Judy Packer-Tursman

Pediatricians have numerous and growing concerns about the known and unknown risks of electronic cigarettes, and the industry’s aggressive, "unfettered" marketing that often targets children is particularly worrisome, a representative of the American Academy of Pediatrics said at a Senate hearing June 18.

"Pediatricians think it’s only a matter of time before a young child dies from e-cigarettes," Dr. Susanne E. Tanski, chair of the AAP Tobacco Consortium, an advisory group dedicated to protecting children and youth from tobacco, told the Senate Committee on Commerce, Science, and Transportation.

©goldy/Thinkstockphotos.com

Dr. Tanski, a pediatrician at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., noted that e-cigarettes come in candy flavors, such as Cotton Candy and Atomic Fireball, which are tempting to children. She said e-cigarettes are not required to be sold in childproof containers and, contrary to claims, they do not contain benign ingredients.

E-cigarettes, battery-operated devices that vaporize nicotine, also may be a pathway to children’s use of regular cigarettes, Dr. Tanski said. Any potential reduction in harm in adults who use them as an alternative to regular cigarettes remains unproven, she added.

Moreover, e-cigarettes are causing the "renormalization" and "reglamorization" of smoking through ubiquitous TV ads and celebrity endorsements that appeal to children, Dr. Tanski and others testified.

Dr. Tanski cited troubling statistics: The use of e-cigarettes more than doubled in a single year (from 4.7% in 2011 to 10.0% in 2012), with 1.78 million U.S. students reporting e-cigarette use in 2012. She said a recent Internet-based study conducted in 2013-2014 found even higher rates of use: 14% of 13- to 17-year-olds had tried e-cigarettes, and 9% currently used them.

During the hearing, Jason Healy, president of blu eCigs, and Craig Weiss, president of NJoy, spent two-and-a-half hours defending industry marketing practices that include making heavy use of social media, running TV commercials, and sponsoring sporting events. Both insisted that their marketing is not aimed at young people, and their products are an important alternative for 40 million adult smokers in the United States.

Mr. Healy said blu eCigs, which is owned by tobacco company Lorillard Inc., has adopted voluntary marketing restrictions, and markets e-cigarettes only in places where at least 85% of the audience is adult. He said flavors "keep adults interested" in the product, and 51 is the average age of its user.

Mr. Weiss said e-cigarettes "give a positive alternative to people who cannot or will not quit." Later, he said in response to direct questioning by Sen. Jay Rockefeller (D-W.V.), the commerce panel’s chair: "I don’t think our ads appeal to young people."

Opening the hearing, Sen. Rockefeller warned that he is "emotionally on edge on this whole subject." He said marketing of e-cigarettes has been "soaring, including and especially to young people." He cited a 256% increase in youths’ exposure to TV commercials for e-cigarettes between 2011 and 2013, and a recent report finding that TV commercials and print ads for e-cigarettes are reaching millions of youths.

America’s youth "seem to be getting the message pretty clearly," even though the industry asserts that it is not targeting children with its e-cigarette marketing, Sen. Rockefeller said. He said 60 years ago he might have been interested in products with flavors like "Cherry Crush," "Peachy Keen," "Bazooka Joe," and "Gummy Bear," but now he is not. "That’s not adult stuff. That’s aimed at children," he said.

Citing the generations of Americans who became addicted to nicotine in regular cigarettes and other tobacco products, Sen. Rockefeller wondered whether e-cigarettes could do the same thing. "We figure about 4,000 kids in West Virginia are affected by this. Badly," he said. He said poison control centers are getting a rising number of calls on e-cigarettes, particularly involving children under the age of 5.

The senator accused the industry of widely marketing a product when its long-term health consequences remain unknown and questions about whether e-cigarettes contain toxins other than nicotine remain unanswered. "You want to make money, so you plunge in, get what you can" – until the Food and Drug Administration steps in to regulate, he said, adding that such regulation could take a long time.

(In April, the FDA proposed regulating e-cigarettes, adding warning labels and banning sales to anyone under 18, which already is being done in several states. No marketing restrictions were placed on e-cigarette makers and there is no ban on fruit or candy flavors, which cannot be used in regular cigarettes.)

"Simply stated, children and teens should not be ‘guinea pigs’ as we await more research," Sen. Rockefeller said. Noting that the tobacco control law’s restrictions don’t currently cover e-cigarettes, he summed it up this way: "A loophole in the law. A chance to rake in cash. Worry about the kids later."

Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, testified that e-cigarettes, properly regulated, might help regular tobacco smokers quit. But he said the government’s failure to act swiftly to regulate e-cigarettes and "irresponsible actions" by companies have created a market that has "outpaced the science." He accused the e-cigarette industry of using the same tactics as those used by Big Tobacco for 50 years, including "cool" characters, cartoons, and themes of freedom and sex. "To this day, the tobacco industry doesn’t admit to running a single ad targeting kids," he said.

Unless something is done, the United States faces "a potential tsunami" of e-cigarette marketing, Mr. Myers said. "Flavors like Cinnamon Bun, being sold over the Internet with virtually no controls ... [T]here is an urgent need for the government to step in and help our kids."

Pediatricians have numerous and growing concerns about the known and unknown risks of electronic cigarettes, and the industry’s aggressive, "unfettered" marketing that often targets children is particularly worrisome, a representative of the American Academy of Pediatrics said at a Senate hearing June 18.

"Pediatricians think it’s only a matter of time before a young child dies from e-cigarettes," Dr. Susanne E. Tanski, chair of the AAP Tobacco Consortium, an advisory group dedicated to protecting children and youth from tobacco, told the Senate Committee on Commerce, Science, and Transportation.

©goldy/Thinkstockphotos.com

Dr. Tanski, a pediatrician at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., noted that e-cigarettes come in candy flavors, such as Cotton Candy and Atomic Fireball, which are tempting to children. She said e-cigarettes are not required to be sold in childproof containers and, contrary to claims, they do not contain benign ingredients.

E-cigarettes, battery-operated devices that vaporize nicotine, also may be a pathway to children’s use of regular cigarettes, Dr. Tanski said. Any potential reduction in harm in adults who use them as an alternative to regular cigarettes remains unproven, she added.

