Doug Brunk

Congenital Zika syndrome should be added to the differential diagnosis of congenital infections and arthrogryposis (joint contractures), results from a case series study in Brazil suggest.

“Brain impairment in the presence of microcephaly is the main characteristic of a congenital Zika virus syndrome,” researchers led by Vanessa van der Linden, MD, wrote in a study published online Aug. 9 in the BMJ. “However, little is still known about this condition and its clinical spectrum, which also concerns newborns with a normal head circumference. Two studies have described the association between arthrogryposis and microcephaly in newborns presumed to have congenital Zika virus infection [See Morb Mortal Wkly. Rep. 2016;65:59-62 and Ultrasound Obstet Gynecol. 2016;47:6-7].” The authors went on to note that while arthrogryposis might be considered more of a sign than a specific disease, “it might be associated with several disorders. However, there are no reports in the literature about other congenital infections in humans associated with arthrogryposis.”

©Devonyu/Thinkstock

Dr. van der Linden, a pediatric neurologist with the Association for Assistance of Disabled Children, Recife, Brazil, and her associates retrospectively evaluated the medical records of seven patients with arthrogryposis associated with congenital infection believed to be caused by Zika virus, during the Brazilian microcephaly epidemic (BMJ. 2016;354:i3899). The main outcomes of interest were clinical, radiologic, and electromyographic findings, and likely collaboration between clinical and primary neurological abnormalities.

The researchers reported that brain images of all seven children revealed characteristics of congenital infection and arthrogryposis. Two children (29%) tested positive for IgM antibody for Zika virus in the cerebrospinal fluid, while arthrogryposis was present in the arms and legs of six children (86%) and in the legs of one child (14%). In addition, hip x-rays showed bilateral dislocation in all seven children and subluxation of the knee associated with genu valgus in three (43%). No evidence of abnormalities was seen on high-definition ultrasonography of the joints, but moderate signs of remodeling of the motor units and a reduced recruitment pattern were found on needle electromyography. Results from brain computed tomography conducted in all seven patients and magnetic resonance imaging conducted in five revealed malformations of cortical development, calcifications predominantly in the cortex and subcortical white matter, reduction in brain volume, ventriculomegaly, and hypoplasia of the brainstem and cerebellum. Spinal MRI conducted in four children showed apparent thinning of the cord and reduced ventral roots.

“Further research is needed with a larger number of cases to study the neurological abnormalities behind arthrogryposis, including histopathology of autopsy samples or tissues from stillborn babies,” the researchers concluded. “As we do not know the potential implications of congenital Zika virus infection as it evolves, children must receive orthopedic follow-up, even those with a standard first orthopedic evaluation, because they could develop musculoskeletal deformities secondary to neurological impairment, central or peripheral, or both, as these occur in patients with cerebral palsy and other chronic encephalopathies.”

The researchers reported having no financial disclosures.

[email protected]

Congenital Zika syndrome should be added to the differential diagnosis of congenital infections and arthrogryposis (joint contractures), results from a case series study in Brazil suggest.

“Brain impairment in the presence of microcephaly is the main characteristic of a congenital Zika virus syndrome,” researchers led by Vanessa van der Linden, MD, wrote in a study published online Aug. 9 in the BMJ. “However, little is still known about this condition and its clinical spectrum, which also concerns newborns with a normal head circumference. Two studies have described the association between arthrogryposis and microcephaly in newborns presumed to have congenital Zika virus infection [See Morb Mortal Wkly. Rep. 2016;65:59-62 and Ultrasound Obstet Gynecol. 2016;47:6-7].” The authors went on to note that while arthrogryposis might be considered more of a sign than a specific disease, “it might be associated with several disorders. However, there are no reports in the literature about other congenital infections in humans associated with arthrogryposis.”

©Devonyu/Thinkstock

Dr. van der Linden, a pediatric neurologist with the Association for Assistance of Disabled Children, Recife, Brazil, and her associates retrospectively evaluated the medical records of seven patients with arthrogryposis associated with congenital infection believed to be caused by Zika virus, during the Brazilian microcephaly epidemic (BMJ. 2016;354:i3899). The main outcomes of interest were clinical, radiologic, and electromyographic findings, and likely collaboration between clinical and primary neurological abnormalities.

The researchers reported that brain images of all seven children revealed characteristics of congenital infection and arthrogryposis. Two children (29%) tested positive for IgM antibody for Zika virus in the cerebrospinal fluid, while arthrogryposis was present in the arms and legs of six children (86%) and in the legs of one child (14%). In addition, hip x-rays showed bilateral dislocation in all seven children and subluxation of the knee associated with genu valgus in three (43%). No evidence of abnormalities was seen on high-definition ultrasonography of the joints, but moderate signs of remodeling of the motor units and a reduced recruitment pattern were found on needle electromyography. Results from brain computed tomography conducted in all seven patients and magnetic resonance imaging conducted in five revealed malformations of cortical development, calcifications predominantly in the cortex and subcortical white matter, reduction in brain volume, ventriculomegaly, and hypoplasia of the brainstem and cerebellum. Spinal MRI conducted in four children showed apparent thinning of the cord and reduced ventral roots.

“Further research is needed with a larger number of cases to study the neurological abnormalities behind arthrogryposis, including histopathology of autopsy samples or tissues from stillborn babies,” the researchers concluded. “As we do not know the potential implications of congenital Zika virus infection as it evolves, children must receive orthopedic follow-up, even those with a standard first orthopedic evaluation, because they could develop musculoskeletal deformities secondary to neurological impairment, central or peripheral, or both, as these occur in patients with cerebral palsy and other chronic encephalopathies.”

The researchers reported having no financial disclosures.

[email protected]

Congenital Zika syndrome should be added to the differential diagnosis of congenital infections and arthrogryposis (joint contractures), results from a case series study in Brazil suggest.

“Brain impairment in the presence of microcephaly is the main characteristic of a congenital Zika virus syndrome,” researchers led by Vanessa van der Linden, MD, wrote in a study published online Aug. 9 in the BMJ. “However, little is still known about this condition and its clinical spectrum, which also concerns newborns with a normal head circumference. Two studies have described the association between arthrogryposis and microcephaly in newborns presumed to have congenital Zika virus infection [See Morb Mortal Wkly. Rep. 2016;65:59-62 and Ultrasound Obstet Gynecol. 2016;47:6-7].” The authors went on to note that while arthrogryposis might be considered more of a sign than a specific disease, “it might be associated with several disorders. However, there are no reports in the literature about other congenital infections in humans associated with arthrogryposis.”

©Devonyu/Thinkstock

Dr. van der Linden, a pediatric neurologist with the Association for Assistance of Disabled Children, Recife, Brazil, and her associates retrospectively evaluated the medical records of seven patients with arthrogryposis associated with congenital infection believed to be caused by Zika virus, during the Brazilian microcephaly epidemic (BMJ. 2016;354:i3899). The main outcomes of interest were clinical, radiologic, and electromyographic findings, and likely collaboration between clinical and primary neurological abnormalities.

The researchers reported that brain images of all seven children revealed characteristics of congenital infection and arthrogryposis. Two children (29%) tested positive for IgM antibody for Zika virus in the cerebrospinal fluid, while arthrogryposis was present in the arms and legs of six children (86%) and in the legs of one child (14%). In addition, hip x-rays showed bilateral dislocation in all seven children and subluxation of the knee associated with genu valgus in three (43%). No evidence of abnormalities was seen on high-definition ultrasonography of the joints, but moderate signs of remodeling of the motor units and a reduced recruitment pattern were found on needle electromyography. Results from brain computed tomography conducted in all seven patients and magnetic resonance imaging conducted in five revealed malformations of cortical development, calcifications predominantly in the cortex and subcortical white matter, reduction in brain volume, ventriculomegaly, and hypoplasia of the brainstem and cerebellum. Spinal MRI conducted in four children showed apparent thinning of the cord and reduced ventral roots.

“Further research is needed with a larger number of cases to study the neurological abnormalities behind arthrogryposis, including histopathology of autopsy samples or tissues from stillborn babies,” the researchers concluded. “As we do not know the potential implications of congenital Zika virus infection as it evolves, children must receive orthopedic follow-up, even those with a standard first orthopedic evaluation, because they could develop musculoskeletal deformities secondary to neurological impairment, central or peripheral, or both, as these occur in patients with cerebral palsy and other chronic encephalopathies.”

The researchers reported having no financial disclosures.

[email protected]

SAN DIEGO – Hospital safety culture may positively influence certain surgical patient outcomes, results from a study of 56 Illinois hospitals demonstrated.

“Efforts to improve awareness of safety and quality improvement principles should be encouraged at both the surgical system and hospital levels,” David D. Odell, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference. “Safety culture itself is a concept [that] is increasingly viewed as important in the delivery of high-quality care. Yet in the surgical world, very little is known about how hospital culture actually influences outcomes for our patients.”

Dr. Odell, a thoracic surgeon at Northwestern Memorial Hospital, Chicago, discussed results from a study by the Illinois Surgical Quality Improvement Collaborative, a group of Illinois hospitals working together to improve the quality of surgical care in the state. Participants in the Collaborative include 56 hospitals, including all academic medical centers in the state, as well as 11 rural hospitals. Combined, these facilities perform 60% of general surgery operations in the state and 80% of all complex operations, impacting more than 600,000 patients each year.

In an effort to evaluate the relationship between hospital safety culture and surgical patient outcomes, Dr. Odell and his associates invited staff of Collaborative members to complete the Safety Attitudes Questionnaire (SAQ), a 56-item validated tool for assessment of hospital culture. Domains focused on were teamwork, communication, engagement, and leadership. The SAQ was given to administrators, staff, and front-line providers “to measure safety culture across all levels of the hospital,” Dr. Odell said. Percent positive responses were calculated at the hospital level for each of the eight domains to calculate a composite measure of safety. The researchers measured the impact of safety culture by assessing positive SAQ response rates. Outcome variables of interest were morbidity, mortality, death or serious morbidity, and readmission. Hospital-level risk-adjusted event rates and linear regression models were used to assess the impact of safety culture while controlling for teaching status, rural location, trauma center designation, hospital control (management), and the annual surgical volume.

Of the 49 participating hospitals represented in the survey responses, 49% had an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency program, 12% were rural, 61% provided trauma care, 35% had a religious affiliation, 57% were “other” not-for-profit, and the mean total surgical volume was 11,412 cases.

Dr. Odell reported that by domain, SAQ responses were most positive for operating room safety and lowest for hospital management. “That doesn’t necessarily reflect the management’s outcomes only, but the views of those who took the survey toward management,” he said.

When the researchers evaluated the impact of a more-positive safety culture on the risk-adjusted outcome measures, they observed a statistically significant impact on morbidity following surgery (P = .02). The trend was similar although not statistically significant for death/serious morbidity (P = .08), mortality (P =. 20), or readmission (P = .68).

Dr. Odell acknowledged certain limitations of the study, including its retrospective design and the fact that the SAQ is a subjective assessment tool. “Not all [staff invited] were surveyed,” he added. “We sent out just under 1,400 surveys and we had a response rate of 44%.”

Staff from participating institutions of the Collaborative meet on a semiannual basis to share ideas, celebrate successes and learn from each other’s experiences, Dr. Odell said. Ongoing efforts to improve safety culture include fostering opportunities for mentorship in quality improvement and process improvement endeavors, as well as the provision of educational materials targeted at all levels of hospital staff “so that we can get everyone thinking and speaking the same language when it comes to quality improvement,” he said.

The Collaborative is funded by Blue Cross Blue Shield of Illinois. Dr. Odell reported having no financial disclosures.

[email protected]

SAN DIEGO – Hospital safety culture may positively influence certain surgical patient outcomes, results from a study of 56 Illinois hospitals demonstrated.

“Efforts to improve awareness of safety and quality improvement principles should be encouraged at both the surgical system and hospital levels,” David D. Odell, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference. “Safety culture itself is a concept [that] is increasingly viewed as important in the delivery of high-quality care. Yet in the surgical world, very little is known about how hospital culture actually influences outcomes for our patients.”

Dr. Odell, a thoracic surgeon at Northwestern Memorial Hospital, Chicago, discussed results from a study by the Illinois Surgical Quality Improvement Collaborative, a group of Illinois hospitals working together to improve the quality of surgical care in the state. Participants in the Collaborative include 56 hospitals, including all academic medical centers in the state, as well as 11 rural hospitals. Combined, these facilities perform 60% of general surgery operations in the state and 80% of all complex operations, impacting more than 600,000 patients each year.

In an effort to evaluate the relationship between hospital safety culture and surgical patient outcomes, Dr. Odell and his associates invited staff of Collaborative members to complete the Safety Attitudes Questionnaire (SAQ), a 56-item validated tool for assessment of hospital culture. Domains focused on were teamwork, communication, engagement, and leadership. The SAQ was given to administrators, staff, and front-line providers “to measure safety culture across all levels of the hospital,” Dr. Odell said. Percent positive responses were calculated at the hospital level for each of the eight domains to calculate a composite measure of safety. The researchers measured the impact of safety culture by assessing positive SAQ response rates. Outcome variables of interest were morbidity, mortality, death or serious morbidity, and readmission. Hospital-level risk-adjusted event rates and linear regression models were used to assess the impact of safety culture while controlling for teaching status, rural location, trauma center designation, hospital control (management), and the annual surgical volume.

Of the 49 participating hospitals represented in the survey responses, 49% had an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency program, 12% were rural, 61% provided trauma care, 35% had a religious affiliation, 57% were “other” not-for-profit, and the mean total surgical volume was 11,412 cases.

