Federal Practitioner

A professional is someone who can do his best work when he doesn’t feel like it. 
Alistair Cooke

When I was a young person with no idea about growing up to be something, my father used to tell me there were 4 learned professions: medicine to heal the body, law to protect the body politic, teaching to nurture the mind, and the clergy to care for the soul.¹ That adage, or some version of it, is attributed to a variety of sources, likely because it captures something essential and timeless about the learned professions. I write this as a much older person, and it has been my privilege to have worked in some capacity in all 4 of these venerable vocations.

There are many more recognized professions now than in my father’s time with new ones still emerging as the world becomes more complicated and specialized. In November 2025, however, the growth of the professions was dealt a serious blow when the US Department of Education (DOE) redefined what constitutes a profession for the purpose of federal funding of graduate degrees.² The internet is understandably abuzz with opinions across the political spectrum. What is missing from many of these discussions is an understanding of the criteria for a profession and, even more importantly, who has the authority to decide when an individual or a group has met that standard.

But first, what and why did the DOE make this change? The One Big Beautiful Bill Act charged the DOE with reducing what it claims is massive overspending on graduate education by limiting the programs that meet the definition of a “professional degree” eligible for higher funding. Of my father’s 4, medicine (including dentistry) and law made the cut with students in those professions able to borrow up to $200,000 in direct unsubsidized student loans while those in other programs would be limited to $100,000.²

As one of the oldest and most respected professions in America, nursing has received the most media attention, yet there are also other important and valued professions that are missing from the DOE list.³ The excluded professions also include: physician assistants, physical therapists, audiologists, architects, accountants, educators, and social workers. The proposed regulatory changes are not yet finalized and Congressional representatives, health care experts, and a myriad of professional associations have rightly objected the reclassification will only worsen the critical shortage of nurses, teachers, and other helping professions the country is already facing.⁴

There are thousands of federal health care professionals who worked long and hard to achieve their goals whom this Act undervalues. Moreover, the regulatory change leaves many students enrolled in education and training programs under federal practice auspices confused and overwhelmed. Perhaps they can take some hope and inspiration from the recognition that historically and philosophically, no agency or administration can unilaterally define what is a profession.

The literature on professionalism is voluminous, in large part because it has been surprisingly difficult to reach a consensus definition. A proposed definition from scholars captures most of the key aspects of a profession. While it is drawn from the medical literature, it applies to most of the caring professions the DOE disqualified. For pedagogic purposes, the definition is parsed into discrete criteria in the Table.⁵

Even this simple summary makes it obvious that a government agency alone could not possibly have the competence to determine who meets these complex technical and moral criteria. The members of the profession must assume a primary role in that determination. The complicated history of the professions shows that the locus of these decisions has resided in various combinations of educational institutions, such as nursing schools,⁶ professional societies (eg, National Association of Social Workers),⁷ and certifying boards (eg, National Commission on Certification of Physician Assistants).⁸ States, not the federal government, have long played a key part in defining professions in the US, through their authority to grant licenses to practice.⁹

In response to criticism, the DOE has stated that “the definition of a ‘professional degree’ is an internal definition used by the Department of Education to distinguish among programs that qualify for higher loan limits, not a value judgment about the importance of programs. It has no bearing on whether a program is professional in nature or not.”² Given the ancient compact between society and the professions in which the government subsidizes the training of professionals dedicated to public service, it is hard to see how these changes can be dismissed as merely semantic and not a promissory breach.¹⁰

I recognize that this abstract editorial is little comfort to beleaguered and demoralized professionals and students. Still, it offers a voice of support for each federal practitioner or trainee who fulfills the epigraph’s description of a professional day after day. The nurse who works the extra shift without complaint or resentment so that veterans receive the care they deserve, the social worker who responds on a weekend night to an active duty family without food so they do not spend another night hungry, and the physician assistant who makes it into the isolated public health clinic despite the terrible weather so there is someone ready to take care for patients in need. The proposed policy shift cannot in any meaningful sense rob them of their identity as individuals committed to a code of caring. However, without an intact social compact, it may well remove their practical ability to remain and enter the helping professions to the detriment of us all.

A professional is someone who can do his best work when he doesn’t feel like it. 
Alistair Cooke

When I was a young person with no idea about growing up to be something, my father used to tell me there were 4 learned professions: medicine to heal the body, law to protect the body politic, teaching to nurture the mind, and the clergy to care for the soul.¹ That adage, or some version of it, is attributed to a variety of sources, likely because it captures something essential and timeless about the learned professions. I write this as a much older person, and it has been my privilege to have worked in some capacity in all 4 of these venerable vocations.

There are many more recognized professions now than in my father’s time with new ones still emerging as the world becomes more complicated and specialized. In November 2025, however, the growth of the professions was dealt a serious blow when the US Department of Education (DOE) redefined what constitutes a profession for the purpose of federal funding of graduate degrees.² The internet is understandably abuzz with opinions across the political spectrum. What is missing from many of these discussions is an understanding of the criteria for a profession and, even more importantly, who has the authority to decide when an individual or a group has met that standard.

But first, what and why did the DOE make this change? The One Big Beautiful Bill Act charged the DOE with reducing what it claims is massive overspending on graduate education by limiting the programs that meet the definition of a “professional degree” eligible for higher funding. Of my father’s 4, medicine (including dentistry) and law made the cut with students in those professions able to borrow up to $200,000 in direct unsubsidized student loans while those in other programs would be limited to $100,000.²

As one of the oldest and most respected professions in America, nursing has received the most media attention, yet there are also other important and valued professions that are missing from the DOE list.³ The excluded professions also include: physician assistants, physical therapists, audiologists, architects, accountants, educators, and social workers. The proposed regulatory changes are not yet finalized and Congressional representatives, health care experts, and a myriad of professional associations have rightly objected the reclassification will only worsen the critical shortage of nurses, teachers, and other helping professions the country is already facing.⁴

There are thousands of federal health care professionals who worked long and hard to achieve their goals whom this Act undervalues. Moreover, the regulatory change leaves many students enrolled in education and training programs under federal practice auspices confused and overwhelmed. Perhaps they can take some hope and inspiration from the recognition that historically and philosophically, no agency or administration can unilaterally define what is a profession.

The literature on professionalism is voluminous, in large part because it has been surprisingly difficult to reach a consensus definition. A proposed definition from scholars captures most of the key aspects of a profession. While it is drawn from the medical literature, it applies to most of the caring professions the DOE disqualified. For pedagogic purposes, the definition is parsed into discrete criteria in the Table.⁵

Even this simple summary makes it obvious that a government agency alone could not possibly have the competence to determine who meets these complex technical and moral criteria. The members of the profession must assume a primary role in that determination. The complicated history of the professions shows that the locus of these decisions has resided in various combinations of educational institutions, such as nursing schools,⁶ professional societies (eg, National Association of Social Workers),⁷ and certifying boards (eg, National Commission on Certification of Physician Assistants).⁸ States, not the federal government, have long played a key part in defining professions in the US, through their authority to grant licenses to practice.⁹

In response to criticism, the DOE has stated that “the definition of a ‘professional degree’ is an internal definition used by the Department of Education to distinguish among programs that qualify for higher loan limits, not a value judgment about the importance of programs. It has no bearing on whether a program is professional in nature or not.”² Given the ancient compact between society and the professions in which the government subsidizes the training of professionals dedicated to public service, it is hard to see how these changes can be dismissed as merely semantic and not a promissory breach.¹⁰

I recognize that this abstract editorial is little comfort to beleaguered and demoralized professionals and students. Still, it offers a voice of support for each federal practitioner or trainee who fulfills the epigraph’s description of a professional day after day. The nurse who works the extra shift without complaint or resentment so that veterans receive the care they deserve, the social worker who responds on a weekend night to an active duty family without food so they do not spend another night hungry, and the physician assistant who makes it into the isolated public health clinic despite the terrible weather so there is someone ready to take care for patients in need. The proposed policy shift cannot in any meaningful sense rob them of their identity as individuals committed to a code of caring. However, without an intact social compact, it may well remove their practical ability to remain and enter the helping professions to the detriment of us all.

