Friday, 6 April 2012

Hospitals are not Hotels... by Theresa Brown published in NYT

Interesting and a different view coming from a prolific writer on patient's care in USA. Raises interesting points on what should considered as benchmarks of care in Indian healthcare senario especially in the corporate hospitals where "patients" are now usually reffered to as Customers or Clients.-- read the article below

YOU should never do this procedure without pain medicine,” the senior surgeon told a resident. “This is one of the most painful things we do.”
She wasn’t scolding, just firm, and she was telling the truth. The patient needed pleurodesis, a treatment that involves abrading the lining of the lungs in an attempt to stop fluid from collecting there. A tube inserted between the two layers of protective lung tissue drains the liquid, and then an irritant is slowly injected back into the tube. The tissue becomes inflamed and sticks together, the idea being that fluid cannot accumulate where there’s no space.
I have watched patients go through pleurodesis, and even with pain medication, they suffer. We injure them in this controlled, short-term way to prevent long-term recurrence of a much more serious problem: fluid around the lungs makes it very hard to breathe.
A lot of what we do in medicine, and especially in modern hospital care, adheres to this same formulation. We hurt people because it’s the only way we know to make them better. This is the nature of our work, which is why the growing focus on measuring “patient satisfaction” as a way to judge the quality of a hospital’s care is worrisomely off the mark.
For several years now, hospitals around the country have been independently collecting data in different categories of patient satisfaction. More recently, the Centers for Medicare and Medicaid Services developed the Hospital Consumer Assessment of Healthcare Providers and Systems survey and announced that by October 2012, Medicare reimbursements and bonuses were going to be linked in part to scores on the survey.
The survey evaluates behaviors that are integral to quality care: How good was the communication in the hospital? Were patients educated about all new medications? On discharge, were the instructions the patient received clear?
These are important questions. But implied in the proposal is a troubling misapprehension of how unpleasant a lot of actual health care is. The survey measures the “patient experience of care” to generate information important to “consumers.” Put colloquially, it evaluates hospital patients’ level of satisfaction.
The problem with this metric is that a lot of hospital care is, like pleurodesis, invasive, painful and even dehumanizing. Surgery leaves incisional pain as well as internal hurts from the removal of a gallbladder or tumor, or the repair of a broken bone. Chemotherapy weakens the immune system. We might like to say it shouldn’t be, but physical pain, and its concomitant emotional suffering, tend to be inseparable from standard care.
What’s more, recent research suggests that judging care in terms of desirable customer experiences could be expensive and may even be dangerous. A new paper by Joshua Fenton, an assistant professor at the University of California, Davis, and colleagues found that higher satisfaction scores correlated with greater use of hospital services (driving up costs), but also with increased mortality.
The paper examined patient satisfaction only with physicians, rather than hospitals, and the link between satisfaction and death is obviously uncertain. Still, the results suggest that focusing on what patients want — a certain test, a specific drug — may mean they get less of what they actually need.
In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can’t, at the expense of what it should.
To evaluate the patient experience in a way that can be meaningfully translated to the public, we need to ask deeper questions, about whether our procedures accomplished what they were supposed to and whether patients did get better despite the suffering imposed by our care.
We also need to honestly assess our treatment of patients for whom curative care is no longer an option.
I had such a patient. He was an octogenarian, but spry, and he looked astoundingly healthy. He’d been sent to us with a newly diagnosed blood cancer, along with a promise from the referring hospital that we could make him well.
But we couldn’t. He was too old to tolerate the standard chemotherapy, the medical fellow on duty told him. When I came into his room a little later he said to me, with a stunned and yearning look, “Well, he made it sound like I don’t have a lot of options.” The depth of alienation, hopelessness and terror that he was feeling must have been unbearable.
The final questions on the survey ask patients to rate the hospital on a scale from worst to best, and whether they would recommend the hospital to family and friends. How would my octogenarian patient have answered? A physician in our hospital had just told him that he would die sooner than expected. Did that make us the best hospital he’d ever been in, or the worst?
Hospitals are not hotels, and although hospital patients may in some ways be informed consumers, they’re predominantly sick, needy people, depending on us, the nurses and doctors, to get them through a very tough physical time. They do not come to us for vacation, but because they need the specialized, often painful help that only we can provide. Sadly, sometimes we cannot give them the kind of help they need.
If the Centers for Medicare and Medicaid is to evaluate the patient experience and link the results to reimbursement, it needs to incorporate questions that address the complete and expected hospital experience. It’s fair and even valuable to compare hospitals on the basis of how well they maintain standards of patient engagement. But a survey focused on “satisfaction” elides the true nature of the work that hospitals do. In order to heal, we must first hurt.

