Monthly Archives: February 2012

UK surgeons add their voices to speak out against Medical Tourism

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As we’ve written before, local plastic surgeons are fighting the loss of income from medical tourism.  In the UK, where 1 in 20 patients (in one poll) have used medical tourism, are adding to the dissent.  This isn’t the first time British plastic surgeons have spoken out against medical tourism – in fact, British physicians were the first ones to publish commentaries against the practice of traveling overseas for surgery in professional journals.   Last year, they released a statement condeming this practice.

Now, these surgeons are speaking out in the popular press.  The irony is, while these statements are primarily aimed at people travelling to India – as readers of our sister site know, they just as easily could apply to the United States (and our large contingent of ‘phony docs.’

But how much of this is real?  and how much of this is hype to boost their own sagging practices?  It’s hard to know since much of the ‘data’ is based on polls of UK plastic surgeons.

In related news, Las Vegas has started a new task force to weed out phony/ fake doctors operating in the hispanic community after several highly publicized incidents – including several deaths.

More stories from Cartagena Surgery:

How to investigate a potential surgeon

Busting a fake clinic in Los Angeles

Unqualified Arizona doc heads to trial after several patient deaths

The ‘fix a flat’ doc

The original fix a flat doc story

Follow cartagena surgery for more stories..

The latest HIPEC headlines

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More ongoing research trials to validate HIPEC as a potential treatment for ovarian cancer.

The University Hospitals of Cleveland, Ohio recently started several new clinical trials to test the effectiveness of hyperthermic intra-peritoneal chemotherapy  in women with ovarian and endometrial cancer.  Unfortunately, the trials are small (around 60 woman) which means that even positive results will be far from definitive for researchers involved in the HIPEC debate.  It also offers only limited opportunities for patients with ovarian cancer to receive potentially life-saving treatment.

Medpage recently published a nice overview on ovarian cancer and the current treatment modalities – which can be seen here.

More on HIPEC: here at Bogota Surgery:

What is HIPEC? What’s it used for?

Who does HIPEC?

HIPEC updates:

Update #1

American plastic surgeons lash out against medical tourism

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As I’ve mentioned in a few of our older posts – medical tourism makes many American plastic surgeons very, very unhappy.   While many of their complaints are legitimate (patients could get inferior care, infections etc..) all of these complaints or comments apply to their American peers as well.  (On my sister site, we tackle many of the dubious practices in the USA (eye doctors performing liposuction, ‘fake’ doctors injecting people with fix-a-flat, and all those dentists, and hair salons injecting Botox.)

But today I take issue with Dr. Michael A. Bogdan, a plastic surgeon currently practicing in Southlake, Texas.  (Hope everyone is impressed in his degree in Zoology.) But back to the serious issues..

Dr. Bogdan recently authored an article published on Medscape questioning medical tourism in light of the PIP implant scare.  (The full article is re-posted below.)  While he makes some legitimate points in the article, (points that we have discussed here) about the lack of scrutiny on the medical travel agencies themselves, and the lack of data about complications from medical tourism surgeries – he grossly oversteps when he attempts to place the blame for the PIP implants on the feet of the medical tourism industry.

When you consider the THOUSANDS of medical devices (including different versions of breast implants) that have been recalled in the United States in the past 25 years – it undermines his whole premise.  I also find it somewhat offensive that he a.) dismisses all foreign surgeons as using faulty/ inferior equipment – that’s a wide, wide brush to use, Dr. Bogman.. 

and more importantly, b.) that in a small way – he almost sounds to me like he thinks that people who travel abroad for their surgical care – deserve to have these kinds of problems and complications.  Very uncool, and shame on you, Dr. Bogman.

In reality, Dr, Bogman and many other plastic surgeons here in the USA are lashing out at the bad economy which has dampened the public’s enthusiasm for surgical self-improvement.  (Though this article indicates the economy is recovering.)  It’s likely that as a plastic surgeon in Texas (a border state) that Dr. Bogman, seller of such procedural combinations as the ‘mommy makeover’ is feeling the loss of patients more than, let’s say a surgeon in Virginia..

More tellingly, and surprisingly, he doesn’t suggest that patients should research their surgeon – wherever and whoever they are.

