I know that collectively, we can turn AJO into a product worthy of its title. We know our past reputation. We are no longer that journal. Spend some time to get to know the “new AJO”, and make some room on your shelves, because the information between the covers will provide a template to implement new technologies and revenue streams into your practice and help fulfill your commitment to learning.
As orthopedic surgeons, we’ve made a commitment to lifelong learning. I can’t think of a single surgery that I perform the same way I did when I was in training. With rapidly evolving technology, continuously advancing procedures, and ever-increasing documentation requirements, it’s hard to stay on top of it all. We know your time is precious and that you have less of it than ever before. What little time you have that is not dedicated to work is reserved for your family or your hobbies. There’s no time to read every orthopedic journal, many filled with articles that have no practical value to your practice. That’s why we’ve created the new AJO. Our goal, as an editorial staff, is to provide a journal where every article, column, and feature contains information that directly benefits your practice, your patients, or your bottom line, and keeps you informed of the latest techniques, procedures, and products. We will help surgeons “work smarter, not harder,” implement new technologies into their practices, and find creative revenue streams that are both legal and compliant.
We’ve assembled a team of talented editors to accomplish this task, and will introduce them throughout the coming year. In this issue, you will meet our Deputy Editors-in-Chief and some of our new Associate Editors who’ve collaborated to bring you the “new AJO”.
At this year’s Academy, the AJO launched an extensive rebranding. We have a new look, a new logo, and a new creative directive. The journal will now feature new columns, invited articles, and innovative surgical techniques. We will publish 5 issues for the remainder of 2016. Our March/April issue is a special edition dedicated to baseball. In time for Spring Training/Opening Day, this issue includes articles from Major League Baseball’s physicians and trainers, a “Codes to Know” segment, “Tips of the Trade,” and a “Tools of the Trade” feature. “The Baseball Issue” will set the tone for what readers can expect from the “new AJO”.
Our first feature article, written by Jed Kuhn, takes a philosophical look at the evolution of the throwing shoulder, and invites the reader to help unlock some of the great shoulder anatomy mysteries by viewing them from a time when throwing was an activity of daily living. In ancient times, if you couldn’t throw, you couldn’t eat. We know that children who play baseball remodel their shoulder to allow for increased external rotation. Read Dr. Kuhn’s article and imagine when a shoulder optimized for throwing was a competitive advantage for survival.
Our second feature article is written by Stan Conte, a legend of the game and longtime trainer for the Los Angeles Dodgers. Dr. Conte studied injury trends in baseball over the past 18 seasons and provides an analysis of the staggering cost of placing players on the disabled list.
A baseball issue could not be complete without an article on Tommy John surgery. In this issue, AJO shares a revolutionary new technique for treating players with MUCL tears by author Jeffrey Dugas. Named the “Internal Brace”, Dr. Dugas shares his technique for augmenting the injured MUCL and we are proud to bring it to you first.
A recurring feature in the new AJO will be a section we refer to as “Codes to Know.” In partnership with Karen Zupko, AJO will present little-known coding secrets and proper coding techniques to help you get reimbursed appropriately for your work. This month, in the first article of a 3-part series, Alan Hirahara teaches us how to properly code for a diagnostic ultrasound examination of the shoulder. The article includes templates available for download to assist you with proper documentation. Parts 2 and 3 will provide a tutorial on the proper technique for examinations and injections.
While shoulder and elbow injuries get more attention, Major League Baseball’s Injury Panel has produced a look at the staggering amount of knee injuries over the 2011-2014 seasons, inspiring us to feature the knee in our 2 “Trade” Columns.
The “Tips of the Trade” column will continue, featuring this month a guide to identifying and treating meniscal root tears. A new segment, referred to as “Tools of the Trade,” reviews the latest products for all-inside meniscal repair. Our “Tools” section will feature announcements and reviews of the hottest new products, with a buying guide and surgical pearls from the surgeons who know them best.
