Physicians are spending twice as much time on electronic health records as they are face to face with patients, according to a new study by the American Medical Association.

Researchers observed 57 physicians in four specialties (family medicine, internal medicine, cardiology, and orthopedics) and found that for every hour of direct clinical face time with patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Additionally, based on diaries kept by 21 of the participating physicians, another 1-2 hours of personal time were spent each night doing additional computer and clerical work, according to the study published Sept. 5 in Annals of Internal Medicine (2016. doi: 10.7326/M16-0961).

©iStock/Thinkstock.com

“Over the years, doctors have recognized that more and more of their time was spent on nonpatient care, activities but probably haven’t recognized the magnitude of that change,” Christine Sinsky, MD, vice president of professional satisfaction at the AMA and lead author on the study, said in an interview. “Our study was able to help to quantify that and paint that picture.”

Overall, physicians spent 27% of their day dealing directly with patients, while 49% of the time was spent on EHR and desk work. In the examination room with patients, physicians spent 53% of time on direct clinical face time and 37% on EHR and desk work.

The situation “is the cumulative effect of many, many well-intended efforts that individually might have made sense, but taken collectively have paradoxically made it harder for physicians to deliver quality of care and harder for patients to get the quality of care they deserve,” she said.

EHR development should be focused on reducing the time-cost of providing care on their platforms, Dr. Sinsky recommended.

She noted that for her practice, it takes 32 clicks to order and record a flu shot. “I think vendors have a responsibility to minimize time, to minimize clicks involved in a task.”

She added that “regulators have a responsibility to not just add more and more regulations without first identifying the time-cost of complying with that regulation and without adding up the total cost of complying with regulation.”

Future regulations on EHRs must add flexibility when it comes to who is entering information into the system, she said. “Many regulations are either written with the explicit statement – or it is implied or an institution might overinterpret the regulation – that the physician is the one who must do the keyboarding into the record,” she said, noting that although not primarily studied in the research, preliminary data suggests that doctors who had documentation support were able to spend more time with their patients.

Finally, physicians themselves need to be stronger advocates for the changes they need to enable them to better serve their patients.

In addition to Dr. Sinsky, three other study authors are employed by AMA, which funded the study. No other financial conflicts were reported.

gtwachtman@frontlinemedcom.com

Physicians are spending twice as much time on electronic health records as they are face to face with patients, according to a new study by the American Medical Association.

Researchers observed 57 physicians in four specialties (family medicine, internal medicine, cardiology, and orthopedics) and found that for every hour of direct clinical face time with patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Additionally, based on diaries kept by 21 of the participating physicians, another 1-2 hours of personal time were spent each night doing additional computer and clerical work, according to the study published Sept. 5 in Annals of Internal Medicine (2016. doi: 10.7326/M16-0961).

©iStock/Thinkstock.com

“Over the years, doctors have recognized that more and more of their time was spent on nonpatient care, activities but probably haven’t recognized the magnitude of that change,” Christine Sinsky, MD, vice president of professional satisfaction at the AMA and lead author on the study, said in an interview. “Our study was able to help to quantify that and paint that picture.”

Overall, physicians spent 27% of their day dealing directly with patients, while 49% of the time was spent on EHR and desk work. In the examination room with patients, physicians spent 53% of time on direct clinical face time and 37% on EHR and desk work.

The situation “is the cumulative effect of many, many well-intended efforts that individually might have made sense, but taken collectively have paradoxically made it harder for physicians to deliver quality of care and harder for patients to get the quality of care they deserve,” she said.

EHR development should be focused on reducing the time-cost of providing care on their platforms, Dr. Sinsky recommended.

She noted that for her practice, it takes 32 clicks to order and record a flu shot. “I think vendors have a responsibility to minimize time, to minimize clicks involved in a task.”

She added that “regulators have a responsibility to not just add more and more regulations without first identifying the time-cost of complying with that regulation and without adding up the total cost of complying with regulation.”

Future regulations on EHRs must add flexibility when it comes to who is entering information into the system, she said. “Many regulations are either written with the explicit statement – or it is implied or an institution might overinterpret the regulation – that the physician is the one who must do the keyboarding into the record,” she said, noting that although not primarily studied in the research, preliminary data suggests that doctors who had documentation support were able to spend more time with their patients.

Finally, physicians themselves need to be stronger advocates for the changes they need to enable them to better serve their patients.

In addition to Dr. Sinsky, three other study authors are employed by AMA, which funded the study. No other financial conflicts were reported.

gtwachtman@frontlinemedcom.com

Physicians are spending twice as much time on electronic health records as they are face to face with patients, according to a new study by the American Medical Association.

Researchers observed 57 physicians in four specialties (family medicine, internal medicine, cardiology, and orthopedics) and found that for every hour of direct clinical face time with patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Additionally, based on diaries kept by 21 of the participating physicians, another 1-2 hours of personal time were spent each night doing additional computer and clerical work, according to the study published Sept. 5 in Annals of Internal Medicine (2016. doi: 10.7326/M16-0961).

©iStock/Thinkstock.com

“Over the years, doctors have recognized that more and more of their time was spent on nonpatient care, activities but probably haven’t recognized the magnitude of that change,” Christine Sinsky, MD, vice president of professional satisfaction at the AMA and lead author on the study, said in an interview. “Our study was able to help to quantify that and paint that picture.”

Overall, physicians spent 27% of their day dealing directly with patients, while 49% of the time was spent on EHR and desk work. In the examination room with patients, physicians spent 53% of time on direct clinical face time and 37% on EHR and desk work.

The situation “is the cumulative effect of many, many well-intended efforts that individually might have made sense, but taken collectively have paradoxically made it harder for physicians to deliver quality of care and harder for patients to get the quality of care they deserve,” she said.

EHR development should be focused on reducing the time-cost of providing care on their platforms, Dr. Sinsky recommended.

She noted that for her practice, it takes 32 clicks to order and record a flu shot. “I think vendors have a responsibility to minimize time, to minimize clicks involved in a task.”

She added that “regulators have a responsibility to not just add more and more regulations without first identifying the time-cost of complying with that regulation and without adding up the total cost of complying with regulation.”

Future regulations on EHRs must add flexibility when it comes to who is entering information into the system, she said. “Many regulations are either written with the explicit statement – or it is implied or an institution might overinterpret the regulation – that the physician is the one who must do the keyboarding into the record,” she said, noting that although not primarily studied in the research, preliminary data suggests that doctors who had documentation support were able to spend more time with their patients.

Finally, physicians themselves need to be stronger advocates for the changes they need to enable them to better serve their patients.

In addition to Dr. Sinsky, three other study authors are employed by AMA, which funded the study. No other financial conflicts were reported.

gtwachtman@frontlinemedcom.com

A fourth case of bacterial infection harboring the mcr-1 gene has been reported in a child recently returned from a visit to the Caribbean, according to a case report published Sept. 9 in Morbidity and Mortality Weekly Report.

The mcr-1 gene, which confers resistance to the last-resort antibiotic colistin, was first reported in China and is the first plasmid-mediated colistin-resistance mechanism to be identified. Since its discovery in 2015, cases have been reported in Africa, Asia, Europe, South America, and North America.

Janice Haney Carr/CDC

In this case report, a young patient developed fever and bloody diarrhea 2 days before returning to the United States from a 2-week visit to the Caribbean. The child were treated with the paromomycin and a stool specimen was collected on June 16, with follow-up cultures on June 18 and June 23.

All revealed Escherichia coli O157 harboring mcr-1. The isolates also carried a plasmid bla_CMY-2 gene, which confers resistance to third-generation cephalosporins. Stool cultures taken on June 24 and July 1 were negative for E. coli O157 (MMWR. 2016 Sep 9. http://dx.doi.org/10.15585/mmwr.mm6536e3).

Family members in close contact with the patient also were tested; all were found to be negative. Similarly, 16 environmental samples collected from the kitchen and diaper-changing area of the patient’s home were negative for mcr-1.

Researchers reported that the patient was “typically healthy,” and the child’s diet included fruit, dairy products, and meat. While on vacation in the Caribbean, the child ate meat purchased at a live animal market but did not visit the market personally. The child also had contact with a pet dog and cat.

“At this time, CDC recommends that Enterobacteriaceae isolates with a colistin or polymyxin B MIC plus or minus 4 mcg/mL be tested for the presence of mcr-1; testing is available through CDC,” wrote Dr. Amber M. Vasquez and her colleagues from the Centers for Disease Control and Prevention. “Prompt reporting of mcr-1–carrying isolates to public health officials allows for a rapid response to identify transmission and limit further spread.”

A fourth case of bacterial infection harboring the mcr-1 gene has been reported in a child recently returned from a visit to the Caribbean, according to a case report published Sept. 9 in Morbidity and Mortality Weekly Report.

The mcr-1 gene, which confers resistance to the last-resort antibiotic colistin, was first reported in China and is the first plasmid-mediated colistin-resistance mechanism to be identified. Since its discovery in 2015, cases have been reported in Africa, Asia, Europe, South America, and North America.

Janice Haney Carr/CDC

In this case report, a young patient developed fever and bloody diarrhea 2 days before returning to the United States from a 2-week visit to the Caribbean. The child were treated with the paromomycin and a stool specimen was collected on June 16, with follow-up cultures on June 18 and June 23.

All revealed Escherichia coli O157 harboring mcr-1. The isolates also carried a plasmid bla_CMY-2 gene, which confers resistance to third-generation cephalosporins. Stool cultures taken on June 24 and July 1 were negative for E. coli O157 (MMWR. 2016 Sep 9. http://dx.doi.org/10.15585/mmwr.mm6536e3).

Family members in close contact with the patient also were tested; all were found to be negative. Similarly, 16 environmental samples collected from the kitchen and diaper-changing area of the patient’s home were negative for mcr-1.

Researchers reported that the patient was “typically healthy,” and the child’s diet included fruit, dairy products, and meat. While on vacation in the Caribbean, the child ate meat purchased at a live animal market but did not visit the market personally. The child also had contact with a pet dog and cat.

“At this time, CDC recommends that Enterobacteriaceae isolates with a colistin or polymyxin B MIC plus or minus 4 mcg/mL be tested for the presence of mcr-1; testing is available through CDC,” wrote Dr. Amber M. Vasquez and her colleagues from the Centers for Disease Control and Prevention. “Prompt reporting of mcr-1–carrying isolates to public health officials allows for a rapid response to identify transmission and limit further spread.”