But read the article from Medscape.com yourself and decide:

The Cost of Medical Tourism by Michael A. Bogdan, MD

Complications From International Surgery Tourism Melendez MM, Alizadeh K Aesthet Surg J. 2011;31:694-697

Summary Medical tourism (ie, traveling outside the home country to undergo medical treatment) is a rising trend. An estimated 2.5 million Americans traveled abroad in 2011 to undergo healthcare procedures. This results in a significant direct opportunity cost to the US healthcare system. Complications from these procedures also affect the US healthcare system because patients often require treatment and have no compensation recourse from insurance. For cosmetic or other procedures that are not covered by insurance, economic motivators are driving medical tourism because some international clinics offer procedures at significantly lower costs, possibly by compromising the quality of care.

Very little data have been available to assess the outcomes, follow-up, and complication rates for patients undergoing cosmetic procedures abroad. The authors of this study distributed a 15-question survey to 2000 active members of the American Society of Plastic Surgeons about experiences treating patients with complications from procedures that they underwent during medical tourism. The response rate was acknowledged to be low, at 18%. Of the respondents, 80% had treated patients with complications arising from surgical tourism. Complications included infection (31%), dehiscence (19%), contour abnormalities (9%), and hematoma (4%). The majority of respondents reported not receiving any compensation for the care delivered to these patients.

Viewpoint Some patients travel to other states or countries seeking specialized care from surgeons who are experts in their field. In these cases, the patients understand that they will be paying a premium for the expertise, as well as the added expenses incurred for travel and lodging. These patients would be paying significantly more than they would have by undergoing the same procedure locally, but they consider the additional cost worthwhile due to the expected higher level of care.

The majority of patients who are attracted to medical tourism have a different motivation — they are trying to attain an equivalent level of care for a lower cost. Consumers are traditionally driven by price rather than quality and generally do not consider issues regarding follow-up and potential complications. Although reputable international clinics that offer high-quality care do exist, the greater majority that are trying to attract medical tourism patients are doing so by offering low prices. Overhead costs may be lower in other countries, but the level of regulation is also lower. Thus, the accepted standards of care tend to be lower as well.

A recent example of this issue is the current crisis involving breast implants manufactured by Poly Implant Prothèse (PIP).[1] Instead of using medical-grade silicone to manufacture these implants, PIP used substandard industrial-grade silicone as a cost-saving measure. Probably because of this, the implants have a markedly higher rate of rupture than other available breast implants. The International Society of Aesthetic Plastic Surgery recommends removal or exchange of these implants to avoid further health risks.[2]

PIP implants have not been used in the US since 2000, owing to the Food and Drug Administration’s (FDA) decision that the premarket approval application was inadequate.[3] In addition to blocking the use of these implants in the United States, the FDA sent a warning letter to the manufacturer discussing inadequacies in the manufacturing process.[4]

PIP implants have a significantly lower price point than implants approved for use in the United States and are therefore competitive in countries with less stringent regulation. International surgeons trying to entice patients with lower costs could easily justify using PIP implants. In my own practice, I have met patients who were lured overseas for less expensive surgery and ended up with PIP implants. These patients are now faced with additional expenditures for surgery to address complications.

If you have influence over a patient’s decision on where to undergo surgery, advise them of the adage: Buyer beware; you get what you pay for.

The case against ‘extreme makeovers’

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While extreme plastic surgery makeovers (or multiple plastic surgery procedures at once) make for great television – they aren’t safe.  Prolonged (multi-hour, multi-procedure) surgeries place patients at greater risk of complications from anesthesia, bleeding, etc.  These ‘Mommy Makeovers’ sound like a good idea to patients – one surgery, less money and faster results – but the truth is – they just aren’t a good or safe idea.

Now an article by Laura Newman, [originally published  in Dermatol Surg. 2012;38:171-179] and re-posted at Medscape.com drives home that fact.

Combination Cosmetic Surgeries, General Anesthesia Drive AEs

February 9, 2012 — The use of general anesthesia, the performance of liposuction under general anesthesia, and a combination of surgical procedures significantly increase the risk for adverse events (AEs) in office-based surgery, according to reviews of statewide mandatory AE reporting in Florida and Alabama. More than two thirds of deaths and three quarters of hospital transfers were associated with cosmetic surgery performed under general anesthesia, according to an article published in the February issue of Dermatologic Surgery.