While we are discussing the lower extremity, we should point out that we plan to do the “leg work” for you. Each AJO issue will have handouts that can be downloaded from our website and utilized in your practice. Read Robin West’s article entitled “Interval Throwing and Hitting Programs in Baseball: Biomechanics and Rehabilitation,” and download Return to Throwing and Hitting programs your patients and therapists can use.
Finally, I’d like to thank our previous Editor-in-Chief Dr. Peter McCann for his stewardship the last 10 years and recognize him for his dedication to the journal.
Thank you for reading AJO and for continuing to do so in the future. I know that collectively, we can turn AJO into a product worthy of its title. We know our past reputation. We are no longer that journal. Spend some time to get to know the “new AJO”, and make some room on your shelves, because the information between the covers will provide a template to implement new technologies and revenue streams into your practice and help fulfill your commitment to learning.
Putting a lid on precious bodily fluids
An old and true chestnut is that people are roughly 60% water and that we evolved in a lineage of land-based life selected to have complex and finely tuned mechanisms to maintain proper internal levels of salts and fluids. When the processes that regulate these are out of whack, bad things happen.
As I recently reported, surgeons at Johns Hopkins Hospital, Baltimore, have documented that excess fluid retention in patients who have just undergone heart surgery was the most common factor driving these patients back to the hospital during the 30 days after their index discharge. Dr. John V. Conte Jr., a Johns Hopkins cardiac surgeon, told me that patients often retain 5-10 pounds of excess fluid during the weeks immediately following heart surgery, and if they have trouble voiding this tsunami that can accumulate in their chest from pleural effusions, they develop acute problems, most notably difficulty breathing.
As a consequence, heart surgery patients with the highest risk for complications from fluid overload following their operation include those with severe chronic lung disease and those who develop acute renal failure postoperatively.
Problems with postsurgical fluid balance that lead to rehospitalization sound remarkably like the fluid-balance issue that also drives rehospitalization in patients with hard-to-control heart failure. Acute decompensation episodes in heart failure patients are triggered by fluid overload that manifests as severe dyspnea (and peripheral edema) that sends patients to the hospital. Patients with kidney dysfunction in addition to heart failure are particularly vulnerable to decompensation events.
“Fluid is an issue for both heart failure and heart surgery patients. Fluid is the common pathway to readmissions,” Dr. Conte noted when I spoke with him recently.
The parallels between the two disorders run deeper. To combat fluid overload, both types of patients need aggressive diuresis. Results from at least some studies also suggest that heart failure patients benefit clinically and also need fewer hospitalizations when they are closely monitored at home to provide early warning of incipient fluid overload that can be nipped by prompt treatment. The same approach may also help cut rehospitalization rates in recent heart surgery patients; Dr. Conte plans to soon test this strategy in a formal study.
Another parallel is that improved fluid management in these patients when they are at home may also help the hospitals that initially treat them by reducing the hospitals’ risk from financial penalties imposed by the Centers for Medicare & Medicaid Services. In fiscal year 2017, which starts in July 2016, CMS adds 30-day rehospitalization following coronary artery bypass grafting to its short list of hospital readmission types that can generate a monetary penalty from the agency’s Readmissions Reduction Program when a hospital’s numbers exceed national norms.
The CMS plans to soon start penalizing for seven types of excess rehospitalizations and the fact that two of the seven result in large part from deranged fluid balance shows just how important successful fluid management is these days, both to patients and to the hospitals and clinicians that treat them.
On Twitter @mitchelzoler
An old and true chestnut is that people are roughly 60% water and that we evolved in a lineage of land-based life selected to have complex and finely tuned mechanisms to maintain proper internal levels of salts and fluids. When the processes that regulate these are out of whack, bad things happen.
