Tax Fraud Blotter: 'Refund Acquisition Fee'
October 11, 2015
By Jeff Stimpson
A roundup of our favorite recent tax fraud cases.
Newark, N.J.: Preparer Sixto Rodriguez, 52, of Kissimmee, Fla., has pleaded guilty to filing a false tax return on behalf of himself for tax year 2007, and aiding and assisting in the filing of a false and fraudulent tax return on behalf of another for tax year 2009, resulting in tax losses of $321,061.
According to case documents and court statements, Rodriguez, who operated the Teaneck, N.J., tax prep firm 1-2-3 Taxes, admitted to inflating education credits, charitable donations, unreimbursed business expenses and rental losses that he knew his clients had not actually incurred. He also admitted reporting only $1,600 of the $237,179 his business made in 2007.
Both the false filing charges to which Rodriguez pleaded guilty carry a maximum of three years in prison and a $250,000 fine. Sentencing is Feb. 8, 2016.
Kansas City, Kan.: Preparer Prayshana Washington, 28, has pleaded guilty to one count of preparing false income tax returns and one count of aggravated ID theft in connection with preparing false income tax returns in the names of prison inmates.
In her plea, she admitted that from 2012 to 2015 she was in the business of preparing individual income tax returns for clients, who generally paid between $500 and $1,000 for her services. She admitted preparing a 2012 return for a client that included false claims about dependents, false household help income and false American Opportunity Credits.
She also admitted directing the IRS to deposit fraudulent returns onto prepaid debit cards and mail them to addresses she controlled and obtaining names, dates of birth and Social Security numbers for prison inmates and preparing fraudulent returns in their names.
Tax loss exceeded $400,000, authorities said.
Hacienda Heights, Calif.: Preparer Calvin Tyrone Ridgill, 61, has been sentenced to three years in prison and a year of supervised release for aiding and assisting in the preparation of false tax returns.
Ridgill, who was convicted in 1998 for preparing false returns, also agreed to be barred for life from aiding or assisting in the preparation of federal income tax returns for anyone other than himself and his legal spouse. A federal judge rejected Ridgill's plea for leniency, finding that he had shown an egregious disregard for the tax laws.
According to the plea agreement, from 2010 through 2012, Ridgill prepared federal returns for clients claiming false or inflated income refunds based on false deductions, including phony losses from the sale of business property, Schedule E losses, mortgage interest deductions or false mortgage points. Tax losses exceeded $400,000.
Ridgill was ordered to pay $357,477 in restitution to the IRS. The government argued Ridgill's assets were more than sufficient to pay the ordered restitution, including a home in Whittier and a vacation property in Truckee, Calif.
West Hartford, Conn.: Preparer Hai T. Le, 44, has been sentenced to 10 days of imprisonment, three years of supervised release and 240 hours of community service, and been ordered to pay full restitution to the U.S. Treasury for filing false tax returns.
According to court documents and statements, Le, who previously pleaded guilty, prepared federal returns for individuals in his community, many of whom were family or friends. Le typically asked clients to provide him their prior returns, purportedly so that he could verify relevant information.
Le prepared the current-year return, but also made and kept copies of the prior returns. After some clients received the current year's refund, Le used the prior returns to prepare false amended returns purportedly on behalf of his clients.
The amended returns included false information, including unwarranted residential energy credits, education credits, and tuition and fees deductions to inflate phony additional refunds. Unknown to his clients, Le filed the amended returns with the IRS and included his own residence as the return address. In most cases, the IRS sent a refund check to the listed address and Le then endorsed his client's name and his own on the reverse of the check to make it appear that the check had been signed over to him. He then deposited the check into one of his bank accounts.
Between March and August of 2010, he prepared and filed 28 fraudulent federal amended tax returns for a total of $138,826 in refunds. Six refunds totaling $32,752 were stopped prior to a check being issued. Le returned approximately $77,000 of the stolen money when confronted by the IRS and now owes the remainder with the ordered restitution.
Reseda, Calif.: Preparer Duffy R. Dashner, a.k.a. Kevin Dashner, 42, has been sentenced to 57 months in prison and three years of supervised release, and been ordered to pay $1,769,418 in restitution to the IRS after pleading guilty to one count of conspiracy to submit false claims.