The study, derived from 10-year data from Florida and 6-year data from in Alabama, “confirms trends that have been previously identified in earlier analyses of this data,” write the authors, led by John Starling III, MD, from the Skin Cancer Center, Cincinnati, and the Department of Dermatology, University of Cincinnati, Ohio.

In a companion commentary, C. William Hanke, MD, from the Laser and Skin Surgery Center of Indiana, Indianapolis, presses for 3 patient safety practices: “(1) Keep the patient awake!… 2) Think twice before supporting a patient’s desire for liposuction that is to be done in conjunction with abdominoplasty under general anesthesia…. 3) “[B]e advocates for prospective, mandatory, verifiable adverse event reporting…[that] should include data from physician offices, ambulatory surgical centers, and hospitals to define and quantify problems that can be largely prevented and eliminated.”

The authors and editorialist are especially critical of liposuction performed under general anesthesia. The study revealed that although liposuction is perhaps one of the most common cosmetic surgical procedures, no deaths occurred in the setting of local anesthesia. “Liposuction under general anesthesia accounted for 32% of cosmetic procedure-related deaths and 22% of all cosmetic procedure-related complications,” the researchers write.

The researchers analyzed mandatory physician AE reports in ambulatory surgery submitted to their respective states, encompassing 10-year data in Florida and 6-year data in Alabama. A total of 309 AEs were reported during an office-based surgery during the 10-year period in Florida, including 46 deaths and 263 reportable complications or transfers to hospital. Cosmetic surgeries performed under general anesthesia accounted for the vast majority of deaths in Florida, with liposuction and abdominoplasty the most frequent procedures.

Six years’ worth of data from Alabama revealed 52 AEs, including 49 complications or hospital transfers and 3 deaths. General anesthesia was implicated in 89% of reported incidents; 42% were cosmetic surgeries. Pulmonary complications, including pulmonary emboli and pulmonary edema, were implicated in many deaths in both states.

Plastic surgeons were linked to nearly 45% of all reported complications in Florida and 42.3% in Alabama, write the researchers. Office accreditation, physician board certification, and hospital privileges all revealed no clear pattern.

One limitation acknowledged by the authors is that case logs of procedures performed under general and intravenous sedation are required in Florida, but are not public domain, and so were unavailable for analysis. In addition, investigators were not able to obtain data on the total number of liposuction procedures performed in either state. The lack of those data prevented them from calculating the overall fatality rate.

As readers of my previous publications know, the majority of surgeons I interviewed expressly do not perform multiple procedures during one surgery.  Also, many of them perform the majority of their procedures under conscious sedation with local anesthesia (which means you are awake, but you don’t care – and you don’t feel anything).

Interview

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One of my recent interviews from one of the sister sites, Cirugiadetorax.org has been featured in the Alumni Association newsletter for the University of Guadalajara medical school.  You can see it here.

It’s an interview with a cardiothoracic surgeon, Dr. Orazio Amabile, who lives and works in Phoenix, Arizona.  (Not all of my writing is Colombia-related.)

In other news, I will be heading down south, to Mexico again for a few months to work on a new project.  I’ll have more details at my sister sites; cartagena surgery and cirugia de torax.

I am hoping to return to Colombia this summer for a brief writing project.  As the dates get closer and closer, I will post more information for my loyal readers.

Hello, Cartagena!

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Hello magazine says Hello to the beautiful Cartagena de Indias in this new article that highlights the romance and ambience of this charming, coastal city that was founded during the swashbuckling days of pirates and buccaneers..

Cartagena de Indias

In other news (from Colombia Reports) – if you can’t make it to Cartagena right now, don’t worry – the city is taking steps to safeguard and protect its rich history for generations of tourists to come.

Mended Hearts & Aggressive Risk Factor Reduction for people with Hyperglycemia

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Busy day today – I am giving a talk with the local Mended Hearts chapter as part of “Heart Month.”  Mended Hearts is a patient-run organization/ support group for people who have had heart attacks, stents or heart surgery.  It’s a place where people can go for encouragement, education or support after a life-changing cardiac event.  I’ve worked with Mended Hearts in the past, so I was pleased when they invited me to give one of my favorite talks this weekend. (I’ve been giving variations on this talk since 2008).

(Some people might consider it a bit ironic that I am giving a lecture on prevention to a group of people who have already been diagnosed with CAD – but we are also talking about overall wellness/ and preventing future events.)

