Please do a follow-up to your article on billing and coding—specifically, on 99215. I realize many physicians are trying to work up from 99213 to 99214. But we have a mature practice with many complex patients and need help working up to 99215.

Here’s an example: A patient comes in with an asthmatic exacerbation due to sinusitis, and it’s likely a level 4. But the original purpose of the visit was a lipid panel review and follow-up for abnormal liver enzymes—another level 4. The patient also wants to discuss his colonoscopy report, which shows the presence of polyps.

Yes, I know I can make such patients schedule 3 separate appointments. But they’ll get mad, their boss will fire them, and it’s inefficient besides. I also know I can spend nearly 40 minutes with them and code for “counseling.” But suppose I can treat the asthma and infection in 6 minutes, discuss and alter the lipid Rx in 4 minutes, and review the colonoscopy results in 2. Now I have a 12-minute visit that I’m stuck billing at the rate of a 99214, which is “typically 25 minutes.”

I know I’m supposed to feel guilty, but I’m not going to do all that “free” work just because I can do it quickly and efficiently. So how do I go from 99214 to 99215 for such complex cases? I’m not going to call other physicians, chat for 40 minutes, or order unneeded tests just so I can “code up,” but I want to be paid for more than the asthma exacerbation because I’m doing more than that.

Andrew Johnstone, MD, Indianapolis

Please do a follow-up to your article on billing and coding—specifically, on 99215. I realize many physicians are trying to work up from 99213 to 99214. But we have a mature practice with many complex patients and need help working up to 99215.

Here’s an example: A patient comes in with an asthmatic exacerbation due to sinusitis, and it’s likely a level 4. But the original purpose of the visit was a lipid panel review and follow-up for abnormal liver enzymes—another level 4. The patient also wants to discuss his colonoscopy report, which shows the presence of polyps.

Yes, I know I can make such patients schedule 3 separate appointments. But they’ll get mad, their boss will fire them, and it’s inefficient besides. I also know I can spend nearly 40 minutes with them and code for “counseling.” But suppose I can treat the asthma and infection in 6 minutes, discuss and alter the lipid Rx in 4 minutes, and review the colonoscopy results in 2. Now I have a 12-minute visit that I’m stuck billing at the rate of a 99214, which is “typically 25 minutes.”

I know I’m supposed to feel guilty, but I’m not going to do all that “free” work just because I can do it quickly and efficiently. So how do I go from 99214 to 99215 for such complex cases? I’m not going to call other physicians, chat for 40 minutes, or order unneeded tests just so I can “code up,” but I want to be paid for more than the asthma exacerbation because I’m doing more than that.

Andrew Johnstone, MD, Indianapolis

Please do a follow-up to your article on billing and coding—specifically, on 99215. I realize many physicians are trying to work up from 99213 to 99214. But we have a mature practice with many complex patients and need help working up to 99215.

Here’s an example: A patient comes in with an asthmatic exacerbation due to sinusitis, and it’s likely a level 4. But the original purpose of the visit was a lipid panel review and follow-up for abnormal liver enzymes—another level 4. The patient also wants to discuss his colonoscopy report, which shows the presence of polyps.

Yes, I know I can make such patients schedule 3 separate appointments. But they’ll get mad, their boss will fire them, and it’s inefficient besides. I also know I can spend nearly 40 minutes with them and code for “counseling.” But suppose I can treat the asthma and infection in 6 minutes, discuss and alter the lipid Rx in 4 minutes, and review the colonoscopy results in 2. Now I have a 12-minute visit that I’m stuck billing at the rate of a 99214, which is “typically 25 minutes.”

I know I’m supposed to feel guilty, but I’m not going to do all that “free” work just because I can do it quickly and efficiently. So how do I go from 99214 to 99215 for such complex cases? I’m not going to call other physicians, chat for 40 minutes, or order unneeded tests just so I can “code up,” but I want to be paid for more than the asthma exacerbation because I’m doing more than that.

Andrew Johnstone, MD, Indianapolis

Jaxon Hernandes, MD, a hospitalist with Apogee Physicians at Clara Maass Medical Center in Belleville, N.J., believes he and his colleagues are positioned perfectly to help properly diagnose asthma, a timely opinion given new Canadian research suggesting the bronchial condition routinely is over-diagnosed.

The study in the Canadian Medical Association Journal (2008;179(11):1121-1131) found up to 30% of adults diagnosed with asthma had no evidence of the condition. It included 496 people from eight Canadian cities who reported a diagnosis of asthma from their physician. The researchers' goal was to determine whether obese people were more likely to be misdiagnosed with asthma, but researchers found the issue was just as prevalent in people of normal weight.

Henderson notes hospitalists rarely make initial diagnoses when a patient is first encountered in the hospital, but once they are admitted, a hospitalist can order peak-flow-rate and spirometric tests. Clinical guidelines recommend using a spirometer to objectively measure long volume and airway flow.

"The hospitalist is in a position where he can get the pulmonologist to do what he needs to do," Dr. Hernandes says. "He can force a diagnosis being made."

Dr. Hernandes adds hospitalists have an onus to order the tests because doctors "may be under-diagnosing the primary issue with a patient or over-diagnosing and psychologically scarring them."

