User login
Surgery indicates higher survival with adrenal cortical carcinoma
CHICAGO –
These findings, uncovered using the largest cancer registry in the United States, will help give physicians insight into what the best course of action is for treating their patients, according to presenters.
“Surgical resection of the primary tumor improved survival in all stages of disease, whereas adjuvant therapy with chemotherapy or radiation improved overall survival only in stage IVpatients,” said Sri Harsha Tella, MD, endocrinologist at the University of South Carolina, Columbia. “These results may help the prognostication of patients in treatment decision making.”
Investigators conducted a retrospective study of 3,185 pathologically confirmed cases of ACC, registered into the National Cancer Database between 2004 and 2015.
Patients were mostly women with an average age of 55 years old and private insurance, with a nearly even split of patients with stage I-III (26%) and stage IV ACC (24%). Nearly three-quarters of those studied chose to have surgery, of which 31% chose open resection.
Patients with stage I-III ACC had a significant median survival rate of 63 months, compared with those who did not have surgery who had an average survival of 8 months.
In patients with stage IV ACC, surgery lengthened overall survival to 19 months, compared with 6 months for those without surgery, according to Dr. Tella and fellow investigators.
While surgery did have a greater positive effect on patients’ live spans across all stages, the impact of chemotherapy and radiation was significant only among stage IV patients who had complete surgery.
Those in the stage IV group who were given post-surgery adjuvant chemotherapy were likely to live an average of nearly 9 more months than did those who did not have chemotherapy after radiation (22 vs. 13), while those given radiation therapy saw an increase in survival by 19 months (29 vs. 10). These increases did not affect stage I-III patients, who had a similar rate of survival regardless of additional therapies after their surgery (24 vs. 25 months).
One possible explanation for why additional therapy made little difference in survival for stage I-III patients is that, given that the tumors did not spread as widely, the surgical procedures were likely to be more effective at removing most of the disease, according to Dr. Tella.
“One of the possibilities is that surgeons were able to get the whole mass out,” Dr. Tella hypothesized in response to a question from attendees. “On the other hand, patients with stage IV ACC may be more likely to have more presence of metastases and so would benefit more greatly from the removal of the primary tumor and then also additional therapy.”
Investigators noted that because of the structure of the registry, they were unable to determine the initiation and duration of chemotherapy, as well as doses of radiation therapy received by the patient.
A more robust database and future stage-specific, prospective clinical trials are needed in order to better understand these findings, Dr. Tella said.
The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Tella SH et al. Endo 2018.
CHICAGO –
These findings, uncovered using the largest cancer registry in the United States, will help give physicians insight into what the best course of action is for treating their patients, according to presenters.
“Surgical resection of the primary tumor improved survival in all stages of disease, whereas adjuvant therapy with chemotherapy or radiation improved overall survival only in stage IVpatients,” said Sri Harsha Tella, MD, endocrinologist at the University of South Carolina, Columbia. “These results may help the prognostication of patients in treatment decision making.”
Investigators conducted a retrospective study of 3,185 pathologically confirmed cases of ACC, registered into the National Cancer Database between 2004 and 2015.
Patients were mostly women with an average age of 55 years old and private insurance, with a nearly even split of patients with stage I-III (26%) and stage IV ACC (24%). Nearly three-quarters of those studied chose to have surgery, of which 31% chose open resection.
Patients with stage I-III ACC had a significant median survival rate of 63 months, compared with those who did not have surgery who had an average survival of 8 months.
In patients with stage IV ACC, surgery lengthened overall survival to 19 months, compared with 6 months for those without surgery, according to Dr. Tella and fellow investigators.
While surgery did have a greater positive effect on patients’ live spans across all stages, the impact of chemotherapy and radiation was significant only among stage IV patients who had complete surgery.
Those in the stage IV group who were given post-surgery adjuvant chemotherapy were likely to live an average of nearly 9 more months than did those who did not have chemotherapy after radiation (22 vs. 13), while those given radiation therapy saw an increase in survival by 19 months (29 vs. 10). These increases did not affect stage I-III patients, who had a similar rate of survival regardless of additional therapies after their surgery (24 vs. 25 months).
One possible explanation for why additional therapy made little difference in survival for stage I-III patients is that, given that the tumors did not spread as widely, the surgical procedures were likely to be more effective at removing most of the disease, according to Dr. Tella.
“One of the possibilities is that surgeons were able to get the whole mass out,” Dr. Tella hypothesized in response to a question from attendees. “On the other hand, patients with stage IV ACC may be more likely to have more presence of metastases and so would benefit more greatly from the removal of the primary tumor and then also additional therapy.”
Investigators noted that because of the structure of the registry, they were unable to determine the initiation and duration of chemotherapy, as well as doses of radiation therapy received by the patient.
A more robust database and future stage-specific, prospective clinical trials are needed in order to better understand these findings, Dr. Tella said.
The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Tella SH et al. Endo 2018.
CHICAGO –
These findings, uncovered using the largest cancer registry in the United States, will help give physicians insight into what the best course of action is for treating their patients, according to presenters.
“Surgical resection of the primary tumor improved survival in all stages of disease, whereas adjuvant therapy with chemotherapy or radiation improved overall survival only in stage IVpatients,” said Sri Harsha Tella, MD, endocrinologist at the University of South Carolina, Columbia. “These results may help the prognostication of patients in treatment decision making.”
Investigators conducted a retrospective study of 3,185 pathologically confirmed cases of ACC, registered into the National Cancer Database between 2004 and 2015.
Patients were mostly women with an average age of 55 years old and private insurance, with a nearly even split of patients with stage I-III (26%) and stage IV ACC (24%). Nearly three-quarters of those studied chose to have surgery, of which 31% chose open resection.
Patients with stage I-III ACC had a significant median survival rate of 63 months, compared with those who did not have surgery who had an average survival of 8 months.
In patients with stage IV ACC, surgery lengthened overall survival to 19 months, compared with 6 months for those without surgery, according to Dr. Tella and fellow investigators.
While surgery did have a greater positive effect on patients’ live spans across all stages, the impact of chemotherapy and radiation was significant only among stage IV patients who had complete surgery.
Those in the stage IV group who were given post-surgery adjuvant chemotherapy were likely to live an average of nearly 9 more months than did those who did not have chemotherapy after radiation (22 vs. 13), while those given radiation therapy saw an increase in survival by 19 months (29 vs. 10). These increases did not affect stage I-III patients, who had a similar rate of survival regardless of additional therapies after their surgery (24 vs. 25 months).
One possible explanation for why additional therapy made little difference in survival for stage I-III patients is that, given that the tumors did not spread as widely, the surgical procedures were likely to be more effective at removing most of the disease, according to Dr. Tella.
“One of the possibilities is that surgeons were able to get the whole mass out,” Dr. Tella hypothesized in response to a question from attendees. “On the other hand, patients with stage IV ACC may be more likely to have more presence of metastases and so would benefit more greatly from the removal of the primary tumor and then also additional therapy.”
Investigators noted that because of the structure of the registry, they were unable to determine the initiation and duration of chemotherapy, as well as doses of radiation therapy received by the patient.
A more robust database and future stage-specific, prospective clinical trials are needed in order to better understand these findings, Dr. Tella said.
The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Tella SH et al. Endo 2018.
REPORTING FROM ENDO 2018
Key clinical point: Patients who undergo surgical resection at all stages are more likely to survive.
Major finding: Patients stage I-III who underwent surgery survived over nearly 8 times longer than non-surgery patients (63 vs. 8 months [P less than .001]).
Study details: Retrospective study of 3,185 adrenal cortical carcinoma cases entered into the National Cancer Database between 2004 and 2015.
Disclosures: The presenter reported no relevant financial disclosures.
Source: Tella SH et al. Endo 2018.
Analytics, board support are quality improvement keys
Jeffrey Glasheen, MD, had not considered focusing on quality improvement (QI) while studying at the University of Wisconsin, Madison. It was not until a medical error led to the death of a family member that his eyes were opened to the potential consequences of a system not invested in care quality.
“I couldn’t square with it because I had spent the last two to three years of my life working with some of the most dedicated, passionate, hard working people who all were trying to improve lives, and the fact that what I was seeing could result in a family member dying just didn’t make sense,” said Dr. Glasheen. “At the time I thought ‘This must be one of those unfortunate things that happens once in a lifetime,’ and I put it on the back burner.”
As more research on medical errors emerged, however, Dr. Glasheen realized his family’s experience was not as unique as he had thought.
It was after reading the now famous Institute of Medicine report, “To err is human,” which found that medical errors were responsible for 44,000-98,000 deaths a year, that Dr. Glasheen resolved to pursue a career in quality improvement.
Because it was early in his medical career, he began on a small level, teaching his residents about the importance of patient safety and giving lessons on core competencies involved in quality care and higher liability. But he quickly expanded his efforts.
“I started with what I had control over,” Dr. Glasheen explained. “From there, I moved to teaching more medical students, which lead to teaching in front of classrooms, which opened the door to the idea of starting a hospitalist training program.”
In 2003, Dr. Glasheen pitched the program to the University of Colorado at Denver, Aurora, where he completed his residency; this pitch led to the development of a hospitalist training program that focused on improving safety outcomes.
He served as the director of the University of Colorado Hospital Medicine Group from 2003 to 2015, during which time he was approached by the dean to assist in creating and leading the hospitalist training program for internal medicine residents.
The first of its kind, the rigorous University of Colorado program was designed to give residents tools useful beyond the clinical setting to become successful health system leaders.
In 2013, Dr. Glasheen and his colleagues founded the Institute for Healthcare Quality, Safety & Efficiency, which is guided by the mission to improve the quality of care provided on the local level. He has since become the chief quality officer for UCHealth and the University of Colorado Hospital Authority and an associate dean for clinical affairs in quality and safety education, as well as continuing to be a professor of medicine.
For those hoping to pursue quality improvement, Dr. Glasheen stressed the importance of a strong basis in data analytics.
“One of the most common things I see with data is people start to chase what’s called common cause variation, which means they’ll look at a run chart over the course of 12 months and react to every up and down when those are essentially random,” Dr. Glasheen said. “Being able to understand when something is particularly significant and when your interventions are actually making an impact is a skill set I think people who are new to quality improvement don’t often have.”
Having support from board members is also critical to success, although starting without such support should not deter future QI leaders.
“There needs to be a vision from the leadership that this work is important, and not just through words but through deeds, because no board in the country will say that quality is not important,” Dr. Glasheen said. “I would say start with small projects you can control, that tie back not only to patient lives but financial performance as well. If you can tell a board you saved the lives of 40 patients who would have died during the year and saved $1-$2 million in the process, the question will shift from whether the board should invest in QI resources to how much should be invested.”
Looking ahead, Dr. Glasheen highlighted the growing importance of hospital-acquired infections, such as surgical-site infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia, as areas that need to be focused on in the QI sphere.
Jeffrey Glasheen, MD, had not considered focusing on quality improvement (QI) while studying at the University of Wisconsin, Madison. It was not until a medical error led to the death of a family member that his eyes were opened to the potential consequences of a system not invested in care quality.
“I couldn’t square with it because I had spent the last two to three years of my life working with some of the most dedicated, passionate, hard working people who all were trying to improve lives, and the fact that what I was seeing could result in a family member dying just didn’t make sense,” said Dr. Glasheen. “At the time I thought ‘This must be one of those unfortunate things that happens once in a lifetime,’ and I put it on the back burner.”
As more research on medical errors emerged, however, Dr. Glasheen realized his family’s experience was not as unique as he had thought.
It was after reading the now famous Institute of Medicine report, “To err is human,” which found that medical errors were responsible for 44,000-98,000 deaths a year, that Dr. Glasheen resolved to pursue a career in quality improvement.
Because it was early in his medical career, he began on a small level, teaching his residents about the importance of patient safety and giving lessons on core competencies involved in quality care and higher liability. But he quickly expanded his efforts.
“I started with what I had control over,” Dr. Glasheen explained. “From there, I moved to teaching more medical students, which lead to teaching in front of classrooms, which opened the door to the idea of starting a hospitalist training program.”
