Surgery may be more effective than medical therapy, according to results from a randomized trial in 78 patients with reflux-related heartburn refractory to proton pump inhibitors (PPIs).

Stuart J. Spechler, MD, from Baylor University Medical Center, Dallas, and coauthors wrote in the New England Journal of Medicine that, for these patients, there were no medical treatment options that had been shown to have long-term benefit, so PPIs were often continued despite not offering adequate symptom relief. Other medical options such as baclofen and neuromodulators often have unacceptable side effects, and studies of their efficacy were few and of short duration.

In this study, patients were randomized either to laparoscopic Nissen fundoplication, treatment with omeprazole plus baclofen with desipramine depending on symptoms, or a control treatment of omeprazole plus placebo.

At 1 year, researchers saw a significantly higher rate of treatment success – defined as 50% or greater improvement in gastroesophageal reflux disease health-related quality of life score – in the surgery group (67%), compared with the medical-treatment group (28%) and control-medical group (12%).

This translated to an unadjusted 138% greater chance of treatment success with surgery, compared with active medical treatment, and a greater than 400% increase for surgery, compared with the control medical treatment.

Researchers also did a prespecified subgroup analysis among people with reflex hypersensitivity or abnormal acid reflux, and found the incidence of success with surgery was 71% and 62%, respectively.

They described this finding as “noteworthy,” given that reflux hypersensitivity was considered a functional disorder that would not be expected to improve with a procedure that didn’t alter abnormal esophageal pain perception.

However, they acknowledged that, as the study did not include a sham-surgery group, they couldn’t determine how much the placebo effect might have contributed to the treatment success of surgery.

They also stressed that the randomized group was a highly selected group of patients, and that the systematic work-up including esophageal multichannel intraluminal impedance pH monitoring could identify a subgroup that might have a better response to surgery than to medical treatment.

Four patients in the surgery group experienced a total of five serious adverse events, including one patients who had a herniated fundoplication treated with repeat surgery; four patients in the active-medical group experienced four serious adverse events; and three patients in the control-medical group experienced five serious adverse events.

The authors noted that 366 patients with PPI-refractory heartburn were originally enrolled in the study, then treated with 20 mg of omeprazole twice daily for 2 weeks with strict instructions to take 20 minutes before breakfast and dinner. Of these patients, 42 had their symptoms relieved by the omeprazole treatment and so were excluded from the randomization.

The “strict instructions” on how to take omeprazole were important, because PPIs only bind to gastric proton pumps that are actively secreting acid, the authors wrote. They also commented that the relative potencies of individual PPIs can vary, so patients not on omeprazole before the study may have responded better to this than other PPIs.

Before randomizations, patients also underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance pH monitoring. This excluded another 23 patients who were found to have non–gastroesophageal reflux disease, including eosinophilic esophagitis, other endoscopic or histologic abnormalities, and manometric abnormalities.

“This trial highlights the critical importance of systematic evaluation, similar to that recommended by Gyawali and Fass for managing the care of patients with PPI-refractory heartburn,” they wrote. “Many patients would not complete this rigorous evaluation, and among those who did, the cause of heartburn in most of them was not [gastroesophageal reflux disease].”

The study was funded by the Department of Veterans Affairs Cooperative Studies Program. Four authors declared consultancies with and/or grants from the pharmaceutical sector.

SOURCE: Spechler SJ et al. N Engl J Med. 2019 Oct 16. doi: 10.1056/NEJMoa1811424.

Surgery may be more effective than medical therapy, according to results from a randomized trial in 78 patients with reflux-related heartburn refractory to proton pump inhibitors (PPIs).

Stuart J. Spechler, MD, from Baylor University Medical Center, Dallas, and coauthors wrote in the New England Journal of Medicine that, for these patients, there were no medical treatment options that had been shown to have long-term benefit, so PPIs were often continued despite not offering adequate symptom relief. Other medical options such as baclofen and neuromodulators often have unacceptable side effects, and studies of their efficacy were few and of short duration.

In this study, patients were randomized either to laparoscopic Nissen fundoplication, treatment with omeprazole plus baclofen with desipramine depending on symptoms, or a control treatment of omeprazole plus placebo.

At 1 year, researchers saw a significantly higher rate of treatment success – defined as 50% or greater improvement in gastroesophageal reflux disease health-related quality of life score – in the surgery group (67%), compared with the medical-treatment group (28%) and control-medical group (12%).

This translated to an unadjusted 138% greater chance of treatment success with surgery, compared with active medical treatment, and a greater than 400% increase for surgery, compared with the control medical treatment.

Researchers also did a prespecified subgroup analysis among people with reflex hypersensitivity or abnormal acid reflux, and found the incidence of success with surgery was 71% and 62%, respectively.

They described this finding as “noteworthy,” given that reflux hypersensitivity was considered a functional disorder that would not be expected to improve with a procedure that didn’t alter abnormal esophageal pain perception.

However, they acknowledged that, as the study did not include a sham-surgery group, they couldn’t determine how much the placebo effect might have contributed to the treatment success of surgery.

They also stressed that the randomized group was a highly selected group of patients, and that the systematic work-up including esophageal multichannel intraluminal impedance pH monitoring could identify a subgroup that might have a better response to surgery than to medical treatment.

Four patients in the surgery group experienced a total of five serious adverse events, including one patients who had a herniated fundoplication treated with repeat surgery; four patients in the active-medical group experienced four serious adverse events; and three patients in the control-medical group experienced five serious adverse events.

The authors noted that 366 patients with PPI-refractory heartburn were originally enrolled in the study, then treated with 20 mg of omeprazole twice daily for 2 weeks with strict instructions to take 20 minutes before breakfast and dinner. Of these patients, 42 had their symptoms relieved by the omeprazole treatment and so were excluded from the randomization.

The “strict instructions” on how to take omeprazole were important, because PPIs only bind to gastric proton pumps that are actively secreting acid, the authors wrote. They also commented that the relative potencies of individual PPIs can vary, so patients not on omeprazole before the study may have responded better to this than other PPIs.

Before randomizations, patients also underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance pH monitoring. This excluded another 23 patients who were found to have non–gastroesophageal reflux disease, including eosinophilic esophagitis, other endoscopic or histologic abnormalities, and manometric abnormalities.

“This trial highlights the critical importance of systematic evaluation, similar to that recommended by Gyawali and Fass for managing the care of patients with PPI-refractory heartburn,” they wrote. “Many patients would not complete this rigorous evaluation, and among those who did, the cause of heartburn in most of them was not [gastroesophageal reflux disease].”

The study was funded by the Department of Veterans Affairs Cooperative Studies Program. Four authors declared consultancies with and/or grants from the pharmaceutical sector.

SOURCE: Spechler SJ et al. N Engl J Med. 2019 Oct 16. doi: 10.1056/NEJMoa1811424.

Surgery may be more effective than medical therapy, according to results from a randomized trial in 78 patients with reflux-related heartburn refractory to proton pump inhibitors (PPIs).

Stuart J. Spechler, MD, from Baylor University Medical Center, Dallas, and coauthors wrote in the New England Journal of Medicine that, for these patients, there were no medical treatment options that had been shown to have long-term benefit, so PPIs were often continued despite not offering adequate symptom relief. Other medical options such as baclofen and neuromodulators often have unacceptable side effects, and studies of their efficacy were few and of short duration.

In this study, patients were randomized either to laparoscopic Nissen fundoplication, treatment with omeprazole plus baclofen with desipramine depending on symptoms, or a control treatment of omeprazole plus placebo.

At 1 year, researchers saw a significantly higher rate of treatment success – defined as 50% or greater improvement in gastroesophageal reflux disease health-related quality of life score – in the surgery group (67%), compared with the medical-treatment group (28%) and control-medical group (12%).

This translated to an unadjusted 138% greater chance of treatment success with surgery, compared with active medical treatment, and a greater than 400% increase for surgery, compared with the control medical treatment.

Researchers also did a prespecified subgroup analysis among people with reflex hypersensitivity or abnormal acid reflux, and found the incidence of success with surgery was 71% and 62%, respectively.

They described this finding as “noteworthy,” given that reflux hypersensitivity was considered a functional disorder that would not be expected to improve with a procedure that didn’t alter abnormal esophageal pain perception.

However, they acknowledged that, as the study did not include a sham-surgery group, they couldn’t determine how much the placebo effect might have contributed to the treatment success of surgery.

They also stressed that the randomized group was a highly selected group of patients, and that the systematic work-up including esophageal multichannel intraluminal impedance pH monitoring could identify a subgroup that might have a better response to surgery than to medical treatment.

Four patients in the surgery group experienced a total of five serious adverse events, including one patients who had a herniated fundoplication treated with repeat surgery; four patients in the active-medical group experienced four serious adverse events; and three patients in the control-medical group experienced five serious adverse events.

The authors noted that 366 patients with PPI-refractory heartburn were originally enrolled in the study, then treated with 20 mg of omeprazole twice daily for 2 weeks with strict instructions to take 20 minutes before breakfast and dinner. Of these patients, 42 had their symptoms relieved by the omeprazole treatment and so were excluded from the randomization.

The “strict instructions” on how to take omeprazole were important, because PPIs only bind to gastric proton pumps that are actively secreting acid, the authors wrote. They also commented that the relative potencies of individual PPIs can vary, so patients not on omeprazole before the study may have responded better to this than other PPIs.

Before randomizations, patients also underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance pH monitoring. This excluded another 23 patients who were found to have non–gastroesophageal reflux disease, including eosinophilic esophagitis, other endoscopic or histologic abnormalities, and manometric abnormalities.

“This trial highlights the critical importance of systematic evaluation, similar to that recommended by Gyawali and Fass for managing the care of patients with PPI-refractory heartburn,” they wrote. “Many patients would not complete this rigorous evaluation, and among those who did, the cause of heartburn in most of them was not [gastroesophageal reflux disease].”

The study was funded by the Department of Veterans Affairs Cooperative Studies Program. Four authors declared consultancies with and/or grants from the pharmaceutical sector.

SOURCE: Spechler SJ et al. N Engl J Med. 2019 Oct 16. doi: 10.1056/NEJMoa1811424.

SEATTLE – After years of relying on oral anticholinergics for treating hyperhidrosis, more options have recently become available, David Pariser, MD, said at the annual Coastal Dermatology Symposium.

