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Tom Collins is a freelance writer in South Florida who has written about medical topics from nasty infections to ethical dilemmas, runaway tumors to tornado-chasing doctors. He travels the globe gathering conference health news and lives in West Palm Beach.
Benefits, drawbacks when hospitalists expand roles
Hospitalists can’t ‘fill all the cracks’ in primary care
As vice chair of the hospital medicine service at Northwell Health, Nick Fitterman, MD, FACP, SFHM, oversees 16 HM groups at 15 hospitals in New York. He says the duties of his hospitalist staff, like those of most U.S. hospitalists, are similar to what they have traditionally been – clinical care on the wards, teaching, comanagement of surgery, quality improvement, committee work, and research. But he has noticed a trend of late: rapid expansion of the hospitalist’s role.
Speaking at an education session at HM18 in Orlando, Dr. Fitterman said the role of the hospitalist is growing to include tasks that might not be as common, but are becoming more familiar all the time: working at infusion centers, caring for patients in skilled nursing facilities, specializing in electronic health record use, colocating in psychiatric hospitals, even being deployed to natural disasters. His list went on, and it was much longer than the list of traditional hospitalist responsibilities.
“Where do we draw the line and say, ‘Wait a minute, our primary site is going to suffer if we continue to get spread this thin. Can we really do it all?” Dr. Fitterman said. As the number of hats hospitalists wear grows ever bigger, he said more thought must be placed into how expansion happens.
The preop clinic
Efren Manjarrez, MD, SFHM, former chief of hospital medicine at the University of Miami, told a cautionary tale about a preoperative clinic staffed by hospitalists that appeared to provide a financial benefit to a hospital – helping to avoid costly last-minute cancellations of surgeries – but that ultimately was shuttered. The hospital, he said, loses $8,000-$10,000 for each case that gets canceled on the same day.
“Think about that just for a minute,” Dr. Manjarrez said. “If 100 cases are canceled during the year at the last minute, that’s a lot of money.”
A preoperative clinic seemed like a worthwhile role for hospitalists – the program was started in Miami by the same doctor who initiated a similar program at Cleveland Clinic. “Surgical cases are what support the hospital [financially], and we’re here to help them along,” Dr. Manjarrez said. “The purpose of hospitalists is to make sure that patients are medically optimized.”
The preop program concept, used in U.S. medicine since the 1990s, was originally started by anesthesiologists, but they may not always be the best fit to staff such programs.
“Anesthesiologists do not manage all beta blockers,” Dr. Manjarrez said. “They don’t manage ACE inhibitors by mouth. They don’t manage all oral diabetes agents, and they sure as heck don’t manage pills that are anticoagulants. That’s the domain of internal medicine. And as patients have become more complex, that’s where hospitalists who [work in] preop clinics have stepped in.”
Studies have found that hospitalists staffing preop clinics have improved quality metrics and some clinical outcomes, including lowering cancellation rates and more appropriate use of beta blockers, he said.
In the Miami program described by Dr. Manjarrez, hospitalists in the preop clinic at first saw only patients who’d been financially cleared as able to pay. But ultimately, a tiered system was developed, and hospitalists saw only patients who were higher risk – those with COPD or stroke patients, for example – without regard to ability to pay.
“The hospital would have to make up any financial deficit at the very end,” Dr. Manjarrez said. This meant there were no longer efficient 5-minute encounters with patients. Instead, visits lasted about 45 minutes, so fewer patients were seen.
The program was successful, in that the same-day cancellation rate for surgeries dropped to less than 0.1% – fewer than 1 in 1,000 – with the preop clinic up and running, Dr. Manjarrez. Still, the hospital decided to end the program. “The hospital no longer wanted to reimburse us,” he said.
A takeaway from this experience for Dr. Manjarrez was that hospitalists need to do a better job of showing the financial benefits in their expanding roles, if they want them to endure.
“At the end of the day, hospitalists do provide value in preoperative clinics,” he said. “But unfortunately, we’re not doing a great job of publishing our data and showing our value.”
At-home care
At Brigham and Women’s Hospital in Boston, hospitalists have demonstrated good results with a program to provide care at home rather than in the hospital.
David Levine, MD, MPH, MA, clinician and investigator at Brigham and Women’s and an instructor in medicine at Harvard Medical School, said that the structure of inpatient care has generally not changed much over decades, despite advances in technology.
“We round on them once a day – if they’re lucky, twice,” he said. “The medicines have changed and imaging has changed, but we really haven’t changed the structure of how we take care of acutely ill adults for almost a hundred years.”
Hospitalizing patients brings unintended consequences. Twenty percent of older adults will become delirious during their stay, 1 out of 3 will lose a level of functional status in the hospital that they’ll never regain, and 1 out of 10 hospitalized patients will experience an adverse event, like an infection or a medication error.
Brigham and Women’s program of at-home care involves “admitting” patients to their homes after being treated in the emergency department. The goal is to reduce costs by 20%, while maintaining quality and safety and improving patients’ quality of life and experience.
Researchers are studying their results. They randomized patients, after the ED determined they required admission, either to admission to the hospital or to their home. The decision on whether to admit was made before the study investigators became involved with the patients, Dr. Levine said.
The program is also intended to improve access to hospitals. Brigham and Women’s is often over 100% capacity in the general medical ward.
Patients in the study needed to live within a 5-mile radius of either Brigham and Women’s Hospital, or Brigham and Women’s Faulkner Hospital, a nearby community hospital. A physician and a registered nurse form the core team; they assess patient needs and ratchet care either up or down, perhaps adding a home health aide or social worker.
The home care team takes advantage of technology: Portable equipment allows a basic metabolic panel to be performed on the spot – for example, a hemoglobin and hematocrit can be produced within 2 minutes. Also, portable ultrasounds and x-rays are used. Doctors keep a “tackle box” of urgent medications such as antibiotics and diuretics.
“We showed a direct cost reduction taking care of patients at home,” Dr. Levine said. There was also a reduction in utilization of care, and an increase in patient activity, with patients taking about 1,800 steps at home, compared with 180 in the hospital. There were no significant changes in safety, quality, or patient experience, he said.
Postdischarge clinics
Lauren Doctoroff, MD, FHM – a hospitalist at Beth Israel Deaconness Medical Center in Boston and assistant professor of medicine at Harvard Medical School – explained another hospitalist-staffed project meant to improve access to care: her center’s postdischarge clinic, which was started in 2009 but is no longer operating.
The clinic tackled the problem of what to do with patients when you discharge them, Dr. Doctoroff said, and its goal was to foster more cooperation between hospitalists and the faculty primary care practice, as well as to improve postdischarge access for patients from that practice.
A dedicated group of hospitalists staffed the clinics, handling medication reconciliation, symptom management, pending tests, and other services the patients were supposed to be getting after discharge, Dr. Doctoroff said.
“We greatly improved access so that when you came to see us you generally saw a hospitalist a week before you would have seen your primary care doctor,” she said. “And that was mostly because we created open access in a clinic that did not have open access. So if a doctor discharging a patient really thought that the patient needed to be seen after discharge, they would often see us.”
Hospitalists considering starting such a clinic have several key questions to consider, Dr. Doctoroff said.
“You need to focus on who the patient population is, the clinic structure, how you plan to staff the clinic, and what your outcomes are – mainly how you will measure performance,” she said.
Dr. Doctoroff said hospitalists are good for this role because “we’re very comfortable with patients who are complicated, and we are very adept at accessing information from the hospitalization. I think, as a hospitalist who spent 5 years seeing patients in a discharge clinic, it greatly enhances my understanding of patients and their challenges at discharge.”
The clinic was closed, she said, in part because it was largely an extension of primary care, and the patient volume wasn’t big enough to justify continuing it.
“Postdischarge clinics are, in a very narrow sense, a bit of a Band-Aid for a really dysfunctional primary care system,” Dr. Doctoroff said. “Ideally, if all you’re doing is providing a postdischarge physician visit, then you really want primary care to be able to do that in order to reengage with their patient. I think this is because postdischarge clinics are construed in a very narrow way to address the simple need to see a patient after discharge. And this may lead to the failure of these clinics, or make them easy to replace. Also, often what patients really need is more than just a physician visit, so a discharge clinic may need to be designed to provide an enhanced array of services.”
Dr. Fitterman said that these stories show that not all role expansion in hospital medicine is good role expansion. The experiences described by Dr. Manjarrez, Dr. Levine, and Dr. Doctoroff demonstrate the challenges hospitalists face as they attempt expansions into new roles, he said.
“We can’t be expected to fill all the cracks in primary care,” Dr. Fitterman said. “As a country we need to really prop up primary care. This all can’t come under the roof of hospital medicine. We need to be part of a patient-centered medical home – but we are not the patient-centered medical home.”
He said the experience with the preop clinic described by Dr. Manjarrez also shows the need for buy-in from hospital or health system administration.
“While most of us are employed by hospitals and want to help meet their needs, we have to be more cautious. We have to look, I think, with a more critical eye, for the value; it may not always be in the dollars coming back in,” he said. “It might be in cost avoidance, such as reducing readmissions, or reducing same-day cancellations in an OR. Unless the C-suite appreciates that value, such programs will be short-lived.”
Hospitalists can’t ‘fill all the cracks’ in primary care
Hospitalists can’t ‘fill all the cracks’ in primary care
As vice chair of the hospital medicine service at Northwell Health, Nick Fitterman, MD, FACP, SFHM, oversees 16 HM groups at 15 hospitals in New York. He says the duties of his hospitalist staff, like those of most U.S. hospitalists, are similar to what they have traditionally been – clinical care on the wards, teaching, comanagement of surgery, quality improvement, committee work, and research. But he has noticed a trend of late: rapid expansion of the hospitalist’s role.
Speaking at an education session at HM18 in Orlando, Dr. Fitterman said the role of the hospitalist is growing to include tasks that might not be as common, but are becoming more familiar all the time: working at infusion centers, caring for patients in skilled nursing facilities, specializing in electronic health record use, colocating in psychiatric hospitals, even being deployed to natural disasters. His list went on, and it was much longer than the list of traditional hospitalist responsibilities.
“Where do we draw the line and say, ‘Wait a minute, our primary site is going to suffer if we continue to get spread this thin. Can we really do it all?” Dr. Fitterman said. As the number of hats hospitalists wear grows ever bigger, he said more thought must be placed into how expansion happens.
The preop clinic
Efren Manjarrez, MD, SFHM, former chief of hospital medicine at the University of Miami, told a cautionary tale about a preoperative clinic staffed by hospitalists that appeared to provide a financial benefit to a hospital – helping to avoid costly last-minute cancellations of surgeries – but that ultimately was shuttered. The hospital, he said, loses $8,000-$10,000 for each case that gets canceled on the same day.
“Think about that just for a minute,” Dr. Manjarrez said. “If 100 cases are canceled during the year at the last minute, that’s a lot of money.”
A preoperative clinic seemed like a worthwhile role for hospitalists – the program was started in Miami by the same doctor who initiated a similar program at Cleveland Clinic. “Surgical cases are what support the hospital [financially], and we’re here to help them along,” Dr. Manjarrez said. “The purpose of hospitalists is to make sure that patients are medically optimized.”