In 2003, Dr. Glasheen pitched the program to the University of Colorado at Denver, Aurora, where he completed his residency; this pitch led to the development of a hospitalist training program that focused on improving safety outcomes.
He served as the director of the University of Colorado Hospital Medicine Group from 2003 to 2015, during which time he was approached by the dean to assist in creating and leading the hospitalist training program for internal medicine residents.
The first of its kind, the rigorous University of Colorado program was designed to give residents tools useful beyond the clinical setting to become successful health system leaders.
In 2013, Dr. Glasheen and his colleagues founded the Institute for Healthcare Quality, Safety & Efficiency, which is guided by the mission to improve the quality of care provided on the local level. He has since become the chief quality officer for UCHealth and the University of Colorado Hospital Authority and an associate dean for clinical affairs in quality and safety education, as well as continuing to be a professor of medicine.
For those hoping to pursue quality improvement, Dr. Glasheen stressed the importance of a strong basis in data analytics.
“One of the most common things I see with data is people start to chase what’s called common cause variation, which means they’ll look at a run chart over the course of 12 months and react to every up and down when those are essentially random,” Dr. Glasheen said. “Being able to understand when something is particularly significant and when your interventions are actually making an impact is a skill set I think people who are new to quality improvement don’t often have.”
Having support from board members is also critical to success, although starting without such support should not deter future QI leaders.
“There needs to be a vision from the leadership that this work is important, and not just through words but through deeds, because no board in the country will say that quality is not important,” Dr. Glasheen said. “I would say start with small projects you can control, that tie back not only to patient lives but financial performance as well. If you can tell a board you saved the lives of 40 patients who would have died during the year and saved $1-$2 million in the process, the question will shift from whether the board should invest in QI resources to how much should be invested.”
Looking ahead, Dr. Glasheen highlighted the growing importance of hospital-acquired infections, such as surgical-site infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia, as areas that need to be focused on in the QI sphere.
Jeffrey Glasheen, MD, had not considered focusing on quality improvement (QI) while studying at the University of Wisconsin, Madison. It was not until a medical error led to the death of a family member that his eyes were opened to the potential consequences of a system not invested in care quality.
“I couldn’t square with it because I had spent the last two to three years of my life working with some of the most dedicated, passionate, hard working people who all were trying to improve lives, and the fact that what I was seeing could result in a family member dying just didn’t make sense,” said Dr. Glasheen. “At the time I thought ‘This must be one of those unfortunate things that happens once in a lifetime,’ and I put it on the back burner.”
As more research on medical errors emerged, however, Dr. Glasheen realized his family’s experience was not as unique as he had thought.
It was after reading the now famous Institute of Medicine report, “To err is human,” which found that medical errors were responsible for 44,000-98,000 deaths a year, that Dr. Glasheen resolved to pursue a career in quality improvement.
Because it was early in his medical career, he began on a small level, teaching his residents about the importance of patient safety and giving lessons on core competencies involved in quality care and higher liability. But he quickly expanded his efforts.
“I started with what I had control over,” Dr. Glasheen explained. “From there, I moved to teaching more medical students, which lead to teaching in front of classrooms, which opened the door to the idea of starting a hospitalist training program.”
In 2003, Dr. Glasheen pitched the program to the University of Colorado at Denver, Aurora, where he completed his residency; this pitch led to the development of a hospitalist training program that focused on improving safety outcomes.
He served as the director of the University of Colorado Hospital Medicine Group from 2003 to 2015, during which time he was approached by the dean to assist in creating and leading the hospitalist training program for internal medicine residents.
The first of its kind, the rigorous University of Colorado program was designed to give residents tools useful beyond the clinical setting to become successful health system leaders.
In 2013, Dr. Glasheen and his colleagues founded the Institute for Healthcare Quality, Safety & Efficiency, which is guided by the mission to improve the quality of care provided on the local level. He has since become the chief quality officer for UCHealth and the University of Colorado Hospital Authority and an associate dean for clinical affairs in quality and safety education, as well as continuing to be a professor of medicine.
For those hoping to pursue quality improvement, Dr. Glasheen stressed the importance of a strong basis in data analytics.
“One of the most common things I see with data is people start to chase what’s called common cause variation, which means they’ll look at a run chart over the course of 12 months and react to every up and down when those are essentially random,” Dr. Glasheen said. “Being able to understand when something is particularly significant and when your interventions are actually making an impact is a skill set I think people who are new to quality improvement don’t often have.”
Having support from board members is also critical to success, although starting without such support should not deter future QI leaders.
“There needs to be a vision from the leadership that this work is important, and not just through words but through deeds, because no board in the country will say that quality is not important,” Dr. Glasheen said. “I would say start with small projects you can control, that tie back not only to patient lives but financial performance as well. If you can tell a board you saved the lives of 40 patients who would have died during the year and saved $1-$2 million in the process, the question will shift from whether the board should invest in QI resources to how much should be invested.”
Looking ahead, Dr. Glasheen highlighted the growing importance of hospital-acquired infections, such as surgical-site infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia, as areas that need to be focused on in the QI sphere.
Medical associations fight American College of Physicians HBA1c recommendations
in a statement released Friday, March 9.
The new guideline, which was published in the Annals of Internal Medicine on March 5 “could prevent many patients from receiving the full benefits of long-term glucose control,” according to a joint statement from the Endocrine Society, American Diabetes Association, American Association of Diabetes Educators, and American Association of Clinical Endocrinologists.
“The main concern here is this statement is too large to apply to most people with type 2 diabetes,” Grazia Aleppo, MD, chair of the Endocrine Society’s Clinical Affairs Core Committee, said in an interview. “We are all in agreement among the societies to include the ACP’s recommendation on individualizing treatment, but there is a big difference in a 1% HbA1c increase.
“A 7% HbA1c reflects the average of about 154 mg/dL on average, but 8% reflects the average of about 183 mg/dL.”
With patients without diabetes averaging between 70 and 99 mg/dL, a jump to 183 is concerning for Dr. Aleppo and her colleagues.
The ACP’s recommendations were determined from analysis of four drug therapy trials, which found aiming HbA1c levels at below 7% put patients at risk for hypoglycemia and cardiovascular events.
While the trials themselves were approved by the ADA, AADE, and AACE, associations expressed concern with the exclusion of important data, including the addition of newly diagnosed patients in the test population and more modern medications that reduce the adverse effects mentioned in the ACP’s reasoning for raising the target levels.
The patients participating in the trials were older and could have already had underlying cardiovascular disease, according to Dr. Aleppo. These factors plus a rapid change to their medication to get them below 6.5% could have instigated a cardiovascular response, which would not be as likely for patients in their 40s who are just being diagnosed.
“A great majority of patients who are seen in the primary care setting usually don’t have advanced diabetes and, in that case, if someone does not have an increased risk for hypoglycemia, which is the concern that the ACP has, they should be kept at the tightest possible control so that when they are much older they have a legacy effect of good control of their disease,” said Dr. Aleppo.** “Also, if you place someone on modern, lower-risk medications that are so much safer today than before, these actually have been shown not only to improve glucose level in high-risk patients, they can actually cause a very big improvement in cardiovascular disease outcomes.”
Sodium-glucose cotransporter 2 inhibitors and glucagonlike peptide-1 receptor agonists are both newer medications with signs of high success, according to Dr. Aleppo.*
At press time the American College of Physicians was unable to provide a statement.
ezimmerman@frontlinemedcom.com
Corrections, 3/12/18: *An earlier version of this article misstated one of the drug classes mentioned.
**An earlier version of this article misstated a reference to the patient group specified.
in a statement released Friday, March 9.
The new guideline, which was published in the Annals of Internal Medicine on March 5 “could prevent many patients from receiving the full benefits of long-term glucose control,” according to a joint statement from the Endocrine Society, American Diabetes Association, American Association of Diabetes Educators, and American Association of Clinical Endocrinologists.
“The main concern here is this statement is too large to apply to most people with type 2 diabetes,” Grazia Aleppo, MD, chair of the Endocrine Society’s Clinical Affairs Core Committee, said in an interview. “We are all in agreement among the societies to include the ACP’s recommendation on individualizing treatment, but there is a big difference in a 1% HbA1c increase.
“A 7% HbA1c reflects the average of about 154 mg/dL on average, but 8% reflects the average of about 183 mg/dL.”
With patients without diabetes averaging between 70 and 99 mg/dL, a jump to 183 is concerning for Dr. Aleppo and her colleagues.
The ACP’s recommendations were determined from analysis of four drug therapy trials, which found aiming HbA1c levels at below 7% put patients at risk for hypoglycemia and cardiovascular events.
While the trials themselves were approved by the ADA, AADE, and AACE, associations expressed concern with the exclusion of important data, including the addition of newly diagnosed patients in the test population and more modern medications that reduce the adverse effects mentioned in the ACP’s reasoning for raising the target levels.
The patients participating in the trials were older and could have already had underlying cardiovascular disease, according to Dr. Aleppo. These factors plus a rapid change to their medication to get them below 6.5% could have instigated a cardiovascular response, which would not be as likely for patients in their 40s who are just being diagnosed.
“A great majority of patients who are seen in the primary care setting usually don’t have advanced diabetes and, in that case, if someone does not have an increased risk for hypoglycemia, which is the concern that the ACP has, they should be kept at the tightest possible control so that when they are much older they have a legacy effect of good control of their disease,” said Dr. Aleppo.** “Also, if you place someone on modern, lower-risk medications that are so much safer today than before, these actually have been shown not only to improve glucose level in high-risk patients, they can actually cause a very big improvement in cardiovascular disease outcomes.”
Sodium-glucose cotransporter 2 inhibitors and glucagonlike peptide-1 receptor agonists are both newer medications with signs of high success, according to Dr. Aleppo.*
At press time the American College of Physicians was unable to provide a statement.
ezimmerman@frontlinemedcom.com
Corrections, 3/12/18: *An earlier version of this article misstated one of the drug classes mentioned.
**An earlier version of this article misstated a reference to the patient group specified.
in a statement released Friday, March 9.
The new guideline, which was published in the Annals of Internal Medicine on March 5 “could prevent many patients from receiving the full benefits of long-term glucose control,” according to a joint statement from the Endocrine Society, American Diabetes Association, American Association of Diabetes Educators, and American Association of Clinical Endocrinologists.
“The main concern here is this statement is too large to apply to most people with type 2 diabetes,” Grazia Aleppo, MD, chair of the Endocrine Society’s Clinical Affairs Core Committee, said in an interview. “We are all in agreement among the societies to include the ACP’s recommendation on individualizing treatment, but there is a big difference in a 1% HbA1c increase.
“A 7% HbA1c reflects the average of about 154 mg/dL on average, but 8% reflects the average of about 183 mg/dL.”
With patients without diabetes averaging between 70 and 99 mg/dL, a jump to 183 is concerning for Dr. Aleppo and her colleagues.
The ACP’s recommendations were determined from analysis of four drug therapy trials, which found aiming HbA1c levels at below 7% put patients at risk for hypoglycemia and cardiovascular events.
While the trials themselves were approved by the ADA, AADE, and AACE, associations expressed concern with the exclusion of important data, including the addition of newly diagnosed patients in the test population and more modern medications that reduce the adverse effects mentioned in the ACP’s reasoning for raising the target levels.
The patients participating in the trials were older and could have already had underlying cardiovascular disease, according to Dr. Aleppo. These factors plus a rapid change to their medication to get them below 6.5% could have instigated a cardiovascular response, which would not be as likely for patients in their 40s who are just being diagnosed.
“A great majority of patients who are seen in the primary care setting usually don’t have advanced diabetes and, in that case, if someone does not have an increased risk for hypoglycemia, which is the concern that the ACP has, they should be kept at the tightest possible control so that when they are much older they have a legacy effect of good control of their disease,” said Dr. Aleppo.** “Also, if you place someone on modern, lower-risk medications that are so much safer today than before, these actually have been shown not only to improve glucose level in high-risk patients, they can actually cause a very big improvement in cardiovascular disease outcomes.”
