Are incentive spirometers useless?

Has this ever happened to you? You walk into a patient's room on postoperative day 1 and find the incentive spirometer still in its plastic wrap. And it's on a windowsill 10 feet from the patient's bed.

Here's another question. Does it matter?

A friend just had a 4-vessel CABG at a major academic center. Despite a lack of evidence that incentive spirometers are effective, he was told to use one in the hospital and to use it hourly at home which he has faithfully done.

That’s right. The effectiveness of incentive spirometry in postoperative cardiac and abdominal surgery patients has never been proven.

Three Cochrane Reviews (2007, 2012, 2014) have been done. In the 2014 review analyzing 12 studies with 1834 subjects who underwent abdominal surgery, the authors noted problems with study methodologies and lack of data on compliance with the use of spirometers. For preventing pulmonary complications, spirometry was not superior to deep breathing exercises or no respiratory intervention at all.

About that $39.35 charge for holding a newborn baby

By now you've probably heard about the hospital that charged $39.35 for a woman who just had a cesarean section to hold her baby.

The baby's father posted a copy of the bill on Reddit, and it drew over 11,800 comments. The story was also widely circulated on Twitter.

At least one labor and delivery nurse on Reddit and a spokesperson for Utah Valley Hospital where the baby was born stated that the charge was not for holding the baby, but rather it was because an extra nurse had to be brought into the room to watch the baby while the first nurse took care of the mother.

I'm not buying it. The only way to justify charging for the presence of a second nurse would be if she had to be called in from home. If the nurse was already in the hospital which I'm sure she was, the five or so minutes that it would take for her to stand by while the mother holds the baby would surely not take her away from the routine duties of a labor and delivery nurse.

This is especially true for Utah Valley Hospital which delivers about 3600 babies per year. Only about 30% of them or about three per day are born by cesarean section.

And who says a second nurse is even required? Most cesarean sections are performed under epidural or spinal anesthesia. The mothers are awake and perfectly capable of holding a newborn child. An anesthesiologist or nurse anesthetist is always in the room and is primarily responsible for caring for the mother anyway.

Like most hospital charges, the $39.35 figure appears to be the product of some bean counter's imagination. Why $39.35? Why not $39.95 or $68.87?

Apparently Intermountain Healthcare (a system which includes Utah Valley Hospital) has some other interesting billing practices. This is what one Reddit commenter had to say:

Hey, I know this world: we had to pay $700 for our son to stay in my wife's room. Here, I'll explain: my wife was billed $700 per night after her c-section, and my son was also billed $700 per night for his room.

Here's the kicker: they shared the same room!! So, I thought it was a mistake, right? So I called the horrible people at Intermountain Healthcare to point out that they had billed two charges for the same room. They're [sic] response? "We bill each patient for the full room charge." Yep, they billed my wife $700 for her room, and my baby $700 for the same room. They also doubled the nurse charges (even though, again, my baby didn't have his own nurses.)

He refused to pay, and the bill was sent to a collection agency.

Congratulations on the birth of your son.

Ethics and uterus transplants

Guest post by @UtilityKnife1

It’s easy to be negative. Given that the return in clinical outcomes relative to cost is too often poor for any clinical innovation (e.g., robotic surgery, home uterine monitoring, bone marrow transplants for breast cancer, etc.), it is a reasonable bet anything new in medicine is lemon. Innovation and technology within health care account for significant portions of per capita growth in health spending among Americans over the last 50 years. In some cases this spending has resulted in real improvements in health outcomes but this is not the case in many settings. So what about spending to transplant a uterus?

Uterine transplant is not new. The procedure has been done in animals, has even resulted in live births among humans, and is not conceptually complicated. A donor uterus including the cervix is sutured to the top of the vagina, and the blood supply is hooked up. Since there is no nervous input into the transplant, it will not contract in any sort of coordinated way and delivery of any fetus must be via cesarean section. Similarly, fetal movements will not be felt in the same way. Any “experience” of pregnancy from a transplanted uterus is thus not totally natural (note the recent patient who underwent uterus transplantation at The Cleveland Clinic said “experiencing” pregnancy was an important reason behind her decision to pursue this surgery).

