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Archive for December, 2015

Bariatrics

Monday, December 21st, 2015

By Helen K. Kelley

According to the Centers for Disease Control and Prevention (CDC), more than one-third (34.9 percent) of all adults in the U.S. are obese, and the rate of adult obesity in the U.S. nearly tripled from 1960 to 2010.

Many individuals who fall into the overweight or morbidly obese categories are desperately searching for a “magic” solution that will take away the pounds permanently. Frustrated with diets and pills that often provide only temporary results, thousands of people are lining up for bariatric procedures, which may provide the closest thing to the permanent solution they seek.

According to the American Society for Metabolic and Bariatric Surgery, bariatric surgery has been shown to be the most effective and durable treatment for morbid obesity, and it helps prevent, improve or resolve more than 40 obesity-related diseases or conditions, including type 2 diabetes, heart disease, obstructive sleep apnea and some cancers.

Atlanta Medicine recently spoke with two Atlanta-area bariatric physicians, who shared their knowledge of how the bariatric landscape has changed over the past several years.

Surgical and Non-Surgical Options Improve Patients’ Weight Loss Success

Jean-Pierre Fritz

Jean-Pierre Fritz, M.D

According to Fritz Jean-Pierre, M.D., a bariatric surgeon with WellStar Health System, improvements in both surgical and nonsurgical options over the past 10 years have resulted in both giving patients better weight loss and giving physicians the ability to better predict that weight loss.

He says the most notable change has been an increase in the selection of a more invasive surgery, the gastric sleeve, over the once-popular lap band and other procedures. The gastric sleeve (sleeve gastrectomy) actually removes approximately 80 percent of the stomach, leaving a tubular pouch that resembles a banana. This procedure, which is less complicated than many other types of bariatric surgery, now comprises over 60 percent of all weight loss surgery procedures performed in the U.S.

“There has been a huge switch in choice of surgeries today. We’ve seen a large increase in patients selecting the sleeve gastrectomy in the past five years,” says Dr. Jean-Pierre. “In addition, we are better able to evaluate our patients’ metabolic conditions today, which helps us in making recommendations for the most appropriate weight loss option.”

Dr. Jean-Pierre adds that non-surgical options can also be very good solutions for some patients who desire to lose weight, especially children and adolescents.

“One of the partners in our practice is an obesity specialist who helps patients determine the weight-loss options available to them and which of those options is best suited. Sometimes, diet and exercise are a better approach,” he says. “For young patients, this is often the first and best choice rather than a surgical intervention, which causes lifelong changes.”

For the patient with a very high Body Mass Index (BMI) and/or various comorbidities like diabetes and high blood pressure, Dr. Jean-Pierre says the more aggressive gastric bypass (Roux-en-Y Gastric Bypass) may be the best option.

Christopher J. Hart

Christopher J. Hart, M.D.

“The gastric bypass is still considered the ‘gold standard’ of weight loss surgeries,” he says. “While it’s more invasive, it has a high rate of success for significant long-term weight loss.”

Lifestyle Change is Key Part of Solution

Christopher J. Hart, M.D., chief of staff and medical director of the Atlanta Bariatric Center at Emory Johns Creek Hospital, says that long-term weight loss success depends on the patient’s commitment to making permanent lifestyle changes to ensure that success after surgery.

“Once a person’s BMI rises above the 30-35 percent range, long-term weight loss with just diet and exercise becomes much harder; it becomes about deprivation,” he says. “So the nice thing about bariatric surgery is that it results in the patient being able to eat less and still feel satisfied.”

However, to obtain lasting results, the patient still has to make lifestyle changes after surgery.

“I tell my patients, ‘I can do a technically perfect surgery, but you will still not lose the weight and get healthy unless you hold up your end of the deal – which means good nutrition and exercise,” he says.

Dr. Hart adds that data compiled over the years for different bariatric procedures is an important tool in developing treatments that can help patients achieve permanent weight loss.

“For example, in the early days of the lap band procedure, there was some experimentation – after a patient reached his or her goal weight, the band was removed. The hope was that the patient had made lifestyle changes that would keep the weight off and would no longer need the band for continued support. The data showed that patients regained the weight because their hunger drive returned,” he says. “It’s important to follow our patients throughout the course of their lives so that we can monitor their progress and success as well as compile data that will be helpful in the future. We can use that data to determine success rates and complications, as well as see how we compare against national statistics.”

