Sharon Worcester

Miami — Etanercept therapy in children and adolescents with moderate to severe plaque psoriasis remained safe, well tolerated, and efficacious in the first 96 weeks of a 5-year open-label extension study, Dr. Richard Langley reported at the annual meeting of the American Academy of Dermatology.

The multicenter study, designed to evaluate long-term safety and efficacy of the immunosuppressant drug in the pediatric population, followed an initial 48-week randomized controlled trial reported in 2008 (N. Engl. J. Med. 2008;358:241-51). Read our story here.

Of 211 patients aged 4-17 years included in the initial trial, 182 (86%) completed that trial or achieved Psoriasis Area Severity Index (PASI) of 50 or better on or after week 12 with no adverse events, and thus were eligible and agreed to participate in the extension study. Of these, most (80%) reported at least one adverse event by week 96 of the extension study, but only three reported a total of five serious adverse events, none of which were infectious or deemed attributable to etanercept, Dr. Langley, director of research in the division of clinical dermatology and cutaneous science at Dalhousie University, Halifax, N.S., said during a poster discussion session.

The most common adverse events were upper respiratory tract infections in 25% of patients, nasopharyngitis in 17%, streptococcal pharyngitis in 13%, headache in 12%, and sinusitis in 11%. Serious adverse events were anxiety in one patient, intestinal obstruction in one patient, and abdominal pain, dehydration, and elective abortion all in one patient, Dr. Langley said, stressing that no opportunistic infections or malignancies occurred, which is particularly important to consider when evaluating the safety of an immunosuppressive agent.

Only two patients in the extension phase withdrew due to adverse events, and neither of these (Crohn’s disease in one, and sinusitis in one) were considered to be due to etanercept. Other patients did withdraw, however, most often due to consent withdrawal (19 patients) and loss to follow-up (14 patients); 140 patients completed 96 weeks of the extension study, and most (89%) of these achieved PASI of 50 or better (relative to baseline in the initial 48-week trial), including 30% who achieved PASI of 90 or better.

The mean PASI improvement was about 70%, and static Physician Global Assessment scores of 0 or 1 (clear or almost clear) were achieved in 47% of patients.

Treatment in both the initial and extension phases of the trial involved once-weekly subcutaneous injection of 0.8 mg/kg of etanercept, with a maximum dose of 50 mg/kg. Patients were also allowed to use standard topical treatments.

The conclusion at this stage of the trial is that etanercept is acceptably safe in this population at 96 weeks, Dr. Langley said, adding that this is the longest extension in a randomized controlled trial of patients receiving etanercept. No new adverse events or serious adverse events were seen, compared with the initial research.

“We believe this supports the continued study [of etanercept] and we will continue to follow these patients up to 5 years for infections and major adverse events,” he said.

Dr. Langley disclosed that he was an adviser and investigator for Amgen, and he has received grants and honoraria from Amgen. This trial was funded by Immunex Corp., a wholly-owned subsidiary of Amgen. Amgen and Wyeth Pharmaceuticals Inc. (now a part of Pfizer) together market Enbrel (etanercept).

Miami — Etanercept therapy in children and adolescents with moderate to severe plaque psoriasis remained safe, well tolerated, and efficacious in the first 96 weeks of a 5-year open-label extension study, Dr. Richard Langley reported at the annual meeting of the American Academy of Dermatology.

The multicenter study, designed to evaluate long-term safety and efficacy of the immunosuppressant drug in the pediatric population, followed an initial 48-week randomized controlled trial reported in 2008 (N. Engl. J. Med. 2008;358:241-51). Read our story here.

Of 211 patients aged 4-17 years included in the initial trial, 182 (86%) completed that trial or achieved Psoriasis Area Severity Index (PASI) of 50 or better on or after week 12 with no adverse events, and thus were eligible and agreed to participate in the extension study. Of these, most (80%) reported at least one adverse event by week 96 of the extension study, but only three reported a total of five serious adverse events, none of which were infectious or deemed attributable to etanercept, Dr. Langley, director of research in the division of clinical dermatology and cutaneous science at Dalhousie University, Halifax, N.S., said during a poster discussion session.

The most common adverse events were upper respiratory tract infections in 25% of patients, nasopharyngitis in 17%, streptococcal pharyngitis in 13%, headache in 12%, and sinusitis in 11%. Serious adverse events were anxiety in one patient, intestinal obstruction in one patient, and abdominal pain, dehydration, and elective abortion all in one patient, Dr. Langley said, stressing that no opportunistic infections or malignancies occurred, which is particularly important to consider when evaluating the safety of an immunosuppressive agent.

Only two patients in the extension phase withdrew due to adverse events, and neither of these (Crohn’s disease in one, and sinusitis in one) were considered to be due to etanercept. Other patients did withdraw, however, most often due to consent withdrawal (19 patients) and loss to follow-up (14 patients); 140 patients completed 96 weeks of the extension study, and most (89%) of these achieved PASI of 50 or better (relative to baseline in the initial 48-week trial), including 30% who achieved PASI of 90 or better.

The mean PASI improvement was about 70%, and static Physician Global Assessment scores of 0 or 1 (clear or almost clear) were achieved in 47% of patients.

Treatment in both the initial and extension phases of the trial involved once-weekly subcutaneous injection of 0.8 mg/kg of etanercept, with a maximum dose of 50 mg/kg. Patients were also allowed to use standard topical treatments.

The conclusion at this stage of the trial is that etanercept is acceptably safe in this population at 96 weeks, Dr. Langley said, adding that this is the longest extension in a randomized controlled trial of patients receiving etanercept. No new adverse events or serious adverse events were seen, compared with the initial research.

“We believe this supports the continued study [of etanercept] and we will continue to follow these patients up to 5 years for infections and major adverse events,” he said.

Dr. Langley disclosed that he was an adviser and investigator for Amgen, and he has received grants and honoraria from Amgen. This trial was funded by Immunex Corp., a wholly-owned subsidiary of Amgen. Amgen and Wyeth Pharmaceuticals Inc. (now a part of Pfizer) together market Enbrel (etanercept).

Miami — Etanercept therapy in children and adolescents with moderate to severe plaque psoriasis remained safe, well tolerated, and efficacious in the first 96 weeks of a 5-year open-label extension study, Dr. Richard Langley reported at the annual meeting of the American Academy of Dermatology.

The multicenter study, designed to evaluate long-term safety and efficacy of the immunosuppressant drug in the pediatric population, followed an initial 48-week randomized controlled trial reported in 2008 (N. Engl. J. Med. 2008;358:241-51). Read our story here.

Of 211 patients aged 4-17 years included in the initial trial, 182 (86%) completed that trial or achieved Psoriasis Area Severity Index (PASI) of 50 or better on or after week 12 with no adverse events, and thus were eligible and agreed to participate in the extension study. Of these, most (80%) reported at least one adverse event by week 96 of the extension study, but only three reported a total of five serious adverse events, none of which were infectious or deemed attributable to etanercept, Dr. Langley, director of research in the division of clinical dermatology and cutaneous science at Dalhousie University, Halifax, N.S., said during a poster discussion session.

The most common adverse events were upper respiratory tract infections in 25% of patients, nasopharyngitis in 17%, streptococcal pharyngitis in 13%, headache in 12%, and sinusitis in 11%. Serious adverse events were anxiety in one patient, intestinal obstruction in one patient, and abdominal pain, dehydration, and elective abortion all in one patient, Dr. Langley said, stressing that no opportunistic infections or malignancies occurred, which is particularly important to consider when evaluating the safety of an immunosuppressive agent.

Only two patients in the extension phase withdrew due to adverse events, and neither of these (Crohn’s disease in one, and sinusitis in one) were considered to be due to etanercept. Other patients did withdraw, however, most often due to consent withdrawal (19 patients) and loss to follow-up (14 patients); 140 patients completed 96 weeks of the extension study, and most (89%) of these achieved PASI of 50 or better (relative to baseline in the initial 48-week trial), including 30% who achieved PASI of 90 or better.

The mean PASI improvement was about 70%, and static Physician Global Assessment scores of 0 or 1 (clear or almost clear) were achieved in 47% of patients.

Treatment in both the initial and extension phases of the trial involved once-weekly subcutaneous injection of 0.8 mg/kg of etanercept, with a maximum dose of 50 mg/kg. Patients were also allowed to use standard topical treatments.

The conclusion at this stage of the trial is that etanercept is acceptably safe in this population at 96 weeks, Dr. Langley said, adding that this is the longest extension in a randomized controlled trial of patients receiving etanercept. No new adverse events or serious adverse events were seen, compared with the initial research.

“We believe this supports the continued study [of etanercept] and we will continue to follow these patients up to 5 years for infections and major adverse events,” he said.

Dr. Langley disclosed that he was an adviser and investigator for Amgen, and he has received grants and honoraria from Amgen. This trial was funded by Immunex Corp., a wholly-owned subsidiary of Amgen. Amgen and Wyeth Pharmaceuticals Inc. (now a part of Pfizer) together market Enbrel (etanercept).