A professional is someone who can do his best work when he doesn’t feel like it. 
Alistair Cooke

When I was a young person with no idea about growing up to be something, my father used to tell me there were 4 learned professions: medicine to heal the body, law to protect the body politic, teaching to nurture the mind, and the clergy to care for the soul.¹ That adage, or some version of it, is attributed to a variety of sources, likely because it captures something essential and timeless about the learned professions. I write this as a much older person, and it has been my privilege to have worked in some capacity in all 4 of these venerable vocations.

There are many more recognized professions now than in my father’s time with new ones still emerging as the world becomes more complicated and specialized. In November 2025, however, the growth of the professions was dealt a serious blow when the US Department of Education (DOE) redefined what constitutes a profession for the purpose of federal funding of graduate degrees.² The internet is understandably abuzz with opinions across the political spectrum. What is missing from many of these discussions is an understanding of the criteria for a profession and, even more importantly, who has the authority to decide when an individual or a group has met that standard.

But first, what and why did the DOE make this change? The One Big Beautiful Bill Act charged the DOE with reducing what it claims is massive overspending on graduate education by limiting the programs that meet the definition of a “professional degree” eligible for higher funding. Of my father’s 4, medicine (including dentistry) and law made the cut with students in those professions able to borrow up to $200,000 in direct unsubsidized student loans while those in other programs would be limited to $100,000.²

As one of the oldest and most respected professions in America, nursing has received the most media attention, yet there are also other important and valued professions that are missing from the DOE list.³ The excluded professions also include: physician assistants, physical therapists, audiologists, architects, accountants, educators, and social workers. The proposed regulatory changes are not yet finalized and Congressional representatives, health care experts, and a myriad of professional associations have rightly objected the reclassification will only worsen the critical shortage of nurses, teachers, and other helping professions the country is already facing.⁴

There are thousands of federal health care professionals who worked long and hard to achieve their goals whom this Act undervalues. Moreover, the regulatory change leaves many students enrolled in education and training programs under federal practice auspices confused and overwhelmed. Perhaps they can take some hope and inspiration from the recognition that historically and philosophically, no agency or administration can unilaterally define what is a profession.

The literature on professionalism is voluminous, in large part because it has been surprisingly difficult to reach a consensus definition. A proposed definition from scholars captures most of the key aspects of a profession. While it is drawn from the medical literature, it applies to most of the caring professions the DOE disqualified. For pedagogic purposes, the definition is parsed into discrete criteria in the Table.⁵

Even this simple summary makes it obvious that a government agency alone could not possibly have the competence to determine who meets these complex technical and moral criteria. The members of the profession must assume a primary role in that determination. The complicated history of the professions shows that the locus of these decisions has resided in various combinations of educational institutions, such as nursing schools,⁶ professional societies (eg, National Association of Social Workers),⁷ and certifying boards (eg, National Commission on Certification of Physician Assistants).⁸ States, not the federal government, have long played a key part in defining professions in the US, through their authority to grant licenses to practice.⁹

In response to criticism, the DOE has stated that “the definition of a ‘professional degree’ is an internal definition used by the Department of Education to distinguish among programs that qualify for higher loan limits, not a value judgment about the importance of programs. It has no bearing on whether a program is professional in nature or not.”² Given the ancient compact between society and the professions in which the government subsidizes the training of professionals dedicated to public service, it is hard to see how these changes can be dismissed as merely semantic and not a promissory breach.¹⁰

I recognize that this abstract editorial is little comfort to beleaguered and demoralized professionals and students. Still, it offers a voice of support for each federal practitioner or trainee who fulfills the epigraph’s description of a professional day after day. The nurse who works the extra shift without complaint or resentment so that veterans receive the care they deserve, the social worker who responds on a weekend night to an active duty family without food so they do not spend another night hungry, and the physician assistant who makes it into the isolated public health clinic despite the terrible weather so there is someone ready to take care for patients in need. The proposed policy shift cannot in any meaningful sense rob them of their identity as individuals committed to a code of caring. However, without an intact social compact, it may well remove their practical ability to remain and enter the helping professions to the detriment of us all.

TOPLINE:

Among patients with ulcerative colitis (UC) who develop colorectal cancer (CRC), greater background mucosal inflammation at the time of CRC diagnosis is associated with progressively worse survival outcomes, with tumors arising within the UC-involved segment having worse prognosis.

METHODOLOGY:

• Patients with UC are at an increased risk for CRC, with risk influenced by the extent and intensity of underlying mucosal inflammation.
• Researchers retrospectively reviewed medical records of patients with UC diagnosed with CRC between 1983 and 2020 at 43 institutions across Japan to determine whether inflammation at cancer diagnosis affected prognosis.
• After endoscopic assessment, tumors were classified as arising inside the UC‑involved segment at diagnosis (within‑area tumors) or outside that segment (outside‑area tumors).
• The Mayo endoscopic score (MES) was used to grade background mucosal inflammation in the within‑area group as inactive (MES 0), mild-moderate (MES 1-2), or severe (MES 3).
• The primary endpoint was 5-year recurrence-free survival, and the secondary endpoint was 5-year cancer-specific survival.

TAKEAWAY:

• Among 723 patients followed for a median of 51 months, 683 had within-area tumors (mean age at CRC diagnosis, 51.8 years; 61.9% male) and 40 had outside-area tumors (mean age at CRC diagnosis, 61.1 years; 60.0% male).
• The within-area group had lower rate of 5-year recurrence-free survival than the outside-area group (75.1% vs 87.6%; P = .022), and lower rate of 5-year cancer-specific survival (81.1% vs 94.3%; P = .038).
• Within-area tumor location independently predicted worse recurrence-free survival (adjusted hazard ratio, 2.99; P = .030).
• In the within‑area group, higher MES was associated with stepwise (although nonsignificant) declines in recurrence‑free survival (inactive, 84.4%; mild-moderate, 79.4%; severe, 73.8%; P = .150). Corresponding cancer‑specific survival rates in these groups declined significantly (89.0%, 84.8%, and 73.8%, respectively; P = .048).

IN PRACTICE:

“These findings shift the clinical focus from inflammation as a risk factor for carcinogenesis to inflammation as a prognostic determinant, highlighting a potential new role for systematic endoscopic assessment of the background mucosa at cancer diagnosis,” the authors wrote.

SOURCE:

This study was led by Akiyoshi Ikebata, Department of Surgery, Keio University School of Medicine, Tokyo, Japan. It was published online in December 2025, in the Journal of Crohn's and Colitis.

LIMITATIONS:

The retrospective design introduced potential for unmeasured confounding and selection bias. The MES was assigned by local physicians without central review, which may have introduced variability. The small size of the outside‑area tumor group increased the risk for baseline imbalances.

DISCLOSURES:

No specific funding source was reported. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Among patients with ulcerative colitis (UC) who develop colorectal cancer (CRC), greater background mucosal inflammation at the time of CRC diagnosis is associated with progressively worse survival outcomes, with tumors arising within the UC-involved segment having worse prognosis.

METHODOLOGY:

• Patients with UC are at an increased risk for CRC, with risk influenced by the extent and intensity of underlying mucosal inflammation.
• Researchers retrospectively reviewed medical records of patients with UC diagnosed with CRC between 1983 and 2020 at 43 institutions across Japan to determine whether inflammation at cancer diagnosis affected prognosis.
• After endoscopic assessment, tumors were classified as arising inside the UC‑involved segment at diagnosis (within‑area tumors) or outside that segment (outside‑area tumors).
• The Mayo endoscopic score (MES) was used to grade background mucosal inflammation in the within‑area group as inactive (MES 0), mild-moderate (MES 1-2), or severe (MES 3).
• The primary endpoint was 5-year recurrence-free survival, and the secondary endpoint was 5-year cancer-specific survival.

