Infections are more common when orthopedic surgeons use metal staples instead of old-fashioned nylon sutures to close wounds, British researchers report.

Infections after surgery can lead to longer hospital stays or readmission after procedures such as knee and hip replacement. Infected wounds can also cause serious complications.

Staples are thought to be faster and easier to use, but there has been concern that they're expensive and could cause more infections.

In a new review, published March 17 online in BMJ, researchers at Norfolk and Norwich University Hospital in England looked at six studies involving 683 wounds that compared sutures to staples.

The researchers found that wounds closed by staples were more than three times more likely to develop superficial infections than those closed by sutures. The rate was four times higher in hip

surgery.

However, the researchers said the studies were generally of poor quality.

Even so, they wrote that patients and doctors should be cautious about using staples to close wounds. 

HealthDay News

Even detailed counseling by doctors doesn't seem to help parents of children having surgery understand or remember all the risks of the procedures, researchers have found.

Before a child can have surgery, a parent or legal guardian must give what's called informed consent. The process has four main elements: disclosure, comprehension, competence and voluntary choice.

"To meet these criteria, the physician must openly communicate to the patient a clear description of the procedure and the goals and benefits of that procedure as well as the risks of, and all alternatives to, surgery," wrote Dr. Daniel P. Nadeau and his colleagues at Walter Reed Army Medical Center. "In the case of pediatric patients, the parents or legal guardians must be counseled concerning their child's surgery."

To assess the process, the researchers focused on 34 parents whose children were having a tonsillectomy or having tubes placed in their ears. The standard informed consent procedure was followed for all of the parents, but 16 also were given detailed information aids. Immediately after counseling and again on the day of their child's surgery, the parents filled out questionnaires designed to assess their knowledge of the procedure and how well they remembered nine specific surgical risks.

On average, there were 6.3 days between the time parents were counseled about risk and their child's surgery. Overall, parents in both groups recalled about 58 percent of the nine surgical risks immediately after counseling and 57 percent on the day of the surgery. But parents who had also received detailed information aids did better at remembering the risks both before and on the day of surgery, recalling six (compared with 4.4, on average) before surgery and 6.25 (vs. 4.17) on the day of surgery.

In both groups, parents with lower education levels remembered more risks than better-educated parents. Mothers remembered more risks than fathers.

"Although formal counseling with detailed data sheets does improve patient surgical risk recall, no parent was able to recall 100 percent [nine of nine] of the intended surgical risks," the researchers wrote. "The overall risk recall rate for this study was 57.5 percent, which is largely disappointing given the effort that was put forth to improve recall."

"Clearly, more efforts need to be made by physicians to study this process to better understand the factors that may affect the informed consent process, with the goal of patients and parents being better informed of the basic risks before surgery," they concluded.

The study was published in the March issue of Archives of Otolaryngology -- Head & Neck Surgery.

HealthDay News

When white and black cancer patients receive similar care at specialized cancer centers, there is no significant difference in cancer death rates, a U.S. study has found.

The finding suggests that where patients receive care may partly account for previous findings of racial disparities in cancer deaths, the study authors say in the March 22 online edition of Cancer.

In the study, researchers from Dartmouth Medical School in Hanover, N.H., analyzed the medical records of more than 200,000 Medicare recipients treated for cancer between 1998 and 2003.

The team focused on one- and three-year death rates for white and black patients with lung, breast, colorectal and prostate cancer.

Across all care settings, compared with white patients, black patients were 13 percent more likely to have died of cancer or other causes at one year, and 23 percent more likely to have died at three years, the study found.

However, when comparing only patients who received care at U.S. National Cancer Institute (NCI) cancer centers, the risk of death at one and three years was about the same for blacks and whites. Black patients treated at NCI cancer centers had lower death rates than those treated elsewhere.

"We have known for some time that African-Americans die in greater numbers from cancer than Caucasians. The question is, why? This research shows that where patients are treated can influence those outcomes significantly," study leader Tracy Onega said in a news release from the American Cancer Society.

"The next step is to understand the components of treatment location that most dramatically affect differences in care, and ultimately outcomes, for all cancer patients," Onega added.

HealthDay News

Since the historic passage of health care-reform legislation by the U.S. House of Representatives on Sunday, and its signing into law by President Barack Obama two days later, many Americans are still wondering, "What's in it for me?"

The new legislation expands coverage to the uninsured of course, but other consumer groups will also be affected, including seniors, young adults and people with employer-sponsored health insurance.

Most Americans who are currently uninsured will be required by law to buy insurance, typically through one of the new state-run insurance exchanges.

Obama signed the heath care reform measure into law midday on Tuesday, while a separate bill containing changes and improvements to the legislation is pending Senate action.

Already, Republican opponents have introduced bills to repeal the health-reform package, and state attorneys general are questioning the legality of a new federal mandate requiring most U.S. citizens to carry health insurance coverage.

HealthDay consulted experts with very different points of view for their take on how the legislation stacks up for consumers. Here's what they said:

People with employer-sponsored health insurance

Throughout his campaign for health reform, Obama insisted that if you like your health plan, you can keep it.

Sara Collins, vice president of the Affordable Health Insurance Program at The Commonwealth Fund in New York City, said that still holds true for people who get their health insurance coverage through a large employer. "Right now, if you're in an employer-based plan, the world doesn't really change for you," she said.

People who get their benefits through small employers, however, may encounter some upheaval. The Congressional Budget Office (CBO) estimated that 8 million to 9 million individuals, mostly lower-wage workers and people who work for smaller employers, could lose their employer-sponsored coverage as a result of the legislation.

The reason: "There will be real economic incentives to move average- and lower-income employees" into newly created health insurance " 'exchanges,' " said John C. Goodman, president of the National Center for Policy Analysis in Dallas, a proponent of free-market reforms.

The uninsured

The legislation expands health insurance to 94 percent of non-elderly Americans. That may not be universal coverage, but it will reduce the ranks of the uninsured by 32 million by 2019, according to the CBO analysis.

Collins described the two ways that people will gain subsidized coverage. One way is by expanding Medicaid eligibility -- up to nearly $30,000 for a family of four. The other way is by subsidizing private coverage through the new insurance exchanges. Families with incomes between $30,000 and $88,000 a year should be eligible for those subsidies.

Young adults

About 30 percent of young adults are currently uninsured, Collins said. To help close the gap in health coverage, lawmakers included a provision in the health-reform package that allows young adults to remain on their parents' health insurance plans up to age 26. That measure, which takes effect this year and enjoys broad bipartisan support, should help close the insurance gap, she noted.

"I have a feeling that the young-adult benefit will be very popular," Collins said. "There's no restrictions on income, so this really addresses what families across the income spectrum really do face with young adults."

Goodman agreed that the coverage extension is good for young adults who are sick, but said that requiring insurers to accept all comers and to charge similar rates regardless of health risk will undermine the individual insurance market.

"If you're a young adult and you're out buying your own insurance, this is going to be a minus for you because premiums are really going to go up," he contended.

People with pre-existing conditions

Beginning this year, people with pre-existing health conditions who have been denied coverage and have been uninsured for six months will be eligible for subsidized coverage through a national high-risk pool program. The pool serves as a temporary fix until the insurance exchanges are up and running, Collins said.

And by 2014, insurers may no longer charge individuals and small businesses higher premiums or deny coverage on the basis of pre-existing conditions.

While health groups hailed the changes, Goodman said the new rules could create problems for insurers if people stay out of the market (and pay penalties for not having insurance) until they are sick. "The fine is quite low compared to the cost of the insurance," he explained.

Medicare beneficiaries

The legislation contains several Medicare enhancements. For example, seniors currently share the cost of preventive services, but beginning in 2011, those tests and treatments will be covered in full.

Medicare Part D's notorious coverage gap -- the so-called "donut hole" -- will also be eliminated by 2020. Currently, many beneficiaries have to foot the bill in the coverage gap, which begins after the enrollee has incurred $2,830 in drug spending and ends only after drug costs exceed $6,440. As part of the new legislation, seniors who reach the coverage gap in 2010 will be eligible for a $250 rebate.

However, the legislation also slashes subsidies to private health plans that serve seniors -- so-called "Medicare Advantage" plans -- and Goodman said the fallout from those cutbacks could become the Obama administration's worst nightmare.

"Right before they vote in November, seniors will be getting letters from insurers telling them their plan is going to be cancelled and they'll have to go back to traditional Medicare," he predicted.

HealthDay News

Planning for care at the end of life can make things easier for people as they die, while reducing stress and depression among loved ones, new research suggests.

With advance care planning, often through documents known as "living wills," people set down how they would like to be treated at the end of their lives. They can pinpoint the kinds of medical and resuscitation services they prefer and appoint people to serve as their surrogate decision makers.

However, researchers have noted that there have been no randomized studies about whether such advance directives actually improve care when people are dying.

In the new study, published online March 24 in BMJ, researchers led by Dr. Karen Detering at Austin Health in Heidelberg, Australia, followed 309 patients, aged 80 years or older, who were admitted to the hospital between 2007 and 2008. Of those, 154 received assistance with advance care planning.

Within six months, 56 of the patients died. The study authors found that end-of-life wishes were known and followed in 86 percent of patients who received the planning assistance, but only 30 percent of the others.

Also, family members reported that they had significantly less stress and depression when their deceased relatives had documented their end-of-life wishes.

HealthDay News

An optimistic outlook might strengthen your body's ability to fight off infection, new research suggests.

The finding doesn't prove that looking on the sunny side leads to better health, but it does add to evidence of a link between attitude and disease by suggesting that "a single person -- with the same personality and genes -- has different immune function when he or she feels more or less optimistic," said study author Suzanne C. Segerstrom, a professor in the department of psychology at the University of Kentucky.

From 2001 to 2005, Segerstrom and a colleague gave surveys to 124 first-year law students. The students, the majority of whom were white (90 percent) and female (55 percent), answered questions about topics such as their levels of optimism about their success in school.

The participants also were given an injection of an antigen that makes the immune system react by creating a bump on the skin. A bigger bump means that the immune system reaction is stronger.

The researchers, who reported their findings in the March issue of Psychological Science, found that the immune response became more powerful in individual students as they became more optimistic over time, and lessened as they became more pessimistic.

But there's more to it. "When people felt more optimistic, they also felt more happy, attentive and joyous, and that accounted for some of the relationship between optimism and immunity," Segerstrom said.

HealthDay News

As jobless Americans lost private health insurance coverage and joined the Medicaid rolls during the recession, U.S. health spending jumped 5.7 percent to $2.5 trillion in 2009, government projections show.

That means that American taxpayers will foot the bill for more than half of U.S. health care expenditure by 2012, the report's authors said.

Overall, health care's share of the gross domestic product (GDP) -- a measure of the value of goods and services produced in the United States -- climbed 1.1 percentage points to 17.3 percent in 2009.

That's the largest one-year increase since 1960, when officials began tracking total U.S. health care spending, analysts noted in a report published online Feb. 4 by the journal Health Affairs.

"This is certainly a very steep rate of growth for health share of GDP," said Christopher J. Truffer, an actuary in the Centers for Medicare and Medicaid Services' (CMS) Office of the Actuary and one of the authors of the report.

Health care's rate of growth eclipsed the rate of overall economic activity in the nation, with GDP tumbling 1.1 percentage points to $14.3 trillion in 2009.

Spending by public payers outpaced private health care spending in 2009, driven by sharp increases in Medicaid enrollment, up 6.5 percent, and spending, up 9.9 percent, the report found.

Overall, the numbers reflect both faster public health spending growth, tied to Medicaid, and slightly faster private health spending growth, but at fairly low levels compared to history, Truffer explained. "So the impact of the recession is being seen in the private health spending growth," he said.

Health spending by private payers in 2009 grew just 3 percent to $1.3 trillion, restrained by a 1.2 percent decline in private health insurance enrollment. That decline occurred despite an increase in federal subsidies to support "COBRA," the continuing health coverage that workers who were enrolled in their employer's health plan may purchase after they're laid off.

Helen Darling, president of the National Business Group on Health, which represents Fortune 500 companies and large public-sector employers that provide health coverage for more than 50 million workers, retirees and family members, said the impact of the recession on the number of unemployed who lost their health coverage "is especially disturbing."

She said there is a pressing need to control health care costs and grow the economy.

"It is a great concern that health care spending continued to rise so sharply when the GDP declined," Darling said. "The nation cannot afford the very expensive health care system we have."

National health spending is projected to reach $4.5 trillion -- nearly double current spending -- and consume 19.3 percent of the GDP by 2019.

While both chambers of Congress have passed separate health reform measures, lawmakers remain stalled on how to advance the legislation. Therefore, the CMS report does not reflect the impact of the proposed reforms.

CMS's spending projections, which provide an 11-year snapshot through 2019, are the result of economic modeling and judgments about future events and trends that influence health spending, the authors explained. However, the projections do not reflect the impact of any health reform proposals.