Drinking 12 or more cups of coffee daily was associated with a significant reduction in the incidence of type 2 diabetes over nearly 8 years, compared with consuming no coffee, according a study.

The study looked at the self-reported coffee intake of the 4,579-person Strong Heart Study, an investigation of cardiovascular disease in 13 American Indian tribes/communities. Participants in that study had baseline data collected during 1989–1992 and were followed for an average of 7.6 years.

Participants in the current analysis were the 1,141 men and women who had normal fasting glucose at baseline, wrote Dr. Ying Zhang of the Oklahoma University Health Sciences Center, Oklahoma City, and associates (Nutr. Metab. Cardiovasc. Dis. 2009; Feb. 18 2010 [doi:10.1016/j.numecd.2009.10.020]).

The 92 (8.1%) participants who reported drinking at least 12 cups of coffee daily had a 67% lower risk (hazard ratio, 0.33) of developing type 2 diabetes during the follow-up period than did non–coffee drinkers, even after adjustment for age, gender, smoking, alcohol use, family history of diabetes, physical activity, and body mass index, the researchers noted.

In fact, coffee consumption was significantly related to diabetes risk only in those people who drank 12 or more cups daily.

The findings support those from several other studies showing a link between caffeine intake and diabetes development, but this is one of the few investigations that focused on a population known to have a high incidence of diabetes and on a group that, at baseline, had normal glucose tolerance.

The study was limited by a lack of available dietary data on the participants. It is plausible that high coffee consumption is a marker for dietary patterns and factors related to diabetes risk but not measured in this study, Dr. Zhang and associates noted.

The study was supported by grants from the National Heart, Lung, and Blood Institute, Bethesda, Md.

A dozen cups of coffee or more per day yielded significant risk reduction.

Source ©Robert Brown/Fotolia.com

Drinking 12 or more cups of coffee daily was associated with a significant reduction in the incidence of type 2 diabetes over nearly 8 years, compared with consuming no coffee, according a study.

The study looked at the self-reported coffee intake of the 4,579-person Strong Heart Study, an investigation of cardiovascular disease in 13 American Indian tribes/communities. Participants in that study had baseline data collected during 1989–1992 and were followed for an average of 7.6 years.

Participants in the current analysis were the 1,141 men and women who had normal fasting glucose at baseline, wrote Dr. Ying Zhang of the Oklahoma University Health Sciences Center, Oklahoma City, and associates (Nutr. Metab. Cardiovasc. Dis. 2009; Feb. 18 2010 [doi:10.1016/j.numecd.2009.10.020]).

The 92 (8.1%) participants who reported drinking at least 12 cups of coffee daily had a 67% lower risk (hazard ratio, 0.33) of developing type 2 diabetes during the follow-up period than did non–coffee drinkers, even after adjustment for age, gender, smoking, alcohol use, family history of diabetes, physical activity, and body mass index, the researchers noted.

In fact, coffee consumption was significantly related to diabetes risk only in those people who drank 12 or more cups daily.

The findings support those from several other studies showing a link between caffeine intake and diabetes development, but this is one of the few investigations that focused on a population known to have a high incidence of diabetes and on a group that, at baseline, had normal glucose tolerance.

The study was limited by a lack of available dietary data on the participants. It is plausible that high coffee consumption is a marker for dietary patterns and factors related to diabetes risk but not measured in this study, Dr. Zhang and associates noted.

The study was supported by grants from the National Heart, Lung, and Blood Institute, Bethesda, Md.

A dozen cups of coffee or more per day yielded significant risk reduction.

Source ©Robert Brown/Fotolia.com

Drinking 12 or more cups of coffee daily was associated with a significant reduction in the incidence of type 2 diabetes over nearly 8 years, compared with consuming no coffee, according a study.

The study looked at the self-reported coffee intake of the 4,579-person Strong Heart Study, an investigation of cardiovascular disease in 13 American Indian tribes/communities. Participants in that study had baseline data collected during 1989–1992 and were followed for an average of 7.6 years.

Participants in the current analysis were the 1,141 men and women who had normal fasting glucose at baseline, wrote Dr. Ying Zhang of the Oklahoma University Health Sciences Center, Oklahoma City, and associates (Nutr. Metab. Cardiovasc. Dis. 2009; Feb. 18 2010 [doi:10.1016/j.numecd.2009.10.020]).

The 92 (8.1%) participants who reported drinking at least 12 cups of coffee daily had a 67% lower risk (hazard ratio, 0.33) of developing type 2 diabetes during the follow-up period than did non–coffee drinkers, even after adjustment for age, gender, smoking, alcohol use, family history of diabetes, physical activity, and body mass index, the researchers noted.

In fact, coffee consumption was significantly related to diabetes risk only in those people who drank 12 or more cups daily.

The findings support those from several other studies showing a link between caffeine intake and diabetes development, but this is one of the few investigations that focused on a population known to have a high incidence of diabetes and on a group that, at baseline, had normal glucose tolerance.

The study was limited by a lack of available dietary data on the participants. It is plausible that high coffee consumption is a marker for dietary patterns and factors related to diabetes risk but not measured in this study, Dr. Zhang and associates noted.

The study was supported by grants from the National Heart, Lung, and Blood Institute, Bethesda, Md.

A dozen cups of coffee or more per day yielded significant risk reduction.

Source ©Robert Brown/Fotolia.com

SAN FRANCISCO — Outpatient paracentesis is one-fifth the cost of hospitalization for managing ovarian hyperstimulation syndrome.

The total direct cost (2007 estimates) would be $10,098 for inpatient therapy including first-tier complications, compared with $1,954 for outpatient management, Dr. Joelle E. Taylor reported at the annual meeting of the American Society for Reproductive Medicine.

The finding is based on a decision-tree analysis derived from outcome probabilities and outpatient management effectiveness data from the published literature and from a retrospective chart study.

For the analysis, conservative inpatient treatment was compared with outpatient paracentesis in patients with moderate to severe ovarian hyperstimulation syndrome (OHSS)—a syndrome that occurs in up to 5% of assisted reproductive technology cycles and has potentially severe complications such as thromboembolism and respiratory distress syndrome.

“Early intervention and outpatient management translated into a cost savings of more than $8,100 per patient,” said Dr. Taylor, who was a visiting resident at the National Institute of Child Health and Human Development, Bethesda, Md., at the time the study was conducted. Currently, Dr. Taylor is an ob.gyn. at Wake Forest University, Winston-Salem, N.C.

Even after varying the probability of admission following outpatient treatment, outpatient paracentesis remained the most cost-effective treatment strategy, and varying the duration of hospitalization showed that inpatient and outpatient treatment costs were comparable only when the hospital stay was 0.71 days or less, Dr. Taylor noted.

Furthermore, if every patient with OHSS who was managed on an outpatient basis required three paracenteses to resolve the syndrome, the outpatient treatment cost increased by less than $900 (to $2,851)—still a marked reduction compared with the cost of inpatient therapy, Dr. Taylor said.

“The cost savings [with outpatient paracentesis] persisted despite a variety of outcome probabilities and treatment scenarios,” she said.

SAN FRANCISCO — Outpatient paracentesis is one-fifth the cost of hospitalization for managing ovarian hyperstimulation syndrome.

The total direct cost (2007 estimates) would be $10,098 for inpatient therapy including first-tier complications, compared with $1,954 for outpatient management, Dr. Joelle E. Taylor reported at the annual meeting of the American Society for Reproductive Medicine.

The finding is based on a decision-tree analysis derived from outcome probabilities and outpatient management effectiveness data from the published literature and from a retrospective chart study.

For the analysis, conservative inpatient treatment was compared with outpatient paracentesis in patients with moderate to severe ovarian hyperstimulation syndrome (OHSS)—a syndrome that occurs in up to 5% of assisted reproductive technology cycles and has potentially severe complications such as thromboembolism and respiratory distress syndrome.

“Early intervention and outpatient management translated into a cost savings of more than $8,100 per patient,” said Dr. Taylor, who was a visiting resident at the National Institute of Child Health and Human Development, Bethesda, Md., at the time the study was conducted. Currently, Dr. Taylor is an ob.gyn. at Wake Forest University, Winston-Salem, N.C.

Even after varying the probability of admission following outpatient treatment, outpatient paracentesis remained the most cost-effective treatment strategy, and varying the duration of hospitalization showed that inpatient and outpatient treatment costs were comparable only when the hospital stay was 0.71 days or less, Dr. Taylor noted.

Furthermore, if every patient with OHSS who was managed on an outpatient basis required three paracenteses to resolve the syndrome, the outpatient treatment cost increased by less than $900 (to $2,851)—still a marked reduction compared with the cost of inpatient therapy, Dr. Taylor said.

“The cost savings [with outpatient paracentesis] persisted despite a variety of outcome probabilities and treatment scenarios,” she said.

SAN FRANCISCO — Outpatient paracentesis is one-fifth the cost of hospitalization for managing ovarian hyperstimulation syndrome.

The total direct cost (2007 estimates) would be $10,098 for inpatient therapy including first-tier complications, compared with $1,954 for outpatient management, Dr. Joelle E. Taylor reported at the annual meeting of the American Society for Reproductive Medicine.

