Dr. Kathleen Ross, president of Doctors of B.C. Custom Photography / PNG
Some B.C. surgeons who operate on extremely obese patients are being paid a 25 per cent surcharge because surgeries on such patients often take longer and are riskier.
The change came into effect a few months ago for some physicians and will soon kick in for more medical specialists.
It came about after a survey three years ago showed that obese patients were falling through cracks. All but a handful of the B.C. surgeons who responded said they had delayed or declined to perform elective surgery on patients with a body mass index, or BMI, higher than 38. Four in five surgeons said they had delayed or declined to perform surgery over concerns about complications in patients with a BMI of 30 to 34.
Doctors of B.C. and the Ministry of Health have been working to solve the problem. General surgeons and anesthesiologists were the first to negotiate surcharges meant to compensate for added risks and time involved in treating obese patients. Gynecologists/obstetricians are also expected to get a surcharge soon.
Dr. Kathleen Ross, the new president of Doctors of B.C., said the government didn’t come up with extra money. Instead, money was reallocated from what’s called the available amount given to sections of physicians. Within sections like anesthesiology, fees shrunk for some procedures to allow for the surcharge which is referred to as a “BMI modifier.”
Although obesity is typically defined as a BMI over 30, the premium only applies for operations on patients with a BMI over 35. Several other provinces offer surgeons a premium.
“This is in recognition of the fact that in obese patients, there may be more complications and areas of the body are more difficult to access,” Ross said. “Operations are more technically complex.”
Dr. Stephen Kaye, an obstetrician/gynecologist, said obesity affects all of patient treatment, making the initial evaluation, the surgery and post-operative care more complex.
Obese patients can have higher rates of infections, require longer hospital stays and more hospital readmissions. It takes longer to prepare obese patients for surgery, including getting them in position on larger operating room tables. Getting them sedated takes longer, said Kaye, who is co-president of the Doctors of B.C. section of obstetrics and gynecologists.
“Specialized equipment and retractors are required in order to visualize and reach the surgical site,” he said. “When operating on the abdomen and pelvis, for example, the distance between the skin surface and the abdominal contents is increased by the thickness of the fat of the abdominal wall.
“These are high-risk patients and increasingly, the care of these patients is being concentrated in the hands of a fewer number of physicians who are willing to accept the patients and have the expertise or who work in hospitals that have greater resources to provide such care,” Kaye said.
In the case of a hysterectomy, for example, the $654 fee paid to a gynecologist/obstetrician would rise by $72 for every 15 minutes beyond the standard two hours. For anesthesiologists sedating hysterectomy patients, the fee would be billed at $38 minutes for every 15 minutes but the BMI modifier would add an extra $20 for every 15 minutes beyond the two-hour typical surgery time.
Some anesthesiologists and other surgical specialists are paid through contracts so their compensation would be structured differently.
Dr. Curtis Smecher, an anesthesiologist at Abbotsford Hospital and president of the B.C. Anesthesiologists Society, said that in the last round of negotiations, each section of physicians was given a pot of money to distribute for pressing needs and the BMI bonus was a high priority for doctors in his area.
“It’s a bit like shuffling deck chairs,” he said about the reallocation, adding that he won’t be surprised if orthopedic surgeons are next to seek the premium since surgeries like joint replacements are far more difficult in obese patients.
Anesthesiologists say their management of obese patients is more complex because of thicker necks, chests, and abdomens in such patients who often have sleep apnea and reduced lung and heart function, which can affect airway management and ventilation during anesthesia.
Physician services cost taxpayers almost $5 billion a year. Ross would not disclose how funds are being shuffled around to pay the premiums, but in the latest Physician Master Agreement with the government, there was also some shifting of funds to address disparities between physician groups. For example, cataract fees to ophthalmologists were reduced about 18 per cent, from $425 a year to $350.
Health Minister Adrian Dix. Francis Georgian / PNG
Health minister Adrian Dix said he’s taking the rare step of ordering an independent review into a patient’s death because of the family’s continuing concerns after the initial investigation conducted by two health agencies.
