Damian McNamara

The timing of polio immunization doses to optimize protection of U.S. children against importation or outbreaks is a central feature of a new Policy Statement from the American Academy of Pediatrics.

"The policy is intended to clarify the optimal interval of dosing for polio vaccine and the need for a booster dose at 4 to 6 years old regardless of the timing of prior doses," Dr. Michael E. Pichichero said in an interview. "The timing of a booster dose to provide sustained protection over time and avoid early waning of immunity is key."

The American Academy of Pediatrics (AAP) recommends a four-dose, standard schedule for administration of inactivated poliovirus vaccine (IPV) to U.S. children. The statement recommends doses at 2 months, 4 months, at 6 months through 18 months, and again at 4 years through 6 years of age.

The timing and spacing of doses is important. The minimum age for the first dose is 6 weeks. In addition, the minimum interval should be 4 weeks between doses one and two and between doses two and three. The final, booster dose should be administered at least 6 months after the preceding dose.

"Clinicians should know that a dose should be provided to the child between 4 and 6 years even if there were four doses given before that time," said Dr. Mary Ann Jackson, one of the 13 members of the American Academy of Pediatrics (AAP) Committee of Infectious Diseases that wrote the policy statement (Pediatrics 2011;128:805-8).

"The optimal dosing schedule is scientifically based and reflects our knowledge that wider spacing of doses is associated with stronger immune responses," said Dr. Pichichero, a clinical professor of pediatrics and infectious diseases at the University of Rochester (N.Y.) Medical Center. He was not involved in writing the policy statement.

In contrast, use of minimum dosing intervals is recommended for babies at imminent risk of exposure to circulating polioviruses through travel to a country where polio is endemic or through an outbreak. The policy statement reads: "Although not ideal, the greater majority of infants vaccinated at the minimum age with minimum intervals are protected from polio, and with imminent risk of exposure, the benefits of using the abbreviated schedule far outweigh any risks of failure to induce a protective immune response."

"The timing of a [polio] booster dose to provide sustained protection over time and avoid early waning of immunity is key."

"Circulation of polio in the United States stopped several decades ago, and there was hope that global eradication was imminent. However, polio cases continue to occur in countries around the world," said Dr. Jackson, chief, Section of Infectious Diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo.

"The updated polio policy from the AAP is important to emphasize the routine schedule and to alert families to the risk of exposure to polio related to international travel."

"The recent spread of polio from Pakistan to China – a country which had been polio-free for 10 years – is a sign of how important it is to remain vigilant with respect to polio immunization," Dr. Jackson said. To date, reported cases in China include six children under age 3 years and four young adults, with one death. "The country has taken a very strong stand and plans to immunize more than 8 million people over several weeks – a daunting task."

In addition to Pakistan, pockets of endemic poliovirus remain in India, Afghanistan, and Nigeria. These four countries never interrupted indigenous transmission of the virus and exported the poliovirus to 19 other countries that reported cases in 2009. The number of cases of wild poliovirus infections worldwide decreased from 1,604 in 2009 to 1,304 in 2010, but the number of countries reporting polio cases last year increased to 20. Chad, the Democratic Republic of the Congo, Angola, and Sudan, for example, have known or suspected re-establishment of disease.

"Many of the children who are travelers to at risk countries are going with their parents to visit relatives. These families may be less likely to seek specific travel medicine clinic referral but generally most have a medical home that provides immunization," Dr. Jackson said. "This makes the pediatric providers’ role in providing appropriate vaccines in addition to providing other travel counseling especially important."

The committee recommends widespread use of IPV to maintain high levels of polio immunity in the U.S. population given risk for importation of pathogenic polioviruses. Individual protection is important, they added, because if polio is introduced, pockets of under-immunized children in the country might sustain transmission of the virus.

The standard vaccine schedule can be used for immunocompromised or immunodeficient children. The vaccine is inactivated and therefore safe in this patient population. The committee added a caveat, however, that IPV may not be as effective for protection of these children, compared to children with normal immune systems.

IPV has become the vaccine of choice to fight polio since 2000 in the United States, the AAP committee noted, replacing oral poliovirus vaccine. IPV is currently licensed as one single IPV product (Ipol/Poliovax, Sanofi Pasteur) and three combination vaccine products: DTaP-HepB-IPV (Pediarix, GlaxoSmithKline); DTaP-IPV/Hib (Pentacel, Sanofi Pasteur); and DTaP-IPV (Kinrix, GlaxoSmithKline).

The policy statement recommends a fifth dose be given when DTap-IPV/Hib is used for the first four doses. Specifically, IPV alone or DTaP-IPV should be administered on or after a child’s fourth birthday. Again, at least a 6-month interval is recommended before administration of the final (fifth) dose.

A final recommendation in the statement addresses vaccination of adults, not children. The committee wrote that adults at increased risk of exposure to wild-type poliovirus and who previously completed primary immunization with IPV or OPV can receive additional protection via a single IPV dose.

Dr. Pichichero and Dr. Jackson said that they had no relevant disclosures.

The timing of polio immunization doses to optimize protection of U.S. children against importation or outbreaks is a central feature of a new Policy Statement from the American Academy of Pediatrics.

"The policy is intended to clarify the optimal interval of dosing for polio vaccine and the need for a booster dose at 4 to 6 years old regardless of the timing of prior doses," Dr. Michael E. Pichichero said in an interview. "The timing of a booster dose to provide sustained protection over time and avoid early waning of immunity is key."

The American Academy of Pediatrics (AAP) recommends a four-dose, standard schedule for administration of inactivated poliovirus vaccine (IPV) to U.S. children. The statement recommends doses at 2 months, 4 months, at 6 months through 18 months, and again at 4 years through 6 years of age.

The timing and spacing of doses is important. The minimum age for the first dose is 6 weeks. In addition, the minimum interval should be 4 weeks between doses one and two and between doses two and three. The final, booster dose should be administered at least 6 months after the preceding dose.

"Clinicians should know that a dose should be provided to the child between 4 and 6 years even if there were four doses given before that time," said Dr. Mary Ann Jackson, one of the 13 members of the American Academy of Pediatrics (AAP) Committee of Infectious Diseases that wrote the policy statement (Pediatrics 2011;128:805-8).

"The optimal dosing schedule is scientifically based and reflects our knowledge that wider spacing of doses is associated with stronger immune responses," said Dr. Pichichero, a clinical professor of pediatrics and infectious diseases at the University of Rochester (N.Y.) Medical Center. He was not involved in writing the policy statement.

In contrast, use of minimum dosing intervals is recommended for babies at imminent risk of exposure to circulating polioviruses through travel to a country where polio is endemic or through an outbreak. The policy statement reads: "Although not ideal, the greater majority of infants vaccinated at the minimum age with minimum intervals are protected from polio, and with imminent risk of exposure, the benefits of using the abbreviated schedule far outweigh any risks of failure to induce a protective immune response."

"The timing of a [polio] booster dose to provide sustained protection over time and avoid early waning of immunity is key."

"Circulation of polio in the United States stopped several decades ago, and there was hope that global eradication was imminent. However, polio cases continue to occur in countries around the world," said Dr. Jackson, chief, Section of Infectious Diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo.

"The updated polio policy from the AAP is important to emphasize the routine schedule and to alert families to the risk of exposure to polio related to international travel."

"The recent spread of polio from Pakistan to China – a country which had been polio-free for 10 years – is a sign of how important it is to remain vigilant with respect to polio immunization," Dr. Jackson said. To date, reported cases in China include six children under age 3 years and four young adults, with one death. "The country has taken a very strong stand and plans to immunize more than 8 million people over several weeks – a daunting task."

In addition to Pakistan, pockets of endemic poliovirus remain in India, Afghanistan, and Nigeria. These four countries never interrupted indigenous transmission of the virus and exported the poliovirus to 19 other countries that reported cases in 2009. The number of cases of wild poliovirus infections worldwide decreased from 1,604 in 2009 to 1,304 in 2010, but the number of countries reporting polio cases last year increased to 20. Chad, the Democratic Republic of the Congo, Angola, and Sudan, for example, have known or suspected re-establishment of disease.

"Many of the children who are travelers to at risk countries are going with their parents to visit relatives. These families may be less likely to seek specific travel medicine clinic referral but generally most have a medical home that provides immunization," Dr. Jackson said. "This makes the pediatric providers’ role in providing appropriate vaccines in addition to providing other travel counseling especially important."

The committee recommends widespread use of IPV to maintain high levels of polio immunity in the U.S. population given risk for importation of pathogenic polioviruses. Individual protection is important, they added, because if polio is introduced, pockets of under-immunized children in the country might sustain transmission of the virus.

The standard vaccine schedule can be used for immunocompromised or immunodeficient children. The vaccine is inactivated and therefore safe in this patient population. The committee added a caveat, however, that IPV may not be as effective for protection of these children, compared to children with normal immune systems.

IPV has become the vaccine of choice to fight polio since 2000 in the United States, the AAP committee noted, replacing oral poliovirus vaccine. IPV is currently licensed as one single IPV product (Ipol/Poliovax, Sanofi Pasteur) and three combination vaccine products: DTaP-HepB-IPV (Pediarix, GlaxoSmithKline); DTaP-IPV/Hib (Pentacel, Sanofi Pasteur); and DTaP-IPV (Kinrix, GlaxoSmithKline).

The policy statement recommends a fifth dose be given when DTap-IPV/Hib is used for the first four doses. Specifically, IPV alone or DTaP-IPV should be administered on or after a child’s fourth birthday. Again, at least a 6-month interval is recommended before administration of the final (fifth) dose.

A final recommendation in the statement addresses vaccination of adults, not children. The committee wrote that adults at increased risk of exposure to wild-type poliovirus and who previously completed primary immunization with IPV or OPV can receive additional protection via a single IPV dose.

Dr. Pichichero and Dr. Jackson said that they had no relevant disclosures.

The timing of polio immunization doses to optimize protection of U.S. children against importation or outbreaks is a central feature of a new Policy Statement from the American Academy of Pediatrics.

"The policy is intended to clarify the optimal interval of dosing for polio vaccine and the need for a booster dose at 4 to 6 years old regardless of the timing of prior doses," Dr. Michael E. Pichichero said in an interview. "The timing of a booster dose to provide sustained protection over time and avoid early waning of immunity is key."

The American Academy of Pediatrics (AAP) recommends a four-dose, standard schedule for administration of inactivated poliovirus vaccine (IPV) to U.S. children. The statement recommends doses at 2 months, 4 months, at 6 months through 18 months, and again at 4 years through 6 years of age.

The timing and spacing of doses is important. The minimum age for the first dose is 6 weeks. In addition, the minimum interval should be 4 weeks between doses one and two and between doses two and three. The final, booster dose should be administered at least 6 months after the preceding dose.

"Clinicians should know that a dose should be provided to the child between 4 and 6 years even if there were four doses given before that time," said Dr. Mary Ann Jackson, one of the 13 members of the American Academy of Pediatrics (AAP) Committee of Infectious Diseases that wrote the policy statement (Pediatrics 2011;128:805-8).

"The optimal dosing schedule is scientifically based and reflects our knowledge that wider spacing of doses is associated with stronger immune responses," said Dr. Pichichero, a clinical professor of pediatrics and infectious diseases at the University of Rochester (N.Y.) Medical Center. He was not involved in writing the policy statement.

In contrast, use of minimum dosing intervals is recommended for babies at imminent risk of exposure to circulating polioviruses through travel to a country where polio is endemic or through an outbreak. The policy statement reads: "Although not ideal, the greater majority of infants vaccinated at the minimum age with minimum intervals are protected from polio, and with imminent risk of exposure, the benefits of using the abbreviated schedule far outweigh any risks of failure to induce a protective immune response."

"The timing of a [polio] booster dose to provide sustained protection over time and avoid early waning of immunity is key."

"Circulation of polio in the United States stopped several decades ago, and there was hope that global eradication was imminent. However, polio cases continue to occur in countries around the world," said Dr. Jackson, chief, Section of Infectious Diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo.

"The updated polio policy from the AAP is important to emphasize the routine schedule and to alert families to the risk of exposure to polio related to international travel."

"The recent spread of polio from Pakistan to China – a country which had been polio-free for 10 years – is a sign of how important it is to remain vigilant with respect to polio immunization," Dr. Jackson said. To date, reported cases in China include six children under age 3 years and four young adults, with one death. "The country has taken a very strong stand and plans to immunize more than 8 million people over several weeks – a daunting task."

In addition to Pakistan, pockets of endemic poliovirus remain in India, Afghanistan, and Nigeria. These four countries never interrupted indigenous transmission of the virus and exported the poliovirus to 19 other countries that reported cases in 2009. The number of cases of wild poliovirus infections worldwide decreased from 1,604 in 2009 to 1,304 in 2010, but the number of countries reporting polio cases last year increased to 20. Chad, the Democratic Republic of the Congo, Angola, and Sudan, for example, have known or suspected re-establishment of disease.

"Many of the children who are travelers to at risk countries are going with their parents to visit relatives. These families may be less likely to seek specific travel medicine clinic referral but generally most have a medical home that provides immunization," Dr. Jackson said. "This makes the pediatric providers’ role in providing appropriate vaccines in addition to providing other travel counseling especially important."

The committee recommends widespread use of IPV to maintain high levels of polio immunity in the U.S. population given risk for importation of pathogenic polioviruses. Individual protection is important, they added, because if polio is introduced, pockets of under-immunized children in the country might sustain transmission of the virus.

The standard vaccine schedule can be used for immunocompromised or immunodeficient children. The vaccine is inactivated and therefore safe in this patient population. The committee added a caveat, however, that IPV may not be as effective for protection of these children, compared to children with normal immune systems.

IPV has become the vaccine of choice to fight polio since 2000 in the United States, the AAP committee noted, replacing oral poliovirus vaccine. IPV is currently licensed as one single IPV product (Ipol/Poliovax, Sanofi Pasteur) and three combination vaccine products: DTaP-HepB-IPV (Pediarix, GlaxoSmithKline); DTaP-IPV/Hib (Pentacel, Sanofi Pasteur); and DTaP-IPV (Kinrix, GlaxoSmithKline).

