New ‘mini’ surgeries offer little over original

New ‘mini’ surgeries offer little over original

From a January 31, 2011 Health Day news item by Lynn Peeples

Single Incision Laparscopic Surgery 3

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NEW YORK (Reuters Health) – A new surgical technique that involves “mini” incisions may not offer many advantages over the already minimally invasive standard, suggests a new review of studies comparing the two types of laparoscopic gallbladder surgeries.

“To be honest, it is really hard to improve on conventional laparoscopic,” senior researcher Dr. Shiva Jayaraman of the University of Toronto told Reuters Health in an e-mail.

The surgical removal of the gallbladder is primarily performed to treat gallstones. The standard “closed” procedure — so called because the abdomen doesn’t need to be opened with a large incision — debuted in 1987. It’s already an improvement over earlier surgeries that left patients in greater pain and with larger scars

But a desire for even better cosmetic results has led to an increasing push toward surgical options that are less and less invasive, said Jayaraman.

To see if the newer options are worthwhile for patients, he and his colleagues looked to the literature for studies that compared conventional laparoscopy in gallbladder surgery to the newer, more cosmetically friendly approach: mini-laparoscopy.

The team pulled together 18 studies conducted between 1999 and 2007, including a total of more than 1,500 patients.

They found that the odds of a surgery technique failing — and being completed by a different procedure — were more than twice as high for a patient undergoing mini-laparoscopy compared to the conventional version: 10 percent versus 4 percent.

However, while failed conventional laparoscopic surgeries are always converted to open procedures, mini-laparoscopies could simply transition into conventional laparoscopies.

This higher failure rate of the mini-laparoscopy might also be reflecting the newness of the procedure to surgeons, and the difficulties they may have learning it.

The smaller cuts and miniature tools involved in mini-laparoscopy did provide somewhat better cosmetic results. A month after the surgery, patients gave their scars an average rating of one on a scale of one to ten, while the average score in the conventional group was a three.

Most patients undergoing either conventional or mini-laparoscopy to remove their gallbladder go home the same day as their surgery, and return to work within four to six weeks. Mini-laparoscopy patients in Jayaraman’s study returned to their normal activities slightly sooner than the conventional laparoscopy patients, report the researchers in the Annals of Surgery.***

“That may represent a cost-savings to society from less work days lost,” noted Jayaraman.

The length of the surgery and risks of complications, including severe bleeding and infections, were similar between the groups. No deaths occurred from either surgery.

The researchers note that specialized equipment could put a slightly higher price tag on mini-laparoscopy, although the reusability of the instruments should keep costs comparable. Conventional laparoscopy runs around $7,000.

Jayaraman’s team suggests that more research is needed to clarify the costs and benefits of mini-laparoscopy, and if certain variations on the technique are better than others.

“Conventional laparoscopic gallbladder surgery is very successful at providing minimally-invasive, cosmetic, and effective treatment of diseases of the gallbladder,” said Jayaraman.

“In the end, both of these approaches are very safe,” he added. “If cosmetics is very important to a patient, then a ‘mini’ approach might be a good option.”

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Odds of Quitting Smoking May Be Clear on Scans

Odds of Quitting Smoking May Be Clear on Scans

Activity in front part of brain can predict behavior, researchers say

From the January 31, 2011 Health Day news item by Robert Preidt

MONDAY, Jan. 31 (HealthDay News) — Brain scans can predict a smoker’s chances of being able to quit, according to a new study.

It included 28 heavy smokers recruited from a smoking cessation program. Functional MRI was used to monitor the participants’ brain activity as they watched television ads meant to help people quit smoking.

The researchers contacted the participants one month later and found that they were smoking an average of five cigarettes a day, compared with an average of 21 a day at the start of the study.

But there was considerable variation in how successful individual participants were in reducing their smoking. The researchers found that a reaction in an area of the brain, called the medial prefrontal cortex, while watching the quit-smoking ads was linked to reductions in smoking during the month after the brain scan.

Previous research by the same team suggested that activity in the prefrontal cortex is predictive of behavior change.

In the new study, published in the current issue of Health Psychology,** “we targeted smokers who were already taking action to quit, and we found that neural activity can predict behavior change, above and beyond people’s own assessment of how likely they are to succeed,” study author Emily Falk, director of the Communication Neuroscience Laboratory at the University of Michigan Institute for Social Research and Department of Communication Studies, said in a university news release.