Koldunov/Thinkstock

Hyperhidrosis is among the dermatological conditions that have the greatest impact on quality of life, and it can be particularly concerning to teens, said Dr. Pariser, professor of dermatology at Eastern Virginia Medical School, Norfolk. He referred to some new developments for an old, often misunderstood, standby: antiperspirants. “I am amazed that many people do not know the difference between an antiperspirant and a deodorant,” he said, pointing out that antiperspirants contain active ingredients – aluminum and zirconium salts – that block sweat glands, while deodorants contain a masking fragrance.

There are new-generation topical antiperspirants available over the counter, with descriptions that include “clinical strength” or “clinical protection” on the labels; they come in a box and cost about twice as much as standard products. “But they are better, and they work just as well as some of the commercial preparations,” Dr. Pariser said at the meeting, jointly presented by the University of Louisville and Global Academy for Medical Education.

One issue he highlighted was that antiperspirants are often misapplied. They shouldn’t be applied on wet skin because they react with water to create hydrochloric acid, which can irritate the skin, he said. The best time to apply an antiperspirant is right before bedtime, since it gives the salts time to clog sweat pores before sweat or water can interfere. “The plugs last for a couple of days,” so there’s no need to worry about rinsing the product off during a morning shower, he noted.

Additional therapeutic options include agents like oral glycopyrrolate, starting at a low dose (1 mg twice per day), increasing by 1 mg/day weekly until efficacy is achieved or limited by adverse events. There is also a glycopyrrolate oral solution 1mg/5ml (Cuvposa) that can be used in children.

A topical version of the anticholinergic glycopyrronium tosylate, applied using an infused cloth, was approved for treating axillary hyperhidrosis in June2018 and offers the potential for an enhanced local anticholinergic effect. Dr. Pariser, one of the authors, discussed the recently published results of two pivotal studies that found good improvement in a specially-designed quality of life endpoint (J Am Acad Derm. 2019; Jan;80[1]:128-138.e2).

Efficacy in a subanalysis of 44 pediatric subjects (ages 9-16 years) was similar as those reported in adults, and the rate of those reporting dry mouth (24% in both age groups) was similar. Of concern was a 16% rate of mydriasis in the pediatric group, compared with 6% in the older group. One patient even wound up in the emergency room for a stroke work-up as a result, said Dr. Pariser, who is confident that the problem was caused by inadvertent exposure to the eye during application. He advises patients to avoid contact with the eyes.

Other approaches to treatment of hyperhidrosis include oxybutynin, iontophoresis, an microwave thermolysis (which may also reduce odor and hair). Endoscopic thoracic sympathectomy is effective but is the most invasive option; botulinum toxin is a minimally invasive alternative to surgery.

For those who sweat when they experience anxiety, propranolol 5-10 mg taken about 1 hour before an event that could cause hyperhydrosis can be effective, said Dr. Pariser, who recommends a test dose. “I don’t normally tell patients to try something at home. But they should try this at home” before using it prior to an important event, he added.

Dr. Pariser is a consultant and/or investigator for Dermira, Brickell Biotech, TheraVida, Atacama, TDI Surgitech, Dermavant, and Revance Therapeutics. He has not done commercial speaking, has not been on speaker’s bureaus, and has no stock or options in any company.

This publication and Global Academy for Medical Education are owned by the same parent company.

SEATTLE – After years of relying on oral anticholinergics for treating hyperhidrosis, more options have recently become available, David Pariser, MD, said at the annual Coastal Dermatology Symposium.

Koldunov/Thinkstock

Hyperhidrosis is among the dermatological conditions that have the greatest impact on quality of life, and it can be particularly concerning to teens, said Dr. Pariser, professor of dermatology at Eastern Virginia Medical School, Norfolk. He referred to some new developments for an old, often misunderstood, standby: antiperspirants. “I am amazed that many people do not know the difference between an antiperspirant and a deodorant,” he said, pointing out that antiperspirants contain active ingredients – aluminum and zirconium salts – that block sweat glands, while deodorants contain a masking fragrance.

There are new-generation topical antiperspirants available over the counter, with descriptions that include “clinical strength” or “clinical protection” on the labels; they come in a box and cost about twice as much as standard products. “But they are better, and they work just as well as some of the commercial preparations,” Dr. Pariser said at the meeting, jointly presented by the University of Louisville and Global Academy for Medical Education.

One issue he highlighted was that antiperspirants are often misapplied. They shouldn’t be applied on wet skin because they react with water to create hydrochloric acid, which can irritate the skin, he said. The best time to apply an antiperspirant is right before bedtime, since it gives the salts time to clog sweat pores before sweat or water can interfere. “The plugs last for a couple of days,” so there’s no need to worry about rinsing the product off during a morning shower, he noted.

Additional therapeutic options include agents like oral glycopyrrolate, starting at a low dose (1 mg twice per day), increasing by 1 mg/day weekly until efficacy is achieved or limited by adverse events. There is also a glycopyrrolate oral solution 1mg/5ml (Cuvposa) that can be used in children.

A topical version of the anticholinergic glycopyrronium tosylate, applied using an infused cloth, was approved for treating axillary hyperhidrosis in June2018 and offers the potential for an enhanced local anticholinergic effect. Dr. Pariser, one of the authors, discussed the recently published results of two pivotal studies that found good improvement in a specially-designed quality of life endpoint (J Am Acad Derm. 2019; Jan;80[1]:128-138.e2).

Efficacy in a subanalysis of 44 pediatric subjects (ages 9-16 years) was similar as those reported in adults, and the rate of those reporting dry mouth (24% in both age groups) was similar. Of concern was a 16% rate of mydriasis in the pediatric group, compared with 6% in the older group. One patient even wound up in the emergency room for a stroke work-up as a result, said Dr. Pariser, who is confident that the problem was caused by inadvertent exposure to the eye during application. He advises patients to avoid contact with the eyes.

Other approaches to treatment of hyperhidrosis include oxybutynin, iontophoresis, an microwave thermolysis (which may also reduce odor and hair). Endoscopic thoracic sympathectomy is effective but is the most invasive option; botulinum toxin is a minimally invasive alternative to surgery.

For those who sweat when they experience anxiety, propranolol 5-10 mg taken about 1 hour before an event that could cause hyperhydrosis can be effective, said Dr. Pariser, who recommends a test dose. “I don’t normally tell patients to try something at home. But they should try this at home” before using it prior to an important event, he added.

Dr. Pariser is a consultant and/or investigator for Dermira, Brickell Biotech, TheraVida, Atacama, TDI Surgitech, Dermavant, and Revance Therapeutics. He has not done commercial speaking, has not been on speaker’s bureaus, and has no stock or options in any company.

This publication and Global Academy for Medical Education are owned by the same parent company.

SEATTLE – After years of relying on oral anticholinergics for treating hyperhidrosis, more options have recently become available, David Pariser, MD, said at the annual Coastal Dermatology Symposium.

Koldunov/Thinkstock

Hyperhidrosis is among the dermatological conditions that have the greatest impact on quality of life, and it can be particularly concerning to teens, said Dr. Pariser, professor of dermatology at Eastern Virginia Medical School, Norfolk. He referred to some new developments for an old, often misunderstood, standby: antiperspirants. “I am amazed that many people do not know the difference between an antiperspirant and a deodorant,” he said, pointing out that antiperspirants contain active ingredients – aluminum and zirconium salts – that block sweat glands, while deodorants contain a masking fragrance.

There are new-generation topical antiperspirants available over the counter, with descriptions that include “clinical strength” or “clinical protection” on the labels; they come in a box and cost about twice as much as standard products. “But they are better, and they work just as well as some of the commercial preparations,” Dr. Pariser said at the meeting, jointly presented by the University of Louisville and Global Academy for Medical Education.

One issue he highlighted was that antiperspirants are often misapplied. They shouldn’t be applied on wet skin because they react with water to create hydrochloric acid, which can irritate the skin, he said. The best time to apply an antiperspirant is right before bedtime, since it gives the salts time to clog sweat pores before sweat or water can interfere. “The plugs last for a couple of days,” so there’s no need to worry about rinsing the product off during a morning shower, he noted.

Additional therapeutic options include agents like oral glycopyrrolate, starting at a low dose (1 mg twice per day), increasing by 1 mg/day weekly until efficacy is achieved or limited by adverse events. There is also a glycopyrrolate oral solution 1mg/5ml (Cuvposa) that can be used in children.

A topical version of the anticholinergic glycopyrronium tosylate, applied using an infused cloth, was approved for treating axillary hyperhidrosis in June2018 and offers the potential for an enhanced local anticholinergic effect. Dr. Pariser, one of the authors, discussed the recently published results of two pivotal studies that found good improvement in a specially-designed quality of life endpoint (J Am Acad Derm. 2019; Jan;80[1]:128-138.e2).

Efficacy in a subanalysis of 44 pediatric subjects (ages 9-16 years) was similar as those reported in adults, and the rate of those reporting dry mouth (24% in both age groups) was similar. Of concern was a 16% rate of mydriasis in the pediatric group, compared with 6% in the older group. One patient even wound up in the emergency room for a stroke work-up as a result, said Dr. Pariser, who is confident that the problem was caused by inadvertent exposure to the eye during application. He advises patients to avoid contact with the eyes.

Other approaches to treatment of hyperhidrosis include oxybutynin, iontophoresis, an microwave thermolysis (which may also reduce odor and hair). Endoscopic thoracic sympathectomy is effective but is the most invasive option; botulinum toxin is a minimally invasive alternative to surgery.

For those who sweat when they experience anxiety, propranolol 5-10 mg taken about 1 hour before an event that could cause hyperhydrosis can be effective, said Dr. Pariser, who recommends a test dose. “I don’t normally tell patients to try something at home. But they should try this at home” before using it prior to an important event, he added.

Dr. Pariser is a consultant and/or investigator for Dermira, Brickell Biotech, TheraVida, Atacama, TDI Surgitech, Dermavant, and Revance Therapeutics. He has not done commercial speaking, has not been on speaker’s bureaus, and has no stock or options in any company.

This publication and Global Academy for Medical Education are owned by the same parent company.

Among athletes with concussion, the effects of the injury on brain physiology may persist when they return to play and 1 year later.

MRI measures from 24 athletes with concussion significantly differed from those of controls at various time points and changed over time, according to a study published in Neurology. “Different aspects of brain physiology have different patterns of long-term recovery,” the researchers wrote.