The preop program concept, used in U.S. medicine since the 1990s, was originally started by anesthesiologists, but they may not always be the best fit to staff such programs.
“Anesthesiologists do not manage all beta blockers,” Dr. Manjarrez said. “They don’t manage ACE inhibitors by mouth. They don’t manage all oral diabetes agents, and they sure as heck don’t manage pills that are anticoagulants. That’s the domain of internal medicine. And as patients have become more complex, that’s where hospitalists who [work in] preop clinics have stepped in.”
Studies have found that hospitalists staffing preop clinics have improved quality metrics and some clinical outcomes, including lowering cancellation rates and more appropriate use of beta blockers, he said.
In the Miami program described by Dr. Manjarrez, hospitalists in the preop clinic at first saw only patients who’d been financially cleared as able to pay. But ultimately, a tiered system was developed, and hospitalists saw only patients who were higher risk – those with COPD or stroke patients, for example – without regard to ability to pay.
“The hospital would have to make up any financial deficit at the very end,” Dr. Manjarrez said. This meant there were no longer efficient 5-minute encounters with patients. Instead, visits lasted about 45 minutes, so fewer patients were seen.
The program was successful, in that the same-day cancellation rate for surgeries dropped to less than 0.1% – fewer than 1 in 1,000 – with the preop clinic up and running, Dr. Manjarrez. Still, the hospital decided to end the program. “The hospital no longer wanted to reimburse us,” he said.
A takeaway from this experience for Dr. Manjarrez was that hospitalists need to do a better job of showing the financial benefits in their expanding roles, if they want them to endure.
“At the end of the day, hospitalists do provide value in preoperative clinics,” he said. “But unfortunately, we’re not doing a great job of publishing our data and showing our value.”
At-home care
At Brigham and Women’s Hospital in Boston, hospitalists have demonstrated good results with a program to provide care at home rather than in the hospital.
David Levine, MD, MPH, MA, clinician and investigator at Brigham and Women’s and an instructor in medicine at Harvard Medical School, said that the structure of inpatient care has generally not changed much over decades, despite advances in technology.
“We round on them once a day – if they’re lucky, twice,” he said. “The medicines have changed and imaging has changed, but we really haven’t changed the structure of how we take care of acutely ill adults for almost a hundred years.”
Hospitalizing patients brings unintended consequences. Twenty percent of older adults will become delirious during their stay, 1 out of 3 will lose a level of functional status in the hospital that they’ll never regain, and 1 out of 10 hospitalized patients will experience an adverse event, like an infection or a medication error.
Brigham and Women’s program of at-home care involves “admitting” patients to their homes after being treated in the emergency department. The goal is to reduce costs by 20%, while maintaining quality and safety and improving patients’ quality of life and experience.
Researchers are studying their results. They randomized patients, after the ED determined they required admission, either to admission to the hospital or to their home. The decision on whether to admit was made before the study investigators became involved with the patients, Dr. Levine said.
The program is also intended to improve access to hospitals. Brigham and Women’s is often over 100% capacity in the general medical ward.
Patients in the study needed to live within a 5-mile radius of either Brigham and Women’s Hospital, or Brigham and Women’s Faulkner Hospital, a nearby community hospital. A physician and a registered nurse form the core team; they assess patient needs and ratchet care either up or down, perhaps adding a home health aide or social worker.
The home care team takes advantage of technology: Portable equipment allows a basic metabolic panel to be performed on the spot – for example, a hemoglobin and hematocrit can be produced within 2 minutes. Also, portable ultrasounds and x-rays are used. Doctors keep a “tackle box” of urgent medications such as antibiotics and diuretics.
“We showed a direct cost reduction taking care of patients at home,” Dr. Levine said. There was also a reduction in utilization of care, and an increase in patient activity, with patients taking about 1,800 steps at home, compared with 180 in the hospital. There were no significant changes in safety, quality, or patient experience, he said.
Postdischarge clinics
Lauren Doctoroff, MD, FHM – a hospitalist at Beth Israel Deaconness Medical Center in Boston and assistant professor of medicine at Harvard Medical School – explained another hospitalist-staffed project meant to improve access to care: her center’s postdischarge clinic, which was started in 2009 but is no longer operating.
The clinic tackled the problem of what to do with patients when you discharge them, Dr. Doctoroff said, and its goal was to foster more cooperation between hospitalists and the faculty primary care practice, as well as to improve postdischarge access for patients from that practice.
A dedicated group of hospitalists staffed the clinics, handling medication reconciliation, symptom management, pending tests, and other services the patients were supposed to be getting after discharge, Dr. Doctoroff said.
“We greatly improved access so that when you came to see us you generally saw a hospitalist a week before you would have seen your primary care doctor,” she said. “And that was mostly because we created open access in a clinic that did not have open access. So if a doctor discharging a patient really thought that the patient needed to be seen after discharge, they would often see us.”
Hospitalists considering starting such a clinic have several key questions to consider, Dr. Doctoroff said.
“You need to focus on who the patient population is, the clinic structure, how you plan to staff the clinic, and what your outcomes are – mainly how you will measure performance,” she said.
Dr. Doctoroff said hospitalists are good for this role because “we’re very comfortable with patients who are complicated, and we are very adept at accessing information from the hospitalization. I think, as a hospitalist who spent 5 years seeing patients in a discharge clinic, it greatly enhances my understanding of patients and their challenges at discharge.”
The clinic was closed, she said, in part because it was largely an extension of primary care, and the patient volume wasn’t big enough to justify continuing it.
“Postdischarge clinics are, in a very narrow sense, a bit of a Band-Aid for a really dysfunctional primary care system,” Dr. Doctoroff said. “Ideally, if all you’re doing is providing a postdischarge physician visit, then you really want primary care to be able to do that in order to reengage with their patient. I think this is because postdischarge clinics are construed in a very narrow way to address the simple need to see a patient after discharge. And this may lead to the failure of these clinics, or make them easy to replace. Also, often what patients really need is more than just a physician visit, so a discharge clinic may need to be designed to provide an enhanced array of services.”
Dr. Fitterman said that these stories show that not all role expansion in hospital medicine is good role expansion. The experiences described by Dr. Manjarrez, Dr. Levine, and Dr. Doctoroff demonstrate the challenges hospitalists face as they attempt expansions into new roles, he said.
“We can’t be expected to fill all the cracks in primary care,” Dr. Fitterman said. “As a country we need to really prop up primary care. This all can’t come under the roof of hospital medicine. We need to be part of a patient-centered medical home – but we are not the patient-centered medical home.”
He said the experience with the preop clinic described by Dr. Manjarrez also shows the need for buy-in from hospital or health system administration.
“While most of us are employed by hospitals and want to help meet their needs, we have to be more cautious. We have to look, I think, with a more critical eye, for the value; it may not always be in the dollars coming back in,” he said. “It might be in cost avoidance, such as reducing readmissions, or reducing same-day cancellations in an OR. Unless the C-suite appreciates that value, such programs will be short-lived.”
As vice chair of the hospital medicine service at Northwell Health, Nick Fitterman, MD, FACP, SFHM, oversees 16 HM groups at 15 hospitals in New York. He says the duties of his hospitalist staff, like those of most U.S. hospitalists, are similar to what they have traditionally been – clinical care on the wards, teaching, comanagement of surgery, quality improvement, committee work, and research. But he has noticed a trend of late: rapid expansion of the hospitalist’s role.
Speaking at an education session at HM18 in Orlando, Dr. Fitterman said the role of the hospitalist is growing to include tasks that might not be as common, but are becoming more familiar all the time: working at infusion centers, caring for patients in skilled nursing facilities, specializing in electronic health record use, colocating in psychiatric hospitals, even being deployed to natural disasters. His list went on, and it was much longer than the list of traditional hospitalist responsibilities.
“Where do we draw the line and say, ‘Wait a minute, our primary site is going to suffer if we continue to get spread this thin. Can we really do it all?” Dr. Fitterman said. As the number of hats hospitalists wear grows ever bigger, he said more thought must be placed into how expansion happens.
The preop clinic
Efren Manjarrez, MD, SFHM, former chief of hospital medicine at the University of Miami, told a cautionary tale about a preoperative clinic staffed by hospitalists that appeared to provide a financial benefit to a hospital – helping to avoid costly last-minute cancellations of surgeries – but that ultimately was shuttered. The hospital, he said, loses $8,000-$10,000 for each case that gets canceled on the same day.
“Think about that just for a minute,” Dr. Manjarrez said. “If 100 cases are canceled during the year at the last minute, that’s a lot of money.”
A preoperative clinic seemed like a worthwhile role for hospitalists – the program was started in Miami by the same doctor who initiated a similar program at Cleveland Clinic. “Surgical cases are what support the hospital [financially], and we’re here to help them along,” Dr. Manjarrez said. “The purpose of hospitalists is to make sure that patients are medically optimized.”
The preop program concept, used in U.S. medicine since the 1990s, was originally started by anesthesiologists, but they may not always be the best fit to staff such programs.
“Anesthesiologists do not manage all beta blockers,” Dr. Manjarrez said. “They don’t manage ACE inhibitors by mouth. They don’t manage all oral diabetes agents, and they sure as heck don’t manage pills that are anticoagulants. That’s the domain of internal medicine. And as patients have become more complex, that’s where hospitalists who [work in] preop clinics have stepped in.”
Studies have found that hospitalists staffing preop clinics have improved quality metrics and some clinical outcomes, including lowering cancellation rates and more appropriate use of beta blockers, he said.
In the Miami program described by Dr. Manjarrez, hospitalists in the preop clinic at first saw only patients who’d been financially cleared as able to pay. But ultimately, a tiered system was developed, and hospitalists saw only patients who were higher risk – those with COPD or stroke patients, for example – without regard to ability to pay.
“The hospital would have to make up any financial deficit at the very end,” Dr. Manjarrez said. This meant there were no longer efficient 5-minute encounters with patients. Instead, visits lasted about 45 minutes, so fewer patients were seen.
The program was successful, in that the same-day cancellation rate for surgeries dropped to less than 0.1% – fewer than 1 in 1,000 – with the preop clinic up and running, Dr. Manjarrez. Still, the hospital decided to end the program. “The hospital no longer wanted to reimburse us,” he said.
A takeaway from this experience for Dr. Manjarrez was that hospitalists need to do a better job of showing the financial benefits in their expanding roles, if they want them to endure.
“At the end of the day, hospitalists do provide value in preoperative clinics,” he said. “But unfortunately, we’re not doing a great job of publishing our data and showing our value.”
At-home care
At Brigham and Women’s Hospital in Boston, hospitalists have demonstrated good results with a program to provide care at home rather than in the hospital.
David Levine, MD, MPH, MA, clinician and investigator at Brigham and Women’s and an instructor in medicine at Harvard Medical School, said that the structure of inpatient care has generally not changed much over decades, despite advances in technology.
“We round on them once a day – if they’re lucky, twice,” he said. “The medicines have changed and imaging has changed, but we really haven’t changed the structure of how we take care of acutely ill adults for almost a hundred years.”
Hospitalizing patients brings unintended consequences. Twenty percent of older adults will become delirious during their stay, 1 out of 3 will lose a level of functional status in the hospital that they’ll never regain, and 1 out of 10 hospitalized patients will experience an adverse event, like an infection or a medication error.