Dr. Odell reported that by domain, SAQ responses were most positive for operating room safety and lowest for hospital management. “That doesn’t necessarily reflect the management’s outcomes only, but the views of those who took the survey toward management,” he said.

When the researchers evaluated the impact of a more-positive safety culture on the risk-adjusted outcome measures, they observed a statistically significant impact on morbidity following surgery (P = .02). The trend was similar although not statistically significant for death/serious morbidity (P = .08), mortality (P =. 20), or readmission (P = .68).

Dr. Odell acknowledged certain limitations of the study, including its retrospective design and the fact that the SAQ is a subjective assessment tool. “Not all [staff invited] were surveyed,” he added. “We sent out just under 1,400 surveys and we had a response rate of 44%.”

Staff from participating institutions of the Collaborative meet on a semiannual basis to share ideas, celebrate successes and learn from each other’s experiences, Dr. Odell said. Ongoing efforts to improve safety culture include fostering opportunities for mentorship in quality improvement and process improvement endeavors, as well as the provision of educational materials targeted at all levels of hospital staff “so that we can get everyone thinking and speaking the same language when it comes to quality improvement,” he said.

The Collaborative is funded by Blue Cross Blue Shield of Illinois. Dr. Odell reported having no financial disclosures.

[email protected]

SAN DIEGO – Hospital safety culture may positively influence certain surgical patient outcomes, results from a study of 56 Illinois hospitals demonstrated.

“Efforts to improve awareness of safety and quality improvement principles should be encouraged at both the surgical system and hospital levels,” David D. Odell, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference. “Safety culture itself is a concept [that] is increasingly viewed as important in the delivery of high-quality care. Yet in the surgical world, very little is known about how hospital culture actually influences outcomes for our patients.”

Dr. Odell, a thoracic surgeon at Northwestern Memorial Hospital, Chicago, discussed results from a study by the Illinois Surgical Quality Improvement Collaborative, a group of Illinois hospitals working together to improve the quality of surgical care in the state. Participants in the Collaborative include 56 hospitals, including all academic medical centers in the state, as well as 11 rural hospitals. Combined, these facilities perform 60% of general surgery operations in the state and 80% of all complex operations, impacting more than 600,000 patients each year.

In an effort to evaluate the relationship between hospital safety culture and surgical patient outcomes, Dr. Odell and his associates invited staff of Collaborative members to complete the Safety Attitudes Questionnaire (SAQ), a 56-item validated tool for assessment of hospital culture. Domains focused on were teamwork, communication, engagement, and leadership. The SAQ was given to administrators, staff, and front-line providers “to measure safety culture across all levels of the hospital,” Dr. Odell said. Percent positive responses were calculated at the hospital level for each of the eight domains to calculate a composite measure of safety. The researchers measured the impact of safety culture by assessing positive SAQ response rates. Outcome variables of interest were morbidity, mortality, death or serious morbidity, and readmission. Hospital-level risk-adjusted event rates and linear regression models were used to assess the impact of safety culture while controlling for teaching status, rural location, trauma center designation, hospital control (management), and the annual surgical volume.

Of the 49 participating hospitals represented in the survey responses, 49% had an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency program, 12% were rural, 61% provided trauma care, 35% had a religious affiliation, 57% were “other” not-for-profit, and the mean total surgical volume was 11,412 cases.

Dr. Odell reported that by domain, SAQ responses were most positive for operating room safety and lowest for hospital management. “That doesn’t necessarily reflect the management’s outcomes only, but the views of those who took the survey toward management,” he said.

When the researchers evaluated the impact of a more-positive safety culture on the risk-adjusted outcome measures, they observed a statistically significant impact on morbidity following surgery (P = .02). The trend was similar although not statistically significant for death/serious morbidity (P = .08), mortality (P =. 20), or readmission (P = .68).

Dr. Odell acknowledged certain limitations of the study, including its retrospective design and the fact that the SAQ is a subjective assessment tool. “Not all [staff invited] were surveyed,” he added. “We sent out just under 1,400 surveys and we had a response rate of 44%.”

Staff from participating institutions of the Collaborative meet on a semiannual basis to share ideas, celebrate successes and learn from each other’s experiences, Dr. Odell said. Ongoing efforts to improve safety culture include fostering opportunities for mentorship in quality improvement and process improvement endeavors, as well as the provision of educational materials targeted at all levels of hospital staff “so that we can get everyone thinking and speaking the same language when it comes to quality improvement,” he said.

The Collaborative is funded by Blue Cross Blue Shield of Illinois. Dr. Odell reported having no financial disclosures.

[email protected]

SAN DIEGO – A project to assess geriatric-specific variables for inclusion in the American College of Surgeons/National Surgical Quality Improvement Program National Conference is underway, according to Thomas N. Robinson, MD.

Dr. Robinson discussed results from the ACS-NSQIP Geriatric Surgery Pilot Collaborative, an effort launched in January 2014 with the ultimate goal of evaluating specific geriatric variables for incorporation into the ACS NSQIP set of essential variables collected by all participating hospitals.

Dr. Robinson, professor of surgery at the University of Colorado, Denver, said that 23 clinical sites in the United States are currently studying the following geriatric-specific variables in surgery patients aged 65 and older:

• Origin from home with support (to determine baseline functional status: lives alone at home, lives with support in home, origin status not from home).

• Discharge functional health status (ability to perform activities of daily living).

• Discharge with/without services (to capture care needs upon discharge).

• Preoperative use of a mobility aid.

• Preoperative history of prior falls.

• Postoperative history of pressure ulcer.

• Fall risk on discharge.

• New mobility aid on discharge.

• History of dementia.

• Competency status on admission.

• Postoperative delirium (yes or no).

• Hospice care on admission (yes or no).

• Do Not Resuscitate (DNR) order in place on admission (yes or no).

• DNR order during hospitalization (yes or no).

• Setting where DNR order was placed.

• Postoperative palliative care consult (yes or no).

• 30-day postoperative outcomes: functional health status (ability to perform activities of daily living), physical function compared with baseline, and living location.

The number of surgery cases in the collaborative grew from 7,235 in the first 6 months of 2014 to 24,835 cases in the last 6 months of 2015. The top 10 operations were total joint arthroplasty (29%), colectomy (12%), spine (8%), hip fracture (7%), carotid endarterectomy (4%), hysterectomy (4%), lung resection (2%), open lower extremity bypass (2%), laparoscopic cholecystectomy (2%), and pancreatectomy (2%).

Dr. Robinson reported that the rate of preoperative dementia among cases studied in the collaborative was 10%. “The incorporation of dementia into a surgical dataset represents an important step forward in providing quality surgical care for the elderly,” he said. “Dementia is a global public health concern.” He went on to note that patients with dementia have a 2.5-fold increased risk of developing postoperative delirium, making it “the perfect place to start a quality project. One in three cases of delirium is preventable. In our data set, delirium is associated with a hospital stay that’s 4 days longer, an increased chance of requiring discharge to an institutional care facility, an increased chance of a serious complication, and a higher 30-day mortality.”

Simple, low-tech bedside interventions such as ambulating in the hall three times a day, orienting the person, having the person sleep at night rather than sleep during the day, and avoiding medications with high risk for adverse events in older adults can prevent postoperative delirium, Dr. Robinson said.

One way that the Geriatric Surgery Pilot Collaborative can improve the surgical care of older adults is by fostering quality programs initiated at the participating local hospitals. “Preserving function after hospital stays is a first major goal,” he said. Another strategy involves creating a multidisciplinary frailty assessment to aid with decision making and risk assessment. “This takes into consideration NSQIP variables such as function, nutrition, comorbidity burden, cognition, social vulnerability, and mobility,” he said. The final and ultimate goal of the geriatric surgery collaborative is to establish a foundation of quality measurement for the Coalition for Quality in Geriatric Surgery, a project initiated by the American College of Surgeons to systematically improve the surgical care of older adults.

Dr. Robinson reported having no relevant financial disclosures.

[email protected]

SAN DIEGO – A project to assess geriatric-specific variables for inclusion in the American College of Surgeons/National Surgical Quality Improvement Program National Conference is underway, according to Thomas N. Robinson, MD.

Dr. Robinson discussed results from the ACS-NSQIP Geriatric Surgery Pilot Collaborative, an effort launched in January 2014 with the ultimate goal of evaluating specific geriatric variables for incorporation into the ACS NSQIP set of essential variables collected by all participating hospitals.

Dr. Robinson, professor of surgery at the University of Colorado, Denver, said that 23 clinical sites in the United States are currently studying the following geriatric-specific variables in surgery patients aged 65 and older:

• Origin from home with support (to determine baseline functional status: lives alone at home, lives with support in home, origin status not from home).

• Discharge functional health status (ability to perform activities of daily living).

• Discharge with/without services (to capture care needs upon discharge).

• Preoperative use of a mobility aid.

• Preoperative history of prior falls.

• Postoperative history of pressure ulcer.

• Fall risk on discharge.

• New mobility aid on discharge.

• History of dementia.

• Competency status on admission.

• Postoperative delirium (yes or no).

• Hospice care on admission (yes or no).

• Do Not Resuscitate (DNR) order in place on admission (yes or no).

• DNR order during hospitalization (yes or no).

• Setting where DNR order was placed.

• Postoperative palliative care consult (yes or no).

• 30-day postoperative outcomes: functional health status (ability to perform activities of daily living), physical function compared with baseline, and living location.

The number of surgery cases in the collaborative grew from 7,235 in the first 6 months of 2014 to 24,835 cases in the last 6 months of 2015. The top 10 operations were total joint arthroplasty (29%), colectomy (12%), spine (8%), hip fracture (7%), carotid endarterectomy (4%), hysterectomy (4%), lung resection (2%), open lower extremity bypass (2%), laparoscopic cholecystectomy (2%), and pancreatectomy (2%).

Dr. Robinson reported that the rate of preoperative dementia among cases studied in the collaborative was 10%. “The incorporation of dementia into a surgical dataset represents an important step forward in providing quality surgical care for the elderly,” he said. “Dementia is a global public health concern.” He went on to note that patients with dementia have a 2.5-fold increased risk of developing postoperative delirium, making it “the perfect place to start a quality project. One in three cases of delirium is preventable. In our data set, delirium is associated with a hospital stay that’s 4 days longer, an increased chance of requiring discharge to an institutional care facility, an increased chance of a serious complication, and a higher 30-day mortality.”

Simple, low-tech bedside interventions such as ambulating in the hall three times a day, orienting the person, having the person sleep at night rather than sleep during the day, and avoiding medications with high risk for adverse events in older adults can prevent postoperative delirium, Dr. Robinson said.

One way that the Geriatric Surgery Pilot Collaborative can improve the surgical care of older adults is by fostering quality programs initiated at the participating local hospitals. “Preserving function after hospital stays is a first major goal,” he said. Another strategy involves creating a multidisciplinary frailty assessment to aid with decision making and risk assessment. “This takes into consideration NSQIP variables such as function, nutrition, comorbidity burden, cognition, social vulnerability, and mobility,” he said. The final and ultimate goal of the geriatric surgery collaborative is to establish a foundation of quality measurement for the Coalition for Quality in Geriatric Surgery, a project initiated by the American College of Surgeons to systematically improve the surgical care of older adults.

Dr. Robinson reported having no relevant financial disclosures.

[email protected]

SAN DIEGO – A project to assess geriatric-specific variables for inclusion in the American College of Surgeons/National Surgical Quality Improvement Program National Conference is underway, according to Thomas N. Robinson, MD.

Dr. Robinson discussed results from the ACS-NSQIP Geriatric Surgery Pilot Collaborative, an effort launched in January 2014 with the ultimate goal of evaluating specific geriatric variables for incorporation into the ACS NSQIP set of essential variables collected by all participating hospitals.

Dr. Robinson, professor of surgery at the University of Colorado, Denver, said that 23 clinical sites in the United States are currently studying the following geriatric-specific variables in surgery patients aged 65 and older:

• Origin from home with support (to determine baseline functional status: lives alone at home, lives with support in home, origin status not from home).

• Discharge functional health status (ability to perform activities of daily living).

• Discharge with/without services (to capture care needs upon discharge).

• Preoperative use of a mobility aid.

• Preoperative history of prior falls.

• Postoperative history of pressure ulcer.

• Fall risk on discharge.

• New mobility aid on discharge.

• History of dementia.

• Competency status on admission.

• Postoperative delirium (yes or no).

• Hospice care on admission (yes or no).

• Do Not Resuscitate (DNR) order in place on admission (yes or no).

• DNR order during hospitalization (yes or no).

• Setting where DNR order was placed.

• Postoperative palliative care consult (yes or no).

• 30-day postoperative outcomes: functional health status (ability to perform activities of daily living), physical function compared with baseline, and living location.

The number of surgery cases in the collaborative grew from 7,235 in the first 6 months of 2014 to 24,835 cases in the last 6 months of 2015. The top 10 operations were total joint arthroplasty (29%), colectomy (12%), spine (8%), hip fracture (7%), carotid endarterectomy (4%), hysterectomy (4%), lung resection (2%), open lower extremity bypass (2%), laparoscopic cholecystectomy (2%), and pancreatectomy (2%).

Dr. Robinson reported that the rate of preoperative dementia among cases studied in the collaborative was 10%. “The incorporation of dementia into a surgical dataset represents an important step forward in providing quality surgical care for the elderly,” he said. “Dementia is a global public health concern.” He went on to note that patients with dementia have a 2.5-fold increased risk of developing postoperative delirium, making it “the perfect place to start a quality project. One in three cases of delirium is preventable. In our data set, delirium is associated with a hospital stay that’s 4 days longer, an increased chance of requiring discharge to an institutional care facility, an increased chance of a serious complication, and a higher 30-day mortality.”

