Feature

This time, it didn’t take much persuading for Mary Murphy to embrace home hospice. When her mother was dying from Alzheimer’s disease in 2020, she had been reluctant until she saw what a help it was. So when her husband, Willie, neared the end of his life, she embraced hospice again.

The Murphys’ house in a leafy Nashville, Tenn., neighborhood is their happy place – full of their treasures.

“He’s good to me – buys me anything I want,” she said, as she pulled a milky glass vase out of a floor-to-ceiling cabinet with mirrored shelves.

Willie bought Mary the display case to help her to show off the trinkets she picks up at estate sales.

Down the hall, Willie was lying in their bed, now unable to speak. His heart was giving out.

“You gonna wake up for a minute?” she asked, cradling his head. She patted his back while he cleared his throat. “Cough it out.”

Mary had been the primary caregiver for her husband, but she gets help from a new hospice agency in Nashville focused on increasing the use of end-of-life comfort care by Black families. Heart and Soul Hospice is owned and operated by people who share the same cultural background as the patients they aim to serve.

In their application to obtain a certificate of need in Tennessee, the hospice owners made it clear they are Black and intend to serve everyone but will focus on African Americans, who are currently underserved. Tennessee data shows that in Nashville just 19% of hospice patients are Black, although they make up 27% of the capital city’s population.

Though the area already had numerous hospice agencies, regulators granted Heart and Soul permission to operate, based primarily on the value of educating an underserved group.

In Ms. Murphy’s first hospice experience, her mother had been living with dementia for decades. Still, Ms. Murphy had concerns about transitioning her mother to hospice. She felt as if she was giving up on her mom.

“My first thought was death,” she said.

National data shows that Black Medicare patients and their families are not making the move to comfort care as often as white patients are. Roughly 41% of Black Medicare beneficiaries who died in 2019 were enrolled in hospice, compared with 54% of White patients, according to data compiled annually by the National Hospice and Palliative Care Organization.

Ms. Murphy’s mother survived nearly 3 years on hospice. The benefit is meant for those in the final 6 months of life, but predicting when the end will come is difficult, especially in cases of dementia. Hospice provides palliative care for the dying and support for caregivers for a long as the process lasts.

Ms. Murphy did most of the caregiving – which can be overwhelming – but hospice helped with a few baths a week, medication in the mail and any medical equipment they needed.

And most important to Ms. Murphy was the emotional support, which came mostly from her hospice nurse.

“Wasn’t no doctor going to come here, hold my hand, stay here until the funeral home came for her,” she said about the day her mother died.

Last year, on the day after Thanksgiving, Willie Murphy died. And the same hospice nurse was at the Murphy home within minutes. She’d already stopped by that morning to check on him and returned as soon as Mary called and told her he wasn’t breathing.

“If you don’t feel like: ‘Oh my God, thank God I have hospice,’ if you can’t say that, then we’re doing something wrong,” said Keisha Mason, Heart and Soul’s director of nursing.

Ms. Mason, like Ms. Murphy, is Black and said that in her view there’s nothing fundamental keeping Black patients from using hospice except learning what the service can offer and that it’s basically free to patients – paid for by Medicare, Medicaid, and most private health plans.

“I say to them, ‘If you see a bill, then call us, because you should not,’” she said.

As Ms. Mason helped launch this new hospice agency, she began using new language, calling hospice more than a Medicare benefit. She describes it as an entitlement.

“Just as you are entitled to unemployment, as you are entitled to Social Security, you are entitled to a hospice benefit,” she said.

The investors in Heart and Soul include David Turner, owner of CNS Hospice in Detroit; Nashville pastor the Rev. Sandy McClain; and André Lee, a former hospital administrator on the campus of Meharry Medical College, a historically Black institution in Nashville.

Mr. Lee and Mr. Turner also started a Black-focused hospice agency in Michigan and have plans to replicate the model in other states.

More families need to consider home hospice as an alternative for end-of-life care, Mr. Lee said. Nursing homes are pricey. And even with Medicare, a hospital bill can be hefty.

“You’ll go in there and they’ll eat you alive,” he said. “I hate to say [something] bad about hospitals, but it’s true.”

Hospice research hasn’t come up with clear reasons to explain the gap between White and Black families’ use of the benefit. Some experts speculate it’s related to spiritual beliefs and widespread mistrust in the medical system because of decades of discrimination.

The hospice industry’s national trade group, the National Hospice and Palliative Care Organization, released a diversity and inclusion toolkit and a guide to reaching more Black patients. It recommends connecting with influential DJs, partnering with Black pastors and simply hiring more Black nurses.

Bridging the gap is not overly complicated, Mr. Lee said.

“A lot of hospices don’t employ enough Black people,” he said. “We all feel comfortable when you see someone over there that looks like you.”

Well-established hospice agencies have attempted to minimize barriers with their own diversity initiatives. Michelle Drayton of Visiting Nurse Service of New York said her large agency has met with ministers who counsel families dealing with failing health.

“Many of them did not fully understand what hospice was,” she said. “They had many of the same sort of misperceptions.”

Every hospice company, whether it’s an upstart or one of the nation’s oldest, can promote end-of-life education and ease care disparities, Ms. Drayton said. “We’re not just handing out a brochure,” she added.

This story is part of a partnership that includes Nashville Public Radio, NPR, and KHN. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

This time, it didn’t take much persuading for Mary Murphy to embrace home hospice. When her mother was dying from Alzheimer’s disease in 2020, she had been reluctant until she saw what a help it was. So when her husband, Willie, neared the end of his life, she embraced hospice again.

The Murphys’ house in a leafy Nashville, Tenn., neighborhood is their happy place – full of their treasures.

“He’s good to me – buys me anything I want,” she said, as she pulled a milky glass vase out of a floor-to-ceiling cabinet with mirrored shelves.

Willie bought Mary the display case to help her to show off the trinkets she picks up at estate sales.

Down the hall, Willie was lying in their bed, now unable to speak. His heart was giving out.

“You gonna wake up for a minute?” she asked, cradling his head. She patted his back while he cleared his throat. “Cough it out.”

Mary had been the primary caregiver for her husband, but she gets help from a new hospice agency in Nashville focused on increasing the use of end-of-life comfort care by Black families. Heart and Soul Hospice is owned and operated by people who share the same cultural background as the patients they aim to serve.

In their application to obtain a certificate of need in Tennessee, the hospice owners made it clear they are Black and intend to serve everyone but will focus on African Americans, who are currently underserved. Tennessee data shows that in Nashville just 19% of hospice patients are Black, although they make up 27% of the capital city’s population.

Though the area already had numerous hospice agencies, regulators granted Heart and Soul permission to operate, based primarily on the value of educating an underserved group.

In Ms. Murphy’s first hospice experience, her mother had been living with dementia for decades. Still, Ms. Murphy had concerns about transitioning her mother to hospice. She felt as if she was giving up on her mom.

“My first thought was death,” she said.

National data shows that Black Medicare patients and their families are not making the move to comfort care as often as white patients are. Roughly 41% of Black Medicare beneficiaries who died in 2019 were enrolled in hospice, compared with 54% of White patients, according to data compiled annually by the National Hospice and Palliative Care Organization.

Ms. Murphy’s mother survived nearly 3 years on hospice. The benefit is meant for those in the final 6 months of life, but predicting when the end will come is difficult, especially in cases of dementia. Hospice provides palliative care for the dying and support for caregivers for a long as the process lasts.

Ms. Murphy did most of the caregiving – which can be overwhelming – but hospice helped with a few baths a week, medication in the mail and any medical equipment they needed.

And most important to Ms. Murphy was the emotional support, which came mostly from her hospice nurse.

“Wasn’t no doctor going to come here, hold my hand, stay here until the funeral home came for her,” she said about the day her mother died.

Last year, on the day after Thanksgiving, Willie Murphy died. And the same hospice nurse was at the Murphy home within minutes. She’d already stopped by that morning to check on him and returned as soon as Mary called and told her he wasn’t breathing.

“If you don’t feel like: ‘Oh my God, thank God I have hospice,’ if you can’t say that, then we’re doing something wrong,” said Keisha Mason, Heart and Soul’s director of nursing.

Ms. Mason, like Ms. Murphy, is Black and said that in her view there’s nothing fundamental keeping Black patients from using hospice except learning what the service can offer and that it’s basically free to patients – paid for by Medicare, Medicaid, and most private health plans.

“I say to them, ‘If you see a bill, then call us, because you should not,’” she said.

As Ms. Mason helped launch this new hospice agency, she began using new language, calling hospice more than a Medicare benefit. She describes it as an entitlement.

“Just as you are entitled to unemployment, as you are entitled to Social Security, you are entitled to a hospice benefit,” she said.

The investors in Heart and Soul include David Turner, owner of CNS Hospice in Detroit; Nashville pastor the Rev. Sandy McClain; and André Lee, a former hospital administrator on the campus of Meharry Medical College, a historically Black institution in Nashville.

Mr. Lee and Mr. Turner also started a Black-focused hospice agency in Michigan and have plans to replicate the model in other states.

More families need to consider home hospice as an alternative for end-of-life care, Mr. Lee said. Nursing homes are pricey. And even with Medicare, a hospital bill can be hefty.

“You’ll go in there and they’ll eat you alive,” he said. “I hate to say [something] bad about hospitals, but it’s true.”

Hospice research hasn’t come up with clear reasons to explain the gap between White and Black families’ use of the benefit. Some experts speculate it’s related to spiritual beliefs and widespread mistrust in the medical system because of decades of discrimination.

The hospice industry’s national trade group, the National Hospice and Palliative Care Organization, released a diversity and inclusion toolkit and a guide to reaching more Black patients. It recommends connecting with influential DJs, partnering with Black pastors and simply hiring more Black nurses.

Bridging the gap is not overly complicated, Mr. Lee said.

“A lot of hospices don’t employ enough Black people,” he said. “We all feel comfortable when you see someone over there that looks like you.”

Well-established hospice agencies have attempted to minimize barriers with their own diversity initiatives. Michelle Drayton of Visiting Nurse Service of New York said her large agency has met with ministers who counsel families dealing with failing health.

“Many of them did not fully understand what hospice was,” she said. “They had many of the same sort of misperceptions.”

Every hospice company, whether it’s an upstart or one of the nation’s oldest, can promote end-of-life education and ease care disparities, Ms. Drayton said. “We’re not just handing out a brochure,” she added.

This story is part of a partnership that includes Nashville Public Radio, NPR, and KHN. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

This time, it didn’t take much persuading for Mary Murphy to embrace home hospice. When her mother was dying from Alzheimer’s disease in 2020, she had been reluctant until she saw what a help it was. So when her husband, Willie, neared the end of his life, she embraced hospice again.

The Murphys’ house in a leafy Nashville, Tenn., neighborhood is their happy place – full of their treasures.

“He’s good to me – buys me anything I want,” she said, as she pulled a milky glass vase out of a floor-to-ceiling cabinet with mirrored shelves.

Willie bought Mary the display case to help her to show off the trinkets she picks up at estate sales.

Down the hall, Willie was lying in their bed, now unable to speak. His heart was giving out.

“You gonna wake up for a minute?” she asked, cradling his head. She patted his back while he cleared his throat. “Cough it out.”

Mary had been the primary caregiver for her husband, but she gets help from a new hospice agency in Nashville focused on increasing the use of end-of-life comfort care by Black families. Heart and Soul Hospice is owned and operated by people who share the same cultural background as the patients they aim to serve.

In their application to obtain a certificate of need in Tennessee, the hospice owners made it clear they are Black and intend to serve everyone but will focus on African Americans, who are currently underserved. Tennessee data shows that in Nashville just 19% of hospice patients are Black, although they make up 27% of the capital city’s population.

Though the area already had numerous hospice agencies, regulators granted Heart and Soul permission to operate, based primarily on the value of educating an underserved group.

In Ms. Murphy’s first hospice experience, her mother had been living with dementia for decades. Still, Ms. Murphy had concerns about transitioning her mother to hospice. She felt as if she was giving up on her mom.

“My first thought was death,” she said.

National data shows that Black Medicare patients and their families are not making the move to comfort care as often as white patients are. Roughly 41% of Black Medicare beneficiaries who died in 2019 were enrolled in hospice, compared with 54% of White patients, according to data compiled annually by the National Hospice and Palliative Care Organization.

Ms. Murphy’s mother survived nearly 3 years on hospice. The benefit is meant for those in the final 6 months of life, but predicting when the end will come is difficult, especially in cases of dementia. Hospice provides palliative care for the dying and support for caregivers for a long as the process lasts.

Ms. Murphy did most of the caregiving – which can be overwhelming – but hospice helped with a few baths a week, medication in the mail and any medical equipment they needed.

And most important to Ms. Murphy was the emotional support, which came mostly from her hospice nurse.

“Wasn’t no doctor going to come here, hold my hand, stay here until the funeral home came for her,” she said about the day her mother died.

Last year, on the day after Thanksgiving, Willie Murphy died. And the same hospice nurse was at the Murphy home within minutes. She’d already stopped by that morning to check on him and returned as soon as Mary called and told her he wasn’t breathing.

“If you don’t feel like: ‘Oh my God, thank God I have hospice,’ if you can’t say that, then we’re doing something wrong,” said Keisha Mason, Heart and Soul’s director of nursing.

Ms. Mason, like Ms. Murphy, is Black and said that in her view there’s nothing fundamental keeping Black patients from using hospice except learning what the service can offer and that it’s basically free to patients – paid for by Medicare, Medicaid, and most private health plans.

“I say to them, ‘If you see a bill, then call us, because you should not,’” she said.

As Ms. Mason helped launch this new hospice agency, she began using new language, calling hospice more than a Medicare benefit. She describes it as an entitlement.

“Just as you are entitled to unemployment, as you are entitled to Social Security, you are entitled to a hospice benefit,” she said.

The investors in Heart and Soul include David Turner, owner of CNS Hospice in Detroit; Nashville pastor the Rev. Sandy McClain; and André Lee, a former hospital administrator on the campus of Meharry Medical College, a historically Black institution in Nashville.

Mr. Lee and Mr. Turner also started a Black-focused hospice agency in Michigan and have plans to replicate the model in other states.

More families need to consider home hospice as an alternative for end-of-life care, Mr. Lee said. Nursing homes are pricey. And even with Medicare, a hospital bill can be hefty.

“You’ll go in there and they’ll eat you alive,” he said. “I hate to say [something] bad about hospitals, but it’s true.”

Hospice research hasn’t come up with clear reasons to explain the gap between White and Black families’ use of the benefit. Some experts speculate it’s related to spiritual beliefs and widespread mistrust in the medical system because of decades of discrimination.

The hospice industry’s national trade group, the National Hospice and Palliative Care Organization, released a diversity and inclusion toolkit and a guide to reaching more Black patients. It recommends connecting with influential DJs, partnering with Black pastors and simply hiring more Black nurses.

Bridging the gap is not overly complicated, Mr. Lee said.

“A lot of hospices don’t employ enough Black people,” he said. “We all feel comfortable when you see someone over there that looks like you.”

Well-established hospice agencies have attempted to minimize barriers with their own diversity initiatives. Michelle Drayton of Visiting Nurse Service of New York said her large agency has met with ministers who counsel families dealing with failing health.

“Many of them did not fully understand what hospice was,” she said. “They had many of the same sort of misperceptions.”

Every hospice company, whether it’s an upstart or one of the nation’s oldest, can promote end-of-life education and ease care disparities, Ms. Drayton said. “We’re not just handing out a brochure,” she added.

This story is part of a partnership that includes Nashville Public Radio, NPR, and KHN. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Many states have restored restrictions on telehealth use that they suspended earlier in the COVID-19 pandemic, according to a new report jointly prepared by the Reason Institute, the Pioneer Institute, and the Cicero Institute.

Among the most important restrictions that have been reinstated in some states are those barring requirements for insurers to cover telehealth and regulations that prohibit telehealth visits across state lines, unless the physician is licensed in both states.

“Only three states – Arizona, Florida, and Indiana – allow all health care providers to easily practice telehealth across state lines,” says a news release on the think tanks’ report. “Forty-seven others have arbitrary barriers in place that limit patients’ access to specialists and available appointments based purely on residency.”

“Once the [state-based] public health emergency declarations started to end or executive orders were withdrawn, many of the new flexibilities for providers, insurers, and patients were lost overnight,” Vittorio Nastasi, a policy analyst at Reason Foundation and a co-author of the report, says in the news release. “States need to adopt a number of telehealth reforms to provide their residents better access to this safe and effective virtual care.”

On a positive note, the report says, most states have removed the requirement that a patient must first see a provider in person before they can use telehealth services. The exceptions are Tennessee, Alaska, and West Virginia, which require an in-person visit before certain telehealth services can be provided.

In addition, 20 states allow nurse practitioners to conduct telehealth visits without being under the supervision of a physician. Prior to the pandemic, some states allowed only doctors to use telehealth, the report says, but, during the COVID crisis, “the acute shortage of providers in many counties adds to the need for more kinds of providers to be able to use it.”

A number of states place restrictions on the telehealth modalities that can be utilized. Under the definition by the American Telemedicine Association, telehealth includes audio-video visits, remote patient monitoring, and “store and forward” telemedicine, which entails collecting clinical information and sending it to another site for evaluation. The latter method is particularly useful for consultations with specialists, the report notes.
 

Coverage mandates and payment parity

The report also examines other parameters of telehealth regulations in each state, including whether they have telehealth coverage mandates and whether they require physicians to be paid the same amount for similar types of in-person and telehealth visits.

The report views insurance mandates as beneficial, but not if they require coverage of all virtual services. While telehealth can be a game changer for post-stroke care and for other “treatment-intensive conditions,” the report says, the evidence of better outcomes for other conditions treated through telehealth is far less certain. Therefore, it advises states to “protect flexibility so that new innovative models can emerge.”

Ateev Mehrotra, MD, a professor at Harvard Medical School who studies telehealth, agrees that it offers more value in some clinical situations than in others. “High value is improving quality or outcomes at a reasonable cost,” he told this news organization. “If a telemedicine visit for stroke can save a person’s life and prevent disability, let’s pay for it. A telemedicine visit for a cold may not be necessary. Mom’s chicken soup is fine.”

A little over half of the states still require payment parity, according to the report. While these regulations are intended to promote the use of telehealth, the authors note, they can increase the growth of health care costs. Moreover, they argue, it’s hard to defend equal payments for virtual visits when the overhead required to deliver them – such as office rental, utility, and labor costs – is much lower than that for in-person visits. Also, it makes no sense for health systems to charge facility fees for telehealth visits when these visits can be initiated from anywhere, they say.

Dr. Mehrotra concurs with this view. “If you see someone in your office, your fee includes all the overhead for your office, and it’s a substantial cost,” he says. “For many procedures, it’s more than half of the cost. If you have a telemedicine visit and you’re at home, why would you pay the same amount? The visit may take the same amount of time, but all the money that goes for overhead is not accounted for.”
 

Telemedicine across state lines

The report’s contention about the difficulty of conducting telehealth encounters across most state lines seems to be at odds with the growth in the Interstate Medical Licensure Compact, which makes it easier for physicians in one compact member state to get licensed in others. Currently, 35 states belong to the compact, Joe Knickrehm, vice president of communications for the Federation of State Medical Boards, told this news organization.

In addition, he says, “12 state boards issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines to allow for the practice of telemedicine.”

The catch, Dr. Mehrotra says, is that, despite the streamlining of license applications in compact member states, the fees charged by the state boards are still very high – a point that the report also makes. “If I want to have broad scope of practice, I’d have to pay thousands of dollars to many states. The license fees start to add up. Also, I have to keep track of each state’s CME requirements, which are all different. Keeping up with all of that is an administration burden, and it’s a pain.”

Mr. Knickrehm contends that obtaining multiple licenses via the compact “is generally less expensive for physicians than the cost of requesting transcripts, fingerprints, and other necessary paperwork each time they apply for licensure in a new state. Physicians are seeing the benefits of an expedited process that allows them to begin practicing more quickly [in other states].”

Dr. Mehrotra says he has seen the same retrenchment in state telehealth regulations that the report references. However, he says, “CMS [the Centers for Medicare & Medicaid Services] has signaled that at least through 2022 and maybe into 2023, they’ll continue their extensions of telemedicine [pandemic regulations].” After that, Congress would have to decide whether to make the changes permanent.

“Right now, it’s hard for me to see how a payer is going to pull back on telehealth, unless there’s ample evidence of overuse of telehealth,” he argues. “With the public and providers liking telehealth, it’s hard to say on theoretical grounds that we should stop using it. That’s why Medicare and others have extended it and why Congress will too.”

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

Many states have restored restrictions on telehealth use that they suspended earlier in the COVID-19 pandemic, according to a new report jointly prepared by the Reason Institute, the Pioneer Institute, and the Cicero Institute.

Among the most important restrictions that have been reinstated in some states are those barring requirements for insurers to cover telehealth and regulations that prohibit telehealth visits across state lines, unless the physician is licensed in both states.

“Only three states – Arizona, Florida, and Indiana – allow all health care providers to easily practice telehealth across state lines,” says a news release on the think tanks’ report. “Forty-seven others have arbitrary barriers in place that limit patients’ access to specialists and available appointments based purely on residency.”

“Once the [state-based] public health emergency declarations started to end or executive orders were withdrawn, many of the new flexibilities for providers, insurers, and patients were lost overnight,” Vittorio Nastasi, a policy analyst at Reason Foundation and a co-author of the report, says in the news release. “States need to adopt a number of telehealth reforms to provide their residents better access to this safe and effective virtual care.”

On a positive note, the report says, most states have removed the requirement that a patient must first see a provider in person before they can use telehealth services. The exceptions are Tennessee, Alaska, and West Virginia, which require an in-person visit before certain telehealth services can be provided.

In addition, 20 states allow nurse practitioners to conduct telehealth visits without being under the supervision of a physician. Prior to the pandemic, some states allowed only doctors to use telehealth, the report says, but, during the COVID crisis, “the acute shortage of providers in many counties adds to the need for more kinds of providers to be able to use it.”

A number of states place restrictions on the telehealth modalities that can be utilized. Under the definition by the American Telemedicine Association, telehealth includes audio-video visits, remote patient monitoring, and “store and forward” telemedicine, which entails collecting clinical information and sending it to another site for evaluation. The latter method is particularly useful for consultations with specialists, the report notes.
 

Coverage mandates and payment parity

The report also examines other parameters of telehealth regulations in each state, including whether they have telehealth coverage mandates and whether they require physicians to be paid the same amount for similar types of in-person and telehealth visits.

The report views insurance mandates as beneficial, but not if they require coverage of all virtual services. While telehealth can be a game changer for post-stroke care and for other “treatment-intensive conditions,” the report says, the evidence of better outcomes for other conditions treated through telehealth is far less certain. Therefore, it advises states to “protect flexibility so that new innovative models can emerge.”

Ateev Mehrotra, MD, a professor at Harvard Medical School who studies telehealth, agrees that it offers more value in some clinical situations than in others. “High value is improving quality or outcomes at a reasonable cost,” he told this news organization. “If a telemedicine visit for stroke can save a person’s life and prevent disability, let’s pay for it. A telemedicine visit for a cold may not be necessary. Mom’s chicken soup is fine.”