While guidelines for safe return to play mainly rely on the resolution of symptoms, “the findings in this study indicate that more research is needed ... to better understand optimal recovery time from a biological standpoint,” wrote first author Nathan W. Churchill, PhD, a researcher at St. Michael’s Hospital in Toronto, and colleagues.

The study provides “evidence of incomplete or ongoing recovery” when athletes return to play, which could entail “a potential risk for long-term sequelae, given the evidence of worse outcomes if a second concussion occurs before recovery is complete,” according to the investigators. In addition, the study reinforces that neurobiological recovery varies across individuals and might depend on the initial clinical presentation.

To examine whether concussion-related brain changes dissipate by 1 year after athletes receive medical clearance to return to play, Dr. Churchill and colleagues analyzed MRI data from 24 college athletes with concussion and 122 control athletes without concussion.

Athletes with concussion were scanned within 1 week of the injury, at return to play a median of 27 days after the concussion, and 1 year after return to play. Control athletes were scanned before the start of the season. Participants’ sports included volleyball, hockey, soccer, football, rugby, basketball, lacrosse, and water polo. The participants had a mean age of about 20 years, and about half were women.

Athletes with concussion had elevated mean diffusivity within 1 week of injury, at return to play, and 1 year later, compared with controls. In athletes with concussion, cerebral blood flow was elevated soon after concussion, normal at return to play, and decreased 1 year later, relative to controls. Global functional connectivity increased and white matter fractional anisotropy decreased near the time of injury and at return to play, but these measures did not significantly differ from those of controls at 1 year.

The study did not capture MRI changes between return to play and 1 year later. In addition, MRI changes might be influenced by a lack of training before resuming play, as well as by exertion and subconcussive impacts after returning to play, the authors noted.

The Canadian Institutes of Health Research, the Canadian Institute for Military and Veterans Health Research, and Siemens Healthineers Canada supported the study. Siemens makes the MRI equipment used in the study. Dr. Churchill and colleagues had no relevant disclosures.

jremaly@mdedge.com

SOURCE: Churchill NW et al. Neurology. 2019 Oct 16. doi: 10.1212/WNL.0000000000008523.
 

Among athletes with concussion, the effects of the injury on brain physiology may persist when they return to play and 1 year later.

MRI measures from 24 athletes with concussion significantly differed from those of controls at various time points and changed over time, according to a study published in Neurology. “Different aspects of brain physiology have different patterns of long-term recovery,” the researchers wrote.

While guidelines for safe return to play mainly rely on the resolution of symptoms, “the findings in this study indicate that more research is needed ... to better understand optimal recovery time from a biological standpoint,” wrote first author Nathan W. Churchill, PhD, a researcher at St. Michael’s Hospital in Toronto, and colleagues.

The study provides “evidence of incomplete or ongoing recovery” when athletes return to play, which could entail “a potential risk for long-term sequelae, given the evidence of worse outcomes if a second concussion occurs before recovery is complete,” according to the investigators. In addition, the study reinforces that neurobiological recovery varies across individuals and might depend on the initial clinical presentation.

To examine whether concussion-related brain changes dissipate by 1 year after athletes receive medical clearance to return to play, Dr. Churchill and colleagues analyzed MRI data from 24 college athletes with concussion and 122 control athletes without concussion.

Athletes with concussion were scanned within 1 week of the injury, at return to play a median of 27 days after the concussion, and 1 year after return to play. Control athletes were scanned before the start of the season. Participants’ sports included volleyball, hockey, soccer, football, rugby, basketball, lacrosse, and water polo. The participants had a mean age of about 20 years, and about half were women.

Athletes with concussion had elevated mean diffusivity within 1 week of injury, at return to play, and 1 year later, compared with controls. In athletes with concussion, cerebral blood flow was elevated soon after concussion, normal at return to play, and decreased 1 year later, relative to controls. Global functional connectivity increased and white matter fractional anisotropy decreased near the time of injury and at return to play, but these measures did not significantly differ from those of controls at 1 year.

The study did not capture MRI changes between return to play and 1 year later. In addition, MRI changes might be influenced by a lack of training before resuming play, as well as by exertion and subconcussive impacts after returning to play, the authors noted.

The Canadian Institutes of Health Research, the Canadian Institute for Military and Veterans Health Research, and Siemens Healthineers Canada supported the study. Siemens makes the MRI equipment used in the study. Dr. Churchill and colleagues had no relevant disclosures.

jremaly@mdedge.com

SOURCE: Churchill NW et al. Neurology. 2019 Oct 16. doi: 10.1212/WNL.0000000000008523.
 

Among athletes with concussion, the effects of the injury on brain physiology may persist when they return to play and 1 year later.

MRI measures from 24 athletes with concussion significantly differed from those of controls at various time points and changed over time, according to a study published in Neurology. “Different aspects of brain physiology have different patterns of long-term recovery,” the researchers wrote.

While guidelines for safe return to play mainly rely on the resolution of symptoms, “the findings in this study indicate that more research is needed ... to better understand optimal recovery time from a biological standpoint,” wrote first author Nathan W. Churchill, PhD, a researcher at St. Michael’s Hospital in Toronto, and colleagues.

The study provides “evidence of incomplete or ongoing recovery” when athletes return to play, which could entail “a potential risk for long-term sequelae, given the evidence of worse outcomes if a second concussion occurs before recovery is complete,” according to the investigators. In addition, the study reinforces that neurobiological recovery varies across individuals and might depend on the initial clinical presentation.

To examine whether concussion-related brain changes dissipate by 1 year after athletes receive medical clearance to return to play, Dr. Churchill and colleagues analyzed MRI data from 24 college athletes with concussion and 122 control athletes without concussion.

Athletes with concussion were scanned within 1 week of the injury, at return to play a median of 27 days after the concussion, and 1 year after return to play. Control athletes were scanned before the start of the season. Participants’ sports included volleyball, hockey, soccer, football, rugby, basketball, lacrosse, and water polo. The participants had a mean age of about 20 years, and about half were women.

Athletes with concussion had elevated mean diffusivity within 1 week of injury, at return to play, and 1 year later, compared with controls. In athletes with concussion, cerebral blood flow was elevated soon after concussion, normal at return to play, and decreased 1 year later, relative to controls. Global functional connectivity increased and white matter fractional anisotropy decreased near the time of injury and at return to play, but these measures did not significantly differ from those of controls at 1 year.

The study did not capture MRI changes between return to play and 1 year later. In addition, MRI changes might be influenced by a lack of training before resuming play, as well as by exertion and subconcussive impacts after returning to play, the authors noted.

The Canadian Institutes of Health Research, the Canadian Institute for Military and Veterans Health Research, and Siemens Healthineers Canada supported the study. Siemens makes the MRI equipment used in the study. Dr. Churchill and colleagues had no relevant disclosures.

jremaly@mdedge.com

SOURCE: Churchill NW et al. Neurology. 2019 Oct 16. doi: 10.1212/WNL.0000000000008523.
 

A new study has found that, although the Affordable Care Act (ACA) increased health insurance coverage in states that expanded their Medicaid program, the expansion did not translate into improved access to care or decreased preventable hospitalizations of patients with systemic lupus erythematosus (SLE).

juststock/gettyimages

“Our findings emphasize the importance of addressing systemic problems with American healthcare delivery at multiple levels,” wrote Elizabeth A. Brown, PhD, of the Medical University of South Carolina, Charleston, and her coauthors. The study was published in Arthritis Care & Research.

To examine the effects of the ACA’s Medicaid expansion on lupus patients when it was implemented Jan. 1, 2014, the researchers launched a retrospective, quasi‐experimental study using administrative data from eight states to compare eight quarterly time points in the 2 years prior to implementation against seven quarterly time points in the 2 years after implementation. Four states expanded Medicaid under the ACA – Arizona, Kentucky, New Jersey, and New York – and four of them did not – Florida, Georgia, South Carolina, and Wisconsin.

During the study period, there were 204,150 lupus hospitalizations across all eight states during the 15 quarters, 53% of which occurred in the four states that did not expand Medicaid. Although the investigators’ base model found that the probability of a preventable hospitalization did not increase over time (odds ratio, 1.004; 95% confidence interval, 0.996-1.013), the four expansion states had significantly higher odds of having preventable hospitalizations in the final adjusted model (OR, 1.302; 95% CI, 1.119-1.515).

Variables that contributed to higher odds of a preventable hospitalization included age: Lupus patients who were 55-64 years old had considerably higher odds for preventable lupus hospitalizations than did patients who were 20-34 years old (OR, 1.488; 95% CI, 1.415-1.564). In addition, those with a median household income under $42,000 had higher odds of hospitalization when compared with those making over $68,000 (OR, 1.138; 95% CI, 1.415-1.564), as did those on Medicaid compared with those on private insurance (OR, 1.298; 95% CI, 1.238-1.361).

The authors acknowledged their study’s limitations, including relying on potential coding errors within administrative data. In addition, they were unable to factor in Medicaid marketing, enrollment strategies, or other related actions undertaken in each of the eight states.

The study was partially supported by the South Carolina Clinical & Translational Research Institute via a National Center for Advancing Translational Sciences grant. The authors reported no conflicts of interest.

SOURCE: Brown EA et al. Arthritis Care Res. 2019 Sept 28. doi: 10.1002/acr.24080

A new study has found that, although the Affordable Care Act (ACA) increased health insurance coverage in states that expanded their Medicaid program, the expansion did not translate into improved access to care or decreased preventable hospitalizations of patients with systemic lupus erythematosus (SLE).

juststock/gettyimages

“Our findings emphasize the importance of addressing systemic problems with American healthcare delivery at multiple levels,” wrote Elizabeth A. Brown, PhD, of the Medical University of South Carolina, Charleston, and her coauthors. The study was published in Arthritis Care & Research.

To examine the effects of the ACA’s Medicaid expansion on lupus patients when it was implemented Jan. 1, 2014, the researchers launched a retrospective, quasi‐experimental study using administrative data from eight states to compare eight quarterly time points in the 2 years prior to implementation against seven quarterly time points in the 2 years after implementation. Four states expanded Medicaid under the ACA – Arizona, Kentucky, New Jersey, and New York – and four of them did not – Florida, Georgia, South Carolina, and Wisconsin.

During the study period, there were 204,150 lupus hospitalizations across all eight states during the 15 quarters, 53% of which occurred in the four states that did not expand Medicaid. Although the investigators’ base model found that the probability of a preventable hospitalization did not increase over time (odds ratio, 1.004; 95% confidence interval, 0.996-1.013), the four expansion states had significantly higher odds of having preventable hospitalizations in the final adjusted model (OR, 1.302; 95% CI, 1.119-1.515).