Moreover, e-cigarettes are causing the "renormalization" and "reglamorization" of smoking through ubiquitous TV ads and celebrity endorsements that appeal to children, Dr. Tanski and others testified.

Dr. Tanski cited troubling statistics: The use of e-cigarettes more than doubled in a single year (from 4.7% in 2011 to 10.0% in 2012), with 1.78 million U.S. students reporting e-cigarette use in 2012. She said a recent Internet-based study conducted in 2013-2014 found even higher rates of use: 14% of 13- to 17-year-olds had tried e-cigarettes, and 9% currently used them.

During the hearing, Jason Healy, president of blu eCigs, and Craig Weiss, president of NJoy, spent two-and-a-half hours defending industry marketing practices that include making heavy use of social media, running TV commercials, and sponsoring sporting events. Both insisted that their marketing is not aimed at young people, and their products are an important alternative for 40 million adult smokers in the United States.

Mr. Healy said blu eCigs, which is owned by tobacco company Lorillard Inc., has adopted voluntary marketing restrictions, and markets e-cigarettes only in places where at least 85% of the audience is adult. He said flavors "keep adults interested" in the product, and 51 is the average age of its user.

Mr. Weiss said e-cigarettes "give a positive alternative to people who cannot or will not quit." Later, he said in response to direct questioning by Sen. Jay Rockefeller (D-W.V.), the commerce panel’s chair: "I don’t think our ads appeal to young people."

Opening the hearing, Sen. Rockefeller warned that he is "emotionally on edge on this whole subject." He said marketing of e-cigarettes has been "soaring, including and especially to young people." He cited a 256% increase in youths’ exposure to TV commercials for e-cigarettes between 2011 and 2013, and a recent report finding that TV commercials and print ads for e-cigarettes are reaching millions of youths.

America’s youth "seem to be getting the message pretty clearly," even though the industry asserts that it is not targeting children with its e-cigarette marketing, Sen. Rockefeller said. He said 60 years ago he might have been interested in products with flavors like "Cherry Crush," "Peachy Keen," "Bazooka Joe," and "Gummy Bear," but now he is not. "That’s not adult stuff. That’s aimed at children," he said.

Citing the generations of Americans who became addicted to nicotine in regular cigarettes and other tobacco products, Sen. Rockefeller wondered whether e-cigarettes could do the same thing. "We figure about 4,000 kids in West Virginia are affected by this. Badly," he said. He said poison control centers are getting a rising number of calls on e-cigarettes, particularly involving children under the age of 5.

The senator accused the industry of widely marketing a product when its long-term health consequences remain unknown and questions about whether e-cigarettes contain toxins other than nicotine remain unanswered. "You want to make money, so you plunge in, get what you can" – until the Food and Drug Administration steps in to regulate, he said, adding that such regulation could take a long time.

(In April, the FDA proposed regulating e-cigarettes, adding warning labels and banning sales to anyone under 18, which already is being done in several states. No marketing restrictions were placed on e-cigarette makers and there is no ban on fruit or candy flavors, which cannot be used in regular cigarettes.)

"Simply stated, children and teens should not be ‘guinea pigs’ as we await more research," Sen. Rockefeller said. Noting that the tobacco control law’s restrictions don’t currently cover e-cigarettes, he summed it up this way: "A loophole in the law. A chance to rake in cash. Worry about the kids later."

Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, testified that e-cigarettes, properly regulated, might help regular tobacco smokers quit. But he said the government’s failure to act swiftly to regulate e-cigarettes and "irresponsible actions" by companies have created a market that has "outpaced the science." He accused the e-cigarette industry of using the same tactics as those used by Big Tobacco for 50 years, including "cool" characters, cartoons, and themes of freedom and sex. "To this day, the tobacco industry doesn’t admit to running a single ad targeting kids," he said.

Unless something is done, the United States faces "a potential tsunami" of e-cigarette marketing, Mr. Myers said. "Flavors like Cinnamon Bun, being sold over the Internet with virtually no controls ... [T]here is an urgent need for the government to step in and help our kids."

Pediatricians have numerous and growing concerns about the known and unknown risks of electronic cigarettes, and the industry’s aggressive, "unfettered" marketing that often targets children is particularly worrisome, a representative of the American Academy of Pediatrics said at a Senate hearing June 18.

"Pediatricians think it’s only a matter of time before a young child dies from e-cigarettes," Dr. Susanne E. Tanski, chair of the AAP Tobacco Consortium, an advisory group dedicated to protecting children and youth from tobacco, told the Senate Committee on Commerce, Science, and Transportation.

©goldy/Thinkstockphotos.com

Dr. Tanski, a pediatrician at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., noted that e-cigarettes come in candy flavors, such as Cotton Candy and Atomic Fireball, which are tempting to children. She said e-cigarettes are not required to be sold in childproof containers and, contrary to claims, they do not contain benign ingredients.

E-cigarettes, battery-operated devices that vaporize nicotine, also may be a pathway to children’s use of regular cigarettes, Dr. Tanski said. Any potential reduction in harm in adults who use them as an alternative to regular cigarettes remains unproven, she added.

Moreover, e-cigarettes are causing the "renormalization" and "reglamorization" of smoking through ubiquitous TV ads and celebrity endorsements that appeal to children, Dr. Tanski and others testified.

Dr. Tanski cited troubling statistics: The use of e-cigarettes more than doubled in a single year (from 4.7% in 2011 to 10.0% in 2012), with 1.78 million U.S. students reporting e-cigarette use in 2012. She said a recent Internet-based study conducted in 2013-2014 found even higher rates of use: 14% of 13- to 17-year-olds had tried e-cigarettes, and 9% currently used them.

During the hearing, Jason Healy, president of blu eCigs, and Craig Weiss, president of NJoy, spent two-and-a-half hours defending industry marketing practices that include making heavy use of social media, running TV commercials, and sponsoring sporting events. Both insisted that their marketing is not aimed at young people, and their products are an important alternative for 40 million adult smokers in the United States.