The reason to perform a uterine transplant is most easy to understand in those settings where a woman is born without a uterus (although in these cases they should have ovaries). Getting pregnant with a transplanted uterus requires in vitro fertilization. The organ recipient will have to take anti-rejection drugs, and when pregnancy is no longer desired, the uterus should be removed to avoid prolonged exposure to these drugs. None of this is an ordinary part of the pregnancy experience to say nothing of the implications for the fetus.

Health Care and the $20,000 Bruise: A different take

Twitter is buzzing about yet another medical billing horror story. This one appeared in the Wall Street Journal and was written by Eric Michael David who is an MD PhD JD and an officer at a biotech company.

He saw a large, swollen bruise on his three-year-old son's head several days after falling off his scooter. Other than the bruise, no other abnormalities were mentioned. He took the boy to "one of the top pediatric emergency rooms in the country" to have a CT scan done. It showed "a small, 11-day-old bleed inside his head, which was healing, and insignificant."

Dr. David received a bill for $20,000, $17,000 of which had been paid by his insurance company. He was responsible for the remaining $3000.

He noted a $10,000 charge for a trauma team activation which he said never happened. After a lengthy series of exchanges with the hospital's billing department and Dr. David having to prove that a trauma team activation was unwarranted and not permitted by certain regulations, he was able to have the charge rescinded.

The essay went on for some 1200 words listing the steps that he went through. He correctly described what a mess American healthcare delivery is and why as long as overuse and upcoding are rewarded, the Affordable Care Act will not fix it.

Dr. David was right to contest the $10,000 charge for a trauma team activation that wasn't indicated and didn't even occur.

What he didn't address was this.

Why would a doctor who said that he had "served on trauma teams in two of the busiest hospitals in New York City" feel the need to take his apparently asymptomatic son with an 11-day-old injury to an emergency room for a CT scan?

Doesn't this imply overuse of a different type?

Secondary questions:

Did anyone bring up the issue of radiation from the CT scan?
Did the docs in the ED think a CT scan was necessary?
"Inside his head" is a rather odd phrase. Does it mean intracranial? Intracerebral?
Was "one of the top pediatric emergency rooms in the country" the only option or could this asymptomatic boy have been seen in a doctor's office?
Why is the charge for a trauma team activation $10,000?

Just how screwed up is the US medical system?

Let me count the ways.

Here are three recent stories that highlight what's wrong with our medical system.

An in-depth report by the Tampa Bay Times found that hospitals in Florida are charging exorbitant fees for patients arriving at trauma centers. It led with an account of a patient who spent 40 minutes in a Fort Pierce trauma center before being transferred to another institution for a higher level of care. After some diagnostic tests were done, he was on his way. The tab for the 40 minutes? $32,727.

The Times found that the average charge for a trauma center activation was over $10,000 and the highest was $33,000. For-profit hospitals tended to charge the most. These charges were billed regardless of nature of the injuries, be they minor cuts or abrasions. And as is customary today, the uninsured were charged the full amounts.

Hospital administrators admitted that the charges were based on what other hospitals charged and had no relationship to what resources were used. The fees did not include bills for physician services, which were separate.

A lawyer tries (unsuccessfully) to take down Skeptical Scalpel

A trial lawyer named Max Kennerly has taken issue with a piece I wrote called "Can defensive medicine ever be stopped?" It appeared last week on KevinMD.

On his blog, he he says defensive medicine is a "myth" and accuses me of many wrongs, too numerous to detail here.

I will address a few of them.

He read my post but apparently did so selectively. He failed to note that I agreed with him that tort reform did not reduce the cost of medical care in states that have enacted it. This was documented by a paper from the National Center for Policy Analysis which I cited.

He went on to criticize three brief examples of defensive medicine that I mentioned in my post—about abdominal pain, a wound infection after colon surgery, and chest pain.

