Tara Haelle

SAN ANTONIO – Opioids do not mix well with sleep, interfering with breathing and increasing the risk of central sleep apnea, explained Anita Rajagopal, MD, a pulmonologist in private practice in Indianapolis.

“The chronic respiratory suppressant effects of opioids are well described,” Dr. Rajagopal told attendees at the annual meeting of the American College of Chest Physicians. “The most characteristic signs of chronic opioid effects are irregular central apneas, ataxic breathing, Biot’s respiration and hypoxemia, mainly during NREM sleep.”

Dr. Rajagopal reviewed the research on the effects of opioid use, primarily for therapeutic use, during sleep, especially highlighting the adverse respiratory effects.

In one small study of 24 patients, ages 18-75, who were taking long-term opioids for chronic pain, 46% had severe sleep-disordered breathing, defined as an apnea-hypopnea index greater than 30/hour (J Clin Sleep Med. 2014 Aug 15;10[8]:847-52).

When compared to sleep clinic patients referred for sleep disordered breathing, the participants taking opioids had a higher frequency of central apneas and a lower arousal index. Further, the researchers found that “morphine equivalent doses correlated with the severity of sleep-disordered breathing.”

In another study, a systematic review from 2015, researchers sought to characterize the clinical features of sleep-disordered breathing associated with chronic opioid therapy (Anesth Analg. 2015 Jun;120[6]:1273-85). They identified eight studies with 560 patients, about a quarter of whom (24%) had central sleep apnea.

Once again, “The morphine equivalent daily dose was strongly associated with the severity of the sleep disordered breathing, predominantly central sleep apnea, with a morphine equivalent daily dose of more than 200 mg being a threshold of particular concern,” the researchers reported.

Patients receiving methadone therapy for heroin addiction are not spared the respiratory risks of opioids during sleep. Dr. Rajagopal shared research revealing that patients receiving methadone treatment for at least two months had a blunted hypercapnic respiratory response and increased hypoxemic ventilatory response, changes related to respiratory rate but not tidal volume.

“All mu-opioid receptor agonists can cause complex and potentially lethal effects on respiration during sleep,” Dr. Rajagopal said as she shared evidence from a 2007 study that compared breathing patterns during sleep between 60 patients taking chronic opioids and 60 matched patients not taking opioids (J Clin Sleep Med. 2007 Aug 15;3[5]:455-61).

That study found chronic opioid use to be associated with increased central apneas and reduced arterial oxygen saturation during wakefulness and NREM sleep. Again, a dose-response relationship emerged between morphine dose equivalent and the apnea-hypopnea, obstructive apnea, hypopnea and central apnea indices (P less than .001).

Patients who took opioids long-term were also more likely to have ataxic or irregular breathing during NREM sleep, compared with patients not taking opioids.

In yet another meta-analysis and systematic review she related, researchers found across 803 patients in seven studies that long-term opioids users had a modestly increased risk for central sleep apnea but no similar increased risk for obstructive sleep apnea (J Clin Sleep Med. 2016 Apr 15;12[4]:617-25).

“REM and slow-wave sleep are decreased across all categories of opioid use — intravenous morphine, oral morphine, or methadone and heroin,” she said.

Since some patients are still going to need opioids, such as methadone therapy for those recovering from opioid use disorder, it’s important to understand appropriate effective treatments for central sleep apnea.

“CPAP [continuous positive airway pressure] is generally ineffective for opioid-induced sleep apnea and may augment central events,” Dr. Rajagopal explained, but adaptive servo ventilation (ASV) is effective for opioid-induced central apneas.

In one study of 20 patients receiving opioid therapy and referred for obstructive apnea, for example, the participants were diagnosed instead with central sleep apnea (J Clin Sleep Med. 2014 Jun 15;10[6]:637-43). The 16 patients who received CPAP continued to show central sleep apnea, with an AHI of 34 events/hour and central-apnea index (CAI) of 20 events/hour. Even after a four-week break before restarting CPAP, patients’ apnea did not resolve.

