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Critical Care Commentary: Highlights from the 2016 hospital-acquired and ventilator-associated pneumonia guideline
The 2016 hospital-acquired and ventilator-associated pneumonia guidelines, sponsored by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS), and endorsed by the American College of Chest Physicians (CHEST), Society of Critical Care Medicine (SCCM), and the Society for Healthcare Epidemiology, was published recently (Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63[5]:575-82).
This Critical Care Commentary aims to provide the highlights of the new guideline and to motivate readers to read the complete report that best represents the primary intent of the guideline panelists.
The new guideline was written using the Grading of Recommendations Assessment, Development, and Evaluation methodology. This was the framework to address all clinical questions referred to as PICOs (patient; intervention; comparator; outcome), which can be explicitly seen in the published guideline. For every PICO question, the wording “we suggest” was used for a weak recommendation (lack of high confidence; further evidence could change it), and “we recommend” was used for a strong recommendation (high confidence; further evidence is unlikely to change it). Also, part of the panel framework was the requirement to disclose any actual, potential, or perceived conflicts of interest for each panelist to be accepted to participate, as well as to remain in the panel for the duration of the process. The cochairs remained free of any financial conflicts during the entire process.
Choosing an empiric antibiotic regimen for patients with HAP and VAP requires balancing the potentially competing goals of ensuring that likely infecting pathogens are covered while avoiding excess antibiotic use. In order to guide clinicians on empiric antibiotic therapy, the panel performed a comprehensive review of the potential risk factors for HAP and VAP. For VAP, three factors associated with disease severity (septic shock at time of VAP, ARDS preceding VAP, and acute renal replacement prior to VAP onset) and two epidemiologic factors (prior use of IV antibiotic use within 90 days, and 5 or more days of hospitalization prior to the occurrence of VAP) made the final risk factors list. For HAP, only the prior use of IV antibiotics within 90 days was associated with risk for MDR. However, because of the limitations and small number of studies on HAP only, the panel decided to add risk factors for mortality (ventilator support for HAP and septic shock) as surrogates for MDR risk factors in patients with HAP, as these factors presumably increase the risk of poor outcomes if there is initial inadequate empiric therapy.
In conjunction with the bedside evaluation of risk factors for MDR, the guideline recommends the use of local antibiograms not only to guide empiric therapy but also to decide if antibiotic coverage for MDR is needed. Ideally, the antibiogram should be based on the specific ICU, but if this is not feasible, or the hospital is of small size, an institutional antibiogram can also be helpful. The first benefit of local antibiograms is derived from the knowledge gained regarding the prevalence of each microorganism; for example, if only 3% of all VAP or HAP in a given unit or hospital is caused by Pseudomonas aeruginosa, it is likely that an empiric coverage for this microorganism will neither be necessary nor appropriate for most patients. The second benefit is derived from the knowledge concerning the frequency of MDR microorganisms within the unit or hospital: for example, patients with VAP in units where 10%-20% of Staphylococcus aureus isolates are resistant to methicillin, or greater than 10% of gram-negative isolates are resistant to an agent being considered for monotherapy, should receive antibiotics for MDR infections. With these two critical pieces of information, the clinician will have a higher probability of starting the correct empiric antibiotics, and, consequently, improve the survival outcomes of patients with HAP and VAP.
The choice of the empirical treatment of VAP and HAP becomes a natural derivation of the three main factors discussed above: (1) epidemiologic history of antibiotics’ use and prior hospitalization length, (2) local antibiogram for the prevalence and resistance of microorganisms, and (3) disease severity and risk of mortality by the identification of septic shock, ARDS, and acute renal replacement therapy. For example, if 17% of all VAPs in your unit is from P aeruginosa (which is the national prevalence in patients with VAP), and 8% of these strains are resistant to an agent being considered for gram-negative monotherapy, not prescribing double coverage for P aeruginosa would still result in initial appropriate therapy in 98.6% (derived from 1-[0.17 x 0.08]) of cases. The reason why the panelists chose the threshold of 10% for P aeruginosa, and 10%-20% for S aureus, was based on the national prevalence rates reported by the Centers for Disease Control and Prevention, with the goal of limiting the initial inappropriate antibiotic therapy decision to less than 5% of all cases. We strongly believe that this “epidemiologic/antibiogram/disease severity” approach to select the empiric therapy is both clinically intuitive and essential to improve patients’ outcomes. Further, this approach will substantially reduce the unnecessary use of double antibiotic therapy in patients with VAP or HAP.
This guideline suggests that the use of inhaled antibiotic therapy in conjunction with IV antibiotics may benefit patients with VAP or HAP from MDR microorganisms that are sensitive to only polymyxins or aminoglycosides. The panel also suggested that the use of pharmacokinetic and pharmacodynamics should be used to optimize the administration of antibiotic therapy for all patients with HAP or VAP.
Last, after an extensive review and multiple analyses of all available evidence, the panel concluded that the majority of patients with HAP or VAP should be treated with 7 days of therapy, independent of the microorganism causing the pneumonia. In several meta-analyses performed by the panelists to evaluate all patients with VAP, as well as only patients with VAP caused by nonfermenting gram-negative organisms such as Pseudomonas species, Stenotrophomonas species, and Acinetobacter species, the panel did not find differences between short and long courses of antibiotics regarding mortality, clinical cure, pneumonia recurrence, and mechanical ventilation duration. In recognition of the individual needs of each patient, we made a remark that shorter or longer duration of antibiotics may be indicated, depending upon the rate of improvement of clinical, radiologic, and laboratory parameters. Several adjunctive methods of deescalation were assessed, but only procalcitonin was suggested to aid health care providers to shorten the course of antibiotic therapy.
In conclusion, the authors of this 2016 HAP/VAP IDSA/ATS guideline hope to achieve the ultimate goal of improving the treatment and outcomes of patients with HAP and VAP and reducing unnecessary antibiotic use.
Dr. Kalil is with the department of internal medicine, division of infectious diseases, University of Nebraska Medical Center, Omaha; Dr. Metersky is with the division of pulmonary and critical care medicine, University of Connecticut, Farmington.
The 2016 hospital-acquired and ventilator-associated pneumonia guidelines, sponsored by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS), and endorsed by the American College of Chest Physicians (CHEST), Society of Critical Care Medicine (SCCM), and the Society for Healthcare Epidemiology, was published recently (Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63[5]:575-82).
This Critical Care Commentary aims to provide the highlights of the new guideline and to motivate readers to read the complete report that best represents the primary intent of the guideline panelists.
The new guideline was written using the Grading of Recommendations Assessment, Development, and Evaluation methodology. This was the framework to address all clinical questions referred to as PICOs (patient; intervention; comparator; outcome), which can be explicitly seen in the published guideline. For every PICO question, the wording “we suggest” was used for a weak recommendation (lack of high confidence; further evidence could change it), and “we recommend” was used for a strong recommendation (high confidence; further evidence is unlikely to change it). Also, part of the panel framework was the requirement to disclose any actual, potential, or perceived conflicts of interest for each panelist to be accepted to participate, as well as to remain in the panel for the duration of the process. The cochairs remained free of any financial conflicts during the entire process.
Choosing an empiric antibiotic regimen for patients with HAP and VAP requires balancing the potentially competing goals of ensuring that likely infecting pathogens are covered while avoiding excess antibiotic use. In order to guide clinicians on empiric antibiotic therapy, the panel performed a comprehensive review of the potential risk factors for HAP and VAP. For VAP, three factors associated with disease severity (septic shock at time of VAP, ARDS preceding VAP, and acute renal replacement prior to VAP onset) and two epidemiologic factors (prior use of IV antibiotic use within 90 days, and 5 or more days of hospitalization prior to the occurrence of VAP) made the final risk factors list. For HAP, only the prior use of IV antibiotics within 90 days was associated with risk for MDR. However, because of the limitations and small number of studies on HAP only, the panel decided to add risk factors for mortality (ventilator support for HAP and septic shock) as surrogates for MDR risk factors in patients with HAP, as these factors presumably increase the risk of poor outcomes if there is initial inadequate empiric therapy.
In conjunction with the bedside evaluation of risk factors for MDR, the guideline recommends the use of local antibiograms not only to guide empiric therapy but also to decide if antibiotic coverage for MDR is needed. Ideally, the antibiogram should be based on the specific ICU, but if this is not feasible, or the hospital is of small size, an institutional antibiogram can also be helpful. The first benefit of local antibiograms is derived from the knowledge gained regarding the prevalence of each microorganism; for example, if only 3% of all VAP or HAP in a given unit or hospital is caused by Pseudomonas aeruginosa, it is likely that an empiric coverage for this microorganism will neither be necessary nor appropriate for most patients. The second benefit is derived from the knowledge concerning the frequency of MDR microorganisms within the unit or hospital: for example, patients with VAP in units where 10%-20% of Staphylococcus aureus isolates are resistant to methicillin, or greater than 10% of gram-negative isolates are resistant to an agent being considered for monotherapy, should receive antibiotics for MDR infections. With these two critical pieces of information, the clinician will have a higher probability of starting the correct empiric antibiotics, and, consequently, improve the survival outcomes of patients with HAP and VAP.
The choice of the empirical treatment of VAP and HAP becomes a natural derivation of the three main factors discussed above: (1) epidemiologic history of antibiotics’ use and prior hospitalization length, (2) local antibiogram for the prevalence and resistance of microorganisms, and (3) disease severity and risk of mortality by the identification of septic shock, ARDS, and acute renal replacement therapy. For example, if 17% of all VAPs in your unit is from P aeruginosa (which is the national prevalence in patients with VAP), and 8% of these strains are resistant to an agent being considered for gram-negative monotherapy, not prescribing double coverage for P aeruginosa would still result in initial appropriate therapy in 98.6% (derived from 1-[0.17 x 0.08]) of cases. The reason why the panelists chose the threshold of 10% for P aeruginosa, and 10%-20% for S aureus, was based on the national prevalence rates reported by the Centers for Disease Control and Prevention, with the goal of limiting the initial inappropriate antibiotic therapy decision to less than 5% of all cases. We strongly believe that this “epidemiologic/antibiogram/disease severity” approach to select the empiric therapy is both clinically intuitive and essential to improve patients’ outcomes. Further, this approach will substantially reduce the unnecessary use of double antibiotic therapy in patients with VAP or HAP.
This guideline suggests that the use of inhaled antibiotic therapy in conjunction with IV antibiotics may benefit patients with VAP or HAP from MDR microorganisms that are sensitive to only polymyxins or aminoglycosides. The panel also suggested that the use of pharmacokinetic and pharmacodynamics should be used to optimize the administration of antibiotic therapy for all patients with HAP or VAP.
Last, after an extensive review and multiple analyses of all available evidence, the panel concluded that the majority of patients with HAP or VAP should be treated with 7 days of therapy, independent of the microorganism causing the pneumonia. In several meta-analyses performed by the panelists to evaluate all patients with VAP, as well as only patients with VAP caused by nonfermenting gram-negative organisms such as Pseudomonas species, Stenotrophomonas species, and Acinetobacter species, the panel did not find differences between short and long courses of antibiotics regarding mortality, clinical cure, pneumonia recurrence, and mechanical ventilation duration. In recognition of the individual needs of each patient, we made a remark that shorter or longer duration of antibiotics may be indicated, depending upon the rate of improvement of clinical, radiologic, and laboratory parameters. Several adjunctive methods of deescalation were assessed, but only procalcitonin was suggested to aid health care providers to shorten the course of antibiotic therapy.
In conclusion, the authors of this 2016 HAP/VAP IDSA/ATS guideline hope to achieve the ultimate goal of improving the treatment and outcomes of patients with HAP and VAP and reducing unnecessary antibiotic use.
Dr. Kalil is with the department of internal medicine, division of infectious diseases, University of Nebraska Medical Center, Omaha; Dr. Metersky is with the division of pulmonary and critical care medicine, University of Connecticut, Farmington.
The 2016 hospital-acquired and ventilator-associated pneumonia guidelines, sponsored by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS), and endorsed by the American College of Chest Physicians (CHEST), Society of Critical Care Medicine (SCCM), and the Society for Healthcare Epidemiology, was published recently (Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63[5]:575-82).
This Critical Care Commentary aims to provide the highlights of the new guideline and to motivate readers to read the complete report that best represents the primary intent of the guideline panelists.
