In the Medicare population alone, the rate of complex spinal surgery has increased roughly 15-fold since 2002. A 2008 economic analysis found that the costs associated with spinal disorders and surgery now exceed that of diabetes and cardiovascular disease.

One might expect surgeons and hospitals would be reimbursed by Medicare at similar rates for similar surgical procedures; however, a new 

Researchers from the Center for Healthcare Outcome and Policy at the University of Michigan in Ann Arbor examined variation in episode payments for spine surgery in the national Medicare population. Their interest was in identifying root causes when they observed variations. To conduct the study, they identified all patients (N=185,954) in the national fee-for-service Medicare population undergoing spinal stenosis, spondylolisthesis, or lumbar disc herniation surgeries between 2005 and 2007.

The researchers ranked hospitals from least to most expensive and placed them in quintiles. Average episode payments to hospitals in the highest quintile were $34,171, more than double those made to hospitals in the lowest quintile ($15,997). After risk- and price-adjustment, total episode payments to hospitals in the highest quintile remained 47% higher than those in the lowest quintile.

Procedure choice influenced total episode payment heavily. However, after adjusting for procedure choice, hospitals in the highest quintile remained 28% more expensive than those in the lowest.

Discretionary services accounted for the bulk of the differences. Use of post-acute care was the biggest driver of residual variation. Subgroup analyses for disc herniation, spinal stenosis, and spondylolisthesis showed that regardless of underlying diagnosis, hospitals that were expensive for one condition were expensive across all spinal diagnoses.

The authors conclude that high-cost hospitals could focus on spinal fusion use and post-acute care to reduce costs.

Articles

Featured Articles

One might expect surgeons and hospitals would be reimbursed by Medicare at similar rates for similar surgical procedures; however, a new study in Spine Journal indicates that is not the case.

Back Surgery Cost Varies by Location

Healthy skin, mucous membranes, hair, and nails need adequate iron. When patients are iron-deficient, their pallor, fragile or concave nails, and brittle hair are clinical clues. They also tend to suffer as the deficiency magnifies with itching, skin infection (impetigo, boils and candidiasis), and inflammation at the corners of the mouth, according to 

 discussing iron’s role in the skin in 

Iron is the most common element on Earth, and iron proteins are found in all living organisms. Regardless of its abundance, iron’s physiologic role in human health is still not clearly understood. Elevated iron levels in macrophages can induce unrestrained proinflammatory macrophage activation.

Within the epidermis and dermis, iron concentrations vary considerably as do its oxidative states (Fe

). We know that the skin is critical to iron homeostatis because iron is not excreted actively in physiologic processes, but rather lost primarily through skin desquamation. Iron is more heavily concentrated in sun-exposed areas, and some of its oxidative states interact with reactive oxygen species to slow free radical damage.

This article highlights iron’s role as a potential therapeutic target in the skin. In the future, topical chelators and novel agents will be available to improve wound healing in patients with iron aberrations or inflammatory states.

The authors cover iron’s known roles in several processes, as well as recent experimental findings concerning anemia and blood volume’s impact on wound healing. They also discuss 2 conditions — rheumatoid arthritis and lupus erythematosus &mdash; that are associated with dysregulation of local cutaneous iron homeostasis.

In terms of wound healing, both inadequate and overabundant iron affects the process. Older studies looked at iron with a focus on wound-strengths. More recent work looks more closely at macroscopic health and re-epithelialization. Iron deficiency without inflammation probably undermines skin remodeling. Iron deficiency with inflammation can increase macrophage iron and serve as an inflammatory galvanizer. In both cases, it’s critical to treat the underlying causes of iron dysfunction.

No article on iron would be complete without a discussion of local cutaneous depositions, and the authors cover iron overload in good detail. In patients who have hereditary hemochromatosis, skin iron levels rise as iron overload increases. The authors note that clinically, some physicians are using quantitative nuclear microscopy to decide when to start, change or stop phlebotomy therapy.

In the future, topical chelators and novel agents will be available to improve wound healing in patients with iron aberrations or inflammatory states.