The Vancouver individual, whose identity is being withheld, died in November 2018 and the only detail Dix would disclose is that paramedics had difficulty “accessing” the patient.
Dix conceded it is rare for health ministers to intervene in such cases and this is the first time he has done so since he became health minister two years ago. But he felt it was important for family members who told him that they wanted “fresh” eyes on the circumstances leading to the death.
“I just felt we needed to do more,” he said, referring to the patient safety review that B.C. Emergency Health Services and Provincial Health Services Authority carried out right after the death.
The new review will delve into the medical care in the weeks before the death and the emergency response “in the hours surrounding the death.”
The previous investigation was conducted with so-called Section 51 protection, which means there is no public disclosure. Section 51 safety reviews are conducted to see if anything can be learned from a death and suggest steps to prevent reoccurences.
Dix said the new study will have more transparency and will give family members more access to information and findings; the report will also be made although some information may be redacted “for the sake of privacy.”
Dix said he could have referred the case to the Patient Care Quality Review Board but in this case, there was a “technical glitch” that would have meant passing a new regulation. So, he said he decided to refer the case to Dr. Jim Christensen, an emergency physician at St. Paul’s Hospital in Vancouver and head of the academic department of medicine at the University of British Columbia. He will be assisted by Dr. Michael Feldman, the paramedic services medical director and provincial dispatch medical director at Toronto’s Sunnybrook Centre for Prehospital Medicine.
In a purposely vague media release, the ministry of health said the review panel will have the “co-operation” of four agencies — Providence Health Care, VCH, BCEHS and PHSA.
“British Columbians can and do rely on our emergency responders when they are at their most vulnerable,” Dix said in the announcement. “Whenever we are faced with a case that may warrant a review, we look to independent experts who can look for learnings and suggest improvements that will benefit patients, first responders and the system as a whole.”
The government will receive the report by July.
Officials with PHSA would not comment on the internal review process that has already taken place. On its website, PHSA states: “When a patient safety event occurs, the goal is immediate management, disclosure and analysis of the event through a structured process, focused on system improvement, that aims to identify what happened, how and why it happened, whether there are any ways to reduce the risk of recurrence and make care safer. PHSA conducts patient safety event reviews in accordance with Section 51 of the B.C. Evidence Act.”
The review is meant to enable “full, open and candid discussions amongst health care professionals” with the goal of improving care for future patients. Further education or policy changes may be recommended.
“Patient safety event reviews do not preclude health-care professionals from cooperating in other reviews by outside investigative bodies, such as the police or regulators, nor do they shield health care professionals or PHSA from potential civil suits.”
When Peggy Mahoney discovered she had a rare liver condition and required a transplant, it came as a shock.
“No one saw it coming because I was a granola-eating, exercising, healthy person,” said Mahoney, of Victoria.
Thankfully, her son was a match for the life-saving transplant.
But Mahoney said she was shocked again to learn how much money she would need to set aside to follow through on her treatment.
All transplants in B.C. are done in Vancouver, where the medical expertise required to assemble transplant teams is available.
The cost of the medical care and the travel to Vancouver is covered by the province.
But transplant patients then have to spend several months living near the hospital after their procedure for follow-up care. They also need to have a caregiver with them to provide support.
Those extra costs fall to the patient and can be as much as $20,000, Mahoney said.
“At that point, almost three years on disability, a lot of my liquid assets were gone,” she said.
“You want to scream at that point: ‘sick person here’. I was not very healthy, to try and come up with that kind of money.”
Mahoney managed to make her finances work, and had a successful liver transplant in 2012. As a counsellor, she now helps other critically ill patients navigate the medical system.
And she worries the rising cost of living in Vancouver has exacerbated the financial burden for transplant patients.
“A lot of these systems were developed in the 1980s where that wasn’t the same kind of financial hardship as it is today.”
Treatment and monitoring
Organ transplants are a highly complex procedure and patients must stay near the medical facility to be closely monitored by their transplant team for roughly three months, said Dr. David Landsberg, Transplant B.C.’s provincial medical director for transplant services.
While the need to stay in Vancouver can be a financial challenge, the team works with patients to ensure they have a plan, he said.