Jaxon Hernandes, MD, a hospitalist with Apogee Physicians at Clara Maass Medical Center in Belleville, N.J., believes he and his colleagues are positioned perfectly to help properly diagnose asthma, a timely opinion given new Canadian research suggesting the bronchial condition routinely is over-diagnosed.

The study in the Canadian Medical Association Journal (2008;179(11):1121-1131) found up to 30% of adults diagnosed with asthma had no evidence of the condition. It included 496 people from eight Canadian cities who reported a diagnosis of asthma from their physician. The researchers' goal was to determine whether obese people were more likely to be misdiagnosed with asthma, but researchers found the issue was just as prevalent in people of normal weight.

Henderson notes hospitalists rarely make initial diagnoses when a patient is first encountered in the hospital, but once they are admitted, a hospitalist can order peak-flow-rate and spirometric tests. Clinical guidelines recommend using a spirometer to objectively measure long volume and airway flow.

"The hospitalist is in a position where he can get the pulmonologist to do what he needs to do," Dr. Hernandes says. "He can force a diagnosis being made."

Dr. Hernandes adds hospitalists have an onus to order the tests because doctors "may be under-diagnosing the primary issue with a patient or over-diagnosing and psychologically scarring them."

Jaxon Hernandes, MD, a hospitalist with Apogee Physicians at Clara Maass Medical Center in Belleville, N.J., believes he and his colleagues are positioned perfectly to help properly diagnose asthma, a timely opinion given new Canadian research suggesting the bronchial condition routinely is over-diagnosed.

The study in the Canadian Medical Association Journal (2008;179(11):1121-1131) found up to 30% of adults diagnosed with asthma had no evidence of the condition. It included 496 people from eight Canadian cities who reported a diagnosis of asthma from their physician. The researchers' goal was to determine whether obese people were more likely to be misdiagnosed with asthma, but researchers found the issue was just as prevalent in people of normal weight.

Henderson notes hospitalists rarely make initial diagnoses when a patient is first encountered in the hospital, but once they are admitted, a hospitalist can order peak-flow-rate and spirometric tests. Clinical guidelines recommend using a spirometer to objectively measure long volume and airway flow.

"The hospitalist is in a position where he can get the pulmonologist to do what he needs to do," Dr. Hernandes says. "He can force a diagnosis being made."

Dr. Hernandes adds hospitalists have an onus to order the tests because doctors "may be under-diagnosing the primary issue with a patient or over-diagnosing and psychologically scarring them."

A small Illinois hospital has joined the ranks of facilities—including its neighbors—in adding a hospital medicine (HM) program. The Genesis Medical Center, Illini Campus, in Silvas, Ill., began providing full-time hospitalist coverage on Dec. 1.

As the influx of hospitalists allowed local primary care physicians to stop making hospital visits, the Illini Campus rushed to fill the gap with its own HM program. "We were the last acute care hospital to implement a hospitalist program," says Chuck Bruhn, CEO of Illini Campus. "It had become a medical community issue."

Illini Campus, located near the Quad Cities on the western Illinois-eastern Iowa border, is a 149-bed facility with an average daily census of 50 to 55 patients. Its sister facility, the Genesis Medical Center in Davenport, Iowa, has had a successful hospital medicine program since 2005. Genesis' agreement with Cogent Healthcare, Inc., recently expanded to manage the program at Illini Campus, with round-the-clock coverage, including one full-time hospitalist.

Just two weeks after implementation, "the hospitalist program is growing much more rapidly than we had anticipated," Bruhn says. "They’re already covering a census of 14 patients a day. We're already talking about adding a physician extender."

Bruhn is pleased with the way the fledgling program has taken root. "We see it as a definite improvement, not only to quality and continuity of care, but to expediency of care. And the hospitalists provide additional support; they provide education to our clinical staff."

A small Illinois hospital has joined the ranks of facilities—including its neighbors—in adding a hospital medicine (HM) program. The Genesis Medical Center, Illini Campus, in Silvas, Ill., began providing full-time hospitalist coverage on Dec. 1.

As the influx of hospitalists allowed local primary care physicians to stop making hospital visits, the Illini Campus rushed to fill the gap with its own HM program. "We were the last acute care hospital to implement a hospitalist program," says Chuck Bruhn, CEO of Illini Campus. "It had become a medical community issue."

Illini Campus, located near the Quad Cities on the western Illinois-eastern Iowa border, is a 149-bed facility with an average daily census of 50 to 55 patients. Its sister facility, the Genesis Medical Center in Davenport, Iowa, has had a successful hospital medicine program since 2005. Genesis' agreement with Cogent Healthcare, Inc., recently expanded to manage the program at Illini Campus, with round-the-clock coverage, including one full-time hospitalist.

Just two weeks after implementation, "the hospitalist program is growing much more rapidly than we had anticipated," Bruhn says. "They’re already covering a census of 14 patients a day. We're already talking about adding a physician extender."

Bruhn is pleased with the way the fledgling program has taken root. "We see it as a definite improvement, not only to quality and continuity of care, but to expediency of care. And the hospitalists provide additional support; they provide education to our clinical staff."

