As healthcare evolves, we increasingly need Rapid Response teams in primary care.
This article was first published on Sunday, February 23, 2020 in MedPage Today.
By Fred N. Pelzman, MD, MedPage Today
Over the past few months, in our happy little outpatient world, we've had several episodes of really sick patients showing up for their appointments, and some patients who seriously and rapidly deteriorated during their brief time visiting with us.
As our patient population ages and gets more complex, with an ever greater list of health conditions and medications, we are seeing sicker and sicker patients in our office for routine care.
Patients that many years ago would've been taken care of in the inpatient world, are now being managed without hospitalization, with complex collaboration among multiple providers.
And patients who were evaluated in the emergency room and sent home with a careful follow-up plan often show up at our office with that plan not being fully carried out, and thus once again quite ill.
Despite the fact that we are right across the street from our hospital, we are very much an ambulatory outpatient site. Our patients show up, wait in the waiting room, see us in the exam room, get their labs and vaccines done, and then, for the most part, go home.
Every once in a while things don't go quite as planned.
Sure, there are the occasional slips and falls, the vasovagal syncope after a vaccine or phlebotomy, or the patient just a little dehydrated from their upper respiratory infection or diarrheal illness, but occasionally things go very far south very quickly.
Just over these past few months we've dealt with refractory hypoglycemia with altered mental status, unremitting seizures, severe asthma exacerbations requiring intubation, respiratory failure from COPD, and one patient who presented with a cough who was found to be in an unstable arrhythmia with severe hypotension.
Not your typical day at the office.
Our team has always responded well, but it's clear when we talk about these things afterwards that our systems could be better.
It's never a good sign when the providers taking care of the patients are as tachycardic and diaphoretic as the sick person they are attending to.
For most of this, we really are just out of practice at this stuff.
Our staff goes through mock drills, practicing all the tasks, but when the rare thing happens, it still sends a little shiver of panic down our spines.
It's kind of like that old line about anesthesiology: hours of boredom punctuated by moments of terror.
It's time we rethink and redesign a 21st-century Rapid Response team for clinical emergencies in the outpatient world.
When I was in high school, I got a summer internship working on a National Science Foundation project, helping to program a computer to calculate complex formulas of ocean temperature and salinity.
I remember the computer room where we had to take our punch cards, load them into the hopper, and then watch them feed one by one into the belly of this massive beast, hoping it wouldn't get jammed. The computer itself took up half the floor of the lab where we worked, enclosed behind walls in its own air-conditioned room, and you needed special permission to enter.
Today, my phone (and now even my watch!) have more computing power than that behemoth did.
This is the way I feel about the defibrillator we've had in our practice.
Hospital issued, it hasn't been upgraded in over a decade to the best of my knowledge, and sits waiting on a huge cart that we keep in the hallway of our practice.
Every morning, our charge nurse dutifully turns it on and runs its safety checks, and logs that it's in working order.
Never been used.
Thinking about this, I realized that every Starbucks and restaurant in New York City is better outfitted and prepared for sudden cardiac death than we were.
So I bought several shiny compact modern AEDs, and mounted them in each practice area around our office.
Everyone got an email about these, along with links to a website with instructional videos, and we reviewed how to use these devices at our faculty and staff meetings.
Just the other day, I surveyed our residents, staff, and faculty, and most did not know where they were, and did not recall how to use them.
Some did not even know we had them.
We need many of the items that are in the inpatient crash cart, but since we use them so rarely, they often expired as they lay waiting to be used, leading to huge costs and waste.
We need IV access, oxygen, and aspirin. We need Narcan for the opioid overdose that happens in the waiting room. We need D-50 for refractory hypoglycemia, along with glucagon.
We need point-of-care testing for glucose and electrolytes.
We need everyone to know where the defibrillators are, and how to use them.
We need everyone to keep BLS and ACLS certifications up-to-date.
We need trained teams, where everyone knows their roles, and everyone knows how to react.
On the inpatient world, over at the hospital, we've always had a Code Blue team for when things have gone wrong, and several years ago they developed a Rapid Response team as well, who are available to respond to any clinical deterioration proactively to avoid things going from bad to worse.
Most of us can hear the sounds of those overhead pages in our dreams: "Code Blue, cardiac team, 10 North"
Over in the hospital they had the advantage of that overhead paging system, and everyone wears a pager or has some telecommunication device that makes them instantly reachable.
Over here, no one carries a pager anymore, and while there are telephones in every room, our intercom system was disconnected many years ago.
We have a new team that's working to develop what our outpatient Rapid Response team should look like, and what it needs to have, but one critical thing we are challenged with at the moment is trying to figure out how to make everybody reachable.
Yes, we're right across the street from the hospital, and a quick call to 911 will bring paramedics to our door, but there certainly are things we want to do in the interim to prevent further clinical deterioration in those precious minutes.
Years ago we had what we used to call the "walk-in doc," a provider who was freed from other clinical duties and assigned to stand ready and waiting for clinical emergencies.
Eventually we retired this role, as it felt like that poor provider spent the whole day standing waiting for the acute MI or stroke to walk through our door, only to go home unrequited.
At this point I'm loathe to buy everybody yet another walkie-talkie device, or insist everyone start wearing their pagers again, or make them carry their cellphones all time.
Perhaps the solution is just reactivating our intercom system, so that help can be called to the place it's needed when it's needed.