Brigham and Women’s program of at-home care involves “admitting” patients to their homes after being treated in the emergency department. The goal is to reduce costs by 20%, while maintaining quality and safety and improving patients’ quality of life and experience.
Researchers are studying their results. They randomized patients, after the ED determined they required admission, either to admission to the hospital or to their home. The decision on whether to admit was made before the study investigators became involved with the patients, Dr. Levine said.
The program is also intended to improve access to hospitals. Brigham and Women’s is often over 100% capacity in the general medical ward.
Patients in the study needed to live within a 5-mile radius of either Brigham and Women’s Hospital, or Brigham and Women’s Faulkner Hospital, a nearby community hospital. A physician and a registered nurse form the core team; they assess patient needs and ratchet care either up or down, perhaps adding a home health aide or social worker.
The home care team takes advantage of technology: Portable equipment allows a basic metabolic panel to be performed on the spot – for example, a hemoglobin and hematocrit can be produced within 2 minutes. Also, portable ultrasounds and x-rays are used. Doctors keep a “tackle box” of urgent medications such as antibiotics and diuretics.
“We showed a direct cost reduction taking care of patients at home,” Dr. Levine said. There was also a reduction in utilization of care, and an increase in patient activity, with patients taking about 1,800 steps at home, compared with 180 in the hospital. There were no significant changes in safety, quality, or patient experience, he said.
Postdischarge clinics
Lauren Doctoroff, MD, FHM – a hospitalist at Beth Israel Deaconness Medical Center in Boston and assistant professor of medicine at Harvard Medical School – explained another hospitalist-staffed project meant to improve access to care: her center’s postdischarge clinic, which was started in 2009 but is no longer operating.
The clinic tackled the problem of what to do with patients when you discharge them, Dr. Doctoroff said, and its goal was to foster more cooperation between hospitalists and the faculty primary care practice, as well as to improve postdischarge access for patients from that practice.
A dedicated group of hospitalists staffed the clinics, handling medication reconciliation, symptom management, pending tests, and other services the patients were supposed to be getting after discharge, Dr. Doctoroff said.
“We greatly improved access so that when you came to see us you generally saw a hospitalist a week before you would have seen your primary care doctor,” she said. “And that was mostly because we created open access in a clinic that did not have open access. So if a doctor discharging a patient really thought that the patient needed to be seen after discharge, they would often see us.”
Hospitalists considering starting such a clinic have several key questions to consider, Dr. Doctoroff said.
“You need to focus on who the patient population is, the clinic structure, how you plan to staff the clinic, and what your outcomes are – mainly how you will measure performance,” she said.
Dr. Doctoroff said hospitalists are good for this role because “we’re very comfortable with patients who are complicated, and we are very adept at accessing information from the hospitalization. I think, as a hospitalist who spent 5 years seeing patients in a discharge clinic, it greatly enhances my understanding of patients and their challenges at discharge.”
The clinic was closed, she said, in part because it was largely an extension of primary care, and the patient volume wasn’t big enough to justify continuing it.
“Postdischarge clinics are, in a very narrow sense, a bit of a Band-Aid for a really dysfunctional primary care system,” Dr. Doctoroff said. “Ideally, if all you’re doing is providing a postdischarge physician visit, then you really want primary care to be able to do that in order to reengage with their patient. I think this is because postdischarge clinics are construed in a very narrow way to address the simple need to see a patient after discharge. And this may lead to the failure of these clinics, or make them easy to replace. Also, often what patients really need is more than just a physician visit, so a discharge clinic may need to be designed to provide an enhanced array of services.”
Dr. Fitterman said that these stories show that not all role expansion in hospital medicine is good role expansion. The experiences described by Dr. Manjarrez, Dr. Levine, and Dr. Doctoroff demonstrate the challenges hospitalists face as they attempt expansions into new roles, he said.
“We can’t be expected to fill all the cracks in primary care,” Dr. Fitterman said. “As a country we need to really prop up primary care. This all can’t come under the roof of hospital medicine. We need to be part of a patient-centered medical home – but we are not the patient-centered medical home.”
He said the experience with the preop clinic described by Dr. Manjarrez also shows the need for buy-in from hospital or health system administration.
“While most of us are employed by hospitals and want to help meet their needs, we have to be more cautious. We have to look, I think, with a more critical eye, for the value; it may not always be in the dollars coming back in,” he said. “It might be in cost avoidance, such as reducing readmissions, or reducing same-day cancellations in an OR. Unless the C-suite appreciates that value, such programs will be short-lived.”
Rethinking preop testing
ORLANDO – Michael Rothberg, MD, a nocturnist who works at Presbyterian Rust Medical Center in Albuquerque, often is torn when asked to routinely perform preoperative tests, such as ECGs, on patients.
On the one hand, Dr. Rothberg knows that for many patients there is almost certainly no benefit to some of the tests. On the other hand, surgeons expect the tests to be performed – so, for the sake of collegiality, patients often have tests ordered that hospitalists suspect are unnecessary.
This was a big part of why Dr. Rothberg decided to come a day early to HM18, held in early April in Orlando, to attend the pre-course “Essentials of Perioperative Medicine and Co-Management for the Hospitalist.” He was looking for expert guidance on which patients need what tests before surgery, and also how to better determine what preoperative tests are a waste of time and money for certain patients, so that he’ll be armed with useful information when he went back to his medical center.
“I can slap something on the surgeon’s desk and say, ‘Here’s why we’re not doing it,’ ” Dr. Rothberg said.
At the HM18 pre-course, experts gave guidance on the benefits of hospitalist involvement in perioperative care and offered points to consider when assessing cardiac and pulmonary risk before surgeries. Hospitalists then broke into groups to brainstorm techniques that could improve their perioperative work.
She noted how surgical safety checklists have been shown to improve morbidity and mortality, as seen with a checklist developed by the World Health Organization and in California, where an enhanced recovery program at 20 hospitals has been successful.
“I think the reason we see changes in each of those … from pre to post when they implement, is because people start to communicate and collaborate,” she said. “I think that’s the secret sauce, and you can take that back home with you.”
Assessing risk
As for preoperative testing, history is replete with examples of tests once considered crucial but that have proven to be unimportant for many patients, including preoperative carotid endarterectomy, preop ECG, preop coronary revasularization, and preop lab work.
“I was always listening for bruits years ago,” Dr. Grant said. “I’ve sort of stopped doing that now. You’ll hear it, you won’t know what to do with it. We used to take care of those things before surgery. We now know that’s not helpful for patients without symptoms.”
Dr. Cohn’s philosophy is to not suggest a delay without firm evidence that it is necessary. “I try not to interfere with surgery unless I feel that there is significant risk,” he said.
In workshop discussions at the HM18 pre-course, hospitalists considered their contributions to preoperative care and ways they might be able to contribute more effectively. Among their ideas were better communication with anesthesiology – regarded as severely lacking by many hospitalists in the session – as well as designating smaller perioperative teams to foster knowledge and greater trust with surgeons.
Aron Mednick, MD, FHM, director of the comanagement service at Tisch Hospital, NYU Langone Medical Center, New York, said his group talked about an “identify, mitigate, propose, and resolve” method – identifying services or conditions with a high rate of preoperative problems, finding data on how to solve them, and proposing ways to get hospitalists involved in the solution.
“We noted that a lot of people experience resistance with getting hospitalists involved in care early,” he said. “So one of the ways to do this is actually to identify problems and start above the surgeon, at the CMO and COO level, and then move down through department chairs and, basically, impose our existence on the care of the patient.”
ORLANDO – Michael Rothberg, MD, a nocturnist who works at Presbyterian Rust Medical Center in Albuquerque, often is torn when asked to routinely perform preoperative tests, such as ECGs, on patients.
On the one hand, Dr. Rothberg knows that for many patients there is almost certainly no benefit to some of the tests. On the other hand, surgeons expect the tests to be performed – so, for the sake of collegiality, patients often have tests ordered that hospitalists suspect are unnecessary.
This was a big part of why Dr. Rothberg decided to come a day early to HM18, held in early April in Orlando, to attend the pre-course “Essentials of Perioperative Medicine and Co-Management for the Hospitalist.” He was looking for expert guidance on which patients need what tests before surgery, and also how to better determine what preoperative tests are a waste of time and money for certain patients, so that he’ll be armed with useful information when he went back to his medical center.
“I can slap something on the surgeon’s desk and say, ‘Here’s why we’re not doing it,’ ” Dr. Rothberg said.
At the HM18 pre-course, experts gave guidance on the benefits of hospitalist involvement in perioperative care and offered points to consider when assessing cardiac and pulmonary risk before surgeries. Hospitalists then broke into groups to brainstorm techniques that could improve their perioperative work.
She noted how surgical safety checklists have been shown to improve morbidity and mortality, as seen with a checklist developed by the World Health Organization and in California, where an enhanced recovery program at 20 hospitals has been successful.
“I think the reason we see changes in each of those … from pre to post when they implement, is because people start to communicate and collaborate,” she said. “I think that’s the secret sauce, and you can take that back home with you.”
Assessing risk
As for preoperative testing, history is replete with examples of tests once considered crucial but that have proven to be unimportant for many patients, including preoperative carotid endarterectomy, preop ECG, preop coronary revasularization, and preop lab work.
“I was always listening for bruits years ago,” Dr. Grant said. “I’ve sort of stopped doing that now. You’ll hear it, you won’t know what to do with it. We used to take care of those things before surgery. We now know that’s not helpful for patients without symptoms.”
Dr. Cohn’s philosophy is to not suggest a delay without firm evidence that it is necessary. “I try not to interfere with surgery unless I feel that there is significant risk,” he said.
In workshop discussions at the HM18 pre-course, hospitalists considered their contributions to preoperative care and ways they might be able to contribute more effectively. Among their ideas were better communication with anesthesiology – regarded as severely lacking by many hospitalists in the session – as well as designating smaller perioperative teams to foster knowledge and greater trust with surgeons.
Aron Mednick, MD, FHM, director of the comanagement service at Tisch Hospital, NYU Langone Medical Center, New York, said his group talked about an “identify, mitigate, propose, and resolve” method – identifying services or conditions with a high rate of preoperative problems, finding data on how to solve them, and proposing ways to get hospitalists involved in the solution.
“We noted that a lot of people experience resistance with getting hospitalists involved in care early,” he said. “So one of the ways to do this is actually to identify problems and start above the surgeon, at the CMO and COO level, and then move down through department chairs and, basically, impose our existence on the care of the patient.”
ORLANDO – Michael Rothberg, MD, a nocturnist who works at Presbyterian Rust Medical Center in Albuquerque, often is torn when asked to routinely perform preoperative tests, such as ECGs, on patients.
On the one hand, Dr. Rothberg knows that for many patients there is almost certainly no benefit to some of the tests. On the other hand, surgeons expect the tests to be performed – so, for the sake of collegiality, patients often have tests ordered that hospitalists suspect are unnecessary.
This was a big part of why Dr. Rothberg decided to come a day early to HM18, held in early April in Orlando, to attend the pre-course “Essentials of Perioperative Medicine and Co-Management for the Hospitalist.” He was looking for expert guidance on which patients need what tests before surgery, and also how to better determine what preoperative tests are a waste of time and money for certain patients, so that he’ll be armed with useful information when he went back to his medical center.