Mr. Healy said blu eCigs, which is owned by tobacco company Lorillard Inc., has adopted voluntary marketing restrictions, and markets e-cigarettes only in places where at least 85% of the audience is adult. He said flavors "keep adults interested" in the product, and 51 is the average age of its user.

Mr. Weiss said e-cigarettes "give a positive alternative to people who cannot or will not quit." Later, he said in response to direct questioning by Sen. Jay Rockefeller (D-W.V.), the commerce panel’s chair: "I don’t think our ads appeal to young people."

Opening the hearing, Sen. Rockefeller warned that he is "emotionally on edge on this whole subject." He said marketing of e-cigarettes has been "soaring, including and especially to young people." He cited a 256% increase in youths’ exposure to TV commercials for e-cigarettes between 2011 and 2013, and a recent report finding that TV commercials and print ads for e-cigarettes are reaching millions of youths.

America’s youth "seem to be getting the message pretty clearly," even though the industry asserts that it is not targeting children with its e-cigarette marketing, Sen. Rockefeller said. He said 60 years ago he might have been interested in products with flavors like "Cherry Crush," "Peachy Keen," "Bazooka Joe," and "Gummy Bear," but now he is not. "That’s not adult stuff. That’s aimed at children," he said.

Citing the generations of Americans who became addicted to nicotine in regular cigarettes and other tobacco products, Sen. Rockefeller wondered whether e-cigarettes could do the same thing. "We figure about 4,000 kids in West Virginia are affected by this. Badly," he said. He said poison control centers are getting a rising number of calls on e-cigarettes, particularly involving children under the age of 5.

The senator accused the industry of widely marketing a product when its long-term health consequences remain unknown and questions about whether e-cigarettes contain toxins other than nicotine remain unanswered. "You want to make money, so you plunge in, get what you can" – until the Food and Drug Administration steps in to regulate, he said, adding that such regulation could take a long time.

(In April, the FDA proposed regulating e-cigarettes, adding warning labels and banning sales to anyone under 18, which already is being done in several states. No marketing restrictions were placed on e-cigarette makers and there is no ban on fruit or candy flavors, which cannot be used in regular cigarettes.)

"Simply stated, children and teens should not be ‘guinea pigs’ as we await more research," Sen. Rockefeller said. Noting that the tobacco control law’s restrictions don’t currently cover e-cigarettes, he summed it up this way: "A loophole in the law. A chance to rake in cash. Worry about the kids later."

Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, testified that e-cigarettes, properly regulated, might help regular tobacco smokers quit. But he said the government’s failure to act swiftly to regulate e-cigarettes and "irresponsible actions" by companies have created a market that has "outpaced the science." He accused the e-cigarette industry of using the same tactics as those used by Big Tobacco for 50 years, including "cool" characters, cartoons, and themes of freedom and sex. "To this day, the tobacco industry doesn’t admit to running a single ad targeting kids," he said.

Unless something is done, the United States faces "a potential tsunami" of e-cigarette marketing, Mr. Myers said. "Flavors like Cinnamon Bun, being sold over the Internet with virtually no controls ... [T]here is an urgent need for the government to step in and help our kids."

Clinicians would better serve their seriously ill elderly patients by improving communication to avoid emergency surgery that could prove to be too intense and potentially harmful, according to a study published online in Annals of Surgery (Ann. Surg. 2014 May 23 [doi: 10.1097/SLA.0000000000000721]).

Dr. Zara Cooper and her colleagues from Brigham and Women’s Hospital, Boston, conducted a wide-ranging literature review to ascertain factors that lead to communication challenges and nonbeneficial surgery at the end of life.

"Elderly patients with serious illness often receive poor-quality end-of-life care, leading to high rates of emergency department use, hospital and intensive care unit admissions, and in-hospital death, and low rates of hospice referral. High-intensity treatments near the end of life often are burdensome and prolong suffering without meeting patients’ personal goals," the researchers wrote.

If surgeons assume that patients favor life-prolonging treatment, they may opt to provide interventions that are immediately lifesaving but add little to the patient’s quality of life and may prolong, or even accelerate, the dying process, the researchers said. Studies have shown that nearly 1 in 10 Medicare patients who die have surgery in the last week of their lives (Lancet 2011;378:1408-13).

"Unable to quickly elucidate the gravity of the underlying illness and assess the patients’ understanding of their disease, surgeons may hesitate to engage in conversations about patient preferences and aggressive palliation as an alternative to invasive treatment," the authors wrote.

To avoid such communication pitfalls, the study recommends:

• Advance care planning around surgery: Even in an emergency setting, clinicians can set treatment goals early and revisit them if the patient’s condition deteriorates. Emergency surgeons should engage the patient’s primary and specialty providers whenever possible to participate in clinical decisions.

• Education and training: Surgeons routinely encountering seriously ill elderly patients should consider learning evidence-based communication strategies, including how to handle intense emotions, discuss prognosis, and deliver basic palliative-care interventions in a structured format with expert guidance.

• Structured communication: The goal is not to divert elderly patients with limited life expectancy from potentially life-prolonging surgery, but instead to determine patients’ priorities up front to better enable surgeons to recommend treatments. Such communication also should determine health states unacceptable to the patient, and affirm the clinician’s commitment to the patient’s well-being.

• Further research: More information is needed on patient-centered surgical outcomes for elderly patients with serious illness, including survival beyond 30 days, functional outcomes, health-related quality of life, transitions of care, and quality of death.

According to the study, physicians likely opt for invasive treatment of this vulnerable population out of concern about possible legal repercussions if they withhold it. But even when the patient’s prognosis is clear, legal concerns are minimal, and the patient is willing to discuss death and dying, many surgeons lack training in how to discuss death or provide a palliative approach to care, the researchers said.

Thus, surgeons may fail to respond to social cues relevant to end-of-life care or provide support, and instead "frequently employ defensive strategies" such as focusing on medical details, the study found.

Patients in distress often rely on surrogate decision-makers, the researchers noted. Given the disconnect between surrogates’ expectations and what medical treatment realistically can offer, surrogates may consent to treatments that they believe will prolong and restore quality of life when in fact such interventions are associated with physical or psychological suffering and scant, if any, benefit.

The authors did not receive funding support for this work and declared no conflicts of interest.