So everyone knows they are needed, and everyone knows their role, and everyone has the tools they need when they need them.
Well-intended laws on remote prescribing stand in the way.
This article was first published on Wednesday, February 19, 2020 in MedPage Today.
By Shannon Firth, Washington Correspondent, MedPage Today
WASHINGTON -- Psychiatrists urged lawmakers to support the expansion of telepsychiatry and to remove barriers to care for patients in remote and underserved areas, during a Capitol Hill briefing on Tuesday sponsored by the American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry.
The panel's core recommendations included eliminating what are known as "originating geographic site requirements" and relaxing restrictions on in-home telehealth visits. Panelists also highlighted difficulties related to remote prescribing and obtaining licensure in other states.
"A sick person is a sick person and we should be able to take care of them where they live," said panel member Robert Caudill, MD, professor of psychiatry at the University of Louisville in Kentucky.
While there remains reluctance in some circles around telepsychiatry, there are cases where it may be the best option for that patient. One patient, who he referred to as Sandy was "suicidal every single day of her life."
Caudill saw Sandy 20 years ago, before he used telemedicine. She had survived horrible trauma and stayed as his patient over several years as he moved to offices in different cities. In his slides he showed photographs of some of the incredibly long bridges Sandy would have to drive across over various rivers in order to receive treatment. Sandy's suicidal thoughts included jumping and driving off those same bridges.
While she is no longer alive, Caudill said, she was an example of someone for whom telemedicine could have been useful.
Shabana Khan, MD, assistant professor of child and adolescent psychiatry at NYU Langone in New York City, spoke about the difficulty of caring for patients, particularly those who move out of state for college.
Licensure issues are "huge," she said.
The patient's psychiatrist has to ensure he or she is licensed in the state where the patient now lives in order to continue serving that patient. In Florida, psychiatrists can register as an out-of-state practitioner and some states have limited special registrations for telemedicine, "but that's falling out of favor," Khan said.
Additionally 29 states, the District of Columbia, and Guam have an interstate compact where if a practitioner has a "full, unencumbered license" he or she can serve patients in the other states in the compact.
But even then practitioners must get licensed in those other states, pay an administrative fee, and meet each state's continuing education requirements and practice standards.
"It can get very complicated" and costly, she said.
APA President Bruce Schwartz, MD, the briefing's moderator, estimated the cost of licensure in one state is about $1,000 for a 2-year period.
The idea of a national licensure process has surfaced over the years, but hasn't gotten traction because as Kahn explained each state still wants to be able to regulate its own licensure process.
More than one panelist spoke about another challenge: the unintended consequences of a decades-old law called the Ryan Haight Act which bars providers from prescribing certain medications without an in-person visit.
The goal of the 2008 law was to shutter internet pharmacies, but telemedicine somehow became "collateral damage," Caudill said.
Schwartz noted that the SUPPORT Act of 2018 gave the Drug Enforcement Administration a deadline of October 2019 to issue regulations to clarify "the limited circumstances" under which prescribers could get authorization to prescribe remotely and to develop procedures, but the DEA failed to do so.
Caudill said the uncertainty around prescribing has kept some clinicians from participating in telemedicine, and called on the audience to do "whatever you can do to help with that."
Study: More than a third who asked for limited treatment still got intensive care.
This article was first published on Saturday, February 16, 2020 in MedPage Today.
By Salynn Boyles, Contributing Writer
ORLANDO -- Among patients with chronic illnesses nearing the end of life who had physician orders to limit treatment, more than one in three received ICU care that appeared inconsistent with their written wishes, a researcher reported here.
In the retrospective cohort study, 18% of patients hospitalized within 6 months of death whose Physician Orders for Life-Sustaining Treatment (POLST) requested "limited additional interventions" or "comfort measures only" received POLST-discordant life-sustaining treatments, according to Robert Y. Lee, MD, of the University of Washington in Seattle.
And 38% of patients with POLST received intensive care that was potentially discordant with their stated wishes, Lee reported at the Society of Critical Care Medicine (SCCM) congress, and simultaneously in JAMA.
However, treatment-limiting POLSTs were associated with significantly lower rates of ICU admission compared with full-treatment POLSTs in the retrospective analysis of outcomes among 1,818 deceased patients with POLSTs.
Lee told MedPage Today that while POLSTs have been shown to give much needed guidance to emergency medical services (EMS) personnel, "once you get to the hospital it is a little less clear from the evidence if POLST orders are having an impact."
Still, he added that it was reassuring that treatment-limiting POLSTs appeared to reduce unwanted ICU admissions among gravely ill patients.
But understanding why so many patients with treatment-limiting POLSTs received seemingly discordant care is more complicated, he stated.
"Our study was not designed to say whether the care these patients received was appropriate or inappropriate, or whether they requested the care they got," he explained. "The patients or a family member may have changed their minds, or they may not have envisioned the scenario that brought them to the ICU."
Newly installed SCCM President Lewis J. Kaplan, MD, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, told MedPage Today that "I have absolute faith that doctors aren't intentionally ignoring their patient's wishes."
But "There is a great deal of nuance here," he said. "Say a patient with a [life-limiting] chronic disease ruptures a spleen or fractures a rib. That patient may be very happy to be on a ventilator, because they will recover."
The study examined the association between POLST order and ICU admission during the last hospitalization of before death among patients with POLSTs (mean age 70.8m, 41% women). A composite of life-sustaining treatments, including mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation, was a secondary outcome.