“I can slap something on the surgeon’s desk and say, ‘Here’s why we’re not doing it,’ ” Dr. Rothberg said.
At the HM18 pre-course, experts gave guidance on the benefits of hospitalist involvement in perioperative care and offered points to consider when assessing cardiac and pulmonary risk before surgeries. Hospitalists then broke into groups to brainstorm techniques that could improve their perioperative work.
She noted how surgical safety checklists have been shown to improve morbidity and mortality, as seen with a checklist developed by the World Health Organization and in California, where an enhanced recovery program at 20 hospitals has been successful.
“I think the reason we see changes in each of those … from pre to post when they implement, is because people start to communicate and collaborate,” she said. “I think that’s the secret sauce, and you can take that back home with you.”
Assessing risk
As for preoperative testing, history is replete with examples of tests once considered crucial but that have proven to be unimportant for many patients, including preoperative carotid endarterectomy, preop ECG, preop coronary revasularization, and preop lab work.
“I was always listening for bruits years ago,” Dr. Grant said. “I’ve sort of stopped doing that now. You’ll hear it, you won’t know what to do with it. We used to take care of those things before surgery. We now know that’s not helpful for patients without symptoms.”
Dr. Cohn’s philosophy is to not suggest a delay without firm evidence that it is necessary. “I try not to interfere with surgery unless I feel that there is significant risk,” he said.
In workshop discussions at the HM18 pre-course, hospitalists considered their contributions to preoperative care and ways they might be able to contribute more effectively. Among their ideas were better communication with anesthesiology – regarded as severely lacking by many hospitalists in the session – as well as designating smaller perioperative teams to foster knowledge and greater trust with surgeons.
Aron Mednick, MD, FHM, director of the comanagement service at Tisch Hospital, NYU Langone Medical Center, New York, said his group talked about an “identify, mitigate, propose, and resolve” method – identifying services or conditions with a high rate of preoperative problems, finding data on how to solve them, and proposing ways to get hospitalists involved in the solution.
“We noted that a lot of people experience resistance with getting hospitalists involved in care early,” he said. “So one of the ways to do this is actually to identify problems and start above the surgeon, at the CMO and COO level, and then move down through department chairs and, basically, impose our existence on the care of the patient.”
REPORTING FROM HM18
Eye-opening findings cast spondyloarthritis in new light, expert says
SANDESTIN, FLA. – Recent findings have led to eye-opening results in the axial spondyloarthritis (SpA) field, including a surprisingly high number of patients with inflammatory back pain who don’t progress to the disease, healthy people who develop SpA-like details on imaging, and significant gender differences in the efficacy of biologic therapy, said Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego.
The findings could lead clinicians to see the disease differently and consult with patients in new ways, he said.
Just over 20% of the patients progressed to SpA within 5 years, and about 30% over 15 years. But after 5 years, the condition resolved in over 30% of patients – and after 15 years, it resolved in almost half.
In about 5% of patients, symptoms persisted but the condition remained unidentified.
“A lot of people with inflammatory back pain, it doesn’t continue to be an issue – this goes out a decade and a half,” Dr. Kavanaugh said. “I was surprised with this. I would have guess that over this many years, more people would have developed ankylosing spondylitis, but they don’t.”
He said that clinicians should cite this information in their discussions with patients. They should review their case and evaluate spinal symptoms, but let them know that the condition might not progress and might not be permanent.
“I would use this information and say, ‘Well you’re having inflammatory back pain, but let’s go review things,’ ” he said. “ ‘If you don’t have the true spondyloarthropathy or ankylosing spondylitis now, there’s a chance that this will go away. It’s almost 50-50, or we still don’t know what it is even if you’re having some symptoms (after 15 years).’ ”
Other important findings underscore the need for a complete clinical picture rather than just findings on imaging for an axial SpA diagnosis, Dr. Kavanaugh said. Researchers examined MRI images of new military recruits who were healthy with no back pain (Rheumatology [Oxford]. 2018 Mar 1;57[3]:508-13). They found that 23% of them at baseline – and 37% after strenuous training – had MRI findings that would qualify as positive for spondyloarthritis by Assessment of Spondyloarthritis international Society criteria. But they wouldn’t meet the definition of disease.
More recent findings showed similar results in imaging of healthy runners and hockey players (Arthritis Rheumatol. 2018 May;70[5]:736-45), with 30%-40% of them having MRI findings that would be considered positive on ASAS, Dr. Kavanaugh said.
“These were just people who were out stressing their joints,” he said. “We were super excited at the start of having MRI because now we can look and evaluate the activity within a joint. But I think, like everything, we have to take it with a little bit of caution. Just in and of itself, without the clinical picture, it does not diagnose axial spondyloarthropathy.”
In another recent study, women with axial SpA were found to have significantly lower responses over time than men with axial SpA (J Rheumatol. 2018 Feb;45[2]:195-201). Dr. Kavanaugh said that there might be some selection bias because of the higher male prevalence of disease but said the findings were noteworthy, especially in light of findings in animal models suggesting gender differences in disease expression and response to treatment.
“I think this is fascinating,” he said. “I think there’s a lot more to come for this.”
Dr. Kavanaugh reported financial relationships with AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Gilead, Genentech, Novartis, Pfizer, and other companies.
SANDESTIN, FLA. – Recent findings have led to eye-opening results in the axial spondyloarthritis (SpA) field, including a surprisingly high number of patients with inflammatory back pain who don’t progress to the disease, healthy people who develop SpA-like details on imaging, and significant gender differences in the efficacy of biologic therapy, said Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego.
The findings could lead clinicians to see the disease differently and consult with patients in new ways, he said.
Just over 20% of the patients progressed to SpA within 5 years, and about 30% over 15 years. But after 5 years, the condition resolved in over 30% of patients – and after 15 years, it resolved in almost half.
In about 5% of patients, symptoms persisted but the condition remained unidentified.
“A lot of people with inflammatory back pain, it doesn’t continue to be an issue – this goes out a decade and a half,” Dr. Kavanaugh said. “I was surprised with this. I would have guess that over this many years, more people would have developed ankylosing spondylitis, but they don’t.”
He said that clinicians should cite this information in their discussions with patients. They should review their case and evaluate spinal symptoms, but let them know that the condition might not progress and might not be permanent.
“I would use this information and say, ‘Well you’re having inflammatory back pain, but let’s go review things,’ ” he said. “ ‘If you don’t have the true spondyloarthropathy or ankylosing spondylitis now, there’s a chance that this will go away. It’s almost 50-50, or we still don’t know what it is even if you’re having some symptoms (after 15 years).’ ”
Other important findings underscore the need for a complete clinical picture rather than just findings on imaging for an axial SpA diagnosis, Dr. Kavanaugh said. Researchers examined MRI images of new military recruits who were healthy with no back pain (Rheumatology [Oxford]. 2018 Mar 1;57[3]:508-13). They found that 23% of them at baseline – and 37% after strenuous training – had MRI findings that would qualify as positive for spondyloarthritis by Assessment of Spondyloarthritis international Society criteria. But they wouldn’t meet the definition of disease.
More recent findings showed similar results in imaging of healthy runners and hockey players (Arthritis Rheumatol. 2018 May;70[5]:736-45), with 30%-40% of them having MRI findings that would be considered positive on ASAS, Dr. Kavanaugh said.
“These were just people who were out stressing their joints,” he said. “We were super excited at the start of having MRI because now we can look and evaluate the activity within a joint. But I think, like everything, we have to take it with a little bit of caution. Just in and of itself, without the clinical picture, it does not diagnose axial spondyloarthropathy.”
In another recent study, women with axial SpA were found to have significantly lower responses over time than men with axial SpA (J Rheumatol. 2018 Feb;45[2]:195-201). Dr. Kavanaugh said that there might be some selection bias because of the higher male prevalence of disease but said the findings were noteworthy, especially in light of findings in animal models suggesting gender differences in disease expression and response to treatment.
“I think this is fascinating,” he said. “I think there’s a lot more to come for this.”
Dr. Kavanaugh reported financial relationships with AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Gilead, Genentech, Novartis, Pfizer, and other companies.
SANDESTIN, FLA. – Recent findings have led to eye-opening results in the axial spondyloarthritis (SpA) field, including a surprisingly high number of patients with inflammatory back pain who don’t progress to the disease, healthy people who develop SpA-like details on imaging, and significant gender differences in the efficacy of biologic therapy, said Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego.
The findings could lead clinicians to see the disease differently and consult with patients in new ways, he said.
Just over 20% of the patients progressed to SpA within 5 years, and about 30% over 15 years. But after 5 years, the condition resolved in over 30% of patients – and after 15 years, it resolved in almost half.
In about 5% of patients, symptoms persisted but the condition remained unidentified.
“A lot of people with inflammatory back pain, it doesn’t continue to be an issue – this goes out a decade and a half,” Dr. Kavanaugh said. “I was surprised with this. I would have guess that over this many years, more people would have developed ankylosing spondylitis, but they don’t.”
He said that clinicians should cite this information in their discussions with patients. They should review their case and evaluate spinal symptoms, but let them know that the condition might not progress and might not be permanent.
“I would use this information and say, ‘Well you’re having inflammatory back pain, but let’s go review things,’ ” he said. “ ‘If you don’t have the true spondyloarthropathy or ankylosing spondylitis now, there’s a chance that this will go away. It’s almost 50-50, or we still don’t know what it is even if you’re having some symptoms (after 15 years).’ ”
Other important findings underscore the need for a complete clinical picture rather than just findings on imaging for an axial SpA diagnosis, Dr. Kavanaugh said. Researchers examined MRI images of new military recruits who were healthy with no back pain (Rheumatology [Oxford]. 2018 Mar 1;57[3]:508-13). They found that 23% of them at baseline – and 37% after strenuous training – had MRI findings that would qualify as positive for spondyloarthritis by Assessment of Spondyloarthritis international Society criteria. But they wouldn’t meet the definition of disease.
More recent findings showed similar results in imaging of healthy runners and hockey players (Arthritis Rheumatol. 2018 May;70[5]:736-45), with 30%-40% of them having MRI findings that would be considered positive on ASAS, Dr. Kavanaugh said.
“These were just people who were out stressing their joints,” he said. “We were super excited at the start of having MRI because now we can look and evaluate the activity within a joint. But I think, like everything, we have to take it with a little bit of caution. Just in and of itself, without the clinical picture, it does not diagnose axial spondyloarthropathy.”
In another recent study, women with axial SpA were found to have significantly lower responses over time than men with axial SpA (J Rheumatol. 2018 Feb;45[2]:195-201). Dr. Kavanaugh said that there might be some selection bias because of the higher male prevalence of disease but said the findings were noteworthy, especially in light of findings in animal models suggesting gender differences in disease expression and response to treatment.
“I think this is fascinating,” he said. “I think there’s a lot more to come for this.”
Dr. Kavanaugh reported financial relationships with AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Gilead, Genentech, Novartis, Pfizer, and other companies.
EXPERT ANALYSIS FROM CCR 18
Caution crucial for stem cell transplant in scleroderma, despite potential interest
SANDESTIN, FLA. – An expert called for restraint with the use of stem cell transplantation in scleroderma at the annual Congress of Clinical Rheumatology, emphasizing that the early mortality risk shows that the patient group that should be considered for the treatment is very narrow.