It’s one of my favorite lectures because it’s an informal style presentation – so I encourage listeners to participate in the discussion – and ask questions.  We also review a case study at the end – where we have a bit of role reversal as I invite listeners to be the NP for a minute and devise treatment strategies for the imaginary patient..  (and my audience usually does a great job – which just proves how powerful a motivated person can be when it comes to healthcare.. If all people were like my audiences, people would be a lot healthier.)   I’ve included a quick summary of my lecture here for interested readers.  (Just the basics – for more specific or detailed information such as information on lipo-proteins, see your doctor.)

Aggressive Risk Factor Reduction 

When talking about healthcare and risk factor reduction, we need to use measurable, and achievable goals.. No ‘nebulous’ statements like ‘improve blood pressure’, or ‘lose weight.’  Instead – we give concrete, and specific goals based on the most relevant and up-to-date clinical evidence.

1.  Hypertension / Blood pressure control – normal B/P is 110/ 70.   National guidelines for diabetics recommends systolic blood pressure less than 130, and a diastolic b/p less than 90.

2.  Hyperlipidemia/ dyslipidemia

LDL cholesterol less than 70

HDL greater than 50

– statin therapy recommended for all diabetics.
3.  Microaluminuria – small protein particles found in urine.  This is an early indicator of on-going kidney damage.   All diabetics should be on an ace-inhibitor (the ‘prils’ such as lisinopril, fosinopril, enalapril).

These medications will help SLOW the damage, but the best treatment is TIGHT glucose control.

4.  Hyperglycemia – (not diabetes)

Hyperglycemia causes damage.  Period.  This includes so-called ‘pre-diabetes’ and gestational diabetes (see slides for more information.)

– Check your hemoglobin A1c, and control your glucose

– Fasting and post-prandial (2 hours after meals) glucose testing.  Remember that post-prandial readings will rise earlier in the course of the disease, so if you re only testing in the mornings – you might miss crucial information needed for your treatment.

– Currently ONLY metformin and insulin therapies have been shown to have long-term benefits.  (The twenty – plus other medications may make ‘the numbers’ look pretty – but there is little long-term evidence to support their use.

Previously, we skirted around to test ALL of our cardiothoracic patients as part of a screening protocol – new guidelines recommend screening of all hospital patients.

5. Endothelial inflammation – hyperglycemia ‘encourages’ endothelial inflammation and vascular damage (it’s the hallmark of the disease) so the best way to treat this is with anti-platelet therapy such as a baby aspirin (ASA).  Recent literature suggests that ASA may do more harm than good in some people, so check with your doctor..

There’s a lot more information to go over (it’s a 45 minute talk) so I’ve decided to post my lecture slides here for anyone to use, but I do ask that people please give appropriate credit.  Cardiac Complications of Diabetes ppt slides.

More references:

Australian treatment guidelines

The best thing about being an unknown writer

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While the underperformance of my writing, is often daunting and disappointing – it does offer several real advantages (to both myself, and my modest audience.)

1.  The unvarnished truth –as an unknown writer, I get access to, and write about the ‘unvarnished’ truth.   Since I’m not a household name, or a bestseller – most of the people I interviewed didn’t bother to hide anything (including unsafe practices in several instances.)

Also, since I’m not Dr. Oz, or Oprah – I could go ahead and write exactly what I saw.. (Good/ bad/ ugly/ whatever.)

Afterall – there was no big publishing house to protect from legal action, and very little incentive for people to sue.

    Sure, I saw some appalling practices, and sure,  I wrote about them in full and devastating detail – giving full names, dates, locations etc but none of the affected facilities or physicians will sue..)    Why would they?  For starters – everything I wrote was the truth – and secondly (more importantly to these individuals)  – few people are buying/ reading these books – so why bring attention to it??

Of course, for the most part – I saw excellent physicians, in outstanding facilities providing patient’s with outstanding and high-quality care – but not always.  And it’s the ‘not always’ that people should be read about..  But – if I became Dr. Oz or some other big name writer – that would be the first thing that would get lost..

I wouldn’t be some nameless, faceless nurse watching from the sidelines.  People wouldn’t let me observe at will – things would be staged, and artificial – and the authenticity of my writing would be lost.. (Just like the authenticity of Joint Commission inspections that are announced a year in advance.)