A total of 401 patients (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment.
Lee and colleagues reported that 31% (95% CI 26%-35%) of patients with comfort-only orders were admitted to ICUs versus 46% (95% CI 42%-49%) with limited-intervention orders and 62% (95% CI 58%-66%) with full-treatment orders.
Also, one or more life-sustaining treatments were delivered to 14% (95% CI 11%-17%) of patients with comfort-only orders and to 20% (95% CI 17%-23%) of patients with limited-intervention orders.
Compared with patients with full-treatment POLSTs, patients who had the comfort-only and limited-intervention POLSTs were significantly less likely to receive ICU admission:
Comfort only: 123/401 (31%) vs 406/656 (62%), adjusted relative risk 0.53 (95% CI 0.45-0.62)
Limited interventions: 349/761 (46%) vs 406/656 (62%), aRR 0.79 (95% CI 0.71-0.87)
The authors also reported that patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer:
Comfort only: 41/181 (23%) vs 80/220 (36%), aRR 0.60 (95% CI 0.43-0.85)
Limited interventions: 100/321 (31%) vs 215/440 (49%), aRR 0.63 (95% CI 0.51-0.78)
In addition, dementia patients who had comfort-only orders received less POLST-discordant care than those without dementia (23/111 or 21% vs 98/290 or 34%, aRR 0.44, 95% CI 0.29-0.67).
And patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care:
Comfort only: 29/64 (45%) vs 92/337 (27%), aRR 1.52 (95% CI 1.08-2.14)
Limited interventions: 51/91 (56%) vs 264/670 (39%), aRR 1.36 (95% CI 1.09-1.68)
Among patients with comfort-only and limited-intervention POLSTs, 38% (95% CI 35%-40%) received POLST-discordant care, according to Lee's group.
Old age was associated with significantly less POLST-discordant care in patients with orders directing limited interventions (aRR 0.93 per 10 years, 95% CI 0.88-1.00), they found.
A study limitation was that enrolled patients with POLSTs were hospitalized near the end of life so the findings do not apply to patients with POLSTs who are not hospitalized near the end of life. "Therefore, the results of this study may overestimate the incidence of POLST-discordant care among all patients with POLSTs," Lee and colleagues cautioned.
In an accompanying editorial, Robert Truog, MD, of the Center for Bioethics at Harvard Medical School in Boston, and Terri Fried, MD, of Yale School of Medicine in New Haven, Connecticut, wrote that while it is not clear if the seemingly discordant care identified in the study was actually consistent with the patients' wishes at the time of care, the findings provide "a strong signal that many patients received overtreatment at the end of life, defined either as treatment that is unwanted or treatment that is unlikely to be beneficial."
They said the study provides important new information about "the relationship between POLSTs and overtreatment of patients who are close to death. These insights will assist clinicians in developing strategies to help ensure that patients hospitalized near the end of life receive only those treatments that are both desired and beneficial."
The study was funded by the NIH, Cambia Health Foundation, and the University of Washington Medicine.
Lee disclosed support from the NIH and the National Heart, Lung, and Blood Institute. Co-authors disclosed support from multiple entities and/or multiple relevant relationships with industry.
Truog disclosed relevant relationships from Sanofi and Covance. Fried disclosed support from the NIH.
WASHINGTON -- Much of the current congressional legislation on surprise billing is too friendly to health insurers, Sen. Bill Cassidy, MD (R-La.), said here Wednesday at the American Medical Association's (AMA) annual advocacy conference.
Cassidy, a hepatologist, described how he and a bipartisan group of Senate colleagues worked for 2 years to develop legislation on the issue. Their bill, known as the "Stopping The Outrageous Practice of Surprise Medical Bills," or the STOP Surprise Medical Bills Act of 2019, would pay out-of-network physicians an interim payment based on a benchmark rate, but if the doctor wasn't satisfied with that amount, he or she could proceed to "baseball-style" arbitration, in which the doctor and the insurer submit a proposed price to an independent arbiter, who would decide what the payment should be.
The bill also addresses the issue of narrow provider networks. "Under our bill, if there's an insurance company that has a narrow, narrow network, the arbiter is instructed to look at that and be prejudicial against the insurance company," said Cassidy. On the other hand, "if the doctor or the doctors' group does not contract with anybody, the arbiter would look at that prejudicially against them ... We address it indirectly, but address it powerfully." Cassidy's bill has garnered 15 Republican and 14 Democratic cosponsors but has not otherwise advanced.
Meanwhile, Sen. Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.), the chairman and ranking member, respectively, of the Senate Health, Education, Labor & Pensions (HELP) Committee, have been working on their own bill, the Lower Health Care Costs Act of 2019, which was "very insurance-friendly," said Cassidy. That bill would pay doctors and hospitals that are out-of-network the median contracted rate that in-network doctors and hospitals receive for the same services in their local geographic area.
"It's basically modeled after the California law which all my California doctors tell me is awful -- in which insurance companies cancel contracts and then they have the negotiating power and they establish" their own rate. "You put that into a rural hospital setting, and you're going to have a payment from the commercial side, which is going to put that rural hospital out of business. You and I know that," he said to the assembled physicians. "We know that if you've got a bad payer mix, you make up for that bad payer mix by charging the commercials more, but if the commercials can cancel the contract and pay you whatever they want to, they're going to pay you far less than your cost of doing business, and your rural hospital goes out of business."