Charitable organizations such as Kidney Foundation, Happy Liver Society, Heart Home Society, David Foster Foundation and Ronald McDonald House also help provide affordable places for patients to stay during their treatment.
“We work very carefully with patients to help them find the right support, the right accommodations,” Landsberg said.
While he has heard of patients who decide against being added to the organ transplant list due to the cost and challenges of treatment, Landsberg said no one is turned away over financial need.
“I don’t know of anybody that would ever have been denied a transplant, just on the basis of they didn’t have the funds.”
But Mahoney hopes more can be done to ensure no one ever has to choose whether they can afford to save their own life.
In B.C., a record 502 organ transplants were conducted in 2018. Over 1.35 million British Columbians have registered their wishes to be an organ donor.
The Fraser Health Authority says it is investigating after Chilliwack Mayor Ken Popove raised concerns about a 76-year-old woman who was discharged from Surrey Memorial Hospital and sent by taxi to the Chilliwack Salvation Army shelter, despite mobility and incontinence issues.
On Thursday, the mayor requested a meeting with Fraser Health CEO Dr. Victoria Lee to discuss “why vulnerable people are being sent to Chilliwack homeless shelters from another community.”
He cited the case of an elderly woman who had no family in Chilliwack, but arrived at the local shelter from the Surrey hospital in early February. Shelter staff were not prepared to care for her medical needs, which included severe incontinence.
“Constantly cleaning up fecal matter … is a serious concern for both staff and shelter clients,” said Popove in a letter to Lee.
Fraser Health spokesman Dixon Tam said Fraser Health makes “every effort” to find homeless patients a place to go when they are clinically stable and ready to leave the hospital, but “finding suitable housing is a challenge across our region.”
Tam said: “We are committed to continue to work closely with B.C. Housing and our municipal partners to develop more options. At the same time, we need to be careful not to use hospital beds as an alternative to stable housing.”
Abbotsford homeless advocate Jesse Wegenast said he wasn’t surprised to read the Chilliwack mayor’s account in the newspaper, “but only because it’s such a common practice.”
Wegenast’s organization, The 5 and 2 Ministries, opened a winter homeless shelter in Abbotsford on Nov. 1. The next day, he received a call from a Vancouver General Hospital administrator asking if he had space for an 81-year-old patient.
Wegenast said he often says no to accepting patients because the shelter is not open 24 hours and people must leave during the day. He’s had requests to take people with severe mobility issues, as well as those who need help with toileting or washing.
“The people who work at shelters are often very compassionate, and if the hospital says, ‘Well, we’re not keeping them,’ they feel obligated to help,” said Wegenast.
The pastor said he’s rarely seen people in shelters receive home care or followup care, and it’s also difficult for them to get prescriptions filled.
Wegenast helped a low-income senior on Friday who recently had half of his foot amputated. The man lives in an apartment and was receiving home care to help with dressing changes, but he’d been unable to get antibiotics for five days since being released from hospital.
“When you have people exiting acute care at the hospital and there’s no one to follow that up, it’s bad for that person’s health, and it’s also bad for public health in general,” he said.
Unlike Wegenast, Warren Macintyre was surprised to read about the Chilliwack woman’s situation because it confirmed that the experience he’d had with Fraser Health was not uncommon.
“I really had no idea this kind of thing was going on,” he said.
Three weeks ago, a close family member was admitted to Surrey Memorial after suffering from alcohol withdrawal, said Macintyre. He was placed on life support in the intensive care unit for about 10 days. When he was stable, he planned to enter a treatment program in Abbotsford, but there weren’t any beds available until March 14.
“We were told the plan was to keep him in hospital until then, but I got a call Wednesday telling me he’d been discharged,” said Macintyre.
Surrey Memorial had sent his relative to the treatment centre, where staff repeated they had no space, so he was returned to the hospital. The man, who had been staying at the Maple Ridge Salvation Army before his hospital admission, took a cab to a friend’s house.
His family is hoping he’ll be able to stay sober until he can get into treatment March 14.
“I told the hospital, if he goes back on the booze, he’ll be right back here,” said Macintyre.