TAKEAWAY:

• Among 723 patients followed for a median of 51 months, 683 had within-area tumors (mean age at CRC diagnosis, 51.8 years; 61.9% male) and 40 had outside-area tumors (mean age at CRC diagnosis, 61.1 years; 60.0% male).
• The within-area group had lower rate of 5-year recurrence-free survival than the outside-area group (75.1% vs 87.6%; P = .022), and lower rate of 5-year cancer-specific survival (81.1% vs 94.3%; P = .038).
• Within-area tumor location independently predicted worse recurrence-free survival (adjusted hazard ratio, 2.99; P = .030).
• In the within‑area group, higher MES was associated with stepwise (although nonsignificant) declines in recurrence‑free survival (inactive, 84.4%; mild-moderate, 79.4%; severe, 73.8%; P = .150). Corresponding cancer‑specific survival rates in these groups declined significantly (89.0%, 84.8%, and 73.8%, respectively; P = .048).

IN PRACTICE:

“These findings shift the clinical focus from inflammation as a risk factor for carcinogenesis to inflammation as a prognostic determinant, highlighting a potential new role for systematic endoscopic assessment of the background mucosa at cancer diagnosis,” the authors wrote.

SOURCE:

This study was led by Akiyoshi Ikebata, Department of Surgery, Keio University School of Medicine, Tokyo, Japan. It was published online in December 2025, in the Journal of Crohn's and Colitis.

LIMITATIONS:

The retrospective design introduced potential for unmeasured confounding and selection bias. The MES was assigned by local physicians without central review, which may have introduced variability. The small size of the outside‑area tumor group increased the risk for baseline imbalances.

DISCLOSURES:

No specific funding source was reported. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Among patients with ulcerative colitis (UC) who develop colorectal cancer (CRC), greater background mucosal inflammation at the time of CRC diagnosis is associated with progressively worse survival outcomes, with tumors arising within the UC-involved segment having worse prognosis.

METHODOLOGY:

• Patients with UC are at an increased risk for CRC, with risk influenced by the extent and intensity of underlying mucosal inflammation.
• Researchers retrospectively reviewed medical records of patients with UC diagnosed with CRC between 1983 and 2020 at 43 institutions across Japan to determine whether inflammation at cancer diagnosis affected prognosis.
• After endoscopic assessment, tumors were classified as arising inside the UC‑involved segment at diagnosis (within‑area tumors) or outside that segment (outside‑area tumors).
• The Mayo endoscopic score (MES) was used to grade background mucosal inflammation in the within‑area group as inactive (MES 0), mild-moderate (MES 1-2), or severe (MES 3).
• The primary endpoint was 5-year recurrence-free survival, and the secondary endpoint was 5-year cancer-specific survival.

TAKEAWAY:

• Among 723 patients followed for a median of 51 months, 683 had within-area tumors (mean age at CRC diagnosis, 51.8 years; 61.9% male) and 40 had outside-area tumors (mean age at CRC diagnosis, 61.1 years; 60.0% male).
• The within-area group had lower rate of 5-year recurrence-free survival than the outside-area group (75.1% vs 87.6%; P = .022), and lower rate of 5-year cancer-specific survival (81.1% vs 94.3%; P = .038).
• Within-area tumor location independently predicted worse recurrence-free survival (adjusted hazard ratio, 2.99; P = .030).
• In the within‑area group, higher MES was associated with stepwise (although nonsignificant) declines in recurrence‑free survival (inactive, 84.4%; mild-moderate, 79.4%; severe, 73.8%; P = .150). Corresponding cancer‑specific survival rates in these groups declined significantly (89.0%, 84.8%, and 73.8%, respectively; P = .048).

IN PRACTICE:

“These findings shift the clinical focus from inflammation as a risk factor for carcinogenesis to inflammation as a prognostic determinant, highlighting a potential new role for systematic endoscopic assessment of the background mucosa at cancer diagnosis,” the authors wrote.

SOURCE:

This study was led by Akiyoshi Ikebata, Department of Surgery, Keio University School of Medicine, Tokyo, Japan. It was published online in December 2025, in the Journal of Crohn's and Colitis.

LIMITATIONS:

The retrospective design introduced potential for unmeasured confounding and selection bias. The MES was assigned by local physicians without central review, which may have introduced variability. The small size of the outside‑area tumor group increased the risk for baseline imbalances.

DISCLOSURES:

No specific funding source was reported. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Among patients with high-risk malignant colorectal polyps, 19% had residual disease, with rates of 25% in the immediate surgery group vs 9% in the nonoperative management group. The rate of rectum and sphincter preservation in the nonoperative surveillance group was over 90%, and all recurrences were successfully treated with salvage surgery or chemoradiotherapy.

METHODOLOGY:

• Although guidelines in the US recommend colorectal resection when a malignant colorectal polyp has high-risk features, some patients choose nonoperative management instead to avoid the associated averse effects and impact on quality of life. The safety of nonoperative management, however, remains unclear.
• A single-center cohort study conducted between 2015 and 2022 included 336 patients who underwent polypectomy in the colon (n = 226) or rectum (n = 110) and had at least one high-risk feature. High-risk features included positive margins, piecemeal resection with unclear margin, lymphovascular invasion, perineural invasion, poor differentiation, and tumor budding.
• The analysis compared rates of residual disease between those who had immediate surgery (62%) and nonoperative management (38%) following the removal of a malignant polyp, 15% of whom (n = 19) received systemic chemotherapy after polypectomy.
• Researchers also assessed the rates of distant metastasis between the two groups and the association between specific high-risk features and residual disease or post-treatment complications.

TAKEAWAY:

• In the overall population, 19% of patients had residual disease (63 of 336). Among the 208 patients who had immediate surgery, 25% (n = 51) had residual disease, including 9% (n = 19) with residual disease in the bowel wall and 19% (n = 39) in locoregional lymph nodes. Postoperative complications occurred in 12% of patients (n = 25) in the immediate surgery group, with 3% (n = 7) having complications considered grade 3 or higher.
• Among the 128 patients who received nonoperative surveillance, 9% (n = 12) developed recurrence during surveillance, 6% (n = 7) in the bowel wall and 4% (n = 5) in locoregional lymph nodes. All recurrences in the nonoperative surveillance group were successfully treated with either salvage surgery (n = 6) or chemoradiotherapy (n = 6).
• Among patients in the nonoperative group with a malignant polyp removed from the rectum, the rate of rectum preservation was 94% (74 of 79 patients); the sphincter preservation rate was 91% for tumors < 5 cm from the anal verge.
• Distant metastases occurred in 2% of all patients across both groups.

IN PRACTICE:

"The risk of residual disease after the removal of a malignant colorectal polyp with [high-risk features] is considerable, but nonoperative management offers the potential for organ preservation, with the availability of effective salvage options if rectal cancer is detected," the authors of the study concluded.

SOURCE:

The study, led by Thikhamporn Tawantanakorn, MD, and Martin R. Weiser, MD, of Memorial Sloan Kettering Cancer Center in New York City, was published online in JCO Oncology Advances.

LIMITATIONS:

The researchers noted several limitations, including variable follow-up among patients and challenges in assessing polypectomy histology, particularly after piecemeal resection, which limited evaluation of certain high-risk features such as tumor budding. Additionally, as the study was conducted at a specialized cancer center with dedicated gastrointestinal pathology and radiology services and readily available office endoscopy, the results may not be fully generalizable to less specialized centers.

DISCLOSURES:

Jinru Shia, MD, reported receiving consulting fees from Paige.AI and research funding through their institution. Andrea Cercek, MD, disclosed consulting roles with multiple pharmaceutical companies, including GlaxoSmithKline, Incyte, Merck, and others, as well as research funding from GlaxoSmithKline and Pfizer. Weiser reported receiving royalties as a section editor for UpToDate. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Among patients with high-risk malignant colorectal polyps, 19% had residual disease, with rates of 25% in the immediate surgery group vs 9% in the nonoperative management group. The rate of rectum and sphincter preservation in the nonoperative surveillance group was over 90%, and all recurrences were successfully treated with salvage surgery or chemoradiotherapy.