Alexander's bill passed the HELP committee in June by a vote of 20-3 but hasn't yet been acted on by the full Senate, although some of its provisions unrelated to surprise billing have been included in other legislation. "In fairness to his staff, they came to the realization that rural hospitals are going to have a problem and they're trying to do something on the back end, but I still don't think this is the best solution," said Cassidy.
In addition, the House is also working on the issue, with a bill in the Energy & Commerce Committee that "looks a lot like the HELP committee bill, but there is significant opposition to that," Cassidy said. The House Ways & Means Committee on Wednesday passed a bill known as the Consumer Protections Against Surprise Medical Bills Act which is "closest to the STOP Act, but I still have some problems with the Ways & Means bill," he said. That's because "they don't have the interim payment; they have a facilitated glide path to arbitration, and the point at which the arbiter begins to make the arbiter's consideration is around the median network price. We think ... that becomes an anchor."
Meanwhile, the House Education & Labor Committee passed through its own bill on Tuesday "which all the physicians opposed, no matter what their party," Cassidy said; that bill would set a benchmark rate for out-of-network bills but also would allow for arbitration in certain situations with high-dollar bills.
Cassidy exhorted AMA members to support his bill during their Wednesday "lobby day" with their legislators. "When you meet with somebody today, be that a staffer, a representative, or a senator, if you decided which of these bills you'd like, then advocate for that bill," he said. "But I would hope you'd advocate for something such as what we have proposed, that there be an interim payment; that small two- or three-person group has the cash flow they need to stay in business."
Sen. John Barrasso (R-Wyo.), who spoke at the conference earlier on Wednesday, criticized "Medicare for All" proposals in which all doctors would be paid Medicare rates, noting that in the old days, Medicare allowed doctors to "balance bill" patients for bills that were higher than the amount Medicare was willing to pay.
"That is now illegal. But if you're really going to solve some of the healthcare crisis, if every physician were paid under a 'Medicare for All' plan at Medicare rates, hospitals couldn't stay open, physicians' offices couldn't stay open," he said. So balance billing "is something I've always supported. There are many people that say, 'I'd be happy to do that.' But to say everybody's at the Medicare rate, it's not sustainable. Unless we can focus on balance billing, it's not a sustainable model."
AMA president Patrice Harris, MD, did not endorse a particular bill but said the association's policy was "number one, keep the patient out of the middle" and that "we definitely believe arbitration/mediation is important." If benchmarking is done, it shouldn't be done by insurers. "We have to look at all of the contours around who is deciding what a rate might be, but the biggest piece is the ability for physicians to have a level playing field as they go into arbitration," she added.
Human-to-human transmission in China likely occurred from near the beginning.
This article was first published on Wednesday, January 29, 2020 in MedPage Today.
By Molly Walker, Associate Editor, MedPage Today January 29, 2020
Human-to-human transmission of the novel coronavirus was occurring since mid-December 2019 in China, with the outbreak initially doubling in size every week, researchers found.
Based on the first 425 cases with novel coronavirus-infected pneumonia, the epidemic appeared to double in size every 7.4 days in its earliest stages, with a basic reproductive number estimated at 2.2, reported Zijian Feng, M. Med, of the Chinese Center for Disease Control and Prevention in Beijing, and colleagues.
In addition, mean incubation period was about five days, with the 95th percentile at 12.5 days, the researchers wrote in the New England Journal of Medicine.
"Considerable efforts to reduce transmission will be required to control outbreaks if similar dynamics apply elsewhere," they noted.
Interestingly, the authors noted that while over half of those cases were linked to exposure to Wuhan's Huanan Seafood Market, the widely reported source of the outbreak in the earliest days of the virus, "it is now clear that human-to-human transmission is occurring and that the epidemic has been gradually growing in recent weeks."
Human-to-human transmission of novel coronavirus outside China is on the minds of the international community, particularly as the World Health Organization convenes its emergency committee on Thursday to decide whether the outbreak constitutes an international health emergency. Reuters reported a fifth case of novel coronavirus in France late Wednesday, in the daughter of a man, age 80, who was hospitalized with the disease.
But the reproductive number -- the average number of people who will contract the virus from one infected person -- is also of considerable interest, as it determines how efficiently the virus can transmit among the population. Based on their data, Feng and colleagues estimated a basic reproductive number for novel coronavirus of 2.2 (95% CI 1.4-3.9), which falls into the widely reported "between 1.5 and 3" basic reproductive number for the virus.
"We're still learning a lot about the transmission of the virus, so the reproductive number is going to change rapidly," Amesh Adalja, MD, spokesperson, Infectious Diseases Society of America, told MedPage Today, speaking in general about the reproductive number of the virus.
Adalja also cautioned against putting a lot of emphasis into the reproductive number or using it as "a special magic number that applies to all situations," because each patient has his or her own reproductive number.
"If you isolate a patient and they don't transmit the virus to anybody, then their reproductive number is zero," he said.
Feng and colleagues examined data from the first 425 laboratory-confirmed cases of patients with novel coronavirus-infected pneumonia up through Jan. 22. Median age of patients was 59, though they ranged from age 15-89, and 56% were men. There were no cases in children younger than age 15, the authors said. Estimates of the epidemic growth rate were calculated from cases with symptom onset from Dec. 10 to Jan. 4.
