Mortality, costs higher for women with cardiovascular disease

HEART DISEASE SHOULD top the list of women’s health concerns. Women disproportionately fear dying from breast cancer compared to heart disease, dutifully scheduling annual mammography, oblivious to their cardiovascular risks. There is little demand by women and the medical community for an urgent agenda or a “march for the cure” for heart disease in women.

Cardiovascular disease (CVD) is the single most common cause of death in women and men. Despite widespread assumptions to the contrary, women have accounted for more than one-half of the almost 1 million deaths due to heart disease and stroke in the United States annually since 1984. Women, compared to men, especially those under the age of 50 years, experience higher rates of recurrent myocardial infarction, heart failure and mortality after a first myocardial infarction, and are more likely to be misdiagnosed or diagnosed late in the course of their illness.

Annual hospitalizations and mortality for heart failure and total CVD expenditures are greater for women than men. While mortality from cardiovascular diseases has significantly declined over the past three decades, women have not experienced the same reductions in death and disability as have men. This significant gender-related mortality gap persists due to a combination of low awareness, misconceptions by physicians and women, gender-based physiologic differences, and disparities in care.

While these data might initially appear discouraging, improving these measures represents a significant opportunity to improve women’s CVD outcomes as well reduce overall healthcare expenditures by providing optimal screening and preventive services, appropriate and accurate diagnostic tests and timely cardiac care.

LESS THERAPY FOR WOMEN

The underlying causes for these disparities are multifactorial and the solutions complex. Gender-based disparities in preventive, diagnostic and therapeutic interventions are present on multiple levels. Women receive fewer cardiac diagnostic evaluations and less intensive therapy, from preventive interventions, to revascularization procedures to aspirin prescriptions. Even after a diagnosis of heart disease, gender-based differences in provision of care are present.

Women hospitalized with myocardial infarction are more likely than men to be managed by generalists, rather than referred for cardiology consultation, and are less likely to be transferred from community hospitals to centers for advanced care—practices associated with poorer short-term outcomes.

Additionally, societal and individual misconceptions about cardiovascular risk and what a heart patient “looks like,” along with inadequate gender-specific research data on cardiovascular disease and risk factors, contribute to lower awareness and poorer outcomes. While women’s symptoms can sometimes be challenging to address, both women and their physicians can be too quick to attribute potential manifestations of cardiac disease to menopause or aging. It is important to counteract the widely held belief that women do not develop heart disease except at advanced ages by raising physicians’ “index of suspicion” for cardiovascular disease in women.

There is also a growing body of literature documenting important biologic gender differences in CVD that may impact clinical care delivery. There are obvious differences due to the effects of gonadal hormones. However, differences in symptoms, accuracy of diagnostic tests, response to therapy, prevalence and relative risk of cardiovascular risk factors, as well as social and behavioral issues have all been identified. It is not always apparent whether or not these differences warrant a variation in established practice.

Many early cardiovascular clinical trials routinely exclude women or make no effort to enroll women in sufficient numbers to draw gender-based conclusions. With few exceptions, women currently make up only 20% to 30% of participants in cardiovascular clinical trials. Even when women are included as research subjects, it is often difficult to determine their outcomes from published reports. Only a quarter of recent cardiovascular trial results published in major U.S. internal medicine and cardiology journals reported gender-specific outcomes.

The lack of relevant research in women has resulted in a substantial and persistent gender-based knowledge gap about everything from the symptoms of heart attack in women, to the risks and benefits of commonly used cardiovascular diagnostic tests and therapies. Better evidence from properly designed research studies can better serve women with CVD.

An important example is the National Heart, Lung and Blood Institute (NHLBI)-funded multi-center Women’s Ischemic Syndrome Evaluation (WISE) study of approximately 900 women who underwent coronary angiography for chest pain symptoms and a multitude of other investigations designed to better characterize ischemic heart disease in women. We have already learned a great deal from numerous WISE publications that have underscored the value of gender-specific research and fundamentally changed the understanding of chest pain, CVD risk factors, vascular function, hormone interactions and atherosclerosis in women.

Cardiovascular clinical trial design must include women in adequate numbers to provide gender-specific data, and that data must be analyzed and reported by gender.

Systemic contributions to differences in cardiovascular care for women also include physician practice and referral patterns. In the United States, many women receive all or most of their medical care from specialists in obstetrics and gynecology during their reproductive years and continue those relationships well past menopause, or until a significant non-gynecologic illness occurs. Traditionally, there has been a greater focus on reproductive and breast health than on other health risks, and less awareness and self efficacy among these specialists about early cardiovascular risk identification and treatment.

RISK FACTORS ON THE RISE

The rise in risk factor prevalence in younger women, especially smoking, obesity and diabetes, has led to a growing number of individuals at high risk who do not look like typical heart patients. Reducing women’s future burden of CVD will depend heavily on improved preventive measures which currently fall short of recommendations. Simply taking what has been proven effective, and widely and appropriately applying it to women, can markedly improve care and outcomes.

Critical to this effort is continued education about women’s cardiovascular risks, symptoms and the use of appropriate diagnostic tests and therapies.

The most recent guideline, published in 2007 by the American Heart Assn. and endorsed by multiple professional and patient organizations, has simplified the risk assessment and decision-making process for easier implementation in daily practice.

The guidelines encourage clinicians and patients to focus on reducing long-term, rather than 10-year CVD risk. With few exceptions, those therapies that have been shown efficacious in men also prevent CVD in women and should be recommended to women at risk.

Sharonne Hayes, MD, FACC, is the director of the Mayo Clinic Women’s Heart Clinic and associate professor of medicine for the Mayo Clinic College of Medicine.

OR Technology: A Glimpse Into The Future

As we move into 2010, a new wave of technology awaits us. Highly-developed health information technology (HIT)-driven systems and equipment are becoming the standard in many operating rooms (ORs), whether they are in a single-specialty ambulatory surgery centers (ASCs) or advanced surgical hospitals. It is important to stay up-to-date on these new technologies which not only reduce medical errors, but improve patient comfort and post discharge follow-up. The following case studies highlight this trend.