METHODOLOGY:

• Although guidelines in the US recommend colorectal resection when a malignant colorectal polyp has high-risk features, some patients choose nonoperative management instead to avoid the associated averse effects and impact on quality of life. The safety of nonoperative management, however, remains unclear.
• A single-center cohort study conducted between 2015 and 2022 included 336 patients who underwent polypectomy in the colon (n = 226) or rectum (n = 110) and had at least one high-risk feature. High-risk features included positive margins, piecemeal resection with unclear margin, lymphovascular invasion, perineural invasion, poor differentiation, and tumor budding.
• The analysis compared rates of residual disease between those who had immediate surgery (62%) and nonoperative management (38%) following the removal of a malignant polyp, 15% of whom (n = 19) received systemic chemotherapy after polypectomy.
• Researchers also assessed the rates of distant metastasis between the two groups and the association between specific high-risk features and residual disease or post-treatment complications.

TAKEAWAY:

• In the overall population, 19% of patients had residual disease (63 of 336). Among the 208 patients who had immediate surgery, 25% (n = 51) had residual disease, including 9% (n = 19) with residual disease in the bowel wall and 19% (n = 39) in locoregional lymph nodes. Postoperative complications occurred in 12% of patients (n = 25) in the immediate surgery group, with 3% (n = 7) having complications considered grade 3 or higher.
• Among the 128 patients who received nonoperative surveillance, 9% (n = 12) developed recurrence during surveillance, 6% (n = 7) in the bowel wall and 4% (n = 5) in locoregional lymph nodes. All recurrences in the nonoperative surveillance group were successfully treated with either salvage surgery (n = 6) or chemoradiotherapy (n = 6).
• Among patients in the nonoperative group with a malignant polyp removed from the rectum, the rate of rectum preservation was 94% (74 of 79 patients); the sphincter preservation rate was 91% for tumors < 5 cm from the anal verge.
• Distant metastases occurred in 2% of all patients across both groups.

IN PRACTICE:

"The risk of residual disease after the removal of a malignant colorectal polyp with [high-risk features] is considerable, but nonoperative management offers the potential for organ preservation, with the availability of effective salvage options if rectal cancer is detected," the authors of the study concluded.

SOURCE:

The study, led by Thikhamporn Tawantanakorn, MD, and Martin R. Weiser, MD, of Memorial Sloan Kettering Cancer Center in New York City, was published online in JCO Oncology Advances.

LIMITATIONS:

The researchers noted several limitations, including variable follow-up among patients and challenges in assessing polypectomy histology, particularly after piecemeal resection, which limited evaluation of certain high-risk features such as tumor budding. Additionally, as the study was conducted at a specialized cancer center with dedicated gastrointestinal pathology and radiology services and readily available office endoscopy, the results may not be fully generalizable to less specialized centers.

DISCLOSURES:

Jinru Shia, MD, reported receiving consulting fees from Paige.AI and research funding through their institution. Andrea Cercek, MD, disclosed consulting roles with multiple pharmaceutical companies, including GlaxoSmithKline, Incyte, Merck, and others, as well as research funding from GlaxoSmithKline and Pfizer. Weiser reported receiving royalties as a section editor for UpToDate. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Among patients with high-risk malignant colorectal polyps, 19% had residual disease, with rates of 25% in the immediate surgery group vs 9% in the nonoperative management group. The rate of rectum and sphincter preservation in the nonoperative surveillance group was over 90%, and all recurrences were successfully treated with salvage surgery or chemoradiotherapy.

METHODOLOGY:

• Although guidelines in the US recommend colorectal resection when a malignant colorectal polyp has high-risk features, some patients choose nonoperative management instead to avoid the associated averse effects and impact on quality of life. The safety of nonoperative management, however, remains unclear.
• A single-center cohort study conducted between 2015 and 2022 included 336 patients who underwent polypectomy in the colon (n = 226) or rectum (n = 110) and had at least one high-risk feature. High-risk features included positive margins, piecemeal resection with unclear margin, lymphovascular invasion, perineural invasion, poor differentiation, and tumor budding.
• The analysis compared rates of residual disease between those who had immediate surgery (62%) and nonoperative management (38%) following the removal of a malignant polyp, 15% of whom (n = 19) received systemic chemotherapy after polypectomy.
• Researchers also assessed the rates of distant metastasis between the two groups and the association between specific high-risk features and residual disease or post-treatment complications.

TAKEAWAY:

• In the overall population, 19% of patients had residual disease (63 of 336). Among the 208 patients who had immediate surgery, 25% (n = 51) had residual disease, including 9% (n = 19) with residual disease in the bowel wall and 19% (n = 39) in locoregional lymph nodes. Postoperative complications occurred in 12% of patients (n = 25) in the immediate surgery group, with 3% (n = 7) having complications considered grade 3 or higher.
• Among the 128 patients who received nonoperative surveillance, 9% (n = 12) developed recurrence during surveillance, 6% (n = 7) in the bowel wall and 4% (n = 5) in locoregional lymph nodes. All recurrences in the nonoperative surveillance group were successfully treated with either salvage surgery (n = 6) or chemoradiotherapy (n = 6).
• Among patients in the nonoperative group with a malignant polyp removed from the rectum, the rate of rectum preservation was 94% (74 of 79 patients); the sphincter preservation rate was 91% for tumors < 5 cm from the anal verge.
• Distant metastases occurred in 2% of all patients across both groups.

IN PRACTICE:

"The risk of residual disease after the removal of a malignant colorectal polyp with [high-risk features] is considerable, but nonoperative management offers the potential for organ preservation, with the availability of effective salvage options if rectal cancer is detected," the authors of the study concluded.

SOURCE:

The study, led by Thikhamporn Tawantanakorn, MD, and Martin R. Weiser, MD, of Memorial Sloan Kettering Cancer Center in New York City, was published online in JCO Oncology Advances.

LIMITATIONS:

The researchers noted several limitations, including variable follow-up among patients and challenges in assessing polypectomy histology, particularly after piecemeal resection, which limited evaluation of certain high-risk features such as tumor budding. Additionally, as the study was conducted at a specialized cancer center with dedicated gastrointestinal pathology and radiology services and readily available office endoscopy, the results may not be fully generalizable to less specialized centers.

DISCLOSURES:

Jinru Shia, MD, reported receiving consulting fees from Paige.AI and research funding through their institution. Andrea Cercek, MD, disclosed consulting roles with multiple pharmaceutical companies, including GlaxoSmithKline, Incyte, Merck, and others, as well as research funding from GlaxoSmithKline and Pfizer. Weiser reported receiving royalties as a section editor for UpToDate. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

The FDA has granted accelerated approval for a subcutaneous (SC) formulation of mosunetuzumab (Lunsumio VELO, Roche) for the treatment of certain adults with relapsed or refractory follicular lymphoma.

Specifically, the CD20 × CD3 bispecific antibody — which was initially approved as an intravenous (IV) formulation and was the first of its kind approved for relapsed or refractory follicular lymphoma after at least 2 prior lines of therapy — is now approved for SC administration in the same setting, according to a Roche press release.

SC delivery reduces treatment time to about 1 minute compared with the 2–4 hours required with IV infusion. Like the IV formulation, the SC version can be administered in the outpatient setting and is a fixed-duration treatment given for a defined period, Roche noted, adding that “[b]y contrast, treat-to-progression treatment options are designed to be given to patients indefinitely until disease progression or until treatment can no longer be tolerated.”

Full approval, which may be contingent on verification of benefit in a confirmatory trial, was based on findings from the phase 1/2 G029781 study of both IV and SC formulations in patients with relapsed or refractory non–Hodgkin lymphoma, including follicular lymphoma.