Clinicians would better serve their seriously ill elderly patients by improving communication to avoid emergency surgery that could prove to be too intense and potentially harmful, according to a study published online in Annals of Surgery (Ann. Surg. 2014 May 23 [doi: 10.1097/SLA.0000000000000721]).

Dr. Zara Cooper and her colleagues from Brigham and Women’s Hospital, Boston, conducted a wide-ranging literature review to ascertain factors that lead to communication challenges and nonbeneficial surgery at the end of life.

"Elderly patients with serious illness often receive poor-quality end-of-life care, leading to high rates of emergency department use, hospital and intensive care unit admissions, and in-hospital death, and low rates of hospice referral. High-intensity treatments near the end of life often are burdensome and prolong suffering without meeting patients’ personal goals," the researchers wrote.

If surgeons assume that patients favor life-prolonging treatment, they may opt to provide interventions that are immediately lifesaving but add little to the patient’s quality of life and may prolong, or even accelerate, the dying process, the researchers said. Studies have shown that nearly 1 in 10 Medicare patients who die have surgery in the last week of their lives (Lancet 2011;378:1408-13).

"Unable to quickly elucidate the gravity of the underlying illness and assess the patients’ understanding of their disease, surgeons may hesitate to engage in conversations about patient preferences and aggressive palliation as an alternative to invasive treatment," the authors wrote.

To avoid such communication pitfalls, the study recommends:

• Advance care planning around surgery: Even in an emergency setting, clinicians can set treatment goals early and revisit them if the patient’s condition deteriorates. Emergency surgeons should engage the patient’s primary and specialty providers whenever possible to participate in clinical decisions.

• Education and training: Surgeons routinely encountering seriously ill elderly patients should consider learning evidence-based communication strategies, including how to handle intense emotions, discuss prognosis, and deliver basic palliative-care interventions in a structured format with expert guidance.

• Structured communication: The goal is not to divert elderly patients with limited life expectancy from potentially life-prolonging surgery, but instead to determine patients’ priorities up front to better enable surgeons to recommend treatments. Such communication also should determine health states unacceptable to the patient, and affirm the clinician’s commitment to the patient’s well-being.

• Further research: More information is needed on patient-centered surgical outcomes for elderly patients with serious illness, including survival beyond 30 days, functional outcomes, health-related quality of life, transitions of care, and quality of death.

According to the study, physicians likely opt for invasive treatment of this vulnerable population out of concern about possible legal repercussions if they withhold it. But even when the patient’s prognosis is clear, legal concerns are minimal, and the patient is willing to discuss death and dying, many surgeons lack training in how to discuss death or provide a palliative approach to care, the researchers said.

Thus, surgeons may fail to respond to social cues relevant to end-of-life care or provide support, and instead "frequently employ defensive strategies" such as focusing on medical details, the study found.

Patients in distress often rely on surrogate decision-makers, the researchers noted. Given the disconnect between surrogates’ expectations and what medical treatment realistically can offer, surrogates may consent to treatments that they believe will prolong and restore quality of life when in fact such interventions are associated with physical or psychological suffering and scant, if any, benefit.

The authors did not receive funding support for this work and declared no conflicts of interest.

Clinicians would better serve their seriously ill elderly patients by improving communication to avoid emergency surgery that could prove to be too intense and potentially harmful, according to a study published online in Annals of Surgery (Ann. Surg. 2014 May 23 [doi: 10.1097/SLA.0000000000000721]).

Dr. Zara Cooper and her colleagues from Brigham and Women’s Hospital, Boston, conducted a wide-ranging literature review to ascertain factors that lead to communication challenges and nonbeneficial surgery at the end of life.

"Elderly patients with serious illness often receive poor-quality end-of-life care, leading to high rates of emergency department use, hospital and intensive care unit admissions, and in-hospital death, and low rates of hospice referral. High-intensity treatments near the end of life often are burdensome and prolong suffering without meeting patients’ personal goals," the researchers wrote.

If surgeons assume that patients favor life-prolonging treatment, they may opt to provide interventions that are immediately lifesaving but add little to the patient’s quality of life and may prolong, or even accelerate, the dying process, the researchers said. Studies have shown that nearly 1 in 10 Medicare patients who die have surgery in the last week of their lives (Lancet 2011;378:1408-13).

"Unable to quickly elucidate the gravity of the underlying illness and assess the patients’ understanding of their disease, surgeons may hesitate to engage in conversations about patient preferences and aggressive palliation as an alternative to invasive treatment," the authors wrote.

To avoid such communication pitfalls, the study recommends:

• Advance care planning around surgery: Even in an emergency setting, clinicians can set treatment goals early and revisit them if the patient’s condition deteriorates. Emergency surgeons should engage the patient’s primary and specialty providers whenever possible to participate in clinical decisions.

• Education and training: Surgeons routinely encountering seriously ill elderly patients should consider learning evidence-based communication strategies, including how to handle intense emotions, discuss prognosis, and deliver basic palliative-care interventions in a structured format with expert guidance.

• Structured communication: The goal is not to divert elderly patients with limited life expectancy from potentially life-prolonging surgery, but instead to determine patients’ priorities up front to better enable surgeons to recommend treatments. Such communication also should determine health states unacceptable to the patient, and affirm the clinician’s commitment to the patient’s well-being.

• Further research: More information is needed on patient-centered surgical outcomes for elderly patients with serious illness, including survival beyond 30 days, functional outcomes, health-related quality of life, transitions of care, and quality of death.

According to the study, physicians likely opt for invasive treatment of this vulnerable population out of concern about possible legal repercussions if they withhold it. But even when the patient’s prognosis is clear, legal concerns are minimal, and the patient is willing to discuss death and dying, many surgeons lack training in how to discuss death or provide a palliative approach to care, the researchers said.

Thus, surgeons may fail to respond to social cues relevant to end-of-life care or provide support, and instead "frequently employ defensive strategies" such as focusing on medical details, the study found.

Patients in distress often rely on surrogate decision-makers, the researchers noted. Given the disconnect between surrogates’ expectations and what medical treatment realistically can offer, surrogates may consent to treatments that they believe will prolong and restore quality of life when in fact such interventions are associated with physical or psychological suffering and scant, if any, benefit.