The new guideline was written using the Grading of Recommendations Assessment, Development, and Evaluation methodology. This was the framework to address all clinical questions referred to as PICOs (patient; intervention; comparator; outcome), which can be explicitly seen in the published guideline. For every PICO question, the wording “we suggest” was used for a weak recommendation (lack of high confidence; further evidence could change it), and “we recommend” was used for a strong recommendation (high confidence; further evidence is unlikely to change it). Also, part of the panel framework was the requirement to disclose any actual, potential, or perceived conflicts of interest for each panelist to be accepted to participate, as well as to remain in the panel for the duration of the process. The cochairs remained free of any financial conflicts during the entire process.
Choosing an empiric antibiotic regimen for patients with HAP and VAP requires balancing the potentially competing goals of ensuring that likely infecting pathogens are covered while avoiding excess antibiotic use. In order to guide clinicians on empiric antibiotic therapy, the panel performed a comprehensive review of the potential risk factors for HAP and VAP. For VAP, three factors associated with disease severity (septic shock at time of VAP, ARDS preceding VAP, and acute renal replacement prior to VAP onset) and two epidemiologic factors (prior use of IV antibiotic use within 90 days, and 5 or more days of hospitalization prior to the occurrence of VAP) made the final risk factors list. For HAP, only the prior use of IV antibiotics within 90 days was associated with risk for MDR. However, because of the limitations and small number of studies on HAP only, the panel decided to add risk factors for mortality (ventilator support for HAP and septic shock) as surrogates for MDR risk factors in patients with HAP, as these factors presumably increase the risk of poor outcomes if there is initial inadequate empiric therapy.
In conjunction with the bedside evaluation of risk factors for MDR, the guideline recommends the use of local antibiograms not only to guide empiric therapy but also to decide if antibiotic coverage for MDR is needed. Ideally, the antibiogram should be based on the specific ICU, but if this is not feasible, or the hospital is of small size, an institutional antibiogram can also be helpful. The first benefit of local antibiograms is derived from the knowledge gained regarding the prevalence of each microorganism; for example, if only 3% of all VAP or HAP in a given unit or hospital is caused by Pseudomonas aeruginosa, it is likely that an empiric coverage for this microorganism will neither be necessary nor appropriate for most patients. The second benefit is derived from the knowledge concerning the frequency of MDR microorganisms within the unit or hospital: for example, patients with VAP in units where 10%-20% of Staphylococcus aureus isolates are resistant to methicillin, or greater than 10% of gram-negative isolates are resistant to an agent being considered for monotherapy, should receive antibiotics for MDR infections. With these two critical pieces of information, the clinician will have a higher probability of starting the correct empiric antibiotics, and, consequently, improve the survival outcomes of patients with HAP and VAP.
The choice of the empirical treatment of VAP and HAP becomes a natural derivation of the three main factors discussed above: (1) epidemiologic history of antibiotics’ use and prior hospitalization length, (2) local antibiogram for the prevalence and resistance of microorganisms, and (3) disease severity and risk of mortality by the identification of septic shock, ARDS, and acute renal replacement therapy. For example, if 17% of all VAPs in your unit is from P aeruginosa (which is the national prevalence in patients with VAP), and 8% of these strains are resistant to an agent being considered for gram-negative monotherapy, not prescribing double coverage for P aeruginosa would still result in initial appropriate therapy in 98.6% (derived from 1-[0.17 x 0.08]) of cases. The reason why the panelists chose the threshold of 10% for P aeruginosa, and 10%-20% for S aureus, was based on the national prevalence rates reported by the Centers for Disease Control and Prevention, with the goal of limiting the initial inappropriate antibiotic therapy decision to less than 5% of all cases. We strongly believe that this “epidemiologic/antibiogram/disease severity” approach to select the empiric therapy is both clinically intuitive and essential to improve patients’ outcomes. Further, this approach will substantially reduce the unnecessary use of double antibiotic therapy in patients with VAP or HAP.
This guideline suggests that the use of inhaled antibiotic therapy in conjunction with IV antibiotics may benefit patients with VAP or HAP from MDR microorganisms that are sensitive to only polymyxins or aminoglycosides. The panel also suggested that the use of pharmacokinetic and pharmacodynamics should be used to optimize the administration of antibiotic therapy for all patients with HAP or VAP.
Last, after an extensive review and multiple analyses of all available evidence, the panel concluded that the majority of patients with HAP or VAP should be treated with 7 days of therapy, independent of the microorganism causing the pneumonia. In several meta-analyses performed by the panelists to evaluate all patients with VAP, as well as only patients with VAP caused by nonfermenting gram-negative organisms such as Pseudomonas species, Stenotrophomonas species, and Acinetobacter species, the panel did not find differences between short and long courses of antibiotics regarding mortality, clinical cure, pneumonia recurrence, and mechanical ventilation duration. In recognition of the individual needs of each patient, we made a remark that shorter or longer duration of antibiotics may be indicated, depending upon the rate of improvement of clinical, radiologic, and laboratory parameters. Several adjunctive methods of deescalation were assessed, but only procalcitonin was suggested to aid health care providers to shorten the course of antibiotic therapy.
In conclusion, the authors of this 2016 HAP/VAP IDSA/ATS guideline hope to achieve the ultimate goal of improving the treatment and outcomes of patients with HAP and VAP and reducing unnecessary antibiotic use.
Dr. Kalil is with the department of internal medicine, division of infectious diseases, University of Nebraska Medical Center, Omaha; Dr. Metersky is with the division of pulmonary and critical care medicine, University of Connecticut, Farmington.
Optimal adjuvant endocrine therapy use in breast cancer remains elusive
Appropriate use of adjuvant endocrine therapy for breast cancer improved over a 10-year period, but optimal use has not been achieved, according to findings from a retrospective review of more than 980,000 women with stages I-III breast cancer.
As a result, an estimated 14,630 lives were unnecessarily lost during the study period, according to Bobby M. Daly, MD, of Memorial Sloan Kettering Cancer Center in New York, and his colleagues.
Of the 981,729 women in the National Cancer Database from Jan. 1, 2004, to Dec. 31, 2013, who received all or part of their care at the reporting institution and who met eligibility criteria, 818,435 had hormone receptor positive (HR+) disease and 163,294 had hormone receptor negative (HR-) disease.
The percentage of HR+ patients receiving adjuvant endocrine therapy (AET) increased from 69.8% in 2004 to 82.4% in 2013 (annual percentage change, 1.51%), and the percentage of HR- patients decreased from 5.2% to 3.4% during the same time period (annual percentage change, -0.17%), the authors reported online Feb. 2 in JAMA Oncology (2017 Feb 2. doi: 10.1001jamaoncol.2016.6380).
Notably, receipt of AET varied significantly by age, race, geographic location, and receptor status. For example, more than 80% of those aged 50-69 years received AET, compared with 79.1% of those younger than age 40 years and 60.5% of those 80 years or older. African American and Hispanic patients were less likely than non-Hispanic white patients to receive AET (76.4% and 75.9% vs. 79.0%, respectively). The latter finding could be an important contributing factor to the racial disparity in breast cancer survival, the authors noted.
Facility factors also played a role in AET receipt; the rate of receipt varied substantially by facility volume and geographic location.
“We found that facilities in west south central states and low-volume institutions were more likely to misuse and underuse AET,” the investigators wrote, noting that these deficits could affect breast cancer mortality, as geographic differences in such mortality are well documented.
AET receipt also varied based on hormone receptor status, tumor size, and local treatment. Surgery and radiotherapy were the factors most significantly associated with appropriate AET receipt, with only 45% of those who underwent lumpectomy without radiotherapy receiving AET, compared with 90.1% of those receiving postmastectomy radiotherapy, 85.5% in those with postlumpectomy radiotherapy, and 73.2% of those with mastectomy alone.
Women included in this study were age 18 years or older (mean age, 60.8 years). Those undergoing surgery but receiving no neoadjuvant systemic treatment were eligible. Those with prior cancer diagnoses or with missing hormone receptor or AET status were excluded.
Based on recent trial results, the American Society of Clinical Oncology updated treatment guidelines in 2016 to recommend ovarian suppression for 5 years in combination with AET for high-risk premenopausal women, and AET alone both for women with stage I breast cancers that don’t warrant chemotherapy and for node-negative cancers of 1.0 cm or less.
“Similarly, the National Quality Forum (cancer measure 0220) endorsed tamoxifen or a third-generation aromatase inhibitor (considered or administered) within 1 year of diagnosis as a marker of quality care for patients with HR+ American Joint Committee on Cancer stage T1cN0M0, II, or III disease,” the researchers wrote. Studies demonstrated benefit with AET even in those with node-negative cancers of 1.0 cm or less, they added.
Improving adherence to these guidelines has lifesaving potential. In the current cohort, receipt of AET was associated with a 29% relative risk reduction in mortality, after adjusting for numerous patient, disease, and facility-related factors. This suggests that if all women with HR+ disease received AET in concordance with guidelines, 14,630 more lives would have been saved over the 10-year study period, the investigators said.
As for approaches that could help improve the appropriate use of AET, the findings of this cohort study support those from previous studies suggesting that a team-based approach is of benefit.
The finding that local treatments are key factors associated with appropriate AET use suggests that patients who undergo radiotherapy may be more likely to receive standard-of-care therapy in general, the authors explained, adding that “with more physicians involved in a patient’s care, these patients would be more likely to be recommended for guideline concordant care.
“Facilitation of multidisciplinary team-based care may help optimize guideline-concordant treatment by ensuring patients are not lost to follow-up and are recommended for evidence-based care,” the study authors concluded.
Their hope is that with the coming launch of the Medicare Access and Chip Reauthorization Act and value-based reimbursement, efforts will be made to close the quality gap affecting patients in certain age groups, racial minority groups, and geographic regions, and to thereby prevent the loss of lives.
MACRA may boost outcomes
In an interview, Dr. Daly said he believes the coming changes with respect to value-based reimbursement will indeed have an important impact on outcomes.
“The oncology care model, for example, mandates that physicians document that they are providing guideline-concordant care,” said Dr. Daly, assistant attending physician at Memorial Sloan Kettering Cancer Center. “There are also new technologies such as oncology clinical pathways ... that also try to ensure that all patients are receiving care according to guidelines.”
Further, the increasing use of team-based approaches to care and the incorporation of “tumor boards” might explain the growth in optimal AET usage seen in this cohort.
Dr. Daly said he was surprised to find that certain patient groups were being left behind, such as those with estrogen receptor-negative/progesterone receptor-positive disease, African American patients, and younger and older patients, who were less likely to receive AET.
“I think that helps us also focus on patient populations we can target to make sure they are receiving optimal care,” he said, stressing that the findings have important policy implications for figuring out why those patients are being left behind, and raising the standard of care for all patients.
“We are making great strides to providing appropriate guideline-concordant care for breast cancer patients, but there’s still room to improve,” he said.
Dr. Daly serves as a director of and receives compensation from Quadrant Holdings. Frontline Medical News is a subsidiary of Quadrant Holdings. Dr. Daly also reported financial relationships with CVS Health, Johnson & Johnson, McKesson, and Walgreens Boots Alliance.
Appropriate use of adjuvant endocrine therapy for breast cancer improved over a 10-year period, but optimal use has not been achieved, according to findings from a retrospective review of more than 980,000 women with stages I-III breast cancer.
As a result, an estimated 14,630 lives were unnecessarily lost during the study period, according to Bobby M. Daly, MD, of Memorial Sloan Kettering Cancer Center in New York, and his colleagues.
Of the 981,729 women in the National Cancer Database from Jan. 1, 2004, to Dec. 31, 2013, who received all or part of their care at the reporting institution and who met eligibility criteria, 818,435 had hormone receptor positive (HR+) disease and 163,294 had hormone receptor negative (HR-) disease.
The percentage of HR+ patients receiving adjuvant endocrine therapy (AET) increased from 69.8% in 2004 to 82.4% in 2013 (annual percentage change, 1.51%), and the percentage of HR- patients decreased from 5.2% to 3.4% during the same time period (annual percentage change, -0.17%), the authors reported online Feb. 2 in JAMA Oncology (2017 Feb 2. doi: 10.1001jamaoncol.2016.6380).
Notably, receipt of AET varied significantly by age, race, geographic location, and receptor status. For example, more than 80% of those aged 50-69 years received AET, compared with 79.1% of those younger than age 40 years and 60.5% of those 80 years or older. African American and Hispanic patients were less likely than non-Hispanic white patients to receive AET (76.4% and 75.9% vs. 79.0%, respectively). The latter finding could be an important contributing factor to the racial disparity in breast cancer survival, the authors noted.