Variables that contributed to higher odds of a preventable hospitalization included age: Lupus patients who were 55-64 years old had considerably higher odds for preventable lupus hospitalizations than did patients who were 20-34 years old (OR, 1.488; 95% CI, 1.415-1.564). In addition, those with a median household income under $42,000 had higher odds of hospitalization when compared with those making over $68,000 (OR, 1.138; 95% CI, 1.415-1.564), as did those on Medicaid compared with those on private insurance (OR, 1.298; 95% CI, 1.238-1.361).

The authors acknowledged their study’s limitations, including relying on potential coding errors within administrative data. In addition, they were unable to factor in Medicaid marketing, enrollment strategies, or other related actions undertaken in each of the eight states.

The study was partially supported by the South Carolina Clinical & Translational Research Institute via a National Center for Advancing Translational Sciences grant. The authors reported no conflicts of interest.

SOURCE: Brown EA et al. Arthritis Care Res. 2019 Sept 28. doi: 10.1002/acr.24080

A new study has found that, although the Affordable Care Act (ACA) increased health insurance coverage in states that expanded their Medicaid program, the expansion did not translate into improved access to care or decreased preventable hospitalizations of patients with systemic lupus erythematosus (SLE).

juststock/gettyimages

“Our findings emphasize the importance of addressing systemic problems with American healthcare delivery at multiple levels,” wrote Elizabeth A. Brown, PhD, of the Medical University of South Carolina, Charleston, and her coauthors. The study was published in Arthritis Care & Research.

To examine the effects of the ACA’s Medicaid expansion on lupus patients when it was implemented Jan. 1, 2014, the researchers launched a retrospective, quasi‐experimental study using administrative data from eight states to compare eight quarterly time points in the 2 years prior to implementation against seven quarterly time points in the 2 years after implementation. Four states expanded Medicaid under the ACA – Arizona, Kentucky, New Jersey, and New York – and four of them did not – Florida, Georgia, South Carolina, and Wisconsin.

During the study period, there were 204,150 lupus hospitalizations across all eight states during the 15 quarters, 53% of which occurred in the four states that did not expand Medicaid. Although the investigators’ base model found that the probability of a preventable hospitalization did not increase over time (odds ratio, 1.004; 95% confidence interval, 0.996-1.013), the four expansion states had significantly higher odds of having preventable hospitalizations in the final adjusted model (OR, 1.302; 95% CI, 1.119-1.515).

Variables that contributed to higher odds of a preventable hospitalization included age: Lupus patients who were 55-64 years old had considerably higher odds for preventable lupus hospitalizations than did patients who were 20-34 years old (OR, 1.488; 95% CI, 1.415-1.564). In addition, those with a median household income under $42,000 had higher odds of hospitalization when compared with those making over $68,000 (OR, 1.138; 95% CI, 1.415-1.564), as did those on Medicaid compared with those on private insurance (OR, 1.298; 95% CI, 1.238-1.361).

The authors acknowledged their study’s limitations, including relying on potential coding errors within administrative data. In addition, they were unable to factor in Medicaid marketing, enrollment strategies, or other related actions undertaken in each of the eight states.

The study was partially supported by the South Carolina Clinical & Translational Research Institute via a National Center for Advancing Translational Sciences grant. The authors reported no conflicts of interest.

SOURCE: Brown EA et al. Arthritis Care Res. 2019 Sept 28. doi: 10.1002/acr.24080

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.

Cameravit/iStock/Getty Images

Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.

You may have survived the gauntlet of medical school and residency relatively unscathed. But does your current work environment bring back memories of how stressed you felt on the worst days during your training? Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?

Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.

You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.

This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.

Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.

As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.

Cameravit/iStock/Getty Images

Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.

You may have survived the gauntlet of medical school and residency relatively unscathed. But does your current work environment bring back memories of how stressed you felt on the worst days during your training? Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?

Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.

You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.

This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.

Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.

As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.

Cameravit/iStock/Getty Images

Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.

You may have survived the gauntlet of medical school and residency relatively unscathed. But does your current work environment bring back memories of how stressed you felt on the worst days during your training? Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?

Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.

You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.

This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.

Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.

As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

WASHINGTON – Evidence continues to mount that infants born to moms infected with Zika virus during pregnancy can have neurodevelopmental abnormalities as they age even if they showed no defects at birth, based on follow-up of 890 Colombian children tracked by epidemiologists from the U.S. Centers for Disease Control and Prevention.

Among the 890 neonates born to mothers apparently infected with Zika during pregnancy and followed for up to 2 years, 40 of the 852 (5%) without a detectable birth defect at delivery went on to show some type of neurodevelopmental sequelae during up to 24 months of age, Margaret Honein, PhD, said at an annual scientific meeting on infectious diseases.

In addition, among the children without birth defects at delivery who received follow-up examinations out to about 2 years, the incidence of “alerts” for possible neurodevelopmental issues was 15%-20% for each of the four domains studied (gross motor, fine motor, hearing and language, and personal and social functions), said Dr. Honein, an epidemiologist and chief of the birth defects branch of the CDC. In contrast, 17 of the 38 children (45%) followed who had identifiable birth defects at delivery also showed neurodevelopmental abnormalities when reexamined as long as 2 years after birth. These possible neurodevelopmental abnormalities, designated as alerts, were identified in comparison with a contemporaneous cohort of children born to uninfected mothers in the same regions of Colombia and assessed by the CDC researchers.

This cohort of children born to mothers who became infected with Zika virus during the 2016 Colombian epidemic will not undergo any planned, additional follow-up beyond the initial 2 years, Dr. Honein noted.

The findings she reported were consistent with observations from a much smaller cohort of 70 infants born to Colombian mothers infected with Zika virus while pregnant who had a normal head circumference and a normal clinical examination at delivery. When assessed once or twice 4-18 months after birth, these 70 infants showed an overall greater than one standard deviation (z-score) drop in their scores on the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA) metric by 12 months after birth and continuing out to 18 months, said Sarah B. Mulkey, MD, a fetal-neonatal neurologist at Children’s National Health System in Washington. These deficits were especially pronounced in the mobility and social cognition domains of the four-domain WIDEA metric. The social cognition domain is an important predictor of later problems with executive function and other neurologic disorders, Dr. Mulkey said while reporting her findings in a separate talk at the meeting. She acknowledged that the analysis was flawed by comparing the WIDEA outcomes of the Zika virus–exposed children to healthy children from either inner-city Chicago or Canada. Dr. Mulkey said that she and her associates plan to characterize a population of Zika virus–unexposed children in Colombia to use for future comparisons.

The study reported by Dr. Honein involved an enhanced surveillance program launched by the CDC in 2016 in three regions of Colombia and included 1,190 pregnancies accompanied by Zika symptoms in the mother and with a reported pregnancy outcome, including 1,185 live births. Nearly half of the Zika infections occurred during the first trimester, and 34% occurred during the second trimester. However, fewer than a third of the pregnant women underwent some type of laboratory testing to confirm their infection, either by serology or by a DNA-based assay, and of these 28% had a positive finding. Dr. Honein cautioned that many of the specimens that tested negative for Zika virus may have been false negatives.

The birth defects identified among the infants born from an apparently affected pregnancy included brain abnormalities, eye anomalies, and microcephaly, with 5% of the 1,185 live births showing one or more of these outcomes. The neurodevelopmental deficits identified during follow-up of 890 of the children out to 2 years included seizures; abnormalities of tone, movement, or swallowing; and impairments of vision or hearing.

mzoler@mdedge.com

WASHINGTON – Evidence continues to mount that infants born to moms infected with Zika virus during pregnancy can have neurodevelopmental abnormalities as they age even if they showed no defects at birth, based on follow-up of 890 Colombian children tracked by epidemiologists from the U.S. Centers for Disease Control and Prevention.

Among the 890 neonates born to mothers apparently infected with Zika during pregnancy and followed for up to 2 years, 40 of the 852 (5%) without a detectable birth defect at delivery went on to show some type of neurodevelopmental sequelae during up to 24 months of age, Margaret Honein, PhD, said at an annual scientific meeting on infectious diseases.

In addition, among the children without birth defects at delivery who received follow-up examinations out to about 2 years, the incidence of “alerts” for possible neurodevelopmental issues was 15%-20% for each of the four domains studied (gross motor, fine motor, hearing and language, and personal and social functions), said Dr. Honein, an epidemiologist and chief of the birth defects branch of the CDC. In contrast, 17 of the 38 children (45%) followed who had identifiable birth defects at delivery also showed neurodevelopmental abnormalities when reexamined as long as 2 years after birth. These possible neurodevelopmental abnormalities, designated as alerts, were identified in comparison with a contemporaneous cohort of children born to uninfected mothers in the same regions of Colombia and assessed by the CDC researchers.

This cohort of children born to mothers who became infected with Zika virus during the 2016 Colombian epidemic will not undergo any planned, additional follow-up beyond the initial 2 years, Dr. Honein noted.

The findings she reported were consistent with observations from a much smaller cohort of 70 infants born to Colombian mothers infected with Zika virus while pregnant who had a normal head circumference and a normal clinical examination at delivery. When assessed once or twice 4-18 months after birth, these 70 infants showed an overall greater than one standard deviation (z-score) drop in their scores on the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA) metric by 12 months after birth and continuing out to 18 months, said Sarah B. Mulkey, MD, a fetal-neonatal neurologist at Children’s National Health System in Washington. These deficits were especially pronounced in the mobility and social cognition domains of the four-domain WIDEA metric. The social cognition domain is an important predictor of later problems with executive function and other neurologic disorders, Dr. Mulkey said while reporting her findings in a separate talk at the meeting. She acknowledged that the analysis was flawed by comparing the WIDEA outcomes of the Zika virus–exposed children to healthy children from either inner-city Chicago or Canada. Dr. Mulkey said that she and her associates plan to characterize a population of Zika virus–unexposed children in Colombia to use for future comparisons.

The study reported by Dr. Honein involved an enhanced surveillance program launched by the CDC in 2016 in three regions of Colombia and included 1,190 pregnancies accompanied by Zika symptoms in the mother and with a reported pregnancy outcome, including 1,185 live births. Nearly half of the Zika infections occurred during the first trimester, and 34% occurred during the second trimester. However, fewer than a third of the pregnant women underwent some type of laboratory testing to confirm their infection, either by serology or by a DNA-based assay, and of these 28% had a positive finding. Dr. Honein cautioned that many of the specimens that tested negative for Zika virus may have been false negatives.