The authors did not receive funding support for this work and declared no conflicts of interest.

Clinicians seem to be overusing "low-value" medical services that provide little or no benefit to Medicare beneficiaries, according to a report published online May 12 in JAMA Internal Medicine.

In the study, Harvard researchers developed 26 claims-based measures drawn from evidence-based lists of services providing minimal clinical benefit. Categories included low-value cancer screening, diagnostic and preventive testing, imaging, and surgical procedures. In all, the study tracked more than 1.3 million Medicare beneficiaries’ claims from 2009, analyzing the proportion of them receiving such services, mean-per-beneficiary service use, and the proportion of total spending devoted to the services.

Among the study’s 26 designated measures of low-value services: cervical cancer screening for women 65 years and older, computed tomography scanning of the sinuses for uncomplicated acute rhinosinusitis, head imaging for uncomplicated headache, preoperative cardiac stress testing, and back imaging for patients with nonspecific low back pain. Researchers tweaked measures by age, symptoms, and site of care, creating different levels of sensitivity for each measure (i.e., a more sensitive, less specific baseline definition, along with a less sensitive, more specific definition with additional restrictions).

Nationwide, between 25% and 42% of beneficiaries received low-value services, accounting for as much as $8.4 billion, or 2.7% of annual spending for services covered by Medicare Parts A and B, the researchers estimated (JAMA Intern. Med. 2014 [doi: 10.1001/jamainternmed.2014.1541]).

"Now that we have this measurement tool, we can use it to try to better understand when overuse is happening and what can be done to reduce it," Aaron Schwartz, the study’s lead author, who is in the MD-PhD program at Harvard Medical School, Boston, said in an interview.

Researchers sought to "cast a broad net" in creating a low-value medical services index that could be tracked over time and used to evaluate various reform efforts, Mr. Schwartz said. "For the vast majority of services, whether it’s ‘low value’ or ‘high value’ really depends on the patient and the clinical setting," he said. Analyzing the use of different services within various geographic areas, researchers found that even geographic areas spending less on low-value Medicare services "still spent a lot on them," he said.

Payment reforms, such as global – or bundled – payment models, could afford greater discretion to clinicians in identifying low-value services and in finding incentives to eliminate them, according to Mr. Schwartz. "Our team generally favors proposals that retain provider discretion at point of care," he said.

The study’s results are "consistent with extensive overuse in the system ... even with just 26 measures," Mr. Schwartz noted. But many claims-based measures of overuse may not be accurate enough to support targeted coverage or payment policies without resulting in unintended consequences, he cautioned.

Arkansas Medicaid Director Dr. William Golden said the Harvard study’s findings are not surprising, with physicians’ overuse of "low-value" services extending beyond Medicare. But new payment strategies and financial incentives, such as those employed by his state Medicaid program, seem to be helping to change such practice patterns and manage total cost of care, he said.

"Low-value activities are embedded throughout the routine orders of health care," Dr. Golden said in an interview. "Since Arkansas Medicaid has made health providers accountable for total cost of care and included shared savings and cost sharing, the health care community has invested the time and energy to retrain clinical reflexive behavior. Delineation of effective strategies coupled with financial incentives has promise to be a promising strategy in our state."

Mr. Schwartz reported having no conflicts of interest.

Clinicians seem to be overusing "low-value" medical services that provide little or no benefit to Medicare beneficiaries, according to a report published online May 12 in JAMA Internal Medicine.

In the study, Harvard researchers developed 26 claims-based measures drawn from evidence-based lists of services providing minimal clinical benefit. Categories included low-value cancer screening, diagnostic and preventive testing, imaging, and surgical procedures. In all, the study tracked more than 1.3 million Medicare beneficiaries’ claims from 2009, analyzing the proportion of them receiving such services, mean-per-beneficiary service use, and the proportion of total spending devoted to the services.

Among the study’s 26 designated measures of low-value services: cervical cancer screening for women 65 years and older, computed tomography scanning of the sinuses for uncomplicated acute rhinosinusitis, head imaging for uncomplicated headache, preoperative cardiac stress testing, and back imaging for patients with nonspecific low back pain. Researchers tweaked measures by age, symptoms, and site of care, creating different levels of sensitivity for each measure (i.e., a more sensitive, less specific baseline definition, along with a less sensitive, more specific definition with additional restrictions).

Nationwide, between 25% and 42% of beneficiaries received low-value services, accounting for as much as $8.4 billion, or 2.7% of annual spending for services covered by Medicare Parts A and B, the researchers estimated (JAMA Intern. Med. 2014 [doi: 10.1001/jamainternmed.2014.1541]).

"Now that we have this measurement tool, we can use it to try to better understand when overuse is happening and what can be done to reduce it," Aaron Schwartz, the study’s lead author, who is in the MD-PhD program at Harvard Medical School, Boston, said in an interview.

Researchers sought to "cast a broad net" in creating a low-value medical services index that could be tracked over time and used to evaluate various reform efforts, Mr. Schwartz said. "For the vast majority of services, whether it’s ‘low value’ or ‘high value’ really depends on the patient and the clinical setting," he said. Analyzing the use of different services within various geographic areas, researchers found that even geographic areas spending less on low-value Medicare services "still spent a lot on them," he said.

Payment reforms, such as global – or bundled – payment models, could afford greater discretion to clinicians in identifying low-value services and in finding incentives to eliminate them, according to Mr. Schwartz. "Our team generally favors proposals that retain provider discretion at point of care," he said.

The study’s results are "consistent with extensive overuse in the system ... even with just 26 measures," Mr. Schwartz noted. But many claims-based measures of overuse may not be accurate enough to support targeted coverage or payment policies without resulting in unintended consequences, he cautioned.

Arkansas Medicaid Director Dr. William Golden said the Harvard study’s findings are not surprising, with physicians’ overuse of "low-value" services extending beyond Medicare. But new payment strategies and financial incentives, such as those employed by his state Medicaid program, seem to be helping to change such practice patterns and manage total cost of care, he said.