A small Illinois hospital has joined the ranks of facilities—including its neighbors—in adding a hospital medicine (HM) program. The Genesis Medical Center, Illini Campus, in Silvas, Ill., began providing full-time hospitalist coverage on Dec. 1.

As the influx of hospitalists allowed local primary care physicians to stop making hospital visits, the Illini Campus rushed to fill the gap with its own HM program. "We were the last acute care hospital to implement a hospitalist program," says Chuck Bruhn, CEO of Illini Campus. "It had become a medical community issue."

Illini Campus, located near the Quad Cities on the western Illinois-eastern Iowa border, is a 149-bed facility with an average daily census of 50 to 55 patients. Its sister facility, the Genesis Medical Center in Davenport, Iowa, has had a successful hospital medicine program since 2005. Genesis' agreement with Cogent Healthcare, Inc., recently expanded to manage the program at Illini Campus, with round-the-clock coverage, including one full-time hospitalist.

Just two weeks after implementation, "the hospitalist program is growing much more rapidly than we had anticipated," Bruhn says. "They’re already covering a census of 14 patients a day. We're already talking about adding a physician extender."

Bruhn is pleased with the way the fledgling program has taken root. "We see it as a definite improvement, not only to quality and continuity of care, but to expediency of care. And the hospitalists provide additional support; they provide education to our clinical staff."

The recent suspension of a New York City doctor who failed to report a gunshot wound suffered by a football star is an opportunity for hospitalists to revisit their own reporting requirements, the president of SHM's NYC chapter says.

Josyann Abisaab, MD, of New York-Presbyterian Hospital/Weill Cornell Medical Center, was suspended after treating New York Giants wide receiver Plaxico Burress on Nov. 29. Less than a year after catching the winning touchdown pass in the Giants' Super Bowl victory, Burress, who told police he accidentally shot himself in the thigh at a NYC nightclub, has been suspended by the league and charged with criminal possession of a gun.

"I was not aware that something like this needed a report to the police," says Bradley Flansbaum, DO, MPH, chief of hospitalist services at Lenox Hill Hospital in Manhattan and president of SHM’s NYC chapter. "It opened up space in my brain. If I were confronted with this, when would I know when to and when not to call the police?"

Complicating matters is the fact hospitalists may have to report issues to more than just law enforcement; depending on diagnoses and patient histories, doctors may have to notify state and federal health agencies or social service departments. Rules vary by state, so Dr. Flansbaum says hospitalists would do well to brush up on their requirements and liabilities.

"I may not know the rules," Dr. Flansbaum said, "but I certainly would speak to the right people here and ask them: 'What are my obligations? How do I protect myself and the patient?' " He recommends hospitalists verify local requirements with their hospital administration.

The recent suspension of a New York City doctor who failed to report a gunshot wound suffered by a football star is an opportunity for hospitalists to revisit their own reporting requirements, the president of SHM's NYC chapter says.

Josyann Abisaab, MD, of New York-Presbyterian Hospital/Weill Cornell Medical Center, was suspended after treating New York Giants wide receiver Plaxico Burress on Nov. 29. Less than a year after catching the winning touchdown pass in the Giants' Super Bowl victory, Burress, who told police he accidentally shot himself in the thigh at a NYC nightclub, has been suspended by the league and charged with criminal possession of a gun.

"I was not aware that something like this needed a report to the police," says Bradley Flansbaum, DO, MPH, chief of hospitalist services at Lenox Hill Hospital in Manhattan and president of SHM’s NYC chapter. "It opened up space in my brain. If I were confronted with this, when would I know when to and when not to call the police?"

Complicating matters is the fact hospitalists may have to report issues to more than just law enforcement; depending on diagnoses and patient histories, doctors may have to notify state and federal health agencies or social service departments. Rules vary by state, so Dr. Flansbaum says hospitalists would do well to brush up on their requirements and liabilities.

"I may not know the rules," Dr. Flansbaum said, "but I certainly would speak to the right people here and ask them: 'What are my obligations? How do I protect myself and the patient?' " He recommends hospitalists verify local requirements with their hospital administration.

The recent suspension of a New York City doctor who failed to report a gunshot wound suffered by a football star is an opportunity for hospitalists to revisit their own reporting requirements, the president of SHM's NYC chapter says.

Josyann Abisaab, MD, of New York-Presbyterian Hospital/Weill Cornell Medical Center, was suspended after treating New York Giants wide receiver Plaxico Burress on Nov. 29. Less than a year after catching the winning touchdown pass in the Giants' Super Bowl victory, Burress, who told police he accidentally shot himself in the thigh at a NYC nightclub, has been suspended by the league and charged with criminal possession of a gun.

"I was not aware that something like this needed a report to the police," says Bradley Flansbaum, DO, MPH, chief of hospitalist services at Lenox Hill Hospital in Manhattan and president of SHM’s NYC chapter. "It opened up space in my brain. If I were confronted with this, when would I know when to and when not to call the police?"

Complicating matters is the fact hospitalists may have to report issues to more than just law enforcement; depending on diagnoses and patient histories, doctors may have to notify state and federal health agencies or social service departments. Rules vary by state, so Dr. Flansbaum says hospitalists would do well to brush up on their requirements and liabilities.