So in many ways – while my lack of commercial success can be frustrating (since I rely on my own funds to travel and perform research) – it’s this very lack of success that gives me the opportunity to give readers the real information they need and want.

So thank you, for not buying my book.

Well mannered folks..

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Received a nice thank you note from President Juan Manual Santos in the mail this afternoon for the copy of the book I sent..  I may not be politically active, but good manners are always appreciated – and President Santos is certainly well-mannered.

Thank you, President Santos – for making my day!

Mr. Juan Manual Santos, President of Colombia

PGA tour comes to Bogota..

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The misnamed “*Nationwide’ PGA golf tour kicks off in Bogotá, Colombia next week with former United States president, Bill Clinton in attendance.   Former president Clinton will play in the Pacific Rubiales Colombia Pro-Am on February 16th at the Country Club of Bogotá.  Golfers will be competing for their share of a $600,000 purse..

For a run down of the other competitors, click here.   Native Colombian David Vanegas will be representing his home country in the tournament.

More about the Pacific Rubiales Colombia Championship

The full PGA Tour Schedule for 2012

* I am guessing ‘Nationwide’ insurance is one of the big sponsors of this event.

Looks like Panama may bite off more than they can chew..

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In a recently published story, the government of Panama is now offering medical  insurance for all tourists to Panama for free.  This insurance is not  ‘Complication Insurance’ which is offered by private surgeons in Colombia and other countries for patients traveling specifically for medical tourism.  Complication insurance covers all possible medical complications resulting from medical procedures at the designated clinic or destination..

No – Panama is taking the European and socialized medicine approach and is offering general medical coverage for ALL short-term travelers to Panama.  (The long-term exclusion is a wise move given the numbers of Americans and other overseas residents who make Panama their retirement home.)  This insurance resembles typical travel policies in that it covers injuries, accidents and other medical situations that may occur while on vacation..  I just hope the Panamanian government hasn’t underestimated its tourists and their injury/ illness potential.

Now readers – don’t get any wild ideas.. This is not the time to stress that ‘trick knee’ while hiking to visit the Naso-Teribes..

Meanwhile, Costa Rica is making a pitch for more corporate clients such as Pepsi-Cola.  These multi-national corporations can potentially bring hundreds of millions of healthcare dollars by diverting their employees to medical tourism destination such as Costa Rica.  (Like Colombia – Costa Rica is an ideal destination for North Americans due to proximity, quality and diversity of services available.)

A new medical center for Bogota?

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There’s a new article over at IMTJ about a new medical facility being built in Bogotá – but it’s not the facility itself that is interesting (sounds like a new private cosmetic surgery mega-clinic).

It’s the statistics within the article that caught my eye.  I’m not sure how accurate these statistics are, but if true – it confirms much of what we’ve been saying here at Bogotá Surgery.  I’ve placed a direct quote from the article below:

“According to Colombia’s Ministry of Commerce, Industry and Tourism the most popular treatments sought by visitors are heart surgery (41%), general surgery (13%), gastric band surgery (10%), cosmetic surgery (10%), cancer treatment (6%), orthopedic treatment (4%, dental care (2%) and eyecare (1%).”

If this information is even remotely accurate – it confirms what many of within the medical tourism have been saying – and contradicts much of the popular media reports.

People aren’t just going overseas for breast implants and face-lifts – people are going overseas for essential lifesaving treatments, and procedures to improve their quality of life.

This is an important distinction to  make, but many people tend to see cosmetic procedures as frivolous, and consider the issues around medical tourism, and travel health to be equally unconcerning*.  So when they see flashy news stories (good or bad) about patients having overseas surgery (which the media usually portrays as plastic surgery) they shrug and change the channel.

Hmmm.. patient died of liposuction in Mexico (or Phoenix or India..)  Or Heidi whatshername had 26 procedures at a clinic overseas..

But as these statistics show – that’s not the reality of medical tourism – and that’s what makes all of the issues around it even more important.

People may not get fired up about insurance coverage for medical tourism for cosmetic surgery – but what about tumor resection?  or mobility restoring orthopedic procedures? Or as cited above, life-saving heart surgery?

When put into this context – the government (President Obama’s) stance against medical tourism looks a little less democratic – particularly given the state of American healthcare.