The objective response rate and complete response rate with SC formulation were 75% and 59%, respectively. The median duration of response was 22.4 months.

Adverse reactions occurring in at least 20% of patients were injection site reactions, fatigue, rash, cytokine release syndrome (CRS), SARS–CoV–2 infection, musculoskeletal pain, and diarrhea. CRS occurred in 30% of patients. Most of those events were low-grade, and all resolved after a median of 2 days.

“This approval is a significant step in broadening access to effective treatments for people living with follicular lymphoma,” stated Ian Flinn, MD, PhD, of Tennessee Oncology and OneOncology. “With its manageable cytokine release syndrome profile and reduced administration time, Lunsumio VELO enables oncologists to deliver advanced care in community practice settings.”

A version of this article first appeared on Medscape.com.

The FDA has granted accelerated approval for a subcutaneous (SC) formulation of mosunetuzumab (Lunsumio VELO, Roche) for the treatment of certain adults with relapsed or refractory follicular lymphoma.

Specifically, the CD20 × CD3 bispecific antibody — which was initially approved as an intravenous (IV) formulation and was the first of its kind approved for relapsed or refractory follicular lymphoma after at least 2 prior lines of therapy — is now approved for SC administration in the same setting, according to a Roche press release.

SC delivery reduces treatment time to about 1 minute compared with the 2–4 hours required with IV infusion. Like the IV formulation, the SC version can be administered in the outpatient setting and is a fixed-duration treatment given for a defined period, Roche noted, adding that “[b]y contrast, treat-to-progression treatment options are designed to be given to patients indefinitely until disease progression or until treatment can no longer be tolerated.”

Full approval, which may be contingent on verification of benefit in a confirmatory trial, was based on findings from the phase 1/2 G029781 study of both IV and SC formulations in patients with relapsed or refractory non–Hodgkin lymphoma, including follicular lymphoma.

The objective response rate and complete response rate with SC formulation were 75% and 59%, respectively. The median duration of response was 22.4 months.

Adverse reactions occurring in at least 20% of patients were injection site reactions, fatigue, rash, cytokine release syndrome (CRS), SARS–CoV–2 infection, musculoskeletal pain, and diarrhea. CRS occurred in 30% of patients. Most of those events were low-grade, and all resolved after a median of 2 days.

“This approval is a significant step in broadening access to effective treatments for people living with follicular lymphoma,” stated Ian Flinn, MD, PhD, of Tennessee Oncology and OneOncology. “With its manageable cytokine release syndrome profile and reduced administration time, Lunsumio VELO enables oncologists to deliver advanced care in community practice settings.”

A version of this article first appeared on Medscape.com.

The FDA has granted accelerated approval for a subcutaneous (SC) formulation of mosunetuzumab (Lunsumio VELO, Roche) for the treatment of certain adults with relapsed or refractory follicular lymphoma.

Specifically, the CD20 × CD3 bispecific antibody — which was initially approved as an intravenous (IV) formulation and was the first of its kind approved for relapsed or refractory follicular lymphoma after at least 2 prior lines of therapy — is now approved for SC administration in the same setting, according to a Roche press release.

SC delivery reduces treatment time to about 1 minute compared with the 2–4 hours required with IV infusion. Like the IV formulation, the SC version can be administered in the outpatient setting and is a fixed-duration treatment given for a defined period, Roche noted, adding that “[b]y contrast, treat-to-progression treatment options are designed to be given to patients indefinitely until disease progression or until treatment can no longer be tolerated.”

Full approval, which may be contingent on verification of benefit in a confirmatory trial, was based on findings from the phase 1/2 G029781 study of both IV and SC formulations in patients with relapsed or refractory non–Hodgkin lymphoma, including follicular lymphoma.

The objective response rate and complete response rate with SC formulation were 75% and 59%, respectively. The median duration of response was 22.4 months.

Adverse reactions occurring in at least 20% of patients were injection site reactions, fatigue, rash, cytokine release syndrome (CRS), SARS–CoV–2 infection, musculoskeletal pain, and diarrhea. CRS occurred in 30% of patients. Most of those events were low-grade, and all resolved after a median of 2 days.

“This approval is a significant step in broadening access to effective treatments for people living with follicular lymphoma,” stated Ian Flinn, MD, PhD, of Tennessee Oncology and OneOncology. “With its manageable cytokine release syndrome profile and reduced administration time, Lunsumio VELO enables oncologists to deliver advanced care in community practice settings.”

A version of this article first appeared on Medscape.com.

TOPLINE:

Rural cancer survivors experience significantly higher rates of chronic pain at 43.0% than those among urban survivors at 33.5%. Even after controlling for demographics and health conditions, rural residents showed 21% higher odds of experiencing chronic pain.

METHODOLOGY:

• Chronic pain prevalence among cancer survivors is twice that of the general US population and is associated with numerous negative outcomes. Rural residence is frequently linked to debilitating long-term survivorship effects, and current data lack information on whether chronic pain disparity exists specifically for rural cancer survivors.
• Researchers pooled data from the 2019–2021 and 2023 National Health Interview Survey, a cross–sectional survey conducted by the National Center for Health Statistics.
• Analysis included 5542 adult cancer survivors diagnosed within the previous 5 years, with 51.6% female participants and 48.4% male participants.
• Chronic pain was defined as pain experienced on most or all days over the past 3 months, following National Center for Health Statistics conventions.
• Rural residence classification was based on noncore or nonmetropolitan counties using the modified National Center for Health Statistics Urban–Rural Classification Scheme for Counties.

TAKEAWAY:

• Rural cancer survivors showed significantly higher odds of experiencing chronic pain compared with urban survivors (odds ratio [OR], 1.21; 95% CI, 1.01-1.45).
• Rural survivors were more likely to be non–Hispanic White, have less than a 4-year college degree, have an income below 200% of the federal poverty level, and have slightly more chronic health conditions.
• Having an income below 100% of the federal poverty level was associated with doubled odds of chronic pain (OR, 2.07; 95% CI, 1.54-2.77) compared with having an income at least four times the federal poverty level.
• Each additional health condition increased the odds of experiencing chronic pain by 32% (OR, 1.32; 95% CI, 1.26-1.39).

IN PRACTICE:

“Policymakers and health systems should work to close this gap by increasing the availability of pain management resources for rural cancer survivors. Approaches could include innovative payment models for integrative medicine in rural areas or supporting rural clinician access to pain specialists,” the authors of the study wrote.

SOURCE:

This study was led by Hyojin Choi, PhD, Department of Family Medicine, The Robert Larner MD College of Medicine, University of Vermont in Burlington, Vermont. It was published online in JAMA Network Open.

LIMITATIONS:

The authors note that the cross–sectional design of the study and limited information on individual respondents’ use of multimodal pain treatment options constrain the interpretation of findings.

DISCLOSURES:

The authors did not report any relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Rural cancer survivors experience significantly higher rates of chronic pain at 43.0% than those among urban survivors at 33.5%. Even after controlling for demographics and health conditions, rural residents showed 21% higher odds of experiencing chronic pain.

METHODOLOGY:

• Chronic pain prevalence among cancer survivors is twice that of the general US population and is associated with numerous negative outcomes. Rural residence is frequently linked to debilitating long-term survivorship effects, and current data lack information on whether chronic pain disparity exists specifically for rural cancer survivors.
• Researchers pooled data from the 2019–2021 and 2023 National Health Interview Survey, a cross–sectional survey conducted by the National Center for Health Statistics.
• Analysis included 5542 adult cancer survivors diagnosed within the previous 5 years, with 51.6% female participants and 48.4% male participants.
• Chronic pain was defined as pain experienced on most or all days over the past 3 months, following National Center for Health Statistics conventions.
• Rural residence classification was based on noncore or nonmetropolitan counties using the modified National Center for Health Statistics Urban–Rural Classification Scheme for Counties.