"I may not know the rules," Dr. Flansbaum said, "but I certainly would speak to the right people here and ask them: 'What are my obligations? How do I protect myself and the patient?' " He recommends hospitalists verify local requirements with their hospital administration.

Question: Is sodium bicarbonate superior to sodium chloride in preventing contrast-induced nephropathy in patients with chronic kidney disease (CKD) undergoing coronary angiography?

Background: Sodium bicarbonate has been suggested as a possible strategy to prevent contrast-induced nephropathy—a condition that can lead to prolonged hospitalization, increased healthcare costs, and substantial morbidity and mortality.

Study design: Randomized, controlled, single-blind study.

Setting: Kaiser Permanente Medical Center, Los Angeles.

Synopsis: Data were collected over 12 months by selecting 353 patients with stable CKD undergoing coronary angiography who were 18 or older and had an estimated glomerular filtration rate (GFR) of 60mL/min/1.73m² or less and one or more of diabetes mellitus, congestive heart failure, hypertension, or age older than 75 years. Patients were randomized to received sodium chloride (n=178) and sodium bicarbonate (n=175) at the same rate and duration.

There was no statistical difference in the primary endpoint (p=0.82), which was a 25% or greater decrease in the GFR on days 1 through 4 after contrast exposure.

Study results were limited by several factors; most importantly, it was not a double-blinded study and was performed at a single center. Also, the sodium content of the two fluids varied; normal saline carried 154mEq and sodium bicarbonate 130mEq of sodium, respectively.

Bottom line: Hydration with sodium bicarbonate is not superior to sodium chloride in preventing contrast-induced nephropathy in patients with moderate to severe CKD undergoing coronary angiography.

Citation: JAMA. 2008;300(9):1038-1046

—Reviewed for the e-wire by Elbert Chun, MD, John Vazquez, MD, Larry Beer, MD, Maged Doss, MD, Vana Bollineni, MD, Mohammed S. Singapuri, MD, Dan Dressler, MD, MsCR, Emory University Hospital, Atlanta

Question: Is sodium bicarbonate superior to sodium chloride in preventing contrast-induced nephropathy in patients with chronic kidney disease (CKD) undergoing coronary angiography?

Background: Sodium bicarbonate has been suggested as a possible strategy to prevent contrast-induced nephropathy—a condition that can lead to prolonged hospitalization, increased healthcare costs, and substantial morbidity and mortality.

Study design: Randomized, controlled, single-blind study.

Setting: Kaiser Permanente Medical Center, Los Angeles.

Synopsis: Data were collected over 12 months by selecting 353 patients with stable CKD undergoing coronary angiography who were 18 or older and had an estimated glomerular filtration rate (GFR) of 60mL/min/1.73m² or less and one or more of diabetes mellitus, congestive heart failure, hypertension, or age older than 75 years. Patients were randomized to received sodium chloride (n=178) and sodium bicarbonate (n=175) at the same rate and duration.

There was no statistical difference in the primary endpoint (p=0.82), which was a 25% or greater decrease in the GFR on days 1 through 4 after contrast exposure.

Study results were limited by several factors; most importantly, it was not a double-blinded study and was performed at a single center. Also, the sodium content of the two fluids varied; normal saline carried 154mEq and sodium bicarbonate 130mEq of sodium, respectively.

Bottom line: Hydration with sodium bicarbonate is not superior to sodium chloride in preventing contrast-induced nephropathy in patients with moderate to severe CKD undergoing coronary angiography.

Citation: JAMA. 2008;300(9):1038-1046

—Reviewed for the e-wire by Elbert Chun, MD, John Vazquez, MD, Larry Beer, MD, Maged Doss, MD, Vana Bollineni, MD, Mohammed S. Singapuri, MD, Dan Dressler, MD, MsCR, Emory University Hospital, Atlanta

Question: Is sodium bicarbonate superior to sodium chloride in preventing contrast-induced nephropathy in patients with chronic kidney disease (CKD) undergoing coronary angiography?

Background: Sodium bicarbonate has been suggested as a possible strategy to prevent contrast-induced nephropathy—a condition that can lead to prolonged hospitalization, increased healthcare costs, and substantial morbidity and mortality.

Study design: Randomized, controlled, single-blind study.

Setting: Kaiser Permanente Medical Center, Los Angeles.

Synopsis: Data were collected over 12 months by selecting 353 patients with stable CKD undergoing coronary angiography who were 18 or older and had an estimated glomerular filtration rate (GFR) of 60mL/min/1.73m² or less and one or more of diabetes mellitus, congestive heart failure, hypertension, or age older than 75 years. Patients were randomized to received sodium chloride (n=178) and sodium bicarbonate (n=175) at the same rate and duration.

There was no statistical difference in the primary endpoint (p=0.82), which was a 25% or greater decrease in the GFR on days 1 through 4 after contrast exposure.

Study results were limited by several factors; most importantly, it was not a double-blinded study and was performed at a single center. Also, the sodium content of the two fluids varied; normal saline carried 154mEq and sodium bicarbonate 130mEq of sodium, respectively.