The policy statement recommends a fifth dose be given when DTap-IPV/Hib is used for the first four doses. Specifically, IPV alone or DTaP-IPV should be administered on or after a child’s fourth birthday. Again, at least a 6-month interval is recommended before administration of the final (fifth) dose.

A final recommendation in the statement addresses vaccination of adults, not children. The committee wrote that adults at increased risk of exposure to wild-type poliovirus and who previously completed primary immunization with IPV or OPV can receive additional protection via a single IPV dose.

Dr. Pichichero and Dr. Jackson said that they had no relevant disclosures.

Patient age plays a large role in changes over time to stimulant use for treatment of attention-deficit/hyperactivity disorder, according to a study of survey data from 1996 to 2008. Differences in ethnicity, insurance status, and geographic location also were associated with significant differences in use of these medications.

Reported stimulant use among children and adolescents in the United States grew significantly between 2.4% in 1996 and 3.5% in 2008. Researchers reported a 3.4% annual overall increase behind this slow and consistent increase in use of methylphenidate, dexmethylphenidate, pemoline, amphetamines, and/or dextroamphetamine.

An estimated 2.8 million children and teenagers reported use of one or more of these stimulant agents in 2008, according to an advance online report of the findings (Am. J. Psychiatry; Zuvekas and Vitiello. AiA:1-7).

Adolescents accounted for the greatest increase in use of stimulants for attention-deficit/hyperactivity disorder (ADHD), from 2.3% in 1996 to 5.0% in 2008, or an annual increase of 6.5%. "The continuous, steep increase in stimulant utilization in adolescents likely reflects the recent realization that ADHD tends to persist in puberty, causing significant functional impairment," wrote study authors Samuel H. Zuvekas, Ph.D., and Dr. Benedetto Vitiello.

They evaluated data from the annual, nationally representative MEPS (Medical Expenditure Panel Survey). The MEPS includes data on prescription drug use directly from household respondents and from pharmacies that they reported using during the survey.

Stimulant use remained the highest among children aged 6-12 years old, with no significant change during the study period. For example, 4.2% in this age group reported use in 1996 vs. 5.1% in 2008.

In contrast, stimulants were seldom used in children younger than 6 years during the duration of the study and dropped to very low rates in more recent years, the study reveals. Reported use toggled between 0.3% and 0.4% in the years from 1996 to 2003, and thereafter remained at 0.1% each year up until 2008.

Boys continue to use stimulants at a rate approximately three times greater than girls (5.3% vs. 1.6% in 2008, for example), a ratio that did not significantly change between 1996 and 2008.

Ethnicity, however, did account for some variation in ADHD treatment use. Although use overall increased among children from racial and ethnic minority groups, it remained lower than rates for non-Hispanic white children. For example, in 2008 4.4% of white children reported stimulant use, compared with 3.0% of black and 2.1% of Hispanic children. These differences could be explained, in part, because parents of black or Hispanic children are less likely to report ADHD, compared with parents of white children, the authors noted. Health and socioeconomic factors, including birth weight, income, and insurance coverage, did not account for these differences.

Insurance status made a difference on the overall sample, however. Children without health insurance had a much lower utilization rate, 1.3%, compared with 3.4% of those covered by private insurance and 4.3% of children with public insurance. Interestingly, the prevalence of stimulant use for ADHD did not vary significantly by family income level during the study period.

Geography also made a difference the researchers reported consistently and significantly lower use in the Western United States, compared with the Northeast, for example. In the West, utilization was 1.2% in 1996 and 1.6% in 2008. In contrast, the rates in the Northeast grew from 1.8% in 1996 to 4.6% in 2008. Rates elsewhere likewise increased, although not as significantly, from 2.6% to 3.9% in the Midwest and from 3.2% to 4.0% in the South, reported Dr. Zuvekas, an economist with the Agency for Healthcare Research and Quality, and Dr. Vitiello, a psychiatrist with the National Institute of Mental Health.

Overall, most children with ADHD are not treated with stimulants, the authors noted. They compared their findings with published estimates of ADHD diagnosis in community-based studies (J. Am. Acad. Child Adolesc. Psychiatry 2010;49:980-9; MMWR 2010;59:1439-43).

They explained that some children present with milder symptoms and stimulants tend to be prescribed for more severe forms of the condition. This was backed in their report by higher utilization among children reporting more significant impairment on the Columbia Impairment Scale. Treatment of ADHD with nonstimulant medication and psychosocial interventions also were likely contribute to lower use of stimulant medications.

Limitations of the study include a reliance on self-reported stimulant use, a lack of means to validate reported ADHD diagnoses, and a lack of statistical power in the MEPS database to assess nonstimulant medication use or use of combination treatment for ADHD.

Study authors Dr. Zuvekas and Dr. Vitiello reported they had no relevant financial disclosures.

Patient age plays a large role in changes over time to stimulant use for treatment of attention-deficit/hyperactivity disorder, according to a study of survey data from 1996 to 2008. Differences in ethnicity, insurance status, and geographic location also were associated with significant differences in use of these medications.

Reported stimulant use among children and adolescents in the United States grew significantly between 2.4% in 1996 and 3.5% in 2008. Researchers reported a 3.4% annual overall increase behind this slow and consistent increase in use of methylphenidate, dexmethylphenidate, pemoline, amphetamines, and/or dextroamphetamine.

An estimated 2.8 million children and teenagers reported use of one or more of these stimulant agents in 2008, according to an advance online report of the findings (Am. J. Psychiatry; Zuvekas and Vitiello. AiA:1-7).

Adolescents accounted for the greatest increase in use of stimulants for attention-deficit/hyperactivity disorder (ADHD), from 2.3% in 1996 to 5.0% in 2008, or an annual increase of 6.5%. "The continuous, steep increase in stimulant utilization in adolescents likely reflects the recent realization that ADHD tends to persist in puberty, causing significant functional impairment," wrote study authors Samuel H. Zuvekas, Ph.D., and Dr. Benedetto Vitiello.

They evaluated data from the annual, nationally representative MEPS (Medical Expenditure Panel Survey). The MEPS includes data on prescription drug use directly from household respondents and from pharmacies that they reported using during the survey.

Stimulant use remained the highest among children aged 6-12 years old, with no significant change during the study period. For example, 4.2% in this age group reported use in 1996 vs. 5.1% in 2008.

In contrast, stimulants were seldom used in children younger than 6 years during the duration of the study and dropped to very low rates in more recent years, the study reveals. Reported use toggled between 0.3% and 0.4% in the years from 1996 to 2003, and thereafter remained at 0.1% each year up until 2008.

Boys continue to use stimulants at a rate approximately three times greater than girls (5.3% vs. 1.6% in 2008, for example), a ratio that did not significantly change between 1996 and 2008.

Ethnicity, however, did account for some variation in ADHD treatment use. Although use overall increased among children from racial and ethnic minority groups, it remained lower than rates for non-Hispanic white children. For example, in 2008 4.4% of white children reported stimulant use, compared with 3.0% of black and 2.1% of Hispanic children. These differences could be explained, in part, because parents of black or Hispanic children are less likely to report ADHD, compared with parents of white children, the authors noted. Health and socioeconomic factors, including birth weight, income, and insurance coverage, did not account for these differences.

Insurance status made a difference on the overall sample, however. Children without health insurance had a much lower utilization rate, 1.3%, compared with 3.4% of those covered by private insurance and 4.3% of children with public insurance. Interestingly, the prevalence of stimulant use for ADHD did not vary significantly by family income level during the study period.

Geography also made a difference the researchers reported consistently and significantly lower use in the Western United States, compared with the Northeast, for example. In the West, utilization was 1.2% in 1996 and 1.6% in 2008. In contrast, the rates in the Northeast grew from 1.8% in 1996 to 4.6% in 2008. Rates elsewhere likewise increased, although not as significantly, from 2.6% to 3.9% in the Midwest and from 3.2% to 4.0% in the South, reported Dr. Zuvekas, an economist with the Agency for Healthcare Research and Quality, and Dr. Vitiello, a psychiatrist with the National Institute of Mental Health.

Overall, most children with ADHD are not treated with stimulants, the authors noted. They compared their findings with published estimates of ADHD diagnosis in community-based studies (J. Am. Acad. Child Adolesc. Psychiatry 2010;49:980-9; MMWR 2010;59:1439-43).

They explained that some children present with milder symptoms and stimulants tend to be prescribed for more severe forms of the condition. This was backed in their report by higher utilization among children reporting more significant impairment on the Columbia Impairment Scale. Treatment of ADHD with nonstimulant medication and psychosocial interventions also were likely contribute to lower use of stimulant medications.

Limitations of the study include a reliance on self-reported stimulant use, a lack of means to validate reported ADHD diagnoses, and a lack of statistical power in the MEPS database to assess nonstimulant medication use or use of combination treatment for ADHD.

Study authors Dr. Zuvekas and Dr. Vitiello reported they had no relevant financial disclosures.

Patient age plays a large role in changes over time to stimulant use for treatment of attention-deficit/hyperactivity disorder, according to a study of survey data from 1996 to 2008. Differences in ethnicity, insurance status, and geographic location also were associated with significant differences in use of these medications.

Reported stimulant use among children and adolescents in the United States grew significantly between 2.4% in 1996 and 3.5% in 2008. Researchers reported a 3.4% annual overall increase behind this slow and consistent increase in use of methylphenidate, dexmethylphenidate, pemoline, amphetamines, and/or dextroamphetamine.

An estimated 2.8 million children and teenagers reported use of one or more of these stimulant agents in 2008, according to an advance online report of the findings (Am. J. Psychiatry; Zuvekas and Vitiello. AiA:1-7).

Adolescents accounted for the greatest increase in use of stimulants for attention-deficit/hyperactivity disorder (ADHD), from 2.3% in 1996 to 5.0% in 2008, or an annual increase of 6.5%. "The continuous, steep increase in stimulant utilization in adolescents likely reflects the recent realization that ADHD tends to persist in puberty, causing significant functional impairment," wrote study authors Samuel H. Zuvekas, Ph.D., and Dr. Benedetto Vitiello.

They evaluated data from the annual, nationally representative MEPS (Medical Expenditure Panel Survey). The MEPS includes data on prescription drug use directly from household respondents and from pharmacies that they reported using during the survey.

Stimulant use remained the highest among children aged 6-12 years old, with no significant change during the study period. For example, 4.2% in this age group reported use in 1996 vs. 5.1% in 2008.

In contrast, stimulants were seldom used in children younger than 6 years during the duration of the study and dropped to very low rates in more recent years, the study reveals. Reported use toggled between 0.3% and 0.4% in the years from 1996 to 2003, and thereafter remained at 0.1% each year up until 2008.

Boys continue to use stimulants at a rate approximately three times greater than girls (5.3% vs. 1.6% in 2008, for example), a ratio that did not significantly change between 1996 and 2008.

Ethnicity, however, did account for some variation in ADHD treatment use. Although use overall increased among children from racial and ethnic minority groups, it remained lower than rates for non-Hispanic white children. For example, in 2008 4.4% of white children reported stimulant use, compared with 3.0% of black and 2.1% of Hispanic children. These differences could be explained, in part, because parents of black or Hispanic children are less likely to report ADHD, compared with parents of white children, the authors noted. Health and socioeconomic factors, including birth weight, income, and insurance coverage, did not account for these differences.

Insurance status made a difference on the overall sample, however. Children without health insurance had a much lower utilization rate, 1.3%, compared with 3.4% of those covered by private insurance and 4.3% of children with public insurance. Interestingly, the prevalence of stimulant use for ADHD did not vary significantly by family income level during the study period.

Geography also made a difference the researchers reported consistently and significantly lower use in the Western United States, compared with the Northeast, for example. In the West, utilization was 1.2% in 1996 and 1.6% in 2008. In contrast, the rates in the Northeast grew from 1.8% in 1996 to 4.6% in 2008. Rates elsewhere likewise increased, although not as significantly, from 2.6% to 3.9% in the Midwest and from 3.2% to 4.0% in the South, reported Dr. Zuvekas, an economist with the Agency for Healthcare Research and Quality, and Dr. Vitiello, a psychiatrist with the National Institute of Mental Health.

Overall, most children with ADHD are not treated with stimulants, the authors noted. They compared their findings with published estimates of ADHD diagnosis in community-based studies (J. Am. Acad. Child Adolesc. Psychiatry 2010;49:980-9; MMWR 2010;59:1439-43).

They explained that some children present with milder symptoms and stimulants tend to be prescribed for more severe forms of the condition. This was backed in their report by higher utilization among children reporting more significant impairment on the Columbia Impairment Scale. Treatment of ADHD with nonstimulant medication and psychosocial interventions also were likely contribute to lower use of stimulant medications.

Limitations of the study include a reliance on self-reported stimulant use, a lack of means to validate reported ADHD diagnoses, and a lack of statistical power in the MEPS database to assess nonstimulant medication use or use of combination treatment for ADHD.

Study authors Dr. Zuvekas and Dr. Vitiello reported they had no relevant financial disclosures.

A common chemotherapy regimen gets reclassified as high risk for emesis; a new approach is recommended to tackle treatments with high emetic potential; and a particular antiemetic drug is now preferred for patients at moderate risk – these are among the changes to clinical practice guidelines from the American Society of Clinical Oncology.

The guidelines also include new recommendations for preventing nausea and vomiting associated with radiation treatment.

Treatment-related nausea and vomiting is reported by more than half of patients. If it is severe enough, dehydration and other adverse health effects can result and can limit treatment and patient outcomes.

One key change to the guidelines involves the chemotherapeutic agents anthracycline and cyclophosphamide, each of which carries a moderate risk for emesis if used alone. However, when the two are prescribed together, the patient’s risk for emesis is high. This upstaging to high risk is important, the authors wrote, because these agents are commonly combined, particularly to combat breast cancer and non-Hodgkin’s lymphoma.

For this and other high-risk therapies, the guidelines now recommend use of newer antiemetics. For example, a 5-hydroxytryptamine-3 (5-HT₃) receptor antagonist in combination with dexamethasone and a neurokinin 1 (NK₁) receptor antagonist is suggested to prevent significant nausea and vomiting.