Facility factors also played a role in AET receipt; the rate of receipt varied substantially by facility volume and geographic location.
“We found that facilities in west south central states and low-volume institutions were more likely to misuse and underuse AET,” the investigators wrote, noting that these deficits could affect breast cancer mortality, as geographic differences in such mortality are well documented.
AET receipt also varied based on hormone receptor status, tumor size, and local treatment. Surgery and radiotherapy were the factors most significantly associated with appropriate AET receipt, with only 45% of those who underwent lumpectomy without radiotherapy receiving AET, compared with 90.1% of those receiving postmastectomy radiotherapy, 85.5% in those with postlumpectomy radiotherapy, and 73.2% of those with mastectomy alone.
Women included in this study were age 18 years or older (mean age, 60.8 years). Those undergoing surgery but receiving no neoadjuvant systemic treatment were eligible. Those with prior cancer diagnoses or with missing hormone receptor or AET status were excluded.
Based on recent trial results, the American Society of Clinical Oncology updated treatment guidelines in 2016 to recommend ovarian suppression for 5 years in combination with AET for high-risk premenopausal women, and AET alone both for women with stage I breast cancers that don’t warrant chemotherapy and for node-negative cancers of 1.0 cm or less.
“Similarly, the National Quality Forum (cancer measure 0220) endorsed tamoxifen or a third-generation aromatase inhibitor (considered or administered) within 1 year of diagnosis as a marker of quality care for patients with HR+ American Joint Committee on Cancer stage T1cN0M0, II, or III disease,” the researchers wrote. Studies demonstrated benefit with AET even in those with node-negative cancers of 1.0 cm or less, they added.
Improving adherence to these guidelines has lifesaving potential. In the current cohort, receipt of AET was associated with a 29% relative risk reduction in mortality, after adjusting for numerous patient, disease, and facility-related factors. This suggests that if all women with HR+ disease received AET in concordance with guidelines, 14,630 more lives would have been saved over the 10-year study period, the investigators said.
As for approaches that could help improve the appropriate use of AET, the findings of this cohort study support those from previous studies suggesting that a team-based approach is of benefit.
The finding that local treatments are key factors associated with appropriate AET use suggests that patients who undergo radiotherapy may be more likely to receive standard-of-care therapy in general, the authors explained, adding that “with more physicians involved in a patient’s care, these patients would be more likely to be recommended for guideline concordant care.
“Facilitation of multidisciplinary team-based care may help optimize guideline-concordant treatment by ensuring patients are not lost to follow-up and are recommended for evidence-based care,” the study authors concluded.
Their hope is that with the coming launch of the Medicare Access and Chip Reauthorization Act and value-based reimbursement, efforts will be made to close the quality gap affecting patients in certain age groups, racial minority groups, and geographic regions, and to thereby prevent the loss of lives.
MACRA may boost outcomes
In an interview, Dr. Daly said he believes the coming changes with respect to value-based reimbursement will indeed have an important impact on outcomes.
“The oncology care model, for example, mandates that physicians document that they are providing guideline-concordant care,” said Dr. Daly, assistant attending physician at Memorial Sloan Kettering Cancer Center. “There are also new technologies such as oncology clinical pathways ... that also try to ensure that all patients are receiving care according to guidelines.”
Further, the increasing use of team-based approaches to care and the incorporation of “tumor boards” might explain the growth in optimal AET usage seen in this cohort.
Dr. Daly said he was surprised to find that certain patient groups were being left behind, such as those with estrogen receptor-negative/progesterone receptor-positive disease, African American patients, and younger and older patients, who were less likely to receive AET.
“I think that helps us also focus on patient populations we can target to make sure they are receiving optimal care,” he said, stressing that the findings have important policy implications for figuring out why those patients are being left behind, and raising the standard of care for all patients.
“We are making great strides to providing appropriate guideline-concordant care for breast cancer patients, but there’s still room to improve,” he said.
Dr. Daly serves as a director of and receives compensation from Quadrant Holdings. Frontline Medical News is a subsidiary of Quadrant Holdings. Dr. Daly also reported financial relationships with CVS Health, Johnson & Johnson, McKesson, and Walgreens Boots Alliance.
Appropriate use of adjuvant endocrine therapy for breast cancer improved over a 10-year period, but optimal use has not been achieved, according to findings from a retrospective review of more than 980,000 women with stages I-III breast cancer.
As a result, an estimated 14,630 lives were unnecessarily lost during the study period, according to Bobby M. Daly, MD, of Memorial Sloan Kettering Cancer Center in New York, and his colleagues.
Of the 981,729 women in the National Cancer Database from Jan. 1, 2004, to Dec. 31, 2013, who received all or part of their care at the reporting institution and who met eligibility criteria, 818,435 had hormone receptor positive (HR+) disease and 163,294 had hormone receptor negative (HR-) disease.
The percentage of HR+ patients receiving adjuvant endocrine therapy (AET) increased from 69.8% in 2004 to 82.4% in 2013 (annual percentage change, 1.51%), and the percentage of HR- patients decreased from 5.2% to 3.4% during the same time period (annual percentage change, -0.17%), the authors reported online Feb. 2 in JAMA Oncology (2017 Feb 2. doi: 10.1001jamaoncol.2016.6380).
Notably, receipt of AET varied significantly by age, race, geographic location, and receptor status. For example, more than 80% of those aged 50-69 years received AET, compared with 79.1% of those younger than age 40 years and 60.5% of those 80 years or older. African American and Hispanic patients were less likely than non-Hispanic white patients to receive AET (76.4% and 75.9% vs. 79.0%, respectively). The latter finding could be an important contributing factor to the racial disparity in breast cancer survival, the authors noted.
Facility factors also played a role in AET receipt; the rate of receipt varied substantially by facility volume and geographic location.
“We found that facilities in west south central states and low-volume institutions were more likely to misuse and underuse AET,” the investigators wrote, noting that these deficits could affect breast cancer mortality, as geographic differences in such mortality are well documented.
AET receipt also varied based on hormone receptor status, tumor size, and local treatment. Surgery and radiotherapy were the factors most significantly associated with appropriate AET receipt, with only 45% of those who underwent lumpectomy without radiotherapy receiving AET, compared with 90.1% of those receiving postmastectomy radiotherapy, 85.5% in those with postlumpectomy radiotherapy, and 73.2% of those with mastectomy alone.
Women included in this study were age 18 years or older (mean age, 60.8 years). Those undergoing surgery but receiving no neoadjuvant systemic treatment were eligible. Those with prior cancer diagnoses or with missing hormone receptor or AET status were excluded.
Based on recent trial results, the American Society of Clinical Oncology updated treatment guidelines in 2016 to recommend ovarian suppression for 5 years in combination with AET for high-risk premenopausal women, and AET alone both for women with stage I breast cancers that don’t warrant chemotherapy and for node-negative cancers of 1.0 cm or less.
“Similarly, the National Quality Forum (cancer measure 0220) endorsed tamoxifen or a third-generation aromatase inhibitor (considered or administered) within 1 year of diagnosis as a marker of quality care for patients with HR+ American Joint Committee on Cancer stage T1cN0M0, II, or III disease,” the researchers wrote. Studies demonstrated benefit with AET even in those with node-negative cancers of 1.0 cm or less, they added.
Improving adherence to these guidelines has lifesaving potential. In the current cohort, receipt of AET was associated with a 29% relative risk reduction in mortality, after adjusting for numerous patient, disease, and facility-related factors. This suggests that if all women with HR+ disease received AET in concordance with guidelines, 14,630 more lives would have been saved over the 10-year study period, the investigators said.
As for approaches that could help improve the appropriate use of AET, the findings of this cohort study support those from previous studies suggesting that a team-based approach is of benefit.
The finding that local treatments are key factors associated with appropriate AET use suggests that patients who undergo radiotherapy may be more likely to receive standard-of-care therapy in general, the authors explained, adding that “with more physicians involved in a patient’s care, these patients would be more likely to be recommended for guideline concordant care.
“Facilitation of multidisciplinary team-based care may help optimize guideline-concordant treatment by ensuring patients are not lost to follow-up and are recommended for evidence-based care,” the study authors concluded.
Their hope is that with the coming launch of the Medicare Access and Chip Reauthorization Act and value-based reimbursement, efforts will be made to close the quality gap affecting patients in certain age groups, racial minority groups, and geographic regions, and to thereby prevent the loss of lives.
MACRA may boost outcomes
In an interview, Dr. Daly said he believes the coming changes with respect to value-based reimbursement will indeed have an important impact on outcomes.
“The oncology care model, for example, mandates that physicians document that they are providing guideline-concordant care,” said Dr. Daly, assistant attending physician at Memorial Sloan Kettering Cancer Center. “There are also new technologies such as oncology clinical pathways ... that also try to ensure that all patients are receiving care according to guidelines.”
Further, the increasing use of team-based approaches to care and the incorporation of “tumor boards” might explain the growth in optimal AET usage seen in this cohort.
Dr. Daly said he was surprised to find that certain patient groups were being left behind, such as those with estrogen receptor-negative/progesterone receptor-positive disease, African American patients, and younger and older patients, who were less likely to receive AET.
“I think that helps us also focus on patient populations we can target to make sure they are receiving optimal care,” he said, stressing that the findings have important policy implications for figuring out why those patients are being left behind, and raising the standard of care for all patients.
“We are making great strides to providing appropriate guideline-concordant care for breast cancer patients, but there’s still room to improve,” he said.
Dr. Daly serves as a director of and receives compensation from Quadrant Holdings. Frontline Medical News is a subsidiary of Quadrant Holdings. Dr. Daly also reported financial relationships with CVS Health, Johnson & Johnson, McKesson, and Walgreens Boots Alliance.
FROM JAMA ONCOLOGY
Key clinical point:
Major finding: Receipt of AET was associated with a 29% relative risk reduction in mortality; use of AET in concordance with guidelines would have saved an estimated 14,630 additional lives over 10 years.
Data source: A retrospective cohort study of 981,729 women with breast cancer.
Disclosures: Dr. Daly serves as a director of and receives compensation from Quadrant Holdings. Frontline Medical News is a subsidiary of Quadrant Holdings. Dr. Daly also reported financial relationships with CVS Health, Johnson & Johnson, McKesson, and Walgreens Boots Alliance.
Neuropathic pain puts cancer survivors out of work
AMSTERDAM – Five years after a cancer diagnosis, patients who report having chronic neuropathic pain are twice as likely to be out of work as patients who report having no neuropathic pain, authors of a large longitudinal study said.
“For middle-term cancer survivors, suffering from chronic neuropathic pain unfortunately predicts labor-market exit,” said Marc-Karim Bendiane, from Aix-Marseille University in Marseille, France.
Pain is still frequently underdiagnosed, poorly managed, and undertreated among cancer survivors, and there is a need for alternatives to analgesics for control of chronic neuropathic pain (CNP), Mr. Bendiane said at an annual congress sponsored by the European Cancer Organisation.
Mr. Bendiane and colleagues used data from VICAN, a longitudinal survey of issues of concern to cancer survivors 2 years and 5 years after a diagnosis. The cohort consists of patients diagnosed with cancers who comprise 88% of all cancer diagnoses in France, including cancers of the breast; colon and rectum; lip, oral cavity, and pharynx; kidney; cervix; endometrium; non-Hodgkin lymphoma; melanoma; thyroid; bladder; and prostate.
To assess CNP, the researchers used data from a seven-item questionnaire designed to identify neuropathic characteristics of pain experienced by patients in the 2 weeks prior to a comprehensive patient interview.
Of the 982 patients who were working at the time of diagnosis, 36% reported pain within the previous 2 weeks, and of this group, 79% had chronic pain of neuropathic origin. CNP was more common in women than in men (P less than .01); in college-educated people, compared with less-educated people (P less than .001); those who had undergone chemotherapy, compared with no chemotherapy (P less than .001); and those who had radiotherapy vs. no radiotherapy (P less than .001).
For each cancer site, the prevalence of CNP among 5-year cancer survivors was substantially higher than the overall prevalence in France of 7%. For example, 34% of patients with cancers of the cervix and endometrium reported CNP, as did 29.9% of patients who survived cancers of the lip, oral cavity, and pharynx, 32.1% of lung cancer survivors, and 32.7% of breast cancer survivors.