The birth defects identified among the infants born from an apparently affected pregnancy included brain abnormalities, eye anomalies, and microcephaly, with 5% of the 1,185 live births showing one or more of these outcomes. The neurodevelopmental deficits identified during follow-up of 890 of the children out to 2 years included seizures; abnormalities of tone, movement, or swallowing; and impairments of vision or hearing.

mzoler@mdedge.com

WASHINGTON – Evidence continues to mount that infants born to moms infected with Zika virus during pregnancy can have neurodevelopmental abnormalities as they age even if they showed no defects at birth, based on follow-up of 890 Colombian children tracked by epidemiologists from the U.S. Centers for Disease Control and Prevention.

Among the 890 neonates born to mothers apparently infected with Zika during pregnancy and followed for up to 2 years, 40 of the 852 (5%) without a detectable birth defect at delivery went on to show some type of neurodevelopmental sequelae during up to 24 months of age, Margaret Honein, PhD, said at an annual scientific meeting on infectious diseases.

In addition, among the children without birth defects at delivery who received follow-up examinations out to about 2 years, the incidence of “alerts” for possible neurodevelopmental issues was 15%-20% for each of the four domains studied (gross motor, fine motor, hearing and language, and personal and social functions), said Dr. Honein, an epidemiologist and chief of the birth defects branch of the CDC. In contrast, 17 of the 38 children (45%) followed who had identifiable birth defects at delivery also showed neurodevelopmental abnormalities when reexamined as long as 2 years after birth. These possible neurodevelopmental abnormalities, designated as alerts, were identified in comparison with a contemporaneous cohort of children born to uninfected mothers in the same regions of Colombia and assessed by the CDC researchers.

This cohort of children born to mothers who became infected with Zika virus during the 2016 Colombian epidemic will not undergo any planned, additional follow-up beyond the initial 2 years, Dr. Honein noted.

The findings she reported were consistent with observations from a much smaller cohort of 70 infants born to Colombian mothers infected with Zika virus while pregnant who had a normal head circumference and a normal clinical examination at delivery. When assessed once or twice 4-18 months after birth, these 70 infants showed an overall greater than one standard deviation (z-score) drop in their scores on the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA) metric by 12 months after birth and continuing out to 18 months, said Sarah B. Mulkey, MD, a fetal-neonatal neurologist at Children’s National Health System in Washington. These deficits were especially pronounced in the mobility and social cognition domains of the four-domain WIDEA metric. The social cognition domain is an important predictor of later problems with executive function and other neurologic disorders, Dr. Mulkey said while reporting her findings in a separate talk at the meeting. She acknowledged that the analysis was flawed by comparing the WIDEA outcomes of the Zika virus–exposed children to healthy children from either inner-city Chicago or Canada. Dr. Mulkey said that she and her associates plan to characterize a population of Zika virus–unexposed children in Colombia to use for future comparisons.

The study reported by Dr. Honein involved an enhanced surveillance program launched by the CDC in 2016 in three regions of Colombia and included 1,190 pregnancies accompanied by Zika symptoms in the mother and with a reported pregnancy outcome, including 1,185 live births. Nearly half of the Zika infections occurred during the first trimester, and 34% occurred during the second trimester. However, fewer than a third of the pregnant women underwent some type of laboratory testing to confirm their infection, either by serology or by a DNA-based assay, and of these 28% had a positive finding. Dr. Honein cautioned that many of the specimens that tested negative for Zika virus may have been false negatives.

The birth defects identified among the infants born from an apparently affected pregnancy included brain abnormalities, eye anomalies, and microcephaly, with 5% of the 1,185 live births showing one or more of these outcomes. The neurodevelopmental deficits identified during follow-up of 890 of the children out to 2 years included seizures; abnormalities of tone, movement, or swallowing; and impairments of vision or hearing.

mzoler@mdedge.com

It is often fun and sometimes exhausting watching the speed with which children run around or switch from one game to another. A lot of us were attracted to pediatrics to share the quick joy of children and also the speed of their physical recovery. We get to see premature infants gain an ounce a day, and see wounds heal in less than a week. We give advice on sleep and see success in a month. We and the families get used to quick fixes.

SyhinStas/iStock/Getty Images Plus

Parents and children are forewarned and reassured by our knowledge about how long things typically take: Respiratory syncytial virus (RSV) peaks in 5 days, colic lessens in 3 months, changing sleep patterns takes 3 weeks, habit formation 6 weeks, menses come 2 years after breast development, and so on. But the timing of daily parenting is rarely as predictable. Sometimes a child’s clock is running fast, making waiting even seconds for a snack or a bathroom difficult; other times are slow, as when walking down the sidewalk noticing every leaf. The child’s clock is independent of the adult’s – and complicated by clocks of siblings.

Parent pace also is determined by many factors unrelated to the child: work demands, deadlines, train schedules, something in the oven, needs of siblings, and so on. To those can be added intrinsic factors affecting parent’s tolerance to shifting pace to the child’s such as temperament, fatigue, illness, pain, or even adult ADHD. And don’t forget caffeine (or other drugs) affecting the internal metronome. When impatience with the child is a complaint, it is useful to ask, “What makes waiting for your child difficult for you?”

When discussing time, I find it important to discuss the poison “s-word” of parenting – “should.” This trickster often comes from time illusions in childrearing. After seeing so many behaviors change quickly, parents expect all change to be equally fast. She should be able to sleep through the night by now! He should be able to dress and get to the table in 5 minutes. And sometimes it is the parent’s s-word that creates pain – I should love pushing for as long as she wants to swing, if I am a good parent. The problem with thinking “should” is that it implies willful or moral behavior, and it may prompt a judgmental or punitive parental response.

One major issue with timing is called “transition trouble.” Otherwise well intentioned, cooperative children who take longer to shift their attention from homework to shower can be seen as oppositional. Worse yet, if the example used is from playing video games (something fun) to getting to the bus stop (an undesirable shift), you may hear parents critically say, “He only wants to do what he wants to do.” When examining examples (always key to helping with behavior), pointing out that all kinds of transitions are difficult for this child may be educational and allow for a more reasoned response. And specifically being on electronics puts adults as well as children in a time warp which is hard to escape.

There are many kinds of thwarted expectations, but expectations about how long things take are pretty universal. Frustration generates anger and even can lead to violence, such as road rage. Children – who all step to the beat of a different drummer, especially those with different “clocks” such as in ADHD – may experience frustration most of the day. This can manifest as irritability for them and sometimes as an irritable response back from the parent.

The first step in adapting to differences in parent and child pace is to realize that time is the problem. Naming it, saying “we are on toddler time,” can be a “signal to self” to slow down. Generations of children loved Mr. Rogers because he always conveyed having all the time in the world for the person he was with. It actually does not take as long as it feels at first to do this. Listening while keeping eye contact, breathing deeply, and waiting until two breaths after the child goes silent before speaking or moving conveys your interest and respect. For some behaviors, such as tantrums, such quiet attention may be all that is needed to resolve the issue. We adults can practice this, but even infants can be helped to develop patience by reinforcement with brief attention from their caregivers for tiny increments of waiting.

I sometimes suggest that parents time behaviors to develop perspective, reset expectations, practice waiting, and perhaps even distract themselves from intervening and making things worse by lending attention to negative behaviors. Timing as observation can be helpful for tantrums, breath holding spells, whining, and sibling squabbles; maximum times for baths and video games; minimum times for meals, sitting to poop, and special time. Timers are not just for Time Out! “Visual timers” that show green then yellow then red and sometimes flashing lights as warnings of an upcoming stopping point are helpful for children preschool and older. These timers help them to develop a better sense of time and begin managing their own transitions. A game of guessing how long things take can build timing skills and patience. I think every child past preschool benefits from a wristwatch, first to build time sense, and second to avoid looking at a smartphone to see the hour, then being distracted by content! Diaries of behaviors over time are a staple of behavior change plans, with the added benefit of lending perspective on actually how often and how long a troublesome behavior occurs. Practicing mindfulness – nonjudgmental watching of our thoughts and feelings, often with deep breathing and relaxation – also can help both children and adults build time tolerance.

Children have little control over their daily schedule. Surrendering when you can for them to do things at their own pace can reduce their frustration, build the parent-child relationship, and promote positive behaviors. Plus family life is more enjoyable lived slower. You even can remind parents that “the days are long but the years are short” before their children will be grown and gone.
 

Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.

It is often fun and sometimes exhausting watching the speed with which children run around or switch from one game to another. A lot of us were attracted to pediatrics to share the quick joy of children and also the speed of their physical recovery. We get to see premature infants gain an ounce a day, and see wounds heal in less than a week. We give advice on sleep and see success in a month. We and the families get used to quick fixes.

SyhinStas/iStock/Getty Images Plus

Parents and children are forewarned and reassured by our knowledge about how long things typically take: Respiratory syncytial virus (RSV) peaks in 5 days, colic lessens in 3 months, changing sleep patterns takes 3 weeks, habit formation 6 weeks, menses come 2 years after breast development, and so on. But the timing of daily parenting is rarely as predictable. Sometimes a child’s clock is running fast, making waiting even seconds for a snack or a bathroom difficult; other times are slow, as when walking down the sidewalk noticing every leaf. The child’s clock is independent of the adult’s – and complicated by clocks of siblings.

Parent pace also is determined by many factors unrelated to the child: work demands, deadlines, train schedules, something in the oven, needs of siblings, and so on. To those can be added intrinsic factors affecting parent’s tolerance to shifting pace to the child’s such as temperament, fatigue, illness, pain, or even adult ADHD. And don’t forget caffeine (or other drugs) affecting the internal metronome. When impatience with the child is a complaint, it is useful to ask, “What makes waiting for your child difficult for you?”

When discussing time, I find it important to discuss the poison “s-word” of parenting – “should.” This trickster often comes from time illusions in childrearing. After seeing so many behaviors change quickly, parents expect all change to be equally fast. She should be able to sleep through the night by now! He should be able to dress and get to the table in 5 minutes. And sometimes it is the parent’s s-word that creates pain – I should love pushing for as long as she wants to swing, if I am a good parent. The problem with thinking “should” is that it implies willful or moral behavior, and it may prompt a judgmental or punitive parental response.