As I recently reported, surgeons at Johns Hopkins Hospital, Baltimore, have documented that excess fluid retention in patients who have just undergone heart surgery was the most common factor driving these patients back to the hospital during the 30 days after their index discharge. Dr. John V. Conte Jr., a Johns Hopkins cardiac surgeon, told me that patients often retain 5-10 pounds of excess fluid during the weeks immediately following heart surgery, and if they have trouble voiding this tsunami that can accumulate in their chest from pleural effusions, they develop acute problems, most notably difficulty breathing.
As a consequence, heart surgery patients with the highest risk for complications from fluid overload following their operation include those with severe chronic lung disease and those who develop acute renal failure postoperatively.
Problems with postsurgical fluid balance that lead to rehospitalization sound remarkably like the fluid-balance issue that also drives rehospitalization in patients with hard-to-control heart failure. Acute decompensation episodes in heart failure patients are triggered by fluid overload that manifests as severe dyspnea (and peripheral edema) that sends patients to the hospital. Patients with kidney dysfunction in addition to heart failure are particularly vulnerable to decompensation events.
“Fluid is an issue for both heart failure and heart surgery patients. Fluid is the common pathway to readmissions,” Dr. Conte noted when I spoke with him recently.
The parallels between the two disorders run deeper. To combat fluid overload, both types of patients need aggressive diuresis. Results from at least some studies also suggest that heart failure patients benefit clinically and also need fewer hospitalizations when they are closely monitored at home to provide early warning of incipient fluid overload that can be nipped by prompt treatment. The same approach may also help cut rehospitalization rates in recent heart surgery patients; Dr. Conte plans to soon test this strategy in a formal study.
Another parallel is that improved fluid management in these patients when they are at home may also help the hospitals that initially treat them by reducing the hospitals’ risk from financial penalties imposed by the Centers for Medicare & Medicaid Services. In fiscal year 2017, which starts in July 2016, CMS adds 30-day rehospitalization following coronary artery bypass grafting to its short list of hospital readmission types that can generate a monetary penalty from the agency’s Readmissions Reduction Program when a hospital’s numbers exceed national norms.
The CMS plans to soon start penalizing for seven types of excess rehospitalizations and the fact that two of the seven result in large part from deranged fluid balance shows just how important successful fluid management is these days, both to patients and to the hospitals and clinicians that treat them.
On Twitter @mitchelzoler
An old and true chestnut is that people are roughly 60% water and that we evolved in a lineage of land-based life selected to have complex and finely tuned mechanisms to maintain proper internal levels of salts and fluids. When the processes that regulate these are out of whack, bad things happen.
As I recently reported, surgeons at Johns Hopkins Hospital, Baltimore, have documented that excess fluid retention in patients who have just undergone heart surgery was the most common factor driving these patients back to the hospital during the 30 days after their index discharge. Dr. John V. Conte Jr., a Johns Hopkins cardiac surgeon, told me that patients often retain 5-10 pounds of excess fluid during the weeks immediately following heart surgery, and if they have trouble voiding this tsunami that can accumulate in their chest from pleural effusions, they develop acute problems, most notably difficulty breathing.
As a consequence, heart surgery patients with the highest risk for complications from fluid overload following their operation include those with severe chronic lung disease and those who develop acute renal failure postoperatively.
Problems with postsurgical fluid balance that lead to rehospitalization sound remarkably like the fluid-balance issue that also drives rehospitalization in patients with hard-to-control heart failure. Acute decompensation episodes in heart failure patients are triggered by fluid overload that manifests as severe dyspnea (and peripheral edema) that sends patients to the hospital. Patients with kidney dysfunction in addition to heart failure are particularly vulnerable to decompensation events.
“Fluid is an issue for both heart failure and heart surgery patients. Fluid is the common pathway to readmissions,” Dr. Conte noted when I spoke with him recently.
The parallels between the two disorders run deeper. To combat fluid overload, both types of patients need aggressive diuresis. Results from at least some studies also suggest that heart failure patients benefit clinically and also need fewer hospitalizations when they are closely monitored at home to provide early warning of incipient fluid overload that can be nipped by prompt treatment. The same approach may also help cut rehospitalization rates in recent heart surgery patients; Dr. Conte plans to soon test this strategy in a formal study.