According to court documents, Dashner and his co-conspirators, including Mark R. Maness, operated a business called O.I.D. Process through which they helped others to prepare and file individual federal income tax returns that claimed false original issue discount interest income and federal tax withholdings, resulting in fraudulent claims for refunds.
Dashner and Maness charged clients of O.I.D. Process a non-refundable registration fee to join the organization and a 20 percent "refund acquisition fee" for any refund check issued by the IRS. The pair also operated a Web site and conducted weekly conference calls with clients to promote their business and to assist clients in preparing and filing OID returns. Dashner and Maness required clients to change their mailing address with the IRS to the address of another co-conspirator who was an attorney in San Francisco.
O.I.D. Process's clients filed approximately 200 OID returns claiming refunds that totaled approximately $228 million.
Maness, who previously pleaded guilty to conspiracy to submit false claims against the U.S., was sentenced in February to 41 months in prison and ordered to pay $1,176,668 restitution.
2 Comments
Burientaxman, Likely no comment on the $226 million because of privacy. The erroneous refunds are not part of the litigation thus not in the public view. Hopefully their "clients" are being examined to recover the bogus claims.
Posted by: Kelly M | October 13, 2015 7:23 AM
(Page 1 of 2)
The pace of change in the CPA profession is getting faster, and not enough accountants are ready, according to New York State Society of CPAs executive director Joanne Barry.
Joanne Barry
Speaking Thursday during an Accountants Club of America luncheon in Manhattan, Barry talked about a host of recent trends. "The landscape is changing dramatically, and not enough CPAs that I speak to are aware of the dramatic changes that are happening in the profession and how the profession needs to be responsive to what's going on, more so than they have been in recent years," she said.
She pointed to the need for rapid adaptation to change. "The firms that are succeeding are making their moves on a chessboard," she said. "If you're a good chess player, you're always anticipating the next two or three moves. Those next two or three moves aren't going to happen in the next two or three years. They're going to happen within the next two or three months. That's how fast the pace of change is happening when I speak to CPAs who are really involved in trying to dramatically shake up their firms."
Changing Demographics
She noted that demographics have had an extremely disruptive impact on firms, with more firms moving in the direction of having non-CPA owners. The client world is also changing, with virtual CPA firms servicing clients remotely. Younger generations are also filling more positions at firms as Baby Boomers retire, although not quickly enough for many firms to be able to fill their ranks, causing more and more of them to merge together. Generation X and Millennials are less interested in working their way up through the ranks and paying their dues by feeding the copy machine. Millennials tend to do their networking through social media rather than by going to networking events.
She noted that demographics have had an extremely disruptive impact on firms, with more firms moving in the direction of having non-CPA owners. The client world is also changing, with virtual CPA firms servicing clients remotely. Younger generations are also filling more positions at firms as Baby Boomers retire, although not quickly enough for many firms to be able to fill their ranks, causing more and more of them to merge together. Generation X and Millennials are less interested in working their way up through the ranks and paying their dues by feeding the copy machine. Millennials tend to do their networking through social media rather than by going to networking events.
She noted that 71 percent of CPA firms in New York now have a "business casual" dress code, while only 6 percent require traditional business attire such as a jacket and tie all the time.
"Firms are trying to accommodate and change the culture," said Barry.
More firms have also been accommodating their employees by allowing them to work remotely, she noted. Plus, more firms have been doing away with basing their fees on billable hours. "It's value-based pricing, not hours-based pricing, and a lot of firms are moving in that direction," said Barry.
CPA Exam Takers
Firms are increasingly using technology and non-CPAs, freeing up CPAs to do higher-level, more strategic work.
Firms are increasingly using technology and non-CPAs, freeing up CPAs to do higher-level, more strategic work.
More students than ever before in New York State are studying accounting, and there is not enough space to accommodate all of them. "However those students are not sitting for the CPA Exam," Barry added. "The number of exam takers has been flat for two and a half years now. Why? We don't know for sure."
The American Institute of CPAs and the American Accounting Association are doing research to find out why. "One thing we did find out is that the messaging from the managing partners and the senior partners in the firm is directly connected to the number of candidates who have the ability to sit for the exam and have the motivation to do so," she said.