Iron, Skin, and Wound Healing

The cost of American healthcare is staggering, and, often, the bill is padded with unnecessary or even harmful tests, procedures, and prescriptions.

The Chicago-based ABIM Foundation worked with dozens of professional organizations and 

 to reduce waste in the healthcare system. A total of 58 professional organizations have joined them to create a list called 

Things Physicians and Providers Should Question, 

and 6 of these organizations represent surgeons.

In addition to the lists that advise surgeons’ healthcare colleagues, documents called 

Patient-Friendly Resources from Specialty Societies and Consumer Reports 

are also available to stimulate conversations that improve care and eliminate unnecessary tests and procedures.

Each list includes specific, evidence-based recommendations providers and patients should discuss to determine each individual patient’s most appropriate care. The lists cover unnecessary tests, procedures and drugs. The documents also describe the evidence (or lack thereof) that led to the recommendation.

Among the recommendations that come from the surgical experts are these:

The Society of Thoracic Surgeons offers 5 

starting with “Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to non-cardiac thoracic surgery.” The society’s recommendations primarily focus on advising against testing performed in the absence of symptoms or risk factors. Find them 

The American Academy of Orthopaedic Surgeon’s list includes, “Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.” Its 5 “don’ts” tend to focus on interventions with no proven benefit. Find them 

From the American Academy of Otolaryngology — Head and Neck Surgery Foundation, physicians learn, “Don’t obtain computed tomography (CT) or magnetic resonance imaging (MRI) in patients with a primary complaint of hoarseness prior to examining the larynx.” The academy’s recommendations are split between inappropriate antibiotic use and inappropriate imaging. Find them 

The American Society of Plastic Surgeons advises, “Avoid performing routine and follow-up mammograms of reconstructed breasts after mastectomies.” Four of its 5 recommendations address breast surgery, and the fifth advises against plain X-rays (recommending CT scan instead) in facial trauma. Find them 

The American Association of Neurological Surgeons and Congress of Neurological Surgeons says, “Don’t routinely use seizure prophylaxis in patients following ischemic stroke,” because the evidence doesn’t support routine prophylaxis with antiepileptic drugs unless the patient has a seizure. Three of their recommendations address brain injury or aneurism, with the last targeting low back pain. Find them 

The American College of Surgeons (ACS) warns healthcare providers, “Don’t do computed tomography for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.” The ACS’ other recommendations are the most varied of all the surgical organizations, and they can be found 

The Choosing Wisely site also offers downloadable patient leaflets on chest x-rays, echocardiogram, heart imaging, lab tests, medical assessments and stress tests before surgery, advising patients that, often, these tests are superfluous.

The project reminds its audience that recommendations should not be used to establish coverage decisions or exclusions. The recommendations are guidelines to determine an appropriate treatment plan with input from the patient and the healthcare team.

As a part of the Choosing Wisely campaign, 6 organizations representing surgeons have contributed lists  of tests and procedures that can be unnecessary and a waste of money.

Carving the Fat from Patient Surgical Care

Oculoplastic eyelid procedures can be painful; and since postoperative pain can be somatic, visceral, or neuropathic, multimodal postoperative pain control regimens are smart.

Preemptive analgesia has been employed in many procedures to decrease inflammatory pain related to procedural manipulation, decrease the patient’s pain memory response, and circumvent long-term postoperative pain. In several types of surgery, researchers have determined that a perioperative dose of pregabalin (Lyrica) — a 3-alkylated gamma-amino butyric acid analog that modulates neuropathic pain &mdash; reduces postoperative pain.

Researchers from several centers across the United States have conducted a small study in patients undergoing eyelid surgery and determined that pregabalin may be a useful analgesic in oculoplastic surgery, as well. Their 

Ophthalmic Plastic and Reconstructive Surgery

The prospective, randomized, double-blind, placebo-controlled trial, enrolled oculofacial plastic surgery patients (N=49) at the University of Colorado Eye Center consecutively. Enrollment began in October 2011 and ended in September 2012. Fifteen minutes to an hour before surgery, the researchers administered either placebo (n=23) or 150 mg pregabalin (n=26).