Enhancing Communication, Collaboration and Education: An Olympus Case Study

Three years after adopting integrated ENDOALPHA ORs, Penn State Hershey Medical Center is ready for more. As the only teaching hospital in central Pennsylvania, Penn State Milton S. Hershey Medical Center is one of the area’s largest healthcare providers. The hospital is equipped with 23 surgical suites and its department of surgery performs more than 19,000 procedures annually.

Staying Ahead of the Technology Curve

As industry trends move toward minimally invasive techniques, the hospital was quick to understand the benefits of integrated surgical suites as a way to stay competitive with the specialized technology demands of increasingly sophisticated procedures. “Several years ago, we realized we had a need for advanced, integrated technologies in our OR as we anticipated the convergence of laparoscopic and flexible endoscopic instrumentation,” says Randy Haluck, MD, professor of surgery and division chief for minimally invasive surgery and bariatrics. “We also recognized the need for a sophisticated system relative to data acquisition, storage, and transfer.”

Penn State Hershey began the process of integration in 2005, building three new Olympus ENDOALPHA surgical suites in 2006 and then converting two existing ORs to ENDOALPHAs the following year. The hospital anticipates completion of four more integrated ORs, for a total of 27 surgical rooms with one-third of them set up as state-of-the-art ENDOALPHAs this year.

Taking a Comprehensive Approach

True systems integration goes beyond the equipment and operating platform. It also takes into account the ergonomic design, workflow and technology optimization of each surgical suite. This means designing rooms with ceiling-mounted booms for holding imaging equipment and monitors off the floor, allowing for more efficient post-procedure clean-up and ergonomic positioning of monitors during the procedure. It means integrated equipment (scopes, imaging platforms, monitors, video and accessories) that work together and can be easily interchanged during a procedure. And it means a cohesive information management system for patient and procedural data, images, and audio that can be captured, stored, and retrieved from both inside and outside the sterile field. “We needed to have multiple surgical services using the same operating room, between general surgery, urology and minimally invasive GYN surgery,” says Gerald Harkins, MD, medical director for minimally invasive GYN surgery. “We’re all able to function in the ENDOALPHA laparoscopic suites, and it’s been a fantastic platform for that utilization.”

Experiencing the Installation Process

Olympus offers turnkey solutions, working with customers from start to finish on the design, construction and set-up of integrated operating and intervention rooms. “The flexibility of Olympus’ ENDOALPHA system means it can be easily customized to create a right-sized solution unique to each facility,” says David Alexander, Penn State Hershey’s Olympus integration consultant. “We were able to incorporate their legacy equipment along with their pre-existing video-conferencing system and streaming video package into their ENDOALPHA ORs to create one seamless solution. Hershey proved to be very knowledgeable, so it was a highly collaborative effort.”

Taking Centralized Control

The nerve center for each ENDOALPHA OR is a centralized control panel. With audio, video, data and images all controlled via a single touch screen, clinicians have the power to connect, communicate and collaborate with others outside the procedure room. Clinicians can also control surgical and room lighting, in-room observation cameras and all information and imaging systems without ever leaving the sterile field. To further enhance efficiency, the ENDOALPHA system provides preset capabilities so that monitors, lighting and all equipment can be custom-tailored to surgeon preferences and made available at the press of a button.

Communication, Collaboration, and Education

Penn State Hershey Medical Center’s custom-placed displays ensure all team members have the perfect view of live images. They regularly create video networks for sharing, collaboration and education from within and outside the hospital. “There’s no question that the Olympus system has dramatically changed how we teach in the OR,” says Peter Dillon, MD, chairman of Penn State Hershey’s surgery department and surgical director of perioperative services. “We’re now able to broadcast these procedures to first- and second-year medical students, exciting them about the wonders of surgery at a much earlier stage in their training. So it really has changed dramatically and in a very exciting fashion how we teach.” Haluck adds that it also gives the Penn State Hershey team a better way to collaborate with other physicians and share information with patients. “We can educate other physicians and record images for colleagues or bring them in when needed to confer and/or assist on a procedure. We are also able to show patients what their surgery was about and why they were having problems. That’s a great benefit to us, and certainly patients appreciate it as well.”

Interventional Radiology Breaks New Ground: A Skytron Case Study

Philips and Skytron have teamed up to help fully realize the promise of a hybrid angiography suite by implementing new cardiovascular solutions with the latest Allura Xper FD technology from Philips and state-of-the-art surgical lighting and boom technology from Skytron.

For more than a decade, Barry T. Katzen, MD, medical director of Baptist Cardiac and Vascular Institute (BCVI) in Miami, has pioneered the integration of surgical and interventional procedures. Katzen and his team continue to show that surgical procedures in an angiographic environment can be accomplished with the same degree of efficiency as in an OR.

“The specialties of interventional radiology and vascular surgery bring more to each other when we work together,” Katzen says. “Procedures that help drive this relationship include aneurysms of the thoracic aorta and abdominal aorta. Having an environment where we can use a surgical option allows us to think out of the box for individualized patient solutions.”

In 2008, Philips Healthcare and Skytron entered into a collaborative agreement to provide comprehensive, integrated solutions for the cardiovascular environment. Katzen seized the opportunity to refine the surroundings. Based on a well-coordinated plan from Philips and Skytron, a room at BCVI underwent a significant upgrade to enhance hybrid functionality.

“One of the great advantages of the new room design is it’s so spacious that we can all function effectively without being in each other’s way. Information can be transferred to the head of the bed — to the anesthesiologist — down to where we’re working very easily,” says James F. Benenati, MD, medical director of the peripheral vascular laboratory.