Another parallel is that improved fluid management in these patients when they are at home may also help the hospitals that initially treat them by reducing the hospitals’ risk from financial penalties imposed by the Centers for Medicare & Medicaid Services. In fiscal year 2017, which starts in July 2016, CMS adds 30-day rehospitalization following coronary artery bypass grafting to its short list of hospital readmission types that can generate a monetary penalty from the agency’s Readmissions Reduction Program when a hospital’s numbers exceed national norms.
The CMS plans to soon start penalizing for seven types of excess rehospitalizations and the fact that two of the seven result in large part from deranged fluid balance shows just how important successful fluid management is these days, both to patients and to the hospitals and clinicians that treat them.
On Twitter @mitchelzoler
ThriveNYC could help treat and destigmatize mental, behavioral disorders
Can a broad public health campaign have an impact on addressing stigma, and getting people with mental health and substance use problems the help they need? New York City First Lady Chirlane McCray thinks it can.
Late last year, Ms. McCray spearheaded an ambitious public health initiative that Mayor Bill de Blasio’s administration hopes will be used as a model for other cities across the country. It’s called ThriveNYC: A Mental Health Roadmap for All. The roadmap is guided by six core principles: Change the culture, act early, close treatment gaps, partner with communities, use data better, and strengthen the government’s ability to lead.
“We want to change the way we deliver services in this system,” Ms. McCray, chair of the Mayor’s Fund to Advance New York City, told me in a recent interview. The effort involves more than 20 city agencies, 54 initiatives grounded in best practices, and $850 million allocated over the next 4 years.
A key element of ThriveNYC is its plan to train 250,000 New Yorkers “to better recognize the signs, symptoms, and risk factors of mental illness and addiction, and more effectively provide support,” according to the release announcing the initiative. The training component will be based on Mental Health First Aid, a program disseminated by the National Council for Behavioral Health and Missouri Department of Mental Health. More than 6,000 New Yorkers have been trained over the last several years to administer Mental Health First Aid under the city’s Department of Health and Mental Hygiene, and an additional 10,000 people will be trained by the end of ThriveNYC’s first year, Ms. McCray said in recent testimony before the New York City Council’s Committee on Mental Health.
The roadmap also encompasses teaching emotional skills to children in early childhood programs, and increasing screening and treatment for maternal depression as well as an expansion of supportive housing.
In addition, a core of 400 physicians will be recruited to work in mental health and substance use clinics. “We need 400,000 additional hours of outpatient services,” she told me. Another important step in the roadmap, particularly in light of the Cultural Formulation guidelines in the DSM-5, is the recognition that the mental health workforce needs to be culturally and linguistically diverse.
Ms. McCray said her interest in mental health goes back many years. “My parents suffered from depression,” she said. “Later, our daughter came to us and said she had been diagnosed with anxiety and depression. I could not figure out why this was not being talked about.”
Before she and her team came up with the plan, Ms. McCray said, she traveled to all of the boroughs and talked with New Yorkers to discover just how prevalent mental illness is. About 20% of adult New Yorkers will have a mental disorder in any given year, she said. This correlates well with national statistics. “How can so many people be suffering from something that is treatable?” she asked. “If someone has a sprained ankle, people know what to do.”
She is so right. I have told many people in denial that if you have broken leg you know what to do and do it, or if you get a piece of dirt in your eye and can’t get it out, you find an eye specialist. The list goes on. With mental illness, all too many people remain in the darkness of denial.
This plan also could help people with serious and chronic mental illness beyond depression. As I wrote recently, improving the quality of life for patients with serious and chronic mental illness requires commitment on the part of the mental health community to exert influence on policymakers and business leaders “so that outpatient care is brought up to the standards envisioned decades ago” when psychiatric hospitals were emptied (“Better treatment is long overdue,” Clinical Psychiatry News, August 2015, p. 10). “Psychiatric patients, who are among the most vulnerable people in our society, deserve this.”