The finding is based on a decision-tree analysis derived from outcome probabilities and outpatient management effectiveness data from the published literature and from a retrospective chart study.

For the analysis, conservative inpatient treatment was compared with outpatient paracentesis in patients with moderate to severe ovarian hyperstimulation syndrome (OHSS)—a syndrome that occurs in up to 5% of assisted reproductive technology cycles and has potentially severe complications such as thromboembolism and respiratory distress syndrome.

“Early intervention and outpatient management translated into a cost savings of more than $8,100 per patient,” said Dr. Taylor, who was a visiting resident at the National Institute of Child Health and Human Development, Bethesda, Md., at the time the study was conducted. Currently, Dr. Taylor is an ob.gyn. at Wake Forest University, Winston-Salem, N.C.

Even after varying the probability of admission following outpatient treatment, outpatient paracentesis remained the most cost-effective treatment strategy, and varying the duration of hospitalization showed that inpatient and outpatient treatment costs were comparable only when the hospital stay was 0.71 days or less, Dr. Taylor noted.

Furthermore, if every patient with OHSS who was managed on an outpatient basis required three paracenteses to resolve the syndrome, the outpatient treatment cost increased by less than $900 (to $2,851)—still a marked reduction compared with the cost of inpatient therapy, Dr. Taylor said.

“The cost savings [with outpatient paracentesis] persisted despite a variety of outcome probabilities and treatment scenarios,” she said.

SAN FRANCISCO — The transfer of more than one embryo during in vitro fertilization has a substantial adverse residual effect on intrauterine growth—even when only one fetal heart is detected on early ultrasound, findings from a large historical cohort study suggest.

A review of data from 23,999 singleton live births resulting from assisted reproductive technology cycles performed from 2004 to 2006 showed that the risk for intrauterine growth restriction increased significantly with the number of embryos transferred; compared with one embryo transferred, the risks were increased by 16%, 24%, 34% and 56% when two, three, four, or five embryos were transferred, respectively, Barbara Luke, Sc.D., reported at the annual meeting of the American Society for Reproductive Medicine.

No differences were seen in preterm birth weights based on the number of embryos transferred.

Also, factors such as maternal age, birth weight (mean of 3,243 g), length of gestation (mean of 265 days), and birth weight for gestation (z score, mean of 0.30 standard deviation units) did not differ significantly across the embryo transfer groups, noted Dr. Luke of Michigan State University, East Lansing.

Preterm birth was defined as birth prior to 37 weeks' gestation, and intrauterine growth restriction was defined as a z score of less than −1. The z score is a measure of intrauterine growth adequacy, with a mean of 0 (indicating the 50th percentile of intrauterine growth), she explained.

The findings support the theory that there is a critical period during which abnormal placentation related to the transfer of multiple embryos may adversely affect pregnancy—even for singletons, Dr. Luke concluded.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — The transfer of more than one embryo during in vitro fertilization has a substantial adverse residual effect on intrauterine growth—even when only one fetal heart is detected on early ultrasound, findings from a large historical cohort study suggest.

A review of data from 23,999 singleton live births resulting from assisted reproductive technology cycles performed from 2004 to 2006 showed that the risk for intrauterine growth restriction increased significantly with the number of embryos transferred; compared with one embryo transferred, the risks were increased by 16%, 24%, 34% and 56% when two, three, four, or five embryos were transferred, respectively, Barbara Luke, Sc.D., reported at the annual meeting of the American Society for Reproductive Medicine.

No differences were seen in preterm birth weights based on the number of embryos transferred.

Also, factors such as maternal age, birth weight (mean of 3,243 g), length of gestation (mean of 265 days), and birth weight for gestation (z score, mean of 0.30 standard deviation units) did not differ significantly across the embryo transfer groups, noted Dr. Luke of Michigan State University, East Lansing.

Preterm birth was defined as birth prior to 37 weeks' gestation, and intrauterine growth restriction was defined as a z score of less than −1. The z score is a measure of intrauterine growth adequacy, with a mean of 0 (indicating the 50th percentile of intrauterine growth), she explained.

The findings support the theory that there is a critical period during which abnormal placentation related to the transfer of multiple embryos may adversely affect pregnancy—even for singletons, Dr. Luke concluded.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — The transfer of more than one embryo during in vitro fertilization has a substantial adverse residual effect on intrauterine growth—even when only one fetal heart is detected on early ultrasound, findings from a large historical cohort study suggest.

A review of data from 23,999 singleton live births resulting from assisted reproductive technology cycles performed from 2004 to 2006 showed that the risk for intrauterine growth restriction increased significantly with the number of embryos transferred; compared with one embryo transferred, the risks were increased by 16%, 24%, 34% and 56% when two, three, four, or five embryos were transferred, respectively, Barbara Luke, Sc.D., reported at the annual meeting of the American Society for Reproductive Medicine.

No differences were seen in preterm birth weights based on the number of embryos transferred.

Also, factors such as maternal age, birth weight (mean of 3,243 g), length of gestation (mean of 265 days), and birth weight for gestation (z score, mean of 0.30 standard deviation units) did not differ significantly across the embryo transfer groups, noted Dr. Luke of Michigan State University, East Lansing.

Preterm birth was defined as birth prior to 37 weeks' gestation, and intrauterine growth restriction was defined as a z score of less than −1. The z score is a measure of intrauterine growth adequacy, with a mean of 0 (indicating the 50th percentile of intrauterine growth), she explained.

The findings support the theory that there is a critical period during which abnormal placentation related to the transfer of multiple embryos may adversely affect pregnancy—even for singletons, Dr. Luke concluded.

ELSEVIER GLOBAL MEDICAL NEWS

Breast cancer survivors are more likely to receive recommended care when they see both an oncology specialist and a primary care physician, data from a study of trends in survivor care between 1998 and 2002 in nearly 24,000 survivors suggest.

Claire F. Snyder, Ph.D., of Johns Hopkins University, Baltimore, and her colleagues used data from the Surveillance, Epidemiology and End Results Medicare-linked database (SEER-Medicare) to look at preventive, screening, and surveillance care trends in the 23,731 survivors of stage I-III breast cancer who were older than age 65 years, in fee-for-service Medicare, and diagnosed between 1998 and 2002. The survivors were grouped into five cohorts based on their year of diagnosis, and trends in this population were compared with those in controls.

Most survivors (55%–60% in each cohort) were followed during their first year of survivorship by both a primary care physician and an oncology specialist. The percentage of survivors who were followed by only an oncology specialist increased, and the percentage who were followed by only a primary care physician decreased over the study period, Dr. Snyder said.

The study was funded by the American Cancer Society.

Those patients who were seen by both types of providers were shown after risk adjustment to be more likely to receive each of the types of preventive care that were measured (J. Clin. Oncol. 2009 Jan. 21 [doi:10.1200/JCO.2008.18.0950]).

Of all survivors who were seeing both a primary care physician and an oncology specialist, 60% received flu shots, compared with fewer than about 50% in the other physician-mix groups; nearly 40% received cholesterol screening, compared with between 20% and just over 30% in the other groups; about 33% received colorectal cancer screening, compared with about 13%–22% in the other groups; and about 18% underwent bone densitometry, compared with fewer than 14% in the other groups, Dr. Snyder said.

The study was limited by the inclusion of only those survivors who were older than age 65 years in the Medicare fee-for-service program, and by the lack of data on why specific preventive services were or were not provided.

The findings emphasize the importance of coordination of care between both types of providers in providing follow-up care, she concluded.

In an earlier iteration of the study, data comparing 23,731 survivors with an equal number of “screening controls” (defined as those matched by age, ethnicity, sex, and region, as well as mammogram in the survivor's year of diagnosis) were presented by Dr. Snyder at the annual meeting of the American Society of Clinical Oncology.

Breast cancer survivors were found to be less likely to receive preventive care, with the exception of mammography, than were screening controls. However, trends over time in survivors' care tended to be better than in screening controls, Dr. Snyder said. No differences were seen over time in trends in primary care provider visits, but survivors' visits to other physician specialists increased faster than did those of controls.

Both survivors and screening controls received more flu shots (with similar increases over time in both groups), and more cholesterol screening (with a faster increase in rates among survivors over time) in 2002, compared with 1998. Also, more survivors received bone densitometry in 2002, compared with 1998; the rate in screening controls didn't change significantly over time. In the case of colorectal cancer screening, both groups received less screening in 2002, compared with 1998, she said.

Those patients who were seen by both types of providers were more likely to receive preventive care. DR. SNYDER

Breast cancer survivors are more likely to receive recommended care when they see both an oncology specialist and a primary care physician, data from a study of trends in survivor care between 1998 and 2002 in nearly 24,000 survivors suggest.

Claire F. Snyder, Ph.D., of Johns Hopkins University, Baltimore, and her colleagues used data from the Surveillance, Epidemiology and End Results Medicare-linked database (SEER-Medicare) to look at preventive, screening, and surveillance care trends in the 23,731 survivors of stage I-III breast cancer who were older than age 65 years, in fee-for-service Medicare, and diagnosed between 1998 and 2002. The survivors were grouped into five cohorts based on their year of diagnosis, and trends in this population were compared with those in controls.