Barry suggested that more CPA firms should spread the word about taking the exam to their employees, as well as pay for CPA candidates to take the test, give them time off to study for it and pay for the licensing fees. "That's going to impact hiring needs in the future," she said.
Many firms are even hiring students who choose not to sit for the CPA Exam and bringing them into the firm anyway. "Another trend we're seeing is that firms are moving away from the attest area and more and more into consulting work, so they're using the best and brightest non-exam takers to build on their non-attest services." Many of those who get hired end up working in technology consulting.
Between 2007 and 2014, there was a jump from 13 percent to 26 percent in non-accounting graduates hired by CPA firms, Barry pointed out. "That's the kind of recruiting that's happening on campus now, in addition to recruiting for CPA candidates," she said.
There are also inclusion changes underway in the profession, with firms trying to increase the number of "underrepresented minorities."
"We've been trying to address this change since the 1980s, when there was less than 1 percent of African Americans in the profession on a national basis," said Barry. "That needle has moved just a little bit since the mid-1980s. It's still in the low single-digit numbers. Yet the client base here in New York in particular is much more diverse than ever before."
She noted that younger CPAs want to see more diversity in CPA firms and not seeing diversity makes them uncomfortable.
New York CPA Trends
Barry also previewed some of the results of a recent survey by Rosenberg Associates for the New York State Society of CPAs on trends in the profession in New York. The full results will appear in an upcoming issue of the NYSSCPA's CPA Journal.
Barry also previewed some of the results of a recent survey by Rosenberg Associates for the New York State Society of CPAs on trends in the profession in New York. The full results will appear in an upcoming issue of the NYSSCPA's CPA Journal.
Average annual revenue growth in 2014 for firms over $2 million averaged 6.7 percent in New York. "That's a pretty good number," said Barry. "The bad news, however, is that's about the same as the number from the prior year, and when the impact of mergers is figured in, organic growth slightly declined. Firms have been so active in the M&A market and the efforts that need to go into that with absorbing the clients together, that it's taking away the focus on organic growth that the firms need for developing business. The second negative is that New York firms are being held back in all parts of the state by the acute shortage of staff, and when that happens, practice development has to be curtailed. Some firms are being forced to drop their least lucrative clients so they can expend their energy in servicing the more lucrative ones."
In terms of retirement trends, nationally the number of partners over the age of 50 rose to 65 percent. In New York, the average age of partners is 55. "The greying of the profession is happening everywhere," said Barry. "The aging partner base continues to drive up the mergers. Many firms simply don't have a succession plan in place, and that's why this merger frenzy is going on. The mandatory retirement age in New York stretches from 65 years old to 72 years old, and that's ticking up as well because more and more small firms in particular are hanging on longer because they don't have succession plans, so that number has been ticking up."
The survey found that 64.2 percent of CPA firms in New York lack a succession plan.
The percentage of firms with mandatory retirement age provisions rose from 81 to 88 percent in two years. "Firms are grappling with partners hanging on to their equity longer," said Barry. "Younger partners don't see a way in, so there's now a lot of frenzy between firms to hire away potential partners who can get on the partner track more quickly at another firm."
Baby Boomers are aging as well, and when those clients sell their businesses, Barry pointed out, in many cases they're selling them to underrepresented minority groups who are not well integrated into the firms at this point. "It becomes just a lot of turbulence and a lot of issues that need to be deal with," she said.
Most firm partners in New York continue to be white males over the age of 50. The average age of managing partners is 56. "Professional staff turnover is about 17 percent, up from 15.5 percent last year," said Barry. "What does that mean? The work is there. CPA firms have a lot of work, but they can't find the talent to get it done, and sometimes that's at the expense of growing the firm. More and more partners are beginning to say that a CPA with skill and experience and the right attitude and the desire to become partner, the drive to become partner, that type of person has become a unicorn, and we know that a unicorn is a mythical creature that doesn't really exist. So the tug of war ensues between firms."
1 Comment
i certainly hope the tends of cpa candidate is flat or slow rise does not alter the cpa exam as to becoming easier. cpas need that and deserve that edge. we are the elite club and we should let it be known in our pay and in our company status. tuvm!!!!!!! if you want it; go get it!!!