After receiving ASV, however, the average AHI dropped to 11 events/hour and CAI dropped to 0 events/hour. Those changes were accompanied by improvements in oxygen saturation, with the oxyhemoglobin saturation nadir increasing from 83% to 90%.

Similarly, a prospective multi-center observational trial assessed 27 patients with central apnea after they used ASV at home for three months (Chest. 2015 Dec;148[6]:1454-1461). The participants began with an average AHI of 55 and CAI of 23 at baseline. CPAP dropped these values only to an AHI of 33 and CAI of 10, but treatment with ASV dropped them to an AHI of 4 and CAI of 0 (P less than .001).

SAN ANTONIO – Opioids do not mix well with sleep, interfering with breathing and increasing the risk of central sleep apnea, explained Anita Rajagopal, MD, a pulmonologist in private practice in Indianapolis.

“The chronic respiratory suppressant effects of opioids are well described,” Dr. Rajagopal told attendees at the annual meeting of the American College of Chest Physicians. “The most characteristic signs of chronic opioid effects are irregular central apneas, ataxic breathing, Biot’s respiration and hypoxemia, mainly during NREM sleep.”

Dr. Rajagopal reviewed the research on the effects of opioid use, primarily for therapeutic use, during sleep, especially highlighting the adverse respiratory effects.

In one small study of 24 patients, ages 18-75, who were taking long-term opioids for chronic pain, 46% had severe sleep-disordered breathing, defined as an apnea-hypopnea index greater than 30/hour (J Clin Sleep Med. 2014 Aug 15;10[8]:847-52).

When compared to sleep clinic patients referred for sleep disordered breathing, the participants taking opioids had a higher frequency of central apneas and a lower arousal index. Further, the researchers found that “morphine equivalent doses correlated with the severity of sleep-disordered breathing.”

In another study, a systematic review from 2015, researchers sought to characterize the clinical features of sleep-disordered breathing associated with chronic opioid therapy (Anesth Analg. 2015 Jun;120[6]:1273-85). They identified eight studies with 560 patients, about a quarter of whom (24%) had central sleep apnea.

Once again, “The morphine equivalent daily dose was strongly associated with the severity of the sleep disordered breathing, predominantly central sleep apnea, with a morphine equivalent daily dose of more than 200 mg being a threshold of particular concern,” the researchers reported.

Patients receiving methadone therapy for heroin addiction are not spared the respiratory risks of opioids during sleep. Dr. Rajagopal shared research revealing that patients receiving methadone treatment for at least two months had a blunted hypercapnic respiratory response and increased hypoxemic ventilatory response, changes related to respiratory rate but not tidal volume.

“All mu-opioid receptor agonists can cause complex and potentially lethal effects on respiration during sleep,” Dr. Rajagopal said as she shared evidence from a 2007 study that compared breathing patterns during sleep between 60 patients taking chronic opioids and 60 matched patients not taking opioids (J Clin Sleep Med. 2007 Aug 15;3[5]:455-61).

That study found chronic opioid use to be associated with increased central apneas and reduced arterial oxygen saturation during wakefulness and NREM sleep. Again, a dose-response relationship emerged between morphine dose equivalent and the apnea-hypopnea, obstructive apnea, hypopnea and central apnea indices (P less than .001).

Patients who took opioids long-term were also more likely to have ataxic or irregular breathing during NREM sleep, compared with patients not taking opioids.

In yet another meta-analysis and systematic review she related, researchers found across 803 patients in seven studies that long-term opioids users had a modestly increased risk for central sleep apnea but no similar increased risk for obstructive sleep apnea (J Clin Sleep Med. 2016 Apr 15;12[4]:617-25).

“REM and slow-wave sleep are decreased across all categories of opioid use — intravenous morphine, oral morphine, or methadone and heroin,” she said.

Since some patients are still going to need opioids, such as methadone therapy for those recovering from opioid use disorder, it’s important to understand appropriate effective treatments for central sleep apnea.