Most survivors (55%–60% in each cohort) were followed during their first year of survivorship by both a primary care physician and an oncology specialist. The percentage of survivors who were followed by only an oncology specialist increased, and the percentage who were followed by only a primary care physician decreased over the study period, Dr. Snyder said.

The study was funded by the American Cancer Society.

Those patients who were seen by both types of providers were shown after risk adjustment to be more likely to receive each of the types of preventive care that were measured (J. Clin. Oncol. 2009 Jan. 21 [doi:10.1200/JCO.2008.18.0950]).

Of all survivors who were seeing both a primary care physician and an oncology specialist, 60% received flu shots, compared with fewer than about 50% in the other physician-mix groups; nearly 40% received cholesterol screening, compared with between 20% and just over 30% in the other groups; about 33% received colorectal cancer screening, compared with about 13%–22% in the other groups; and about 18% underwent bone densitometry, compared with fewer than 14% in the other groups, Dr. Snyder said.

The study was limited by the inclusion of only those survivors who were older than age 65 years in the Medicare fee-for-service program, and by the lack of data on why specific preventive services were or were not provided.

The findings emphasize the importance of coordination of care between both types of providers in providing follow-up care, she concluded.

In an earlier iteration of the study, data comparing 23,731 survivors with an equal number of “screening controls” (defined as those matched by age, ethnicity, sex, and region, as well as mammogram in the survivor's year of diagnosis) were presented by Dr. Snyder at the annual meeting of the American Society of Clinical Oncology.

Breast cancer survivors were found to be less likely to receive preventive care, with the exception of mammography, than were screening controls. However, trends over time in survivors' care tended to be better than in screening controls, Dr. Snyder said. No differences were seen over time in trends in primary care provider visits, but survivors' visits to other physician specialists increased faster than did those of controls.

Both survivors and screening controls received more flu shots (with similar increases over time in both groups), and more cholesterol screening (with a faster increase in rates among survivors over time) in 2002, compared with 1998. Also, more survivors received bone densitometry in 2002, compared with 1998; the rate in screening controls didn't change significantly over time. In the case of colorectal cancer screening, both groups received less screening in 2002, compared with 1998, she said.

Those patients who were seen by both types of providers were more likely to receive preventive care. DR. SNYDER

Breast cancer survivors are more likely to receive recommended care when they see both an oncology specialist and a primary care physician, data from a study of trends in survivor care between 1998 and 2002 in nearly 24,000 survivors suggest.

Claire F. Snyder, Ph.D., of Johns Hopkins University, Baltimore, and her colleagues used data from the Surveillance, Epidemiology and End Results Medicare-linked database (SEER-Medicare) to look at preventive, screening, and surveillance care trends in the 23,731 survivors of stage I-III breast cancer who were older than age 65 years, in fee-for-service Medicare, and diagnosed between 1998 and 2002. The survivors were grouped into five cohorts based on their year of diagnosis, and trends in this population were compared with those in controls.

Most survivors (55%–60% in each cohort) were followed during their first year of survivorship by both a primary care physician and an oncology specialist. The percentage of survivors who were followed by only an oncology specialist increased, and the percentage who were followed by only a primary care physician decreased over the study period, Dr. Snyder said.

The study was funded by the American Cancer Society.

Those patients who were seen by both types of providers were shown after risk adjustment to be more likely to receive each of the types of preventive care that were measured (J. Clin. Oncol. 2009 Jan. 21 [doi:10.1200/JCO.2008.18.0950]).

Of all survivors who were seeing both a primary care physician and an oncology specialist, 60% received flu shots, compared with fewer than about 50% in the other physician-mix groups; nearly 40% received cholesterol screening, compared with between 20% and just over 30% in the other groups; about 33% received colorectal cancer screening, compared with about 13%–22% in the other groups; and about 18% underwent bone densitometry, compared with fewer than 14% in the other groups, Dr. Snyder said.

The study was limited by the inclusion of only those survivors who were older than age 65 years in the Medicare fee-for-service program, and by the lack of data on why specific preventive services were or were not provided.

The findings emphasize the importance of coordination of care between both types of providers in providing follow-up care, she concluded.

In an earlier iteration of the study, data comparing 23,731 survivors with an equal number of “screening controls” (defined as those matched by age, ethnicity, sex, and region, as well as mammogram in the survivor's year of diagnosis) were presented by Dr. Snyder at the annual meeting of the American Society of Clinical Oncology.

Breast cancer survivors were found to be less likely to receive preventive care, with the exception of mammography, than were screening controls. However, trends over time in survivors' care tended to be better than in screening controls, Dr. Snyder said. No differences were seen over time in trends in primary care provider visits, but survivors' visits to other physician specialists increased faster than did those of controls.

Both survivors and screening controls received more flu shots (with similar increases over time in both groups), and more cholesterol screening (with a faster increase in rates among survivors over time) in 2002, compared with 1998. Also, more survivors received bone densitometry in 2002, compared with 1998; the rate in screening controls didn't change significantly over time. In the case of colorectal cancer screening, both groups received less screening in 2002, compared with 1998, she said.

Those patients who were seen by both types of providers were more likely to receive preventive care. DR. SNYDER

Financial strain associated with vaccine costs and reimbursement levels is increasingly reported by physicians in private practice who provide vaccinations to children and adolescents, a study shows.

However, in a related study, cost and reimbursement levels were found to vary widely across the United States, suggesting that individual practices should pay careful attention to these factors and seek opportunities to improve on them.

In the first study, Dr. Gary L. Freed and his associates at the University of Michigan, Ann Arbor, conducted a cross-sectional mail survey of a random sample of pediatricians and family physicians who purchase private stock of vaccine. About half of the 357 pediatricians and the 240 family physicians who responded said their practice had delayed purchase of certain vaccines for financial reasons, and 53% had experienced decreases in profit margins from immunizations in the 3 years prior to the survey. A decrease of more than 20% in profit margins was reported by 21% of respondents. These responses did not differ by specialty.

Furthermore, 21% of respondents strongly disagreed that reimbursements for vaccine purchases are adequate, and 17% strongly disagreed that reimbursement for administration of vaccine is adequate.

Importantly, 11% of respondents (5% of pediatricians and 21% of family physicians) said that they had seriously considered ending the practice of providing vaccines to patients, the investigators reported (Pediatrics 2008;122:1319-24).

Research has addressed the effects of vaccine cost increases on public-sector vaccine financing, but this is among the first studies to address the effect on private-sector physicians.

In regard to the fact that 34% of decision makers in family practice have seriously considered whether they should stop providing vaccines to privately insured patients, the investigators noted that “this may be a harbinger of future actions among a significant group of family physicians.”

The relevance of this possibility is likely limited for the nation's private-sector capacity for immunization delivery because pediatricians provide the majority of immunizations for children and adolescents, but it is of particular concern in rural areas, where family physicians are the predominant source of children's primary care.

In their own effort to better understand some of the pressures and to evaluate potential solutions, the investigators launched another study looking at vaccine price and reimbursement levels.

Using a cross-sectional survey of a convenience sample of 76 private practices in California, Georgia, Michigan, New York, and Texas, they found that prices vary widely, with differences in maximum and minimum prices paid per dose varying between $4 and $30. Significant variations also exist in reimbursement levels for vaccine purchase, with differences in maximum and minimum reimbursement levels ranging from $8 to more than $80.

The mean net yield per dose ranged from $3 to $24 among the practices, with some practices reporting a positive net yield of nearly $39, while 11% of practices reported a negative net yield for the same vaccine. Also, the mean reimbursement levels varied from about 80% up to 123% (Pediatrics 2008;122:1325-31).

These findings underscore the need for individual practices to pay close attention to their costs and reimbursements, and to seek opportunities–such as those afforded by discount and rebate programs–to improve their bottom line, Dr. Freed and his associates noted.

Such programs, as described by respondents, include prompt payment, online payment, volume discounts, and promotional pricing (such as back-to-school promotions), among others.

“At the practice level, [the variation in vaccine costs and reimbursement levels] underscores the need for practices to be cognizant of their own costs and reimbursements for vaccines,” they wrote.

The Centers for Disease Control and Prevention funded the two studies.

Financial strain associated with vaccine costs and reimbursement levels is increasingly reported by physicians in private practice who provide vaccinations to children and adolescents, a study shows.

However, in a related study, cost and reimbursement levels were found to vary widely across the United States, suggesting that individual practices should pay careful attention to these factors and seek opportunities to improve on them.

In the first study, Dr. Gary L. Freed and his associates at the University of Michigan, Ann Arbor, conducted a cross-sectional mail survey of a random sample of pediatricians and family physicians who purchase private stock of vaccine. About half of the 357 pediatricians and the 240 family physicians who responded said their practice had delayed purchase of certain vaccines for financial reasons, and 53% had experienced decreases in profit margins from immunizations in the 3 years prior to the survey. A decrease of more than 20% in profit margins was reported by 21% of respondents. These responses did not differ by specialty.