Posted by: wia-nam | October 12, 2015 9:51 PM
Magazines Try New Tactic: Money Back if Ad Fails to Deliver
Industry trade group seeks to counter perception that magazines are losing clout with readers
ENLARGE A newsstand in New Orleans. U.S. magazine print ad spending is expected to shrink 1.8% this year. Photo: Gerald Herbert/Associated Press
By
Jeffrey A. Trachtenberg
Magazine publishers say it is an offer advertisers can't refuse. Their money back—or free ad pages—if sales don't increase after running print ads in their publications.
The new industry guarantee was organized by the MPA, the Association of Magazine Media, which said that 16 major media companies representing 72% of the total magazine audience in the U.S. qualify to offer the program. These include Time Inc. ; Meredith Corp. ; Hearst Magazines, a unit of Hearst Corp.; and Condé Nast, a unit of Advance Publications Inc.
A year ago, the industry trade group moved to boost publisher credibility with marketers by launching a monthly audience measurement tool that counts how many readers are consuming magazine content in print and online (including video), and via their smartphones, computers (desktop and laptops) and tablets.
Both initiatives reflect the association's efforts to counter the perception that magazines are losing clout with readers as witnessed by a decline in print advertising. U.S. magazine print ad spending is expected to shrink 1.8% this year to $17.4 billion, according to a forecast from ZenithOptimedia, a media buying firm owned by Publicis Groupe SA.
"Print is the heritage format of this industry and advertisers have pulled their business back disproportionately," said Mary Berner, the trade group's former chief executive, who quarterbacked the guarantee strategy. This week she joins radio station owner Cumulus Media Inc. as its CEO.
ENLARGE One media buyer said the guarantee could spark an increase in print spending, although it is too early to tell.
"Any time you can provide data that proves print works, it's a good thing; a guarantee makes it even better," said Brenda White, an executive vice president of the media-buying agency Starcom USA, a unit of Paris-based Publicis Groupe SA .
To qualify for the guarantee, a print campaign needs to reach approximately 125 million adults 18 years old and over an average of three times during a 12-month period, be it through ads in a single title or across a company's entire portfolio of magazines. This assures that enough people see the print advertising to drive sales. Marketers also have to increase their business with individual publishers, in part to help cover the cost of providing measurement for the campaign.
In addition, the products being advertised have to be sold by retailers whose results are measured by third-party research firms such as Nielsen Catalina Solutions, which measures data from drugstores, grocery stores, supermarkets and mass merchants like Target Corp. and Wal-Mart Stores Inc.
Advertisement
One antitrust attorney, Michael Lindsay, a partner and co-chair of the antitrust practice at Dorsey & Whitney LLP, a national law firm based in Minneapolis, said the industry guarantee didn't appear to violate antitrust law. The issue of an antitrust violation would only arise if there were an implicit or explicit agreement between the members of the magazine trade group that limited competition between them, he said.
Ms. Berner said that the trade organization's members were free to offer any guarantee they chose.
Nielsen Catalina Solutions matches magazine subscriber data to shopper loyalty cards and then links them to anonymous households. The results are compared to a similar panel consisting of households not exposed to the ads to determine if sales were increased by exposure to the print ads.
"It's about assuring a level of accountability," said Adam Paulisick, senior vice president of marketing and strategy at Nielsen Catalina Solutions.
A number of magazine companies have tested guarantees in recent years. Time Inc., for example, has offered a print ad sales guarantee across all its magazines since January, and says it has shown that on average every dollar invested in a print ad returns an uptick of $17 in sales.
Meredith Corp. , which owns such publications as Shape, Family Circle, and Better Homes and Gardens, has offered its advertisers a print ad sales guarantee since 2011. Meredith said it has never had to provide a cash rebate or free advertising space to a marketer.
"There is a control group that receives our magazines, and a second group that doesn't," said Tom Harty, president of Meredith's National Media Group. "We're able to prove that the only reason that one group's spending on specific products has increased is because it saw our print ads. That's why this program is so interesting. It works."
—Suzanne Vranica contributed to this article.
Write to Jeffrey A. Trachtenberg at jeffrey.trachtenberg@wsj.com
Sharing Penance For Bad Accounting
By Bloomberg
(FROM THE WALL STREET JOURNAL 10/13/15) By Maxwell Murphy Stock Market Quotes, Business News, Financial News from http://www.ibloomberg.net
When errors are found in a company's books, the responsibility often falls on the finance chief and chief executive who signed off on the numbers. And it is up to the board of directors to decide whether they should be penalized by returning some of their compensation.