Bottom line: Hydration with sodium bicarbonate is not superior to sodium chloride in preventing contrast-induced nephropathy in patients with moderate to severe CKD undergoing coronary angiography.

Citation: JAMA. 2008;300(9):1038-1046

—Reviewed for the e-wire by Elbert Chun, MD, John Vazquez, MD, Larry Beer, MD, Maged Doss, MD, Vana Bollineni, MD, Mohammed S. Singapuri, MD, Dan Dressler, MD, MsCR, Emory University Hospital, Atlanta

Imatinib tablet

SAN FRANCISCO—The longest duration study of imatinib treatment for patients with Ph+ CML shows 86% of patients are still alive 7 years after beginning therapy.

The International Randomized Interferon versus STI571 (IRIS) study revealed only 1 early chronic-phase patient progressed to a more advanced phase between years 6 and 7, Stephen O’Brien, MD, PhD, of Newcastle University in the UK, said at the 50th Annual Meeting of the American Society of Hematology.

IRIS is an open-label, phase 3 clinical trial enrolling 1106 newly diagnosed patients with chronic phase Ph+ CML in 177 centers across 16 countries. One group of 553 patients received imatinib 400 mg per day. Another group of 553 patients received a target dose of interferon (IFN) of 5 MIU/m²/day in combination with cytarabine at 20 mg/m²/day for 10 days each month.

Because of tolerability issues, lack of response, or loss of response, 65% of patients in the IFN/cytarabine arm crossed over to the imatinib arm. Only 3% of patients in the imatinib arm crossed over to the IFN/cytarabine arm.

A low rate of progression has been reported every year since this trial began in 2001. Seven percent of patients treated with imatinib progressed to advanced phases of CML after 7 years. Of the 456 patients (82%) who achieved a complete cytogenetic response, 17% lost their response and 3% progressed to advanced phases. 

“After 1 year of treatment, there is a small risk of progression,” Dr O’Brien said. “If patients achieve and maintain a complete cytogenetic response after 3 years, they are fairly safe.”

Treatment with imatinib in the IRIS study was well tolerated, he said. No new serious adverse events occurred between the sixth and seventh year of treatment.

The results from the IRIS study also reveal that, by year 6, 85% to 90% of patients still taking imatinib achieved a major molecular response. This key milestone indicates a reduction in the abnormal protein responsible for the uncontrolled production of abnormal white blood cells and may be a sensitive predictor of long-term progression-free survival.

“There was a steady improvement in major molecular responses between 4 and 7 years of treatment,” said Timothy Hughes, MD, of the Institute of Medical and Veterinary Science in Adelaide, Australia. “By 7 years, the vast majority of patients who achieved a complete cytogenetic response also achieved a major molecular response.”

A major molecular response at any time point represents a “safe haven” for patients, Dr Hughes said. Both molecular and cytogenetic evaluations should be used to guide treatment decisions until a complete cytogenetic response is achieved, followed by measurements of molecular assessments.

“In this, the seventh year of the IRIS study, CML patients treated with imatinib continue to demonstrate impressive long-term survival,” Dr O’Brien said. “Imatinib 400 mg daily is confirmed as the standard of care for the initial therapy of chronic-phase CML.”

Imatinib, the first therapy to inhibit the activity of Bcr-Abl, revolutionized the treatment of Ph+ CML, Dr O’Brien said. Prior to imatinib, about 50% of patients with Ph+ CML progressed from the initial phase to more advanced stages after 3 to 5 years. Once patients reached the final blast crisis phase, survival was generally 3 to 6 months.

Imatinib tablet

SAN FRANCISCO—The longest duration study of imatinib treatment for patients with Ph+ CML shows 86% of patients are still alive 7 years after beginning therapy.

The International Randomized Interferon versus STI571 (IRIS) study revealed only 1 early chronic-phase patient progressed to a more advanced phase between years 6 and 7, Stephen O’Brien, MD, PhD, of Newcastle University in the UK, said at the 50th Annual Meeting of the American Society of Hematology.

IRIS is an open-label, phase 3 clinical trial enrolling 1106 newly diagnosed patients with chronic phase Ph+ CML in 177 centers across 16 countries. One group of 553 patients received imatinib 400 mg per day. Another group of 553 patients received a target dose of interferon (IFN) of 5 MIU/m²/day in combination with cytarabine at 20 mg/m²/day for 10 days each month.

Because of tolerability issues, lack of response, or loss of response, 65% of patients in the IFN/cytarabine arm crossed over to the imatinib arm. Only 3% of patients in the imatinib arm crossed over to the IFN/cytarabine arm.

A low rate of progression has been reported every year since this trial began in 2001. Seven percent of patients treated with imatinib progressed to advanced phases of CML after 7 years. Of the 456 patients (82%) who achieved a complete cytogenetic response, 17% lost their response and 3% progressed to advanced phases. 

“After 1 year of treatment, there is a small risk of progression,” Dr O’Brien said. “If patients achieve and maintain a complete cytogenetic response after 3 years, they are fairly safe.”

Treatment with imatinib in the IRIS study was well tolerated, he said. No new serious adverse events occurred between the sixth and seventh year of treatment.