Sodium-glucose cotransporter 2 inhibitors and glucagonlike peptide-1 receptor agonists are both newer medications with signs of high success, according to Dr. Aleppo.*
At press time the American College of Physicians was unable to provide a statement.
ezimmerman@frontlinemedcom.com
Corrections, 3/12/18: *An earlier version of this article misstated one of the drug classes mentioned.
**An earlier version of this article misstated a reference to the patient group specified.
Nonendoscopic nonmalignant polyp surgery increasing despite greater risk
Rate of nonendoscopic surgeries for nonmalignant colorectal polyps significantly increased from 5.9 to 9.4 per 100,000 people from 2000 to 2014, according to a study in Gastroenterology.
These surgeries are not only associated with a much higher risk to patients than endoscopic procedures, but they are significantly less cost effective, confusing investigators as to the cause of the increase.
“The literature to date is clear that endoscopic resection is the preferred management of nonmalignant colorectal polyps,” Anne Peery, MD, gastroenterologist at the University of North Carolina at Chapel Hill, and colleagues explained. “Among patients who have surgery for a nonmalignant colorectal polyp, 14% will have at least one major short-term postoperative event.”
Data from 1,230,458 surgeries conducted during 2000-2014 and recorded in the Healthcare Cost and Utilization Project National Inpatients Sample were included in this study. Patients who underwent a nonendoscopic procedure for nonmalignant polyps were predominantly non-Hispanic white, covered by Medicare, from the highest household income range, and an average age of 66 years.
While non-Hispanic white patients had the highest overall rate increase by ethnicity, rising from 5.6 to 10.5 per 100,000 population, rates in non-Hispanic black and Hispanic patients also rose significantly, increasing from 3.5 to 5.8 per 100,000 population, and from 1.1 to 3.7 per 100,000 population, respectively.
Regionally, rates of surgery were higher in the Midwest (10.8 per 100,000) and the South (10.6 per 100,000) than in the Northeast (7.8 per 100,000) and West (7.5 per 100,000). Incidence rates rose equally during the study period for both men and women.
Large urban teaching hospitals were found to have the largest rate increase when data were stratified by teaching status, a finding which caught Dr. Peery and fellow investigators by surprise.
“We had hypothesized that surgery for nonmalignant colorectal polyps would be both uncommon and declining in teaching hospitals where providers are more likely to be familiar with current guidelines and to have access to endoscopic mucosal resection,” wrote the investigators. “Instead, we found that surgery for nonmalignant colorectal polyps is both common and significantly increasing in teaching hospitals.”
The investigators first hypothesized the increased rate in teaching hospitals could be due to a higher concentration of case referrals to these high-volume centers, following a trend of centralizing cancer procedures. However, there has been no other sign that colon and rectal cancer procedures are following this trend.
Another option considered by Dr. Peery and her colleagues was that increased procedures may stem from a rise in colorectal cancer screening; however, the data indicate screenings did not change from 2010 to 2015, leaving investigators with few final guesses to go on.
“It is also conceivable that increasing production pressure and inadequate reimbursement for endoscopic mucosal resection may persuade endoscopists to refer patients with complex nonmalignant colorectal polyps for surgery,” said Dr. Peery and fellow investigators. “Finally, there is the issue of risk ... for endoscopists without additional training in advanced endoscopic resection, these risks may be perceived as too great, especially when they have the option of referring for a surgical resection.”
There is a possibility that the incidence of surgery was over- or underestimated, as investigators were using ICD-9 codes to identify cases, and patients with diverticulitis were also excluded, which may have affected results.
The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Peery A et al. Gastroenterology. 2018 Jan 6. doi: 10.1053/j.gastro.2018.01.003.
In this comprehensive analysis, Peery et al. found a rising incidence of surgery for nonmalignant colorectal polyps despite relatively stable colorectal cancer screening rates and with decreasing incidence of colorectal cancer surgery.
In a separate study, the authors found that 14% of patients who underwent surgical resection of nonmalignant colorectal polyps had a major postoperative event. Other population-based studies have reported similar incidence of surgical complications.
This report thus raises concern for inappropriate surgical referral. While reimbursement models may play a role, many factors are involved with surgical referral. Complex polypectomy, often using endoscopic mucosal resection techniques to remove large polyps, is associated with higher rates of bleeding, perforation, and incomplete resection, compared with standard polypectomies. The decision to refer to surgery or to attempt endoscopic resection is based on provider experience and polyp characteristics, including suspicion for malignancy. Current literature suggests that surgical removal is recommended less frequently by specialists in complex polypectomy, compared with nonspecialists.
Given this study’s findings, health systems should consider including surgical referral rates in their quality measures. Thus, high-quality endoscopy centers would ensure that complex polyps are appropriately characterized and initially managed by endoscopists experienced in complex polypectomy. This is especially important with the increasing repertoire of endoscopic alternatives to surgery that we can offer our patients.
Gyanprakash A. Ketwaroo, MD, MSc, is an an assistant professor, division of gastroenterology and hepatology, Baylor College of Medicine, Houston. He has no conflicts.
In this comprehensive analysis, Peery et al. found a rising incidence of surgery for nonmalignant colorectal polyps despite relatively stable colorectal cancer screening rates and with decreasing incidence of colorectal cancer surgery.
In a separate study, the authors found that 14% of patients who underwent surgical resection of nonmalignant colorectal polyps had a major postoperative event. Other population-based studies have reported similar incidence of surgical complications.
This report thus raises concern for inappropriate surgical referral. While reimbursement models may play a role, many factors are involved with surgical referral. Complex polypectomy, often using endoscopic mucosal resection techniques to remove large polyps, is associated with higher rates of bleeding, perforation, and incomplete resection, compared with standard polypectomies. The decision to refer to surgery or to attempt endoscopic resection is based on provider experience and polyp characteristics, including suspicion for malignancy. Current literature suggests that surgical removal is recommended less frequently by specialists in complex polypectomy, compared with nonspecialists.
Given this study’s findings, health systems should consider including surgical referral rates in their quality measures. Thus, high-quality endoscopy centers would ensure that complex polyps are appropriately characterized and initially managed by endoscopists experienced in complex polypectomy. This is especially important with the increasing repertoire of endoscopic alternatives to surgery that we can offer our patients.
Gyanprakash A. Ketwaroo, MD, MSc, is an an assistant professor, division of gastroenterology and hepatology, Baylor College of Medicine, Houston. He has no conflicts.
In this comprehensive analysis, Peery et al. found a rising incidence of surgery for nonmalignant colorectal polyps despite relatively stable colorectal cancer screening rates and with decreasing incidence of colorectal cancer surgery.
In a separate study, the authors found that 14% of patients who underwent surgical resection of nonmalignant colorectal polyps had a major postoperative event. Other population-based studies have reported similar incidence of surgical complications.
This report thus raises concern for inappropriate surgical referral. While reimbursement models may play a role, many factors are involved with surgical referral. Complex polypectomy, often using endoscopic mucosal resection techniques to remove large polyps, is associated with higher rates of bleeding, perforation, and incomplete resection, compared with standard polypectomies. The decision to refer to surgery or to attempt endoscopic resection is based on provider experience and polyp characteristics, including suspicion for malignancy. Current literature suggests that surgical removal is recommended less frequently by specialists in complex polypectomy, compared with nonspecialists.
Given this study’s findings, health systems should consider including surgical referral rates in their quality measures. Thus, high-quality endoscopy centers would ensure that complex polyps are appropriately characterized and initially managed by endoscopists experienced in complex polypectomy. This is especially important with the increasing repertoire of endoscopic alternatives to surgery that we can offer our patients.
Gyanprakash A. Ketwaroo, MD, MSc, is an an assistant professor, division of gastroenterology and hepatology, Baylor College of Medicine, Houston. He has no conflicts.
Rate of nonendoscopic surgeries for nonmalignant colorectal polyps significantly increased from 5.9 to 9.4 per 100,000 people from 2000 to 2014, according to a study in Gastroenterology.
These surgeries are not only associated with a much higher risk to patients than endoscopic procedures, but they are significantly less cost effective, confusing investigators as to the cause of the increase.
“The literature to date is clear that endoscopic resection is the preferred management of nonmalignant colorectal polyps,” Anne Peery, MD, gastroenterologist at the University of North Carolina at Chapel Hill, and colleagues explained. “Among patients who have surgery for a nonmalignant colorectal polyp, 14% will have at least one major short-term postoperative event.”
Data from 1,230,458 surgeries conducted during 2000-2014 and recorded in the Healthcare Cost and Utilization Project National Inpatients Sample were included in this study. Patients who underwent a nonendoscopic procedure for nonmalignant polyps were predominantly non-Hispanic white, covered by Medicare, from the highest household income range, and an average age of 66 years.
While non-Hispanic white patients had the highest overall rate increase by ethnicity, rising from 5.6 to 10.5 per 100,000 population, rates in non-Hispanic black and Hispanic patients also rose significantly, increasing from 3.5 to 5.8 per 100,000 population, and from 1.1 to 3.7 per 100,000 population, respectively.
Regionally, rates of surgery were higher in the Midwest (10.8 per 100,000) and the South (10.6 per 100,000) than in the Northeast (7.8 per 100,000) and West (7.5 per 100,000). Incidence rates rose equally during the study period for both men and women.
Large urban teaching hospitals were found to have the largest rate increase when data were stratified by teaching status, a finding which caught Dr. Peery and fellow investigators by surprise.
“We had hypothesized that surgery for nonmalignant colorectal polyps would be both uncommon and declining in teaching hospitals where providers are more likely to be familiar with current guidelines and to have access to endoscopic mucosal resection,” wrote the investigators. “Instead, we found that surgery for nonmalignant colorectal polyps is both common and significantly increasing in teaching hospitals.”
The investigators first hypothesized the increased rate in teaching hospitals could be due to a higher concentration of case referrals to these high-volume centers, following a trend of centralizing cancer procedures. However, there has been no other sign that colon and rectal cancer procedures are following this trend.
Another option considered by Dr. Peery and her colleagues was that increased procedures may stem from a rise in colorectal cancer screening; however, the data indicate screenings did not change from 2010 to 2015, leaving investigators with few final guesses to go on.
“It is also conceivable that increasing production pressure and inadequate reimbursement for endoscopic mucosal resection may persuade endoscopists to refer patients with complex nonmalignant colorectal polyps for surgery,” said Dr. Peery and fellow investigators. “Finally, there is the issue of risk ... for endoscopists without additional training in advanced endoscopic resection, these risks may be perceived as too great, especially when they have the option of referring for a surgical resection.”
There is a possibility that the incidence of surgery was over- or underestimated, as investigators were using ICD-9 codes to identify cases, and patients with diverticulitis were also excluded, which may have affected results.
The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Peery A et al. Gastroenterology. 2018 Jan 6. doi: 10.1053/j.gastro.2018.01.003.
Rate of nonendoscopic surgeries for nonmalignant colorectal polyps significantly increased from 5.9 to 9.4 per 100,000 people from 2000 to 2014, according to a study in Gastroenterology.
These surgeries are not only associated with a much higher risk to patients than endoscopic procedures, but they are significantly less cost effective, confusing investigators as to the cause of the increase.
“The literature to date is clear that endoscopic resection is the preferred management of nonmalignant colorectal polyps,” Anne Peery, MD, gastroenterologist at the University of North Carolina at Chapel Hill, and colleagues explained. “Among patients who have surgery for a nonmalignant colorectal polyp, 14% will have at least one major short-term postoperative event.”
Data from 1,230,458 surgeries conducted during 2000-2014 and recorded in the Healthcare Cost and Utilization Project National Inpatients Sample were included in this study. Patients who underwent a nonendoscopic procedure for nonmalignant polyps were predominantly non-Hispanic white, covered by Medicare, from the highest household income range, and an average age of 66 years.
While non-Hispanic white patients had the highest overall rate increase by ethnicity, rising from 5.6 to 10.5 per 100,000 population, rates in non-Hispanic black and Hispanic patients also rose significantly, increasing from 3.5 to 5.8 per 100,000 population, and from 1.1 to 3.7 per 100,000 population, respectively.