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When Does My Patient Need a Medical Geneticist?

Monday, December 21st, 2015

SanchezBy Rossana Sánchez, M.D.

Medical Genetics is a vast and rapidly advancing field. With an estimated 20,000 to 25,000 genes in the human genome, mutations in these genes give rise to many disorders. The scope of practice of a geneticist is necessarily broad, encompassing inpatient and outpatient consultations for inherited conditions and congenital malformations, for genetic counseling and risk assessment, for treatment of genetic diseases and prevention of complications, as well as for ordering genetic and genomic testing1. The focus of genetics as a science is not solely on the patient, either, but also the patient’s family.

Preconception and Prenatal

The need for a medical geneticist may arise very early, sometimes even prenatally. As the science advances, mothers-to-be are offered special screening options for genetic conditions, such as the first and second trimester screen and the newer noninvasive prenatal testing (NIPT)2. These tests are designed to screen for aneuploidies (abnormal chromosomal numbers) of select chromosomes in the fetus via maternal blood. Common disorders caused by aneuploidies are trisomy 21 or Down syndrome, trisomy 13 and trisomy 18. It is common to offer this testing to mothers who are over 35 years of age, which is called “advanced maternal age.” The reason this age was originally chosen as an ideal screening time is because the risk of having a baby with Down syndrome was comparable to the risk of having a miscarriage as a result of an invasive procedure like amniocentesis to confirm this same diagnosis.

Usually, a certified genetic counselor explains all testing to parents and discusses age-related chromosomal problems when presenting results. If any of the screening tests are positive, then the mother should be offered confirmatory testing via amniocentesis. If an aneuploidy is diagnosed, then she and her partner will receive further genetic counseling so they have adequate information about the disease and understand their options. Confirmatory testing may also be offered if there are any fetal abnormalities seen in the ultrasound, including abnormal nuchal (posterior neck) translucency. Prenatal testing via amniocentesis or chorionic villus sampling (CVS) can also be offered for other genetic conditions that are present in the family if the mutations for a disease are known. Antenatal testing may also be offered to couples who have a family history of a disorder and wish to know if they are carriers and to couples with multiple (more than two) miscarriages or multiple stillbirths.

Some couples may also need preconception genetic testing. This is known as carrier testing or a carrier screen3. Most people are carriers of genetic disorders that are recessive, and females can be carriers of X-linked disorders. Carriers do not usually have any signs or symptoms; however, if both partners in a couple are carriers for the same recessive condition, then the chances of a child being affected are 25 percent for each pregnancy. If a mother is a carrier of an X-linked disorder, then males have a 50 percent chance of being affected, and females have a 50 percent chance of being carriers.

Ethnicity may also affect the chances of being carriers of certain disorders. For example, cystic fibrosis is well known to be more common in Caucasians, Tay-Sachs is more common in the Jewish population, and sickle cell disease is more common in African Americans. This is why initiatives like the Jewish Screen, or JScreen, started. It initially screened for common mutations in genes that caused diseases in this population, but it has now expanded to include more genes and full gene sequencing to detect mutations in other populations, becoming a pan-ethnic carrier screen.

Couples who are carriers of a known genetic disorder and whose mutations are known also have a chance to deliver healthy children via pre-implantation genetic diagnosis, or PGD4. This is a procedure used to screen embryos made via in vitro fertilization for genetic conditions, and then only unaffected embryos are implanted in the mother.

Neonatal

After birth, if any malformation is noted in a baby, a geneticist should be consulted. Common birth defects include cleft lip and palate or a congenital heart defect, which may be isolated and nonsyndromic, meaning it is not related to other findings. These defects may also be seen as part of other disorders. A geneticist might recognize patterns that lead to a specific diagnosis or suggest a need for testing. It is common to order a chromosomal microarray test when there are multiple congenital anomalies that are not explained by maternal exposures or deformations in utero5. This test helps uncover missing or extra copies of genetic material, known as deletions and duplications, respectively, which may explain the myriad of symptoms a baby has. If a diagnosis is confirmed, then there will be counseling with the family to discuss the diagnosis, possible complications and risks of recurrence.