Simple, low-tech bedside interventions such as ambulating in the hall three times a day, orienting the person, having the person sleep at night rather than sleep during the day, and avoiding medications with high risk for adverse events in older adults can prevent postoperative delirium, Dr. Robinson said.

One way that the Geriatric Surgery Pilot Collaborative can improve the surgical care of older adults is by fostering quality programs initiated at the participating local hospitals. “Preserving function after hospital stays is a first major goal,” he said. Another strategy involves creating a multidisciplinary frailty assessment to aid with decision making and risk assessment. “This takes into consideration NSQIP variables such as function, nutrition, comorbidity burden, cognition, social vulnerability, and mobility,” he said. The final and ultimate goal of the geriatric surgery collaborative is to establish a foundation of quality measurement for the Coalition for Quality in Geriatric Surgery, a project initiated by the American College of Surgeons to systematically improve the surgical care of older adults.

Dr. Robinson reported having no relevant financial disclosures.

[email protected]

SAN DIEGO – Readmission rates and the underlying reasons for them vary between medical specialties following surgery in children, a study of national data suggests.

“Hospital readmission is a very hot topic, particularly in light of the Affordable Care Act,” Afif N. Kulaylat, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference. “Beyond economic costs there are very tangible costs to patients that we must consider. Readmissions have been associated with significant morbidity for patients. They often herald or implicate a postoperative complication. There are also indirect costs to patients and families such as time off from school or work.”

Dr. Kulaylat, of the division of pediatric surgery at Penn State Children’s Hospital, Hershey, Penn., presented findings from a retrospective analysis of NSQIP Pediatric (NSQIP-P), an ongoing collaboration between the ACS and the American Pediatric Surgical Association to improve the care of young patients. The researchers evaluated NSQIP-P data from 2013 and 2014 and focused on unplanned readmission within 30 days, including reasons for readmission based on NSQIP-P readmission categories and ICD-9 readmission codes as categorized by the AHRQ Clinical Classification Software. Multivariate logistic regression was used to evaluate factors associated with unplanned readmission.

Dr. Kulaylat reported results from a cohort of 129,849 patients cared for by 64 NSQIP-P participating hospitals. Among these, the all-cause readmission rate was 4.7%. After excluding patients with planned readmissions, the unplanned readmission rate was found to be 3.9%. From this cohort, 28% required reoperation within 30 days, and the median time from discharge to unplanned readmission was 8 days, with an interquartile range between 3 and 14 days.

Among the procedures captured in NSQIP-P, neurosurgery accounted for the highest readmission rate (10.8%), followed by general/thoracic surgery (5.2%), urology (2.6%), ENT (2%), orthopedic (1.9%), and plastic and reconstructive surgery (1.3%). The most common reason for readmission was surgical site infection at 23%, followed by GI complications such as ileus, obstruction, and constipation (17%); pulmonary-related complications (9%); device-related complications including shunt malfunction (8%); neurologic (7%); pain (6%); other medical diseases (6%); sepsis (5%); electrolytes/dehydration (5%); and urinary tract infection (UTI, 3%). It is estimated that at least two-thirds of unplanned readmissions (63%) were directly related to surgery. “These reasons for readmission and their frequency closely parallel what is seen in adults, with the exception of bleeding complications, which were rare in children compared to adults,” Dr. Kulaylat said.

The top five CPT codes associated with readmissions were laparoscopic appendectomy, laparoscopic gastrostomy tube placement, and three additional codes related to placement and replacement/revision of ventricular shunts/catheters.

Reasons for readmission varied among specialties. For example, among general and thoracic surgery, surgical-site infections (SSI) and GI-related issues dominated, while in neurosurgery SSI and device issues dominated. In urology, UTIs were the most frequent, while ENT had a greater proportion of pulmonary complications. Certain patient variables were also associated with an increased risk of hospital readmission, including comorbidities related to GI, CNS, renal, and immunosuppression and nutrition (P less than .001 for all). The strongest association was the occurrence of a postoperative complication, namely a post-discharge complication.

“The granularity of NSQIP-P can continue to be refined to help predict who is likely to get readmitted or if specific follow-up strategies might identify those headed to readmission,” remarked Robert E. Cilley, MD, a senior author and surgeon-in-chief at Penn State Children’s Hospital. Dr. Kulaylat acknowledged certain limitations of the study, including its retrospective design, the potential for data entry/data interpretation error, and that the researchers were unable to adjust for clustering at the hospital level. Directions of future research include a plan to study readmissions and predictive factors at the procedural level, establish risk-adjusted specialty/procedural-specific benchmarks for readmission rates, and refine the accuracy and reliability of the readmission data. “With these NSQIP-P data there is substantial opportunity for quality improvement as we strive to improve the care of children everywhere,” Dr. Kulaylat said. He reported having no relevant disclosures.

[email protected]

SAN DIEGO – Readmission rates and the underlying reasons for them vary between medical specialties following surgery in children, a study of national data suggests.

“Hospital readmission is a very hot topic, particularly in light of the Affordable Care Act,” Afif N. Kulaylat, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference. “Beyond economic costs there are very tangible costs to patients that we must consider. Readmissions have been associated with significant morbidity for patients. They often herald or implicate a postoperative complication. There are also indirect costs to patients and families such as time off from school or work.”

Dr. Kulaylat, of the division of pediatric surgery at Penn State Children’s Hospital, Hershey, Penn., presented findings from a retrospective analysis of NSQIP Pediatric (NSQIP-P), an ongoing collaboration between the ACS and the American Pediatric Surgical Association to improve the care of young patients. The researchers evaluated NSQIP-P data from 2013 and 2014 and focused on unplanned readmission within 30 days, including reasons for readmission based on NSQIP-P readmission categories and ICD-9 readmission codes as categorized by the AHRQ Clinical Classification Software. Multivariate logistic regression was used to evaluate factors associated with unplanned readmission.

Dr. Kulaylat reported results from a cohort of 129,849 patients cared for by 64 NSQIP-P participating hospitals. Among these, the all-cause readmission rate was 4.7%. After excluding patients with planned readmissions, the unplanned readmission rate was found to be 3.9%. From this cohort, 28% required reoperation within 30 days, and the median time from discharge to unplanned readmission was 8 days, with an interquartile range between 3 and 14 days.

Among the procedures captured in NSQIP-P, neurosurgery accounted for the highest readmission rate (10.8%), followed by general/thoracic surgery (5.2%), urology (2.6%), ENT (2%), orthopedic (1.9%), and plastic and reconstructive surgery (1.3%). The most common reason for readmission was surgical site infection at 23%, followed by GI complications such as ileus, obstruction, and constipation (17%); pulmonary-related complications (9%); device-related complications including shunt malfunction (8%); neurologic (7%); pain (6%); other medical diseases (6%); sepsis (5%); electrolytes/dehydration (5%); and urinary tract infection (UTI, 3%). It is estimated that at least two-thirds of unplanned readmissions (63%) were directly related to surgery. “These reasons for readmission and their frequency closely parallel what is seen in adults, with the exception of bleeding complications, which were rare in children compared to adults,” Dr. Kulaylat said.

The top five CPT codes associated with readmissions were laparoscopic appendectomy, laparoscopic gastrostomy tube placement, and three additional codes related to placement and replacement/revision of ventricular shunts/catheters.

Reasons for readmission varied among specialties. For example, among general and thoracic surgery, surgical-site infections (SSI) and GI-related issues dominated, while in neurosurgery SSI and device issues dominated. In urology, UTIs were the most frequent, while ENT had a greater proportion of pulmonary complications. Certain patient variables were also associated with an increased risk of hospital readmission, including comorbidities related to GI, CNS, renal, and immunosuppression and nutrition (P less than .001 for all). The strongest association was the occurrence of a postoperative complication, namely a post-discharge complication.

“The granularity of NSQIP-P can continue to be refined to help predict who is likely to get readmitted or if specific follow-up strategies might identify those headed to readmission,” remarked Robert E. Cilley, MD, a senior author and surgeon-in-chief at Penn State Children’s Hospital. Dr. Kulaylat acknowledged certain limitations of the study, including its retrospective design, the potential for data entry/data interpretation error, and that the researchers were unable to adjust for clustering at the hospital level. Directions of future research include a plan to study readmissions and predictive factors at the procedural level, establish risk-adjusted specialty/procedural-specific benchmarks for readmission rates, and refine the accuracy and reliability of the readmission data. “With these NSQIP-P data there is substantial opportunity for quality improvement as we strive to improve the care of children everywhere,” Dr. Kulaylat said. He reported having no relevant disclosures.

[email protected]

SAN DIEGO – Readmission rates and the underlying reasons for them vary between medical specialties following surgery in children, a study of national data suggests.

“Hospital readmission is a very hot topic, particularly in light of the Affordable Care Act,” Afif N. Kulaylat, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference. “Beyond economic costs there are very tangible costs to patients that we must consider. Readmissions have been associated with significant morbidity for patients. They often herald or implicate a postoperative complication. There are also indirect costs to patients and families such as time off from school or work.”

Dr. Kulaylat, of the division of pediatric surgery at Penn State Children’s Hospital, Hershey, Penn., presented findings from a retrospective analysis of NSQIP Pediatric (NSQIP-P), an ongoing collaboration between the ACS and the American Pediatric Surgical Association to improve the care of young patients. The researchers evaluated NSQIP-P data from 2013 and 2014 and focused on unplanned readmission within 30 days, including reasons for readmission based on NSQIP-P readmission categories and ICD-9 readmission codes as categorized by the AHRQ Clinical Classification Software. Multivariate logistic regression was used to evaluate factors associated with unplanned readmission.

Dr. Kulaylat reported results from a cohort of 129,849 patients cared for by 64 NSQIP-P participating hospitals. Among these, the all-cause readmission rate was 4.7%. After excluding patients with planned readmissions, the unplanned readmission rate was found to be 3.9%. From this cohort, 28% required reoperation within 30 days, and the median time from discharge to unplanned readmission was 8 days, with an interquartile range between 3 and 14 days.

Among the procedures captured in NSQIP-P, neurosurgery accounted for the highest readmission rate (10.8%), followed by general/thoracic surgery (5.2%), urology (2.6%), ENT (2%), orthopedic (1.9%), and plastic and reconstructive surgery (1.3%). The most common reason for readmission was surgical site infection at 23%, followed by GI complications such as ileus, obstruction, and constipation (17%); pulmonary-related complications (9%); device-related complications including shunt malfunction (8%); neurologic (7%); pain (6%); other medical diseases (6%); sepsis (5%); electrolytes/dehydration (5%); and urinary tract infection (UTI, 3%). It is estimated that at least two-thirds of unplanned readmissions (63%) were directly related to surgery. “These reasons for readmission and their frequency closely parallel what is seen in adults, with the exception of bleeding complications, which were rare in children compared to adults,” Dr. Kulaylat said.

The top five CPT codes associated with readmissions were laparoscopic appendectomy, laparoscopic gastrostomy tube placement, and three additional codes related to placement and replacement/revision of ventricular shunts/catheters.

Reasons for readmission varied among specialties. For example, among general and thoracic surgery, surgical-site infections (SSI) and GI-related issues dominated, while in neurosurgery SSI and device issues dominated. In urology, UTIs were the most frequent, while ENT had a greater proportion of pulmonary complications. Certain patient variables were also associated with an increased risk of hospital readmission, including comorbidities related to GI, CNS, renal, and immunosuppression and nutrition (P less than .001 for all). The strongest association was the occurrence of a postoperative complication, namely a post-discharge complication.

“The granularity of NSQIP-P can continue to be refined to help predict who is likely to get readmitted or if specific follow-up strategies might identify those headed to readmission,” remarked Robert E. Cilley, MD, a senior author and surgeon-in-chief at Penn State Children’s Hospital. Dr. Kulaylat acknowledged certain limitations of the study, including its retrospective design, the potential for data entry/data interpretation error, and that the researchers were unable to adjust for clustering at the hospital level. Directions of future research include a plan to study readmissions and predictive factors at the procedural level, establish risk-adjusted specialty/procedural-specific benchmarks for readmission rates, and refine the accuracy and reliability of the readmission data. “With these NSQIP-P data there is substantial opportunity for quality improvement as we strive to improve the care of children everywhere,” Dr. Kulaylat said. He reported having no relevant disclosures.

[email protected]

Nonpharmacological factors including being female and having cardiovascular disease have an impact on early response among patients hospitalized with cellulitis, a single-center prospective study found.

“Cellulitis is usually caused by beta-hemolytic streptococci (BHS) susceptible to penicillin and other narrow-spectrum antibiotics,” researchers led by Trond Bruun, MD, of the department of clinical science at the University of Bergen, Norway, wrote in a study published online on July 11, 2016, in Clinical Infectious Diseases.

“However, there are significant treatment challenges, including overuse of broad-spectrum and intravenous antibiotics, difficulties regarding when to initiate rescue therapy and when to stop treatment, as well as frequent recurrences. Toxin effects and profound local inflammation, not necessarily corresponding to bacterial burden or antibiotic needs, may contribute to these problems.”

In an effort to better understand the clinical course, response dynamics, and associated factors involved with cellulitis care, the researchers evaluated 216 patients hospitalized with the condition at Haukeland University Hospital, Norway. They analyzed clinical and biochemical response data during the first 3 days of treatment in relation to baseline factors, antibiotic use, surgery, and outcome (Clin Infect Dis. 2016 Jul 11. pii: ciw463. [Epub ahead of print]).