A little over half of the states still require payment parity, according to the report. While these regulations are intended to promote the use of telehealth, the authors note, they can increase the growth of health care costs. Moreover, they argue, it’s hard to defend equal payments for virtual visits when the overhead required to deliver them – such as office rental, utility, and labor costs – is much lower than that for in-person visits. Also, it makes no sense for health systems to charge facility fees for telehealth visits when these visits can be initiated from anywhere, they say.

Dr. Mehrotra concurs with this view. “If you see someone in your office, your fee includes all the overhead for your office, and it’s a substantial cost,” he says. “For many procedures, it’s more than half of the cost. If you have a telemedicine visit and you’re at home, why would you pay the same amount? The visit may take the same amount of time, but all the money that goes for overhead is not accounted for.”
 

Telemedicine across state lines

The report’s contention about the difficulty of conducting telehealth encounters across most state lines seems to be at odds with the growth in the Interstate Medical Licensure Compact, which makes it easier for physicians in one compact member state to get licensed in others. Currently, 35 states belong to the compact, Joe Knickrehm, vice president of communications for the Federation of State Medical Boards, told this news organization.

In addition, he says, “12 state boards issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines to allow for the practice of telemedicine.”

The catch, Dr. Mehrotra says, is that, despite the streamlining of license applications in compact member states, the fees charged by the state boards are still very high – a point that the report also makes. “If I want to have broad scope of practice, I’d have to pay thousands of dollars to many states. The license fees start to add up. Also, I have to keep track of each state’s CME requirements, which are all different. Keeping up with all of that is an administration burden, and it’s a pain.”

Mr. Knickrehm contends that obtaining multiple licenses via the compact “is generally less expensive for physicians than the cost of requesting transcripts, fingerprints, and other necessary paperwork each time they apply for licensure in a new state. Physicians are seeing the benefits of an expedited process that allows them to begin practicing more quickly [in other states].”

Dr. Mehrotra says he has seen the same retrenchment in state telehealth regulations that the report references. However, he says, “CMS [the Centers for Medicare & Medicaid Services] has signaled that at least through 2022 and maybe into 2023, they’ll continue their extensions of telemedicine [pandemic regulations].” After that, Congress would have to decide whether to make the changes permanent.

“Right now, it’s hard for me to see how a payer is going to pull back on telehealth, unless there’s ample evidence of overuse of telehealth,” he argues. “With the public and providers liking telehealth, it’s hard to say on theoretical grounds that we should stop using it. That’s why Medicare and others have extended it and why Congress will too.”

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

Many states have restored restrictions on telehealth use that they suspended earlier in the COVID-19 pandemic, according to a new report jointly prepared by the Reason Institute, the Pioneer Institute, and the Cicero Institute.

Among the most important restrictions that have been reinstated in some states are those barring requirements for insurers to cover telehealth and regulations that prohibit telehealth visits across state lines, unless the physician is licensed in both states.

“Only three states – Arizona, Florida, and Indiana – allow all health care providers to easily practice telehealth across state lines,” says a news release on the think tanks’ report. “Forty-seven others have arbitrary barriers in place that limit patients’ access to specialists and available appointments based purely on residency.”

“Once the [state-based] public health emergency declarations started to end or executive orders were withdrawn, many of the new flexibilities for providers, insurers, and patients were lost overnight,” Vittorio Nastasi, a policy analyst at Reason Foundation and a co-author of the report, says in the news release. “States need to adopt a number of telehealth reforms to provide their residents better access to this safe and effective virtual care.”

On a positive note, the report says, most states have removed the requirement that a patient must first see a provider in person before they can use telehealth services. The exceptions are Tennessee, Alaska, and West Virginia, which require an in-person visit before certain telehealth services can be provided.

In addition, 20 states allow nurse practitioners to conduct telehealth visits without being under the supervision of a physician. Prior to the pandemic, some states allowed only doctors to use telehealth, the report says, but, during the COVID crisis, “the acute shortage of providers in many counties adds to the need for more kinds of providers to be able to use it.”

A number of states place restrictions on the telehealth modalities that can be utilized. Under the definition by the American Telemedicine Association, telehealth includes audio-video visits, remote patient monitoring, and “store and forward” telemedicine, which entails collecting clinical information and sending it to another site for evaluation. The latter method is particularly useful for consultations with specialists, the report notes.
 

Coverage mandates and payment parity

The report also examines other parameters of telehealth regulations in each state, including whether they have telehealth coverage mandates and whether they require physicians to be paid the same amount for similar types of in-person and telehealth visits.

The report views insurance mandates as beneficial, but not if they require coverage of all virtual services. While telehealth can be a game changer for post-stroke care and for other “treatment-intensive conditions,” the report says, the evidence of better outcomes for other conditions treated through telehealth is far less certain. Therefore, it advises states to “protect flexibility so that new innovative models can emerge.”

Ateev Mehrotra, MD, a professor at Harvard Medical School who studies telehealth, agrees that it offers more value in some clinical situations than in others. “High value is improving quality or outcomes at a reasonable cost,” he told this news organization. “If a telemedicine visit for stroke can save a person’s life and prevent disability, let’s pay for it. A telemedicine visit for a cold may not be necessary. Mom’s chicken soup is fine.”

A little over half of the states still require payment parity, according to the report. While these regulations are intended to promote the use of telehealth, the authors note, they can increase the growth of health care costs. Moreover, they argue, it’s hard to defend equal payments for virtual visits when the overhead required to deliver them – such as office rental, utility, and labor costs – is much lower than that for in-person visits. Also, it makes no sense for health systems to charge facility fees for telehealth visits when these visits can be initiated from anywhere, they say.

Dr. Mehrotra concurs with this view. “If you see someone in your office, your fee includes all the overhead for your office, and it’s a substantial cost,” he says. “For many procedures, it’s more than half of the cost. If you have a telemedicine visit and you’re at home, why would you pay the same amount? The visit may take the same amount of time, but all the money that goes for overhead is not accounted for.”
 

Telemedicine across state lines

The report’s contention about the difficulty of conducting telehealth encounters across most state lines seems to be at odds with the growth in the Interstate Medical Licensure Compact, which makes it easier for physicians in one compact member state to get licensed in others. Currently, 35 states belong to the compact, Joe Knickrehm, vice president of communications for the Federation of State Medical Boards, told this news organization.

In addition, he says, “12 state boards issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines to allow for the practice of telemedicine.”

The catch, Dr. Mehrotra says, is that, despite the streamlining of license applications in compact member states, the fees charged by the state boards are still very high – a point that the report also makes. “If I want to have broad scope of practice, I’d have to pay thousands of dollars to many states. The license fees start to add up. Also, I have to keep track of each state’s CME requirements, which are all different. Keeping up with all of that is an administration burden, and it’s a pain.”

Mr. Knickrehm contends that obtaining multiple licenses via the compact “is generally less expensive for physicians than the cost of requesting transcripts, fingerprints, and other necessary paperwork each time they apply for licensure in a new state. Physicians are seeing the benefits of an expedited process that allows them to begin practicing more quickly [in other states].”

Dr. Mehrotra says he has seen the same retrenchment in state telehealth regulations that the report references. However, he says, “CMS [the Centers for Medicare & Medicaid Services] has signaled that at least through 2022 and maybe into 2023, they’ll continue their extensions of telemedicine [pandemic regulations].” After that, Congress would have to decide whether to make the changes permanent.

“Right now, it’s hard for me to see how a payer is going to pull back on telehealth, unless there’s ample evidence of overuse of telehealth,” he argues. “With the public and providers liking telehealth, it’s hard to say on theoretical grounds that we should stop using it. That’s why Medicare and others have extended it and why Congress will too.”

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

In 2014, when the Food and Drug Administration found serious problems with a life-sustaining heart pump, its warning letter to the manufacturer threatened to notify other federal health agencies about the inspection’s findings.

But for years, no such alert ever went out. Instead, the agency added the warning letter to an online database alongside thousands of others, following its typical procedures, an FDA spokesperson said.

Agencies such as the Centers for Medicare & Medicaid Services and the U.S. Department of Veterans Affairs went on paying to implant the HeartWare Ventricular Assist Device, or HVAD, in new patients even though federal inspectors had found problems with the device linked to patient deaths and injuries.

Taxpayer dollars continued to flow to the original device maker, HeartWare, and then to the company that acquired it in 2016, Medtronic, for 7 years while the issues raised in the warning letter remained unresolved.

If crucial safety information in FDA warning letters doesn’t make it to other arms of the government responsible for deciding which medical devices to pay for, experts said patients are the ones put at risk.

“It’s clearly a breakdown of communication,” said Dr. Rita Redberg, a cardiologist at the University of California, San Francisco, who researches medical device safety and regulation. “It’s not just the money, obviously. It’s people’s lives.”

The FDA acknowledged that it doesn’t directly notify other agencies when it issues warning letters, pointing instead to its online database, which is accessible to both government officials and the public. “The FDA’s decisions are intended to be patient-centric with the health and safety of device users as our highest priority,” the agency spokesperson said in an email.

The HeartWare letter was removed from the public database about 2 years ago, even though the problems remained unresolved and patients were still receiving implants. The database clears out letters that are more than 5 years old.

CMS, which oversees the Medicare and Medicaid programs, would not say why it continued paying for a device that didn’t meet government standards. It directed questions about the HeartWare warning letter to the FDA. “CMS does not have oversight of the manufacturing and related safety assessments of a medical device manufacturer,” a spokesperson said in an email.

The spokesperson noted that CMS requires heart pump patients to have specialized medical teams managing their care, which should monitor FDA communications regarding safety of devices.

CMS doesn’t track data on devices by manufacturer, so it’s essentially impossible to calculate its total spending on HVADs. One 2018 medical journal study found that Medicare and Medicaid paid for more than half the cost of all heart pump implants from 2009 to 2014. If that rate of spending continued, CMS may have spent more than $400 million on implanting HVADs since 2014.

A spokesperson for the VA said his agency was never notified about the HeartWare warning letter. The VA paid HeartWare and Medtronic more than $3 million after the FDA issued the letter in 2014. It offered this explanation for why: “It’s important to note that FDA Warning Letters are notifications issued to manufacturers found to be in significant violation of federal regulations. They are not product recalls.”

In the case of the HVAD, the FDA’s failure to make sure its warning reached beyond the manufacturer may have had life-and-death consequences.

In August, ProPublica reported that federal inspectors continued finding problems at the HVAD’s manufacturing plant for years. Meanwhile, the FDA received thousands of reports of suspicious deaths and injuries and more than a dozen high-risk safety alerts from the manufacturer.

The documents detailed one horrifying device failure after another. A father of four died after his device suddenly failed and his teenage daughter couldn’t resuscitate him. Another patient’s heart tissue was charred after a pump short-circuited and overheated. A teenager died after vomiting blood as his mother struggled to restart a defective pump.

In June, Medtronic ended sales and implants of the device, citing new data that showed patients with HVADs had a higher rate of deaths and strokes than those with a competing heart pump.

Medtronic declined to comment for this story. It has previously said it believed that after the 2014 warning letter the benefits of the HVAD still outweighed the risks for patients with severe heart failure.

Experts said the lack of communication between federal agencies when serious device problems are found is baffling but not surprising. It fits a broader trend of device regulators focusing more on evaluating new products than monitoring the ones already on the market.

“The priority is to get more medical devices out there, paid for and getting used,” said Dr. Joseph Ross, a professor of medicine and public health at Yale University who studies medical device regulation.

Other U.S. health care regulators move more forcefully when providers and suppliers don’t meet the government’s minimum safety requirements for an extended period, putting patients at risk.

Take hospitals. When inspectors find a facility is not meeting safety standards, CMS can issue an immediate jeopardy citation and, if problems aren’t fixed, move to withhold federal payments, which make up substantial portions of most hospitals’ revenues. In the rare cases when hospitals don’t take sufficient action, CMS follows through and revokes funding.

Redberg, the UCSF cardiologist, said the lack of similar action for medical devices offers a clear “opportunity for improvement.” At minimum, the FDA could establish processes to directly inform other agencies when it issues warning letters and finds serious problems with devices being sold in the United States.

“If the agency’s mission is to protect public health, they would want to do these things and move quickly,” she said.

This story was originally published on ProPublica. ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive their biggest stories as soon as they’re published.

In 2014, when the Food and Drug Administration found serious problems with a life-sustaining heart pump, its warning letter to the manufacturer threatened to notify other federal health agencies about the inspection’s findings.

But for years, no such alert ever went out. Instead, the agency added the warning letter to an online database alongside thousands of others, following its typical procedures, an FDA spokesperson said.

Agencies such as the Centers for Medicare & Medicaid Services and the U.S. Department of Veterans Affairs went on paying to implant the HeartWare Ventricular Assist Device, or HVAD, in new patients even though federal inspectors had found problems with the device linked to patient deaths and injuries.

Taxpayer dollars continued to flow to the original device maker, HeartWare, and then to the company that acquired it in 2016, Medtronic, for 7 years while the issues raised in the warning letter remained unresolved.

If crucial safety information in FDA warning letters doesn’t make it to other arms of the government responsible for deciding which medical devices to pay for, experts said patients are the ones put at risk.

“It’s clearly a breakdown of communication,” said Dr. Rita Redberg, a cardiologist at the University of California, San Francisco, who researches medical device safety and regulation. “It’s not just the money, obviously. It’s people’s lives.”

The FDA acknowledged that it doesn’t directly notify other agencies when it issues warning letters, pointing instead to its online database, which is accessible to both government officials and the public. “The FDA’s decisions are intended to be patient-centric with the health and safety of device users as our highest priority,” the agency spokesperson said in an email.

The HeartWare letter was removed from the public database about 2 years ago, even though the problems remained unresolved and patients were still receiving implants. The database clears out letters that are more than 5 years old.

CMS, which oversees the Medicare and Medicaid programs, would not say why it continued paying for a device that didn’t meet government standards. It directed questions about the HeartWare warning letter to the FDA. “CMS does not have oversight of the manufacturing and related safety assessments of a medical device manufacturer,” a spokesperson said in an email.

The spokesperson noted that CMS requires heart pump patients to have specialized medical teams managing their care, which should monitor FDA communications regarding safety of devices.

CMS doesn’t track data on devices by manufacturer, so it’s essentially impossible to calculate its total spending on HVADs. One 2018 medical journal study found that Medicare and Medicaid paid for more than half the cost of all heart pump implants from 2009 to 2014. If that rate of spending continued, CMS may have spent more than $400 million on implanting HVADs since 2014.

A spokesperson for the VA said his agency was never notified about the HeartWare warning letter. The VA paid HeartWare and Medtronic more than $3 million after the FDA issued the letter in 2014. It offered this explanation for why: “It’s important to note that FDA Warning Letters are notifications issued to manufacturers found to be in significant violation of federal regulations. They are not product recalls.”

In the case of the HVAD, the FDA’s failure to make sure its warning reached beyond the manufacturer may have had life-and-death consequences.

In August, ProPublica reported that federal inspectors continued finding problems at the HVAD’s manufacturing plant for years. Meanwhile, the FDA received thousands of reports of suspicious deaths and injuries and more than a dozen high-risk safety alerts from the manufacturer.

The documents detailed one horrifying device failure after another. A father of four died after his device suddenly failed and his teenage daughter couldn’t resuscitate him. Another patient’s heart tissue was charred after a pump short-circuited and overheated. A teenager died after vomiting blood as his mother struggled to restart a defective pump.

In June, Medtronic ended sales and implants of the device, citing new data that showed patients with HVADs had a higher rate of deaths and strokes than those with a competing heart pump.

Medtronic declined to comment for this story. It has previously said it believed that after the 2014 warning letter the benefits of the HVAD still outweighed the risks for patients with severe heart failure.

Experts said the lack of communication between federal agencies when serious device problems are found is baffling but not surprising. It fits a broader trend of device regulators focusing more on evaluating new products than monitoring the ones already on the market.

“The priority is to get more medical devices out there, paid for and getting used,” said Dr. Joseph Ross, a professor of medicine and public health at Yale University who studies medical device regulation.

Other U.S. health care regulators move more forcefully when providers and suppliers don’t meet the government’s minimum safety requirements for an extended period, putting patients at risk.

Take hospitals. When inspectors find a facility is not meeting safety standards, CMS can issue an immediate jeopardy citation and, if problems aren’t fixed, move to withhold federal payments, which make up substantial portions of most hospitals’ revenues. In the rare cases when hospitals don’t take sufficient action, CMS follows through and revokes funding.

Redberg, the UCSF cardiologist, said the lack of similar action for medical devices offers a clear “opportunity for improvement.” At minimum, the FDA could establish processes to directly inform other agencies when it issues warning letters and finds serious problems with devices being sold in the United States.

“If the agency’s mission is to protect public health, they would want to do these things and move quickly,” she said.

This story was originally published on ProPublica. ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive their biggest stories as soon as they’re published.

In 2014, when the Food and Drug Administration found serious problems with a life-sustaining heart pump, its warning letter to the manufacturer threatened to notify other federal health agencies about the inspection’s findings.

But for years, no such alert ever went out. Instead, the agency added the warning letter to an online database alongside thousands of others, following its typical procedures, an FDA spokesperson said.

Agencies such as the Centers for Medicare & Medicaid Services and the U.S. Department of Veterans Affairs went on paying to implant the HeartWare Ventricular Assist Device, or HVAD, in new patients even though federal inspectors had found problems with the device linked to patient deaths and injuries.

Taxpayer dollars continued to flow to the original device maker, HeartWare, and then to the company that acquired it in 2016, Medtronic, for 7 years while the issues raised in the warning letter remained unresolved.

If crucial safety information in FDA warning letters doesn’t make it to other arms of the government responsible for deciding which medical devices to pay for, experts said patients are the ones put at risk.

“It’s clearly a breakdown of communication,” said Dr. Rita Redberg, a cardiologist at the University of California, San Francisco, who researches medical device safety and regulation. “It’s not just the money, obviously. It’s people’s lives.”

The FDA acknowledged that it doesn’t directly notify other agencies when it issues warning letters, pointing instead to its online database, which is accessible to both government officials and the public. “The FDA’s decisions are intended to be patient-centric with the health and safety of device users as our highest priority,” the agency spokesperson said in an email.

The HeartWare letter was removed from the public database about 2 years ago, even though the problems remained unresolved and patients were still receiving implants. The database clears out letters that are more than 5 years old.

CMS, which oversees the Medicare and Medicaid programs, would not say why it continued paying for a device that didn’t meet government standards. It directed questions about the HeartWare warning letter to the FDA. “CMS does not have oversight of the manufacturing and related safety assessments of a medical device manufacturer,” a spokesperson said in an email.

The spokesperson noted that CMS requires heart pump patients to have specialized medical teams managing their care, which should monitor FDA communications regarding safety of devices.

CMS doesn’t track data on devices by manufacturer, so it’s essentially impossible to calculate its total spending on HVADs. One 2018 medical journal study found that Medicare and Medicaid paid for more than half the cost of all heart pump implants from 2009 to 2014. If that rate of spending continued, CMS may have spent more than $400 million on implanting HVADs since 2014.

A spokesperson for the VA said his agency was never notified about the HeartWare warning letter. The VA paid HeartWare and Medtronic more than $3 million after the FDA issued the letter in 2014. It offered this explanation for why: “It’s important to note that FDA Warning Letters are notifications issued to manufacturers found to be in significant violation of federal regulations. They are not product recalls.”

In the case of the HVAD, the FDA’s failure to make sure its warning reached beyond the manufacturer may have had life-and-death consequences.

In August, ProPublica reported that federal inspectors continued finding problems at the HVAD’s manufacturing plant for years. Meanwhile, the FDA received thousands of reports of suspicious deaths and injuries and more than a dozen high-risk safety alerts from the manufacturer.

The documents detailed one horrifying device failure after another. A father of four died after his device suddenly failed and his teenage daughter couldn’t resuscitate him. Another patient’s heart tissue was charred after a pump short-circuited and overheated. A teenager died after vomiting blood as his mother struggled to restart a defective pump.

In June, Medtronic ended sales and implants of the device, citing new data that showed patients with HVADs had a higher rate of deaths and strokes than those with a competing heart pump.

Medtronic declined to comment for this story. It has previously said it believed that after the 2014 warning letter the benefits of the HVAD still outweighed the risks for patients with severe heart failure.

Experts said the lack of communication between federal agencies when serious device problems are found is baffling but not surprising. It fits a broader trend of device regulators focusing more on evaluating new products than monitoring the ones already on the market.

“The priority is to get more medical devices out there, paid for and getting used,” said Dr. Joseph Ross, a professor of medicine and public health at Yale University who studies medical device regulation.

Other U.S. health care regulators move more forcefully when providers and suppliers don’t meet the government’s minimum safety requirements for an extended period, putting patients at risk.

Take hospitals. When inspectors find a facility is not meeting safety standards, CMS can issue an immediate jeopardy citation and, if problems aren’t fixed, move to withhold federal payments, which make up substantial portions of most hospitals’ revenues. In the rare cases when hospitals don’t take sufficient action, CMS follows through and revokes funding.

Redberg, the UCSF cardiologist, said the lack of similar action for medical devices offers a clear “opportunity for improvement.” At minimum, the FDA could establish processes to directly inform other agencies when it issues warning letters and finds serious problems with devices being sold in the United States.

“If the agency’s mission is to protect public health, they would want to do these things and move quickly,” she said.

This story was originally published on ProPublica. ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive their biggest stories as soon as they’re published.

Patients with chronic low back pain who participated in therapeutic aquatic exercise had superior improvement in function, pain, quality of life, sleep quality, and mental state, compared with those who received physical therapy, in a new study.

“This is the first study to compare the efficacy of therapeutic aquatic exercise and physical therapy modalities in the treatment of chronic low back pain,” senior coauthors Pei-Jie Chen, PhD and Xue-Qiang Wang, PhD, both of the department of sport rehabilitation, Shanghai (China) University of Sport, wrote in JAMA Network Open. “Therapeutic aquatic exercise is a safe treatment for chronic low back pain and most participants who received it were willing to recommend it to other patients with chronic low back pain.”

As compared with individuals in the physical therapy modalities arm, the therapeutic aquatic exercise experienced greater relief of disability at all time points assessed: after the 3-month intervention, at the 6-month follow-up, and at the 12-month follow-up.

Commenting on the study, Linda Girgis, MD, FAAFP, a family physician in private practice in South River, N.J., agreed that aquatic therapy is a great tool for many chronic low back patients. “It helps them get active for one and do things that may exacerbate their symptoms doing the same exercises on land,” noted Dr. Girgis, who also is a clinical assistant professor at Robert Wood Johnson Medical School, New Brunswick.

She pointed out that access to a pool can be a problem. “But I have found a few physical therapy places in my area that do have access to a pool, and I refer appropriate patients there,” added Dr. Girgis, who was not involved with the study. “I have also found it works well for other types of pain, such as knee and hip pain. It is not for everyone but I have seen some patients get great benefit from it when they didn’t get any with traditional physical therapy.”
 

Aquatic therapy was more beneficial

Low back pain is a common condition, and clinical practice guidelines currently recommend therapeutic exercise and physical therapy modalities. Among the modalities that are available, therapeutic aquatic exercise is often prescribed for chronic low back pain, and it is becoming increasingly popular for treatment of chronic low back pain, the authors stated in their paper. The authors noted that water is an ideal environment for conducting an exercise program given its various properties, including buoyancy pressure, density, thermal capacity, and conductivity.