Study participants recorded pain scores on visual analog scales (range zero to 100) at one to 2 hours, 2 to 4 hours, 8 to 12 hours, 20 to 28 hours, and 36 to 48 hours. They also recorded their acetaminophen doses.

The participants’ average age 68 and they were approximately evenly divided between the sexes.

They underwent a wide range of procedures, including blepharoplasty (18), canthoplasty (11), ptosis repair (15), eyelid retraction repair (2), pentagonal wedge resection (1), and MOHS reconstruction (2).

Participants who received pregabalin reported average pain scores that were 5.5 points lower than those in the placebo group. Pregabalin-treated patient took half as much acetaminophen postoperatively (1.3 g) as the placebo group did (2.6 g).

The researchers noted that pregabalin’s impact was greatest in the first 12 hours postoperatively, but this was not a significant finding. Pregabilin-treated patients experienced more side effects than those in the placebo group, but the difference was also insignificant. Larger studies are needed to replicate these findings.

A perioperative dose of pregabalin can reduce pain after an oculoplastic eyelid procedure, according to the results of a small study.

Pregabalin for Perioperative Pain after Oculare Surgery

As more pediatric surgical procedures being conducted as same-day procedures, parents are assuming responsibility for their children’s immediate post-operative pain management. Even minor procedures can cause considerable post-operative pain; however, due to misconceptions parents have about pediatric pain relievers or a misunderstanding about how to medicate effectively, parents may aggravate the child’s pain.

Parents also may give inadequate doses or wait until the child’s pain is spiraling out of control. Another factor — child temperament &mdash; may also influence parental behavior.

Researchers in Orange County, CA, addressed how children’s temperament (activity, emotionality, shyness, and sociability) can affect parent dosing in a 

. The authors enrolled 286 Spanish- and English-speaking parents of children who had outpatient elective surgery.

Parents administered a total of 544 doses of acetaminophen over post-operatively. Approximately 70% of the acetaminophen doses parents administered were sub-therapeutic. About 40% of codeine doses were below the therapeutic range.

For ibuprofen, 90% of doses were appropriate, and almost all doses of hydrocodone were correct. The authors suggest that prescription drugs are labeled with exact doses, which may account for the difference.

Children rated by their parents as emotional in temperament received more acetaminophen, ibuprofen, and hydrocodone (but not codeine). These children appeared to be more vocal about their needs. Surprisingly, children rated as having shy behavior were the most likely to receive analgesics; the researchers indicate that shyness can be interpreted as negative emotionality, which suggests parents read shy behavior as needy behavior.

“Dimensions of children’s temperament, specifically emotionality, predict analgesic administration by parents following surgery even after controlling for confounding variables,” the authors concluded.

They urge clinicians to tailor analgesia and consider proximal factors (e.g., type of surgery, pain severity) and distal factors (e.g., child temperament) factors.

As more pediatric surgical procedures being conducted as same-day procedures, parents are assuming responsibility for their children's immediate post-operative pain management.

How Child Temperament Affects Analgesic Dosing at Home

When Americans turn on their TVs, there’s more than a 50/50 chance they’ll tune into some type of reality program. Home and garden, cooking, antiques, and vapid celebrity lives seem to consume the wavelengths. And, since 

 captured a significant market share, so do new shows about cosmetic surgery. When Americans aren’t watching TV, they are often obsessed with social media.

Researchers from Brooklyn College in New York report that appearance-altering realities in television and social media are not just a recreational pastime for Americans. They influence attitudes toward cosmetic surgery.

Plastic and Reconstructive Surgery and the Transplantation Bulletin

, the researchers survey asked 126 college students about their Facebook, Twitter, and reality television habits. In particular, they determined how participants perceived cosmetic surgery programs in terms of realism.

Participants who perceived realism in reality TV shows were most likely to find cosmetic surgery acceptable socially — meaning, if others approved, then they would pursue cosmetic surgery. They also perceived intrapersonal benefits and were more likely to consider it for themselves.

Participants who followed any reality television character program on Twitter (which has more traffic than Facebook) were significantly more likely to find cosmetic surgery socially acceptable. Facebook behavior was not associated with specific attitudes toward cosmetic surgery.