Results published earlier this year found a long-term benefit for myeloablative autologous stem cell transplantation, compared with cyclophosphamide, and were highly encouraging – but only in patients with severe disease (N Engl J Med. 2018;378:35-47). This might prompt patients to express interest in the treatment, many of whom are not suitable, said Janet Pope, MD, chair of rheumatology at St. Joseph’s Health Care in London, Ont.
Because of mortality seen in the first year in the stem cell transplant group, the benefit over cyclophosphamide was seen only in subsequent years, Dr. Pope stressed.
Consideration of the approach is only appropriate for patients with early diffuse scleroderma who have a 50% mortality risk over 5 years, Dr. Pope said. Patients in the SCOT trial had a modified Rodnan Skin Score (mRSS) of 30, with an average forced vital capacity of 74%, and 73 of the 75 patients in the trial had lung involvement. Essentially, Dr. Pope said, these are patients with some organ involvement that could be lethal, but not such severe organ involvement that it requires a transplant.
“These are our sick patients,” she said.
The results published this year are even more definitive, Dr. Pope said, considering that they largely meshed with results out of Europe, published in 2014, that showed that the stem cell transplant benefit was not seen after the first year because of early mortality (JAMA. 2014 Jun 25;311[24]:2490-8). In that trial, a 10% mortality risk was seen in the first year in the transplant group, and then a benefit to transplant in the long term over cyclophosphamide.
“These are very complementary positive trials,” Dr. Pope said. “We don’t want to kill 10% of our patients who don’t have perceived high chance of mortality in the next 5 years. ... These patients are highly selected, but I think it gives our patients hope and, for some of my patients, this will be a treatment for them.”
The long-term efficacy is also encouraging in that new but less potent treatments might yield good long-term results without the early deaths, she said. “It gives an idea and hope, and it helps us to understand that maybe with immune modulation, without the nuclear blast of stem cell transplant, maybe we can do better for our patients.”
Dr. Pope reported relevant financial relationships with Actelion, Bayer, Merck, Bristol-Myers Squibb, and Roche.
SANDESTIN, FLA. – An expert called for restraint with the use of stem cell transplantation in scleroderma at the annual Congress of Clinical Rheumatology, emphasizing that the early mortality risk shows that the patient group that should be considered for the treatment is very narrow.
Results published earlier this year found a long-term benefit for myeloablative autologous stem cell transplantation, compared with cyclophosphamide, and were highly encouraging – but only in patients with severe disease (N Engl J Med. 2018;378:35-47). This might prompt patients to express interest in the treatment, many of whom are not suitable, said Janet Pope, MD, chair of rheumatology at St. Joseph’s Health Care in London, Ont.
Because of mortality seen in the first year in the stem cell transplant group, the benefit over cyclophosphamide was seen only in subsequent years, Dr. Pope stressed.
Consideration of the approach is only appropriate for patients with early diffuse scleroderma who have a 50% mortality risk over 5 years, Dr. Pope said. Patients in the SCOT trial had a modified Rodnan Skin Score (mRSS) of 30, with an average forced vital capacity of 74%, and 73 of the 75 patients in the trial had lung involvement. Essentially, Dr. Pope said, these are patients with some organ involvement that could be lethal, but not such severe organ involvement that it requires a transplant.
“These are our sick patients,” she said.
The results published this year are even more definitive, Dr. Pope said, considering that they largely meshed with results out of Europe, published in 2014, that showed that the stem cell transplant benefit was not seen after the first year because of early mortality (JAMA. 2014 Jun 25;311[24]:2490-8). In that trial, a 10% mortality risk was seen in the first year in the transplant group, and then a benefit to transplant in the long term over cyclophosphamide.
“These are very complementary positive trials,” Dr. Pope said. “We don’t want to kill 10% of our patients who don’t have perceived high chance of mortality in the next 5 years. ... These patients are highly selected, but I think it gives our patients hope and, for some of my patients, this will be a treatment for them.”
The long-term efficacy is also encouraging in that new but less potent treatments might yield good long-term results without the early deaths, she said. “It gives an idea and hope, and it helps us to understand that maybe with immune modulation, without the nuclear blast of stem cell transplant, maybe we can do better for our patients.”
Dr. Pope reported relevant financial relationships with Actelion, Bayer, Merck, Bristol-Myers Squibb, and Roche.
SANDESTIN, FLA. – An expert called for restraint with the use of stem cell transplantation in scleroderma at the annual Congress of Clinical Rheumatology, emphasizing that the early mortality risk shows that the patient group that should be considered for the treatment is very narrow.
Results published earlier this year found a long-term benefit for myeloablative autologous stem cell transplantation, compared with cyclophosphamide, and were highly encouraging – but only in patients with severe disease (N Engl J Med. 2018;378:35-47). This might prompt patients to express interest in the treatment, many of whom are not suitable, said Janet Pope, MD, chair of rheumatology at St. Joseph’s Health Care in London, Ont.
Because of mortality seen in the first year in the stem cell transplant group, the benefit over cyclophosphamide was seen only in subsequent years, Dr. Pope stressed.
Consideration of the approach is only appropriate for patients with early diffuse scleroderma who have a 50% mortality risk over 5 years, Dr. Pope said. Patients in the SCOT trial had a modified Rodnan Skin Score (mRSS) of 30, with an average forced vital capacity of 74%, and 73 of the 75 patients in the trial had lung involvement. Essentially, Dr. Pope said, these are patients with some organ involvement that could be lethal, but not such severe organ involvement that it requires a transplant.
“These are our sick patients,” she said.
The results published this year are even more definitive, Dr. Pope said, considering that they largely meshed with results out of Europe, published in 2014, that showed that the stem cell transplant benefit was not seen after the first year because of early mortality (JAMA. 2014 Jun 25;311[24]:2490-8). In that trial, a 10% mortality risk was seen in the first year in the transplant group, and then a benefit to transplant in the long term over cyclophosphamide.
“These are very complementary positive trials,” Dr. Pope said. “We don’t want to kill 10% of our patients who don’t have perceived high chance of mortality in the next 5 years. ... These patients are highly selected, but I think it gives our patients hope and, for some of my patients, this will be a treatment for them.”
The long-term efficacy is also encouraging in that new but less potent treatments might yield good long-term results without the early deaths, she said. “It gives an idea and hope, and it helps us to understand that maybe with immune modulation, without the nuclear blast of stem cell transplant, maybe we can do better for our patients.”
Dr. Pope reported relevant financial relationships with Actelion, Bayer, Merck, Bristol-Myers Squibb, and Roche.
EXPERT ANALYSIS FROM CCR 18
Newer IgG4 testing proving effective in assessing patients
SANDESTIN, FLA. – New forms of IgG4 testing could be more helpful in making diagnoses of immunoglobulin G4-related disease, an expert said at the annual Congress of Clinical Rheumatology, while cautioning that the diagnosis is more about histology and pattern of involvement than antibody testing.
Arezou Khosroshahi, MD, of Emory University, Atlanta, said that the IgG4 levels found in serum using nephelometry can often be low in patients who otherwise show signs of the disease, which can affect a wide array of organs and typically involves elevated IgG4. Newer forms of testing – enzyme-linked ImmunoSpot (ELISPOT) and quantitative reverse transcription polymerase chain reaction (RT-qPCR) – could be more telling, she said.
But she found that, on flow cytometry, 88% of the woman’s circulating B cells were positive for IgG4, so the woman was treated with rituximab to deplete these cells.
“When the B cells were gone, we had release of the IgG4 in the serum and now we could pick it up with nephelometry,” she said.
This missed IgG4 with nephelometry prompted researchers to turn to ELISPOT, a sensitive method to count antibody-secreting cells. The test works well by capturing the antibodies’ presence right after they’re secreted, before they can become lost to receptor binding or in other ways.
“This was a better assay to measure the IgG4 antibodies rather than nephelometry,” she said.
Perhaps even better, studies in Europe have found that RT-qPCR testing for IgG4 RNA can be effective. This type of testing is easier than ELISPOT, and “they are finding the sensitivity to be much superior to nephelometry for immunoglobulin levels,” Dr. Khosroshahi said.
The higher the levels of IgG4, the more likely an IgG4-related disease diagnosis is warranted, and higher levels tend to lead to worse outcomes, she said.
She waved a caution flag, though: Other diseases can involve elevated IgG4, and even a normal IgG4 level does not necessarily rule out the disease. Other evaluations really form the cornerstone of the diagnosis of IgG4-related disease, she said.
“There should be characteristic histology and of course IgG4-staining, but more importantly, pattern of organ involvement. It’s very important,” Dr. Khosroshahi said. “If there is a mass in the pancreas and there is salivary gland and parotid gland swellings and other features of that going on, you are more concerned that that is a process going on.”
Dr. Khosroshahi had no relevant disclosures.
SANDESTIN, FLA. – New forms of IgG4 testing could be more helpful in making diagnoses of immunoglobulin G4-related disease, an expert said at the annual Congress of Clinical Rheumatology, while cautioning that the diagnosis is more about histology and pattern of involvement than antibody testing.
Arezou Khosroshahi, MD, of Emory University, Atlanta, said that the IgG4 levels found in serum using nephelometry can often be low in patients who otherwise show signs of the disease, which can affect a wide array of organs and typically involves elevated IgG4. Newer forms of testing – enzyme-linked ImmunoSpot (ELISPOT) and quantitative reverse transcription polymerase chain reaction (RT-qPCR) – could be more telling, she said.
But she found that, on flow cytometry, 88% of the woman’s circulating B cells were positive for IgG4, so the woman was treated with rituximab to deplete these cells.
“When the B cells were gone, we had release of the IgG4 in the serum and now we could pick it up with nephelometry,” she said.
This missed IgG4 with nephelometry prompted researchers to turn to ELISPOT, a sensitive method to count antibody-secreting cells. The test works well by capturing the antibodies’ presence right after they’re secreted, before they can become lost to receptor binding or in other ways.
“This was a better assay to measure the IgG4 antibodies rather than nephelometry,” she said.
Perhaps even better, studies in Europe have found that RT-qPCR testing for IgG4 RNA can be effective. This type of testing is easier than ELISPOT, and “they are finding the sensitivity to be much superior to nephelometry for immunoglobulin levels,” Dr. Khosroshahi said.
The higher the levels of IgG4, the more likely an IgG4-related disease diagnosis is warranted, and higher levels tend to lead to worse outcomes, she said.
She waved a caution flag, though: Other diseases can involve elevated IgG4, and even a normal IgG4 level does not necessarily rule out the disease. Other evaluations really form the cornerstone of the diagnosis of IgG4-related disease, she said.
“There should be characteristic histology and of course IgG4-staining, but more importantly, pattern of organ involvement. It’s very important,” Dr. Khosroshahi said. “If there is a mass in the pancreas and there is salivary gland and parotid gland swellings and other features of that going on, you are more concerned that that is a process going on.”
Dr. Khosroshahi had no relevant disclosures.
SANDESTIN, FLA. – New forms of IgG4 testing could be more helpful in making diagnoses of immunoglobulin G4-related disease, an expert said at the annual Congress of Clinical Rheumatology, while cautioning that the diagnosis is more about histology and pattern of involvement than antibody testing.