TAKEAWAY:

• Rural cancer survivors showed significantly higher odds of experiencing chronic pain compared with urban survivors (odds ratio [OR], 1.21; 95% CI, 1.01-1.45).
• Rural survivors were more likely to be non–Hispanic White, have less than a 4-year college degree, have an income below 200% of the federal poverty level, and have slightly more chronic health conditions.
• Having an income below 100% of the federal poverty level was associated with doubled odds of chronic pain (OR, 2.07; 95% CI, 1.54-2.77) compared with having an income at least four times the federal poverty level.
• Each additional health condition increased the odds of experiencing chronic pain by 32% (OR, 1.32; 95% CI, 1.26-1.39).

IN PRACTICE:

“Policymakers and health systems should work to close this gap by increasing the availability of pain management resources for rural cancer survivors. Approaches could include innovative payment models for integrative medicine in rural areas or supporting rural clinician access to pain specialists,” the authors of the study wrote.

SOURCE:

This study was led by Hyojin Choi, PhD, Department of Family Medicine, The Robert Larner MD College of Medicine, University of Vermont in Burlington, Vermont. It was published online in JAMA Network Open.

LIMITATIONS:

The authors note that the cross–sectional design of the study and limited information on individual respondents’ use of multimodal pain treatment options constrain the interpretation of findings.

DISCLOSURES:

The authors did not report any relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Rural cancer survivors experience significantly higher rates of chronic pain at 43.0% than those among urban survivors at 33.5%. Even after controlling for demographics and health conditions, rural residents showed 21% higher odds of experiencing chronic pain.

METHODOLOGY:

• Chronic pain prevalence among cancer survivors is twice that of the general US population and is associated with numerous negative outcomes. Rural residence is frequently linked to debilitating long-term survivorship effects, and current data lack information on whether chronic pain disparity exists specifically for rural cancer survivors.
• Researchers pooled data from the 2019–2021 and 2023 National Health Interview Survey, a cross–sectional survey conducted by the National Center for Health Statistics.
• Analysis included 5542 adult cancer survivors diagnosed within the previous 5 years, with 51.6% female participants and 48.4% male participants.
• Chronic pain was defined as pain experienced on most or all days over the past 3 months, following National Center for Health Statistics conventions.
• Rural residence classification was based on noncore or nonmetropolitan counties using the modified National Center for Health Statistics Urban–Rural Classification Scheme for Counties.

TAKEAWAY:

• Rural cancer survivors showed significantly higher odds of experiencing chronic pain compared with urban survivors (odds ratio [OR], 1.21; 95% CI, 1.01-1.45).
• Rural survivors were more likely to be non–Hispanic White, have less than a 4-year college degree, have an income below 200% of the federal poverty level, and have slightly more chronic health conditions.
• Having an income below 100% of the federal poverty level was associated with doubled odds of chronic pain (OR, 2.07; 95% CI, 1.54-2.77) compared with having an income at least four times the federal poverty level.
• Each additional health condition increased the odds of experiencing chronic pain by 32% (OR, 1.32; 95% CI, 1.26-1.39).

IN PRACTICE:

“Policymakers and health systems should work to close this gap by increasing the availability of pain management resources for rural cancer survivors. Approaches could include innovative payment models for integrative medicine in rural areas or supporting rural clinician access to pain specialists,” the authors of the study wrote.

SOURCE:

This study was led by Hyojin Choi, PhD, Department of Family Medicine, The Robert Larner MD College of Medicine, University of Vermont in Burlington, Vermont. It was published online in JAMA Network Open.

LIMITATIONS:

The authors note that the cross–sectional design of the study and limited information on individual respondents’ use of multimodal pain treatment options constrain the interpretation of findings.

DISCLOSURES:

The authors did not report any relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Emergency department (ED) visits by veterans for low-acuity conditions declined following the US Department of Veterans Affairs (VA) virtual care expansion in March 2020 and remained 12% below the baseline rate through February 2023.

METHODOLOGY:

• Researchers conducted a retrospective cross-sectional analysis using data from the VA Corporate Data Warehouse, including 10,364,893 ED visits (54.3% low-acuity visits) by about 2.6 million veterans (mean age, 60.8 years; 89.6% men; 63.7% White individuals) between March 2017 and February 2023.
• They evaluated the impact of the virtual care expansion — defined as the transition to virtual visits, including telephone and video care — which was implemented from March to May 2020, and assessed outcomes through that period.
• The primary outcome was the change in monthly counts of low-acuity visits to VA EDs, assessed using an interrupted time series analysis. The analysis focused on two intervention points: March 2020 (the start of the pandemic and virtual care scale-up) and May 2020 (when virtual care plateaued).
• A secondary analysis assessed the characteristics of ED users with low-acuity visits before and after the virtual care expansion, using 2 years of data — baseline pre-expansion year 3 (March 2019 to February 2020) and post-expansion year 3 (March 2022 to February 2023).

TAKEAWAY:

• Low-acuity ED utilization dropped by 24,514 visits (P < .001) in March 2020, followed by a modest increase of 7863 visits per month (P = .047) after May 2020, but remained 12.4% below the baseline rate by the end of February 2023.
• High-acuity visits showed similar patterns, with an initial decrease of 22,197 visits in March 2020 (P < .001) and a subsequent increase of 4180 visits per month in the post-expansion period (P = .05).
• Increased virtual care utilization was not significantly associated with reduced ED use for selected low-acuity conditions. The largest relative reductions were observed for major depression (42.4%), gastroenteritis (38.3%), and conjunctivitis (35.6%), whereas the largest absolute reductions occurred in low back pain, knee pain, and cellulitis.
• ED users with low-acuity ED visits in the post-expansion period were more likely to have 100% VA service connection (20.2% vs 14.6%), less medically complex (mean Elixhauser comorbidity score, 3.8 vs 4.2), and more likely to be classified as highly disabled (55.0% vs 48.1%) compared with those in the pre-expansion period.

IN PRACTICE:

“In this national, cross-sectional study, low-acuity ED utilization declined after the VA’s expansion of virtual care. While shifting low-acuity care away from ED settings toward virtual options may improve the value and efficiency of services, questions remain about the effects on quality and patient satisfaction,” the authors wrote. “Further research should be directed at exploring patient- and system-level factors that influence care-seeking decisions for low-acuity conditions,” they added.

SOURCE:

The study was led by Anu Ramachandran, MD, MPH, VA Palo Alto Health Care System, Menlo Park, California. It was published online on JAMA Network Open.

LIMITATIONS:

The classification of visits as low acuity in this study was based on International Classification of Diseases, Tenth Revision codes and discharge disposition; this classification did not imply inappropriate ED use as factors such as symptom severity, medical comorbidities, and access to care — which can influence care-seeking decisions — were not captured. The study did not assess all potential alternatives, including VA Urgent Care centers. Additionally, although virtual care use increased as ED visits declined, the models did not provide evidence of direct substitution.

DISCLOSURES:

The study received support from grants from the Department of VA, Veterans Health Administration, Office of Health Systems Research and Development. One author reported receiving research support through Department of VA Office of Health Systems Research and Development interagency agreement, whereas another reported receiving grant support from the VA Health Services Research program and being employed by the Veterans Affairs during the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Emergency department (ED) visits by veterans for low-acuity conditions declined following the US Department of Veterans Affairs (VA) virtual care expansion in March 2020 and remained 12% below the baseline rate through February 2023.

METHODOLOGY:

• Researchers conducted a retrospective cross-sectional analysis using data from the VA Corporate Data Warehouse, including 10,364,893 ED visits (54.3% low-acuity visits) by about 2.6 million veterans (mean age, 60.8 years; 89.6% men; 63.7% White individuals) between March 2017 and February 2023.
• They evaluated the impact of the virtual care expansion — defined as the transition to virtual visits, including telephone and video care — which was implemented from March to May 2020, and assessed outcomes through that period.
• The primary outcome was the change in monthly counts of low-acuity visits to VA EDs, assessed using an interrupted time series analysis. The analysis focused on two intervention points: March 2020 (the start of the pandemic and virtual care scale-up) and May 2020 (when virtual care plateaued).
• A secondary analysis assessed the characteristics of ED users with low-acuity visits before and after the virtual care expansion, using 2 years of data — baseline pre-expansion year 3 (March 2019 to February 2020) and post-expansion year 3 (March 2022 to February 2023).