“CPAP [continuous positive airway pressure] is generally ineffective for opioid-induced sleep apnea and may augment central events,” Dr. Rajagopal explained, but adaptive servo ventilation (ASV) is effective for opioid-induced central apneas.

In one study of 20 patients receiving opioid therapy and referred for obstructive apnea, for example, the participants were diagnosed instead with central sleep apnea (J Clin Sleep Med. 2014 Jun 15;10[6]:637-43). The 16 patients who received CPAP continued to show central sleep apnea, with an AHI of 34 events/hour and central-apnea index (CAI) of 20 events/hour. Even after a four-week break before restarting CPAP, patients’ apnea did not resolve.

After receiving ASV, however, the average AHI dropped to 11 events/hour and CAI dropped to 0 events/hour. Those changes were accompanied by improvements in oxygen saturation, with the oxyhemoglobin saturation nadir increasing from 83% to 90%.

Similarly, a prospective multi-center observational trial assessed 27 patients with central apnea after they used ASV at home for three months (Chest. 2015 Dec;148[6]:1454-1461). The participants began with an average AHI of 55 and CAI of 23 at baseline. CPAP dropped these values only to an AHI of 33 and CAI of 10, but treatment with ASV dropped them to an AHI of 4 and CAI of 0 (P less than .001).

SAN ANTONIO – Opioids do not mix well with sleep, interfering with breathing and increasing the risk of central sleep apnea, explained Anita Rajagopal, MD, a pulmonologist in private practice in Indianapolis.

“The chronic respiratory suppressant effects of opioids are well described,” Dr. Rajagopal told attendees at the annual meeting of the American College of Chest Physicians. “The most characteristic signs of chronic opioid effects are irregular central apneas, ataxic breathing, Biot’s respiration and hypoxemia, mainly during NREM sleep.”

Dr. Rajagopal reviewed the research on the effects of opioid use, primarily for therapeutic use, during sleep, especially highlighting the adverse respiratory effects.

In one small study of 24 patients, ages 18-75, who were taking long-term opioids for chronic pain, 46% had severe sleep-disordered breathing, defined as an apnea-hypopnea index greater than 30/hour (J Clin Sleep Med. 2014 Aug 15;10[8]:847-52).

When compared to sleep clinic patients referred for sleep disordered breathing, the participants taking opioids had a higher frequency of central apneas and a lower arousal index. Further, the researchers found that “morphine equivalent doses correlated with the severity of sleep-disordered breathing.”

In another study, a systematic review from 2015, researchers sought to characterize the clinical features of sleep-disordered breathing associated with chronic opioid therapy (Anesth Analg. 2015 Jun;120[6]:1273-85). They identified eight studies with 560 patients, about a quarter of whom (24%) had central sleep apnea.

Once again, “The morphine equivalent daily dose was strongly associated with the severity of the sleep disordered breathing, predominantly central sleep apnea, with a morphine equivalent daily dose of more than 200 mg being a threshold of particular concern,” the researchers reported.

Patients receiving methadone therapy for heroin addiction are not spared the respiratory risks of opioids during sleep. Dr. Rajagopal shared research revealing that patients receiving methadone treatment for at least two months had a blunted hypercapnic respiratory response and increased hypoxemic ventilatory response, changes related to respiratory rate but not tidal volume.

“All mu-opioid receptor agonists can cause complex and potentially lethal effects on respiration during sleep,” Dr. Rajagopal said as she shared evidence from a 2007 study that compared breathing patterns during sleep between 60 patients taking chronic opioids and 60 matched patients not taking opioids (J Clin Sleep Med. 2007 Aug 15;3[5]:455-61).

That study found chronic opioid use to be associated with increased central apneas and reduced arterial oxygen saturation during wakefulness and NREM sleep. Again, a dose-response relationship emerged between morphine dose equivalent and the apnea-hypopnea, obstructive apnea, hypopnea and central apnea indices (P less than .001).