"Low-value activities are embedded throughout the routine orders of health care," Dr. Golden said in an interview. "Since Arkansas Medicaid has made health providers accountable for total cost of care and included shared savings and cost sharing, the health care community has invested the time and energy to retrain clinical reflexive behavior. Delineation of effective strategies coupled with financial incentives has promise to be a promising strategy in our state."

Mr. Schwartz reported having no conflicts of interest.

Clinicians seem to be overusing "low-value" medical services that provide little or no benefit to Medicare beneficiaries, according to a report published online May 12 in JAMA Internal Medicine.

In the study, Harvard researchers developed 26 claims-based measures drawn from evidence-based lists of services providing minimal clinical benefit. Categories included low-value cancer screening, diagnostic and preventive testing, imaging, and surgical procedures. In all, the study tracked more than 1.3 million Medicare beneficiaries’ claims from 2009, analyzing the proportion of them receiving such services, mean-per-beneficiary service use, and the proportion of total spending devoted to the services.

Among the study’s 26 designated measures of low-value services: cervical cancer screening for women 65 years and older, computed tomography scanning of the sinuses for uncomplicated acute rhinosinusitis, head imaging for uncomplicated headache, preoperative cardiac stress testing, and back imaging for patients with nonspecific low back pain. Researchers tweaked measures by age, symptoms, and site of care, creating different levels of sensitivity for each measure (i.e., a more sensitive, less specific baseline definition, along with a less sensitive, more specific definition with additional restrictions).

Nationwide, between 25% and 42% of beneficiaries received low-value services, accounting for as much as $8.4 billion, or 2.7% of annual spending for services covered by Medicare Parts A and B, the researchers estimated (JAMA Intern. Med. 2014 [doi: 10.1001/jamainternmed.2014.1541]).

"Now that we have this measurement tool, we can use it to try to better understand when overuse is happening and what can be done to reduce it," Aaron Schwartz, the study’s lead author, who is in the MD-PhD program at Harvard Medical School, Boston, said in an interview.

Researchers sought to "cast a broad net" in creating a low-value medical services index that could be tracked over time and used to evaluate various reform efforts, Mr. Schwartz said. "For the vast majority of services, whether it’s ‘low value’ or ‘high value’ really depends on the patient and the clinical setting," he said. Analyzing the use of different services within various geographic areas, researchers found that even geographic areas spending less on low-value Medicare services "still spent a lot on them," he said.

Payment reforms, such as global – or bundled – payment models, could afford greater discretion to clinicians in identifying low-value services and in finding incentives to eliminate them, according to Mr. Schwartz. "Our team generally favors proposals that retain provider discretion at point of care," he said.

The study’s results are "consistent with extensive overuse in the system ... even with just 26 measures," Mr. Schwartz noted. But many claims-based measures of overuse may not be accurate enough to support targeted coverage or payment policies without resulting in unintended consequences, he cautioned.

Arkansas Medicaid Director Dr. William Golden said the Harvard study’s findings are not surprising, with physicians’ overuse of "low-value" services extending beyond Medicare. But new payment strategies and financial incentives, such as those employed by his state Medicaid program, seem to be helping to change such practice patterns and manage total cost of care, he said.

"Low-value activities are embedded throughout the routine orders of health care," Dr. Golden said in an interview. "Since Arkansas Medicaid has made health providers accountable for total cost of care and included shared savings and cost sharing, the health care community has invested the time and energy to retrain clinical reflexive behavior. Delineation of effective strategies coupled with financial incentives has promise to be a promising strategy in our state."

Mr. Schwartz reported having no conflicts of interest.

Pediatricians should expect high quality care from freestanding urgent care facilities for their patients and should reconsider whether to send children to facilities that can’t meet that standard of care.

That’s according to a policy statement from the American Academy of Pediatrics published April 28 (Pediatrics 2014;133:950-3).

Among the tenets of the new policy statement:

• Emergency preparedness. Freestanding urgent care centers serving children should be able to provide timely assessment and stabilization, resuscitation if needed, and to initiate the transfer of children with emergencies.

Providers at freestanding urgent care centers should be capable of initiating pediatric life support during all hours of operation, according to the policy statement. Facilities should have prearranged triage, transfer, and transport agreements with area hospitals and local emergency medical services, and participate in community disaster plans.

• Scope of practice: Freestanding urgent care centers should set limits on intensity and scope of care, use evidence-based treatment approaches for common pediatric complaints, and know how to identify and manage child abuse or neglect and how to manage children with special needs.

• Medical home: Such centers should support the medical home model by providing services not routinely available in medical homes and offering an alternative if the medical home is unavailable.

Referring physicians should provide necessary clinical information to urgent care centers and be available "to provide consultation and context" for patients’ management, according to the policy statement. Facilities, in turn, should keep appropriate records and communicate promptly with medical homes.

Nationwide, urgent care centers in the United States handle more than 160 million adult and pediatric visits annually, according to the Urgent Care Association of America. Overall, 14% of people seeking treatment at such facilities are aged 13 years or younger, and another 15% are between the ages of 14 and 22 years.

State regulation of freestanding urgent care centers varies greatly, the AAP policy statement notes, as do facilities’ services, though often they include simple suturing and splinting, laboratory tests, and x-rays.

Dr. Gregory Conners of the AAP Committee on Pediatric Emergency Medicine and lead author of the policy statement cites the need to define clearly when urgent care is appropriate for children and make sure it is well integrated with the child’s primary care.

"The medical home provider ought to make sure the urgent care center is meeting these [AAP] standards," Dr. Conners said. "If not, the primary care provider should reconsider whether to send children there or not."

Dr. Conners, chief of the division of emergency and urgent care at Children’s Mercy Hospital in Kansas City, Mo., also stressed the need for more research into the nature, scope, quality, and outcomes of pediatric urgent care to determine what is and isn’t working.

Dr. Nathan Newman, president of the urgent care association, said in an interview that the urgent care association is pleased with the collaborative nature of the AAP policy.

"Well-managed urgent care facilities do improve the health of children in their communities ... and the key going forward is integration, because health care is a local phenomenon and urgent care centers are not competing with primary care physicians," he said. "We want to extend the capability."