The exterior of Surrey Memorial Hospital. Arlen Redekop / PNG files
Chilliwack Mayor Ken Popove is demanding answers from the Fraser Health Authority after a 76-year-old woman with mobility and severe incontinence issues was discharged from Surrey Memorial Hospital and sent by taxi to the Chilliwack Salvation Army shelter early last month.
In a letter to Fraser Health CEO Dr. Victoria Lee, the mayor said he is aware of two cases in which shelter staff were asked to take patients from the Surrey hospital without being told about the care they required.
“A homeless shelter is no place for a person with health concerns or special medical needs,” the mayor said in the letter, which was sent to Fraser Health on Tuesday. “Discharging patients into homeless shelters when they still require some level of care is not an acceptable practice. Homeless shelters provide clients with a cot for the night which is not suitable for a recently discharged patient.”
In his letter, the mayor recounted the case of an elderly woman who arrived from the hospital by taxi on Feb. 2.
“According to the Salvation Army, this elderly individual arrived with a walker and some significant health concerns, including incontinence, and is unable to clean herself,” said Popove. “Shortly after her arrival, it was clear that the Salvation Army would be unable to accommodate her at their shelter due to sanitary and safety concerns.”
The woman was transferred to a temporary shelter without stairs, but “her physical and mental health needs continued to make it impossible for staff to care for her.” She left the shelter on her own and returned to the Salvation Army.
On Feb. 22, the shelter received another call from Fraser Health about a man who was being discharged from Surrey Memorial and needed a bed.
“After further investigation, they learned that the patient was in a wheelchair, had open wounds on his feet and needed to be in a hospital bed,” said the mayor. “This information was not disclosed by the social worker, and shelter staff realized they would be unable to provide the level of care this individual requires.”
The mayor asked the Fraser Health CEO to answer several questions, including whether hospitals regularly discharge patients into homeless shelters.
“I would like to know why vulnerable people are being sent to Chilliwack homeless shelters from another community,” Popove added. “How is it possible that a 76-year-old woman with multiple significant health concerns could have been discharged from Surrey Memorial Hospital and sent via taxi to a homeless shelter in Chilliwack over 70 kilometres away from her home, friends and family?”
Popove asked for a meeting with Lee to discuss the situation and “to ensure this woman is reconnected with her community and proper care.”
Fraser Health spokesperson Tasleem Juma said Fraser Health received the letter late Wednesday and is looking into the mayor’s claims. She could not comment on specific cases, but explained that patients are sometimes discharged from hospital into a shelter when they are “deemed to be medically stable.”
Like someone who is being discharged to a home, Fraser Health ensures community supports are in place for the person, and shelter staff are informed and must agree to the situation, she said.
Juma was unable to say if Fraser Health staff followed this procedure in the two cases mentioned by Popove in his letter.
A bottle of Suboxone similar to the one nurses at St. Paul’s Hospital will be giving to patients discharged from the emergency department following an opioid overdose. [PNG Merlin Archive] Handout: Providence Health Care / PNG
Patients who visit St. Paul’s after an opioid overdose will now leave the hospital’s emergency department with a supply of addiction-treatment pills.
Providence Health Care and Vancouver Coastal Health have launched a pilot program at the downtown hospital that gives these patients bottles containing three days worth of Suboxone, provided by a specially trained addiction nurse. They will form a plan for follow-up care and get clear instructions about when to take the pills.
A nurse will direct the patients toward follow-up treatment and community resources, including the St. Paul’s Rapid Access Addiction Clinic. The free clinic provides people with immediate short-term addictions treatment and transfers them to a community care provider for longer-term rehabilitation.
Dr. Andrew Kestler, an emergency department physician at St. Paul’s and the project’s co-lead, said the program will save lives.
“People who get started on opioid agonist therapy — that could be Suboxone or methadone — live longer,” Kestler said. “We know that it reduces deaths in people who have opioid-use disorder, and we know that it reduces the need for emergency department visits.”
The B.C. Centre on Substance Use will evaluate whether the pilot program leads to a decrease in overdoses, hospital visits and deaths, and to improved engagement in care.