Two previously published systematic reviews have suggested that therapeutic aquatic exercise may be able to reduce the intensity of back pain and improve function in this population. But to date, evidence regarding long-term benefits in patients with chronic low back pain is very limited and there haven’t been any studies comparing the efficacy of therapeutic aquatic exercise and physical therapy modalities for chronic low back pain, according to the authors.

In this study, 113 individuals with chronic low back pain were randomized to either therapeutic aquatic exercise or to physical therapy, with an endpoint of efficacy regarding disability. This was measured using the Roland-Morris Disability Questionnaire.

Scores ranged from 0 to 24, with higher scores indicating more severe disability. Secondary endpoints included pain intensity, quality of life, sleep quality, and recommendation of intervention, and these were rated using various standardized tools.

Those randomized to the therapeutic aquatic exercise group had about an hour of therapy, beginning with a 10-minute active warm-up session to enhance neuromuscular activation, then an exercise session for 40 minutes followed by a 10-minute cooldown.

The physical therapy group received transcutaneous electrical nerve stimulation and infrared ray thermal therapy, also for 60 minutes. Both groups received these interventions twice a week for 3 months.

The overall mean age of the cohort was 31.0 years, and they were almost evenly divided by gender; 54 were men (47.8%), and 59 were women (52.2%).

As compared with the physical therapy group, individuals participating in therapeutic aquatic exercise group showed improvement in disability by an additional −1.77 points (95% confidence interval, −3.02 to −0.51) at the end of the 3-month intervention; at 6 months it was −2.42 points (95% CI, −4.13 to −0.70) and −3.61 points (95% CI, −5.63 to −1.58) at the 12-month follow-up (P < .001 for overall group x time interaction).

Functional improvement did not appear to be significantly affected by confounders that included age, sex, body mass index, low back pain duration, educational level, or pain level.

For secondary outcomes, those in the therapeutic aquatic exercise group demonstrated improvement in the most severe pain by an additional −0.79 points (95% CI, −1.31 to −0.27) after the 3-month intervention, −1.34 points (95% CI, −2.06 to −0.62) at 6 months, and −2.04 points (95% CI, −2.75 to −1.34) at the 12-month follow-up (P < .001 for overall group x time interaction), as compared with the physical therapy group. All pain scores differed significantly between the two groups at every time point.

In addition, individuals in the therapeutic aquatic exercise group showed more improvements on the 36-item Short-form Health Survey (overall group x time interaction, P = .003), Pittsburgh Sleep Quality Index (overall group x time interaction, P = .02), Tampa Scale for Kinesiophobia (overall group x time interaction, P < .001), and Fear-Avoidance Beliefs Questionnaire (physical activity subscale overall group x time interaction, P = .04), as compared with the physical therapy group. These improvements were also not influenced by confounders.

Finally, at the 12-month follow-up point, those in the aquatic therapy group had significantly greater improvements in the number of participants who met the minimal clinically important difference in pain (at least a 2-point improvement on the numeric rating scale).
 

More outside experts’ takes

“The current research evidence does suggest indeed that aquatic exercise therapy is suitable and often better than land exercise, passive relaxation, or other treatments for many people with low back pain,” commented Stelios Psycharakis PhD, senior lecturer in biomechanics, Institute for Sport, Physical Education and Health Sciences, University of Edinburgh.

He also noted that since low back pain is an issue affecting about 80% of all people at some stage of their life, it is “improbable that one could identify a single type of treatment or exercise therapy that would be suitable for every person with this problem.”

Dr. Psycharakis pointed out that there are also some contraindications for aquatic therapy, such as incontinence and skin conditions. “Other than that though, clinicians should definitely consider aquatic exercise therapy when advising people with chronic low back pain,” he said.

Justin M. Lantz, DPT, agreed that the study showed therapeutic aquatic exercise appears to be safe and beneficial in some patients with chronic low back pain, but he also shared limitations of the new research.

“The study has notable limitations as it did not include patients above 65 years old, pain levels were generally low for the subjects involved, and it did not include a treatment group with land therapeutic exercise – so it is difficult to determine if the beneficial effects reported were due to active exercise or because the exercises were performed in water,” said Dr. Lantz, director of the spine physical therapy fellowship program at the University of Southern California, Los Angeles, and an assistant professor of clinical physical therapy.

He also pointed out that, since active exercise has been shown to be beneficial and is advocated in multiple clinical practice guidelines for chronic low back pain, “it would be helpful to determine if the true effects on pain and disability were due to the water environment or the effect of active exercise itself.”

“Due to the significant positive long-term effects and limited adverse events reported, I believe this study supports the use of therapeutic aquatic exercise in select patient populations with chronic low back pain and should be considered as a part of a rehabilitation treatment plan if accessibility is feasible,” Dr. Lantz said.

The authors of the paper, Dr. Girgis, and Dr. Psycharakis had no conflicts of interest. Justin Lantz is a physical therapy consultant to SI-Bone.

Patients with chronic low back pain who participated in therapeutic aquatic exercise had superior improvement in function, pain, quality of life, sleep quality, and mental state, compared with those who received physical therapy, in a new study.

“This is the first study to compare the efficacy of therapeutic aquatic exercise and physical therapy modalities in the treatment of chronic low back pain,” senior coauthors Pei-Jie Chen, PhD and Xue-Qiang Wang, PhD, both of the department of sport rehabilitation, Shanghai (China) University of Sport, wrote in JAMA Network Open. “Therapeutic aquatic exercise is a safe treatment for chronic low back pain and most participants who received it were willing to recommend it to other patients with chronic low back pain.”

As compared with individuals in the physical therapy modalities arm, the therapeutic aquatic exercise experienced greater relief of disability at all time points assessed: after the 3-month intervention, at the 6-month follow-up, and at the 12-month follow-up.

Commenting on the study, Linda Girgis, MD, FAAFP, a family physician in private practice in South River, N.J., agreed that aquatic therapy is a great tool for many chronic low back patients. “It helps them get active for one and do things that may exacerbate their symptoms doing the same exercises on land,” noted Dr. Girgis, who also is a clinical assistant professor at Robert Wood Johnson Medical School, New Brunswick.

She pointed out that access to a pool can be a problem. “But I have found a few physical therapy places in my area that do have access to a pool, and I refer appropriate patients there,” added Dr. Girgis, who was not involved with the study. “I have also found it works well for other types of pain, such as knee and hip pain. It is not for everyone but I have seen some patients get great benefit from it when they didn’t get any with traditional physical therapy.”
 

Aquatic therapy was more beneficial

Low back pain is a common condition, and clinical practice guidelines currently recommend therapeutic exercise and physical therapy modalities. Among the modalities that are available, therapeutic aquatic exercise is often prescribed for chronic low back pain, and it is becoming increasingly popular for treatment of chronic low back pain, the authors stated in their paper. The authors noted that water is an ideal environment for conducting an exercise program given its various properties, including buoyancy pressure, density, thermal capacity, and conductivity.

Two previously published systematic reviews have suggested that therapeutic aquatic exercise may be able to reduce the intensity of back pain and improve function in this population. But to date, evidence regarding long-term benefits in patients with chronic low back pain is very limited and there haven’t been any studies comparing the efficacy of therapeutic aquatic exercise and physical therapy modalities for chronic low back pain, according to the authors.

In this study, 113 individuals with chronic low back pain were randomized to either therapeutic aquatic exercise or to physical therapy, with an endpoint of efficacy regarding disability. This was measured using the Roland-Morris Disability Questionnaire.

Scores ranged from 0 to 24, with higher scores indicating more severe disability. Secondary endpoints included pain intensity, quality of life, sleep quality, and recommendation of intervention, and these were rated using various standardized tools.

Those randomized to the therapeutic aquatic exercise group had about an hour of therapy, beginning with a 10-minute active warm-up session to enhance neuromuscular activation, then an exercise session for 40 minutes followed by a 10-minute cooldown.

The physical therapy group received transcutaneous electrical nerve stimulation and infrared ray thermal therapy, also for 60 minutes. Both groups received these interventions twice a week for 3 months.

The overall mean age of the cohort was 31.0 years, and they were almost evenly divided by gender; 54 were men (47.8%), and 59 were women (52.2%).

As compared with the physical therapy group, individuals participating in therapeutic aquatic exercise group showed improvement in disability by an additional −1.77 points (95% confidence interval, −3.02 to −0.51) at the end of the 3-month intervention; at 6 months it was −2.42 points (95% CI, −4.13 to −0.70) and −3.61 points (95% CI, −5.63 to −1.58) at the 12-month follow-up (P < .001 for overall group x time interaction).

Functional improvement did not appear to be significantly affected by confounders that included age, sex, body mass index, low back pain duration, educational level, or pain level.

For secondary outcomes, those in the therapeutic aquatic exercise group demonstrated improvement in the most severe pain by an additional −0.79 points (95% CI, −1.31 to −0.27) after the 3-month intervention, −1.34 points (95% CI, −2.06 to −0.62) at 6 months, and −2.04 points (95% CI, −2.75 to −1.34) at the 12-month follow-up (P < .001 for overall group x time interaction), as compared with the physical therapy group. All pain scores differed significantly between the two groups at every time point.

In addition, individuals in the therapeutic aquatic exercise group showed more improvements on the 36-item Short-form Health Survey (overall group x time interaction, P = .003), Pittsburgh Sleep Quality Index (overall group x time interaction, P = .02), Tampa Scale for Kinesiophobia (overall group x time interaction, P < .001), and Fear-Avoidance Beliefs Questionnaire (physical activity subscale overall group x time interaction, P = .04), as compared with the physical therapy group. These improvements were also not influenced by confounders.

Finally, at the 12-month follow-up point, those in the aquatic therapy group had significantly greater improvements in the number of participants who met the minimal clinically important difference in pain (at least a 2-point improvement on the numeric rating scale).
 

More outside experts’ takes

“The current research evidence does suggest indeed that aquatic exercise therapy is suitable and often better than land exercise, passive relaxation, or other treatments for many people with low back pain,” commented Stelios Psycharakis PhD, senior lecturer in biomechanics, Institute for Sport, Physical Education and Health Sciences, University of Edinburgh.

He also noted that since low back pain is an issue affecting about 80% of all people at some stage of their life, it is “improbable that one could identify a single type of treatment or exercise therapy that would be suitable for every person with this problem.”

Dr. Psycharakis pointed out that there are also some contraindications for aquatic therapy, such as incontinence and skin conditions. “Other than that though, clinicians should definitely consider aquatic exercise therapy when advising people with chronic low back pain,” he said.

Justin M. Lantz, DPT, agreed that the study showed therapeutic aquatic exercise appears to be safe and beneficial in some patients with chronic low back pain, but he also shared limitations of the new research.

“The study has notable limitations as it did not include patients above 65 years old, pain levels were generally low for the subjects involved, and it did not include a treatment group with land therapeutic exercise – so it is difficult to determine if the beneficial effects reported were due to active exercise or because the exercises were performed in water,” said Dr. Lantz, director of the spine physical therapy fellowship program at the University of Southern California, Los Angeles, and an assistant professor of clinical physical therapy.

He also pointed out that, since active exercise has been shown to be beneficial and is advocated in multiple clinical practice guidelines for chronic low back pain, “it would be helpful to determine if the true effects on pain and disability were due to the water environment or the effect of active exercise itself.”

“Due to the significant positive long-term effects and limited adverse events reported, I believe this study supports the use of therapeutic aquatic exercise in select patient populations with chronic low back pain and should be considered as a part of a rehabilitation treatment plan if accessibility is feasible,” Dr. Lantz said.

The authors of the paper, Dr. Girgis, and Dr. Psycharakis had no conflicts of interest. Justin Lantz is a physical therapy consultant to SI-Bone.

Patients with chronic low back pain who participated in therapeutic aquatic exercise had superior improvement in function, pain, quality of life, sleep quality, and mental state, compared with those who received physical therapy, in a new study.

“This is the first study to compare the efficacy of therapeutic aquatic exercise and physical therapy modalities in the treatment of chronic low back pain,” senior coauthors Pei-Jie Chen, PhD and Xue-Qiang Wang, PhD, both of the department of sport rehabilitation, Shanghai (China) University of Sport, wrote in JAMA Network Open. “Therapeutic aquatic exercise is a safe treatment for chronic low back pain and most participants who received it were willing to recommend it to other patients with chronic low back pain.”

As compared with individuals in the physical therapy modalities arm, the therapeutic aquatic exercise experienced greater relief of disability at all time points assessed: after the 3-month intervention, at the 6-month follow-up, and at the 12-month follow-up.

Commenting on the study, Linda Girgis, MD, FAAFP, a family physician in private practice in South River, N.J., agreed that aquatic therapy is a great tool for many chronic low back patients. “It helps them get active for one and do things that may exacerbate their symptoms doing the same exercises on land,” noted Dr. Girgis, who also is a clinical assistant professor at Robert Wood Johnson Medical School, New Brunswick.

She pointed out that access to a pool can be a problem. “But I have found a few physical therapy places in my area that do have access to a pool, and I refer appropriate patients there,” added Dr. Girgis, who was not involved with the study. “I have also found it works well for other types of pain, such as knee and hip pain. It is not for everyone but I have seen some patients get great benefit from it when they didn’t get any with traditional physical therapy.”
 

Aquatic therapy was more beneficial

Low back pain is a common condition, and clinical practice guidelines currently recommend therapeutic exercise and physical therapy modalities. Among the modalities that are available, therapeutic aquatic exercise is often prescribed for chronic low back pain, and it is becoming increasingly popular for treatment of chronic low back pain, the authors stated in their paper. The authors noted that water is an ideal environment for conducting an exercise program given its various properties, including buoyancy pressure, density, thermal capacity, and conductivity.

Two previously published systematic reviews have suggested that therapeutic aquatic exercise may be able to reduce the intensity of back pain and improve function in this population. But to date, evidence regarding long-term benefits in patients with chronic low back pain is very limited and there haven’t been any studies comparing the efficacy of therapeutic aquatic exercise and physical therapy modalities for chronic low back pain, according to the authors.

In this study, 113 individuals with chronic low back pain were randomized to either therapeutic aquatic exercise or to physical therapy, with an endpoint of efficacy regarding disability. This was measured using the Roland-Morris Disability Questionnaire.

Scores ranged from 0 to 24, with higher scores indicating more severe disability. Secondary endpoints included pain intensity, quality of life, sleep quality, and recommendation of intervention, and these were rated using various standardized tools.

Those randomized to the therapeutic aquatic exercise group had about an hour of therapy, beginning with a 10-minute active warm-up session to enhance neuromuscular activation, then an exercise session for 40 minutes followed by a 10-minute cooldown.

The physical therapy group received transcutaneous electrical nerve stimulation and infrared ray thermal therapy, also for 60 minutes. Both groups received these interventions twice a week for 3 months.

The overall mean age of the cohort was 31.0 years, and they were almost evenly divided by gender; 54 were men (47.8%), and 59 were women (52.2%).

As compared with the physical therapy group, individuals participating in therapeutic aquatic exercise group showed improvement in disability by an additional −1.77 points (95% confidence interval, −3.02 to −0.51) at the end of the 3-month intervention; at 6 months it was −2.42 points (95% CI, −4.13 to −0.70) and −3.61 points (95% CI, −5.63 to −1.58) at the 12-month follow-up (P < .001 for overall group x time interaction).

Functional improvement did not appear to be significantly affected by confounders that included age, sex, body mass index, low back pain duration, educational level, or pain level.

For secondary outcomes, those in the therapeutic aquatic exercise group demonstrated improvement in the most severe pain by an additional −0.79 points (95% CI, −1.31 to −0.27) after the 3-month intervention, −1.34 points (95% CI, −2.06 to −0.62) at 6 months, and −2.04 points (95% CI, −2.75 to −1.34) at the 12-month follow-up (P < .001 for overall group x time interaction), as compared with the physical therapy group. All pain scores differed significantly between the two groups at every time point.

In addition, individuals in the therapeutic aquatic exercise group showed more improvements on the 36-item Short-form Health Survey (overall group x time interaction, P = .003), Pittsburgh Sleep Quality Index (overall group x time interaction, P = .02), Tampa Scale for Kinesiophobia (overall group x time interaction, P < .001), and Fear-Avoidance Beliefs Questionnaire (physical activity subscale overall group x time interaction, P = .04), as compared with the physical therapy group. These improvements were also not influenced by confounders.

Finally, at the 12-month follow-up point, those in the aquatic therapy group had significantly greater improvements in the number of participants who met the minimal clinically important difference in pain (at least a 2-point improvement on the numeric rating scale).
 

More outside experts’ takes

“The current research evidence does suggest indeed that aquatic exercise therapy is suitable and often better than land exercise, passive relaxation, or other treatments for many people with low back pain,” commented Stelios Psycharakis PhD, senior lecturer in biomechanics, Institute for Sport, Physical Education and Health Sciences, University of Edinburgh.

He also noted that since low back pain is an issue affecting about 80% of all people at some stage of their life, it is “improbable that one could identify a single type of treatment or exercise therapy that would be suitable for every person with this problem.”

Dr. Psycharakis pointed out that there are also some contraindications for aquatic therapy, such as incontinence and skin conditions. “Other than that though, clinicians should definitely consider aquatic exercise therapy when advising people with chronic low back pain,” he said.

Justin M. Lantz, DPT, agreed that the study showed therapeutic aquatic exercise appears to be safe and beneficial in some patients with chronic low back pain, but he also shared limitations of the new research.

“The study has notable limitations as it did not include patients above 65 years old, pain levels were generally low for the subjects involved, and it did not include a treatment group with land therapeutic exercise – so it is difficult to determine if the beneficial effects reported were due to active exercise or because the exercises were performed in water,” said Dr. Lantz, director of the spine physical therapy fellowship program at the University of Southern California, Los Angeles, and an assistant professor of clinical physical therapy.

He also pointed out that, since active exercise has been shown to be beneficial and is advocated in multiple clinical practice guidelines for chronic low back pain, “it would be helpful to determine if the true effects on pain and disability were due to the water environment or the effect of active exercise itself.”

“Due to the significant positive long-term effects and limited adverse events reported, I believe this study supports the use of therapeutic aquatic exercise in select patient populations with chronic low back pain and should be considered as a part of a rehabilitation treatment plan if accessibility is feasible,” Dr. Lantz said.

The authors of the paper, Dr. Girgis, and Dr. Psycharakis had no conflicts of interest. Justin Lantz is a physical therapy consultant to SI-Bone.

The new 2021 coronary revascularization guidelines are spurring controversy, as surgical associations raise concerns about the interpretation of the evidence behind key recommendations and the makeup of the writing committee.

The guideline was published in December by the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI), and replaces the 2011 coronary artery bypass surgery (CABG) and the 2011 and 2015 percutaneous coronary intervention (PCI) guidelines.

The American Association for Thoracic Surgery (AATS) and Society of Thoracic Surgeons (STS) were part of the development of the document but have withdrawn their support, citing three areas of concern in a recent editorial in Annals of Thoracic Surgery.

“I do have to emphasize this is not just the AATS and STS – the European societies, Latin American societies, Asian societies, and even cardiologists are all coming out against these guidelines,” Joseph F. Sabik III, MD, University Hospitals Cleveland Medical Center, lead author of the editorial, said in an interview. “So, I think that tells us that something didn’t go right here.”

The main objection is the downgrading of CABG surgery from a class 1 to weak 2b recommendation to improve survival in patients with three-vessel coronary artery disease (CAD) and normal left ventricular function.

The ISCHEMIA trial was used to support this two-level downgrade and a class 1 to 2a downgrade for CABG in three-vessel CAD with mild to moderate left ventricular dysfunction. But the trial wasn’t powered for survival, only 20% of patients underwent CABG as the initial invasive strategy, and patients were followed for less than 5 years, the editorialists observed.

At the same time, there’s plenty of observational and randomized studies such as SYNTAX, EXCEL, and FAME 3 showing a clear survival benefit of CABG over PCI, Dr. Sabik said. “The criticism is that these are old studies and aren’t applicable today, but we don’t understand downgrading without any evidence suggesting it [CABG] isn’t effective anymore.”
 

CABG and PCI treated as equal

AATS and STS also object to the new guidelines treating PCI and CABG as equivalent revascularization strategies in decreasing ischemic events. Both were given a 2b recommendation for survival with triple-vessel disease, but randomized trials have demonstrated not only lower mortality with surgery but fewer reinterventions and myocardial infarctions.

“None of that gets acknowledged in the guidelines; they are treated equally,” Dr. Sabik said. “So if you’re going to say that CABG isn’t any better than medical therapy, in our mind, you have to say that PCI is worse than medical therapy. And we don’t believe that, I want you to know. We just think that the logic doesn’t make any sense. The committee used what it wanted to but didn’t use many things that committees have used in the past to give CABG a level 1 recommendation.”

The downgrade is also at odds with the 2018 European Society of Cardiology (ESC)/ European Association for Cardio-Thoracic Surgery (EACTS) guidelines, which give CABG a class 1 recommendation in three-vessel CAD as well as one- or two-vessel CAD with proximal left atrial descending artery stenosis.

In a Dec. 14 letter to the ACC/AHA Joint Committee, the Latin American Association of Cardiac and Endovascular Surgery (LACES) also called out the guideline committee for the 2b class of recommendation (COR) for PCI and CABG, saying it contradicts the text, which “clearly considers” the need to give a weaker endorsement for PCI than for CABG in patients with multivessel CAD.

“Considering that this section has the most significant impact due to the prevalence of stable ischemic heart disease in patients with multivessel CAD, such a contradiction may affect the lives and survival of millions of patients worldwide and have a major socioeconomic impact,” the letter states.

“Therefore, LACES respectfully but vehemently believes the Task Force should seriously reconsider the wording and recommendations in this specific large group of patients.”
 

Class I for radial conduit

AATS and STS also express concern about the new class 1 recommendation for the radial artery as a conduit in CABG. They note this is higher than bilateral internal mammary artery grafting and based on a meta-analysis of six relatively small studies with very strict inclusion criteria favorable for radial artery usage and patency.

“There’s a lot of studies that showed if you use the radial artery incorrectly, you have worse outcomes, and that’s what scares us a bit,” Dr. Sabik said. “If they’re giving it a class 1 recommendation, does that mean that becomes standard of care and could that cause patient harm? We think that level 1 is too high and that a [class] 2a with qualifications would be appropriate.”
 

Unequal footing

In a Dec. 23 letter, EACTS said it is “extremely concerned” about downgrading the COR for CABG without new randomized controlled trials to support the decision or to reject previously held evidence.

“The downgrading of CABG, and placing PCI at the same COR, does not meet our interpretation of the evidence, and may lead to avoidable loss of life,” EACTS officials said. “These guidelines also have implications on patient care: A COR IIb entails that CABG may not be reimbursable in some countries.”

EACTS called on AHA, ACC, and SCAI to review the evidence and called out the makeup of the guideline writing committee. “It is astonishing that no surgical association was involved, coauthored, or endorsed these guidelines.”

The AATS and STS each had a single representative on the guidelines’ writing committee but note that the six remaining surgeons were chosen by the ACC and AHA. Surgeons were also in the minority and only a majority was needed to approve the guidelines, highlighting the need to revisit the guideline development process to ensure equal representation by multidisciplinary experts across specialties.