In addition, a new NK1 receptor agonist, fosaprepitant (Emend, Merck), is available as a new, 1-day intravenous formulation of aprepitant, which needs to be infused over 3 days. The therapeutic equivalence of these two drugs was demonstrated in a large trial (J. Clin. Oncol. 2011;29:1495-501) and thus either one is appropriate, according to the guidelines. The briefer administration of fosaprepitant "may represent a more convenient or feasible option for some patients," the guideline update committee noted.

These and other revisions are based on new research findings since the last update to the guidelines in 2006. The 14-member committee reviewed 37 randomized, controlled trials, searched the Cochrane Collaboration Library, and evaluated presentations from the annual meetings of the American Society of Clinical Oncology and the Multinational Association of Supportive Care in Cancer.

The antiemetic recommendations are categorized according to the emesis risk of the chemotherapy regimens. For example, palonosetron (Aloxi, Helsinn Healthcare), is listed as preferential for moderate–emetic-risk regimens when given on day 1 and when combined with dexamethasone on days 1-3. If palonosetron is not available, the authors state that granisetron or ondansetron may be substituted.

In addition, a single, 8-mg dexamethasone dose alone is appropriate before the first dose of cancer-fighting agents associated with a low risk for emesis. And no antiemetic prophylaxis is necessary for chemotherapy regimens deemed to have minimal risk, according to the guidelines. These recommendations have remained the same since the last guideline update.

Recommendations regarding radiation treatment are likewise stratified by risk for emesis. For example, when a radiation course carries a high emetic risk, the guidelines recommend a 5-HT₃ agent prior to each fraction and for at least 24 hours following completion of radiotherapy. The update committee dropped the recommendation that this therapy be given with or without a corticosteroid and added that a 5-day course of dexamethasone is indicated during fractions one to five.

For moderate-risk radiation therapy, a 5-HT₃ antagonist before each fraction throughout radiotherapy remains the recommendation, with addition of a short course of dexamethasone during fractions one to five.

And for low-risk radiotherapy, the committee recommends a 5-HT₃ antagonist alone as either prophylaxis or rescue. This represents a change from the 2006 recommendation for administration of a 5-HT₃ agent before each fraction.

For minimal-risk radiotherapy, the new recommendation is for rescue therapy with either a dopamine receptor antagonist or a 5-HT₃ antagonist. This is similar to the 2006 recommendation for a dopamine or serotonin receptor antagonist on an as-needed basis.

When rescue antiemetic therapy is given, the authors recommend that prophylactic treatment be continued until radiotherapy is completed.

Other major themes of the guidelines include a need for continued symptom monitoring and a recognition that clinicians tend to underestimate the incidence of nausea; therefore, nausea is often less well controlled than emesis.

Some members of the update committee had the following financial disclosures: Dr. Paul Hesketh is a consultant to Eisai, GlaxoSmithKline, Helsinn, and Merck; Dr. Mark G. Kris is a consultant to Sanofi-Aventis and GlaxoSmithKline; and Dr. Petra C. Feyer is a consultant to GSK and Merck. Dr. Rebecca Clark-Snow receives honoraria from Merck, and Dr. Feyer receives honoraria from Merck, GSK, and Roche.

A common chemotherapy regimen gets reclassified as high risk for emesis; a new approach is recommended to tackle treatments with high emetic potential; and a particular antiemetic drug is now preferred for patients at moderate risk – these are among the changes to clinical practice guidelines from the American Society of Clinical Oncology.

The guidelines also include new recommendations for preventing nausea and vomiting associated with radiation treatment.

Treatment-related nausea and vomiting is reported by more than half of patients. If it is severe enough, dehydration and other adverse health effects can result and can limit treatment and patient outcomes.

One key change to the guidelines involves the chemotherapeutic agents anthracycline and cyclophosphamide, each of which carries a moderate risk for emesis if used alone. However, when the two are prescribed together, the patient’s risk for emesis is high. This upstaging to high risk is important, the authors wrote, because these agents are commonly combined, particularly to combat breast cancer and non-Hodgkin’s lymphoma.

For this and other high-risk therapies, the guidelines now recommend use of newer antiemetics. For example, a 5-hydroxytryptamine-3 (5-HT₃) receptor antagonist in combination with dexamethasone and a neurokinin 1 (NK₁) receptor antagonist is suggested to prevent significant nausea and vomiting.

In addition, a new NK1 receptor agonist, fosaprepitant (Emend, Merck), is available as a new, 1-day intravenous formulation of aprepitant, which needs to be infused over 3 days. The therapeutic equivalence of these two drugs was demonstrated in a large trial (J. Clin. Oncol. 2011;29:1495-501) and thus either one is appropriate, according to the guidelines. The briefer administration of fosaprepitant "may represent a more convenient or feasible option for some patients," the guideline update committee noted.

These and other revisions are based on new research findings since the last update to the guidelines in 2006. The 14-member committee reviewed 37 randomized, controlled trials, searched the Cochrane Collaboration Library, and evaluated presentations from the annual meetings of the American Society of Clinical Oncology and the Multinational Association of Supportive Care in Cancer.

The antiemetic recommendations are categorized according to the emesis risk of the chemotherapy regimens. For example, palonosetron (Aloxi, Helsinn Healthcare), is listed as preferential for moderate–emetic-risk regimens when given on day 1 and when combined with dexamethasone on days 1-3. If palonosetron is not available, the authors state that granisetron or ondansetron may be substituted.

In addition, a single, 8-mg dexamethasone dose alone is appropriate before the first dose of cancer-fighting agents associated with a low risk for emesis. And no antiemetic prophylaxis is necessary for chemotherapy regimens deemed to have minimal risk, according to the guidelines. These recommendations have remained the same since the last guideline update.

Recommendations regarding radiation treatment are likewise stratified by risk for emesis. For example, when a radiation course carries a high emetic risk, the guidelines recommend a 5-HT₃ agent prior to each fraction and for at least 24 hours following completion of radiotherapy. The update committee dropped the recommendation that this therapy be given with or without a corticosteroid and added that a 5-day course of dexamethasone is indicated during fractions one to five.

For moderate-risk radiation therapy, a 5-HT₃ antagonist before each fraction throughout radiotherapy remains the recommendation, with addition of a short course of dexamethasone during fractions one to five.

And for low-risk radiotherapy, the committee recommends a 5-HT₃ antagonist alone as either prophylaxis or rescue. This represents a change from the 2006 recommendation for administration of a 5-HT₃ agent before each fraction.

For minimal-risk radiotherapy, the new recommendation is for rescue therapy with either a dopamine receptor antagonist or a 5-HT₃ antagonist. This is similar to the 2006 recommendation for a dopamine or serotonin receptor antagonist on an as-needed basis.

When rescue antiemetic therapy is given, the authors recommend that prophylactic treatment be continued until radiotherapy is completed.

Other major themes of the guidelines include a need for continued symptom monitoring and a recognition that clinicians tend to underestimate the incidence of nausea; therefore, nausea is often less well controlled than emesis.

Some members of the update committee had the following financial disclosures: Dr. Paul Hesketh is a consultant to Eisai, GlaxoSmithKline, Helsinn, and Merck; Dr. Mark G. Kris is a consultant to Sanofi-Aventis and GlaxoSmithKline; and Dr. Petra C. Feyer is a consultant to GSK and Merck. Dr. Rebecca Clark-Snow receives honoraria from Merck, and Dr. Feyer receives honoraria from Merck, GSK, and Roche.

A common chemotherapy regimen gets reclassified as high risk for emesis; a new approach is recommended to tackle treatments with high emetic potential; and a particular antiemetic drug is now preferred for patients at moderate risk – these are among the changes to clinical practice guidelines from the American Society of Clinical Oncology.

The guidelines also include new recommendations for preventing nausea and vomiting associated with radiation treatment.

Treatment-related nausea and vomiting is reported by more than half of patients. If it is severe enough, dehydration and other adverse health effects can result and can limit treatment and patient outcomes.

One key change to the guidelines involves the chemotherapeutic agents anthracycline and cyclophosphamide, each of which carries a moderate risk for emesis if used alone. However, when the two are prescribed together, the patient’s risk for emesis is high. This upstaging to high risk is important, the authors wrote, because these agents are commonly combined, particularly to combat breast cancer and non-Hodgkin’s lymphoma.

For this and other high-risk therapies, the guidelines now recommend use of newer antiemetics. For example, a 5-hydroxytryptamine-3 (5-HT₃) receptor antagonist in combination with dexamethasone and a neurokinin 1 (NK₁) receptor antagonist is suggested to prevent significant nausea and vomiting.

In addition, a new NK1 receptor agonist, fosaprepitant (Emend, Merck), is available as a new, 1-day intravenous formulation of aprepitant, which needs to be infused over 3 days. The therapeutic equivalence of these two drugs was demonstrated in a large trial (J. Clin. Oncol. 2011;29:1495-501) and thus either one is appropriate, according to the guidelines. The briefer administration of fosaprepitant "may represent a more convenient or feasible option for some patients," the guideline update committee noted.

These and other revisions are based on new research findings since the last update to the guidelines in 2006. The 14-member committee reviewed 37 randomized, controlled trials, searched the Cochrane Collaboration Library, and evaluated presentations from the annual meetings of the American Society of Clinical Oncology and the Multinational Association of Supportive Care in Cancer.

The antiemetic recommendations are categorized according to the emesis risk of the chemotherapy regimens. For example, palonosetron (Aloxi, Helsinn Healthcare), is listed as preferential for moderate–emetic-risk regimens when given on day 1 and when combined with dexamethasone on days 1-3. If palonosetron is not available, the authors state that granisetron or ondansetron may be substituted.

In addition, a single, 8-mg dexamethasone dose alone is appropriate before the first dose of cancer-fighting agents associated with a low risk for emesis. And no antiemetic prophylaxis is necessary for chemotherapy regimens deemed to have minimal risk, according to the guidelines. These recommendations have remained the same since the last guideline update.

Recommendations regarding radiation treatment are likewise stratified by risk for emesis. For example, when a radiation course carries a high emetic risk, the guidelines recommend a 5-HT₃ agent prior to each fraction and for at least 24 hours following completion of radiotherapy. The update committee dropped the recommendation that this therapy be given with or without a corticosteroid and added that a 5-day course of dexamethasone is indicated during fractions one to five.

For moderate-risk radiation therapy, a 5-HT₃ antagonist before each fraction throughout radiotherapy remains the recommendation, with addition of a short course of dexamethasone during fractions one to five.

And for low-risk radiotherapy, the committee recommends a 5-HT₃ antagonist alone as either prophylaxis or rescue. This represents a change from the 2006 recommendation for administration of a 5-HT₃ agent before each fraction.

For minimal-risk radiotherapy, the new recommendation is for rescue therapy with either a dopamine receptor antagonist or a 5-HT₃ antagonist. This is similar to the 2006 recommendation for a dopamine or serotonin receptor antagonist on an as-needed basis.

When rescue antiemetic therapy is given, the authors recommend that prophylactic treatment be continued until radiotherapy is completed.

Other major themes of the guidelines include a need for continued symptom monitoring and a recognition that clinicians tend to underestimate the incidence of nausea; therefore, nausea is often less well controlled than emesis.

Some members of the update committee had the following financial disclosures: Dr. Paul Hesketh is a consultant to Eisai, GlaxoSmithKline, Helsinn, and Merck; Dr. Mark G. Kris is a consultant to Sanofi-Aventis and GlaxoSmithKline; and Dr. Petra C. Feyer is a consultant to GSK and Merck. Dr. Rebecca Clark-Snow receives honoraria from Merck, and Dr. Feyer receives honoraria from Merck, GSK, and Roche.

ORLANDO – Do you practice family medicine in a region where Medicare is the "better payer," where there is a low number of primary care physicians per capita, and/or where residents get their training but leave to practice elsewhere?

If so, you might be in a "distressed practice environment," and the American Academy of Family Physicians wants to hear from you.

Alerted to these dire circumstances by the New Jersey Academy of Family Physicians, the national academy is in "information gathering mode" to determine a strategy to help family physicians in the affected areas – but concerns reach beyond the Garden State, AAFP President Glen Stream said.

"We are concerned that this is happening in other states in the country," Dr. Stream said at a town hall session held during the annual Congress of Delegates of the American Academy of Family Physicians. "We want detailed information on how to proceed to get objective data to inform our advocacy in this regard."

"This is an issue we feel is very important, not only to New Jersey, but as you said, there are many other areas around the country. We heard that loud and clear from some other chapters," said Dr. Robert Eidus, president of the New Jersey chapter.

New Jersey has the third fewest primary care physicians per capita and ranks fourth highest nationwide in terms of specialists, Dr. Eidus said. "That creates a situation, not surprisingly, where costs are high. What do payers do at this point? They ratchet down fees, not using a scalpel but using a bludgeon."

In some regions of the state, family physicians receive private insurance payments that are 50%-60% of the Medicare rate.

"Having an oligopoly of payers is another issue," said Dr. Eidus, a family physician with a private practice in Cranford, N.J.

Although it varies, a distressed practice environment can arise when two or three major health plans hold the great majority of market share in an area, Dr. Stream said in an interview. "As a result, they offer contracts at a very low payment."

The national academy plans to develop a strategy to encourage private health plans to increase payments for primary care services, including adoption of the Medicare 10% initiative for primary care, according to a report issued by the AAFP board of directors at the congress.

"Pay particular attention to paragraph nine [of the report]," said Dr. Dennis F. Saver, a delegate from Florida. "It is wonderfully understated as a ‘particularly vexing problem’ that insurance companies who are members of the Patient-Centered Primary Care Collaborative [PCPCC] are paying primary care physicians less than the going rate." They need to be held accountable, he added.

That portion of the report states, in part, that some private health plans that are "actively involved in Patient-Centered Medical Home pilots with the intention of shoring up primary care are the very same plans that are offering preferred provider organization (PPO) contracts to family physicians that only pay a fraction of Medicare payment, threatening the financial viability and survival of small practices."

The national academy brought the conflict to the attention of the PCPCC board of directors, Dr. Stream said, and the board plans to meet with key health plans during their annual summit in October. At the same time, the AAFP plans to hold one-on-one meetings with the five top insurers involved in PCPCC, starting with United Healthcare.

Those meetings with top insurer members of the PCPCC are important, Dr. Eidus said, because "they talk the talk but are not walking the walk."