The report also finds that:

• Public health spending will accelerate in the latter years of the projection period as aging baby boomers move from private coverage into Medicare.
• Partly due to the increase in public enrollment, spending on hospital and physician services is up. Hospital spending increased 5.9 percent to $760.6 billion in 2009, up from 4.5 percent the prior year. Spending on physician and clinical services spiked 6.3 percent to $527.6 billion, up from 5 percent in 2008.
• Spending on prescription drugs rose 5.2 percent, a gain of 2 percentage points, in 2009, reflecting an increase in per-person use of drugs, an increase in the use of antiviral drugs to treat H1N1 (swine flu), and faster price growth in brand-name drugs.

"Higher price growth among brand names is likely due to new brand drugs launched with higher prices," Darling said. She added that employers, health plans and pharmacy benefit managers have noticed significant price increases, "possibly in anticipation of health care reform and concerns about higher industry taxes."

HealthDay News

Maggots used to treat chronic wounds can be killed by a type of bacteria that infects the wounds, Danish researchers say.

Use of maggots to disinfect wounds (maggot debridement therapy) is standard procedure at wound care centers worldwide. The maggots consume dead tissue and ingest bacteria that are killed in the gut. In addition, the maggots secrete antimicrobial compounds into the wound that reduce inflammation and promote healing.

This study found that maggots applied to simulated wounds that were heavily infected with Pseudomonas aeruginosa bacteria weren't able to treat the wound and died within 20 hours.

P. aeruginosa -- which causes many hospital-acquired infections -- is often associated with chronic wounds in which bacteria clump together to form biofilms. Bacteria in biofilms have a "communication system" called quorum sensing (QS) that makes them more resistant to the patient's immune system and antibiotics.

"When we blocked the QS signaling pathways in the bacteria, the maggots were much better at surviving and potentially cleansing the wounds," study leader Dr. Anders Schou Andersen said in a news release from the Society for General Microbiology.

The findings, published Feb. 5 in the journal Microbiology, could lead to more effective treatment of wounds and new types of antibiotics, the researchers said.

"If we can find the specific bacterial mechanism that kills the maggots, we could target this when developing new treatments. For example, wounds infected with P. aeruginosa could be treated with an agent that interrupts bacterial signaling to ensure the success of maggot therapy and thereby wound healing," Andersen said.

HealthDay News

Want to know how healthy your county is?

Now you can find out.

A new ranking of nearly every county in the nation shows significant disparities in the overall health of residents, depending on where they live.

Researchers from University of Wisconsin's Population Health Institute and the Robert Wood Johnson Foundation used data on premature deaths, self-reports about health and factors such as smoking rates, obesity, teen births, the percentage of children in poverty and number of liquor stores vs. grocery stores to rank more than 3,000 counties nationwide against others in their state.

Researchers then chose each state's healthiest county and compared it to each state's unhealthiest county. Among the findings:

• Suburban and urban counties tend to be healthier than rural counties. About 48 percent of the healthiest counties were urban or suburban, while 84 percent of the unhealthiest counties were rural.
• The unhealthiest counties had 2.5 times the premature death rate, or people who die under age 75, than the healthiest counties.
• Residents of the unhealthiest counties were more than twice as likely to consider themselves in fair or poor health than those in the healthiest counties.
• Those in the least healthy counties were 60 percent more likely to be admitted to the hospital for a preventable condition. Misuse of hospitals for non-emergency or preventable conditions is often a symptom of not having access to outpatient care and primary care doctors, either because of lack of insurance or lack of providers.
• Children are three times more likely to live in poverty in the least healthy counties (30 percent) compared to the healthiest counties (9 percent).
• Counties ranked the unhealthiest are less likely to have at least one grocery store where people can buy healthy foods such as fresh produce. About 33 percent of zip codes in the unhealthiest counties had a grocery store, while 47 percent of zip codes in the healthiest counties had a grocery store.

Dr. Patrick Remington, associate dean for public health at the University of Wisconsin, said the rankings are a call to action for state and local social service providers, environmental health experts, health care professionals, educators, elected officials and other community leaders to identify where their region is falling short and how they can improve.

"Whenever you rank people or places or teams or colleges, people pay attention. They want to know where they are on the list and they want to know what factors were included in the ranking," Remington said. "Everyone in the nation can look at this report and see how the health of where they live or work compares to their neighboring counties and to other counties in the state."

In the study, researchers ranked counties on two overall measures: health outcomes, which included information on mortality, self-reported health and low birth weight babies; and about 25 other factors that can impact health but don't directly measure it. Those factors included rates of motor vehicle accidents, uninsured adults and violent crime; the number of primary care doctors in an area and usage of hospice for the terminally ill; measures of air pollution, liquor store density and the percentage of high school and college graduates.

Because each state collects data differently, the study ranks states only against others in the same state, Remington explained. That also means that one state's "unhealthy" could be another state's "healthy" and vice versa.

For example, it's possible that a relatively unhealthy county in a state such as Vermont, which was ranked the healthiest in the nation by a recent report, "America's Health Rankings," could actually be healthier than a relatively healthy county in Mississippi, ranked the least healthy state.

Maggie Elehwany, vice president of government affairs and policy for the non-profit National Rural Health Association, said she was not surprised to see that rural counties tended to have poorer overall health.

"We believe there are greater health disparities in rural counties," Elehwany said. "It's an older population per capita, a sicker population per capita, which means they have more heart disease and diabetes, and it's a poorer population per capita, which means they are more dependent on state and federal programs such as Medicaid and Medicare."

Rural areas also tend to have higher rates of people without any health insurance at all, as well as a lack of primary care doctors. When you couple those factors with the sheer distances people have to travel to seek medical care, getting proper treatment and follow up for chronic illnesses often doesn't happen, Elehwany explained.

About 20 percent to 25 percent of the U.S. population live in rural areas, she added.

HealthDay News

Surging use of improved medical technology, including new drugs, is driving up life expectancy for Americans and driving down rates of major killers such as heart disease and cancer, a new national health report finds.

At the same time, some things about the nation's health that experts hoped were changing actually did not, the report found, and the use and misuse of medical technology may also be a factor behind the ever-increasing cost of health care.

The findings are included in a report, entitled "Health, United States, 2009," issued Wednesday by the U.S. National Center for Health Statistics, part of the Centers for Disease Control and Prevention.

Although Americans are living longer than ever before -- 77.9 years on average -- "a lot of things that should have been changing aren't really changing that much," said Amy B. Bernstein, chief of the Analytic Studies Branch in the Office of Analysis and Epidemiology at the U.S. National Center for Health Statistics.

"Cigarette smoking has pretty much leveled off," she said. "There is still 20 percent of the population that smokes; that's bad. People are not exercising more. Obesity is not decreasing."

Obesity has doubled over the past three decades, from 15 percent of adults in 1976 to 35 percent by 2006, according to the report. As of 2006, 15 to 18 percent of school-age children and adolescents were overweight.

These are things that should be changing and need to be worked on, Bernstein said.

The annual report on the nation's health also found that:

• Heart disease, cancer and stroke, in that order, remain the three leading causes of death in the United States, although deaths attributed to all three have declined.
• About 10 percent of Americans rate their health as only "fair or poor," an increase since the last report.
• Americans' use of medications has tripled, with 47 percent of U.S. residents now taking at least one prescription drug. Half of adults older than 45 take diabetes medications, and 10 times as many people took cholesterol-lowering drugs from 2003 to 2006 as took the drugs from 1988 to 1994.
• More Americans are going without health insurance, with almost 8 percent of those aged 18 to 64 uninsured, according to the report, based on data collected in 2007, before the worst of the current economic crunch set in.

Nonetheless, Americans are living longer, which might be due in large part to the ever-increasing use of medical technology.

HealthDay News

Your doctor suggests you have an operation. But how do you go about finding a qualified surgeon?

If you or someone you know is considering surgery, The American College of Surgeons recommends that you screen for the following qualifications:

• Board Certification. A good indication of a surgeon's competence is certification by a surgical board that is approved by the American Board of Medical Specialties (ABMS).
• Association with an accredited hospital or outpatient surgery center. Your surgeon will arrange for your operation to be performed in a hospital where he or she has staff privileges. It is a good idea to make sure that the hospital has been accredited by the Joint Commission on Accreditation of Healthcare Organizations.
• Fellowship in the American College of Surgeons. The letters FACS after a surgeon's name indicate that he or she is a Fellow of the American College of Surgeons (ACS). Fellows of the College are almost always board-certified surgeons whose education, training, professional qualifications, surgical competence, and ethical conduct have been approved by the College.

HealthDay News

Cutting off the flow of blood to the arm by repeatedly inflating a blood pressure cuff appears to reduce the amount of tissue damaged during a heart attack, a new Danish study shows.

This procedure somehow has a protective effect on heart muscle, by mechanisms that are not yet understood, the researchers said.

In a study of 142 patients being rushed to a hospital for treatment of severe heart attacks, the amount of heart tissue saved for those who got the treatment, called induced ischemia, was 30 percent greater than for those who didn't, according to a report in the Feb. 27 issue of The Lancet.

"For patients being transported to the hospital for acute myocardial infarction [heart attack], we inflated the blood pressure cuff for five minutes, relaxed it and repeated it four times," said study author Dr. Hans Erik Botker, a professor of cardiology at Aarhus University Hospital in Skejby.

While the initial results appear promising, induced ischemia is not being used routinely, Botker said. "We have demonstrated cardioprotection by decrease of the infarct [damaged heart muscle]," he explained. "But this is a surrogate marker. The question is whether it translates into clinical benefit for the patient. We have shown improvement during hospitalization, but it was not sustained for more than 30 days. Now, we need to follow more patients for longer times to clarify whether there is clinical benefit."

The induced ischemia trial is the latest in a long series of studies, first in animals and now in humans, which started with the observation that brief stoppages of blood flow can improve the ability of an organ to withstand stress, Botker said. He and his colleagues have been working with the technique since 2002, with animal experiments followed by trials in people undergoing bypass surgery and now the heart attack trial.

More studies are needed to determine whether the procedure reduces the incidence of congestive heart failure and death, Botker said. "To be honest, we need these clinical endpoints," he said. "To show that the therapy translates into clinical benefit, that is the next step…"

A report in the Feb. 26 online edition of The Lancet described a study led by British researchers that found that surgery to remove blockages in the carotid artery, the main blood vessel to the brain, is safer and better at preventing a stroke than implanting a stent, a thin metal tube, to improve blood flow.

HealthDay News

Why do so many people in top positions fail to follow the ethical rules that they promote? New research suggests that power makes people more strict about other people's actions, but less strict about their own.

"According to our research, power and influence can cause a severe disconnect between public judgment and private behavior, and as a result, the powerful are stricter in their judgment of others while being more lenient toward their own actions," Adam Galinsky, co-author of the new study and the Morris and Alice Kaplan Professor of Ethics and Decision in Management at Northwestern University's Kellogg School, said in a news release from the Association for Psychological Science.

The study authors simulated the moral choices made by powerful people by assigning study participants to various roles. Some served as "prime minister" while others were "civil servants." The researchers then asked the participants to cope with moral questions related to issues regarding traffic rules, taxes and stolen property.

Various experiments showed that those with the most power were more hypocritical in their own behavior but stricter about judging others. Those who didn't feel they were entitled to their power were harder on themselves than others, a phenomenon the study authors called "hypercrisy."

"Ultimately, patterns of hypocrisy and hypercrisy perpetuate social inequality. The powerful impose rules and restraints on others while disregarding these restraints for themselves, whereas the powerless collaborate in reproducing social inequality because they don't feel the same entitlement," Galinsky explained.

The study will be published in an upcoming issue of the journal Psychological Science.
 

Stroke victims brought to a hospital on a weekend are more likely to receive the powerful clot-dissolving drug tPA than those who arrive on a weekday, a study finds. 

It's an unexpected finding, since the study was triggered by a previous report showing that aggressive treatment for heart attacks was more likely to be given during the week rather than the weekend, noted study lead author Abby S. Kazley, assistant professor of health administration and policy at the Medical University of South Carolina.

The heart attack study sent Kazley and her colleagues searching through the records of almost 79,000 people admitted to Virginia hospitals between 1998 and 2006 with ischemic strokes, in which a clot blocks a brain blood vessel.

The research team found that relatively few patients received tissue plasminogen activator (tPA), which works quickly to break up clots. In fact, only 543 of the 58,378 people admitted on weekdays got the drug, compared to 229 of the 20,279 admitted on weekends. The numbers show that the weekend stroke victims were 20 percent more likely to be given tPA than weekday arrivals.

"That seemed counterintuitive, but the more we considered it the more likely it appeared to be the case," Kazley said. Her team published the findings in the January issue of the Archives of Neurology.

During the week, neurologists are more likely to be involved with routine procedures, she noted. "Because there are fewer such elective procedures on weekends, patients have better access to expertise and better access to diagnostic technology such as CT [computed tomography] scanners," Kazley reasoned. "They are also more likely to present at an earlier time, since they are less likely to have to battle traffic to get to the hospital."