A Room That Works

BCVI’s surgical team appreciates the changes made. Katzen believes the upgrade has created a better environment for all involved. A recent experience demonstrated how the teams successfully combined surgical access with an interventional solution. A patient presented with critical narrowing of an artery to the brain and chest, and a narrowing of that same artery in the neck. “It was a very complex situation,” recalls Katzen, “but we combined our skills. The surgeons removed the plaque in the neck with an endarterectomy and we used that same access to go down and stent the chest.”

Installation With Minimal Impact

“We’re a busy lab and taking a room down for a period of time is always an inconvenience,” says Katzen. “The one thing everybody remarked upon was how fast this upgrade was accomplished.” In two and a half weeks, Philips and Skytron, working closely with the implementation team at BCVI, completed the staging and upgrade. The new room reflected the input of interventional radiologists, surgeons and anesthesiologists, with each group helping to define the clinical specifications to make it a multi-disciplinary environment.

OR Technology Update: A Steris Case Study

The epitome of surgical technology today is one OR in which surgeons can perform image-guided, catheter-based interventional procedures; minimally invasive endoscopic procedures; extremely precise robotic surgery; or full open surgery, depending on the case load or discoveries made in surgery. In this type of hybrid OR, integrated imaging, computerized patient information and live video routing technologies instantly display test results and critical real-time information on high-definition monitors in the sterile field. This allows surgeons and staff to ascertain the most timely and accurate diagnosis and treatment for the patient. It also helps them achieve the most flexible and effective uses of the room and optimize scheduling and utilization.

These are also the types of rooms in which medical leaders and pioneers train residents and other clinicians, develop new minimally invasive procedures, such as natural orifice trans-luminal endoscopic surgery (NOTES) and trans-catheter heart valve replacement and master new surgical devices.

These highly advanced rooms can incorporate advanced communications, connectivity, LED surgical lighting and high-definition visualization such as intra-operative fluoroscopy, intra-operative computerized tomography, magnetic resonance imaging, image-guided navigation, 3D software extrapolations of the imaging, robotics and many other technologies. Each of these tools are important in today’s hybrid OR, but when integrated correctly they form a seamless whole that is greater than the sum of its parts.

To accomplish this synergy, STERIS collaborates with leading manufacturers to design and install customized, integrated HD360°™ Hybrid ORs for healthcare facilities. STERIS project design managers configure STERIS’s open infrastructure Harmony® Lighting and Visualization systems, equipment management systems and advanced integration technologies with interoperative imaging, robotics, endoscopic and video technologies and more. The result is a suite that enables fully informed staff, highly efficient procedures, extremely flexible room use, successful surgeon recruitment, medical education, ongoing surgical innovation, leading edge robotic surgery, telemedicine, and new possibilities yet to be imagined.

OR Technology Update: A Berchtold Case Study

Problem

Before hybrid ORs existed, imaging and communications capabilities were not an option during cardiovascular and neurosurgery operations, resulting in patients getting diagnosed and treated in two different visits. Separate procedures and imaging consultation can be costlier for patients and surgeons, can result in additional stress, more down time and longer hospital stays for the patient, and are not conducive to emergencies that sometimes arise during surgery.

Solution

Combine minimally invasive and interventional surgical technologies with medical imaging and communications equipment in one operating room: the hybrid OR.

A growing trend involving endovascular procedures during cardiovascular and neurological surgeries requires equipment to accommodate open and closed procedures in the same room, even at the same time, although this is not necessarily planned from the start. The new hybrid OR model provides the surgeon flexibility in performing a variety of interventional, imaging and surgical services in one setting, eliminating the need to transfer the patient.

For example, two of the most popular hybrid ORs are for cardiovascular and neurosurgical procedures:

» Neurosurgical hybrid ORs can include magnetic resonance imaging (MRI); computed tomography (CT) and angiography equipment within a neurosurgical operating room.

»Cardiovascular hybrid ORs often features: Fixed ceiling- or floor-mounted C-arms, ultrasound and endoscopy equipment, coupled with cardiac catheter laboratories.

Because a hybrid OR is specifically designed for endovascular procedures, careful planning from the beginning can help to ensure all rooms are equipped with necessary tools. Some tips to consider while creating a specially designed hybrid OR include:

»Identify factors that are important to the hospital team, such as, should all equipment hanging from the ceiling (surgical arms, flat panel arms, etc.) be able to cover the whole patient in all orientations?

»Think as far ahead as you possibly can to “future proof” the room, reducing the need to renovate the OR moving forward. For example, what is the most extreme type of procedure the team might do in the OR? Then outfit the room in preparation for the procedure.

»Involve the end user at the very start of the project to give a real world perspective for offering scenarios, as well as discussing needs and concerns. This can include nurses, surgical technicians and staff, as well as anesthesiologists.

»Consult with the vendor providing lights, booms and imaging equipment to accommodate all of their needs. For example, many imaging companies have different requirements for ceiling heights.

Hybrid therapies enable hospitals and clinicians to provide less invasive care that is safe and cost-effective for the patient. Careful planning can lead to an effective hybrid operating room design that offers the following benefits:

» Cost-effective operations for patients and surgeons, with better outcomes.

» Reduced stress, faster recovery and reduced hospital stays for the patient.

»Safer procedures, especially in the case of an emergency.

New Bair Paws® Gown Brings “Flex Appeal” to Patient Warming: An Arizant Case Study

The recent Centers for Medicare and Medicaid Services (CMS) adoption of the SCIP-Infection-10 normothermia quality measure has made it more important than ever to simplify the process of warming every surgical patient. Arizant Healthcare’s latest innovation in forced-air warming, the Bair Paws Flex gown, does just that by incorporating a surgical warming product — Bair Hugger blankets — into a comfortable patient gown that warms before, during and after surgery.

While clinical versatility is a key benefit of the Bair Paws Flex gown, so is the practical economic approach of standardizing multiple warming capabilities into one gown that can accommodate most perioperative warming needs. While helping to improve outcomes and boosting patient satisfaction, the Bair Paws Flex gown may save facilities money by supplanting multiple OR warming blankets and the warmed cotton blankets and gowns often used to comfort patients.