Patients who took opioids long-term were also more likely to have ataxic or irregular breathing during NREM sleep, compared with patients not taking opioids.

In yet another meta-analysis and systematic review she related, researchers found across 803 patients in seven studies that long-term opioids users had a modestly increased risk for central sleep apnea but no similar increased risk for obstructive sleep apnea (J Clin Sleep Med. 2016 Apr 15;12[4]:617-25).

“REM and slow-wave sleep are decreased across all categories of opioid use — intravenous morphine, oral morphine, or methadone and heroin,” she said.

Since some patients are still going to need opioids, such as methadone therapy for those recovering from opioid use disorder, it’s important to understand appropriate effective treatments for central sleep apnea.

“CPAP [continuous positive airway pressure] is generally ineffective for opioid-induced sleep apnea and may augment central events,” Dr. Rajagopal explained, but adaptive servo ventilation (ASV) is effective for opioid-induced central apneas.

In one study of 20 patients receiving opioid therapy and referred for obstructive apnea, for example, the participants were diagnosed instead with central sleep apnea (J Clin Sleep Med. 2014 Jun 15;10[6]:637-43). The 16 patients who received CPAP continued to show central sleep apnea, with an AHI of 34 events/hour and central-apnea index (CAI) of 20 events/hour. Even after a four-week break before restarting CPAP, patients’ apnea did not resolve.

After receiving ASV, however, the average AHI dropped to 11 events/hour and CAI dropped to 0 events/hour. Those changes were accompanied by improvements in oxygen saturation, with the oxyhemoglobin saturation nadir increasing from 83% to 90%.

Similarly, a prospective multi-center observational trial assessed 27 patients with central apnea after they used ASV at home for three months (Chest. 2015 Dec;148[6]:1454-1461). The participants began with an average AHI of 55 and CAI of 23 at baseline. CPAP dropped these values only to an AHI of 33 and CAI of 10, but treatment with ASV dropped them to an AHI of 4 and CAI of 0 (P less than .001).

AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.

RapidEye/iStock/Getty Images Plus

The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)

The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.

More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*

Their social marginalization leads many to seek illegal means of securing income and housing: Prostitution is one of the two most common offenses that land transgender people in prison. The other is substance use.

“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.

Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.

“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.

“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”

Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.

Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.

• The person’s name, because it might pose to safety and security of facility.
• Charges against the inmate.
• The inmate’s personal characteristics.
• Risk to the inmate or other inmates at the facility.
• Hormone status.
• Recommendations by the inmate’s medical doctor.
• The inmate’s preference.
• Any concerns about staff threats to the inmate’s safety.

But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.

Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.

Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.

“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.

*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.

AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.

RapidEye/iStock/Getty Images Plus

The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)

The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.

More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*

Their social marginalization leads many to seek illegal means of securing income and housing: Prostitution is one of the two most common offenses that land transgender people in prison. The other is substance use.

“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.

Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.

“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.

“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”

Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.

Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.

• The person’s name, because it might pose to safety and security of facility.
• Charges against the inmate.
• The inmate’s personal characteristics.
• Risk to the inmate or other inmates at the facility.
• Hormone status.
• Recommendations by the inmate’s medical doctor.
• The inmate’s preference.
• Any concerns about staff threats to the inmate’s safety.

But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.

Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.

Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.

“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.

*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.

AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.

RapidEye/iStock/Getty Images Plus

The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)

The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.

More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*

Their social marginalization leads many to seek illegal means of securing income and housing: Prostitution is one of the two most common offenses that land transgender people in prison. The other is substance use.

“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.

Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.

“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.

“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”

Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.

Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.

• The person’s name, because it might pose to safety and security of facility.
• Charges against the inmate.
• The inmate’s personal characteristics.
• Risk to the inmate or other inmates at the facility.
• Hormone status.
• Recommendations by the inmate’s medical doctor.
• The inmate’s preference.
• Any concerns about staff threats to the inmate’s safety.

But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.

Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.

Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.

“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.

*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.