Regionally, rates of surgery were higher in the Midwest (10.8 per 100,000) and the South (10.6 per 100,000) than in the Northeast (7.8 per 100,000) and West (7.5 per 100,000). Incidence rates rose equally during the study period for both men and women.
Large urban teaching hospitals were found to have the largest rate increase when data were stratified by teaching status, a finding which caught Dr. Peery and fellow investigators by surprise.
“We had hypothesized that surgery for nonmalignant colorectal polyps would be both uncommon and declining in teaching hospitals where providers are more likely to be familiar with current guidelines and to have access to endoscopic mucosal resection,” wrote the investigators. “Instead, we found that surgery for nonmalignant colorectal polyps is both common and significantly increasing in teaching hospitals.”
The investigators first hypothesized the increased rate in teaching hospitals could be due to a higher concentration of case referrals to these high-volume centers, following a trend of centralizing cancer procedures. However, there has been no other sign that colon and rectal cancer procedures are following this trend.
Another option considered by Dr. Peery and her colleagues was that increased procedures may stem from a rise in colorectal cancer screening; however, the data indicate screenings did not change from 2010 to 2015, leaving investigators with few final guesses to go on.
“It is also conceivable that increasing production pressure and inadequate reimbursement for endoscopic mucosal resection may persuade endoscopists to refer patients with complex nonmalignant colorectal polyps for surgery,” said Dr. Peery and fellow investigators. “Finally, there is the issue of risk ... for endoscopists without additional training in advanced endoscopic resection, these risks may be perceived as too great, especially when they have the option of referring for a surgical resection.”
There is a possibility that the incidence of surgery was over- or underestimated, as investigators were using ICD-9 codes to identify cases, and patients with diverticulitis were also excluded, which may have affected results.
The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Peery A et al. Gastroenterology. 2018 Jan 6. doi: 10.1053/j.gastro.2018.01.003.
FROM GASTROENTEROLOGY
Key clinical point: Surgical resections for nonmalignant colorectal polyps are increasing while safer endoscopic procedures are available.
Major finding: Incidence rate of surgery for nonmalignant polyps has increased from 5.9 to 9.4 per 100,000 adults from 2000 to 2014.
Study details: A retrospective study of 1,230,458 surgeries recorded in the Healthcare Cost and Utilization Project National Inpatient Sample from 2000 to 2014.
Disclosures: The authors reported no relevant financial disclosures.
Source: Peery A et al. Gastroenterology. 2018 Jan 6. doi: 10.1053/j.gastro.2018.01.003.
ACP recommends new ideal hemoglobin A1c range for type 2 diabetes
, according to recommendations by the American College of Physicians.
But the guidance drew strong condemnation from diabetes and endocrinology organizations, which warned the higher target range could do more harm than good.
Evidence presented in the ACP statement shows the intensive therapy commonly used to reach the previous target of 6.5%-7% is likely either to increase risk of adverse cardiovascular and hypoglycemic events or have the same risk as less intensive therapy.
“Treatment with drugs targeted to 7%, in contrast to 8%, does not prevent heart attacks or strokes,” said Jack Ende, MD, president of the ACP. “But it does result in substantial harm, including low blood sugar, increased medication burden, and increased cost.”
The ACP recommends clinicians should talk with patients about creating personalized treatment plans based on the risks and benefits of different drugs, what the patients prefers, life expectancy, and cost of care.
Previous guidelines on reaching HbA1c had been developed to reduce micro- and macrovascular complications; however, evidence that lowering levels also would lower events was not substantial enough to prove correct, as results were limited to reductions in less serious complications, according to Dr. Ende.
Physicians whose patients have HbA1c levels less than 6.5% are advised to deintensify patients’ pharmacologic therapy by reducing the dosage, or taking a medication out completely.
New guidelines were based on evaluation of four drug-therapy trials, which encompassed long- and short-term effects of intensive pharmacological therapy compared with more moderate treatment.
In the Veterans Affairs Diabetes Trial, patients given intensive treatment found no reduction in major cardiovascular, microvascular events, or death in a 5.6-year follow-up. The intensive group did show fewer cardiovascular events after a longer period of time – 12 years – but this difference was small (8.6 events per 1,000 patient-years), according to the investigators.
Because of these long-term improvements, which were found across almost all studies evaluated, the ACP also recommends treatment of symptoms related to hyperglycemia instead of HbA1c for patients with lower life expectancy, including those older than 80 years, those in nursing homes, and those with chronic conditions such as cancer or dementia.
“Setting stringent targets in these populations is not an optimal approach, and clinicians should instead focus on treating to reduce symptoms from both disease and treatment,” wrote Amir Qaseem, MD, PhD, vice president, Clinical Policy and Center for Evidence Reviews, ACP, and fellow investigators. “The ACP guidance statement in persons with a life expectancy less than 10 years is based on the small death or cardiovascular benefit of lower HbA1c targets through at least 10 years, which should be balanced with treatment harms.”
The policy implications of these recommendations address physician performance evaluations, which the ACP recommends should not have a target HbA1c level below 8%, nor any target level for patients with limited life expectancies.
But many diabetes organizations aren't embracing the new target levels.
The ACP's recommendations could keep many diabetes patients from achieving all the benefits from long-term intensive glucose control, warned the Endocrine Society, the American Diabetes Association, the American Association for Clinical Endocrinologists, and the American Association of Diabetes Educators in a joint statement. And the ACP's recommendations overlook the positive impact that newer diabetes drugs have shown on morbidity and mortality in high-risk type 2 diabetes patients.
Coauthor Michael J. Barry, MD, reported receiving grants from the nonprofit Healthwise, outside of this statement.
All other authors reported no relevant financial disclosures.
, according to recommendations by the American College of Physicians.
But the guidance drew strong condemnation from diabetes and endocrinology organizations, which warned the higher target range could do more harm than good.
Evidence presented in the ACP statement shows the intensive therapy commonly used to reach the previous target of 6.5%-7% is likely either to increase risk of adverse cardiovascular and hypoglycemic events or have the same risk as less intensive therapy.
“Treatment with drugs targeted to 7%, in contrast to 8%, does not prevent heart attacks or strokes,” said Jack Ende, MD, president of the ACP. “But it does result in substantial harm, including low blood sugar, increased medication burden, and increased cost.”
The ACP recommends clinicians should talk with patients about creating personalized treatment plans based on the risks and benefits of different drugs, what the patients prefers, life expectancy, and cost of care.
Previous guidelines on reaching HbA1c had been developed to reduce micro- and macrovascular complications; however, evidence that lowering levels also would lower events was not substantial enough to prove correct, as results were limited to reductions in less serious complications, according to Dr. Ende.
Physicians whose patients have HbA1c levels less than 6.5% are advised to deintensify patients’ pharmacologic therapy by reducing the dosage, or taking a medication out completely.
New guidelines were based on evaluation of four drug-therapy trials, which encompassed long- and short-term effects of intensive pharmacological therapy compared with more moderate treatment.
In the Veterans Affairs Diabetes Trial, patients given intensive treatment found no reduction in major cardiovascular, microvascular events, or death in a 5.6-year follow-up. The intensive group did show fewer cardiovascular events after a longer period of time – 12 years – but this difference was small (8.6 events per 1,000 patient-years), according to the investigators.
Because of these long-term improvements, which were found across almost all studies evaluated, the ACP also recommends treatment of symptoms related to hyperglycemia instead of HbA1c for patients with lower life expectancy, including those older than 80 years, those in nursing homes, and those with chronic conditions such as cancer or dementia.
“Setting stringent targets in these populations is not an optimal approach, and clinicians should instead focus on treating to reduce symptoms from both disease and treatment,” wrote Amir Qaseem, MD, PhD, vice president, Clinical Policy and Center for Evidence Reviews, ACP, and fellow investigators. “The ACP guidance statement in persons with a life expectancy less than 10 years is based on the small death or cardiovascular benefit of lower HbA1c targets through at least 10 years, which should be balanced with treatment harms.”
The policy implications of these recommendations address physician performance evaluations, which the ACP recommends should not have a target HbA1c level below 8%, nor any target level for patients with limited life expectancies.
But many diabetes organizations aren't embracing the new target levels.
The ACP's recommendations could keep many diabetes patients from achieving all the benefits from long-term intensive glucose control, warned the Endocrine Society, the American Diabetes Association, the American Association for Clinical Endocrinologists, and the American Association of Diabetes Educators in a joint statement. And the ACP's recommendations overlook the positive impact that newer diabetes drugs have shown on morbidity and mortality in high-risk type 2 diabetes patients.
Coauthor Michael J. Barry, MD, reported receiving grants from the nonprofit Healthwise, outside of this statement.
All other authors reported no relevant financial disclosures.
, according to recommendations by the American College of Physicians.
But the guidance drew strong condemnation from diabetes and endocrinology organizations, which warned the higher target range could do more harm than good.
Evidence presented in the ACP statement shows the intensive therapy commonly used to reach the previous target of 6.5%-7% is likely either to increase risk of adverse cardiovascular and hypoglycemic events or have the same risk as less intensive therapy.
“Treatment with drugs targeted to 7%, in contrast to 8%, does not prevent heart attacks or strokes,” said Jack Ende, MD, president of the ACP. “But it does result in substantial harm, including low blood sugar, increased medication burden, and increased cost.”
The ACP recommends clinicians should talk with patients about creating personalized treatment plans based on the risks and benefits of different drugs, what the patients prefers, life expectancy, and cost of care.
Previous guidelines on reaching HbA1c had been developed to reduce micro- and macrovascular complications; however, evidence that lowering levels also would lower events was not substantial enough to prove correct, as results were limited to reductions in less serious complications, according to Dr. Ende.
Physicians whose patients have HbA1c levels less than 6.5% are advised to deintensify patients’ pharmacologic therapy by reducing the dosage, or taking a medication out completely.
New guidelines were based on evaluation of four drug-therapy trials, which encompassed long- and short-term effects of intensive pharmacological therapy compared with more moderate treatment.
In the Veterans Affairs Diabetes Trial, patients given intensive treatment found no reduction in major cardiovascular, microvascular events, or death in a 5.6-year follow-up. The intensive group did show fewer cardiovascular events after a longer period of time – 12 years – but this difference was small (8.6 events per 1,000 patient-years), according to the investigators.
Because of these long-term improvements, which were found across almost all studies evaluated, the ACP also recommends treatment of symptoms related to hyperglycemia instead of HbA1c for patients with lower life expectancy, including those older than 80 years, those in nursing homes, and those with chronic conditions such as cancer or dementia.
“Setting stringent targets in these populations is not an optimal approach, and clinicians should instead focus on treating to reduce symptoms from both disease and treatment,” wrote Amir Qaseem, MD, PhD, vice president, Clinical Policy and Center for Evidence Reviews, ACP, and fellow investigators. “The ACP guidance statement in persons with a life expectancy less than 10 years is based on the small death or cardiovascular benefit of lower HbA1c targets through at least 10 years, which should be balanced with treatment harms.”
The policy implications of these recommendations address physician performance evaluations, which the ACP recommends should not have a target HbA1c level below 8%, nor any target level for patients with limited life expectancies.
But many diabetes organizations aren't embracing the new target levels.
The ACP's recommendations could keep many diabetes patients from achieving all the benefits from long-term intensive glucose control, warned the Endocrine Society, the American Diabetes Association, the American Association for Clinical Endocrinologists, and the American Association of Diabetes Educators in a joint statement. And the ACP's recommendations overlook the positive impact that newer diabetes drugs have shown on morbidity and mortality in high-risk type 2 diabetes patients.
Coauthor Michael J. Barry, MD, reported receiving grants from the nonprofit Healthwise, outside of this statement.
All other authors reported no relevant financial disclosures.
FROM ANNALS OF INTERNAL MEDICINE
Nonopioid analgesics have no major disadvantages vs. opioids for chronic pain
Patients treated with opioids for moderate to severe chronic back pain or knee or hip osteoarthritis pain saw no significant improvement when results were compared with treatment using acetaminophen or nonsteroidal anti-inflammatory drugs in the randomized SPACE study.