A fourth case of bacterial infection harboring the mcr-1 gene has been reported in a child recently returned from a visit to the Caribbean, according to a case report published Sept. 9 in Morbidity and Mortality Weekly Report.

The mcr-1 gene, which confers resistance to the last-resort antibiotic colistin, was first reported in China and is the first plasmid-mediated colistin-resistance mechanism to be identified. Since its discovery in 2015, cases have been reported in Africa, Asia, Europe, South America, and North America.

Janice Haney Carr/CDC

In this case report, a young patient developed fever and bloody diarrhea 2 days before returning to the United States from a 2-week visit to the Caribbean. The child were treated with the paromomycin and a stool specimen was collected on June 16, with follow-up cultures on June 18 and June 23.

All revealed Escherichia coli O157 harboring mcr-1. The isolates also carried a plasmid bla_CMY-2 gene, which confers resistance to third-generation cephalosporins. Stool cultures taken on June 24 and July 1 were negative for E. coli O157 (MMWR. 2016 Sep 9. http://dx.doi.org/10.15585/mmwr.mm6536e3).

Family members in close contact with the patient also were tested; all were found to be negative. Similarly, 16 environmental samples collected from the kitchen and diaper-changing area of the patient’s home were negative for mcr-1.

Researchers reported that the patient was “typically healthy,” and the child’s diet included fruit, dairy products, and meat. While on vacation in the Caribbean, the child ate meat purchased at a live animal market but did not visit the market personally. The child also had contact with a pet dog and cat.

“At this time, CDC recommends that Enterobacteriaceae isolates with a colistin or polymyxin B MIC plus or minus 4 mcg/mL be tested for the presence of mcr-1; testing is available through CDC,” wrote Dr. Amber M. Vasquez and her colleagues from the Centers for Disease Control and Prevention. “Prompt reporting of mcr-1–carrying isolates to public health officials allows for a rapid response to identify transmission and limit further spread.”

Recent wars have led to innovations in military trauma care that can be applied to civilians, say the authors of a JAMA Viewpoint published in June.¹

During the Afghanistan and Iraq wars, the percentage of wounded soldiers who died as a result of their injuries reached its lowest point in recorded history, writes lead author Donald M. Berwick, MD, MPP, of the Institute for Healthcare Improvement in Cambridge, Mass., along with colleagues from the National Academies of Sciences, Engineering, and Medicine in Washington, D.C.

“Effective bleeding-control measures, improved resuscitation techniques, and aggressive neurocritical care interventions are among many advances that saved lives on the battlefield that otherwise would have been lost,” they write.

The reduction in injury-related deaths is in part due to the Military Health System and its Joint Trauma System embracing a culture of continuous performance improvement and an agile approach, a model called “focused empiricism,” the authors say. A new report from the National Academies of Sciences, Engineering, and Medicine clarifies the components of such a learning health system, which can also be applied to civilian care:

• Leadership and a culture of learning: “A learning health system must be stewarded by leadership committed to nurturing a culture of continuous learning and improvement. ... Such a system should unite military and civilian trauma care leaders around a common, core aim established at the highest level in the nation; namely, to achieve zero preventable deaths after injury and minimize trauma-related disability.”
• Transparency and incentives for quality trauma care: “Trauma care practitioners at all levels, including trauma surgeons and other physicians, nurses, technicians, and prehospital care personnel, should have access to data on their performance relative to that of their peers.”
• Systems for ensuring an expert trauma care workforce: “A joint, integrated network of military and civilian trauma centers should be created as a training platform to prepare and sustain an expert workforce and to promote the translation of best practices between sectors.”

The progress made by the military’s trauma system could be lost, the writers conclude, without concerted efforts to disseminate and maintain the advances. The authors note that in the United States, there are nearly 150,000 deaths from trauma each year, and injury is the third-leading cause of death.

The “hundreds of thousands of civilians who have sustained trauma deserve the benefits of care improvements achieved in military medicine,” they conclude.

Reference

1. Berwick DM, Downey AS, Cornett EA. A national trauma care system to achieve zero preventable deaths after injury: recommendations from a National Academies of Sciences, Engineering, and Medicine report [published online ahead of print June 17, 2006]. JAMA. doi:10.1001/jama.2016.8524.

Quick Byte

Rating RTLS Options

The healthcare industry typically uses real-time location systems (RTLS) to help improve care quality, workflow efficiency, and bottom lines, according to a recent article in HealthcareITNews. The research firm KLAS rated 11 RTLS vendors and gave Centrak the highest overall performance score, beating competitors including AwarePoint, Cerner, GE Healthcare, and Intelligent Insights.

Reference

1. Siwicki B. KLAS ranks real-time location systems from AwarePoint, Cerner, CenTrak, Versus and others. HealthcareITNews website. Accessed July 13, 2016.

Recent wars have led to innovations in military trauma care that can be applied to civilians, say the authors of a JAMA Viewpoint published in June.¹

During the Afghanistan and Iraq wars, the percentage of wounded soldiers who died as a result of their injuries reached its lowest point in recorded history, writes lead author Donald M. Berwick, MD, MPP, of the Institute for Healthcare Improvement in Cambridge, Mass., along with colleagues from the National Academies of Sciences, Engineering, and Medicine in Washington, D.C.

“Effective bleeding-control measures, improved resuscitation techniques, and aggressive neurocritical care interventions are among many advances that saved lives on the battlefield that otherwise would have been lost,” they write.

The reduction in injury-related deaths is in part due to the Military Health System and its Joint Trauma System embracing a culture of continuous performance improvement and an agile approach, a model called “focused empiricism,” the authors say. A new report from the National Academies of Sciences, Engineering, and Medicine clarifies the components of such a learning health system, which can also be applied to civilian care:

• Leadership and a culture of learning: “A learning health system must be stewarded by leadership committed to nurturing a culture of continuous learning and improvement. ... Such a system should unite military and civilian trauma care leaders around a common, core aim established at the highest level in the nation; namely, to achieve zero preventable deaths after injury and minimize trauma-related disability.”
• Transparency and incentives for quality trauma care: “Trauma care practitioners at all levels, including trauma surgeons and other physicians, nurses, technicians, and prehospital care personnel, should have access to data on their performance relative to that of their peers.”
• Systems for ensuring an expert trauma care workforce: “A joint, integrated network of military and civilian trauma centers should be created as a training platform to prepare and sustain an expert workforce and to promote the translation of best practices between sectors.”

The progress made by the military’s trauma system could be lost, the writers conclude, without concerted efforts to disseminate and maintain the advances. The authors note that in the United States, there are nearly 150,000 deaths from trauma each year, and injury is the third-leading cause of death.

The “hundreds of thousands of civilians who have sustained trauma deserve the benefits of care improvements achieved in military medicine,” they conclude.

Reference

1. Berwick DM, Downey AS, Cornett EA. A national trauma care system to achieve zero preventable deaths after injury: recommendations from a National Academies of Sciences, Engineering, and Medicine report [published online ahead of print June 17, 2006]. JAMA. doi:10.1001/jama.2016.8524.

Quick Byte

Rating RTLS Options

The healthcare industry typically uses real-time location systems (RTLS) to help improve care quality, workflow efficiency, and bottom lines, according to a recent article in HealthcareITNews. The research firm KLAS rated 11 RTLS vendors and gave Centrak the highest overall performance score, beating competitors including AwarePoint, Cerner, GE Healthcare, and Intelligent Insights.

Reference

1. Siwicki B. KLAS ranks real-time location systems from AwarePoint, Cerner, CenTrak, Versus and others. HealthcareITNews website. Accessed July 13, 2016.

Recent wars have led to innovations in military trauma care that can be applied to civilians, say the authors of a JAMA Viewpoint published in June.¹

During the Afghanistan and Iraq wars, the percentage of wounded soldiers who died as a result of their injuries reached its lowest point in recorded history, writes lead author Donald M. Berwick, MD, MPP, of the Institute for Healthcare Improvement in Cambridge, Mass., along with colleagues from the National Academies of Sciences, Engineering, and Medicine in Washington, D.C.

“Effective bleeding-control measures, improved resuscitation techniques, and aggressive neurocritical care interventions are among many advances that saved lives on the battlefield that otherwise would have been lost,” they write.

The reduction in injury-related deaths is in part due to the Military Health System and its Joint Trauma System embracing a culture of continuous performance improvement and an agile approach, a model called “focused empiricism,” the authors say. A new report from the National Academies of Sciences, Engineering, and Medicine clarifies the components of such a learning health system, which can also be applied to civilian care:

• Leadership and a culture of learning: “A learning health system must be stewarded by leadership committed to nurturing a culture of continuous learning and improvement. ... Such a system should unite military and civilian trauma care leaders around a common, core aim established at the highest level in the nation; namely, to achieve zero preventable deaths after injury and minimize trauma-related disability.”
• Transparency and incentives for quality trauma care: “Trauma care practitioners at all levels, including trauma surgeons and other physicians, nurses, technicians, and prehospital care personnel, should have access to data on their performance relative to that of their peers.”
• Systems for ensuring an expert trauma care workforce: “A joint, integrated network of military and civilian trauma centers should be created as a training platform to prepare and sustain an expert workforce and to promote the translation of best practices between sectors.”

The progress made by the military’s trauma system could be lost, the writers conclude, without concerted efforts to disseminate and maintain the advances. The authors note that in the United States, there are nearly 150,000 deaths from trauma each year, and injury is the third-leading cause of death.

The “hundreds of thousands of civilians who have sustained trauma deserve the benefits of care improvements achieved in military medicine,” they conclude.

Reference

1. Berwick DM, Downey AS, Cornett EA. A national trauma care system to achieve zero preventable deaths after injury: recommendations from a National Academies of Sciences, Engineering, and Medicine report [published online ahead of print June 17, 2006]. JAMA. doi:10.1001/jama.2016.8524.

Quick Byte

Rating RTLS Options

The healthcare industry typically uses real-time location systems (RTLS) to help improve care quality, workflow efficiency, and bottom lines, according to a recent article in HealthcareITNews. The research firm KLAS rated 11 RTLS vendors and gave Centrak the highest overall performance score, beating competitors including AwarePoint, Cerner, GE Healthcare, and Intelligent Insights.