He noted that the association launched a new accreditation program in March for urgent care centers that includes standards for governance, patient care processes, quality improvement, physical environment, health record management, and patient privacy.

The AAP policy statement does not address pediatric care at hospital-based urgent care facilities, hospital-based or freestanding emergency departments, or retail-based clinics.

Pediatricians should expect high quality care from freestanding urgent care facilities for their patients and should reconsider whether to send children to facilities that can’t meet that standard of care.

That’s according to a policy statement from the American Academy of Pediatrics published April 28 (Pediatrics 2014;133:950-3).

Among the tenets of the new policy statement:

• Emergency preparedness. Freestanding urgent care centers serving children should be able to provide timely assessment and stabilization, resuscitation if needed, and to initiate the transfer of children with emergencies.

Providers at freestanding urgent care centers should be capable of initiating pediatric life support during all hours of operation, according to the policy statement. Facilities should have prearranged triage, transfer, and transport agreements with area hospitals and local emergency medical services, and participate in community disaster plans.

• Scope of practice: Freestanding urgent care centers should set limits on intensity and scope of care, use evidence-based treatment approaches for common pediatric complaints, and know how to identify and manage child abuse or neglect and how to manage children with special needs.

• Medical home: Such centers should support the medical home model by providing services not routinely available in medical homes and offering an alternative if the medical home is unavailable.

Referring physicians should provide necessary clinical information to urgent care centers and be available "to provide consultation and context" for patients’ management, according to the policy statement. Facilities, in turn, should keep appropriate records and communicate promptly with medical homes.

Nationwide, urgent care centers in the United States handle more than 160 million adult and pediatric visits annually, according to the Urgent Care Association of America. Overall, 14% of people seeking treatment at such facilities are aged 13 years or younger, and another 15% are between the ages of 14 and 22 years.

State regulation of freestanding urgent care centers varies greatly, the AAP policy statement notes, as do facilities’ services, though often they include simple suturing and splinting, laboratory tests, and x-rays.

Dr. Gregory Conners of the AAP Committee on Pediatric Emergency Medicine and lead author of the policy statement cites the need to define clearly when urgent care is appropriate for children and make sure it is well integrated with the child’s primary care.

"The medical home provider ought to make sure the urgent care center is meeting these [AAP] standards," Dr. Conners said. "If not, the primary care provider should reconsider whether to send children there or not."

Dr. Conners, chief of the division of emergency and urgent care at Children’s Mercy Hospital in Kansas City, Mo., also stressed the need for more research into the nature, scope, quality, and outcomes of pediatric urgent care to determine what is and isn’t working.

Dr. Nathan Newman, president of the urgent care association, said in an interview that the urgent care association is pleased with the collaborative nature of the AAP policy.

"Well-managed urgent care facilities do improve the health of children in their communities ... and the key going forward is integration, because health care is a local phenomenon and urgent care centers are not competing with primary care physicians," he said. "We want to extend the capability."

He noted that the association launched a new accreditation program in March for urgent care centers that includes standards for governance, patient care processes, quality improvement, physical environment, health record management, and patient privacy.

The AAP policy statement does not address pediatric care at hospital-based urgent care facilities, hospital-based or freestanding emergency departments, or retail-based clinics.

Pediatricians should expect high quality care from freestanding urgent care facilities for their patients and should reconsider whether to send children to facilities that can’t meet that standard of care.

That’s according to a policy statement from the American Academy of Pediatrics published April 28 (Pediatrics 2014;133:950-3).

Among the tenets of the new policy statement:

• Emergency preparedness. Freestanding urgent care centers serving children should be able to provide timely assessment and stabilization, resuscitation if needed, and to initiate the transfer of children with emergencies.

Providers at freestanding urgent care centers should be capable of initiating pediatric life support during all hours of operation, according to the policy statement. Facilities should have prearranged triage, transfer, and transport agreements with area hospitals and local emergency medical services, and participate in community disaster plans.

• Scope of practice: Freestanding urgent care centers should set limits on intensity and scope of care, use evidence-based treatment approaches for common pediatric complaints, and know how to identify and manage child abuse or neglect and how to manage children with special needs.

• Medical home: Such centers should support the medical home model by providing services not routinely available in medical homes and offering an alternative if the medical home is unavailable.

Referring physicians should provide necessary clinical information to urgent care centers and be available "to provide consultation and context" for patients’ management, according to the policy statement. Facilities, in turn, should keep appropriate records and communicate promptly with medical homes.

Nationwide, urgent care centers in the United States handle more than 160 million adult and pediatric visits annually, according to the Urgent Care Association of America. Overall, 14% of people seeking treatment at such facilities are aged 13 years or younger, and another 15% are between the ages of 14 and 22 years.

State regulation of freestanding urgent care centers varies greatly, the AAP policy statement notes, as do facilities’ services, though often they include simple suturing and splinting, laboratory tests, and x-rays.

Dr. Gregory Conners of the AAP Committee on Pediatric Emergency Medicine and lead author of the policy statement cites the need to define clearly when urgent care is appropriate for children and make sure it is well integrated with the child’s primary care.

"The medical home provider ought to make sure the urgent care center is meeting these [AAP] standards," Dr. Conners said. "If not, the primary care provider should reconsider whether to send children there or not."

Dr. Conners, chief of the division of emergency and urgent care at Children’s Mercy Hospital in Kansas City, Mo., also stressed the need for more research into the nature, scope, quality, and outcomes of pediatric urgent care to determine what is and isn’t working.

Dr. Nathan Newman, president of the urgent care association, said in an interview that the urgent care association is pleased with the collaborative nature of the AAP policy.

"Well-managed urgent care facilities do improve the health of children in their communities ... and the key going forward is integration, because health care is a local phenomenon and urgent care centers are not competing with primary care physicians," he said. "We want to extend the capability."

He noted that the association launched a new accreditation program in March for urgent care centers that includes standards for governance, patient care processes, quality improvement, physical environment, health record management, and patient privacy.

The AAP policy statement does not address pediatric care at hospital-based urgent care facilities, hospital-based or freestanding emergency departments, or retail-based clinics.

One in three children aged 18 and under in the United States now has public health insurance coverage, according to a new report funded by the Robert Wood Johnson Foundation.

