Doug Brunk

SAN DIEGO – The mean survival of men who initially presented with a prostate-specific antigen score of 100 ng/mL or greater was just 18 months, results from a single-center study showed.

In an effort to provide insight into the consequences of not screening for prostate cancer, researchers at Santa Clara Valley Medical Center, San Jose, Calif., – a county hospital affiliated with the Stanford (Calif.) University that serves a large underinsured population – evaluated the impact of initial prostate-specific antigen (PSA) levels of 100 ng/mL or greater on patient morbidity and mortality. "What we hypothesized is that they would do pretty well because with newer forms of treatment, and once they get into our system, we have comprehensive care that we can provide to them," Dr. Jeffrey H. Reese, chief of the division of urology at Santa Clara Valley Medical Center, said during a press briefing at the annual meeting of the American Urological Association. However, "what we found is that they did not do well at all."

Dr. Reese reported results from 71 men with a mean age of 67 years who presented with a mean PSA score of 100 ng/mL or greater between 1998 and 2008 – none of whom had received a prior prostate cancer screening at the medical center. The median PSA at presentation was 399 ng/mL, and the median survival was 18 months. "These patients did profoundly worse than what we would have expected," Dr. Reese said. Only 9.6% of the patients survived beyond 3 years.

About 80% of patients had chronic pain from their disease. Common comorbidities included hospitalization (64%), chronic catheterization (29%), spinal cord compression (19%), and compression fracture (17%).

"There are a variety of reasons why [these men] are not being screened," Dr. Reese said. "This is a population that either has no health insurance or minimal health insurance. Some were brought in by concerned family members. Some were immigrants. I think our public hospitals represent a snapshot of what prostate cancer was like before PSA screening. It was not uncommon to have these patients come in with widely metastatic disease. There would be consequences to not screening for PSA, if we were just to abandon it entirely."

He described death from prostate cancer as "a really bad way to die. It’s painful and prolonged. There’s a profound price to pay for this disease."

Study coauthor Dr. Winifred Adams, a urology fellow at the Stanford University, acknowledged that the relatively small sample of 71 patients was a limitation. "We wonder: Is this just a problem of metastatic disease, or is it more of a PSA issue of over 100? So we need to go back and look at all patients with metastatic disease versus those who have PSA over 100 and see if the outcome is the same," Dr. Adams said.

The researchers reported having no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – The mean survival of men who initially presented with a prostate-specific antigen score of 100 ng/mL or greater was just 18 months, results from a single-center study showed.

In an effort to provide insight into the consequences of not screening for prostate cancer, researchers at Santa Clara Valley Medical Center, San Jose, Calif., – a county hospital affiliated with the Stanford (Calif.) University that serves a large underinsured population – evaluated the impact of initial prostate-specific antigen (PSA) levels of 100 ng/mL or greater on patient morbidity and mortality. "What we hypothesized is that they would do pretty well because with newer forms of treatment, and once they get into our system, we have comprehensive care that we can provide to them," Dr. Jeffrey H. Reese, chief of the division of urology at Santa Clara Valley Medical Center, said during a press briefing at the annual meeting of the American Urological Association. However, "what we found is that they did not do well at all."

Dr. Reese reported results from 71 men with a mean age of 67 years who presented with a mean PSA score of 100 ng/mL or greater between 1998 and 2008 – none of whom had received a prior prostate cancer screening at the medical center. The median PSA at presentation was 399 ng/mL, and the median survival was 18 months. "These patients did profoundly worse than what we would have expected," Dr. Reese said. Only 9.6% of the patients survived beyond 3 years.

About 80% of patients had chronic pain from their disease. Common comorbidities included hospitalization (64%), chronic catheterization (29%), spinal cord compression (19%), and compression fracture (17%).

"There are a variety of reasons why [these men] are not being screened," Dr. Reese said. "This is a population that either has no health insurance or minimal health insurance. Some were brought in by concerned family members. Some were immigrants. I think our public hospitals represent a snapshot of what prostate cancer was like before PSA screening. It was not uncommon to have these patients come in with widely metastatic disease. There would be consequences to not screening for PSA, if we were just to abandon it entirely."

He described death from prostate cancer as "a really bad way to die. It’s painful and prolonged. There’s a profound price to pay for this disease."

Study coauthor Dr. Winifred Adams, a urology fellow at the Stanford University, acknowledged that the relatively small sample of 71 patients was a limitation. "We wonder: Is this just a problem of metastatic disease, or is it more of a PSA issue of over 100? So we need to go back and look at all patients with metastatic disease versus those who have PSA over 100 and see if the outcome is the same," Dr. Adams said.

The researchers reported having no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – The mean survival of men who initially presented with a prostate-specific antigen score of 100 ng/mL or greater was just 18 months, results from a single-center study showed.

In an effort to provide insight into the consequences of not screening for prostate cancer, researchers at Santa Clara Valley Medical Center, San Jose, Calif., – a county hospital affiliated with the Stanford (Calif.) University that serves a large underinsured population – evaluated the impact of initial prostate-specific antigen (PSA) levels of 100 ng/mL or greater on patient morbidity and mortality. "What we hypothesized is that they would do pretty well because with newer forms of treatment, and once they get into our system, we have comprehensive care that we can provide to them," Dr. Jeffrey H. Reese, chief of the division of urology at Santa Clara Valley Medical Center, said during a press briefing at the annual meeting of the American Urological Association. However, "what we found is that they did not do well at all."

Dr. Reese reported results from 71 men with a mean age of 67 years who presented with a mean PSA score of 100 ng/mL or greater between 1998 and 2008 – none of whom had received a prior prostate cancer screening at the medical center. The median PSA at presentation was 399 ng/mL, and the median survival was 18 months. "These patients did profoundly worse than what we would have expected," Dr. Reese said. Only 9.6% of the patients survived beyond 3 years.

About 80% of patients had chronic pain from their disease. Common comorbidities included hospitalization (64%), chronic catheterization (29%), spinal cord compression (19%), and compression fracture (17%).

"There are a variety of reasons why [these men] are not being screened," Dr. Reese said. "This is a population that either has no health insurance or minimal health insurance. Some were brought in by concerned family members. Some were immigrants. I think our public hospitals represent a snapshot of what prostate cancer was like before PSA screening. It was not uncommon to have these patients come in with widely metastatic disease. There would be consequences to not screening for PSA, if we were just to abandon it entirely."

He described death from prostate cancer as "a really bad way to die. It’s painful and prolonged. There’s a profound price to pay for this disease."

Study coauthor Dr. Winifred Adams, a urology fellow at the Stanford University, acknowledged that the relatively small sample of 71 patients was a limitation. "We wonder: Is this just a problem of metastatic disease, or is it more of a PSA issue of over 100? So we need to go back and look at all patients with metastatic disease versus those who have PSA over 100 and see if the outcome is the same," Dr. Adams said.

The researchers reported having no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – Long-acting reversible contraceptives reduced teen pregnancy by 56%, compared with national statistics for teens overall, preliminary results from an ongoing analysis demonstrated.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Tessa Madden shared updated findings from the Contraceptive CHOICE Project, an effort to promote LARC use in the St. Louis region and to measure acceptability, satisfaction, side effects, and the rates of continuation across a variety of contraceptive methods, including LARCs. The goals were to increase IUD use in the St. Louis region from 1%-2% to 6% or greater, to improve the rates of postabortion IUD use from less than 1% to 10% or greater, and to increase the use of contraceptive implants to 3% or greater.

The investigators also hypothesized that teen pregnancy rates would decline by 10%. "It turns out that we were overly conservative in our estimates for what we could do," said Dr. Madden of Washington University in St. Louis. "We also hypothesized that women who got a LARC method would have higher rates of continuation and higher rates of satisfaction, compared with women who were using shorter-acting reversible methods."

Study participants included 9,256 women who lived in either the city of St. Louis or St. Louis County. The women were 14-45 years of age, were either currently sexually active or planning on becoming sexually active, did not want to become pregnant in the next 12 months, and were willing to start a new contraceptive method. Two-thirds of the participants enrolled at the Washington University School of Medicine, while the remainder enrolled at one of 13 partner community clinics.

Participants who enrolled in the clinical university site underwent formal standardized counseling. "Trained contraceptive counselors read a script to participants before they enrolled in the project, and they had models to demonstrate the different kinds of contraceptive methods," Dr. Madden explained. Study participants "heard about contraceptive methods in a tier-based approach, so they heard about the most effective methods first." Those who enrolled at the community clinic underwent "usual" counseling.

In a study from the first 5,087 enrolled in the Contraceptive CHOICE Project, Dr. Madden and her associates reported that at 12 months, 86% of patients who chose a LARC were still using it, compared with only 55% of those who chose a non-LARC method (Obstet. Gynecol. 2011;117:1105-13). This closely mirrored the percentage of patients who reported overall satisfaction with their chosen birth control method (84% in the LARC group vs. 53% in the non-LARC group). Comparing LARC and non-LARC methods, we see that 84% of participants were satisfied with their LARC method at 12-months, compared with 53% of participants using non-LARC methods.

At the meeting, Dr. Madden discussed preliminary findings from the overall study population, as well as from a cohort of 1,404 adolescents in CHOICE, who were aged 14-19 at the time of enrollment. Of the adolescents, 63% were black, 30% were white, and the rest were from other racial groups. Half of the teens had a prior pregnancy.

A full 75% of women in the overall population chose an IUD or an implant, compared with 72% of the adolescents, "which is still pretty high," Dr. Madden said. Implant use in the overall population was 17%, compared with 34% among adolescents. "Implants were more acceptable to the younger teens, and IUDs become more acceptable to the older teens," she noted.

Only 7% of those under age 20 years discontinued any LARC by 6 months, compared with 8% of those aged 20 years and older, a difference that was not statistically significant (P = .17). "I’m hoping this can help put to bed the notion that teens get these [LARC] methods and then decide 6 weeks later that they want the [device] out," Dr. Madden said. "This does not happen in most cases."

The annual pregnancy rate among adolescents in CHOICE who chose a LARC was 29.9/1,000, compared with the 2008 U.S. teen pregnancy rate of 67.8/1,000, a reduction of 56%.

The findings matter, she added, "because LARCs really are better at preventing unintended pregnancy compared with non-LARC methods. Our follow-up rates at 1 year are greater than 90%. We found that women who were using contraceptive pills, patches, or rings had a 20-fold increased risk of unintended pregnancy, compared with women using a LARC method. We also found that LARCs were just as effective in young women compared with older women."

Dr. Madden predicted that consumer interest in LARCs will continue to grow because "more women and adolescents are asking for these methods. They’re reading about them online and people are blogging about them, so they’re more empowered to ask for them."

Dr. Madden disclosed that she receives honoraria for serving on an advisory board for Bayer Healthcare Pharmaceuticals and that she receives research funding from Merck.

dbrunk@frontlinemedcom.com

SAN DIEGO – Long-acting reversible contraceptives reduced teen pregnancy by 56%, compared with national statistics for teens overall, preliminary results from an ongoing analysis demonstrated.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Tessa Madden shared updated findings from the Contraceptive CHOICE Project, an effort to promote LARC use in the St. Louis region and to measure acceptability, satisfaction, side effects, and the rates of continuation across a variety of contraceptive methods, including LARCs. The goals were to increase IUD use in the St. Louis region from 1%-2% to 6% or greater, to improve the rates of postabortion IUD use from less than 1% to 10% or greater, and to increase the use of contraceptive implants to 3% or greater.

The investigators also hypothesized that teen pregnancy rates would decline by 10%. "It turns out that we were overly conservative in our estimates for what we could do," said Dr. Madden of Washington University in St. Louis. "We also hypothesized that women who got a LARC method would have higher rates of continuation and higher rates of satisfaction, compared with women who were using shorter-acting reversible methods."