At a recent meeting of the physician advocacy board for Humana Insurance, "I pointed out that in southwestern Ohio, the Cincinnati area, there are now many physicians who are under Medicare for their payment schedules," said Dr. Brian Bachelder, an alternate delegate from Ohio. "Humana, as of Sept. 1, brought their payment levels down to what other competitors in the area were paying," Dr. Bachelder said. "Yet at the meeting, they were talking about going out and trying to engage more primary care physicians – particularly family physicians – in the Humana fold, and even hiring family physicians to work for Humana.

"I pointed out the contradiction ... and they had nothing to say about it," Dr. Bachelder asserted.

A net loss of new physicians is another adverse effect of distressed practice environments, Dr. Eidus said. "We have a fair amount of residency programs in the state, but we’re net exporters. We’re exporting more ... despite the fact that we have a shortage in primary care.

"We also recognize that it’s not in the best interest of the citizens of New Jersey, or any other state, to have family medicine or primary care deserts," Dr. Eidus said. "We have that happening in New Jersey."

The AAFP Commission on Quality and Practice will review all feedback and data collected on distressed practice environments. Dr. Stream said the issue will be a major focus at the next leadership forum in May 2012.

ORLANDO – Do you practice family medicine in a region where Medicare is the "better payer," where there is a low number of primary care physicians per capita, and/or where residents get their training but leave to practice elsewhere?

If so, you might be in a "distressed practice environment," and the American Academy of Family Physicians wants to hear from you.

Alerted to these dire circumstances by the New Jersey Academy of Family Physicians, the national academy is in "information gathering mode" to determine a strategy to help family physicians in the affected areas – but concerns reach beyond the Garden State, AAFP President Glen Stream said.

"We are concerned that this is happening in other states in the country," Dr. Stream said at a town hall session held during the annual Congress of Delegates of the American Academy of Family Physicians. "We want detailed information on how to proceed to get objective data to inform our advocacy in this regard."

"This is an issue we feel is very important, not only to New Jersey, but as you said, there are many other areas around the country. We heard that loud and clear from some other chapters," said Dr. Robert Eidus, president of the New Jersey chapter.

New Jersey has the third fewest primary care physicians per capita and ranks fourth highest nationwide in terms of specialists, Dr. Eidus said. "That creates a situation, not surprisingly, where costs are high. What do payers do at this point? They ratchet down fees, not using a scalpel but using a bludgeon."

In some regions of the state, family physicians receive private insurance payments that are 50%-60% of the Medicare rate.

"Having an oligopoly of payers is another issue," said Dr. Eidus, a family physician with a private practice in Cranford, N.J.

Although it varies, a distressed practice environment can arise when two or three major health plans hold the great majority of market share in an area, Dr. Stream said in an interview. "As a result, they offer contracts at a very low payment."

The national academy plans to develop a strategy to encourage private health plans to increase payments for primary care services, including adoption of the Medicare 10% initiative for primary care, according to a report issued by the AAFP board of directors at the congress.

"Pay particular attention to paragraph nine [of the report]," said Dr. Dennis F. Saver, a delegate from Florida. "It is wonderfully understated as a ‘particularly vexing problem’ that insurance companies who are members of the Patient-Centered Primary Care Collaborative [PCPCC] are paying primary care physicians less than the going rate." They need to be held accountable, he added.

That portion of the report states, in part, that some private health plans that are "actively involved in Patient-Centered Medical Home pilots with the intention of shoring up primary care are the very same plans that are offering preferred provider organization (PPO) contracts to family physicians that only pay a fraction of Medicare payment, threatening the financial viability and survival of small practices."

The national academy brought the conflict to the attention of the PCPCC board of directors, Dr. Stream said, and the board plans to meet with key health plans during their annual summit in October. At the same time, the AAFP plans to hold one-on-one meetings with the five top insurers involved in PCPCC, starting with United Healthcare.

Those meetings with top insurer members of the PCPCC are important, Dr. Eidus said, because "they talk the talk but are not walking the walk."

At a recent meeting of the physician advocacy board for Humana Insurance, "I pointed out that in southwestern Ohio, the Cincinnati area, there are now many physicians who are under Medicare for their payment schedules," said Dr. Brian Bachelder, an alternate delegate from Ohio. "Humana, as of Sept. 1, brought their payment levels down to what other competitors in the area were paying," Dr. Bachelder said. "Yet at the meeting, they were talking about going out and trying to engage more primary care physicians – particularly family physicians – in the Humana fold, and even hiring family physicians to work for Humana.

"I pointed out the contradiction ... and they had nothing to say about it," Dr. Bachelder asserted.

A net loss of new physicians is another adverse effect of distressed practice environments, Dr. Eidus said. "We have a fair amount of residency programs in the state, but we’re net exporters. We’re exporting more ... despite the fact that we have a shortage in primary care.

"We also recognize that it’s not in the best interest of the citizens of New Jersey, or any other state, to have family medicine or primary care deserts," Dr. Eidus said. "We have that happening in New Jersey."

The AAFP Commission on Quality and Practice will review all feedback and data collected on distressed practice environments. Dr. Stream said the issue will be a major focus at the next leadership forum in May 2012.

ORLANDO – Do you practice family medicine in a region where Medicare is the "better payer," where there is a low number of primary care physicians per capita, and/or where residents get their training but leave to practice elsewhere?

If so, you might be in a "distressed practice environment," and the American Academy of Family Physicians wants to hear from you.

Alerted to these dire circumstances by the New Jersey Academy of Family Physicians, the national academy is in "information gathering mode" to determine a strategy to help family physicians in the affected areas – but concerns reach beyond the Garden State, AAFP President Glen Stream said.

"We are concerned that this is happening in other states in the country," Dr. Stream said at a town hall session held during the annual Congress of Delegates of the American Academy of Family Physicians. "We want detailed information on how to proceed to get objective data to inform our advocacy in this regard."

"This is an issue we feel is very important, not only to New Jersey, but as you said, there are many other areas around the country. We heard that loud and clear from some other chapters," said Dr. Robert Eidus, president of the New Jersey chapter.

New Jersey has the third fewest primary care physicians per capita and ranks fourth highest nationwide in terms of specialists, Dr. Eidus said. "That creates a situation, not surprisingly, where costs are high. What do payers do at this point? They ratchet down fees, not using a scalpel but using a bludgeon."

In some regions of the state, family physicians receive private insurance payments that are 50%-60% of the Medicare rate.

"Having an oligopoly of payers is another issue," said Dr. Eidus, a family physician with a private practice in Cranford, N.J.

Although it varies, a distressed practice environment can arise when two or three major health plans hold the great majority of market share in an area, Dr. Stream said in an interview. "As a result, they offer contracts at a very low payment."

The national academy plans to develop a strategy to encourage private health plans to increase payments for primary care services, including adoption of the Medicare 10% initiative for primary care, according to a report issued by the AAFP board of directors at the congress.

"Pay particular attention to paragraph nine [of the report]," said Dr. Dennis F. Saver, a delegate from Florida. "It is wonderfully understated as a ‘particularly vexing problem’ that insurance companies who are members of the Patient-Centered Primary Care Collaborative [PCPCC] are paying primary care physicians less than the going rate." They need to be held accountable, he added.

That portion of the report states, in part, that some private health plans that are "actively involved in Patient-Centered Medical Home pilots with the intention of shoring up primary care are the very same plans that are offering preferred provider organization (PPO) contracts to family physicians that only pay a fraction of Medicare payment, threatening the financial viability and survival of small practices."

The national academy brought the conflict to the attention of the PCPCC board of directors, Dr. Stream said, and the board plans to meet with key health plans during their annual summit in October. At the same time, the AAFP plans to hold one-on-one meetings with the five top insurers involved in PCPCC, starting with United Healthcare.

Those meetings with top insurer members of the PCPCC are important, Dr. Eidus said, because "they talk the talk but are not walking the walk."

At a recent meeting of the physician advocacy board for Humana Insurance, "I pointed out that in southwestern Ohio, the Cincinnati area, there are now many physicians who are under Medicare for their payment schedules," said Dr. Brian Bachelder, an alternate delegate from Ohio. "Humana, as of Sept. 1, brought their payment levels down to what other competitors in the area were paying," Dr. Bachelder said. "Yet at the meeting, they were talking about going out and trying to engage more primary care physicians – particularly family physicians – in the Humana fold, and even hiring family physicians to work for Humana.

"I pointed out the contradiction ... and they had nothing to say about it," Dr. Bachelder asserted.

A net loss of new physicians is another adverse effect of distressed practice environments, Dr. Eidus said. "We have a fair amount of residency programs in the state, but we’re net exporters. We’re exporting more ... despite the fact that we have a shortage in primary care.

"We also recognize that it’s not in the best interest of the citizens of New Jersey, or any other state, to have family medicine or primary care deserts," Dr. Eidus said. "We have that happening in New Jersey."

The AAFP Commission on Quality and Practice will review all feedback and data collected on distressed practice environments. Dr. Stream said the issue will be a major focus at the next leadership forum in May 2012.

ORLANDO – Although some proposals at the American Academy of Family Physicians’ Congress of Delegates ignited relatively little debate, one could almost perceive a collective exhale when some of the more contentious resolutions were finally put to a final vote.

With more that 100,000 members among its ranks for the first time, the academy was careful to deliberate and consider where its official stance should be on such issues as access to over-the-counter contraception for low-income women, the health benefits of same-sex marriage, the development of collaborative agreements with nurse practitioners, and the protection of open communication between physicians and patients when it comes to gun safety.

Here’s at look at how resolutions on some of the more high-profile issues fared:

• OTC contraception. The "Removing Barriers to Over-the-Counter Contraception for Low-Income Women" resolution yielded considerable debate. In its initial form, the resolution called for the AAFP "to urge the U.S. Congress and federal and state agencies to provide Medicaid coverage for all family planning drugs and supplies approved by the [Food and Drug Administration] for over-the-counter sale and to not require a prescription for such coverage."

The Reference Committee on Advocacy, in its recommendations to the full academy, stated that it acknowledged the need for low-income individuals to have access both to OTC and prescription contraception. The committee discussed whether it was advisable to require prescriptions for OTC contraception, weighing the desire to discuss contraception as part of a comprehensive patient encounter vs. the potential barrier a prescription requirement could pose.

Ultimately, the AAFP passed a substitute resolution that addressed many of the issues raised, including the less-controversial call for expanded insurance coverage. The approved resolution stated that the AAFP "supports policies and legislation that would require public and private insurance plans to provide coverage for family planning drugs and supplies that are FDA approved, including those for sale over the counter."

• Same-sex marriage. The discussion over a proposed resolution entitled "Healthy Benefits of Same Gender Marriage – Not Just a Social Issue" was notable for both the polarity and prolonged duration of the testimony. Proponents of the resolution pointed to an American Medical Association resolution, approved earlier this year, that states that exclusion from civil marriage contributes to health care disparities that affect same-sex households. Supporters also noted that evidence on behalf of improved health associated with civil marriage is strong, according to recommendations from the Reference Committee on Advocacy.

Opponents of the resolution said its approval would make the AAFP the only physician organization to fully support marriage equality for same-sex couples. They also stated that the resolution would essentially legislate morality, and that marriage is a state issue and therefore outside the realm of the academy as a whole.

Ultimately, the reference committee recommended a substitute resolution, one that "would convey the AAFP’s commitment to oppose discrimination and support equality but would not need to use the controversial term of ‘marriage’ to arrive at the desired conclusion." Based on that recommendation, the following resolution was adopted: "That the AAFP support full legal equality for same-gender families to contribute to overall health and longevity, [to improve] family stability and to benefit children of Gay, Lesbian, Bisexual, Transgender (GLBT) families."

• Nurse practitioners. The Reference Committee on Practice Enhancement tackled another controversial resolution: that the AAFP, "through an appropriate avenue, study and develop a functional, mutually beneficial practice collaborative agreement template between nurse practitioners and family physicians."

Supporters of this amended, substitute resolution pointed to a lack of standardization on the content, detail, or scope of such agreements across the country, including in states that require such agreements. Opponents said the resolution could be seen as a tacit approval of independent practice by nurse practitioners. An alternate delegate from Arizona, Dr. Andrew Carroll, pointed out that "when you endorse nurse practitioners but don’t have anything for physician assistants ... you risk offending every PA who works with a physician." The resolution did not pass.

• The RUC, guns, and pseudoephedrine. Of the 46 proposed resolutions at the congress, most were either approved or referred. Put on hold, or officially referred to the AAFP Board of Directors for further evaluation, were four resolutions that called for immediate withdrawal of the AAFP from the RUC (Relative Value Scale Update Committee) or creation of alternatives to the RUC, including an independent relative value scale advisory board to the Centers for Medicare and Medicaid Services.

Also deferred was a resolution to send a letter to the National Rifle Association that outlined a shared recognition of the importance of gun safety while also condemning any impingement on physicians’ ability to counsel patients on that issue, in reference to a Florida law passed earlier this year.

Not adopted was a resolution to support federal legislation that would designate pseudoephedrine a controlled substance available only by prescription. Also voted down was a resolution for the AAFP to officially promote the drinking of tap water vs. bottled water. Proponents cited the municipal monitoring of tap water safety and the environmental impact of discarded plastic water bottles. Opponents pointed to an inability to vouch for the safety of all tap water throughout the country.

A resolution was put forth to not renew a collaboration between AAFP and the Coca-Cola Co. – an alliance that was hotly debated at the 2010 congress and still controversial at this year’s meeting. That resolution was not adopted.

Another industry relationship resolution was adopted, however – one that would "encourage organizations that enter into mutually beneficial arrangements with the AAFP to utilize the services of family physicians for their workforce." Initially crafted to state that employees should be directed to patient-centered medical homes, the resolution was seen by some delegates as premature, given the limited number of such homes available.

In the passed-with-very-little debate category, delegates approved a resolution against the expansion of the scope of practice for naturopaths. Similarly, a resolution to emphasize the dire situation regarding graduate medical education passed as follows: "The AAFP recognizes [that] the funding for and distribution of positions for graduate medical education (GME) is in crisis in the United States, and that meaningful and urgent reform is urgently needed."