And hospitals that meet the standards for certification as stroke treatment centers are required to maintain the same level of treatment on weekends as on weekdays, she pointed out.

Terminally ill patients have much to consider, from whether they want to die at home or in the hospital to whether they want doctors to continue aggressive treatment or focus on making them comfortable during their final weeks or months.

Yet those difficult, emotional conversations aren't happening nearly as often, or as early, as they ought to be, say researchers who surveyed a national sample of almost 4,100 physicians who treat cancer patients.

Given a hypothetical example of a cancer patient with four to six months to live but who was still feeling well, 65 percent said they would discuss a prognosis. But only 26 percent of doctors said they would discuss hospice with the patient, 21 percent said they would discuss where the patient would like to die and only 44 percent said they would discuss resuscitation preferences.

Instead, some doctors said they would wait until the patient was feeling worse or until there were no more treatment options. That runs counter to current guidelines, which recommend having end-of-life discussions when patients have less than a year to live.

"There are guidelines out there that say if patients are terminal and have a year to live, they should get some information about options for improving the quality of their death," said lead study author Dr. Nancy Keating, associate professor of medicine and health care policy at Brigham and Women's Hospital and Harvard Medical School. "This includes their DNR [do not resuscitate] status, hospice enrollment and where they would prefer to die. Most doctors don't talk to their patients about these things until later than is recommended."

The study will be published in the Jan. 11 online edition of the journal Cancer.

There are many reasons why doctors aren't having these discussions as often as they should, said Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society. The conversations can be time consuming and emotionally wrought.

And estimating how long someone has to live is an inexact science. A doctor may have a sense of how long someone has, but an individual patient may die much sooner or later than that, Lichtenfeld said.

"It's difficult to turn to another human being and say, 'I think you have six to 12 months to live,'" Lichtenfeld said. "Doctors are trained to save lives. They want to believe, and the patient wants to believe, they are going to be different from the average. Doctors don't want to take away that hope."

Not only are doctors treading a fine line between being unnecessarily bleak and giving patients the opportunity to make choices, patients can differ in how much they want to be told. "Some want to know more than others," Keating said. "The issue is everybody deserves to hear a little about what the options are and how aggressive they want treatments to be."

Families can be another complicating factor, Lichtenfeld said. Even when patients say they no longer want to continue treatment and instead want only palliative care, heartbroken family members can resist, urging the loved one to keep fighting.

As the nation grapples with reining in health care costs, the survey also raises the issue of doctors offering expensive chemotherapy for terminally ill patients even when there's little chance it will work, Keating said. Other research has shown that the use of chemotherapy is increasing at the end of life, even for cancers generally considered unresponsive to the drugs, according to background information in the article.

"It may be that doctors are just not comfortable talking about something that is challenging, difficult and time consuming," Keating said. "It may also be that doctors are not reimbursed for these discussions but they are for ordering another CT scan or round of chemotherapy. The survey suggests to us that doctors may be throwing out another treatment but not helping the patient understand there is no cure."

Younger physicians were more likely than older physicians to have end-of-life discussions with patients, possibly indicating that current medical training places more emphasis on palliative care.

If doctors don't bring up end-of-life issues, patients need to bring it up with their physicians, making sure their wishes are known, Keating said. Hospice is comfort-oriented care, most often offered at home, for those who are terminally ill.

The stress of caring for a disabled spouse increases the risk of stroke substantially, and the increased risk is greater for husbands than for wives, a new study finds.

"We followed 767 people out of a large study who were caring for a spouse with any disabling condition," said William E. Haley, a clinical psychologist who is a professor in the School of Aging Studies at the University of South Florida in Tampa. "The spouses who had the highest scores for strain had the highest risk scores for stroke."

Strain was measured on a standard score by asking the participants how many days during the past week they had felt depressed, lonely, sad or had crying spells. The answers were matched to the Framingham Stroke Risk Score, which measures risk factors such as age, blood pressure, blood cholesterol levels, smoking and diabetes.

The study is published in the Jan. 14 online edition of Stroke.

A high score on the measure of strain was associated with an overall 23 percent higher risk of stroke. The association was stronger in husbands than in wives. It was highest in black men with high caregiving strain, with a 26.9 percent increased risk of stroke in the next 10 years.

"We showed that African-American men have the highest risk for stroke of any demographic group," Haley said. "The risk is nearly doubled for the highest-strain African-American men," he added.

"For the most part, when men are caregivers they use more paid services," Haley said. "It's likely that men who are not getting help, African-American men in particular, experience tremendous strain. Women are more prepared to be caregivers, and show less risk tied to strain."

It's not clear whether the high-risk scores will result in an increased incidence of stroke, he noted. "We haven't followed enough people for long enough to do that analysis," Haley said. "Over the next several years, we will have the ability to see whether high degrees of strain lead to a higher incidence of stroke and mortality."

Caregivers who feel the strain can and should seek help, he advised. "We do know already that caregivers can benefit from all sorts of counseling," Haley said. "We encourage those caregivers to get additional assistance."

Another study in the same issue of the journal, this one from Sweden, found that only half to three-quarters of people who survived strokes were still taking recommended drugs to prevent a new stroke two years later.

The study of more than 21,000 stroke survivors, average age 75, found that two years later, 26 percent had stopped taking drugs to control high blood pressure, 44 percent had stopped taking cholesterol-lowering statins, 36 percent had stopped taking clot-preventing medications and 55 percent were not taking the blood thinner warfarin.

It's not clear whether the same pattern of noncompliance is true for the United States, wrote the neurologists from Umea University Hospital, but "it is very much so here," said Dr. Bruce Ovbiagele, director of the stroke prevention program at the University of California, Los Angeles.

There are several possible explanations for failure to take such basic measures to prevent another stroke, Ovbiagele said. "On the part of the patients, many patients are not clear that they need to be on these medications indefinitely," he noted.

Physicians can also be at fault, Ovbiagele added. "Some providers are not as insistent about educating patients about how long they need to be on these medications," he said. "Most evidence of their value comes from relatively short studies, so providers may not think it is evident that they have to be continued."

Patient compliance with medication instructions after a stroke is best when "there is some structured interventional program to support it," Ovbiagele said.

Adding fish oil to intravenous solutions proved beneficial for intensive care patients with the potentially lethal blood infection known as sepsis, a new study finds.

The study, published Jan. 19 in the journal Critical Care, compared 13 patients who received fish oil in the normal IV nutrient solution given to patients with sepsis, and 10 patients who received traditional solutions. The patients who received the fish oil had lower levels of inflammatory chemicals in their blood, achieved better lung function, and had a shorter hospital stay.

"This is the first study of this particular fish oil solution in septic patients in the ICU. The positive results are important since they indicate that the use of such an emulsion in this group of patients will improve clinical outcomes, in comparison with the standard mix," researcher Philip Calder, of the University of Southampton in England, said in a news release.

"Recently, there has been increased interest in the fat and oil component of vein-delivered nutrition, with the realization that it not only supplies energy and essential building blocks, but may also provide bioactive fatty acids," Calder said.

"Traditional solutions use soybean oil, which does not contain the omega-3 fatty acids contained in a fish oil that act to reduce inflammatory responses. In fact, soybean oil is rich in omega-6 acids that may actually promote inflammation in an excessive or unbalanced supply," he explained.

HealthDay News

Researchers report that they've developed a new formula for a disinfectant that's effective against bacteria, viruses, fungi and even prions, the proteins that cause mad cow disease.

The fast-acting disinfectant, they say, could be especially helpful to hospitals, where it could, for instance, be used to rid surgical instruments of germs.

According to a report in the February issue of the Journal of General Virology, the disinfectant kills a variety of pathogens. Examples include those that are resistant to ordinary disinfectants, such as the germs that cause a tuberculosis-like illness in people with weakened immune systems and viruses that apparently could cause polio, the report says.

Even prions, which can malfunction and cause diseases that poke holes in the brain, fell victim to the disinfectant, the researchers report.

"Standard formulations that eliminate prions are very corrosive," the study's lead researcher, Dr. Michael Beekes, of the Robert Koch Institute in Berlin, said in news release from the journal's publisher. "The solution we've come up with is not only safer and more material-friendly, but easy to prepare, cheap and highly effective against a wide variety of infectious agents."

The researchers report that the disinfectant combines an alkaline detergent formula with alcohol.

HealthDay News

A new national survey finds that most medical students think that knowledge of complementary and alternative medicine could help Western doctors do a better job.

Complementary and alternative medicine, or CAM, includes such therapies as acupuncture, yoga, massage and herbal treatments.

"Even with the high prevalence of CAM use today, most physicians still know little about nonconventional forms of medicine," Michael S. Goldstein, senior research scientist at the University of California, Los Angeles, and senior author of the study, said in a university news release. "Investigating medical students' attitudes and knowledge will help us assess whether this may change in the future."

The findings were published online Jan. 20 in Evidence-based Complementary and Alternative Medicine.

New technology has made it possible, for the first time, to track the potentially deadly bacteria MRSA around the world or from one person to another, a new study reports.

The ability to track MRSA (methicillin-resistant Staphylococcus aureus) can help scientists figure out how the bacteria mutates and spreads so fast. It also could lead to better ways to control the infection as well as other emerging "superbugs," researchers say.

"This is the first demonstration of a new approach to genome sequencing," Stephen Bentley, from the Wellcome Trust Sanger Institute in England and senior author of the study, said during a Wednesday teleconference.

"This is set to revolutionize genetic sequencing in general, and, I believe, a particular impact will be seen with bacteria, and more particularly, those bacteria which cause infectious disease," he said.

The aspect of MRSA that makes it so concerning is that it is resistant to many antibiotics. One theory holds that the bacteria developed in response to the overuse of antibiotics. The current treatment is with an antibiotic called vancomycin, but the fear is that the bacteria could become resistant to this drug, too.

Although MRSA is usually not serious in healthy people, it can cause serious complications, including organ failure and death, if it enters the bloodstream. The presence of MRSA in hospitals is a particularly worrisome occurrence.

The new findings are published in the Jan. 22 issue of Science.

HealthDay News

A new treatment for a widespread and virulent bacterial infection, Clostridium difficile, appears to dramatically cut recurrence, researchers report.

C. difficile infections have doubled in recent years, and one epidemic strain has caused severe outbreaks in hospitals and long-term care facilities, where the infection is most common. About 300,000 to 500,000 Americans contract C. difficile infections each year, and recurrences are common.

"Treatment of patients with C. difficile with two novel antibodies resulted in a 72 percent reduction in the number of patients that would recur with that disease," said lead researcher Dr. Donna Ambrosino, executive director of MassBiologics, the company that developed the monoclonal antibodies, and a professor of pediatrics at the University of Massachusetts Medical School.

The report was published in the Jan. 21 issue of the New England Journal of Medicine.

"The biggest issue beyond the initial disease is that even though [people] get better from the initial disease, they go on to have recurrences, and this treatment is preventing those recurrences," she explained.

C. difficile, which settles in the gastrointestinal tract, often strikes people receiving prolonged

antibiotic treatment for other infections. It can cause severe diarrhea and damage the lining of the large intestine.

Treatment usually involves antibiotics, which also wipe out normal bowel flora, according to an accompanying editorial in the journal.

After antibiotic treatment, two toxins remain in the body that can cause a relapse. Moreover, the toxins resulting from the epidemic strain appear to cause more severe illness, a higher rate of relapse and about 7 percent mortality, Ambrosino said.

"The toxins are more of a problem than the actual bacteria," said Dr. Marc Siegel, an associate professor of medicine at NYU Langone Medical Center in New York City.

The two new monoclonal antibodies -- antibodies that are cloned in the laboratory from a single hybrid cell -- are designed to remove both toxins, thereby preventing a recurrence.

HealthDay News

Critically ill patients in intensive care who aren't sedated require fewer days on mechanical ventilation and spend less time in the intensive care unit than those who are sedated, new research suggests.

The Danish study included 113 critically ill adult patients expected to need mechanical ventilation for more than 24 hours. The patients were randomly assigned to receive no sedation or sedation (20 milligrams per milliliter (mg/mL) propofol for 48 hours, 1 mg/mL midazolam thereafter) with daily interruption until awake. They were followed for 28 days.

The 55 patients who were not sedated had more days without ventilation than the 58 patients who were sedated (13.8 days versus 9.6 days, respectively) and spent less time in the intensive care unit (13.1 days versus 22.8 days, respectively).

"Findings from our study show that in critically ill patients receiving mechanical ventilation, a protocol of no sedation significantly increased the number of days without ventilation in a 28-day period compared with daily interruption of sedation," wrote the researchers at the Odense University Hospital, University of Southern Denmark.

"Use of no sedation was also associated with a significant reduction in the length of stay in the intensive care unit and in hospital," they added. "Results from this single-center study suggest that a strategy of no sedation is promising, but a multicenter trial is needed to show that the benefits of this strategy can be reproduced in other facilities."

The study findings were released online Jan. 28 in advance of publication in an upcoming print issue of The Lancet.