Study participants included 9,256 women who lived in either the city of St. Louis or St. Louis County. The women were 14-45 years of age, were either currently sexually active or planning on becoming sexually active, did not want to become pregnant in the next 12 months, and were willing to start a new contraceptive method. Two-thirds of the participants enrolled at the Washington University School of Medicine, while the remainder enrolled at one of 13 partner community clinics.

Participants who enrolled in the clinical university site underwent formal standardized counseling. "Trained contraceptive counselors read a script to participants before they enrolled in the project, and they had models to demonstrate the different kinds of contraceptive methods," Dr. Madden explained. Study participants "heard about contraceptive methods in a tier-based approach, so they heard about the most effective methods first." Those who enrolled at the community clinic underwent "usual" counseling.

In a study from the first 5,087 enrolled in the Contraceptive CHOICE Project, Dr. Madden and her associates reported that at 12 months, 86% of patients who chose a LARC were still using it, compared with only 55% of those who chose a non-LARC method (Obstet. Gynecol. 2011;117:1105-13). This closely mirrored the percentage of patients who reported overall satisfaction with their chosen birth control method (84% in the LARC group vs. 53% in the non-LARC group). Comparing LARC and non-LARC methods, we see that 84% of participants were satisfied with their LARC method at 12-months, compared with 53% of participants using non-LARC methods.

At the meeting, Dr. Madden discussed preliminary findings from the overall study population, as well as from a cohort of 1,404 adolescents in CHOICE, who were aged 14-19 at the time of enrollment. Of the adolescents, 63% were black, 30% were white, and the rest were from other racial groups. Half of the teens had a prior pregnancy.

A full 75% of women in the overall population chose an IUD or an implant, compared with 72% of the adolescents, "which is still pretty high," Dr. Madden said. Implant use in the overall population was 17%, compared with 34% among adolescents. "Implants were more acceptable to the younger teens, and IUDs become more acceptable to the older teens," she noted.

Only 7% of those under age 20 years discontinued any LARC by 6 months, compared with 8% of those aged 20 years and older, a difference that was not statistically significant (P = .17). "I’m hoping this can help put to bed the notion that teens get these [LARC] methods and then decide 6 weeks later that they want the [device] out," Dr. Madden said. "This does not happen in most cases."

The annual pregnancy rate among adolescents in CHOICE who chose a LARC was 29.9/1,000, compared with the 2008 U.S. teen pregnancy rate of 67.8/1,000, a reduction of 56%.

The findings matter, she added, "because LARCs really are better at preventing unintended pregnancy compared with non-LARC methods. Our follow-up rates at 1 year are greater than 90%. We found that women who were using contraceptive pills, patches, or rings had a 20-fold increased risk of unintended pregnancy, compared with women using a LARC method. We also found that LARCs were just as effective in young women compared with older women."

Dr. Madden predicted that consumer interest in LARCs will continue to grow because "more women and adolescents are asking for these methods. They’re reading about them online and people are blogging about them, so they’re more empowered to ask for them."

Dr. Madden disclosed that she receives honoraria for serving on an advisory board for Bayer Healthcare Pharmaceuticals and that she receives research funding from Merck.

dbrunk@frontlinemedcom.com

SAN DIEGO – Long-acting reversible contraceptives reduced teen pregnancy by 56%, compared with national statistics for teens overall, preliminary results from an ongoing analysis demonstrated.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Tessa Madden shared updated findings from the Contraceptive CHOICE Project, an effort to promote LARC use in the St. Louis region and to measure acceptability, satisfaction, side effects, and the rates of continuation across a variety of contraceptive methods, including LARCs. The goals were to increase IUD use in the St. Louis region from 1%-2% to 6% or greater, to improve the rates of postabortion IUD use from less than 1% to 10% or greater, and to increase the use of contraceptive implants to 3% or greater.

The investigators also hypothesized that teen pregnancy rates would decline by 10%. "It turns out that we were overly conservative in our estimates for what we could do," said Dr. Madden of Washington University in St. Louis. "We also hypothesized that women who got a LARC method would have higher rates of continuation and higher rates of satisfaction, compared with women who were using shorter-acting reversible methods."

Study participants included 9,256 women who lived in either the city of St. Louis or St. Louis County. The women were 14-45 years of age, were either currently sexually active or planning on becoming sexually active, did not want to become pregnant in the next 12 months, and were willing to start a new contraceptive method. Two-thirds of the participants enrolled at the Washington University School of Medicine, while the remainder enrolled at one of 13 partner community clinics.

Participants who enrolled in the clinical university site underwent formal standardized counseling. "Trained contraceptive counselors read a script to participants before they enrolled in the project, and they had models to demonstrate the different kinds of contraceptive methods," Dr. Madden explained. Study participants "heard about contraceptive methods in a tier-based approach, so they heard about the most effective methods first." Those who enrolled at the community clinic underwent "usual" counseling.

In a study from the first 5,087 enrolled in the Contraceptive CHOICE Project, Dr. Madden and her associates reported that at 12 months, 86% of patients who chose a LARC were still using it, compared with only 55% of those who chose a non-LARC method (Obstet. Gynecol. 2011;117:1105-13). This closely mirrored the percentage of patients who reported overall satisfaction with their chosen birth control method (84% in the LARC group vs. 53% in the non-LARC group). Comparing LARC and non-LARC methods, we see that 84% of participants were satisfied with their LARC method at 12-months, compared with 53% of participants using non-LARC methods.

At the meeting, Dr. Madden discussed preliminary findings from the overall study population, as well as from a cohort of 1,404 adolescents in CHOICE, who were aged 14-19 at the time of enrollment. Of the adolescents, 63% were black, 30% were white, and the rest were from other racial groups. Half of the teens had a prior pregnancy.

A full 75% of women in the overall population chose an IUD or an implant, compared with 72% of the adolescents, "which is still pretty high," Dr. Madden said. Implant use in the overall population was 17%, compared with 34% among adolescents. "Implants were more acceptable to the younger teens, and IUDs become more acceptable to the older teens," she noted.

Only 7% of those under age 20 years discontinued any LARC by 6 months, compared with 8% of those aged 20 years and older, a difference that was not statistically significant (P = .17). "I’m hoping this can help put to bed the notion that teens get these [LARC] methods and then decide 6 weeks later that they want the [device] out," Dr. Madden said. "This does not happen in most cases."

The annual pregnancy rate among adolescents in CHOICE who chose a LARC was 29.9/1,000, compared with the 2008 U.S. teen pregnancy rate of 67.8/1,000, a reduction of 56%.

The findings matter, she added, "because LARCs really are better at preventing unintended pregnancy compared with non-LARC methods. Our follow-up rates at 1 year are greater than 90%. We found that women who were using contraceptive pills, patches, or rings had a 20-fold increased risk of unintended pregnancy, compared with women using a LARC method. We also found that LARCs were just as effective in young women compared with older women."

Dr. Madden predicted that consumer interest in LARCs will continue to grow because "more women and adolescents are asking for these methods. They’re reading about them online and people are blogging about them, so they’re more empowered to ask for them."

Dr. Madden disclosed that she receives honoraria for serving on an advisory board for Bayer Healthcare Pharmaceuticals and that she receives research funding from Merck.

dbrunk@frontlinemedcom.com

SAN DIEGO – Most ovarian cysts in adolescents will resolve, but those greater than 100 mL in size are the most predictive of ovarian pathology and need for surgical intervention.

The findings, presented during a poster session at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, come from a study of 78 adolescent females at Children’s Mercy Hospital, Kansas City, who were given a diagnostic ICD-9 code consistent with ovarian cyst or mass between 2004 and 2012.

"There is insufficient documentation that most cysts will either decrease in size or resolve, but clear criteria for conservative management in this group has not been described," researchers led by Dr. Crystal Meacham wrote in the poster. "When indicated, laparoscopic intervention of ovarian cysts in adolescents has been well studied and is the preferred surgical approach."

In an effort to determine predictive characteristics that would aid in safe observation and expectant management versus the need for surgical intervention, Dr. Meacham and her associates limited their analysis to adolescents with ovarian cysts greater than or equal to 3 cm in largest diameter on imaging. They recorded cyst volume at initial presentation and follow-up imaging was recorded. Cysts were categorized into three groups based on size: small (0-49 mL), medium (50-100 mL), and large (greater than 100 mL).

The average cyst volume at initial imaging was 62.17 mL, while the average volume at follow-up imaging was 25.81 mL, a reduction that reached statistical significance (P is less than .0001). Of the 78 cysts, 61 (90%) resolved and 17 did not. The researchers found that cysts in the large-volume category were most likely to persist and require surgical intervention.

"Level of cyst complexity is not a predictive characteristic for ovarian cyst resolution nor an indication for surgical management," they wrote. "The pathology most consistent with cysts of the large-volume category, and thus requiring surgery, is serous cystadenoma. Large cyst volume is most predictive of ovarian pathology and need for surgical intervention."

The researchers had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Most ovarian cysts in adolescents will resolve, but those greater than 100 mL in size are the most predictive of ovarian pathology and need for surgical intervention.

The findings, presented during a poster session at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, come from a study of 78 adolescent females at Children’s Mercy Hospital, Kansas City, who were given a diagnostic ICD-9 code consistent with ovarian cyst or mass between 2004 and 2012.

"There is insufficient documentation that most cysts will either decrease in size or resolve, but clear criteria for conservative management in this group has not been described," researchers led by Dr. Crystal Meacham wrote in the poster. "When indicated, laparoscopic intervention of ovarian cysts in adolescents has been well studied and is the preferred surgical approach."

In an effort to determine predictive characteristics that would aid in safe observation and expectant management versus the need for surgical intervention, Dr. Meacham and her associates limited their analysis to adolescents with ovarian cysts greater than or equal to 3 cm in largest diameter on imaging. They recorded cyst volume at initial presentation and follow-up imaging was recorded. Cysts were categorized into three groups based on size: small (0-49 mL), medium (50-100 mL), and large (greater than 100 mL).

The average cyst volume at initial imaging was 62.17 mL, while the average volume at follow-up imaging was 25.81 mL, a reduction that reached statistical significance (P is less than .0001). Of the 78 cysts, 61 (90%) resolved and 17 did not. The researchers found that cysts in the large-volume category were most likely to persist and require surgical intervention.

"Level of cyst complexity is not a predictive characteristic for ovarian cyst resolution nor an indication for surgical management," they wrote. "The pathology most consistent with cysts of the large-volume category, and thus requiring surgery, is serous cystadenoma. Large cyst volume is most predictive of ovarian pathology and need for surgical intervention."

The researchers had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Most ovarian cysts in adolescents will resolve, but those greater than 100 mL in size are the most predictive of ovarian pathology and need for surgical intervention.

The findings, presented during a poster session at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, come from a study of 78 adolescent females at Children’s Mercy Hospital, Kansas City, who were given a diagnostic ICD-9 code consistent with ovarian cyst or mass between 2004 and 2012.

"There is insufficient documentation that most cysts will either decrease in size or resolve, but clear criteria for conservative management in this group has not been described," researchers led by Dr. Crystal Meacham wrote in the poster. "When indicated, laparoscopic intervention of ovarian cysts in adolescents has been well studied and is the preferred surgical approach."

In an effort to determine predictive characteristics that would aid in safe observation and expectant management versus the need for surgical intervention, Dr. Meacham and her associates limited their analysis to adolescents with ovarian cysts greater than or equal to 3 cm in largest diameter on imaging. They recorded cyst volume at initial presentation and follow-up imaging was recorded. Cysts were categorized into three groups based on size: small (0-49 mL), medium (50-100 mL), and large (greater than 100 mL).