Five years after diagnosis, 22.6% of patients who had been employed in 2010 were out of work in 2015.
The presence of CNP was associated with a nearly twofold greater risk of unemployment (adjusted odds ratio, 1.96; P less than .001) in a multivariate logistic regression analysis comparing employed and unemployed patients and controlling for social and demographic characteristics, job characteristics at diagnosis, and medical factors such as tumor site, prognosis, and treatment type.
The French National Cancer Institute and INSERM, the National Institute for Research in Health and Medicine, supported the study. The investigators reported no conflicts of interest.
AMSTERDAM – Five years after a cancer diagnosis, patients who report having chronic neuropathic pain are twice as likely to be out of work as patients who report having no neuropathic pain, authors of a large longitudinal study said.
“For middle-term cancer survivors, suffering from chronic neuropathic pain unfortunately predicts labor-market exit,” said Marc-Karim Bendiane, from Aix-Marseille University in Marseille, France.
Pain is still frequently underdiagnosed, poorly managed, and undertreated among cancer survivors, and there is a need for alternatives to analgesics for control of chronic neuropathic pain (CNP), Mr. Bendiane said at an annual congress sponsored by the European Cancer Organisation.
Mr. Bendiane and colleagues used data from VICAN, a longitudinal survey of issues of concern to cancer survivors 2 years and 5 years after a diagnosis. The cohort consists of patients diagnosed with cancers who comprise 88% of all cancer diagnoses in France, including cancers of the breast; colon and rectum; lip, oral cavity, and pharynx; kidney; cervix; endometrium; non-Hodgkin lymphoma; melanoma; thyroid; bladder; and prostate.
To assess CNP, the researchers used data from a seven-item questionnaire designed to identify neuropathic characteristics of pain experienced by patients in the 2 weeks prior to a comprehensive patient interview.
Of the 982 patients who were working at the time of diagnosis, 36% reported pain within the previous 2 weeks, and of this group, 79% had chronic pain of neuropathic origin. CNP was more common in women than in men (P less than .01); in college-educated people, compared with less-educated people (P less than .001); those who had undergone chemotherapy, compared with no chemotherapy (P less than .001); and those who had radiotherapy vs. no radiotherapy (P less than .001).
For each cancer site, the prevalence of CNP among 5-year cancer survivors was substantially higher than the overall prevalence in France of 7%. For example, 34% of patients with cancers of the cervix and endometrium reported CNP, as did 29.9% of patients who survived cancers of the lip, oral cavity, and pharynx, 32.1% of lung cancer survivors, and 32.7% of breast cancer survivors.
Five years after diagnosis, 22.6% of patients who had been employed in 2010 were out of work in 2015.
The presence of CNP was associated with a nearly twofold greater risk of unemployment (adjusted odds ratio, 1.96; P less than .001) in a multivariate logistic regression analysis comparing employed and unemployed patients and controlling for social and demographic characteristics, job characteristics at diagnosis, and medical factors such as tumor site, prognosis, and treatment type.
The French National Cancer Institute and INSERM, the National Institute for Research in Health and Medicine, supported the study. The investigators reported no conflicts of interest.
AMSTERDAM – Five years after a cancer diagnosis, patients who report having chronic neuropathic pain are twice as likely to be out of work as patients who report having no neuropathic pain, authors of a large longitudinal study said.
“For middle-term cancer survivors, suffering from chronic neuropathic pain unfortunately predicts labor-market exit,” said Marc-Karim Bendiane, from Aix-Marseille University in Marseille, France.
Pain is still frequently underdiagnosed, poorly managed, and undertreated among cancer survivors, and there is a need for alternatives to analgesics for control of chronic neuropathic pain (CNP), Mr. Bendiane said at an annual congress sponsored by the European Cancer Organisation.
Mr. Bendiane and colleagues used data from VICAN, a longitudinal survey of issues of concern to cancer survivors 2 years and 5 years after a diagnosis. The cohort consists of patients diagnosed with cancers who comprise 88% of all cancer diagnoses in France, including cancers of the breast; colon and rectum; lip, oral cavity, and pharynx; kidney; cervix; endometrium; non-Hodgkin lymphoma; melanoma; thyroid; bladder; and prostate.
To assess CNP, the researchers used data from a seven-item questionnaire designed to identify neuropathic characteristics of pain experienced by patients in the 2 weeks prior to a comprehensive patient interview.
Of the 982 patients who were working at the time of diagnosis, 36% reported pain within the previous 2 weeks, and of this group, 79% had chronic pain of neuropathic origin. CNP was more common in women than in men (P less than .01); in college-educated people, compared with less-educated people (P less than .001); those who had undergone chemotherapy, compared with no chemotherapy (P less than .001); and those who had radiotherapy vs. no radiotherapy (P less than .001).
For each cancer site, the prevalence of CNP among 5-year cancer survivors was substantially higher than the overall prevalence in France of 7%. For example, 34% of patients with cancers of the cervix and endometrium reported CNP, as did 29.9% of patients who survived cancers of the lip, oral cavity, and pharynx, 32.1% of lung cancer survivors, and 32.7% of breast cancer survivors.
Five years after diagnosis, 22.6% of patients who had been employed in 2010 were out of work in 2015.
The presence of CNP was associated with a nearly twofold greater risk of unemployment (adjusted odds ratio, 1.96; P less than .001) in a multivariate logistic regression analysis comparing employed and unemployed patients and controlling for social and demographic characteristics, job characteristics at diagnosis, and medical factors such as tumor site, prognosis, and treatment type.
The French National Cancer Institute and INSERM, the National Institute for Research in Health and Medicine, supported the study. The investigators reported no conflicts of interest.
Key clinical point: Chronic neuropathic pain is a barrier to employment for many cancer survivors.
Major finding: Cancer survivors with chronic neuropathic pain were twice as likely to be unemployed 5 years after diagnosis as patients with no pain.
Data source: Longitudinal study of French cancer survivors.
Disclosures: The French National Cancer Institute and INSERM, the National Institute for Research in Health and Medicine, supported the study. The investigators reported no conflicts of interest.
Toddlers’ neurodevelopmental deficits linked with maternal diabetes
LAS VEGAS – Children born to obese women with insulin resistance during pregnancy showed significantly impaired neurodevelopment at 2 years of age, compared with children born to obese mothers without insulin resistance in a prospective observational study with 75 pregnant women.
The neurodevelopmental deficits were specific for the domains of motor function and attention, and the deficits correlated with several markers of abnormal glucose and fat metabolism in the insulin-resistant women, Alison G. Cahill, MD, said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
“The differences in neurodevelopment appear to not be global but instead specifically affect domains of motor development and attention,” said Dr. Cahill, chief of maternal fetal medicine at Washington University in St. Louis. “These findings are consistent with results from animal studies that suggest certain brain regions are more sensitive than others to metabolic abnormalities” while in utero.
“These are among the first data in humans to characterize the impact of metabolic abnormalities on brain development,” she added.
Dr. Cahill said that results from the lean mothers uniformly matched those from the obese mothers without insulin resistance, and so for brevity she only reported results from the obese control group.
Average gestational age at birth was 37 weeks in the insulin-resistant mothers and 38.7 weeks among the obese mothers without insulin resistance, a significant difference. Birth weight averaged 3,617 g in the mothers with insulin resistance and 3,373 g in the mothers without insulin resistance, a difference that was not statistically significant.
Dr. Cahill and her associates assessed the 2-year-olds with a battery of behavioral and functional assessments. They measured motor function, cognition, and language with the Bayley Scales of Infant and Toddler Development, prespecified as the study’s primary endpoint. They also applied the Modified Checklist for Autism in Toddlers (M-CHAT), as well as the Infant-Toddler Social and Emotional Assessment (ITSEA) to assess competence, externalizing, internalizing, and dysregulation.
The results of these analyses showed statistically significant deficits for the motor composite score on the Bayley assessment and for the competence component of the ITSEA assessment, Dr. Cahill reported. The average composite Bayley motor score was 88 in children from mothers with insulin resistance and 98 in the control children, a statistically significant difference.
Further analyses showed that the motor deficit was primarily in fine motor function, and that motor scores were depressed throughout the entire cohort of children born to mothers with insulin resistance.
Depressed competence scores on the ITSEA assessment reflect attention abnormalities, she explained.
A final analysis examined the correlation between the motor deficits identified and various metabolic tests of fat, glucose, and protein metabolism run on the enrolled mothers during the last weeks of gestation. This showed significant links between depressed motor development and maternal lipolytic rate, plasma free fatty acids, and hepatic glucose output.
This finding “suggests an association between abnormal lipid and glucose metabolism in mothers and aspects of neurodevelopment” in their children, Dr. Cahill said.
Dr. Cahill had no disclosures.
mzoler@frontlinemedcom.com On Twitter @mitchelzoler
LAS VEGAS – Children born to obese women with insulin resistance during pregnancy showed significantly impaired neurodevelopment at 2 years of age, compared with children born to obese mothers without insulin resistance in a prospective observational study with 75 pregnant women.
The neurodevelopmental deficits were specific for the domains of motor function and attention, and the deficits correlated with several markers of abnormal glucose and fat metabolism in the insulin-resistant women, Alison G. Cahill, MD, said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
“The differences in neurodevelopment appear to not be global but instead specifically affect domains of motor development and attention,” said Dr. Cahill, chief of maternal fetal medicine at Washington University in St. Louis. “These findings are consistent with results from animal studies that suggest certain brain regions are more sensitive than others to metabolic abnormalities” while in utero.
“These are among the first data in humans to characterize the impact of metabolic abnormalities on brain development,” she added.
Dr. Cahill said that results from the lean mothers uniformly matched those from the obese mothers without insulin resistance, and so for brevity she only reported results from the obese control group.
Average gestational age at birth was 37 weeks in the insulin-resistant mothers and 38.7 weeks among the obese mothers without insulin resistance, a significant difference. Birth weight averaged 3,617 g in the mothers with insulin resistance and 3,373 g in the mothers without insulin resistance, a difference that was not statistically significant.
Dr. Cahill and her associates assessed the 2-year-olds with a battery of behavioral and functional assessments. They measured motor function, cognition, and language with the Bayley Scales of Infant and Toddler Development, prespecified as the study’s primary endpoint. They also applied the Modified Checklist for Autism in Toddlers (M-CHAT), as well as the Infant-Toddler Social and Emotional Assessment (ITSEA) to assess competence, externalizing, internalizing, and dysregulation.
The results of these analyses showed statistically significant deficits for the motor composite score on the Bayley assessment and for the competence component of the ITSEA assessment, Dr. Cahill reported. The average composite Bayley motor score was 88 in children from mothers with insulin resistance and 98 in the control children, a statistically significant difference.
Further analyses showed that the motor deficit was primarily in fine motor function, and that motor scores were depressed throughout the entire cohort of children born to mothers with insulin resistance.
Depressed competence scores on the ITSEA assessment reflect attention abnormalities, she explained.
A final analysis examined the correlation between the motor deficits identified and various metabolic tests of fat, glucose, and protein metabolism run on the enrolled mothers during the last weeks of gestation. This showed significant links between depressed motor development and maternal lipolytic rate, plasma free fatty acids, and hepatic glucose output.
This finding “suggests an association between abnormal lipid and glucose metabolism in mothers and aspects of neurodevelopment” in their children, Dr. Cahill said.
Dr. Cahill had no disclosures.
mzoler@frontlinemedcom.com On Twitter @mitchelzoler
LAS VEGAS – Children born to obese women with insulin resistance during pregnancy showed significantly impaired neurodevelopment at 2 years of age, compared with children born to obese mothers without insulin resistance in a prospective observational study with 75 pregnant women.
The neurodevelopmental deficits were specific for the domains of motor function and attention, and the deficits correlated with several markers of abnormal glucose and fat metabolism in the insulin-resistant women, Alison G. Cahill, MD, said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
“The differences in neurodevelopment appear to not be global but instead specifically affect domains of motor development and attention,” said Dr. Cahill, chief of maternal fetal medicine at Washington University in St. Louis. “These findings are consistent with results from animal studies that suggest certain brain regions are more sensitive than others to metabolic abnormalities” while in utero.
“These are among the first data in humans to characterize the impact of metabolic abnormalities on brain development,” she added.
Dr. Cahill said that results from the lean mothers uniformly matched those from the obese mothers without insulin resistance, and so for brevity she only reported results from the obese control group.