The results from the IRIS study also reveal that, by year 6, 85% to 90% of patients still taking imatinib achieved a major molecular response. This key milestone indicates a reduction in the abnormal protein responsible for the uncontrolled production of abnormal white blood cells and may be a sensitive predictor of long-term progression-free survival.

“There was a steady improvement in major molecular responses between 4 and 7 years of treatment,” said Timothy Hughes, MD, of the Institute of Medical and Veterinary Science in Adelaide, Australia. “By 7 years, the vast majority of patients who achieved a complete cytogenetic response also achieved a major molecular response.”

A major molecular response at any time point represents a “safe haven” for patients, Dr Hughes said. Both molecular and cytogenetic evaluations should be used to guide treatment decisions until a complete cytogenetic response is achieved, followed by measurements of molecular assessments.

“In this, the seventh year of the IRIS study, CML patients treated with imatinib continue to demonstrate impressive long-term survival,” Dr O’Brien said. “Imatinib 400 mg daily is confirmed as the standard of care for the initial therapy of chronic-phase CML.”

Imatinib, the first therapy to inhibit the activity of Bcr-Abl, revolutionized the treatment of Ph+ CML, Dr O’Brien said. Prior to imatinib, about 50% of patients with Ph+ CML progressed from the initial phase to more advanced stages after 3 to 5 years. Once patients reached the final blast crisis phase, survival was generally 3 to 6 months.

Imatinib tablet

SAN FRANCISCO—The longest duration study of imatinib treatment for patients with Ph+ CML shows 86% of patients are still alive 7 years after beginning therapy.

The International Randomized Interferon versus STI571 (IRIS) study revealed only 1 early chronic-phase patient progressed to a more advanced phase between years 6 and 7, Stephen O’Brien, MD, PhD, of Newcastle University in the UK, said at the 50th Annual Meeting of the American Society of Hematology.

IRIS is an open-label, phase 3 clinical trial enrolling 1106 newly diagnosed patients with chronic phase Ph+ CML in 177 centers across 16 countries. One group of 553 patients received imatinib 400 mg per day. Another group of 553 patients received a target dose of interferon (IFN) of 5 MIU/m²/day in combination with cytarabine at 20 mg/m²/day for 10 days each month.

Because of tolerability issues, lack of response, or loss of response, 65% of patients in the IFN/cytarabine arm crossed over to the imatinib arm. Only 3% of patients in the imatinib arm crossed over to the IFN/cytarabine arm.

A low rate of progression has been reported every year since this trial began in 2001. Seven percent of patients treated with imatinib progressed to advanced phases of CML after 7 years. Of the 456 patients (82%) who achieved a complete cytogenetic response, 17% lost their response and 3% progressed to advanced phases. 

“After 1 year of treatment, there is a small risk of progression,” Dr O’Brien said. “If patients achieve and maintain a complete cytogenetic response after 3 years, they are fairly safe.”

Treatment with imatinib in the IRIS study was well tolerated, he said. No new serious adverse events occurred between the sixth and seventh year of treatment.

The results from the IRIS study also reveal that, by year 6, 85% to 90% of patients still taking imatinib achieved a major molecular response. This key milestone indicates a reduction in the abnormal protein responsible for the uncontrolled production of abnormal white blood cells and may be a sensitive predictor of long-term progression-free survival.

“There was a steady improvement in major molecular responses between 4 and 7 years of treatment,” said Timothy Hughes, MD, of the Institute of Medical and Veterinary Science in Adelaide, Australia. “By 7 years, the vast majority of patients who achieved a complete cytogenetic response also achieved a major molecular response.”

A major molecular response at any time point represents a “safe haven” for patients, Dr Hughes said. Both molecular and cytogenetic evaluations should be used to guide treatment decisions until a complete cytogenetic response is achieved, followed by measurements of molecular assessments.

“In this, the seventh year of the IRIS study, CML patients treated with imatinib continue to demonstrate impressive long-term survival,” Dr O’Brien said. “Imatinib 400 mg daily is confirmed as the standard of care for the initial therapy of chronic-phase CML.”

Imatinib, the first therapy to inhibit the activity of Bcr-Abl, revolutionized the treatment of Ph+ CML, Dr O’Brien said. Prior to imatinib, about 50% of patients with Ph+ CML progressed from the initial phase to more advanced stages after 3 to 5 years. Once patients reached the final blast crisis phase, survival was generally 3 to 6 months.

San Francisco—Researchers confirmed the safety and efficacy of a lower dose of dabigatran etexilate in elderly hip and total knee replacement surgery patients.

Dabigatran is a new oral thrombin inhibitor recently approved in Europe for the prevention of VTE in patients undergoing this surgery. Ola E. Dahl, MD, of the Thrombosis Research Institute in London, reported the results of a post hoc pooled analysis of 2 pivotal trials comparing dabigatran with enoxaparin at the 50th Annual Meeting of the American Society of Hematology.

Dr Dahl and colleagues analyzed 883 patients older than 75 years who were enrolled in the RE-MODEL and RE-NOVATE trials. Researchers evaluated 220 mg and 150 mg once-daily doses of dabigatran compared to a 40 mg daily dose of enoxaparin.