SAN ANTONIO – Understanding the experience of “moral distress” in critical care is essential because of its potential negative effects on health care providers and the need to prevent or address those effects, according to Marian Altman, PhD, RN, a clinical practice specialist from the American Association of Critical Care Nurses.

Tara Haelle/MDedge News

Dr. Altman spoke about moral distress as part of a panel discussion at the annual meeting of the American College of Chest Physicians on how to handle nonbeneficial treatment requests from families, including the legal and ethical obligations of care providers when a patient is receiving life-sustaining treatment.

“The key point about moral distress is that these are personal constraints, and so the choices of what is best for a patient often conflicts with what is best for the organization,” Dr. Altman told CHEST 2018 attendees. “It could conflict with what’s best for the care providers, the family, or even other patients, and so it’s that personal experience of moral compromise that often originates in this broader practice of our routine.”

While it does not necessarily occur frequently, moral distress is intense when it does occur.

“It really threatens the identity and the integrity of those who experience it because they truly believe they are seriously compromised with this deep personal effect,” Dr. Altman said.

Dr. Altman credited Andrew Jameton, a bioethicist who authored a seminal book on ethical issues in nursing in 1984, with defining exactly what moral distress is: “painful feelings and/or the psychological disequilibrium that occurs when a person is conscious of the morally appropriate action a situation requires but cannot carry out that action because of the institutionalized obstacles, such as lack of time, lack of supervisory support, exercise of medical power, and institutional policy or legal limits.” Or, in plainer terms, “Moral distress occurs when one knows the ethically correct action to take but feels powerless to take that action,” as Elizabeth G. Epstein, PhD, RN, and Sarah Delgado, MSN, RN, wrote in the Online Journal of Issues in Nursing.

To understand moral distress, it’s important to know what it’s not, too, Dr. Altman said. It’s not the daily stress of work or compassion fatigue or even burnout, though it can lead to burnout.

“Burnout is the state of physical, emotional, and mental fatigue and exhaustion caused by long-term involvement in situations that are emotionally demanding,” Dr. Altman said. “Burnout has been linked with moral distress, but they are two very different things.”

It’s also not a disagreement among colleagues or “an excuse to avoid a challenging situation.” In fact, the No. 1 cause of moral distress, in study after study, Dr. Altman said, is providing medical care, particularly medically futile care.

“Providing really unnecessary treatments and providing end-of-life care can lead to it as well as complex patients and challenging situations,” Dr. Altman said. Other causes include inadequate staffing, incompetent providers, poor communication, and advanced technology used to sustain life.

Though people often associate moral distress with intensive care, it can occur “wherever care is provided” and can “affect all members of the health care team,” Dr. Altman said. Though the early research into moral distress focused on critical care nurses, the field has since exploded, across all medical disciplines and in countries around the world.

That research has revealed how intensely moral distress can impact the psychological, biological, and social health of people. Physical symptoms that can result from moral distress include diarrhea, headache, heart palpitations, neck pain, muscle aches, and vomiting. The emotions it rouses include frustration, fear, anger, anxiety, and, especially, powerlessness and guilt.

Moral distress can lead to burnout and dissatisfaction in individuals and, subsequently, reduced retention and productivity within institutions. Health care providers who experience moral distress may leave their position, their unit, or the profession altogether.

“That can have a huge impact in a time when we need many more health care providers to care for this exploding population,” Dr. Altman said. It can also negatively influence the patient-provider relationship, potentially affecting the quantity and safety of care delivered, she explained.

But there are ways to address moral distress, she said.

“We’re not going to eradicate it because we will never eradicate critical care or end-of-life care, and those are the causes that lead to moral distress,” Dr. Altman said. “But what we can do, and what the research is now focusing on, is concentrate on improving our work environment, and help people recognize that they’re experiencing moral distress before it gets to burnout … or mitigating moral distress when it occurs.”

Those improvements include fostering both a positive ethical environment, with ethics education, an ethics committee, and on-site ethics experts, and a healthy work environment with collaboration and skillful communication.