ORLANDO – Although some proposals at the American Academy of Family Physicians’ Congress of Delegates ignited relatively little debate, one could almost perceive a collective exhale when some of the more contentious resolutions were finally put to a final vote.

With more that 100,000 members among its ranks for the first time, the academy was careful to deliberate and consider where its official stance should be on such issues as access to over-the-counter contraception for low-income women, the health benefits of same-sex marriage, the development of collaborative agreements with nurse practitioners, and the protection of open communication between physicians and patients when it comes to gun safety.

Here’s at look at how resolutions on some of the more high-profile issues fared:

• OTC contraception. The "Removing Barriers to Over-the-Counter Contraception for Low-Income Women" resolution yielded considerable debate. In its initial form, the resolution called for the AAFP "to urge the U.S. Congress and federal and state agencies to provide Medicaid coverage for all family planning drugs and supplies approved by the [Food and Drug Administration] for over-the-counter sale and to not require a prescription for such coverage."

The Reference Committee on Advocacy, in its recommendations to the full academy, stated that it acknowledged the need for low-income individuals to have access both to OTC and prescription contraception. The committee discussed whether it was advisable to require prescriptions for OTC contraception, weighing the desire to discuss contraception as part of a comprehensive patient encounter vs. the potential barrier a prescription requirement could pose.

Ultimately, the AAFP passed a substitute resolution that addressed many of the issues raised, including the less-controversial call for expanded insurance coverage. The approved resolution stated that the AAFP "supports policies and legislation that would require public and private insurance plans to provide coverage for family planning drugs and supplies that are FDA approved, including those for sale over the counter."

• Same-sex marriage. The discussion over a proposed resolution entitled "Healthy Benefits of Same Gender Marriage – Not Just a Social Issue" was notable for both the polarity and prolonged duration of the testimony. Proponents of the resolution pointed to an American Medical Association resolution, approved earlier this year, that states that exclusion from civil marriage contributes to health care disparities that affect same-sex households. Supporters also noted that evidence on behalf of improved health associated with civil marriage is strong, according to recommendations from the Reference Committee on Advocacy.

Opponents of the resolution said its approval would make the AAFP the only physician organization to fully support marriage equality for same-sex couples. They also stated that the resolution would essentially legislate morality, and that marriage is a state issue and therefore outside the realm of the academy as a whole.

Ultimately, the reference committee recommended a substitute resolution, one that "would convey the AAFP’s commitment to oppose discrimination and support equality but would not need to use the controversial term of ‘marriage’ to arrive at the desired conclusion." Based on that recommendation, the following resolution was adopted: "That the AAFP support full legal equality for same-gender families to contribute to overall health and longevity, [to improve] family stability and to benefit children of Gay, Lesbian, Bisexual, Transgender (GLBT) families."

• Nurse practitioners. The Reference Committee on Practice Enhancement tackled another controversial resolution: that the AAFP, "through an appropriate avenue, study and develop a functional, mutually beneficial practice collaborative agreement template between nurse practitioners and family physicians."

Supporters of this amended, substitute resolution pointed to a lack of standardization on the content, detail, or scope of such agreements across the country, including in states that require such agreements. Opponents said the resolution could be seen as a tacit approval of independent practice by nurse practitioners. An alternate delegate from Arizona, Dr. Andrew Carroll, pointed out that "when you endorse nurse practitioners but don’t have anything for physician assistants ... you risk offending every PA who works with a physician." The resolution did not pass.

• The RUC, guns, and pseudoephedrine. Of the 46 proposed resolutions at the congress, most were either approved or referred. Put on hold, or officially referred to the AAFP Board of Directors for further evaluation, were four resolutions that called for immediate withdrawal of the AAFP from the RUC (Relative Value Scale Update Committee) or creation of alternatives to the RUC, including an independent relative value scale advisory board to the Centers for Medicare and Medicaid Services.

Also deferred was a resolution to send a letter to the National Rifle Association that outlined a shared recognition of the importance of gun safety while also condemning any impingement on physicians’ ability to counsel patients on that issue, in reference to a Florida law passed earlier this year.

Not adopted was a resolution to support federal legislation that would designate pseudoephedrine a controlled substance available only by prescription. Also voted down was a resolution for the AAFP to officially promote the drinking of tap water vs. bottled water. Proponents cited the municipal monitoring of tap water safety and the environmental impact of discarded plastic water bottles. Opponents pointed to an inability to vouch for the safety of all tap water throughout the country.

A resolution was put forth to not renew a collaboration between AAFP and the Coca-Cola Co. – an alliance that was hotly debated at the 2010 congress and still controversial at this year’s meeting. That resolution was not adopted.

Another industry relationship resolution was adopted, however – one that would "encourage organizations that enter into mutually beneficial arrangements with the AAFP to utilize the services of family physicians for their workforce." Initially crafted to state that employees should be directed to patient-centered medical homes, the resolution was seen by some delegates as premature, given the limited number of such homes available.

In the passed-with-very-little debate category, delegates approved a resolution against the expansion of the scope of practice for naturopaths. Similarly, a resolution to emphasize the dire situation regarding graduate medical education passed as follows: "The AAFP recognizes [that] the funding for and distribution of positions for graduate medical education (GME) is in crisis in the United States, and that meaningful and urgent reform is urgently needed."

ORLANDO – Although some proposals at the American Academy of Family Physicians’ Congress of Delegates ignited relatively little debate, one could almost perceive a collective exhale when some of the more contentious resolutions were finally put to a final vote.

With more that 100,000 members among its ranks for the first time, the academy was careful to deliberate and consider where its official stance should be on such issues as access to over-the-counter contraception for low-income women, the health benefits of same-sex marriage, the development of collaborative agreements with nurse practitioners, and the protection of open communication between physicians and patients when it comes to gun safety.

Here’s at look at how resolutions on some of the more high-profile issues fared:

• OTC contraception. The "Removing Barriers to Over-the-Counter Contraception for Low-Income Women" resolution yielded considerable debate. In its initial form, the resolution called for the AAFP "to urge the U.S. Congress and federal and state agencies to provide Medicaid coverage for all family planning drugs and supplies approved by the [Food and Drug Administration] for over-the-counter sale and to not require a prescription for such coverage."

The Reference Committee on Advocacy, in its recommendations to the full academy, stated that it acknowledged the need for low-income individuals to have access both to OTC and prescription contraception. The committee discussed whether it was advisable to require prescriptions for OTC contraception, weighing the desire to discuss contraception as part of a comprehensive patient encounter vs. the potential barrier a prescription requirement could pose.

Ultimately, the AAFP passed a substitute resolution that addressed many of the issues raised, including the less-controversial call for expanded insurance coverage. The approved resolution stated that the AAFP "supports policies and legislation that would require public and private insurance plans to provide coverage for family planning drugs and supplies that are FDA approved, including those for sale over the counter."

• Same-sex marriage. The discussion over a proposed resolution entitled "Healthy Benefits of Same Gender Marriage – Not Just a Social Issue" was notable for both the polarity and prolonged duration of the testimony. Proponents of the resolution pointed to an American Medical Association resolution, approved earlier this year, that states that exclusion from civil marriage contributes to health care disparities that affect same-sex households. Supporters also noted that evidence on behalf of improved health associated with civil marriage is strong, according to recommendations from the Reference Committee on Advocacy.

Opponents of the resolution said its approval would make the AAFP the only physician organization to fully support marriage equality for same-sex couples. They also stated that the resolution would essentially legislate morality, and that marriage is a state issue and therefore outside the realm of the academy as a whole.

Ultimately, the reference committee recommended a substitute resolution, one that "would convey the AAFP’s commitment to oppose discrimination and support equality but would not need to use the controversial term of ‘marriage’ to arrive at the desired conclusion." Based on that recommendation, the following resolution was adopted: "That the AAFP support full legal equality for same-gender families to contribute to overall health and longevity, [to improve] family stability and to benefit children of Gay, Lesbian, Bisexual, Transgender (GLBT) families."

• Nurse practitioners. The Reference Committee on Practice Enhancement tackled another controversial resolution: that the AAFP, "through an appropriate avenue, study and develop a functional, mutually beneficial practice collaborative agreement template between nurse practitioners and family physicians."

Supporters of this amended, substitute resolution pointed to a lack of standardization on the content, detail, or scope of such agreements across the country, including in states that require such agreements. Opponents said the resolution could be seen as a tacit approval of independent practice by nurse practitioners. An alternate delegate from Arizona, Dr. Andrew Carroll, pointed out that "when you endorse nurse practitioners but don’t have anything for physician assistants ... you risk offending every PA who works with a physician." The resolution did not pass.

• The RUC, guns, and pseudoephedrine. Of the 46 proposed resolutions at the congress, most were either approved or referred. Put on hold, or officially referred to the AAFP Board of Directors for further evaluation, were four resolutions that called for immediate withdrawal of the AAFP from the RUC (Relative Value Scale Update Committee) or creation of alternatives to the RUC, including an independent relative value scale advisory board to the Centers for Medicare and Medicaid Services.

Also deferred was a resolution to send a letter to the National Rifle Association that outlined a shared recognition of the importance of gun safety while also condemning any impingement on physicians’ ability to counsel patients on that issue, in reference to a Florida law passed earlier this year.

Not adopted was a resolution to support federal legislation that would designate pseudoephedrine a controlled substance available only by prescription. Also voted down was a resolution for the AAFP to officially promote the drinking of tap water vs. bottled water. Proponents cited the municipal monitoring of tap water safety and the environmental impact of discarded plastic water bottles. Opponents pointed to an inability to vouch for the safety of all tap water throughout the country.

A resolution was put forth to not renew a collaboration between AAFP and the Coca-Cola Co. – an alliance that was hotly debated at the 2010 congress and still controversial at this year’s meeting. That resolution was not adopted.

Another industry relationship resolution was adopted, however – one that would "encourage organizations that enter into mutually beneficial arrangements with the AAFP to utilize the services of family physicians for their workforce." Initially crafted to state that employees should be directed to patient-centered medical homes, the resolution was seen by some delegates as premature, given the limited number of such homes available.

In the passed-with-very-little debate category, delegates approved a resolution against the expansion of the scope of practice for naturopaths. Similarly, a resolution to emphasize the dire situation regarding graduate medical education passed as follows: "The AAFP recognizes [that] the funding for and distribution of positions for graduate medical education (GME) is in crisis in the United States, and that meaningful and urgent reform is urgently needed."

ORLANDO – Part update, part rallying cry, the policy leaders of the American Academy of Family Physicians updated delegates this week on how the academy is getting more aggressive and more specific in its demands to increase the role of, and reimbursement for, primary care physicians through the American Medical Association committee that advises on Medicare payments.

There has been no official word yet from the Relative Value Scale Update Committee (RUC) in response to a public letter sent by the AAFP to RUC chair Dr. Barbara Levy in June, said Dr. Lori Heim, outgoing chair of the AAFP board of directors.

Although the AAFP has sent letters in the past, this time they set a specific deadline for a response – Mar. 1, 2012 – and outlined some very specific requests.

The AAFP wants the RUC to add four additional primary care seats (one each for the AAFP, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association); add a seat for geriatrics; add three new seats for "external representatives" that could include patients, employers, health systems, and health plans; and institute voting transparency.

"Payment is front and center for a lot of what we are doing and for a lot of the problems we’re seeing throughout the country in terms of primary care," Dr. Heim said at the annual AAFP Congress of Delegates.

"We know primary care is particularly disadvantaged because of how the RUC is composed. If Medicare is undervaluing us, then that bottom is even lower than what we can sustain," she added.

Although the AAFP also is advocating for increased payment from private insurers, it all goes back to Medicare, said Dr. Heim, who is also a family physician in Vass, N.C.

"Our objective is to increase payment for primary care physicians," she explained. "We know if we cannot afford to keep our doors open, it affects our community."

While awaiting a response from the RUC, the AAFP also is devising its own recommendations on primary care payment to send to the Centers for Medicare and Medicaid Services. To accomplish that, the academy formed the AAFP Primary Care Valuation Task Force. The group includes 22 members from a variety of disciplines, including policy makers, payment experts, patients, employers, and AAFP board members. "Having that variety of voices is incredibly helpful," Dr. Heim said.

AAFP members will be able to follow task force progress. "We are going to be transparent, because that is what we want the RUC to do," Dr. Heim said.

Should They Stay or Go?

Some AAFP delegates, however, weren’t willing to wait for a response from the RUC. Four resolutions to immediately withdraw from the RUC and/or form an alternative, independent relative value scale advisory board to CMS were introduced at the congress.

After RUC wrangling, or "extensive, impassioned testimony on all sides," the AAFP Reference Committee on Practice Enhancement decided it was premature for the academy to leave the RUC. They also stated that the majority of AFFP members support the current strategy to lobby for greater representation. The reference committee recommended referring the four resolutions to the board of directors, and a vote by delegates approved this move.

So, the wait continues for a response from RUC. No matter what happens, "the board will tackle it and make a very deliberate decision whenever we find out what RUC tell us," said Dr. Roland Goertz, who replaces Dr. Heim this month as chair of the board.

Dr. Goertz added that the RUC committee asked him to attend their meeting Sept. 23, 2011, at which he’ll be allotted 5 minutes to explain the AAFP position in person.

Dr. Paul Fischer and colleagues in Georgia took a more aggressive approach when they filed a lawsuit against CMS earlier this year. "The basis of this suit has to do with the RUC," Dr. Fischer said at the congress. Because of a lack of transparency, "the relationship between the RUC and Medicare is clearly illegal."

The RUC also came up in a couple of questions during a candidate forum with the two men vying to become AAFP president-elect. They each replied no when asked if the academy should join in the lawsuit against the RUC. Dr. Jeffrey J. Cain, a family physician from Denver, said the AAFP should not sue the RUC at the same time they are negotiating with them. "Did any of you grow up in a small town? One lesson you learn is you don’t sue the guy fixing your car until you get your keys back."

The other candidate, Dr. George W. Shannon, pointed out that lawsuits can take a long time to resolve and could go past the March 2012 deadline for the RUC response. He prefers the current strategy to approach the RUC and request greater representation.

Each candidate also was asked: If March 2012 arrives and there is still no significant change in the RUC, what will be your recommendation?