The Securities and Exchange Commission is about to issue new rules that would take away a board's discretion in such cases, and would require companies to punish accounting missteps by clawing back pay from a wider range of top executives. Failure to do so could cost a company its stock listing.
Many companies object to the proposed rules, which are awaiting the SEC's final approval after a public-comment period ended last month. Corporate critics say the rules could wallop executives who had no knowledge of errors in the books or any role in overseeing them.
"It is overbroad in its reach," said Timothy Donnelly, chief administrative officer and general counsel of American Vanguard Corp. Boards want to avoid a situation in which, for example, a chief technology officer would be punished "if the [chief financial officer] decided to cook up some ridiculous scheme," or vice versa, he said.
American Vanguard, a California chemical maker, has a clawback policy in place, as do nearly 90% of the nation's 100 largest public companies, says a recent study by law firm Shearman & Sterling LLP. Eight years ago, barely a third of them had such a policy.
Oil companies Exxon Mobil Corp. and Chevron Corp. and package-delivery giant FedEx Corp., said in their comment letters that the proposed rules were too rigid and usurped too much of a board's authority. They called for changes they said would make the impact less onerous.
The Dodd-Frank Act of 2010 required the SEC to write the rules, in hopes that putting executive pay at risk would discourage fraud and undue risk taking. The rules apply only to pay that is tied to a company's financial performance, a type that is increasingly common.
A recent study by Cornell University and compensation consulting firm Pearl Meyer & Partners LLC suggests more than half of public companies tie some portion of executive pay to total shareholder return — or stock appreciation plus dividend payments — up from 17% about a decade ago.
That is partly because some proxy advisers, such as Institutional Shareholder Services, use that benchmark to shape recommendations to investors about whether they should approve corporate-pay packages.
Many aspects of the proposed rule aren't clear. "There are too many variables" to say what portion of performance-based pay would be at risk under the clawback rules, said compensation lawyer Jim Barrall of Latham & Watkins LLP.
Some critics also say companies could dodge the new rules simply by altering their pay packages. "It could have the unintended consequence" of dialing back the clock to a time when companies didn't disclose the rationale for bonuses, said John Roe, executive director of ISS's Corporate Solutions division, which advises companies on governance policies.
While 86% of S&P 500 companies have voluntary clawback mechanisms in place, Mr. Roe said, smaller firms have a way to go.
Just 44% of the smaller companies in the broader Russell 3000 stock index have adopted a policy, he said.
Not everyone objects to the proposed rules. They should go further, covering a wider range of financial restatements, and force companies to disclose the sums they recovered and the executives involved, wrote Heather Slavkin Corzo, director of the AFL-CIO's office of investment, in a comment letter to the SEC.
The AFL-CIO didn't respond to requests for comment.
Some critics say the new rules are likely to be more of a headache than a tonic. They could be "the final straw of onerous Dodd-Frank rules," said Christina Crooks, director of tax policy for the National Association of Manufacturers. She said the provision requiring clawbacks from all executives was especially troubling, because "you're going to be delisted if you get this wrong."
Companies say they want to keep the teeth in their current clawback policies because the policies protect both the company and its investors. But, under the new rules, "almost everybody will have to rewrite their policy," said Shearman partner Doreen Lilienfeld.
—
Emily Chasan contributed to this article.
Why Double Knee Replacement Might Be Best
Some studies show double knee surgeries are cost-effective, and as safe as single knee procedures, but other large studies conclude getting both knees replaced at the same time carries higher complication risks.
ENLARGE A patient before double knee replacement surgery. Photo: Pete Hausler/The Wall Street Journal
With knee-replacement surgery on the rise, more patients with two bad knees are opting for a controversial procedure that replaces both at the same time.
Simultaneous bilateral knee replacement, as the surgery is known, is a subject of debate among orthopedic surgeons, with conflicting evidence about the risks and benefits. Proponents say it eliminates the need for a second hospital stay and grueling rehabilitation period, reduces time spent under anesthesia and costs less.