The average cyst volume at initial imaging was 62.17 mL, while the average volume at follow-up imaging was 25.81 mL, a reduction that reached statistical significance (P is less than .0001). Of the 78 cysts, 61 (90%) resolved and 17 did not. The researchers found that cysts in the large-volume category were most likely to persist and require surgical intervention.

"Level of cyst complexity is not a predictive characteristic for ovarian cyst resolution nor an indication for surgical management," they wrote. "The pathology most consistent with cysts of the large-volume category, and thus requiring surgery, is serous cystadenoma. Large cyst volume is most predictive of ovarian pathology and need for surgical intervention."

The researchers had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Of men given an ICD-9 diagnosis of erectile dysfunction, 25% receive any treatment for the condition.

Treatment frequency was higher in men who had low levels of testosterone (51% treated) and lower in those who had prostate cancer (15% treated). Treatment frequency did not vary significantly with other associated comorbidities, Dr. Brian T. Helfand said in a press briefing at the annual meeting of the American Urological Association.

Dr. Helfand of the department of urology at NorthShore University Health System in Evanston, Ill., and his associates used an IMS data set to identify 6,228,509 men over the age of 30 years who received an ICD-9 diagnosis of erectile dysfunction (ED) during a 12-month period that ended in July 2011. IMS is a large insurance claims data set that encompasses more than 80% of prescription data in the United States.

Men were classified as treated if they filled a prescription for a phosphodiesterase type-5 (PDE5) inhibitor, injection or urethral prostaglandins, or androgen replacement therapy. They were classified as untreated if they received an ED diagnosis but did not fill a prescription in the study period. The researchers monitored the therapies by prescription frequency, age, comorbidities, and physician specialty.

Among the 25% of men who filled prescriptions, PDE5 was the most commonly prescribed medication (75%), followed by androgen replacement therapy (31%). Fewer than 2% of patients used any prostaglandin therapy. "The men who were in the oldest age groups were the least likely to fill a prescription," Dr. Helfand said.

The greatest proportion of prescriptions overall were ordered by primary care physicians (28%), followed by endocrinologists (27%), and urologists (21%). The remaining 24% were ordered by various other clinicians.

Dr. Helfand said limitations of the study include the exclusion of Medicare data plus lack of information about the severity of ED, efficacy of treatments, and adherence to long-term therapy.

Dr. Ajay Nangia, who is an associate professor of urology at the University of Kansas Medical Center and the moderator of the press briefing, noted that ED is a medical disease that is often a portent of other disorders. Recognizing that men with ED go untreated may mean that they’re also possibly underinvestigated for associated condition such as diabetes, lipid disorders, and risk factors such as smoking.

Dr. Helfand said that he had no relevant financial conflicts to disclose. One of the study authors, Dr. Kevin McVary, disclosed consultant, advisory, or other roles with several companies, including Allergan, Lilly, NxThera, Watson, NeoTract, and GSK.

dbrunk@frontlinemedcom.com

SAN DIEGO – Of men given an ICD-9 diagnosis of erectile dysfunction, 25% receive any treatment for the condition.

Treatment frequency was higher in men who had low levels of testosterone (51% treated) and lower in those who had prostate cancer (15% treated). Treatment frequency did not vary significantly with other associated comorbidities, Dr. Brian T. Helfand said in a press briefing at the annual meeting of the American Urological Association.

Dr. Helfand of the department of urology at NorthShore University Health System in Evanston, Ill., and his associates used an IMS data set to identify 6,228,509 men over the age of 30 years who received an ICD-9 diagnosis of erectile dysfunction (ED) during a 12-month period that ended in July 2011. IMS is a large insurance claims data set that encompasses more than 80% of prescription data in the United States.

Men were classified as treated if they filled a prescription for a phosphodiesterase type-5 (PDE5) inhibitor, injection or urethral prostaglandins, or androgen replacement therapy. They were classified as untreated if they received an ED diagnosis but did not fill a prescription in the study period. The researchers monitored the therapies by prescription frequency, age, comorbidities, and physician specialty.

Among the 25% of men who filled prescriptions, PDE5 was the most commonly prescribed medication (75%), followed by androgen replacement therapy (31%). Fewer than 2% of patients used any prostaglandin therapy. "The men who were in the oldest age groups were the least likely to fill a prescription," Dr. Helfand said.

The greatest proportion of prescriptions overall were ordered by primary care physicians (28%), followed by endocrinologists (27%), and urologists (21%). The remaining 24% were ordered by various other clinicians.

Dr. Helfand said limitations of the study include the exclusion of Medicare data plus lack of information about the severity of ED, efficacy of treatments, and adherence to long-term therapy.

Dr. Ajay Nangia, who is an associate professor of urology at the University of Kansas Medical Center and the moderator of the press briefing, noted that ED is a medical disease that is often a portent of other disorders. Recognizing that men with ED go untreated may mean that they’re also possibly underinvestigated for associated condition such as diabetes, lipid disorders, and risk factors such as smoking.

Dr. Helfand said that he had no relevant financial conflicts to disclose. One of the study authors, Dr. Kevin McVary, disclosed consultant, advisory, or other roles with several companies, including Allergan, Lilly, NxThera, Watson, NeoTract, and GSK.

dbrunk@frontlinemedcom.com

SAN DIEGO – Of men given an ICD-9 diagnosis of erectile dysfunction, 25% receive any treatment for the condition.

Treatment frequency was higher in men who had low levels of testosterone (51% treated) and lower in those who had prostate cancer (15% treated). Treatment frequency did not vary significantly with other associated comorbidities, Dr. Brian T. Helfand said in a press briefing at the annual meeting of the American Urological Association.

Dr. Helfand of the department of urology at NorthShore University Health System in Evanston, Ill., and his associates used an IMS data set to identify 6,228,509 men over the age of 30 years who received an ICD-9 diagnosis of erectile dysfunction (ED) during a 12-month period that ended in July 2011. IMS is a large insurance claims data set that encompasses more than 80% of prescription data in the United States.

Men were classified as treated if they filled a prescription for a phosphodiesterase type-5 (PDE5) inhibitor, injection or urethral prostaglandins, or androgen replacement therapy. They were classified as untreated if they received an ED diagnosis but did not fill a prescription in the study period. The researchers monitored the therapies by prescription frequency, age, comorbidities, and physician specialty.

Among the 25% of men who filled prescriptions, PDE5 was the most commonly prescribed medication (75%), followed by androgen replacement therapy (31%). Fewer than 2% of patients used any prostaglandin therapy. "The men who were in the oldest age groups were the least likely to fill a prescription," Dr. Helfand said.

The greatest proportion of prescriptions overall were ordered by primary care physicians (28%), followed by endocrinologists (27%), and urologists (21%). The remaining 24% were ordered by various other clinicians.

Dr. Helfand said limitations of the study include the exclusion of Medicare data plus lack of information about the severity of ED, efficacy of treatments, and adherence to long-term therapy.

Dr. Ajay Nangia, who is an associate professor of urology at the University of Kansas Medical Center and the moderator of the press briefing, noted that ED is a medical disease that is often a portent of other disorders. Recognizing that men with ED go untreated may mean that they’re also possibly underinvestigated for associated condition such as diabetes, lipid disorders, and risk factors such as smoking.

Dr. Helfand said that he had no relevant financial conflicts to disclose. One of the study authors, Dr. Kevin McVary, disclosed consultant, advisory, or other roles with several companies, including Allergan, Lilly, NxThera, Watson, NeoTract, and GSK.

dbrunk@frontlinemedcom.com

SAN DIEGO – Counseling adolescent females about the use of long-acting reversible contraceptives can be tricky business because not all of them will be forthright with clinicians about their reproductive life needs during office visits.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Aparna Sridhar emphasized the four key components of LARC use in teens: counseling, confidentiality, consent, and cost.

She highlighted the importance of establishing confidentiality before counseling teens on the use of LARCs. Start the dialogue by informing the patient that "all services are provided to you in confidence. Our discussion about birth control methods will remain private unless you give me written permission to share it with someone else," she recommended.

Before discussing LARCs specifically, Dr. Sridhar asks the patient about her readiness for pregnancy, as birth control methods work best when integrated with a reproductive life plan. Sample questions may include: How old do you want to be when you have your first/next child? Why then and not now? How would it be for you if you got pregnant by accident right now? How would your partner feel?

Next, ask specific questions to assess the patient’s fears, worries, and negative information they may have about LARC options. "Do not wait for the adolescent patient to raise concerns," said Dr. Sridhar, a clinical fellow in family planning in the department of obstetrics and gynecology at the University of California, Los Angeles. "Explain in nontechnical terms how each long-acting method works to prevent pregnancy, and assure patients that they can always share concerns and worries."

She also recommends that clinicians elicit what the patient knows about contraceptive methods, ask permission before providing information, and elicit the patient’s reaction to information or advice by asking a question such as, "How would you feel about using this method?" Dr. Sridhar also makes it a point to offer condoms to teen women seeking advice about LARCs and counsels them about the correct way to use them for protection against sexually transmitted infections.

Currently, no state or federal laws require minors to obtain parental consent to get contraception. "Two federal programs – Title X and Medicaid – protect teens’ privacy and prohibit parental consent requirements for teens seeking contraception," she said. "Teens and minors have a right to privacy that includes their ability to use contraception."

Dr. Sridhar said that she had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Counseling adolescent females about the use of long-acting reversible contraceptives can be tricky business because not all of them will be forthright with clinicians about their reproductive life needs during office visits.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Aparna Sridhar emphasized the four key components of LARC use in teens: counseling, confidentiality, consent, and cost.

She highlighted the importance of establishing confidentiality before counseling teens on the use of LARCs. Start the dialogue by informing the patient that "all services are provided to you in confidence. Our discussion about birth control methods will remain private unless you give me written permission to share it with someone else," she recommended.

Before discussing LARCs specifically, Dr. Sridhar asks the patient about her readiness for pregnancy, as birth control methods work best when integrated with a reproductive life plan. Sample questions may include: How old do you want to be when you have your first/next child? Why then and not now? How would it be for you if you got pregnant by accident right now? How would your partner feel?

Next, ask specific questions to assess the patient’s fears, worries, and negative information they may have about LARC options. "Do not wait for the adolescent patient to raise concerns," said Dr. Sridhar, a clinical fellow in family planning in the department of obstetrics and gynecology at the University of California, Los Angeles. "Explain in nontechnical terms how each long-acting method works to prevent pregnancy, and assure patients that they can always share concerns and worries."

She also recommends that clinicians elicit what the patient knows about contraceptive methods, ask permission before providing information, and elicit the patient’s reaction to information or advice by asking a question such as, "How would you feel about using this method?" Dr. Sridhar also makes it a point to offer condoms to teen women seeking advice about LARCs and counsels them about the correct way to use them for protection against sexually transmitted infections.

Currently, no state or federal laws require minors to obtain parental consent to get contraception. "Two federal programs – Title X and Medicaid – protect teens’ privacy and prohibit parental consent requirements for teens seeking contraception," she said. "Teens and minors have a right to privacy that includes their ability to use contraception."

Dr. Sridhar said that she had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Counseling adolescent females about the use of long-acting reversible contraceptives can be tricky business because not all of them will be forthright with clinicians about their reproductive life needs during office visits.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Aparna Sridhar emphasized the four key components of LARC use in teens: counseling, confidentiality, consent, and cost.

She highlighted the importance of establishing confidentiality before counseling teens on the use of LARCs. Start the dialogue by informing the patient that "all services are provided to you in confidence. Our discussion about birth control methods will remain private unless you give me written permission to share it with someone else," she recommended.