Reference

1. Siwicki B. KLAS ranks real-time location systems from AwarePoint, Cerner, CenTrak, Versus and others. HealthcareITNews website. Accessed July 13, 2016.

Erin Kent, PhD

©ASCO/Todd Buchanan 2016

SAN FRANCISCO—New research suggests caring for a loved one with cancer may be more burdensome than caring for a loved one with a different condition.

Researchers analyzed data from “Caregiving in the U.S. 2015,” an online panel study of unpaid adult caregivers.

The team compared cancer and non-cancer caregivers to determine similarities and differences in characteristics and experiences.

The findings were presented at the 2016 Palliative Care in Oncology Symposium (abstract 4).

The study included 1248 caregivers, age 18 and older at the time they were surveyed, who provided care to an adult patient. Seven percent of these caregivers were looking after patients with cancer.

Cancer caregivers reported spending more hours per week providing care than non-cancer caregivers—32.9 and 23.9 hours, respectively.

In addition, cancer caregivers were more likely than other caregivers to communicate with healthcare professionals (82% and 62%, respectively), monitor and adjust patients’ care (76% and 66%, respectively), and advocate on behalf of patients (62% and 49%, respectively).

Despite high levels of engagement with providers, cancer caregivers were nearly twice as likely as non-cancer caregivers to report needing more help and information with making end-of-life decisions—40% and 21%, respectively.

“Our research demonstrates the ripple effect that cancer has on families and patient support systems,” said study investigator Erin Kent, PhD, of the National Cancer Institute in Rockville, Maryland.

“Caregiving can be extremely stressful and demanding—physically, emotionally, and financially. The data show we need to do a better job of supporting these individuals, as their wellbeing is essential to the patient’s quality of life and outcomes.”

Dr Kent emphasized the cyclical nature of cancer care, often requiring short, highly intense periods of time where patients undergo active treatment as a possible reason for the increased intensity in caregiving. She noted that such intensity is also associated with increased caregiver stress and depression.

“Based on our findings, it’s clear we need additional research on caregiving to better understand at what point providers and clinicians should intervene to assess the wellbeing of caregivers,” Dr Kent said.

“Technology, combined with use of a clinical distress rating system, could be promising in the future as a means to ensure caregivers are being supported in a meaningful way.”

Erin Kent, PhD

©ASCO/Todd Buchanan 2016

SAN FRANCISCO—New research suggests caring for a loved one with cancer may be more burdensome than caring for a loved one with a different condition.

Researchers analyzed data from “Caregiving in the U.S. 2015,” an online panel study of unpaid adult caregivers.

The team compared cancer and non-cancer caregivers to determine similarities and differences in characteristics and experiences.

The findings were presented at the 2016 Palliative Care in Oncology Symposium (abstract 4).

The study included 1248 caregivers, age 18 and older at the time they were surveyed, who provided care to an adult patient. Seven percent of these caregivers were looking after patients with cancer.

Cancer caregivers reported spending more hours per week providing care than non-cancer caregivers—32.9 and 23.9 hours, respectively.

In addition, cancer caregivers were more likely than other caregivers to communicate with healthcare professionals (82% and 62%, respectively), monitor and adjust patients’ care (76% and 66%, respectively), and advocate on behalf of patients (62% and 49%, respectively).

Despite high levels of engagement with providers, cancer caregivers were nearly twice as likely as non-cancer caregivers to report needing more help and information with making end-of-life decisions—40% and 21%, respectively.

“Our research demonstrates the ripple effect that cancer has on families and patient support systems,” said study investigator Erin Kent, PhD, of the National Cancer Institute in Rockville, Maryland.

“Caregiving can be extremely stressful and demanding—physically, emotionally, and financially. The data show we need to do a better job of supporting these individuals, as their wellbeing is essential to the patient’s quality of life and outcomes.”

Dr Kent emphasized the cyclical nature of cancer care, often requiring short, highly intense periods of time where patients undergo active treatment as a possible reason for the increased intensity in caregiving. She noted that such intensity is also associated with increased caregiver stress and depression.

“Based on our findings, it’s clear we need additional research on caregiving to better understand at what point providers and clinicians should intervene to assess the wellbeing of caregivers,” Dr Kent said.

“Technology, combined with use of a clinical distress rating system, could be promising in the future as a means to ensure caregivers are being supported in a meaningful way.”

Erin Kent, PhD

©ASCO/Todd Buchanan 2016

SAN FRANCISCO—New research suggests caring for a loved one with cancer may be more burdensome than caring for a loved one with a different condition.

Researchers analyzed data from “Caregiving in the U.S. 2015,” an online panel study of unpaid adult caregivers.

The team compared cancer and non-cancer caregivers to determine similarities and differences in characteristics and experiences.

The findings were presented at the 2016 Palliative Care in Oncology Symposium (abstract 4).

The study included 1248 caregivers, age 18 and older at the time they were surveyed, who provided care to an adult patient. Seven percent of these caregivers were looking after patients with cancer.

Cancer caregivers reported spending more hours per week providing care than non-cancer caregivers—32.9 and 23.9 hours, respectively.

In addition, cancer caregivers were more likely than other caregivers to communicate with healthcare professionals (82% and 62%, respectively), monitor and adjust patients’ care (76% and 66%, respectively), and advocate on behalf of patients (62% and 49%, respectively).

Despite high levels of engagement with providers, cancer caregivers were nearly twice as likely as non-cancer caregivers to report needing more help and information with making end-of-life decisions—40% and 21%, respectively.

“Our research demonstrates the ripple effect that cancer has on families and patient support systems,” said study investigator Erin Kent, PhD, of the National Cancer Institute in Rockville, Maryland.

“Caregiving can be extremely stressful and demanding—physically, emotionally, and financially. The data show we need to do a better job of supporting these individuals, as their wellbeing is essential to the patient’s quality of life and outcomes.”

Dr Kent emphasized the cyclical nature of cancer care, often requiring short, highly intense periods of time where patients undergo active treatment as a possible reason for the increased intensity in caregiving. She noted that such intensity is also associated with increased caregiver stress and depression.

“Based on our findings, it’s clear we need additional research on caregiving to better understand at what point providers and clinicians should intervene to assess the wellbeing of caregivers,” Dr Kent said.

“Technology, combined with use of a clinical distress rating system, could be promising in the future as a means to ensure caregivers are being supported in a meaningful way.”

Opioid-related lawsuits against physicians are on the rise. Common allegations include unnecessary prescribing, failing to heed contraindications, and missing warning signs of a likely overdose, said Ericka L. Adler, a Chicago-based health law attorney. To mitigate your risk of getting sued, legal and clinical experts offer the following advice.

1. Identify at-risk patients

Consider the full range of patient risk factors before prescribing or continuing opioids, said Ilene R. Robeck, MD, director of virtual pain education at Richmond VA Medical Center in St. Petersburg, Fla., and cochair of the National VA PACT Pain Champions Initiative.

“When we look at the overdose data, there used to be a perception that people who overdosed were not taking their medication as prescribed, and that’s not true all the time,” she said. “In fact, in some [studies], half the people who overdose take their medication exactly as prescribed. The problems are related to dose, mixing the opioids with other medications, [patient] age, and underlying medical problems.”

Ensure that therapy considerations related to opioids address the full patient picture, Dr. Robeck advised. For example, patients with liver disease, sleep apnea, chronic obstructive pulmonary disease (COPD), asthma, and kidney disease are more prone to overdose. In addition, while nonmedical use of prescription drugs is highest in patients aged 18-25 years, opioid overdose rates are highest among patients aged 25-54 years, according to the Centers for Disease Control and Prevention.

2. Monitor midlevel providers

Closely monitor and limit opioid prescribing by the midlevel providers you supervise, said pharmacologist and consultant James T. O’Donnell, PharmD. A fair share of medical malpractice lawsuits result from failing to supervise a physician assistant (PA) or nurse practitioner (NP) prescribing or treating pain patients.

“Excessive or inappropriate opiate prescribing will result in legal actions against the supervising physician,” Dr. O’Donnell said. “Close monitoring of midlevel providers requires establishing guidelines for opiate prescribing.”

Develop practice protocols that track and regulate midlevel prescribing and regularly discuss prescribing dangers with staff. Know your state law; the extent to which an NP or PA can prescribe varies widely.

3. Document

Keep detailed records of patient encounters that include specifics of what the patient tells you, said Ms. Adler.

Clear documentation about prior conditions, interactions with other health care providers, and past and current treatments help protect the doctor should liability later arise. In the case of a dishonest patient, clear record keeping could help show that a patient lied or omitted facts if the notes later become evidence in a lawsuit, she said.

“I also think [doctors] should document their policies, so there is clarity and understanding in the relationship,” Ms. Adler said. “Showing a policy where national standards/recommendations are followed will help protect the practice.”

4. Restrict refills

Require prescriber review before patients can obtain refills or new prescriptions for patients who run out of medicine before their next appointment, Dr. O’Donnell said.

“Excessive or early refills for opiate prescriptions are signs of abuse,” he said. “This creates risk to the patient and malpractice risk to the physician.”

It’s also helpful to limit the number of pharmacies used for opioid prescriptions, Ms. Adler said. This makes it easier track medications and narrows the pathway between prescription and drug obtainment.

5. Partner with pharmacists

Work closely with other health providers, such as psychiatrists, therapists, and pharmacists to ensure safe prescribing decisions. Pharmacists have a corresponding responsibility in dispensing opiates, Dr. O’Donnell said.

“Take the pharmacists’ calls regarding your opiates prescriptions,” he advised. “The pharmacist will know what other medicines the patient is taking and may advise of dangerous dosage or interactions.”

6. Require patient agreements

Opioid treatment agreements aid in patient accountability and promote education of drug risks, Dr. Robeck noted. In such contracts, patients agree to fully comply with all aspects of the treatment program and acknowledge that they will not use medication with harmful substances. Other terms can include that patients:

• Only obtain opioid prescriptions from one provider.

• Agree to keep all scheduled medical appointments.

• Promise to undergo urine drug screens as indicated.

• Agree not to share or sell medication.

• Agree not to drive or operate heavy machinery until medication-related drowsiness clears.