"The head of CMS wants a viable alternative on the table. That’s why we have a new task force," Dr. Cain said. "We are using the time right now to develop an alternative method."

"It was a professional, collegial move sending a letter and outlining what our difficulties are, giving RUC two meeting cycles to respond, and saying no matter what they respond, we are going to evaluate," Dr. Shannon said.

Dr. Heim, Dr. Goertz, Dr. Cain, and Dr. Shannon said that they had no relevant financial disclosures.

ORLANDO – Part update, part rallying cry, the policy leaders of the American Academy of Family Physicians updated delegates this week on how the academy is getting more aggressive and more specific in its demands to increase the role of, and reimbursement for, primary care physicians through the American Medical Association committee that advises on Medicare payments.

There has been no official word yet from the Relative Value Scale Update Committee (RUC) in response to a public letter sent by the AAFP to RUC chair Dr. Barbara Levy in June, said Dr. Lori Heim, outgoing chair of the AAFP board of directors.

Although the AAFP has sent letters in the past, this time they set a specific deadline for a response – Mar. 1, 2012 – and outlined some very specific requests.

The AAFP wants the RUC to add four additional primary care seats (one each for the AAFP, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association); add a seat for geriatrics; add three new seats for "external representatives" that could include patients, employers, health systems, and health plans; and institute voting transparency.

"Payment is front and center for a lot of what we are doing and for a lot of the problems we’re seeing throughout the country in terms of primary care," Dr. Heim said at the annual AAFP Congress of Delegates.

"We know primary care is particularly disadvantaged because of how the RUC is composed. If Medicare is undervaluing us, then that bottom is even lower than what we can sustain," she added.

Although the AAFP also is advocating for increased payment from private insurers, it all goes back to Medicare, said Dr. Heim, who is also a family physician in Vass, N.C.

"Our objective is to increase payment for primary care physicians," she explained. "We know if we cannot afford to keep our doors open, it affects our community."

While awaiting a response from the RUC, the AAFP also is devising its own recommendations on primary care payment to send to the Centers for Medicare and Medicaid Services. To accomplish that, the academy formed the AAFP Primary Care Valuation Task Force. The group includes 22 members from a variety of disciplines, including policy makers, payment experts, patients, employers, and AAFP board members. "Having that variety of voices is incredibly helpful," Dr. Heim said.

AAFP members will be able to follow task force progress. "We are going to be transparent, because that is what we want the RUC to do," Dr. Heim said.

Should They Stay or Go?

Some AAFP delegates, however, weren’t willing to wait for a response from the RUC. Four resolutions to immediately withdraw from the RUC and/or form an alternative, independent relative value scale advisory board to CMS were introduced at the congress.

After RUC wrangling, or "extensive, impassioned testimony on all sides," the AAFP Reference Committee on Practice Enhancement decided it was premature for the academy to leave the RUC. They also stated that the majority of AFFP members support the current strategy to lobby for greater representation. The reference committee recommended referring the four resolutions to the board of directors, and a vote by delegates approved this move.

So, the wait continues for a response from RUC. No matter what happens, "the board will tackle it and make a very deliberate decision whenever we find out what RUC tell us," said Dr. Roland Goertz, who replaces Dr. Heim this month as chair of the board.

Dr. Goertz added that the RUC committee asked him to attend their meeting Sept. 23, 2011, at which he’ll be allotted 5 minutes to explain the AAFP position in person.

Dr. Paul Fischer and colleagues in Georgia took a more aggressive approach when they filed a lawsuit against CMS earlier this year. "The basis of this suit has to do with the RUC," Dr. Fischer said at the congress. Because of a lack of transparency, "the relationship between the RUC and Medicare is clearly illegal."

The RUC also came up in a couple of questions during a candidate forum with the two men vying to become AAFP president-elect. They each replied no when asked if the academy should join in the lawsuit against the RUC. Dr. Jeffrey J. Cain, a family physician from Denver, said the AAFP should not sue the RUC at the same time they are negotiating with them. "Did any of you grow up in a small town? One lesson you learn is you don’t sue the guy fixing your car until you get your keys back."

The other candidate, Dr. George W. Shannon, pointed out that lawsuits can take a long time to resolve and could go past the March 2012 deadline for the RUC response. He prefers the current strategy to approach the RUC and request greater representation.

Each candidate also was asked: If March 2012 arrives and there is still no significant change in the RUC, what will be your recommendation?

"The head of CMS wants a viable alternative on the table. That’s why we have a new task force," Dr. Cain said. "We are using the time right now to develop an alternative method."

"It was a professional, collegial move sending a letter and outlining what our difficulties are, giving RUC two meeting cycles to respond, and saying no matter what they respond, we are going to evaluate," Dr. Shannon said.

Dr. Heim, Dr. Goertz, Dr. Cain, and Dr. Shannon said that they had no relevant financial disclosures.

ORLANDO – Part update, part rallying cry, the policy leaders of the American Academy of Family Physicians updated delegates this week on how the academy is getting more aggressive and more specific in its demands to increase the role of, and reimbursement for, primary care physicians through the American Medical Association committee that advises on Medicare payments.

There has been no official word yet from the Relative Value Scale Update Committee (RUC) in response to a public letter sent by the AAFP to RUC chair Dr. Barbara Levy in June, said Dr. Lori Heim, outgoing chair of the AAFP board of directors.

Although the AAFP has sent letters in the past, this time they set a specific deadline for a response – Mar. 1, 2012 – and outlined some very specific requests.

The AAFP wants the RUC to add four additional primary care seats (one each for the AAFP, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association); add a seat for geriatrics; add three new seats for "external representatives" that could include patients, employers, health systems, and health plans; and institute voting transparency.

"Payment is front and center for a lot of what we are doing and for a lot of the problems we’re seeing throughout the country in terms of primary care," Dr. Heim said at the annual AAFP Congress of Delegates.

"We know primary care is particularly disadvantaged because of how the RUC is composed. If Medicare is undervaluing us, then that bottom is even lower than what we can sustain," she added.

Although the AAFP also is advocating for increased payment from private insurers, it all goes back to Medicare, said Dr. Heim, who is also a family physician in Vass, N.C.

"Our objective is to increase payment for primary care physicians," she explained. "We know if we cannot afford to keep our doors open, it affects our community."

While awaiting a response from the RUC, the AAFP also is devising its own recommendations on primary care payment to send to the Centers for Medicare and Medicaid Services. To accomplish that, the academy formed the AAFP Primary Care Valuation Task Force. The group includes 22 members from a variety of disciplines, including policy makers, payment experts, patients, employers, and AAFP board members. "Having that variety of voices is incredibly helpful," Dr. Heim said.

AAFP members will be able to follow task force progress. "We are going to be transparent, because that is what we want the RUC to do," Dr. Heim said.

Should They Stay or Go?

Some AAFP delegates, however, weren’t willing to wait for a response from the RUC. Four resolutions to immediately withdraw from the RUC and/or form an alternative, independent relative value scale advisory board to CMS were introduced at the congress.

After RUC wrangling, or "extensive, impassioned testimony on all sides," the AAFP Reference Committee on Practice Enhancement decided it was premature for the academy to leave the RUC. They also stated that the majority of AFFP members support the current strategy to lobby for greater representation. The reference committee recommended referring the four resolutions to the board of directors, and a vote by delegates approved this move.

So, the wait continues for a response from RUC. No matter what happens, "the board will tackle it and make a very deliberate decision whenever we find out what RUC tell us," said Dr. Roland Goertz, who replaces Dr. Heim this month as chair of the board.

Dr. Goertz added that the RUC committee asked him to attend their meeting Sept. 23, 2011, at which he’ll be allotted 5 minutes to explain the AAFP position in person.

Dr. Paul Fischer and colleagues in Georgia took a more aggressive approach when they filed a lawsuit against CMS earlier this year. "The basis of this suit has to do with the RUC," Dr. Fischer said at the congress. Because of a lack of transparency, "the relationship between the RUC and Medicare is clearly illegal."

The RUC also came up in a couple of questions during a candidate forum with the two men vying to become AAFP president-elect. They each replied no when asked if the academy should join in the lawsuit against the RUC. Dr. Jeffrey J. Cain, a family physician from Denver, said the AAFP should not sue the RUC at the same time they are negotiating with them. "Did any of you grow up in a small town? One lesson you learn is you don’t sue the guy fixing your car until you get your keys back."

The other candidate, Dr. George W. Shannon, pointed out that lawsuits can take a long time to resolve and could go past the March 2012 deadline for the RUC response. He prefers the current strategy to approach the RUC and request greater representation.

Each candidate also was asked: If March 2012 arrives and there is still no significant change in the RUC, what will be your recommendation?

"The head of CMS wants a viable alternative on the table. That’s why we have a new task force," Dr. Cain said. "We are using the time right now to develop an alternative method."

"It was a professional, collegial move sending a letter and outlining what our difficulties are, giving RUC two meeting cycles to respond, and saying no matter what they respond, we are going to evaluate," Dr. Shannon said.

Dr. Heim, Dr. Goertz, Dr. Cain, and Dr. Shannon said that they had no relevant financial disclosures.

ORLANDO – If nothing changes between now and Jan. 1, Medicare payments will be cut by nearly 30%, causing a "catastrophic effect" on family physicians’ ability to run their practices, said Dr. Glen Stream, incoming president of the American Academy of Family Physicians.

While it’s nowhere near certain, the 12 members of the Joint Select Committee on Deficit Reduction – better known as the super committee – could be family medicine’s best shot at getting a quick and permanent fix to Medicare’s sustainable growth rate (SGR) formula.

"What has really turned things a bit different this time is the ‘Super 12’ deficit reduction process that’s in place," said Dr. Roland Goertz, outgoing AAFP president.

This is a unique opportunity because the super committee will have "huge protections" from the usual political wrangling in Washington, Dr. Goertz said during a Town Hall session at the AAFP Congress of Delegates.

For example, any proposed legislation has to remain amendment-free and cannot be filibustered in the Senate. In addition, their proposals are only subject to a simple up or down majority vote.

The challenge, though, is for the AAFP and its membership to get the super committee’s attention, said Dr. Stream.

The AAFP is calling on Congress to repeal the SGR and to provide at least a 3% increase in payments for primary care, said Dr. Stream, a family physician in Spokane, Wash. "Even repealing the SGR is a ‘Band-Aid’ fix on a flawed pay-for-service system. AAFP is looking at models that more properly pay for our services."

The six Democrat and six Republican lawmakers appointed to the super committee are charged with finding $1.5 trillion to cut from the U.S. federal budget by Thanksgiving. Their focus – the entire federal budget, not just health care – is part of the challenge for the AAFP.

"If you think about how many people are trying to contact those 12, it’s got to be immense," said Dr. Goertz, who is also a family physician in Waco, Texas.

"The [AAFP] Board approved what I think is an innovative way to try to reach some of the super 12 and others." The academy will produce videos featuring real family physicians who describe the real impact of these cuts for their practices, Dr. Goertz said. With a nod to the sometimes viral nature of electronic communication, he told town hall participants, "We’re going to ask that all of you send them to everybody you could potentially send them to."

In addition to these videos, the AAFP sent letters to each member of the super committee. Also, in each state these 12 lawmakers call home, the AAFP local chapter requested a meeting. "We have got to mobilize. Our advisors say the most effective thing is getting our member voices heard by the super committee as much as possible," Dr. Goertz said.

This doesn’t mean the AAFP does not have a back-up plan.

"At the same time we are working as hard as we can with the super 12, we are also anticipating that if they do not tackle this ... and the issue of SGR reverts to the routine committees of record in the House and Senate, that we are ready to influence them as best we can," Dr. Goertz said.

The AAFP wants and prefers a permanent fix to SGR, Dr. Goertz said. "If a permanent fix is not possible, we want long-term fix of 5 years and a 3% positive update for primary care services and primary care each year of that 5-year fix."

ORLANDO – If nothing changes between now and Jan. 1, Medicare payments will be cut by nearly 30%, causing a "catastrophic effect" on family physicians’ ability to run their practices, said Dr. Glen Stream, incoming president of the American Academy of Family Physicians.

While it’s nowhere near certain, the 12 members of the Joint Select Committee on Deficit Reduction – better known as the super committee – could be family medicine’s best shot at getting a quick and permanent fix to Medicare’s sustainable growth rate (SGR) formula.

"What has really turned things a bit different this time is the ‘Super 12’ deficit reduction process that’s in place," said Dr. Roland Goertz, outgoing AAFP president.

This is a unique opportunity because the super committee will have "huge protections" from the usual political wrangling in Washington, Dr. Goertz said during a Town Hall session at the AAFP Congress of Delegates.

For example, any proposed legislation has to remain amendment-free and cannot be filibustered in the Senate. In addition, their proposals are only subject to a simple up or down majority vote.

The challenge, though, is for the AAFP and its membership to get the super committee’s attention, said Dr. Stream.

The AAFP is calling on Congress to repeal the SGR and to provide at least a 3% increase in payments for primary care, said Dr. Stream, a family physician in Spokane, Wash. "Even repealing the SGR is a ‘Band-Aid’ fix on a flawed pay-for-service system. AAFP is looking at models that more properly pay for our services."

The six Democrat and six Republican lawmakers appointed to the super committee are charged with finding $1.5 trillion to cut from the U.S. federal budget by Thanksgiving. Their focus – the entire federal budget, not just health care – is part of the challenge for the AAFP.

"If you think about how many people are trying to contact those 12, it’s got to be immense," said Dr. Goertz, who is also a family physician in Waco, Texas.

"The [AAFP] Board approved what I think is an innovative way to try to reach some of the super 12 and others." The academy will produce videos featuring real family physicians who describe the real impact of these cuts for their practices, Dr. Goertz said. With a nod to the sometimes viral nature of electronic communication, he told town hall participants, "We’re going to ask that all of you send them to everybody you could potentially send them to."

In addition to these videos, the AAFP sent letters to each member of the super committee. Also, in each state these 12 lawmakers call home, the AAFP local chapter requested a meeting. "We have got to mobilize. Our advisors say the most effective thing is getting our member voices heard by the super committee as much as possible," Dr. Goertz said.

This doesn’t mean the AAFP does not have a back-up plan.