Better treatment for people with serious and chronic mental illness also creates an environment in which they can get treatment for medical conditions such as cardiovascular disease, diabetes, and hypertension, which are often ignored. Statistically, people with serious and chronic mental illness live about 20 fewer years than do those without mental illness.
We know that we are in the midst of a shortage of psychiatrists. Primary care physicians often step in to help us treat illnesses such as depression, but the demand for care also is overwhelming their ranks. Meanwhile, about 350,000 psychiatric patients are housed in our prison system, many for minor crimes related to their illnesses, and an additional 250,000 people are in homeless shelters because of the lack of psychiatrically supervised safe housing, according to data from the Treatment Advocacy Center and the National Institute of Corrections. When that scenario is juxtaposed to the number of psychiatric beds available 50 years ago – 650,000 compared with 65,000 today, it quickly becomes clear that this is a crisis.
Ms. McCray’s roadmap is a bold experiment that could be the start of fundamental changes to the landscape for people with mental illness – not only in New York. It also could prove to be a national blueprint. One of its greatest strengths is its potential to help destigmatize mental illness and truly bring mental health care into the mainstream of health care delivery. Implementing the roadmap slowly and with a small group of people, however, would give it the best chance of success.
Those of us who advocate on behalf of people with mental illness, including the American Psychiatric Association, should take a look at what’s going on in New York City and see how we can help. In fact, perhaps the APA should call on Ms. McCray as a keynote speaker. In the meantime, we’ll find out more when ThriveNYC holds a workforce summit that Ms. McCray told me will be held to discuss some of these issues.
Dr. London is a psychiatrist who trained at NYU Langone Medical Center and Bellevue Hospital, both in New York, and developed and ran a short-term psychotherapy program at the medical center from 1975 through 1995. He has been a newspaper columnist for more than 30 years. He has no conflicts of interest.
Can a broad public health campaign have an impact on addressing stigma, and getting people with mental health and substance use problems the help they need? New York City First Lady Chirlane McCray thinks it can.
Late last year, Ms. McCray spearheaded an ambitious public health initiative that Mayor Bill de Blasio’s administration hopes will be used as a model for other cities across the country. It’s called ThriveNYC: A Mental Health Roadmap for All. The roadmap is guided by six core principles: Change the culture, act early, close treatment gaps, partner with communities, use data better, and strengthen the government’s ability to lead.
“We want to change the way we deliver services in this system,” Ms. McCray, chair of the Mayor’s Fund to Advance New York City, told me in a recent interview. The effort involves more than 20 city agencies, 54 initiatives grounded in best practices, and $850 million allocated over the next 4 years.
A key element of ThriveNYC is its plan to train 250,000 New Yorkers “to better recognize the signs, symptoms, and risk factors of mental illness and addiction, and more effectively provide support,” according to the release announcing the initiative. The training component will be based on Mental Health First Aid, a program disseminated by the National Council for Behavioral Health and Missouri Department of Mental Health. More than 6,000 New Yorkers have been trained over the last several years to administer Mental Health First Aid under the city’s Department of Health and Mental Hygiene, and an additional 10,000 people will be trained by the end of ThriveNYC’s first year, Ms. McCray said in recent testimony before the New York City Council’s Committee on Mental Health.
The roadmap also encompasses teaching emotional skills to children in early childhood programs, and increasing screening and treatment for maternal depression as well as an expansion of supportive housing.
In addition, a core of 400 physicians will be recruited to work in mental health and substance use clinics. “We need 400,000 additional hours of outpatient services,” she told me. Another important step in the roadmap, particularly in light of the Cultural Formulation guidelines in the DSM-5, is the recognition that the mental health workforce needs to be culturally and linguistically diverse.
Ms. McCray said her interest in mental health goes back many years. “My parents suffered from depression,” she said. “Later, our daughter came to us and said she had been diagnosed with anxiety and depression. I could not figure out why this was not being talked about.”