HealthDay News

About 50 percent of intensive care unit patients worldwide suffer infections, which increase their risk of dying in the hospital, a new study finds. 

Researchers analyzed data collected on a single day (May 8, 2007) on 13,796 patients, aged 18 and older, in 1,265 ICUs in 75 countries. They found that 51 percent of patients were classified as infected and 71 percent were receiving antibiotics for treatment or prevention of infections. 

Lungs were the most common site of infections (64 percent), followed by the abdomen and bloodstream. 

The longer patients spent in an ICU, the more likely they were to acquire an infection. The infection rate for patients who'd been in an ICU for a day or less was 32 percent, compared with 70 percent for patients in an ICU for more than seven days. 

The ICU death rate for infected patients was more than twice that of noninfected patients (25 percent vs. 11 percent), as was the in-hospital death rate (33 percent vs. 15 percent). 

HealthDay News

A potentially deadly stomach infection is on the rise outside of hospital settings, especially among the elderly, researchers warn.

The germ that causes the condition, known as Clostridium difficile, can create serious symptoms, including diarrhea and an inflammation of the colon, that can be fatal. The infection can be difficult to treat because the bacteria have become immune to some drugs.

The bacteria have been found mostly in hospitals, nursing homes and similar facilities.

"Recent reports have shown increasing incidence and severity of C. difficile infection, especially in the older population," Dr. Darrell Pardi, a Mayo Clinic gastroenterologist and senior author of a study on the situation, said in a Mayo news release. "Our study examines why the cases are on the rise and who is getting the infection."

The findings were presented recently at the American College of Gastroenterology annual meeting, in San Diego.

The researchers examined 385 cases of disease caused by the germ from 1991 to 2005 to see if more were being acquired in places other than a hospital.

They found that people who got sick outside of a hospital were younger -- a median of 50 years old versus 72 -- and had less severe cases.

"The growing incidence of C. difficile infection in both inpatient and outpatient settings could be linked to the increasing usage of antibiotics and to the possibility that C. difficile may be getting resistant to some of our newer antibiotics," Pardi said.

Health experts have gotten better at spotting the bacteria in hospitals and nursing homes, he said, but "now doctors and patients need to be more aware that you can get this infection as an outpatient and that a case of diarrhea or abdominal cramps at home could become serious."

The germ kills an estimated 5,000 people in the United States each year, according to the U.S. Centers for Disease Control and Prevention. 

HealthDay News

A small study finds that even adults who know what medicines they take at home can't accurately name the drugs they're getting in the hospital.

Forty-four percent of patients believed they were receiving a medication in the hospital that was not actually prescribed. A patient who normally receives a blood pressure medicine, for example, may have thought the medicine was continued when, in fact, it was not.

Ninety-six percent of patients failed to recall one or more of the medicines that they had been prescribed during their stay, according to the study, which is published Dec. 10 in the Journal of Hospital Medicine.

"I don't think that's surprising at all. I think that that's the natural consequence of the way in which hospital culture is designed. Patients are given their medicines and they take their medicines," said study author Dr. Ethan Cumbler, an assistant professor of medicine at the University of Colorado Denver and director of the University of Colorado Hospital Acute Care for the Elderly Service.

"It's actually a very different culture than what goes on in the outpatient setting, where patients actually are expected to know what they were taking, when they're supposed to take it and for what reason," he explained.

But the stakes are just as great -- if not greater -- in the hospital.

Say an antibiotic was prescribed. If the patient was allergic to a particular antibiotic and knew which drug he or she was about to receive, that person could play a role in averting the medication error before the drug was administered, Cumbler reasoned.

Or, a kidney transplant patient normally takes certain medicines to prevent rejection of the organ, but a dose might be accidentally skipped.

"If the patient knows what medicines they're supposed to be getting and when, then they're sort of one extra layer of protection to make sure that things go well," he said. "If they don't know what medicines they're supposed to be getting or when, then they are dependent on hospital systems to work flawlessly, and the sad fact is that hospital systems in any hospital don't work flawlessly."

Kevin Colgan, corporate director of pharmacy at Rush University Medical Center in Chicago and immediate past president of the American Society of Health-System Pharmacists, was surprised that so many patients did not know what drugs their doctor has prescribed.

"It means that evidently it was not well-communicated with them what their plan of care was," he said.

To catch medication errors, patients first have to know something about the medicines they're taking. So for this study, Cumbler and colleagues surveyed 50 adults between the ages of 21 and 89 at the University of Colorado Hospital. All were knowledgeable about the medicines they were taking before admission.

Patients were then asked to write down all the medicines they thought doctors were prescribing for them while they were in the hospital. Researchers compared that list to the actual medication administration record -- the list of medications that were being given to them in the hospital.

Medicines prescribed but not listed by the patient counted as errors of omission, while medicines listed by the patient but not actually prescribed counted as errors of commission.

On average, patients omitted 6.8 medications, most commonly antibiotics (17 percent), cardiovascular medications (16 percent) and antithrombotics (15 percent), the researchers found.

Only 28 percent of patients said they'd seen their hospital medication list, although 78 percent would like to have been given such a list, and 81 percent said it would improve their satisfaction with their care, the study authors noted.

"There are a group of patients that want to be more involved," Cumbler noted, "and I think this raises the question, 'How can we help them be more involved?'"

What's more, for some patients, especially those who are older and cognitively impaired, more involvement may not be desirable and, in fact, may have disadvantages, he noted.

Colgan described a number of things patients can do to get more involved in their own medication management:

• Keep a list of medications you take so you can provide an accurate medication history when you check into the hospital.
• During your stay, ask: "What's that name of the drug you're giving me? What will it do? And what adverse drug reactions should I expect?"
• Before discharge, learn about any medications you'll be taking at home.

HealthDay News

Surgical patients whose incisions become infected with antibiotic-resistant bacteria are at greatly increased risk for hospital readmission and death, claims a new study that found that treating this type of infection can cost as much as $60,000 per patient.

Duke University Medical Center researchers examined the 90-day postoperative outcomes of 659 patients. Some had surgical site infections caused by methicillin-resistant Staphylococcus aureus

(MRSA), some were infected with methicillin-susceptible Staphylococcus aureus (MSSA), and others had no infection.

"We found that patients with surgical site infections due to MRSA were 35 times more likely to be readmitted and seven times more likely to die within 90 days compared to uninfected surgical patients," lead author Dr. Deverick J. Anderson, an infectious diseases specialist, said in a news release. "These patients also required more than three weeks of additional hospitalization and accrued more than $60,000 in additional charges."

The study also found that patients with MRSA averaged six more days of hospitalization and $24,000 more in additional hospital charges than those with MSSA. However, the researchers were surprised that those infected with MRSA didn't have a higher risk of death than those with MSSA.

"For the seven hospitals we looked at, the total estimated cost resulting from surgical site infections due to MRSA was more than $19 million. That's a staggering amount, which demonstrates an area of cost-saving potential for these institutions and other community hospitals," Anderson said.

The study was published online Dec. 15 in the journal PLoS One. 

HealthDay News

The approximately 2 million older adults who undergo common abdominal operations each year are at higher risk than others of suffering complications and early death, researchers find.

Little was known about the specific risks facing people 65 and older, the researchers said. "For clinicians, patients and families considering abdominal surgical procedures, informed decision making is challenging because of limited data regarding the risks of adverse perioperative events associated with advancing age," they write in the December issue of Archives of Surgery.

The researchers, from the University of Washington School of Medicine in Seattle, examined medical records of 101,318 adults age 65 or older who underwent abdominal procedures from 1987 to 2004. The operations included cholecystectomy (gall bladder removal), hysterectomy, colectomy and other procedures.

Of the patients, 17.3 percent had complications within 90 days and 5.4 percent died. As patients got older, so did the rate of complications and deaths -- to 22.7 percent and 16.7 percent, respectively, for those 90 and older.

"After adjusting for demographic, patient and surgical characteristics as well as hospital volume, the odds of early postoperative death increased considerably with each advance in age category," the researchers wrote. "These associations were found among patients with both cancer and noncancer diagnoses and for both elective and nonelective admissions.

"Older adults may be less able to adapt to the stress of surgery or to the added stress of any postoperative complication, greatly increasing their risk of early mortality," the researchers added. "These effects appear to be additive, highlighting the need for interventions to both prevent decline among older patients and avoid postsurgical complications." 

HealthDay News

New research holds bad news for health officials worried about a potentially lethal infection called MRSA that haunts hospitals: A strain that infects the bloodstream is five times more deadly than other strains.

To make matters worse, the USA600 strain appears to be at least partially immune to an antibiotic that's used to treat the condition, the researchers have found.

A full half of patients infected with the strain died within a month, according to a study scheduled to be presented at the annual meeting of the Infectious Diseases Society of America, held Oct. 29 to Nov. 1 in Philadelphia. That's nearly five times the death rate of other people infected with MRSA, and 10 to 30 percent of those who acquire MRSA infections in the bloodstream die within a month, the study found.

MRSA, or methicillin-resistant Staphylococcus aureus, causes infections in the skin and bloodstream. It can also infect surgical wounds and cause pneumonia. In most cases, it sickens people in the hospital, but cases are becoming more common outside the health-care community, according to information in a news release from the Henry Ford Health System.

Researchers think it's possible that the USA600 strain is unique. But they don't know if other factors -- such as the age of patients -- could be at play.

Those who developed the USA600 strain tended to be older than those who acquired other MRSA strains, averaging 64 compared with 52 years old, the study noted.

"While many MRSA strains are associated with poor outcomes, the USA600 strain has shown to be more lethal and cause high mortality rates," Dr. Carol Moore, the study's lead author and a research investigator at the Henry Ford Hospital's division of infectious diseases, said in the news release.

"In light of the potential for the spread of this virulent and resistant strain and its associated mortality," she said, "it is essential that more effort be directed to better understanding this strain to develop measures for managing it."

MRSA is challenging to treat because strains can be immune to many medications. The USA600 strain appears to be more immune than other strains to the drug vancomycin, which often still has the power to vanquish MRSA. 

HealthDay News

A potentially deadly stomach infection is on the rise outside of hospital settings, especially among the elderly, researchers warn.

The germ that causes the condition, known as Clostridium difficile, can create serious symptoms, including diarrhea and an inflammation of the colon, that can be fatal. The infection can be difficult to treat because the bacteria have become immune to some drugs.

The bacteria have been found mostly in hospitals, nursing homes and similar facilities.

"Recent reports have shown increasing incidence and severity of C. difficile infection, especially in the older population," Dr. Darrell Pardi, a Mayo Clinic gastroenterologist and senior author of a study on the situation, said in a Mayo news release. "Our study examines why the cases are on the rise and who is getting the infection."

The findings were presented recently at the American College of Gastroenterology annual meeting, in San Diego.

The researchers examined 385 cases of disease caused by the germ from 1991 to 2005 to see if more were being acquired in places other than a hospital.

They found that people who got sick outside of a hospital were younger -- a median of 50 years old versus 72 -- and had less severe cases.

"The growing incidence of C. difficile infection in both inpatient and outpatient settings could be linked to the increasing usage of antibiotics and to the possibility that C. difficile may be getting resistant to some of our newer antibiotics," Pardi said.

Health experts have gotten better at spotting the bacteria in hospitals and nursing homes, he said, but "now doctors and patients need to be more aware that you can get this infection as an outpatient and that a case of diarrhea or abdominal cramps at home could become serious."

The germ kills an estimated 5,000 people in the United States each year, according to the U.S. Centers for Disease Control and Prevention. 

HealthDay News

The United States lags behind other developed countries in a range of health-care practices, according to a new international survey of primary care doctors.

"We spend far more than any of the other countries in the survey, yet a majority of U.S. primary care doctors say their patients often can't afford care, and a wide majority of primary care physicians don't have advanced computer systems to access patient test results, anticipate and avoid medication errors or support care for chronically ill patients," Cathy Schoen, senior vice president of the Commonwealth Fund, which conducted the survey, said in a news release from the organization, a private foundation that focuses on health-care issues.

The International Health Policy Survey, published online Nov. 5 in Health Affairs, found that:

• About 58 percent of U.S. primary doctors polled said their parents often have trouble paying for their treatment and medications.
• Half reported having to deal with insurance companies regarding restrictions on care.
• More than two thirds of the doctors said their offices cannot handle patients after hours, meaning people with urgent health problems must go to emergency rooms. That contrasts with other countries in the survey, where such resources are more common.
• Less than half of the doctors surveyed reported using computerized medical records, compared with 99 percent in the Netherlands and almost as many in New Zealand and Norway.

"The patient-centered chronic care model originated in the U.S., yet other countries are moving forward faster to support care teams including nurses, spending time with patients, and assuring access to after-hours," said Schoen, who also was lead author of the report on the survey.

"The study underscores the pressing need for national reforms to close the performance gap to improve outcomes and reduce costs," she said.

HealthDay News

A new "atlas" of bacterial life on and within the human body has uncovered the fact that your palms, feet and forearms are a veritable United Nations of germs.