These findings may help restructure how physicians treat patients with chronic pain in order to decrease the risk of opioid addiction in a population that is particularly susceptible.
“Long-term opioid therapy became a standard approach to managing chronic musculoskeletal pain despite a lack of high-quality data on benefits and harms,” wrote Erin E. Krebs, MD, MPH, core investigator at the Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research, and her colleagues. “Rising rates of opioid overdose deaths have raised questions about prescribing opioids for chronic pain management.”
In the 12-month SPACE (Strategies for Prescribing Analgesics Comparative Effectiveness) trial published March 6 in JAMA, the investigators reported randomizing a total of 240 patients to treatment with immediate-release opioids (morphine, oxycodone, or hydrocodone/acetaminophen) or acetaminophen or nonsteroidal anti-inflammatory drugs. The patients came from the Minneapolis VA system between June 2013 and December 2015. Patients in the opioid group were on average 57 years old, while those in the nonopioid group had an average age of 60 years. Men comprised 87% of all patients, and both groups were predominantly white (86%-88%) with chronic back pain (65%). The investigators excluded patients with physiological opioid dependence from ongoing opioid use.
Patients taking opioids saw no significant improvement in the primary outcome of pain-related function on the seven-item Brief Pain Inventory (BPI) interference scale over those taking nonopioids at the end of the 12-month period (P = .58), according to Dr. Krebs and her fellow investigators.
The main secondary outcome of pain intensity using the four-item BPI severity scale improved significantly more among the nonopioid group, which reported an average score of 3.5, compared with 4.0 in the opioid group (P = .03). However, the small difference of 0.5 is less than the minimal clinically important difference of 1.0, according to the investigators.
Anxiety control was the only secondary outcome measure that was significantly better among patients in the opioid group, which was unsurprising to the investigators. “This finding is consistent with the role of the endogenous opioid system in stress and emotional suffering,” they wrote.
The investigators were uncertain about the significance of this small difference because overall anxiety levels were low, with 9% of patients reporting moderate severity anxiety symptoms at baseline.
Patients in the opioid group took a mean of 1.7 analgesics during the study period, compared with 3.8 in the nonopioid group. In the nonopioid group, the mean number of months that nonopioid analgesics were prescribed ranged from 2.6 for acetaminophen to 5.9 with oral NSAIDs. In this group, tramadol was prescribed to no more than 11% of patients during any particular month and was dispensed for a mean of 0.4 months overall.
Patients in the opioid group took opioids for a mean of 8.1 months, with all other analgesics taken for a mean of 0.4 months or less. The authors noted that in “each 90-day follow-up period, fewer than 15% of patients in the opioid group had a mean dispensed dosage of 50 morphine-equivalent mg/day or more.” Patients could be titrated up to a maximum daily dosage of 100 morphine-equivalent mg/day.
Patients prescribed opioids were significantly more likely to report medication-related symptoms, and while misuse was not significantly higher in the opioid group, the investigators said that “Overall, opioids did not demonstrate any advantage over nonopioid medications that could potentially outweigh their greater risk of harms.”
Further studies will need to include a more diverse population, they noted.
The study was funded by an award from the U.S. Department of Veterans Affairs Health Services Research and Development Service. The investigators reported no relevant disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Krebs EE et al. JAMA. 2018 Mar 6;319(9):872-82
Patients treated with opioids for moderate to severe chronic back pain or knee or hip osteoarthritis pain saw no significant improvement when results were compared with treatment using acetaminophen or nonsteroidal anti-inflammatory drugs in the randomized SPACE study.
These findings may help restructure how physicians treat patients with chronic pain in order to decrease the risk of opioid addiction in a population that is particularly susceptible.
“Long-term opioid therapy became a standard approach to managing chronic musculoskeletal pain despite a lack of high-quality data on benefits and harms,” wrote Erin E. Krebs, MD, MPH, core investigator at the Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research, and her colleagues. “Rising rates of opioid overdose deaths have raised questions about prescribing opioids for chronic pain management.”
In the 12-month SPACE (Strategies for Prescribing Analgesics Comparative Effectiveness) trial published March 6 in JAMA, the investigators reported randomizing a total of 240 patients to treatment with immediate-release opioids (morphine, oxycodone, or hydrocodone/acetaminophen) or acetaminophen or nonsteroidal anti-inflammatory drugs. The patients came from the Minneapolis VA system between June 2013 and December 2015. Patients in the opioid group were on average 57 years old, while those in the nonopioid group had an average age of 60 years. Men comprised 87% of all patients, and both groups were predominantly white (86%-88%) with chronic back pain (65%). The investigators excluded patients with physiological opioid dependence from ongoing opioid use.
Patients taking opioids saw no significant improvement in the primary outcome of pain-related function on the seven-item Brief Pain Inventory (BPI) interference scale over those taking nonopioids at the end of the 12-month period (P = .58), according to Dr. Krebs and her fellow investigators.
The main secondary outcome of pain intensity using the four-item BPI severity scale improved significantly more among the nonopioid group, which reported an average score of 3.5, compared with 4.0 in the opioid group (P = .03). However, the small difference of 0.5 is less than the minimal clinically important difference of 1.0, according to the investigators.
Anxiety control was the only secondary outcome measure that was significantly better among patients in the opioid group, which was unsurprising to the investigators. “This finding is consistent with the role of the endogenous opioid system in stress and emotional suffering,” they wrote.
The investigators were uncertain about the significance of this small difference because overall anxiety levels were low, with 9% of patients reporting moderate severity anxiety symptoms at baseline.
Patients in the opioid group took a mean of 1.7 analgesics during the study period, compared with 3.8 in the nonopioid group. In the nonopioid group, the mean number of months that nonopioid analgesics were prescribed ranged from 2.6 for acetaminophen to 5.9 with oral NSAIDs. In this group, tramadol was prescribed to no more than 11% of patients during any particular month and was dispensed for a mean of 0.4 months overall.
Patients in the opioid group took opioids for a mean of 8.1 months, with all other analgesics taken for a mean of 0.4 months or less. The authors noted that in “each 90-day follow-up period, fewer than 15% of patients in the opioid group had a mean dispensed dosage of 50 morphine-equivalent mg/day or more.” Patients could be titrated up to a maximum daily dosage of 100 morphine-equivalent mg/day.
Patients prescribed opioids were significantly more likely to report medication-related symptoms, and while misuse was not significantly higher in the opioid group, the investigators said that “Overall, opioids did not demonstrate any advantage over nonopioid medications that could potentially outweigh their greater risk of harms.”
Further studies will need to include a more diverse population, they noted.
The study was funded by an award from the U.S. Department of Veterans Affairs Health Services Research and Development Service. The investigators reported no relevant disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Krebs EE et al. JAMA. 2018 Mar 6;319(9):872-82
Patients treated with opioids for moderate to severe chronic back pain or knee or hip osteoarthritis pain saw no significant improvement when results were compared with treatment using acetaminophen or nonsteroidal anti-inflammatory drugs in the randomized SPACE study.
These findings may help restructure how physicians treat patients with chronic pain in order to decrease the risk of opioid addiction in a population that is particularly susceptible.
“Long-term opioid therapy became a standard approach to managing chronic musculoskeletal pain despite a lack of high-quality data on benefits and harms,” wrote Erin E. Krebs, MD, MPH, core investigator at the Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research, and her colleagues. “Rising rates of opioid overdose deaths have raised questions about prescribing opioids for chronic pain management.”
In the 12-month SPACE (Strategies for Prescribing Analgesics Comparative Effectiveness) trial published March 6 in JAMA, the investigators reported randomizing a total of 240 patients to treatment with immediate-release opioids (morphine, oxycodone, or hydrocodone/acetaminophen) or acetaminophen or nonsteroidal anti-inflammatory drugs. The patients came from the Minneapolis VA system between June 2013 and December 2015. Patients in the opioid group were on average 57 years old, while those in the nonopioid group had an average age of 60 years. Men comprised 87% of all patients, and both groups were predominantly white (86%-88%) with chronic back pain (65%). The investigators excluded patients with physiological opioid dependence from ongoing opioid use.
Patients taking opioids saw no significant improvement in the primary outcome of pain-related function on the seven-item Brief Pain Inventory (BPI) interference scale over those taking nonopioids at the end of the 12-month period (P = .58), according to Dr. Krebs and her fellow investigators.
The main secondary outcome of pain intensity using the four-item BPI severity scale improved significantly more among the nonopioid group, which reported an average score of 3.5, compared with 4.0 in the opioid group (P = .03). However, the small difference of 0.5 is less than the minimal clinically important difference of 1.0, according to the investigators.
Anxiety control was the only secondary outcome measure that was significantly better among patients in the opioid group, which was unsurprising to the investigators. “This finding is consistent with the role of the endogenous opioid system in stress and emotional suffering,” they wrote.
The investigators were uncertain about the significance of this small difference because overall anxiety levels were low, with 9% of patients reporting moderate severity anxiety symptoms at baseline.
Patients in the opioid group took a mean of 1.7 analgesics during the study period, compared with 3.8 in the nonopioid group. In the nonopioid group, the mean number of months that nonopioid analgesics were prescribed ranged from 2.6 for acetaminophen to 5.9 with oral NSAIDs. In this group, tramadol was prescribed to no more than 11% of patients during any particular month and was dispensed for a mean of 0.4 months overall.
Patients in the opioid group took opioids for a mean of 8.1 months, with all other analgesics taken for a mean of 0.4 months or less. The authors noted that in “each 90-day follow-up period, fewer than 15% of patients in the opioid group had a mean dispensed dosage of 50 morphine-equivalent mg/day or more.” Patients could be titrated up to a maximum daily dosage of 100 morphine-equivalent mg/day.
Patients prescribed opioids were significantly more likely to report medication-related symptoms, and while misuse was not significantly higher in the opioid group, the investigators said that “Overall, opioids did not demonstrate any advantage over nonopioid medications that could potentially outweigh their greater risk of harms.”
Further studies will need to include a more diverse population, they noted.
The study was funded by an award from the U.S. Department of Veterans Affairs Health Services Research and Development Service. The investigators reported no relevant disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Krebs EE et al. JAMA. 2018 Mar 6;319(9):872-82
FROM JAMA
Key clinical point: Opioids and nonopioid analgesics provided similar improvements in pain-related function for patients with chronic pain.
Major finding: Patients taking opioids did not show significant improvement in pain-related function, compared with those taking nonopioids (P = .58).
Study details: A 12-month, randomized trial of 240 patients with chronic back, knee, or hip pain, gathered from a Veterans Affairs clinic between June 2013 to December 2015.
Disclosures: The study was funded by an award from the U.S. Department of Veterans Affairs Health Services Research and Development Service. The investigators reported no relevant disclosures.
Source: Krebs E et al. JAMA. 2018;319(9):872-82
Opioid deaths in the ED increase nationally
Opioid-related deaths in emergency departments increased by approximately 30% across all regions of the United States between 2016 and 2017, according to the Centers for Disease Control and Prevention.
Analysis of 91 million ED visits from the CDC’s National Syndromic Surveillance Program and Enhanced State Opioid Overdose Surveillance database found significant increases in opioid overdose deaths in 16 states, reaching as high as 109% in Wisconsin and 106% in Delaware, CDC officials said during a press briefing.
“We are currently seeing the highest drug overdose death rate ever recorded in the United States, driven by prescription opioids and by illicit opioids such as heroin and illicitly manufactured fentanyl,” said Anne Schuchat, MD, acting CDC director. “In 2016, there were more than 63,000 drug overdose deaths, and more than 42,000 of those deaths involved an opioid.”
Of the 91 million visits, a total of 261,755 were suspected of opioid overdoses across both databases.
The greatest increase was seen in the Midwest region (69.7%), followed by the West (40.3%), Northeast (21.3%), Southwest (20.2%), and Southeast (14%).
Death rates rose across all demographics, regardless of sex or age.