"At the same time we are working as hard as we can with the super 12, we are also anticipating that if they do not tackle this ... and the issue of SGR reverts to the routine committees of record in the House and Senate, that we are ready to influence them as best we can," Dr. Goertz said.

The AAFP wants and prefers a permanent fix to SGR, Dr. Goertz said. "If a permanent fix is not possible, we want long-term fix of 5 years and a 3% positive update for primary care services and primary care each year of that 5-year fix."

ORLANDO – If nothing changes between now and Jan. 1, Medicare payments will be cut by nearly 30%, causing a "catastrophic effect" on family physicians’ ability to run their practices, said Dr. Glen Stream, incoming president of the American Academy of Family Physicians.

While it’s nowhere near certain, the 12 members of the Joint Select Committee on Deficit Reduction – better known as the super committee – could be family medicine’s best shot at getting a quick and permanent fix to Medicare’s sustainable growth rate (SGR) formula.

"What has really turned things a bit different this time is the ‘Super 12’ deficit reduction process that’s in place," said Dr. Roland Goertz, outgoing AAFP president.

This is a unique opportunity because the super committee will have "huge protections" from the usual political wrangling in Washington, Dr. Goertz said during a Town Hall session at the AAFP Congress of Delegates.

For example, any proposed legislation has to remain amendment-free and cannot be filibustered in the Senate. In addition, their proposals are only subject to a simple up or down majority vote.

The challenge, though, is for the AAFP and its membership to get the super committee’s attention, said Dr. Stream.

The AAFP is calling on Congress to repeal the SGR and to provide at least a 3% increase in payments for primary care, said Dr. Stream, a family physician in Spokane, Wash. "Even repealing the SGR is a ‘Band-Aid’ fix on a flawed pay-for-service system. AAFP is looking at models that more properly pay for our services."

The six Democrat and six Republican lawmakers appointed to the super committee are charged with finding $1.5 trillion to cut from the U.S. federal budget by Thanksgiving. Their focus – the entire federal budget, not just health care – is part of the challenge for the AAFP.

"If you think about how many people are trying to contact those 12, it’s got to be immense," said Dr. Goertz, who is also a family physician in Waco, Texas.

"The [AAFP] Board approved what I think is an innovative way to try to reach some of the super 12 and others." The academy will produce videos featuring real family physicians who describe the real impact of these cuts for their practices, Dr. Goertz said. With a nod to the sometimes viral nature of electronic communication, he told town hall participants, "We’re going to ask that all of you send them to everybody you could potentially send them to."

In addition to these videos, the AAFP sent letters to each member of the super committee. Also, in each state these 12 lawmakers call home, the AAFP local chapter requested a meeting. "We have got to mobilize. Our advisors say the most effective thing is getting our member voices heard by the super committee as much as possible," Dr. Goertz said.

This doesn’t mean the AAFP does not have a back-up plan.

"At the same time we are working as hard as we can with the super 12, we are also anticipating that if they do not tackle this ... and the issue of SGR reverts to the routine committees of record in the House and Senate, that we are ready to influence them as best we can," Dr. Goertz said.

The AAFP wants and prefers a permanent fix to SGR, Dr. Goertz said. "If a permanent fix is not possible, we want long-term fix of 5 years and a 3% positive update for primary care services and primary care each year of that 5-year fix."

Major Finding: A total of 63% of patients with familial hemiplegic migraine reported at least one environmental trigger factor.

Data Source: Questionnaire mailed to 75 patients with familial hemiplegic migraine.

Disclosures: Dr. Hansen said that he had no relevant financial disclosures.

BERLIN – The factors that patients report to be triggers of familial hemiplegic migraine appear to coincide in many instances with the same triggers reported by migraine patients with and without aura, according to findings from a questionnaire-based study.

Questionnaires completed by 75 patients with familial hemiplegic migraine (FHM) indicated that 63% have between 1 and 12 triggers, whereas the remaining 37% said no environmental triggers precede their attacks, Dr. Jakob Hansen said at the congress, which was sponsored by the International Headache Society and the American Headache Society.

At least half of the respondents reported that, most commonly, acute stress (following a stressful event) triggered FHM, followed in frequency by sunlight and other bright lights; acute stress (during a stressful episode); intense emotional influences; and sleep disturbances (too little or too much sleep).

“If you can identify and avoid these trigger factors, that actually might be helpful in your clinical practice, so talk to your patients about this,” said Dr. Hansen, a research fellow at the Danish Headache Center at the University of Copenhagen.

The pattern of trigger factors for FHM and those previously reported for migraine with aura and migraine without aura “seem to match pretty well,” he said. For example, acute stress (following a stressful event) topped the list for both FHM and migraine without aura patients.

“Now we have some data that [FHM] does not seem to be so different from the more common types of migraine,” Dr. Hansen said. He added that although neurologists consider FHM a distinct headache type, the alignment of triggers suggests some shared etiology or physiology.

The researchers asked the patients to rate 16 possible environmental factors that trigger headaches on the questionnaire using a scale of 0 (never) to 4 (always).

Although patients report some of these same triggers in face-to-face consultations with physicians, “what our patients tell us triggers their headaches [can differ],” Dr. Hansen said. Patients often said these factors include hormones; foods such as cheese, red wine, or chocolate; weather changes; and medication. “Some will say, 'I get this from my mother,' which in part could be true, especially if they suffer from familial hemiplegic migraine.”

Among the patients who selected at least one trigger for FHM on the questionnaire, 36% reported at least one trigger factor that often or always (questionnaire response of 3 or 4, respectively) precipitated a FHM attack, he said.

A total 76% of patients reported at least one FHM attack within the past year. More members of this group identified at least one trigger factor than did those without a recent attack (76% vs. 11%, respectively). Only 15 participants reported solely having FHM headaches. Other patients also reported experiencing migraines with and without aura (29), migraines with aura (25), and migraines without aura (6).

A meeting attendee questioned the accuracy of patient self-reports, suggesting that, if asked, patients tend to overreport the number of factors that trigger their migraines. “It's interesting that one-third of our patients did not report any trigger factors. It seemed they answered truthfully,” Dr. Hansen replied.

Major Finding: A total of 63% of patients with familial hemiplegic migraine reported at least one environmental trigger factor.

Data Source: Questionnaire mailed to 75 patients with familial hemiplegic migraine.

Disclosures: Dr. Hansen said that he had no relevant financial disclosures.

BERLIN – The factors that patients report to be triggers of familial hemiplegic migraine appear to coincide in many instances with the same triggers reported by migraine patients with and without aura, according to findings from a questionnaire-based study.

Questionnaires completed by 75 patients with familial hemiplegic migraine (FHM) indicated that 63% have between 1 and 12 triggers, whereas the remaining 37% said no environmental triggers precede their attacks, Dr. Jakob Hansen said at the congress, which was sponsored by the International Headache Society and the American Headache Society.

At least half of the respondents reported that, most commonly, acute stress (following a stressful event) triggered FHM, followed in frequency by sunlight and other bright lights; acute stress (during a stressful episode); intense emotional influences; and sleep disturbances (too little or too much sleep).

“If you can identify and avoid these trigger factors, that actually might be helpful in your clinical practice, so talk to your patients about this,” said Dr. Hansen, a research fellow at the Danish Headache Center at the University of Copenhagen.

The pattern of trigger factors for FHM and those previously reported for migraine with aura and migraine without aura “seem to match pretty well,” he said. For example, acute stress (following a stressful event) topped the list for both FHM and migraine without aura patients.

“Now we have some data that [FHM] does not seem to be so different from the more common types of migraine,” Dr. Hansen said. He added that although neurologists consider FHM a distinct headache type, the alignment of triggers suggests some shared etiology or physiology.

The researchers asked the patients to rate 16 possible environmental factors that trigger headaches on the questionnaire using a scale of 0 (never) to 4 (always).

Although patients report some of these same triggers in face-to-face consultations with physicians, “what our patients tell us triggers their headaches [can differ],” Dr. Hansen said. Patients often said these factors include hormones; foods such as cheese, red wine, or chocolate; weather changes; and medication. “Some will say, 'I get this from my mother,' which in part could be true, especially if they suffer from familial hemiplegic migraine.”

Among the patients who selected at least one trigger for FHM on the questionnaire, 36% reported at least one trigger factor that often or always (questionnaire response of 3 or 4, respectively) precipitated a FHM attack, he said.

A total 76% of patients reported at least one FHM attack within the past year. More members of this group identified at least one trigger factor than did those without a recent attack (76% vs. 11%, respectively). Only 15 participants reported solely having FHM headaches. Other patients also reported experiencing migraines with and without aura (29), migraines with aura (25), and migraines without aura (6).

A meeting attendee questioned the accuracy of patient self-reports, suggesting that, if asked, patients tend to overreport the number of factors that trigger their migraines. “It's interesting that one-third of our patients did not report any trigger factors. It seemed they answered truthfully,” Dr. Hansen replied.

Major Finding: A total of 63% of patients with familial hemiplegic migraine reported at least one environmental trigger factor.

Data Source: Questionnaire mailed to 75 patients with familial hemiplegic migraine.

Disclosures: Dr. Hansen said that he had no relevant financial disclosures.

BERLIN – The factors that patients report to be triggers of familial hemiplegic migraine appear to coincide in many instances with the same triggers reported by migraine patients with and without aura, according to findings from a questionnaire-based study.

Questionnaires completed by 75 patients with familial hemiplegic migraine (FHM) indicated that 63% have between 1 and 12 triggers, whereas the remaining 37% said no environmental triggers precede their attacks, Dr. Jakob Hansen said at the congress, which was sponsored by the International Headache Society and the American Headache Society.

At least half of the respondents reported that, most commonly, acute stress (following a stressful event) triggered FHM, followed in frequency by sunlight and other bright lights; acute stress (during a stressful episode); intense emotional influences; and sleep disturbances (too little or too much sleep).

“If you can identify and avoid these trigger factors, that actually might be helpful in your clinical practice, so talk to your patients about this,” said Dr. Hansen, a research fellow at the Danish Headache Center at the University of Copenhagen.

The pattern of trigger factors for FHM and those previously reported for migraine with aura and migraine without aura “seem to match pretty well,” he said. For example, acute stress (following a stressful event) topped the list for both FHM and migraine without aura patients.

“Now we have some data that [FHM] does not seem to be so different from the more common types of migraine,” Dr. Hansen said. He added that although neurologists consider FHM a distinct headache type, the alignment of triggers suggests some shared etiology or physiology.

The researchers asked the patients to rate 16 possible environmental factors that trigger headaches on the questionnaire using a scale of 0 (never) to 4 (always).

Although patients report some of these same triggers in face-to-face consultations with physicians, “what our patients tell us triggers their headaches [can differ],” Dr. Hansen said. Patients often said these factors include hormones; foods such as cheese, red wine, or chocolate; weather changes; and medication. “Some will say, 'I get this from my mother,' which in part could be true, especially if they suffer from familial hemiplegic migraine.”

Among the patients who selected at least one trigger for FHM on the questionnaire, 36% reported at least one trigger factor that often or always (questionnaire response of 3 or 4, respectively) precipitated a FHM attack, he said.

A total 76% of patients reported at least one FHM attack within the past year. More members of this group identified at least one trigger factor than did those without a recent attack (76% vs. 11%, respectively). Only 15 participants reported solely having FHM headaches. Other patients also reported experiencing migraines with and without aura (29), migraines with aura (25), and migraines without aura (6).

A meeting attendee questioned the accuracy of patient self-reports, suggesting that, if asked, patients tend to overreport the number of factors that trigger their migraines. “It's interesting that one-third of our patients did not report any trigger factors. It seemed they answered truthfully,” Dr. Hansen replied.

Major Finding: Of 63 patients who shared common characteristics for a new form of headache attributed to airplane travel, 60 reported having at least one attack occur during the landing phase.

Data Source: A questionnaire-based study of 63 people with headache attributed to airplane travel.

Disclosures: Dr. Mainardi said that he had no relevant financial disclosures.

BERLIN – Reports from airline passengers who experience sudden onset, severe, and short-duration headaches – primarily during landing – contain enough common and unique features to support a new, distinct form of headache, according to a study.

“There are some peculiar, common characteristics,” Dr. Federico Mainardi said at the congress, which was sponsored by the International Headache Society and the American Headache Society. A total of 63 people who responded to a questionnaire cited the common factors of strict unilateral presentation, absence of companion symptoms, and spontaneous resolution once they were on the ground and at the airport.

Sinus conditions sometimes cause severe headaches in migraine patients, Dr. Mainardi said, but only two participants reported concurrent sinusitis. This and other physiologic explanations were ruled out for the remainder, including a subset who underwent MRI and sinus CT scanning, said Dr. Mainardi, a neurologist at the Headache Centre at S.S. Giovanni e Paolo Hospital, Venice, Italy.

Because 60 of the 63 participants had at least one attack occur during the landing phase, Dr. Mainardi suggested that patients with a history of these attacks should take nonsteroidal anti-inflammatory drug prophylaxis either before takeoff on a short flight or during a longer flight. Some respondents reported that this strategy prevented attacks.

Most of the participants (46) did not experience a “headache attributed to airplane travel” during their first experience flying. Many people had repeat attacks, including 15 patients who reported attacks on more than half their flights and 9 who had an attack each time they flew.

Dr. Mainardi described his first case and, together with seven other cases published in the literature, he and his colleagues devised specific criteria for these headaches: repeated attacks, occurrence during airplane travel, duration up to 20 minutes, and frontoperiorbital location (J. Headache Pain 2007;8:196-9).

Dr. Mainardi said that after the publication of the criteria he and his associates received e-mails from people worldwide experiencing the same kind of headache. Of these 69 contacts, 63 returned a completed questionnaire in which they described and rated their experience. Their mean age was 37 years, and 41 (65%) of the respondents were men. Using International Classification of Headache Disorders (ICHD-II) criteria on the questionnaire, 35 (56%) had a concomitant primary headache, including 15 who reported tension type headaches, 11 who reported migraine with aura, and 3 who met criteria for probable tension type headache. Six reported more than one primary headache type. No participant suffered from cluster headache.

All patients rated their attacks as “severe” or “very severe.” These headaches negatively influenced the decision to fly in the future for 44 respondents (70%).