The median age of the patients was 55 years and 57% had a lower extremity infection. After 1 day of treatment, the researchers found that 55% of evaluable patients (116 of 211) had cessation of lesion spread and 52% (109 of 211) had improvement of local inflammation. Local clinical response – defined as a combination of cessation of lesion spread and improvement of local inflammation – was observed in 39% of patients (82 of 212), while local clinical response or biochemical response was seen in 74% of cases (148 of 200).

Nonpharmacological factors found to predict nonresponse on treatment day 3 were cardiovascular disease (odds ratio, 2.83), female gender (OR, 2.09), and a higher body mass index (OR, 1.03). A shorter duration of symptoms and cellulitis other than typical erysipelas were also predictive of nonresponse on treatment day 3. On the other hand, baseline factors were not predictive of clinical failure assessed post treatment.

Among patients who received antibiotic treatment escalation within 2 days of starting treatment, most (90%) had nonresponse on treatment day 1, but only 5% had inappropriate initial therapy. Nonresponse on treatment day 3 was a predictor of treatment duration exceeding 14 days, but not of clinical failure.

“Overall, the study indicates that nonantibiotic factors with impact on early treatment response should be considered as an integrated part of the clinical management of cellulitis,” the researchers concluded. “This may improve individualization of treatment and reduce costs and unnecessary rescue therapy.”

The study was supported by a research grant from the department of clinical science at the University of Bergen. The researchers reported having no financial disclosures.

[email protected]

Nonpharmacological factors including being female and having cardiovascular disease have an impact on early response among patients hospitalized with cellulitis, a single-center prospective study found.

“Cellulitis is usually caused by beta-hemolytic streptococci (BHS) susceptible to penicillin and other narrow-spectrum antibiotics,” researchers led by Trond Bruun, MD, of the department of clinical science at the University of Bergen, Norway, wrote in a study published online on July 11, 2016, in Clinical Infectious Diseases.

“However, there are significant treatment challenges, including overuse of broad-spectrum and intravenous antibiotics, difficulties regarding when to initiate rescue therapy and when to stop treatment, as well as frequent recurrences. Toxin effects and profound local inflammation, not necessarily corresponding to bacterial burden or antibiotic needs, may contribute to these problems.”

In an effort to better understand the clinical course, response dynamics, and associated factors involved with cellulitis care, the researchers evaluated 216 patients hospitalized with the condition at Haukeland University Hospital, Norway. They analyzed clinical and biochemical response data during the first 3 days of treatment in relation to baseline factors, antibiotic use, surgery, and outcome (Clin Infect Dis. 2016 Jul 11. pii: ciw463. [Epub ahead of print]).

The median age of the patients was 55 years and 57% had a lower extremity infection. After 1 day of treatment, the researchers found that 55% of evaluable patients (116 of 211) had cessation of lesion spread and 52% (109 of 211) had improvement of local inflammation. Local clinical response – defined as a combination of cessation of lesion spread and improvement of local inflammation – was observed in 39% of patients (82 of 212), while local clinical response or biochemical response was seen in 74% of cases (148 of 200).

Nonpharmacological factors found to predict nonresponse on treatment day 3 were cardiovascular disease (odds ratio, 2.83), female gender (OR, 2.09), and a higher body mass index (OR, 1.03). A shorter duration of symptoms and cellulitis other than typical erysipelas were also predictive of nonresponse on treatment day 3. On the other hand, baseline factors were not predictive of clinical failure assessed post treatment.

Among patients who received antibiotic treatment escalation within 2 days of starting treatment, most (90%) had nonresponse on treatment day 1, but only 5% had inappropriate initial therapy. Nonresponse on treatment day 3 was a predictor of treatment duration exceeding 14 days, but not of clinical failure.

“Overall, the study indicates that nonantibiotic factors with impact on early treatment response should be considered as an integrated part of the clinical management of cellulitis,” the researchers concluded. “This may improve individualization of treatment and reduce costs and unnecessary rescue therapy.”

The study was supported by a research grant from the department of clinical science at the University of Bergen. The researchers reported having no financial disclosures.

[email protected]

Nonpharmacological factors including being female and having cardiovascular disease have an impact on early response among patients hospitalized with cellulitis, a single-center prospective study found.

“Cellulitis is usually caused by beta-hemolytic streptococci (BHS) susceptible to penicillin and other narrow-spectrum antibiotics,” researchers led by Trond Bruun, MD, of the department of clinical science at the University of Bergen, Norway, wrote in a study published online on July 11, 2016, in Clinical Infectious Diseases.

“However, there are significant treatment challenges, including overuse of broad-spectrum and intravenous antibiotics, difficulties regarding when to initiate rescue therapy and when to stop treatment, as well as frequent recurrences. Toxin effects and profound local inflammation, not necessarily corresponding to bacterial burden or antibiotic needs, may contribute to these problems.”

In an effort to better understand the clinical course, response dynamics, and associated factors involved with cellulitis care, the researchers evaluated 216 patients hospitalized with the condition at Haukeland University Hospital, Norway. They analyzed clinical and biochemical response data during the first 3 days of treatment in relation to baseline factors, antibiotic use, surgery, and outcome (Clin Infect Dis. 2016 Jul 11. pii: ciw463. [Epub ahead of print]).

The median age of the patients was 55 years and 57% had a lower extremity infection. After 1 day of treatment, the researchers found that 55% of evaluable patients (116 of 211) had cessation of lesion spread and 52% (109 of 211) had improvement of local inflammation. Local clinical response – defined as a combination of cessation of lesion spread and improvement of local inflammation – was observed in 39% of patients (82 of 212), while local clinical response or biochemical response was seen in 74% of cases (148 of 200).

Nonpharmacological factors found to predict nonresponse on treatment day 3 were cardiovascular disease (odds ratio, 2.83), female gender (OR, 2.09), and a higher body mass index (OR, 1.03). A shorter duration of symptoms and cellulitis other than typical erysipelas were also predictive of nonresponse on treatment day 3. On the other hand, baseline factors were not predictive of clinical failure assessed post treatment.

Among patients who received antibiotic treatment escalation within 2 days of starting treatment, most (90%) had nonresponse on treatment day 1, but only 5% had inappropriate initial therapy. Nonresponse on treatment day 3 was a predictor of treatment duration exceeding 14 days, but not of clinical failure.

“Overall, the study indicates that nonantibiotic factors with impact on early treatment response should be considered as an integrated part of the clinical management of cellulitis,” the researchers concluded. “This may improve individualization of treatment and reduce costs and unnecessary rescue therapy.”

The study was supported by a research grant from the department of clinical science at the University of Bergen. The researchers reported having no financial disclosures.

[email protected]

SAN DIEGO – Multihospital collaboration and implementation of enhanced recovery have the potential to improve outcomes, in particular, length of hospital stay, results from a pilot study showed.

“Given the importance of patient engagement, enhanced recovery has the potential to improve patient experience and provide high-value health care,” Julia R. Berian, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference.

Dr. Berian, the James C. Thompson Geriatric Surgery Research Fellow at the University of Chicago Medical Center, presented findings from the Enhanced Recovery in NSQIP (ERIN) Pilot, a collaborative effort by 16 ACS-NSQIP hospitals to improve length of stay in patients who undergo colectomy, a procedure that has been shown to have an adverse event rate of 28.9% and an average length of stay of 9.8 days for those who experience an adverse event (J Am Coll Surg. 2008; 207[5]:698-704).

Implementation of the ERIN Pilot showed reductions in length of hospital stay and morbidity among colectomy patients. The average length of stay decreased by 1.2 days (from a mean of 6.6 among preimplementation cases to 5.4 days among post implementation cases; P less than .0001). Morbidity also decreased from 14% to 11% (P = .01), but the rate of readmission was 11% for both pre- and postimplementation cases. In the adjusted model, the enhanced recovery protocol decreased the risk of prolonged length of stay by 40% (odds ratio, 0.6; 95% confidence interval, 0.5-0.8).

For the ERIN Pilot, she and her associates participated in monthly conference calls for collaborative experience and expert guidance from project leaders Julie Thacker, MD, and Liane Feldman, MD. Enhanced recovery protocols were tailored to each individual hospital. Data were collected before and after implementation using 14 novel ERIN variables, including preoperative elements such as defining expectations and minimizing starvation, intraoperative variables such as optimizing fluid management and minimizing surgical trauma, and postoperative elements such as aggressive adherence to best practices including feeding, early ambulation, and minimizing the use of tethers such as urinary catheters.

The researchers evaluated procedure-targeted colectomy cases performed between July 2013 and June 2015, and excluded emergency cases or those with preoperative sepsis. They used bivariate analysis and multivariate logistic regression with forward selection, and the outcome of interest, prolonged hospital length of stay, was specified by the standard ACS NSQIP definition: greater than the 75th percentile of uncomplicated cases.

Dr. Berian reported results from 2,523 colectomies performed prior to implementation of the ERIN Pilot process and 823 colectomies performed after implementation of the process. The researchers observed no differences between the preimplementation and postimplementation cases in terms of sex, preoperative functional status, hypertension, renal failure, ascites, diabetes, disseminated cancer, or use of steroids for inflammatory bowel disease. However, compared with preimplementation colectomies, a significantly higher proportion of postimplementation cases were white (77% vs. 68%, respectively), had heart failure (2.8% vs. 1.2%), had chronic obstructive pulmonary disease (7.8% vs. 5.3%), were American Society of Anesthesiologists (ASA) class 1 and 2 ( 50.2% vs. 44.7%), were smokers (21.6% vs. 16.7%), had unintentional weight loss (7.7% vs. 5.7%), had used mechanical bowel prep (77% vs. 53%), and used more oral antibiotics (68% vs. 33%).

On the other hand, compared with preimplementation cases, there were significantly fewer bleeding disorders in the postimplementation colectomies (3.9% vs. 6.4%), as well as fewer cases with preoperative systemic inflammatory response syndrome (2.9% vs. 5.4%) and open surgery approaches (31.7% vs. 42.3%).

Dr. Berian disclosed that her fellowship position is funded by the John A. Hartford Foundation.

[email protected]

SAN DIEGO – Multihospital collaboration and implementation of enhanced recovery have the potential to improve outcomes, in particular, length of hospital stay, results from a pilot study showed.

“Given the importance of patient engagement, enhanced recovery has the potential to improve patient experience and provide high-value health care,” Julia R. Berian, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference.

Dr. Berian, the James C. Thompson Geriatric Surgery Research Fellow at the University of Chicago Medical Center, presented findings from the Enhanced Recovery in NSQIP (ERIN) Pilot, a collaborative effort by 16 ACS-NSQIP hospitals to improve length of stay in patients who undergo colectomy, a procedure that has been shown to have an adverse event rate of 28.9% and an average length of stay of 9.8 days for those who experience an adverse event (J Am Coll Surg. 2008; 207[5]:698-704).

Implementation of the ERIN Pilot showed reductions in length of hospital stay and morbidity among colectomy patients. The average length of stay decreased by 1.2 days (from a mean of 6.6 among preimplementation cases to 5.4 days among post implementation cases; P less than .0001). Morbidity also decreased from 14% to 11% (P = .01), but the rate of readmission was 11% for both pre- and postimplementation cases. In the adjusted model, the enhanced recovery protocol decreased the risk of prolonged length of stay by 40% (odds ratio, 0.6; 95% confidence interval, 0.5-0.8).

For the ERIN Pilot, she and her associates participated in monthly conference calls for collaborative experience and expert guidance from project leaders Julie Thacker, MD, and Liane Feldman, MD. Enhanced recovery protocols were tailored to each individual hospital. Data were collected before and after implementation using 14 novel ERIN variables, including preoperative elements such as defining expectations and minimizing starvation, intraoperative variables such as optimizing fluid management and minimizing surgical trauma, and postoperative elements such as aggressive adherence to best practices including feeding, early ambulation, and minimizing the use of tethers such as urinary catheters.

The researchers evaluated procedure-targeted colectomy cases performed between July 2013 and June 2015, and excluded emergency cases or those with preoperative sepsis. They used bivariate analysis and multivariate logistic regression with forward selection, and the outcome of interest, prolonged hospital length of stay, was specified by the standard ACS NSQIP definition: greater than the 75th percentile of uncomplicated cases.

Dr. Berian reported results from 2,523 colectomies performed prior to implementation of the ERIN Pilot process and 823 colectomies performed after implementation of the process. The researchers observed no differences between the preimplementation and postimplementation cases in terms of sex, preoperative functional status, hypertension, renal failure, ascites, diabetes, disseminated cancer, or use of steroids for inflammatory bowel disease. However, compared with preimplementation colectomies, a significantly higher proportion of postimplementation cases were white (77% vs. 68%, respectively), had heart failure (2.8% vs. 1.2%), had chronic obstructive pulmonary disease (7.8% vs. 5.3%), were American Society of Anesthesiologists (ASA) class 1 and 2 ( 50.2% vs. 44.7%), were smokers (21.6% vs. 16.7%), had unintentional weight loss (7.7% vs. 5.7%), had used mechanical bowel prep (77% vs. 53%), and used more oral antibiotics (68% vs. 33%).

On the other hand, compared with preimplementation cases, there were significantly fewer bleeding disorders in the postimplementation colectomies (3.9% vs. 6.4%), as well as fewer cases with preoperative systemic inflammatory response syndrome (2.9% vs. 5.4%) and open surgery approaches (31.7% vs. 42.3%).

Dr. Berian disclosed that her fellowship position is funded by the John A. Hartford Foundation.

[email protected]

SAN DIEGO – Multihospital collaboration and implementation of enhanced recovery have the potential to improve outcomes, in particular, length of hospital stay, results from a pilot study showed.