Average gestational age at birth was 37 weeks in the insulin-resistant mothers and 38.7 weeks among the obese mothers without insulin resistance, a significant difference. Birth weight averaged 3,617 g in the mothers with insulin resistance and 3,373 g in the mothers without insulin resistance, a difference that was not statistically significant.
Dr. Cahill and her associates assessed the 2-year-olds with a battery of behavioral and functional assessments. They measured motor function, cognition, and language with the Bayley Scales of Infant and Toddler Development, prespecified as the study’s primary endpoint. They also applied the Modified Checklist for Autism in Toddlers (M-CHAT), as well as the Infant-Toddler Social and Emotional Assessment (ITSEA) to assess competence, externalizing, internalizing, and dysregulation.
The results of these analyses showed statistically significant deficits for the motor composite score on the Bayley assessment and for the competence component of the ITSEA assessment, Dr. Cahill reported. The average composite Bayley motor score was 88 in children from mothers with insulin resistance and 98 in the control children, a statistically significant difference.
Further analyses showed that the motor deficit was primarily in fine motor function, and that motor scores were depressed throughout the entire cohort of children born to mothers with insulin resistance.
Depressed competence scores on the ITSEA assessment reflect attention abnormalities, she explained.
A final analysis examined the correlation between the motor deficits identified and various metabolic tests of fat, glucose, and protein metabolism run on the enrolled mothers during the last weeks of gestation. This showed significant links between depressed motor development and maternal lipolytic rate, plasma free fatty acids, and hepatic glucose output.
This finding “suggests an association between abnormal lipid and glucose metabolism in mothers and aspects of neurodevelopment” in their children, Dr. Cahill said.
Dr. Cahill had no disclosures.
mzoler@frontlinemedcom.com On Twitter @mitchelzoler
Key clinical point:
Major finding: The Bayley motor scale score averaged 88 in children from insulin-resistant mothers and 98 when no insulin resistance existed.
Data source: Prospective, single-center observational study with 75 pregnant women.
Disclosures: Dr. Cahill had no disclosures.
Study finds community-hospital lung cancer screening feasible
HOUSTON – Implementing a lung cancer screening program in a community hospital setting is feasible and saves lives, but implementation comes with its share of challenges, results from a single-center analysis demonstrated.
“Deaths from lung cancer surpass mortality of all other malignancies,” Simran Randhawa, MD, said during a press briefing at the annual meeting of the Society of Thoracic Surgeons. “The majority of lung cancers are found at an advanced stage, and the 5-year overall survival has only marginally improved over the past 40 years, and is approximately 17% according to recent data.
“Most people who die from lung cancer are former smokers,” said Dr. Randhawa, of the Einstein Healthcare Network, Philadelphia. “Former smokers cannot benefit from primary prevention, so this is where lung cancer screening comes into action.”
In 2011, the National Lung Screening Trial (NLST) showed a 20% relative reduction in lung cancer death with annual low-dose CT of the chest in high-risk patients. The reduction in mortality by any cause was by 6.7%.
“The number needed to be screened to prevent one death is 320, which may seem like a lot, but it is a very competitive number when compared to mammography or colonoscopy,” Dr. Randhawa said. “Lung cancer screening is also cost effective. It costs about $73,000 per quality adjusted life year, which can be further improved if offered with smoking cessation intervention.”
In October 2013, Einstein Healthcare Network offered a free lung cancer screening program. The purpose of the current study, which was led by Doraid Jarrar, MD, at the University of Pennsylvania, Philadelphia, was to evaluate the feasibility of establishing a lung cancer screening program in a community hospital system, to identify barriers to adoption, and to benchmark their experience with NLST results.
They promoted the screening program through flyers, radio programs, face-to-face information sessions, and a multidisciplinary lung symposium, prospectively collected data over 12 months, and decided patient eligibility based on NLST criteria. Results were reported using the Lung CT Screening Reporting and Data System (Lung-RADS).
Dr. Randhawa reported results from a total of 278 patients. Their average age was 64 years, 62% were female, 65% were African American, and the average number of pack years was 43.
Most (88%) were diagnosed with Lung-RADS 1 or 2 (negative or benign appearance), 7% were Lung-RADS 3 (probably benign but requiring close follow-up with CT scan), and 5% were Lung-RADS 4 (suspicious with a chance of malignancy).
Of the 11 patients who were diagnosed with Lung-RADS 4, 4 underwent lifesaving lung resection surgery for stage 1 disease, 1 patient was diagnosed with stage 4 disease, and the rest were either benign on follow-up or lost to follow-up.
“On further investigation, we found that 60% of the patients who showed up for the lung cancer screening were referred to us by their primary care physician, 22% had heard about our program through flyers as well as radio advertisements, 2% via Web search, and 1% through newsletters,” Dr. Randhawa said.
At the end of the study period, the researchers distributed a survey to all primary care and referring physicians. About 42% said they referred more than 10 patients in the last year, while 16% made no such referrals. When asked if they knew that lung cancer screening is recommended by the U.S. Preventive Services Task Force on par with mammography and colonoscopy, 74% said that they knew, but 26% indicated that they were not aware of that fact.
“When asked about any barriers they may have encountered, one physician commented on the lack of time to counsel his patients,” Dr. Randhawa said. “Most of the physicians expressed concerns about precertification [delays] and requirement for prior authorization for lung cancer screening.”
She acknowledged certain limitations of the study, including its small sample size and the fact that the researchers interviewed primary care physicians catering to an underserved population in the community, “which is not comparable to the NLST population,” she said.
“However, [our results] could be potentially more generalizable,” Dr. Randhawa noted. “In the future, we hope that there is evolving technology used for CT screening with reduction in radiation dose, and more accurate biomarkers will be developed to identify patients at highest risk for lung cancer. We aim to save lives through early detection of lung cancer with responsible CT lung screening.”
One of the study authors, Tracy Kane, MD, disclosed being a member of the speakers bureau for AstraZeneca and receiving honoraria from the company. The other researchers reported having no financial disclosures.
HOUSTON – Implementing a lung cancer screening program in a community hospital setting is feasible and saves lives, but implementation comes with its share of challenges, results from a single-center analysis demonstrated.
“Deaths from lung cancer surpass mortality of all other malignancies,” Simran Randhawa, MD, said during a press briefing at the annual meeting of the Society of Thoracic Surgeons. “The majority of lung cancers are found at an advanced stage, and the 5-year overall survival has only marginally improved over the past 40 years, and is approximately 17% according to recent data.
“Most people who die from lung cancer are former smokers,” said Dr. Randhawa, of the Einstein Healthcare Network, Philadelphia. “Former smokers cannot benefit from primary prevention, so this is where lung cancer screening comes into action.”
In 2011, the National Lung Screening Trial (NLST) showed a 20% relative reduction in lung cancer death with annual low-dose CT of the chest in high-risk patients. The reduction in mortality by any cause was by 6.7%.
“The number needed to be screened to prevent one death is 320, which may seem like a lot, but it is a very competitive number when compared to mammography or colonoscopy,” Dr. Randhawa said. “Lung cancer screening is also cost effective. It costs about $73,000 per quality adjusted life year, which can be further improved if offered with smoking cessation intervention.”
In October 2013, Einstein Healthcare Network offered a free lung cancer screening program. The purpose of the current study, which was led by Doraid Jarrar, MD, at the University of Pennsylvania, Philadelphia, was to evaluate the feasibility of establishing a lung cancer screening program in a community hospital system, to identify barriers to adoption, and to benchmark their experience with NLST results.
They promoted the screening program through flyers, radio programs, face-to-face information sessions, and a multidisciplinary lung symposium, prospectively collected data over 12 months, and decided patient eligibility based on NLST criteria. Results were reported using the Lung CT Screening Reporting and Data System (Lung-RADS).
Dr. Randhawa reported results from a total of 278 patients. Their average age was 64 years, 62% were female, 65% were African American, and the average number of pack years was 43.
Most (88%) were diagnosed with Lung-RADS 1 or 2 (negative or benign appearance), 7% were Lung-RADS 3 (probably benign but requiring close follow-up with CT scan), and 5% were Lung-RADS 4 (suspicious with a chance of malignancy).
Of the 11 patients who were diagnosed with Lung-RADS 4, 4 underwent lifesaving lung resection surgery for stage 1 disease, 1 patient was diagnosed with stage 4 disease, and the rest were either benign on follow-up or lost to follow-up.
“On further investigation, we found that 60% of the patients who showed up for the lung cancer screening were referred to us by their primary care physician, 22% had heard about our program through flyers as well as radio advertisements, 2% via Web search, and 1% through newsletters,” Dr. Randhawa said.
At the end of the study period, the researchers distributed a survey to all primary care and referring physicians. About 42% said they referred more than 10 patients in the last year, while 16% made no such referrals. When asked if they knew that lung cancer screening is recommended by the U.S. Preventive Services Task Force on par with mammography and colonoscopy, 74% said that they knew, but 26% indicated that they were not aware of that fact.
“When asked about any barriers they may have encountered, one physician commented on the lack of time to counsel his patients,” Dr. Randhawa said. “Most of the physicians expressed concerns about precertification [delays] and requirement for prior authorization for lung cancer screening.”
She acknowledged certain limitations of the study, including its small sample size and the fact that the researchers interviewed primary care physicians catering to an underserved population in the community, “which is not comparable to the NLST population,” she said.
“However, [our results] could be potentially more generalizable,” Dr. Randhawa noted. “In the future, we hope that there is evolving technology used for CT screening with reduction in radiation dose, and more accurate biomarkers will be developed to identify patients at highest risk for lung cancer. We aim to save lives through early detection of lung cancer with responsible CT lung screening.”
One of the study authors, Tracy Kane, MD, disclosed being a member of the speakers bureau for AstraZeneca and receiving honoraria from the company. The other researchers reported having no financial disclosures.
HOUSTON – Implementing a lung cancer screening program in a community hospital setting is feasible and saves lives, but implementation comes with its share of challenges, results from a single-center analysis demonstrated.
“Deaths from lung cancer surpass mortality of all other malignancies,” Simran Randhawa, MD, said during a press briefing at the annual meeting of the Society of Thoracic Surgeons. “The majority of lung cancers are found at an advanced stage, and the 5-year overall survival has only marginally improved over the past 40 years, and is approximately 17% according to recent data.
“Most people who die from lung cancer are former smokers,” said Dr. Randhawa, of the Einstein Healthcare Network, Philadelphia. “Former smokers cannot benefit from primary prevention, so this is where lung cancer screening comes into action.”
In 2011, the National Lung Screening Trial (NLST) showed a 20% relative reduction in lung cancer death with annual low-dose CT of the chest in high-risk patients. The reduction in mortality by any cause was by 6.7%.
“The number needed to be screened to prevent one death is 320, which may seem like a lot, but it is a very competitive number when compared to mammography or colonoscopy,” Dr. Randhawa said. “Lung cancer screening is also cost effective. It costs about $73,000 per quality adjusted life year, which can be further improved if offered with smoking cessation intervention.”
In October 2013, Einstein Healthcare Network offered a free lung cancer screening program. The purpose of the current study, which was led by Doraid Jarrar, MD, at the University of Pennsylvania, Philadelphia, was to evaluate the feasibility of establishing a lung cancer screening program in a community hospital system, to identify barriers to adoption, and to benchmark their experience with NLST results.
They promoted the screening program through flyers, radio programs, face-to-face information sessions, and a multidisciplinary lung symposium, prospectively collected data over 12 months, and decided patient eligibility based on NLST criteria. Results were reported using the Lung CT Screening Reporting and Data System (Lung-RADS).
Dr. Randhawa reported results from a total of 278 patients. Their average age was 64 years, 62% were female, 65% were African American, and the average number of pack years was 43.
Most (88%) were diagnosed with Lung-RADS 1 or 2 (negative or benign appearance), 7% were Lung-RADS 3 (probably benign but requiring close follow-up with CT scan), and 5% were Lung-RADS 4 (suspicious with a chance of malignancy).
Of the 11 patients who were diagnosed with Lung-RADS 4, 4 underwent lifesaving lung resection surgery for stage 1 disease, 1 patient was diagnosed with stage 4 disease, and the rest were either benign on follow-up or lost to follow-up.
“On further investigation, we found that 60% of the patients who showed up for the lung cancer screening were referred to us by their primary care physician, 22% had heard about our program through flyers as well as radio advertisements, 2% via Web search, and 1% through newsletters,” Dr. Randhawa said.