The researchers note that all study participants were from one college, so the results may not apply across the nation or all demographics. They did not identify which cosmetic reality shows participants preferred, so they could not find specific shows’ magnitude of influence.

Reality TV characters have significant influence on viewers, and the authors note that cosmetic plastic surgeons who advertise their services on cosmetic surgery reality television programs or on Twitter feeds that discuss cosmetic surgery reality TV may benefit.

“These reality television programs portray cosmetic surgery in a positive manner, and viewers with increased perceived realism will be a potential receptive audience toward such advertising,” the authors concluded.

Appearance-altering realities in television and social media are not just a recreational pastime for Americans. They influence attitudes toward cosmetic surgery.

Cosmetic Surgery Goes Primetime

Stress urinary incontinence (SUI) is more than an annoying problem—it has been associated with poor quality of life, social isolation, and depression.

Conservative management has few risks and is reversible, but requires considerable effort on the patient’s part, which leads to high rates of abandonment and low success rates by the end of one year of treatment. Meanwhile, surgical therapy with midurethral slings (MUS) boasts success rates of 85% to 95% with few side effects, and many studies have reported superior results with MUS and good patient satisfaction. With no algorithm to guide treatment, which path balances cost and efficacy best?

American Journal of Obstetrics & Gynecology,

 indicates using surgical intervention earlier may be cost effective. The study describes a decision tree model developed by researchers at Stanford University School of Medicine in California.

The team compared the costs and cost effectiveness of 3 initial treatment strategies, delineating probabilities of SUI after 12 months of use of a continence pessary, pelvic floor muscle therapy (PFMT), and MUS. The researchers developed cost data using Medicare 2012 dollars.

Regardless of how inexpensive the treatment with a continence pessary, its effectivenees was always lower than MUS, and it was never a preferred approach.

The model acknowledged MUS-associated morbidities (mesh erosion, retention, de novo urge incontinence, and recurrent SUI). Regardless, compared to PFMT, initial treatment of SUI with MUS was the more cost-effective strategy with an incremental cost effectiveness ratio of $32,132/quality-adjusted life year.

Stress urinary incontinence has been associated with poor quality of life, social isolation, and depression. A new study compared the cost and cost effectiveness of 3 treatment strategies.

Stress Urinary Incontinence: Go Directly to Surgery?

The finding that patients with epilepsy have a higher incidence of delusions, hallucinations, and disorganized behaviors than the general population is controversial as some researchers suggest this is an apparent overrepresentation because of sampling errors or inadequate control groups.

However, most researchers acknowledge that drug-resistant temporal lobe epilepsy has been linked to increased risk of psychotic disorders. Up to 18% of these patients have psychoses. If the disorders are truly linked, one might think patients with comorbid epilepsy and psychoses who undergo surgery for their epilepsy would also see improvements in their psychoses. This is not always the case. Instead, some patients develop new psychoses or depression.

 indicating surgery to address drug-resistant epilepsy may improve psychoses.

The researchers identified surgical candidates with drug-resistant temporal lobe epilepsy and comorbid psychoses between 2000 and 2010 and followed participants, prospectively, for 2 years after surgery. During the study period, 89 patients were admitted to the epilepsy surgery program, 14 of which (15.7%) were identified as having comorbid psychoses.

After surgery, 71% of patients had good epilepsy outcomes as measured by reduced seizure activity and improved functioning; 6 patients (43%) were free of psychiatric complications; 3 patients (21%) with chronic interictal psychosis experienced the same level of psychiatric illness as they had preoperatively; 3patients (21%) developed acute and transient psychotic symptoms; and 2 patients (14%) developed depression.

Traditionally, neurosurgeons were less likely to operate on epileptics with preexisting psychosis, believing surgery would not improve and may worsen psychiatric symptoms postoperatively. In recent years, neurosurgeons are more likely to consider these patients, especially if psychiatric supervision is provided.

The authors report that approximately half of patients with transient psychotic episodes before surgery had good psychiatric outcomes. Although, half of patients had mild psychiatric complications, they were managed successfully with antipsychotics, antidepressants, topiramate reduction, or their presurgical antipsychotic regimens.