TAKEAWAY:

• Low-acuity ED utilization dropped by 24,514 visits (P < .001) in March 2020, followed by a modest increase of 7863 visits per month (P = .047) after May 2020, but remained 12.4% below the baseline rate by the end of February 2023.
• High-acuity visits showed similar patterns, with an initial decrease of 22,197 visits in March 2020 (P < .001) and a subsequent increase of 4180 visits per month in the post-expansion period (P = .05).
• Increased virtual care utilization was not significantly associated with reduced ED use for selected low-acuity conditions. The largest relative reductions were observed for major depression (42.4%), gastroenteritis (38.3%), and conjunctivitis (35.6%), whereas the largest absolute reductions occurred in low back pain, knee pain, and cellulitis.
• ED users with low-acuity ED visits in the post-expansion period were more likely to have 100% VA service connection (20.2% vs 14.6%), less medically complex (mean Elixhauser comorbidity score, 3.8 vs 4.2), and more likely to be classified as highly disabled (55.0% vs 48.1%) compared with those in the pre-expansion period.

IN PRACTICE:

“In this national, cross-sectional study, low-acuity ED utilization declined after the VA’s expansion of virtual care. While shifting low-acuity care away from ED settings toward virtual options may improve the value and efficiency of services, questions remain about the effects on quality and patient satisfaction,” the authors wrote. “Further research should be directed at exploring patient- and system-level factors that influence care-seeking decisions for low-acuity conditions,” they added.

SOURCE:

The study was led by Anu Ramachandran, MD, MPH, VA Palo Alto Health Care System, Menlo Park, California. It was published online on JAMA Network Open.

LIMITATIONS:

The classification of visits as low acuity in this study was based on International Classification of Diseases, Tenth Revision codes and discharge disposition; this classification did not imply inappropriate ED use as factors such as symptom severity, medical comorbidities, and access to care — which can influence care-seeking decisions — were not captured. The study did not assess all potential alternatives, including VA Urgent Care centers. Additionally, although virtual care use increased as ED visits declined, the models did not provide evidence of direct substitution.

DISCLOSURES:

The study received support from grants from the Department of VA, Veterans Health Administration, Office of Health Systems Research and Development. One author reported receiving research support through Department of VA Office of Health Systems Research and Development interagency agreement, whereas another reported receiving grant support from the VA Health Services Research program and being employed by the Veterans Affairs during the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Emergency department (ED) visits by veterans for low-acuity conditions declined following the US Department of Veterans Affairs (VA) virtual care expansion in March 2020 and remained 12% below the baseline rate through February 2023.

METHODOLOGY:

• Researchers conducted a retrospective cross-sectional analysis using data from the VA Corporate Data Warehouse, including 10,364,893 ED visits (54.3% low-acuity visits) by about 2.6 million veterans (mean age, 60.8 years; 89.6% men; 63.7% White individuals) between March 2017 and February 2023.
• They evaluated the impact of the virtual care expansion — defined as the transition to virtual visits, including telephone and video care — which was implemented from March to May 2020, and assessed outcomes through that period.
• The primary outcome was the change in monthly counts of low-acuity visits to VA EDs, assessed using an interrupted time series analysis. The analysis focused on two intervention points: March 2020 (the start of the pandemic and virtual care scale-up) and May 2020 (when virtual care plateaued).
• A secondary analysis assessed the characteristics of ED users with low-acuity visits before and after the virtual care expansion, using 2 years of data — baseline pre-expansion year 3 (March 2019 to February 2020) and post-expansion year 3 (March 2022 to February 2023).

TAKEAWAY:

• Low-acuity ED utilization dropped by 24,514 visits (P < .001) in March 2020, followed by a modest increase of 7863 visits per month (P = .047) after May 2020, but remained 12.4% below the baseline rate by the end of February 2023.
• High-acuity visits showed similar patterns, with an initial decrease of 22,197 visits in March 2020 (P < .001) and a subsequent increase of 4180 visits per month in the post-expansion period (P = .05).
• Increased virtual care utilization was not significantly associated with reduced ED use for selected low-acuity conditions. The largest relative reductions were observed for major depression (42.4%), gastroenteritis (38.3%), and conjunctivitis (35.6%), whereas the largest absolute reductions occurred in low back pain, knee pain, and cellulitis.
• ED users with low-acuity ED visits in the post-expansion period were more likely to have 100% VA service connection (20.2% vs 14.6%), less medically complex (mean Elixhauser comorbidity score, 3.8 vs 4.2), and more likely to be classified as highly disabled (55.0% vs 48.1%) compared with those in the pre-expansion period.

IN PRACTICE:

“In this national, cross-sectional study, low-acuity ED utilization declined after the VA’s expansion of virtual care. While shifting low-acuity care away from ED settings toward virtual options may improve the value and efficiency of services, questions remain about the effects on quality and patient satisfaction,” the authors wrote. “Further research should be directed at exploring patient- and system-level factors that influence care-seeking decisions for low-acuity conditions,” they added.

SOURCE:

The study was led by Anu Ramachandran, MD, MPH, VA Palo Alto Health Care System, Menlo Park, California. It was published online on JAMA Network Open.

LIMITATIONS:

The classification of visits as low acuity in this study was based on International Classification of Diseases, Tenth Revision codes and discharge disposition; this classification did not imply inappropriate ED use as factors such as symptom severity, medical comorbidities, and access to care — which can influence care-seeking decisions — were not captured. The study did not assess all potential alternatives, including VA Urgent Care centers. Additionally, although virtual care use increased as ED visits declined, the models did not provide evidence of direct substitution.

DISCLOSURES:

The study received support from grants from the Department of VA, Veterans Health Administration, Office of Health Systems Research and Development. One author reported receiving research support through Department of VA Office of Health Systems Research and Development interagency agreement, whereas another reported receiving grant support from the VA Health Services Research program and being employed by the Veterans Affairs during the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Veterans received a diagnosis of transthyretin amyloid cardiomyopathy (ATTR-CM) a median of 490 days after heart failure (HF) diagnosis. Those who had atrial fibrillation, coronary artery disease, or chronic kidney disease experienced longer diagnostic delays, whereas older or Black patients experienced shorter delays.

METHODOLOGY:

• Researchers conducted a retrospective cohort study using data from the US Veterans Health Administration to quantify the time from HF diagnosis to ATTR-CM diagnosis and identify predictors of delays in diagnosis.
• They included veterans with HF and incident ATTR-CM diagnosed between 2016 and 2022; these veterans were identified using an algorithm based on diagnoses and medications.
• The final analysis included 2557 veterans, with a median age of 80.5 years; 99.5% were men, and 56.3% were White individuals.
• Assessments captured the time from the first HF diagnosis, the first outpatient prescription for a loop diuretic, and the first hospitalization for HF to the first ATTR-CM diagnosis, along with demographics and comorbidities.
• The primary outcome was the number of days from incident HF diagnosis to incident ATTR-CM diagnosis; a delay of > 6 months was considered meaningful.

TAKEAWAY:

• The median time from HF diagnosis to ATTR-CM diagnosis was 490 days. Overall, 65% of veterans experienced diagnostic delays > 6 months, and > 25% had delays longer than 3 years.
• Factors associated with a shorter time to ATTR-CM diagnosis included Black race (adjusted odds ratio [aOR], 0.71; 95% CI, 0.57-0.88) and older age (aOR per 10 years, 0.66; 95% CI, 0.59-0.73).
• The likelihood of longer diagnostic delays was higher in patients with coronary artery disease (aOR, 1.38; 95% CI, 1.15-1.64) and chronic kidney disease (aOR, 1.79; 95% CI, 1.50-2.15). Those with atrial fibrillation were more likely to have longer delays, although the lower bound of 95% CI was borderline (aOR, 1.21; 95% CI, 1.00-1.45).
• Among veterans with prior prescriptions of loop diuretics, the median time from the first prescription to ATTR-CM diagnosis was 835 days. Among those with a prior hospitalization for HF, the median time from hospitalization to ATTR-CM diagnosis was 300 days.

