The abusive, manipulative and just plain nasty treatment that many healthcare professionals get from their peers on a daily basis has got to stop, says the Joint Commission in a new Sentinel Event Alert, the first to deal with the hot-button issue of lateral violence in the workplace.

"The inherent stresses of dealing with high stakes, high-emotion situations can contribute to occasional intimidating or disruptive behavior, particularly in the presence of factors such as fatigue," warns the alert. "Individual care providers who exhibit characteristics such as self-centeredness, immaturity or defensiveness can be more prone to unprofessional behavior."

This disruptive behavior, which can range from verbal and physical aggression to passive hostilities like refusing to cooperate with colleagues, can heighten the risk of medical errors and poor outcomes, reduce patient satisfaction, increase costs and drive quality professionals out of the business, says the commission.

"It is important for organizations to take a stand by clearly identifying such behaviors and refusing to tolerate them," says Joint Commission President Mark R. Chassin, MD, MPP, MPH, in a statement.

To that end, the commission has established 11 steps for accredited hospitals, surgery centers and other healthcare organizations to take by Jan. 1, 2009, including the following:

The physician-owners of specialty hospitals are more likely to refer patients to the facility for surgery, imaging and other procedures than non-owners are, according to a study published in the July issue of the journal Medical Care

To determine this effect, Jean Mitchell, PhD, a professor of public policy at Georgetown University, analyzed the practice patterns for physicians who did and did not become part-owners at one of two specialty hospitals in Tulsa, Okla., one a spine hospital, the other an orthopedic hospital.

She found that the part-owners were far more likely to refer their patients for certain procedures. Complex spinal fusion surgery schedulings, for instance, jumped from 0.1 percent before a physician's ownership to 6.51 percent after, while the figure remained at less than one percent for physicians with no ownership.

During the same time, physician-owners referred fewer patients for less expensive spinal surgeries, even as such referrals from non-owners increased. Physician-owners were also more likely to refer patients for ancillary services such as physical therapy and MRI scans to the specialty hospitals.

Dr. Mitchell attributes these referral patterns to their financial incentive. "Physician incomes in real terms have declined since the mid-1990's, in part due to Medicare and private insurance cutting the rates for surgeries, diagnostic procedures and office-based procedures," she says. "If you see your income going down, it's natural to try to bring it back up, and expanding the scope of practice by becoming owners of a specialty hospital is one way for physicians to do that."

She says her findings suggest that health care expenditures will be substantially greater for patients treated at these facilities compared to patients who get care from healthcare providers who do not use self-referrals.

Nathan Hall

Nearly one-fourth of cadaver ligaments implanted in young athletes during ACL reconstructions fail, a discovery that may promote the use of grafts taken from the patients' own tissue. The findings were announced last week at the American Orthopaedic Society for Sports Medicine's annual meeting in Orlando, Fla.

Researchers spent two years monitoring 64 patients who underwent ACL reconstruction with a cadaver ligament. They found that 15 patients (23.4 percent) required a second knee reconstruction due to injury, graft failure or low scores on post-op outcome measures.

The failure of cadaver ligaments occurred in patients 40 years and younger who were active in sports that place stress on the ACL ligament, including tennis, basketball, soccer and downhill skiing, says the study's co-author, Kurre Luber, MD, an orthopedic surgery fellow at Mississippi Sports Medicine and Orthopaedic Center in Jackson, Miss.

"Certainly, it would be naive to think that only the graft selection led to these failures. We also need to look at surgical technique," such as single- versus double-bundle procedures, says Dr. Luber. "Better outcome measures also need to be developed. However, this study definitely raises questions about the validity of using cadaver tissue in this patient subgroup."

Patients over 40 years old who received cadaver implants had a 2.4 percent failure rate, much lower than the younger cohort. "While there are obvious benefits of using the cadaver ligament, like avoiding a second surgical site on the patient, a quicker return to work and less postoperative pain, for a young patient who is very active, it may not be the right choice," says the study's corresponding author, Gene Barrett, MD, of the Mississippi Sports Medicine and Orthopaedic Center.

Daniel Cook