Surgery to address drug-resistant epilepsy may improve psychoses, according to a study.

Surgery May Help Epilepsy and Psychoses

Almost daily, articles and editorials urge physicians to address the problem of inappropriate antibiotic prescribing, which increases duration of antibiotic treatment and hospital length of stay. The issue also has created multidrug-resistant organisms, and increased mortality rates.

The media would lead the public to believe that this is an easy problem to correct, and that it can be rectified if prescribers draw a line in the sand and stay behind it. However, in the surgical suite, the issue is much more complicated. The possibility of surgical site infection and sepsis is a serious concern and as the nature of empiric therapy relies on experience or observation alone, error is possible.

Researchers from the University of Virginia in Charlottesville were interested in identifying independent risk factors associated with inappropriate, empiric antimicrobial therapy for the treatment of severe sepsis. Their 

 of a prospectively maintained database of all surgical/trauma patients admitted to a tertiary care center appears in the July 2014 issue of the 

The investigators analyzed data from 1996 to 2007, looking patients who developed postsurgical sepsis and they identified 2,855 patients who experienced 7,158 infections. Surgeons prescribed empiric antibiotics appropriately for 5,073 infections (2,258 patients or 71%). They selected inappropriate antibiotics in 2,085 infections (597 patients or 29%).

The authors found surgeons were more likely to use inappropriate agents in patients older than 54 years, recipients of blood product transfusion, or patients who acquired nosocomial infections, had APACHE II scores between 16 and 20, or had white blood cell counts between 13.4 and 18.8.

Infection site independently predicted inappropriate, empiric antimicrobial therapy. Pleura, wound, central nervous system, peritoneal, and catheter-associated infections were most likely to be associated with inappropriate prescribing.

 was also associated with inappropriate empiric therapy. The authors suggest that these organisms often represent superinfection, and most patients involved had been treated with other antibiotics in the recent past.

In this facility, inappropriate empiric therapy was linked to longer length of stay and duration of antimicrobial use. However, it did not increase mortality.

The authors suggest that broadening coverage against resistant gram-positive organisms and developing rapid microbiologic assays with improved sensitivity and specificity will decrease inappropriate prescribing.

Inappropriate Antibiotic Prescribing: It's Complicated

Surgeons and endocrinologists have wondered if bisphosphonate use might reduce revision hip replacements, and a new 

Most (but not all) patients who receive a hip replacement are elderly and can be expected to retain the prosthesis for 15 to 20 years. While many retain their first hip replacement for life, patients who have hip replacement surgery at a young age or have very active physical lifestyles may need revisions. In the United States, 18 of every 100 hip replacements are revisions and the most common cause is aseptic loosening.

A multinational team of researchers conducted this retrospective cohort study using Danish registries that follow 5.5 million individuals. They identified 80,342 adults older than 40 years of age undergoing total joint replacement between 1998 and 2007 and excluded patients with diagnoses that would confound the results. They classified participants as bisphosphonate users if they had been on treatment for more than 6 months. They examined duration of use, medication possession ratio, timing of therapy initiation (pre/post-op), and implant survival.

Approximately 2% of participants (1,590) were bisphosphonate users. The researchers paired 1,558 of them to 8,966 non-users to evaluate revision risk over the 2.61-year study period. Among the bisphosphonate users 27, or 1.73%, underwent revision surgery. Among the matched cohort, 399, or 4.45%, needed revisions.

Data analysis showed that bisphosphonate use reduced the risk of revision by 59%. Patients with the longest bisphosphonate treatment durations and/or best adherence rates had the lowest risk of revision. Using sensitivity analysis, the researchers demonstrated their findings were unlikely to be confounded by patient co-morbidity or health-seeking behavior.

The authors concluded that oral bisphosphonate users are at 59% reduced risk of revision, but noted their findings only applied in patients who initiated bisphosphonates after arthroplasty surgery. They postulated that bisphosphonates initiated after arthroplasty surgery could reduce inflammation-mediated osteolysis around the implant and reduce related loosening.

Surgeons and endocrinologists have wondered if bisphosphonate use might reduce revision hip replacements, and a new study indicates they may help.

August 2014