The primary efficacy endpoint was total number of VTEs and all-cause mortality. Both doses of dabigatran reduced total VTEs compared to enoxaparin, though not significantly.

However, the higher dose of dabigatran produced a significant difference in the secondary endpoint, major VTEs and VTE-related mortality. Four of 216 patients (1.9%) receiving the 220 mg dose had a major VTE, compared with 13 of 218 patients receiving enoxaparin (P=0.045).

The safety endpoint was the difference in major bleeding events, including surgical site bleeding, which accounts for up to 90% of bleeding in these patients. Major bleeding events occurred in 3.7% of the patients receiving dabigatran at 220 mg and 1.4% receiving 150 mg, compared to 2.9% in the enoxaparin group. The study was not powered to show significance in the safety endpoint.

“If you look into the dabigatran regimens versus enoxaparin, you see that we have more efficacious 200 mg dosing with slightly increased bleeding,” Dr Dahl said. “The 150 mg dose has the same efficacy level, but with a little less bleeding. And that is exactly the profile we are looking for in the elderly.”

San Francisco—Researchers confirmed the safety and efficacy of a lower dose of dabigatran etexilate in elderly hip and total knee replacement surgery patients.

Dabigatran is a new oral thrombin inhibitor recently approved in Europe for the prevention of VTE in patients undergoing this surgery. Ola E. Dahl, MD, of the Thrombosis Research Institute in London, reported the results of a post hoc pooled analysis of 2 pivotal trials comparing dabigatran with enoxaparin at the 50th Annual Meeting of the American Society of Hematology.

Dr Dahl and colleagues analyzed 883 patients older than 75 years who were enrolled in the RE-MODEL and RE-NOVATE trials. Researchers evaluated 220 mg and 150 mg once-daily doses of dabigatran compared to a 40 mg daily dose of enoxaparin.

The primary efficacy endpoint was total number of VTEs and all-cause mortality. Both doses of dabigatran reduced total VTEs compared to enoxaparin, though not significantly.

However, the higher dose of dabigatran produced a significant difference in the secondary endpoint, major VTEs and VTE-related mortality. Four of 216 patients (1.9%) receiving the 220 mg dose had a major VTE, compared with 13 of 218 patients receiving enoxaparin (P=0.045).

The safety endpoint was the difference in major bleeding events, including surgical site bleeding, which accounts for up to 90% of bleeding in these patients. Major bleeding events occurred in 3.7% of the patients receiving dabigatran at 220 mg and 1.4% receiving 150 mg, compared to 2.9% in the enoxaparin group. The study was not powered to show significance in the safety endpoint.

“If you look into the dabigatran regimens versus enoxaparin, you see that we have more efficacious 200 mg dosing with slightly increased bleeding,” Dr Dahl said. “The 150 mg dose has the same efficacy level, but with a little less bleeding. And that is exactly the profile we are looking for in the elderly.”

San Francisco—Researchers confirmed the safety and efficacy of a lower dose of dabigatran etexilate in elderly hip and total knee replacement surgery patients.

Dabigatran is a new oral thrombin inhibitor recently approved in Europe for the prevention of VTE in patients undergoing this surgery. Ola E. Dahl, MD, of the Thrombosis Research Institute in London, reported the results of a post hoc pooled analysis of 2 pivotal trials comparing dabigatran with enoxaparin at the 50th Annual Meeting of the American Society of Hematology.

Dr Dahl and colleagues analyzed 883 patients older than 75 years who were enrolled in the RE-MODEL and RE-NOVATE trials. Researchers evaluated 220 mg and 150 mg once-daily doses of dabigatran compared to a 40 mg daily dose of enoxaparin.

The primary efficacy endpoint was total number of VTEs and all-cause mortality. Both doses of dabigatran reduced total VTEs compared to enoxaparin, though not significantly.

However, the higher dose of dabigatran produced a significant difference in the secondary endpoint, major VTEs and VTE-related mortality. Four of 216 patients (1.9%) receiving the 220 mg dose had a major VTE, compared with 13 of 218 patients receiving enoxaparin (P=0.045).

The safety endpoint was the difference in major bleeding events, including surgical site bleeding, which accounts for up to 90% of bleeding in these patients. Major bleeding events occurred in 3.7% of the patients receiving dabigatran at 220 mg and 1.4% receiving 150 mg, compared to 2.9% in the enoxaparin group. The study was not powered to show significance in the safety endpoint.

“If you look into the dabigatran regimens versus enoxaparin, you see that we have more efficacious 200 mg dosing with slightly increased bleeding,” Dr Dahl said. “The 150 mg dose has the same efficacy level, but with a little less bleeding. And that is exactly the profile we are looking for in the elderly.”

Dr. Jonathan Friedberg discusses an experimental targeted oral agent, fostamatinib, that's being used to treat diffuse large B-cell lymphoma and chronic lymphocytic leukemia. Jane MacNeil of Elsevier Global Medical News (EGMN) reports from the annual meeting of the American Society of Hematology.