“I hope the cardiology and surgical societies can come together and figure out how we do this better in the future, and we take a look again at these guidelines and come up with what we think is appropriate, especially since this is not just AATS and STS,” Dr. Sabik said.

In an emailed statement, the ACC/AHA said the AATS and STS representatives “actively participated throughout the writing process the past 3 years” and that the AATS and STS were involved in the “extensive peer review process” for the document with a reviewer from each organization. Nevertheless, AATS and STS both elected not to endorse the guidelines when at the organizational approval stage.

“Consequently, the AATS representative chose to stay with the committee and be recognized as having been appointed on behalf of the ACC and the AHA,” according to the statement. “The STS representative chose to withdraw from the committee and is not listed as a writing committee member on the final guideline. The final guideline reflects the latest evidence-based recommendations for coronary artery revascularization, as agreed by the ACC, AHA, SCAI, and the full writing committee.”

Despite pleas from the surgical groups to reconsider the evidence, “there is no further review process for the revascularization guideline,” the ACC/AHA spokesperson noted.

Jennifer S. Lawton, MD, chief of cardiac surgery at Johns Hopkins University, Baltimore, and guideline writing committee chair, did not respond to numerous requests for comment.

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

The new 2021 coronary revascularization guidelines are spurring controversy, as surgical associations raise concerns about the interpretation of the evidence behind key recommendations and the makeup of the writing committee.

The guideline was published in December by the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI), and replaces the 2011 coronary artery bypass surgery (CABG) and the 2011 and 2015 percutaneous coronary intervention (PCI) guidelines.

The American Association for Thoracic Surgery (AATS) and Society of Thoracic Surgeons (STS) were part of the development of the document but have withdrawn their support, citing three areas of concern in a recent editorial in Annals of Thoracic Surgery.

“I do have to emphasize this is not just the AATS and STS – the European societies, Latin American societies, Asian societies, and even cardiologists are all coming out against these guidelines,” Joseph F. Sabik III, MD, University Hospitals Cleveland Medical Center, lead author of the editorial, said in an interview. “So, I think that tells us that something didn’t go right here.”

The main objection is the downgrading of CABG surgery from a class 1 to weak 2b recommendation to improve survival in patients with three-vessel coronary artery disease (CAD) and normal left ventricular function.

The ISCHEMIA trial was used to support this two-level downgrade and a class 1 to 2a downgrade for CABG in three-vessel CAD with mild to moderate left ventricular dysfunction. But the trial wasn’t powered for survival, only 20% of patients underwent CABG as the initial invasive strategy, and patients were followed for less than 5 years, the editorialists observed.

At the same time, there’s plenty of observational and randomized studies such as SYNTAX, EXCEL, and FAME 3 showing a clear survival benefit of CABG over PCI, Dr. Sabik said. “The criticism is that these are old studies and aren’t applicable today, but we don’t understand downgrading without any evidence suggesting it [CABG] isn’t effective anymore.”
 

CABG and PCI treated as equal

AATS and STS also object to the new guidelines treating PCI and CABG as equivalent revascularization strategies in decreasing ischemic events. Both were given a 2b recommendation for survival with triple-vessel disease, but randomized trials have demonstrated not only lower mortality with surgery but fewer reinterventions and myocardial infarctions.

“None of that gets acknowledged in the guidelines; they are treated equally,” Dr. Sabik said. “So if you’re going to say that CABG isn’t any better than medical therapy, in our mind, you have to say that PCI is worse than medical therapy. And we don’t believe that, I want you to know. We just think that the logic doesn’t make any sense. The committee used what it wanted to but didn’t use many things that committees have used in the past to give CABG a level 1 recommendation.”

The downgrade is also at odds with the 2018 European Society of Cardiology (ESC)/ European Association for Cardio-Thoracic Surgery (EACTS) guidelines, which give CABG a class 1 recommendation in three-vessel CAD as well as one- or two-vessel CAD with proximal left atrial descending artery stenosis.

In a Dec. 14 letter to the ACC/AHA Joint Committee, the Latin American Association of Cardiac and Endovascular Surgery (LACES) also called out the guideline committee for the 2b class of recommendation (COR) for PCI and CABG, saying it contradicts the text, which “clearly considers” the need to give a weaker endorsement for PCI than for CABG in patients with multivessel CAD.

“Considering that this section has the most significant impact due to the prevalence of stable ischemic heart disease in patients with multivessel CAD, such a contradiction may affect the lives and survival of millions of patients worldwide and have a major socioeconomic impact,” the letter states.

“Therefore, LACES respectfully but vehemently believes the Task Force should seriously reconsider the wording and recommendations in this specific large group of patients.”
 

Class I for radial conduit

AATS and STS also express concern about the new class 1 recommendation for the radial artery as a conduit in CABG. They note this is higher than bilateral internal mammary artery grafting and based on a meta-analysis of six relatively small studies with very strict inclusion criteria favorable for radial artery usage and patency.

“There’s a lot of studies that showed if you use the radial artery incorrectly, you have worse outcomes, and that’s what scares us a bit,” Dr. Sabik said. “If they’re giving it a class 1 recommendation, does that mean that becomes standard of care and could that cause patient harm? We think that level 1 is too high and that a [class] 2a with qualifications would be appropriate.”
 

Unequal footing

In a Dec. 23 letter, EACTS said it is “extremely concerned” about downgrading the COR for CABG without new randomized controlled trials to support the decision or to reject previously held evidence.

“The downgrading of CABG, and placing PCI at the same COR, does not meet our interpretation of the evidence, and may lead to avoidable loss of life,” EACTS officials said. “These guidelines also have implications on patient care: A COR IIb entails that CABG may not be reimbursable in some countries.”

EACTS called on AHA, ACC, and SCAI to review the evidence and called out the makeup of the guideline writing committee. “It is astonishing that no surgical association was involved, coauthored, or endorsed these guidelines.”

The AATS and STS each had a single representative on the guidelines’ writing committee but note that the six remaining surgeons were chosen by the ACC and AHA. Surgeons were also in the minority and only a majority was needed to approve the guidelines, highlighting the need to revisit the guideline development process to ensure equal representation by multidisciplinary experts across specialties.

“I hope the cardiology and surgical societies can come together and figure out how we do this better in the future, and we take a look again at these guidelines and come up with what we think is appropriate, especially since this is not just AATS and STS,” Dr. Sabik said.

In an emailed statement, the ACC/AHA said the AATS and STS representatives “actively participated throughout the writing process the past 3 years” and that the AATS and STS were involved in the “extensive peer review process” for the document with a reviewer from each organization. Nevertheless, AATS and STS both elected not to endorse the guidelines when at the organizational approval stage.

“Consequently, the AATS representative chose to stay with the committee and be recognized as having been appointed on behalf of the ACC and the AHA,” according to the statement. “The STS representative chose to withdraw from the committee and is not listed as a writing committee member on the final guideline. The final guideline reflects the latest evidence-based recommendations for coronary artery revascularization, as agreed by the ACC, AHA, SCAI, and the full writing committee.”

Despite pleas from the surgical groups to reconsider the evidence, “there is no further review process for the revascularization guideline,” the ACC/AHA spokesperson noted.

Jennifer S. Lawton, MD, chief of cardiac surgery at Johns Hopkins University, Baltimore, and guideline writing committee chair, did not respond to numerous requests for comment.

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

The new 2021 coronary revascularization guidelines are spurring controversy, as surgical associations raise concerns about the interpretation of the evidence behind key recommendations and the makeup of the writing committee.

The guideline was published in December by the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI), and replaces the 2011 coronary artery bypass surgery (CABG) and the 2011 and 2015 percutaneous coronary intervention (PCI) guidelines.

The American Association for Thoracic Surgery (AATS) and Society of Thoracic Surgeons (STS) were part of the development of the document but have withdrawn their support, citing three areas of concern in a recent editorial in Annals of Thoracic Surgery.

“I do have to emphasize this is not just the AATS and STS – the European societies, Latin American societies, Asian societies, and even cardiologists are all coming out against these guidelines,” Joseph F. Sabik III, MD, University Hospitals Cleveland Medical Center, lead author of the editorial, said in an interview. “So, I think that tells us that something didn’t go right here.”

The main objection is the downgrading of CABG surgery from a class 1 to weak 2b recommendation to improve survival in patients with three-vessel coronary artery disease (CAD) and normal left ventricular function.

The ISCHEMIA trial was used to support this two-level downgrade and a class 1 to 2a downgrade for CABG in three-vessel CAD with mild to moderate left ventricular dysfunction. But the trial wasn’t powered for survival, only 20% of patients underwent CABG as the initial invasive strategy, and patients were followed for less than 5 years, the editorialists observed.

At the same time, there’s plenty of observational and randomized studies such as SYNTAX, EXCEL, and FAME 3 showing a clear survival benefit of CABG over PCI, Dr. Sabik said. “The criticism is that these are old studies and aren’t applicable today, but we don’t understand downgrading without any evidence suggesting it [CABG] isn’t effective anymore.”
 

CABG and PCI treated as equal

AATS and STS also object to the new guidelines treating PCI and CABG as equivalent revascularization strategies in decreasing ischemic events. Both were given a 2b recommendation for survival with triple-vessel disease, but randomized trials have demonstrated not only lower mortality with surgery but fewer reinterventions and myocardial infarctions.

“None of that gets acknowledged in the guidelines; they are treated equally,” Dr. Sabik said. “So if you’re going to say that CABG isn’t any better than medical therapy, in our mind, you have to say that PCI is worse than medical therapy. And we don’t believe that, I want you to know. We just think that the logic doesn’t make any sense. The committee used what it wanted to but didn’t use many things that committees have used in the past to give CABG a level 1 recommendation.”

The downgrade is also at odds with the 2018 European Society of Cardiology (ESC)/ European Association for Cardio-Thoracic Surgery (EACTS) guidelines, which give CABG a class 1 recommendation in three-vessel CAD as well as one- or two-vessel CAD with proximal left atrial descending artery stenosis.

In a Dec. 14 letter to the ACC/AHA Joint Committee, the Latin American Association of Cardiac and Endovascular Surgery (LACES) also called out the guideline committee for the 2b class of recommendation (COR) for PCI and CABG, saying it contradicts the text, which “clearly considers” the need to give a weaker endorsement for PCI than for CABG in patients with multivessel CAD.

“Considering that this section has the most significant impact due to the prevalence of stable ischemic heart disease in patients with multivessel CAD, such a contradiction may affect the lives and survival of millions of patients worldwide and have a major socioeconomic impact,” the letter states.

“Therefore, LACES respectfully but vehemently believes the Task Force should seriously reconsider the wording and recommendations in this specific large group of patients.”
 

Class I for radial conduit

AATS and STS also express concern about the new class 1 recommendation for the radial artery as a conduit in CABG. They note this is higher than bilateral internal mammary artery grafting and based on a meta-analysis of six relatively small studies with very strict inclusion criteria favorable for radial artery usage and patency.

“There’s a lot of studies that showed if you use the radial artery incorrectly, you have worse outcomes, and that’s what scares us a bit,” Dr. Sabik said. “If they’re giving it a class 1 recommendation, does that mean that becomes standard of care and could that cause patient harm? We think that level 1 is too high and that a [class] 2a with qualifications would be appropriate.”
 

Unequal footing

In a Dec. 23 letter, EACTS said it is “extremely concerned” about downgrading the COR for CABG without new randomized controlled trials to support the decision or to reject previously held evidence.

“The downgrading of CABG, and placing PCI at the same COR, does not meet our interpretation of the evidence, and may lead to avoidable loss of life,” EACTS officials said. “These guidelines also have implications on patient care: A COR IIb entails that CABG may not be reimbursable in some countries.”

EACTS called on AHA, ACC, and SCAI to review the evidence and called out the makeup of the guideline writing committee. “It is astonishing that no surgical association was involved, coauthored, or endorsed these guidelines.”

The AATS and STS each had a single representative on the guidelines’ writing committee but note that the six remaining surgeons were chosen by the ACC and AHA. Surgeons were also in the minority and only a majority was needed to approve the guidelines, highlighting the need to revisit the guideline development process to ensure equal representation by multidisciplinary experts across specialties.

“I hope the cardiology and surgical societies can come together and figure out how we do this better in the future, and we take a look again at these guidelines and come up with what we think is appropriate, especially since this is not just AATS and STS,” Dr. Sabik said.

In an emailed statement, the ACC/AHA said the AATS and STS representatives “actively participated throughout the writing process the past 3 years” and that the AATS and STS were involved in the “extensive peer review process” for the document with a reviewer from each organization. Nevertheless, AATS and STS both elected not to endorse the guidelines when at the organizational approval stage.

“Consequently, the AATS representative chose to stay with the committee and be recognized as having been appointed on behalf of the ACC and the AHA,” according to the statement. “The STS representative chose to withdraw from the committee and is not listed as a writing committee member on the final guideline. The final guideline reflects the latest evidence-based recommendations for coronary artery revascularization, as agreed by the ACC, AHA, SCAI, and the full writing committee.”

Despite pleas from the surgical groups to reconsider the evidence, “there is no further review process for the revascularization guideline,” the ACC/AHA spokesperson noted.

Jennifer S. Lawton, MD, chief of cardiac surgery at Johns Hopkins University, Baltimore, and guideline writing committee chair, did not respond to numerous requests for comment.

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

Older adults who avoided hospital admission with at-home geriatric assessment and home-based care incurred significantly lower costs compared with those hospitalized, in a new study.

The comprehensive geriatric assessment (CGA) is an established strategy for guiding care of older adults in a hospital setting, but its use in other settings has not been well studied, Surya Singh, PhD, of the University of Oxford (England), and colleagues wrote in their paper published in Age and Ageing. Hospital at home is active treatment by health care professionals in the patient’s home for a condition that otherwise would require acute hospital inpatient care, for a limited time period.

Interest in providing health care in the home as an alternative to hospitalization is on the rise as a way to improve patient outcomes and reduce costs, but actual cost-effectiveness data on HAH interventions are limited, the authors said. “Wide scale implementation of such services has also been constrained by the practical difficulties of designing and delivering services that cut across primary and secondary care, might involve social care and require different workforce and funding arrangements.”

In this study, the researchers conducted a cost-effectiveness analysis alongside a randomized trial of an admission avoidance CGA hospital at home (CGAHAH) service as an alternative to hospital admission. They identified individuals aged 65 years and older who were living in the community but being considered for an unplanned hospital admission in the United Kingdom. A total of 700 individuals were randomized to CGAHAH and 355 to hospital care using a 2:1 ratio. Patients were assessed at baseline in the community or in an acute care setting before being transferred to CGAHAH service. These services included access to social workers, home care, district nursing, community rehabilitation, community mental health services and acute hospital services, such as diagnostic tests and transfer to hospital. The core workforce usually included consultant geriatricians, junior doctors, nurse practitioners, health care assistants or support workers, physiotherapists, occupational therapists, and community pharmacists. There were at least daily virtual ward rounds
 

Comparison between HAH and in-hospital groups

Patients in the CGAHAH group had a mean of 7.17 days of care, and those in hospital had a mean of 4.92 hospital days. At 6 months’ follow-up, the mean number of care days was 9.47 in the CGAHAH group and 10.58 in the hospital group, which was a nonsignificant difference.

“For complete cases, we found that allocation to CGAHAH resulted in 3 fewer days in hospital, a difference that was reduced to 1 day at 6 months follow-up,” the researchers wrote.

Overall, after adjusting for baseline variables, the health and social care costs after 6 months were less for CGAHAH than admission to hospital. The average cost differences between the two were approximately $3,000 or 2,265 pounds. The cost difference remained and increased to a mean difference of 2,840 pounds in favor of HAH after adding informal care/societal costs.

In addition, patients randomized to CGAHAH were less likely to have been admitted to long-term residential care at 6 months follow-up, compared with the hospital group; the mean days in residential care at 6 months were 3.43 and 6.14, respectively.

Both groups showed an approximate 15% decrease in measures of quality of life from baseline to 6 months, and no differences were noted in quality-adjusted survival between the groups.
 

Pandemic ‘has accelerated interest’ in HAH

“Health systems around the world are exploring alternatives to hospital admission, such as hospital at home, to act as a buffer to the increasing demand for hospital care,” corresponding author Sasha Shepperd, MSc, DPhil, said in an interview. “This is partly due to a growing older population with increased health needs, but also an emphasis on providing health care that limits a decline in capacity for the older population. Inevitably, the COVID-19 pandemic has accelerated interest in hospital at home to create additional acute health care capacity.”

The take home-message supports the home service option. “If you can access a hospital-at-home service, consider this as an option for older people who would otherwise be admitted to hospital and are eligible for hospital at home care. However, is important that the provision of hospital at home is adequately resourced, and that families and caregivers are supported,” she said.

“Barriers include delivering a different type of service that requires easy access to hospital services, including admission if required; a trained workforce to provide multidisciplinary care in a patient’s home; and ensuring a good fit with existing health and social care services,” Dr. Shepperd said.

Future research areas include the demands placed on caregivers from hospital-at-home services, and how the provision of hospital at home impacts hospital and community services, she added.

Findings support use of HAH

The data from the current study support the use of a hospital at home concept, especially in the geriatric age population, for acute health conditions that could be managed at home rather than acutely in a hospital-based environment,” Noel Deep, MD, emphasized in an interview.

Dr. Deep, who is a general internist in group practice in Antigo, Wisc., said he was not surprised by the study findings.

“I am a big proponent of the hospital at home approach to taking care of patients who can be safely and appropriately managed in the familiarity and comfort of their own home environment with help from physicians, nurses, and other home health care services,” he said. “It is a valuable option for appropriately screened and selected patients to be provided this approach to management of their acute health care situations.”

Primary care physicians should explore using HAH when faced with the decision of admitting an elderly individual to the hospital for management of an acute worsening of a chronic medical condition or a reversible acute illness, said Dr. Deep, who serves on the editorial advisory board of Internal Medicine News.

The current study reinforces previous studies and data showing the benefits of managing acute health problems of elderly individuals in their home environment. These benefits include “an opportunity to free up the emergency rooms and hospitals for providing care to those individuals who truly would be best served by being admitted to the hospital,” Dr. Deep explained. Home care for the elderly “would also lead to decreased utilization of the personal protective equipment and limit exposure of the vulnerable elderly individuals to the coronavirus. Primary care physicians should always explore this possibility of providing care to the patients in their homes if it is a viable option.

“While our practice environment [in the United States] is slightly different than that referenced in this article, many, if not almost all, of our primary care physicians provide care to the geriatric age population and provide assessment and management which would be comparable to this comprehensive geriatric assessment that is discussed in the article,” and many primary care physicians have seen similar results in outcomes that the study shows, said Dr. Deep. The available research and expert opinions are quite similar and agree upon the positive outcomes in terms of providing the CGAHAH approach.
 

Study is important but raises questions

The study is important because patient-centered, effective care should be the goal of any health system, William Golden, MD, of the University of Arkansas for Medical Sciences, Little Rock, said in an interview. 

Dr. Golden also noted that the study raised a number of questions. How each patient entered the treatment protocol was not clear. “Similarly, it is not clear whether admission criteria and resource costs in England cross to the United States experience.”

“Having close follow up of patients at home as opposed to an ‘observation status’ could be a nice innovation, but more details are needed to consider implementation in a specific community setting,” he emphasized.

As for the clinical value of the study for primary care, “primary care professionals should welcome well-staffed alternatives to inpatient care for select patient presentations,” said Dr. Golden, who is also a member of the editorial advisory board of Internal Medicine News.

The current study does not identify the conditions that were treated at home and the logistics of delivering such services, which limits comparison with what experts have seen in practice in terms of outcomes using the CGAHAH, he said. “Interested practitioners would benefit from literature detailing the staffing and decision support tools that form the core framework of this innovation.”
 

Limitations and strengths of study, according to authors

The study findings were limited by several factors including the calculation of CGAHAH based on service budgets, rather than from collecting information on the actual resources used; potential errors in patients’ estimation of their informal care; and lack of data on a differential impact of CGAHAH for underserved communities, the researchers noted.

However, the results were strengthened by the large study population and randomized design, and support the value of CGAHAH, which addresses the need for management of multiple long-term conditions and the potential decline in functional and cognitive ability in older adults, they said. Providing CGAHAH as an alternative to admission to hospital for older people, with a focus on multidimensional assessment, is one option that might reduce reliance on hospitalization and residential care and at a lower cost.

The study was supported by the National Institute for Health Research, and several coauthors received individual grants from the NIHR, with no other financial conflicts to disclose. Dr. Golden and Dr. Deep had no financial conflicts to disclose.

Older adults who avoided hospital admission with at-home geriatric assessment and home-based care incurred significantly lower costs compared with those hospitalized, in a new study.

The comprehensive geriatric assessment (CGA) is an established strategy for guiding care of older adults in a hospital setting, but its use in other settings has not been well studied, Surya Singh, PhD, of the University of Oxford (England), and colleagues wrote in their paper published in Age and Ageing. Hospital at home is active treatment by health care professionals in the patient’s home for a condition that otherwise would require acute hospital inpatient care, for a limited time period.

Interest in providing health care in the home as an alternative to hospitalization is on the rise as a way to improve patient outcomes and reduce costs, but actual cost-effectiveness data on HAH interventions are limited, the authors said. “Wide scale implementation of such services has also been constrained by the practical difficulties of designing and delivering services that cut across primary and secondary care, might involve social care and require different workforce and funding arrangements.”

In this study, the researchers conducted a cost-effectiveness analysis alongside a randomized trial of an admission avoidance CGA hospital at home (CGAHAH) service as an alternative to hospital admission. They identified individuals aged 65 years and older who were living in the community but being considered for an unplanned hospital admission in the United Kingdom. A total of 700 individuals were randomized to CGAHAH and 355 to hospital care using a 2:1 ratio. Patients were assessed at baseline in the community or in an acute care setting before being transferred to CGAHAH service. These services included access to social workers, home care, district nursing, community rehabilitation, community mental health services and acute hospital services, such as diagnostic tests and transfer to hospital. The core workforce usually included consultant geriatricians, junior doctors, nurse practitioners, health care assistants or support workers, physiotherapists, occupational therapists, and community pharmacists. There were at least daily virtual ward rounds
 

Comparison between HAH and in-hospital groups

Patients in the CGAHAH group had a mean of 7.17 days of care, and those in hospital had a mean of 4.92 hospital days. At 6 months’ follow-up, the mean number of care days was 9.47 in the CGAHAH group and 10.58 in the hospital group, which was a nonsignificant difference.

“For complete cases, we found that allocation to CGAHAH resulted in 3 fewer days in hospital, a difference that was reduced to 1 day at 6 months follow-up,” the researchers wrote.

Overall, after adjusting for baseline variables, the health and social care costs after 6 months were less for CGAHAH than admission to hospital. The average cost differences between the two were approximately $3,000 or 2,265 pounds. The cost difference remained and increased to a mean difference of 2,840 pounds in favor of HAH after adding informal care/societal costs.

In addition, patients randomized to CGAHAH were less likely to have been admitted to long-term residential care at 6 months follow-up, compared with the hospital group; the mean days in residential care at 6 months were 3.43 and 6.14, respectively.