Furthermore, 21% of respondents strongly disagreed that reimbursements for vaccine purchases are adequate, and 17% strongly disagreed that reimbursement for administration of vaccine is adequate.

Importantly, 11% of respondents (5% of pediatricians and 21% of family physicians) said that they had seriously considered ending the practice of providing vaccines to patients, the investigators reported (Pediatrics 2008;122:1319-24).

Research has addressed the effects of vaccine cost increases on public-sector vaccine financing, but this is among the first studies to address the effect on private-sector physicians.

In regard to the fact that 34% of decision makers in family practice have seriously considered whether they should stop providing vaccines to privately insured patients, the investigators noted that “this may be a harbinger of future actions among a significant group of family physicians.”

The relevance of this possibility is likely limited for the nation's private-sector capacity for immunization delivery because pediatricians provide the majority of immunizations for children and adolescents, but it is of particular concern in rural areas, where family physicians are the predominant source of children's primary care.

In their own effort to better understand some of the pressures and to evaluate potential solutions, the investigators launched another study looking at vaccine price and reimbursement levels.

Using a cross-sectional survey of a convenience sample of 76 private practices in California, Georgia, Michigan, New York, and Texas, they found that prices vary widely, with differences in maximum and minimum prices paid per dose varying between $4 and $30. Significant variations also exist in reimbursement levels for vaccine purchase, with differences in maximum and minimum reimbursement levels ranging from $8 to more than $80.

The mean net yield per dose ranged from $3 to $24 among the practices, with some practices reporting a positive net yield of nearly $39, while 11% of practices reported a negative net yield for the same vaccine. Also, the mean reimbursement levels varied from about 80% up to 123% (Pediatrics 2008;122:1325-31).

These findings underscore the need for individual practices to pay close attention to their costs and reimbursements, and to seek opportunities–such as those afforded by discount and rebate programs–to improve their bottom line, Dr. Freed and his associates noted.

Such programs, as described by respondents, include prompt payment, online payment, volume discounts, and promotional pricing (such as back-to-school promotions), among others.

“At the practice level, [the variation in vaccine costs and reimbursement levels] underscores the need for practices to be cognizant of their own costs and reimbursements for vaccines,” they wrote.

The Centers for Disease Control and Prevention funded the two studies.

Financial strain associated with vaccine costs and reimbursement levels is increasingly reported by physicians in private practice who provide vaccinations to children and adolescents, a study shows.

However, in a related study, cost and reimbursement levels were found to vary widely across the United States, suggesting that individual practices should pay careful attention to these factors and seek opportunities to improve on them.

In the first study, Dr. Gary L. Freed and his associates at the University of Michigan, Ann Arbor, conducted a cross-sectional mail survey of a random sample of pediatricians and family physicians who purchase private stock of vaccine. About half of the 357 pediatricians and the 240 family physicians who responded said their practice had delayed purchase of certain vaccines for financial reasons, and 53% had experienced decreases in profit margins from immunizations in the 3 years prior to the survey. A decrease of more than 20% in profit margins was reported by 21% of respondents. These responses did not differ by specialty.

Furthermore, 21% of respondents strongly disagreed that reimbursements for vaccine purchases are adequate, and 17% strongly disagreed that reimbursement for administration of vaccine is adequate.

Importantly, 11% of respondents (5% of pediatricians and 21% of family physicians) said that they had seriously considered ending the practice of providing vaccines to patients, the investigators reported (Pediatrics 2008;122:1319-24).

Research has addressed the effects of vaccine cost increases on public-sector vaccine financing, but this is among the first studies to address the effect on private-sector physicians.

In regard to the fact that 34% of decision makers in family practice have seriously considered whether they should stop providing vaccines to privately insured patients, the investigators noted that “this may be a harbinger of future actions among a significant group of family physicians.”

The relevance of this possibility is likely limited for the nation's private-sector capacity for immunization delivery because pediatricians provide the majority of immunizations for children and adolescents, but it is of particular concern in rural areas, where family physicians are the predominant source of children's primary care.

In their own effort to better understand some of the pressures and to evaluate potential solutions, the investigators launched another study looking at vaccine price and reimbursement levels.

Using a cross-sectional survey of a convenience sample of 76 private practices in California, Georgia, Michigan, New York, and Texas, they found that prices vary widely, with differences in maximum and minimum prices paid per dose varying between $4 and $30. Significant variations also exist in reimbursement levels for vaccine purchase, with differences in maximum and minimum reimbursement levels ranging from $8 to more than $80.

The mean net yield per dose ranged from $3 to $24 among the practices, with some practices reporting a positive net yield of nearly $39, while 11% of practices reported a negative net yield for the same vaccine. Also, the mean reimbursement levels varied from about 80% up to 123% (Pediatrics 2008;122:1325-31).

These findings underscore the need for individual practices to pay close attention to their costs and reimbursements, and to seek opportunities–such as those afforded by discount and rebate programs–to improve their bottom line, Dr. Freed and his associates noted.

Such programs, as described by respondents, include prompt payment, online payment, volume discounts, and promotional pricing (such as back-to-school promotions), among others.

“At the practice level, [the variation in vaccine costs and reimbursement levels] underscores the need for practices to be cognizant of their own costs and reimbursements for vaccines,” they wrote.

The Centers for Disease Control and Prevention funded the two studies.

Chronically ill inpatients who receive care of greater intensity rate the care less favorably than do those who receive care of lesser intensity, a new study shows.

Additionally, patients' ratings of satisfaction with their hospital care correlate with objective measures of technical quality for the hospital, according to Dr. John E. Wennberg, founder and director emeritus of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H., and his colleagues.

The findings appear to underscore the importance of coordination of patient care and communication with patients, the investigators said (Health Affairs 2009;28:103–12).

Good coordination and communication can lead to greater efficiency in health care, and efficient care is “entirely compatible with the sort of care that patients would like to receive,” Dr. David Goodman, one of the paper's coauthors, said in an interview.

“One has to separate out the 'more' from the 'better.' There are many instances when the newest technologic advance and the most highly specialized physician absolutely lead to the best quality of care and the best outcomes, and also to the best patient experiences. This study does not question that in any way,” said Dr. Goodman, professor of pediatrics and community and family medicine at the Center for Health Policy Research at Dartmouth.

For the study, the investigators used data from a national survey of patients' hospital experiences known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), which is a project of the Centers for Medicare and Medicaid Services (CMS). Data from the survey, which included patients from 2,517 U.S. hospitals, were used along with CMS measures of technical process quality and were linked with data from the Dartmouth Atlas of Health Care. All data were adjusted for age, sex, race, and type and number of chronic illnesses.

Across 306 hospital referral regions, there was wide variation in health care intensity—as measured by the hospital care intensity (HCI) index, a measure of time spent in the hospital and the intensity of physician intervention during hospitalization—and other factors such as per capita Medicare spending, physician labor, bed input, and terminal care intensity.

HCI index scores varied as much as fourfold between regions at the higher end and the lower end of the scale. For example, the HCI index score for the Newark, N.J., region was 90% above the national average, while the score for the Salt Lake City region was 49% below the national average.

Patients living in regions with more aggressive patterns of care rated hospitals lower than did patients in areas with less aggressive care. About 14% of patients from hospitals with HCI scores in the highest quintile gave their hospital care low ratings, compared with 9% of patients from hospitals with HCI scores in the lowest quintile.

Of note, the tendency toward an association between low ratings and high HCI scores was seen regardless of whether there was a low or high number of primary care physicians in the region, but negative ratings were less likely in regions where primary care (vs. specialist care) dominated.

Hospitals with lower technical quality scores (based on performance in the management of acute MI and heart failure) also had lower overall patient ratings. Poor coordination of care and lack of communication with patients may explain why patients with chronic illnesses who receive more hospital care report worse personal experiences while in the hospital, the investigators suggested.

Regions with conservative use of inpatient care and happier patients used less physician labor for managing chronic illnesses. The mix of primary care and medical specialists also may play a role. Regions where primary care dominates tend to be more conservative in the use of acute care hospitals, suggesting that care coordination “may be an important factor in promoting conservative care,” the investigators noted.

The number of physicians involved in a patient's care also appears to influence ratings. “If having too many physicians leads to disorganized care and duplication of services, this may provide an explanation not only for the poorer performance on technical quality measures, but also for the association between the percentage of patients seeing ten or more physicians and a negative hospital rating,” they wrote.

Another factor that appears to be associated with patient ratings is the way medical practice is organized; large group practices dominated in regions that ranked in the lowest quintile of HCI index scores.

Based on the findings, it appears that “efforts to encourage better coordination of care, rather than simply training more physicians or spending more money, hold the key to future health care reform,” the investigators concluded.

High-quality, carefully coordinated care should not be confused with delivery of more services, coauthor Dr. Goodman said.

“Unfortunately, I think we have very strong financial incentives that operate in many health systems for delivering higher quantity,” he said, noting that physicians are paid for independently delivering a particular service, not for coordination of care.