Mr. Kennerly writes, "a young girl with lower abdominal pain gets an ultrasound for appendicitis (among the least invasive, least expensive, and most helpful tests in history — remember this funny GE ad for their portable ultrasound?)."

Do more hospital resources equal better care?

For surgical patients, the answer is "Yes."

A recent study from England found that mortality rates for patients admitted with high-risk general surgery diagnoses were significantly lower in National Health Service Trust hospitals that used more CT scans and ultrasounds and had more ICU beds.

During the first decade of this century, nearly 368,000 patients were admitted as emergencies to English hospitals with surgical diagnoses carrying mortality rates in excess of 5%.

The diseases were bowel obstruction, liver/biliary conditions, hernias with obstruction or gangrene, peritonitis, gastrointestinal ulcers, perforated diverticulitis, bowel ischemia and miscellaneous diagnoses.

The 30-day risk-adjusted in-hospital mortality rate for the eight illnesses was 15.5% with a range of 9.2% in low-mortality hospital trusts (LMHTs) to 18.2% in high mortality hospital trusts (HMHTs). An operation was performed in 37.4% of patients, and 14.9% were readmitted within 28 days.

Three factors significantly differentiated LMHTs from HMHTs:

LMHTs had 20 ICU beds per 1000 beds vs. 14 for HMHTs, p = 0.017.

LMHTs performed 24.6 CT scans per bed per year vs. 17.2 for HMHTs, p < 0.001.

LMHTs performed 42.5 ultrasounds per bed per year vs. 30 for HMHTs, p < 0.001.

Some limitations of the study included the fact that it was based on administrative data. There was no way to determine if the increased use of imaging or availability of ICU beds had a direct effect on patients admitted with emergency surgical diagnoses. Also, variables such as delays in surgery or competence of surgeons could not be investigated.

Despite its limitations, this study is provocative.

No doubt the HMHT hospitals, which have fewer ICU beds and perform fewer imaging studies, are not as expensive.

But the study suggests that if you have the misfortune to arrive at an HMHT hospital with one of the surgical diagnoses listed above, you may have twice the chance of dying than if you had gone to an LMHT hospital that utilizes more resources.

This study is supported by a Viewpoint article in October's JAMA Surgery which looked at two studies of postoperative care in the UK and Europe. In both papers, many seriously ill postoperative patients did not receive appropriate levels of critical care. "Among patients who died during hospitalization after major surgical procedures in the United Kingdom in 2001, approximately 8.5% were admitted to an ICU at some point in their hospital stay. During the same period in the United States, this figure was 7 times greater, 61%."

In the European study, only 5% of surgery patients had planned admissions to intensive care, and 75% of those who died postop did not spend any time in an ICU.

The authors added, "in efforts to achieve good surgical outcomes, there really may be no free lunch: tradeoffs between cost and quality are inherent to the contemporary delivery of intraoperative and postoperative care."

What do you think?

Robotic surgery controversies simmer

I'm involved in a protracted and good-natured (I hope) debate about the merits of robotic surgery with a University of Pittsburgh urologist named Ben Davies. Today he tweeted the following (with translation for the Twitter averse):

“I would love for a $ISRG [stock symbol for Intuitive, makers of the robot] MD hater (like @Skepticscalpel) to actually watch 10 open RRPs [radical retropubic prostatectomies] then watch a 10 robotic RRP. Call me with results”

Dr. Davies is a rabid proponent of robotic prostatectomy and by his own admission, is pretty good at it.

I will admit that robotic surgery may indeed be better than open or standard laparoscopic prostatectomy. There is a lot of level 3 evidence to suggest that.

However, a PubMed search today fails to reveal any randomized trials of robotic vs. open or laparoscopic prostatectomy. All research on this subject has been retrospective with the potential flaws associated with that type of study, selection bias, unknown confounding variables, unblinded authors, etc.