While Delaware recorded some of the highest increases in deaths, Massachusetts, New Hampshire, and Rhode Island decreased, although not within statistical significance.
“These decreases may possibly be related to implementation of interventions, including expansion of access to medication-assisted treatment,” said Dr. Schuchat. “The decrease in Kentucky during this period of time may reflect some fluctuations in drug supply.”
In a comparison of urban and rural areas, large and medium metropolitan communities had the sharpest increase, at 45%.
To combat the rise in deaths, the CDC is encouraging an increase in naloxone distribution and training for first responders and community members.
The agency also recommends that local health departments begin using ED data to alert local communities when opioid-related deaths rise.
“This is a very difficult and fast-moving epidemic, and there are no easy solutions,” Dr. Schuchat said. [These data send] “a wake-up call about the need to improve what happens when patients leave the emergency department; all of us working together, government, public health, the medical community, law enforcement, and community members themselves can help fight this epidemic and save lives.”
ezimmerman@frontlinemedcom.com
SOURCE: Vivolo-Kantor AM et al. MMWR Morb Mortal Wkly Rep. 6 Mar 2018. doi: 10.15585/mmwr.mm6709e1.
Opioid-related deaths in emergency departments increased by approximately 30% across all regions of the United States between 2016 and 2017, according to the Centers for Disease Control and Prevention.
Analysis of 91 million ED visits from the CDC’s National Syndromic Surveillance Program and Enhanced State Opioid Overdose Surveillance database found significant increases in opioid overdose deaths in 16 states, reaching as high as 109% in Wisconsin and 106% in Delaware, CDC officials said during a press briefing.
“We are currently seeing the highest drug overdose death rate ever recorded in the United States, driven by prescription opioids and by illicit opioids such as heroin and illicitly manufactured fentanyl,” said Anne Schuchat, MD, acting CDC director. “In 2016, there were more than 63,000 drug overdose deaths, and more than 42,000 of those deaths involved an opioid.”
Of the 91 million visits, a total of 261,755 were suspected of opioid overdoses across both databases.
The greatest increase was seen in the Midwest region (69.7%), followed by the West (40.3%), Northeast (21.3%), Southwest (20.2%), and Southeast (14%).
Death rates rose across all demographics, regardless of sex or age.
While Delaware recorded some of the highest increases in deaths, Massachusetts, New Hampshire, and Rhode Island decreased, although not within statistical significance.
“These decreases may possibly be related to implementation of interventions, including expansion of access to medication-assisted treatment,” said Dr. Schuchat. “The decrease in Kentucky during this period of time may reflect some fluctuations in drug supply.”
In a comparison of urban and rural areas, large and medium metropolitan communities had the sharpest increase, at 45%.
To combat the rise in deaths, the CDC is encouraging an increase in naloxone distribution and training for first responders and community members.
The agency also recommends that local health departments begin using ED data to alert local communities when opioid-related deaths rise.
“This is a very difficult and fast-moving epidemic, and there are no easy solutions,” Dr. Schuchat said. [These data send] “a wake-up call about the need to improve what happens when patients leave the emergency department; all of us working together, government, public health, the medical community, law enforcement, and community members themselves can help fight this epidemic and save lives.”
ezimmerman@frontlinemedcom.com
SOURCE: Vivolo-Kantor AM et al. MMWR Morb Mortal Wkly Rep. 6 Mar 2018. doi: 10.15585/mmwr.mm6709e1.
Opioid-related deaths in emergency departments increased by approximately 30% across all regions of the United States between 2016 and 2017, according to the Centers for Disease Control and Prevention.
Analysis of 91 million ED visits from the CDC’s National Syndromic Surveillance Program and Enhanced State Opioid Overdose Surveillance database found significant increases in opioid overdose deaths in 16 states, reaching as high as 109% in Wisconsin and 106% in Delaware, CDC officials said during a press briefing.
“We are currently seeing the highest drug overdose death rate ever recorded in the United States, driven by prescription opioids and by illicit opioids such as heroin and illicitly manufactured fentanyl,” said Anne Schuchat, MD, acting CDC director. “In 2016, there were more than 63,000 drug overdose deaths, and more than 42,000 of those deaths involved an opioid.”
Of the 91 million visits, a total of 261,755 were suspected of opioid overdoses across both databases.
The greatest increase was seen in the Midwest region (69.7%), followed by the West (40.3%), Northeast (21.3%), Southwest (20.2%), and Southeast (14%).
Death rates rose across all demographics, regardless of sex or age.
While Delaware recorded some of the highest increases in deaths, Massachusetts, New Hampshire, and Rhode Island decreased, although not within statistical significance.
“These decreases may possibly be related to implementation of interventions, including expansion of access to medication-assisted treatment,” said Dr. Schuchat. “The decrease in Kentucky during this period of time may reflect some fluctuations in drug supply.”
In a comparison of urban and rural areas, large and medium metropolitan communities had the sharpest increase, at 45%.
To combat the rise in deaths, the CDC is encouraging an increase in naloxone distribution and training for first responders and community members.
The agency also recommends that local health departments begin using ED data to alert local communities when opioid-related deaths rise.
“This is a very difficult and fast-moving epidemic, and there are no easy solutions,” Dr. Schuchat said. [These data send] “a wake-up call about the need to improve what happens when patients leave the emergency department; all of us working together, government, public health, the medical community, law enforcement, and community members themselves can help fight this epidemic and save lives.”
ezimmerman@frontlinemedcom.com
SOURCE: Vivolo-Kantor AM et al. MMWR Morb Mortal Wkly Rep. 6 Mar 2018. doi: 10.15585/mmwr.mm6709e1.
FROM MMWR
Preoperative penicillin allergy tests could decrease SSI
Patients with reported penicillin allergies are significantly more likely to develop surgical site infections, according to a study conducted at Massachusetts General Hospital in Boston.
With new evidence reporting 90%-99% of patients with a reported allergy are not actually allergic, conducting a preoperative allergy test could improve treatment choice and decrease the risk of SSI, as well as the notable financial burden associated with it. Thus, “systematic, preoperative penicillin allergy evaluations in surgical patients may not only improve antibiotic choice but also decrease SSI risk,” according to Kimberly Blumenthal, MD, the quality director for the department of allergy and immunology at Massachusetts General Hospital, and her fellow investigators.
Surgeries performed were hip arthroplasty, knee arthroplasty, hysterectomy, colon surgery, or coronary artery bypass grafting.
Of the patients studied, 922 (11%) reported a penicillin allergy; most had minor reactions, such as rashes (37.5%) or urticaria (18%). “Only 5 reactions to penicillin represented contraindications to receiving a beta-lactam; the vast majority of patients would have tolerated first-line recommended cephalosporin prophylaxis had allergy evaluation been pursued,“ according to Dr. Blumenthal and her colleagues.
Overall, a total of 241 (2.7%) patients contracted an SSI. In a multivariate analysis, patients who had reported a penicillin allergy were 50% more likely to develop an SSI than those who had no reported allergy (adjusted odds ratio, 1.5; P = .04).
Risk may even be higher than 50% in the general health care population because this health center has a relatively low rate of SSIs, compared with many other hospitals, Dr. Blumenthal and her fellow investigators stated.
The increased risk primarily concerns the treatment used because those with a reported allergy were more likely than those without the allergy to be given clindamycin (48.8% vs. 3.1%, respectively), vancomycin (34.7% vs. 3.3%), gentamicin (24% vs. 2.8%), or fluoroquinolones (6.8% vs. 1.3%) instead of the most commonly used antibiotic, cefazolin (12.2% vs. 92.4%).
Patients given antibiotics other than cefazolin were usually given treatment outside of the perioperative window, which could severely increase the likelihood for developing an SSI, according to investigators. Of patients given vancomycin, 97.5% did not receive their treatment in the recommended time frame, compared with 1.7% of those given cefazolin.
“Increased odds of SSI among patients reporting a penicillin allergy in this cohort was entirely due to the use of beta-lactam–alternative perioperative antibiotics,” wrote to Dr. Blumenthal and her colleagues. “Patients with reported penicillin allergy in this study were not only less likely to receive the most effective perioperative antibiotic, they were also less likely to receive prophylaxis in the recommended time frame for optimal tissue concentration.”
While allergy assessments before surgery are currently recommended, there are no specifically outlined methods for these evaluations, which leads many providers to take what has been deemed the safer route of giving patients beta-lactam–alternative antibiotics instead, Dr. Blumenthal and her colleagues suggested.
The research was supported by the National Institutes of Health, and the investigators reported having no relevant conflicts.
ezimmerman@frontlinemedcom.com
SOURCE: Blumenthal K et al. Clin Infect Dis. 2018 Jan 18;66(3):329-36.
Patients with reported penicillin allergies are significantly more likely to develop surgical site infections, according to a study conducted at Massachusetts General Hospital in Boston.
With new evidence reporting 90%-99% of patients with a reported allergy are not actually allergic, conducting a preoperative allergy test could improve treatment choice and decrease the risk of SSI, as well as the notable financial burden associated with it. Thus, “systematic, preoperative penicillin allergy evaluations in surgical patients may not only improve antibiotic choice but also decrease SSI risk,” according to Kimberly Blumenthal, MD, the quality director for the department of allergy and immunology at Massachusetts General Hospital, and her fellow investigators.
Surgeries performed were hip arthroplasty, knee arthroplasty, hysterectomy, colon surgery, or coronary artery bypass grafting.
Of the patients studied, 922 (11%) reported a penicillin allergy; most had minor reactions, such as rashes (37.5%) or urticaria (18%). “Only 5 reactions to penicillin represented contraindications to receiving a beta-lactam; the vast majority of patients would have tolerated first-line recommended cephalosporin prophylaxis had allergy evaluation been pursued,“ according to Dr. Blumenthal and her colleagues.
Overall, a total of 241 (2.7%) patients contracted an SSI. In a multivariate analysis, patients who had reported a penicillin allergy were 50% more likely to develop an SSI than those who had no reported allergy (adjusted odds ratio, 1.5; P = .04).
Risk may even be higher than 50% in the general health care population because this health center has a relatively low rate of SSIs, compared with many other hospitals, Dr. Blumenthal and her fellow investigators stated.
The increased risk primarily concerns the treatment used because those with a reported allergy were more likely than those without the allergy to be given clindamycin (48.8% vs. 3.1%, respectively), vancomycin (34.7% vs. 3.3%), gentamicin (24% vs. 2.8%), or fluoroquinolones (6.8% vs. 1.3%) instead of the most commonly used antibiotic, cefazolin (12.2% vs. 92.4%).
Patients given antibiotics other than cefazolin were usually given treatment outside of the perioperative window, which could severely increase the likelihood for developing an SSI, according to investigators. Of patients given vancomycin, 97.5% did not receive their treatment in the recommended time frame, compared with 1.7% of those given cefazolin.
“Increased odds of SSI among patients reporting a penicillin allergy in this cohort was entirely due to the use of beta-lactam–alternative perioperative antibiotics,” wrote to Dr. Blumenthal and her colleagues. “Patients with reported penicillin allergy in this study were not only less likely to receive the most effective perioperative antibiotic, they were also less likely to receive prophylaxis in the recommended time frame for optimal tissue concentration.”
While allergy assessments before surgery are currently recommended, there are no specifically outlined methods for these evaluations, which leads many providers to take what has been deemed the safer route of giving patients beta-lactam–alternative antibiotics instead, Dr. Blumenthal and her colleagues suggested.
The research was supported by the National Institutes of Health, and the investigators reported having no relevant conflicts.
ezimmerman@frontlinemedcom.com
SOURCE: Blumenthal K et al. Clin Infect Dis. 2018 Jan 18;66(3):329-36.
Patients with reported penicillin allergies are significantly more likely to develop surgical site infections, according to a study conducted at Massachusetts General Hospital in Boston.
With new evidence reporting 90%-99% of patients with a reported allergy are not actually allergic, conducting a preoperative allergy test could improve treatment choice and decrease the risk of SSI, as well as the notable financial burden associated with it. Thus, “systematic, preoperative penicillin allergy evaluations in surgical patients may not only improve antibiotic choice but also decrease SSI risk,” according to Kimberly Blumenthal, MD, the quality director for the department of allergy and immunology at Massachusetts General Hospital, and her fellow investigators.