Just One Gown Warms From Start to Finish

Before surgery, patients appreciate the Flex gown for its controllable warmth; they can simply dial the temperature of the air flowing through the gown to a level that’s comfortable. The surgical warming products built into the gown are unknown to the patient because they are deployed only by surgical staff.

In the operating room, the same Bair Paws Flex gown offers clinicians the ease and convenience of having multiple patient warming options available during surgery. Seamlessly integrated into the gown are: a head drape, adhesive tape to isolate the surgical field, and deployable arm extensions to transition into a Bair Hugger upper body blanket with tie strips. A second insert in the lower portion of the gown may be used to prewarm before surgery and then warm again as a lower body blanket once in the OR. The gown’s design allows upper or lower body warming for any surgical positioning — supine, prone or lateral.

After the procedure is over, the upper body blanket arm extensions, head drape and surgical tape strip perforate off, returning the garment to a standard warming gown for post-operative use through the lower warming blanket insert.

The Bair Paws Flex gown is comfortable for patients, convenient for clinicians and warms from pre-op to the OR to PACU. Best of all, it’s also economical. One gown handles almost all your warming needs, including contributing to quality goals like SCIP-10 and improved patient satisfaction. It incorporates a highly effective surgical warming device directly into a soft, comfortable hospital gown that does something positive for patients and hospital staff. It’s not just a gown. The Bair Paws Flex gown is a patient warming and patient satisfaction tool. It’s the future of patient warming, and it’s available today.

Practicing Arthroscopic Surgery on Computers, Not People: A Toltech/Sensable Case Study

Learning diagnostic knee arthroscopy is not unlike learning to play the violin — both art forms require a mixture of cognitive and proprioceptive skills that can only be developed through rigorous practice. And while both require intensive mentoring, surgical apprenticeship is unique in its resulting increase in operating room time and potentially patient risk. Just as with a violin that makes no sound, little can be learned from surrogate surgical environments having no objective feedback, including costly and labor-intensive cadaver training. And little transference of either skill can be expected from computer based training lacking the feel of the instrument(s).

In late 2009 the University of Michigan Medical Center’s Orthopaedic Surgery department, led by James Carpenter, MD, became an early adopter of the Knee Arthroscopy Surgery Trainer (KAST) from Touch of Life Technologies (ToLTech). This simulator was co-developed with the American Academy of Orthopaedic Surgeons (AAOS), Arthroscopy Association of North America (AANA), and the American Board of Orthopaedic Surgery (ABOS). It provides both cognitive and haptically-enabled skills training for the proper and efficient techniques required for diagnostic arthroscopy of the knee as done on an outpatient basis — including training to competency, and a modality for complete evaluation of residents’ skills.

In the KAST simulator, trainees hold a customized stylus in each hand — emulating the probe and camera used in actual surgery — that are attached to PHANTOM® force-feedback haptic devices, made by SensAble Technologies. The haptic devices allow trainees to navigate in true 3D space while interacting with high-resolution models that are viewed on-screen, as if through an actual arthroscope. The force feedback devices are programmed to push back on the user’s hand to deliver the “feeling” of the soft tissue, cartilage, and ligaments involved in knee arthroscopy.

The “Virtual Mentor” in KAST guides, critiques, and scores the resident on each part of the procedure. In one module, trainees must perform three steps for examining the medial meniscus with a probe. The Mentor requires the trainee to score 100 percent on each step before attempting subsequent tasks, and finally a time-trial. A special “cheater view,” only available at the novice level, shows the outside image of the knee (seen in the right hand portion of the Mentor screen), to help residents understand where the tools they are using are located with respect to the anatomy. KAST switches seamlessly between a right and a left knee, forcing the trainee to be ambidextrous with respect to the camera and probe.

Haptically-enabled surgical simulation provides cognitive and skills-based training — freeing up the outpatient facility’s attending physicians to teach higher-level skills, and giving residents unlimited autonomous practice opportunities. It allows residents’ skills to be objectively measured and validated before they undertake procedures on patients. The University of Michigan Health System’s Orthopaedic Surgery department plans trials comparing beginning residents who have trained on KAST, against a control group. Separate validation studies led by the AAOS using KAST are underway nationwide during 2010.

American Diabetes Association revises diabetes guidelines

The American Diabetes Association (ADA) has revised clinical practice recommendations for diabetes diagnosis to promote hemoglobin A1c as a faster, easier diagnostic test that could help reduce the number of undiagnosed patients and better identify patients with prediabetes. The new recommendations are published in the January supplement of Diabetes Care.

“There are several revisions and updates included in the American Diabetes Association’s 2010 Clinical Practice Recommendations that will potentially impact how health plans care for the many individuals with type 1 and type 2 diabetes and those at risk for diabetes,” says Richard M. Bergenstal, MD, president, Medicine and Science, American Diabetes Association and Executive Director, International Diabetes Center. “A significant change is that the ADA now recommends the A1C test can be used to diagnose diabetes or identify those at high risk for developing diabetes. Patients can prevent complications and suffering, and health plans can minimize long costs if diabetes is detected and treated effectively early or if diabetes can be prevented.

The A1c test, which measures average blood glucose levels for a period of up to 3 months, was previously used only to evaluate diabetic control with time. An A1c level of approximately 5% indicates the absence of diabetes, and according to the revised evidence-based guidelines, an A1c score of 5.7% to 6.4% indicates prediabetes, and an A1c level of 6.5% or higher indicates the presence of diabetes.

Extensive revisions to the section “Diabetes Self-Management Education” are based on new evidence. The goals of diabetes self-management education are to improve adherence to the standard of care, to educate patients regarding appropriate glycemic targets, and to increase the percentage of patients achieving target A1c levels.