Contracts can help patients remain informed about the dangers and benefits of medications, while protecting the physician’s right to terminate treatment if the patient violates the agreement, Ms. Adler said. One sample agreement can be found here.

7. Involve family members

Family members and caregivers are critical to a patient’s opioid therapy plan, Dr. Robeck said. Discuss with patients ahead of time the potential for family member involvement. Family or the patient’s support system should be educated about the patient’s medications, the risks, and how to respond in an emergency.

“It may be life saving,” Dr. Robeck said. “It’s very important for the physician to communicate with the family. There may be times you want the family to come [to appointments].”

Such communication can ensure that family members’ concerns about a patient are conveyed to physicians. Family and caregivers can also have a role in improving home conditions to assist with pain management for the patient, she said. Family education in using a naloxone rescue kit in the event of a possible overdose is essential.

“Giving the patient naloxone to prevent an overdose is more than just handing them the nasal spray or the self-injector, it’s also about educating them and the family about the true risks of these medications,” Dr. Robeck said.

8. Watch for red flags

Be cognizant of warning signs that patients may be addicted, Ms. Adler advised. Patients who demand medications, act impatiently about waiting for refills, or refuse to answer questions about their history should raise alarm bells, she said. Patients who travel long distances for pain medication also should raise question marks, Dr. O’Donnell adds.

“If the patient is in too much of a hurry to wait for records or to get a urine test, that’s a red flag,” Ms. Adler said. “When doctors are not sure, the safest bet is to refer to a pain specialist.”

Consider the criteria for opioid use disorder, Dr. Robeck noted. The condition is defined as a problematic pattern of opioid use leading to clinically significant impairment or distress. Signs of opioid use disorder include recurrent use by patients resulting in a failure to fulfill major role obligations at work or home, continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by opioids, and spending a great deal of time in activities necessary to obtain the opioid, use the opioid, or recover from use, according to the American Psychiatric Association.

9. Develop an exit plan

Before starting a patient on opioid therapy, have a plan in place in case something goes awry, Dr. Robeck said. Create an exit strategy that includes both pharmacological and nonpharmacological resources from which to draw from should problems arise. Make sure you have a plan for tapering patients off opioids when necessary. This may include getting help from other clinicians in the community, she said.

“Those patients need very careful follow-up,” Dr. Robeck. “The rate of the taper needs to occur based on level of risk. Whenever possible, we try to taper patients slowly.”

10. Do your research

Always check your state’s prescription drug–monitoring program (PDMP) when prescribing an opiate to a new patient, Mr. O’Donnell advised.

Currently, 49 states and Guam have operational PDMP databases. The PDMP Training and Technical Assistance Center offers information about each PDMP, state pharmacy and practitioner data, drug schedules monitored, patient information data, and legislation dates and citations.

Perhaps most importantly, know best prescribing practices, Dr. Robeck said. Earlier this year, the CDC released guidelines for prescribing opioids for chronic pain.

“Thoroughly understand the CDC guidelines,” she said. “These are the keys to understanding where opioids fit into your plan of medications and nonpharmacological therapies for pain.”

agallegos@frontlinemedcom.com

On Twitter @legal_med

Opioid-related lawsuits against physicians are on the rise. Common allegations include unnecessary prescribing, failing to heed contraindications, and missing warning signs of a likely overdose, said Ericka L. Adler, a Chicago-based health law attorney. To mitigate your risk of getting sued, legal and clinical experts offer the following advice.

1. Identify at-risk patients

Consider the full range of patient risk factors before prescribing or continuing opioids, said Ilene R. Robeck, MD, director of virtual pain education at Richmond VA Medical Center in St. Petersburg, Fla., and cochair of the National VA PACT Pain Champions Initiative.

“When we look at the overdose data, there used to be a perception that people who overdosed were not taking their medication as prescribed, and that’s not true all the time,” she said. “In fact, in some [studies], half the people who overdose take their medication exactly as prescribed. The problems are related to dose, mixing the opioids with other medications, [patient] age, and underlying medical problems.”

Ensure that therapy considerations related to opioids address the full patient picture, Dr. Robeck advised. For example, patients with liver disease, sleep apnea, chronic obstructive pulmonary disease (COPD), asthma, and kidney disease are more prone to overdose. In addition, while nonmedical use of prescription drugs is highest in patients aged 18-25 years, opioid overdose rates are highest among patients aged 25-54 years, according to the Centers for Disease Control and Prevention.

2. Monitor midlevel providers

Closely monitor and limit opioid prescribing by the midlevel providers you supervise, said pharmacologist and consultant James T. O’Donnell, PharmD. A fair share of medical malpractice lawsuits result from failing to supervise a physician assistant (PA) or nurse practitioner (NP) prescribing or treating pain patients.

“Excessive or inappropriate opiate prescribing will result in legal actions against the supervising physician,” Dr. O’Donnell said. “Close monitoring of midlevel providers requires establishing guidelines for opiate prescribing.”

Develop practice protocols that track and regulate midlevel prescribing and regularly discuss prescribing dangers with staff. Know your state law; the extent to which an NP or PA can prescribe varies widely.

3. Document

Keep detailed records of patient encounters that include specifics of what the patient tells you, said Ms. Adler.

Clear documentation about prior conditions, interactions with other health care providers, and past and current treatments help protect the doctor should liability later arise. In the case of a dishonest patient, clear record keeping could help show that a patient lied or omitted facts if the notes later become evidence in a lawsuit, she said.

“I also think [doctors] should document their policies, so there is clarity and understanding in the relationship,” Ms. Adler said. “Showing a policy where national standards/recommendations are followed will help protect the practice.”

4. Restrict refills

Require prescriber review before patients can obtain refills or new prescriptions for patients who run out of medicine before their next appointment, Dr. O’Donnell said.

“Excessive or early refills for opiate prescriptions are signs of abuse,” he said. “This creates risk to the patient and malpractice risk to the physician.”

It’s also helpful to limit the number of pharmacies used for opioid prescriptions, Ms. Adler said. This makes it easier track medications and narrows the pathway between prescription and drug obtainment.

5. Partner with pharmacists

Work closely with other health providers, such as psychiatrists, therapists, and pharmacists to ensure safe prescribing decisions. Pharmacists have a corresponding responsibility in dispensing opiates, Dr. O’Donnell said.

“Take the pharmacists’ calls regarding your opiates prescriptions,” he advised. “The pharmacist will know what other medicines the patient is taking and may advise of dangerous dosage or interactions.”

6. Require patient agreements

Opioid treatment agreements aid in patient accountability and promote education of drug risks, Dr. Robeck noted. In such contracts, patients agree to fully comply with all aspects of the treatment program and acknowledge that they will not use medication with harmful substances. Other terms can include that patients:

• Only obtain opioid prescriptions from one provider.

• Agree to keep all scheduled medical appointments.

• Promise to undergo urine drug screens as indicated.

• Agree not to share or sell medication.

• Agree not to drive or operate heavy machinery until medication-related drowsiness clears.

Contracts can help patients remain informed about the dangers and benefits of medications, while protecting the physician’s right to terminate treatment if the patient violates the agreement, Ms. Adler said. One sample agreement can be found here.

7. Involve family members

Family members and caregivers are critical to a patient’s opioid therapy plan, Dr. Robeck said. Discuss with patients ahead of time the potential for family member involvement. Family or the patient’s support system should be educated about the patient’s medications, the risks, and how to respond in an emergency.

“It may be life saving,” Dr. Robeck said. “It’s very important for the physician to communicate with the family. There may be times you want the family to come [to appointments].”

Such communication can ensure that family members’ concerns about a patient are conveyed to physicians. Family and caregivers can also have a role in improving home conditions to assist with pain management for the patient, she said. Family education in using a naloxone rescue kit in the event of a possible overdose is essential.

“Giving the patient naloxone to prevent an overdose is more than just handing them the nasal spray or the self-injector, it’s also about educating them and the family about the true risks of these medications,” Dr. Robeck said.

8. Watch for red flags

Be cognizant of warning signs that patients may be addicted, Ms. Adler advised. Patients who demand medications, act impatiently about waiting for refills, or refuse to answer questions about their history should raise alarm bells, she said. Patients who travel long distances for pain medication also should raise question marks, Dr. O’Donnell adds.

“If the patient is in too much of a hurry to wait for records or to get a urine test, that’s a red flag,” Ms. Adler said. “When doctors are not sure, the safest bet is to refer to a pain specialist.”

Consider the criteria for opioid use disorder, Dr. Robeck noted. The condition is defined as a problematic pattern of opioid use leading to clinically significant impairment or distress. Signs of opioid use disorder include recurrent use by patients resulting in a failure to fulfill major role obligations at work or home, continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by opioids, and spending a great deal of time in activities necessary to obtain the opioid, use the opioid, or recover from use, according to the American Psychiatric Association.

9. Develop an exit plan

Before starting a patient on opioid therapy, have a plan in place in case something goes awry, Dr. Robeck said. Create an exit strategy that includes both pharmacological and nonpharmacological resources from which to draw from should problems arise. Make sure you have a plan for tapering patients off opioids when necessary. This may include getting help from other clinicians in the community, she said.

“Those patients need very careful follow-up,” Dr. Robeck. “The rate of the taper needs to occur based on level of risk. Whenever possible, we try to taper patients slowly.”

10. Do your research

Always check your state’s prescription drug–monitoring program (PDMP) when prescribing an opiate to a new patient, Mr. O’Donnell advised.

Currently, 49 states and Guam have operational PDMP databases. The PDMP Training and Technical Assistance Center offers information about each PDMP, state pharmacy and practitioner data, drug schedules monitored, patient information data, and legislation dates and citations.

Perhaps most importantly, know best prescribing practices, Dr. Robeck said. Earlier this year, the CDC released guidelines for prescribing opioids for chronic pain.

“Thoroughly understand the CDC guidelines,” she said. “These are the keys to understanding where opioids fit into your plan of medications and nonpharmacological therapies for pain.”

agallegos@frontlinemedcom.com

On Twitter @legal_med

Opioid-related lawsuits against physicians are on the rise. Common allegations include unnecessary prescribing, failing to heed contraindications, and missing warning signs of a likely overdose, said Ericka L. Adler, a Chicago-based health law attorney. To mitigate your risk of getting sued, legal and clinical experts offer the following advice.