In Australia, randomized study of sorts is in progress comparing 200 robotic prostatectomies done by a single surgeon to 200 open prostatectomies done by a different surgeon. A search of ClinicalTrials.gov yields only one other prospective trial in progress. It is a “medico-economic” one from France. There is a trial about whether or not a drain should be used in robotic prostatectomy which assumes that the issue of whether robotic is better than open or standard laparoscopic is settled.

Dr. Davies has a rather narrow view. Although in his field robotic surgery may prove to be better, there is not even anecdotal evidence that it results in improved outcomes for any other type of surgery. Two major gynecologic organizations have recently issued position papers stating that robotic hysterectomy is not indicated for benign disease.

A number of unusual and often devastating complications of robotic surgery are surfacing, which has prompted one state, Massachusetts, to issue an advisory to hospitals.

Defenders of the robot say it's not the technology itself but rather the surgeons who are at fault.

However, the well-documented intense marketing of the robot by its manufacturer and by hospitals attempting to gain market share is pushing surgeons to adopt the method to stay competitive. The amount of training provided may be inadequate and the learning curve for most procedures is unknown but presumed to be long.

So we have a decidedly more expensive technology which even in its possibly most likely area of success, radical prostatectomy, has never been proven more effective in a well-designed prospective study.

I'm afraid I'm going to have to keep pushing on this.

By the way, I appreciate the offer to watch 20 prostatectomies, but must it be 20? How about 4?

Wide disparity found in hospital charges for appendicitis. Why?

If you wonder why hospitals are under fire for outrageous and often baffling accounting practices, look no further than a brief paper published last month in Archives of Internal Medicine.

 

Hospital charges for straightforward appendectomies done for acute appendicitis in California in 2009 were examined with the following inclusion criteria:

• Patients between the ages of 18 and 59
• Hospital stays fewer than 4 days
• Discharged home

For the more than 19,000 records reviewed, the median hospital charge was $33,611 with a low of $1,529 and a high of $182,955. Not included in the article but mentioned in news stories about the paper were more details about the care of the two patients at the extremes of charges.

From the Huffington Post: “The costliest bill, totaling $182,955, involved a woman who also had cancer. She was treated at a hospital in California's Silicon Valley. Her bill didn't show any cancer-related treatment. The smallest bill, $1,529, involved a patient who had her appendix removed in rural Northern California. Otherwise, the cases were similar: Both patients were hospitalized for one day, had minimally invasive surgery, and had similar numbers of procedures and tests on their bills.”

A California Healthline story about this clarifies the issue. It said,“Dave Glyer, CFO for Community Memorial Health System, said that the study ‘assumed that hospital charges matter when they don't,’ making it ‘completely off base.’ He said that insured patients pay rates negotiated by health insurers and that certain uninsured patients are aided by assistance programs.”

It’s all clear to me now. Hospital charges don’t matter.

What if you have no insurance and are not one of the “certain uninsured patients” who are aided by assistance programs? You are on the hook for the entire bill unless you can negotiate too.

What’s not clear is how the median hospital charge for a simple procedure such as an appendectomy can be $36,611 with such a large variation. 

May we see an itemized bill for the $182,955 please?

I Missed My Calling: Hospital Execs’ Pay Astronomical

This is probably not news to many but according to data recently published by the Connecticut Health I-Team, hospital executives are being paid handsomely .

Figures from 2009-10 reveal that 18 executives in Connecticut, a state with only 30 hospitals, made over $1 million per year.

Some of these figures include retirement packages. The top earner was the outgoing president of Hartford Hospital, who made nearly $7 million, with “all but $1.1 million of it nontaxable and retirement benefits.”

Below is a table from the Connecticut Health I-Team showing the top 15 highest paid executives.

Some of the hospitals, Yale-New Haven, St. Raphael's and Hartford, are large. Most are between 300-400 beds, but #13 New Milford is only 85 beds.

I realize that hospital executives have a lot of responsibility, but usually when they make a mistake, no one dies. I doubt they are sued very often either.

When I am reincarnated, I thought I wanted to be a weatherman [See my blog about this here] or maybe a consultant (both jobs with good pay and no accountability), but perhaps hospital executive is the best choice.