Both groups showed an approximate 15% decrease in measures of quality of life from baseline to 6 months, and no differences were noted in quality-adjusted survival between the groups.
 

Pandemic ‘has accelerated interest’ in HAH

“Health systems around the world are exploring alternatives to hospital admission, such as hospital at home, to act as a buffer to the increasing demand for hospital care,” corresponding author Sasha Shepperd, MSc, DPhil, said in an interview. “This is partly due to a growing older population with increased health needs, but also an emphasis on providing health care that limits a decline in capacity for the older population. Inevitably, the COVID-19 pandemic has accelerated interest in hospital at home to create additional acute health care capacity.”

The take home-message supports the home service option. “If you can access a hospital-at-home service, consider this as an option for older people who would otherwise be admitted to hospital and are eligible for hospital at home care. However, is important that the provision of hospital at home is adequately resourced, and that families and caregivers are supported,” she said.

“Barriers include delivering a different type of service that requires easy access to hospital services, including admission if required; a trained workforce to provide multidisciplinary care in a patient’s home; and ensuring a good fit with existing health and social care services,” Dr. Shepperd said.

Future research areas include the demands placed on caregivers from hospital-at-home services, and how the provision of hospital at home impacts hospital and community services, she added.

Findings support use of HAH

The data from the current study support the use of a hospital at home concept, especially in the geriatric age population, for acute health conditions that could be managed at home rather than acutely in a hospital-based environment,” Noel Deep, MD, emphasized in an interview.

Dr. Deep, who is a general internist in group practice in Antigo, Wisc., said he was not surprised by the study findings.

“I am a big proponent of the hospital at home approach to taking care of patients who can be safely and appropriately managed in the familiarity and comfort of their own home environment with help from physicians, nurses, and other home health care services,” he said. “It is a valuable option for appropriately screened and selected patients to be provided this approach to management of their acute health care situations.”

Primary care physicians should explore using HAH when faced with the decision of admitting an elderly individual to the hospital for management of an acute worsening of a chronic medical condition or a reversible acute illness, said Dr. Deep, who serves on the editorial advisory board of Internal Medicine News.

The current study reinforces previous studies and data showing the benefits of managing acute health problems of elderly individuals in their home environment. These benefits include “an opportunity to free up the emergency rooms and hospitals for providing care to those individuals who truly would be best served by being admitted to the hospital,” Dr. Deep explained. Home care for the elderly “would also lead to decreased utilization of the personal protective equipment and limit exposure of the vulnerable elderly individuals to the coronavirus. Primary care physicians should always explore this possibility of providing care to the patients in their homes if it is a viable option.

“While our practice environment [in the United States] is slightly different than that referenced in this article, many, if not almost all, of our primary care physicians provide care to the geriatric age population and provide assessment and management which would be comparable to this comprehensive geriatric assessment that is discussed in the article,” and many primary care physicians have seen similar results in outcomes that the study shows, said Dr. Deep. The available research and expert opinions are quite similar and agree upon the positive outcomes in terms of providing the CGAHAH approach.
 

Study is important but raises questions

The study is important because patient-centered, effective care should be the goal of any health system, William Golden, MD, of the University of Arkansas for Medical Sciences, Little Rock, said in an interview. 

Dr. Golden also noted that the study raised a number of questions. How each patient entered the treatment protocol was not clear. “Similarly, it is not clear whether admission criteria and resource costs in England cross to the United States experience.”

“Having close follow up of patients at home as opposed to an ‘observation status’ could be a nice innovation, but more details are needed to consider implementation in a specific community setting,” he emphasized.

As for the clinical value of the study for primary care, “primary care professionals should welcome well-staffed alternatives to inpatient care for select patient presentations,” said Dr. Golden, who is also a member of the editorial advisory board of Internal Medicine News.

The current study does not identify the conditions that were treated at home and the logistics of delivering such services, which limits comparison with what experts have seen in practice in terms of outcomes using the CGAHAH, he said. “Interested practitioners would benefit from literature detailing the staffing and decision support tools that form the core framework of this innovation.”
 

Limitations and strengths of study, according to authors

The study findings were limited by several factors including the calculation of CGAHAH based on service budgets, rather than from collecting information on the actual resources used; potential errors in patients’ estimation of their informal care; and lack of data on a differential impact of CGAHAH for underserved communities, the researchers noted.

However, the results were strengthened by the large study population and randomized design, and support the value of CGAHAH, which addresses the need for management of multiple long-term conditions and the potential decline in functional and cognitive ability in older adults, they said. Providing CGAHAH as an alternative to admission to hospital for older people, with a focus on multidimensional assessment, is one option that might reduce reliance on hospitalization and residential care and at a lower cost.

The study was supported by the National Institute for Health Research, and several coauthors received individual grants from the NIHR, with no other financial conflicts to disclose. Dr. Golden and Dr. Deep had no financial conflicts to disclose.

Older adults who avoided hospital admission with at-home geriatric assessment and home-based care incurred significantly lower costs compared with those hospitalized, in a new study.

The comprehensive geriatric assessment (CGA) is an established strategy for guiding care of older adults in a hospital setting, but its use in other settings has not been well studied, Surya Singh, PhD, of the University of Oxford (England), and colleagues wrote in their paper published in Age and Ageing. Hospital at home is active treatment by health care professionals in the patient’s home for a condition that otherwise would require acute hospital inpatient care, for a limited time period.

Interest in providing health care in the home as an alternative to hospitalization is on the rise as a way to improve patient outcomes and reduce costs, but actual cost-effectiveness data on HAH interventions are limited, the authors said. “Wide scale implementation of such services has also been constrained by the practical difficulties of designing and delivering services that cut across primary and secondary care, might involve social care and require different workforce and funding arrangements.”

In this study, the researchers conducted a cost-effectiveness analysis alongside a randomized trial of an admission avoidance CGA hospital at home (CGAHAH) service as an alternative to hospital admission. They identified individuals aged 65 years and older who were living in the community but being considered for an unplanned hospital admission in the United Kingdom. A total of 700 individuals were randomized to CGAHAH and 355 to hospital care using a 2:1 ratio. Patients were assessed at baseline in the community or in an acute care setting before being transferred to CGAHAH service. These services included access to social workers, home care, district nursing, community rehabilitation, community mental health services and acute hospital services, such as diagnostic tests and transfer to hospital. The core workforce usually included consultant geriatricians, junior doctors, nurse practitioners, health care assistants or support workers, physiotherapists, occupational therapists, and community pharmacists. There were at least daily virtual ward rounds
 

Comparison between HAH and in-hospital groups

Patients in the CGAHAH group had a mean of 7.17 days of care, and those in hospital had a mean of 4.92 hospital days. At 6 months’ follow-up, the mean number of care days was 9.47 in the CGAHAH group and 10.58 in the hospital group, which was a nonsignificant difference.

“For complete cases, we found that allocation to CGAHAH resulted in 3 fewer days in hospital, a difference that was reduced to 1 day at 6 months follow-up,” the researchers wrote.

Overall, after adjusting for baseline variables, the health and social care costs after 6 months were less for CGAHAH than admission to hospital. The average cost differences between the two were approximately $3,000 or 2,265 pounds. The cost difference remained and increased to a mean difference of 2,840 pounds in favor of HAH after adding informal care/societal costs.

In addition, patients randomized to CGAHAH were less likely to have been admitted to long-term residential care at 6 months follow-up, compared with the hospital group; the mean days in residential care at 6 months were 3.43 and 6.14, respectively.

Both groups showed an approximate 15% decrease in measures of quality of life from baseline to 6 months, and no differences were noted in quality-adjusted survival between the groups.
 

Pandemic ‘has accelerated interest’ in HAH

“Health systems around the world are exploring alternatives to hospital admission, such as hospital at home, to act as a buffer to the increasing demand for hospital care,” corresponding author Sasha Shepperd, MSc, DPhil, said in an interview. “This is partly due to a growing older population with increased health needs, but also an emphasis on providing health care that limits a decline in capacity for the older population. Inevitably, the COVID-19 pandemic has accelerated interest in hospital at home to create additional acute health care capacity.”

The take home-message supports the home service option. “If you can access a hospital-at-home service, consider this as an option for older people who would otherwise be admitted to hospital and are eligible for hospital at home care. However, is important that the provision of hospital at home is adequately resourced, and that families and caregivers are supported,” she said.

“Barriers include delivering a different type of service that requires easy access to hospital services, including admission if required; a trained workforce to provide multidisciplinary care in a patient’s home; and ensuring a good fit with existing health and social care services,” Dr. Shepperd said.

Future research areas include the demands placed on caregivers from hospital-at-home services, and how the provision of hospital at home impacts hospital and community services, she added.

Findings support use of HAH

The data from the current study support the use of a hospital at home concept, especially in the geriatric age population, for acute health conditions that could be managed at home rather than acutely in a hospital-based environment,” Noel Deep, MD, emphasized in an interview.

Dr. Deep, who is a general internist in group practice in Antigo, Wisc., said he was not surprised by the study findings.

“I am a big proponent of the hospital at home approach to taking care of patients who can be safely and appropriately managed in the familiarity and comfort of their own home environment with help from physicians, nurses, and other home health care services,” he said. “It is a valuable option for appropriately screened and selected patients to be provided this approach to management of their acute health care situations.”

Primary care physicians should explore using HAH when faced with the decision of admitting an elderly individual to the hospital for management of an acute worsening of a chronic medical condition or a reversible acute illness, said Dr. Deep, who serves on the editorial advisory board of Internal Medicine News.

The current study reinforces previous studies and data showing the benefits of managing acute health problems of elderly individuals in their home environment. These benefits include “an opportunity to free up the emergency rooms and hospitals for providing care to those individuals who truly would be best served by being admitted to the hospital,” Dr. Deep explained. Home care for the elderly “would also lead to decreased utilization of the personal protective equipment and limit exposure of the vulnerable elderly individuals to the coronavirus. Primary care physicians should always explore this possibility of providing care to the patients in their homes if it is a viable option.

“While our practice environment [in the United States] is slightly different than that referenced in this article, many, if not almost all, of our primary care physicians provide care to the geriatric age population and provide assessment and management which would be comparable to this comprehensive geriatric assessment that is discussed in the article,” and many primary care physicians have seen similar results in outcomes that the study shows, said Dr. Deep. The available research and expert opinions are quite similar and agree upon the positive outcomes in terms of providing the CGAHAH approach.
 

Study is important but raises questions

The study is important because patient-centered, effective care should be the goal of any health system, William Golden, MD, of the University of Arkansas for Medical Sciences, Little Rock, said in an interview. 

Dr. Golden also noted that the study raised a number of questions. How each patient entered the treatment protocol was not clear. “Similarly, it is not clear whether admission criteria and resource costs in England cross to the United States experience.”

“Having close follow up of patients at home as opposed to an ‘observation status’ could be a nice innovation, but more details are needed to consider implementation in a specific community setting,” he emphasized.

As for the clinical value of the study for primary care, “primary care professionals should welcome well-staffed alternatives to inpatient care for select patient presentations,” said Dr. Golden, who is also a member of the editorial advisory board of Internal Medicine News.

The current study does not identify the conditions that were treated at home and the logistics of delivering such services, which limits comparison with what experts have seen in practice in terms of outcomes using the CGAHAH, he said. “Interested practitioners would benefit from literature detailing the staffing and decision support tools that form the core framework of this innovation.”
 

Limitations and strengths of study, according to authors

The study findings were limited by several factors including the calculation of CGAHAH based on service budgets, rather than from collecting information on the actual resources used; potential errors in patients’ estimation of their informal care; and lack of data on a differential impact of CGAHAH for underserved communities, the researchers noted.

However, the results were strengthened by the large study population and randomized design, and support the value of CGAHAH, which addresses the need for management of multiple long-term conditions and the potential decline in functional and cognitive ability in older adults, they said. Providing CGAHAH as an alternative to admission to hospital for older people, with a focus on multidimensional assessment, is one option that might reduce reliance on hospitalization and residential care and at a lower cost.

The study was supported by the National Institute for Health Research, and several coauthors received individual grants from the NIHR, with no other financial conflicts to disclose. Dr. Golden and Dr. Deep had no financial conflicts to disclose.

If a fish can drive …

Have you ever seen a sparrow swim? Have you ever seen an elephant fly? How about a goldfish driving a car? Well, one of these is not just something out of a children’s book.

In a recent study, investigators from Ben-Gurion University did the impossible and got a fish to drive a robotic car on land. How?

PxHere

No, there wasn’t a tiny steering wheel inside the tank. The researchers created a tank with video recognition ability to sync with the fish. This video shows that the car, on which the tank sat, would navigate in the direction that the fish swam. The goal was to get the fish to “drive” toward a visual target, and with a little training the fish was successful regardless of start point, the researchers explained.

So what does that tell us about the brain and behavior? Shachar Givon, who was part of the research team, said the “study hints that navigational ability is universal rather than specific to the environment.”

The study’s domain transfer methodology (putting one species in the environment of another and have them cope with an unfamiliar task) shows that other animals also have the cognitive ability to transfer skills from one terrestrial environment to another.

That leads us to lesson two. Goldfish are much smarter than we think. So please don’t tap on the glass.
 

We prefer ‘It’s not writing a funny LOTME article’!

So many medical journals spend all their time grappling with such silly dilemmas as curing cancer or beating COVID-19. Boring! Fortunately, the BMJ dares to stand above the rest by dedicating its Christmas issue to answering the real issues in medicine. And what was the biggest question? Which is the more accurate idiom: “It’s not rocket science,” or “It’s not brain surgery”?

Tumisu/Pixabay

English researchers collected data from 329 aerospace engineers and 72 neurosurgeons who took the Great British Intelligence Test and compared the results against 18,000 people in the general public.

The engineers and neurosurgeons were basically identical in four of the six domains, but neurosurgeons had the advantage when it came to semantic problem solving and engineers had an edge at mental manipulation and attention. The aerospace engineers were identical to the public in all domains, but neurosurgeons held an advantage in problem-solving speed and a disadvantage in memory recall speed.

The researchers noted that exposure to Latin and Greek etymologies during their education gave neurosurgeons the advantage in semantic problem solving, while the aerospace engineers’ advantage in mental manipulation stems from skills taught during engineering training.

But is there a definitive answer to the question? If you’ve got an easy task in front of you, which is more accurate to say: “It’s not rocket science” or “It’s not brain surgery”? Can we get a drum roll?

It’s not brain surgery! At least, as long as the task doesn’t involve rapid problem solving. The investigators hedged further by saying that “It’s a walk in the park” is probably more accurate. Plus, “other specialties might deserve to be on that pedestal, and future work should aim to determine the most deserving profession,” they wrote. Well, at least we’ve got something to look forward to in BMJ’s next Christmas issue.
 

For COVID-19, a syringe is the sheep of things to come

The logical approach to fighting COVID-19 hasn’t really worked with a lot of people, so how about something more emotional?

ChiemSeherin/Pixabay

People love animals, so they might be a good way to promote the use of vaccines and masks. Puppies are awfully cute, and so are koalas and pandas. And who can say no to a sea otter?

Well, forget it. Instead, we’ve got elephants … and sheep … and goats. Oh my.

First, elephant Santas. The Jirasartwitthaya school in Ayutthaya, Thailand, was recently visited by five elephants in Santa Claus costumes who handed out hand sanitizer and face masks to the students, Reuters said.

“I’m so glad that I got a balloon from the elephant. My heart is pounding very fast,” student Biuon Greham said. And balloons. The elephants handed out sanitizer and masks and balloons. There’s a sentence we never thought we’d write.

And those sheep and goats we mentioned? That was a different party.

Hanspeter Etzold, who “works with shepherds, companies, and animals to run team-building events in the northern German town of Schneverdingen,” according to Reuters, had an idea to promote the use of the COVID-19 vaccine. And yes, it involved sheep and goats.

Mr. Etzold worked with shepherd Wiebke Schmidt-Kochan, who arranged her 700 goats and sheep into the shape of a 100-meter-long syringe using bits of bread laying on the ground. “Sheep are such likable animals – maybe they can get the message over better,” Mr. Etzold told AP.

If those are the carrots in an animals-as-carrots-and-sticks approach, then maybe this golf-club-chomping crab could be the stick. We’re certainly not going to argue with it.
 

To be or not to be … seen

Increased Zoom meetings have been another side effect of the COVID-19 pandemic as more and more people have been working and learning from home.

filadendron/E+

If a fish can drive …

Have you ever seen a sparrow swim? Have you ever seen an elephant fly? How about a goldfish driving a car? Well, one of these is not just something out of a children’s book.

In a recent study, investigators from Ben-Gurion University did the impossible and got a fish to drive a robotic car on land. How?

PxHere

No, there wasn’t a tiny steering wheel inside the tank. The researchers created a tank with video recognition ability to sync with the fish. This video shows that the car, on which the tank sat, would navigate in the direction that the fish swam. The goal was to get the fish to “drive” toward a visual target, and with a little training the fish was successful regardless of start point, the researchers explained.

So what does that tell us about the brain and behavior? Shachar Givon, who was part of the research team, said the “study hints that navigational ability is universal rather than specific to the environment.”

The study’s domain transfer methodology (putting one species in the environment of another and have them cope with an unfamiliar task) shows that other animals also have the cognitive ability to transfer skills from one terrestrial environment to another.

That leads us to lesson two. Goldfish are much smarter than we think. So please don’t tap on the glass.
 

We prefer ‘It’s not writing a funny LOTME article’!

So many medical journals spend all their time grappling with such silly dilemmas as curing cancer or beating COVID-19. Boring! Fortunately, the BMJ dares to stand above the rest by dedicating its Christmas issue to answering the real issues in medicine. And what was the biggest question? Which is the more accurate idiom: “It’s not rocket science,” or “It’s not brain surgery”?

Tumisu/Pixabay

English researchers collected data from 329 aerospace engineers and 72 neurosurgeons who took the Great British Intelligence Test and compared the results against 18,000 people in the general public.

The engineers and neurosurgeons were basically identical in four of the six domains, but neurosurgeons had the advantage when it came to semantic problem solving and engineers had an edge at mental manipulation and attention. The aerospace engineers were identical to the public in all domains, but neurosurgeons held an advantage in problem-solving speed and a disadvantage in memory recall speed.

The researchers noted that exposure to Latin and Greek etymologies during their education gave neurosurgeons the advantage in semantic problem solving, while the aerospace engineers’ advantage in mental manipulation stems from skills taught during engineering training.

But is there a definitive answer to the question? If you’ve got an easy task in front of you, which is more accurate to say: “It’s not rocket science” or “It’s not brain surgery”? Can we get a drum roll?

It’s not brain surgery! At least, as long as the task doesn’t involve rapid problem solving. The investigators hedged further by saying that “It’s a walk in the park” is probably more accurate. Plus, “other specialties might deserve to be on that pedestal, and future work should aim to determine the most deserving profession,” they wrote. Well, at least we’ve got something to look forward to in BMJ’s next Christmas issue.
 

For COVID-19, a syringe is the sheep of things to come

The logical approach to fighting COVID-19 hasn’t really worked with a lot of people, so how about something more emotional?

ChiemSeherin/Pixabay

People love animals, so they might be a good way to promote the use of vaccines and masks. Puppies are awfully cute, and so are koalas and pandas. And who can say no to a sea otter?

Well, forget it. Instead, we’ve got elephants … and sheep … and goats. Oh my.

First, elephant Santas. The Jirasartwitthaya school in Ayutthaya, Thailand, was recently visited by five elephants in Santa Claus costumes who handed out hand sanitizer and face masks to the students, Reuters said.

“I’m so glad that I got a balloon from the elephant. My heart is pounding very fast,” student Biuon Greham said. And balloons. The elephants handed out sanitizer and masks and balloons. There’s a sentence we never thought we’d write.

And those sheep and goats we mentioned? That was a different party.

Hanspeter Etzold, who “works with shepherds, companies, and animals to run team-building events in the northern German town of Schneverdingen,” according to Reuters, had an idea to promote the use of the COVID-19 vaccine. And yes, it involved sheep and goats.

Mr. Etzold worked with shepherd Wiebke Schmidt-Kochan, who arranged her 700 goats and sheep into the shape of a 100-meter-long syringe using bits of bread laying on the ground. “Sheep are such likable animals – maybe they can get the message over better,” Mr. Etzold told AP.

If those are the carrots in an animals-as-carrots-and-sticks approach, then maybe this golf-club-chomping crab could be the stick. We’re certainly not going to argue with it.
 

To be or not to be … seen

Increased Zoom meetings have been another side effect of the COVID-19 pandemic as more and more people have been working and learning from home.

filadendron/E+

If a fish can drive …

Have you ever seen a sparrow swim? Have you ever seen an elephant fly? How about a goldfish driving a car? Well, one of these is not just something out of a children’s book.

In a recent study, investigators from Ben-Gurion University did the impossible and got a fish to drive a robotic car on land. How?

PxHere

No, there wasn’t a tiny steering wheel inside the tank. The researchers created a tank with video recognition ability to sync with the fish. This video shows that the car, on which the tank sat, would navigate in the direction that the fish swam. The goal was to get the fish to “drive” toward a visual target, and with a little training the fish was successful regardless of start point, the researchers explained.

So what does that tell us about the brain and behavior? Shachar Givon, who was part of the research team, said the “study hints that navigational ability is universal rather than specific to the environment.”

The study’s domain transfer methodology (putting one species in the environment of another and have them cope with an unfamiliar task) shows that other animals also have the cognitive ability to transfer skills from one terrestrial environment to another.

That leads us to lesson two. Goldfish are much smarter than we think. So please don’t tap on the glass.
 

We prefer ‘It’s not writing a funny LOTME article’!

So many medical journals spend all their time grappling with such silly dilemmas as curing cancer or beating COVID-19. Boring! Fortunately, the BMJ dares to stand above the rest by dedicating its Christmas issue to answering the real issues in medicine. And what was the biggest question? Which is the more accurate idiom: “It’s not rocket science,” or “It’s not brain surgery”?

Tumisu/Pixabay

English researchers collected data from 329 aerospace engineers and 72 neurosurgeons who took the Great British Intelligence Test and compared the results against 18,000 people in the general public.

The engineers and neurosurgeons were basically identical in four of the six domains, but neurosurgeons had the advantage when it came to semantic problem solving and engineers had an edge at mental manipulation and attention. The aerospace engineers were identical to the public in all domains, but neurosurgeons held an advantage in problem-solving speed and a disadvantage in memory recall speed.

The researchers noted that exposure to Latin and Greek etymologies during their education gave neurosurgeons the advantage in semantic problem solving, while the aerospace engineers’ advantage in mental manipulation stems from skills taught during engineering training.

But is there a definitive answer to the question? If you’ve got an easy task in front of you, which is more accurate to say: “It’s not rocket science” or “It’s not brain surgery”? Can we get a drum roll?

It’s not brain surgery! At least, as long as the task doesn’t involve rapid problem solving. The investigators hedged further by saying that “It’s a walk in the park” is probably more accurate. Plus, “other specialties might deserve to be on that pedestal, and future work should aim to determine the most deserving profession,” they wrote. Well, at least we’ve got something to look forward to in BMJ’s next Christmas issue.
 

For COVID-19, a syringe is the sheep of things to come

The logical approach to fighting COVID-19 hasn’t really worked with a lot of people, so how about something more emotional?