Monday, 19 March 2012

Recent advances in knee replacement surgery-- Techniques and Technology


Total knee replacement surgery has been a safe and effective surgery for treatment of advanced stages of knee arthritis. It has been in use for many decades and over the years many advances in technology, surgical techniques and material have enabled this surgery to become even more precise with better and longer lasting  results and allow quick recovery. I have attempted to explain some of these advances in simple words

Advancement in Technology--Computer Navigated Knee Surgery

Computer navigation in total knee replacement has been in clinical use for last 10 years in US and UK and it attempts to correct some of the problems faced in traditional total knee replacement. Accurate placement of a knee replacement is one of the most important predictors of longevity of knee replacement. Minor misalignment can lead to early loosening, early polyethylene wear and poor function. Computer navigation allows the surgeon to accurately check and adjust, if necessary, each step along the way, whilst performing the knee replacement, which still allows the surgeon to exercise his skill and judgement for optimal positioning of the implant.

The computer navigation system works by combining computers, infrared cameras and instruments that reflect infrared light back to the camera. This permits the surgeon to finely adjust the position of the new knee with certainty, so that he or she can orientate the replacement joint to function optimally. The surgeon is always in control of the operation and only uses the computer to provide information on where to place the new knee.

When using the computer navigation system, pins are required, to be temporarily inserted into the bone; they are then removed once the new knee is inserted. This requires two very small (half a cm long) additional incisions to be made on the skin over the shin bone in addition to the standard scar used to insert the new knee, which is over the front of the knee.

Numerous studies have shown that the information from the computer navigation provides patients with a more precise operation to those performed with the standard instruments. It was thought to be a breakthrough technological advance, however one of the main reasons why this technology is not more widespread is that it can take longer to perform the surgery using the computer navigation system, additional costly equipments are needed and it needs two small additional incisions. Some of the drawbacks of this technology are now addressed by Patient matched instruments which is described below.

Advancement in Technology--Custom made Instruments/Patient matched Instruments

One of the most recent recent advancement is the development is Patient Matched Instrumentation. These patient-specific surgical instruments are custom made for the precise alignment of patient’s knee, potentially increasing implant longevity.
This techniques requires MRI (Magnetic Resonance Images) and X-Ray images of patient’s affected leg into an advanced web-based software program, which will generate virtual images of the knee. Surgical instruments and guides are then designed and built, mapping out specific bone cuts to accurately align the implant to the knee. These knee instruments are specifically made as per the size and shape of the patient’s  knee bones and take 6 weeks to get ready.
There are several distinct advantages of this technology. It removes multiple steps from the traditional surgical technique and shortens surgical time as most of the planning about size and placement of implants takes place preoperatively using computer software programme.  This may lead to less blood loss and a lower risk of infection.

 Patient Matched instruments allow surgeon to achieve precise alignment of the knee implants, potentially reducing wear – a leading cause of early implant failure.Customized instruments enable a less invasive surgical procedure which can reduce soft tissue and muscle damage which may speed the recovery time.

A knee implant accurately aligned may not only feel more natural, but may also last longer than traditional knee replacements.

Advancement in technique-Minimally Invasive Knee (MIS) surgery

 I don’t think minimally invasive surgery is the kind of “disruptive technology” that is going to revolutionize total knee replacement, which is already a safe, effective, time tested operation. The gains, if any, are likely to be marginal, and I think these other approaches to postoperative care can probably match them. So my advice to the patients is to not to focus on the length of the incision because it will be irrelevant within 2-3 months of surgery! What would really matter in the long term would be the position of their implants !!!  Advances in technology like computer navigated  surgery  and patient matched instruments are helpful for the surgeon to achieve this goal.

Advancement in materials—Highly crosslinked Polyethylene and Ceramic implants

The plastic insert (polyethylene) that is used as a substitute of the cartilage in the artificial knee gradually wears out with time.  There has been a major advancement in the quality of these plastic inserts and by producing crosslinking in its structure, the durability if these inserts have increased manifolds in experimental studies. These Highly cross-linked plastic inserts and now available in both knee and hip replacement implants and should be offered to all patient and must always be used in young patients.  Similarly using ceramic implants instead of Metallic implants have shown to reduce the wear of this plastic insert further and should be offered to young patients who need knee replacement surgery. Ceramic implants have been used routinely in hipreplacement surgery for many years.

For Further Information regarding Knee and Hip replacement surgery visit my website

Dr Jayant Arora

MS(Orth), FNB(Orth), MRCS(Ed)

Fellowship Joint replacement and Arthroscopy, Newcastle,UK

Senior Consultant and Joint replacement Surgeon

Columbia Asia hospital

For appointments at Hospital in Gurgaon contact: 01243989896

For appointments at Dwarka clinic Contact: 01132313201

Mobile 9873830947

Monday, 2 January 2012

ACL Injury—an undetected epidemic!