Before discussing LARCs specifically, Dr. Sridhar asks the patient about her readiness for pregnancy, as birth control methods work best when integrated with a reproductive life plan. Sample questions may include: How old do you want to be when you have your first/next child? Why then and not now? How would it be for you if you got pregnant by accident right now? How would your partner feel?

Next, ask specific questions to assess the patient’s fears, worries, and negative information they may have about LARC options. "Do not wait for the adolescent patient to raise concerns," said Dr. Sridhar, a clinical fellow in family planning in the department of obstetrics and gynecology at the University of California, Los Angeles. "Explain in nontechnical terms how each long-acting method works to prevent pregnancy, and assure patients that they can always share concerns and worries."

She also recommends that clinicians elicit what the patient knows about contraceptive methods, ask permission before providing information, and elicit the patient’s reaction to information or advice by asking a question such as, "How would you feel about using this method?" Dr. Sridhar also makes it a point to offer condoms to teen women seeking advice about LARCs and counsels them about the correct way to use them for protection against sexually transmitted infections.

Currently, no state or federal laws require minors to obtain parental consent to get contraception. "Two federal programs – Title X and Medicaid – protect teens’ privacy and prohibit parental consent requirements for teens seeking contraception," she said. "Teens and minors have a right to privacy that includes their ability to use contraception."

Dr. Sridhar said that she had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – The number of urologists practicing in the United States is expected to decrease by 29% between 2009 and 2025, according to a new analysis.

"It’s one thing if the demand for urologists is going up and the supply is stable, but to have the demand go up and the supply almost falling off of a cliff is worrisome," Dr. Raj S. Pruthi said in an interview at the annual meeting of the American Urological Association. "The people who will be hardest hit by this are ones who already struggle with access: those who live in rural communities."

Dr. Pruthi and his colleagues used stock and flow models, starting with the supply of urologists in 2009. They added new entrants from the graduate medical education (GME) pipeline and subtracted attrition from training and from the workforce due to retirement or breaks from practice. The forecast model estimates a 29% head count reduction and a 25% decrease in the full-time equivalent (FTE) supply of urologists between 2009 and 2025. The projected decrease is more than four times greater than the Health Resources and Services Administration’s Physician Supply Model, which estimated a 7% decrease over the same time period.

Dr. Pruthi warned that none of the proposed changes to GME (recommendations from the Council of Graduate Medical Education’s 16th report or a recent proposal to Congress) will increase GME enough to offset the projected decline in head count. "GME funding has been capped since 1996," he said. "We’re setting forth a recipe for a very big problem that we’re going to have for future generations in terms of who’s going to take care of" a rapidly aging population.

As the Affordable Health Care Act takes shape, "one thing that’s not been considered adequately is physician supply," added Dr. Pruthi, chief of urologic surgery at the University of North Carolina at Chapel Hill. "Are there enough of us to help care for the population? That needs to be part of the calculus. We need to do efficient, appropriate care. We need to cut health care costs, but we have to remember our physician supply."

The shrinking number of urologists could affect mortality rates, as research has demonstrated an association between a higher density of urologists in a defined area and lower mortality from prostate, bladder, and kidney cancer. "As supply contracts, rural areas are likely to have an even greater loss of urologic surgeons since these areas have a higher percentage of surgeons closer to retirement age than urban areas," the researchers noted in their abstract. "The result may decrease access to screening, medical and surgical treatment for urologic conditions."

Dr. Pruthi acknowledged that the ability to predict physician demand is an imprecise science. However, "there is indirect data to suggest that our demand isn’t going to go away. It’s only going to go up with that rising incidence and with the rising number of aging baby boomers. Second, we don’t know the appropriate ratio of supply and demand. If you have limited supply, you have limited access. Is our culture accepting of that? Some of these limitations to access may have health consequences."

He and his associates plan to conduct more detailed work on the projection model, including the impact of increasing numbers of women entering the urology field. "About 5% of urologists are female, but in current residency matching the numbers are about 25% female," he said. "What impact will that have? We don’t know yet."

Dr. Pruthi said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – The number of urologists practicing in the United States is expected to decrease by 29% between 2009 and 2025, according to a new analysis.

"It’s one thing if the demand for urologists is going up and the supply is stable, but to have the demand go up and the supply almost falling off of a cliff is worrisome," Dr. Raj S. Pruthi said in an interview at the annual meeting of the American Urological Association. "The people who will be hardest hit by this are ones who already struggle with access: those who live in rural communities."

Dr. Pruthi and his colleagues used stock and flow models, starting with the supply of urologists in 2009. They added new entrants from the graduate medical education (GME) pipeline and subtracted attrition from training and from the workforce due to retirement or breaks from practice. The forecast model estimates a 29% head count reduction and a 25% decrease in the full-time equivalent (FTE) supply of urologists between 2009 and 2025. The projected decrease is more than four times greater than the Health Resources and Services Administration’s Physician Supply Model, which estimated a 7% decrease over the same time period.

Dr. Pruthi warned that none of the proposed changes to GME (recommendations from the Council of Graduate Medical Education’s 16th report or a recent proposal to Congress) will increase GME enough to offset the projected decline in head count. "GME funding has been capped since 1996," he said. "We’re setting forth a recipe for a very big problem that we’re going to have for future generations in terms of who’s going to take care of" a rapidly aging population.

As the Affordable Health Care Act takes shape, "one thing that’s not been considered adequately is physician supply," added Dr. Pruthi, chief of urologic surgery at the University of North Carolina at Chapel Hill. "Are there enough of us to help care for the population? That needs to be part of the calculus. We need to do efficient, appropriate care. We need to cut health care costs, but we have to remember our physician supply."

The shrinking number of urologists could affect mortality rates, as research has demonstrated an association between a higher density of urologists in a defined area and lower mortality from prostate, bladder, and kidney cancer. "As supply contracts, rural areas are likely to have an even greater loss of urologic surgeons since these areas have a higher percentage of surgeons closer to retirement age than urban areas," the researchers noted in their abstract. "The result may decrease access to screening, medical and surgical treatment for urologic conditions."

Dr. Pruthi acknowledged that the ability to predict physician demand is an imprecise science. However, "there is indirect data to suggest that our demand isn’t going to go away. It’s only going to go up with that rising incidence and with the rising number of aging baby boomers. Second, we don’t know the appropriate ratio of supply and demand. If you have limited supply, you have limited access. Is our culture accepting of that? Some of these limitations to access may have health consequences."

He and his associates plan to conduct more detailed work on the projection model, including the impact of increasing numbers of women entering the urology field. "About 5% of urologists are female, but in current residency matching the numbers are about 25% female," he said. "What impact will that have? We don’t know yet."

Dr. Pruthi said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – The number of urologists practicing in the United States is expected to decrease by 29% between 2009 and 2025, according to a new analysis.

"It’s one thing if the demand for urologists is going up and the supply is stable, but to have the demand go up and the supply almost falling off of a cliff is worrisome," Dr. Raj S. Pruthi said in an interview at the annual meeting of the American Urological Association. "The people who will be hardest hit by this are ones who already struggle with access: those who live in rural communities."

Dr. Pruthi and his colleagues used stock and flow models, starting with the supply of urologists in 2009. They added new entrants from the graduate medical education (GME) pipeline and subtracted attrition from training and from the workforce due to retirement or breaks from practice. The forecast model estimates a 29% head count reduction and a 25% decrease in the full-time equivalent (FTE) supply of urologists between 2009 and 2025. The projected decrease is more than four times greater than the Health Resources and Services Administration’s Physician Supply Model, which estimated a 7% decrease over the same time period.

Dr. Pruthi warned that none of the proposed changes to GME (recommendations from the Council of Graduate Medical Education’s 16th report or a recent proposal to Congress) will increase GME enough to offset the projected decline in head count. "GME funding has been capped since 1996," he said. "We’re setting forth a recipe for a very big problem that we’re going to have for future generations in terms of who’s going to take care of" a rapidly aging population.

As the Affordable Health Care Act takes shape, "one thing that’s not been considered adequately is physician supply," added Dr. Pruthi, chief of urologic surgery at the University of North Carolina at Chapel Hill. "Are there enough of us to help care for the population? That needs to be part of the calculus. We need to do efficient, appropriate care. We need to cut health care costs, but we have to remember our physician supply."

The shrinking number of urologists could affect mortality rates, as research has demonstrated an association between a higher density of urologists in a defined area and lower mortality from prostate, bladder, and kidney cancer. "As supply contracts, rural areas are likely to have an even greater loss of urologic surgeons since these areas have a higher percentage of surgeons closer to retirement age than urban areas," the researchers noted in their abstract. "The result may decrease access to screening, medical and surgical treatment for urologic conditions."

Dr. Pruthi acknowledged that the ability to predict physician demand is an imprecise science. However, "there is indirect data to suggest that our demand isn’t going to go away. It’s only going to go up with that rising incidence and with the rising number of aging baby boomers. Second, we don’t know the appropriate ratio of supply and demand. If you have limited supply, you have limited access. Is our culture accepting of that? Some of these limitations to access may have health consequences."

He and his associates plan to conduct more detailed work on the projection model, including the impact of increasing numbers of women entering the urology field. "About 5% of urologists are female, but in current residency matching the numbers are about 25% female," he said. "What impact will that have? We don’t know yet."

Dr. Pruthi said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – Adolescents who participated in a centering pregnancy program were more likely to obtain long-acting reversible contraception and were less likely to have postpartum depression, compared with their peers in two control groups, results from a single-center study demonstrated.

"Although the number of adolescent pregnancies each year has declined, it’s still a major issue facing our teens," Dr. Gayatri Chhatre said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"The United States has the highest teen pregnancy rate in the Western industrialized world, with 418,870 teen pregnancies in 2012 alone [Curr. Opin. Pediatr. 2012;24:446-52]. This is a huge problem because adolescents in pregnancy are at increased risk for adverse outcomes, including gestational morbidity and mortality, low-birth-weight infants, excessive weight gain in pregnancy, and most importantly, repeat unintended pregnancy," said Dr. Chhatre, a fourth-year resident at Washington (D.C.) Hospital Medical Center.

One way to address this issue, she said, is with centering pregnancy (CP), a program developed by nurse practitioner Sharon Schindler Rising in the 1990s. Dr. Chhatre described CP as "a model of care that aims to provide all components of prenatal care in one accessible process. Visits are divided into one-on-one time with providers, as well as group discussions with 8-12 women at similar gestational ages on various topics ranging from what to expect in pregnancy to what to expect postpartum and contraception options."

For the current study, Dr. Chhatre and her associates reviewed 150 adolescent females aged 21 years and younger who received prenatal care through the ob.gyn. clinics at the medical center between 2008 and 2012. Fifty of the patients participated in a CP program while patients in two other groups served as time- and age-matched controls: 50 who received single-provider prenatal care (SPPC) and 50 who received multiple-provider prenatal care (MPPC).

Outcome measures evaluated included weight gain during pregnancy, missed prenatal care appointments, feeding method, postpartum follow-up, and postpartum contraception. The researchers used chi-square analysis to compare outcomes between the three groups at a two-tailed alpha of 0.05.

Dr Chhatre reported that the only statistically significant difference in demographics was a slightly higher proportion of African American patients in the CP group than in the MPPC group (96 vs. 88%, respectively). No difference in preexisting medical conditions, nulliparous status, or substance abuse was observed among the three groups.

More than half of patients in the CP group (62%) met Institute of Medicine guidelines for weight gain during pregnancy, compared with 37% of those in the MPPC group and 40% of those in the SPPC group, a difference that was statistically significant compared with both control groups. However, there were no differences between the three groups in the rates of preterm delivery, cesarean section, or admission to the neonatal intensive care unit.