The scientists, using sophisticated gene-sequencing technologies, pinpointed specific bacterial types and where they like to thrive on and within the body. They found a wide variability of bacteria, depending on the spot on the body. They also found that bacterial colonies differed person to person, with each individual carrying his or her own "personalized" assortment of microorganisms.

"We've always known that there are microbes on us and in us," said study author Noah Fierer, an assistant professor of microbial ecology at the University of Colorado at Boulder. "But we weren't always able to isolate them and differentiate them from each other. With these new techniques, we can."

"Each of us is really an archipelago of distinct habitats, at least as far as bacteria are concerned," added senior study author Robert Knight, an assistant professor of chemistry and biochemistry and computer science at the University of Colorado. "It's truly amazing how different the sites within the same body are, and how different the corresponding sites on different people are."

The team's work is being published Nov. 5 in the online version of Science. The study builds on earlier research, including a 2008 study that found that women had a greater diversity of bacteria on their palms than men.

The mapping project focused on seven to nine men and women, who were examined four times each over a three-month period.

Researchers swabbed 27 different sites, searching for bacteria in virtually every nook and cranny, from hair to ear wax, mouth to nostril and trunk and legs.

So, where are the most popular places for bacteria to hang out? They seem to like the gut (no surprise there), forearms, palms, index fingers, the backs of the knees and soles of the feet, according to the study. At least that is where some of the most diverse and thriving colonies take root. 

HealthDay News

Family doctors are now taking more time consulting with adult patients, seeing them more often and improving the quality of visits, a new study suggests.

"Patients spent more time with their primary care physicians during office visits in 2005 than they did almost a decade earlier, and overall they seemed to receive better care," said Dr. Lena M. Chen, from the University of Michigan Health System, the lead researcher of a study reported in the Nov. 9 issue of the Archives of Internal Medicine.

Just as the U.S. health care system is struggling to improve care and lower costs, the researchers noted that the population is aging and doctor income is falling, leading some to worry that doctors might cut patient visits shorter to make up the short fall.

"Any efforts to increase efficiency in primary care should take into account the association between time spent with a physician and quality of care," Chen said. 

HealthDay News

While overall care of heart attack patients in the United States is good, gaps remain in the treatment of patients 80 and older, a new study suggests.

Researchers analyzed 2000-2009 data on 156,677 heart attack patients treated at 416 centers enrolled in the American Heart Association's "Get With the Guidelines -- Coronary Artery Disease" program.

The analysis revealed that 86 percent of patients aged 80 and older received early beta blocker therapy, compared with 90 percent of patients aged 64 or younger. Only 43 percent of patients 80 and older received balloon angioplasty within 90 minutes of hospital arrival, compared with 54 percent of younger patients.

Older patients had a far higher rate of in-hospital deaths (11.8 percent vs. 2.4 percent) and were less likely than younger ones to be taking statins when discharged from hospital (76 percent vs. 92 percent).

Co-existing health conditions were more common in the older patients than in the younger patients, noted Dr. Gregg C. Fonarow of the University of California, Los Angeles Medical Center and colleagues.

The study, to be presented Monday at the American Heart Association's annual meeting in Orlando, Fla., shows there is room to improve care and outcomes in older heart attack patients, the researchers said. 

HealthDay News

Strains of antibiotic-resistant infections normally found in the community are increasingly showing up among hospital outpatients, raising the risk that inpatients could become infected, new research says.

From 1999 to 2006, researchers found a sevenfold increase in the incidence of outpatients with methicillin-resistant Staphylococcus aureus (MRSA) infections. Outpatients include people treated in emergency departments or surgical centers but not admitted, or at doctors' offices associated with hospitals.

This poses a risk to inpatients because many resources are used by both sets of patients. These include surgical centers and the doctors themselves, who often treat patients both inside and outside of hospitals.

"What this is suggesting is that outpatients are a significant source of MRSA, especially community-associated MRSA strains," said the study's lead author, Eili Klein, a doctoral candidate at Princeton University and a researcher at Resources for the Future, a Washington, D.C.-based think tank. "This suggests the need for incentives to make sure hospitals are not only taking steps to prevent hospital-associated strains from spreading among inpatients, but preventing the spread of community-associated strains through shared resources."

The study is published in the December issue of Emerging Infectious Diseases.

MRSA, which burst into the public consciousness in the 1990s, is named for its resistance to methicillin and other antibiotics. There are several strains, including those that emerged in hospitals, called "hospital associated," and those that emerged outside hospitals and tend to spread in schools and gyms, called "community associated."

While both types can cause serious, life-threatening illness, hospital-acquired strains are generally more virulent. The bacteria can get into wounds, causing deadly blood or lung infections. About 20,000 people in the United States die each year from the MRSA infections, according to background information in the study.

Community-associated strains have also caused some deaths in otherwise healthy people, including several children who were killed by MRSA infections in the late 1990s. Typically, however, community-associated strains cause skin or other soft tissue infections that are treatable with newer antibiotics.

According to the research, the number of hospital-associated infections remained relatively stable from 1999 to 2003, even decreasing a bit from 2003 to 2005. Some of the reduction was due to better infection-control measures, such as more thorough and frequent hand washing among doctors, Klein said.

Community-associated strains, however, are becoming far more commonplace. Among outpatients with staph infections, MRSA infections increased by more than 90 percent, according to the data culled from 300 microbiology labs serving hospitals across the nation.

Most of the increase was due to community-associated strains, which rose from 3.6 percent of all MRSA infections in 1999 to 28.2 percent in 2006, the study found.

The increases pose a risk to hospital inpatients, who may become infected by contaminated equipment in surgical centers used for inpatients and outpatients or by the doctors themselves.

The study did not find an increase in hospital-associated strains spreading in the community. 

HealthDay News

Hospital workers who see many patients may play a disproportionate role in spreading dangerous hospital-acquired infections, a new study finds. 

These so-called peripatetic workers, such as radiologists or physical therapists, visit many patients in the course of a day, said Laura Temime, a researcher at the Conservatoire National des Arts et Metiers in Paris, and lead author of a study published online Oct. 19 in the Proceedings of the National Academy of Sciences. 

"Although to my knowledge, an increased super-spreading potential of 'peripatetic' health-care workers has never really been formalized as a major hypothesis, there have been several reports of nosocomial outbreaks that have been traced back to such 'peripatetic' health-care workers," Temime said. 

Her study adds to the evidence, she said. The study used a mathematical model of a hypothetical intensive care unit that was presumed free of the pathogen to see how easily hospital-based infections, such as methicillin-resistant Staphylococcus aureus (MRSA) spread. 

Containing these outbreaks is of grave importance, public health officials agreed. 

For the study, Temime divided workers into three groups -- a nurse-like group, which made frequent visits to a small number of patients assigned to them; a physician-like group, which made infrequent visits to a larger number of patients, and the peripatetic group, which visits all patients daily, such as physical therapists. 

Next, using a complex mathematical model, the researchers assumed how long the patients would stay -- an average of 10 days -- and how much exposure they would have to each of the three categories of workers, plus how compliant the workers were with hand washing. 

Then they computed the impact. They found infection rates increased by up to three times more when a peripatetic worker failed to wash his hands, compared to workers in the other groups. 

The conclusions sound very logical, said Dr. Zachary Rubin, an epidemiologist at Santa Monica-UCLA Medical Center and Orthopaedic Hospital in Santa Monica. However, he added, "this is a mathematical model, and you have to do studies with human beings to see if the data is still true or not." 

Temime said she and her colleagues are doing just that. They are involved in a European project called Mastering Hospital Antimicrobial Resistance (MOSAR), in which data on exposures and bacterial colonization will be collected on patients and health-care workers. "We are planning to use this data to validate our model," Temime said. 

For now, many hospitals are stepping up efforts to promote hand washing among employees. Because the peripatetic workers have "major superspreading potential," the study authors recommend individual surveillance of these health-care workers. 

Rubin said that hospitalized patients shouldn't be shy about asking the health-care workers who come in contact with them to follow infection control guidelines. Some hospitals have posted signs in patient rooms asking "Did your health-care worker wash his hands?" to make patients more aware of the importance of hand washing, he said. 

"If a patient is concerned [about lack of hygiene from a health-care worker], he can always talk to the head nurse or charge nurse," Rubin said, as well as the hospital's patient advocate or his own physician. 

HealthDay News

Want cheaper health care? Consider moving across the state line.  

A new report finds that health-care costs, quality and the ability of people to access care vary widely, depending on where you live. And compared with two years ago, the gap is widening in some places.  

The findings come from a state-by-state scorecard on health care issued by the Commonwealth Fund Commission on a High Performance Health System.

The researchers found that:

·         Fewer adults are covered by health insurance in most states compared with 2007.
·         Health-care costs are rising.
·         Most states are doing a better job of covering children because of the federal Children's Health Insurance Program.
·         Hospitals and nursing homes have dramatically improved in some areas.

The top-performing states, according to the report, are Vermont, Hawaii, Iowa, Minnesota, Maine and New Hampshire. 

"Leading states have raised the bar for better access, quality of care and reducing disparities," Cathy Schoen, Commonwealth Fund senior vice president and a study co-author, said in a news release from the organization. "Where you live in the U.S. matters in terms of your health care, and it shouldn't." 

Major variations surfaced. In Nevada, for example, 23 percent of Medicare beneficiaries returned to hospitals within 30 days of their last stay. The number was only 13 percent in Oregon.  

And in Mississippi, a third of adult diabetics got the recommended preventive care, compared with two-thirds in Minnesota.  

"The differences we see among the states translate to real lives and dollars," Karen Davis, Commonwealth Fund president, said in the news release. "If we can enact health reforms that give all states the opportunity to do as well as the best states, we will save lives, improve quality and cut costs." 

HealthDay News

Patients who don't trust the health-care system are more likely to postpone treatment, potentially hurting their own health and raising overall health care costs, a new study suggests.

Researchers surveyed 401 Baltimore residents, the majority of whom were black, about their attitudes toward the health care system, including doctors, hospitals and insurance companies.

The survey found that people who doubted the trustworthiness of the medical care system were more likely to ignore medical advice, neglect to go to follow-up appointments or to fill prescriptions.

Patients who were suspicious of the system were also more likely to admit to putting off medical care that doctors told them was necessary.

The study will appear online in Health Services Research.

HealthDay News

Attending surgeons and obstetricians/gynecologists who get fewer than six hours of sleep between procedures risk increasing the rate of surgical complications, according to Harvard researchers.

A lot of attention has been paid to the long hours that residents and interns work and the increase in medical errors brought on by their fatigue, but the new study found the same problems among practicing physicians.

"Attending surgeons and obstetricians/gynecologists, like resident physicians and nurses, are vulnerable to the effects of fatigue and extended work shifts on performance and patient care," said Dr. Jeffrey M. Rothschild, a physician at Brigham and Women's Hospital in Boston and the lead researcher on the study.

"The risk of performing post-nighttime cases without sufficient rest may be especially important in hospitals without backup support or house staff physicians to assist a fatigued attending physician," he added.

The report is published in the Oct. 14 issue of the Journal of the American Medical Association.

HealthDay News

Adults with a poor education are also likely to have poor health, a growing body of evidence suggests.

Study after study has confirmed the link, and now experts are zeroing in on the reasons for it and what can be done.

"Persons with a higher education tend to have better jobs, and better income, better benefits," said David R. Williams, a professor of public health at the Harvard School of Public Health and staff director for the Robert Wood Johnson Foundation's Commission to Build a Healthier America.

Those benefits, he said, go beyond health benefits to include such other factors as having the leeway to take a day off or part of a day to see a doctor. People with higher levels of education "tend to have more resources to cope with stress and life, to live in better neighborhoods," Williams said. They have stress, of course, but also more resources to cope with it -- such as access to a health club to exercise away the stress -- than do people with less education, he said.

HealthDay News

Dying hospital patients in the United States are nearly five times more likely to spend their last days in the intensive care unit than patients in England, finds a new study, and U.S. patients over age 85 are eight times more likely to be in the ICU when they die.

That's the conclusion of Columbia University researchers who compared data from England and from seven states (Florida, Massachusetts, New Jersey, New York, Texas, Virginia and Washington).

Of all patients discharged from the hospital, 2.2 percent in England received intensive care, compared to 19.3 percent in the United States, according to the report published in the Nov. 1 issue of the American Journal of Respiratory and Critical Care Medicine.

The death rate among patients who received intensive care in England was nearly three times higher than in the United States (19.6 percent versus 7.4 percent). However, only 10.6 percent of hospital deaths in England involved the ICU, compared with 47.1 percent in the United States. Among patients over 85, 1.3 percent in England received ICU care, compared with 11 percent of those in the United States, the researchers found. Rates of ICU care for young adults and children were similar in both countries.