ChiemSeherin/Pixabay

People love animals, so they might be a good way to promote the use of vaccines and masks. Puppies are awfully cute, and so are koalas and pandas. And who can say no to a sea otter?

Well, forget it. Instead, we’ve got elephants … and sheep … and goats. Oh my.

First, elephant Santas. The Jirasartwitthaya school in Ayutthaya, Thailand, was recently visited by five elephants in Santa Claus costumes who handed out hand sanitizer and face masks to the students, Reuters said.

“I’m so glad that I got a balloon from the elephant. My heart is pounding very fast,” student Biuon Greham said. And balloons. The elephants handed out sanitizer and masks and balloons. There’s a sentence we never thought we’d write.

And those sheep and goats we mentioned? That was a different party.

Hanspeter Etzold, who “works with shepherds, companies, and animals to run team-building events in the northern German town of Schneverdingen,” according to Reuters, had an idea to promote the use of the COVID-19 vaccine. And yes, it involved sheep and goats.

Mr. Etzold worked with shepherd Wiebke Schmidt-Kochan, who arranged her 700 goats and sheep into the shape of a 100-meter-long syringe using bits of bread laying on the ground. “Sheep are such likable animals – maybe they can get the message over better,” Mr. Etzold told AP.

If those are the carrots in an animals-as-carrots-and-sticks approach, then maybe this golf-club-chomping crab could be the stick. We’re certainly not going to argue with it.
 

To be or not to be … seen

Increased Zoom meetings have been another side effect of the COVID-19 pandemic as more and more people have been working and learning from home.

filadendron/E+

Laura Dover, MD, had carefully timed her pregnancy around the four exams required to achieve board certification in radiation oncology. But when the pandemic hit in 2020, the final test, offered each May, was pushed to October – the week of her due date.

It would be impossible for her to fly the 2,500 miles from New York to the test site in Tucson, Ariz., when she could go into labor at any moment. She asked the American Board of Radiology – which oversees the process – if she could take the oral exam on Zoom or shift the timing a few weeks earlier or later.

The response: If she decided not to sit for the exam in person on the date specified, she would have to wait an entire year for the next test.

“I felt: Angry. Sad. Helpless. Inconsequential,” Dr. Dover tweeted. “But I will not be silent.”

The experience motivated Dr. Dover and six colleagues to conduct a study about how radiation oncology’s onerous four-exam board certification process has disproportionately burdened women.

The study, published online in Practical Radiation Oncology on Nov. 3, 2021, revealed that almost 60% of the early-career female radiation oncologists surveyed had delayed or were timing their pregnancies to accommodate their board exams. Women who chose to delay pregnancy were 2.5 times more likely to experience infertility.

“When we started doing the study, we didn’t realize just how common it was for people to wrap so much of their [family planning decisions] around taking these board exams,” said study coauthor Adrianna Henson Masters, MD, a radiation oncologist at Springfield (Ill.) Clinic. “How crazy is that? And no one’s talking about it.”

However, once the study appeared online, physicians took to Twitter to comment on the challenges of the board certification process, while others demanded change. One radiation oncologist even shared her decision not to have a child until she passed her board exams.

The study also got the attention of the American Board of Radiology, which governs certification for the specialty. In a response, leaders of the organization agreed that “the issues raised are significant and worthy of thoughtful consideration” and highlighted how, in light of the COVID-19 pandemic, the board has provided greater flexibility to the exam process – transitioning to remote testing and offering two dates for each exam in 2021.

But will the changes last? And will they help reduce the burden these exams place on families and family planning?
 

Inside board certification before the pandemic

While other specialties require one or two exams for board certification, radiation oncology is the only medical field that requires candidates pass four exams – three qualifying written tests, followed by a certifying oral exam. Since 2004, these exams, which cover physics, radiation biology, and clinical radiation oncology, have taken place over 3 years at specific locations across the country.

Radiation oncology residents have reported spending hundreds of hours preparing for each of these high-stakes evaluations. Fail or miss one and an already time-consuming process draws out, with major repercussions for career advancement and earnings.

“Passing and achieving board certification is the capstone of medical specialty training and, for many, is a prerequisite for attaining partnership or a promotion,” said study coauthor Chelain Goodman, MD, PhD, a radiation oncologist at the University of Texas MD Anderson Cancer Center, Houston.

To top it off, this process may be contributing to the gender disparity in radiation oncology, the study suggests. Only 25%-30% of practicing radiation oncologists are women, making it one of the lowest-ranking specialties when it comes to female representation.

“I think [this exam process] creates some disincentive when female medical students see that these are issues that early-career radiation oncologists are facing,” said Dr. Dover, who practices at Memorial Sloan Kettering Cancer Center, New York. “[Students may instead] choose a specialty that they believe will be more supportive of them and their family planning goals. That’s definitely a big concern for a field that wants to attract the top candidates.”

For those who do pick radiation oncology, the system of board exams often requires prospective parents to choose among three options: Try to time delivery before or between exams, put off pregnancy or adoption until exams are done, or delay board certification.
 

A balancing act: Board exams and family planning

Like Dr. Dover, Dr. Masters opted for door No. 1. She tried to time the birth of her daughter to fall several months before her first board exam.

She hoped her careful planning would reduce the stress of both major life events. But that was not the case. At 35 weeks, Dr. Masters found herself in the hospital with preeclampsia and symptomatic hypertension.

While receiving a magnesium sulfate drip to prevent a seizure, she frantically typed her patient list before her vision got too blurry to see the screen.

“That is ridiculous,” Dr. Masters said. “But so is a system that makes this the expectation [for pregnant physicians].”

During her hospital stay, Dr. Masters was induced. She suspects the stress of prepping for the board exam coupled with being pregnant and continuing to work long hours as a resident contributed to her pregnancy complications.

This juggling act can bleed into exam day as well. When interviewing women for their study, Dr. Masters and colleagues uncovered personal accounts of the challenges pregnant women and new mothers faced during their exams.

One woman described being granted lactation accommodation ahead of time, but when she arrived for her first two written exams, the testing center had no record of her request. She ended up breast-pumping in a coat closet next to the cleaning supplies while her male coresidents ate lunch and reviewed their notes.

“I started my physics exam in tears, completely anxious,” she reported. “I didn’t get to eat lunch. I was physically uncomfortable and emotionally wiped during both exams.”

Another woman had contractions during her written clinical boards, but “thankfully” passed her exam and gave birth 2 days later.

“It might sound crazy that we would put ourselves through things like that just to take an exam,” Dr. Dover said. “But because it does have the potential to sharply shape our early professional trajectory, we push through it. Otherwise, we’re going to be left behind by our male peers.”

This pressure to push through can be intense.

Still recovering from a difficult pregnancy, Dr. Masters returned to work when her daughter was just 5 weeks old. Although not ready to return to work, she felt too scared to ask for more time off after seeing other new mothers receive negative comments about not working hard enough.

Enter door No. 2: The pregnancy and postpregnancy experiences were so traumatizing that she decided to put off trying for a second child until after her exams.

Now board certified and 38 years old, Dr. Masters is worried she won’t be able to conceive as easily as before.

“So, we’re stuck in limbo, starting the process again and being nervous about it because what if it’s not so easy at this age?” she said. “And what if it could have been easy, in different circumstances, with a different specialty?”

Dr. Masters’ concerns are justified. Of the 126 women interviewed for the study, those who delayed pregnancy because of the board exams were significantly more likely to have fertility problems (46% vs. 18%), and 20% reported experiencing infertility.

This finding dovetails with previous research showing that almost 25% of female physicians who attempt to become pregnant are diagnosed with infertility – nearly twice the rate of the general population. This high rate of infertility has been attributed to professional pressures and stress, long hours on the job, and delaying pregnancy during medical training.

But choosing door No. 3 – focusing on family over exams – has downsides as well. Board certification is a prerequisite for almost every partnership position or promotion track within academic medicine and delaying certification can significantly hinder a physician’s career and finances.

Radiation oncologists who aren’t certified often remain in salaried positions until they can make partnership and earn a portion of the practice’s profits, “which could easily change your annual compensation by six digits,” Dr. Dover said.

According to the team’s study, annual compensation typically increases by $30,000-$50,000 after board certification, with some reporting an increase of over $100,000. That salary hike also impacts physicians’ ability to pay off medical school loans, make financial investments, and afford the cost of childcare.

In other words, when it comes to family planning, there’s often no good option.
 

Change on the horizon

When the pandemic struck, the American Board of Radiology quickly went into triage mode, postponing in-person board certification exams scheduled in 2020 and brainstorming solutions.

By June, the organization announced that the exams would switch to a virtual format in 2021. Each test would be offered twice – once early in the year for candidates like Dover whose postponed 2020 exams had ultimately been canceled, and then again for those already planning to take their tests in 2021.

The shift to remote testing was a boon. Taking the tests from home not only allowed candidates to forgo the cost, stress, and time of travel, it also mitigated the burden of juggling pregnancy and parenting needs.

For example, Courtney Hentz, MD, a pediatric radiation oncologist at Loyola University Chicago, Maywood, Ill., and a study coauthor, was given the choice to take a virtual exam in one day with two breastfeeding breaks or to spread the exam over 2 days with one breastfeeding break each day.

“Transitioning exams to a virtual format has been a really big achievement that the American Board of Radiology should be applauded for,” Dr. Dover said.

Not only that, offering the exams multiple times a year has “significantly increased flexibility for candidates as they juggle completing residency, starting at their first practice, and balancing time with their family,” Dr. Goodman added.

Brent Wagner, MD, MBA, executive director of the American Board of Radiology, Tucson, Ariz., said in an interviewthat remote exams are here to stay. “I don’t foresee us ever going back to in-person board exams,” said Dr. Wagner, a diagnostic radiologist. “Administering exams remotely last year worked better than I could have expected.”

Dr. Wagner said the American Board of Radiology also plans to keep two dates for the oral certifying exam for the foreseeable future, though will revert to one date for the written qualifying exams.

“In a perfect world, we’d offer an exam every quarter,” he said. However, providing multiple dates for the written exams “is not practical with a cohort of a few hundred people,” given the staff resources needed to create and score twice the number of items each year. The board did not rule out reassessing this decision in the future, “as examination development software improves and more resources become available.”

Another big change, proposed by Dr. Dover, Dr. Goodman, and others, would be to combine the four exams into fewer tests, such as consolidating the three written exams into one. Such a shift would allow physicians to launch their careers sooner and begin focusing on other career-advancing endeavors such as research and publishing. It would also significantly improve radiation oncologists’ quality of life.

“The amount of time that you spend studying for these very high-level, high-stakes exams really puts a toll on your mental health,” Dr. Dover said. “The longer it’s dragged out, the longer you’re dealing with that, and it contributes tremendously to poor job satisfaction and work-life balance.” 

The American Board of Radiology said it is discussing options for consolidating the exams, but the challenge with combining the three written exams into one comes down to scoring. “We need to get a statistically valid result in all three categories,” Dr. Wagner said.

Another recent change: The American Board of Radiology is now allowing residents flexibility on the sequence of the written exams.

“In the past, we said you had to pass the physics exam before moving on to clinical radiology, but now we’re letting residents decide the order for themselves,” Dr. Wagner said. “This change may introduce more flexibility for someone who missed their first opportunity to take the physics exam but is ready to take the clinical exam.”

Dr. Wagner added: “We’re learning as we go, and I tell our staff that there’s no reason we should think we’re done making improvements. It’s going to keep getting better.”

The recent changes have already made a difference to radiation oncologists. And many hope to build on this new foundation to move the specialty toward a more family-friendly, equitable culture.

“I think as people in a caregiver profession, it’s hard to prioritize doing things for yourself or your own family sometimes; it’s hard to speak up and say: ‘We need something different,’ ” Dr. Masters said. “I think we have [an opportunity] to capitalize on the momentum we have now.”

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

Laura Dover, MD, had carefully timed her pregnancy around the four exams required to achieve board certification in radiation oncology. But when the pandemic hit in 2020, the final test, offered each May, was pushed to October – the week of her due date.

It would be impossible for her to fly the 2,500 miles from New York to the test site in Tucson, Ariz., when she could go into labor at any moment. She asked the American Board of Radiology – which oversees the process – if she could take the oral exam on Zoom or shift the timing a few weeks earlier or later.

The response: If she decided not to sit for the exam in person on the date specified, she would have to wait an entire year for the next test.

“I felt: Angry. Sad. Helpless. Inconsequential,” Dr. Dover tweeted. “But I will not be silent.”

The experience motivated Dr. Dover and six colleagues to conduct a study about how radiation oncology’s onerous four-exam board certification process has disproportionately burdened women.

The study, published online in Practical Radiation Oncology on Nov. 3, 2021, revealed that almost 60% of the early-career female radiation oncologists surveyed had delayed or were timing their pregnancies to accommodate their board exams. Women who chose to delay pregnancy were 2.5 times more likely to experience infertility.

“When we started doing the study, we didn’t realize just how common it was for people to wrap so much of their [family planning decisions] around taking these board exams,” said study coauthor Adrianna Henson Masters, MD, a radiation oncologist at Springfield (Ill.) Clinic. “How crazy is that? And no one’s talking about it.”

However, once the study appeared online, physicians took to Twitter to comment on the challenges of the board certification process, while others demanded change. One radiation oncologist even shared her decision not to have a child until she passed her board exams.

The study also got the attention of the American Board of Radiology, which governs certification for the specialty. In a response, leaders of the organization agreed that “the issues raised are significant and worthy of thoughtful consideration” and highlighted how, in light of the COVID-19 pandemic, the board has provided greater flexibility to the exam process – transitioning to remote testing and offering two dates for each exam in 2021.

But will the changes last? And will they help reduce the burden these exams place on families and family planning?
 

Inside board certification before the pandemic

While other specialties require one or two exams for board certification, radiation oncology is the only medical field that requires candidates pass four exams – three qualifying written tests, followed by a certifying oral exam. Since 2004, these exams, which cover physics, radiation biology, and clinical radiation oncology, have taken place over 3 years at specific locations across the country.

Radiation oncology residents have reported spending hundreds of hours preparing for each of these high-stakes evaluations. Fail or miss one and an already time-consuming process draws out, with major repercussions for career advancement and earnings.

“Passing and achieving board certification is the capstone of medical specialty training and, for many, is a prerequisite for attaining partnership or a promotion,” said study coauthor Chelain Goodman, MD, PhD, a radiation oncologist at the University of Texas MD Anderson Cancer Center, Houston.

To top it off, this process may be contributing to the gender disparity in radiation oncology, the study suggests. Only 25%-30% of practicing radiation oncologists are women, making it one of the lowest-ranking specialties when it comes to female representation.

“I think [this exam process] creates some disincentive when female medical students see that these are issues that early-career radiation oncologists are facing,” said Dr. Dover, who practices at Memorial Sloan Kettering Cancer Center, New York. “[Students may instead] choose a specialty that they believe will be more supportive of them and their family planning goals. That’s definitely a big concern for a field that wants to attract the top candidates.”

For those who do pick radiation oncology, the system of board exams often requires prospective parents to choose among three options: Try to time delivery before or between exams, put off pregnancy or adoption until exams are done, or delay board certification.
 

A balancing act: Board exams and family planning

Like Dr. Dover, Dr. Masters opted for door No. 1. She tried to time the birth of her daughter to fall several months before her first board exam.

She hoped her careful planning would reduce the stress of both major life events. But that was not the case. At 35 weeks, Dr. Masters found herself in the hospital with preeclampsia and symptomatic hypertension.

While receiving a magnesium sulfate drip to prevent a seizure, she frantically typed her patient list before her vision got too blurry to see the screen.

“That is ridiculous,” Dr. Masters said. “But so is a system that makes this the expectation [for pregnant physicians].”

During her hospital stay, Dr. Masters was induced. She suspects the stress of prepping for the board exam coupled with being pregnant and continuing to work long hours as a resident contributed to her pregnancy complications.

This juggling act can bleed into exam day as well. When interviewing women for their study, Dr. Masters and colleagues uncovered personal accounts of the challenges pregnant women and new mothers faced during their exams.

One woman described being granted lactation accommodation ahead of time, but when she arrived for her first two written exams, the testing center had no record of her request. She ended up breast-pumping in a coat closet next to the cleaning supplies while her male coresidents ate lunch and reviewed their notes.

“I started my physics exam in tears, completely anxious,” she reported. “I didn’t get to eat lunch. I was physically uncomfortable and emotionally wiped during both exams.”

Another woman had contractions during her written clinical boards, but “thankfully” passed her exam and gave birth 2 days later.

“It might sound crazy that we would put ourselves through things like that just to take an exam,” Dr. Dover said. “But because it does have the potential to sharply shape our early professional trajectory, we push through it. Otherwise, we’re going to be left behind by our male peers.”

This pressure to push through can be intense.

Still recovering from a difficult pregnancy, Dr. Masters returned to work when her daughter was just 5 weeks old. Although not ready to return to work, she felt too scared to ask for more time off after seeing other new mothers receive negative comments about not working hard enough.

Enter door No. 2: The pregnancy and postpregnancy experiences were so traumatizing that she decided to put off trying for a second child until after her exams.

Now board certified and 38 years old, Dr. Masters is worried she won’t be able to conceive as easily as before.

“So, we’re stuck in limbo, starting the process again and being nervous about it because what if it’s not so easy at this age?” she said. “And what if it could have been easy, in different circumstances, with a different specialty?”

Dr. Masters’ concerns are justified. Of the 126 women interviewed for the study, those who delayed pregnancy because of the board exams were significantly more likely to have fertility problems (46% vs. 18%), and 20% reported experiencing infertility.

This finding dovetails with previous research showing that almost 25% of female physicians who attempt to become pregnant are diagnosed with infertility – nearly twice the rate of the general population. This high rate of infertility has been attributed to professional pressures and stress, long hours on the job, and delaying pregnancy during medical training.

But choosing door No. 3 – focusing on family over exams – has downsides as well. Board certification is a prerequisite for almost every partnership position or promotion track within academic medicine and delaying certification can significantly hinder a physician’s career and finances.

Radiation oncologists who aren’t certified often remain in salaried positions until they can make partnership and earn a portion of the practice’s profits, “which could easily change your annual compensation by six digits,” Dr. Dover said.

According to the team’s study, annual compensation typically increases by $30,000-$50,000 after board certification, with some reporting an increase of over $100,000. That salary hike also impacts physicians’ ability to pay off medical school loans, make financial investments, and afford the cost of childcare.

In other words, when it comes to family planning, there’s often no good option.
 

Change on the horizon

When the pandemic struck, the American Board of Radiology quickly went into triage mode, postponing in-person board certification exams scheduled in 2020 and brainstorming solutions.

By June, the organization announced that the exams would switch to a virtual format in 2021. Each test would be offered twice – once early in the year for candidates like Dover whose postponed 2020 exams had ultimately been canceled, and then again for those already planning to take their tests in 2021.

The shift to remote testing was a boon. Taking the tests from home not only allowed candidates to forgo the cost, stress, and time of travel, it also mitigated the burden of juggling pregnancy and parenting needs.

For example, Courtney Hentz, MD, a pediatric radiation oncologist at Loyola University Chicago, Maywood, Ill., and a study coauthor, was given the choice to take a virtual exam in one day with two breastfeeding breaks or to spread the exam over 2 days with one breastfeeding break each day.

“Transitioning exams to a virtual format has been a really big achievement that the American Board of Radiology should be applauded for,” Dr. Dover said.

Not only that, offering the exams multiple times a year has “significantly increased flexibility for candidates as they juggle completing residency, starting at their first practice, and balancing time with their family,” Dr. Goodman added.

Brent Wagner, MD, MBA, executive director of the American Board of Radiology, Tucson, Ariz., said in an interviewthat remote exams are here to stay. “I don’t foresee us ever going back to in-person board exams,” said Dr. Wagner, a diagnostic radiologist. “Administering exams remotely last year worked better than I could have expected.”

Dr. Wagner said the American Board of Radiology also plans to keep two dates for the oral certifying exam for the foreseeable future, though will revert to one date for the written qualifying exams.

“In a perfect world, we’d offer an exam every quarter,” he said. However, providing multiple dates for the written exams “is not practical with a cohort of a few hundred people,” given the staff resources needed to create and score twice the number of items each year. The board did not rule out reassessing this decision in the future, “as examination development software improves and more resources become available.”

Another big change, proposed by Dr. Dover, Dr. Goodman, and others, would be to combine the four exams into fewer tests, such as consolidating the three written exams into one. Such a shift would allow physicians to launch their careers sooner and begin focusing on other career-advancing endeavors such as research and publishing. It would also significantly improve radiation oncologists’ quality of life.

“The amount of time that you spend studying for these very high-level, high-stakes exams really puts a toll on your mental health,” Dr. Dover said. “The longer it’s dragged out, the longer you’re dealing with that, and it contributes tremendously to poor job satisfaction and work-life balance.” 

The American Board of Radiology said it is discussing options for consolidating the exams, but the challenge with combining the three written exams into one comes down to scoring. “We need to get a statistically valid result in all three categories,” Dr. Wagner said.

Another recent change: The American Board of Radiology is now allowing residents flexibility on the sequence of the written exams.

“In the past, we said you had to pass the physics exam before moving on to clinical radiology, but now we’re letting residents decide the order for themselves,” Dr. Wagner said. “This change may introduce more flexibility for someone who missed their first opportunity to take the physics exam but is ready to take the clinical exam.”

Dr. Wagner added: “We’re learning as we go, and I tell our staff that there’s no reason we should think we’re done making improvements. It’s going to keep getting better.”

The recent changes have already made a difference to radiation oncologists. And many hope to build on this new foundation to move the specialty toward a more family-friendly, equitable culture.

“I think as people in a caregiver profession, it’s hard to prioritize doing things for yourself or your own family sometimes; it’s hard to speak up and say: ‘We need something different,’ ” Dr. Masters said. “I think we have [an opportunity] to capitalize on the momentum we have now.”

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

Laura Dover, MD, had carefully timed her pregnancy around the four exams required to achieve board certification in radiation oncology. But when the pandemic hit in 2020, the final test, offered each May, was pushed to October – the week of her due date.

It would be impossible for her to fly the 2,500 miles from New York to the test site in Tucson, Ariz., when she could go into labor at any moment. She asked the American Board of Radiology – which oversees the process – if she could take the oral exam on Zoom or shift the timing a few weeks earlier or later.

The response: If she decided not to sit for the exam in person on the date specified, she would have to wait an entire year for the next test.

“I felt: Angry. Sad. Helpless. Inconsequential,” Dr. Dover tweeted. “But I will not be silent.”

The experience motivated Dr. Dover and six colleagues to conduct a study about how radiation oncology’s onerous four-exam board certification process has disproportionately burdened women.

The study, published online in Practical Radiation Oncology on Nov. 3, 2021, revealed that almost 60% of the early-career female radiation oncologists surveyed had delayed or were timing their pregnancies to accommodate their board exams. Women who chose to delay pregnancy were 2.5 times more likely to experience infertility.

“When we started doing the study, we didn’t realize just how common it was for people to wrap so much of their [family planning decisions] around taking these board exams,” said study coauthor Adrianna Henson Masters, MD, a radiation oncologist at Springfield (Ill.) Clinic. “How crazy is that? And no one’s talking about it.”