All patients denied consuming alcohol prior to the attacks and none gained relief from measures such as chewing, swallowing, or performing a Valsalva maneuver. The duration of flight was not a factor associated with the headache attacks, Dr. Mainardi said.

A video interview with Dr. Mainardi can be viewed with the QR code, or by visiting www.clinicalneurologynews.com

Major Finding: Of 63 patients who shared common characteristics for a new form of headache attributed to airplane travel, 60 reported having at least one attack occur during the landing phase.

Data Source: A questionnaire-based study of 63 people with headache attributed to airplane travel.

Disclosures: Dr. Mainardi said that he had no relevant financial disclosures.

BERLIN – Reports from airline passengers who experience sudden onset, severe, and short-duration headaches – primarily during landing – contain enough common and unique features to support a new, distinct form of headache, according to a study.

“There are some peculiar, common characteristics,” Dr. Federico Mainardi said at the congress, which was sponsored by the International Headache Society and the American Headache Society. A total of 63 people who responded to a questionnaire cited the common factors of strict unilateral presentation, absence of companion symptoms, and spontaneous resolution once they were on the ground and at the airport.

Sinus conditions sometimes cause severe headaches in migraine patients, Dr. Mainardi said, but only two participants reported concurrent sinusitis. This and other physiologic explanations were ruled out for the remainder, including a subset who underwent MRI and sinus CT scanning, said Dr. Mainardi, a neurologist at the Headache Centre at S.S. Giovanni e Paolo Hospital, Venice, Italy.

Because 60 of the 63 participants had at least one attack occur during the landing phase, Dr. Mainardi suggested that patients with a history of these attacks should take nonsteroidal anti-inflammatory drug prophylaxis either before takeoff on a short flight or during a longer flight. Some respondents reported that this strategy prevented attacks.

Most of the participants (46) did not experience a “headache attributed to airplane travel” during their first experience flying. Many people had repeat attacks, including 15 patients who reported attacks on more than half their flights and 9 who had an attack each time they flew.

Dr. Mainardi described his first case and, together with seven other cases published in the literature, he and his colleagues devised specific criteria for these headaches: repeated attacks, occurrence during airplane travel, duration up to 20 minutes, and frontoperiorbital location (J. Headache Pain 2007;8:196-9).

Dr. Mainardi said that after the publication of the criteria he and his associates received e-mails from people worldwide experiencing the same kind of headache. Of these 69 contacts, 63 returned a completed questionnaire in which they described and rated their experience. Their mean age was 37 years, and 41 (65%) of the respondents were men. Using International Classification of Headache Disorders (ICHD-II) criteria on the questionnaire, 35 (56%) had a concomitant primary headache, including 15 who reported tension type headaches, 11 who reported migraine with aura, and 3 who met criteria for probable tension type headache. Six reported more than one primary headache type. No participant suffered from cluster headache.

All patients rated their attacks as “severe” or “very severe.” These headaches negatively influenced the decision to fly in the future for 44 respondents (70%).

All patients denied consuming alcohol prior to the attacks and none gained relief from measures such as chewing, swallowing, or performing a Valsalva maneuver. The duration of flight was not a factor associated with the headache attacks, Dr. Mainardi said.

A video interview with Dr. Mainardi can be viewed with the QR code, or by visiting www.clinicalneurologynews.com

Major Finding: Of 63 patients who shared common characteristics for a new form of headache attributed to airplane travel, 60 reported having at least one attack occur during the landing phase.

Data Source: A questionnaire-based study of 63 people with headache attributed to airplane travel.

Disclosures: Dr. Mainardi said that he had no relevant financial disclosures.

BERLIN – Reports from airline passengers who experience sudden onset, severe, and short-duration headaches – primarily during landing – contain enough common and unique features to support a new, distinct form of headache, according to a study.

“There are some peculiar, common characteristics,” Dr. Federico Mainardi said at the congress, which was sponsored by the International Headache Society and the American Headache Society. A total of 63 people who responded to a questionnaire cited the common factors of strict unilateral presentation, absence of companion symptoms, and spontaneous resolution once they were on the ground and at the airport.

Sinus conditions sometimes cause severe headaches in migraine patients, Dr. Mainardi said, but only two participants reported concurrent sinusitis. This and other physiologic explanations were ruled out for the remainder, including a subset who underwent MRI and sinus CT scanning, said Dr. Mainardi, a neurologist at the Headache Centre at S.S. Giovanni e Paolo Hospital, Venice, Italy.

Because 60 of the 63 participants had at least one attack occur during the landing phase, Dr. Mainardi suggested that patients with a history of these attacks should take nonsteroidal anti-inflammatory drug prophylaxis either before takeoff on a short flight or during a longer flight. Some respondents reported that this strategy prevented attacks.

Most of the participants (46) did not experience a “headache attributed to airplane travel” during their first experience flying. Many people had repeat attacks, including 15 patients who reported attacks on more than half their flights and 9 who had an attack each time they flew.

Dr. Mainardi described his first case and, together with seven other cases published in the literature, he and his colleagues devised specific criteria for these headaches: repeated attacks, occurrence during airplane travel, duration up to 20 minutes, and frontoperiorbital location (J. Headache Pain 2007;8:196-9).

Dr. Mainardi said that after the publication of the criteria he and his associates received e-mails from people worldwide experiencing the same kind of headache. Of these 69 contacts, 63 returned a completed questionnaire in which they described and rated their experience. Their mean age was 37 years, and 41 (65%) of the respondents were men. Using International Classification of Headache Disorders (ICHD-II) criteria on the questionnaire, 35 (56%) had a concomitant primary headache, including 15 who reported tension type headaches, 11 who reported migraine with aura, and 3 who met criteria for probable tension type headache. Six reported more than one primary headache type. No participant suffered from cluster headache.

All patients rated their attacks as “severe” or “very severe.” These headaches negatively influenced the decision to fly in the future for 44 respondents (70%).

All patients denied consuming alcohol prior to the attacks and none gained relief from measures such as chewing, swallowing, or performing a Valsalva maneuver. The duration of flight was not a factor associated with the headache attacks, Dr. Mainardi said.

A video interview with Dr. Mainardi can be viewed with the QR code, or by visiting www.clinicalneurologynews.com

Major Finding: Asking patients if they take attack treatments for headache more than 10 days per month and if this practice is regular identifies medication overuse headache with 95% sensitivity and 80% specificity.

Data Source: Validation study of 77 headache patients treated at a headache treatment center.

Disclosures: Dr. Dousset said that she had no relevant financial disclosures.

BERLIN – “Do you take an attack treatment more than 10 days per month?” “Is this intake on a regular basis?”

With these two questions, clinicians at a headache treatment center in France quickly screened and identified patients with medication overuse headache, according to a validation study of the screening questions.

The traditional approach to diagnosis of medication overuse headache involving the revised International Classification of Headache Disorders (ICHD-II) criteria requires a face-to-face interview that takes considerable clinician time and expertise, Dr. Virginie Dousset said at the congress, which was sponsored by the International Headache Society and the American Headache Society.

Dr. Dousset and her colleagues transformed the second edition ICHD-II criteria into four simplified questions for a patient self-administered screening tool. To determine its sensitivity and specificity, they recruited 79 consecutive patients between September 2009 and February 2010. All participants presented for their first evaluation at the Bordeaux Headache Centre at the University of Bordeaux, where Dr. Dousset is director.

After 2 participants withdrew, 42 patients with medication overuse headache and 35 migraine sufferers without medication overuse were assessed further. Investigators compared their responses to the questions with diagnoses made by headache specialists using the formal ICHD-II criteria.

The initial screen featured four questions. But when the two questions regarding attack treatment frequency and regular use of medications were combined, they had the best sensitivity (95%) and specificity (80%) for identification of medication overuse headache.

The question, “Do you have headache on 15 days or more per month?” had 81% sensitivity and 85% specificity. A fourth question that asked about headache duration exceeding 3 months had 98% sensitivity but a specificity of only 18%. Therefore, this item was dropped for insufficient discrimination between medication overuse and other types of headache, Dr. Dousset said.

Participants included both men and women aged 18 years or older with a normal clinical examination. They had no primary headache type other than migraine. Mean age was significantly higher in the medication overuse headache cohort at 47 years, compared with a mean of 37 years in the migraine cohort. Both groups consisted mostly of women: 81% with medication overuse headache and 63% with migraine.

The self-questionnaire and neurologic diagnosis were performed independently on the same day. A nurse unaware of the neurologic diagnosis supervised patients but offered no help on the questionnaire. The neurologist was blinded to the results of the patient questionnaire.

“We have to ask the question about applicability [of the screening questionnaire] outside headache centers,” Dr. Dousset said. Although that is the focus of future research, she said she believes asking these two questions will prove an effective screening method for patients seen in a primary care setting as well.

A video interview with Dr. Dousset can be viewed by using the QR code, or by visiting www.clinicalneurologynews.com

Major Finding: Asking patients if they take attack treatments for headache more than 10 days per month and if this practice is regular identifies medication overuse headache with 95% sensitivity and 80% specificity.

Data Source: Validation study of 77 headache patients treated at a headache treatment center.

Disclosures: Dr. Dousset said that she had no relevant financial disclosures.

BERLIN – “Do you take an attack treatment more than 10 days per month?” “Is this intake on a regular basis?”

With these two questions, clinicians at a headache treatment center in France quickly screened and identified patients with medication overuse headache, according to a validation study of the screening questions.

The traditional approach to diagnosis of medication overuse headache involving the revised International Classification of Headache Disorders (ICHD-II) criteria requires a face-to-face interview that takes considerable clinician time and expertise, Dr. Virginie Dousset said at the congress, which was sponsored by the International Headache Society and the American Headache Society.

Dr. Dousset and her colleagues transformed the second edition ICHD-II criteria into four simplified questions for a patient self-administered screening tool. To determine its sensitivity and specificity, they recruited 79 consecutive patients between September 2009 and February 2010. All participants presented for their first evaluation at the Bordeaux Headache Centre at the University of Bordeaux, where Dr. Dousset is director.

After 2 participants withdrew, 42 patients with medication overuse headache and 35 migraine sufferers without medication overuse were assessed further. Investigators compared their responses to the questions with diagnoses made by headache specialists using the formal ICHD-II criteria.

The initial screen featured four questions. But when the two questions regarding attack treatment frequency and regular use of medications were combined, they had the best sensitivity (95%) and specificity (80%) for identification of medication overuse headache.

The question, “Do you have headache on 15 days or more per month?” had 81% sensitivity and 85% specificity. A fourth question that asked about headache duration exceeding 3 months had 98% sensitivity but a specificity of only 18%. Therefore, this item was dropped for insufficient discrimination between medication overuse and other types of headache, Dr. Dousset said.

Participants included both men and women aged 18 years or older with a normal clinical examination. They had no primary headache type other than migraine. Mean age was significantly higher in the medication overuse headache cohort at 47 years, compared with a mean of 37 years in the migraine cohort. Both groups consisted mostly of women: 81% with medication overuse headache and 63% with migraine.

The self-questionnaire and neurologic diagnosis were performed independently on the same day. A nurse unaware of the neurologic diagnosis supervised patients but offered no help on the questionnaire. The neurologist was blinded to the results of the patient questionnaire.

“We have to ask the question about applicability [of the screening questionnaire] outside headache centers,” Dr. Dousset said. Although that is the focus of future research, she said she believes asking these two questions will prove an effective screening method for patients seen in a primary care setting as well.

A video interview with Dr. Dousset can be viewed by using the QR code, or by visiting www.clinicalneurologynews.com

Major Finding: Asking patients if they take attack treatments for headache more than 10 days per month and if this practice is regular identifies medication overuse headache with 95% sensitivity and 80% specificity.

Data Source: Validation study of 77 headache patients treated at a headache treatment center.

Disclosures: Dr. Dousset said that she had no relevant financial disclosures.

BERLIN – “Do you take an attack treatment more than 10 days per month?” “Is this intake on a regular basis?”

With these two questions, clinicians at a headache treatment center in France quickly screened and identified patients with medication overuse headache, according to a validation study of the screening questions.

The traditional approach to diagnosis of medication overuse headache involving the revised International Classification of Headache Disorders (ICHD-II) criteria requires a face-to-face interview that takes considerable clinician time and expertise, Dr. Virginie Dousset said at the congress, which was sponsored by the International Headache Society and the American Headache Society.

Dr. Dousset and her colleagues transformed the second edition ICHD-II criteria into four simplified questions for a patient self-administered screening tool. To determine its sensitivity and specificity, they recruited 79 consecutive patients between September 2009 and February 2010. All participants presented for their first evaluation at the Bordeaux Headache Centre at the University of Bordeaux, where Dr. Dousset is director.

After 2 participants withdrew, 42 patients with medication overuse headache and 35 migraine sufferers without medication overuse were assessed further. Investigators compared their responses to the questions with diagnoses made by headache specialists using the formal ICHD-II criteria.

The initial screen featured four questions. But when the two questions regarding attack treatment frequency and regular use of medications were combined, they had the best sensitivity (95%) and specificity (80%) for identification of medication overuse headache.

The question, “Do you have headache on 15 days or more per month?” had 81% sensitivity and 85% specificity. A fourth question that asked about headache duration exceeding 3 months had 98% sensitivity but a specificity of only 18%. Therefore, this item was dropped for insufficient discrimination between medication overuse and other types of headache, Dr. Dousset said.

Participants included both men and women aged 18 years or older with a normal clinical examination. They had no primary headache type other than migraine. Mean age was significantly higher in the medication overuse headache cohort at 47 years, compared with a mean of 37 years in the migraine cohort. Both groups consisted mostly of women: 81% with medication overuse headache and 63% with migraine.

The self-questionnaire and neurologic diagnosis were performed independently on the same day. A nurse unaware of the neurologic diagnosis supervised patients but offered no help on the questionnaire. The neurologist was blinded to the results of the patient questionnaire.

“We have to ask the question about applicability [of the screening questionnaire] outside headache centers,” Dr. Dousset said. Although that is the focus of future research, she said she believes asking these two questions will prove an effective screening method for patients seen in a primary care setting as well.

A video interview with Dr. Dousset can be viewed by using the QR code, or by visiting www.clinicalneurologynews.com