Arezou Khosroshahi, MD, of Emory University, Atlanta, said that the IgG4 levels found in serum using nephelometry can often be low in patients who otherwise show signs of the disease, which can affect a wide array of organs and typically involves elevated IgG4. Newer forms of testing – enzyme-linked ImmunoSpot (ELISPOT) and quantitative reverse transcription polymerase chain reaction (RT-qPCR) – could be more telling, she said.
But she found that, on flow cytometry, 88% of the woman’s circulating B cells were positive for IgG4, so the woman was treated with rituximab to deplete these cells.
“When the B cells were gone, we had release of the IgG4 in the serum and now we could pick it up with nephelometry,” she said.
This missed IgG4 with nephelometry prompted researchers to turn to ELISPOT, a sensitive method to count antibody-secreting cells. The test works well by capturing the antibodies’ presence right after they’re secreted, before they can become lost to receptor binding or in other ways.
“This was a better assay to measure the IgG4 antibodies rather than nephelometry,” she said.
Perhaps even better, studies in Europe have found that RT-qPCR testing for IgG4 RNA can be effective. This type of testing is easier than ELISPOT, and “they are finding the sensitivity to be much superior to nephelometry for immunoglobulin levels,” Dr. Khosroshahi said.
The higher the levels of IgG4, the more likely an IgG4-related disease diagnosis is warranted, and higher levels tend to lead to worse outcomes, she said.
She waved a caution flag, though: Other diseases can involve elevated IgG4, and even a normal IgG4 level does not necessarily rule out the disease. Other evaluations really form the cornerstone of the diagnosis of IgG4-related disease, she said.
“There should be characteristic histology and of course IgG4-staining, but more importantly, pattern of organ involvement. It’s very important,” Dr. Khosroshahi said. “If there is a mass in the pancreas and there is salivary gland and parotid gland swellings and other features of that going on, you are more concerned that that is a process going on.”
Dr. Khosroshahi had no relevant disclosures.
EXPERT ANALYSIS FROM CCR 18
Conservative early approach likely best, RA expert says
SANDESTIN, FLA. – A conservative approach to early rheumatoid arthritis treatment has carried the day in the practice of Gerd R. Burmester, MD.
In a talk at the annual Congress of Clinical Rheumatology, Dr. Burmester said that, although there is room to argue for a more aggressive approach, with more intense treatment early, a less aggressive philosophy has worked well in his clinic.
Dr. Burmester, director of rheumatology and clinical immunology at Charite-University in Berlin and a past president of the European League Against Rheumatism (EULAR), said he drew inspiration from the results of the 2015 study CARE-RA, in which patients were treated with initial therapy of methotrexate plus sulfasalazine and a fairly high dose of 60 mg of prednisolone; methotrexate plus leflunomide plus 30 mg of prednisolone; or just methotrexate plus 30 mg of prednisolone that is quickly tapered down (Ann Rheum Dis. 2015 Jan;74[1]:27-34).
“Everyone would say, ‘Okay, this is quite easy – the more intensive drug regimen should give you better results,’ ” Dr. Burmester said. “But if you look at the data, there’s no difference.” And after just 8 weeks, the patients’ corticosteroid dose was down to 5 mg.
This, he said, “has changed my daily typical practice, quite a bit.”
“I start with, usually, 15 mg of methotrexate subcutaneously,” because of better efficacy and less liver toxicity than oral administration, he said, or an oral dose if a patient resists the subcutaneous administration or there is another reason to avoid it. “And I add 30 mg of prednisone and taper it down – 30, 20, 12.5 mg, and then down to 5 and eventually discontinued altogether.”
“This is an interesting scheme,” he said. “And this is exactly what I do with my patients.”
His approach might be worth noting not only for his leadership roles, but because of his fastidious approach to being a clinician – he said he still, personally, takes every patient’s 28-joint Disease Activity Score and Simple Disease Activity Index at every visit.
In a recent paper, he argued, along with prominent Canadian rheumatologist Janet Pope, both sides of the debate, for and against more aggressive treatment – methotrexate combined with conventional synthetic or biologic DMARDs – very early in the disease course (Lancet. 2017 Jun 10;389[10086]:2338-48).
“If you use a combination treatment with a biologic right away, what might be the advantages?” he said. “More patients would achieve rapid remission. It might result in long-term benefits, less joint damage, higher chance of reducing therapy in the future.”
On the other hand, he said, there are disadvantages.
“This is, of course, more expensive, if you use a biologic up front in early RA,” he said. “Not all patients of course need it, and some have also side effects.” He added that little time is lost if a treat-to-target principle is followed. Plus, patients tend to be more accepting of monotherapy than combination therapy at the start of treatment, and combination therapy might require more time spent in the clinic.
Data from German databases, dating back to 1997, show that far more patients are reaching remission today after several years of treatment (Z Rheumatol. 2017 Feb;76[1]:50-7). But, he added, “It’s not yet perfect. ... We still have quite a few patients who are in moderate disease activity” despite the availability of so many treatment options.
“There’s still, of course, a huge unmet need in this devastating disease if you don’t treat it correctly.”
Dr. Burmester reports receiving clinical trial support and/or honoraria for lectures and consulting from AbbVie, Bristol-Myers Squibb, Lilly, Roche, MedImmune, Merck Sharpe & Dohme, Pfizer, Sanofi, and UCB.
SANDESTIN, FLA. – A conservative approach to early rheumatoid arthritis treatment has carried the day in the practice of Gerd R. Burmester, MD.
In a talk at the annual Congress of Clinical Rheumatology, Dr. Burmester said that, although there is room to argue for a more aggressive approach, with more intense treatment early, a less aggressive philosophy has worked well in his clinic.
Dr. Burmester, director of rheumatology and clinical immunology at Charite-University in Berlin and a past president of the European League Against Rheumatism (EULAR), said he drew inspiration from the results of the 2015 study CARE-RA, in which patients were treated with initial therapy of methotrexate plus sulfasalazine and a fairly high dose of 60 mg of prednisolone; methotrexate plus leflunomide plus 30 mg of prednisolone; or just methotrexate plus 30 mg of prednisolone that is quickly tapered down (Ann Rheum Dis. 2015 Jan;74[1]:27-34).
“Everyone would say, ‘Okay, this is quite easy – the more intensive drug regimen should give you better results,’ ” Dr. Burmester said. “But if you look at the data, there’s no difference.” And after just 8 weeks, the patients’ corticosteroid dose was down to 5 mg.
This, he said, “has changed my daily typical practice, quite a bit.”
“I start with, usually, 15 mg of methotrexate subcutaneously,” because of better efficacy and less liver toxicity than oral administration, he said, or an oral dose if a patient resists the subcutaneous administration or there is another reason to avoid it. “And I add 30 mg of prednisone and taper it down – 30, 20, 12.5 mg, and then down to 5 and eventually discontinued altogether.”
“This is an interesting scheme,” he said. “And this is exactly what I do with my patients.”
His approach might be worth noting not only for his leadership roles, but because of his fastidious approach to being a clinician – he said he still, personally, takes every patient’s 28-joint Disease Activity Score and Simple Disease Activity Index at every visit.
In a recent paper, he argued, along with prominent Canadian rheumatologist Janet Pope, both sides of the debate, for and against more aggressive treatment – methotrexate combined with conventional synthetic or biologic DMARDs – very early in the disease course (Lancet. 2017 Jun 10;389[10086]:2338-48).
“If you use a combination treatment with a biologic right away, what might be the advantages?” he said. “More patients would achieve rapid remission. It might result in long-term benefits, less joint damage, higher chance of reducing therapy in the future.”
On the other hand, he said, there are disadvantages.
“This is, of course, more expensive, if you use a biologic up front in early RA,” he said. “Not all patients of course need it, and some have also side effects.” He added that little time is lost if a treat-to-target principle is followed. Plus, patients tend to be more accepting of monotherapy than combination therapy at the start of treatment, and combination therapy might require more time spent in the clinic.
Data from German databases, dating back to 1997, show that far more patients are reaching remission today after several years of treatment (Z Rheumatol. 2017 Feb;76[1]:50-7). But, he added, “It’s not yet perfect. ... We still have quite a few patients who are in moderate disease activity” despite the availability of so many treatment options.
“There’s still, of course, a huge unmet need in this devastating disease if you don’t treat it correctly.”
Dr. Burmester reports receiving clinical trial support and/or honoraria for lectures and consulting from AbbVie, Bristol-Myers Squibb, Lilly, Roche, MedImmune, Merck Sharpe & Dohme, Pfizer, Sanofi, and UCB.
SANDESTIN, FLA. – A conservative approach to early rheumatoid arthritis treatment has carried the day in the practice of Gerd R. Burmester, MD.
In a talk at the annual Congress of Clinical Rheumatology, Dr. Burmester said that, although there is room to argue for a more aggressive approach, with more intense treatment early, a less aggressive philosophy has worked well in his clinic.
Dr. Burmester, director of rheumatology and clinical immunology at Charite-University in Berlin and a past president of the European League Against Rheumatism (EULAR), said he drew inspiration from the results of the 2015 study CARE-RA, in which patients were treated with initial therapy of methotrexate plus sulfasalazine and a fairly high dose of 60 mg of prednisolone; methotrexate plus leflunomide plus 30 mg of prednisolone; or just methotrexate plus 30 mg of prednisolone that is quickly tapered down (Ann Rheum Dis. 2015 Jan;74[1]:27-34).
“Everyone would say, ‘Okay, this is quite easy – the more intensive drug regimen should give you better results,’ ” Dr. Burmester said. “But if you look at the data, there’s no difference.” And after just 8 weeks, the patients’ corticosteroid dose was down to 5 mg.
This, he said, “has changed my daily typical practice, quite a bit.”
“I start with, usually, 15 mg of methotrexate subcutaneously,” because of better efficacy and less liver toxicity than oral administration, he said, or an oral dose if a patient resists the subcutaneous administration or there is another reason to avoid it. “And I add 30 mg of prednisone and taper it down – 30, 20, 12.5 mg, and then down to 5 and eventually discontinued altogether.”
“This is an interesting scheme,” he said. “And this is exactly what I do with my patients.”
His approach might be worth noting not only for his leadership roles, but because of his fastidious approach to being a clinician – he said he still, personally, takes every patient’s 28-joint Disease Activity Score and Simple Disease Activity Index at every visit.
In a recent paper, he argued, along with prominent Canadian rheumatologist Janet Pope, both sides of the debate, for and against more aggressive treatment – methotrexate combined with conventional synthetic or biologic DMARDs – very early in the disease course (Lancet. 2017 Jun 10;389[10086]:2338-48).
“If you use a combination treatment with a biologic right away, what might be the advantages?” he said. “More patients would achieve rapid remission. It might result in long-term benefits, less joint damage, higher chance of reducing therapy in the future.”
On the other hand, he said, there are disadvantages.
“This is, of course, more expensive, if you use a biologic up front in early RA,” he said. “Not all patients of course need it, and some have also side effects.” He added that little time is lost if a treat-to-target principle is followed. Plus, patients tend to be more accepting of monotherapy than combination therapy at the start of treatment, and combination therapy might require more time spent in the clinic.