“These results bring us one step closer to the ability to use functional magnetic resonance imaging to select the messages that are most likely to affect behavior change both at the individual and population levels,” Falk said. “It seems that our brain activity may provide information that introspection does not.”

SOURCE: University of Michigan Institute for Social Research, news release, Jan. 31, 2011

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Hospital spending may pay off for some conditions

Hospital spending may pay off for some conditions

 

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From the January 31, 2011 Reuters news item by Genevra Pittman

NEW YORK (Reuters Health) — Hospitals that spend more money treating patients with acute illnesses may be better at keeping those patients alive, suggests a new study.

The finding is in line with recent research, but it challenges an assumption held by many policymakers that hospitals can be forced to spend less without significant consequences for patient health.

“The traditional literature on spending is that quality isn’t higher (in hospitals that spend more),” said Mary Beth Landrum, who studies health care policy at Harvard Medical School and did not participate in the research. But, “when you start looking at specific groups of patients, you may actually find that there is some benefit for some of the increased spending,” she told Reuters Health.

The current study included people treated for heart attack, heart failure, stroke, hip fracture, pneumonia and serious stomach bleeding. Researchers led by Dr. John Romley of the University of Southern California looked at records for more than 2.5 million of these patients admitted to California hospitals during the years 1999 through 2008.

Romley’s team calculated how likely the patients were to survive their hospital stay, then compared those numbers to how much money the hospitals typically spent to treat the conditions in question.

For each of the six conditions, they found the highest-spending hospitals spent more than three times as much as the lowest-spenders.

Those hospitals ranking in the bottom-fifth for expenditures on heart failure and hip fracture, for instance, averaged $5,100 caring for a heart failure patient and $8,000 treating a hip fracture. The top-fifth-spending hospitals for the same conditions averaged $19,000 on a heart failure patient and $29,000 on one with hip fracture.

For each of the conditions examined higher spending was also linked to higher patient survival.

Patients treated at the highest-spending hospitals for heart failure, for example, had a 25 percent smaller chance of dying while they were there than patients treated at lowest-spending hospitals.

During the second half of the study (2004 to 2008) the mortality differences seen with high or low spending on hip fracture patients were extremely small, but overall the researchers say the numbers show money does seem to make a difference in survival.

If all patients in the study who were treated at the lowest-spending hospitals had instead been treated at the highest-spending facilities, the authors calculated that about 18,000 fewer people would have died during the first half of the study, and 14,000 fewer during the second half.

What exactly high-spending hospitals are doing to save lives is not completely clear.

Previous research suggests hospitals that spend more money don’t have fewer complications during care — they may just be more prepared to notice and address complications quickly, said Dr. Amber Barnato, who studies end-of-life care at the University of Pittsburgh and was not involved in the current study.

“There must be something about paying close attention, which might mean more staff, more eyes on the patients,” Barnato told Reuters Health. In addition, she said, “there might be a greater willingness to do intensive things to rescue someone, like put them on a breathing machine (or) put them in the (intensive care unit).”

The findings, published in the Annals of Internal Medicine,*** are in line with a few recent studies, including one showing that hospitals where heart failure is treated frequently give better care but also spend more money per patient than hospitals that treat the condition less frequently.

Together such studies challenge the assumption that much of hospital spending is inefficient and that hospitals could perform just as well with smaller budgets, researchers say.

That debate has been an important part of the controversy surrounding new health care reform legislation, which will cut back Medicare spending on hospitals, Romley noted.

“If the results are real … that would suggest these reductions across the board in hospital spending might lead to worse outcomes for some patients,” Romley told Reuters Health. That doesn’t mean cuts wouldn’t still be cost-effective, if money elsewhere could better improve public health. But, he added, “it is important to understand the trade-offs.”

The new findings need to become part of the national debate on how best to allocate money to protect the health of the general population — but they don’t change the fact that health care funding isn’t in unlimited supply, Barnato said.

Even if patients with serious illnesses such as the ones examined in the current study do make it out of the hospital alive, many die within a year, and some of the money used on end-of-life care might save more lives if it was used to address preventable childhood diseases or obesity, for example, she said.

“A hospital that spends more money can have slightly better quality or safety,” Barnato explained, “and that spending might still not result in better population health.”

SOURCE: http://bit.ly/an7XRm Annals of Internal Medicine, online January 31, 2011.