"These numbers need to be interpreted with caution as the differences in mortality for ICU patients likely reflect the higher severity of illness of patients admitted in the first place in England," lead author Dr. Hannah Wunsch, an assistant professor of anesthesiology and critical care medicine, said in a news release from the American Thoracic Society. "The data do bring up the interesting question of how much intensive care is beneficial. Doing more may not always be better," she added.

"In England, there is universal health care through the National Health Service, and there is also much lower per-capita expenditure on intensive care services when compared to the U.S.," Wunsch said. "The use of intensive care in England is limited by supply to a greater degree than it is in the U.S. and there are consequently implicit and explicit decisions regarding who gets those limited services. We wished to examine what different decisions are made," she explained.

"Whether less intensive care for very elderly patients who are dying is a form of rationing or is actually better recognition of what constitutes appropriate care at the end of life warrants further research," Wunsch said. "These findings highlight the urgent need to understand whether there is overuse of intensive care in the U.S., or under-use in England."

HealthDay News

The emergence of antibiotic-resistant bacteria continues to present a major public health problem, said scientists gathering at one of the world's largest infectious diseases meetings Friday. 

Chief among the concerns are resistant gram-negative bacteria and bacteria that appears to be infecting younger and otherwise healthier people. The troubling trend is compounded by another concerning fact: a paucity of new antibiotics coming down the pipeline, they added. 

"Antibiotic development is dying, and we are running out of drugs. We have organisms that are already resistant to every antibiotic we can throw at them," said Dr. Brad Spellberg, a member of the Infectious Diseases Society of America's (IDSA) Antimicrobial Availability Task Force and an assistant professor of medicine at UCLA. "What will be increasingly seen in the coming decade is a dramatic decline in the availability of new antibiotics, which are desperately needed."

Spellberg spoke during a teleconference from the IDSA annual meeting in Philadelphia. 

Antibiotic resistance, even to new drugs, has become such an issue with nasty gram-negative bacteria that clinicians have had to reach back into the arsenal, resurrecting a drug that hadn't been used much in 20 years, polymyxin. 

But now pathogens are becoming resistant to that drug as well, analysis of lab samples at one New York City hospital showed.

"Although the prevalence of gram-negative bacteria resistant to polymyxin is currently at a relatively low level of around 6 percent, we noted over a relatively short two-year timeframe that the prevalence of resistance to that agent increased by about 50 percent," said Dr. Jason Kessler, lead author of a study detailing the findings, which are scheduled to be presented at the meeting. 

"In addition, amongst all of the isolates we evaluated, more than 30 percent demonstrated resistance to at least five classes of antibiotics, meaning that most of those isolates or most of those bacteria probably could only be treated with polymyxin, suggesting the prevalence of very highly drug-resistant gram-negative infection is on the rise in our facility," added Kessler, who is a clinical fellow in the division of infectious diseases at Columbia University in New York City. 

Other infections are targeting younger people and moving from hospitals into the community and back into hospitals. 

Clostridium difficile, a common hospital infection, for instance, is now hitting people who have not been in the hospital. These patients have a median age of 53, versus a median age of 70 in hospitals, said Dr. Ghinwa Dumyati, lead author of this study and an associate professor of medicine at the University of Rochester School of Medicine and Dentistry.  

It's not clear exactly where these community cases are coming from, but many of the people, although healthy, were taking antibiotics, suggesting that the medications "are still an important factor in the development of C. difficile in the community," Dumyati said. 

Similarly, methicillin-resistant Staphylococcus aureus (MRSA) is causing severe illness in younger, healthy people, although the infections are not resulting in either death or long hospital stays, according to another study. The fact that the patients were younger and healthier may have decreased the risk of death," said study author Dr. Fernanda Lessa, of the U.S. Centers for Disease Control and Prevention. 

MRSA infections in emergency rooms have increased 211 percent between 2000 and 2008, another study found. The incidence in multi-drug-resistant Acinetobacter baumannii, a gram-negative bacteria, is also on the rise, largely in the hospital, said researchers from Henry Ford Hospital in Detroit. 

HealthDay News

Many hospitals don't make it onto the U.S. News & World Report list of best hospitals for heart disease but still perform well in some measurements regarding heart failure, researchers say. 

"If you really want to know how a hospital compares in the areas of heart failure mortality and readmission, you should look directly at government statistics for those measures and not assume that only the hospitals on the list are the best in the care of heart failure patients," senior study author Dr. Harlan M. Krumholz, a professor of medicine and outcomes research at Yale University School of Medicine, said in a news release from the American Heart Association.  

Krumholz and colleagues looked at the magazine's 50 top hospitals for heart disease and compared them with 4,700 other U.S. hospitals using federal data. 

Patients at ranked hospitals were slightly more likely to survive for 30 days after heart failure. But the death rates at these hospitals varied widely, from 7.9 percent to 12.4 percent, the study found. 

"With this list, you're identifying a group that on average does better, but some that are not better than average," Krumholz said.

The ranked hospitals were not better overall by another measure: They scored about the same as non-ranked hospitals when it came to the percentage of patients who were readmitted within 30 days, the researchers found. 

"The ways in which these hospitals are excelling in mortality do not seem to be transferring to excellence in transitioning people from being in the hospital to staying out of the hospital," Krumholz added. 

The study appears online Sept. 1 in Circulation: Cardiovascular Quality and Outcomes. 

HealthDay News

Patients who don't trust the health-care system are more likely to postpone treatment, potentially hurting their own health and raising overall health care costs, a new study suggests.

Researchers surveyed 401 Baltimore residents, the majority of whom were black, about their attitudes toward the health care system, including doctors, hospitals and insurance companies.

The survey found that people who doubted the trustworthiness of the medical care system were more likely to ignore medical advice, neglect to go to follow-up appointments or to fill prescriptions.

Patients who were suspicious of the system were also more likely to admit to putting off medical care that doctors told them was necessary.

The study will appear online in Health Services Research. 

HealthDay News

Scheduling a prime daytime slot to undergo an orthopedic procedure may lower your risk of an unplanned follow-up surgery later on, a new study has found.

The study, published in the September issue of The Journal of Bone and Joint Surgery, found little difference otherwise for healing, recovery time and major complication rates between certain orthopedic surgeries done during the day (between 6 a.m. and 4 p.m.) and those done after hours (4 p.m. to 6 a.m.).

"Although everyone wants to be treated immediately, it may be in a patient's best interest to wait until morning. The reality is that the on-call night surgical team may not be well rested, as it is likely they had just finished a normal day shift," study lead author Dr. William M. Ricci, chief of the Orthopaedic Trauma Service at the Washington University School of Medicine in St. Louis, said in a news release issued by the American Academy of Orthopaedic Surgeons.

The study of 203 surgeries to repair either a fractured thigh or shin bone found a higher incidence of follow-up surgery to remove painful hardware (often a supportive rod called an intramedullary nail fixation that was placed to stabilize the broken bone) in the after-hours patients than the daytime patients -- 27 percent versus 3 percent, respectively.

"The results of the study suggest that the system is working fairly well and it is not always best to rush a patient to the OR in the middle of the night. Naturally, when the medical condition is emergent and time is a critical factor, immediate surgery should proceed regardless of time of day," Ricci said in the news release.

"For non-emergent fracture care, sufficient daytime resources should be made available to avoid unnecessary night-time surgery," he added.  

HealthDay News

Spending on health care is growing so fast that it will devour much more of the American economy in the future and take even larger chunks out of personal income, a new study warns.

Even if spending stops growing so much, it will account for more than half of the increases in the salary that Americans will make over the next 75 years, according to researchers at Harvard University and the University of Michigan.

"These projections make the impact of health care spending more dire," the authors of the study wrote in the September/October issue of Health Affairs.

The study, an update of previous work published in 2003, projects health spending through the year 2083. The researchers estimate that devoting more than half of future personal income growth to health care is "affordable," even though it's not ideal and would pose major challenges for the United States.

The researchers predict that state governments will need to further cut back on education and welfare to pay for health care, and families will also have to cut their own budgets in order to pay for medical services.

In another study in the same issue of Health Affairs, economists estimate that medical technology accounted for between 27 percent and 48 percent of the growth in health spending since 1960, which is less than previous estimates.

HealthDay News

A new study questions the value of hospital report cards and national rankings when it comes to neurology and neurosurgery.

Researchers with Loyola University Health System in Chicago say the mortality index, a statistic to gauge the number of deaths a facility has in a given area of medical care, may be inflated -- indicating a higher-than-normal death rate -- at hospitals that specialize in severe traumas, have busy emergency departments or have high numbers of patients on government-subsidized Medicaid.

"A hospital with a lower mortality index may not be a better hospital for patient care, but rather a place where the patient mix has been refined or limited," study senior author Dr. Thomas Origitano, chairman of the Loyola medical school's department of neurological surgery, said in a university news release.

HealthDay News

Among patients who encounter serious kidney problems while hospitalized, those who require dialysis are not at increased risk of dying if they are able to recover and leave, but they are more likely to need dialysis on a regular basis in the future, researchers say.

According to the authors of a new study published in the Sept. 16 issue of the Journal of the American Medical Association, kidney injuries are common among adults who receive care in hospitals. In many cases, these patients require dialysis, and an estimated 45 percent to 70 percent die while in the hospital.

But little research has been done to find out about what happens to patients if they survive and are able to leave the hospital, the study authors noted.

Ron Wald, of St. Michael's Hospital in Toronto, and colleagues looked at patients in Ontario, Canada, who experienced a kidney injury while hospitalized and required dialysis but survived and didn't need dialysis for at least a month.

After three years, the researchers "found that survivors of a hospitalization complicated by acute kidney injury requiring dialysis were approximately three times more likely to require chronic dialysis compared with those without acute kidney injury. However, no difference was observed between these groups for long-term mortality."

In an accompanying commentary, two doctors stressed that kidney disease shouldn't be neglected. "Given the extraordinarily high rates of morbidity and mortality observed in chronic kidney disease patients and acute kidney injury patients, the complex interconnection between them, and increasing incidence of both, kidney disease prevention and treatment should be a major public health priority." 

HealthDay News

Among acutely ill patients who travel by emergency air transport, one in 20 experience a "critical event" -- they die, suffer from dangerously low blood pressure or need to be resuscitated, Canadian researchers have found.

Women are at special risk, as are those with heart disease, traumatic injuries and other problems, according to the study by Dr. Jeff Singh, of the University Health Network in Toronto, and colleagues.

The observation that women are more at risk of adverse events "may be attributable to differences in disease presentations, differential treatment or differences in referral patterns and transport requests between men and women," the study authors explained in a news release from CMAJ, the Canadian Medical Association Journal.

The study looked at 19,228 adults who were transported by air in Ontario, Canada. The researchers found that better preparation before the patients were transported could have prevented many of the problems.

"This data may provide insight for medical crew training regarding likely in-flight medical management scenarios, or markers for more robust stabilization of patients by hospital staff preparing patients for transport," Dr. Alex Isakov, of the department of emergency medicine at Emory University in Atlanta, wrote in a commentary accompanying the study. "It may also help in the development of evidence-based criteria for dispatch."

The study findings appear in the Sept. 14 issue of CMAJ.

HealthDay News

Patients in intensive care units often have little chance to move around, putting them at risk of muscle wasting and threatening their prospects of recovery. But new research now suggests that mild physical-therapy exercises could boost their chances of getting better.

"Our ICU patients are telling us that they want to be awake and moving. Gone are the days when we should only think of critically ill patients on complete bed rest," said Dr. Dale Needham, a physician at Johns Hopkins Medicine and senior researcher of a report published online Sept. 21 in the journal Critical Care Medicine, in a news release from Johns Hopkins.

Needham previously published research that said most patients suffer from extended fatigue and extensive recovery after undergoing bed rest in the ICU.

The new report lists muscle-strengthening exercises that patients can attempt despite being critically ill. They include walking, undergoing electrical stimulation to the legs, and cycling in bed using a special stationary device.

Needham's team, including two physical therapists, have tested the exercises on more than 400 patients at the Johns Hopkins ICU.

The results of the research are preliminary and need to be confirmed over longer periods of time. But the study authors found that patients who exercised appear to be leaving the hospital sooner, stronger and happier, according to the news release.

The researchers will continue their work by testing the long-term effects of the exercises on patients at a number of hospitals.

HealthDay News

Fatigue isn't the only contributor to medical errors among medical residents. A new study finds that financial woes, family concerns and other elements of distress also play a major role in potentially fatal mistakes.

Fatigue and distress among doctors are known causes of medical errors, but Mayo Clinic researchers say that theirs is the first study to show how each contributes to mistakes. And they recommend that distress be considered independently of fatigue when new training guidelines are considered.

"Changes to the process of physician training should address both resident fatigue and distress to improve resident and patient safety as both factors independently increase the risk of self-reported major medical errors," said lead researcher Dr. Colin P. West, a internist at the Mayo Clinic in Rochester, Minn.

Fatigue, along with lower quality of life, burnout, depressive

symptoms and other signs of distress, independently led to increased

rates of self-reported major medical errors among internal medicine residents, West said.

