Articles Posted in Surgery

allchildrens-300x220When big hospitals aim to get even more giant, they do so at risk of the quality of care they offer to their patients — and they can do much damage to their brand and hard-to-repair reputations. That may be a reality that elite Johns Hopkins may be discovering.

The Tampa Bay Times deserves credit for its detailed take-down of the “internationally renowned,” Baltimore-based medical institution for the deaths and harms suffered by child heart patients at All Children’s hospital in Florida. Johns Hopkins took it over, and, according to the newspaper, within a half dozen years made a debacle of its well-regarded pediatric heart surgery program, which worsened until youngsters were dying at a “stunning rate.”

As the newspaper reported, based on a year’s investigation of the All Children’s program:

hpvshot-300x231Women may need to double-up on their consultations with their specialists about treatment for serious gynecological concerns, as new studies have raised troubling questions about a much-touted minimally invasive surgery for early-stage cervical cancer.

These concerns, in a more perfect world, also would prompt greater questioning and oversight by doctors, hospitals, regulators, and lawmakers of surgical “innovations.”

The procedure now in question removes the uterus, part of the vagina, and other surrounding tissues via small incisions and with special laparoscopic instruments, including robots. Surgeons have advocated for this surgery rather than making a large incision in an “open” procedure, arguing the less invasive approach promotes less discomfort and faster healing for patients.

leapfrog-300x300A familiar health care advocacy group will expand its grading of 2,000 or so hospitals across the country to also provide new safety and quality information on 5,600 stand-alone surgical centers that perform millions of procedures annually.

It may seem like a small step, and the devil will be in the details of the new data that will be voluntarily reported, analyzed, and then made public by the Leapfrog Group, a national health care nonprofit that describes itself as being “driven by employers and other purchasers of health care.”

Surgical centers have burgeoned because they can be nimbler than the hospitals and academic medical centers they now outnumber. The centers can be set up without hospitals’ high overhead costs, including for staff and equipment that may be unnecessary for a specialty practice. The facilities also can be set up closer to patients, theoretically offering them greater access and convenience, including with easy navigation and parking.

aspirinDoctors subject older patients to risky, costly, invasive, and painful tests and treatments, perhaps with good intention but also because they fail to see that the seniors in their care are individuals with specific situations with real needs that must be considered.

If  physicians too readily accept conventional wisdom in their field, for example, they may push patients 65 and older to take low-aspirin, with the popular but mistaken belief that this practice will help prevent heart attacks, strokes, and dementia. This doesn’t work, and, it increases the risk in seniors of “significant bleeding in the digestive tract, brain or other sites that required transfusions or admission to the hospital,” the New York Times reported.

The newspaper cited a trio of studies, published in the New England Journal of Medicine and based on “more than 19,000 people, including whites 70 and older, and blacks and Hispanics 65 and older. They took low-dose aspirin — 100 milligrams — or a placebo every day for a median of 4.7 years.”

cduntsch-300x300It carries the plot line of a compelling crime story: A knife-wielding assailant works his way into exclusive institutions across a metropolis. There, time after time, he rips into  victims, inflicting great pain and suffering. He acts under the noses of people who should know better. He gets stopped only when someone in law enforcement steps beyond norms to bring him to justice. There’s even a systemic flaw that makes the drug abusing criminal’s acts more awful.

It’s painful and tragic, however, that the saga of Christopher Duntsch, aka “Dr. Death,” is all too gory, true, and potentially avoidable. It has become even more public via modern technology, an increasingly popular and free podcast by Laura Beil on the Wondery site.

Duntsch, now serving a life sentence in prison, moved from one hospital to another in Dallas, where the cancer-researcher and neurosurgeon morphed himself into a spinal surgeon. He was awful. Colleagues reported him to hospitals and medical licensing officials. They stepped in front of him in operating suites and took instruments out of his hands during surgeries. Duntsch, D magazine says, abused drugs, partied, and talked about having wild sex often before long, complex operations. There have been reports that he may intentionally have tried to maim patients. His surgeries were tied to deaths.