1. Identify at-risk patients

Consider the full range of patient risk factors before prescribing or continuing opioids, said Ilene R. Robeck, MD, director of virtual pain education at Richmond VA Medical Center in St. Petersburg, Fla., and cochair of the National VA PACT Pain Champions Initiative.

“When we look at the overdose data, there used to be a perception that people who overdosed were not taking their medication as prescribed, and that’s not true all the time,” she said. “In fact, in some [studies], half the people who overdose take their medication exactly as prescribed. The problems are related to dose, mixing the opioids with other medications, [patient] age, and underlying medical problems.”

Ensure that therapy considerations related to opioids address the full patient picture, Dr. Robeck advised. For example, patients with liver disease, sleep apnea, chronic obstructive pulmonary disease (COPD), asthma, and kidney disease are more prone to overdose. In addition, while nonmedical use of prescription drugs is highest in patients aged 18-25 years, opioid overdose rates are highest among patients aged 25-54 years, according to the Centers for Disease Control and Prevention.

2. Monitor midlevel providers

Closely monitor and limit opioid prescribing by the midlevel providers you supervise, said pharmacologist and consultant James T. O’Donnell, PharmD. A fair share of medical malpractice lawsuits result from failing to supervise a physician assistant (PA) or nurse practitioner (NP) prescribing or treating pain patients.

“Excessive or inappropriate opiate prescribing will result in legal actions against the supervising physician,” Dr. O’Donnell said. “Close monitoring of midlevel providers requires establishing guidelines for opiate prescribing.”

Develop practice protocols that track and regulate midlevel prescribing and regularly discuss prescribing dangers with staff. Know your state law; the extent to which an NP or PA can prescribe varies widely.

3. Document

Keep detailed records of patient encounters that include specifics of what the patient tells you, said Ms. Adler.

Clear documentation about prior conditions, interactions with other health care providers, and past and current treatments help protect the doctor should liability later arise. In the case of a dishonest patient, clear record keeping could help show that a patient lied or omitted facts if the notes later become evidence in a lawsuit, she said.

“I also think [doctors] should document their policies, so there is clarity and understanding in the relationship,” Ms. Adler said. “Showing a policy where national standards/recommendations are followed will help protect the practice.”

4. Restrict refills

Require prescriber review before patients can obtain refills or new prescriptions for patients who run out of medicine before their next appointment, Dr. O’Donnell said.

“Excessive or early refills for opiate prescriptions are signs of abuse,” he said. “This creates risk to the patient and malpractice risk to the physician.”

It’s also helpful to limit the number of pharmacies used for opioid prescriptions, Ms. Adler said. This makes it easier track medications and narrows the pathway between prescription and drug obtainment.

5. Partner with pharmacists

Work closely with other health providers, such as psychiatrists, therapists, and pharmacists to ensure safe prescribing decisions. Pharmacists have a corresponding responsibility in dispensing opiates, Dr. O’Donnell said.

“Take the pharmacists’ calls regarding your opiates prescriptions,” he advised. “The pharmacist will know what other medicines the patient is taking and may advise of dangerous dosage or interactions.”

6. Require patient agreements

Opioid treatment agreements aid in patient accountability and promote education of drug risks, Dr. Robeck noted. In such contracts, patients agree to fully comply with all aspects of the treatment program and acknowledge that they will not use medication with harmful substances. Other terms can include that patients:

• Only obtain opioid prescriptions from one provider.

• Agree to keep all scheduled medical appointments.

• Promise to undergo urine drug screens as indicated.

• Agree not to share or sell medication.

• Agree not to drive or operate heavy machinery until medication-related drowsiness clears.

Contracts can help patients remain informed about the dangers and benefits of medications, while protecting the physician’s right to terminate treatment if the patient violates the agreement, Ms. Adler said. One sample agreement can be found here.

7. Involve family members

Family members and caregivers are critical to a patient’s opioid therapy plan, Dr. Robeck said. Discuss with patients ahead of time the potential for family member involvement. Family or the patient’s support system should be educated about the patient’s medications, the risks, and how to respond in an emergency.

“It may be life saving,” Dr. Robeck said. “It’s very important for the physician to communicate with the family. There may be times you want the family to come [to appointments].”

Such communication can ensure that family members’ concerns about a patient are conveyed to physicians. Family and caregivers can also have a role in improving home conditions to assist with pain management for the patient, she said. Family education in using a naloxone rescue kit in the event of a possible overdose is essential.

“Giving the patient naloxone to prevent an overdose is more than just handing them the nasal spray or the self-injector, it’s also about educating them and the family about the true risks of these medications,” Dr. Robeck said.

8. Watch for red flags

Be cognizant of warning signs that patients may be addicted, Ms. Adler advised. Patients who demand medications, act impatiently about waiting for refills, or refuse to answer questions about their history should raise alarm bells, she said. Patients who travel long distances for pain medication also should raise question marks, Dr. O’Donnell adds.

“If the patient is in too much of a hurry to wait for records or to get a urine test, that’s a red flag,” Ms. Adler said. “When doctors are not sure, the safest bet is to refer to a pain specialist.”

Consider the criteria for opioid use disorder, Dr. Robeck noted. The condition is defined as a problematic pattern of opioid use leading to clinically significant impairment or distress. Signs of opioid use disorder include recurrent use by patients resulting in a failure to fulfill major role obligations at work or home, continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by opioids, and spending a great deal of time in activities necessary to obtain the opioid, use the opioid, or recover from use, according to the American Psychiatric Association.

9. Develop an exit plan

Before starting a patient on opioid therapy, have a plan in place in case something goes awry, Dr. Robeck said. Create an exit strategy that includes both pharmacological and nonpharmacological resources from which to draw from should problems arise. Make sure you have a plan for tapering patients off opioids when necessary. This may include getting help from other clinicians in the community, she said.

“Those patients need very careful follow-up,” Dr. Robeck. “The rate of the taper needs to occur based on level of risk. Whenever possible, we try to taper patients slowly.”

10. Do your research

Always check your state’s prescription drug–monitoring program (PDMP) when prescribing an opiate to a new patient, Mr. O’Donnell advised.

Currently, 49 states and Guam have operational PDMP databases. The PDMP Training and Technical Assistance Center offers information about each PDMP, state pharmacy and practitioner data, drug schedules monitored, patient information data, and legislation dates and citations.

Perhaps most importantly, know best prescribing practices, Dr. Robeck said. Earlier this year, the CDC released guidelines for prescribing opioids for chronic pain.

“Thoroughly understand the CDC guidelines,” she said. “These are the keys to understanding where opioids fit into your plan of medications and nonpharmacological therapies for pain.”

agallegos@frontlinemedcom.com

On Twitter @legal_med

LONDON – Real-life experience shows that stopping treatment with a long-acting beta-agonist (LABA) does not worsen asthma control, nor does it lead to any immediate decline in lung function.

Spirometric parameters were similar before and 3 weeks after stopping LABA therapy in an observational study of 58 patients who had stable asthma and were being treated with an inhaled corticosteroid (ICS) and a LABA.

©tupungato/Thinkstock.com

The forced expiratory volume in 1 second (FEV₁) was 88.8% at baseline and 89.5% at the 3-week visit after stepping down their LABA therapy (P = .55). Patients’ average peak expiratory flow rate was 462 L/min both before and after LABA withdrawal.

In addition, no changes were seen in lung function based on impulse oscillometry, a noninvasive method for measuring airway resistance and reactance (Chest. 2014;146[3]:841-7). Similar levels of fractional exhaled nitric oxide (FeNO, 38 and 36 ppb) were recorded.

The findings were presented at the annual congress of the European Respiratory Society (ERS) and have been published in an early online edition of the Annals of Allergy, Asthma & Immunology (doi: 10.1016/j.anai.2016.07.022).

“About 45% of the UK adult asthma population are taking step 3 GINA [Global Initiative for Asthma] therapy, which is ICS/LABA,” explained Sunny Jabbal, MD, of the Scottish Centre for Respiratory Research at Ninewells Hospital in Dundee, Scotland, where the study was conducted. Patients should be on the lowest of the five steps in the 2016 GINA guidelines that achieve asthma control and should be regularly reviewed.

To test whether the LABA could be safely withdrawn, that is stepped down to ICS only [GINA step 2], Dr. Jabbal and colleagues studied 58 patients with a mean age of 39 years. All had well-controlled asthma, and had been receiving ICS/LABA for at least 3 months with no asthma exacerbations requiring treatment. None of the patients were current smokers.

At study entry, patients underwent spirometry, impulse oscillometry, and had FeNO measured. Their LABA was then stopped, and patients were reassessed 3 weeks later. “In accordance with GINA, their ICS dose was also reduced by approximately 25%,” Dr. Jabbal said.

Patients recorded their symptoms and short-term reliever (albuterol) use on simple diary cards. They were also given a 24-hour emergency mobile number, but no calls were received and no adverse events reported. The mean daily symptom score recorded during the step down process was 0.4 (out of a possible score of 3), and the mean albuterol usage was one puff per day.

One of the chairs of the session, Omar Usmani, MD, of Imperial College London noted that some clinicians are “very apprehensive” about stopping LABA and stepping down ICS therapy in their patients.

This was a short-term study, Dr. Jabbal acknowledged. Although a follow-up of 3 weeks may be enough to determine the effects of stopping a LABA, that time may not be sufficient to assess the effects of stepping down the ICS. Further real-life studies are needed to evaluate outcomes such as exacerbations and overall quality of life.

Improved adherence with ICS therapy after LABA withdrawal might explain the lack of deleterious effects, or perhaps some patients may not have initially needed an ICS/LABA combination, he speculated. Maybe even the steroid dose could be reduced further in this particular patient population.

The study received no commercial funding. Dr. Jabbal had no conflicts of interest related to his presentation.

LONDON – Real-life experience shows that stopping treatment with a long-acting beta-agonist (LABA) does not worsen asthma control, nor does it lead to any immediate decline in lung function.

Spirometric parameters were similar before and 3 weeks after stopping LABA therapy in an observational study of 58 patients who had stable asthma and were being treated with an inhaled corticosteroid (ICS) and a LABA.