Adolescents in the SPPC group were more likely to solely breast-feed compared with those in the CP or MPPC groups (50% vs. 40% and 20%, respectively), while patients in the CP group were significantly more likely to include breast-feeding with their bottle-feeding compared with those in the MPPC or SPPC groups (32% vs. 14% and 10%, respectively). In addition, a significantly higher proportion of patients in the CP group were compliant with the 6-week postpartum visit compared with those in the SPPC group (68% vs. 42%; the rate for the MPPC group was 49%).

The researchers also found that patients in the CP group were significantly more likely to obtain postpartum long-acting reversible contraception than patients in the MPPC or SPPC groups (76% vs. 53% and 54%, respectively). Patients in the CP group also were significantly less likely to have a repeat pregnancy within 12 months than were patients in the MPPC group (2% vs. 17%).

Finally, no patients in the CP group received a diagnosis of postpartum depression, compared with 4% of those in the MPPC group and 2% of those in the SPPC group, a difference that reached statistical significance.

Dr. Chhatre said that she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – Adolescents who participated in a centering pregnancy program were more likely to obtain long-acting reversible contraception and were less likely to have postpartum depression, compared with their peers in two control groups, results from a single-center study demonstrated.

"Although the number of adolescent pregnancies each year has declined, it’s still a major issue facing our teens," Dr. Gayatri Chhatre said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"The United States has the highest teen pregnancy rate in the Western industrialized world, with 418,870 teen pregnancies in 2012 alone [Curr. Opin. Pediatr. 2012;24:446-52]. This is a huge problem because adolescents in pregnancy are at increased risk for adverse outcomes, including gestational morbidity and mortality, low-birth-weight infants, excessive weight gain in pregnancy, and most importantly, repeat unintended pregnancy," said Dr. Chhatre, a fourth-year resident at Washington (D.C.) Hospital Medical Center.

One way to address this issue, she said, is with centering pregnancy (CP), a program developed by nurse practitioner Sharon Schindler Rising in the 1990s. Dr. Chhatre described CP as "a model of care that aims to provide all components of prenatal care in one accessible process. Visits are divided into one-on-one time with providers, as well as group discussions with 8-12 women at similar gestational ages on various topics ranging from what to expect in pregnancy to what to expect postpartum and contraception options."

For the current study, Dr. Chhatre and her associates reviewed 150 adolescent females aged 21 years and younger who received prenatal care through the ob.gyn. clinics at the medical center between 2008 and 2012. Fifty of the patients participated in a CP program while patients in two other groups served as time- and age-matched controls: 50 who received single-provider prenatal care (SPPC) and 50 who received multiple-provider prenatal care (MPPC).

Outcome measures evaluated included weight gain during pregnancy, missed prenatal care appointments, feeding method, postpartum follow-up, and postpartum contraception. The researchers used chi-square analysis to compare outcomes between the three groups at a two-tailed alpha of 0.05.

Dr Chhatre reported that the only statistically significant difference in demographics was a slightly higher proportion of African American patients in the CP group than in the MPPC group (96 vs. 88%, respectively). No difference in preexisting medical conditions, nulliparous status, or substance abuse was observed among the three groups.

More than half of patients in the CP group (62%) met Institute of Medicine guidelines for weight gain during pregnancy, compared with 37% of those in the MPPC group and 40% of those in the SPPC group, a difference that was statistically significant compared with both control groups. However, there were no differences between the three groups in the rates of preterm delivery, cesarean section, or admission to the neonatal intensive care unit.

Adolescents in the SPPC group were more likely to solely breast-feed compared with those in the CP or MPPC groups (50% vs. 40% and 20%, respectively), while patients in the CP group were significantly more likely to include breast-feeding with their bottle-feeding compared with those in the MPPC or SPPC groups (32% vs. 14% and 10%, respectively). In addition, a significantly higher proportion of patients in the CP group were compliant with the 6-week postpartum visit compared with those in the SPPC group (68% vs. 42%; the rate for the MPPC group was 49%).

The researchers also found that patients in the CP group were significantly more likely to obtain postpartum long-acting reversible contraception than patients in the MPPC or SPPC groups (76% vs. 53% and 54%, respectively). Patients in the CP group also were significantly less likely to have a repeat pregnancy within 12 months than were patients in the MPPC group (2% vs. 17%).

Finally, no patients in the CP group received a diagnosis of postpartum depression, compared with 4% of those in the MPPC group and 2% of those in the SPPC group, a difference that reached statistical significance.

Dr. Chhatre said that she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – Adolescents who participated in a centering pregnancy program were more likely to obtain long-acting reversible contraception and were less likely to have postpartum depression, compared with their peers in two control groups, results from a single-center study demonstrated.

"Although the number of adolescent pregnancies each year has declined, it’s still a major issue facing our teens," Dr. Gayatri Chhatre said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"The United States has the highest teen pregnancy rate in the Western industrialized world, with 418,870 teen pregnancies in 2012 alone [Curr. Opin. Pediatr. 2012;24:446-52]. This is a huge problem because adolescents in pregnancy are at increased risk for adverse outcomes, including gestational morbidity and mortality, low-birth-weight infants, excessive weight gain in pregnancy, and most importantly, repeat unintended pregnancy," said Dr. Chhatre, a fourth-year resident at Washington (D.C.) Hospital Medical Center.

One way to address this issue, she said, is with centering pregnancy (CP), a program developed by nurse practitioner Sharon Schindler Rising in the 1990s. Dr. Chhatre described CP as "a model of care that aims to provide all components of prenatal care in one accessible process. Visits are divided into one-on-one time with providers, as well as group discussions with 8-12 women at similar gestational ages on various topics ranging from what to expect in pregnancy to what to expect postpartum and contraception options."

For the current study, Dr. Chhatre and her associates reviewed 150 adolescent females aged 21 years and younger who received prenatal care through the ob.gyn. clinics at the medical center between 2008 and 2012. Fifty of the patients participated in a CP program while patients in two other groups served as time- and age-matched controls: 50 who received single-provider prenatal care (SPPC) and 50 who received multiple-provider prenatal care (MPPC).

Outcome measures evaluated included weight gain during pregnancy, missed prenatal care appointments, feeding method, postpartum follow-up, and postpartum contraception. The researchers used chi-square analysis to compare outcomes between the three groups at a two-tailed alpha of 0.05.

Dr Chhatre reported that the only statistically significant difference in demographics was a slightly higher proportion of African American patients in the CP group than in the MPPC group (96 vs. 88%, respectively). No difference in preexisting medical conditions, nulliparous status, or substance abuse was observed among the three groups.

More than half of patients in the CP group (62%) met Institute of Medicine guidelines for weight gain during pregnancy, compared with 37% of those in the MPPC group and 40% of those in the SPPC group, a difference that was statistically significant compared with both control groups. However, there were no differences between the three groups in the rates of preterm delivery, cesarean section, or admission to the neonatal intensive care unit.

Adolescents in the SPPC group were more likely to solely breast-feed compared with those in the CP or MPPC groups (50% vs. 40% and 20%, respectively), while patients in the CP group were significantly more likely to include breast-feeding with their bottle-feeding compared with those in the MPPC or SPPC groups (32% vs. 14% and 10%, respectively). In addition, a significantly higher proportion of patients in the CP group were compliant with the 6-week postpartum visit compared with those in the SPPC group (68% vs. 42%; the rate for the MPPC group was 49%).

The researchers also found that patients in the CP group were significantly more likely to obtain postpartum long-acting reversible contraception than patients in the MPPC or SPPC groups (76% vs. 53% and 54%, respectively). Patients in the CP group also were significantly less likely to have a repeat pregnancy within 12 months than were patients in the MPPC group (2% vs. 17%).

Finally, no patients in the CP group received a diagnosis of postpartum depression, compared with 4% of those in the MPPC group and 2% of those in the SPPC group, a difference that reached statistical significance.

Dr. Chhatre said that she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – Adding hospitalist services is perhaps the most challenging of all the additional revenue opportunities for ED revenue stream expansion and diversification.

Part of the challenge is the differences in Relative Value Units (RVUs) between initial hospital care (CPT codes 99221-223) and subsequent hospital care (CPT codes 99231-33), Dr. Michael A. Granovsky said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

"If you have a 3-day hospital stay, you have 1 day of initial care and 2 days of subsequent care, and there’s a huge revenue difference," explained Dr. Granovsky, a reimbursement and coding expert who is president of Bedford, Mass.–based LogixHealth. For example, the 2013 CMS payment for CPT code 99221 (low-severity care provided within 30 minutes) is $99.34, compared with $38.11 for CPT code 99231 (patient is stable or recovering and the encounter takes 15 minutes or less). "When looking at a pro forma for a hospital medicine group [you want to know] what the length of stay is," said Dr Granovsky, who is also the editor of "ED Coding Alert."

Hospitalists are often called upon to provide a vast array of services, including providing critical care (CPT code 99291), putting in a central line (CPT code 36556), performing CPR (CPT code 92950), and intubation (CPT code 31500). Basic costs to setting up a hospitalist service include salary, benefits, malpractice insurance, and billing. "The hospitalists need some meaningful practice infrastructure in place as well," Dr. Granovsky noted. "Hospitalists need management or clerical support. With a little education it’s probably a good idea for the hospitalists to fill out a charge ticket for coding."

The main advantage to providing hospitalist services is to "further cement the relationship within the hospital and protect your ED contract," he said. "This can help you streamline and control the admission process."

Fully fee-for-service hospitalist groups frequently require a stipend and the typical payer might be 55% Medicare, 10% Medicaid, 12% commercial insurance, 13% Blue Cross Blue Shield, and 10% self-responsible. Hospitalists turn over an average of 60 patients per week, "which generates about $70,000/month in revenue, which would be equal to $840,000 in 1 year," Dr. Granovsky said. "However, it can cost as much as $970,000 in salary and benefits for six full-time physicians to cover services 24 hours per day. Add in vacations, billing services, malpractice insurance and other services, and you have a big gap between the $840,000 that comes in and the $970,000, which is the cost for just putting the providers in place. As a result, typical hospitalist services require a stipend of several hundred thousand dollars just to break even."

Other ED revenue stream expansion and diversification opportunities he discussed include the following:

• Urgent care centers. Dr. Granovsky characterized this as a volume-driven business that requires 22-25 patients/day for the provider to break even. The first step is choosing the right location for the center "because you are volume dependent, and the volume is dependent on foot traffic," he said. "A new urgent care center could compete with your ED Fast Track if it’s too close by. Don’t risk your own money for a de novo site based on a consultant’s estimate of potential patient volumes. I would be very conservative [in estimating your market potential] when it comes to patient volumes. Not only is your general location important, but you also need easy patient access and convenient parking. I have not seen one significantly successful urgent care clinic that was not on the first floor."

Urgent care centers fall into one of three place of service (POS) designations: POS 20 is described as an office or clinic other than an ED for unscheduled, ambulatory patients seeking immediate attention. POS 22 is an outpatient hospital clinic that is typically on the hospital’s cost report and POS 11 is a nonhospital setting where routine care such as health exams, diagnosis, and treatment is provided on an ambulatory basis.

Clinicians who practice in POS 20, POS 22, and POS 11 settings typically report the office/other outpatient codes 99201-99205 for new patients and 99211-99215 for established patients. "There is a 25%-30% decrease in reimbursement for the same ankle sprain, sore throat, or otitis media when you see them the second time as an established patient," said Dr. Granovsky, who chairs ACEP’s Coding and Nomenclature Committee. "So whenever you look at a pro forma and run financials for an urgent care center, you have to assume that your per-patient revenue is going to decrease over time because your case mix over time will move predominately to established patients."