“The 2010 Standards or Medical Care present new data to emphasize how important it is to teach diabetes self-management so health plans need to be sure they have a recognized education program in place that facilitates patient centered team care,” Bergenstal says. “There is also new evidence reviewed that will give health plans information on effective strategies to improve diabetes care and develop treatment targets in the outpatient and inpatient setting. Educating patients and providers that good diabetes care means control of blood glucose (while avoiding hypoglycemia and excessive weight gain), as well as controlling blood pressure and cholesterol is critical to preventing complications. Effective and appropriate use of new technologies like insulin pump and continuous glucose monitoring are also reviewed in light of new studies released in the last year and health plans should review this data to be able to effectively communicate with patients and providers.”

Optical technique can identify early diagnosis

An early diagnosis of common ocular diseases can be determined via an optical technique that had never before been used for this purpose, researchers from the University of Granada said. The researchers studied the image quality in subjects affected by one of two pathologies, finding a greater amount of ocular aberrations and a higher level of scattering (term associated with the dispersion that light suffers when passing through the various ocular media) in affected eyes compared with results in healthy eyes.

Age-related macular degeneration (AMD) is the leading cause of central vision loss in developed countries, and mainly affects people over 50 years of age. As far as keratitis is concerned, this condition causes inflammation of the cornea and can cause blindness, due to the severe alterations that the corneal surface may suffer.

Carolina Herrera Ortiz and colleagues measured the image quality with two optical instruments and used a psychophysical test for assessing visual performance. Results from patients with AMD were compared with those obtained from a control group of similar age without any ocular pathology. Thus, the researchers could verify that for individuals affected by this condition there is an increased level of ocular scattering that could be mainly due to the disruption suffered by the light reflected in the damaged retina of the AMD eyes, because a priori optics are not expected to be altered, since it is a retinal pathology. The studies will be published in Cornea and Journal of Modern Optics.

Researchers Find Demand for Cosmetic Procedures, Dermatologic Surgery Rising Rapidly

Physicians looking for a way to boost their revenue stream and expand their clinical expertise are turning their attention to aesthetic medicine, a field whose services span minimally invasive cosmetic procedures from peels, injections and laser services, to more invasive procedures such as plastic surgery. It’s a niche some experts believe is fairly recession-proof.

While plastic surgery has demonstrated significant sensitivity to weaknesses in the U.S. economy, according to a national procedural statistics report released this spring by the American Society of Plastic Surgeons (ASPS), minimally invasive procedures (up by 5 percent since 2007) are still popular, which confirms the so-called “Lipstick Effect” that is observed during economic downtimes; the term was coined by Leonard Lauder, chairman of Estee Lauder, who witnessed a surge in lipstick sales following the events of 9/11. Conventional wisdom tells us that during times of economic and social instability, consumers substitute small, affordable luxuries for their bigger, more expensive splurges. This concept translates to aesthetic medicine and surgical services in that patients are now foregoing or postponing pricier and more invasive procedures and opting for cheaper, less risky and more temporary fixes, such as injections and dermal fillers instead of face lifts.

This is substantiated by statistics from the American Society for Aesthetic Plastic Surgery (ASAPS), which reports that non-surgical procedures showing the most growth were laser skin resurfacing (up 12 percent), Calcium hydroxylapatite (Radwiance) injections (up 3 percent) and chemical peels (up 2.9 percent).

Cindy Graf, principal of Cindy Graf Consulting LLC, an expert in the field of aesthetic medicine practice management, and a faculty member of the IAPAM, confirms this trend. “People will always want to improve their looks to feel better about themselves” Graf says. “Another important factor that plays into this trend is gaining or keeping employment in this economic downturn. When people who are in their 40s or 50s lose their jobs, they tend to do non-surgical procedures like Botox injections or other rejuvenation procedures to make themselves more viable candidates as they try to compete in the job market.”

Physicians can make aesthetic medicine procedures attractive to patients by promoting them as rejuvenation opportunities as well as bundling procedures to improve a patient’s perception of value-added services. Equally important, these minimally-invasive procedures can offer physicians an additional cash profit center as an ancillary service to their existing ambulatory surgeries.

Graf says physicians who want to get into aesthetic medicine should proceed with optimistic caution, first ensuring that they have two very important elements in place. The first is a firm grasp on the realities of day-to-day operations. “I think that aesthetic medicine is recession-proof, but in these challenging economic times, physicians must control their overhead costs,” Graf says. “Instead of building a freestanding medical spa, I recommend that physicians add aesthetic medicine services to their existing practices first to build a clientele. One of the reasons why the medical spa industry has faltered is that a physician will spend hundreds of thousands of dollars building these places, and because of the equipment and staffing required, the high overhead becomes too much to keep up with when combined with high marketing costs. But if you go into it with a modest overhead, just adding aesthetic medicine services to your existing practice, or doing a small build-out, and then keeping costs under control, it can be a wonderful opportunity, even in this economy.”

The second key to success is having what Graf calls a “natural bridge” from an existing practice to an aesthetic medicine service line. “The physicians who are best able to cross-sell into aesthetics are those who can use this natural bridge – a common patient demographic or an existing surgical service line most complimentary to aesthetic procedures,” she explains. “For example, an OB-GYN practice has a natural bridge because the specialty already has the right patient demographic to begin with.”

Graf continues, “This field will continue to be lucrative. That’s why we continue to see interest from everyone, including core doctors such as dermatologists, as well as from physicians in other specialties because their reimbursements have been so severely cut by Medicare and insurance companies. In many practices, the costs are continuing to rise but year after year, the reimbursements are continuing to be cut, and it puts physicians in very stressful positions. Because of the nature of aesthetic medicine procedures, it’s much more pleasant and can be almost considered as a break from the stress of general medicine and surgery. So many physicians, like OB-GYNs, are getting out of their specialties because of the skyrocketing costs of malpractice insurance premiums, and they looking for a revenue stream to make up for the practices they are giving up. Aesthetic medicine can work well for emergency room physicians who work four days on and have three days off – they have long stretches of time they can devote to an aesthetic medicine practice. At my seminars I see all kinds of physicians practicing in everything from dermatology to neurology, to orthopedics; some of their nurses come with them, and I also see aestheticians who try to align themselves with a physician to launch a practice.”