At the end of the study period, the researchers distributed a survey to all primary care and referring physicians. About 42% said they referred more than 10 patients in the last year, while 16% made no such referrals. When asked if they knew that lung cancer screening is recommended by the U.S. Preventive Services Task Force on par with mammography and colonoscopy, 74% said that they knew, but 26% indicated that they were not aware of that fact.
“When asked about any barriers they may have encountered, one physician commented on the lack of time to counsel his patients,” Dr. Randhawa said. “Most of the physicians expressed concerns about precertification [delays] and requirement for prior authorization for lung cancer screening.”
She acknowledged certain limitations of the study, including its small sample size and the fact that the researchers interviewed primary care physicians catering to an underserved population in the community, “which is not comparable to the NLST population,” she said.
“However, [our results] could be potentially more generalizable,” Dr. Randhawa noted. “In the future, we hope that there is evolving technology used for CT screening with reduction in radiation dose, and more accurate biomarkers will be developed to identify patients at highest risk for lung cancer. We aim to save lives through early detection of lung cancer with responsible CT lung screening.”
One of the study authors, Tracy Kane, MD, disclosed being a member of the speakers bureau for AstraZeneca and receiving honoraria from the company. The other researchers reported having no financial disclosures.
Key clinical point:
Major finding: Of patients who participated in a community screening program over the course of 1 year, 88% were diagnosed with Lung-RADS 1 or 2, 7% were Lung-RADS 3, and 5% were Lung-RADS 4.
Data source: A 12-month prospective study of 278 patients at risk for lung cancer.
Disclosures: One of the study authors, Tracy Kane, MD, disclosed being a member of the speakers bureau for AstraZeneca and receiving honoraria from the company. The other researchers reported having no financial disclosures.
VIDEO: Public reporting of congenital heart disease outcomes should be easily understood
HOUSTON – Survival statistics, surgeon-specific experience, and complication rates are the types of information most sought by parents of children with congenital heart disease, results from a large survey suggest.
Future efforts in public reporting for congenital heart surgery outcomes should have better methods for presenting the data in a valid, easily interpreted format, explained study investigator Mallory L. Irons, MD, an integrated cardiac surgery resident at the Hospital of the University of Pennsylvania, Philadelphia.
“We’re doing a good job of public reporting currently, but what we’re doing is not meeting the needs of all of our stakeholders – in this case, the parents of children with congenital heart disease,” Dr. Irons said in an interview at the annual meeting of the Society of Thoracic Surgeons. “The optimal public reporting scheme still has yet to be determined.”
Dr. Irons reported having no financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
HOUSTON – Survival statistics, surgeon-specific experience, and complication rates are the types of information most sought by parents of children with congenital heart disease, results from a large survey suggest.
Future efforts in public reporting for congenital heart surgery outcomes should have better methods for presenting the data in a valid, easily interpreted format, explained study investigator Mallory L. Irons, MD, an integrated cardiac surgery resident at the Hospital of the University of Pennsylvania, Philadelphia.
“We’re doing a good job of public reporting currently, but what we’re doing is not meeting the needs of all of our stakeholders – in this case, the parents of children with congenital heart disease,” Dr. Irons said in an interview at the annual meeting of the Society of Thoracic Surgeons. “The optimal public reporting scheme still has yet to be determined.”
Dr. Irons reported having no financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
HOUSTON – Survival statistics, surgeon-specific experience, and complication rates are the types of information most sought by parents of children with congenital heart disease, results from a large survey suggest.
Future efforts in public reporting for congenital heart surgery outcomes should have better methods for presenting the data in a valid, easily interpreted format, explained study investigator Mallory L. Irons, MD, an integrated cardiac surgery resident at the Hospital of the University of Pennsylvania, Philadelphia.
“We’re doing a good job of public reporting currently, but what we’re doing is not meeting the needs of all of our stakeholders – in this case, the parents of children with congenital heart disease,” Dr. Irons said in an interview at the annual meeting of the Society of Thoracic Surgeons. “The optimal public reporting scheme still has yet to be determined.”
Dr. Irons reported having no financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
FROM THE STS ANNUAL MEETING HOUSTON
Our new year’s resolutions
Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.
– Benjamin Franklin
Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.
Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.
As we have spoken with many of our colleagues, it has become clear to us that many clinicians have learned how to be “just proficient enough” in their use of their EHR; they are not pulling out their hair every 5 minutes in frustration, but they have not taken the extra time and effort that are needed to optimize their productivity. To efficiently use an EHR requires some time spent designing templates and macros to make it easy to repetitively carry out common tasks.
A lot of physicians – particularly physicians over 40 years of age – are still typing their notes with the ol’ two-finger hunt-and-peck technique. This is incredibly time consuming, inefficient, and frustrating.
While many solutions have been proposed, including having a scribe walk around with the doctor, the simplest and easiest to implement is voice transcription. Even though medical transcription software is expensive, the return on investment is large for those who do not type well. After a short period of training on the software, notes are generally of higher quality and are finished considerably faster than when typing. The technology also has the ability to learn the names of frequently used consultants, medications, and procedures, so users don’t even have to type uncommon names or words.
Another area in which we hope to advance over the next year is working more effectively as a team to share the documentation burden. Nurses and medical assistants – within the boundaries of their licensing – can be empowered to document in predefined areas of the chart as much as possible.
For example, given the fact that the prevalence of depression is about twice as high in patients with diabetes as it is in the general population, our medical assistants now screen our diabetes patients with a PHQ-2 depression screen and record the results in the chart. This has been good for our patients, satisfying for our medical assistants, and has offloaded this task from the doctors.
We need to think of more areas where we can facilitate team care and really make everyone – physicians, nurses, front staff, and patients – more satisfied with the care that is being given.
Most EHRs have a reminder function – the ability to prompt a user to follow up on an abnormal x-ray or lab results in case a patient does not come back into the office as recommended. Our sense is that most of us are not using this function. It is worth finding out how to use it and giving it a try.
Patient portals have gained a lot of traction over the past few years. For a little while, we were really making an effort to have patients register, so that currently many (but by far not most) of our patients have signed up. We want to make better use of this fantastic resource.
We say “fantastic” because when we talk to patients (or friends or family) who use the portal, they have shared that it really makes their lives easier. They are able to see their labs, ponder the meaning of their results (perhaps of a slightly high glucose or an LDL cholesterol level), and if they have questions, they can correspond electronically with their care providers. It enhances care and allows us to spend less time on the phone, while giving patients better access to information.
New year’s resolutions are an opportunity for reflection and optimism. As we look back on the past year, we should learn from our experience and approach the year in front of us with greater enthusiasm, in the hope that through that enthusiasm we can continue to grow, be better and healthier, and simply be more like the people we want to be.
The electronic health record affects all of our interactions with patients and colleagues, and, when not used optimally, encroaches into our personal and family lives. It is a perfect place to focus during the new year to enable us to have more productive, effective, and happier times both in the office and at home.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.
– Benjamin Franklin
Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.
Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.
As we have spoken with many of our colleagues, it has become clear to us that many clinicians have learned how to be “just proficient enough” in their use of their EHR; they are not pulling out their hair every 5 minutes in frustration, but they have not taken the extra time and effort that are needed to optimize their productivity. To efficiently use an EHR requires some time spent designing templates and macros to make it easy to repetitively carry out common tasks.
A lot of physicians – particularly physicians over 40 years of age – are still typing their notes with the ol’ two-finger hunt-and-peck technique. This is incredibly time consuming, inefficient, and frustrating.
While many solutions have been proposed, including having a scribe walk around with the doctor, the simplest and easiest to implement is voice transcription. Even though medical transcription software is expensive, the return on investment is large for those who do not type well. After a short period of training on the software, notes are generally of higher quality and are finished considerably faster than when typing. The technology also has the ability to learn the names of frequently used consultants, medications, and procedures, so users don’t even have to type uncommon names or words.
Another area in which we hope to advance over the next year is working more effectively as a team to share the documentation burden. Nurses and medical assistants – within the boundaries of their licensing – can be empowered to document in predefined areas of the chart as much as possible.
For example, given the fact that the prevalence of depression is about twice as high in patients with diabetes as it is in the general population, our medical assistants now screen our diabetes patients with a PHQ-2 depression screen and record the results in the chart. This has been good for our patients, satisfying for our medical assistants, and has offloaded this task from the doctors.
We need to think of more areas where we can facilitate team care and really make everyone – physicians, nurses, front staff, and patients – more satisfied with the care that is being given.
Most EHRs have a reminder function – the ability to prompt a user to follow up on an abnormal x-ray or lab results in case a patient does not come back into the office as recommended. Our sense is that most of us are not using this function. It is worth finding out how to use it and giving it a try.
Patient portals have gained a lot of traction over the past few years. For a little while, we were really making an effort to have patients register, so that currently many (but by far not most) of our patients have signed up. We want to make better use of this fantastic resource.
We say “fantastic” because when we talk to patients (or friends or family) who use the portal, they have shared that it really makes their lives easier. They are able to see their labs, ponder the meaning of their results (perhaps of a slightly high glucose or an LDL cholesterol level), and if they have questions, they can correspond electronically with their care providers. It enhances care and allows us to spend less time on the phone, while giving patients better access to information.
New year’s resolutions are an opportunity for reflection and optimism. As we look back on the past year, we should learn from our experience and approach the year in front of us with greater enthusiasm, in the hope that through that enthusiasm we can continue to grow, be better and healthier, and simply be more like the people we want to be.
The electronic health record affects all of our interactions with patients and colleagues, and, when not used optimally, encroaches into our personal and family lives. It is a perfect place to focus during the new year to enable us to have more productive, effective, and happier times both in the office and at home.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.
– Benjamin Franklin
Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.
Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.
As we have spoken with many of our colleagues, it has become clear to us that many clinicians have learned how to be “just proficient enough” in their use of their EHR; they are not pulling out their hair every 5 minutes in frustration, but they have not taken the extra time and effort that are needed to optimize their productivity. To efficiently use an EHR requires some time spent designing templates and macros to make it easy to repetitively carry out common tasks.
A lot of physicians – particularly physicians over 40 years of age – are still typing their notes with the ol’ two-finger hunt-and-peck technique. This is incredibly time consuming, inefficient, and frustrating.
While many solutions have been proposed, including having a scribe walk around with the doctor, the simplest and easiest to implement is voice transcription. Even though medical transcription software is expensive, the return on investment is large for those who do not type well. After a short period of training on the software, notes are generally of higher quality and are finished considerably faster than when typing. The technology also has the ability to learn the names of frequently used consultants, medications, and procedures, so users don’t even have to type uncommon names or words.
Another area in which we hope to advance over the next year is working more effectively as a team to share the documentation burden. Nurses and medical assistants – within the boundaries of their licensing – can be empowered to document in predefined areas of the chart as much as possible.
For example, given the fact that the prevalence of depression is about twice as high in patients with diabetes as it is in the general population, our medical assistants now screen our diabetes patients with a PHQ-2 depression screen and record the results in the chart. This has been good for our patients, satisfying for our medical assistants, and has offloaded this task from the doctors.
We need to think of more areas where we can facilitate team care and really make everyone – physicians, nurses, front staff, and patients – more satisfied with the care that is being given.
Most EHRs have a reminder function – the ability to prompt a user to follow up on an abnormal x-ray or lab results in case a patient does not come back into the office as recommended. Our sense is that most of us are not using this function. It is worth finding out how to use it and giving it a try.
Patient portals have gained a lot of traction over the past few years. For a little while, we were really making an effort to have patients register, so that currently many (but by far not most) of our patients have signed up. We want to make better use of this fantastic resource.
We say “fantastic” because when we talk to patients (or friends or family) who use the portal, they have shared that it really makes their lives easier. They are able to see their labs, ponder the meaning of their results (perhaps of a slightly high glucose or an LDL cholesterol level), and if they have questions, they can correspond electronically with their care providers. It enhances care and allows us to spend less time on the phone, while giving patients better access to information.
New year’s resolutions are an opportunity for reflection and optimism. As we look back on the past year, we should learn from our experience and approach the year in front of us with greater enthusiasm, in the hope that through that enthusiasm we can continue to grow, be better and healthier, and simply be more like the people we want to be.