IN PRACTICE:

“This study supports the need for increased testing for ATTR-CM, thorough evaluation of cardiomyopathy etiologies at the time of HF diagnosis, and the need for new interventions that shorten the diagnostic delay in ATTR-CM,” the researchers reported.

SOURCE:

This study was led by Gabriela Spencer-Bonilla, MD, MSc, of Stanford University School of Medicine in Stanford, California. It was published online on JACC .

LIMITATIONS:

The analysis was limited to veterans engaged long enough for diagnoses of both HF and ATTR-CM. The findings may not be generalized to women given the predominantly male cohort. Echocardiography and ATTR subtype or genetic data were unavailable.

DISCLOSURES:

This study received funding from AstraZeneca. Four authors reported being the employees and stockholders of AstraZeneca. Several authors reported receiving research funding, consulting fees, and/or having equity in multiple pharmaceutical and healthcare companies, including Novo Nordisk, Bridge Bio, and Pfizer. Two authors reported receiving support from the American Heart Association, with one of them also receiving support from the National Institutes of Health.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Veterans received a diagnosis of transthyretin amyloid cardiomyopathy (ATTR-CM) a median of 490 days after heart failure (HF) diagnosis. Those who had atrial fibrillation, coronary artery disease, or chronic kidney disease experienced longer diagnostic delays, whereas older or Black patients experienced shorter delays.

METHODOLOGY:

• Researchers conducted a retrospective cohort study using data from the US Veterans Health Administration to quantify the time from HF diagnosis to ATTR-CM diagnosis and identify predictors of delays in diagnosis.
• They included veterans with HF and incident ATTR-CM diagnosed between 2016 and 2022; these veterans were identified using an algorithm based on diagnoses and medications.
• The final analysis included 2557 veterans, with a median age of 80.5 years; 99.5% were men, and 56.3% were White individuals.
• Assessments captured the time from the first HF diagnosis, the first outpatient prescription for a loop diuretic, and the first hospitalization for HF to the first ATTR-CM diagnosis, along with demographics and comorbidities.
• The primary outcome was the number of days from incident HF diagnosis to incident ATTR-CM diagnosis; a delay of > 6 months was considered meaningful.

TAKEAWAY:

• The median time from HF diagnosis to ATTR-CM diagnosis was 490 days. Overall, 65% of veterans experienced diagnostic delays > 6 months, and > 25% had delays longer than 3 years.
• Factors associated with a shorter time to ATTR-CM diagnosis included Black race (adjusted odds ratio [aOR], 0.71; 95% CI, 0.57-0.88) and older age (aOR per 10 years, 0.66; 95% CI, 0.59-0.73).
• The likelihood of longer diagnostic delays was higher in patients with coronary artery disease (aOR, 1.38; 95% CI, 1.15-1.64) and chronic kidney disease (aOR, 1.79; 95% CI, 1.50-2.15). Those with atrial fibrillation were more likely to have longer delays, although the lower bound of 95% CI was borderline (aOR, 1.21; 95% CI, 1.00-1.45).
• Among veterans with prior prescriptions of loop diuretics, the median time from the first prescription to ATTR-CM diagnosis was 835 days. Among those with a prior hospitalization for HF, the median time from hospitalization to ATTR-CM diagnosis was 300 days.

IN PRACTICE:

“This study supports the need for increased testing for ATTR-CM, thorough evaluation of cardiomyopathy etiologies at the time of HF diagnosis, and the need for new interventions that shorten the diagnostic delay in ATTR-CM,” the researchers reported.

SOURCE:

This study was led by Gabriela Spencer-Bonilla, MD, MSc, of Stanford University School of Medicine in Stanford, California. It was published online on JACC .

LIMITATIONS:

The analysis was limited to veterans engaged long enough for diagnoses of both HF and ATTR-CM. The findings may not be generalized to women given the predominantly male cohort. Echocardiography and ATTR subtype or genetic data were unavailable.

DISCLOSURES:

This study received funding from AstraZeneca. Four authors reported being the employees and stockholders of AstraZeneca. Several authors reported receiving research funding, consulting fees, and/or having equity in multiple pharmaceutical and healthcare companies, including Novo Nordisk, Bridge Bio, and Pfizer. Two authors reported receiving support from the American Heart Association, with one of them also receiving support from the National Institutes of Health.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Veterans received a diagnosis of transthyretin amyloid cardiomyopathy (ATTR-CM) a median of 490 days after heart failure (HF) diagnosis. Those who had atrial fibrillation, coronary artery disease, or chronic kidney disease experienced longer diagnostic delays, whereas older or Black patients experienced shorter delays.

METHODOLOGY:

• Researchers conducted a retrospective cohort study using data from the US Veterans Health Administration to quantify the time from HF diagnosis to ATTR-CM diagnosis and identify predictors of delays in diagnosis.
• They included veterans with HF and incident ATTR-CM diagnosed between 2016 and 2022; these veterans were identified using an algorithm based on diagnoses and medications.
• The final analysis included 2557 veterans, with a median age of 80.5 years; 99.5% were men, and 56.3% were White individuals.
• Assessments captured the time from the first HF diagnosis, the first outpatient prescription for a loop diuretic, and the first hospitalization for HF to the first ATTR-CM diagnosis, along with demographics and comorbidities.
• The primary outcome was the number of days from incident HF diagnosis to incident ATTR-CM diagnosis; a delay of > 6 months was considered meaningful.

TAKEAWAY:

• The median time from HF diagnosis to ATTR-CM diagnosis was 490 days. Overall, 65% of veterans experienced diagnostic delays > 6 months, and > 25% had delays longer than 3 years.
• Factors associated with a shorter time to ATTR-CM diagnosis included Black race (adjusted odds ratio [aOR], 0.71; 95% CI, 0.57-0.88) and older age (aOR per 10 years, 0.66; 95% CI, 0.59-0.73).
• The likelihood of longer diagnostic delays was higher in patients with coronary artery disease (aOR, 1.38; 95% CI, 1.15-1.64) and chronic kidney disease (aOR, 1.79; 95% CI, 1.50-2.15). Those with atrial fibrillation were more likely to have longer delays, although the lower bound of 95% CI was borderline (aOR, 1.21; 95% CI, 1.00-1.45).
• Among veterans with prior prescriptions of loop diuretics, the median time from the first prescription to ATTR-CM diagnosis was 835 days. Among those with a prior hospitalization for HF, the median time from hospitalization to ATTR-CM diagnosis was 300 days.

IN PRACTICE:

“This study supports the need for increased testing for ATTR-CM, thorough evaluation of cardiomyopathy etiologies at the time of HF diagnosis, and the need for new interventions that shorten the diagnostic delay in ATTR-CM,” the researchers reported.

SOURCE:

This study was led by Gabriela Spencer-Bonilla, MD, MSc, of Stanford University School of Medicine in Stanford, California. It was published online on JACC .

LIMITATIONS:

The analysis was limited to veterans engaged long enough for diagnoses of both HF and ATTR-CM. The findings may not be generalized to women given the predominantly male cohort. Echocardiography and ATTR subtype or genetic data were unavailable.

DISCLOSURES:

This study received funding from AstraZeneca. Four authors reported being the employees and stockholders of AstraZeneca. Several authors reported receiving research funding, consulting fees, and/or having equity in multiple pharmaceutical and healthcare companies, including Novo Nordisk, Bridge Bio, and Pfizer. Two authors reported receiving support from the American Heart Association, with one of them also receiving support from the National Institutes of Health.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.