Surgeries performed were hip arthroplasty, knee arthroplasty, hysterectomy, colon surgery, or coronary artery bypass grafting.
Of the patients studied, 922 (11%) reported a penicillin allergy; most had minor reactions, such as rashes (37.5%) or urticaria (18%). “Only 5 reactions to penicillin represented contraindications to receiving a beta-lactam; the vast majority of patients would have tolerated first-line recommended cephalosporin prophylaxis had allergy evaluation been pursued,“ according to Dr. Blumenthal and her colleagues.
Overall, a total of 241 (2.7%) patients contracted an SSI. In a multivariate analysis, patients who had reported a penicillin allergy were 50% more likely to develop an SSI than those who had no reported allergy (adjusted odds ratio, 1.5; P = .04).
Risk may even be higher than 50% in the general health care population because this health center has a relatively low rate of SSIs, compared with many other hospitals, Dr. Blumenthal and her fellow investigators stated.
The increased risk primarily concerns the treatment used because those with a reported allergy were more likely than those without the allergy to be given clindamycin (48.8% vs. 3.1%, respectively), vancomycin (34.7% vs. 3.3%), gentamicin (24% vs. 2.8%), or fluoroquinolones (6.8% vs. 1.3%) instead of the most commonly used antibiotic, cefazolin (12.2% vs. 92.4%).
Patients given antibiotics other than cefazolin were usually given treatment outside of the perioperative window, which could severely increase the likelihood for developing an SSI, according to investigators. Of patients given vancomycin, 97.5% did not receive their treatment in the recommended time frame, compared with 1.7% of those given cefazolin.
“Increased odds of SSI among patients reporting a penicillin allergy in this cohort was entirely due to the use of beta-lactam–alternative perioperative antibiotics,” wrote to Dr. Blumenthal and her colleagues. “Patients with reported penicillin allergy in this study were not only less likely to receive the most effective perioperative antibiotic, they were also less likely to receive prophylaxis in the recommended time frame for optimal tissue concentration.”
While allergy assessments before surgery are currently recommended, there are no specifically outlined methods for these evaluations, which leads many providers to take what has been deemed the safer route of giving patients beta-lactam–alternative antibiotics instead, Dr. Blumenthal and her colleagues suggested.
The research was supported by the National Institutes of Health, and the investigators reported having no relevant conflicts.
ezimmerman@frontlinemedcom.com
SOURCE: Blumenthal K et al. Clin Infect Dis. 2018 Jan 18;66(3):329-36.
FROM CLINICAL INFECTIOUS DISEASES
Key clinical point: Patients with reported penicillin allergies are at higher risk of developing a surgical site infection.
Major finding: Having a penicillin allergy was associated with a 50% increased risk of developing a surgical site infection, compared with those without the allergy (adjusted odds ratio, 1.5; P = .04).
Study details: Retrospective cohort study of 8,385 patients operated on at Massachusetts General Hospital, Boston, during 2010-2014.
Disclosures: The research was supported by the National Institutes of Health, and the investigators reported having no relevant conflicts.
Source: Blumenthal K et al. Clin Infect Dis. 2018 Jan 18;66(3):329-36.
Suicidal behaviors are associated with discordant sexual orientation in teens
Teenagers with discordant sexual orientation are more likely to experience nonfatal suicidal behaviors, according to results of a study published in the American Journal of Preventative Medicine.
“In this study, discordance refers to reporting sexual contact that is inconsistent with a respondent’s sexual identity. ... Discrimination, stigma, prejudice, rejection, and societal norms may put pressure on sexual minorities to present a sexual identity inconsistent with their true sexual identity or to act in a manner inconsistent with their sexual identity,” said Francis Annor, PhD, of the Centers for Disease Control and Prevention, and fellow investigators.
“In considering the health and well-being of youth, sexual identity and sexual behavior and their intersection should be considered for their association with the mental health and well-being of adolescents,” according to Dr. Annor and his colleagues. “Some adolescents reporting discordance may have needs that should be considered when developing and implementing suicide prevention programs.”
For this study, investigators analyzed survey questions from 6,790 high school students queried during the 2015 national Youth Risk Behavior Survey.
Sexual discordance was measured by asking students their sexual orientation and the gender of any sexual partners they may have had. Students who responded as being bisexual or who had not experienced sexual contact before were excluded from final analysis.
Students were majority male (56% vs. 44%), white (54.8%), and heterosexual (97.8%), and sexually concordant (96.1%).
When analyzing suicidal tendencies among students, teens who were sexually discordant were 70% more likely to report thinking about, or planning, suicide. High risk for nonfatal suicidal behaviors was significantly more common among discordant students, compared with concordant students (46.3% vs .22.4%, P less than .0001). Students who were gay or lesbian were significantly more likely to report sexual orientation discordance than heterosexual students (32% vs. 3%, P less than .001).
Sexual discordance also was common among students who were female, black, bullied on school property, used marijuana, or physically forced to have sexual intercourse.
Dr. Annor and fellow investigators theorized that the association between discordance and suicidal ideation may stem from self-discrepancy, which can lead to increased anxiety, stress, or depression.
Another theory was that the stress was induced from being a minority, which is supported by the increased number of nonfatal suicidal behaviors in students who were discordant, female, or gay or lesbian, according to investigators. “The minority stress theory suggests that stigma experienced by sexual minorities may cause chronic, cumulative stress that may negatively impact both mental and physical health,” Dr. Francis and associates explained. “Minority stress has been associated with increased depression, overall poor physical health, and increased risk of chronic disease diagnosis.”
To help prevent these suicidal tendencies, Dr. Annor and colleagues suggested using a multipronged public health approach, including using CDC suicide prevention materials, creating safe spaces for kids to understand their developing sexual identities, and further studies to examine risk among discordant teens and nonfatal suicidal behaviors.
The findings of this study are limited by the use of only high school students, which excludes what may be a significant part of the population. Certain aspects of the survey, including no specific definition of sexual contact, as well as the self-reported nature of the information, might have affected findings. Finally, some of those involved in the study may not have been fully aware of their sexual preference at this age and may have experimented with those of the opposite sex as their reported sexual preference, and this may not have been associated with distress, the researchers said.
Dr. Annor and associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Annor F et al. Am J Prev Med. 2018. doi: 10.1016/j.amepre.2018.01.013
Teenagers with discordant sexual orientation are more likely to experience nonfatal suicidal behaviors, according to results of a study published in the American Journal of Preventative Medicine.
“In this study, discordance refers to reporting sexual contact that is inconsistent with a respondent’s sexual identity. ... Discrimination, stigma, prejudice, rejection, and societal norms may put pressure on sexual minorities to present a sexual identity inconsistent with their true sexual identity or to act in a manner inconsistent with their sexual identity,” said Francis Annor, PhD, of the Centers for Disease Control and Prevention, and fellow investigators.
“In considering the health and well-being of youth, sexual identity and sexual behavior and their intersection should be considered for their association with the mental health and well-being of adolescents,” according to Dr. Annor and his colleagues. “Some adolescents reporting discordance may have needs that should be considered when developing and implementing suicide prevention programs.”
For this study, investigators analyzed survey questions from 6,790 high school students queried during the 2015 national Youth Risk Behavior Survey.
Sexual discordance was measured by asking students their sexual orientation and the gender of any sexual partners they may have had. Students who responded as being bisexual or who had not experienced sexual contact before were excluded from final analysis.
Students were majority male (56% vs. 44%), white (54.8%), and heterosexual (97.8%), and sexually concordant (96.1%).
When analyzing suicidal tendencies among students, teens who were sexually discordant were 70% more likely to report thinking about, or planning, suicide. High risk for nonfatal suicidal behaviors was significantly more common among discordant students, compared with concordant students (46.3% vs .22.4%, P less than .0001). Students who were gay or lesbian were significantly more likely to report sexual orientation discordance than heterosexual students (32% vs. 3%, P less than .001).
Sexual discordance also was common among students who were female, black, bullied on school property, used marijuana, or physically forced to have sexual intercourse.
Dr. Annor and fellow investigators theorized that the association between discordance and suicidal ideation may stem from self-discrepancy, which can lead to increased anxiety, stress, or depression.
Another theory was that the stress was induced from being a minority, which is supported by the increased number of nonfatal suicidal behaviors in students who were discordant, female, or gay or lesbian, according to investigators. “The minority stress theory suggests that stigma experienced by sexual minorities may cause chronic, cumulative stress that may negatively impact both mental and physical health,” Dr. Francis and associates explained. “Minority stress has been associated with increased depression, overall poor physical health, and increased risk of chronic disease diagnosis.”
To help prevent these suicidal tendencies, Dr. Annor and colleagues suggested using a multipronged public health approach, including using CDC suicide prevention materials, creating safe spaces for kids to understand their developing sexual identities, and further studies to examine risk among discordant teens and nonfatal suicidal behaviors.
The findings of this study are limited by the use of only high school students, which excludes what may be a significant part of the population. Certain aspects of the survey, including no specific definition of sexual contact, as well as the self-reported nature of the information, might have affected findings. Finally, some of those involved in the study may not have been fully aware of their sexual preference at this age and may have experimented with those of the opposite sex as their reported sexual preference, and this may not have been associated with distress, the researchers said.
Dr. Annor and associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Annor F et al. Am J Prev Med. 2018. doi: 10.1016/j.amepre.2018.01.013
Teenagers with discordant sexual orientation are more likely to experience nonfatal suicidal behaviors, according to results of a study published in the American Journal of Preventative Medicine.
“In this study, discordance refers to reporting sexual contact that is inconsistent with a respondent’s sexual identity. ... Discrimination, stigma, prejudice, rejection, and societal norms may put pressure on sexual minorities to present a sexual identity inconsistent with their true sexual identity or to act in a manner inconsistent with their sexual identity,” said Francis Annor, PhD, of the Centers for Disease Control and Prevention, and fellow investigators.
“In considering the health and well-being of youth, sexual identity and sexual behavior and their intersection should be considered for their association with the mental health and well-being of adolescents,” according to Dr. Annor and his colleagues. “Some adolescents reporting discordance may have needs that should be considered when developing and implementing suicide prevention programs.”
For this study, investigators analyzed survey questions from 6,790 high school students queried during the 2015 national Youth Risk Behavior Survey.
Sexual discordance was measured by asking students their sexual orientation and the gender of any sexual partners they may have had. Students who responded as being bisexual or who had not experienced sexual contact before were excluded from final analysis.
Students were majority male (56% vs. 44%), white (54.8%), and heterosexual (97.8%), and sexually concordant (96.1%).
When analyzing suicidal tendencies among students, teens who were sexually discordant were 70% more likely to report thinking about, or planning, suicide. High risk for nonfatal suicidal behaviors was significantly more common among discordant students, compared with concordant students (46.3% vs .22.4%, P less than .0001). Students who were gay or lesbian were significantly more likely to report sexual orientation discordance than heterosexual students (32% vs. 3%, P less than .001).
Sexual discordance also was common among students who were female, black, bullied on school property, used marijuana, or physically forced to have sexual intercourse.
Dr. Annor and fellow investigators theorized that the association between discordance and suicidal ideation may stem from self-discrepancy, which can lead to increased anxiety, stress, or depression.
Another theory was that the stress was induced from being a minority, which is supported by the increased number of nonfatal suicidal behaviors in students who were discordant, female, or gay or lesbian, according to investigators. “The minority stress theory suggests that stigma experienced by sexual minorities may cause chronic, cumulative stress that may negatively impact both mental and physical health,” Dr. Francis and associates explained. “Minority stress has been associated with increased depression, overall poor physical health, and increased risk of chronic disease diagnosis.”
To help prevent these suicidal tendencies, Dr. Annor and colleagues suggested using a multipronged public health approach, including using CDC suicide prevention materials, creating safe spaces for kids to understand their developing sexual identities, and further studies to examine risk among discordant teens and nonfatal suicidal behaviors.