The electronic health record affects all of our interactions with patients and colleagues, and, when not used optimally, encroaches into our personal and family lives. It is a perfect place to focus during the new year to enable us to have more productive, effective, and happier times both in the office and at home.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Bortezomib-based regimen led to durable remissions in mantle cell lymphoma
SAN DIEGO – For adults with mantle cell lymphoma, adding bortezomib to a modified hyper-CVAD (VcR-CVAD) regimen followed by rituximab maintenance induced durable remissions at rates resembling those seen with more intensive chemotherapy followed by autologous hematopoietic stem cell transplantation, according to long-term results from a multicenter phase II trial.
Two-thirds of patients were alive and 50% remained in remission after a median follow-up period of 7.8 years, said Julie E. Chang, MD, who reported the results of the study at the annual meeting of the American Society of Hematology. “VcR-CVAD is a moderate-intensity chemotherapy regimen that is tolerable for many older and less fit adult patients as first-line therapy of mantle cell lymphoma,” she emphasized.
Mantle cell lymphoma lacks a clear standard first-line therapy, noted Dr. Chang of the University of Wisconsin in Madison. “We hypothesized that the addition of bortezomib would improve the complete response rate, and maintenance rituximab would improve the remission duration,” she said.
To test that idea, she and her associates enrolled 30 adults with histologically confirmed mantle cell lymphoma who had received either no treatment or just one cycle of CHOP or CHOP-like chemotherapy.
Patients received six 21-day cycles of VcR-CVAD induction chemotherapy. This regimen consisted of rituximab (375 mg/m2 IV) on day 1; bortezomib (1.3 mg/m2 IV) on days 1 and 4; cyclophosphamide (300 mg/m2 IV every 12 hours) on days 1 through 3; doxorubicin (50 mg/m2 IV given as a continuous infusion) on days 1 and 2; vincristine (1 mg IV) on day 3; and dexamethasone (40 mg orally) on days 1 through 4.
Patients were permitted all supportive care measures, including prophylaxis for tumor lysis syndrome, transfusions, and antibiotics. Those with at least a partial response received rituximab consolidation (375 mg/m2 IV per week for 4 weeks) followed by rituximab maintenance (375 mg/m2 IV every 12 weeks for 5 years).
Median age was 61 years (range, 48-74 years), 80% of patients were male, all had advanced-stage disease, 60% were mantle cell lymphoma international prognostic index (MIPI) medium or high risk, and six had blastic morphology, the researchers noted.
Estimated 6-year rates of progression-free and overall survival were 53% (95% confidence interval, 38%-75%) and 70% (95% CI, 55%-84%), respectively. Neither age nor MIPI score significantly affected the chances of progression-free or overall survival, but there was a trend toward worse survival among MIPI high-risk patients.
The 10 deaths included 5 from progressive disease, 3 from complications after allogeneic transplant, and 2 from unrelated causes. No patients who remained progression free for 5 years subsequently relapsed, nor were there late toxicities related to treatment.
A recent phase III trial (N Engl J Med. 2015 Mar 5;372[10]:944-53) confirmed the benefits of adding bortezomib to standard immunochemotherapy in mantle cell lymphoma, Dr. Chang noted. “VcR-CVAD remains an effective therapy choice for initial treatment of MCL, both in younger and older MCL populations,” she concluded.
Dr. Chang had no relevant disclosures. Senior author Brad S. Kahl, MD, disclosed ties to Celgene, Gilead, Infinity, Juno, Pharmacyclics, and Seattle Genetics.
SAN DIEGO – For adults with mantle cell lymphoma, adding bortezomib to a modified hyper-CVAD (VcR-CVAD) regimen followed by rituximab maintenance induced durable remissions at rates resembling those seen with more intensive chemotherapy followed by autologous hematopoietic stem cell transplantation, according to long-term results from a multicenter phase II trial.
Two-thirds of patients were alive and 50% remained in remission after a median follow-up period of 7.8 years, said Julie E. Chang, MD, who reported the results of the study at the annual meeting of the American Society of Hematology. “VcR-CVAD is a moderate-intensity chemotherapy regimen that is tolerable for many older and less fit adult patients as first-line therapy of mantle cell lymphoma,” she emphasized.
Mantle cell lymphoma lacks a clear standard first-line therapy, noted Dr. Chang of the University of Wisconsin in Madison. “We hypothesized that the addition of bortezomib would improve the complete response rate, and maintenance rituximab would improve the remission duration,” she said.
To test that idea, she and her associates enrolled 30 adults with histologically confirmed mantle cell lymphoma who had received either no treatment or just one cycle of CHOP or CHOP-like chemotherapy.
Patients received six 21-day cycles of VcR-CVAD induction chemotherapy. This regimen consisted of rituximab (375 mg/m2 IV) on day 1; bortezomib (1.3 mg/m2 IV) on days 1 and 4; cyclophosphamide (300 mg/m2 IV every 12 hours) on days 1 through 3; doxorubicin (50 mg/m2 IV given as a continuous infusion) on days 1 and 2; vincristine (1 mg IV) on day 3; and dexamethasone (40 mg orally) on days 1 through 4.
Patients were permitted all supportive care measures, including prophylaxis for tumor lysis syndrome, transfusions, and antibiotics. Those with at least a partial response received rituximab consolidation (375 mg/m2 IV per week for 4 weeks) followed by rituximab maintenance (375 mg/m2 IV every 12 weeks for 5 years).
Median age was 61 years (range, 48-74 years), 80% of patients were male, all had advanced-stage disease, 60% were mantle cell lymphoma international prognostic index (MIPI) medium or high risk, and six had blastic morphology, the researchers noted.
Estimated 6-year rates of progression-free and overall survival were 53% (95% confidence interval, 38%-75%) and 70% (95% CI, 55%-84%), respectively. Neither age nor MIPI score significantly affected the chances of progression-free or overall survival, but there was a trend toward worse survival among MIPI high-risk patients.
The 10 deaths included 5 from progressive disease, 3 from complications after allogeneic transplant, and 2 from unrelated causes. No patients who remained progression free for 5 years subsequently relapsed, nor were there late toxicities related to treatment.
A recent phase III trial (N Engl J Med. 2015 Mar 5;372[10]:944-53) confirmed the benefits of adding bortezomib to standard immunochemotherapy in mantle cell lymphoma, Dr. Chang noted. “VcR-CVAD remains an effective therapy choice for initial treatment of MCL, both in younger and older MCL populations,” she concluded.
Dr. Chang had no relevant disclosures. Senior author Brad S. Kahl, MD, disclosed ties to Celgene, Gilead, Infinity, Juno, Pharmacyclics, and Seattle Genetics.
SAN DIEGO – For adults with mantle cell lymphoma, adding bortezomib to a modified hyper-CVAD (VcR-CVAD) regimen followed by rituximab maintenance induced durable remissions at rates resembling those seen with more intensive chemotherapy followed by autologous hematopoietic stem cell transplantation, according to long-term results from a multicenter phase II trial.
Two-thirds of patients were alive and 50% remained in remission after a median follow-up period of 7.8 years, said Julie E. Chang, MD, who reported the results of the study at the annual meeting of the American Society of Hematology. “VcR-CVAD is a moderate-intensity chemotherapy regimen that is tolerable for many older and less fit adult patients as first-line therapy of mantle cell lymphoma,” she emphasized.
Mantle cell lymphoma lacks a clear standard first-line therapy, noted Dr. Chang of the University of Wisconsin in Madison. “We hypothesized that the addition of bortezomib would improve the complete response rate, and maintenance rituximab would improve the remission duration,” she said.
To test that idea, she and her associates enrolled 30 adults with histologically confirmed mantle cell lymphoma who had received either no treatment or just one cycle of CHOP or CHOP-like chemotherapy.
Patients received six 21-day cycles of VcR-CVAD induction chemotherapy. This regimen consisted of rituximab (375 mg/m2 IV) on day 1; bortezomib (1.3 mg/m2 IV) on days 1 and 4; cyclophosphamide (300 mg/m2 IV every 12 hours) on days 1 through 3; doxorubicin (50 mg/m2 IV given as a continuous infusion) on days 1 and 2; vincristine (1 mg IV) on day 3; and dexamethasone (40 mg orally) on days 1 through 4.
Patients were permitted all supportive care measures, including prophylaxis for tumor lysis syndrome, transfusions, and antibiotics. Those with at least a partial response received rituximab consolidation (375 mg/m2 IV per week for 4 weeks) followed by rituximab maintenance (375 mg/m2 IV every 12 weeks for 5 years).
Median age was 61 years (range, 48-74 years), 80% of patients were male, all had advanced-stage disease, 60% were mantle cell lymphoma international prognostic index (MIPI) medium or high risk, and six had blastic morphology, the researchers noted.
Estimated 6-year rates of progression-free and overall survival were 53% (95% confidence interval, 38%-75%) and 70% (95% CI, 55%-84%), respectively. Neither age nor MIPI score significantly affected the chances of progression-free or overall survival, but there was a trend toward worse survival among MIPI high-risk patients.
The 10 deaths included 5 from progressive disease, 3 from complications after allogeneic transplant, and 2 from unrelated causes. No patients who remained progression free for 5 years subsequently relapsed, nor were there late toxicities related to treatment.
A recent phase III trial (N Engl J Med. 2015 Mar 5;372[10]:944-53) confirmed the benefits of adding bortezomib to standard immunochemotherapy in mantle cell lymphoma, Dr. Chang noted. “VcR-CVAD remains an effective therapy choice for initial treatment of MCL, both in younger and older MCL populations,” she concluded.
Dr. Chang had no relevant disclosures. Senior author Brad S. Kahl, MD, disclosed ties to Celgene, Gilead, Infinity, Juno, Pharmacyclics, and Seattle Genetics.
Key clinical point: First-line therapy with bortezomib plus modified hyper-CVAD followed by rituximab maintenance induced durable remissions in mantle cell lymphoma.
Major finding: Two-thirds of patients were alive and 50% remained in remission after a median follow-up period of 7.8 years.
Data source: A multicenter phase II trial of 30 adults with mantle cell lymphoma who were treatment-naïve or had received only one cycle of CHOP or CHOP-like chemotherapy.
Disclosures: Dr. Chang had no relevant disclosures. Senior author Brad S. Kahl, MD, disclosed ties to Celgene, Gilead, Infinity, Juno, Pharmacyclics, and Seattle Genetics.
Model: Quadrivalent vaccine could cost effectively cut MSM’s HPV-related cancers
Use of a quadrivalent HPV vaccine in men who have sex with men, administered in genitourinary specialty clinics, would cost effectively provide herd immunity against the ill effects of the virus, particularly anogenital warts and male HPV-related cancers, according to an English mathematical model.
Mark Jit, PhD, a professor of vaccine epidemiology at the London School of Hygiene & Tropical Medicine, and his colleagues considered in which settings HPV vaccination delivery would have the greatest effect size; the patterns of sexual behavior in MSM leading to the transmission of HPV 6, 11, 16, and 18; and the costs and quality adjusted life year (QALY) implications of disease outcomes (Clin Infect Dis. 2016 Dec 23. doi: 10.1093/cid/ciw845).
Clinic attendance rates were based on genitourinary clinic returns in England recorded in public health surveillance data recorded between 2009 and 2012, stratified according to diagnosed HIV-positive status. Also modeled were the effects of vaccination in MSM between the ages of 16 and 40 years, according to groups aged 16-25 years, 16-30 years, 16-35 years, and 16-40 years. Models for ages on either side of 16 or 40 years were not considered because of confidentiality constraints in the former and limited specialty clinic use in the latter.
Herd protection likely would be notable in the first year, because of the breadth of the age ranges modeled, Dr. Jit and his colleagues determined. Specifically, the models predicted a 35% decline in incidence rates of anogenital warts within 5 years of initiating the vaccine across all MSM men seen in specialty clinics. If only HIV-positive MSM across the age groups were vaccinated, the models predicted a 5-year decline of 15%.
Declines predicted in HPV-related cancers would happen more slowly, because progression from infection to malignancies tends to occur over years. For example, there would be a 55% reduction over 100 years for anal cancer if all 16- to 40-year-old MSM attending specialty clinics are offered vaccination. However, the reduction rate would drop to 40% in that same time period if only HIV-positive men across the age groups were vaccinated.
Using a cost-effectiveness threshold of 20,000 British pounds (about $24,500) per QALY, with no more than a 10% probability that the incremental cost-effectiveness ratio would exceed 30,000 pounds per QALY ($36,710), Dr. Jit and his colleagues determined that using a quadrivalent HPV vaccination in MSM between ages 16 and 40 years in the specialty clinic setting would be cost effective if delivery cost an average of 63 pounds ($77) per dose.