Bundle-300x151Federal regulators may be forced to reconsider their plans to curtail a cost-containing experiment that affects some of the most commonly performed surgeries — knee and hip replacement procedures that hundreds of thousands of seniors undergo annually through their Medicare coverage at a cost to taxpayers of billions of dollars.

Under the Affordable Care Act, doctors and hospitals were pushed to adopt a new and different way to think about and to bill for these surgeries, which, by the way, aren’t risk free. Instead of patients getting flooded with bills from each provider involved — the lab, radiologist, anesthesiologist, surgeon, hospital, and so forth — Obamacare got all the parties together and told them they would get a single, “bundled payment.” Hospitals, typically, then acted as the chief point of contact, getting the providers to figure their fair share, billing patients (once), and collecting reimbursements and distributing them appropriately.

The system seemed to work: costs declined, the quality of care went up, and patients expressed relief that their mailboxes weren’t jammed with a blizzard of the usual incomprehensible medical bills. But doctors, hospitals, and insurers kept grumbling. The Trump Administration and Republicans in Congress, as part of their relentless and counter-factual assault on the ACA (more on that in a second), took aim at bundled payments and talked about changing and eliminating this approach.

costhospitals-300x218Hip and knee replacements  have become some of the nation’s most commonly performed surgeries with hundreds of thousands of Americans, many of them older, having their knees or hips replaced with metal, plastic or ceramic each year. Uncle Sam’s Medicare program is paying around $7 billion annually for all this work. But here’s a nasty revelation about knee replacements, in particular: Hospitals don’t know how much they cost.

In case you ever doubted the profit-seeking motive in these institutions’ practices, the Wall Street Journal reported some eyebrow-raising information on hospital pricing and costs, based on a Wisconsin facility’s rigorous efficiency study of knee replacements.

The procedure had risen in price by 3 percent a year for almost a decade, hitting a $50,000 cost per such surgery by 2016, including coverage for the expense of surgeons and anesthesiologists.

kaisertavr-300x175When big hospitals and their doctors jostle with competitors in smaller and medium-sized facilities over who gets to perform an important and booming kind of surgery, it’s not a pretty sight — nor might it be obvious with which institutions patients ought to side.

Phil Galewitz of the independent, nonpartisan Kaiser Health News Service does consumers a service with his reporting on recent bureaucratic brawling in Baltimore before federal regulators charged with determining where surgeons may replace leaky valves without open heart procedures.

As Galewitz explains, surgeons and medical device makers for a few years now have worked together to develop a new way to fix defective valves for tens of thousands of patients too frail to undergo open heart operations that, among other things, involve getting their chests cracked open. Surgeons, instead, can snake a catheter through patients’ blood vessels, into their heart, and shove aside the leaking valve, replacing it with a new model.

kprobes-300x167An innovation in medical treatment — which was supposed to offer more affordable, accessible, and even convenient care — instead may be getting swamped with safety problems that long have plagued hospitals and academic medical centers.

USA Today and Kaiser Health News Service deserve credit for digging into patients’ nightmares with specialized surgical centers, not only those performing “routine” procedures but also those handling increasingly longer, more complex, and difficult operations. The many surgeries, once the province only of big and well-staffed hospitals, put patients at risk, the newspaper reported, saying:

[Our] investigation found that surgery centers operate under such an uneven mix of rules across U.S. states that fatalities or serious injuries can result in no warning to government officials, much less to potential patients. The gaps in oversight enable centers hit with federal regulators’ toughest sanctions to keep operating, according to interviews, a review of hundreds of pages of court filings and government records obtained under open records laws. No rule stops a doctor exiled by a hospital for misconduct from opening a surgery center down the street.

Robots are the shiny new toys of surgery in American hospitals. They promise ultra-precise, tiny cuts that give patients faster healing and better outcomes. Wherever you live, your local TV news outlets have likely run uncritical, gee-whiz stories about hospitals and surgeons bringing in these robots, featuring glowing patient testimonials.

So what’s not to like? You need to watch a new documentary airing Friday night on Netflix to get the other side of the story, and there’s plenty. And also about other medical devices that promise much but deliver more pain than benefit.

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