“Given the importance of patient engagement, enhanced recovery has the potential to improve patient experience and provide high-value health care,” Julia R. Berian, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference.

Dr. Berian, the James C. Thompson Geriatric Surgery Research Fellow at the University of Chicago Medical Center, presented findings from the Enhanced Recovery in NSQIP (ERIN) Pilot, a collaborative effort by 16 ACS-NSQIP hospitals to improve length of stay in patients who undergo colectomy, a procedure that has been shown to have an adverse event rate of 28.9% and an average length of stay of 9.8 days for those who experience an adverse event (J Am Coll Surg. 2008; 207[5]:698-704).

Implementation of the ERIN Pilot showed reductions in length of hospital stay and morbidity among colectomy patients. The average length of stay decreased by 1.2 days (from a mean of 6.6 among preimplementation cases to 5.4 days among post implementation cases; P less than .0001). Morbidity also decreased from 14% to 11% (P = .01), but the rate of readmission was 11% for both pre- and postimplementation cases. In the adjusted model, the enhanced recovery protocol decreased the risk of prolonged length of stay by 40% (odds ratio, 0.6; 95% confidence interval, 0.5-0.8).

For the ERIN Pilot, she and her associates participated in monthly conference calls for collaborative experience and expert guidance from project leaders Julie Thacker, MD, and Liane Feldman, MD. Enhanced recovery protocols were tailored to each individual hospital. Data were collected before and after implementation using 14 novel ERIN variables, including preoperative elements such as defining expectations and minimizing starvation, intraoperative variables such as optimizing fluid management and minimizing surgical trauma, and postoperative elements such as aggressive adherence to best practices including feeding, early ambulation, and minimizing the use of tethers such as urinary catheters.

The researchers evaluated procedure-targeted colectomy cases performed between July 2013 and June 2015, and excluded emergency cases or those with preoperative sepsis. They used bivariate analysis and multivariate logistic regression with forward selection, and the outcome of interest, prolonged hospital length of stay, was specified by the standard ACS NSQIP definition: greater than the 75th percentile of uncomplicated cases.

Dr. Berian reported results from 2,523 colectomies performed prior to implementation of the ERIN Pilot process and 823 colectomies performed after implementation of the process. The researchers observed no differences between the preimplementation and postimplementation cases in terms of sex, preoperative functional status, hypertension, renal failure, ascites, diabetes, disseminated cancer, or use of steroids for inflammatory bowel disease. However, compared with preimplementation colectomies, a significantly higher proportion of postimplementation cases were white (77% vs. 68%, respectively), had heart failure (2.8% vs. 1.2%), had chronic obstructive pulmonary disease (7.8% vs. 5.3%), were American Society of Anesthesiologists (ASA) class 1 and 2 ( 50.2% vs. 44.7%), were smokers (21.6% vs. 16.7%), had unintentional weight loss (7.7% vs. 5.7%), had used mechanical bowel prep (77% vs. 53%), and used more oral antibiotics (68% vs. 33%).

On the other hand, compared with preimplementation cases, there were significantly fewer bleeding disorders in the postimplementation colectomies (3.9% vs. 6.4%), as well as fewer cases with preoperative systemic inflammatory response syndrome (2.9% vs. 5.4%) and open surgery approaches (31.7% vs. 42.3%).

Dr. Berian disclosed that her fellowship position is funded by the John A. Hartford Foundation.

[email protected]

The use of sterile or nonsterile gloves during outpatient dermatologic and dental procedures resulted in similar rates of postoperative surgical site infections (SSIs), results from a large systematic review and meta-analysis demonstrated.

“During the past few decades, the use of surgical gloves has become standard practice to prevent postoperative wound infections or surgical site infection,” researchers led by Dr. Jerry Brewer wrote in a study published online Aug. 3, 2016 in JAMA Dermatology. “However, whether the use of sterile vs. non-sterile gloves makes a difference in the development of postoperative SSIs in the setting of cutaneous and minor outpatient surgical procedures remains unclear.”

In an effort to examine that question, Dr. Brewer of the division of dermatologic surgery at Mayo Clinic, Rochester, Minn., and his associates conducted a systematic review and meta-analysis of randomized clinical trials and comparative studies with information on sterile vs. non-sterile gloves in outpatient surgical procedures (JAMA Dermatol. 2016 Aug. 3. doi: 10.1001/jamadermatol.2016.1965). Patients in the studies underwent outpatient cutaneous or mucosal surgical procedures, including Mohs micrographic surgery, repair of a laceration, standard excisions, and tooth extractions.

The final meta-analysis included 11,071 patients from 13 studies. Of these, 6,040 underwent procedures with sterile gloves and 5,031 underwent procedures with nonsterile gloves. The researchers reported that a total of 228 patients (2.1%) had a postoperative SSI, including 107 in the nonsterile glove group (2.1%), and 121 in the sterile glove group (2%). The overall relative risk for an SSI with nonsterile glove use was 1.06.

In an interview, Dr. Brewer estimated that sterile gloves cost anywhere from $0.27 to $1.29 per pair, compared with about 8 cents per pair for clean nonsterile gloves. “This cost difference may not seem like much, but if you think about all the surgeries that are done on a regular basis across the country, that’s a huge difference in cost,” he said.

The authors acknowledged certain limitations of the study, including the potential for selection bias, since many of the studies included in the meta-analysis were observational. They also noted that findings from some previous studies on the topic run counter to theirs (see Dermatol. Surg. 2010; 36[10]:1529-36 and J. Hosp. Infect. 2007;65[3]:258-63 ). “Although the broad use of nonsterile clean gloves may be justified, caution is advised in generalizing this justification to more advanced outpatient surgical procedures that may not pertain to the information summarized in this review and meta-analysis,” they concluded. “Future study could include whether duration of surgery and complexity of the repair influence postoperative SSI development in the setting of sterile vs. nonsterile gloves.”

The researchers reported having no financial disclosures.

[email protected]

The use of sterile or nonsterile gloves during outpatient dermatologic and dental procedures resulted in similar rates of postoperative surgical site infections (SSIs), results from a large systematic review and meta-analysis demonstrated.

“During the past few decades, the use of surgical gloves has become standard practice to prevent postoperative wound infections or surgical site infection,” researchers led by Dr. Jerry Brewer wrote in a study published online Aug. 3, 2016 in JAMA Dermatology. “However, whether the use of sterile vs. non-sterile gloves makes a difference in the development of postoperative SSIs in the setting of cutaneous and minor outpatient surgical procedures remains unclear.”

In an effort to examine that question, Dr. Brewer of the division of dermatologic surgery at Mayo Clinic, Rochester, Minn., and his associates conducted a systematic review and meta-analysis of randomized clinical trials and comparative studies with information on sterile vs. non-sterile gloves in outpatient surgical procedures (JAMA Dermatol. 2016 Aug. 3. doi: 10.1001/jamadermatol.2016.1965). Patients in the studies underwent outpatient cutaneous or mucosal surgical procedures, including Mohs micrographic surgery, repair of a laceration, standard excisions, and tooth extractions.

The final meta-analysis included 11,071 patients from 13 studies. Of these, 6,040 underwent procedures with sterile gloves and 5,031 underwent procedures with nonsterile gloves. The researchers reported that a total of 228 patients (2.1%) had a postoperative SSI, including 107 in the nonsterile glove group (2.1%), and 121 in the sterile glove group (2%). The overall relative risk for an SSI with nonsterile glove use was 1.06.

In an interview, Dr. Brewer estimated that sterile gloves cost anywhere from $0.27 to $1.29 per pair, compared with about 8 cents per pair for clean nonsterile gloves. “This cost difference may not seem like much, but if you think about all the surgeries that are done on a regular basis across the country, that’s a huge difference in cost,” he said.

The authors acknowledged certain limitations of the study, including the potential for selection bias, since many of the studies included in the meta-analysis were observational. They also noted that findings from some previous studies on the topic run counter to theirs (see Dermatol. Surg. 2010; 36[10]:1529-36 and J. Hosp. Infect. 2007;65[3]:258-63 ). “Although the broad use of nonsterile clean gloves may be justified, caution is advised in generalizing this justification to more advanced outpatient surgical procedures that may not pertain to the information summarized in this review and meta-analysis,” they concluded. “Future study could include whether duration of surgery and complexity of the repair influence postoperative SSI development in the setting of sterile vs. nonsterile gloves.”

The researchers reported having no financial disclosures.

[email protected]

The use of sterile or nonsterile gloves during outpatient dermatologic and dental procedures resulted in similar rates of postoperative surgical site infections (SSIs), results from a large systematic review and meta-analysis demonstrated.

“During the past few decades, the use of surgical gloves has become standard practice to prevent postoperative wound infections or surgical site infection,” researchers led by Dr. Jerry Brewer wrote in a study published online Aug. 3, 2016 in JAMA Dermatology. “However, whether the use of sterile vs. non-sterile gloves makes a difference in the development of postoperative SSIs in the setting of cutaneous and minor outpatient surgical procedures remains unclear.”

In an effort to examine that question, Dr. Brewer of the division of dermatologic surgery at Mayo Clinic, Rochester, Minn., and his associates conducted a systematic review and meta-analysis of randomized clinical trials and comparative studies with information on sterile vs. non-sterile gloves in outpatient surgical procedures (JAMA Dermatol. 2016 Aug. 3. doi: 10.1001/jamadermatol.2016.1965). Patients in the studies underwent outpatient cutaneous or mucosal surgical procedures, including Mohs micrographic surgery, repair of a laceration, standard excisions, and tooth extractions.

The final meta-analysis included 11,071 patients from 13 studies. Of these, 6,040 underwent procedures with sterile gloves and 5,031 underwent procedures with nonsterile gloves. The researchers reported that a total of 228 patients (2.1%) had a postoperative SSI, including 107 in the nonsterile glove group (2.1%), and 121 in the sterile glove group (2%). The overall relative risk for an SSI with nonsterile glove use was 1.06.

In an interview, Dr. Brewer estimated that sterile gloves cost anywhere from $0.27 to $1.29 per pair, compared with about 8 cents per pair for clean nonsterile gloves. “This cost difference may not seem like much, but if you think about all the surgeries that are done on a regular basis across the country, that’s a huge difference in cost,” he said.

The authors acknowledged certain limitations of the study, including the potential for selection bias, since many of the studies included in the meta-analysis were observational. They also noted that findings from some previous studies on the topic run counter to theirs (see Dermatol. Surg. 2010; 36[10]:1529-36 and J. Hosp. Infect. 2007;65[3]:258-63 ). “Although the broad use of nonsterile clean gloves may be justified, caution is advised in generalizing this justification to more advanced outpatient surgical procedures that may not pertain to the information summarized in this review and meta-analysis,” they concluded. “Future study could include whether duration of surgery and complexity of the repair influence postoperative SSI development in the setting of sterile vs. nonsterile gloves.”

The researchers reported having no financial disclosures.

[email protected]

SAN DIEGO – Implementation of a simple colon bundle decreased the rate of colonic and enteric resections faster, compared with improvements seen for other procedures, according to a study that involved 23 hospitals in Tennessee.

At the American College of Surgeons/National Surgical Quality Improvement Program National Conference, Brian J. Daley, MD, discussed findings from an analysis conducted by members of the Tennessee Surgical Quality Collaborative (TSQC), which he described as “a collection of surgeons who put aside their hospital and regional affiliations to work together to help each other and to help our fellow Tennesseans.” Established in 2008 with member hospitals, the TSQC has grown to 23 member hospitals, including 18 community hospitals and 5 academic medical centers. It provides data on nearly 600 surgeons across the state. “While this only represents about half of the surgical procedures in the state, there is sufficient statistical power to make comments about our surgical performance,” said Dr. Daley of the department of surgery at  the University of Tennessee Medical Center, Knoxville.

©Dmitrii Kotin/Thinkstock.com

To quantify TSQC’s impact on surgical outcomes, surgeons at the member hospitals evaluated the TSQC colon bundle, which was developed in 2012 and implemented in 2013. It bundles four processes of care: maintaining intraoperative oxygen delivery, maintaining a temperature of 36° C, making sure the patient’s blood glucose is normal, and choosing the appropriate antibiotics. “We kept it simple: easy, not expensive, and hopefully helpful,” Dr. Daley said.

With other procedures as a baseline, they used statistical analyses to determine if implementation of the bundle led to an incremental acceleration of reduced complications, compared with other improvements observed in other procedures. “To understand our outcomes, we needed to prove three points: that the trend improved [a negative trend in the resection rate], that this negative trend was more negative than trends for other comparator procedures, and that the trend for intercept was not equal to the comparator in any way,” Dr. Daley explained.

Following adoption of the bundle, he and his associates observed that the rate of decrease in postoperative recurrences was greater in colectomy, compared with that for all other surgical procedures (P less than .001 for both the trend and the intercept statistical models). Adoption of the bundle also positively impacted decreases in postoperative recurrences among enterectomy cases (P less than .001 for both the trend and the intercept statistical models).

“We were able to demonstrate that our TSQC bundle paid dividends in improving colectomy outcomes,” Dr. Daley concluded. “We have seen these efforts spill over into enterectomy. From this we can also infer that participation in the collaborative improves outcomes and is imperative to maintain the acceleration in surgical improvement.”

Dr. Daley reported that he and his coauthors had no relevant financial disclosures.

[email protected]

SAN DIEGO – Implementation of a simple colon bundle decreased the rate of colonic and enteric resections faster, compared with improvements seen for other procedures, according to a study that involved 23 hospitals in Tennessee.

