Surgery Not an Afternoon Delight
As Dinnertime Nears, Anesthesia Complications Rise
Patients whose surgeries began around 4 p.m. are about four times more likely to request pain medication and experience post-operative nausea and vomiting than those whose surgeries started around 9 a.m., a new study suggests.

Researchers compared the risk of complications related to anesthesia in more than 90,000 surgeries performed at Duke University Medical Center between 2000 and 2004. The results showed the likelihood of anesthesia-related problems was lowest in surgeries that started in the morning and highest among those beginning in late afternoon. The study appears in the August issue of Quality and Safety in Health Care.

Researchers divided the types of problems into three categories: error (including administration of wrong medications or wrong doses) harm (including prolonged sedation, wound infection and nausea and vomiting after surgery) and "other adverse events" (including pain management).

The results showed 31 cases of error, 667 of harm, and 1,995 in the "other" category. The researchers say about one-half the complications in the "other" category were related to management of the patient's pain, and 35 percent of the harm events were due to nausea and vomiting after surgery. In addition to these problems, researchers also identified more than 9,400 cases of administrative delay, which increased significantly in the afternoon and may have contributed to the rise in anesthesia-related problems found at that time. The delays included waiting for lab test results, doctors running late, staff's not being available to transport patients and rooms' not being ready in time.

"This is one of the first studies to show that there is a difference in patient outcomes depending on the start time of surgery," says researcher Melanie Wright, a human factors specialist at the Duke University Human Simulation and Patient Safety Center, in a news release.

- Dan O'Connor

Battle Lines Drawn in Pennsylvania
Legislation That Would Bar Physician Self-referrals
A bill proposed in the Pennsylvania Senate aims to prohibit physicians from referring patients to facilities in which they have a financial interest. Sen. Pat Vance (R-31) introduced SB 1293 to regulate physician self-referrals, which she says result in over-utilization of healthcare services, increases in healthcare costs, and in some cases, adversely affects the quality of healthcare.

Pennsylvania's ASCs show a statewide average profit margin of almost 19 percent, as compared to the 3.2 percent realized by the state's acute care hospitals, says Jim Redmond, senior vice president of legislative services for the Hospital and Healthsystem Association of Pennsylvania.

"The development of ASCs and imaging centers has put many of our community hospitals in a vulnerable position," says Mr. Redmond. "These centers take patients who are well insured and relatively low-risk, leaving our hospitals with those who are uninsured or on Medicaid."

While Mr. Redmond says losing revenue-generating procedures to limited-service facilities weakens the financial standings of hospitals and jeopardizes their ability to provide lower-margin services, the Pennsylvania Medical Society calls the proposed legislation one-sided. "This is an anti-competitive bill and we need to be concerned with patients' access to care," says Chuck Moran, the society's spokesman. "Pennsylvania is a rural state and some services would not be available in some underserved communities if not for physician-owned facilities."

Ms. Vance's bill exempts physicians who make referrals to facilities they jointly own with a hospital, if the total financial interests of all physicians don't exceed 40 percent. Despite the controversy surrounding this bill, Mr. Redmond believes joint ventures between physicians and hospitals are the wave of the future in Pennsylvania.

- Daniel Cook

Anesthesia Hardest Hit in Proposed Medicare Cuts
Anesthesia, hand surgery, ophthalmology and orthopedic surgery would see the biggest Medicare payment cuts if Congress doesn't act on the new practice expense methodology and changes in work values that CMS proposed in the June 29 Federal Register before it adjourns in October.

The changes are the result of CMS's recently conducted Five Year Review and are set to be implemented on Jan. 1, 2007.

Because federal law requires payment changes to be budget-neutral, cuts to some specialties are needed to offset increases to others. "The Relative-Value Update Committee submitted recommendations to CMS on 422 codes, and CMS accepted 71 percent of the recommendations," says the American Society of Hematology in a statement summarizing changes in the practice expense methodology. "The most significant changes are the substantial increases in work values for many of the high volume evaluation and management services" -?which means that many surgical specialties lose out.

• Anesthesia provider payments would be cut 10 percent over the next four years, with MDs' payments cut 6 percent and CRNAs' payments cut 8 percent beginning Jan. 1.
• Ophthalmology payments would be cut 6 percent over the next four years, starting with a 2 percent cut in 2007.
• Orthopedic surgery payments would be cut 5 percent over four years, starting with a 2 percent cut next year.
• Hand surgery payments would be cut 5 percent over four years, starting with a 1 percent cut in 2007.

The only outpatient surgical specialties that will see more than a 1 percent increase, according to Table 54 of the "Five Year Review of Work Relative Value Units Under the Physician Fee Schedule," are dermatology (7 percent), gastroenterology (5 percent), podiatry (3 percent) and oral/maxillofacial surgery (2 percent).

- Stephanie Wasek

$9 Million Wrongful Death Lawsuit
Jury Clears Surgeons, Finds Hospital Negligent in Woman's Death
A Kentucky jury awarded the family of a woman who died as a result of medical negligence $9 million in damages earlier this month.

Jennifer Beglin, 40, had elective rectal surgery at the University of Louisville Hospital in July 2003 and died three months later. The jury cleared her two surgeons of wrongdoing and placed the responsibility solely on the hospital. According to the lawsuit, Ms. Beglin, who had Crohn's disease, suffered severe blood loss during the procedure. A blood transfusion was delayed despite more than a dozen calls to the hospital's blood bank a floor beneath the OR. Ms. Beglin suffered brain damage and was left in a comatose state.

Court documents showed Ms. Beglin had a history of bleeding problems. But the plaintiff's attorney told jurors there was no documentation of what blood would be needed or when it would be needed, and evidence proved that many calls were made for blood. According to the lawyer, doctors were heard screaming "Get me the blood!" while Ms. Beglin lay dying on the operating table.

Hospital lawyers said everything was done according to protocol. Because the hospital is a level one trauma center, blood is always available and pre-ordering blood for a routine operation isn't necessary. The hospital says it plans to appeal.

- Dan O'Connor