* This is not the opinion of the author – but an accurate reflection of statements made in multiple articles and news stories

 

In other news:  Joint Commission take note:  The Indian Health Commission plans to perform surprise health inspections of Indian facilities to ensure quality standards.  (Joint Commission announces their impending visits months ahead of time.)  Joint Commission is the organization that accredits most American hospitals.

Now available in the Kindle Lending Library!

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Now you can read Bogotá! for free in the Kindle lending library..  (I hope this inspires some generosity among critics for impoverished medical writers – leave some positive feedback about the book!!)

 

 

Will Medicare cover TAVI/ TAVR?

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Updates to this story have been posted here.

In an article re-post from the Heart.org, Lisa Nainggolan discusses a recent memo issued by Medicare & Medicaid services (CMS) on potential coverage for TAVI/ TAVR.    This memo lays out the necessary criteria and conditions that must be met for CMS coverage.

Don’t have medicaid or medicare?  Well, the privately insured should still sit up and take notice:  CMS decisions usually set the pace for everyone else – meaning, if Medicare won’t pay for it – then Blue Cross, Anthem and most of the big private insurances won’t either.

CMS draft of proposed coverage – the Heart.org 

Lisa Nainggolan

Baltimore, MD – The US Centers for Medicare & Medicaid Services (CMS) has issued a memo detailing its proposed coverage for transcatheter aortic-valve replacement (TAVR) [1]. The move follows a request for national coverage determination (NCD) from the ACC and Society for Thoracic Surgeons (STS), made last September.

The memo—which is a draft and will be open for public comment until March 3—outlines the conditions under which the CMS will cover TAVR, also known as transcatheter aortic-valve implantation (TAVI), and follows hard on the heels of an expert consensus document on the new technology, published earlier this week.

An estimated 45 000 patients have received TAVI worldwide, with most procedures so far being performed in Europe. US approval of the Edwards Sapien valve at the end of last year means that the country must now gear up to introduce this technology nationwide, and the expert guidance has been designed to act as a roadmap for the rollout of TAVI in the US.

Five conditions must be met for Medicare coverage of TAVR

TAVR will be covered for the treatment of severe symptomatic aortic-valve stenosis only, says the CMS, and the following five conditions must be met:

  • The procedure is performed for an approved indication with a valve and implantation system that has received FDA approval for this indication.
  • Two cardiac surgeons have evaluated the patient’s suitability for open valve-replacement surgery. (traditional cardiac surgery)
  • The procedure is performed in a facility that meets certain requirements with regard to surgical and interventional cardiology expertise. In addition, institutions with prior TAVR experience must participate in ongoing trials or postapproval studies, and all centers performing TAVR must commit to the “heart-team” concept and enroll in a prospective national TAVR study.
  • TAVR must be carried out by sufficiently qualified and experienced physicians.
  • The treating team must participate in a national registry that enrolls TAVR patients and tracks the following outcomes: major stroke; all-cause mortality; minor stroke/transient ischemic attack; major vascular events; and acute renal injury.

For unlabeled uses of TAVI, the CMS proposes coverage only in the context of a clinical trial, for which it lists 13 conditions.

The CMS also indicates that it will not cover TAVR for any other indications not specified in its memo, nor will it cover the procedure in patients who also have concomitant conditions, including: mixed aortic-valve disease; isolated aortic regurgitation; untreated clinically significant coronary artery disease requiring revascularization; hypertrophic cardiomyopathy; echocardiographic evidence of intracardiac mass; significant aortic disease; and severe obstructive calcification or tortuosity of the iliofemoral vessel or small vessel size.

It’s a mixed win for American cardiologists and cardiac surgeons – and certainly opens the door to the expanded use of this criteria.  The good news is that CMS is taking the initiative to stem off a flood of inappropriate procedures.  The release of this memo, along with the recent publication of new guidelines re-affirming the role of CABG, and relegating PCI to specific circumstances  is almost certainly a response to the numerous scandals and allegations affecting cardiology in 2011 (and ongoing.)

Which hospitals should have TAVR/ TAVI programs?

This article outlines the basic requirements for a safe and successful TAVR program – including the minimum skill requirements for surgeons and interventionalists.

But I suspect – it won’t be long before more and more hospitals open their own programs.  This article highlights the financial gains for hospitals with TAVR programs.