At the American College of Surgeons/National Surgical Quality Improvement Program National Conference, Brian J. Daley, MD, discussed findings from an analysis conducted by members of the Tennessee Surgical Quality Collaborative (TSQC), which he described as “a collection of surgeons who put aside their hospital and regional affiliations to work together to help each other and to help our fellow Tennesseans.” Established in 2008 with member hospitals, the TSQC has grown to 23 member hospitals, including 18 community hospitals and 5 academic medical centers. It provides data on nearly 600 surgeons across the state. “While this only represents about half of the surgical procedures in the state, there is sufficient statistical power to make comments about our surgical performance,” said Dr. Daley of the department of surgery at  the University of Tennessee Medical Center, Knoxville.

©Dmitrii Kotin/Thinkstock.com

To quantify TSQC’s impact on surgical outcomes, surgeons at the member hospitals evaluated the TSQC colon bundle, which was developed in 2012 and implemented in 2013. It bundles four processes of care: maintaining intraoperative oxygen delivery, maintaining a temperature of 36° C, making sure the patient’s blood glucose is normal, and choosing the appropriate antibiotics. “We kept it simple: easy, not expensive, and hopefully helpful,” Dr. Daley said.

With other procedures as a baseline, they used statistical analyses to determine if implementation of the bundle led to an incremental acceleration of reduced complications, compared with other improvements observed in other procedures. “To understand our outcomes, we needed to prove three points: that the trend improved [a negative trend in the resection rate], that this negative trend was more negative than trends for other comparator procedures, and that the trend for intercept was not equal to the comparator in any way,” Dr. Daley explained.

Following adoption of the bundle, he and his associates observed that the rate of decrease in postoperative recurrences was greater in colectomy, compared with that for all other surgical procedures (P less than .001 for both the trend and the intercept statistical models). Adoption of the bundle also positively impacted decreases in postoperative recurrences among enterectomy cases (P less than .001 for both the trend and the intercept statistical models).

“We were able to demonstrate that our TSQC bundle paid dividends in improving colectomy outcomes,” Dr. Daley concluded. “We have seen these efforts spill over into enterectomy. From this we can also infer that participation in the collaborative improves outcomes and is imperative to maintain the acceleration in surgical improvement.”

Dr. Daley reported that he and his coauthors had no relevant financial disclosures.

[email protected]

SAN DIEGO – Implementation of a simple colon bundle decreased the rate of colonic and enteric resections faster, compared with improvements seen for other procedures, according to a study that involved 23 hospitals in Tennessee.

At the American College of Surgeons/National Surgical Quality Improvement Program National Conference, Brian J. Daley, MD, discussed findings from an analysis conducted by members of the Tennessee Surgical Quality Collaborative (TSQC), which he described as “a collection of surgeons who put aside their hospital and regional affiliations to work together to help each other and to help our fellow Tennesseans.” Established in 2008 with member hospitals, the TSQC has grown to 23 member hospitals, including 18 community hospitals and 5 academic medical centers. It provides data on nearly 600 surgeons across the state. “While this only represents about half of the surgical procedures in the state, there is sufficient statistical power to make comments about our surgical performance,” said Dr. Daley of the department of surgery at  the University of Tennessee Medical Center, Knoxville.

©Dmitrii Kotin/Thinkstock.com

To quantify TSQC’s impact on surgical outcomes, surgeons at the member hospitals evaluated the TSQC colon bundle, which was developed in 2012 and implemented in 2013. It bundles four processes of care: maintaining intraoperative oxygen delivery, maintaining a temperature of 36° C, making sure the patient’s blood glucose is normal, and choosing the appropriate antibiotics. “We kept it simple: easy, not expensive, and hopefully helpful,” Dr. Daley said.

With other procedures as a baseline, they used statistical analyses to determine if implementation of the bundle led to an incremental acceleration of reduced complications, compared with other improvements observed in other procedures. “To understand our outcomes, we needed to prove three points: that the trend improved [a negative trend in the resection rate], that this negative trend was more negative than trends for other comparator procedures, and that the trend for intercept was not equal to the comparator in any way,” Dr. Daley explained.

Following adoption of the bundle, he and his associates observed that the rate of decrease in postoperative recurrences was greater in colectomy, compared with that for all other surgical procedures (P less than .001 for both the trend and the intercept statistical models). Adoption of the bundle also positively impacted decreases in postoperative recurrences among enterectomy cases (P less than .001 for both the trend and the intercept statistical models).

“We were able to demonstrate that our TSQC bundle paid dividends in improving colectomy outcomes,” Dr. Daley concluded. “We have seen these efforts spill over into enterectomy. From this we can also infer that participation in the collaborative improves outcomes and is imperative to maintain the acceleration in surgical improvement.”

Dr. Daley reported that he and his coauthors had no relevant financial disclosures.

[email protected]

The cost of new medicines for patients infected with hepatitis C virus vary widely around the globe, especially when adjusted for national wealth, results from an economic analysis led by World Health Organization officials suggest.

“These prices threaten the sustainability of health systems in many countries and prevent large-scale provision of treatment,” Suzanne Hill, PhD, of the World Health Organization, Geneva, and her associates wrote (PLoS Med. 2016 May 31;[5]:e1002032. doi:10.1371/journal.pmed.1002032).

“Stakeholders should implement a fairer pricing framework to deliver lower prices that take account of affordability. Without lower prices, countries are unlikely to be able to increase investment to minimize the burden of hepatitis C.”

In an effort to calculate the potential total cost of sofosbuvir and ledipasvir/sofosbuvir for different national health systems and individual patients in 30 countries, the researchers obtained 2015 prices for a 12-week course of treatment with the medications for as many countries as possible. Sources of reference were the Pharma Price Information service of the Austrian public health institute Gesundheit Österreich GmbH, national government and drug reimbursement authority website, and press releases.

Using data compiled between July 17, 2015, and Jan. 25, 2016, medication prices in Organisation for Economic Co-operation and Development (OECD) member countries and certain low- and middle-income countries were converted to U.S. dollars using period average exchange rates and were adjusted for purchasing power parity (PPP). “We analyzed prices compared to national economic performance and estimated market size and the cost of these drugs in terms of countries’ annual total pharmaceutical expenditure (TPE) and in terms of the duration of time an individual would need to work to pay for treatment out of pocket,” the researchers explained. “Patient affordability was calculated using 2014 OECD average annual wages, supplemented International Labour Organization median wages where necessary.”

Dr. Sullivan and her associates found that HCV medication prices varied significantly across countries, especially when adjusted for national wealth. For example, the median price of a 12-week course of sofosbuvir across 26 OECD countries was $42,017 in U.S. dollars, ranging from $37,729 in Japan to $64,680 in the United States. At the same time, countries in central and eastern Europe had higher PPP-adjusted prices, compared with other countries. For example, the PPP-adjusted prices of sofosbuvir in Poland and Turkey were $101,063 and $70,331, respectively, compared with a price of $64,680 in the Unite States. At the same time, the PPP-adjusted price of ledipasvir/sofosbuvir in Poland was $118,754, compared with a price of $72,765 in the United States.

The researchers also found that the PPP-adjusted price of a full course of sofosbuvir alone would be equivalent to at least 1 year of the PPP-adjusted average earnings for individuals in 12 of the 30 countries analyzed. In Poland, Slovakia, Portugal, and Turkey, a course of sofosbuvir alone would cost at least 2 years’ of average annual wages. “This analysis is conservative because prices were ex-factory prices with an assumed 23% price reduction, and did not include supply chain mark-ups and other costs such as the cost of diagnosis, daclatasvir, ribavirin, and health service costs,” they wrote.

They characterized the costs of sofosbuvir and ledipasvir/sofosbuvir as “not ‘affordable’ for most OECD countries at the nominal and PPP-adjusted prices, with Central and Eastern European countries being the most affected. While determining what is affordable or not is a value judgment, funding these treatments in these national health systems would consume large proportions of their TPE and increase pressure on existing budgets.”

They acknowledged certain limitations of the analysis, including the accuracy of the estimates of the numbers of people infected and of the price information that was accessible. “We have also not included all likely costs, such as the costs of combination treatment with ribavirin, other health care services, and increases in the duration of treatment in patients with cirrhosis; thus, our budget impact estimates are underestimates of the cost of treatment. We are also aware that in some countries, the prices are probably lower than the publicly accessible prices because of confidential discounts or rebates negotiated with the manufacturer.”

Dr. Hill disclosed that she is a member of the PLoS Medicine editorial board.

[email protected]

The cost of new medicines for patients infected with hepatitis C virus vary widely around the globe, especially when adjusted for national wealth, results from an economic analysis led by World Health Organization officials suggest.

“These prices threaten the sustainability of health systems in many countries and prevent large-scale provision of treatment,” Suzanne Hill, PhD, of the World Health Organization, Geneva, and her associates wrote (PLoS Med. 2016 May 31;[5]:e1002032. doi:10.1371/journal.pmed.1002032).

“Stakeholders should implement a fairer pricing framework to deliver lower prices that take account of affordability. Without lower prices, countries are unlikely to be able to increase investment to minimize the burden of hepatitis C.”

In an effort to calculate the potential total cost of sofosbuvir and ledipasvir/sofosbuvir for different national health systems and individual patients in 30 countries, the researchers obtained 2015 prices for a 12-week course of treatment with the medications for as many countries as possible. Sources of reference were the Pharma Price Information service of the Austrian public health institute Gesundheit Österreich GmbH, national government and drug reimbursement authority website, and press releases.

Using data compiled between July 17, 2015, and Jan. 25, 2016, medication prices in Organisation for Economic Co-operation and Development (OECD) member countries and certain low- and middle-income countries were converted to U.S. dollars using period average exchange rates and were adjusted for purchasing power parity (PPP). “We analyzed prices compared to national economic performance and estimated market size and the cost of these drugs in terms of countries’ annual total pharmaceutical expenditure (TPE) and in terms of the duration of time an individual would need to work to pay for treatment out of pocket,” the researchers explained. “Patient affordability was calculated using 2014 OECD average annual wages, supplemented International Labour Organization median wages where necessary.”

Dr. Sullivan and her associates found that HCV medication prices varied significantly across countries, especially when adjusted for national wealth. For example, the median price of a 12-week course of sofosbuvir across 26 OECD countries was $42,017 in U.S. dollars, ranging from $37,729 in Japan to $64,680 in the United States. At the same time, countries in central and eastern Europe had higher PPP-adjusted prices, compared with other countries. For example, the PPP-adjusted prices of sofosbuvir in Poland and Turkey were $101,063 and $70,331, respectively, compared with a price of $64,680 in the Unite States. At the same time, the PPP-adjusted price of ledipasvir/sofosbuvir in Poland was $118,754, compared with a price of $72,765 in the United States.

The researchers also found that the PPP-adjusted price of a full course of sofosbuvir alone would be equivalent to at least 1 year of the PPP-adjusted average earnings for individuals in 12 of the 30 countries analyzed. In Poland, Slovakia, Portugal, and Turkey, a course of sofosbuvir alone would cost at least 2 years’ of average annual wages. “This analysis is conservative because prices were ex-factory prices with an assumed 23% price reduction, and did not include supply chain mark-ups and other costs such as the cost of diagnosis, daclatasvir, ribavirin, and health service costs,” they wrote.

They characterized the costs of sofosbuvir and ledipasvir/sofosbuvir as “not ‘affordable’ for most OECD countries at the nominal and PPP-adjusted prices, with Central and Eastern European countries being the most affected. While determining what is affordable or not is a value judgment, funding these treatments in these national health systems would consume large proportions of their TPE and increase pressure on existing budgets.”

They acknowledged certain limitations of the analysis, including the accuracy of the estimates of the numbers of people infected and of the price information that was accessible. “We have also not included all likely costs, such as the costs of combination treatment with ribavirin, other health care services, and increases in the duration of treatment in patients with cirrhosis; thus, our budget impact estimates are underestimates of the cost of treatment. We are also aware that in some countries, the prices are probably lower than the publicly accessible prices because of confidential discounts or rebates negotiated with the manufacturer.”

Dr. Hill disclosed that she is a member of the PLoS Medicine editorial board.

[email protected]

The cost of new medicines for patients infected with hepatitis C virus vary widely around the globe, especially when adjusted for national wealth, results from an economic analysis led by World Health Organization officials suggest.

“These prices threaten the sustainability of health systems in many countries and prevent large-scale provision of treatment,” Suzanne Hill, PhD, of the World Health Organization, Geneva, and her associates wrote (PLoS Med. 2016 May 31;[5]:e1002032. doi:10.1371/journal.pmed.1002032).

“Stakeholders should implement a fairer pricing framework to deliver lower prices that take account of affordability. Without lower prices, countries are unlikely to be able to increase investment to minimize the burden of hepatitis C.”

In an effort to calculate the potential total cost of sofosbuvir and ledipasvir/sofosbuvir for different national health systems and individual patients in 30 countries, the researchers obtained 2015 prices for a 12-week course of treatment with the medications for as many countries as possible. Sources of reference were the Pharma Price Information service of the Austrian public health institute Gesundheit Österreich GmbH, national government and drug reimbursement authority website, and press releases.

Using data compiled between July 17, 2015, and Jan. 25, 2016, medication prices in Organisation for Economic Co-operation and Development (OECD) member countries and certain low- and middle-income countries were converted to U.S. dollars using period average exchange rates and were adjusted for purchasing power parity (PPP). “We analyzed prices compared to national economic performance and estimated market size and the cost of these drugs in terms of countries’ annual total pharmaceutical expenditure (TPE) and in terms of the duration of time an individual would need to work to pay for treatment out of pocket,” the researchers explained. “Patient affordability was calculated using 2014 OECD average annual wages, supplemented International Labour Organization median wages where necessary.”