However, once the study appeared online, physicians took to Twitter to comment on the challenges of the board certification process, while others demanded change. One radiation oncologist even shared her decision not to have a child until she passed her board exams.

The study also got the attention of the American Board of Radiology, which governs certification for the specialty. In a response, leaders of the organization agreed that “the issues raised are significant and worthy of thoughtful consideration” and highlighted how, in light of the COVID-19 pandemic, the board has provided greater flexibility to the exam process – transitioning to remote testing and offering two dates for each exam in 2021.

But will the changes last? And will they help reduce the burden these exams place on families and family planning?
 

Inside board certification before the pandemic

While other specialties require one or two exams for board certification, radiation oncology is the only medical field that requires candidates pass four exams – three qualifying written tests, followed by a certifying oral exam. Since 2004, these exams, which cover physics, radiation biology, and clinical radiation oncology, have taken place over 3 years at specific locations across the country.

Radiation oncology residents have reported spending hundreds of hours preparing for each of these high-stakes evaluations. Fail or miss one and an already time-consuming process draws out, with major repercussions for career advancement and earnings.

“Passing and achieving board certification is the capstone of medical specialty training and, for many, is a prerequisite for attaining partnership or a promotion,” said study coauthor Chelain Goodman, MD, PhD, a radiation oncologist at the University of Texas MD Anderson Cancer Center, Houston.

To top it off, this process may be contributing to the gender disparity in radiation oncology, the study suggests. Only 25%-30% of practicing radiation oncologists are women, making it one of the lowest-ranking specialties when it comes to female representation.

“I think [this exam process] creates some disincentive when female medical students see that these are issues that early-career radiation oncologists are facing,” said Dr. Dover, who practices at Memorial Sloan Kettering Cancer Center, New York. “[Students may instead] choose a specialty that they believe will be more supportive of them and their family planning goals. That’s definitely a big concern for a field that wants to attract the top candidates.”

For those who do pick radiation oncology, the system of board exams often requires prospective parents to choose among three options: Try to time delivery before or between exams, put off pregnancy or adoption until exams are done, or delay board certification.
 

A balancing act: Board exams and family planning

Like Dr. Dover, Dr. Masters opted for door No. 1. She tried to time the birth of her daughter to fall several months before her first board exam.

She hoped her careful planning would reduce the stress of both major life events. But that was not the case. At 35 weeks, Dr. Masters found herself in the hospital with preeclampsia and symptomatic hypertension.

While receiving a magnesium sulfate drip to prevent a seizure, she frantically typed her patient list before her vision got too blurry to see the screen.

“That is ridiculous,” Dr. Masters said. “But so is a system that makes this the expectation [for pregnant physicians].”

During her hospital stay, Dr. Masters was induced. She suspects the stress of prepping for the board exam coupled with being pregnant and continuing to work long hours as a resident contributed to her pregnancy complications.

This juggling act can bleed into exam day as well. When interviewing women for their study, Dr. Masters and colleagues uncovered personal accounts of the challenges pregnant women and new mothers faced during their exams.

One woman described being granted lactation accommodation ahead of time, but when she arrived for her first two written exams, the testing center had no record of her request. She ended up breast-pumping in a coat closet next to the cleaning supplies while her male coresidents ate lunch and reviewed their notes.

“I started my physics exam in tears, completely anxious,” she reported. “I didn’t get to eat lunch. I was physically uncomfortable and emotionally wiped during both exams.”

Another woman had contractions during her written clinical boards, but “thankfully” passed her exam and gave birth 2 days later.

“It might sound crazy that we would put ourselves through things like that just to take an exam,” Dr. Dover said. “But because it does have the potential to sharply shape our early professional trajectory, we push through it. Otherwise, we’re going to be left behind by our male peers.”

This pressure to push through can be intense.

Still recovering from a difficult pregnancy, Dr. Masters returned to work when her daughter was just 5 weeks old. Although not ready to return to work, she felt too scared to ask for more time off after seeing other new mothers receive negative comments about not working hard enough.

Enter door No. 2: The pregnancy and postpregnancy experiences were so traumatizing that she decided to put off trying for a second child until after her exams.

Now board certified and 38 years old, Dr. Masters is worried she won’t be able to conceive as easily as before.

“So, we’re stuck in limbo, starting the process again and being nervous about it because what if it’s not so easy at this age?” she said. “And what if it could have been easy, in different circumstances, with a different specialty?”

Dr. Masters’ concerns are justified. Of the 126 women interviewed for the study, those who delayed pregnancy because of the board exams were significantly more likely to have fertility problems (46% vs. 18%), and 20% reported experiencing infertility.

This finding dovetails with previous research showing that almost 25% of female physicians who attempt to become pregnant are diagnosed with infertility – nearly twice the rate of the general population. This high rate of infertility has been attributed to professional pressures and stress, long hours on the job, and delaying pregnancy during medical training.

But choosing door No. 3 – focusing on family over exams – has downsides as well. Board certification is a prerequisite for almost every partnership position or promotion track within academic medicine and delaying certification can significantly hinder a physician’s career and finances.

Radiation oncologists who aren’t certified often remain in salaried positions until they can make partnership and earn a portion of the practice’s profits, “which could easily change your annual compensation by six digits,” Dr. Dover said.

According to the team’s study, annual compensation typically increases by $30,000-$50,000 after board certification, with some reporting an increase of over $100,000. That salary hike also impacts physicians’ ability to pay off medical school loans, make financial investments, and afford the cost of childcare.

In other words, when it comes to family planning, there’s often no good option.
 

Change on the horizon

When the pandemic struck, the American Board of Radiology quickly went into triage mode, postponing in-person board certification exams scheduled in 2020 and brainstorming solutions.

By June, the organization announced that the exams would switch to a virtual format in 2021. Each test would be offered twice – once early in the year for candidates like Dover whose postponed 2020 exams had ultimately been canceled, and then again for those already planning to take their tests in 2021.

The shift to remote testing was a boon. Taking the tests from home not only allowed candidates to forgo the cost, stress, and time of travel, it also mitigated the burden of juggling pregnancy and parenting needs.

For example, Courtney Hentz, MD, a pediatric radiation oncologist at Loyola University Chicago, Maywood, Ill., and a study coauthor, was given the choice to take a virtual exam in one day with two breastfeeding breaks or to spread the exam over 2 days with one breastfeeding break each day.

“Transitioning exams to a virtual format has been a really big achievement that the American Board of Radiology should be applauded for,” Dr. Dover said.

Not only that, offering the exams multiple times a year has “significantly increased flexibility for candidates as they juggle completing residency, starting at their first practice, and balancing time with their family,” Dr. Goodman added.

Brent Wagner, MD, MBA, executive director of the American Board of Radiology, Tucson, Ariz., said in an interviewthat remote exams are here to stay. “I don’t foresee us ever going back to in-person board exams,” said Dr. Wagner, a diagnostic radiologist. “Administering exams remotely last year worked better than I could have expected.”

Dr. Wagner said the American Board of Radiology also plans to keep two dates for the oral certifying exam for the foreseeable future, though will revert to one date for the written qualifying exams.

“In a perfect world, we’d offer an exam every quarter,” he said. However, providing multiple dates for the written exams “is not practical with a cohort of a few hundred people,” given the staff resources needed to create and score twice the number of items each year. The board did not rule out reassessing this decision in the future, “as examination development software improves and more resources become available.”

Another big change, proposed by Dr. Dover, Dr. Goodman, and others, would be to combine the four exams into fewer tests, such as consolidating the three written exams into one. Such a shift would allow physicians to launch their careers sooner and begin focusing on other career-advancing endeavors such as research and publishing. It would also significantly improve radiation oncologists’ quality of life.

“The amount of time that you spend studying for these very high-level, high-stakes exams really puts a toll on your mental health,” Dr. Dover said. “The longer it’s dragged out, the longer you’re dealing with that, and it contributes tremendously to poor job satisfaction and work-life balance.” 

The American Board of Radiology said it is discussing options for consolidating the exams, but the challenge with combining the three written exams into one comes down to scoring. “We need to get a statistically valid result in all three categories,” Dr. Wagner said.

Another recent change: The American Board of Radiology is now allowing residents flexibility on the sequence of the written exams.

“In the past, we said you had to pass the physics exam before moving on to clinical radiology, but now we’re letting residents decide the order for themselves,” Dr. Wagner said. “This change may introduce more flexibility for someone who missed their first opportunity to take the physics exam but is ready to take the clinical exam.”

Dr. Wagner added: “We’re learning as we go, and I tell our staff that there’s no reason we should think we’re done making improvements. It’s going to keep getting better.”

The recent changes have already made a difference to radiation oncologists. And many hope to build on this new foundation to move the specialty toward a more family-friendly, equitable culture.

“I think as people in a caregiver profession, it’s hard to prioritize doing things for yourself or your own family sometimes; it’s hard to speak up and say: ‘We need something different,’ ” Dr. Masters said. “I think we have [an opportunity] to capitalize on the momentum we have now.”

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

An obesity prevention program targeted at parents of infants benefited not only firstborn infants but their second-born siblings as well, a new study suggests.

According to a statement from the National Institutes of Health, who funded the study, it is the first such infant obesity intervention to show the spillover effect. Findings were published online Dec. 21, 2021, in Obesity.

The program is called Infants Growing on Healthy Trajectories (INSIGHT) responsive parenting (RP) intervention, and it included guidance on feeding, sleep, interactive play, and regulating emotion.

Parents were given guidance by nurses who came to their homes on how to respond when their child is drowsy, sleeping, fussy, and alert. They also learned how to put infants to bed drowsy, but awake, and avoid feeding infants to get them to sleep; how to respond to infants waking up at night; when to start solid foods; how to limit inactive time; and how to use growth charts.

The control group program focused on safety and matched the guidance categories. For example, early visits included information on prevention of sudden infant death syndrome for sleep, breast milk storage and formula for feeding, and safe bathing.

Jennifer S. Savage, Center for Childhood Obesity Research, Penn State University, University Park, led the study that enrolled 117 infants in a randomized controlled trial. Mother and firstborn children were randomized to the RP or home safety intervention (control) group 10-14 days after delivery. Their second-born siblings were enrolled in an observation-only ancillary study.

Second-born children were delivered 2.5 (standard deviation, 0.9) years after firstborns. Anthropometrics were measured in both siblings at ages 3, 16, 28, and 52 weeks.

Firstborn children at 1 year had a body mass index (BMI) that was 0.44 kg/m² lower than the control group (95% confidence interval, −0.82 to −0.06), and second-born children whose parents received the RP intervention with their first child had BMI that was 0.36 kg/m² lower.

“What we saw here is that it worked again,” coauthor Ian Paul, MD, MSc, professor of pediatrics and public health sciences at Penn State University, Hershey, said in an interview.

“Once we imprint them with a certain approach to parenting with the first child, they’re doing the same thing with the second child, which is wonderful to see,” he said.

He noted that this happened with second children without any reinforcements or booster information.

Dr. Paul said it’s still not clear which of the interventions – whether related to feeding techniques or sleeping or activity – helps most. And for each family the problematic behaviors may be different.

Responsive parenting programs have shown success previously among firstborns, the authors wrote, but 80% of those children grow up with younger siblings, so an intervention that also benefits them is important.

Weighing the costs of the intervention

The intervention was extensive. It involved four hour-plus nurse visits a year, often by the same nurse who built a relationship with the family.

But Ms. Savage said that it is possible to replicate INSIGHT on a larger scale in the United States with the dozens of home visitation models.

“Currently, 21 home visitation models meet the U.S. Department of Health & Human Services criteria for evidence of effectiveness, such as Nurse Family Partnership, Family Check-up, and Early Head Start Home Based Option. There is an opportunity to use home visitation models at the national scale to potentially interrupt the cycle of poor multigenerational outcomes such as obesity,” she said.

Dr. Paul said the initial investment “can save money in the long term,” given what’s at stake. “We know that 20%-25% of 2- to 5-year-olds are already overweight or obese and if they are already overweight or obese at that age, that;’s likely to persist.”

However, he acknowledged that staff shortages and costs are a challenge.

“Other countries have made that investment in their health care system,” he said. “In the U.S. only a fraction of new mothers and babies get home visitation. The kind of work that we did for obesity prevention has not yet been incorporated into evidence-based models of home visitation, though it certainly could be.”

Dr. Paul said his team is hoping to collaborate with others in the near future on expanding this program to such models of home visitation.

Telehealth, though a less desirable option, compared with in-home visits, could also be utilized, he said.

Short of the comprehensive intervention, he said, many of the concepts can be put into practice by pediatricians and parents.

Dr. Paul noted that the Robert Wood Johnson Foundation has endorsed “responsive feeding” as the preferred approach to feeding infants and toddlers. Responsive feeding – helping parents recognize hunger and satiety cues as opposed to other distress cues – is a big part of the intervention.

“Feeding to soothe is not the preferred approach,” he said. “Food and milk and formula should be used for hunger.” That’s something pediatricians may not be stressing to parents, he said.

Pediatricians can also counsel parents on not using food as a reward. “We shouldn’t be giving kids M&Ms to teach them how to potty train,” he said.
 

‘Promising’ findings

Charles Wood, MD, a childhood obesity specialist at Duke University, Durham, N.C., who was not part of the study, called the findings “very promising.”

It also makes sense that the “aha moments” of first-time parents learning from the INSIGHT intervention would carry over to the second sibling, he said.

Dr. Wood agreed costs are a big factor. However, he said, the potential downstream costs of not preventing obesity are worse. And this study indicates the benefits may keep spreading with future siblings.

Dr. Wood said accessing obesity interventions outside the pediatrician visit can also help. Connecting patients with support groups or dietitians or with a counselor from Women, Infants, and Children can help. However, consistent messaging among the providers is key, he noted.

Dr. Wood’s research group is investigating text messaging platforms so parents can get answer to real-time questions, such as those about feeding behaviors.

He pointed to a limitation the authors mention, which is that the study was done in mostly White, highly educated, higher-income families.

“There’s a big problem with racial disparities and obesity,” Dr. Wood noted. “We definitely need solutions that address disparities as well.”

Mothers included in the study had given birth for the first time and their infants were enrolled after birth from a single maternity ward between January 2012 and March 2014. Major eligibility criteria were that the babies were full term (at least 37 weeks’ gestation), single births, and delivered to English-speaking mothers at least 20 years of age. Infants who weighed less than 2,500 g at birth were excluded.

The paper’s authors and Dr. Wood declared no relevant financial relationships.

This research was supported by the National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases; and the Department of Agriculture.

An obesity prevention program targeted at parents of infants benefited not only firstborn infants but their second-born siblings as well, a new study suggests.

According to a statement from the National Institutes of Health, who funded the study, it is the first such infant obesity intervention to show the spillover effect. Findings were published online Dec. 21, 2021, in Obesity.

The program is called Infants Growing on Healthy Trajectories (INSIGHT) responsive parenting (RP) intervention, and it included guidance on feeding, sleep, interactive play, and regulating emotion.

Parents were given guidance by nurses who came to their homes on how to respond when their child is drowsy, sleeping, fussy, and alert. They also learned how to put infants to bed drowsy, but awake, and avoid feeding infants to get them to sleep; how to respond to infants waking up at night; when to start solid foods; how to limit inactive time; and how to use growth charts.

The control group program focused on safety and matched the guidance categories. For example, early visits included information on prevention of sudden infant death syndrome for sleep, breast milk storage and formula for feeding, and safe bathing.

Jennifer S. Savage, Center for Childhood Obesity Research, Penn State University, University Park, led the study that enrolled 117 infants in a randomized controlled trial. Mother and firstborn children were randomized to the RP or home safety intervention (control) group 10-14 days after delivery. Their second-born siblings were enrolled in an observation-only ancillary study.

Second-born children were delivered 2.5 (standard deviation, 0.9) years after firstborns. Anthropometrics were measured in both siblings at ages 3, 16, 28, and 52 weeks.

Firstborn children at 1 year had a body mass index (BMI) that was 0.44 kg/m² lower than the control group (95% confidence interval, −0.82 to −0.06), and second-born children whose parents received the RP intervention with their first child had BMI that was 0.36 kg/m² lower.

“What we saw here is that it worked again,” coauthor Ian Paul, MD, MSc, professor of pediatrics and public health sciences at Penn State University, Hershey, said in an interview.

“Once we imprint them with a certain approach to parenting with the first child, they’re doing the same thing with the second child, which is wonderful to see,” he said.

He noted that this happened with second children without any reinforcements or booster information.

Dr. Paul said it’s still not clear which of the interventions – whether related to feeding techniques or sleeping or activity – helps most. And for each family the problematic behaviors may be different.

Responsive parenting programs have shown success previously among firstborns, the authors wrote, but 80% of those children grow up with younger siblings, so an intervention that also benefits them is important.

Weighing the costs of the intervention

The intervention was extensive. It involved four hour-plus nurse visits a year, often by the same nurse who built a relationship with the family.

But Ms. Savage said that it is possible to replicate INSIGHT on a larger scale in the United States with the dozens of home visitation models.

“Currently, 21 home visitation models meet the U.S. Department of Health & Human Services criteria for evidence of effectiveness, such as Nurse Family Partnership, Family Check-up, and Early Head Start Home Based Option. There is an opportunity to use home visitation models at the national scale to potentially interrupt the cycle of poor multigenerational outcomes such as obesity,” she said.

Dr. Paul said the initial investment “can save money in the long term,” given what’s at stake. “We know that 20%-25% of 2- to 5-year-olds are already overweight or obese and if they are already overweight or obese at that age, that;’s likely to persist.”

However, he acknowledged that staff shortages and costs are a challenge.

“Other countries have made that investment in their health care system,” he said. “In the U.S. only a fraction of new mothers and babies get home visitation. The kind of work that we did for obesity prevention has not yet been incorporated into evidence-based models of home visitation, though it certainly could be.”

Dr. Paul said his team is hoping to collaborate with others in the near future on expanding this program to such models of home visitation.

Telehealth, though a less desirable option, compared with in-home visits, could also be utilized, he said.

Short of the comprehensive intervention, he said, many of the concepts can be put into practice by pediatricians and parents.

Dr. Paul noted that the Robert Wood Johnson Foundation has endorsed “responsive feeding” as the preferred approach to feeding infants and toddlers. Responsive feeding – helping parents recognize hunger and satiety cues as opposed to other distress cues – is a big part of the intervention.

“Feeding to soothe is not the preferred approach,” he said. “Food and milk and formula should be used for hunger.” That’s something pediatricians may not be stressing to parents, he said.

Pediatricians can also counsel parents on not using food as a reward. “We shouldn’t be giving kids M&Ms to teach them how to potty train,” he said.
 

‘Promising’ findings

Charles Wood, MD, a childhood obesity specialist at Duke University, Durham, N.C., who was not part of the study, called the findings “very promising.”

It also makes sense that the “aha moments” of first-time parents learning from the INSIGHT intervention would carry over to the second sibling, he said.

Dr. Wood agreed costs are a big factor. However, he said, the potential downstream costs of not preventing obesity are worse. And this study indicates the benefits may keep spreading with future siblings.

Dr. Wood said accessing obesity interventions outside the pediatrician visit can also help. Connecting patients with support groups or dietitians or with a counselor from Women, Infants, and Children can help. However, consistent messaging among the providers is key, he noted.

Dr. Wood’s research group is investigating text messaging platforms so parents can get answer to real-time questions, such as those about feeding behaviors.

He pointed to a limitation the authors mention, which is that the study was done in mostly White, highly educated, higher-income families.

“There’s a big problem with racial disparities and obesity,” Dr. Wood noted. “We definitely need solutions that address disparities as well.”

Mothers included in the study had given birth for the first time and their infants were enrolled after birth from a single maternity ward between January 2012 and March 2014. Major eligibility criteria were that the babies were full term (at least 37 weeks’ gestation), single births, and delivered to English-speaking mothers at least 20 years of age. Infants who weighed less than 2,500 g at birth were excluded.

The paper’s authors and Dr. Wood declared no relevant financial relationships.

This research was supported by the National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases; and the Department of Agriculture.

An obesity prevention program targeted at parents of infants benefited not only firstborn infants but their second-born siblings as well, a new study suggests.

According to a statement from the National Institutes of Health, who funded the study, it is the first such infant obesity intervention to show the spillover effect. Findings were published online Dec. 21, 2021, in Obesity.

The program is called Infants Growing on Healthy Trajectories (INSIGHT) responsive parenting (RP) intervention, and it included guidance on feeding, sleep, interactive play, and regulating emotion.

Parents were given guidance by nurses who came to their homes on how to respond when their child is drowsy, sleeping, fussy, and alert. They also learned how to put infants to bed drowsy, but awake, and avoid feeding infants to get them to sleep; how to respond to infants waking up at night; when to start solid foods; how to limit inactive time; and how to use growth charts.

The control group program focused on safety and matched the guidance categories. For example, early visits included information on prevention of sudden infant death syndrome for sleep, breast milk storage and formula for feeding, and safe bathing.

Jennifer S. Savage, Center for Childhood Obesity Research, Penn State University, University Park, led the study that enrolled 117 infants in a randomized controlled trial. Mother and firstborn children were randomized to the RP or home safety intervention (control) group 10-14 days after delivery. Their second-born siblings were enrolled in an observation-only ancillary study.

Second-born children were delivered 2.5 (standard deviation, 0.9) years after firstborns. Anthropometrics were measured in both siblings at ages 3, 16, 28, and 52 weeks.

Firstborn children at 1 year had a body mass index (BMI) that was 0.44 kg/m² lower than the control group (95% confidence interval, −0.82 to −0.06), and second-born children whose parents received the RP intervention with their first child had BMI that was 0.36 kg/m² lower.

“What we saw here is that it worked again,” coauthor Ian Paul, MD, MSc, professor of pediatrics and public health sciences at Penn State University, Hershey, said in an interview.

“Once we imprint them with a certain approach to parenting with the first child, they’re doing the same thing with the second child, which is wonderful to see,” he said.

He noted that this happened with second children without any reinforcements or booster information.

Dr. Paul said it’s still not clear which of the interventions – whether related to feeding techniques or sleeping or activity – helps most. And for each family the problematic behaviors may be different.

Responsive parenting programs have shown success previously among firstborns, the authors wrote, but 80% of those children grow up with younger siblings, so an intervention that also benefits them is important.

Weighing the costs of the intervention

The intervention was extensive. It involved four hour-plus nurse visits a year, often by the same nurse who built a relationship with the family.

But Ms. Savage said that it is possible to replicate INSIGHT on a larger scale in the United States with the dozens of home visitation models.

“Currently, 21 home visitation models meet the U.S. Department of Health & Human Services criteria for evidence of effectiveness, such as Nurse Family Partnership, Family Check-up, and Early Head Start Home Based Option. There is an opportunity to use home visitation models at the national scale to potentially interrupt the cycle of poor multigenerational outcomes such as obesity,” she said.

Dr. Paul said the initial investment “can save money in the long term,” given what’s at stake. “We know that 20%-25% of 2- to 5-year-olds are already overweight or obese and if they are already overweight or obese at that age, that;’s likely to persist.”

However, he acknowledged that staff shortages and costs are a challenge.

“Other countries have made that investment in their health care system,” he said. “In the U.S. only a fraction of new mothers and babies get home visitation. The kind of work that we did for obesity prevention has not yet been incorporated into evidence-based models of home visitation, though it certainly could be.”