Total urgent care start-up costs range from $600,000 to $800,000. Ongoing expenses include rent, personnel, practice management, legal accounting insurance, billing, equipment and maintenance. "Providing higher-acuity services – Level 3 and Level 4 ER services seems to be the trend right now," he said. "A typical site may generate $100-$120/visit."

The general recipe for success is to have 25 patient visits per day, which translates into about 600 patient visits per month, or $60,000/month in revenue. "Some combination of patient revenue based on your contracted rate and volume needs to exceed your fixed cost," Dr. Granovsky said. "Good payer contracts are key. Before you spend a lot of money to open an urgent care clinic, do a little research to find out what your contracted rates will be. If those rates are poor, you’ll never make your money back. Partnering with a hospital is a conservative way to do it."

• Freestanding EDs. These facilities are typically owned and operated by a hospital or by a group of emergency medicine physicians. The business model can be profitable but many states require a Certificate of Need (CON) process in order to open one. "Unless you are a hospital it’s very hard to get through the CON regulatory process," Dr. Granovsky emphasized. "It’s expensive, daunting, and the cards are stacked against you. But some states, including Texas, Arizona, and Colorado, don’t require a CON. That’s one of the reasons why freestanding emergency departments owned by entrepreneurial physicians have prospered in those states."

Freestanding EDs can perform pretty much all the essential functions of a hospital-based ED except admit patients. As in the case of urgent care centers, location determines your payer mix. They may or may not participate with Medicare and Medicaid. Some freestanding centers can break even with as few as 12 patients per day.

"A single patient can potentially generate more than $500, even more if the patient requires sophisticated ancillary testing," he said. "You typically need to have a couple of million dollars to get started. Large ED groups are typically ones pursuing this, or you need investor partnering."

Dr. Granovsky said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – Adding hospitalist services is perhaps the most challenging of all the additional revenue opportunities for ED revenue stream expansion and diversification.

Part of the challenge is the differences in Relative Value Units (RVUs) between initial hospital care (CPT codes 99221-223) and subsequent hospital care (CPT codes 99231-33), Dr. Michael A. Granovsky said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

"If you have a 3-day hospital stay, you have 1 day of initial care and 2 days of subsequent care, and there’s a huge revenue difference," explained Dr. Granovsky, a reimbursement and coding expert who is president of Bedford, Mass.–based LogixHealth. For example, the 2013 CMS payment for CPT code 99221 (low-severity care provided within 30 minutes) is $99.34, compared with $38.11 for CPT code 99231 (patient is stable or recovering and the encounter takes 15 minutes or less). "When looking at a pro forma for a hospital medicine group [you want to know] what the length of stay is," said Dr Granovsky, who is also the editor of "ED Coding Alert."

Hospitalists are often called upon to provide a vast array of services, including providing critical care (CPT code 99291), putting in a central line (CPT code 36556), performing CPR (CPT code 92950), and intubation (CPT code 31500). Basic costs to setting up a hospitalist service include salary, benefits, malpractice insurance, and billing. "The hospitalists need some meaningful practice infrastructure in place as well," Dr. Granovsky noted. "Hospitalists need management or clerical support. With a little education it’s probably a good idea for the hospitalists to fill out a charge ticket for coding."

The main advantage to providing hospitalist services is to "further cement the relationship within the hospital and protect your ED contract," he said. "This can help you streamline and control the admission process."

Fully fee-for-service hospitalist groups frequently require a stipend and the typical payer might be 55% Medicare, 10% Medicaid, 12% commercial insurance, 13% Blue Cross Blue Shield, and 10% self-responsible. Hospitalists turn over an average of 60 patients per week, "which generates about $70,000/month in revenue, which would be equal to $840,000 in 1 year," Dr. Granovsky said. "However, it can cost as much as $970,000 in salary and benefits for six full-time physicians to cover services 24 hours per day. Add in vacations, billing services, malpractice insurance and other services, and you have a big gap between the $840,000 that comes in and the $970,000, which is the cost for just putting the providers in place. As a result, typical hospitalist services require a stipend of several hundred thousand dollars just to break even."

Other ED revenue stream expansion and diversification opportunities he discussed include the following:

• Urgent care centers. Dr. Granovsky characterized this as a volume-driven business that requires 22-25 patients/day for the provider to break even. The first step is choosing the right location for the center "because you are volume dependent, and the volume is dependent on foot traffic," he said. "A new urgent care center could compete with your ED Fast Track if it’s too close by. Don’t risk your own money for a de novo site based on a consultant’s estimate of potential patient volumes. I would be very conservative [in estimating your market potential] when it comes to patient volumes. Not only is your general location important, but you also need easy patient access and convenient parking. I have not seen one significantly successful urgent care clinic that was not on the first floor."

Urgent care centers fall into one of three place of service (POS) designations: POS 20 is described as an office or clinic other than an ED for unscheduled, ambulatory patients seeking immediate attention. POS 22 is an outpatient hospital clinic that is typically on the hospital’s cost report and POS 11 is a nonhospital setting where routine care such as health exams, diagnosis, and treatment is provided on an ambulatory basis.

Clinicians who practice in POS 20, POS 22, and POS 11 settings typically report the office/other outpatient codes 99201-99205 for new patients and 99211-99215 for established patients. "There is a 25%-30% decrease in reimbursement for the same ankle sprain, sore throat, or otitis media when you see them the second time as an established patient," said Dr. Granovsky, who chairs ACEP’s Coding and Nomenclature Committee. "So whenever you look at a pro forma and run financials for an urgent care center, you have to assume that your per-patient revenue is going to decrease over time because your case mix over time will move predominately to established patients."

Total urgent care start-up costs range from $600,000 to $800,000. Ongoing expenses include rent, personnel, practice management, legal accounting insurance, billing, equipment and maintenance. "Providing higher-acuity services – Level 3 and Level 4 ER services seems to be the trend right now," he said. "A typical site may generate $100-$120/visit."

The general recipe for success is to have 25 patient visits per day, which translates into about 600 patient visits per month, or $60,000/month in revenue. "Some combination of patient revenue based on your contracted rate and volume needs to exceed your fixed cost," Dr. Granovsky said. "Good payer contracts are key. Before you spend a lot of money to open an urgent care clinic, do a little research to find out what your contracted rates will be. If those rates are poor, you’ll never make your money back. Partnering with a hospital is a conservative way to do it."

• Freestanding EDs. These facilities are typically owned and operated by a hospital or by a group of emergency medicine physicians. The business model can be profitable but many states require a Certificate of Need (CON) process in order to open one. "Unless you are a hospital it’s very hard to get through the CON regulatory process," Dr. Granovsky emphasized. "It’s expensive, daunting, and the cards are stacked against you. But some states, including Texas, Arizona, and Colorado, don’t require a CON. That’s one of the reasons why freestanding emergency departments owned by entrepreneurial physicians have prospered in those states."

Freestanding EDs can perform pretty much all the essential functions of a hospital-based ED except admit patients. As in the case of urgent care centers, location determines your payer mix. They may or may not participate with Medicare and Medicaid. Some freestanding centers can break even with as few as 12 patients per day.

"A single patient can potentially generate more than $500, even more if the patient requires sophisticated ancillary testing," he said. "You typically need to have a couple of million dollars to get started. Large ED groups are typically ones pursuing this, or you need investor partnering."

Dr. Granovsky said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – Adding hospitalist services is perhaps the most challenging of all the additional revenue opportunities for ED revenue stream expansion and diversification.

Part of the challenge is the differences in Relative Value Units (RVUs) between initial hospital care (CPT codes 99221-223) and subsequent hospital care (CPT codes 99231-33), Dr. Michael A. Granovsky said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

"If you have a 3-day hospital stay, you have 1 day of initial care and 2 days of subsequent care, and there’s a huge revenue difference," explained Dr. Granovsky, a reimbursement and coding expert who is president of Bedford, Mass.–based LogixHealth. For example, the 2013 CMS payment for CPT code 99221 (low-severity care provided within 30 minutes) is $99.34, compared with $38.11 for CPT code 99231 (patient is stable or recovering and the encounter takes 15 minutes or less). "When looking at a pro forma for a hospital medicine group [you want to know] what the length of stay is," said Dr Granovsky, who is also the editor of "ED Coding Alert."

Hospitalists are often called upon to provide a vast array of services, including providing critical care (CPT code 99291), putting in a central line (CPT code 36556), performing CPR (CPT code 92950), and intubation (CPT code 31500). Basic costs to setting up a hospitalist service include salary, benefits, malpractice insurance, and billing. "The hospitalists need some meaningful practice infrastructure in place as well," Dr. Granovsky noted. "Hospitalists need management or clerical support. With a little education it’s probably a good idea for the hospitalists to fill out a charge ticket for coding."

The main advantage to providing hospitalist services is to "further cement the relationship within the hospital and protect your ED contract," he said. "This can help you streamline and control the admission process."

Fully fee-for-service hospitalist groups frequently require a stipend and the typical payer might be 55% Medicare, 10% Medicaid, 12% commercial insurance, 13% Blue Cross Blue Shield, and 10% self-responsible. Hospitalists turn over an average of 60 patients per week, "which generates about $70,000/month in revenue, which would be equal to $840,000 in 1 year," Dr. Granovsky said. "However, it can cost as much as $970,000 in salary and benefits for six full-time physicians to cover services 24 hours per day. Add in vacations, billing services, malpractice insurance and other services, and you have a big gap between the $840,000 that comes in and the $970,000, which is the cost for just putting the providers in place. As a result, typical hospitalist services require a stipend of several hundred thousand dollars just to break even."

Other ED revenue stream expansion and diversification opportunities he discussed include the following:

• Urgent care centers. Dr. Granovsky characterized this as a volume-driven business that requires 22-25 patients/day for the provider to break even. The first step is choosing the right location for the center "because you are volume dependent, and the volume is dependent on foot traffic," he said. "A new urgent care center could compete with your ED Fast Track if it’s too close by. Don’t risk your own money for a de novo site based on a consultant’s estimate of potential patient volumes. I would be very conservative [in estimating your market potential] when it comes to patient volumes. Not only is your general location important, but you also need easy patient access and convenient parking. I have not seen one significantly successful urgent care clinic that was not on the first floor."

Urgent care centers fall into one of three place of service (POS) designations: POS 20 is described as an office or clinic other than an ED for unscheduled, ambulatory patients seeking immediate attention. POS 22 is an outpatient hospital clinic that is typically on the hospital’s cost report and POS 11 is a nonhospital setting where routine care such as health exams, diagnosis, and treatment is provided on an ambulatory basis.

Clinicians who practice in POS 20, POS 22, and POS 11 settings typically report the office/other outpatient codes 99201-99205 for new patients and 99211-99215 for established patients. "There is a 25%-30% decrease in reimbursement for the same ankle sprain, sore throat, or otitis media when you see them the second time as an established patient," said Dr. Granovsky, who chairs ACEP’s Coding and Nomenclature Committee. "So whenever you look at a pro forma and run financials for an urgent care center, you have to assume that your per-patient revenue is going to decrease over time because your case mix over time will move predominately to established patients."

Total urgent care start-up costs range from $600,000 to $800,000. Ongoing expenses include rent, personnel, practice management, legal accounting insurance, billing, equipment and maintenance. "Providing higher-acuity services – Level 3 and Level 4 ER services seems to be the trend right now," he said. "A typical site may generate $100-$120/visit."

The general recipe for success is to have 25 patient visits per day, which translates into about 600 patient visits per month, or $60,000/month in revenue. "Some combination of patient revenue based on your contracted rate and volume needs to exceed your fixed cost," Dr. Granovsky said. "Good payer contracts are key. Before you spend a lot of money to open an urgent care clinic, do a little research to find out what your contracted rates will be. If those rates are poor, you’ll never make your money back. Partnering with a hospital is a conservative way to do it."