Some studies have found no difference in complication rates after bilateral surgery compared with unilateral surgery. A 2013 study in the Journal of Bone and Joint Surgery estimated the cost of bilateral surgery at $43,401 compared with $72,233 for two separate surgeries staged over time. The study concluded that bilateral surgery is more cost-effective with better outcomes for the average patient than staged procedures for two knees.
But more recent studies have found increased rates of complication such as blood clots that travel to the lung, an increased need for blood transfusions, and a higher risk of death with the bilateral procedure.
The rate of knee replacements in the U.S. almost doubled from 2000 through 2010, according to the Centers for Disease Control and Prevention, and now exceeds 700,000 procedures a year. The CDC doesn't break out data, but studies indicate the percentage of patients who had both knees replaced at the same time has risen from less than 4% in 1999 to more than 6% at present.
Ken McLaughlin, 63, had bilateral knee replacement surgery in October 2014; he spent three nights in the hospital, about a week in a rehabilitation clinic and took a three-month leave from work. He experienced pain but no complications. Photo: Ken McLaughlin
Simultaneous bilateral procedures can be performed either by two surgeons operating in tandem or by a single surgeon who completes one knee and immediately turns to the other.
Although the average age has dropped for patients getting knee surgery, many also have health issues that can increase the risk of complications. In 2013, a consensus group of experts recommended that surgeons use more restrictive criteria to select patients for double knee replacements and exclude those with high cardiac risks. The majority said patients who aren't candidates for simultaneous procedures should get a second one no sooner than three months after the first.
"We've learned a lot from years of data on who has complication issues," says Steven Haas, an orthopedic surgeon at the Hospital for Special Surgery in New York. The hospital avoids bilateral knee surgery in patients who have any type of heart disease, as well as those with a body mass index of 40 or more. Obese patients often have conditions such as diabetes and high blood pressure than can complicate surgery. Typically, Dr. Haas says, he doesn't perform bilateral surgery in patients over 80, and prefers not to do it in those over 75 unless they are in exceptional health.
Advertisement
For healthy patients in their 50s and 60s, "it's an elective decision," Dr. Haas says.
ENLARGE Sandra Lynch, a 62-year-old wedding officiant in Frederick, Md., had trouble with her knees for more than a decade before getting bilateral knee replacement surgery in December 2014. She says she has no regrets. Photo: Sandra Lynch
Nicholas Grosso, president of the Centers for Advanced Orthopaedics in Bethesda, Md., performs bilateral surgery in tandem with another surgeon. A typical hospital stay is three days, compared with two days for single-knee surgery. New anesthetic techniques help control pain after surgery, and as many as 40% of his bilateral patients go directly home. Others go to a rehabilitation facility for about a week, which isn't usually necessary for unilateral patients. Dr. Grosso says overall recovery time is typically the same, with full recovery in about four months.
Ken McLaughlin, 63, had a bilateral knee replacement surgery in October 2014, with Dr. Grosso and a colleague, M. Brian Polsky. Mr. McLaughlin, who was an avid basketball player and volleyball coach, now teaches physical education to developmentally disabled children. Despite several surgeries over the years to repair damage, he had constant pain in both knees. Yet he wanted to put replacement off, he says, "until I couldn't stand it anymore."
After consulting with Dr. Grosso, he decided on bilateral surgery. First, he spent several months getting ready by building up strength in his legs and hamstrings.
Mr. McLaughlin, who lives in Laurel, Md., says it "really hurt" at first after surgery but he stopped taking pain medication after two days. After three nights in the hospital, he spent about a week in a rehabilitation clinic and took a leave from work until mid-January, working out twice a day for an hour and walking around his house. He had no complications and works out at the gym three times weekly. "I'm feeling stronger and getting ready to snow ski this winter," he says.
A study in May in the Journal of Arthroplasty compared cases matched for risks in simultaneous bilateral and unilateral knee surgeries in a database of nearly 44,000 patients. It found no significant difference in the rate of complications including infection, hospital re-admission, or death. But bilateral procedures were associated with increased overall complications and risk of subsequent surgery within 30 days.
Study co-author David Manning, a joint replacement specialist at Northwestern Memorial Hospital in Chicago and associate professor at Northwestern University Feinberg School of Medicine, says he recommends staged procedures over time for patients who need both knees replaced. He doesn't perform bilateral knee replacements.
