Surgery News - January 2009 - (Page 4) NEWS JANUARY 2009 • SURGERY NEWS Obama Raises Hopes for Successful Health Reform Economic woes will require us to ‘also finally address our health care challenge,’ he said. B Y M A RY E L L E N S C H N E I D E R Else vier Global Medical Ne ws arly signals from the incoming Obama administration have many physicians feeling optimistic about the chances for comprehensive health reform. The economy is one reason that health reform may have a greater chance for success now than it did in the Clinton administration, said Dr. Nancy H. Nielsen, president of the American Medical Association (AMA). As more Americans lose their jobs, they are also losing health insurance, driving policy makers to address the issue of the uninsured. “There may be more tension for change now than there has been in the past,” she said. President-elect Barack Obama addressed that tension during a press conference in December when he announced former Sen. Tom Daschle (D-S.D.) as his choice for Health and Human Services secretary. The current state of health care in the United States—with rising premiums and the large number of uninsured Americans—is having a direct and negative impact on the U.S. economy, President-elect Obama said. “If we want to overcome our economic challenges, we must also finally address our health care challenge.” Mr. Obama tapped Sen. Daschle not only as HHS secretary, but also as director of a new White House Office on Health Care Reform. Jeanne M. Lam- brew, Ph.D., a health policy expert who coauthored the health care book “Critical: What We Can Do About the HealthCare Crisis” with Sen. Daschle, was chosen as deputy director of the new White House office. The AMA is pushing Congress and the administration to enact permanent Medicare physician payment reform by eliminating the Sustainable Growth Rate formula, which ties physician payments to the gross domestic product. Without congressional action on the payment formula within the next year, physicians will be faced with a projected 21% cut in Medicare payments starting in 2010, Dr. Nielsen said. If Congress chooses to throw out the SGR formula, it likely will need to authorize some fast-track pilot projects to test some of the most promising models for new payment systems such as global and bundled payments, said Robert Doherty, senior vice president of Governmental Affairs and Public Policy at the American College of Physicians. ACP officials are hoping that the Obama health care reform proposal will include some of their top priorities— coverage of those who are uninsured and improving access to primary care physicians. The experience with the Massachusetts health reform law illustrates that expanding insurance coverage does not guarantee access to care if there are not enough primary care physicians to see all the new patients, said Mr. Doherty. Shoring up the primary care workforce will require an increase in payments for primary care services, an emphasis on primary care in graduate medical education funding, and the creation of programs that would allow primary care physicians to eliminate their medical school debt, he said. ■ Hormonal Therapy Suffices Radiation • ACS Cites Patient Safety Concerns Work Hours • from page 1 out; overall survival rates were about 90% in both groups, reported Dr. Chagpar, director of the multidisciplinary breast cancer program at the University of Louisville’s James Graham Brown Cancer Center. She noted, however, that the study may have been underpowered to detect survival differences and that the two cohorts were not balanced. These limitations could have resulted in a selection bias, said Dr. Amy C. Degnim, a discussant at the meeting. “It appears that the patients’ treating physicians did succeed in identifying the low-risk patients in whom radiation therapy could be omitted,” said Dr. Degnim, an ACS Fellow with the Mayo Clinic in Rochester, Minn., noting that two previous studies have shown benefit from radiation therapy. Dr. Chagpar responded that the reference trials were done before 2000 and showed only small absolute benefits from radiation therapy. The NAFTA trial represents a more contemporary series, in which nearly two-thirds of patients had sentinel lymph node biopsies, she explained. “Therefore, staging may be more accurate in our patients,” she concluded. Aromatase inhibitors have since been incorporated into adjuvant treatment, she added, suggesting that perhaps this will result in even lower recurrence rates within this population. Dr. Chagpar disclosed no conflicts of interest. Dr. Chagpar discusses her findings in a video interview available at http://www.youtube.com/ watch?v=jid3f-XyANM. ■ from page 1 who also commented on the report. “Alternatively, hospitals might be forced to create mechanisms that make resident coverage less indispensable—which would completely change the role of surgical residents and seriously undermine their education.” The IOM committee estimated it would cost about $1.7 billion to hire support staff, other clinicians, or additional residents to cover the cost of current residents’ excess time. Nearly one-quarter of the total amount would go toward bringing residency programs into compliance with the 2003 limits. “One problem was the 24 plus 6—a lot of sleep literature shows that after 16 hours your performance falls off. So 16 hours is the line in the sand for these researchers,” Dr. Tim C. Flynn, a surgeon and vice chair of the ACGME, said at the meeting. Dr. Flynn, an ACS Fellow who is also professor and associate dean of vascular surgery at the University of Florida in Gainesville, emphasized that his comments were his own and did not reflect the position of the ACGME. The IOM also cited the