• Freestanding EDs. These facilities are typically owned and operated by a hospital or by a group of emergency medicine physicians. The business model can be profitable but many states require a Certificate of Need (CON) process in order to open one. "Unless you are a hospital it’s very hard to get through the CON regulatory process," Dr. Granovsky emphasized. "It’s expensive, daunting, and the cards are stacked against you. But some states, including Texas, Arizona, and Colorado, don’t require a CON. That’s one of the reasons why freestanding emergency departments owned by entrepreneurial physicians have prospered in those states."

Freestanding EDs can perform pretty much all the essential functions of a hospital-based ED except admit patients. As in the case of urgent care centers, location determines your payer mix. They may or may not participate with Medicare and Medicaid. Some freestanding centers can break even with as few as 12 patients per day.

"A single patient can potentially generate more than $500, even more if the patient requires sophisticated ancillary testing," he said. "You typically need to have a couple of million dollars to get started. Large ED groups are typically ones pursuing this, or you need investor partnering."

Dr. Granovsky said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – Long-acting reversible contraceptive devices appear safe and effective for adolescents with congenital heart defects and cardiovascular disease, results from a retrospective case series demonstrated.

"Pregnancies can be complicated for patients with congenital cardiac defects," Dr. Anne-Marie Amies Oelschlager said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "Physiologic changes of pregnancy pose an increased risk of complications in women with congenital cardiac anomalies. We know that the levonorgestrel-releasing intrauterine system [LNG-IUS] is effective for heavy menstrual bleeding, endometriosis, and dysmenorrhea. Long-acting reversible contraceptive [LARC] methods also have minimal interaction with other medications, they’re not known to exacerbate hypertension, and they are not known to be thrombogenic."

In one published prospective study of 40 patients aged 20 and older with heart disease who used the copper intrauterine device, no cases of endocarditis occurred (Contraception 2008; 78:315-8). One patient had pelvic inflammatory disease, and there were no expulsions, pregnancies, or early removals other than those due to a desire for pregnancy.

"However, there is limited data regarding the safety and efficacy of LARCs in adolescents with congenital cardiac defects and cardiovascular disease," said Dr. Amies Oelschlager, director of pediatric and adolescent gynecology in the department of obstetrics and gynecology at the University of Washington, Seattle.

In an effort to evaluate the safety and efficacy of LARC methods in adolescents with cardiovascular conditions, she and her associates conducted a retrospective chart study of 30 patients with congenital cardiac anomalies or other cardiovascular disease who were aged 22 or younger and who had a LARC device placed at Seattle Children’s Hospital or at the University of Washington Medical Center between Jan. 1, 2007, and March 1, 2012. The average age on device insertion was 18 years, and 12 patients (40%) reported a previous pregnancy. Contraception was the most commonly cited reason for placement (73%), followed by heavy menstrual bleeding and menstrual suppression (20% each).

All but one of the patients had structural lesions. The most common was ventricular septal defect, which affected six patients (20%). There were also five patients with cardiomyopathy (17%). One patient had rheumatic heart disease, and one had familial tachyarrhythmia.

In the 30 patients studied, 31 devices were placed: 27 LNG IUS in 26 patients (1 patient experienced expulsion of the device and subsequently had another one placed), 1 copper IUD in 1 patient, and 3 etonogestrel implants in 3 patients.

Ten patients (33%) had their IUDs placed immediately after delivery or at their postpartum visit. For the remainder of the patients who did not have their IUDs placed post partum, nine of the IUDs were placed in the clinic (31%), and eight were placed in the operating room (28%).

There were no cases of endocarditis, but two patients experienced subsequent pregnancies. "One occurred 3 months post expulsion, in a patient who was not using a contraceptive," Dr. Amies Oelschlager noted. "The other [patient] had postpartum placement. However, the date of removal was not noted and was reported as a desired pregnancy. Our assumption from our review is that this was a case of a desired removal for a desired pregnancy."

The researchers observed no cases of pelvic inflammatory disease or pregnancies while the implants and IUDs were in place. Twenty-seven of the patients (90%) were continuing LARC use at last follow-up.

Dr. Amies Oelschlager acknowledged certain limitations of the study, including its retrospective design and the potential for selection bias. Also, the duration of IUD use was less than 5 years, and the duration of etonogestrel implant use was less than 3 years. "So we don’t know what the expulsion rates would be farther out, and we don’t know if there will be a higher rate of contraceptive failure in the later years using these devices," she said. For now, "we recommend close monitoring and follow-up with these patients to confirm that their rate of expulsion is low and that they’re receiving adequate contraception."

Dr. Amies Oelschlager said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – Long-acting reversible contraceptive devices appear safe and effective for adolescents with congenital heart defects and cardiovascular disease, results from a retrospective case series demonstrated.

"Pregnancies can be complicated for patients with congenital cardiac defects," Dr. Anne-Marie Amies Oelschlager said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "Physiologic changes of pregnancy pose an increased risk of complications in women with congenital cardiac anomalies. We know that the levonorgestrel-releasing intrauterine system [LNG-IUS] is effective for heavy menstrual bleeding, endometriosis, and dysmenorrhea. Long-acting reversible contraceptive [LARC] methods also have minimal interaction with other medications, they’re not known to exacerbate hypertension, and they are not known to be thrombogenic."

In one published prospective study of 40 patients aged 20 and older with heart disease who used the copper intrauterine device, no cases of endocarditis occurred (Contraception 2008; 78:315-8). One patient had pelvic inflammatory disease, and there were no expulsions, pregnancies, or early removals other than those due to a desire for pregnancy.

"However, there is limited data regarding the safety and efficacy of LARCs in adolescents with congenital cardiac defects and cardiovascular disease," said Dr. Amies Oelschlager, director of pediatric and adolescent gynecology in the department of obstetrics and gynecology at the University of Washington, Seattle.

In an effort to evaluate the safety and efficacy of LARC methods in adolescents with cardiovascular conditions, she and her associates conducted a retrospective chart study of 30 patients with congenital cardiac anomalies or other cardiovascular disease who were aged 22 or younger and who had a LARC device placed at Seattle Children’s Hospital or at the University of Washington Medical Center between Jan. 1, 2007, and March 1, 2012. The average age on device insertion was 18 years, and 12 patients (40%) reported a previous pregnancy. Contraception was the most commonly cited reason for placement (73%), followed by heavy menstrual bleeding and menstrual suppression (20% each).

All but one of the patients had structural lesions. The most common was ventricular septal defect, which affected six patients (20%). There were also five patients with cardiomyopathy (17%). One patient had rheumatic heart disease, and one had familial tachyarrhythmia.

In the 30 patients studied, 31 devices were placed: 27 LNG IUS in 26 patients (1 patient experienced expulsion of the device and subsequently had another one placed), 1 copper IUD in 1 patient, and 3 etonogestrel implants in 3 patients.

Ten patients (33%) had their IUDs placed immediately after delivery or at their postpartum visit. For the remainder of the patients who did not have their IUDs placed post partum, nine of the IUDs were placed in the clinic (31%), and eight were placed in the operating room (28%).

There were no cases of endocarditis, but two patients experienced subsequent pregnancies. "One occurred 3 months post expulsion, in a patient who was not using a contraceptive," Dr. Amies Oelschlager noted. "The other [patient] had postpartum placement. However, the date of removal was not noted and was reported as a desired pregnancy. Our assumption from our review is that this was a case of a desired removal for a desired pregnancy."

The researchers observed no cases of pelvic inflammatory disease or pregnancies while the implants and IUDs were in place. Twenty-seven of the patients (90%) were continuing LARC use at last follow-up.

Dr. Amies Oelschlager acknowledged certain limitations of the study, including its retrospective design and the potential for selection bias. Also, the duration of IUD use was less than 5 years, and the duration of etonogestrel implant use was less than 3 years. "So we don’t know what the expulsion rates would be farther out, and we don’t know if there will be a higher rate of contraceptive failure in the later years using these devices," she said. For now, "we recommend close monitoring and follow-up with these patients to confirm that their rate of expulsion is low and that they’re receiving adequate contraception."

Dr. Amies Oelschlager said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – Long-acting reversible contraceptive devices appear safe and effective for adolescents with congenital heart defects and cardiovascular disease, results from a retrospective case series demonstrated.

"Pregnancies can be complicated for patients with congenital cardiac defects," Dr. Anne-Marie Amies Oelschlager said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "Physiologic changes of pregnancy pose an increased risk of complications in women with congenital cardiac anomalies. We know that the levonorgestrel-releasing intrauterine system [LNG-IUS] is effective for heavy menstrual bleeding, endometriosis, and dysmenorrhea. Long-acting reversible contraceptive [LARC] methods also have minimal interaction with other medications, they’re not known to exacerbate hypertension, and they are not known to be thrombogenic."

In one published prospective study of 40 patients aged 20 and older with heart disease who used the copper intrauterine device, no cases of endocarditis occurred (Contraception 2008; 78:315-8). One patient had pelvic inflammatory disease, and there were no expulsions, pregnancies, or early removals other than those due to a desire for pregnancy.

"However, there is limited data regarding the safety and efficacy of LARCs in adolescents with congenital cardiac defects and cardiovascular disease," said Dr. Amies Oelschlager, director of pediatric and adolescent gynecology in the department of obstetrics and gynecology at the University of Washington, Seattle.

In an effort to evaluate the safety and efficacy of LARC methods in adolescents with cardiovascular conditions, she and her associates conducted a retrospective chart study of 30 patients with congenital cardiac anomalies or other cardiovascular disease who were aged 22 or younger and who had a LARC device placed at Seattle Children’s Hospital or at the University of Washington Medical Center between Jan. 1, 2007, and March 1, 2012. The average age on device insertion was 18 years, and 12 patients (40%) reported a previous pregnancy. Contraception was the most commonly cited reason for placement (73%), followed by heavy menstrual bleeding and menstrual suppression (20% each).

All but one of the patients had structural lesions. The most common was ventricular septal defect, which affected six patients (20%). There were also five patients with cardiomyopathy (17%). One patient had rheumatic heart disease, and one had familial tachyarrhythmia.

In the 30 patients studied, 31 devices were placed: 27 LNG IUS in 26 patients (1 patient experienced expulsion of the device and subsequently had another one placed), 1 copper IUD in 1 patient, and 3 etonogestrel implants in 3 patients.

Ten patients (33%) had their IUDs placed immediately after delivery or at their postpartum visit. For the remainder of the patients who did not have their IUDs placed post partum, nine of the IUDs were placed in the clinic (31%), and eight were placed in the operating room (28%).

There were no cases of endocarditis, but two patients experienced subsequent pregnancies. "One occurred 3 months post expulsion, in a patient who was not using a contraceptive," Dr. Amies Oelschlager noted. "The other [patient] had postpartum placement. However, the date of removal was not noted and was reported as a desired pregnancy. Our assumption from our review is that this was a case of a desired removal for a desired pregnancy."

The researchers observed no cases of pelvic inflammatory disease or pregnancies while the implants and IUDs were in place. Twenty-seven of the patients (90%) were continuing LARC use at last follow-up.

Dr. Amies Oelschlager acknowledged certain limitations of the study, including its retrospective design and the potential for selection bias. Also, the duration of IUD use was less than 5 years, and the duration of etonogestrel implant use was less than 3 years. "So we don’t know what the expulsion rates would be farther out, and we don’t know if there will be a higher rate of contraceptive failure in the later years using these devices," she said. For now, "we recommend close monitoring and follow-up with these patients to confirm that their rate of expulsion is low and that they’re receiving adequate contraception."