With so many practitioners wanting to enter the field, could oversaturation take place? Graf doesn’t think so. “While there is some oversaturation in a few markets, I think the market has not even scratched the surface of it potential yet,” Graf says. “The numbers, even in a down economy, are continuing to grow every year and we are nowhere near saturation, so I think there is tremendous opportunity out there for the wise physician who does his or her homework and who tries to find the right bridge to aesthetic medicine. I encourage physicians to do what they enjoy, tap into the skill mix that they love, offer the kinds of aesthetic services their patients might be interested in, and then specialize in some of those procedures. Physicians shouldn’t try to do absolutely everything to compete sometimes just doing one or two procedures and doing them really well can become a great side practice.”

Graf offers what she believes are the important keys to building a successful cosmetic medicine business:

» Understand the aging face. Understanding facial structure, skin tone, skin types as well as putting together a treatment plan to address the concerns of the aging face that fits into the client’s lifestyle and budget is key.

» Hire a knowledgeable and motivated staff. Every staff member is crucial to the growth and repeat growth of your cosmetic medical business, so they should be able to discuss cosmetic procedures with clients.

» Hire a competent business manager. It should be someone in the practice who has the responsibility for setting and monitoring financial goals, marketing and hiring and training staff for the practice owner.

» Keep up with technology. Rapidly evolving technology in this field requires practitioners to stay current in their knowledge base.

» Provide ongoing training. Stay on top of the latest techniques and advancements in the industry.

» Create an effective marketing plan. Physicians must be able to let existing patients know that they now offer cosmetic procedures? Use point-of-purchase posters, brochures, samples and prescriptions to turn current patients into cosmetic clients. There are many inexpensive grassroots marketing ideas that can be initiated to cross sell cosmetic services within your social and professional areas of influence.

» Stage a seminar. Invite the public and your patients to your office for an informal presentation that includes before-and-after photos of the procedures that you are offering, demonstrate a simple procedure such as a Botox injection, and offer a specially valued package of services to those in attendance.

» Establish a physician-directed skin care program. Developing or carrying a product line is another potential profit center; product sales should be included in every consultation and treatment for higher revenue returns.

» Master the consultation process. Develop a conversational consultation style that focuses on listening to clients’ concerns, putting together a treatment plan that solves her/his concerns and then answering questions that arise. Direct the client to buy by uncovering objections of price, procedure and pain. When the package matches the list of concerns and the three P’s are answered, there is no reason not to buy.

Graf advises, “If your cosmetic medical practice is not producing the revenues that you projected in your business plan, have a hard look at the manner in which you are doing business and see if one or more of these integral keys is missing and by adding these tools, you can bring your business into the profit producing business that you desire.”

Researchers Find Demand for Cosmetic Procedures, Dermatologic Surgery Rising Rapidly

Researchers from Boston University School of Medicine (BUSM) and the Laser and Skin Cancer Center of Indiana, found that there has been a dramatic increase in the number of procedures performed and patient demand for dermatologic healthcare since 2000. The findings, which were recently reported in Dermatologic Surgery, parallels the growth in the age of individuals between the ages of 40 to 55, who make up the Baby Boomer generation.

Using data from the 2001 to 2007 American Society for Dermatologic Surgery (ASDS) member survey, the researchers found that dermatologic surgeons performed an estimated 3.4 million cosmetic and non-cosmetic surgical procedures; in 2007, it was estimated that a total of 7.6 million procedures were performed (120 percent rate of growth between 2001 and 2007). The procedures with the greatest increase during this time period were soft tissue augmentation (405 percent increase), botulinum toxin injections (324 percent increase), and non-ablative skin rejuvenation (laser, light, and radiofrequency sources) (330 percent increase). More modest increases were noted in skin cancer procedures (85 percent increase) and ablative resurfacing procedures (66 percent increase).

According to the researchers, there are two important trends fueling the growth in the number of surgical procedures performed by dermatologic surgeons. “They include the overall advancements in procedural facets of dermatology as a specialty during the last decade combined with the increased societal emphasis on skin cancer prevention and early diagnosis, as well as a desire to prevent and reverse the skin signs of aging,” says lead author Emily Tierney, MD, an assistant professor of dermatology at BUSM.

Tierney further explains, “Dermatologists have been integral to the rapid evolution of photomedicine, with the advances in laser and light devices to treat a diversity of skin conditions. These include actinic keratoses to nonmelanoma skin cancer, pigmentary and vascular disorders, hair and tattoo removal, wrinkles and other signs of photoaging. In addition, the popularity and growth in minimally invasive cosmetic procedures, including botulinum toxin injections, dermal fillers, and nonablative skin rejuvenation techniques (chemical peels and laser, light, and radiofrequency devices) have increased exponentially.”

The researchers anticipate that the role for the dermatologist in a diversity of surgical pursuits, ranging from skin cancer treatment, minimally invasive cosmetic, and laser procedures to complex cosmetic and reconstructive procedures, will continue to grow and expand and contribute to the quality and diversity of procedures performed.

Encourage depression screening for all pregnant women

The Incidence Of Depression runs high, and the utilization growth of antidepressants is a testament to this common condition. Unfortunately, pregnant women who also need to manage depression present a chronic-care challenge for doctors and health plans.

Between 14% and 23% of expectant moms experience depressive symptoms, according to the American Psychiatric Association (APA) and the American College of Obstetrics and Gynecologists (ACOG). Treatment with antidepressants for pregnant women is a bit tricky, prompting discussion about whether to prescribe and whether women already taking the drugs should continue their regimen despite being pregnant.