Some activities perpetuate the idea that more is better. Building more intensive care units and adding hospital capacity takes a huge amount of money that could be better spent on reforming organizations and creating stronger primary care-centered delivery systems, Dr. Goodman said.

He cited proposals by Dr. Elliott S. Fisher, a professor of medicine and community and family medicine at the Dartmouth Medical School, who advocates “the accountable care organization,” in which natural groupings of physicians in a hospital take responsibility for a given population and for measuring quality of care.

Research on this type of organization is ongoing, and data on the approach are anticipated soon, Dr. Goodman noted.

Chronically ill inpatients who receive care of greater intensity rate the care less favorably than do those who receive care of lesser intensity, a new study shows.

Additionally, patients' ratings of satisfaction with their hospital care correlate with objective measures of technical quality for the hospital, according to Dr. John E. Wennberg, founder and director emeritus of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H., and his colleagues.

The findings appear to underscore the importance of coordination of patient care and communication with patients, the investigators said (Health Affairs 2009;28:103–12).

Good coordination and communication can lead to greater efficiency in health care, and efficient care is “entirely compatible with the sort of care that patients would like to receive,” Dr. David Goodman, one of the paper's coauthors, said in an interview.

“One has to separate out the 'more' from the 'better.' There are many instances when the newest technologic advance and the most highly specialized physician absolutely lead to the best quality of care and the best outcomes, and also to the best patient experiences. This study does not question that in any way,” said Dr. Goodman, professor of pediatrics and community and family medicine at the Center for Health Policy Research at Dartmouth.

For the study, the investigators used data from a national survey of patients' hospital experiences known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), which is a project of the Centers for Medicare and Medicaid Services (CMS). Data from the survey, which included patients from 2,517 U.S. hospitals, were used along with CMS measures of technical process quality and were linked with data from the Dartmouth Atlas of Health Care. All data were adjusted for age, sex, race, and type and number of chronic illnesses.

Across 306 hospital referral regions, there was wide variation in health care intensity—as measured by the hospital care intensity (HCI) index, a measure of time spent in the hospital and the intensity of physician intervention during hospitalization—and other factors such as per capita Medicare spending, physician labor, bed input, and terminal care intensity.

HCI index scores varied as much as fourfold between regions at the higher end and the lower end of the scale. For example, the HCI index score for the Newark, N.J., region was 90% above the national average, while the score for the Salt Lake City region was 49% below the national average.

Patients living in regions with more aggressive patterns of care rated hospitals lower than did patients in areas with less aggressive care. About 14% of patients from hospitals with HCI scores in the highest quintile gave their hospital care low ratings, compared with 9% of patients from hospitals with HCI scores in the lowest quintile.

Of note, the tendency toward an association between low ratings and high HCI scores was seen regardless of whether there was a low or high number of primary care physicians in the region, but negative ratings were less likely in regions where primary care (vs. specialist care) dominated.

Hospitals with lower technical quality scores (based on performance in the management of acute MI and heart failure) also had lower overall patient ratings. Poor coordination of care and lack of communication with patients may explain why patients with chronic illnesses who receive more hospital care report worse personal experiences while in the hospital, the investigators suggested.

Regions with conservative use of inpatient care and happier patients used less physician labor for managing chronic illnesses. The mix of primary care and medical specialists also may play a role. Regions where primary care dominates tend to be more conservative in the use of acute care hospitals, suggesting that care coordination “may be an important factor in promoting conservative care,” the investigators noted.

The number of physicians involved in a patient's care also appears to influence ratings. “If having too many physicians leads to disorganized care and duplication of services, this may provide an explanation not only for the poorer performance on technical quality measures, but also for the association between the percentage of patients seeing ten or more physicians and a negative hospital rating,” they wrote.

Another factor that appears to be associated with patient ratings is the way medical practice is organized; large group practices dominated in regions that ranked in the lowest quintile of HCI index scores.

Based on the findings, it appears that “efforts to encourage better coordination of care, rather than simply training more physicians or spending more money, hold the key to future health care reform,” the investigators concluded.

High-quality, carefully coordinated care should not be confused with delivery of more services, coauthor Dr. Goodman said.

“Unfortunately, I think we have very strong financial incentives that operate in many health systems for delivering higher quantity,” he said, noting that physicians are paid for independently delivering a particular service, not for coordination of care.

Some activities perpetuate the idea that more is better. Building more intensive care units and adding hospital capacity takes a huge amount of money that could be better spent on reforming organizations and creating stronger primary care-centered delivery systems, Dr. Goodman said.

He cited proposals by Dr. Elliott S. Fisher, a professor of medicine and community and family medicine at the Dartmouth Medical School, who advocates “the accountable care organization,” in which natural groupings of physicians in a hospital take responsibility for a given population and for measuring quality of care.

Research on this type of organization is ongoing, and data on the approach are anticipated soon, Dr. Goodman noted.

Chronically ill inpatients who receive care of greater intensity rate the care less favorably than do those who receive care of lesser intensity, a new study shows.

Additionally, patients' ratings of satisfaction with their hospital care correlate with objective measures of technical quality for the hospital, according to Dr. John E. Wennberg, founder and director emeritus of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H., and his colleagues.

The findings appear to underscore the importance of coordination of patient care and communication with patients, the investigators said (Health Affairs 2009;28:103–12).

Good coordination and communication can lead to greater efficiency in health care, and efficient care is “entirely compatible with the sort of care that patients would like to receive,” Dr. David Goodman, one of the paper's coauthors, said in an interview.

“One has to separate out the 'more' from the 'better.' There are many instances when the newest technologic advance and the most highly specialized physician absolutely lead to the best quality of care and the best outcomes, and also to the best patient experiences. This study does not question that in any way,” said Dr. Goodman, professor of pediatrics and community and family medicine at the Center for Health Policy Research at Dartmouth.

For the study, the investigators used data from a national survey of patients' hospital experiences known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), which is a project of the Centers for Medicare and Medicaid Services (CMS). Data from the survey, which included patients from 2,517 U.S. hospitals, were used along with CMS measures of technical process quality and were linked with data from the Dartmouth Atlas of Health Care. All data were adjusted for age, sex, race, and type and number of chronic illnesses.

Across 306 hospital referral regions, there was wide variation in health care intensity—as measured by the hospital care intensity (HCI) index, a measure of time spent in the hospital and the intensity of physician intervention during hospitalization—and other factors such as per capita Medicare spending, physician labor, bed input, and terminal care intensity.

HCI index scores varied as much as fourfold between regions at the higher end and the lower end of the scale. For example, the HCI index score for the Newark, N.J., region was 90% above the national average, while the score for the Salt Lake City region was 49% below the national average.

Patients living in regions with more aggressive patterns of care rated hospitals lower than did patients in areas with less aggressive care. About 14% of patients from hospitals with HCI scores in the highest quintile gave their hospital care low ratings, compared with 9% of patients from hospitals with HCI scores in the lowest quintile.

Of note, the tendency toward an association between low ratings and high HCI scores was seen regardless of whether there was a low or high number of primary care physicians in the region, but negative ratings were less likely in regions where primary care (vs. specialist care) dominated.

Hospitals with lower technical quality scores (based on performance in the management of acute MI and heart failure) also had lower overall patient ratings. Poor coordination of care and lack of communication with patients may explain why patients with chronic illnesses who receive more hospital care report worse personal experiences while in the hospital, the investigators suggested.

Regions with conservative use of inpatient care and happier patients used less physician labor for managing chronic illnesses. The mix of primary care and medical specialists also may play a role. Regions where primary care dominates tend to be more conservative in the use of acute care hospitals, suggesting that care coordination “may be an important factor in promoting conservative care,” the investigators noted.

The number of physicians involved in a patient's care also appears to influence ratings. “If having too many physicians leads to disorganized care and duplication of services, this may provide an explanation not only for the poorer performance on technical quality measures, but also for the association between the percentage of patients seeing ten or more physicians and a negative hospital rating,” they wrote.

Another factor that appears to be associated with patient ratings is the way medical practice is organized; large group practices dominated in regions that ranked in the lowest quintile of HCI index scores.

Based on the findings, it appears that “efforts to encourage better coordination of care, rather than simply training more physicians or spending more money, hold the key to future health care reform,” the investigators concluded.

High-quality, carefully coordinated care should not be confused with delivery of more services, coauthor Dr. Goodman said.

“Unfortunately, I think we have very strong financial incentives that operate in many health systems for delivering higher quantity,” he said, noting that physicians are paid for independently delivering a particular service, not for coordination of care.

Some activities perpetuate the idea that more is better. Building more intensive care units and adding hospital capacity takes a huge amount of money that could be better spent on reforming organizations and creating stronger primary care-centered delivery systems, Dr. Goodman said.

He cited proposals by Dr. Elliott S. Fisher, a professor of medicine and community and family medicine at the Dartmouth Medical School, who advocates “the accountable care organization,” in which natural groupings of physicians in a hospital take responsibility for a given population and for measuring quality of care.

Research on this type of organization is ongoing, and data on the approach are anticipated soon, Dr. Goodman noted.