In the neonatal period also comes the challenge of positive newborn screens. In the state of Georgia, we currently screen for more than 40 conditions. The false-positive rate tends to be high, so we must follow many children until confirmatory testing is complete. Some of the babies who are true positives appear clinically ill, even before the screen is back. Thus, inborn errors of metabolism should be considered in cases of suspected sepsis, seizures, lethargy, hyperammonemia or an anion gap acidosis, amongst other findings. In all these cases, a biochemical geneticist and metabolic nutritionist should be contacted and brought into the team treating the patient. If a metabolic condition is diagnosed, then the patient will be followed by geneticists throughout his or her lifetime.

Infancy and Childhood

During infancy and childhood, common reasons to refer to a geneticist include developmental delay or developmental regression and autism or pervasive developmental disorder (PDD). Developmental regression tends to be a more ominous sign but can be seen in many different disorders, including some inborn errors of metabolism like Tay-Sachs, neurological conditions like neuronal ceroid lipofuscinosis or Rett syndrome6,7,8. Developmental delay may be fairly nonspecific and ubiquitous in many disorders. A thorough history, physical exam and pedigree can help focus the diagnosis and target the testing strategy. Moreover, autism and PDD may have an underlying genetic cause, and genetic testing is warranted in the initial stages of evaluation8.

Another concern at this age is muscle weakness or hypotonia; again, this may be due to a number of different disorders, and it is important to rule out spinal muscular atrophy, Prader-Willi syndrome, and muscular dystrophy, amongst other disorders9. A simple CPK screen can help differentiate a muscular dystrophy from other disorders, but it is not always abnormal.

Abnormal growth patterns may also indicate a genetic disorder. Such patterns include both short and tall stature or failure to thrive10. Many skeletal dysplasias present with disproportionate short stature, so measuring a patient’s limbs and obtaining the height of other family members are recommended. Overgrowth syndromes, such as Sotos syndrome, are also seen and usually present with increased weight, height and head circumference that may be present from birth11.

Evidence of congenital or early-onset blindness or deafness warrants a genetics consult. It is important to rule out syndromic causes for these and assess for family history of potentially inherited conditions. One common autosomal dominant trait, for instance, is congenital cataracts. When signs and symptoms of an unknown disease follow a Mendelian pattern of inheritance or there is a family history of a known condition, patients should also be referred to genetics.

Adolescence and Adulthood

We customarily see patients during adolescence who have abnormal growth patterns. Patients with tall stature and other findings of common disorders like Marfan syndrome or Klinefelter syndrome should be assessed by a clinical geneticist11. Many of these patients present with other findings, and the work-up may be started by the primary care physician. If, for instance, a diagnosis of Marfan syndrome is considered, then an eye exam and an echocardiogram could be ordered. Another common reason for referral is abnormal sexual maturation. It is important in these cases to rule out disorders of sex development or intersex conditions12. Chromosomes should be analyzed for both growth abnormalities and sexual maturation anomalies.

In this age group, it is also common to receive referrals for a strong family history of cancer or when the types of cancer are rare. Usually, these patients are seen by a certified counselor in the Cancer Genetic Counseling Clinic who obtains a family history and orders testing for known cancer syndromes13. Depending on which genes are found to have mutations, the risks for different cancers increase in different percentages, and follow up with counselors is warranted to explain recurrence risks, practice guidelines and to offer testing to other relatives at risk.

We commonly receive referrals for mutations in the MTHFR gene, which has been linked to mildly elevated homocysteine levels in blood. Hyperhomocysteinemia has been associated with increased risk of developing cardiovascular disease and venous thrombosis14. That said, a person with the common polymorphisms in the MTHFR gene, even in the homozygous state, but with a normal homocysteine level does not require management or referral to genetics. All women regardless of MTHFR status should take folic acid supplements preconceptionally and during pregnancy to lessen the risk for neural tube defects at the recommended daily allowance of folate (0.4 mg/day) 15.

Table 1. Indications for Medical Genetics Referral

Medical Geneticist

 

 

Abbreviations: AFLP: Acute fatty liver of pregnancy. US: Ultrasound. IUGR: Intrauterine growth restriction. FTT: failure to thrive. PDD: Pervasive developmental delay.

* Table adapted from Reference 16.