Dr. Sullivan and her associates found that HCV medication prices varied significantly across countries, especially when adjusted for national wealth. For example, the median price of a 12-week course of sofosbuvir across 26 OECD countries was $42,017 in U.S. dollars, ranging from $37,729 in Japan to $64,680 in the United States. At the same time, countries in central and eastern Europe had higher PPP-adjusted prices, compared with other countries. For example, the PPP-adjusted prices of sofosbuvir in Poland and Turkey were $101,063 and $70,331, respectively, compared with a price of $64,680 in the Unite States. At the same time, the PPP-adjusted price of ledipasvir/sofosbuvir in Poland was $118,754, compared with a price of $72,765 in the United States.

The researchers also found that the PPP-adjusted price of a full course of sofosbuvir alone would be equivalent to at least 1 year of the PPP-adjusted average earnings for individuals in 12 of the 30 countries analyzed. In Poland, Slovakia, Portugal, and Turkey, a course of sofosbuvir alone would cost at least 2 years’ of average annual wages. “This analysis is conservative because prices were ex-factory prices with an assumed 23% price reduction, and did not include supply chain mark-ups and other costs such as the cost of diagnosis, daclatasvir, ribavirin, and health service costs,” they wrote.

They characterized the costs of sofosbuvir and ledipasvir/sofosbuvir as “not ‘affordable’ for most OECD countries at the nominal and PPP-adjusted prices, with Central and Eastern European countries being the most affected. While determining what is affordable or not is a value judgment, funding these treatments in these national health systems would consume large proportions of their TPE and increase pressure on existing budgets.”

They acknowledged certain limitations of the analysis, including the accuracy of the estimates of the numbers of people infected and of the price information that was accessible. “We have also not included all likely costs, such as the costs of combination treatment with ribavirin, other health care services, and increases in the duration of treatment in patients with cirrhosis; thus, our budget impact estimates are underestimates of the cost of treatment. We are also aware that in some countries, the prices are probably lower than the publicly accessible prices because of confidential discounts or rebates negotiated with the manufacturer.”

Dr. Hill disclosed that she is a member of the PLoS Medicine editorial board.

[email protected]

Until now, there was no blueprint for how to effectively transition pediatric patients with neurologic conditions to adult care: Hard science on the topic is almost nonexistent.

“There is not very much data, yet there is a lot of suggestion that if you do it badly things don’t turn out so well,” said Peter Camfield, MD, a child neurologist and professor emeritus at Dalhousie University in Halifax, Nova Scotia, who has written extensively on the topic (Ann Neurol. 2011;69[3]:437-44 and Epilepsy Curr. 2012;12[Suppl. 3]:13-21). He recalled hearing one story of an adolescent girl who came to see a child neurologist every 6 months, always with her parents. “She had some significant learning disabilities and she didn’t finish high school; she dropped out,” he said. “She was sent to an adult neurologist just with a transfer note and to a nephrologist just with a transfer note.”

The patient never visited the nephrologist. The adult neurologist saw her once, “but she said he was kind of rude and that he wouldn’t see her again,” Dr. Camfield said. “She lived with her boyfriend and eventually at about age 24 she was found dead in bed. She hadn’t taken her medications regularly. The presumption is she died from a seizure. If she had been more prepared for adult medical care, she could have engaged better with the adult neurologist, the kidney part of this thing wouldn’t have been let go, and she presumably would be still alive and making her way.”

In an effort to avoid such tragedies and to define the neurologist’s role in transitioning youth with neurologic conditions into adult care, an interdisciplinary team of child neurologists and other experts spent more than 2 years developing a consensus statement, published online July 27 in Neurology (doi: 10.1212/WNL.0000000000002965). Spearheaded by Lawrence W. Brown, MD, director of the pediatric neuropsychiatry program at The Children’s Hospital of Philadelphia, the consensus statement, “The neurologist’s role in supporting transition to adult health care” is endorsed by the Child Neurology Society, the American Academy of Neurology, and the American Academy of Pediatrics.

Despite broad-based efforts over more than a decade to improve transition of care, such as the Consensus Policy Statement on Health Care Transitions for Young Adults With Special Needs, the Clinical Report: Supporting Health Care Transition from Adolescence to Adulthood in the Medical Home, and the Got Transition Center for Health Care Transition Improvement (a federally funded program located at the National Alliance to Advance Adolescent Health), Dr. Brown expressed his belief that neurologists were unlikely to adopt these recommendations “because they were very hard to put in place, to concretize, and to make practical. We also recognized that child neurology was in many ways behind the eight ball compared to other specialties, at least compared to certain disease-oriented areas such as cystic fibrosis, sickle cell disease, congenital heart disease, and rheumatoid arthritis. These conditions already had attempts to show what the expectations were for the kids and for the doctors, and there were some practical solutions out there.” If transition to adult care is going to be successful, he continued, “it’s not just the neurologist acting in a vacuum, but the neurologist working with the youth and his caregivers as well as with his primary care physician and with other specialists.”

Dr. Brown characterized the new consensus statement as an outline of “common principles that all child neurologists should try to respect” based on a review of the best medical literature and best practices. The first of eight principles contained in the statement recommends that the child neurology team start talking early about the concept of transition to the adult health care system with the youth and caregivers, and document that discussion “no later than the youth’s 13th birthday.”

Mary L. Zupanc, MD, one of the experts who helped author the consensus document, underscored the importance of introducing the notion of transition before the youth turns 13 years of age. Otherwise, “you are playing catch-up all the time,” she said. “Families have to get used to the concept of transition because we have long-term relationships with these individuals and their families. They come to think of us as part of their family. When you first bring up the topic of transition they about have a heart attack, because they can’t imagine a life without including you in it.”

The document’s second common principle recommends that the neurology team assess the youth’s self-management skills annually beginning at age 12. According to the authors, self-management of a medical condition “includes a youth’s understanding of his or her condition and any related limitations, knowledge about and responsibility for his or her own care plan and the need to make informed decisions, and the importance of self-advocacy.”

The statement also recommends phased transition planning at least annually beginning when the youth is 13 years of age. Topics to be discussed at such planning sessions range from the youth’s medical condition and current medications to genetic counseling and issues of puberty and sexuality. The validated Transition Readiness Assessment Questionnaire can be used as well (Acad Pediatr. 2014;14[4]:415-22).

Another principle contained in the consensus statement calls for a comprehensive transition plan by the time the youth is 14 years of age, ideally coordinated by the youth’s primary care provider in collaboration with the youth, caregivers, other health care providers, school personnel, vocational professionals, community services providers, and legal services regarding all aspects of health, financial, and legal care. It tasks the child neurology team with three responsibilities toward the comprehensive care plan: “assuring that an appropriate plan exists” and is created in partnership with the youth and family; “identifying the professional(s) with primary responsibility for overseeing and updating the entire transition plan,” and “providing and updating the neurologic component to this plan – including the ‘transfer packet,’ ” which contains important medical and social information.

In 2011, Dr. Zupanc, division chief of pediatric neurology at Children’s Hospital of Orange County in Orange, Calif., created a multidisciplinary clinic for epilepsy patients that includes nurse practitioners, registered nurses, a pharmacist, a dietitian, a social worker, a neuropsychologist, and a child psychiatrist. When Dr. Zupanc addresses the notion of transition with patients and their families for the first time, it’s not uncommon for her to be accompanied by the social worker and the neuropsychologist, “which I find helpful because parents may start to ask questions about guardianship,” she said. “Many of these parents do not even realize that there has to be an appointed guardian at age 18. We usually seek verification of competency via neuropsychometric testing or school evaluations. This information has to go before a judge to decide whether or not the patient is capable of taking care of himself/herself or if there should be an appointed guardian, typically one or both parents.”

Dr. Zupanc goes on to tell patients and their families that transition of care is a process that’s going to occur over the next 6-8 years. “Some of the patients don’t transition at age 18 years, because they are covered by California Children’s Services until age 22 years,” she said. The age of transition may vary from state to state, depending on insurance coverage and other issues. “Parents and patients get used to the idea that the transition isn’t going to happen tomorrow,” she said. “We explain the whole process. We let them know that we will help them. We also mention that we have adult provider colleagues in the community who are very knowledgeable about epilepsy or their child’s genetic syndrome. We partner with these colleagues, many of whom we have identified over time as willing to take our neurologically complex patients. As the transition process proceeds, we develop a transition packet of important medical information and social information. We will personally have conversations with the physician to whom we are transitioning care. Sometimes, our colleagues at University of California, Irvine, come over to our clinic before the final hand-off, so that the adult provider and the pediatric provider can meet together with the parents and patients in the same room. To us, that is the ideal situation. In this way, both the patients and the parents do not feel as if they are being abandoned.”

Dr. Zupanc, professor of pediatrics at the University of California–Irvine School of Medicine, said that a chief barrier to effective transition of care for pediatric patients with complex neurological problems is identifying clinicians who are willing to accept them into their practice. For example, many young patients with intractable epilepsy have significant concomitant cognitive issues and behavioral issues and/or autistic spectrum disorder. “If you look at surveys of adult providers, they feel enormously uncomfortable and uneducated about autistic spectrum disorder. They do not want to touch these young adolescents/adults,” Dr. Zupanc said. “They’re willing to take a piece of their care but not the entire package, which is problematic.”

The way Dr. Camfield sees it, neurologists have a moral obligation to play an active role in transitioning pediatric patients to adult care. “In many ways, it’s the No. 1 issue for tertiary care pediatrics now: What happens to young people in adulthood; what kind of citizens they turn out to be and how we help that to take place,” said Dr. Camfield, who helped write the consensus statement. “It’s no longer just enough to think, ‘as your child gets to be 16, 17, or 18, that’s it. We’re finished. Our job is done.’ That doesn’t make sense to me.”

In the consensus statement, he and his coauthors call for additional research on transition care practices in neurology moving forward. “Possible metrics for assessment include the rate of appointment completion and follow-up in the adult setting, patient and family satisfaction with transition and the new provider, stable or improved neurologic condition, adherence to care plans, decreased emergency utilization, rate of ‘bounce back’ to pediatric providers, and improved quality of life,” they wrote.

The consensus statement was funded in part by Eisai. Dr. Brown and Dr. Zupanc reported having no financial disclosures relevant to the manuscript. Dr. Camfield disclosed that he has received a speakers honorarium from Biocodex. Neurology Reviews, a publication of Frontline Medical Communications, is a member of the President’s Council of the Child Neurology Foundation.

[email protected]

Until now, there was no blueprint for how to effectively transition pediatric patients with neurologic conditions to adult care: Hard science on the topic is almost nonexistent.

“There is not very much data, yet there is a lot of suggestion that if you do it badly things don’t turn out so well,” said Peter Camfield, MD, a child neurologist and professor emeritus at Dalhousie University in Halifax, Nova Scotia, who has written extensively on the topic (Ann Neurol. 2011;69[3]:437-44 and Epilepsy Curr. 2012;12[Suppl. 3]:13-21). He recalled hearing one story of an adolescent girl who came to see a child neurologist every 6 months, always with her parents. “She had some significant learning disabilities and she didn’t finish high school; she dropped out,” he said. “She was sent to an adult neurologist just with a transfer note and to a nephrologist just with a transfer note.”

The patient never visited the nephrologist. The adult neurologist saw her once, “but she said he was kind of rude and that he wouldn’t see her again,” Dr. Camfield said. “She lived with her boyfriend and eventually at about age 24 she was found dead in bed. She hadn’t taken her medications regularly. The presumption is she died from a seizure. If she had been more prepared for adult medical care, she could have engaged better with the adult neurologist, the kidney part of this thing wouldn’t have been let go, and she presumably would be still alive and making her way.”

In an effort to avoid such tragedies and to define the neurologist’s role in transitioning youth with neurologic conditions into adult care, an interdisciplinary team of child neurologists and other experts spent more than 2 years developing a consensus statement, published online July 27 in Neurology (doi: 10.1212/WNL.0000000000002965). Spearheaded by Lawrence W. Brown, MD, director of the pediatric neuropsychiatry program at The Children’s Hospital of Philadelphia, the consensus statement, “The neurologist’s role in supporting transition to adult health care” is endorsed by the Child Neurology Society, the American Academy of Neurology, and the American Academy of Pediatrics.

Despite broad-based efforts over more than a decade to improve transition of care, such as the Consensus Policy Statement on Health Care Transitions for Young Adults With Special Needs, the Clinical Report: Supporting Health Care Transition from Adolescence to Adulthood in the Medical Home, and the Got Transition Center for Health Care Transition Improvement (a federally funded program located at the National Alliance to Advance Adolescent Health), Dr. Brown expressed his belief that neurologists were unlikely to adopt these recommendations “because they were very hard to put in place, to concretize, and to make practical. We also recognized that child neurology was in many ways behind the eight ball compared to other specialties, at least compared to certain disease-oriented areas such as cystic fibrosis, sickle cell disease, congenital heart disease, and rheumatoid arthritis. These conditions already had attempts to show what the expectations were for the kids and for the doctors, and there were some practical solutions out there.” If transition to adult care is going to be successful, he continued, “it’s not just the neurologist acting in a vacuum, but the neurologist working with the youth and his caregivers as well as with his primary care physician and with other specialists.”

Dr. Brown characterized the new consensus statement as an outline of “common principles that all child neurologists should try to respect” based on a review of the best medical literature and best practices. The first of eight principles contained in the statement recommends that the child neurology team start talking early about the concept of transition to the adult health care system with the youth and caregivers, and document that discussion “no later than the youth’s 13th birthday.”