"In fact, common levels of fatigue and distress are associated with double or triple the risk of these errors," he said.

This is an important distinction, West said, because most current efforts to reform medical training that are intended to promote resident and patient safety have focused on fatigue.

"Our results support this, but suggest that specific attention to promoting resident well-being is needed as well," he said. "We don't know enough about effective ways to promote physician well-being, however, and further research is needed to answer this question."

The report is in the Sept. 23/30 issue of the Journal of the American Medical Association.

HealthDay News

Even an advanced, computerized medical-record system with alerts cannot guarantee that patients will receive timely follow-up care when imaging tests turn up signs of trouble, new research suggests.

"Our findings suggest that an electronic medical record that facilitates transmission and availability of critical imaging results to the health care provider through either automated notification or direct access of primary report does not eliminate the problem of missed test results even when one or more health care providers read the results," write the authors of a study in the Sept. 28 issue of the Archives of Internal Medicine.

HealthDay News

More than half a million kids a year are treated for medication side effects in American outpatient clinics and emergency rooms, according to new data.

Researchers at Children's Hospital Boston analyzed National Center for Health Statistics outpatient data between 1995 and 2005. Among children up to age 18, there were 585,922 visits a year for adverse drug events (ADEs). Most visits were to outpatient clinics, but 22 percent were to hospital emergency departments.

"We found that there are as many as 13 outpatient visits for adverse drug events per 1,000 children, indicating that they are a common complication of pediatric care," study leader Dr. Florence Bourgeois, of Children's division of emergency medicine, said in a news release.

The majority of visits were by children 4 and younger (43 percent), followed by youngsters aged 15 to 18 (23 percent). Skin-related (45 percent) and gastrointestinal (16.5 percent) were the most common types of side effects, and 52 percent of the children had symptoms that suggested an allergic reaction.

Antimicrobials such as penicillin were the most frequently implicated drugs. They were involved in 27.5 percent of all visits and in as many as 40 percent of visits by children under 4.

HealthDay News

PLEASE, for the sake of your family, execute your Advanced Directives and place them in the hands of your healthcare surrogate and primary care physician…

 When deciding whether to turn off life support for a loved one, family members aren't always interested in their doctor's advice, new research shows.

 The finding runs counter to assumptions among critical-care providers that families making such a heart-wrenching choice would welcome a physician's impartial opinion.

Critically ill patients who don't have advance directives often require others to make medical decisions for them, said study author Douglas B. White, of the University of Pittsburgh Medical Center.

Family members often make the decision based on what they believe the patient would have wanted.

"This puts an enormous emotional burden on surrogates; not only are they losing a loved one, they also may feel burdened by guilt about allowing the patient to die," White said. "It was therefore assumed by some in the medical community that a doctor's dispassionate advice could reduce some of that burden and help surrogates make a good decision with less second-guessing themselves."

Researchers showed videos to 169 surrogates recruited from intensive care units at University of California San Francisco Medical Center. The videos depicted a dramatized "family conference" in which surrogates must decide whether to withdraw life support from a loved one who has a small chance of survival with continued treatment, but a high likelihood of being functionally impaired and needing a ventilator.

In one video, the doctor tells the surrogate to make the choice that's consistent with the patient's values, and that only the surrogate knows what that is. In the second video, the doctor tells the surrogate that the patient probably wouldn't want continued attempts to keep him or her alive.

About 56 percent of surrogates said they preferred the video in which the physician offered an opinion to limit life support, while 42 percent preferred the video in which no recommendation was offered. Two percent had no preference.

The study appears in the August 15 issue of the American Journal of Respiratory and Critical Care Medicine.

 HealthDay News

Many parents worry that their child may be the victim of medical errors while in the hospital, a new study has found. 

In a survey of 278 parents of children hospitalized in 2005 at Seattle Children's Hospital, nearly two-thirds reported feeling the need to watch over their child's care to ensure there were no medical errors. 

Parents whose first language was not English were most likely to say they needed to be vigilant about their child's care. The study also found that parents who felt more confident about talking with doctors were less likely to be worried about medical errors.

 The findings were published in a recent issue of the Journal of Hospital Medicine. 

"We need to address parents' concerns about errors and find ways to make them feel comfortable talking to us about their child's care," Dr. Beth A. Tarini, an assistant professor of pediatrics at the University of Michigan Medical School and the study's lead researcher, said in a university news release. "Parents are an underutilized resource in our efforts to prevent medical errors." 

Medical errors are linked to 48,000 to 98,000 deaths a year in the United States, according to the Institute of Medicine. Medical errors also increase length of hospital stay and health-care costs. 

Parents can help prevent medical errors by being an active and informed member of their child's health-care team and by taking part in every decision about their child's health care, says the U.S. Agency for Healthcare Research and Quality. 

Quick defibrillation can increase the chances of survival for hospital patients who have cardiac arrest, but sometimes the treatment is not quick enough and a new study has found that the delays are not due to overloaded or undereducated staff. 

Defibrillation is a process in which an electronic device gives the heart an electric shock. This helps restore normal contraction rhythms in a heart having dangerous arrhythmia or in cardiac arrest. The American Heart Association recommends that defibrillation be performed within two minutes of cardiac arrest. The longer the delay, the less chance the patient has of surviving. 

Previous studies have linked delays to other factors, such as being admitted to the hospital for something other than heart problems or having cardiac arrest at night or on weekends. 

But in this study, experts analyzed records from 7,479 adult in-patients with cardiac arrest at 200 U.S. hospitals. The hospitals completed a detailed survey that included information about the location, hospital teaching status, number of patient beds and the availability of automatic external defibrillators. 

The rates of delayed defibrillation -- a delay being longer than two minutes -- varied from 2.4 percent to more than 50 percent between hospitals, according to the report in the July 27 issue of Archives of Internal Medicine. 

Differences between hospitals accounted for a great deal of the variation, the researchers found. In one example, patients with identical characteristics had a 46 percent higher chance of having a delayed defibrillation at one hospital compared with another. 

Patients at hospitals with fewer defibrillation delays were less likely to die in the hospital. The odds of survival were 41 percent higher in the 25 percent of hospitals with the lowest rates of delays when compared with the 25 percent of hospitals with the most delays, according to the study. 

The findings mystified the researchers. 

"Many of the individual hospital characteristics that we explored -- such as volume, academic status and hospital-wide mortality rate -- were unrelated to hospital performance in defibrillation time," the authors wrote. "This lack of correlation between 'conventional' hospital-level factors and defibrillation time suggests that other unmeasured characteristics are responsible for certain institutions achieving extremely low rates of delayed defibrillation." 

An estimated 50 million, or 42 percent, of the 120 million visits made in 2006 to U.S. hospital emergency departments were billed to the Medicaid and Medicare programs, according to a U.S. government report released Thursday. 

Uninsured patients accounted for nearly 18 percent of emergency department visits nationally, 34 percent were billed to private insurance, and 6 percent were billed to worker's compensation, military health plan administrator Tricare, and other payers, according to the latest News and Numbers from the U.S. Agency for Healthcare Research and Quality. 

Among the other findings:

·         Of the 24.2 million emergency department visits billed to Medicare, 38.3 percent ended with the patients being admitted, compared with 11.2 percent of the 41.5 million visits billed to private insurers, 9.5 percent of the 26 million visits billed to Medicaid, and 6.8 percent of the 21.2 million visits by the uninsured.
·         Uninsured patients were the most frequent users of hospital emergency departments. Their rate of 452 visits per 1,000 people was 1.2 times greater than the rate of 367 per 1,000 people among patients with public or private insurance.
·         The "treat-and-release" rate for uninsured patients was 421 visits per 1,000 people, compared with 301 visits per 1,000 for those with insurance. This is a possible indication that people without insurance use hospital emergency departments as their usual source of care.

 The study is based on an analysis of data from the 2006 Nationwide Emergency Department Sample, which contains records of emergency department visits from about 1,000 community hospitals nationwide. The hospitals account for 20 percent of all U.S. hospital emergency departments.

Even if Congress extends health coverage to the nation's 46 million uninsured Americans, there's no guarantee that everyone will have access to care -- unless payment reforms and new models of care are adopted, some experts say. 

Significantly expanding coverage without reforming health-care delivery is "a recipe for failure," said Alwyn Cassil, a spokeswoman for the Center for Studying Health System Change in Washington, D.C. "You won't be able to sustain the expanded coverage because it will just bankrupt us." 

Spending on health care this year is projected to reach $2.5 trillion, or 17.6 percent of the U.S. gross domestic product, according to a Kaiser Family Foundation analysis of Medicare and Medicaid data. That's up from 7.2 percent in 1970, and by 2018 it could swell to one-fifth of the GDP, which is a measure of all goods and services produced in the United States. 

Meanwhile, a worsening shortage of primary-care providers and rising demand for certain specialists will continue to strain the system, perhaps creating long waits for appointments. 

The existing health-care delivery system cannot seamlessly respond to a surge in demand for services, said Jeffrey Bauer, a medical economist. 

This is "one of the Achilles heels of reform," said Bauer, management consulting partner at Affiliated Computer Services Inc. and leader of the health futures practice at ACS Healthcare Solutions in Chicago. 

"People are already strapped to get a doctor," Bauer said. "As more people have insurance, they will try to get appointments with more doctors, and that will lead to dramatic increases in the time it takes to get an appointment." 

A French study estimates that more than 12 percent of people discharged from a hospital into home health care are infected with MRSA, or methicillin-resistant Staphylococcus aureus, and about 20 percent of them may transmit the organism to others in their household. 

The researchers, Dr. Jean-Christophe Lucet, of Bichat-Claude Bernard Hospital in Paris, and his colleagues, screened 1,501 hospitalized adults for MRSA before they were discharged and found that 191 (12.7 percent) were infected. For the next year, those found to be infected and other people in their households were checked for MRSA every three months. 

The 191 people with MRSA had 188 household contacts who took part in the study. Of those contact, 36 (19 percent) acquired MRSA, but none of them developed an infection. People most likely to be colonized with MRSA included those who were older and those who helped provide health care for the infected person. Sharing the same bed or bedroom did not increase the risk of MRSA transmission, according to the study. 

The findings suggest that MRSA transmission is most likely among people who are at high risk for hand contamination while caring for people, the study's authors noted. 

Because no infections developed in any of the household contacts who acquired MRSA, it's not clear whether such transmission poses a serious public health problem, the researchers said. Regardless, "household contacts should apply infection control measures similar to those recommended in the hospital setting," they wrote. 

Of the people discharged from the hospital with MRSA, about half of those followed for a year were found to be clear of infection, especially those who had become more self-sufficient in daily activities, the researchers said. 

The study is in the Aug. 10/24 issue of Archives of Internal Medicine. 

A decade-long, government-led effort has reduced the death rate for patients hospitalized for heart attacks and improved the performance of hospitals that deal with these daily emergencies, a nationwide study finds. 

Between 1995 and 2006, the in-hospital death rate for Medicare patients treated for heart attacks decreased, from 14.6 percent to 10.1 percent, while the 30-day death rate in such cases dropped from 18.9 percent to 16.1 percent, according to a report in the Aug. 19 issue of the Journal of the American Medical Association.

For the study, a team of cardiologists reviewed the outcomes of more than 2.7 million cases reported by more than 500 hospitals. Over the same period, the 30-day death rate for all other conditions barely changed, from 9 percent in 1995 to 8.6 percent in 2006, the report noted. 

While the decade saw major advances in the drugs and techniques used to treat heart attacks, the key element in the overall improvement was the effort by what was then the Health Care Finance Administration and now is the Center for Medicare & Medicaid Services (CMS), said study author Dr. Harlan M. Krumholz, a professor of medicine at Yale University School of Medicine.

"What CMS did was critical," Krumholz said. While other organizations, such as the American Heart Association (AHA) and the American College of Cardiology, also emphasized good heart care in hospitals, "I don't think it would have happened without a shift by Medicare in saying, 'We have to look at the entire group of hospitals'," he said. 

Until the early 1990s, "the whole idea of quality improvement was to find the bad apples," he said. "The pivotal point was Medicare saying, 'We're not going to focus only on the outliers'."

There were plenty of outliers -- hospitals whose heart attack treatment results lagged behind the outcomes of most others. In the 1990s, heart attack death rates of more than 24 percent were noted at 39 hospitals. In 2006, no U.S. hospital reported such a high rate, and the death rate in the worst 1 percent was 19.5 percent.

Overall, the difference between the results obtained at all hospitals narrowed considerably, from 4.4 percent to 2.9 percent.

Improvement was achieved without coercion, with CMS simply keeping hospitals informed of what could be done, said AHA President Dr. Clyde W. Yancy, director of the Baylor Heart and Vascular Institute in Dallas. This was helped by a legislative mandate requiring hospital reporting of data.

"One of the best strategies to influence behavior is to make a facility or individual physician aware of their own results," Yancy explained. "Medicare was making individual centers aware of their own information." 