One major issue with timing is called “transition trouble.” Otherwise well intentioned, cooperative children who take longer to shift their attention from homework to shower can be seen as oppositional. Worse yet, if the example used is from playing video games (something fun) to getting to the bus stop (an undesirable shift), you may hear parents critically say, “He only wants to do what he wants to do.” When examining examples (always key to helping with behavior), pointing out that all kinds of transitions are difficult for this child may be educational and allow for a more reasoned response. And specifically being on electronics puts adults as well as children in a time warp which is hard to escape.

There are many kinds of thwarted expectations, but expectations about how long things take are pretty universal. Frustration generates anger and even can lead to violence, such as road rage. Children – who all step to the beat of a different drummer, especially those with different “clocks” such as in ADHD – may experience frustration most of the day. This can manifest as irritability for them and sometimes as an irritable response back from the parent.

The first step in adapting to differences in parent and child pace is to realize that time is the problem. Naming it, saying “we are on toddler time,” can be a “signal to self” to slow down. Generations of children loved Mr. Rogers because he always conveyed having all the time in the world for the person he was with. It actually does not take as long as it feels at first to do this. Listening while keeping eye contact, breathing deeply, and waiting until two breaths after the child goes silent before speaking or moving conveys your interest and respect. For some behaviors, such as tantrums, such quiet attention may be all that is needed to resolve the issue. We adults can practice this, but even infants can be helped to develop patience by reinforcement with brief attention from their caregivers for tiny increments of waiting.

I sometimes suggest that parents time behaviors to develop perspective, reset expectations, practice waiting, and perhaps even distract themselves from intervening and making things worse by lending attention to negative behaviors. Timing as observation can be helpful for tantrums, breath holding spells, whining, and sibling squabbles; maximum times for baths and video games; minimum times for meals, sitting to poop, and special time. Timers are not just for Time Out! “Visual timers” that show green then yellow then red and sometimes flashing lights as warnings of an upcoming stopping point are helpful for children preschool and older. These timers help them to develop a better sense of time and begin managing their own transitions. A game of guessing how long things take can build timing skills and patience. I think every child past preschool benefits from a wristwatch, first to build time sense, and second to avoid looking at a smartphone to see the hour, then being distracted by content! Diaries of behaviors over time are a staple of behavior change plans, with the added benefit of lending perspective on actually how often and how long a troublesome behavior occurs. Practicing mindfulness – nonjudgmental watching of our thoughts and feelings, often with deep breathing and relaxation – also can help both children and adults build time tolerance.

Children have little control over their daily schedule. Surrendering when you can for them to do things at their own pace can reduce their frustration, build the parent-child relationship, and promote positive behaviors. Plus family life is more enjoyable lived slower. You even can remind parents that “the days are long but the years are short” before their children will be grown and gone.
 

Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.

It is often fun and sometimes exhausting watching the speed with which children run around or switch from one game to another. A lot of us were attracted to pediatrics to share the quick joy of children and also the speed of their physical recovery. We get to see premature infants gain an ounce a day, and see wounds heal in less than a week. We give advice on sleep and see success in a month. We and the families get used to quick fixes.

SyhinStas/iStock/Getty Images Plus

Parents and children are forewarned and reassured by our knowledge about how long things typically take: Respiratory syncytial virus (RSV) peaks in 5 days, colic lessens in 3 months, changing sleep patterns takes 3 weeks, habit formation 6 weeks, menses come 2 years after breast development, and so on. But the timing of daily parenting is rarely as predictable. Sometimes a child’s clock is running fast, making waiting even seconds for a snack or a bathroom difficult; other times are slow, as when walking down the sidewalk noticing every leaf. The child’s clock is independent of the adult’s – and complicated by clocks of siblings.

Parent pace also is determined by many factors unrelated to the child: work demands, deadlines, train schedules, something in the oven, needs of siblings, and so on. To those can be added intrinsic factors affecting parent’s tolerance to shifting pace to the child’s such as temperament, fatigue, illness, pain, or even adult ADHD. And don’t forget caffeine (or other drugs) affecting the internal metronome. When impatience with the child is a complaint, it is useful to ask, “What makes waiting for your child difficult for you?”

When discussing time, I find it important to discuss the poison “s-word” of parenting – “should.” This trickster often comes from time illusions in childrearing. After seeing so many behaviors change quickly, parents expect all change to be equally fast. She should be able to sleep through the night by now! He should be able to dress and get to the table in 5 minutes. And sometimes it is the parent’s s-word that creates pain – I should love pushing for as long as she wants to swing, if I am a good parent. The problem with thinking “should” is that it implies willful or moral behavior, and it may prompt a judgmental or punitive parental response.

One major issue with timing is called “transition trouble.” Otherwise well intentioned, cooperative children who take longer to shift their attention from homework to shower can be seen as oppositional. Worse yet, if the example used is from playing video games (something fun) to getting to the bus stop (an undesirable shift), you may hear parents critically say, “He only wants to do what he wants to do.” When examining examples (always key to helping with behavior), pointing out that all kinds of transitions are difficult for this child may be educational and allow for a more reasoned response. And specifically being on electronics puts adults as well as children in a time warp which is hard to escape.

There are many kinds of thwarted expectations, but expectations about how long things take are pretty universal. Frustration generates anger and even can lead to violence, such as road rage. Children – who all step to the beat of a different drummer, especially those with different “clocks” such as in ADHD – may experience frustration most of the day. This can manifest as irritability for them and sometimes as an irritable response back from the parent.

The first step in adapting to differences in parent and child pace is to realize that time is the problem. Naming it, saying “we are on toddler time,” can be a “signal to self” to slow down. Generations of children loved Mr. Rogers because he always conveyed having all the time in the world for the person he was with. It actually does not take as long as it feels at first to do this. Listening while keeping eye contact, breathing deeply, and waiting until two breaths after the child goes silent before speaking or moving conveys your interest and respect. For some behaviors, such as tantrums, such quiet attention may be all that is needed to resolve the issue. We adults can practice this, but even infants can be helped to develop patience by reinforcement with brief attention from their caregivers for tiny increments of waiting.

I sometimes suggest that parents time behaviors to develop perspective, reset expectations, practice waiting, and perhaps even distract themselves from intervening and making things worse by lending attention to negative behaviors. Timing as observation can be helpful for tantrums, breath holding spells, whining, and sibling squabbles; maximum times for baths and video games; minimum times for meals, sitting to poop, and special time. Timers are not just for Time Out! “Visual timers” that show green then yellow then red and sometimes flashing lights as warnings of an upcoming stopping point are helpful for children preschool and older. These timers help them to develop a better sense of time and begin managing their own transitions. A game of guessing how long things take can build timing skills and patience. I think every child past preschool benefits from a wristwatch, first to build time sense, and second to avoid looking at a smartphone to see the hour, then being distracted by content! Diaries of behaviors over time are a staple of behavior change plans, with the added benefit of lending perspective on actually how often and how long a troublesome behavior occurs. Practicing mindfulness – nonjudgmental watching of our thoughts and feelings, often with deep breathing and relaxation – also can help both children and adults build time tolerance.

Children have little control over their daily schedule. Surrendering when you can for them to do things at their own pace can reduce their frustration, build the parent-child relationship, and promote positive behaviors. Plus family life is more enjoyable lived slower. You even can remind parents that “the days are long but the years are short” before their children will be grown and gone.
 

Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.

SAN FRANCISCO – An investigational device exemption trial of the Portico valve with FlexNav delivery system showed 1-year clinical results on par with commercially available valves, Gregory P. Fontana, MD, reported at the Transcatheter Cardiovascular Therapeutics annual meeting.

Doug Brunk/MDedge News

In a prospective, open-label study conducted at 52 sites known as PORTICO, Dr. Fontana and colleagues conducted a noninferiority intention-to-treat evaluation of the safety and effectiveness of the self-expanding Portico transcatheter aortic valve replacement system, compared with Food and Drug Administration–approved and commercially available TAVR systems for patients with severe aortic stenosis at high or extreme risk for surgery. Between May 2014 and June 2019, 750 patients from 69 sites were randomized 1:1 to each group. The prespecified primary safety composite endpoint was all-cause mortality, disabling stroke, life-threatening bleeding requiring blood transfusion, acute kidney injury requiring dialysis, or major vascular complications at 30 days, while the primary effectiveness composite endpoint was all-cause mortality or disabling stroke at 1 year.

The mean baseline age of patients was 83 years, 53% were female, and their mean Society of Thoracic Surgeons score was 6.5%. Dr. Fontana, director and chairman of cardiothoracic surgery at the CardioVascular Institute of Los Robles Regional Medical Center, Thousand Oaks, Calif., reported at the meeting sponsored by the Cardiovascular Research Foundation that procedural success was comparable between groups (96.5% for Portico vs, 98.3% for commercially available TAVR, respectively). In addition, patients in both groups met the prespecified primary safety composite endpoint (13.8% vs. 9.6%; P for noninferiority = .03) and the primary effectiveness composite endpoint (14.9% vs. 13.4%, P for noninferiority = .006).

However, the rate of moderate to severe paravalvular leak at 30 days was 6.3% among patients in the Portico valve group, compared with 2.1% of their counterparts in the commercially available TAVR group, a difference that did not reach noninferiority. Dr. Fontana said that a next-generation valve with design modifications to reduce paravalvular leak is being tested in clinical trials.

PORTICO included a separate cohort of 100 patients who underwent Portico valve implantation using the FlexNav Delivery System, which became available after the trial had launched. The primary safety endpoint for the FlexNav cohort was major vascular complication rate at 30 days. This cohort demonstrated no deaths or strokes, low rates of major vascular complications (7.0%) and new permanent pacemaker implants (14.6%), as well as a safety profile comparable with the commercially available valve group in the randomized study (8.0% vs. 9.6%).

“My sense of this device is that presumably it will be another valve we have available to us in the United States,” Pinak B. Shah, MD, a cardiologist at Brigham and Women’s Hospital, Boston, said during a media briefing. “The challenge to all of us is to figure out where it fits in our armamentarium. Is it going to be worth individuals to learn a whole new device when at this point it’s hard to say if there’s a major difference compared to the other self-expanding devices we have now?”

With the new FlexNav delivery system, the Portico valve is characterized by “a very calm, slow delivery,” said Dr. Fontana, who was the study’s coprincipal investigator, along with Raj R. Makkar, MD, director of interventional cardiology at Cedars-Sinai Medical Center, Los Angeles. “The operator can land the valve exactly where they want it. If they’re not happy, they can make some adjustments. I haven’t yet a system in my hands that is as stable as this. The option of having excellent hemodynamics and large cells to engage the coronary system is a unique combination for us in the United States.”