Dr. Paul said his team is hoping to collaborate with others in the near future on expanding this program to such models of home visitation.

Telehealth, though a less desirable option, compared with in-home visits, could also be utilized, he said.

Short of the comprehensive intervention, he said, many of the concepts can be put into practice by pediatricians and parents.

Dr. Paul noted that the Robert Wood Johnson Foundation has endorsed “responsive feeding” as the preferred approach to feeding infants and toddlers. Responsive feeding – helping parents recognize hunger and satiety cues as opposed to other distress cues – is a big part of the intervention.

“Feeding to soothe is not the preferred approach,” he said. “Food and milk and formula should be used for hunger.” That’s something pediatricians may not be stressing to parents, he said.

Pediatricians can also counsel parents on not using food as a reward. “We shouldn’t be giving kids M&Ms to teach them how to potty train,” he said.
 

‘Promising’ findings

Charles Wood, MD, a childhood obesity specialist at Duke University, Durham, N.C., who was not part of the study, called the findings “very promising.”

It also makes sense that the “aha moments” of first-time parents learning from the INSIGHT intervention would carry over to the second sibling, he said.

Dr. Wood agreed costs are a big factor. However, he said, the potential downstream costs of not preventing obesity are worse. And this study indicates the benefits may keep spreading with future siblings.

Dr. Wood said accessing obesity interventions outside the pediatrician visit can also help. Connecting patients with support groups or dietitians or with a counselor from Women, Infants, and Children can help. However, consistent messaging among the providers is key, he noted.

Dr. Wood’s research group is investigating text messaging platforms so parents can get answer to real-time questions, such as those about feeding behaviors.

He pointed to a limitation the authors mention, which is that the study was done in mostly White, highly educated, higher-income families.

“There’s a big problem with racial disparities and obesity,” Dr. Wood noted. “We definitely need solutions that address disparities as well.”

Mothers included in the study had given birth for the first time and their infants were enrolled after birth from a single maternity ward between January 2012 and March 2014. Major eligibility criteria were that the babies were full term (at least 37 weeks’ gestation), single births, and delivered to English-speaking mothers at least 20 years of age. Infants who weighed less than 2,500 g at birth were excluded.

The paper’s authors and Dr. Wood declared no relevant financial relationships.

This research was supported by the National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases; and the Department of Agriculture.

For many adolescents, the first visit to a gynecologist can be intimidating. The prospect of meeting a new doctor who will ask prying, deeply personal questions about sex and menstruation is scary. And, in all likelihood, a parent, older sibling, or friend has warned them about the notorious pelvic exam.

The exact timing of when adolescent patients should start seeing a gynecologist varies based on when a patient starts puberty. Primary care physicians and pediatricians can help teens transition by referring patients to an adolescent-friendly practice and clearing up some of the misconceptions that surround the first gynecology visit. Gynecologists, on the other side of the referral, can help patients transition by guaranteeing confidentiality and creating a safe space for young patients.

This news organization interviewed three experts in adolescent health about when teens should start having their gynecological needs addressed and how their physicians can help them undergo that transition.
 

Age-appropriate care

“Most people get very limited information about their reproductive health,” said Anne-Marie E. Amies Oelschlager, MD, a pediatric and adolescent gynecologist at Seattle Children’s, Seattle, and a member of the American College of Obstetricians and Gynecologists (ACOG) clinical consensus committee on gynecology.

Official guidelines from ACOG call for the initial reproductive health visit to take place between the ages of 13 and 15 years. The exact age may vary, however, depending on the specific needs of the patient.

For example, some patients begin menstruating early, at age 9 or 10, said Mary Romano, MD, MPH, a pediatrician and adolescent medicine specialist at Vanderbilt Children’s Hospital, Nashville, Tenn. Pediatricians who are uncomfortable educating young patients about menstruation should refer the patient to a gynecologist or a pediatric gynecologist for whom such discussions are routine.

If a patient does not have a menstrual cycle by age 14 or 15, that also should be addressed by a family physician or gynecologist, Dr. Romano added.

“The importance here is addressing the reproductive health of the teen starting really at the age of 10 or 12, or once puberty starts,” said Patricia S. Huguelet, MD, a pediatric and adolescent gynecologist at Children’s Hospital Colorado, Aurora. In those early visits, the physician can provide “anticipatory guidance,” counseling the teen on what is normal in terms of menstruation, sex, and relationships, and addressing what is not, she said.

Ideally, patients who were designated female at birth but now identify as male or nonbinary will meet with a gynecologist early on in the gender affirmation process and a gynecologist will continue to consult as part of the patient’s interdisciplinary care team, added Dr. Romano, who counsels LGBTQ+ youth as part of her practice. A gynecologist may support these patients in myriad ways, including helping those who are considering or using puberty blockers and providing reproductive and health education to patients in a way that is sensitive to the patient’s gender identity.
 

Patient referrals

Some pediatricians and family practice physicians may be talking with their patients about topics such as menstrual cycles and contraception. But those who are uncomfortable asking adolescent patients about their reproductive and sexual health should refer them to a gynecologist or specialist in adolescent medicine, Dr. Romano advised.

“The biggest benefit I’ve noticed is often [patients] come from a pediatrician or family medicine provider and they often appreciate the opportunity to talk to a doctor they haven’t met before about the more personal questions they may have,” Dr. Amies Oelschlager said.

Referring adolescents to a specialist who has either trained in adolescent medicine or has experience treating that age group has benefits, Dr. Romano said. Clinicians with that experience understand adolescents are not “mini-adults” but have unique developmental and medical issues. How to counsel and educate them carries unique challenges, she said.

For example, heavy menstrual bleeding is a leading reason a patient – either an adult or an adolescent – presents to a gynecologist, Dr. Huguelet said. But the pathology differs vastly for those two age groups. For patients in their 30s and 40s, polyps and fibroids are common problems associated with heavy bleeding. Those conditions are rare in adolescents, whereas bleeding disorders are common, she said.

Most patients will continue to see their pediatricians and primary care providers for other issues. And in some areas, gynecologists can reinforce advice from pediatricians, such as encouraging patients to get the HPV vaccine, Dr. Amies Oelschlager said.
 

Common misconceptions

Primary care physicians can also dispel common misconceptions teens – and their parents – have about gynecology. Some parents may believe that certain methods of birth control cause cancer or infertility, have concerns about the HPV vaccine, or think hormonal therapies are harmful, Dr. Amies Oelschlager said. But the biggest misconception involves the infamous pelvic exam.

“Lots of patients assume that every time they go to the gynecologist they are going to have a pelvic exam,” she said. “When I say, ‘We don’t have to do that,’ they are so relieved.”

Guidelines have changed since the parents of today’s teens were going to the gynecologist for the first time. Many patients now do not need an initial Pap smear until age 25, following a recent guideline change by the American Cancer Society. (ACOG is considering adopting the same stance but still recommends screening start at 21.) “Most patients do not need an exam, even when it comes to sexual health and screening [for sexually transmitted infections], that can be done without an exam,” Dr. Huguelet said.
 

Confidentiality and comfort

On the other side of the referral, gynecologists should follow several best practices to treat adolescent patients. Arguably the most important part of the initial gynecologic visit is to give patients the option of one-on-one time with the physician with no parent in the room. During that time, the physician should make it clear that what they discuss is confidential and will not be shared with their parent or guardian, Dr. Huguelet said. Patients should also have the option of having a friend or another nonparent individual in the room with them during this one-on-one time with the physician, particularly if the patient does not feel comfortable discussing sensitive subjects completely on her own.

Adolescents receive better care, disclose more, and perceive they are getting better care when the process is confidential, Dr. Romano said. Confidentiality does have limits, however, which physicians should also make sure their patients understand, according to the ACOG guidelines for the initial reproductive visit. These limitations can vary by state depending on issues related to mandatory reporting, insurance billing, and legal requirements of patient notifications of specific services such as abortion.

The use of electronic medical records has raised additional challenges when it comes to communicating privately with adolescent patients, Dr. Amies Oelschlager said. In her practice, she tries to ensure the adolescent is the one with the login information for their records. If not, her office will have the patient’s cell number to text or call securely.

“We feel strongly adolescents should be able to access reproductive health care, mental health care, and care for substance abuse disorders without parental notification,” Dr. Amies Oelschlager said.

Telehealth visits can also be helpful for adolescents coming to gynecology for the first time. And taking the time to establish a rapport with patients at the start of the visit is key, Dr. Huguelet said. By directing questions to the adolescent patient rather than the parent, Dr. Huguelet said, the physician demonstrates that the teen’s treatment needs come first.

ACOG has guidelines on other steps gynecology practices, including those that see both adults and teens, can take to make their offices and visits adolescent-friendly. These steps include asking patients about their preferred names and pronouns at the start of the visit or as part of the initial intake form, training office staff to be comfortable with issues related to adolescent sexuality and gender and sexual diversity among patients, providing a place for teens to wait separately from obstetrics patients, and having age-appropriate literature on hand for adolescents to learn about reproductive health.

After that first reproductive health visit, gynecologists and primary care providers should partner to ensure the whole health of their patients is being addressed, Dr. Huguelet said.

“Collaboration is always going to better serve patients in any area,” said Dr. Romano, “and certainly this area is no different.”

Dr. Amies Oelschlager, Dr. Romano, and Dr. Huguelet have disclosed no relevant financial relationships.

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

For many adolescents, the first visit to a gynecologist can be intimidating. The prospect of meeting a new doctor who will ask prying, deeply personal questions about sex and menstruation is scary. And, in all likelihood, a parent, older sibling, or friend has warned them about the notorious pelvic exam.

The exact timing of when adolescent patients should start seeing a gynecologist varies based on when a patient starts puberty. Primary care physicians and pediatricians can help teens transition by referring patients to an adolescent-friendly practice and clearing up some of the misconceptions that surround the first gynecology visit. Gynecologists, on the other side of the referral, can help patients transition by guaranteeing confidentiality and creating a safe space for young patients.

This news organization interviewed three experts in adolescent health about when teens should start having their gynecological needs addressed and how their physicians can help them undergo that transition.
 

Age-appropriate care

“Most people get very limited information about their reproductive health,” said Anne-Marie E. Amies Oelschlager, MD, a pediatric and adolescent gynecologist at Seattle Children’s, Seattle, and a member of the American College of Obstetricians and Gynecologists (ACOG) clinical consensus committee on gynecology.

Official guidelines from ACOG call for the initial reproductive health visit to take place between the ages of 13 and 15 years. The exact age may vary, however, depending on the specific needs of the patient.

For example, some patients begin menstruating early, at age 9 or 10, said Mary Romano, MD, MPH, a pediatrician and adolescent medicine specialist at Vanderbilt Children’s Hospital, Nashville, Tenn. Pediatricians who are uncomfortable educating young patients about menstruation should refer the patient to a gynecologist or a pediatric gynecologist for whom such discussions are routine.

If a patient does not have a menstrual cycle by age 14 or 15, that also should be addressed by a family physician or gynecologist, Dr. Romano added.

“The importance here is addressing the reproductive health of the teen starting really at the age of 10 or 12, or once puberty starts,” said Patricia S. Huguelet, MD, a pediatric and adolescent gynecologist at Children’s Hospital Colorado, Aurora. In those early visits, the physician can provide “anticipatory guidance,” counseling the teen on what is normal in terms of menstruation, sex, and relationships, and addressing what is not, she said.

Ideally, patients who were designated female at birth but now identify as male or nonbinary will meet with a gynecologist early on in the gender affirmation process and a gynecologist will continue to consult as part of the patient’s interdisciplinary care team, added Dr. Romano, who counsels LGBTQ+ youth as part of her practice. A gynecologist may support these patients in myriad ways, including helping those who are considering or using puberty blockers and providing reproductive and health education to patients in a way that is sensitive to the patient’s gender identity.
 

Patient referrals

Some pediatricians and family practice physicians may be talking with their patients about topics such as menstrual cycles and contraception. But those who are uncomfortable asking adolescent patients about their reproductive and sexual health should refer them to a gynecologist or specialist in adolescent medicine, Dr. Romano advised.

“The biggest benefit I’ve noticed is often [patients] come from a pediatrician or family medicine provider and they often appreciate the opportunity to talk to a doctor they haven’t met before about the more personal questions they may have,” Dr. Amies Oelschlager said.

Referring adolescents to a specialist who has either trained in adolescent medicine or has experience treating that age group has benefits, Dr. Romano said. Clinicians with that experience understand adolescents are not “mini-adults” but have unique developmental and medical issues. How to counsel and educate them carries unique challenges, she said.

For example, heavy menstrual bleeding is a leading reason a patient – either an adult or an adolescent – presents to a gynecologist, Dr. Huguelet said. But the pathology differs vastly for those two age groups. For patients in their 30s and 40s, polyps and fibroids are common problems associated with heavy bleeding. Those conditions are rare in adolescents, whereas bleeding disorders are common, she said.

Most patients will continue to see their pediatricians and primary care providers for other issues. And in some areas, gynecologists can reinforce advice from pediatricians, such as encouraging patients to get the HPV vaccine, Dr. Amies Oelschlager said.
 

Common misconceptions

Primary care physicians can also dispel common misconceptions teens – and their parents – have about gynecology. Some parents may believe that certain methods of birth control cause cancer or infertility, have concerns about the HPV vaccine, or think hormonal therapies are harmful, Dr. Amies Oelschlager said. But the biggest misconception involves the infamous pelvic exam.

“Lots of patients assume that every time they go to the gynecologist they are going to have a pelvic exam,” she said. “When I say, ‘We don’t have to do that,’ they are so relieved.”

Guidelines have changed since the parents of today’s teens were going to the gynecologist for the first time. Many patients now do not need an initial Pap smear until age 25, following a recent guideline change by the American Cancer Society. (ACOG is considering adopting the same stance but still recommends screening start at 21.) “Most patients do not need an exam, even when it comes to sexual health and screening [for sexually transmitted infections], that can be done without an exam,” Dr. Huguelet said.
 

Confidentiality and comfort

On the other side of the referral, gynecologists should follow several best practices to treat adolescent patients. Arguably the most important part of the initial gynecologic visit is to give patients the option of one-on-one time with the physician with no parent in the room. During that time, the physician should make it clear that what they discuss is confidential and will not be shared with their parent or guardian, Dr. Huguelet said. Patients should also have the option of having a friend or another nonparent individual in the room with them during this one-on-one time with the physician, particularly if the patient does not feel comfortable discussing sensitive subjects completely on her own.

Adolescents receive better care, disclose more, and perceive they are getting better care when the process is confidential, Dr. Romano said. Confidentiality does have limits, however, which physicians should also make sure their patients understand, according to the ACOG guidelines for the initial reproductive visit. These limitations can vary by state depending on issues related to mandatory reporting, insurance billing, and legal requirements of patient notifications of specific services such as abortion.

The use of electronic medical records has raised additional challenges when it comes to communicating privately with adolescent patients, Dr. Amies Oelschlager said. In her practice, she tries to ensure the adolescent is the one with the login information for their records. If not, her office will have the patient’s cell number to text or call securely.

“We feel strongly adolescents should be able to access reproductive health care, mental health care, and care for substance abuse disorders without parental notification,” Dr. Amies Oelschlager said.

Telehealth visits can also be helpful for adolescents coming to gynecology for the first time. And taking the time to establish a rapport with patients at the start of the visit is key, Dr. Huguelet said. By directing questions to the adolescent patient rather than the parent, Dr. Huguelet said, the physician demonstrates that the teen’s treatment needs come first.

ACOG has guidelines on other steps gynecology practices, including those that see both adults and teens, can take to make their offices and visits adolescent-friendly. These steps include asking patients about their preferred names and pronouns at the start of the visit or as part of the initial intake form, training office staff to be comfortable with issues related to adolescent sexuality and gender and sexual diversity among patients, providing a place for teens to wait separately from obstetrics patients, and having age-appropriate literature on hand for adolescents to learn about reproductive health.

After that first reproductive health visit, gynecologists and primary care providers should partner to ensure the whole health of their patients is being addressed, Dr. Huguelet said.

“Collaboration is always going to better serve patients in any area,” said Dr. Romano, “and certainly this area is no different.”

Dr. Amies Oelschlager, Dr. Romano, and Dr. Huguelet have disclosed no relevant financial relationships.

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

For many adolescents, the first visit to a gynecologist can be intimidating. The prospect of meeting a new doctor who will ask prying, deeply personal questions about sex and menstruation is scary. And, in all likelihood, a parent, older sibling, or friend has warned them about the notorious pelvic exam.

The exact timing of when adolescent patients should start seeing a gynecologist varies based on when a patient starts puberty. Primary care physicians and pediatricians can help teens transition by referring patients to an adolescent-friendly practice and clearing up some of the misconceptions that surround the first gynecology visit. Gynecologists, on the other side of the referral, can help patients transition by guaranteeing confidentiality and creating a safe space for young patients.

This news organization interviewed three experts in adolescent health about when teens should start having their gynecological needs addressed and how their physicians can help them undergo that transition.
 

Age-appropriate care

“Most people get very limited information about their reproductive health,” said Anne-Marie E. Amies Oelschlager, MD, a pediatric and adolescent gynecologist at Seattle Children’s, Seattle, and a member of the American College of Obstetricians and Gynecologists (ACOG) clinical consensus committee on gynecology.

Official guidelines from ACOG call for the initial reproductive health visit to take place between the ages of 13 and 15 years. The exact age may vary, however, depending on the specific needs of the patient.

For example, some patients begin menstruating early, at age 9 or 10, said Mary Romano, MD, MPH, a pediatrician and adolescent medicine specialist at Vanderbilt Children’s Hospital, Nashville, Tenn. Pediatricians who are uncomfortable educating young patients about menstruation should refer the patient to a gynecologist or a pediatric gynecologist for whom such discussions are routine.

If a patient does not have a menstrual cycle by age 14 or 15, that also should be addressed by a family physician or gynecologist, Dr. Romano added.

“The importance here is addressing the reproductive health of the teen starting really at the age of 10 or 12, or once puberty starts,” said Patricia S. Huguelet, MD, a pediatric and adolescent gynecologist at Children’s Hospital Colorado, Aurora. In those early visits, the physician can provide “anticipatory guidance,” counseling the teen on what is normal in terms of menstruation, sex, and relationships, and addressing what is not, she said.

Ideally, patients who were designated female at birth but now identify as male or nonbinary will meet with a gynecologist early on in the gender affirmation process and a gynecologist will continue to consult as part of the patient’s interdisciplinary care team, added Dr. Romano, who counsels LGBTQ+ youth as part of her practice. A gynecologist may support these patients in myriad ways, including helping those who are considering or using puberty blockers and providing reproductive and health education to patients in a way that is sensitive to the patient’s gender identity.
 

Patient referrals

Some pediatricians and family practice physicians may be talking with their patients about topics such as menstrual cycles and contraception. But those who are uncomfortable asking adolescent patients about their reproductive and sexual health should refer them to a gynecologist or specialist in adolescent medicine, Dr. Romano advised.

“The biggest benefit I’ve noticed is often [patients] come from a pediatrician or family medicine provider and they often appreciate the opportunity to talk to a doctor they haven’t met before about the more personal questions they may have,” Dr. Amies Oelschlager said.

Referring adolescents to a specialist who has either trained in adolescent medicine or has experience treating that age group has benefits, Dr. Romano said. Clinicians with that experience understand adolescents are not “mini-adults” but have unique developmental and medical issues. How to counsel and educate them carries unique challenges, she said.

For example, heavy menstrual bleeding is a leading reason a patient – either an adult or an adolescent – presents to a gynecologist, Dr. Huguelet said. But the pathology differs vastly for those two age groups. For patients in their 30s and 40s, polyps and fibroids are common problems associated with heavy bleeding. Those conditions are rare in adolescents, whereas bleeding disorders are common, she said.

Most patients will continue to see their pediatricians and primary care providers for other issues. And in some areas, gynecologists can reinforce advice from pediatricians, such as encouraging patients to get the HPV vaccine, Dr. Amies Oelschlager said.
 

Common misconceptions

Primary care physicians can also dispel common misconceptions teens – and their parents – have about gynecology. Some parents may believe that certain methods of birth control cause cancer or infertility, have concerns about the HPV vaccine, or think hormonal therapies are harmful, Dr. Amies Oelschlager said. But the biggest misconception involves the infamous pelvic exam.

“Lots of patients assume that every time they go to the gynecologist they are going to have a pelvic exam,” she said. “When I say, ‘We don’t have to do that,’ they are so relieved.”

Guidelines have changed since the parents of today’s teens were going to the gynecologist for the first time. Many patients now do not need an initial Pap smear until age 25, following a recent guideline change by the American Cancer Society. (ACOG is considering adopting the same stance but still recommends screening start at 21.) “Most patients do not need an exam, even when it comes to sexual health and screening [for sexually transmitted infections], that can be done without an exam,” Dr. Huguelet said.
 

Confidentiality and comfort

On the other side of the referral, gynecologists should follow several best practices to treat adolescent patients. Arguably the most important part of the initial gynecologic visit is to give patients the option of one-on-one time with the physician with no parent in the room. During that time, the physician should make it clear that what they discuss is confidential and will not be shared with their parent or guardian, Dr. Huguelet said. Patients should also have the option of having a friend or another nonparent individual in the room with them during this one-on-one time with the physician, particularly if the patient does not feel comfortable discussing sensitive subjects completely on her own.

Adolescents receive better care, disclose more, and perceive they are getting better care when the process is confidential, Dr. Romano said. Confidentiality does have limits, however, which physicians should also make sure their patients understand, according to the ACOG guidelines for the initial reproductive visit. These limitations can vary by state depending on issues related to mandatory reporting, insurance billing, and legal requirements of patient notifications of specific services such as abortion.

The use of electronic medical records has raised additional challenges when it comes to communicating privately with adolescent patients, Dr. Amies Oelschlager said. In her practice, she tries to ensure the adolescent is the one with the login information for their records. If not, her office will have the patient’s cell number to text or call securely.

“We feel strongly adolescents should be able to access reproductive health care, mental health care, and care for substance abuse disorders without parental notification,” Dr. Amies Oelschlager said.

Telehealth visits can also be helpful for adolescents coming to gynecology for the first time. And taking the time to establish a rapport with patients at the start of the visit is key, Dr. Huguelet said. By directing questions to the adolescent patient rather than the parent, Dr. Huguelet said, the physician demonstrates that the teen’s treatment needs come first.

ACOG has guidelines on other steps gynecology practices, including those that see both adults and teens, can take to make their offices and visits adolescent-friendly. These steps include asking patients about their preferred names and pronouns at the start of the visit or as part of the initial intake form, training office staff to be comfortable with issues related to adolescent sexuality and gender and sexual diversity among patients, providing a place for teens to wait separately from obstetrics patients, and having age-appropriate literature on hand for adolescents to learn about reproductive health.

After that first reproductive health visit, gynecologists and primary care providers should partner to ensure the whole health of their patients is being addressed, Dr. Huguelet said.

“Collaboration is always going to better serve patients in any area,” said Dr. Romano, “and certainly this area is no different.”

Dr. Amies Oelschlager, Dr. Romano, and Dr. Huguelet have disclosed no relevant financial relationships.

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