"We decided it is not a safe practice, and it adds risk, so we don't do it," he says.
Last year, a large study comparing the two types of surgery indicated that bilateral patients were at increased risk of both minor and major in-hospital complications as well as death. The study, published in the Journal of Bone and Joint Surgery, included hospital claims data on 24,574 simultaneous bilateral surgeries and 382,496 unilateral procedures.
Surgeon Bryan Springer, a co-author of the study and fellowship director at OrthoCarolina Hip and Knee Center in Charlotte, N.C., says while complication rates are generally low for all knee surgeries, he is "extremely selective" about recommending bilateral surgery. "If you pick your patient appropriately you can do this operation very safely," he says. Dr. Springer performs bilateral surgery with a team, starting the second knee while the first incision is being closed; if there are safety concerns after the first, he won't proceed with the second.
Sandra Lynch, a 62-year-old wedding-officiant in Frederick, Md., had trouble with her knees for more than a decade. But with a busy schedule, she didn't want recovery to take more than four months. Before the procedure, she took a year to exercise, walking daily and building a desk over a disassembled recumbent bike. She had the bilateral knee replacement with Dr. Grosso and Dr. Polsky in December last year.
Afterward, Ms. Lynch was hospitalized for four days. She needed a blood transfusion but was able to manage physical therapy before being transferred to a rehabilitation center for about a week. After bad reactions to narcotic pain medications and an anti-nausea patch, she switched to over-the-counter painkillers. Though she had to use a walker at first, after eight weeks she began to drive and walk without assistance. She is now back to work officiating at weddings and says she has no regrets.
Write to Laura Landro at laura.landro@wsj.com
New Push to Stop Overuse of Antibiotics in Nursing Homes
Up to 75% of prescriptions are incorrect as heath officials open a new front in war on overuse
ENLARGE A nurse cares for an elderly woman in a nursing home. Photo: Doctor Stock/Getty Images
By
Betsy McKay
Rochester, N.Y.
A new front is emerging in the war on the overuse of antibiotics: the nursing home.
Health officials and health-care executives, concerned by a rise in dangerous drug-resistant infections, are turning more attention to nursing homes, where antibiotics are some of the most frequently prescribed medications. They have concentrated over the past several years on curbing misuse of antibiotics in hospitals.
Up to 70% of nursing home residents receive one or more courses of antibiotics every year for urinary tract infections, pneumonia, cellulitis and other suspected conditions, according to researchers. Yet up to 75% of those prescriptions are given incorrectly—either unnecessarily or the prescription is for the wrong drug, dose or duration, the Centers for Disease Control and Prevention says.
One of the biggest culprits, researchers say: misdiagnosed urinary tract infections. Only a quarter to a third of people in nursing homes who are diagnosed have actual symptoms, according to several studies. Most have only vague symptoms like confusion or bacteria in their urine that aren't actually causing an infection, says David Nace, director of long-term care and flu programs at the University of Pittsburgh. UTIs are "the poster child of inappropriate antibiotic use," he says.
ENLARGE Ghinwa Dumyati, an infectious disease physician in the Center for Community Health at the University of Rochester Medical Center. 'In hospitals over the past decade there have been a lot of programs put in place to improve the use of antibiotics, but the same has not really happened broadly in the nursing home,' she says. Photo: J. Adam Fenster/University of Rochester
Such practices spawn the spread of drug-resistant bacteria that can be particularly harmful to the elderly and are very difficult if not impossible to treat, researchers say. They can also lead to drug interaction problems or diarrhea from Clostridium difficile—a common complication in long-term care facilities that can be deadly for people over age 65, says Ghinwa Dumyati, an infectious disease physician in the Center for Community Health at the University of Rochester Medical Center.
Curbing antibiotic overuse is a particularly tall order for nursing homes. Doctors can be reluctant to hold off on prescribing medications because patients are frail, and they sometimes have milder fevers or other symptoms that differ from those in younger adults. Many patients also suffer from dementia or other forms of cognitive impairment and can't tell nurses or doctors what their exact symptoms are.
On top of that, turnover in nursing home staff is high, and antibiotics are frequently prescribed by clinicians who haven't seen the patients, geriatricians say. At many nursing homes, nurses evaluate patients and consult with off-site medical staff for prescriptions.