The Portico valve is not currently FDA approved. The PORTICO study was funded by Abbott. Dr. Fontana disclosed grant/research support from Abbott and Medtronic and consulting fees/honoraria from Abbott, Medtronic, and LivaNova.

dbrunk@mdedge.com

SAN FRANCISCO – An investigational device exemption trial of the Portico valve with FlexNav delivery system showed 1-year clinical results on par with commercially available valves, Gregory P. Fontana, MD, reported at the Transcatheter Cardiovascular Therapeutics annual meeting.

Doug Brunk/MDedge News

In a prospective, open-label study conducted at 52 sites known as PORTICO, Dr. Fontana and colleagues conducted a noninferiority intention-to-treat evaluation of the safety and effectiveness of the self-expanding Portico transcatheter aortic valve replacement system, compared with Food and Drug Administration–approved and commercially available TAVR systems for patients with severe aortic stenosis at high or extreme risk for surgery. Between May 2014 and June 2019, 750 patients from 69 sites were randomized 1:1 to each group. The prespecified primary safety composite endpoint was all-cause mortality, disabling stroke, life-threatening bleeding requiring blood transfusion, acute kidney injury requiring dialysis, or major vascular complications at 30 days, while the primary effectiveness composite endpoint was all-cause mortality or disabling stroke at 1 year.

The mean baseline age of patients was 83 years, 53% were female, and their mean Society of Thoracic Surgeons score was 6.5%. Dr. Fontana, director and chairman of cardiothoracic surgery at the CardioVascular Institute of Los Robles Regional Medical Center, Thousand Oaks, Calif., reported at the meeting sponsored by the Cardiovascular Research Foundation that procedural success was comparable between groups (96.5% for Portico vs, 98.3% for commercially available TAVR, respectively). In addition, patients in both groups met the prespecified primary safety composite endpoint (13.8% vs. 9.6%; P for noninferiority = .03) and the primary effectiveness composite endpoint (14.9% vs. 13.4%, P for noninferiority = .006).

However, the rate of moderate to severe paravalvular leak at 30 days was 6.3% among patients in the Portico valve group, compared with 2.1% of their counterparts in the commercially available TAVR group, a difference that did not reach noninferiority. Dr. Fontana said that a next-generation valve with design modifications to reduce paravalvular leak is being tested in clinical trials.

PORTICO included a separate cohort of 100 patients who underwent Portico valve implantation using the FlexNav Delivery System, which became available after the trial had launched. The primary safety endpoint for the FlexNav cohort was major vascular complication rate at 30 days. This cohort demonstrated no deaths or strokes, low rates of major vascular complications (7.0%) and new permanent pacemaker implants (14.6%), as well as a safety profile comparable with the commercially available valve group in the randomized study (8.0% vs. 9.6%).

“My sense of this device is that presumably it will be another valve we have available to us in the United States,” Pinak B. Shah, MD, a cardiologist at Brigham and Women’s Hospital, Boston, said during a media briefing. “The challenge to all of us is to figure out where it fits in our armamentarium. Is it going to be worth individuals to learn a whole new device when at this point it’s hard to say if there’s a major difference compared to the other self-expanding devices we have now?”

With the new FlexNav delivery system, the Portico valve is characterized by “a very calm, slow delivery,” said Dr. Fontana, who was the study’s coprincipal investigator, along with Raj R. Makkar, MD, director of interventional cardiology at Cedars-Sinai Medical Center, Los Angeles. “The operator can land the valve exactly where they want it. If they’re not happy, they can make some adjustments. I haven’t yet a system in my hands that is as stable as this. The option of having excellent hemodynamics and large cells to engage the coronary system is a unique combination for us in the United States.”

The Portico valve is not currently FDA approved. The PORTICO study was funded by Abbott. Dr. Fontana disclosed grant/research support from Abbott and Medtronic and consulting fees/honoraria from Abbott, Medtronic, and LivaNova.

dbrunk@mdedge.com

SAN FRANCISCO – An investigational device exemption trial of the Portico valve with FlexNav delivery system showed 1-year clinical results on par with commercially available valves, Gregory P. Fontana, MD, reported at the Transcatheter Cardiovascular Therapeutics annual meeting.

Doug Brunk/MDedge News

In a prospective, open-label study conducted at 52 sites known as PORTICO, Dr. Fontana and colleagues conducted a noninferiority intention-to-treat evaluation of the safety and effectiveness of the self-expanding Portico transcatheter aortic valve replacement system, compared with Food and Drug Administration–approved and commercially available TAVR systems for patients with severe aortic stenosis at high or extreme risk for surgery. Between May 2014 and June 2019, 750 patients from 69 sites were randomized 1:1 to each group. The prespecified primary safety composite endpoint was all-cause mortality, disabling stroke, life-threatening bleeding requiring blood transfusion, acute kidney injury requiring dialysis, or major vascular complications at 30 days, while the primary effectiveness composite endpoint was all-cause mortality or disabling stroke at 1 year.

The mean baseline age of patients was 83 years, 53% were female, and their mean Society of Thoracic Surgeons score was 6.5%. Dr. Fontana, director and chairman of cardiothoracic surgery at the CardioVascular Institute of Los Robles Regional Medical Center, Thousand Oaks, Calif., reported at the meeting sponsored by the Cardiovascular Research Foundation that procedural success was comparable between groups (96.5% for Portico vs, 98.3% for commercially available TAVR, respectively). In addition, patients in both groups met the prespecified primary safety composite endpoint (13.8% vs. 9.6%; P for noninferiority = .03) and the primary effectiveness composite endpoint (14.9% vs. 13.4%, P for noninferiority = .006).

However, the rate of moderate to severe paravalvular leak at 30 days was 6.3% among patients in the Portico valve group, compared with 2.1% of their counterparts in the commercially available TAVR group, a difference that did not reach noninferiority. Dr. Fontana said that a next-generation valve with design modifications to reduce paravalvular leak is being tested in clinical trials.

PORTICO included a separate cohort of 100 patients who underwent Portico valve implantation using the FlexNav Delivery System, which became available after the trial had launched. The primary safety endpoint for the FlexNav cohort was major vascular complication rate at 30 days. This cohort demonstrated no deaths or strokes, low rates of major vascular complications (7.0%) and new permanent pacemaker implants (14.6%), as well as a safety profile comparable with the commercially available valve group in the randomized study (8.0% vs. 9.6%).

“My sense of this device is that presumably it will be another valve we have available to us in the United States,” Pinak B. Shah, MD, a cardiologist at Brigham and Women’s Hospital, Boston, said during a media briefing. “The challenge to all of us is to figure out where it fits in our armamentarium. Is it going to be worth individuals to learn a whole new device when at this point it’s hard to say if there’s a major difference compared to the other self-expanding devices we have now?”

With the new FlexNav delivery system, the Portico valve is characterized by “a very calm, slow delivery,” said Dr. Fontana, who was the study’s coprincipal investigator, along with Raj R. Makkar, MD, director of interventional cardiology at Cedars-Sinai Medical Center, Los Angeles. “The operator can land the valve exactly where they want it. If they’re not happy, they can make some adjustments. I haven’t yet a system in my hands that is as stable as this. The option of having excellent hemodynamics and large cells to engage the coronary system is a unique combination for us in the United States.”

The Portico valve is not currently FDA approved. The PORTICO study was funded by Abbott. Dr. Fontana disclosed grant/research support from Abbott and Medtronic and consulting fees/honoraria from Abbott, Medtronic, and LivaNova.

dbrunk@mdedge.com

A new analysis of different health care reform options reveals a potential path toward universal coverage that would result in a decrease in national health care spending.

sndr/istockphoto

The Commonwealth Fund and The Urban Institute looked at eight reform scenarios, including ones that build on the Affordable Care Act and expand to universal coverage or single payer. Two scenarios that continue to utilize private insurance show that, conceptually, broad coverage can be achieved without increasing spending.

“This study is important because it shows that there are several health reform approaches that have the potential to increase the number of people with health insurance, make health care more affordable, and slow cost growth,” David Blumenthal, MD, president of The Commonwealth Fund, said during an Oct. 15 conference call introducing the report.

He called the details that separate the varying models “central to the national debate on health care and health insurance coverage as the 2020 campaign season progresses.”

All the scenarios presented in the report have a foundation in various current Democratic health care reform proposals, although no one specific proposal or legislation is profiled within the eight scenarios presented.

“Our hope is that this extensive analysis will clarify for voters and policy makers the implications of the policy choices before us,” said Sara R. Collins, PhD, the vice president of health care coverage and access at The Commonwealth Fund, during the call.

The first of these scenarios, dubbed “Universal Coverage I: Private and Public Options,” includes continued use of private insurance but also involves a public option and is the first of four options presented in the report to achieve universal coverage by actively enrolling people who are not enrolled in a private plan for one year in the public option with income-scaled premiums. This option would not utilize the ACA employer mandate and would remove the “firewall” that prevents individuals with access to employer-sponsored coverage from accessing financial assistance and seeking individual coverage from the insurance marketplace.

This scenario, as with all but one of the scenarios analyzed in the report, covers all essential benefits as defined in the Affordable Care Act. The only single-payer option that does not cover all of these essential benefits still provides coverage for medically necessary care, including dental, vision, hearing, and long-term services.

The Universal Coverage I scenario does not have any penalties for not carrying insurance, but all legal residents that forgo voluntary coverage from an employer or the marketplace will be automatically enrolled in coverage for which they are responsible for a premium payment.

There would be no expanded access to short-term, limited duration plans as the automatic enrollment to those not voluntarily covered by an employer or in the marketplace would make coverage universal. Federal government spending under this plan increases government health care spending in 2020 by $122.1 billion and $1.5 trillion over 10 years. However, total national spending in this scenario would decrease by $22.6 billion or 0.6% in 2020, compared with current law.

“Universal Coverage II: Enhanced Subsidies” is similar to Universal Coverage I in all other respects other than that it includes more generous premium and cost-sharing subsidies. These additional offerings would push federal government spending up $161.8 billion more in 2020, compared with current law, and to $2 trillion more over the next 10 years, while showing a minimal decrease in total national spending of less than 1% compared with current law.