Before she and her team came up with the plan, Ms. McCray said, she traveled to all of the boroughs and talked with New Yorkers to discover just how prevalent mental illness is. About 20% of adult New Yorkers will have a mental disorder in any given year, she said. This correlates well with national statistics. “How can so many people be suffering from something that is treatable?” she asked. “If someone has a sprained ankle, people know what to do.”
She is so right. I have told many people in denial that if you have broken leg you know what to do and do it, or if you get a piece of dirt in your eye and can’t get it out, you find an eye specialist. The list goes on. With mental illness, all too many people remain in the darkness of denial.
This plan also could help people with serious and chronic mental illness beyond depression. As I wrote recently, improving the quality of life for patients with serious and chronic mental illness requires commitment on the part of the mental health community to exert influence on policymakers and business leaders “so that outpatient care is brought up to the standards envisioned decades ago” when psychiatric hospitals were emptied (“Better treatment is long overdue,” Clinical Psychiatry News, August 2015, p. 10). “Psychiatric patients, who are among the most vulnerable people in our society, deserve this.”
Better treatment for people with serious and chronic mental illness also creates an environment in which they can get treatment for medical conditions such as cardiovascular disease, diabetes, and hypertension, which are often ignored. Statistically, people with serious and chronic mental illness live about 20 fewer years than do those without mental illness.
We know that we are in the midst of a shortage of psychiatrists. Primary care physicians often step in to help us treat illnesses such as depression, but the demand for care also is overwhelming their ranks. Meanwhile, about 350,000 psychiatric patients are housed in our prison system, many for minor crimes related to their illnesses, and an additional 250,000 people are in homeless shelters because of the lack of psychiatrically supervised safe housing, according to data from the Treatment Advocacy Center and the National Institute of Corrections. When that scenario is juxtaposed to the number of psychiatric beds available 50 years ago – 650,000 compared with 65,000 today, it quickly becomes clear that this is a crisis.
Ms. McCray’s roadmap is a bold experiment that could be the start of fundamental changes to the landscape for people with mental illness – not only in New York. It also could prove to be a national blueprint. One of its greatest strengths is its potential to help destigmatize mental illness and truly bring mental health care into the mainstream of health care delivery. Implementing the roadmap slowly and with a small group of people, however, would give it the best chance of success.
Those of us who advocate on behalf of people with mental illness, including the American Psychiatric Association, should take a look at what’s going on in New York City and see how we can help. In fact, perhaps the APA should call on Ms. McCray as a keynote speaker. In the meantime, we’ll find out more when ThriveNYC holds a workforce summit that Ms. McCray told me will be held to discuss some of these issues.
Dr. London is a psychiatrist who trained at NYU Langone Medical Center and Bellevue Hospital, both in New York, and developed and ran a short-term psychotherapy program at the medical center from 1975 through 1995. He has been a newspaper columnist for more than 30 years. He has no conflicts of interest.
Can a broad public health campaign have an impact on addressing stigma, and getting people with mental health and substance use problems the help they need? New York City First Lady Chirlane McCray thinks it can.
Late last year, Ms. McCray spearheaded an ambitious public health initiative that Mayor Bill de Blasio’s administration hopes will be used as a model for other cities across the country. It’s called ThriveNYC: A Mental Health Roadmap for All. The roadmap is guided by six core principles: Change the culture, act early, close treatment gaps, partner with communities, use data better, and strengthen the government’s ability to lead.
“We want to change the way we deliver services in this system,” Ms. McCray, chair of the Mayor’s Fund to Advance New York City, told me in a recent interview. The effort involves more than 20 city agencies, 54 initiatives grounded in best practices, and $850 million allocated over the next 4 years.