Based on exposure data among ten confirmed cases, researchers estimated the mean incubation period was 5.2 days. Duration from illness onset until first medical visit for ill patients was about six days prior to Jan. 1, and down to about 4.5 days during Jan. 1-11.
On the U.S. front, CDC's daily briefing Wednesday afternoon revealed no new cases in the U.S. So far, there are 165 persons under investigation, and 68 of those have tested negative. CDC officials also said that they have evacuated 195 U.S. citizens from Wuhan, who are now on U.S. soil, as reported by the CDC and the Department of Health and Human Services earlier on Wednesday.
CDC officials did say they suspect they will find additional U.S. novel coronavirus cases, either from travelers or from close contacts of travelers from Hubei province in China.
This study was supported by the Ministry of Science and Technology of China, the National Science and Technology Major Projects of China, the China–U.S. Collaborative Program on Emerging and Re-emerging Infectious Disease, and National Mega-Projects for Infectious Disease, the National Natural Science Foundation, the National Institute of Allergy and Infectious Diseases, and the Health and Medical Research Fund (Hong Kong).
Clinicians urged to step up alcohol screening at regular intervals, intervention.
This article first appeared on Wednesday, January 22, 2020 in MedPage Today.
By Kristin Jenkins, Contributing Writer, MedPage Today
More than half of cancer survivors in the U.S. are drinking alcohol, with some going beyond recommended limits and others actually binge drinking, researchers found.
Data from the 2000-2017 National Health Interview Survey on alcohol use and drinking patterns in 34,080 adults with a diagnosis of cancer showed that 56.5% reported using alcohol, according to the study by Nina N. Sanford, MD, of UT Southwestern Medical Center in Dallas, and colleagues.
This included 34.9% of cancer patients who said their alcohol consumption exceeded moderate drinking guidelines and 21.0% who admitted to binge drinking, the authors wrote in the Journal of the National Comprehensive Cancer Network (NCCN).
The study showed that although white race was associated with higher odds of any drinking among cancer survivors, Alaska Natives/American Indians had the highest odds of exceeding moderate drinking levels and engaging in binge drinking. The risk for drinking alcohol at all levels increased with younger age, current or former smoking history, and participation in the more recent survey period.
The study included 6,313 cancer survivors age 50 and younger, and the risks for binge drinking increased over time. Conversely, the risks for drinking or exceeding moderate drinking guidelines did not increase, the researchers said.
"[T]his study shows a gradual but persistent trend in increasing alcohol intake among cancer survivors over the past decade, particularly in binge drinking," the team wrote. "Given that alcohol intake has implications for cancer prevention and is a potentially modifiable risk factor for cancer-specific outcomes, the high prevalence of alcohol use among cancer survivors highlights the need for public health strategies aimed at the reduction of alcohol consumption."
The same associations were observed in a subset of 20,828 patients who reported a cancer diagnosis 5 or more years before the survey was administered. In this subset, 57.1% of patients said they were current drinkers. This included 35.1% who said their drinking exceeded guidelines from the Centers for Disease Control and Prevention (CDC) recommending a limit of one drink per day for women and two drinks per day for men.
In addition, researchers found 20.1% cancer survivors said they engaged in binge drinking (defined as consuming 5 or more drinks on one or more occasions in the past 12 months).
Sanford and co-authors said the survey findings were particularly concerning in the group of cancer survivors ages 18 to 34. Despite emerging evidence that alcohol is associated with worse oncologic outcomes among patients already diagnosed with cancer, 73.5% of young survivors said they drank alcohol and 23.6% met the criteria for binge drinking.
Cancers most often associated with binge drinking -- melanoma, cervical, head and neck, and testicular cancers -- are the types diagnosed most often in younger cancer patients, the researchers added.
In an NCCN news release, Sanford said the researchers were surprised by the high rates of alcohol use, and urged clinicians to increase their efforts to regularly assess alcohol intake in cancer survivors and discuss the potential harms associated with continued drinking.
"We recommend that providers screen for alcohol use at regular intervals and provide resources to assist in cutting down use for those who may engage in excessive drinking behaviors," she said. "Typically, questions about alcohol use are just asked once when the patient first enters the medical system and then copied into subsequent notes as part of the patient's social history."
Asked for his perspective, Jeffrey Peppercorn, MD, MPH, director of the Cancer Survivorship Program at Massachusetts General Hospital in Boston, who was not involved with the study, agreed that clinicians need to step up their game when talking to cancer survivors about modifiable risk factors such as alcohol use and smoking.
"In general, there is room for improvement in how we counsel patients about healthy lifestyle practices after cancer," he told MedPage Today. "There is a need for more research evaluating interventions to improve lifestyle factors, such as alcohol use, smoking, and exercise, that are known to impact cancer outcomes and general health."
The new study demonstrates that alcohol use can be a problem for cancer survivors from every walk of life, Peppercorn continued. "I believe all patients should be screened for excessive alcohol consumption, and we should be prepared to offer assistance and referrals to services for those who need help."
He said the use of pre-clinic or point-of-care screening questionnaires can help clinicians determine alcohol use in cancer survivors, and this may trigger supplemental nursing or social work evaluations, referral to assistance and counseling programs, and targeted educational materials.
Study Details
In the study by Sanford and colleagues, median patient age was 67, 59.5% of survey respondents were women, and 89.1% were white. Smokers, whether current (16.7% of the total) or former (37.8%), were more likely to drink alcohol, and should be counseled to quit smoking, they said, pointing to evidence about the synergistic impact of smoking combined with alcohol use on some cancer subtypes.