Some of the greatest coverage gains have occurred in children from low-income households and among nonwhite and Hispanic children, who have the highest rates of being uninsured.

Nationwide, the proportion of children with private insurance fell from 64.5% in 2008 to 59% in 2012. The declines in private coverage for children were statistically significant in 45 states, but Medicaid and the Children’s Health Insurance Program (CHIP) have more than offset the reductions by covering 33.6% of children in 2012, up from 25.8% in 2008, according to the report.

In 2012, 7.5% of children in the were without health insurance, down from 9.7 percent in 2008. The report, by the University of Minnesota’s State Health Access Data Assistance Center, uses U.S. Census Bureau data from 2008 through 2012, the most recent data available.

Dr. Mary Tierney, a Washington-based pediatrician and nationally recognized expert on Medicaid and CHIP, described the findings as encouraging. "We have in this country done a really good job of getting our children insured," she said in an interview.

Overall, 35 states experienced statistically significant declines in rates of uninsured children and no states showed an increase over the 5 years, according to the report’s state-by-state analysis. Rates of uninsured children ranged from 1.4% in Massachusetts to 17% in Nevada. Oregon had the largest drop in uninsured children, followed by Florida, Delaware, Mississippi, and South Dakota.

While there remains substantial variation in children’s coverage based on income, the report cites a narrowing of the gap between low- and higher-income children. Compared to children with family incomes that were at 400% of poverty level or higher, children with family incomes at or below 138% of the federal poverty level were 4.5 times more likely to be uninsured in 2012 – down from 5.3 times likelier to be uninsured in 2008.

The report cites a reduction in coverage disparities linked to race and ethnicity. In 2012, nonwhite children were 1.3 times more likely to be uninsured than were white children; in 2008, they were 1.5 times likelier to be uninsured. Similarly, the gap has narrowed between uninsured Hispanic and white children, dropping from a rate 2.8 times higher for Hispanic children in 2008 to a rate 2.3 times higher in 2012.

One in three children aged 18 and under in the United States now has public health insurance coverage, according to a new report funded by the Robert Wood Johnson Foundation.

Some of the greatest coverage gains have occurred in children from low-income households and among nonwhite and Hispanic children, who have the highest rates of being uninsured.

Nationwide, the proportion of children with private insurance fell from 64.5% in 2008 to 59% in 2012. The declines in private coverage for children were statistically significant in 45 states, but Medicaid and the Children’s Health Insurance Program (CHIP) have more than offset the reductions by covering 33.6% of children in 2012, up from 25.8% in 2008, according to the report.

In 2012, 7.5% of children in the were without health insurance, down from 9.7 percent in 2008. The report, by the University of Minnesota’s State Health Access Data Assistance Center, uses U.S. Census Bureau data from 2008 through 2012, the most recent data available.

Dr. Mary Tierney, a Washington-based pediatrician and nationally recognized expert on Medicaid and CHIP, described the findings as encouraging. "We have in this country done a really good job of getting our children insured," she said in an interview.

Overall, 35 states experienced statistically significant declines in rates of uninsured children and no states showed an increase over the 5 years, according to the report’s state-by-state analysis. Rates of uninsured children ranged from 1.4% in Massachusetts to 17% in Nevada. Oregon had the largest drop in uninsured children, followed by Florida, Delaware, Mississippi, and South Dakota.

While there remains substantial variation in children’s coverage based on income, the report cites a narrowing of the gap between low- and higher-income children. Compared to children with family incomes that were at 400% of poverty level or higher, children with family incomes at or below 138% of the federal poverty level were 4.5 times more likely to be uninsured in 2012 – down from 5.3 times likelier to be uninsured in 2008.

The report cites a reduction in coverage disparities linked to race and ethnicity. In 2012, nonwhite children were 1.3 times more likely to be uninsured than were white children; in 2008, they were 1.5 times likelier to be uninsured. Similarly, the gap has narrowed between uninsured Hispanic and white children, dropping from a rate 2.8 times higher for Hispanic children in 2008 to a rate 2.3 times higher in 2012.

One in three children aged 18 and under in the United States now has public health insurance coverage, according to a new report funded by the Robert Wood Johnson Foundation.

Some of the greatest coverage gains have occurred in children from low-income households and among nonwhite and Hispanic children, who have the highest rates of being uninsured.

Nationwide, the proportion of children with private insurance fell from 64.5% in 2008 to 59% in 2012. The declines in private coverage for children were statistically significant in 45 states, but Medicaid and the Children’s Health Insurance Program (CHIP) have more than offset the reductions by covering 33.6% of children in 2012, up from 25.8% in 2008, according to the report.

In 2012, 7.5% of children in the were without health insurance, down from 9.7 percent in 2008. The report, by the University of Minnesota’s State Health Access Data Assistance Center, uses U.S. Census Bureau data from 2008 through 2012, the most recent data available.

Dr. Mary Tierney, a Washington-based pediatrician and nationally recognized expert on Medicaid and CHIP, described the findings as encouraging. "We have in this country done a really good job of getting our children insured," she said in an interview.

Overall, 35 states experienced statistically significant declines in rates of uninsured children and no states showed an increase over the 5 years, according to the report’s state-by-state analysis. Rates of uninsured children ranged from 1.4% in Massachusetts to 17% in Nevada. Oregon had the largest drop in uninsured children, followed by Florida, Delaware, Mississippi, and South Dakota.

While there remains substantial variation in children’s coverage based on income, the report cites a narrowing of the gap between low- and higher-income children. Compared to children with family incomes that were at 400% of poverty level or higher, children with family incomes at or below 138% of the federal poverty level were 4.5 times more likely to be uninsured in 2012 – down from 5.3 times likelier to be uninsured in 2008.

The report cites a reduction in coverage disparities linked to race and ethnicity. In 2012, nonwhite children were 1.3 times more likely to be uninsured than were white children; in 2008, they were 1.5 times likelier to be uninsured. Similarly, the gap has narrowed between uninsured Hispanic and white children, dropping from a rate 2.8 times higher for Hispanic children in 2008 to a rate 2.3 times higher in 2012.