“The Management of Depression During Pregnancy: A Report from the American Psychiatric Association and The American College of Obstetricians and Gynecologists,” published in Obstetrics & Gynecology (September 2009) andGeneral Hospital Psychiatry (September/October 2009), weighs the risk and benefits of different treatment options for depression. The new guidelines should serve as a call to obstetricians to look for signs of depression in their patients.

The organizations’ guidelines for pregnant women currently on medication for depression include:

Psychiatrically stable women who prefer to stay on medication may be able to do so after consultation between their psychiatrist and ob-gyn to discuss risks and benefits;

Women who would like to discontinue medication may attempt tapering and discontinuation if they are not experiencing symptoms, depending on psychiatric history;

Women with recurrent depression or who have symptoms despite their medication may benefit from psychotherapy;

Women with severe depression (with suicide attempts, functional incapacitation or weight loss) should remain on medication; and

If a patient refuses medication, alternative treatment and monitoring should be in place, preferably before drug discontinuation.

The study also makes recommendations for pregnant women not on medication for depression, saying risks and benefits of treatment choices should be evaluated and discussed, including factors such as stage of gestation, symptoms, history of depression and other conditions and circumstances (smoking, difficulty gaining weight, etc.).

Nishendu Vasavada, MD, clinical associate professor, Department of Psychiatry at the University of Texas Southwestern Medical Center in Dallas, says it is not unusual for women to be on antidepressants when they get pregnant but cautions against their use in the first trimester.

“It is generally safer to take antidepressants after the first trimester,” he says, recommending the lowest possible dose and the use of Class C drugs. “Women should talk with their providers and find out as much as they can about medication choices to make the best decisions.”

Rajni Lad, MD, medical director at CBHNP, a behavioral health managed care company, agrees and notes added support is beneficial.

“The therapist is able to assess a member’s condition and related issues, oversee medication regimens and communicate with the obstetrician,” he says. “We can determine if a member should remain on an antidepressant once she is pregnant and when it is safe to stop taking the drug. We generally don’t prescribe drugs for depression during a woman’s first trimester, but provide other support.”

CBHNP partnered with its sister company, AmeriHealth Mercy Health Plan, a Medicaid managed care plan in Pennsylvania, in implementing the Perinatal Depression Pilot Program in November 2008. Nurse case managers at AmeriHealth Mercy screen women for depression by phone using a validated set of questions designed for a pregnant population. Those at high-risk (15% on average) are referred to CBHNP behavioral health specialists for evaluation and appropriate interventions.

“While the member is on the phone, a nurse case manager arranges an appointment with a mental health provider to ensure these women receive timely attention. The nurse not only coordinates care but follows the member’s progress, recommends appropriate resources and conducts follow-ups,” says Lawrence Kay, MD, senior medical officer for the health plan. “Access for these women is the most critical issue.”

As of September, 125 women have been screened, nine referred to a behavioral health provider and two to an outpatient clinic.

SPECIAL DELIVERY

After developing a set of healthcare reform principles, King County (Washington State) incorporated them into a Maternal and Child Behavioral Health Pilot, a four-year program that identifies and treats depression in low-income, pregnant women, mothers and their young children. These populations are more likely to suffer from depression and are less likely to obtain treatment due to poverty, lack of community support and substance abuse.

New data presented by the APA illustrate that Medicaid beneficiaries are more vulnerable to depression than other populations. They are more than five times less likely than privately insured patients to attend the recommended three follow-up visits with their physician (5% vs. 29%) in the 12 weeks following diagnosis and a prescription for an antidepressant; less likely to stay on medication for more than 60 days (35% vs. 55%); and half as likely as the privately insured to have their antidepressants augmented or changed—despite equal access to antidepressants.

The pilot, operating in eight ethnically diverse King County safety-net clinics, rests on the evidence that the best way to reduce the negative impact of depression is through early diagnosis and treatment. Anne Shields, manager, community and school partnerships, Public Health, Seattle and King County, notes that screening and follow-up are rare among the low-income population with more attention being paid to children’s health rather than their mothers’.

The pilot’s primary goals are:

Improve mental health outcomes in low-income children through increased access for their mothers to depression screening and treatment;

Improve mental health treatment through the implementation of standardized treatment protocols in primary care; and

Improve primary care providers’ ability to reduce the risk of mental health problems and treat conditions suffered by mothers and children.

Shields says the pilot is guided by the five essential elements of an evidence-based model for depression care known as IMPACT: 1) A PCP works with a care manager to implement a treatment plan. 2) A depression care manager educates the patient about depression, supports medication therapy, coaches patients and monitors their symptoms. 3) The care manager and PCP gain access to a designated psychiatrist. 4) Care managers measure depressive symptoms at the beginning of and throughout treatment, using the PHQ-9 (Patient Health Questionnaire), which evaluates the presence and severity of patients’ depression symptoms. 5) Treatment is adjusted based on clinical outcomes.

“PCPs often don’t know how to screen for depression and don’t have the time, but a care coordinator can serve as an extension of the PCP with the time and skills to offer the best intervention,” Shields says. “It’s easy for a PCP to lose sight of follow-up. One of the best things about our program is access to a psychiatrist who knows how to prescribe appropriate medications for pregnant women, ensure that they are safe to use, provide oversight and change regimens if necessary.

The results are noteworthy. More than 97% of enrolled mothers have been screened at least once for depression using the PHQ-9 tool. All the clinics screen pregnant patients during their prenatal visits; some also have developed successful protocols to screen mothers during their children’s visits. Finally, 75% of women on caseload have participated in numerous follow-up activities, including phone calls, clinic visits and support groups.

CHANGING MOODS FOR MOMS

Shoshana Bennett knows only too well the risks of depression related to pregnancy. As a clinical psychologist in Bodega Bay, Calif., she has learned from her own experiences.