SAN FRANCISCO — Inflammatory bowel disease does not severely alter ovarian reserve but may accelerate loss of primordial follicles in those aged 30 years and older, study results showed.

The investigators measured anti-müllerian hormone—a reliable hormonal marker for evaluating ovarian reserve independently of the menstrual cycle—in 44 women aged 20–41 years who had IBD and were in clinical remission after infliximab treatment for either Crohn's disease (37 patients) or ulcerative colitis (7 patients).

The hormone levels were compared with those of 163 age-matched women undergoing in vitro fertilization who had a normal ovarian response to controlled ovarian stimulation (5–15 oocytes retrieved) and a normal serum anti-müllerian hormone level (>1.5 mcg/L).

The anti-müllerian hormone levels did not differ significantly overall between the IBD and control patients (2.72 vs. 2.12 mcg/L), Dr. Thomas Fréour reported in a poster at the annual meeting of the American Society for Reproductive Medicine.

However, when the women were stratified by age 30 years and older vs. age less than 30 years, the anti-müllerian hormone levels were found to differ in the older women, with those aged 30 years and older having lower levels than controls (2 vs. 2.96 mcg/L). The levels in the younger patients remained comparable in the patients and controls, said Dr. Fréour of the University Hospital Center of Nantes (France).

Inflammatory bowel disease has been shown in previous studies to be associated with female subfertility, mainly through tubal dysfunctions, extensive adhesions, or chirurgical consequences on pelvic function, but alteration of ovarian reserve in those with IBD had not been previously studied, Dr. Fréour noted.

The findings suggest that in reproductive age women 30 years and older who have IBD, a substantially accelerated loss of primordial follicles may occur. This loss might be due to chronic inflammation or to IBD treatments, he noted.

SAN FRANCISCO — Inflammatory bowel disease does not severely alter ovarian reserve but may accelerate loss of primordial follicles in those aged 30 years and older, study results showed.

The investigators measured anti-müllerian hormone—a reliable hormonal marker for evaluating ovarian reserve independently of the menstrual cycle—in 44 women aged 20–41 years who had IBD and were in clinical remission after infliximab treatment for either Crohn's disease (37 patients) or ulcerative colitis (7 patients).

The hormone levels were compared with those of 163 age-matched women undergoing in vitro fertilization who had a normal ovarian response to controlled ovarian stimulation (5–15 oocytes retrieved) and a normal serum anti-müllerian hormone level (>1.5 mcg/L).

The anti-müllerian hormone levels did not differ significantly overall between the IBD and control patients (2.72 vs. 2.12 mcg/L), Dr. Thomas Fréour reported in a poster at the annual meeting of the American Society for Reproductive Medicine.

However, when the women were stratified by age 30 years and older vs. age less than 30 years, the anti-müllerian hormone levels were found to differ in the older women, with those aged 30 years and older having lower levels than controls (2 vs. 2.96 mcg/L). The levels in the younger patients remained comparable in the patients and controls, said Dr. Fréour of the University Hospital Center of Nantes (France).

Inflammatory bowel disease has been shown in previous studies to be associated with female subfertility, mainly through tubal dysfunctions, extensive adhesions, or chirurgical consequences on pelvic function, but alteration of ovarian reserve in those with IBD had not been previously studied, Dr. Fréour noted.

The findings suggest that in reproductive age women 30 years and older who have IBD, a substantially accelerated loss of primordial follicles may occur. This loss might be due to chronic inflammation or to IBD treatments, he noted.

SAN FRANCISCO — Inflammatory bowel disease does not severely alter ovarian reserve but may accelerate loss of primordial follicles in those aged 30 years and older, study results showed.

The investigators measured anti-müllerian hormone—a reliable hormonal marker for evaluating ovarian reserve independently of the menstrual cycle—in 44 women aged 20–41 years who had IBD and were in clinical remission after infliximab treatment for either Crohn's disease (37 patients) or ulcerative colitis (7 patients).

The hormone levels were compared with those of 163 age-matched women undergoing in vitro fertilization who had a normal ovarian response to controlled ovarian stimulation (5–15 oocytes retrieved) and a normal serum anti-müllerian hormone level (>1.5 mcg/L).

The anti-müllerian hormone levels did not differ significantly overall between the IBD and control patients (2.72 vs. 2.12 mcg/L), Dr. Thomas Fréour reported in a poster at the annual meeting of the American Society for Reproductive Medicine.

However, when the women were stratified by age 30 years and older vs. age less than 30 years, the anti-müllerian hormone levels were found to differ in the older women, with those aged 30 years and older having lower levels than controls (2 vs. 2.96 mcg/L). The levels in the younger patients remained comparable in the patients and controls, said Dr. Fréour of the University Hospital Center of Nantes (France).

Inflammatory bowel disease has been shown in previous studies to be associated with female subfertility, mainly through tubal dysfunctions, extensive adhesions, or chirurgical consequences on pelvic function, but alteration of ovarian reserve in those with IBD had not been previously studied, Dr. Fréour noted.

The findings suggest that in reproductive age women 30 years and older who have IBD, a substantially accelerated loss of primordial follicles may occur. This loss might be due to chronic inflammation or to IBD treatments, he noted.

SAN FRANCISCO — The risk of miscarriage of a genetically normal fetus is significantly increased in overweight women, compared with normal weight women, the findings of a retrospective case-control study of 204 miscarriages suggest.

The rate of euploid miscarriage among 204 first trimester missed abortions that occurred between 1999 and 2008 in women at a single center was 53% in those with a body mass index of 25 or greater, compared with 37% in those with a BMI of less than 25. The difference was statistically significant, Dr. Innes V. Landres reported at the annual meeting of the American Society for Reproductive Medicine.

The mean age of the women in both groups was the same (34 years). Those over age 39 years were excluded because of the increased risk of miscarriage in women with advanced maternal age, noted Dr. Landres, a chief resident in obstetrics and gynecology at Stanford (Calif.) University.

The groups also were similar in types of assisted reproductive technologies used and in pregnancy history.

The study was undertaken to explore the cytogenetic results of miscarriages in relation to maternal weight and insulin resistance, Dr. Landres explained.

Both obesity and insulin resistance have been linked with spontaneous abortion and recurrent pregnancy loss. Most spontaneous abortions are a result of fetal aneuploidy, as was the case in 59% of patients overall in this study—67% in those over age 34 years, and 50% in those 34 years and younger. There is some evidence, however, that obesity predisposes women to euploid miscarriage, and that there is an increased rate of spontaneous abortion even among obese women with ovum donation.

For the current study, the medical records of women with first trimester missed abortion, subsequent dilation and curettage, and karyotype analysis of the products of conception were reviewed. Among the patients excluded—other than those older than 39 years—were those patients with a history of diabetes, those using steroids or narcotics, and those with donor eggs or preimplantation genetic diagnosis.

In addition to an increase in euploid miscarriage risk based on BMI, a trend toward increased risk among women with polycystic ovary syndrome, compared with those without PCOS, was observed (48% vs. 39%, respectively), but the difference did not reach statistical significance. Also, no significant differences in euploid miscarriage were seen based on insulin resistance status. However, because all but one of the women with insulin resistance were on insulin-lowering therapy at the time of conception, the conclusions in these populations are limited, Dr. Landres noted.

The findings, which suggest that BMI over 25 is a risk factor for euploid miscarriage, are important, given the fact that BMI (unlike age) is a modifiable risk factor. Although the study is limited by its retrospective nature, lack of power, and multiple confounders for which the investigators could not control, it is nonetheless important that elevated BMI be identified as a risk factor for euploid miscarriage, and that women with elevated BMI be counseled about the importance of lifestyle modification. Also, although more study is needed on the effects of insulin-lowering medications in this population, treatment should be considered.

Additional study of the effects of BMI on endometrial dysfunction and miscarriage rates, as well as on the effects of lifestyle modification, is needed, Dr. Landres concluded.

Elevated BMI should be seen as a risk factor for euploid miscarriage, said Dr. Innes V. Landres. Roman Sivion

SAN FRANCISCO — The risk of miscarriage of a genetically normal fetus is significantly increased in overweight women, compared with normal weight women, the findings of a retrospective case-control study of 204 miscarriages suggest.

The rate of euploid miscarriage among 204 first trimester missed abortions that occurred between 1999 and 2008 in women at a single center was 53% in those with a body mass index of 25 or greater, compared with 37% in those with a BMI of less than 25. The difference was statistically significant, Dr. Innes V. Landres reported at the annual meeting of the American Society for Reproductive Medicine.

The mean age of the women in both groups was the same (34 years). Those over age 39 years were excluded because of the increased risk of miscarriage in women with advanced maternal age, noted Dr. Landres, a chief resident in obstetrics and gynecology at Stanford (Calif.) University.

The groups also were similar in types of assisted reproductive technologies used and in pregnancy history.

The study was undertaken to explore the cytogenetic results of miscarriages in relation to maternal weight and insulin resistance, Dr. Landres explained.

