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The CMG Voice

Doctors Disagree About Whether Steroid Injections Increase Cartilage Loss In Knee Arthritis.

Posted Tuesday, September 26, 2017 by Gene Moen

It’s a common scenario. If you have chronic knee pain but want to avoid the cost and risk of knee surgery, you have periodic injections of corticosteroids. However, a recent study published in the May 16 issue of the Journal of the American Medical Association (JAMA) found that such injections can increase cartilage loss of the course of two years with minimal clinical benefit.

The study was a randomized controlled trial in which researchers compared outcomes between two groups of 70 patients. The average age was 58, and with symptomatic knee osteoarthritis identified through ultrasounds. The subjects underwent MRIs at the beginning and end of the study to see the effects on cartilage. Those who received the injections lost about two times as much cartilage as those in the placebo category (the latter received only saline injections).

Many physicians criticized the study and its findings. One physician commented that the measurable loss of cartilage over a 20 year period would be minimal (the thickness of a fingernail) and should not be a basis for discontinuing such injections. “If the knee is already badly damaged and the patient is not ready or safe for a total knee replacement there is a role for quarterly steroid injections.” Another physician wrote that he has given such injections for more than 20 years, and has thousands of patients who have had great improvement in their symptoms and ability to function.

The study was of quarterly injections given over two years, and one physician commented that this frequency of steroid injections exceeded the guidelines. “If I give you enough of anything it will make it appear dangerous. What’s next? Water can kill you, news at 11.” But yet another physician commented that steroid injections only provide temporary relief, and should not be given unless one wants to pay the price with cartilage damage over decades. He noted that veterinarians know that these injections should be avoided by anyone who wants to preserve their animal rather than replace them.

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Does A C-Section Mean Greater Hysterectomy Risks In The Future?

Posted Thursday, September 21, 2017 by Gene Moen

A large Danish study found that women who undergo C-sections are more likely to have future surgical complications from a hysterectomy. The study was published in JAMA Surgery. The conclusions were that there were higher rates of reoperation and other post-operative complications if a woman had a previous C-section.

The study authors hypothesized that a cesarean delivery resulted in more intra-abdominal adhesions or scarring, which “may complicate future surgery, leading to longer operating time and an increased risk of adverse events.” The adverse events included lower urinary tract injuries, increased need for blood transfusion, and readmission with 30 days. They noted that these same problems may arise in other types of pelvic and abdominal surgeries besides hysterectomies.

Examining the records of more than 7,600 women, the study found that about 12% of women who had cesarean sections before their hysterectomies had surgical complications within 30 days, including bleeding, infection, and perioperative lesions. There was a 30% increased risk of these complications for women who had two or more C-sections. One limitation of the study was noted: it did not control for obesity, and it only included women with a hysterectomy within 19 years of their first birth.

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What Does The “National Practitioner Data Bank” Have To Do With Your Case?

Posted Monday, September 18, 2017 by Gene Moen

In years past, there were stories about doctors who got in trouble in one state, and then moved on to the next, and then to the next, repeating their bad actions or negligent care. There was no way a hospital or insurance company could easily find out the history of a bad doctor. That is why the National Practitioner Data Bank (the “data bank”) was enacted into federal law. Now, every adverse action involving a doctor, whether payment of a malpractice claim or a state disciplinary action, must be reported to the data bank.

The public does not have access to the data bank, but hospitals, healthcare plans, licensing agencies, etc., can get information about past medical malpractice payments or other adverse actions affecting the doctor. So every doctor knows that, if he settles a claim — even for a nominal amount — that information will be accessed whenever he applies for admitting privileges at a new hospital or seeks liability insurance coverage from a new carrier.

What does this have to do with your medical malpractice claim? Almost all medical liability policies include a “consent to settle’ clause. That means the insurance company can’t even discuss settlement with your attorney unless the doctor consents to settlement. That is true even if the insurance company thinks there is liability and wants to settle to avoid additional costs and risks.

The doctor, on the other hand, knows that consenting to settlement will likely lead to some payment and therefore a notice to the data bank about the settlement. What used to be confidential, any settlement now is a “black mark” on the doctor’s record. Needless to say, this discourages the doctor from consenting to settlement.

Many policies have provisions allowing the insurance company to over-ride the doctor’s refusal to consent, but these are rarely utilized. No company wants to have a reputation that it puts its own interests ahead of its insured’s interests, because selling malpractice insurance is a competitive business. There is also some leeway in terms of whether a claim involves allegations of negligence against a particular doctor or whether it is an “institutional” claim against a hospital or clinic. For example, a failure to provide an adverse test result to a patient may be negligence on the part of the doctor, but may be largely a problem with a hospital’s policies and practices about how such results are handled.

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Recent federal investigation uncovers “numerous” patient safety issues at Swedish Cherry Hill

Posted Monday, September 11, 2017 by Tyler Goldberg-Hoss

In response to the Seattle Times articles in February examining Swedish’s neurosurgical department, the state Department of Health began investigating themselves. The DOH recently released its report, finding a number of problem areas that must be solved if Swedish is to remain Medicare eligible.

Such concerns included Swedish’s failure to properly define the role and scope of work performed by medical fellows, failure to address behavioral issues, failure to document which surgical tasks were done by fellows instead of the attending physician, failure to track when the attending was in the operating room, and failure to listen to staff concerns about patient safety within the neurosurgical department.

Other allegations were not substantiated by the DOH investigation. In particular, the investigation did not find that primary surgeons were unavailable for critical portions of surgeries, and that nursing staffing levels were unsafe.

To Swedish’s credit, many of these issues have been addressed prior to this report being released. In particular, Swedish began new policies of largely banning the practice of overlapping surgeries, and monitoring when surgeons were in the operating room.

Mike Baker at the Times has done a phenomenal job, increasing patient safety for everyone in the state. As a result of his investigative work surrounding Swedish, he received the WSAJ Excellent in Journalism Award for 2017.

You can read more about the DOH report here:

Investigators find ‘numerous’ issues related to patient safety at Swedish’s Cherry Hill site

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New study highlights the danger in delaying emergent surgery

Posted Friday, September 8, 2017 by Tyler Goldberg-Hoss

“Emergent” is synonymous with the need for something to occur quickly. Whatever is “emergent” is also acute, pressing, critical, imperative.

In the context of a patient needing surgery, the word takes on even greater weight and importance. You hope and trust that if you or a loved one is in such a situation, whatever surgery is needed will happen right away. The implication is that if it doesn’t, something bad will happen.

Perhaps it didn’t take a study to confirm what may be obvious, but a new study does just that. Recently the results of a study looking at delays in urgent/emergent surgeries were published in the Canadian Medical Association Journal. The study looked particularly at delays at a hospital in Ottawa.

The study found that 19% of such surgeries were delayed, often due to unavailability of an operating room or staff. The study found that those patients had an increased risk of dying while in the hospital: 5% versus 3% of patients who didn’t have a delay in their surgery.

If hospitals and other health care providers didn’t need more of an incentive to reduce that number of delayed surgeries, the study also found that it cost more for the delayed surgery patients.

You can read the full study at the CMAJ website here:

Association of delay of urgent or emergency surgery with mortality and use of health care resources: a propensity score–matched observational cohort study

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