Research has shown that “a higher ethical work environment is correlated with a decrease in moral distress frequency,” Dr. Altman said. And structured communication processes should focus on the goals of care, she said. More formal programs may include moral distress workshops, a moral distress consult service, an ethics consult service, and distress debriefings, during which a facilitator leads providers in a structured, collaborative discussion about a distressing event that has occurred.

SAN ANTONIO – Understanding the experience of “moral distress” in critical care is essential because of its potential negative effects on health care providers and the need to prevent or address those effects, according to Marian Altman, PhD, RN, a clinical practice specialist from the American Association of Critical Care Nurses.

Tara Haelle/MDedge News

Dr. Altman spoke about moral distress as part of a panel discussion at the annual meeting of the American College of Chest Physicians on how to handle nonbeneficial treatment requests from families, including the legal and ethical obligations of care providers when a patient is receiving life-sustaining treatment.

“The key point about moral distress is that these are personal constraints, and so the choices of what is best for a patient often conflicts with what is best for the organization,” Dr. Altman told CHEST 2018 attendees. “It could conflict with what’s best for the care providers, the family, or even other patients, and so it’s that personal experience of moral compromise that often originates in this broader practice of our routine.”

While it does not necessarily occur frequently, moral distress is intense when it does occur.

“It really threatens the identity and the integrity of those who experience it because they truly believe they are seriously compromised with this deep personal effect,” Dr. Altman said.

Dr. Altman credited Andrew Jameton, a bioethicist who authored a seminal book on ethical issues in nursing in 1984, with defining exactly what moral distress is: “painful feelings and/or the psychological disequilibrium that occurs when a person is conscious of the morally appropriate action a situation requires but cannot carry out that action because of the institutionalized obstacles, such as lack of time, lack of supervisory support, exercise of medical power, and institutional policy or legal limits.” Or, in plainer terms, “Moral distress occurs when one knows the ethically correct action to take but feels powerless to take that action,” as Elizabeth G. Epstein, PhD, RN, and Sarah Delgado, MSN, RN, wrote in the Online Journal of Issues in Nursing.

To understand moral distress, it’s important to know what it’s not, too, Dr. Altman said. It’s not the daily stress of work or compassion fatigue or even burnout, though it can lead to burnout.

“Burnout is the state of physical, emotional, and mental fatigue and exhaustion caused by long-term involvement in situations that are emotionally demanding,” Dr. Altman said. “Burnout has been linked with moral distress, but they are two very different things.”

It’s also not a disagreement among colleagues or “an excuse to avoid a challenging situation.” In fact, the No. 1 cause of moral distress, in study after study, Dr. Altman said, is providing medical care, particularly medically futile care.

“Providing really unnecessary treatments and providing end-of-life care can lead to it as well as complex patients and challenging situations,” Dr. Altman said. Other causes include inadequate staffing, incompetent providers, poor communication, and advanced technology used to sustain life.

Though people often associate moral distress with intensive care, it can occur “wherever care is provided” and can “affect all members of the health care team,” Dr. Altman said. Though the early research into moral distress focused on critical care nurses, the field has since exploded, across all medical disciplines and in countries around the world.

That research has revealed how intensely moral distress can impact the psychological, biological, and social health of people. Physical symptoms that can result from moral distress include diarrhea, headache, heart palpitations, neck pain, muscle aches, and vomiting. The emotions it rouses include frustration, fear, anger, anxiety, and, especially, powerlessness and guilt.

Moral distress can lead to burnout and dissatisfaction in individuals and, subsequently, reduced retention and productivity within institutions. Health care providers who experience moral distress may leave their position, their unit, or the profession altogether.

“That can have a huge impact in a time when we need many more health care providers to care for this exploding population,” Dr. Altman said. It can also negatively influence the patient-provider relationship, potentially affecting the quantity and safety of care delivered, she explained.

But there are ways to address moral distress, she said.