By offering vaccination only to HIV-positive MSM between 16 and 40 years, even if the quadrivalent vaccine were to cost as much as 96.50 pounds ($118), it would still be cost effective. A nonavalent vaccine at the same price would also be cost effective, because nearly all HPV-related cancers are linked to HPV 16 and 18. However, a bivalent vaccine was not shown by the models to be cost effective in such a limited program.
The investigators theorized that HIV infection is associated with the rate of HPV-related disease progression. To simplify computation, however, their models only considered the overall cost effectiveness of offering HPV vaccination to either HIV-positive MSM or to MSM regardless of current HIV status. That could mean “the cost effectiveness of MSM vaccination may be even better than reported,” the researchers noted.
This study was funded primarily by the National Institute for Health Research and Public Health England in the United Kingdom. The authors had no relevant disclosures.
Use of a quadrivalent HPV vaccine in men who have sex with men, administered in genitourinary specialty clinics, would cost effectively provide herd immunity against the ill effects of the virus, particularly anogenital warts and male HPV-related cancers, according to an English mathematical model.
Mark Jit, PhD, a professor of vaccine epidemiology at the London School of Hygiene & Tropical Medicine, and his colleagues considered in which settings HPV vaccination delivery would have the greatest effect size; the patterns of sexual behavior in MSM leading to the transmission of HPV 6, 11, 16, and 18; and the costs and quality adjusted life year (QALY) implications of disease outcomes (Clin Infect Dis. 2016 Dec 23. doi: 10.1093/cid/ciw845).
Clinic attendance rates were based on genitourinary clinic returns in England recorded in public health surveillance data recorded between 2009 and 2012, stratified according to diagnosed HIV-positive status. Also modeled were the effects of vaccination in MSM between the ages of 16 and 40 years, according to groups aged 16-25 years, 16-30 years, 16-35 years, and 16-40 years. Models for ages on either side of 16 or 40 years were not considered because of confidentiality constraints in the former and limited specialty clinic use in the latter.
Herd protection likely would be notable in the first year, because of the breadth of the age ranges modeled, Dr. Jit and his colleagues determined. Specifically, the models predicted a 35% decline in incidence rates of anogenital warts within 5 years of initiating the vaccine across all MSM men seen in specialty clinics. If only HIV-positive MSM across the age groups were vaccinated, the models predicted a 5-year decline of 15%.
Declines predicted in HPV-related cancers would happen more slowly, because progression from infection to malignancies tends to occur over years. For example, there would be a 55% reduction over 100 years for anal cancer if all 16- to 40-year-old MSM attending specialty clinics are offered vaccination. However, the reduction rate would drop to 40% in that same time period if only HIV-positive men across the age groups were vaccinated.
Using a cost-effectiveness threshold of 20,000 British pounds (about $24,500) per QALY, with no more than a 10% probability that the incremental cost-effectiveness ratio would exceed 30,000 pounds per QALY ($36,710), Dr. Jit and his colleagues determined that using a quadrivalent HPV vaccination in MSM between ages 16 and 40 years in the specialty clinic setting would be cost effective if delivery cost an average of 63 pounds ($77) per dose.
By offering vaccination only to HIV-positive MSM between 16 and 40 years, even if the quadrivalent vaccine were to cost as much as 96.50 pounds ($118), it would still be cost effective. A nonavalent vaccine at the same price would also be cost effective, because nearly all HPV-related cancers are linked to HPV 16 and 18. However, a bivalent vaccine was not shown by the models to be cost effective in such a limited program.
The investigators theorized that HIV infection is associated with the rate of HPV-related disease progression. To simplify computation, however, their models only considered the overall cost effectiveness of offering HPV vaccination to either HIV-positive MSM or to MSM regardless of current HIV status. That could mean “the cost effectiveness of MSM vaccination may be even better than reported,” the researchers noted.
This study was funded primarily by the National Institute for Health Research and Public Health England in the United Kingdom. The authors had no relevant disclosures.
Use of a quadrivalent HPV vaccine in men who have sex with men, administered in genitourinary specialty clinics, would cost effectively provide herd immunity against the ill effects of the virus, particularly anogenital warts and male HPV-related cancers, according to an English mathematical model.
Mark Jit, PhD, a professor of vaccine epidemiology at the London School of Hygiene & Tropical Medicine, and his colleagues considered in which settings HPV vaccination delivery would have the greatest effect size; the patterns of sexual behavior in MSM leading to the transmission of HPV 6, 11, 16, and 18; and the costs and quality adjusted life year (QALY) implications of disease outcomes (Clin Infect Dis. 2016 Dec 23. doi: 10.1093/cid/ciw845).
Clinic attendance rates were based on genitourinary clinic returns in England recorded in public health surveillance data recorded between 2009 and 2012, stratified according to diagnosed HIV-positive status. Also modeled were the effects of vaccination in MSM between the ages of 16 and 40 years, according to groups aged 16-25 years, 16-30 years, 16-35 years, and 16-40 years. Models for ages on either side of 16 or 40 years were not considered because of confidentiality constraints in the former and limited specialty clinic use in the latter.
Herd protection likely would be notable in the first year, because of the breadth of the age ranges modeled, Dr. Jit and his colleagues determined. Specifically, the models predicted a 35% decline in incidence rates of anogenital warts within 5 years of initiating the vaccine across all MSM men seen in specialty clinics. If only HIV-positive MSM across the age groups were vaccinated, the models predicted a 5-year decline of 15%.
Declines predicted in HPV-related cancers would happen more slowly, because progression from infection to malignancies tends to occur over years. For example, there would be a 55% reduction over 100 years for anal cancer if all 16- to 40-year-old MSM attending specialty clinics are offered vaccination. However, the reduction rate would drop to 40% in that same time period if only HIV-positive men across the age groups were vaccinated.
Using a cost-effectiveness threshold of 20,000 British pounds (about $24,500) per QALY, with no more than a 10% probability that the incremental cost-effectiveness ratio would exceed 30,000 pounds per QALY ($36,710), Dr. Jit and his colleagues determined that using a quadrivalent HPV vaccination in MSM between ages 16 and 40 years in the specialty clinic setting would be cost effective if delivery cost an average of 63 pounds ($77) per dose.
By offering vaccination only to HIV-positive MSM between 16 and 40 years, even if the quadrivalent vaccine were to cost as much as 96.50 pounds ($118), it would still be cost effective. A nonavalent vaccine at the same price would also be cost effective, because nearly all HPV-related cancers are linked to HPV 16 and 18. However, a bivalent vaccine was not shown by the models to be cost effective in such a limited program.
The investigators theorized that HIV infection is associated with the rate of HPV-related disease progression. To simplify computation, however, their models only considered the overall cost effectiveness of offering HPV vaccination to either HIV-positive MSM or to MSM regardless of current HIV status. That could mean “the cost effectiveness of MSM vaccination may be even better than reported,” the researchers noted.
This study was funded primarily by the National Institute for Health Research and Public Health England in the United Kingdom. The authors had no relevant disclosures.
Key clinical point:
Major finding: Substantial declines in HPV-related events in MSM were projected within 5 years of vaccination between ages 16 and 40 years in this cohort.
Data source: Mathematical modeling of HPV 6, 11, 16, and 18 sexual transmission in the MSM population of England.
Disclosures: This study was funded primarily by the National Institute for Health Research and Public Health England in the United Kingdom. The authors had no relevant disclosures.
Everything We Say and Do: Use familiar terminology to allay patients’ fears
Editor’s note: “Everything We Say and Do” is an informational series developed by SHM ’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”
What I say and do
I clearly explain diagnoses and treatment plans in plain terms.
Why I do it
We hear repeatedly from patients and families that a major source of their fear comes from “not knowing.” Fear of the unknown. If our patients and their families do not understand the message we are trying to communicate, these fears will be realized. It is our responsibility to explain their medical situation(s) to them in plain terms that they can comprehend, so as to allay those fears and enable them to become active, informed participants in their care.
How I do it
I start by reminding myself that I want to treat each patient as I would want a member of my own family to be treated. No one else in my family is in the medical field, so this means I must avoid medical terminology and use more familiar, everyday phrases. For example, I say “heart doctor” or “lung doctor” instead of “cardiologist” or “pulmonologist.” I also prefer “sonogram” to “ultrasound” because most people have heard that term in relation to a pregnancy. Even “EEG” and “EKG” need more plain descriptions.
I also try to use common, relatable analogies when explaining diseases. My favorite is to describe COPD (or any restrictive lung disease) like an old, hard sponge as compared with normal lungs, which are like a new, soft sponge.
I use the Teach-Back Method (which has already been well-discussed in this column by Dr. Trina Dorrah) to check for comprehension. If there are still issues with my message not being received as I had hoped, then I try again to find the terminology or an analogy that will connect with that patient.
Hopefully, using familiar, relatable language in this manner gives my patients and their families a better understanding of their diagnoses and care plans, quells their fears, and enhances their experience.
Dr. Sharp is a chief hospitalist with Sound Physicians at UF Health in Jacksonville, Fla., and a member of SHM's Patient Experience Committee.
Editor’s note: “Everything We Say and Do” is an informational series developed by SHM ’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”
What I say and do
I clearly explain diagnoses and treatment plans in plain terms.
Why I do it
We hear repeatedly from patients and families that a major source of their fear comes from “not knowing.” Fear of the unknown. If our patients and their families do not understand the message we are trying to communicate, these fears will be realized. It is our responsibility to explain their medical situation(s) to them in plain terms that they can comprehend, so as to allay those fears and enable them to become active, informed participants in their care.
How I do it
I start by reminding myself that I want to treat each patient as I would want a member of my own family to be treated. No one else in my family is in the medical field, so this means I must avoid medical terminology and use more familiar, everyday phrases. For example, I say “heart doctor” or “lung doctor” instead of “cardiologist” or “pulmonologist.” I also prefer “sonogram” to “ultrasound” because most people have heard that term in relation to a pregnancy. Even “EEG” and “EKG” need more plain descriptions.
I also try to use common, relatable analogies when explaining diseases. My favorite is to describe COPD (or any restrictive lung disease) like an old, hard sponge as compared with normal lungs, which are like a new, soft sponge.
I use the Teach-Back Method (which has already been well-discussed in this column by Dr. Trina Dorrah) to check for comprehension. If there are still issues with my message not being received as I had hoped, then I try again to find the terminology or an analogy that will connect with that patient.
Hopefully, using familiar, relatable language in this manner gives my patients and their families a better understanding of their diagnoses and care plans, quells their fears, and enhances their experience.
Dr. Sharp is a chief hospitalist with Sound Physicians at UF Health in Jacksonville, Fla., and a member of SHM's Patient Experience Committee.
Editor’s note: “Everything We Say and Do” is an informational series developed by SHM ’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”
What I say and do
I clearly explain diagnoses and treatment plans in plain terms.
Why I do it
We hear repeatedly from patients and families that a major source of their fear comes from “not knowing.” Fear of the unknown. If our patients and their families do not understand the message we are trying to communicate, these fears will be realized. It is our responsibility to explain their medical situation(s) to them in plain terms that they can comprehend, so as to allay those fears and enable them to become active, informed participants in their care.
How I do it
I start by reminding myself that I want to treat each patient as I would want a member of my own family to be treated. No one else in my family is in the medical field, so this means I must avoid medical terminology and use more familiar, everyday phrases. For example, I say “heart doctor” or “lung doctor” instead of “cardiologist” or “pulmonologist.” I also prefer “sonogram” to “ultrasound” because most people have heard that term in relation to a pregnancy. Even “EEG” and “EKG” need more plain descriptions.
I also try to use common, relatable analogies when explaining diseases. My favorite is to describe COPD (or any restrictive lung disease) like an old, hard sponge as compared with normal lungs, which are like a new, soft sponge.
I use the Teach-Back Method (which has already been well-discussed in this column by Dr. Trina Dorrah) to check for comprehension. If there are still issues with my message not being received as I had hoped, then I try again to find the terminology or an analogy that will connect with that patient.
Hopefully, using familiar, relatable language in this manner gives my patients and their families a better understanding of their diagnoses and care plans, quells their fears, and enhances their experience.
Dr. Sharp is a chief hospitalist with Sound Physicians at UF Health in Jacksonville, Fla., and a member of SHM's Patient Experience Committee.