The analysis also showed that the odds of drinking alcohol after a cancer diagnosis increased with non-Hispanic ethnicity, higher income, a high school or university degree, and participation in a later survey period. The odds were also increased in survivors who reported their health status as "good."
Factors associated with increasing risk of binge drinking included male gender, self-reported "good" health status, Alaska Native/American Indian race, higher income, younger age, former or current smoking status, and later survey period.
Also commenting in the NCCN news release, Brandon A. Mahal, MD, of the McGraw/Patterson Center for Population Sciences at Dana-Farber Cancer Institute in Boston, said these results also emphasize that more research on alcohol use is needed for all subsets of survivors of cancer, perhaps with a focus on reduction in patients who feel well and report excessive drinking.
"This behavior is ripe for education and intervention in the survivor population," added Crystal S. Denlinger, MD, of Fox Chase Cancer Center in Philadelphia, who is chair of the panel on NCCN's Clinical Practice Guidelines in Oncology Survivorship, and is also quoted in the news release.
Sanford and co-authors reported having no potential conflicts of interest.
Electronic medical record defaults may influence emergency department prescribing.
This article was first published on Tuesday, January 21, 2019 in MedPage Today.
By Judy George, Senior Staff Writer, MedPage Today
Clinicians prescribed fewer opioid pills when default settings in the electronic medical record (EMR) were lower, a prospective study of two large urban emergency departments showed.
Changing the default EMR setting also resulted in a lower proportion of patients discharged from emergency departments (EDs) with prescriptions exceeding CDC recommendations, reported Juan Carlos Montoy, MD, PhD, of the University of California, San Francisco (UCSF), and colleagues in JAMA Internal Medicine.
Though the intervention decreased the number of pills prescribed to patients, it "still let each doctor choose the appropriate quantity for each patient," Montoy explained.
"Doctors are trying to do the right thing when deciding how to treat patients who are in pain," he told MedPage Today. "But they are human and susceptible to the same mistakes in decision-making as everyone else.
"There is a large body of research on behavioral economics looking at how people make decisions for everything from quitting smoking to saving for retirement," Montoy continued. "Our findings extend this research to the practice of medicine and show we can use nudges that have been proven effective in other contexts to help doctors provide better care for patients."
In general, ED clinicians follow opioid prescribing guidelines and small changes, if baseline amounts already are low, may not have a huge effect on reducing risks associated with overprescribing, noted Kit Delgado, MD, MS, of the University of Pennsylvania in Philadelphia, who wasn't involved with the study.
"That being said, there's still some room to get EDs to lower their defaults," Delgado told MedPage Today. "We conducted a recent national survey and found that 10% of EDs had default amounts of 30 tablets which is way too high, suggesting that the EMR may be inadvertently encouraging marked overprescribing for many conditions."
In their study, Montoy and colleagues evaluated opioid prescribing at two EDs -- UCSF Medical Center and Highland Hospital, a trauma center and safety-net teaching hospital in Oakland, California -- between November 2016 and July 2017.
Over 20 weeks, they randomly changed the EMR default settings for commonly prescribed opioids such as oxycodone, combined oxycodone and acetaminophen (Percocet), and combined hydrocodone bitartrate and acetaminophen (Norco), for 4 weeks at a time. Before the study, the default dispensing settings were 20 tablets at UCSF and 12 tablets at Highland.
The researchers tested preset quantities of five, 10, and 15 pills, and null (a blank setting that required clinicians to enter a number) over five 4-week blocks. "There was some risk that after lowering the default to a lower number than the previous setting, patients may have been prescribed fewer pills than their doctor would have otherwise prescribed," Montoy noted. "This small risk was mitigated by always allowing the prescription to be changed to whatever quantity the doctor prescribed, rather than instituting a limit."
Over the course of the study, 104 physicians, nurse practitioners, and physician assistants wrote 4,320 opioid prescriptions. For each tablet increase in default quantity, 0.19 more opioid tablets (95% CI 0.15-0.22) were prescribed. Pairwise comparisons of default quantities (five vs 15 tablets, for example) showed that a lower default setting was associated with fewer pills prescribed in more than half of the comparisons.
The work builds on other research about EMR defaults and short-term opioid prescribing, both in EDs and other settings. A study of post-surgical patients discharged at Yale New Haven Health System, for example, showed that lowering default settings from 30 to 12 pills decreased the amount of opioids prescribed by more than 15%.
"Changing defaults can be a powerful tool to help reset a prescriber's mindset on what an appropriate opioid prescription should be," said Yale researcher Alexander Chiu, MD. "While data is beginning to show how much pain medication an average patient requires for various conditions, many clinicians are still prescribing based on anecdote and historical practice," he told MedPage Today.
Montoy and colleagues noted several limitations to their study. It did not investigate whether default settings affected the proportion of patients prescribed an opioid, the drug that was prescribed, or which patients received opioid prescriptions. Findings may not apply to non-ED clinicians or to other locales, they added. Importantly, the study did not track potential consequences of the intervention, such as undertreated pain or return visits due to inadequately treated pain.
The study was supported by the National Institutes of Health National Center for Advancing Translational Sciences (UCSF Clinical and Translational Institute).
Researchers disclosed relevant relationships with UCSF Clinical and Translational Institute, Par Pharmaceutical, California ED BRIDGE Program, and Collective Medical.