References:

  1. Scope of practice: a statement of the American College of Medical Genetics and Genomics (ACMG). ACMG Board of Directors. Genetics in Medicine (2015)17,e3.
  2. Carmen J. Beamon et al. A single center’s experience with noninvasive prenatal testing. Genetics in Medicine (2014) 16, 681 – 687.
  3. Wayne W. Grody et al. ACMG position statement on prenatal/preconception expanded carrier screening. Genetics in Medicine (2013) 15,482–483
  4. Harvey J. Stern. Clin. Preimplantation Genetic Diagnosis: Prenatal Testing for Embryos Finally Achieving Its PotentialMed. 2014, 3, 280-309.
  5. Jay W. Ellison et al. Clinical Utility of Chromosomal Microarray Analysis. PEDIATRICS (2012) Vol. 130 No.5.
  6. M A Cleary, A Green Developmental delay: when to suspect and how to investigate for an inborn error of metabolism. Arch Dis Child 2005;90:1128–1132.
  7. Anita Rauch et al. Diagnostic Yield of Various Genetic Approaches in Patients with Unexplained Delay or Mental Retardation. AJMG Part A 140A:2063-2074.
  8. Judith H. Miles. Autism spectrum disorders-A genetics review. Gentics in Medicine (2011) Vol 13, No.4.
  9. N. Prasad, C. Prasad. Genetic evaluation of the floppy infant. Seminars in Fetal & Neonatal Medicine 16 (2011) 99 – 108.
  10. M. Wit, W. Kiess, P. Mullis. Genetic evaluation of short stature. Best Practice & Research Clinical Endocrinology & Metabolism 25 (2011) 1
  11. G.Kant, J.M. Wit, m.H. Breuning. Genetic Analysis of Tall Stature. Horm. Res 2005;64:149 – 156.
  12. Ieuan A. Hughes. Disorders of Sex Development: a new definition and classification. Best Practice & Research Clinical Endocrinology & Metabolism Vol. 22, No. 1, pp. 119–134, 2008.
  13. Jill E. Stopfer. Genetic counseling and clinical cancer genetic services. Seminars in Surgical Oncology 2000: 18:347 – 357.
  14. Hickey et al. ACMG Practice Guideline: lack of evidence for MTHFR polymorphism testing. Genetics in Medicine (2013)15,2.
  15. Clarke R, Bennett DA, Parish S, et al. Homocysteine and coronary heart disease: meta-analysis of MTHFR case-control studies, avoiding publication bias. PLoS Med 2012;9:e1001177.
  16. Beth A. Pletcher et al. Indications for genetic referral: a guide for healthcare providers. ACMG Practice Guideline. (2007) Vol 9. No.6.

 

 

 

 

 

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WellStar Brings Transparency to Patient Records

Wednesday, December 16th, 2015
Jon Morris, M.D.

Jon Morris, M.D.

WellStar’s electronic medical record patient portal, WellStar MyChart, will provide patients with round-the-clock access to their providers’ notes in addition to instructions, next steps, medication lists and test results from outpatient medical visits. WellStar is the first Georgia-based health system to offer this service to its patients.

Evidence has shown that patients who become part of the care team are more involved in their healthcare and experience better outcomes with lower costs. When a patient is sick or stressed during a doctor’s visit, they or their caregivers may forget what the doctor said or prescribed. WellStar MyChart takes away the need to remember every detail by allowing the patient the ability to review this important information on their own schedule.

“By implementing ‘open notes’ in our WellStar MyChart patient portal, we are creating a more transparent and collaborative atmosphere for patients to easily understand and access their health information,” said Jon Morris, M.D., chief information officer for WellStar Health System. “This strengthens the relationship between our providers and their patients and caregivers, resulting in better care. We believe it is critical that we expand our care teams to include the patient and others; we know this will help patients manage their care more effectively, better understand any medical problems and engage more effectively with their care providers.”

A national study in 2010 funded by the Robert Wood Johnson Foundation, the philanthropy organization devoted exclusively to health and healthcare, tested the open medical notes concept with 105 primary care physicians and more than 13,000 patients during a year-long voluntary program. Patients consistently reported:

  • Having better recall after visits
  • Feeling more in control of their care
  • Better communication and collaboration with their doctor
  • Feeling better educated
  • Taking medications more effectively
  • Preventing important mistakes
  • Sharing their notes with family, friends and health professionals

“When this study began, it was a fascinating idea in theory,” says Risa Lavizzo-Mourey, M.D., president and CEO of the Robert Wood Johnson Foundation. “Now it has been tested and proven. The evidence is in: Patients support, use and benefit from open medical notes. These results are exciting – and hold tremendous promise for transforming patient care.”