Both obesity and insulin resistance have been linked with spontaneous abortion and recurrent pregnancy loss. Most spontaneous abortions are a result of fetal aneuploidy, as was the case in 59% of patients overall in this study—67% in those over age 34 years, and 50% in those 34 years and younger. There is some evidence, however, that obesity predisposes women to euploid miscarriage, and that there is an increased rate of spontaneous abortion even among obese women with ovum donation.

For the current study, the medical records of women with first trimester missed abortion, subsequent dilation and curettage, and karyotype analysis of the products of conception were reviewed. Among the patients excluded—other than those older than 39 years—were those patients with a history of diabetes, those using steroids or narcotics, and those with donor eggs or preimplantation genetic diagnosis.

In addition to an increase in euploid miscarriage risk based on BMI, a trend toward increased risk among women with polycystic ovary syndrome, compared with those without PCOS, was observed (48% vs. 39%, respectively), but the difference did not reach statistical significance. Also, no significant differences in euploid miscarriage were seen based on insulin resistance status. However, because all but one of the women with insulin resistance were on insulin-lowering therapy at the time of conception, the conclusions in these populations are limited, Dr. Landres noted.

The findings, which suggest that BMI over 25 is a risk factor for euploid miscarriage, are important, given the fact that BMI (unlike age) is a modifiable risk factor. Although the study is limited by its retrospective nature, lack of power, and multiple confounders for which the investigators could not control, it is nonetheless important that elevated BMI be identified as a risk factor for euploid miscarriage, and that women with elevated BMI be counseled about the importance of lifestyle modification. Also, although more study is needed on the effects of insulin-lowering medications in this population, treatment should be considered.

Additional study of the effects of BMI on endometrial dysfunction and miscarriage rates, as well as on the effects of lifestyle modification, is needed, Dr. Landres concluded.

Elevated BMI should be seen as a risk factor for euploid miscarriage, said Dr. Innes V. Landres. Roman Sivion

SAN FRANCISCO — The risk of miscarriage of a genetically normal fetus is significantly increased in overweight women, compared with normal weight women, the findings of a retrospective case-control study of 204 miscarriages suggest.

The rate of euploid miscarriage among 204 first trimester missed abortions that occurred between 1999 and 2008 in women at a single center was 53% in those with a body mass index of 25 or greater, compared with 37% in those with a BMI of less than 25. The difference was statistically significant, Dr. Innes V. Landres reported at the annual meeting of the American Society for Reproductive Medicine.

The mean age of the women in both groups was the same (34 years). Those over age 39 years were excluded because of the increased risk of miscarriage in women with advanced maternal age, noted Dr. Landres, a chief resident in obstetrics and gynecology at Stanford (Calif.) University.

The groups also were similar in types of assisted reproductive technologies used and in pregnancy history.

The study was undertaken to explore the cytogenetic results of miscarriages in relation to maternal weight and insulin resistance, Dr. Landres explained.

Both obesity and insulin resistance have been linked with spontaneous abortion and recurrent pregnancy loss. Most spontaneous abortions are a result of fetal aneuploidy, as was the case in 59% of patients overall in this study—67% in those over age 34 years, and 50% in those 34 years and younger. There is some evidence, however, that obesity predisposes women to euploid miscarriage, and that there is an increased rate of spontaneous abortion even among obese women with ovum donation.

For the current study, the medical records of women with first trimester missed abortion, subsequent dilation and curettage, and karyotype analysis of the products of conception were reviewed. Among the patients excluded—other than those older than 39 years—were those patients with a history of diabetes, those using steroids or narcotics, and those with donor eggs or preimplantation genetic diagnosis.

In addition to an increase in euploid miscarriage risk based on BMI, a trend toward increased risk among women with polycystic ovary syndrome, compared with those without PCOS, was observed (48% vs. 39%, respectively), but the difference did not reach statistical significance. Also, no significant differences in euploid miscarriage were seen based on insulin resistance status. However, because all but one of the women with insulin resistance were on insulin-lowering therapy at the time of conception, the conclusions in these populations are limited, Dr. Landres noted.

The findings, which suggest that BMI over 25 is a risk factor for euploid miscarriage, are important, given the fact that BMI (unlike age) is a modifiable risk factor. Although the study is limited by its retrospective nature, lack of power, and multiple confounders for which the investigators could not control, it is nonetheless important that elevated BMI be identified as a risk factor for euploid miscarriage, and that women with elevated BMI be counseled about the importance of lifestyle modification. Also, although more study is needed on the effects of insulin-lowering medications in this population, treatment should be considered.

Additional study of the effects of BMI on endometrial dysfunction and miscarriage rates, as well as on the effects of lifestyle modification, is needed, Dr. Landres concluded.

Elevated BMI should be seen as a risk factor for euploid miscarriage, said Dr. Innes V. Landres. Roman Sivion

DESTIN, FLA. — Don't be afraid to treat infections empirically in patients in whom you have no definitive diagnosis, if you have considered the differential diagnoses and have ruled out more ominous conditions, Dr. Bari Cunningham said.

"It's okay—and at times, necessary—to treat empirically," said Dr. Cunningham at a meeting sponsored by the Alabama Dermatology Society.

She described the case of a gardener who presented with what appeared to be severe acne on his back. Various acne washes and medications failed to resolve the acne.

The patient's job involved carrying burlap sacks of branches and sticks; he typically carried the bags over his shoulders and slung across his back, said Dr. Cunningham, who assumed the "acne" was actually some kind of inoculation injury.

Various diagnoses were considered, including mycetoma, sporotrichosis, deep fungal infection, and foreign body reactions. Various studies showed granulomas and suppurative inflammation, but they were negative for these differential diagnoses.

Without a diagnosis, Dr. Cunningham, a pediatric dermatologist at the University of California, San Diego, decided to treat empirically after the patient returned complaining of tenderness and extensive drainage from the lesions. The patient was successfully treated with trimethoprim/sulfamethoxazole, clarithromycin, and ciprofloxacin.

"He ultimately completely cleared," she said. The outcome underscores the fact that it is, indeed, okay to treat empirically.

"I really, in retrospect, should have started him right away and not made him wait 4 or 5 months," she said. "I had the pathology—I had everything. There was no reason why I shouldn't have just treated empirically right off the bat."

DESTIN, FLA. — Don't be afraid to treat infections empirically in patients in whom you have no definitive diagnosis, if you have considered the differential diagnoses and have ruled out more ominous conditions, Dr. Bari Cunningham said.

"It's okay—and at times, necessary—to treat empirically," said Dr. Cunningham at a meeting sponsored by the Alabama Dermatology Society.

She described the case of a gardener who presented with what appeared to be severe acne on his back. Various acne washes and medications failed to resolve the acne.

The patient's job involved carrying burlap sacks of branches and sticks; he typically carried the bags over his shoulders and slung across his back, said Dr. Cunningham, who assumed the "acne" was actually some kind of inoculation injury.

Various diagnoses were considered, including mycetoma, sporotrichosis, deep fungal infection, and foreign body reactions. Various studies showed granulomas and suppurative inflammation, but they were negative for these differential diagnoses.

Without a diagnosis, Dr. Cunningham, a pediatric dermatologist at the University of California, San Diego, decided to treat empirically after the patient returned complaining of tenderness and extensive drainage from the lesions. The patient was successfully treated with trimethoprim/sulfamethoxazole, clarithromycin, and ciprofloxacin.

"He ultimately completely cleared," she said. The outcome underscores the fact that it is, indeed, okay to treat empirically.

"I really, in retrospect, should have started him right away and not made him wait 4 or 5 months," she said. "I had the pathology—I had everything. There was no reason why I shouldn't have just treated empirically right off the bat."

DESTIN, FLA. — Don't be afraid to treat infections empirically in patients in whom you have no definitive diagnosis, if you have considered the differential diagnoses and have ruled out more ominous conditions, Dr. Bari Cunningham said.

"It's okay—and at times, necessary—to treat empirically," said Dr. Cunningham at a meeting sponsored by the Alabama Dermatology Society.

She described the case of a gardener who presented with what appeared to be severe acne on his back. Various acne washes and medications failed to resolve the acne.

The patient's job involved carrying burlap sacks of branches and sticks; he typically carried the bags over his shoulders and slung across his back, said Dr. Cunningham, who assumed the "acne" was actually some kind of inoculation injury.

Various diagnoses were considered, including mycetoma, sporotrichosis, deep fungal infection, and foreign body reactions. Various studies showed granulomas and suppurative inflammation, but they were negative for these differential diagnoses.

Without a diagnosis, Dr. Cunningham, a pediatric dermatologist at the University of California, San Diego, decided to treat empirically after the patient returned complaining of tenderness and extensive drainage from the lesions. The patient was successfully treated with trimethoprim/sulfamethoxazole, clarithromycin, and ciprofloxacin.

"He ultimately completely cleared," she said. The outcome underscores the fact that it is, indeed, okay to treat empirically.

"I really, in retrospect, should have started him right away and not made him wait 4 or 5 months," she said. "I had the pathology—I had everything. There was no reason why I shouldn't have just treated empirically right off the bat."