Advertisement
"A lot of the decision-making is done remotely by phone," says Christopher Crnich, an infectious disease specialist at the University of Wisconsin School of Medicine and Public Health who studies antibiotic use and drug-resistant infections in long-term care facilities.
The government and professional groups are taking action. Calling nursing homes the "next frontier" for antibiotic resistance, the Centers for Medicare & Medicaid Services recently proposed new requirements for facilities to track and curb unnecessary use of antibiotics. In September, the CDC issued guidelines to help nursing homes implement such practices.
ENLARGE Diane Kane, the chief medical officer for St. Ann's Community, a not-for-profit health-care system in Rochester, N.Y. 'Every opportunity I get I am always talking about this to our nursing staff,' she says of the misdiagnosis of urinary tract infections. Photo: St. Ann\'s Community
To comply, geriatricians say they will have to dispel a myth—widespread among doctors, nurses, patients and families—that confusion alone or even a fall signals a possible urinary tract infection, says Diane Kane, chief medical officer for St. Ann's Community, a not-for-profit health-care system in Rochester, N.Y. Doctors often order urine tests for such patients which come back positive because about 50% of women and 25% of men in nursing homes have bacteria in their urine, says Dr. Crnich. But the bacteria don't automatically indicate an infection, he says. Bacteria can develop in the urinary tract due to immune system, hormonal, and other changes in aging people, experts say.
Instead, patients should be checked for actual UTI symptoms such as fever, pelvic pain, incontinence or urgency to urinate, and urine tests should be done only on those with UTI symptoms, according to guidelines and campaigns issued in recent years by several professional societies.Others with symptoms of concern should be observed, geriatricians say.
Patients with the most bizarre symptoms are diagnosed with UTIs, says Robin Jump, assistant professor of medicine at Case Western Reserve University and an infectious-disease physician at a veterans hospital in Cleveland. One patient who had bad dreams was treated twice with antibiotics after positive urine tests, she says.
Dr. Jump and other infectious-disease colleagues helped a 160-bed VA long-term care facility reduce use of antibiotics by 30% over 18 months by coaching staff to evaluate patients more carefully for UTIs and other steps, she says.
Genesis HealthCare Corp., which operates more than 500 skilled nursing centers in 34 states, is developing a campaign, set to launch next year, to reduce overdiagnosis of UTIs. It will include clinical education for doctors and nurses, brochures, meetings with families and other initiatives, says JoAnne Reifsnyder, senior vice president of clinical operations and chief nursing officer.
The Kennett Square, Pa., company says it has also increased its roster of full-time providers and trains them to avoid UTI overdiagnosis.
In Rochester, Dr. Dumyati is working with three nursing homes as part of a larger effort to reduce C. difficile infections in the overall community. Over the first six months of 2014, 66% of patients who were treated for UTIs at those facilities had no UTI symptoms. One, part of health-care system St. Ann's Community, took 227 urine cultures during the third quarter of 2014, or 76 on average a month, Dr. Dumyati says. This past July and August, after months of educating staff, urine cultures were down to a monthly average of 44, she says.
Dr. Kane has helped Dr. Dumyati lead the charge to reduce antibiotic overuse. A passionate critic of UTI overdiagnosis, she says Dr. Dumyati's data and her voice as an infectious disease specialist have helped. The data were "eye opening," Dr. Kane says. "When you have dementia, you're going to have good days and you're going to have bad days. When you have dementia and you have a bad day, please don't send a urine, because it's going to be positive."
When his 91 year-old mother, Clarinda, started acting confused recently, John Kirkman says friends and relatives told him it was probably a urinary tract infection. They said, "You just have your doctor prescribe an antibiotic and it takes care of it," he recalls.
Mr. Kirkman, a retired Xerox Corp. field engineer, got a test kit, which gave mixed results. Dr. Kane told him emphatically when she visited Clarinda in her assisted living facility at St. Ann's that confusion alone did not indicate a UTI. "She said if a person has a urinary tract infection they are in pain," he said. "It's not confusion. It is serious pain."
Write to Betsy McKay at betsy.mckay@wsj.com
__._,_.___
No comments:
Post a Comment