 

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Landmark Initiative to Reduce Healthcare-Associated Infections Cuts Deaths Among Medicare Patients in Michigan Intensive Care Units

Landmark Initiative to Reduce Healthcare-Associated Infections Cuts Deaths Among Medicare Patients in Michigan Intensive Care Units

From the January 31, 2011 AHRQ (Agency for Healthcare Research and Quality) press release

Older Americans who were treated in Michigan intensive care units (ICUs) saw larger decreases in their likelihood of dying while hospitalized than similar ICU patients in other Midwestern hospitals, according to a new study evaluating an innovative quality improvement initiative funded by HHS’ Agency for Healthcare Research and Quality (AHRQ). The initiative, known as the Keystone Project, targeted ways to reduce the number of healthcare-associated infections (HAIs). Previous research has shown that targeted quality improvement programs can reduce HAI rates. This study, “Impact of a Statewide Intensive Care Unit Quality Improvement Initiative on Hospital Mortality and Length of Stay: Retrospective Comparative Analysis,” published in today’s British Medical Journal, is the first to link these programs to reduced death rates. “This study gives us assurance that investing in large-scale, evidence-based quality improvement programs can save lives—the most important outcome for patients and doctors,” said AHRQ Director Carolyn M. Clancy, M.D. “AHRQ and others have already initiated work to expand this project nationwide to other ICUs across the country.” Researchers led by Allison Lipitz-Snyderman, Ph.D., of The Johns Hopkins Bloomberg School of Public Health, analyzed Medicare data for ICU patients in Michigan hospitals and 364 hospitals in 11 other Midwestern states. They looked at data before the project was initiated, while it was being phased in, and up to 22 months after implementation. The researchers found that overall a person’s chance of dying decreased by about 24 percent in Michigan after the program was implemented compared to only 16 percent in surrounding Midwestern states where the program was not implemented. “We knew that when we applied safety science principles to the delivery of health care, we would dramatically reduce infections in intensive care units, and now we know we are also saving lives,” says Peter J. Pronovost, M.D., Ph.D., a professor of anesthesiology and critical care medicine at The Johns Hopkins University School of Medicine. Dr. Pronovost led development of the AHRQ-sponsored Keystone Intensive Care Unit Project and implemented it in Michigan hospitals with the help of the Michigan Health and Hospital Association. “These results are very exciting, and further research should be done to address other important issues impacting the safety and quality of patient care,” added Dr. Lipitz-Snyderman. The Keystone Project uses a comprehensive approach that includes promoting a culture of patient safety, improving communication among ICU staff teams, and implementing practices based on guidelines by the Centers for Disease Control and Prevention (CDC), such as checklists and hand washing, to reduce rates of catheter-related bloodstream infections and ventilator-associated pneumonia. AHRQ continues to support the Keystone Project through a contract with the Health Research & Educational Trust, an affiliate of the American Hospital Association, by reaching more hospitals and other settings in addition to ICUs and applying the approach to various HAIs. For AHRQ’s recently funded HAI projects, go to http://www.ahrq.gov/qual/haify10.htm. According to the CDC, HAIs are one of the most common complications of hospital care, accounting for an estimated 1.7 million infections, and 99,000 associated deaths in 2002. These infections are responsible for $28 billion to $34 billion in preventable health care expenses every year. Infectious agents, such as bacteria, found in health care settings can cause patients to develop HAIs when they have surgery or require central lines or urinary tract catheters. The Keystone Project is part of a Department-wide effort to address HAIs, as outlined in the HHS Action Plan to Prevent Healthcare-Associated Infections (http://www.hhs.gov/ash/initiatives/hai/index.html). Partners across HHS, including AHRQ, CDC, the Centers for Medicare & Medicaid Services, and National Institutes of Health, are working together to achieve the goals of the Action Plan. For more information, please contact AHRQ Public Affairs: (301) 427-1864 or (301) 427-1855. Use Twitter to get AHRQ news updates:http://www.twitter.com/ahrqnews/

Additional articles about this news release

• Safety checklist use yields 10 percent drop in hospital deaths (Science Blog)
• Program reduces serious hospital infections – report (Reuters)

Articles about related studies

• Study finds MRSA screening saves hospitals money
• Private room intensive care unites associated with lower infection rates
• More doctors must join nurses, administrators in leading efforts to improve patient safety, outcomes