The findings of this study are limited by the use of only high school students, which excludes what may be a significant part of the population. Certain aspects of the survey, including no specific definition of sexual contact, as well as the self-reported nature of the information, might have affected findings. Finally, some of those involved in the study may not have been fully aware of their sexual preference at this age and may have experimented with those of the opposite sex as their reported sexual preference, and this may not have been associated with distress, the researchers said.
Dr. Annor and associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Annor F et al. Am J Prev Med. 2018. doi: 10.1016/j.amepre.2018.01.013
FROM THE AMERICAN JOURNAL OF PREVENTIVE MEDICINE
Key clinical point:
Major finding: Teens with conflicting answers about sexual preference were 70% more likely to report suicidal ideation than their concordant counterparts.
Study details: Retrospective study of 6,790 high school students surveyed in the 2015 national Youth Risk Behavior Survey.
Disclosures: Dr. Annor and associates reported no relevant financial disclosures.
Source: Annor F et al. Am J Prev Med. 2018. doi: 10.1016/j.amepre.2018.01.013.
CPAP adherence linked to reduced readmissions
Hospitalized patients with obstructive sleep apnea (OSA) who were nonadherent to continuous positive airway pressure (CPAP) treatment were more than three times as likely to be readmitted for complications, according to a study.
Since preventable causes of readmission like congestive heart failure, obstructive lung disease, and diabetes are connected to OSA, boosting adherence rates to sleep apnea treatment could be an effective way to mitigate these risks.
Investigators gathered data for 345 hospitalized patients with OSA who were admitted to the VA Long Beach (Calif.) Healthcare System between January 2007 and December 2015.
Both the adherent and nonadherent groups were mostly white males. The 183 adherent patients were, on average, slightly older than the patients in the nonadherent group (66.3 vs. 62.3 years), while the nonadherent group had a larger proportion of African Americans (19.1%) than did the adherent group (10.4%).
In an analysis of both groups, 28% of nonadherent patients were readmitted within 30 days of discharge, compared with 10.2% of those in the adherent group (P less than .001). Readmission rates were significantly higher for nonadherent patients brought in for all-causes (adjusted odds ratio, 3.52; P less than .001), as were their rates of cardiovascular-related readmission (AOR, 2.31; P = .02).
The cardiovascular-related readmissions were most often caused by atrial fibrillation (29%), myocardial ischemia (22.5%), and congestive heart failure (19.3%) in the group who were not using CPAP. In this same group, urologic problems (10.7%), infections (8.0%), and psychiatric issues (5.3%) were the most common causes for hospital readmissions.
Investigators were surprised to find that the rate of pulmonary-related readmissions was not higher among nonadherent patients, considering the shared characteristics of OSA and COPD.
While nonadherent patients had an adjusted rate of pulmonary-related readmissions of 3.66, the difference between nonadherent and adherent patients was not significant.
“Those with OSA and COPD are considered to have overlap syndrome and, without CPAP therapy, are at higher risk for COPD exacerbation requiring hospitalization, pulmonary hypertension, and mortality,” according to Dr. Truong and her colleagues. “However, the number of patients with pulmonary readmissions was very small, and analysis did not reach statistical or clinical significance.”
Given the single-center nature of the study, these findings have limited generalizability. The study may also have been underpowered to uncover certain differences between the two groups because of the small population size.
Investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: K. Truong et al. J Clin Sleep Med. 2018;14(2):183–9.
The comorbidities associated with obstructive sleep apnea (OSA), such as heart failure, coronary artery disease, diabetes, and stroke, can be detrimental to patients’ care and commonly lead to hospitalization. Not only are these diseases interfering with successful treatment, but financial penalties linked to 30-day readmissions have economic implications for hospitals as well. Increasing CPAP adherence, therefore, may be a low-cost tool to improve hospital outcomes. Dr. Truong and her colleagues find compelling data showing the association of CPAP adherence and reduced 30-day readmissions. However, more work is needed before we can fully back the idea that CPAP adherence will prevent readmissions. While many studies have shown associations between OSA and cardiovascular events, there are no large, randomized trials that show the cardiovascular benefit of CPAP. The current theory is that patients who are adherent to CPAP are more likely to be healthier individuals, which makes them less likely to exhibit the comorbidities that would cause readmissions. A large randomized trial is the next logical step, and with OSA costs estimated at $2,000 annually per patient, it is a step worth pursuing.
Lucas M. Donovan, MD, is a pulmonologist at the University of Washington, Seattle. Martha E. Billings, MD, is an assistant professor in the division of pulmonary and critical care medicine at the University of Washington, Seattle. They reported no conflicts of interest.
The comorbidities associated with obstructive sleep apnea (OSA), such as heart failure, coronary artery disease, diabetes, and stroke, can be detrimental to patients’ care and commonly lead to hospitalization. Not only are these diseases interfering with successful treatment, but financial penalties linked to 30-day readmissions have economic implications for hospitals as well. Increasing CPAP adherence, therefore, may be a low-cost tool to improve hospital outcomes. Dr. Truong and her colleagues find compelling data showing the association of CPAP adherence and reduced 30-day readmissions. However, more work is needed before we can fully back the idea that CPAP adherence will prevent readmissions. While many studies have shown associations between OSA and cardiovascular events, there are no large, randomized trials that show the cardiovascular benefit of CPAP. The current theory is that patients who are adherent to CPAP are more likely to be healthier individuals, which makes them less likely to exhibit the comorbidities that would cause readmissions. A large randomized trial is the next logical step, and with OSA costs estimated at $2,000 annually per patient, it is a step worth pursuing.
Lucas M. Donovan, MD, is a pulmonologist at the University of Washington, Seattle. Martha E. Billings, MD, is an assistant professor in the division of pulmonary and critical care medicine at the University of Washington, Seattle. They reported no conflicts of interest.
The comorbidities associated with obstructive sleep apnea (OSA), such as heart failure, coronary artery disease, diabetes, and stroke, can be detrimental to patients’ care and commonly lead to hospitalization. Not only are these diseases interfering with successful treatment, but financial penalties linked to 30-day readmissions have economic implications for hospitals as well. Increasing CPAP adherence, therefore, may be a low-cost tool to improve hospital outcomes. Dr. Truong and her colleagues find compelling data showing the association of CPAP adherence and reduced 30-day readmissions. However, more work is needed before we can fully back the idea that CPAP adherence will prevent readmissions. While many studies have shown associations between OSA and cardiovascular events, there are no large, randomized trials that show the cardiovascular benefit of CPAP. The current theory is that patients who are adherent to CPAP are more likely to be healthier individuals, which makes them less likely to exhibit the comorbidities that would cause readmissions. A large randomized trial is the next logical step, and with OSA costs estimated at $2,000 annually per patient, it is a step worth pursuing.
Lucas M. Donovan, MD, is a pulmonologist at the University of Washington, Seattle. Martha E. Billings, MD, is an assistant professor in the division of pulmonary and critical care medicine at the University of Washington, Seattle. They reported no conflicts of interest.
Hospitalized patients with obstructive sleep apnea (OSA) who were nonadherent to continuous positive airway pressure (CPAP) treatment were more than three times as likely to be readmitted for complications, according to a study.
Since preventable causes of readmission like congestive heart failure, obstructive lung disease, and diabetes are connected to OSA, boosting adherence rates to sleep apnea treatment could be an effective way to mitigate these risks.
Investigators gathered data for 345 hospitalized patients with OSA who were admitted to the VA Long Beach (Calif.) Healthcare System between January 2007 and December 2015.
Both the adherent and nonadherent groups were mostly white males. The 183 adherent patients were, on average, slightly older than the patients in the nonadherent group (66.3 vs. 62.3 years), while the nonadherent group had a larger proportion of African Americans (19.1%) than did the adherent group (10.4%).
In an analysis of both groups, 28% of nonadherent patients were readmitted within 30 days of discharge, compared with 10.2% of those in the adherent group (P less than .001). Readmission rates were significantly higher for nonadherent patients brought in for all-causes (adjusted odds ratio, 3.52; P less than .001), as were their rates of cardiovascular-related readmission (AOR, 2.31; P = .02).
The cardiovascular-related readmissions were most often caused by atrial fibrillation (29%), myocardial ischemia (22.5%), and congestive heart failure (19.3%) in the group who were not using CPAP. In this same group, urologic problems (10.7%), infections (8.0%), and psychiatric issues (5.3%) were the most common causes for hospital readmissions.
Investigators were surprised to find that the rate of pulmonary-related readmissions was not higher among nonadherent patients, considering the shared characteristics of OSA and COPD.
While nonadherent patients had an adjusted rate of pulmonary-related readmissions of 3.66, the difference between nonadherent and adherent patients was not significant.
“Those with OSA and COPD are considered to have overlap syndrome and, without CPAP therapy, are at higher risk for COPD exacerbation requiring hospitalization, pulmonary hypertension, and mortality,” according to Dr. Truong and her colleagues. “However, the number of patients with pulmonary readmissions was very small, and analysis did not reach statistical or clinical significance.”
Given the single-center nature of the study, these findings have limited generalizability. The study may also have been underpowered to uncover certain differences between the two groups because of the small population size.
Investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: K. Truong et al. J Clin Sleep Med. 2018;14(2):183–9.
Hospitalized patients with obstructive sleep apnea (OSA) who were nonadherent to continuous positive airway pressure (CPAP) treatment were more than three times as likely to be readmitted for complications, according to a study.
Since preventable causes of readmission like congestive heart failure, obstructive lung disease, and diabetes are connected to OSA, boosting adherence rates to sleep apnea treatment could be an effective way to mitigate these risks.
Investigators gathered data for 345 hospitalized patients with OSA who were admitted to the VA Long Beach (Calif.) Healthcare System between January 2007 and December 2015.
Both the adherent and nonadherent groups were mostly white males. The 183 adherent patients were, on average, slightly older than the patients in the nonadherent group (66.3 vs. 62.3 years), while the nonadherent group had a larger proportion of African Americans (19.1%) than did the adherent group (10.4%).
In an analysis of both groups, 28% of nonadherent patients were readmitted within 30 days of discharge, compared with 10.2% of those in the adherent group (P less than .001). Readmission rates were significantly higher for nonadherent patients brought in for all-causes (adjusted odds ratio, 3.52; P less than .001), as were their rates of cardiovascular-related readmission (AOR, 2.31; P = .02).
The cardiovascular-related readmissions were most often caused by atrial fibrillation (29%), myocardial ischemia (22.5%), and congestive heart failure (19.3%) in the group who were not using CPAP. In this same group, urologic problems (10.7%), infections (8.0%), and psychiatric issues (5.3%) were the most common causes for hospital readmissions.
Investigators were surprised to find that the rate of pulmonary-related readmissions was not higher among nonadherent patients, considering the shared characteristics of OSA and COPD.
While nonadherent patients had an adjusted rate of pulmonary-related readmissions of 3.66, the difference between nonadherent and adherent patients was not significant.
“Those with OSA and COPD are considered to have overlap syndrome and, without CPAP therapy, are at higher risk for COPD exacerbation requiring hospitalization, pulmonary hypertension, and mortality,” according to Dr. Truong and her colleagues. “However, the number of patients with pulmonary readmissions was very small, and analysis did not reach statistical or clinical significance.”
Given the single-center nature of the study, these findings have limited generalizability. The study may also have been underpowered to uncover certain differences between the two groups because of the small population size.
Investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: K. Truong et al. J Clin Sleep Med. 2018;14(2):183–9.
FROM THE JOURNAL OF CLINICAL SLEEP MEDICINE
Key clinical point:
Major finding: CPAP-nonadherent patients were 3.5 times more likely to be readmitted within 30 days.
Study details: A retrospective study of 345 patients with obstructive sleep apnea who were hospitalized at a Veterans Affairs hospital between Jan. 1, 2007, and Dec. 31, 2015.
Disclosures: Investigators reported no relevant financial disclosures.
Source: K. Truong et al. J Clin Sleep Med. 2018;14(2):183-9.