“Obstetricians aren’t trained in mood disorders,” she says. “Every pregnant woman should be screened at least once during the first trimester to make sure she isn’t clinically depressed. Women are most vulnerable when they are pregnant but often depression is dismissed as ‘just being pregnant.’ If a woman has trouble sleeping or has no appetite, she may have feelings of anxiousness but is afraid to say anything for fear of being prescribed an antidepressant. Or if she is already taking one, there is a chance she could experience a relapse if her doctor decides to terminate the drug.”

Bennett recommends counseling first and medications second as well as communication between the obstetrician and a mental health specialist.

“Depression can affect the fetus so if symptoms are affecting a woman’s life, she shouldn’t white knuckle it, but instead use appropriate treatment,” she says.

According to Consumer Reports Best Buy Drugs, 60% to 70% of people with depression don’t receive the treatment they need.

Mari Edlin is a frequent contributor to MHE. She is based in Sonoma, Calif.

Congress challenges insurer antitrust exemption

One late change in the House health reform legislation calls for repeal of the decades-old insurance industry exemption from federal antitrust oversight. The move aims to inject more competition in the health insurance market and to prevent price fixing and bid rigging.

Killing the exemption is not likely to have a major impact on the cost or availability of health insurance. The campaign to end this fairly minor regulatory break, though, reflects Congressional intent to set new controls on private insurers. House Democrats advocating repeal acknowledged that the antitrust exemption might not change insurance market competition, but that ending it is still a worthy undertaking.

The antitrust exemption dates back to 1945 and gave states authority to regulate insurance. It was considered appropriate to free insurance companies from federal antitrust laws that regulate similar activities.

Over the years, legal challenges have narrowed the scope of the exemption so that insurers now use it primarily to share information and to standardize risk-rating classifications and forms. Such data can be difficult for small firms to collect on their own, and eliminating these programs, ironically, could provide advantages for dominant insurers.

Repealing the exemption, though, would open the door to more federal investigations into insurer actions that smack of anticompetitive practices or consumer protection violations. And even if repeal fails to make it into final reform legislation, Congress is likely to step up its oversight of industry pricing and marketing activities.

The Senate Commerce Committee already is examining the percentage of premiums insurers spend on beneficiary claims, and how much they keep for administrative expenses, marketing and profits. Committee chairman Jay Rockefeller (D-W.Va.) challenged industry claims that medical loss ratios average 87%, citing regulatory filings that show the proportion is much lower, especially for individual policies. The House reform legislation requires insurers to spend at least 85% of premiums on benefits, and Rockefeller wants to get a similar provision into the Senate bill.

SMALL-BUSINESS POLICIES EXAMINED

Sen. Tom Harkin (D-Iowa), now chairman of the Senate Health, Education, Labor and Pensions Committee, recently launched an investigation of health insurance prices for policies sold to small businesses, picking up on press reports predicting 15% increases for the coming year. Harkin complained at a hearing last month that one new diagnosis of a worker or spouse will send company premiums skyrocketing. He sent letters to the chief executives of Humana, UnitedHealthGroup, WellPoint and Aetna seeking information on how they set rates and premiums for customers with 50 or fewer workers.

The chairman gave the companies only two weeks to provide detailed information on how they set initial and renewal rates for every state where they sell policies to small companies, on average premium increases, and what rates were rejected by state commissioners. The senator also wants data on revenues and payments, administrative expenses and profits, and how each firm calculates its anticipated medical loss ratio for 2010.

And because industry executives would not testify at the hearing, Harkin broadened his probe to explore how many company officers earn more than $5 million.

Jill Wechsler, a veteran reporter, has been covering Capitol Hill since 1994.

FDA Approves New Test to Aid in the Diagnosis of Rheumatoid Arthritis

FDA Approves New Test to Aid in the Diagnosis of Rheumatoid Arthritis

Novel Abbott Test That Aids in the Early Diagnosis of Acute Kidney Injury (AKI) Receives CE Mark

Novel Abbott Test That Aids in the Early Diagnosis of Acute Kidney Injury (AKI) Receives CE Mark

Patients size up physicians

In the context of higher quality care, how well doctors communicate, build trust and perform in other ways patients can judge is important.

A pilot program has shown the feasibility of conducting scientifically valid national surveys of patients regarding their doctors and providing the reports publicly.

Consumers’ Checkbook/Center for the Study of Services (CSS), a nonprofit consumer research organization, surveyed patients in Kansas City, Denver, and Memphis.

“For example, listening is essential to good diagnosis, explaining things is essential if patients are to know how to comply with a treatment plan and be motivated to do so, and both listening and explaining are important if we believe in shared decision making,” says Robert Krughoff, Checkbook’s president. “Falling short on these dimensions represents waste—with incorrect diagnoses, failure of patients to comply and decisions to do treatments that informed patients wouldn’t want.”

The surveys use questions and procedures developed by the Agency for Healthcare Research and Quality and endorsed by the National Quality Forum. In Kansas City, for example, the online reports are based on an average of 58 completed patient surveys per doctor. To select the patients to survey, Checkbook/CSS identified patients who had visits with each doctor within the preceding 12 months based on claims records. This sampling was done in collaboration with Aetna, UnitedHealthcare, CIGNA HealthCare, Blue Cross and Blue Shield of Kansas City, and BlueCross BlueShield of Tennessee.

Participating plans also agreed to license the survey results for a fee to use as they see fit. (Non-participating plans will not be granted use of the survey results.) According to the company, the survey model costs about $100 to $120 per doctor.

Aetna’s Chief Medical Officer Lonny Reisman, MD, believes the approach improves the health plan’s ability to gather sufficient patient feedback on each doctor to provide scientifically valid and meaningful information.

“The more people weighing in, the more credible and useful the information will be,” Dr. Reisman says. “Sharing reliable patient input with doctors and consumers adds a valuable dimension to existing tools that engage health plan members by helping them evaluate quality as well as cost.”

Physicians in the pilot metro areas have been cooperative in survey efforts, says Krughoff.

Next Page »