A key element of ThriveNYC is its plan to train 250,000 New Yorkers “to better recognize the signs, symptoms, and risk factors of mental illness and addiction, and more effectively provide support,” according to the release announcing the initiative. The training component will be based on Mental Health First Aid, a program disseminated by the National Council for Behavioral Health and Missouri Department of Mental Health. More than 6,000 New Yorkers have been trained over the last several years to administer Mental Health First Aid under the city’s Department of Health and Mental Hygiene, and an additional 10,000 people will be trained by the end of ThriveNYC’s first year, Ms. McCray said in recent testimony before the New York City Council’s Committee on Mental Health.
The roadmap also encompasses teaching emotional skills to children in early childhood programs, and increasing screening and treatment for maternal depression as well as an expansion of supportive housing.
In addition, a core of 400 physicians will be recruited to work in mental health and substance use clinics. “We need 400,000 additional hours of outpatient services,” she told me. Another important step in the roadmap, particularly in light of the Cultural Formulation guidelines in the DSM-5, is the recognition that the mental health workforce needs to be culturally and linguistically diverse.
Ms. McCray said her interest in mental health goes back many years. “My parents suffered from depression,” she said. “Later, our daughter came to us and said she had been diagnosed with anxiety and depression. I could not figure out why this was not being talked about.”
Before she and her team came up with the plan, Ms. McCray said, she traveled to all of the boroughs and talked with New Yorkers to discover just how prevalent mental illness is. About 20% of adult New Yorkers will have a mental disorder in any given year, she said. This correlates well with national statistics. “How can so many people be suffering from something that is treatable?” she asked. “If someone has a sprained ankle, people know what to do.”
She is so right. I have told many people in denial that if you have broken leg you know what to do and do it, or if you get a piece of dirt in your eye and can’t get it out, you find an eye specialist. The list goes on. With mental illness, all too many people remain in the darkness of denial.
This plan also could help people with serious and chronic mental illness beyond depression. As I wrote recently, improving the quality of life for patients with serious and chronic mental illness requires commitment on the part of the mental health community to exert influence on policymakers and business leaders “so that outpatient care is brought up to the standards envisioned decades ago” when psychiatric hospitals were emptied (“Better treatment is long overdue,” Clinical Psychiatry News, August 2015, p. 10). “Psychiatric patients, who are among the most vulnerable people in our society, deserve this.”
Better treatment for people with serious and chronic mental illness also creates an environment in which they can get treatment for medical conditions such as cardiovascular disease, diabetes, and hypertension, which are often ignored. Statistically, people with serious and chronic mental illness live about 20 fewer years than do those without mental illness.
We know that we are in the midst of a shortage of psychiatrists. Primary care physicians often step in to help us treat illnesses such as depression, but the demand for care also is overwhelming their ranks. Meanwhile, about 350,000 psychiatric patients are housed in our prison system, many for minor crimes related to their illnesses, and an additional 250,000 people are in homeless shelters because of the lack of psychiatrically supervised safe housing, according to data from the Treatment Advocacy Center and the National Institute of Corrections. When that scenario is juxtaposed to the number of psychiatric beds available 50 years ago – 650,000 compared with 65,000 today, it quickly becomes clear that this is a crisis.
Ms. McCray’s roadmap is a bold experiment that could be the start of fundamental changes to the landscape for people with mental illness – not only in New York. It also could prove to be a national blueprint. One of its greatest strengths is its potential to help destigmatize mental illness and truly bring mental health care into the mainstream of health care delivery. Implementing the roadmap slowly and with a small group of people, however, would give it the best chance of success.
Those of us who advocate on behalf of people with mental illness, including the American Psychiatric Association, should take a look at what’s going on in New York City and see how we can help. In fact, perhaps the APA should call on Ms. McCray as a keynote speaker. In the meantime, we’ll find out more when ThriveNYC holds a workforce summit that Ms. McCray told me will be held to discuss some of these issues.
Dr. London is a psychiatrist who trained at NYU Langone Medical Center and Bellevue Hospital, both in New York, and developed and ran a short-term psychotherapy program at the medical center from 1975 through 1995. He has been a newspaper columnist for more than 30 years. He has no conflicts of interest.