The other two options that would move toward providing everyone with health insurance include a single payer system that covers all ACA essential health benefits, features no premiums, has income-related cost sharing, and covers all legal residents. Private insurance in this scenario is prohibited, and provider payments would be similar to those received in Medicare. Federal government spending would increase in 2020 by $1.5 trillion, compared with current law, and $17.6 trillion over the next 10 years. However, total national spending would decrease by $209.5 billion, or 6%, in 2020 compared with current law. These savings would come from lower provider payments and administrative costs that outweigh increased costs associated with near universal coverage and lower cost-sharing requirements.

A second single payer scenario broadens the benefits and would cover all residents in the United States, including undocumented residents. It would have no cost-sharing requirements.

The “optimal levels at which the payments for hospitals and doctors and other providers should be paid are really unknown at this time,” said Linda Blumberg, PhD, fellow at The Urban Institute’s Health Policy Center and one of the report authors, during the call.

Providing total coverage for all people in the United States is estimated to increase federal spending by $2.8 trillion in 2020 compared with current law, and $34 trillion over 10 years, with much of this increase accounted for by the shift in existing state and private spending to the federal government. At the same time, total national spending would increase by approximately $720 billion in 2020 compared with current law. Even though employer, household, and state spending would decrease, these savings would not be enough to offset increases in federal spending as well as the increased consumption of health care that comes with more generous benefits. The offsets from lower administrative costs and lower provider payments also would not offset higher spending.

The report only looks at health care spending and does not present any suggestions on revenue to offset the spending.

gtwachtman@mdedge.com

SOURCE: Blumberg LJ et al. “From Incremental to Comprehensive Health Insurance Reform: How Various Reform Options Compare On Coverage and Costs.” The Commonwealth Fund and The Urban Institute. 2019 Oct 16.

A new analysis of different health care reform options reveals a potential path toward universal coverage that would result in a decrease in national health care spending.

sndr/istockphoto

The Commonwealth Fund and The Urban Institute looked at eight reform scenarios, including ones that build on the Affordable Care Act and expand to universal coverage or single payer. Two scenarios that continue to utilize private insurance show that, conceptually, broad coverage can be achieved without increasing spending.

“This study is important because it shows that there are several health reform approaches that have the potential to increase the number of people with health insurance, make health care more affordable, and slow cost growth,” David Blumenthal, MD, president of The Commonwealth Fund, said during an Oct. 15 conference call introducing the report.

He called the details that separate the varying models “central to the national debate on health care and health insurance coverage as the 2020 campaign season progresses.”

All the scenarios presented in the report have a foundation in various current Democratic health care reform proposals, although no one specific proposal or legislation is profiled within the eight scenarios presented.

“Our hope is that this extensive analysis will clarify for voters and policy makers the implications of the policy choices before us,” said Sara R. Collins, PhD, the vice president of health care coverage and access at The Commonwealth Fund, during the call.

The first of these scenarios, dubbed “Universal Coverage I: Private and Public Options,” includes continued use of private insurance but also involves a public option and is the first of four options presented in the report to achieve universal coverage by actively enrolling people who are not enrolled in a private plan for one year in the public option with income-scaled premiums. This option would not utilize the ACA employer mandate and would remove the “firewall” that prevents individuals with access to employer-sponsored coverage from accessing financial assistance and seeking individual coverage from the insurance marketplace.

This scenario, as with all but one of the scenarios analyzed in the report, covers all essential benefits as defined in the Affordable Care Act. The only single-payer option that does not cover all of these essential benefits still provides coverage for medically necessary care, including dental, vision, hearing, and long-term services.

The Universal Coverage I scenario does not have any penalties for not carrying insurance, but all legal residents that forgo voluntary coverage from an employer or the marketplace will be automatically enrolled in coverage for which they are responsible for a premium payment.

There would be no expanded access to short-term, limited duration plans as the automatic enrollment to those not voluntarily covered by an employer or in the marketplace would make coverage universal. Federal government spending under this plan increases government health care spending in 2020 by $122.1 billion and $1.5 trillion over 10 years. However, total national spending in this scenario would decrease by $22.6 billion or 0.6% in 2020, compared with current law.

“Universal Coverage II: Enhanced Subsidies” is similar to Universal Coverage I in all other respects other than that it includes more generous premium and cost-sharing subsidies. These additional offerings would push federal government spending up $161.8 billion more in 2020, compared with current law, and to $2 trillion more over the next 10 years, while showing a minimal decrease in total national spending of less than 1% compared with current law.

The other two options that would move toward providing everyone with health insurance include a single payer system that covers all ACA essential health benefits, features no premiums, has income-related cost sharing, and covers all legal residents. Private insurance in this scenario is prohibited, and provider payments would be similar to those received in Medicare. Federal government spending would increase in 2020 by $1.5 trillion, compared with current law, and $17.6 trillion over the next 10 years. However, total national spending would decrease by $209.5 billion, or 6%, in 2020 compared with current law. These savings would come from lower provider payments and administrative costs that outweigh increased costs associated with near universal coverage and lower cost-sharing requirements.

A second single payer scenario broadens the benefits and would cover all residents in the United States, including undocumented residents. It would have no cost-sharing requirements.

The “optimal levels at which the payments for hospitals and doctors and other providers should be paid are really unknown at this time,” said Linda Blumberg, PhD, fellow at The Urban Institute’s Health Policy Center and one of the report authors, during the call.

Providing total coverage for all people in the United States is estimated to increase federal spending by $2.8 trillion in 2020 compared with current law, and $34 trillion over 10 years, with much of this increase accounted for by the shift in existing state and private spending to the federal government. At the same time, total national spending would increase by approximately $720 billion in 2020 compared with current law. Even though employer, household, and state spending would decrease, these savings would not be enough to offset increases in federal spending as well as the increased consumption of health care that comes with more generous benefits. The offsets from lower administrative costs and lower provider payments also would not offset higher spending.

The report only looks at health care spending and does not present any suggestions on revenue to offset the spending.

gtwachtman@mdedge.com

SOURCE: Blumberg LJ et al. “From Incremental to Comprehensive Health Insurance Reform: How Various Reform Options Compare On Coverage and Costs.” The Commonwealth Fund and The Urban Institute. 2019 Oct 16.

A new analysis of different health care reform options reveals a potential path toward universal coverage that would result in a decrease in national health care spending.

sndr/istockphoto

The Commonwealth Fund and The Urban Institute looked at eight reform scenarios, including ones that build on the Affordable Care Act and expand to universal coverage or single payer. Two scenarios that continue to utilize private insurance show that, conceptually, broad coverage can be achieved without increasing spending.

“This study is important because it shows that there are several health reform approaches that have the potential to increase the number of people with health insurance, make health care more affordable, and slow cost growth,” David Blumenthal, MD, president of The Commonwealth Fund, said during an Oct. 15 conference call introducing the report.

He called the details that separate the varying models “central to the national debate on health care and health insurance coverage as the 2020 campaign season progresses.”

All the scenarios presented in the report have a foundation in various current Democratic health care reform proposals, although no one specific proposal or legislation is profiled within the eight scenarios presented.

“Our hope is that this extensive analysis will clarify for voters and policy makers the implications of the policy choices before us,” said Sara R. Collins, PhD, the vice president of health care coverage and access at The Commonwealth Fund, during the call.

The first of these scenarios, dubbed “Universal Coverage I: Private and Public Options,” includes continued use of private insurance but also involves a public option and is the first of four options presented in the report to achieve universal coverage by actively enrolling people who are not enrolled in a private plan for one year in the public option with income-scaled premiums. This option would not utilize the ACA employer mandate and would remove the “firewall” that prevents individuals with access to employer-sponsored coverage from accessing financial assistance and seeking individual coverage from the insurance marketplace.

This scenario, as with all but one of the scenarios analyzed in the report, covers all essential benefits as defined in the Affordable Care Act. The only single-payer option that does not cover all of these essential benefits still provides coverage for medically necessary care, including dental, vision, hearing, and long-term services.

The Universal Coverage I scenario does not have any penalties for not carrying insurance, but all legal residents that forgo voluntary coverage from an employer or the marketplace will be automatically enrolled in coverage for which they are responsible for a premium payment.

There would be no expanded access to short-term, limited duration plans as the automatic enrollment to those not voluntarily covered by an employer or in the marketplace would make coverage universal. Federal government spending under this plan increases government health care spending in 2020 by $122.1 billion and $1.5 trillion over 10 years. However, total national spending in this scenario would decrease by $22.6 billion or 0.6% in 2020, compared with current law.

“Universal Coverage II: Enhanced Subsidies” is similar to Universal Coverage I in all other respects other than that it includes more generous premium and cost-sharing subsidies. These additional offerings would push federal government spending up $161.8 billion more in 2020, compared with current law, and to $2 trillion more over the next 10 years, while showing a minimal decrease in total national spending of less than 1% compared with current law.

The other two options that would move toward providing everyone with health insurance include a single payer system that covers all ACA essential health benefits, features no premiums, has income-related cost sharing, and covers all legal residents. Private insurance in this scenario is prohibited, and provider payments would be similar to those received in Medicare. Federal government spending would increase in 2020 by $1.5 trillion, compared with current law, and $17.6 trillion over the next 10 years. However, total national spending would decrease by $209.5 billion, or 6%, in 2020 compared with current law. These savings would come from lower provider payments and administrative costs that outweigh increased costs associated with near universal coverage and lower cost-sharing requirements.

A second single payer scenario broadens the benefits and would cover all residents in the United States, including undocumented residents. It would have no cost-sharing requirements.

The “optimal levels at which the payments for hospitals and doctors and other providers should be paid are really unknown at this time,” said Linda Blumberg, PhD, fellow at The Urban Institute’s Health Policy Center and one of the report authors, during the call.

Providing total coverage for all people in the United States is estimated to increase federal spending by $2.8 trillion in 2020 compared with current law, and $34 trillion over 10 years, with much of this increase accounted for by the shift in existing state and private spending to the federal government. At the same time, total national spending would increase by approximately $720 billion in 2020 compared with current law. Even though employer, household, and state spending would decrease, these savings would not be enough to offset increases in federal spending as well as the increased consumption of health care that comes with more generous benefits. The offsets from lower administrative costs and lower provider payments also would not offset higher spending.

The report only looks at health care spending and does not present any suggestions on revenue to offset the spending.

gtwachtman@mdedge.com

SOURCE: Blumberg LJ et al. “From Incremental to Comprehensive Health Insurance Reform: How Various Reform Options Compare On Coverage and Costs.” The Commonwealth Fund and The Urban Institute. 2019 Oct 16.