Oh, and how’s your retirement package looking these days?

[This blog appeared on Sermo yesterday and 95% of doctors who voted felt that hospital execs were paid too much (surprise) and only 13% of doctors felt that their retirement situation was "all set."]

Radioactive man? Milford resident pulled over by state police

A few days ago, a 42-year-old man was stopped by a state policeman because radiation coming from his vehicle was detected by a device in the patrol car. Earlier that day, he had undergone a cardiac stress test which involved the injection of a small amount of radioactive isotope into his body. He was released when he produced a doctor’s note stating he had undergone the test. [Full story here.]

Two things make this story interesting.

One, the report reveals the fact that many police cars have radiation detectors that are so sensitive that a man emitting a small amount of radiation while driving could be fingered as a possible terrorist. Despite my being a news junkie, I did not know that such detectors were deployed. Did you?

Now the terrorists know too. What is to stop them from bringing a nuclear weapon into a city now that they are aware of the existence of these detectors and that a note from a doctor can get one off the hook?

The second interesting point involves the stress test. The story says the man had what seems to have been a transient hypertension. There was no mention of any cardiac symptoms or a family history of heart disease. The man is employed as a fireman, a strenuous occupation.

Why was a nuclear stress test ordered?

I am a mere, “non-cognitive” surgeon, but I believe that an asymptomatic 42-year-old fireman with hypertension, episodic or not, does not need a cardiac stress test.

Do you wonder why we spend so much on health care in the United States?

Robots attack America, but Canada not so much

As of December 2011, 1548 surgical robots have been sold and installed in the United States as opposed to 16 in Canada.

The estimated population of the U.S is 313,388,000 and for Canada, 34,764, 600.

Canada has a population that is 11.1% of the U.S. population but Canada has only about 1% as many robots. Or put another way, Canada has 1 surgical robot for every 97 robots in the U.S.

California’s population is 37,691,912, which is about 3 million more than the population of Canada, but California, with 114 robots, has seven times as many robots as Canada.

Here are some more numbers.

Price of the surgical robot: $1.0-2.3 million
Cost of instruments and accessories per procedure: $1300-2200
Annual service agreement: $100,000-170,000 per year.

As the saying goes, “You do the math.”

Data and figures available here.

Medical school tuition. Follow the money?

You may have missed this New York Times story from the other day. For several years, St. George’s University Medical School has been paying New York City’s public hospitals to teach its third- and fourth-year students. Now the school has established a scholarship fund that it will use to try to entice its students to train as primary care physicians and work in the city hospital system.

St. George’s also is offering the public hospitals more money if they will allow more St. George’s students to do their clerkships at those institutions.

So, you say, what’s the problem? It seems that New York City’s medical schools are upset about all this.

Here’s an excerpt from the Times article: “The deal seemed likely to increase friction with the New York City area’s medical schools, which have already complained that St. George’s is squeezing out their own students because it is willing to pay for clinical training. That training has traditionally been perceived as part of the mission of teaching hospitals, to be offered without charge.”

To clarify this. Medical schools like Cornell, Columbia, New York University and Mount Sinai must farm students out to other hospitals because their main medical school hospitals cannot provide enough clinical material for the number of students they have in each class. These venerable schools, with tuitions & fees of nearly $50,000/year, do not pay a single penny to the affiliated hospitals or their teaching physicians. In fact, the hospitals actually pay for the privilege. It’s about the prestige.

We are talking about 50% of a medical student’s tuition over four years. Let’s do some math. Let’s say 150 students at $50,000/year. That’s $7,500,000/year or $15,000,000 for the two years. That does not count the fees that the affiliated hospitals pay the schools.

Note please that this situation is not limited to New York City. To the best of my knowledge, almost all U.S. medical schools have similar arrangements with affiliated hospitals.

A recent editorial in JAMA called for shortening the length of medical school by a year. Somehow I don’t see that happening soon.

Question: Where does that tuition money go?