Heart rate, activity, and sleep data hold promise for population-level influenza tracking.
This article was first published on Thursday, January 16, 2020 in MedPage Today.
By Molly Walker, Associate Editor, MedPage Today.
Fitbits, wearable devices that measure resting heart rate and sleep time, hold promise in measuring flu at the state level, researchers found.
Weeks during which deidentified Fitbit users in five states had elevated heart rates and more sleep time tended to be those when influenza-like illnesses (ILI) were most common in those states, reported Jennifer Radin, PhD, of Scripps Research in La Jolla, California, and colleagues, writing in The Lancet Digital Health.
When the Fitbit data were included in flu-intensity prediction models, Pearson correlations increased by an average 0.12 points (SD 0.07) over the original models, they said, adding, "Correlations of the final models with the CDC ILI rates ranged from 0.84 to 0.97."
"Responding more quickly to influenza outbreaks can prevent further spread and infection, and we were curious to see if sensor data could improve real-time surveillance at the state level," Radin said in a statement.
Google Flu Trends and social media tools like Twitter have attempted to capture real-time flu surveillance data, but the authors noted they have been less than successful, with Google Flu Trends missing early waves of the 2009 H1N1 pandemic strain, as well as overestimating activity during flu outbreaks. They lamented the lack of "objective data streams" to provide real-time flu activity information.
Enter wearable sensors. The authors hypothesized that fitness bands or smart watches "might be able to identify abnormal fluctuations indicting perturbations in one's health, such as an acute infection." They pointed out that acute infections often raise the resting heart rate, and sleep and activity patterns differ when someone is not feeling well.
Radin and colleagues obtained deidentified Fitbit data from a convenience sample of users from March 2016 to March 2018. Users wore a Fitbit for at least 60 days during the study and had only one Fitbit the entire time. The authors noted that to measure population-level changes, they included data from the five states with the most Fitbit use: California, Texas, New York, Illinois, and Pennsylvania.
The Fitbit data were then correlated with ILI reports from the CDC, which generates weekly estimates at the state level.
Overall, about 47,000 users had data included. Users were a mean age of around 43 and 60% were women. Fitbit data improved flu predictions in all five states, the researchers said, citing an improvement of 6% to 33% over baseline models.
"To our knowledge, this is the first study to evaluate the use of [resting heart rate] and sleep data in a large population to predict real-time [influenza-like illness] rates at the state level," the authors wrote.
An accompanying editorial by Cecile Viboud, PhD, of the NIH, and Mauricio Santillana, PhD, of Boston Children's Hospital, characterized the study as "a promising first step towards integrating wearable device measurements in predictive models of infectious diseases."
"We anticipate that Fitbit data could be used as one of several external covariates in predictive models for influenza, along with other health, digital, and social media indicators," the editorialists wrote. "Analysis of repeated individual biological measurements, such as those provided by Fitbit devices, is an enticing way to monitor population health, because measurements are passive, high volume, and noninvasive."
However, they noted that due to interannual variability in flu, additional data would likely require a longer-term research agreement with Fitbit.
Limitations to the data include a lack of an activity variable, which the authors said could control for seasonal fitness or short-term activity changes. Weekly resting heart rate averages might incorporate data where a person is both sick and not sick, which could underestimate illness by lowering the weekly averages, they noted. They also cited sleep measuring devices' low accuracy, though they said it is improving.
"In the future as these devices improve, and with access to 24/7 real-time data, it may be possible to identify rates of influenza on a daily instead of weekly basis," Radin said.
This study was supported by the NIH National Center for Advancing Translational Health.
The authors disclosed no conflicts of interest.
Viboud and Santillana disclosed no conflicts of interest.
About 13% show problems likely to impair their ability to practice medicine.
This article was first published on Tuesday, January 14, 2020 in MedPage Today.
By Judy George, Senior Staff Writer, MedPage Today.
Mandatory testing at one of the nation's top hospitals showed that nearly one in eight clinicians age 70 or older had cognitive deficits that were likely to impair their ability to practice medicine independently.
While 57% of 141 older physicians and practitioners who applied for renewal of hospital privileges at Yale New Haven Hospital demonstrated no cause for concern, the remainder faced yearly re-credentialing or further testing with possible outcomes that included proctored medical practice, resignation, or retirement, reported Leo Cooney, MD, a geriatric medicine professor at Yale Medical School, and Thomas Balcezak, MD, Yale New Haven's chief medical officer, in JAMA.
This may be the first paper to report the results of cognitive testing of late-career clinicians, noted Cooney.
"We found that 12.8% of clinicians who applied for renewal of hospital privileges had cognitive deficits which gave us great concern about their ability to practice medicine independently," he said. "None of these 18 clinicians had been previously brought to the attention of hospital authorities because of concern about their practice abilities," Cooney told MedPage Today.
"When we started this process, I thought it was a good idea, but I wasn't sure about its necessity," he continued. "I now believe that it is essential to review older clinicians. While older clinicians can bring a great deal of experience and expertise to the practice of medicine, we must be sure that they have the cognitive ability to solve problems and make appropriate judgments."
Every year, 20,000 more U.S. physicians turn 65, and, even though half retire by then, many continue practicing for years more, noted Jeffrey Saver, MD, of the University of California Los Angeles, in an accompanying editorial.