Mary L. Zupanc, MD, one of the experts who helped author the consensus document, underscored the importance of introducing the notion of transition before the youth turns 13 years of age. Otherwise, “you are playing catch-up all the time,” she said. “Families have to get used to the concept of transition because we have long-term relationships with these individuals and their families. They come to think of us as part of their family. When you first bring up the topic of transition they about have a heart attack, because they can’t imagine a life without including you in it.”

The document’s second common principle recommends that the neurology team assess the youth’s self-management skills annually beginning at age 12. According to the authors, self-management of a medical condition “includes a youth’s understanding of his or her condition and any related limitations, knowledge about and responsibility for his or her own care plan and the need to make informed decisions, and the importance of self-advocacy.”

The statement also recommends phased transition planning at least annually beginning when the youth is 13 years of age. Topics to be discussed at such planning sessions range from the youth’s medical condition and current medications to genetic counseling and issues of puberty and sexuality. The validated Transition Readiness Assessment Questionnaire can be used as well (Acad Pediatr. 2014;14[4]:415-22).

Another principle contained in the consensus statement calls for a comprehensive transition plan by the time the youth is 14 years of age, ideally coordinated by the youth’s primary care provider in collaboration with the youth, caregivers, other health care providers, school personnel, vocational professionals, community services providers, and legal services regarding all aspects of health, financial, and legal care. It tasks the child neurology team with three responsibilities toward the comprehensive care plan: “assuring that an appropriate plan exists” and is created in partnership with the youth and family; “identifying the professional(s) with primary responsibility for overseeing and updating the entire transition plan,” and “providing and updating the neurologic component to this plan – including the ‘transfer packet,’ ” which contains important medical and social information.

In 2011, Dr. Zupanc, division chief of pediatric neurology at Children’s Hospital of Orange County in Orange, Calif., created a multidisciplinary clinic for epilepsy patients that includes nurse practitioners, registered nurses, a pharmacist, a dietitian, a social worker, a neuropsychologist, and a child psychiatrist. When Dr. Zupanc addresses the notion of transition with patients and their families for the first time, it’s not uncommon for her to be accompanied by the social worker and the neuropsychologist, “which I find helpful because parents may start to ask questions about guardianship,” she said. “Many of these parents do not even realize that there has to be an appointed guardian at age 18. We usually seek verification of competency via neuropsychometric testing or school evaluations. This information has to go before a judge to decide whether or not the patient is capable of taking care of himself/herself or if there should be an appointed guardian, typically one or both parents.”

Dr. Zupanc goes on to tell patients and their families that transition of care is a process that’s going to occur over the next 6-8 years. “Some of the patients don’t transition at age 18 years, because they are covered by California Children’s Services until age 22 years,” she said. The age of transition may vary from state to state, depending on insurance coverage and other issues. “Parents and patients get used to the idea that the transition isn’t going to happen tomorrow,” she said. “We explain the whole process. We let them know that we will help them. We also mention that we have adult provider colleagues in the community who are very knowledgeable about epilepsy or their child’s genetic syndrome. We partner with these colleagues, many of whom we have identified over time as willing to take our neurologically complex patients. As the transition process proceeds, we develop a transition packet of important medical information and social information. We will personally have conversations with the physician to whom we are transitioning care. Sometimes, our colleagues at University of California, Irvine, come over to our clinic before the final hand-off, so that the adult provider and the pediatric provider can meet together with the parents and patients in the same room. To us, that is the ideal situation. In this way, both the patients and the parents do not feel as if they are being abandoned.”

Dr. Zupanc, professor of pediatrics at the University of California–Irvine School of Medicine, said that a chief barrier to effective transition of care for pediatric patients with complex neurological problems is identifying clinicians who are willing to accept them into their practice. For example, many young patients with intractable epilepsy have significant concomitant cognitive issues and behavioral issues and/or autistic spectrum disorder. “If you look at surveys of adult providers, they feel enormously uncomfortable and uneducated about autistic spectrum disorder. They do not want to touch these young adolescents/adults,” Dr. Zupanc said. “They’re willing to take a piece of their care but not the entire package, which is problematic.”

The way Dr. Camfield sees it, neurologists have a moral obligation to play an active role in transitioning pediatric patients to adult care. “In many ways, it’s the No. 1 issue for tertiary care pediatrics now: What happens to young people in adulthood; what kind of citizens they turn out to be and how we help that to take place,” said Dr. Camfield, who helped write the consensus statement. “It’s no longer just enough to think, ‘as your child gets to be 16, 17, or 18, that’s it. We’re finished. Our job is done.’ That doesn’t make sense to me.”

In the consensus statement, he and his coauthors call for additional research on transition care practices in neurology moving forward. “Possible metrics for assessment include the rate of appointment completion and follow-up in the adult setting, patient and family satisfaction with transition and the new provider, stable or improved neurologic condition, adherence to care plans, decreased emergency utilization, rate of ‘bounce back’ to pediatric providers, and improved quality of life,” they wrote.

The consensus statement was funded in part by Eisai. Dr. Brown and Dr. Zupanc reported having no financial disclosures relevant to the manuscript. Dr. Camfield disclosed that he has received a speakers honorarium from Biocodex. Neurology Reviews, a publication of Frontline Medical Communications, is a member of the President’s Council of the Child Neurology Foundation.

[email protected]

Until now, there was no blueprint for how to effectively transition pediatric patients with neurologic conditions to adult care: Hard science on the topic is almost nonexistent.

“There is not very much data, yet there is a lot of suggestion that if you do it badly things don’t turn out so well,” said Peter Camfield, MD, a child neurologist and professor emeritus at Dalhousie University in Halifax, Nova Scotia, who has written extensively on the topic (Ann Neurol. 2011;69[3]:437-44 and Epilepsy Curr. 2012;12[Suppl. 3]:13-21). He recalled hearing one story of an adolescent girl who came to see a child neurologist every 6 months, always with her parents. “She had some significant learning disabilities and she didn’t finish high school; she dropped out,” he said. “She was sent to an adult neurologist just with a transfer note and to a nephrologist just with a transfer note.”

The patient never visited the nephrologist. The adult neurologist saw her once, “but she said he was kind of rude and that he wouldn’t see her again,” Dr. Camfield said. “She lived with her boyfriend and eventually at about age 24 she was found dead in bed. She hadn’t taken her medications regularly. The presumption is she died from a seizure. If she had been more prepared for adult medical care, she could have engaged better with the adult neurologist, the kidney part of this thing wouldn’t have been let go, and she presumably would be still alive and making her way.”

In an effort to avoid such tragedies and to define the neurologist’s role in transitioning youth with neurologic conditions into adult care, an interdisciplinary team of child neurologists and other experts spent more than 2 years developing a consensus statement, published online July 27 in Neurology (doi: 10.1212/WNL.0000000000002965). Spearheaded by Lawrence W. Brown, MD, director of the pediatric neuropsychiatry program at The Children’s Hospital of Philadelphia, the consensus statement, “The neurologist’s role in supporting transition to adult health care” is endorsed by the Child Neurology Society, the American Academy of Neurology, and the American Academy of Pediatrics.

Despite broad-based efforts over more than a decade to improve transition of care, such as the Consensus Policy Statement on Health Care Transitions for Young Adults With Special Needs, the Clinical Report: Supporting Health Care Transition from Adolescence to Adulthood in the Medical Home, and the Got Transition Center for Health Care Transition Improvement (a federally funded program located at the National Alliance to Advance Adolescent Health), Dr. Brown expressed his belief that neurologists were unlikely to adopt these recommendations “because they were very hard to put in place, to concretize, and to make practical. We also recognized that child neurology was in many ways behind the eight ball compared to other specialties, at least compared to certain disease-oriented areas such as cystic fibrosis, sickle cell disease, congenital heart disease, and rheumatoid arthritis. These conditions already had attempts to show what the expectations were for the kids and for the doctors, and there were some practical solutions out there.” If transition to adult care is going to be successful, he continued, “it’s not just the neurologist acting in a vacuum, but the neurologist working with the youth and his caregivers as well as with his primary care physician and with other specialists.”

Dr. Brown characterized the new consensus statement as an outline of “common principles that all child neurologists should try to respect” based on a review of the best medical literature and best practices. The first of eight principles contained in the statement recommends that the child neurology team start talking early about the concept of transition to the adult health care system with the youth and caregivers, and document that discussion “no later than the youth’s 13th birthday.”

Mary L. Zupanc, MD, one of the experts who helped author the consensus document, underscored the importance of introducing the notion of transition before the youth turns 13 years of age. Otherwise, “you are playing catch-up all the time,” she said. “Families have to get used to the concept of transition because we have long-term relationships with these individuals and their families. They come to think of us as part of their family. When you first bring up the topic of transition they about have a heart attack, because they can’t imagine a life without including you in it.”

The document’s second common principle recommends that the neurology team assess the youth’s self-management skills annually beginning at age 12. According to the authors, self-management of a medical condition “includes a youth’s understanding of his or her condition and any related limitations, knowledge about and responsibility for his or her own care plan and the need to make informed decisions, and the importance of self-advocacy.”

The statement also recommends phased transition planning at least annually beginning when the youth is 13 years of age. Topics to be discussed at such planning sessions range from the youth’s medical condition and current medications to genetic counseling and issues of puberty and sexuality. The validated Transition Readiness Assessment Questionnaire can be used as well (Acad Pediatr. 2014;14[4]:415-22).

Another principle contained in the consensus statement calls for a comprehensive transition plan by the time the youth is 14 years of age, ideally coordinated by the youth’s primary care provider in collaboration with the youth, caregivers, other health care providers, school personnel, vocational professionals, community services providers, and legal services regarding all aspects of health, financial, and legal care. It tasks the child neurology team with three responsibilities toward the comprehensive care plan: “assuring that an appropriate plan exists” and is created in partnership with the youth and family; “identifying the professional(s) with primary responsibility for overseeing and updating the entire transition plan,” and “providing and updating the neurologic component to this plan – including the ‘transfer packet,’ ” which contains important medical and social information.

In 2011, Dr. Zupanc, division chief of pediatric neurology at Children’s Hospital of Orange County in Orange, Calif., created a multidisciplinary clinic for epilepsy patients that includes nurse practitioners, registered nurses, a pharmacist, a dietitian, a social worker, a neuropsychologist, and a child psychiatrist. When Dr. Zupanc addresses the notion of transition with patients and their families for the first time, it’s not uncommon for her to be accompanied by the social worker and the neuropsychologist, “which I find helpful because parents may start to ask questions about guardianship,” she said. “Many of these parents do not even realize that there has to be an appointed guardian at age 18. We usually seek verification of competency via neuropsychometric testing or school evaluations. This information has to go before a judge to decide whether or not the patient is capable of taking care of himself/herself or if there should be an appointed guardian, typically one or both parents.”

Dr. Zupanc goes on to tell patients and their families that transition of care is a process that’s going to occur over the next 6-8 years. “Some of the patients don’t transition at age 18 years, because they are covered by California Children’s Services until age 22 years,” she said. The age of transition may vary from state to state, depending on insurance coverage and other issues. “Parents and patients get used to the idea that the transition isn’t going to happen tomorrow,” she said. “We explain the whole process. We let them know that we will help them. We also mention that we have adult provider colleagues in the community who are very knowledgeable about epilepsy or their child’s genetic syndrome. We partner with these colleagues, many of whom we have identified over time as willing to take our neurologically complex patients. As the transition process proceeds, we develop a transition packet of important medical information and social information. We will personally have conversations with the physician to whom we are transitioning care. Sometimes, our colleagues at University of California, Irvine, come over to our clinic before the final hand-off, so that the adult provider and the pediatric provider can meet together with the parents and patients in the same room. To us, that is the ideal situation. In this way, both the patients and the parents do not feel as if they are being abandoned.”

Dr. Zupanc, professor of pediatrics at the University of California–Irvine School of Medicine, said that a chief barrier to effective transition of care for pediatric patients with complex neurological problems is identifying clinicians who are willing to accept them into their practice. For example, many young patients with intractable epilepsy have significant concomitant cognitive issues and behavioral issues and/or autistic spectrum disorder. “If you look at surveys of adult providers, they feel enormously uncomfortable and uneducated about autistic spectrum disorder. They do not want to touch these young adolescents/adults,” Dr. Zupanc said. “They’re willing to take a piece of their care but not the entire package, which is problematic.”

The way Dr. Camfield sees it, neurologists have a moral obligation to play an active role in transitioning pediatric patients to adult care. “In many ways, it’s the No. 1 issue for tertiary care pediatrics now: What happens to young people in adulthood; what kind of citizens they turn out to be and how we help that to take place,” said Dr. Camfield, who helped write the consensus statement. “It’s no longer just enough to think, ‘as your child gets to be 16, 17, or 18, that’s it. We’re finished. Our job is done.’ That doesn’t make sense to me.”

In the consensus statement, he and his coauthors call for additional research on transition care practices in neurology moving forward. “Possible metrics for assessment include the rate of appointment completion and follow-up in the adult setting, patient and family satisfaction with transition and the new provider, stable or improved neurologic condition, adherence to care plans, decreased emergency utilization, rate of ‘bounce back’ to pediatric providers, and improved quality of life,” they wrote.

The consensus statement was funded in part by Eisai. Dr. Brown and Dr. Zupanc reported having no financial disclosures relevant to the manuscript. Dr. Camfield disclosed that he has received a speakers honorarium from Biocodex. Neurology Reviews, a publication of Frontline Medical Communications, is a member of the President’s Council of the Child Neurology Foundation.

[email protected]