©tupungato/Thinkstock.com

The forced expiratory volume in 1 second (FEV₁) was 88.8% at baseline and 89.5% at the 3-week visit after stepping down their LABA therapy (P = .55). Patients’ average peak expiratory flow rate was 462 L/min both before and after LABA withdrawal.

In addition, no changes were seen in lung function based on impulse oscillometry, a noninvasive method for measuring airway resistance and reactance (Chest. 2014;146[3]:841-7). Similar levels of fractional exhaled nitric oxide (FeNO, 38 and 36 ppb) were recorded.

The findings were presented at the annual congress of the European Respiratory Society (ERS) and have been published in an early online edition of the Annals of Allergy, Asthma & Immunology (doi: 10.1016/j.anai.2016.07.022).

“About 45% of the UK adult asthma population are taking step 3 GINA [Global Initiative for Asthma] therapy, which is ICS/LABA,” explained Sunny Jabbal, MD, of the Scottish Centre for Respiratory Research at Ninewells Hospital in Dundee, Scotland, where the study was conducted. Patients should be on the lowest of the five steps in the 2016 GINA guidelines that achieve asthma control and should be regularly reviewed.

To test whether the LABA could be safely withdrawn, that is stepped down to ICS only [GINA step 2], Dr. Jabbal and colleagues studied 58 patients with a mean age of 39 years. All had well-controlled asthma, and had been receiving ICS/LABA for at least 3 months with no asthma exacerbations requiring treatment. None of the patients were current smokers.

At study entry, patients underwent spirometry, impulse oscillometry, and had FeNO measured. Their LABA was then stopped, and patients were reassessed 3 weeks later. “In accordance with GINA, their ICS dose was also reduced by approximately 25%,” Dr. Jabbal said.

Patients recorded their symptoms and short-term reliever (albuterol) use on simple diary cards. They were also given a 24-hour emergency mobile number, but no calls were received and no adverse events reported. The mean daily symptom score recorded during the step down process was 0.4 (out of a possible score of 3), and the mean albuterol usage was one puff per day.

One of the chairs of the session, Omar Usmani, MD, of Imperial College London noted that some clinicians are “very apprehensive” about stopping LABA and stepping down ICS therapy in their patients.

This was a short-term study, Dr. Jabbal acknowledged. Although a follow-up of 3 weeks may be enough to determine the effects of stopping a LABA, that time may not be sufficient to assess the effects of stepping down the ICS. Further real-life studies are needed to evaluate outcomes such as exacerbations and overall quality of life.

Improved adherence with ICS therapy after LABA withdrawal might explain the lack of deleterious effects, or perhaps some patients may not have initially needed an ICS/LABA combination, he speculated. Maybe even the steroid dose could be reduced further in this particular patient population.

The study received no commercial funding. Dr. Jabbal had no conflicts of interest related to his presentation.

LONDON – Real-life experience shows that stopping treatment with a long-acting beta-agonist (LABA) does not worsen asthma control, nor does it lead to any immediate decline in lung function.

Spirometric parameters were similar before and 3 weeks after stopping LABA therapy in an observational study of 58 patients who had stable asthma and were being treated with an inhaled corticosteroid (ICS) and a LABA.

©tupungato/Thinkstock.com

The forced expiratory volume in 1 second (FEV₁) was 88.8% at baseline and 89.5% at the 3-week visit after stepping down their LABA therapy (P = .55). Patients’ average peak expiratory flow rate was 462 L/min both before and after LABA withdrawal.

In addition, no changes were seen in lung function based on impulse oscillometry, a noninvasive method for measuring airway resistance and reactance (Chest. 2014;146[3]:841-7). Similar levels of fractional exhaled nitric oxide (FeNO, 38 and 36 ppb) were recorded.

The findings were presented at the annual congress of the European Respiratory Society (ERS) and have been published in an early online edition of the Annals of Allergy, Asthma & Immunology (doi: 10.1016/j.anai.2016.07.022).

“About 45% of the UK adult asthma population are taking step 3 GINA [Global Initiative for Asthma] therapy, which is ICS/LABA,” explained Sunny Jabbal, MD, of the Scottish Centre for Respiratory Research at Ninewells Hospital in Dundee, Scotland, where the study was conducted. Patients should be on the lowest of the five steps in the 2016 GINA guidelines that achieve asthma control and should be regularly reviewed.

To test whether the LABA could be safely withdrawn, that is stepped down to ICS only [GINA step 2], Dr. Jabbal and colleagues studied 58 patients with a mean age of 39 years. All had well-controlled asthma, and had been receiving ICS/LABA for at least 3 months with no asthma exacerbations requiring treatment. None of the patients were current smokers.

At study entry, patients underwent spirometry, impulse oscillometry, and had FeNO measured. Their LABA was then stopped, and patients were reassessed 3 weeks later. “In accordance with GINA, their ICS dose was also reduced by approximately 25%,” Dr. Jabbal said.

Patients recorded their symptoms and short-term reliever (albuterol) use on simple diary cards. They were also given a 24-hour emergency mobile number, but no calls were received and no adverse events reported. The mean daily symptom score recorded during the step down process was 0.4 (out of a possible score of 3), and the mean albuterol usage was one puff per day.

One of the chairs of the session, Omar Usmani, MD, of Imperial College London noted that some clinicians are “very apprehensive” about stopping LABA and stepping down ICS therapy in their patients.

This was a short-term study, Dr. Jabbal acknowledged. Although a follow-up of 3 weeks may be enough to determine the effects of stopping a LABA, that time may not be sufficient to assess the effects of stepping down the ICS. Further real-life studies are needed to evaluate outcomes such as exacerbations and overall quality of life.

Improved adherence with ICS therapy after LABA withdrawal might explain the lack of deleterious effects, or perhaps some patients may not have initially needed an ICS/LABA combination, he speculated. Maybe even the steroid dose could be reduced further in this particular patient population.

The study received no commercial funding. Dr. Jabbal had no conflicts of interest related to his presentation.

NEWPORT BEACH, CALIF. – Over the past 20 years, the number of medical malpractice claims against dermatologists has remained steady, in the ballpark of 86-123 per year, according to Abel Torres, MD, JD.

In fact, a study that used claims data from the Physician Insurers Association of America between 1985 and 2008 revealed that dermatology ranked 19th among 28 medical specialties evaluated. “The bad news is we’re not ranked 28th, so we’re still getting sued,” said Dr. Torres, professor and chairman of dermatology at Loma Linda (Calif.) University and professor of dermatology at Case Western Reserve University, Cleveland. In the study, 2,704 of 239,756 (1.1%) closed claims in this time period involved dermatologists; only 29% of the claims that involved dermatologists resulted in a payment for the plaintiff, with a median and average indemnity of $35,000 and $137,538, respectively (J Am Acad Dermatol. 2012 Jan;66[1]:78-85).

Speaking at the annual meeting of the Pacific Dermatologic Association, Dr. Torres, who is also current president of the American Academy of Dermatology, said that communication breakdowns between health care providers and patients account for more than 80% of medical errors and adverse events. In addition, ineffective communication can lead to below-average scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), and other surveys, impacting public scrutiny, reputation, referrals, patient retention, and loyalty, and pay for performance. “Physicians who are on the lower third of communication on surveys tend to have 110% more lawsuits than everybody else,” he said.

Dr. Torres underscored the importance of obtaining verbal or written consent with patients prior to performing dermatologic procedures. “You want to discuss material risk, that is, What’s the likely significant risk? What’s a viable alternative? Do you think it’s viable? And if not, be prepared with data to support that. And what’s your rationale of benefit?” he said.

In a study that evaluated informed consent in dermatologic surgery, 85 patients undergoing Mohs surgery were given verbal and written instructions, including information about the potential for 10 possible complications (Dermatol Surg. 2003;29[9]:952-5). The researchers asked the patients to recall the 10 complications at 20 minutes and at 1 week after the informed consent process. The overall group retention rates for both time periods were 27% and 24%, respectively.

“The reality is, people are nervous,” said Dr. Torres, who was not involved with the study. “They’re not focusing well and may not be listening very carefully to you. So when you give them informed consent you need to help them focus on the important issues. Be cautious about diluting the discussion with so much information that they’re not getting the message.”

Lawsuits involving the use of lasers in dermatology are on the rise, according to one study that examined trends in legal cases secondary to cutaneous laser surgery over a 28-year period that peaked in 2010 (JAMA Dermatol. 2013;149[2]:188-93). It found that laser hair removal was the most commonly litigated procedure (63%), followed by lack of informed consent (53%). Nearly half of the cases favored the defendant and the mean indemnity payment was $380,719.

This is in contrast with commonly reported litigation trends where a majority of the cases favor the defendant. The study also found that nearly 40% of cases involved a nonphysician operator. “So you need to be extra careful when you’re dealing with laser procedures, or you’re dealing with nonphysician operators or extenders,” Dr. Torres noted. “In that regard, know the rules in your state; make sure that you’re clear on them. Make sure that the people who are going to [perform the procedures] are appropriately trained. Provide an adequate degree of supervision to make sure that the proper procedure is being followed, especially as it relates to informed consent.”

Another liability risk for clinicians is failing to follow up with patients. “As a doctor, you may have the responsibility to make sure the patient actually saw the specialist and that their reports were acted upon,” Dr. Torres said. “The law requires that you interact with the specialist in the patients’ best interest. Also, if you refer a patient to another doctor and you have a reason to think that [doctor is] incompetent, you may be held accountable. Referring to the wrong specialist can be a pitfall.”

Dermatologists may at times also be liable for providing interpreter services for patients, no matter the size of their office or the number of employees on their payroll. He recommended that physicians explore whether the Canopy Medical Translator APP, a technology that enables clinicians to communicate with patients in 15 languages, can prove useful to them. Funded by the National Institutes of Health, the technology can be run on any device that runs on iOS or Android. “It can take phrases you have and translate them, or translate phrases that patients have to you,” Dr. Torres said.

In his clinical experience, dermatologists can protect themselves from a legal standpoint by maintaining honesty with the patient; showing kindness and concern at each encounter; validating the patient’s complaints about complications without conveying blame; avoiding isolating the patient after a complication; having a remedy planned for the complication, and seeing and communicating with the patient frequently.