Data from German databases, dating back to 1997, show that far more patients are reaching remission today after several years of treatment (Z Rheumatol. 2017 Feb;76[1]:50-7). But, he added, “It’s not yet perfect. ... We still have quite a few patients who are in moderate disease activity” despite the availability of so many treatment options.
“There’s still, of course, a huge unmet need in this devastating disease if you don’t treat it correctly.”
Dr. Burmester reports receiving clinical trial support and/or honoraria for lectures and consulting from AbbVie, Bristol-Myers Squibb, Lilly, Roche, MedImmune, Merck Sharpe & Dohme, Pfizer, Sanofi, and UCB.
EXPERT ANALYSIS FROM CCR 18
VIDEO: Second wave of psoriatic arthritis therapies
SANDESTIN, FLA. – An array of potential new options for psoriatic arthritis offers new targeted options and poses challenges for how to use the drugs, Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, said in a video interview at the annual Congress of Clinical Rheumatology.
“We’re seeing a second wave – a second wave driven by the additional ways that we have to target aspects of the immune system relevant to psoriatic arthritis,” he said.
First used to treat rheumatoid arthritis, monoclonal antibodies to interleukin targets, including IL12 and IL23 (ustekinumab) and IL17 (secukinumab and ixekizumab), have become established psoriatic arthritis therapies. Additionally, the Janus kinase (JAK) inhibitor tofacitinib has become an option.
Other options in the pipeline include the JAK inhibitor baricitinib; the anti-IL23 monoclonal antibodies guselkumab, risankizumab, and tildrakizumab; and even more anti-IL17 therapies, including brodalumab and bimekizumab .
“Now we have the synergy of having novel therapeutic approaches to maybe address some of the different domains of disease,” he said. Despite efforts to develop better biomarkers, it’s hard to predict how an individual patient will respond to a specific therapy. The longer the menu of therapeutic options, the better it is for patients.
As methotrexate remains a go-to treatment for many patients, new data from the SEAM trial assessing etanercept and methotrexate will address the question of whether the conventional drug and tumor necrosis factor inhibitors create therapeutic synergy in patients with psoriatic arthritis.
Dr. Kavanaugh discussed the implications of the trial’s findings, which are expected to go public this summer.
SANDESTIN, FLA. – An array of potential new options for psoriatic arthritis offers new targeted options and poses challenges for how to use the drugs, Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, said in a video interview at the annual Congress of Clinical Rheumatology.
“We’re seeing a second wave – a second wave driven by the additional ways that we have to target aspects of the immune system relevant to psoriatic arthritis,” he said.
First used to treat rheumatoid arthritis, monoclonal antibodies to interleukin targets, including IL12 and IL23 (ustekinumab) and IL17 (secukinumab and ixekizumab), have become established psoriatic arthritis therapies. Additionally, the Janus kinase (JAK) inhibitor tofacitinib has become an option.
Other options in the pipeline include the JAK inhibitor baricitinib; the anti-IL23 monoclonal antibodies guselkumab, risankizumab, and tildrakizumab; and even more anti-IL17 therapies, including brodalumab and bimekizumab .
“Now we have the synergy of having novel therapeutic approaches to maybe address some of the different domains of disease,” he said. Despite efforts to develop better biomarkers, it’s hard to predict how an individual patient will respond to a specific therapy. The longer the menu of therapeutic options, the better it is for patients.
As methotrexate remains a go-to treatment for many patients, new data from the SEAM trial assessing etanercept and methotrexate will address the question of whether the conventional drug and tumor necrosis factor inhibitors create therapeutic synergy in patients with psoriatic arthritis.
Dr. Kavanaugh discussed the implications of the trial’s findings, which are expected to go public this summer.
SANDESTIN, FLA. – An array of potential new options for psoriatic arthritis offers new targeted options and poses challenges for how to use the drugs, Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, said in a video interview at the annual Congress of Clinical Rheumatology.
“We’re seeing a second wave – a second wave driven by the additional ways that we have to target aspects of the immune system relevant to psoriatic arthritis,” he said.
First used to treat rheumatoid arthritis, monoclonal antibodies to interleukin targets, including IL12 and IL23 (ustekinumab) and IL17 (secukinumab and ixekizumab), have become established psoriatic arthritis therapies. Additionally, the Janus kinase (JAK) inhibitor tofacitinib has become an option.
Other options in the pipeline include the JAK inhibitor baricitinib; the anti-IL23 monoclonal antibodies guselkumab, risankizumab, and tildrakizumab; and even more anti-IL17 therapies, including brodalumab and bimekizumab .
“Now we have the synergy of having novel therapeutic approaches to maybe address some of the different domains of disease,” he said. Despite efforts to develop better biomarkers, it’s hard to predict how an individual patient will respond to a specific therapy. The longer the menu of therapeutic options, the better it is for patients.
As methotrexate remains a go-to treatment for many patients, new data from the SEAM trial assessing etanercept and methotrexate will address the question of whether the conventional drug and tumor necrosis factor inhibitors create therapeutic synergy in patients with psoriatic arthritis.
Dr. Kavanaugh discussed the implications of the trial’s findings, which are expected to go public this summer.
REPORTING FROM CCR
VIDEO: Pills alone not the answer for pain management
SANDESTIN, FLA. – More than ever, clinicians need to rely on a multimodal approach to pain management, Katherine Galluzzi, DO, said at the annual Congress of Clinical Rheumatology.
In the era of opioid addiction – in which she said physicians have sometimes been unfairly vilified – pharmaceutical options are limited not only by the threat of abuse but also by governmental regulation, explained Dr. Galluzzi, chair of geriatrics at the Philadelphia College of Osteopathic Medicine.
The underpinning of pain management in the future will need to be cognitive-behavioral therapy, such as changing behavior and meditation; physical approaches, such as exercise and acupuncture; and interventional treatments, such as nerve blocks and trigger-point injections. Pharmacotherapy can’t do it all, nor should it, she said.
“This is what we have, this is what we need to do,” Dr. Galluzzi said. “This impacts the quality of life, and patients need to begin providing self-care. It’s not going to come in the form of a pill. It has to be a commitment between the patient and the physician.”
The Centers for Medicare & Medicaid Services are proposing a new limit on opioid prescriptions for Medicare recipients – a maximum of 90 morphine mg equivalents per day for no more than 7 days. That will affect older people, who are most likely to be in need of pain management, she said. Those on hospice care and experiencing certain cancer pain will be exempt, she noted in an interview.
Concerns about addiction to drugs such as gabapentin and benzodiazepines might make these therapies less of an option in coming years, Dr. Galluzzi added.
Risk evaluation and mitigation strategy training is an important tool for helping physicians weigh the benefits and the risks of opioid prescriptions. Dr. Galluzzi particularly suggests enrolling in a 3-4 hour, in-person program, saying that it’s well worth the time.
“If you haven’t done a risk assessment and mitigation strategies course and you’re an opioid prescriber,” she said, “I highly recommend that you do that.”
SANDESTIN, FLA. – More than ever, clinicians need to rely on a multimodal approach to pain management, Katherine Galluzzi, DO, said at the annual Congress of Clinical Rheumatology.
In the era of opioid addiction – in which she said physicians have sometimes been unfairly vilified – pharmaceutical options are limited not only by the threat of abuse but also by governmental regulation, explained Dr. Galluzzi, chair of geriatrics at the Philadelphia College of Osteopathic Medicine.
The underpinning of pain management in the future will need to be cognitive-behavioral therapy, such as changing behavior and meditation; physical approaches, such as exercise and acupuncture; and interventional treatments, such as nerve blocks and trigger-point injections. Pharmacotherapy can’t do it all, nor should it, she said.
“This is what we have, this is what we need to do,” Dr. Galluzzi said. “This impacts the quality of life, and patients need to begin providing self-care. It’s not going to come in the form of a pill. It has to be a commitment between the patient and the physician.”
The Centers for Medicare & Medicaid Services are proposing a new limit on opioid prescriptions for Medicare recipients – a maximum of 90 morphine mg equivalents per day for no more than 7 days. That will affect older people, who are most likely to be in need of pain management, she said. Those on hospice care and experiencing certain cancer pain will be exempt, she noted in an interview.
Concerns about addiction to drugs such as gabapentin and benzodiazepines might make these therapies less of an option in coming years, Dr. Galluzzi added.
Risk evaluation and mitigation strategy training is an important tool for helping physicians weigh the benefits and the risks of opioid prescriptions. Dr. Galluzzi particularly suggests enrolling in a 3-4 hour, in-person program, saying that it’s well worth the time.
“If you haven’t done a risk assessment and mitigation strategies course and you’re an opioid prescriber,” she said, “I highly recommend that you do that.”
SANDESTIN, FLA. – More than ever, clinicians need to rely on a multimodal approach to pain management, Katherine Galluzzi, DO, said at the annual Congress of Clinical Rheumatology.
In the era of opioid addiction – in which she said physicians have sometimes been unfairly vilified – pharmaceutical options are limited not only by the threat of abuse but also by governmental regulation, explained Dr. Galluzzi, chair of geriatrics at the Philadelphia College of Osteopathic Medicine.
The underpinning of pain management in the future will need to be cognitive-behavioral therapy, such as changing behavior and meditation; physical approaches, such as exercise and acupuncture; and interventional treatments, such as nerve blocks and trigger-point injections. Pharmacotherapy can’t do it all, nor should it, she said.
“This is what we have, this is what we need to do,” Dr. Galluzzi said. “This impacts the quality of life, and patients need to begin providing self-care. It’s not going to come in the form of a pill. It has to be a commitment between the patient and the physician.”
The Centers for Medicare & Medicaid Services are proposing a new limit on opioid prescriptions for Medicare recipients – a maximum of 90 morphine mg equivalents per day for no more than 7 days. That will affect older people, who are most likely to be in need of pain management, she said. Those on hospice care and experiencing certain cancer pain will be exempt, she noted in an interview.
Concerns about addiction to drugs such as gabapentin and benzodiazepines might make these therapies less of an option in coming years, Dr. Galluzzi added.
Risk evaluation and mitigation strategy training is an important tool for helping physicians weigh the benefits and the risks of opioid prescriptions. Dr. Galluzzi particularly suggests enrolling in a 3-4 hour, in-person program, saying that it’s well worth the time.
“If you haven’t done a risk assessment and mitigation strategies course and you’re an opioid prescriber,” she said, “I highly recommend that you do that.”
EXPERT ANALYSIS FROM CCR 18
VIDEO: Skin exam crucial in rheumatic diseases, expert says
SANDESTIN, FLA. – Even when you know a patient’s serology and hear their symptoms and think you have a bead on their rheumatic disease, you might not. It’s vital to check the skin in patients with rheumatic disease to be sure the right disease is being treated and that they don’t actually have a more severe condition that might progress suddenly if left unchecked, said Alisa Femia, MD, assistant professor of dermatology at the annual Congress of Clinical Rheumatology.
In a session filled with pearls for rheumatologists on what to look for on their patients’ skin to help guide diagnosis and treatment, she told the story of a woman whom a rheumatologist colleague had correctly diagnosed with dermatomyositis. She was started on prednisone and mycophenolate mofetil, but her skin disease did not clear.
After examining her skin, Dr. Femia became immediately concerned.