As a society we are gradually beginning to become obsessed with sports apart from cricket. This phenomenon is amply evident by emergence of star sports persons in various fields like tennis, boxing, hockey, golf, badminton, athletic, wrestling etc. They are adored and looked upon as role models by young and old alike. At recreational level, sports allows an escape from pressures of daily life and at elite level, sports is well established as a part of entertainment industry with enormous rewards for the professionals. At both these levels, sports related injuries especially knee ligament injuries remain a constant threat of a prolonged layoff or even a career ending event. These injuries are not only commonly seen in contact sports like football and rugby but also in noncontact sports like golf(Tiger Woods), Cricket (Yuvraj Singh), Badminton (Gopichand), all three sustained an ACL (Anterior Cruciate Ligament ) injury,  the commonest ligament to be injured (60% of all ligament injuries) in the knee. The number of women suffering ACL tears has dramatically increased. This is due in part to the rise in women's athletics. But studies have shown that female athletes are two to four times more likely to suffer ACL tears than male athletes in the same sports. Recent research has shown several factors that contribute to women's higher risk of ACL tears. Women athletes seem less able to tighten their thigh muscles to the same degree as men. This means women don't get their knees to hold as steady allowing them to twist easily. Also, shape of their thigh bone(Femur) puts them at a higher risk of the ACL rubbing on the bone in the event of a twisting injury.

  Data from the western world clearly show that knee injuries may require surgical treatment, prolonged rehabilitation and are the most common cause of permanent disability after a sporting injury. A study done in USA on the prevalence of ACL injuries in the general population has estimated the incidence as 1 case in 3,500 people, resulting in 95,000 new ACL ruptures per year. National Health Service UK (NHS) website reports a similar incidence of 30 cases of ACL injuries for every 100,000 people or a total of approximately 18000 ACL injuries across a population of 60 million every year.  At a similar rate we should see 3.6 lacs patients of ACL injuries per year. This may be a conservative estimate due to low average age of our population compared to the western world. So we may already be in the midst of an epidemic!!

These injuries are easily missed since X-rays are usually normal. A study from British Medical Journal showed an average delay of 22 months before these injuries were diagnosed despite the fact that the patients were seen in the emergency departments of the Hospitals at the time of injury. Infact, 30 % of these patients were assessed by an Orthopedic surgeon without the diagnosis having been recognised.  So we may be in the midst of an undetected epidemic!!!

The symptoms following a tear of the ACL can vary. Usually, the knee joint swells within a short time following the injury. This is due to bleeding into the knee joint from torn blood vessels in the damaged ligament. The instability caused by the torn ligament leads to a feeling of insecurity and giving way of the knee, especially when trying to change direction on the knee. The knee may feel like it wants to slip backwards.

The pain and swelling from the initial injury will usually be gone after two to four weeks, but the knee may still feel unstable. The symptom of instability and the inability to trust the knee for support are what require treatment. Also important in the decision about treatment is the growing realization by orthopedic surgeons that long-term instability leads to early arthritis of the knee.

Diagnosis needs a careful clinical evaluation by an expert knee surgeon as ligaments and tendons do not show up on X-rays. Magnetic Resonance imaging (MRI) is probably the most accurate test for diagnosing a torn ACL without actually looking into the knee.

Treatment of ACL injury does not necessarily involve surgery in all patients. Physiotherapy and bracing may be attempted initially. If the symptoms of instability are not controlled by a brace and rehabilitation program, then surgery may be suggested. The main goal of surgery is to keep the tibia from moving too far forward under the femur bone and to get the knee functioning normally again.

Even when surgery is needed, most surgeons will have their patients attend physical therapy for several visits before the surgery. This practice also reduces the chances of scarring inside the joint and can speed recovery after surgery.

Arthroscopic reconstruction (Keyhole surgery) of ACL injury is the standard of care  and open surgery is not recommended.  Key-hole surgery is most often done with the aid of the arthroscope, although small incisions are usually still required around the knee, but the surgery doesn't require the surgeon to open the joint. The arthroscope is used to view the inside of the knee joint as the surgeon performs the work. The  torn ACL ligament is reconstructed with a piece of  Hamstring muscles tendon or with a part of patellar tendon. This tendon connects the kneecap (patella) to the tibia.

Most ACL reconstructions are now done on an outpatient basis, and many patients go home the same day as the surgery. Some patients stay one or two nights in the hospital if necessary.
View  an animation of the arthroscopic reconstruction of ACL here...

Recovery following surgery involves in a progressive rehabilitation program for four to six months to ensure the best results. During first few weeks following the surgery supervised physiotherapy may be needed followed by self administered exercises at home over the four to six month period.

For further information on ACL injury and its treatment visit