When things go wrong, he offered the “AAA” mnemonic: Always acknowledge a complaint and express empathy; make sure someone you designate is easily accessible to the patient making a complaint, and avoid premature conclusions or comments. “Why? Because you want to maintain honesty with your patients, you want to show kindness and concern and validate patients’ emotions,” Dr. Torres said. “In other words, treat them as you would like to be treated.”

He reported having no financial disclosures.

dbrunk@frontlinemedcom.com

NEWPORT BEACH, CALIF. – Over the past 20 years, the number of medical malpractice claims against dermatologists has remained steady, in the ballpark of 86-123 per year, according to Abel Torres, MD, JD.

In fact, a study that used claims data from the Physician Insurers Association of America between 1985 and 2008 revealed that dermatology ranked 19th among 28 medical specialties evaluated. “The bad news is we’re not ranked 28th, so we’re still getting sued,” said Dr. Torres, professor and chairman of dermatology at Loma Linda (Calif.) University and professor of dermatology at Case Western Reserve University, Cleveland. In the study, 2,704 of 239,756 (1.1%) closed claims in this time period involved dermatologists; only 29% of the claims that involved dermatologists resulted in a payment for the plaintiff, with a median and average indemnity of $35,000 and $137,538, respectively (J Am Acad Dermatol. 2012 Jan;66[1]:78-85).

Speaking at the annual meeting of the Pacific Dermatologic Association, Dr. Torres, who is also current president of the American Academy of Dermatology, said that communication breakdowns between health care providers and patients account for more than 80% of medical errors and adverse events. In addition, ineffective communication can lead to below-average scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), and other surveys, impacting public scrutiny, reputation, referrals, patient retention, and loyalty, and pay for performance. “Physicians who are on the lower third of communication on surveys tend to have 110% more lawsuits than everybody else,” he said.

Dr. Torres underscored the importance of obtaining verbal or written consent with patients prior to performing dermatologic procedures. “You want to discuss material risk, that is, What’s the likely significant risk? What’s a viable alternative? Do you think it’s viable? And if not, be prepared with data to support that. And what’s your rationale of benefit?” he said.

In a study that evaluated informed consent in dermatologic surgery, 85 patients undergoing Mohs surgery were given verbal and written instructions, including information about the potential for 10 possible complications (Dermatol Surg. 2003;29[9]:952-5). The researchers asked the patients to recall the 10 complications at 20 minutes and at 1 week after the informed consent process. The overall group retention rates for both time periods were 27% and 24%, respectively.

“The reality is, people are nervous,” said Dr. Torres, who was not involved with the study. “They’re not focusing well and may not be listening very carefully to you. So when you give them informed consent you need to help them focus on the important issues. Be cautious about diluting the discussion with so much information that they’re not getting the message.”

Lawsuits involving the use of lasers in dermatology are on the rise, according to one study that examined trends in legal cases secondary to cutaneous laser surgery over a 28-year period that peaked in 2010 (JAMA Dermatol. 2013;149[2]:188-93). It found that laser hair removal was the most commonly litigated procedure (63%), followed by lack of informed consent (53%). Nearly half of the cases favored the defendant and the mean indemnity payment was $380,719.

This is in contrast with commonly reported litigation trends where a majority of the cases favor the defendant. The study also found that nearly 40% of cases involved a nonphysician operator. “So you need to be extra careful when you’re dealing with laser procedures, or you’re dealing with nonphysician operators or extenders,” Dr. Torres noted. “In that regard, know the rules in your state; make sure that you’re clear on them. Make sure that the people who are going to [perform the procedures] are appropriately trained. Provide an adequate degree of supervision to make sure that the proper procedure is being followed, especially as it relates to informed consent.”

Another liability risk for clinicians is failing to follow up with patients. “As a doctor, you may have the responsibility to make sure the patient actually saw the specialist and that their reports were acted upon,” Dr. Torres said. “The law requires that you interact with the specialist in the patients’ best interest. Also, if you refer a patient to another doctor and you have a reason to think that [doctor is] incompetent, you may be held accountable. Referring to the wrong specialist can be a pitfall.”

Dermatologists may at times also be liable for providing interpreter services for patients, no matter the size of their office or the number of employees on their payroll. He recommended that physicians explore whether the Canopy Medical Translator APP, a technology that enables clinicians to communicate with patients in 15 languages, can prove useful to them. Funded by the National Institutes of Health, the technology can be run on any device that runs on iOS or Android. “It can take phrases you have and translate them, or translate phrases that patients have to you,” Dr. Torres said.

In his clinical experience, dermatologists can protect themselves from a legal standpoint by maintaining honesty with the patient; showing kindness and concern at each encounter; validating the patient’s complaints about complications without conveying blame; avoiding isolating the patient after a complication; having a remedy planned for the complication, and seeing and communicating with the patient frequently.

When things go wrong, he offered the “AAA” mnemonic: Always acknowledge a complaint and express empathy; make sure someone you designate is easily accessible to the patient making a complaint, and avoid premature conclusions or comments. “Why? Because you want to maintain honesty with your patients, you want to show kindness and concern and validate patients’ emotions,” Dr. Torres said. “In other words, treat them as you would like to be treated.”

He reported having no financial disclosures.

dbrunk@frontlinemedcom.com

NEWPORT BEACH, CALIF. – Over the past 20 years, the number of medical malpractice claims against dermatologists has remained steady, in the ballpark of 86-123 per year, according to Abel Torres, MD, JD.

In fact, a study that used claims data from the Physician Insurers Association of America between 1985 and 2008 revealed that dermatology ranked 19th among 28 medical specialties evaluated. “The bad news is we’re not ranked 28th, so we’re still getting sued,” said Dr. Torres, professor and chairman of dermatology at Loma Linda (Calif.) University and professor of dermatology at Case Western Reserve University, Cleveland. In the study, 2,704 of 239,756 (1.1%) closed claims in this time period involved dermatologists; only 29% of the claims that involved dermatologists resulted in a payment for the plaintiff, with a median and average indemnity of $35,000 and $137,538, respectively (J Am Acad Dermatol. 2012 Jan;66[1]:78-85).

Speaking at the annual meeting of the Pacific Dermatologic Association, Dr. Torres, who is also current president of the American Academy of Dermatology, said that communication breakdowns between health care providers and patients account for more than 80% of medical errors and adverse events. In addition, ineffective communication can lead to below-average scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), and other surveys, impacting public scrutiny, reputation, referrals, patient retention, and loyalty, and pay for performance. “Physicians who are on the lower third of communication on surveys tend to have 110% more lawsuits than everybody else,” he said.

Dr. Torres underscored the importance of obtaining verbal or written consent with patients prior to performing dermatologic procedures. “You want to discuss material risk, that is, What’s the likely significant risk? What’s a viable alternative? Do you think it’s viable? And if not, be prepared with data to support that. And what’s your rationale of benefit?” he said.

In a study that evaluated informed consent in dermatologic surgery, 85 patients undergoing Mohs surgery were given verbal and written instructions, including information about the potential for 10 possible complications (Dermatol Surg. 2003;29[9]:952-5). The researchers asked the patients to recall the 10 complications at 20 minutes and at 1 week after the informed consent process. The overall group retention rates for both time periods were 27% and 24%, respectively.

“The reality is, people are nervous,” said Dr. Torres, who was not involved with the study. “They’re not focusing well and may not be listening very carefully to you. So when you give them informed consent you need to help them focus on the important issues. Be cautious about diluting the discussion with so much information that they’re not getting the message.”

Lawsuits involving the use of lasers in dermatology are on the rise, according to one study that examined trends in legal cases secondary to cutaneous laser surgery over a 28-year period that peaked in 2010 (JAMA Dermatol. 2013;149[2]:188-93). It found that laser hair removal was the most commonly litigated procedure (63%), followed by lack of informed consent (53%). Nearly half of the cases favored the defendant and the mean indemnity payment was $380,719.

This is in contrast with commonly reported litigation trends where a majority of the cases favor the defendant. The study also found that nearly 40% of cases involved a nonphysician operator. “So you need to be extra careful when you’re dealing with laser procedures, or you’re dealing with nonphysician operators or extenders,” Dr. Torres noted. “In that regard, know the rules in your state; make sure that you’re clear on them. Make sure that the people who are going to [perform the procedures] are appropriately trained. Provide an adequate degree of supervision to make sure that the proper procedure is being followed, especially as it relates to informed consent.”

Another liability risk for clinicians is failing to follow up with patients. “As a doctor, you may have the responsibility to make sure the patient actually saw the specialist and that their reports were acted upon,” Dr. Torres said. “The law requires that you interact with the specialist in the patients’ best interest. Also, if you refer a patient to another doctor and you have a reason to think that [doctor is] incompetent, you may be held accountable. Referring to the wrong specialist can be a pitfall.”

Dermatologists may at times also be liable for providing interpreter services for patients, no matter the size of their office or the number of employees on their payroll. He recommended that physicians explore whether the Canopy Medical Translator APP, a technology that enables clinicians to communicate with patients in 15 languages, can prove useful to them. Funded by the National Institutes of Health, the technology can be run on any device that runs on iOS or Android. “It can take phrases you have and translate them, or translate phrases that patients have to you,” Dr. Torres said.

In his clinical experience, dermatologists can protect themselves from a legal standpoint by maintaining honesty with the patient; showing kindness and concern at each encounter; validating the patient’s complaints about complications without conveying blame; avoiding isolating the patient after a complication; having a remedy planned for the complication, and seeing and communicating with the patient frequently.

When things go wrong, he offered the “AAA” mnemonic: Always acknowledge a complaint and express empathy; make sure someone you designate is easily accessible to the patient making a complaint, and avoid premature conclusions or comments. “Why? Because you want to maintain honesty with your patients, you want to show kindness and concern and validate patients’ emotions,” Dr. Torres said. “In other words, treat them as you would like to be treated.”

He reported having no financial disclosures.

dbrunk@frontlinemedcom.com

The Baylor Research Institute and SHM joined forces to provide a new resource to help accelerate adoption of a specific set of patient safety practices (collectively termed the ABCDEF bundle) to mitigate delirium in the ICU. This guide will allow you to impact care at both the individual patient and the institutional levels. It is intended for the broad, multidisciplinary spectrum of personnel involved in hospital-based quality improvement and patient safety efforts, ranging from frontline care providers to executive leaders. View the toolkit and download the guide at www.hospitalmedicine.org/delirium.