“Despite prednisone, despite mycophenolate, here not only does she have Gottron’s papules, but she has erosions within her Gottron’s papules,” Dr. Femia said. The woman also had erosions within papules on her palms.
These were telltale signs of MDA5-associated dermatomyositis, which studies have found to be linked with interstitial lung disease (J Am Acad Dermatol. 2011 Jul;65[1]:25-34). Under her care, these patients ideally undergo lung monitoring every 3 months, Dr. Femia said.
“That is a form of dermatomyositis that you cannot miss,” she said.
The effects of discoid lupus are another reason to take special care in skin examination. Once the disease, which involves a scaling of the skin, is obvious, there can be permanent aesthetic effects that could have been avoided with earlier detection and treatment, Dr. Femia said.
Clinicians should also be on the lookout for volume loss, or contour change, in discoid lupus patients, because that’s a sign of lupus panniculitis, which involves deeper lesions mainly to fatty areas such as the cheeks or thighs. The disease can progress fast, with sudden, massive loss of body volume, so therapy should be escalated quickly, she said.
“We want to treat these patients aggressively in order to avoid this.”
SOURCE: Femia A. CCR 2018.
SANDESTIN, FLA. – Even when you know a patient’s serology and hear their symptoms and think you have a bead on their rheumatic disease, you might not. It’s vital to check the skin in patients with rheumatic disease to be sure the right disease is being treated and that they don’t actually have a more severe condition that might progress suddenly if left unchecked, said Alisa Femia, MD, assistant professor of dermatology at the annual Congress of Clinical Rheumatology.
In a session filled with pearls for rheumatologists on what to look for on their patients’ skin to help guide diagnosis and treatment, she told the story of a woman whom a rheumatologist colleague had correctly diagnosed with dermatomyositis. She was started on prednisone and mycophenolate mofetil, but her skin disease did not clear.
After examining her skin, Dr. Femia became immediately concerned.
“Despite prednisone, despite mycophenolate, here not only does she have Gottron’s papules, but she has erosions within her Gottron’s papules,” Dr. Femia said. The woman also had erosions within papules on her palms.
These were telltale signs of MDA5-associated dermatomyositis, which studies have found to be linked with interstitial lung disease (J Am Acad Dermatol. 2011 Jul;65[1]:25-34). Under her care, these patients ideally undergo lung monitoring every 3 months, Dr. Femia said.
“That is a form of dermatomyositis that you cannot miss,” she said.
The effects of discoid lupus are another reason to take special care in skin examination. Once the disease, which involves a scaling of the skin, is obvious, there can be permanent aesthetic effects that could have been avoided with earlier detection and treatment, Dr. Femia said.
Clinicians should also be on the lookout for volume loss, or contour change, in discoid lupus patients, because that’s a sign of lupus panniculitis, which involves deeper lesions mainly to fatty areas such as the cheeks or thighs. The disease can progress fast, with sudden, massive loss of body volume, so therapy should be escalated quickly, she said.
“We want to treat these patients aggressively in order to avoid this.”
SOURCE: Femia A. CCR 2018.
SANDESTIN, FLA. – Even when you know a patient’s serology and hear their symptoms and think you have a bead on their rheumatic disease, you might not. It’s vital to check the skin in patients with rheumatic disease to be sure the right disease is being treated and that they don’t actually have a more severe condition that might progress suddenly if left unchecked, said Alisa Femia, MD, assistant professor of dermatology at the annual Congress of Clinical Rheumatology.
In a session filled with pearls for rheumatologists on what to look for on their patients’ skin to help guide diagnosis and treatment, she told the story of a woman whom a rheumatologist colleague had correctly diagnosed with dermatomyositis. She was started on prednisone and mycophenolate mofetil, but her skin disease did not clear.
After examining her skin, Dr. Femia became immediately concerned.
“Despite prednisone, despite mycophenolate, here not only does she have Gottron’s papules, but she has erosions within her Gottron’s papules,” Dr. Femia said. The woman also had erosions within papules on her palms.
These were telltale signs of MDA5-associated dermatomyositis, which studies have found to be linked with interstitial lung disease (J Am Acad Dermatol. 2011 Jul;65[1]:25-34). Under her care, these patients ideally undergo lung monitoring every 3 months, Dr. Femia said.
“That is a form of dermatomyositis that you cannot miss,” she said.
The effects of discoid lupus are another reason to take special care in skin examination. Once the disease, which involves a scaling of the skin, is obvious, there can be permanent aesthetic effects that could have been avoided with earlier detection and treatment, Dr. Femia said.
Clinicians should also be on the lookout for volume loss, or contour change, in discoid lupus patients, because that’s a sign of lupus panniculitis, which involves deeper lesions mainly to fatty areas such as the cheeks or thighs. The disease can progress fast, with sudden, massive loss of body volume, so therapy should be escalated quickly, she said.
“We want to treat these patients aggressively in order to avoid this.”
SOURCE: Femia A. CCR 2018.
EXPERT ANALYSIS AT CCR 18
VIDEO: Researchers seek end to early corticosteroid use in AAV
SANDESTIN, FLA. – Clinicians have long wanted to avoid using corticosteroids in the treatment of ANCA-associated vasculitis (AAV). They’re drawing closer to getting their wish, said Christian Pagnoux, MD, of the department of internal medicine at Mount Sinai Hospital in Toronto.
The drugs have been a cornerstone in the treatments of these diseases – including granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) – for decades, but they come at the price of osteoporosis, cardiovascular comorbidities, diabetes, increased infection risk, and other problems.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
The emergence of newer therapies such as rituximab and complement C5a-blocker avacopan could mean less of a reliance on corticosteroids, Dr. Pagnoux said. The ongoing ADVOCATE trial is assessing the efficacy of avacopan with rituximab or cyclophosphamide, with or without a tapered dose of prednisone for the first 21 weeks.
“Whether we can use a lighter, briefer, shorter corticosteroid regimen for induction is really a burning question,” Dr. Pagnoux said. Avacopan “may totally replace corticosteroids in the very near future,” he said.
Another trial taking an intense look at winnowing corticosteroids from GPA and MPA treatment is the eagerly awaited PEXIVAS trial, an international effort of 700 patients that is the largest ever in AAV, Dr. Pagnoux said.
The primary endpoint in the trial is assessing plasma exchange versus no plasma exchange, but the use of corticosteroids is being assessed as well.
“The PEXIVAS [trial] may give you some additional information,” Dr. Pagnoux said. “Patients were not only randomized to receive plasma exchange or no plasma exchange, but they were also randomized to receive the standard regimen of corticosteroids with a slow taper ... or a much faster regimen with a much faster tapering of the corticosteroids.” The fast taper involves a steep drop every week, so that, after just 1 month, doses have fallen from 60 mg to 10 mg.
Dr. Pagnoux said he can imagine the day when corticosteroids can be completely eliminated from induction treatment for GPA and MPA. But he added there are studies looking at the efficacy and safety of the drugs in maintenance treatment even once they’re eliminated from induction, but at far lower doses.
“The good news is that it would only be 5 mg per day, for example.”
SOURCE: Pagnoux C. CCR 2018.
SANDESTIN, FLA. – Clinicians have long wanted to avoid using corticosteroids in the treatment of ANCA-associated vasculitis (AAV). They’re drawing closer to getting their wish, said Christian Pagnoux, MD, of the department of internal medicine at Mount Sinai Hospital in Toronto.
The drugs have been a cornerstone in the treatments of these diseases – including granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) – for decades, but they come at the price of osteoporosis, cardiovascular comorbidities, diabetes, increased infection risk, and other problems.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
The emergence of newer therapies such as rituximab and complement C5a-blocker avacopan could mean less of a reliance on corticosteroids, Dr. Pagnoux said. The ongoing ADVOCATE trial is assessing the efficacy of avacopan with rituximab or cyclophosphamide, with or without a tapered dose of prednisone for the first 21 weeks.
“Whether we can use a lighter, briefer, shorter corticosteroid regimen for induction is really a burning question,” Dr. Pagnoux said. Avacopan “may totally replace corticosteroids in the very near future,” he said.
Another trial taking an intense look at winnowing corticosteroids from GPA and MPA treatment is the eagerly awaited PEXIVAS trial, an international effort of 700 patients that is the largest ever in AAV, Dr. Pagnoux said.
The primary endpoint in the trial is assessing plasma exchange versus no plasma exchange, but the use of corticosteroids is being assessed as well.
“The PEXIVAS [trial] may give you some additional information,” Dr. Pagnoux said. “Patients were not only randomized to receive plasma exchange or no plasma exchange, but they were also randomized to receive the standard regimen of corticosteroids with a slow taper ... or a much faster regimen with a much faster tapering of the corticosteroids.” The fast taper involves a steep drop every week, so that, after just 1 month, doses have fallen from 60 mg to 10 mg.
Dr. Pagnoux said he can imagine the day when corticosteroids can be completely eliminated from induction treatment for GPA and MPA. But he added there are studies looking at the efficacy and safety of the drugs in maintenance treatment even once they’re eliminated from induction, but at far lower doses.
“The good news is that it would only be 5 mg per day, for example.”
SOURCE: Pagnoux C. CCR 2018.
SANDESTIN, FLA. – Clinicians have long wanted to avoid using corticosteroids in the treatment of ANCA-associated vasculitis (AAV). They’re drawing closer to getting their wish, said Christian Pagnoux, MD, of the department of internal medicine at Mount Sinai Hospital in Toronto.
The drugs have been a cornerstone in the treatments of these diseases – including granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) – for decades, but they come at the price of osteoporosis, cardiovascular comorbidities, diabetes, increased infection risk, and other problems.
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The emergence of newer therapies such as rituximab and complement C5a-blocker avacopan could mean less of a reliance on corticosteroids, Dr. Pagnoux said. The ongoing ADVOCATE trial is assessing the efficacy of avacopan with rituximab or cyclophosphamide, with or without a tapered dose of prednisone for the first 21 weeks.
“Whether we can use a lighter, briefer, shorter corticosteroid regimen for induction is really a burning question,” Dr. Pagnoux said. Avacopan “may totally replace corticosteroids in the very near future,” he said.
Another trial taking an intense look at winnowing corticosteroids from GPA and MPA treatment is the eagerly awaited PEXIVAS trial, an international effort of 700 patients that is the largest ever in AAV, Dr. Pagnoux said.
The primary endpoint in the trial is assessing plasma exchange versus no plasma exchange, but the use of corticosteroids is being assessed as well.
“The PEXIVAS [trial] may give you some additional information,” Dr. Pagnoux said. “Patients were not only randomized to receive plasma exchange or no plasma exchange, but they were also randomized to receive the standard regimen of corticosteroids with a slow taper ... or a much faster regimen with a much faster tapering of the corticosteroids.” The fast taper involves a steep drop every week, so that, after just 1 month, doses have fallen from 60 mg to 10 mg.
Dr. Pagnoux said he can imagine the day when corticosteroids can be completely eliminated from induction treatment for GPA and MPA. But he added there are studies looking at the efficacy and safety of the drugs in maintenance treatment even once they’re eliminated from induction, but at far lower doses.
“The good news is that it would only be 5 mg per day, for example.”
SOURCE: Pagnoux C. CCR 2018.
EXPERT ANALYSIS AT CCR 18