compliance issue. “A lack of adherence to current limits on duty hours is common and underreported,” committee authors wrote in an IOM Report Brief. “Therefore, the committee recommends changes to ACGME monitoring practices, including unannounced visits and strengthened whistleblower processes to encourage resident reporting of violations of limits and undue pressure to work too long.” The ACGME plans to meet in March 2009 to review the evidence, Dr. Flynn said. Other IOM recommendations include confining in-house call to every third night without averaging; limiting the frequency of in-hospital night shifts to four nights, with 48 hours off after three or four consecutive nights of duty; and specifying mandatory time off as 5 days per month, 1 day per week, and at least one 48-hour period per month. ■ For a free summary of the report, visit www.iom.edu/CMS/3809/48553/60449/ 60469.aspx. nificantly affect local-regional recurrence or survival.” Dr. Chagpar said that she and her coinvestigators from the University of Louisville (Ky.) tackled the controversial issue because elderly patients often have indolent cancers and comorbidities that can make them more vulnerable to side effects. Two previous trials—one involving patients 70 years and older (N. Engl. J. Med. 2004;351:9717) and one involving patients 50 years and older (N. Engl. J. Med. 2004;351:963-70)—had shown lower recurrence rates with radiation therapy in women receiving adjuvant hormonal treatments after lumpectomy. The NAFTA trial analyzed by Dr. Chagpur’s group randomized 1,709 hormone receptor–positive patients from 1998 to 2002 to hormonal therapy with tamoxifen or toremifene. Within this population, the investigators identified 737 women aged 70 years and older, of whom nearly two-thirds had breast-conserving surgery. This postlumpectomy subgroup had a median age of 76 years and median tumor size of 1.2 cm. None had chemotherapy, and 91% were node negative. The only factors associated with receiving radiation therapy were age (a median of 75 years vs. 76 years in women who did not have radiation therapy) and being lymph node positive (10.2% of the radiation group vs. 4.4% of those spared radiation). Both factors were controlled for in multivariate analyses of recurrence and survival data. At 5 years, actuarial disease-free survival rates were 97.6% with radiation therapy and 95.9% with- including a new recommendation to limit shifts to 16 hours. Since July 2003, when the Accreditation Council for Graduate Medical Education (ACGME) first implemented the work hour restrictions, residents have been allowed to work 30-hour shifts consisting of up to 24 hours for admitting patients and 6 hours for transitional and educational activities. In contrast, the Institute of Medicine (IOM) recommends that the 30 hours include 16 hours for admitting patients, followed by a 5-hour protected period for sleep between 10:00 p.m. and 8:00 a.m. The remaining time may be used for transitional and educational activities. A simpler, second option is a 16-hour shift with no protected sleep time. “The IOM recommendation regarding 16hour shifts could compromise the education of the residents and possibly affect the continuity of patient care that is essential to ensuring that all surgical patients receive safe, effective, and high-quality care before, during, and after surgical procedures,” the ACS wrote in the statement, adding that shorter shifts for admitting patients could further exacerbate the shortage of surgeons in the United States. Those concerns were echoed by Dr. Russell G. Postier, who commented on the report. “The IOM recommendations address one aspect of patient safety—resident fatigue—while ignoring communication issues related to the cross coverage necessary to implement work hour changes, supervision of residents, and lack of continuity of patient care,” said Dr. Postier, an ACS Fellow who is Chair of the Surgery RRC and the department of surgery at the University of Oklahoma Health Sciences Center. He added that the ever-increasing coverage of patients with whom residents are unfamiliar would make their work environment even more stressful. “I am very concerned that, if adopted, these recommendations will only further burden residents, w http://www.youtube.com/watch?v=jid3f-XyANM http://www.iom.edu/CMS/3809/48553/60449/60469.aspx http://www.youtube.com/watch?v=jid3f-XyANM
Table of Contents Feed for the Digital Edition of Surgery News - January 2009 Surgery News - January 2009 Contents The 20/20 Vision Intent to Prevent News From the College: The Year Ahead Thoracic: Tracheal Triumph Practice Trends: Making the Grade Surgery News - January 2009 Surgery News - January 2009 - Contents (Page 1) Surgery News - January 2009 - Contents (Page 2) Surgery News - January 2009 - Contents (Page 3) Surgery News - January 2009 - Contents (Page 4) Surgery News - January 2009 - Contents (Page 5) Surgery News - January 2009 - The 20/20 Vision Intent to Prevent (Page 6) Surgery News - January 2009 - The 20/20 Vision Intent to Prevent (Page 7) Surgery News - January 2009 - News From the College: The Year Ahead (Page 8) Surgery News - January 2009 - News From the College: The Year Ahead (Page 9) Surgery News - January 2009 - Thoracic: Tracheal Triumph (Page 10) Surgery News - January 2009 - Thoracic: Tracheal Triumph (Page 11) Surgery News - January 2009 - Thoracic: Tracheal Triumph (Page 12) Surgery News - January 2009 - Thoracic: Tracheal Triumph (Page 13) Surgery News - January 2009 - Thoracic: Tracheal Triumph (Page 14) Surgery News - January 2009 - Practice Trends: Making the Grade (Page 15) Surgery News - January 2009 - Practice Trends: Making the Grade (Page 16)
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