Patients must be in a sufficient state of withdrawal to start Suboxone, which can lead to six- to 12-hour visits to the emergency department. By letting patients take the pills with them, a common barrier to treatment is reduced for the many people uncomfortable with hospital stays, Kestler said.
Those with opioid-use disorder who visit the hospital but haven’t overdosed are also eligible for the take-home Suboxone, Kestler said.
Subxone, which contains buprenorphine and naloxone, is a medicine which can stop cravings and withdrawal symptoms, and prevent death. It is considered safer than methadone, another leading treatment for opioid addiction, mostly because buprenorphine has a ceiling effect which makes it hard to overdose, Kestler said.
Typically about five or six overdose patients visit St. Paul’s emergency department each day, Kestler said. The hospital sees 10 times more overdose patients than any other hospital in the Vancouver Coastal Health region, according to Providence.
In the first 11 months of 2018, Vancouver Coastal had the highest rate of illicit-drug death of any health region in B.C., at 37 per 100,000 people, according to the B.C. Coroners Service. Of the 1,380 people who died during that period, 408 were in Vancouver Coastal.
Kestler believes the program will prove successful and could be adopted by other emergency departments.
“We’re already sharing some of our ideas and protocols with people around the province but we really hope, with this getting off the ground and having some success, that we can pave the way for broader implementation across the province,” he said.
“I think there’s obviously interest elsewhere in Canada and North America.”
A Vancouver emergency department has become the first in Canada to give overdose patients take-away packs of medication aimed at warding off withdrawal symptoms and getting them into treatment.
Dr. Andrew Kestler, a co-lead of the program at St. Paul’s Hospital, says patients get a three-day supply of Suboxone and easy-to-understand instructions from a nurse.
He says the idea is to prevent barriers to treatment because many patients are not able to even get a prescription filled at a pharmacy after being discharged.
Kestler says five women and three men have so far been given the medication and emergency departments around the province have shown interest in the project that could potentially be adopted across the country.
He says patients from the hospital can also access a clinic in the same building so they can be connected with a doctor in the community before being followed up by an outreach team.
The two-year innovative pilot project will be evaluated by the B.C. Centre on Substance Use in the province with the highest number of overdose deaths in Canada.
British Columbia plans to double the number of deep brain stimulation surgeries for patients with Parkinson’s disease whose symptoms don’t improve with medication.
The Health Ministry says 72 surgeries will be performed in the current fiscal year, up from 36 operations, as part of a program starting in April.
Health Minister Adrian Dix says the surgeries at UBC Hospital in Vancouver will be done within 12 weeks.
Only one neurosurgeon does the surgeries in B.C., and Dix says the province aims to recruit another doctor to increase access for patients who often experience tremors, stiff muscles and balance problems.
Dr. Christopher Honey currently performs the primary surgery as well as replacement of batteries that are like pacemakers implanted in patients’ chests, but Dix says another surgeon will now assist with the latter operation.
Deep brain stimulation is an invasive eight-hour surgery performed while the patient is awake to target a specific area of the brain and alter its activity.
An 18-month pilot project is being expanded across British Columbia after more than double the number of drug-addicted people stayed in treatment to stop them from fatally overdosing.
The initiative, led by the BC Centre for Excellence in HIV/AIDS and Vancouver Coastal Health, uses the same strategy that helped drive down the province’s HIV and AIDS rates.
Dr. Rolando Barrios, the centre’s senior medical director, says it involves tracking patients who don’t show up for appointments and uses a team of doctors, nurses and social workers to follow them through treatment to help with their needs such as housing and employment.
The pilot at 17 clinics in Vancouver involved 1,100 patients and showed seven out of 10 of them stayed in treatment after three months, up from three people, as part of a program that prescribes substitute opioids to curb drug cravings and ward off withdrawal symptoms.
Barrios says retaining people who are addicted to opioids like heroin and fentanyl in treatment is the biggest hurdle in the overdose crisis that has claimed thousands of lives.
He says the expansion of the pilot involves simple steps such as reminding patients when their medication is about to expire and having pharmacies connect with health-care teams when people don’t pick up their medications.
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