The Baylor Research Institute and SHM joined forces to provide a new resource to help accelerate adoption of a specific set of patient safety practices (collectively termed the ABCDEF bundle) to mitigate delirium in the ICU. This guide will allow you to impact care at both the individual patient and the institutional levels. It is intended for the broad, multidisciplinary spectrum of personnel involved in hospital-based quality improvement and patient safety efforts, ranging from frontline care providers to executive leaders. View the toolkit and download the guide at www.hospitalmedicine.org/delirium.

The Baylor Research Institute and SHM joined forces to provide a new resource to help accelerate adoption of a specific set of patient safety practices (collectively termed the ABCDEF bundle) to mitigate delirium in the ICU. This guide will allow you to impact care at both the individual patient and the institutional levels. It is intended for the broad, multidisciplinary spectrum of personnel involved in hospital-based quality improvement and patient safety efforts, ranging from frontline care providers to executive leaders. View the toolkit and download the guide at www.hospitalmedicine.org/delirium.

• A $35 credit toward 2017–2018 dues when recruiting 1 new member.
• A $50 credit toward 2017–2018 dues when recruiting 2–4 new members.
• A $75 credit toward 2017–2018 dues when recruiting 5–9 new members.
• A $125 credit toward 2017–2018 dues when recruiting 10+ new members.

For each member recruited, referrers will receive one entry into a grand-prize drawing to receive complimentary registration to Hospital Medicine 2017 in Las Vegas.

• A $35 credit toward 2017–2018 dues when recruiting 1 new member.
• A $50 credit toward 2017–2018 dues when recruiting 2–4 new members.
• A $75 credit toward 2017–2018 dues when recruiting 5–9 new members.
• A $125 credit toward 2017–2018 dues when recruiting 10+ new members.

For each member recruited, referrers will receive one entry into a grand-prize drawing to receive complimentary registration to Hospital Medicine 2017 in Las Vegas.

• A $35 credit toward 2017–2018 dues when recruiting 1 new member.
• A $50 credit toward 2017–2018 dues when recruiting 2–4 new members.
• A $75 credit toward 2017–2018 dues when recruiting 5–9 new members.
• A $125 credit toward 2017–2018 dues when recruiting 10+ new members.

For each member recruited, referrers will receive one entry into a grand-prize drawing to receive complimentary registration to Hospital Medicine 2017 in Las Vegas.

Ronald M. Epstein, MD

©ASCO/Todd Buchanan 2016

SAN FRANCISCO—Results of the VOICE study showed that training advanced cancer patients and their oncologists on how to communicate resulted in more clinically meaningful discussions between the parties.

However, these discussions did not significantly improve patients’ understanding of their prognosis, have a significant impact on their quality of life or end-of-life care, or significantly improve the

patient-physician relationship.

Ronald Epstein, MD, of the University of Rochester in New York, and his colleagues reported results from this study in JAMA Oncology and at the 2016 Palliative Care in Oncology Symposium (abstract 2).

The VOICE study included 265 patients with stage 3 or 4 cancer, 130 of whom received communication training. As part of the training, patients received a booklet Dr Epstein’s team wrote called “My Cancer Care: What Now? What Next? What I Prefer.”

The patients and their caregivers also met with social workers or nurses to discuss commonly asked questions and how to express their fears, for example, or how to be assertive and state their preferences.

Of the 38 oncologists studied, 19 received communication training. This included mock office sessions with actors (known as standardized patients), video training, and individualized feedback.

Later, the researchers audio-recorded real sessions between the oncologists and patients, then asked both groups to fill out questionnaires. The team coded the interactions and matched the scores to the goals of the training.

Results

The study’s primary endpoint was a composite of 4 communication measures—engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information.

The researchers found that communication training resulted in a significant improvement in this endpoint (P=0.02).

“We have shown, in the first large study of its kind, that it is possible to change the conversation in advanced cancer,” Dr Epstein said. “This is a huge first step.”

However, when Dr Epstein and his colleagues looked at the individual components of the endpoint, only the engaging measure was significantly different between the intervention and control groups.

Communication training had no significant effect on the patient-physician relationship, patients’ quality of life, or healthcare utilization at the end of life.

Likewise, communication training had no significant effect on patients’ understanding of their prognosis, which was assessed by the discordance in 2-year survival estimates and curability estimates between patients and physicians.

“We need to try harder to communicate well so that it’s harder to miscommunicate,” Dr Epstein said. “Simply having the conversation is not enough. The quality of the conversation will influence a mutual understanding between patients and their oncologists.”

The researchers said a limitation of this study may have been the timing of the training, which was only provided once and not timed to key decision points during patients’ trajectories. The effects of the training may have waned over the months, especially as the cancer progressed.

“We need to embed communication interventions into the fabric of everyday clinical care,” Dr Epstein said. “This does not take a lot of time, but, in our audio-recordings, there was precious little dialogue that reaffirmed the human experience and the needs of patients. The next step is to make good communication the rule, not the exception, so that cancer patients’ voices can be heard.”

Ronald M. Epstein, MD

©ASCO/Todd Buchanan 2016

SAN FRANCISCO—Results of the VOICE study showed that training advanced cancer patients and their oncologists on how to communicate resulted in more clinically meaningful discussions between the parties.

However, these discussions did not significantly improve patients’ understanding of their prognosis, have a significant impact on their quality of life or end-of-life care, or significantly improve the

patient-physician relationship.

Ronald Epstein, MD, of the University of Rochester in New York, and his colleagues reported results from this study in JAMA Oncology and at the 2016 Palliative Care in Oncology Symposium (abstract 2).

The VOICE study included 265 patients with stage 3 or 4 cancer, 130 of whom received communication training. As part of the training, patients received a booklet Dr Epstein’s team wrote called “My Cancer Care: What Now? What Next? What I Prefer.”

The patients and their caregivers also met with social workers or nurses to discuss commonly asked questions and how to express their fears, for example, or how to be assertive and state their preferences.

Of the 38 oncologists studied, 19 received communication training. This included mock office sessions with actors (known as standardized patients), video training, and individualized feedback.

Later, the researchers audio-recorded real sessions between the oncologists and patients, then asked both groups to fill out questionnaires. The team coded the interactions and matched the scores to the goals of the training.

Results

The study’s primary endpoint was a composite of 4 communication measures—engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information.

The researchers found that communication training resulted in a significant improvement in this endpoint (P=0.02).

“We have shown, in the first large study of its kind, that it is possible to change the conversation in advanced cancer,” Dr Epstein said. “This is a huge first step.”

However, when Dr Epstein and his colleagues looked at the individual components of the endpoint, only the engaging measure was significantly different between the intervention and control groups.

Communication training had no significant effect on the patient-physician relationship, patients’ quality of life, or healthcare utilization at the end of life.

Likewise, communication training had no significant effect on patients’ understanding of their prognosis, which was assessed by the discordance in 2-year survival estimates and curability estimates between patients and physicians.

“We need to try harder to communicate well so that it’s harder to miscommunicate,” Dr Epstein said. “Simply having the conversation is not enough. The quality of the conversation will influence a mutual understanding between patients and their oncologists.”

The researchers said a limitation of this study may have been the timing of the training, which was only provided once and not timed to key decision points during patients’ trajectories. The effects of the training may have waned over the months, especially as the cancer progressed.

“We need to embed communication interventions into the fabric of everyday clinical care,” Dr Epstein said. “This does not take a lot of time, but, in our audio-recordings, there was precious little dialogue that reaffirmed the human experience and the needs of patients. The next step is to make good communication the rule, not the exception, so that cancer patients’ voices can be heard.”

Ronald M. Epstein, MD

©ASCO/Todd Buchanan 2016

SAN FRANCISCO—Results of the VOICE study showed that training advanced cancer patients and their oncologists on how to communicate resulted in more clinically meaningful discussions between the parties.

However, these discussions did not significantly improve patients’ understanding of their prognosis, have a significant impact on their quality of life or end-of-life care, or significantly improve the

patient-physician relationship.

Ronald Epstein, MD, of the University of Rochester in New York, and his colleagues reported results from this study in JAMA Oncology and at the 2016 Palliative Care in Oncology Symposium (abstract 2).

The VOICE study included 265 patients with stage 3 or 4 cancer, 130 of whom received communication training. As part of the training, patients received a booklet Dr Epstein’s team wrote called “My Cancer Care: What Now? What Next? What I Prefer.”

The patients and their caregivers also met with social workers or nurses to discuss commonly asked questions and how to express their fears, for example, or how to be assertive and state their preferences.

Of the 38 oncologists studied, 19 received communication training. This included mock office sessions with actors (known as standardized patients), video training, and individualized feedback.

Later, the researchers audio-recorded real sessions between the oncologists and patients, then asked both groups to fill out questionnaires. The team coded the interactions and matched the scores to the goals of the training.

Results

The study’s primary endpoint was a composite of 4 communication measures—engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information.

The researchers found that communication training resulted in a significant improvement in this endpoint (P=0.02).

“We have shown, in the first large study of its kind, that it is possible to change the conversation in advanced cancer,” Dr Epstein said. “This is a huge first step.”

However, when Dr Epstein and his colleagues looked at the individual components of the endpoint, only the engaging measure was significantly different between the intervention and control groups.

Communication training had no significant effect on the patient-physician relationship, patients’ quality of life, or healthcare utilization at the end of life.

Likewise, communication training had no significant effect on patients’ understanding of their prognosis, which was assessed by the discordance in 2-year survival estimates and curability estimates between patients and physicians.

“We need to try harder to communicate well so that it’s harder to miscommunicate,” Dr Epstein said. “Simply having the conversation is not enough. The quality of the conversation will influence a mutual understanding between patients and their oncologists.”

The researchers said a limitation of this study may have been the timing of the training, which was only provided once and not timed to key decision points during patients’ trajectories. The effects of the training may have waned over the months, especially as the cancer progressed.

“We need to embed communication interventions into the fabric of everyday clinical care,” Dr Epstein said. “This does not take a lot of time, but, in our audio-recordings, there was precious little dialogue that reaffirmed the human experience and the needs of patients. The next step is to make good communication the rule, not the exception, so that cancer patients’ voices can be heard.”