Dr. Amies Oelschlager said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – In the opinion of Dr. Kirk B. Jensen, efforts to maximize patient throughput in the emergency medicine department are crucial.

A critical driver in patient satisfaction is how much time it takes for a patient to see a physician upon arrival. "I am not saying that the physician is the most important person in the equation in the emergency department, but from an operational standpoint the goal in your emergency department is to get the physician and the patient together as quickly as possible," Dr. Jensen said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

Patient satisfaction surveys are another driver. "We can quibble with the methodology of patient satisfaction surveys but they are clearly here [to stay] and they command our attention and measure our performance," said Dr. Jensen, chief medical officer at Raleigh, N.C.–based BestPractices, a division of EmCare, which provides ED management and staffing solutions. "Patient satisfaction declines as a function of time spent in the ED. The more time people spend with us, the less happy they are."

Another reason to pay attention to patient flow is the threat of malpractice. One review of wait times and claims per 25,000 patient visits at 36 emergency departments in California found that patients who waited more than 60 minutes to be seen were more than four times as likely to file a malpractice claim, compared with those who waited less than 30 minutes. "The longer it takes to see the physician, the more likely you are to get sued," said Dr. Jensen, who was not involved with the study. "There’s a direct, linear correlation. So when you want to get the attention of people on your ED team to rally around throughput and rally around improving productivity, you can always use data on malpractice and the risk of getting sued as a driver for changing behavior."

There is also a financial case for improving patient throughput in the ED. One ED in which Dr. Jensen assisted as a consultant had 40,000 patient visits per year and set out to reduce the average length of stay from 3 hours to 2 hours. "This generated 40,000 hours of new service delivery which meant a potential to see 20,000 more patients," he said. "If your average net revenue is $100 per patient and you can see 20,000 more patients, that creates $2 million in additional revenue for your physician practice and three to five times that for the hospital."

He advises clinicians to think about the path of an ED patient as having a beginning, a middle, and an end, and to look for ways to improve throughput at each juncture. In his experience, the points with the greatest leverage for throughput improvements are on the front end and at the back end. He described the front end as "the fly wheel that makes your ED hum. Focusing on those processes and that operation is critical to getting the kind of patient flow and throughput that you want. There are also opportunities on the back end, especially for those of us who have problems getting patients admitted to the hospital. This requires cooperation from the inpatient members of your team. My recommendation is to start with the front end, achieve some throughput improvement there, and then you are more likely to get the attention and support from hospital administration when you work on the back end."

Dr. Jensen described triage as "a process, not a place. It’s something we do. In a perfect world, triage consists of asking the patient’s name, eliciting a 2- or 3-sentence chief complaint, a set of vital signs, maybe a pain score, and that’s it. It is not a place to do medication reconciliation or to assess and teach about the need for vaccinations."

He advises clinicians to segment ED patients into vertical or horizontal categories. "The horizontal patients are the reason many of us went into emergency medicine in the first place: they’re hurt, sick, or there’s the potential for something seriously wrong," Dr. Jensen explained. "The vertical patients have simple, well-defined illnesses or injuries. We want patients with ankle sprains to get through the ED in 1-2 hours. At the same time, when an 80-year-old gentleman comes in with acute severe abdominal pain, if it takes us 6-8 hours to work up that patient, that’s a good thing. We are providing value-added diagnostic, therapeutic, and observational services. This is about understanding patient flow, segmenting your incoming patient streams, and mapping your care to the needs of those patients."

The goal is to "keep your vertical patients vertical and in motion," he continued. "For horizontal, badly sick, or badly hurt patients, it’s about real estate. You only want patients in beds who need beds, and you want them in beds only for as long as they need to be."

Dr. Jensen concluded by noting that there is no substitute for testing and prototyping a change in throughput process or performance. "You want to test your performance improvement efforts on a small scale, work out the bugs, build the collaboration of your teammates, get the data, and then go to hospital administration [for the support you may require]," he said.

Dr. Jensen said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – In the opinion of Dr. Kirk B. Jensen, efforts to maximize patient throughput in the emergency medicine department are crucial.

A critical driver in patient satisfaction is how much time it takes for a patient to see a physician upon arrival. "I am not saying that the physician is the most important person in the equation in the emergency department, but from an operational standpoint the goal in your emergency department is to get the physician and the patient together as quickly as possible," Dr. Jensen said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

Patient satisfaction surveys are another driver. "We can quibble with the methodology of patient satisfaction surveys but they are clearly here [to stay] and they command our attention and measure our performance," said Dr. Jensen, chief medical officer at Raleigh, N.C.–based BestPractices, a division of EmCare, which provides ED management and staffing solutions. "Patient satisfaction declines as a function of time spent in the ED. The more time people spend with us, the less happy they are."

Another reason to pay attention to patient flow is the threat of malpractice. One review of wait times and claims per 25,000 patient visits at 36 emergency departments in California found that patients who waited more than 60 minutes to be seen were more than four times as likely to file a malpractice claim, compared with those who waited less than 30 minutes. "The longer it takes to see the physician, the more likely you are to get sued," said Dr. Jensen, who was not involved with the study. "There’s a direct, linear correlation. So when you want to get the attention of people on your ED team to rally around throughput and rally around improving productivity, you can always use data on malpractice and the risk of getting sued as a driver for changing behavior."

There is also a financial case for improving patient throughput in the ED. One ED in which Dr. Jensen assisted as a consultant had 40,000 patient visits per year and set out to reduce the average length of stay from 3 hours to 2 hours. "This generated 40,000 hours of new service delivery which meant a potential to see 20,000 more patients," he said. "If your average net revenue is $100 per patient and you can see 20,000 more patients, that creates $2 million in additional revenue for your physician practice and three to five times that for the hospital."

He advises clinicians to think about the path of an ED patient as having a beginning, a middle, and an end, and to look for ways to improve throughput at each juncture. In his experience, the points with the greatest leverage for throughput improvements are on the front end and at the back end. He described the front end as "the fly wheel that makes your ED hum. Focusing on those processes and that operation is critical to getting the kind of patient flow and throughput that you want. There are also opportunities on the back end, especially for those of us who have problems getting patients admitted to the hospital. This requires cooperation from the inpatient members of your team. My recommendation is to start with the front end, achieve some throughput improvement there, and then you are more likely to get the attention and support from hospital administration when you work on the back end."

Dr. Jensen described triage as "a process, not a place. It’s something we do. In a perfect world, triage consists of asking the patient’s name, eliciting a 2- or 3-sentence chief complaint, a set of vital signs, maybe a pain score, and that’s it. It is not a place to do medication reconciliation or to assess and teach about the need for vaccinations."

He advises clinicians to segment ED patients into vertical or horizontal categories. "The horizontal patients are the reason many of us went into emergency medicine in the first place: they’re hurt, sick, or there’s the potential for something seriously wrong," Dr. Jensen explained. "The vertical patients have simple, well-defined illnesses or injuries. We want patients with ankle sprains to get through the ED in 1-2 hours. At the same time, when an 80-year-old gentleman comes in with acute severe abdominal pain, if it takes us 6-8 hours to work up that patient, that’s a good thing. We are providing value-added diagnostic, therapeutic, and observational services. This is about understanding patient flow, segmenting your incoming patient streams, and mapping your care to the needs of those patients."

The goal is to "keep your vertical patients vertical and in motion," he continued. "For horizontal, badly sick, or badly hurt patients, it’s about real estate. You only want patients in beds who need beds, and you want them in beds only for as long as they need to be."

Dr. Jensen concluded by noting that there is no substitute for testing and prototyping a change in throughput process or performance. "You want to test your performance improvement efforts on a small scale, work out the bugs, build the collaboration of your teammates, get the data, and then go to hospital administration [for the support you may require]," he said.

Dr. Jensen said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

SAN DIEGO – In the opinion of Dr. Kirk B. Jensen, efforts to maximize patient throughput in the emergency medicine department are crucial.

A critical driver in patient satisfaction is how much time it takes for a patient to see a physician upon arrival. "I am not saying that the physician is the most important person in the equation in the emergency department, but from an operational standpoint the goal in your emergency department is to get the physician and the patient together as quickly as possible," Dr. Jensen said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

Patient satisfaction surveys are another driver. "We can quibble with the methodology of patient satisfaction surveys but they are clearly here [to stay] and they command our attention and measure our performance," said Dr. Jensen, chief medical officer at Raleigh, N.C.–based BestPractices, a division of EmCare, which provides ED management and staffing solutions. "Patient satisfaction declines as a function of time spent in the ED. The more time people spend with us, the less happy they are."

Another reason to pay attention to patient flow is the threat of malpractice. One review of wait times and claims per 25,000 patient visits at 36 emergency departments in California found that patients who waited more than 60 minutes to be seen were more than four times as likely to file a malpractice claim, compared with those who waited less than 30 minutes. "The longer it takes to see the physician, the more likely you are to get sued," said Dr. Jensen, who was not involved with the study. "There’s a direct, linear correlation. So when you want to get the attention of people on your ED team to rally around throughput and rally around improving productivity, you can always use data on malpractice and the risk of getting sued as a driver for changing behavior."

There is also a financial case for improving patient throughput in the ED. One ED in which Dr. Jensen assisted as a consultant had 40,000 patient visits per year and set out to reduce the average length of stay from 3 hours to 2 hours. "This generated 40,000 hours of new service delivery which meant a potential to see 20,000 more patients," he said. "If your average net revenue is $100 per patient and you can see 20,000 more patients, that creates $2 million in additional revenue for your physician practice and three to five times that for the hospital."

He advises clinicians to think about the path of an ED patient as having a beginning, a middle, and an end, and to look for ways to improve throughput at each juncture. In his experience, the points with the greatest leverage for throughput improvements are on the front end and at the back end. He described the front end as "the fly wheel that makes your ED hum. Focusing on those processes and that operation is critical to getting the kind of patient flow and throughput that you want. There are also opportunities on the back end, especially for those of us who have problems getting patients admitted to the hospital. This requires cooperation from the inpatient members of your team. My recommendation is to start with the front end, achieve some throughput improvement there, and then you are more likely to get the attention and support from hospital administration when you work on the back end."

Dr. Jensen described triage as "a process, not a place. It’s something we do. In a perfect world, triage consists of asking the patient’s name, eliciting a 2- or 3-sentence chief complaint, a set of vital signs, maybe a pain score, and that’s it. It is not a place to do medication reconciliation or to assess and teach about the need for vaccinations."

He advises clinicians to segment ED patients into vertical or horizontal categories. "The horizontal patients are the reason many of us went into emergency medicine in the first place: they’re hurt, sick, or there’s the potential for something seriously wrong," Dr. Jensen explained. "The vertical patients have simple, well-defined illnesses or injuries. We want patients with ankle sprains to get through the ED in 1-2 hours. At the same time, when an 80-year-old gentleman comes in with acute severe abdominal pain, if it takes us 6-8 hours to work up that patient, that’s a good thing. We are providing value-added diagnostic, therapeutic, and observational services. This is about understanding patient flow, segmenting your incoming patient streams, and mapping your care to the needs of those patients."

The goal is to "keep your vertical patients vertical and in motion," he continued. "For horizontal, badly sick, or badly hurt patients, it’s about real estate. You only want patients in beds who need beds, and you want them in beds only for as long as they need to be."

Dr. Jensen concluded by noting that there is no substitute for testing and prototyping a change in throughput process or performance. "You want to test your performance improvement efforts on a small scale, work out the bugs, build the collaboration of your teammates, get the data, and then go to hospital administration [for the support you may require]," he said.

Dr. Jensen said that he had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com