Physician notes provide a concise, comprehensive summary of a patient’s condition.  This information is shared within WellStar’s electronic health record and shared with the patient through WellStar MyChart.

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Piedmont Healthcare Introduces Piedmont On Call

Tuesday, December 15th, 2015

Designed to help consumers get faster treatment for low-acuity, urgent healthcare needs, Piedmont On Call is the first of its kind in Georgia allowing busy consumers to make a trip to the doctor to see a physician on demand.

“Piedmont On Call offers another, more convenient way for consumers to access healthcare services,” said Matt Gove, chief consumer officer at Piedmont Healthcare. “With a quick download of the Piedmont On Call application via smart phone or tablet, patients can be seen by a physician without having to leave home or work.”

Board-certified physicians are available for consultations via Piedmont On Call from 8 a.m. to 8 p.m. every day of the week for $100 per virtual visit.

Rates of conferring with doctors via email, texting or video have doubled in the past two years, according to a new report from The Deloitte Center for Health Solutions. This suggests digital communication between consumers and providers may continue trending upward.

“By meeting consumers where it is most convenient, we are making it easier for them to take charge of their health,” Gove said. “Piedmont On Call is more than a cool, new app. It is rethinking the way we provide care so we can deliver healthcare services the way consumers want to receive them – on their terms.”

Piedmont On Call virtual visits, powered by Alii Healthcare, are not covered by insurance and should not replace regular visits with a primary care physician.

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Athens Regional Health System and Piedmont Healthcare to Enter Exclusive Discussions

Tuesday, December 15th, 2015

The Athens Regional Health System’s Board of Directors voted unanimously in favor of exploring a partnership with Piedmont Healthcare.

Officials with Athens Regional announced they would be seeking a strategic partner to best position the system for the future of healthcare and to create a stronger healthcare network in its region.

“Our organizations share a common vision and culture of high quality patient and family centered care,” Kevin Brown, president and CEO of Piedmont Healthcare, said. “Working together, there’s a clear opportunity for Athens Regional to be a larger, regional hub for healthcare, expanding our collective reach across the state.”

Athens Regionals’ decision authorizes the finalization of a non-binding Letter of Intent with Piedmont and the commencement of an exclusive negotiation period between the two organizations.

“Piedmont demonstrated to us that they have a culture and history of putting people first,” Dr. Charles Peck, president and CEO of Athens Regional, said. “Just like at Athens Regional, Piedmont places the patient at the center of everything they do.”

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NGMMA Meeting

Thursday, December 10th, 2015

December 10, 2015, Dalton Golf & Country Club, Dalton, Ga. For more information, visit Georgia Medical Group Management Association

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Privia Medical Group Expands to Georgia

Thursday, December 10th, 2015
James Sams

Jim Sams, M.D.

Privia Health, LLC, a national physician practice management and population health technology company, announced today the launch of Privia Medical Group- Georgia. PMG – Georgia was formed to help private practices succeed in arrangements that reward doctors for high-quality care. PMG – Georgia physicians have access to population health management programs, infrastructure, technology, and support teams to help improve patient outcomes, and drive cost savings. Atlanta Physician Jim Sams, President of First Georgia Physicians Group, will serve as Market President. Over 30-providers across 7 practice locations have joined PMG – Georgia.

“It is of utmost importance to help private practices achieve Triple Aim goals and be rewarded for the value they create,” said Dr. Sams. “We at First Georgia Physicians Group joined PMG – Georgia because of our strong belief that Privia Medical Group better positions practices to thrive financially while improving patient outcomes.”

Jeff Butler

Jeff Butler

“There is a great opportunity ahead of Georgia’s independent physicians,” said Jeff Butler, CEO and Founder of Privia Medical Group.

Privia Medical Group now operates in 6 states with over 1,200 providers.

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Negative Mood’s Affect on Radiology Procedures

Tuesday, December 8th, 2015

Nadja Kadom, MDPatients who feel scared, distressed or hostile before undergoing an interventional radiology procedure may experience a poor outcome, according to research presented at the Radiological Society of North American Annual Meeting in Chicago on Dec. 3, 2015.