Dr. Jonathan Friedberg discusses an experimental targeted oral agent, fostamatinib, that's being used to treat diffuse large B-cell lymphoma and chronic lymphocytic leukemia. Jane MacNeil of Elsevier Global Medical News (EGMN) reports from the annual meeting of the American Society of Hematology.

Dr. Jonathan Friedberg discusses an experimental targeted oral agent, fostamatinib, that's being used to treat diffuse large B-cell lymphoma and chronic lymphocytic leukemia. Jane MacNeil of Elsevier Global Medical News (EGMN) reports from the annual meeting of the American Society of Hematology.

Dr. Gregory Cheng says patients with chronic idiopathic thrombocytopenia purpura are more likely to achieve target platelet counts when treated with oral eltrombopag. Jane MacNeil of Elsevier Global Medical News (EGMN) reports from the annual meeting of the American Society of Hematology.

Dr. Gregory Cheng says patients with chronic idiopathic thrombocytopenia purpura are more likely to achieve target platelet counts when treated with oral eltrombopag. Jane MacNeil of Elsevier Global Medical News (EGMN) reports from the annual meeting of the American Society of Hematology.

Dr. Gregory Cheng says patients with chronic idiopathic thrombocytopenia purpura are more likely to achieve target platelet counts when treated with oral eltrombopag. Jane MacNeil of Elsevier Global Medical News (EGMN) reports from the annual meeting of the American Society of Hematology.

The Institute of Medicine (IOM) issued a report this month calling for limits to shifts worked by residents, a move that, if implemented, likely means more work for in-house hospitalists, according to one hospital medicine leader.

IOM recommends no change to the current maximum 80-hour workweek for residents, or to the maximum shift length of 30 hours. The report does, however, recommend residents only treat patients for up to 16 hours during their shift, down from the current recommendation of 24 hours. It also suggests residents take an uninterrupted five hours for a continuous sleep period between 10 p.m. and 8 a.m.

In 2003, the Accreditation Council for Graduate Medical Education restricted resident workweeks in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. As mentioned in "While Residents Rest…" in The Hospitalist (August 2006), the resulting shift in workload stressed many hospitals relying on residents for coverage, and some believe it helped boost the need for hospitalists.

In teaching hospitals that follow the IOM recommendations, "I do think this work will go to hospitalists," says Sameer Badlani, MD, a hospitalist and instructor at the University of Chicago. "This is a good thing, in my opinion, as it will enhance the value a hospitalist program brings to an institution."

Dr. Badlani warns hospitals must be willing to help supplement additional costs to their hospitalist service.

The IOM report, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety," is available for purchase online, or you can download a report brief at www.iom.edu/CMS/3809/48553/60449.aspx.

The Institute of Medicine (IOM) issued a report this month calling for limits to shifts worked by residents, a move that, if implemented, likely means more work for in-house hospitalists, according to one hospital medicine leader.

IOM recommends no change to the current maximum 80-hour workweek for residents, or to the maximum shift length of 30 hours. The report does, however, recommend residents only treat patients for up to 16 hours during their shift, down from the current recommendation of 24 hours. It also suggests residents take an uninterrupted five hours for a continuous sleep period between 10 p.m. and 8 a.m.

In 2003, the Accreditation Council for Graduate Medical Education restricted resident workweeks in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. As mentioned in "While Residents Rest…" in The Hospitalist (August 2006), the resulting shift in workload stressed many hospitals relying on residents for coverage, and some believe it helped boost the need for hospitalists.

In teaching hospitals that follow the IOM recommendations, "I do think this work will go to hospitalists," says Sameer Badlani, MD, a hospitalist and instructor at the University of Chicago. "This is a good thing, in my opinion, as it will enhance the value a hospitalist program brings to an institution."

Dr. Badlani warns hospitals must be willing to help supplement additional costs to their hospitalist service.

The IOM report, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety," is available for purchase online, or you can download a report brief at www.iom.edu/CMS/3809/48553/60449.aspx.

The Institute of Medicine (IOM) issued a report this month calling for limits to shifts worked by residents, a move that, if implemented, likely means more work for in-house hospitalists, according to one hospital medicine leader.

IOM recommends no change to the current maximum 80-hour workweek for residents, or to the maximum shift length of 30 hours. The report does, however, recommend residents only treat patients for up to 16 hours during their shift, down from the current recommendation of 24 hours. It also suggests residents take an uninterrupted five hours for a continuous sleep period between 10 p.m. and 8 a.m.

In 2003, the Accreditation Council for Graduate Medical Education restricted resident workweeks in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. As mentioned in "While Residents Rest…" in The Hospitalist (August 2006), the resulting shift in workload stressed many hospitals relying on residents for coverage, and some believe it helped boost the need for hospitalists.

In teaching hospitals that follow the IOM recommendations, "I do think this work will go to hospitalists," says Sameer Badlani, MD, a hospitalist and instructor at the University of Chicago. "This is a good thing, in my opinion, as it will enhance the value a hospitalist program brings to an institution."

Dr. Badlani warns hospitals must be willing to help supplement additional costs to their hospitalist service.

The IOM report, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety," is available for purchase online, or you can download a report brief at www.iom.edu/CMS/3809/48553/60449.aspx.