"U.S. policy makers are counting on these older physicians to do so to help mitigate the nation's growing physician shortage," he wrote. "Currently, an estimated 50 million to 70 million U.S. office visits and 11 million to 20 million hospitalizations each year are overseen by physicians older than 65 years."
Age-based testing of medical professionals is a growing and controversial trend: Scripps Health Care, Intermountain Healthcare, Stanford Hospitals and Clinics, and Penn Medicine are among hospital systems that have implemented cognitive screens for older practitioners.
"Information about the outcomes of these programs is difficult to find, but it is clear that these processes have been challenging," wrote Katrina Armstrong, MD, MS, and Eileen Reynolds, MD, both of Massachusetts General Hospital in Boston, in another editorial accompanying the paper. Stanford physicians rejected plans to use MicroCog, a 1-hour computerized test that assesses five cognitive domains, opting instead for a revised approach with rigorous peer review. And opposition by the Utah Medical Association to MicroCog led to a state law banning its use.
At Yale New Haven, all applicants for reappointment to the medical staff age 70 or older were required to have an objective evaluation of cognitive function as part of the 2-year reappointment process. A neuropsychologist developed a screening battery which was (and still is) kept confidential. The hospital medical executive committee decided that a pass/fail approach would not be used, but performance tests would be considered in the context of clinical privileges.
The battery consisted of 16 brief tests that encompassed information processing, visual scanning and psychomotor efficiency, processing speed and accuracy, working memory, concentration, verbal fluency, and executive function. Time to completion varied from 50 to 90 minutes. Applicants' ages ranged from 69 to 82 and averaged 74. Most (86%) were men and 89% were physicians.
Global cognitive status scores and domain-specific scores were compared with peer, population, and age-group norms. A medical staff review committee that included the previous and current chief medical officer of the hospital, a faculty geriatrician, and the neuropsychologist performing the exams reviewed test results and made recommendations to the medical staff's credentialing committee.
Of 141 applicants, 81 (57.4%) completed the testing requirements and continued the credentialing process; they would be retested in 2 years as part of the regular reappointment process. About 24% proceeded with the credentialing process but, because of minor abnormalities in test results, were scheduled for rescreening in 1 year. Several had limitations in specific domains and were re-tested; three of these applicants were determined to have significant problems and either retired or resigned from the active medical staff.
Eighteen clinicians (12.8% of the 141 tested) demonstrated cognitive deficits that were likely to impair their ability to practice medicine independently. None had been brought to the attention of medical staff leadership due to performance problems. All opted voluntarily to discontinue their practice or move to a closely proctored setting.
Screening programs are always challenging to implement, Armstrong and Reynolds observed. "Because the prevalence of the condition is generally low in the population being screened, false-positive screening results are common unless the test has near-perfect specificity," they wrote. Full assessment of clinical competence, even for medical students and residents, is inexact and evidence that increasing clinician age is associated with worse patient outcomes is "weak at best," they noted. Moreover, using age cutoffs for screeningraises concerns about age discrimination, they added.
A policy like the one at Yale New Haven Hospital has several limitations, Saver pointed out. Because of confidentiality, impaired test performance cannot be correlated with poor medical practice, and independent individuals outside the institution were not involved in decision-making. In addition, the confidential nature of the test battery limited the ability to assess its validity.
Researchers and editorialists reported no conflicts of interest.
Executive health programs may offer the semblance of doing all one can to get ahead on cardiovascular health, but they're ill-advised, researchers warned.
Programs analyzed in a new study offered 12 different cardiovascular screening tests and a resting electrocardiogram, none of which are recommended for asymptomatic adults by professional societies or the U.S. Preventive Services Task Force.
Such executive screening programs run afoul of healthcare's goal of evidence-based cost-effective equitable care, concluded Alan Ge, MA, of St. Louis University School of Medicine, and David Brown, MD, of Washington University School of Medicine in St. Louis, in a research letter in JAMA Internal Medicine.
"The premise of using these tests is that the results may help reduce mortality from cardiovascular disease through earlier disease detection or more precise risk assessment," they wrote.
However, "indiscriminate screening can create a cascade effect and thus violate the principle of primum non nocere (first do no harm) wherein unnecessary tests may create a chain of events resulting in additional ill-advised tests or treatments that may cause avoidable physical or psychological harm," Ge and Brown added.
An accompanying editor's note agreed. "Even if a patient is willing to pay for a test or medication, we should not be willing to cause them harm," wrote editor Rita Redberg, MD, and deputy editor Mitchell Katz, MD.
Furthermore, there's risk for the specialty itself, Ge and Brown suggested.
"Offering executive physicals with tests that are not recommended for healthy persons to anyone who can pay out of pocket potentially sends the message to trainees that a 2-tier health care system is acceptable, and that evidence is not important," they wrote.
Cardiovascular examinations included in executive health screening programs offered by 18 of the 21 top heart hospitals by U.S. News & World Report rankings that responded to the survey (out of 25 contacted) most commonly included a lipid panel (71%) and a cardiac stress test (68%). Cardiac CT scans to get calcium scores or to visualize the coronary arteries was included in 43%.
Hospitals charged from $995 to as much as $25,000 for these programs, including the appointment fee. Only three (10.7%) offer to submit charges to insurance, although it wasn't clear whether insurers would actually reimburseany of the services.
One limitation was that the survey couldn't determine how physicians in the programs might have individually tailored testing differently than what was represented by administrators who provided the information.
The researchers disclosed no relevant relationships with industry.
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