Other striking changes also occurred during the decade. The average hospital stay for a heart attack decreased by nearly 16 percent, from 7.9 days in 1995 to seven days in 2006. Many more survivors were sent to a skilled nursing facility or intermediate care center instead of straight home -- 9.3 percent in 1995-96 vs. 17.4 percent in 2006.

The focus on improvement also came at a unique time in the history of cardiology, when major advances in heart attack treatment became available, Yancy said. 

"There has to be an alignment in the process of care development and the methods used to measure outcome," he said. "You need the best science and the best process of instilling the implementation of these developments." 

Because similar medical advances are not being made across the board, the program that improved heart attack treatment results won't necessarily apply to all cardiac patients, Yancy said. Notably, no such improvement has been seen in people hospitalized with heart failure, the progressive loss of ability to pump blood that can be life-threatening, he said. 

"In heart failure, we don't see nearly the same reduction," Yancy said. "We actually don't have much evidence about how to improve pivotal-point care in heart failure. The result in advanced heart failure has been negative." 

From 1999 to 2008, family premiums for Americans with employer-sponsored health insurance increased 119 percent and could rise another 94 percent, to an average of $23,842 by 2020, if health-care costs continue to increase at current rates, a report released Thursday shows. 

The Commonwealth Fund paper also concluded that national reforms that limit health-care cost increases by 1 percent to 1.5 percent per year would lead to major savings for families and businesses. For example, slowing the annual rate of health spending growth by 1 percent would achieve more than $2,500 in lower family premiums, and reducing the rate of growth by 1.5 percent would lead to more than $3,700 in premium savings compared to current trends. 

"With health spending projected to double if we stay on our current path, middle- and lower-income families are at high risk of losing their coverage or facing long-term stagnant incomes," study author Cathy Shoen, senior vice president of the Commonwealth Fund, said in a news release. "Employers and employees share premium costs, but we know that take-home pay and retirement savings are being sacrificed to maintain health benefits. Reforms that slow the growth of health-care costs could go a long way toward health and financial stability for working families." 

The Commonwealth Fund is a private foundation that supports independent research on health issues. 

A state-by-state analysis revealed that employer-based premiums for family coverage increased an average of 33 percent between 2003 and 2008, ranging from a low of 25 percent in Michigan, Texas and Ohio to a high of 45 percent in Indiana and North Carolina.

In 2008, family premiums were highest in Indiana, Massachusetts, Minnesota and New Hampshire, with the highest premium being more than $13,500. The lowest average premiums -- around $11,000 -- were in Idaho, Iowa and Hawaii. 

"These rapid premium increases aren't sustainable for families or employers," Commonwealth Fund President Karen Davis said in the news release. "If we craft patient-centered reform that focuses on improving quality and efficiency, and bending the cost curve, the insured in every state stand to benefit. We could assure coverage and, over time, make more money available for wages, retirement and other family needs." 

A surgeon's experience doesn't affect trauma patients' chances of survival if they're treated within a structured trauma program, according to a new report.

In the study, researchers examined deaths among almost 14,000 trauma patients treated at the Johns Hopkins Hospital in Baltimore over 10 years (1994-2004). This period included years before and after the hospital hired a highly experienced trauma surgeon to serve as trauma program director.

During the first 3.5 years, 4,499 patients were treated by novice surgeons. During the remaining years, novice surgeons treated 5,783 patients while the experienced surgeon treated 3,612 patients. There were no differences in death rates between patients treated by novice surgeons during the latter years and patients treated by the experienced surgeon, the researchers found.

Patients treated by novice surgeons were 44 percent less likely to die after the hiring of the experienced surgeon as trauma program director.

"Together, these data support the belief that in a structured trauma program, surgeons with vastly different levels of training can safely provide care and obtain equivalent outcomes," the Johns Hopkins University School of Medicine researchers concluded.

"System effects outweigh any potential benefits of individual surgeon experience in the care of trauma patients. The implementation of an organized trauma program with evidence-based protocols and senior surgical guidance may have a greater effect on mortality than individual surgeon experience alone."

The study appears in the August issue of the Archives of Surgery.

 HealthDay News

Minority and low-income Americans are much more likely to suffer from a chronic, debilitating illness than whites and are far less likely to have the kind of coverage that would ensure quality care, according to a new report issued Tuesday by the U.S. Department of Health and Human Services.

For example, nearly half (48 percent) of black adults suffer from some form of chronic condition compared to 39 percent of adults generally, the report found, and one in every five black Americans lacks health insurance, compared to one in every eight whites.

Minorities and low-income Americans are more likely to be sick and less likely to get the care they need," HHS Secretary Kathleen Sebelius said in an agency news release. "These disparities have plagued our health system and our country for too long."

Despite spending $2.2 trillion on health care in 2007 alone, there are still big gaps in the care of white and minority patients as well as rich and poor patients, the HHS report noted.

Some of the other findings from the new report:

• Black Americans are more likely to die from cancer than any other racial or ethnic group. Black men are 50 percent more prone to prostate cancer, for example, than white men.
• While about 9 percent of whites develop adult-onset diabetes, that number rises to 14 percent for Hispanics, 15 percent for blacks, and 18 percent for American Indians.
• Obesity, which is a major risk factor for diabetes, remains much higher among minorities than among whites. For example, 70 percent of black American adults are now obese or overweight.
• Cancer screening rates remain lower for minority and/or poor patients. For example, low-income women are 26 percent less apt to receive a regular mammogram than more affluent women.
• There were even disparities in terms of routine doctor visits. Hispanic and black Americans were much less likely to have a regular primary care physician compared to whites, and black Americans were twice as likely as whites to use a hospital emergency department as a source of medical care.

Much of these disparities come back to a gap in access to health care coverage, the report noted. Among low-income Americans, 4 out of 10 people lack health insurance. In fact, half of America's 46 million uninsured are poor, the HHS report found.

One-third of the uninsured have a chronic illness and they are six times more likely to go without needed care for that condition compared with those who have insurance.

 HealthDay News

• Make sure the facility is accredited by JCI or an equivalent standard-setting organization in the destination country.
• Local laws that mandate procedures for paramedics and other responders
• Insurance policies that allow higher reimbursement when someone is taken to a hospital
• Public misperception about the odds of survival

1. Talk with your doctor. Ask whether it's safe to delay the treatment or procedure. A delay, if approved by your doctor, is an especially good idea if you or a spouse is in line for a job that will pay health benefits or if you've maxed out your flexible spending account for the year.
2. Compare hospital costs. Some insurance company Web sites, such as those for Cigna and Health Net, can tell you what many area hospitals charge insurers. If you have insurance and have to pay a percentage of the bill, finding the least expensive hospital can lower your share. If you don't have insurance, and thus don't have access to an insurer's site, you can get similar data from for-profit companies and use it to negotiate with a hospital. HealthGrades.com charges $7.95 for reports that give the average cost of what an insurer is charged and what the average charge is from a hospital in a region.
3. Get your insurer's OK. Insured patients, once you've settled on a hospital, contact your insurer to get approval for the care (not doing so could mean the insurer will refuse to pay) and to see what it will cover. Some billing experts recommend having your doctor detail the procedure and any pre- and post-care you may need, in writing, for the insurer. Add a copy of that to the file you should be keeping; having paperwork can help rectify any billing errors that come up later.
4. Factor in the hospital deductible. Hospital stays typically have their own deductible, which could be $1,000 or higher, separate from the one you pay for outpatient care.
   
   Expect hospitals to ask for the deductible and any other patient share of the bill on or before service. You don't always have to pay the deductible or your share of the hospital bill immediately, but you do have to come up with a plan to pay it off, says Bernadette Lodge-Lemon, head of patient business services at UCLA.
   
   Cautions Rukavina: "Try to avoid using a credit card to pay a hospital bill, unless you're sure you'll be able to pay it off in full by the due date." Letting the credit card bill go past one cycle adds interest fees and could increase your interest rate. A better idea is to ask the hospital for a no-interest rate payment plan.
   
   If you can't foot your share of the bill, hospitals might be able to discount your deductible, co-pay or co-insurance if you qualify under its financial screening process.
5. Check out possible assistance. If you're not insured, meet with a financial counselor at the hospital as soon as possible. Charity care, discounts and government programs may be able to help. Some hospitals even offer discounts to uninsured and insured patients with incomes higher than 350 percent of the federal poverty level, so do ask.
6. Get an itemized statement. Insured patients will typically get a summarized billing statement; the insurer gets more specific cost information. Request an itemized bill. More than 50 percent of hospital bills reviewed by his company has errors in them, says Jason Beans, head of Rising Medical Solutions, a patient billing consulting firm in Chicago. Errors can include errant decimal points, charges for procedures not done, even care on days you weren't in the hospital.
7. Is a hospital trip necessary? Consider having some tests and procedures, such as colonoscopies, MRIs and CT scans, done in independent centers, which can save hundreds of dollars.
8. Don't ignore it. Ignoring that bill will result in it being turned over to a collection agency. "Pay your bills, even if you can only afford to pay a little at a time," says Rukavina.

David Boucher celebrated his 50th birthday this year by jetting to Bangkok for his first colonoscopy.

There he was seen by a California-educated physician and no shortage of nurses, who verified his identity 15 times before the procedure.

To be sure, Boucher had a secondary motive: He is founder and president of Companion Global Healthcare, a subsidiary of Blue Cross Blue Shield of South Carolina that includes in its network 13 hospitals around the world that have been accredited by the Joint Commission International (JCI).

The JCI, which calls itself the "Good Housekeeping Seal of Approval," has accredited more than 170 hospitals outside of the United States.

An estimated 6 million Americans are traveling each year to such countries as India, Costa Rica, Mexico and Thailand in search of less-expensive treatments for simple and complex procedures. Even France and Belgium tend to be cheaper than the United States.

"People are going abroad for necessary medical treatments such as knee and hip replacements and cardiac procedures," said Devon Herrick, senior fellow with the National Center for Policy Analysis, in Dallas. "And in many countries, especially places like India, the quality is very high and the price can be up to 80 percent less expensive."

And that often includes the airline ticket.

Major U.S. health-care players are jumping on the train, including BlueShield of California. Its "Access Baja" health plan caters to Americans and Mexicans wanting to get medical care in northern Mexico. BridgeHealth International, based in Denver, also has an overseas network.

What's driving the trend?

"The cost of health care in the U.S., combined with the fact that we have a shortage in this country of physicians and, probably more acutely, nurses," responded Boucher. "At the same time, 2008 was the first year of the 'silver tsunami,' with Americans turning 62 at [a rapid] rate," he noted.

"Over half of folks turning 62 opted for early Social Security, and most do not have an employer-sponsored medical program," Boucher added. "There's going to be a sharply increasing number of people that need bypass surgery and hip and knee replacements."

According to the National Center for Policy Analysis, costs for treatment abroad can be as little as one-half to one-fifth the going rate in the United States. As an example, it cited New Delhi's Apollo Hospital, which charges $4,000 for heart surgery, compared with an average of $30,000 in the United States.

A "nose job" might cost $850 in India and $4,500 in the United States. An MRI in Brazil, Costa Rica, India, Mexico, Singapore or Thailand ranges from $200 to $300, but it can be three or four times that much stateside.

To be sure, the trend can have a downside. According to one study from researchers at the David Geffen School of Medicine at the University of California, Los Angeles, people getting kidney transplants overseas tend to experience more complications, including rejection of the organ and severe infections, than do people opting to undergo the procedure in the United States.

And what happens with follow-up care once a so-called medical tourist returns to the United States? And which country's laws prevail if there's a problem?

For the most part, those questions have no standard answers, leaving each person to resolve the issues, and any similar ones, that might come up.

But Herrick says that a little planning and common-sense precautions can minimize the risks. He advises anyone contemplating medical treatment abroad to:

• Make sure the facility is accredited by JCI or an equivalent standard-setting organization in the destination country.
•  Check the credentials of the physicians; many doctors in other countries have been trained in the United States, Europe, Japan, Australia and New Zealand.
• Find a good intermediary to help choose the right facility in the right country. Some hospitals overseas have lower mortality rates than those in so-called developed nations.
• Compare outcomes with other institutions, regardless of where you go.

Herrick said that cost and quality-of-care tend to be higher in Singapore than in Thailand or India, but all three offer extremely good quality and could be considered for more complex procedures.

But he suggested that people go somewhere closer to home -- such as Costa Rica or Mexico -- or stay in the United States for procedures that are generally less exorbitant. Airfare and hotel costs can be prohibitive. Also, Herrick said, "most people would prefer to find a place not quite so far away as a 16-hour plane ride."

Traveling to other countries for medical care "is in its infancy," Herrick said. "I don't think any insurer is doing it in a major, major way. People are testing the waters slowly. Most of the interest really seems to lie with self-insured plans."

According to a small survey conducted by the International Foundation of Employee Benefit Plans, about 11 percent of employers offer overseas benefit options, although it was unclear how extensive the benefits were or if employees were using them.

The The goal, proponents of the concept say, is for everyone -- patients, employers, insurance companies -- to end up paying less

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