Nadja Kadom, MD, acting associate professor of radiology, Emory University School of Medicine, and colleagues at the Boston Medical Center, where Kadom was on the faculty prior to coming to Emory, studied 230 patients who underwent image-guided vascular or kidney interventional radiology procedures in Boston, Mass. Before their interventions, they completed the Positive Affect Negative Affect Schedule (PANAS), a questionnaire to assess their mood, which contained 20 adjectives —10 related to positive affect (PA) and 10 related to negative affect (NA).

“NA or negative mood has been found to be associated with undesirable health outcomes such as hypertension, bradycardia (a slow heart rate) and prolonged hypoxia (reduced supply of oxygen),” says Kadom. “We wanted to look at patients undergoing radiological procedures and see whether a negative mood could play a role in negative events occurring.”

On the mood evaluation, negative adjectives included: distressed, upset, scared, hostile, irritable, plus others; while positive adjectives included: interested, excited, proud, inspired, determined and more. Using a five-point rating scale, the study participants (120 women and 110 men) were asked to indicate how they felt in general – on average – based on these terms, not necessarily just before their procedure began.

Kadom and colleagues grouped the patients based on high and low scores for negative affect and high and low scores for positive affect. Higher scores indicated more overall NA or PA affect.

“We were surprised to find that between the high negative numbers and the low negative numbers, there was a difference in outcomes,” says Kadom. “Patients with high NA had significantly more adverse events than those with low NA,” (22% vs. 12%). “There was no significant difference in adverse outcomes for high versus low PA,” (18% vs. 15%).

The researchers determined that NA was associated with increased heart rate and blood pressure, as well as decreased cardiovascular reactivity. Participants in this study with high NA scores had an increased risk of prolonged hypoxia, hypertensive or hypotensive episodes, prolonged bradycardia and post-operative bleeding.

The effect of high NA was independent of high or low PA. Since NA and PA represent different aspects of mood, they can exist independently of each other. As an example, it is possible that a patient is scared (NA) of undergoing a procedure, and at the same time, is excited (PA) about getting minimally invasive treatment instead of undergoing surgery.

“By using a short questionnaire before an interventional radiology procedure, this study tells us that we may be able to identify patients at risk of having adverse events or poor outcomes in advance of that procedure,” says Kadom. “Our team should then be able to distract negative thinking of patients by talking to them, and by guiding a patient’s thoughts, for example encouraging them to imagine their last great vacation, or assisting in self-guided hypnosis.”

The study was made up of participants ranging in age from 18 to 92 years old, with a mean age of 55.

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57th ASH Annual Meeting and Exposition

Saturday, December 5th, 2015

December 5-8, 2015, Orlando, FL. For more information, visit American Society of Hematology 

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WellStar Board Approves Purchase of Five Tenet Hospitals

Tuesday, December 1st, 2015

WellStar Health System has signed a definitive agreement to purchase Dallas, Texas-based Tenet Healthcare’s five metro Atlanta hospitals.  The WellStar Board of Trustees approved the strategic move following the conclusion of the due diligence period.

WellStar will acquire North Fulton Hospital, Spalding Regional Hospital, Sylvan Grove Hospital, Atlanta Medical Center and its South Campus, as well as Tenet’s complimentary physician practices in Atlanta.  In all, the Tenet facilities include 1,192 licensed hospital beds supported by approximately 4,300 team members and a medical staff of 1,390 physicians and advanced practice professionals.  In addition to the $575 million acquisition, WellStar will assume $86 million in debt related to the lease of North Fulton Hospital.

Following the purchase, the Tenet facilities will become not-for-profit entities within WellStar.

Earlier in November, West Georgia Health’s (WGH) Board of Trustees in LaGrange, Ga. voted to join WellStar.  West Georgia Health operates West Georgia Medical Center, a 276-bed hospital in LaGrange, as well as two long-term care facilities, hospice and home care, among other services.  WGH employs 50 physicians and more than 1,300 team members.

The purchase of the Tenet facilities will be submitted to the Federal Trade Commission for review.  The WGH and WellStar partnership requires the approval of the Georgia Attorney General following a public hearing process.

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