“We’re not going to eradicate it because we will never eradicate critical care or end-of-life care, and those are the causes that lead to moral distress,” Dr. Altman said. “But what we can do, and what the research is now focusing on, is concentrate on improving our work environment, and help people recognize that they’re experiencing moral distress before it gets to burnout … or mitigating moral distress when it occurs.”

Those improvements include fostering both a positive ethical environment, with ethics education, an ethics committee, and on-site ethics experts, and a healthy work environment with collaboration and skillful communication.

Research has shown that “a higher ethical work environment is correlated with a decrease in moral distress frequency,” Dr. Altman said. And structured communication processes should focus on the goals of care, she said. More formal programs may include moral distress workshops, a moral distress consult service, an ethics consult service, and distress debriefings, during which a facilitator leads providers in a structured, collaborative discussion about a distressing event that has occurred.

SAN ANTONIO – Understanding the experience of “moral distress” in critical care is essential because of its potential negative effects on health care providers and the need to prevent or address those effects, according to Marian Altman, PhD, RN, a clinical practice specialist from the American Association of Critical Care Nurses.

Tara Haelle/MDedge News

Dr. Altman spoke about moral distress as part of a panel discussion at the annual meeting of the American College of Chest Physicians on how to handle nonbeneficial treatment requests from families, including the legal and ethical obligations of care providers when a patient is receiving life-sustaining treatment.

“The key point about moral distress is that these are personal constraints, and so the choices of what is best for a patient often conflicts with what is best for the organization,” Dr. Altman told CHEST 2018 attendees. “It could conflict with what’s best for the care providers, the family, or even other patients, and so it’s that personal experience of moral compromise that often originates in this broader practice of our routine.”

While it does not necessarily occur frequently, moral distress is intense when it does occur.

“It really threatens the identity and the integrity of those who experience it because they truly believe they are seriously compromised with this deep personal effect,” Dr. Altman said.

Dr. Altman credited Andrew Jameton, a bioethicist who authored a seminal book on ethical issues in nursing in 1984, with defining exactly what moral distress is: “painful feelings and/or the psychological disequilibrium that occurs when a person is conscious of the morally appropriate action a situation requires but cannot carry out that action because of the institutionalized obstacles, such as lack of time, lack of supervisory support, exercise of medical power, and institutional policy or legal limits.” Or, in plainer terms, “Moral distress occurs when one knows the ethically correct action to take but feels powerless to take that action,” as Elizabeth G. Epstein, PhD, RN, and Sarah Delgado, MSN, RN, wrote in the Online Journal of Issues in Nursing.

To understand moral distress, it’s important to know what it’s not, too, Dr. Altman said. It’s not the daily stress of work or compassion fatigue or even burnout, though it can lead to burnout.

“Burnout is the state of physical, emotional, and mental fatigue and exhaustion caused by long-term involvement in situations that are emotionally demanding,” Dr. Altman said. “Burnout has been linked with moral distress, but they are two very different things.”

It’s also not a disagreement among colleagues or “an excuse to avoid a challenging situation.” In fact, the No. 1 cause of moral distress, in study after study, Dr. Altman said, is providing medical care, particularly medically futile care.

“Providing really unnecessary treatments and providing end-of-life care can lead to it as well as complex patients and challenging situations,” Dr. Altman said. Other causes include inadequate staffing, incompetent providers, poor communication, and advanced technology used to sustain life.

Though people often associate moral distress with intensive care, it can occur “wherever care is provided” and can “affect all members of the health care team,” Dr. Altman said. Though the early research into moral distress focused on critical care nurses, the field has since exploded, across all medical disciplines and in countries around the world.

That research has revealed how intensely moral distress can impact the psychological, biological, and social health of people. Physical symptoms that can result from moral distress include diarrhea, headache, heart palpitations, neck pain, muscle aches, and vomiting. The emotions it rouses include frustration, fear, anger, anxiety, and, especially, powerlessness and guilt.

Moral distress can lead to burnout and dissatisfaction in individuals and, subsequently, reduced retention and productivity within institutions. Health care providers who experience moral distress may leave their position, their unit, or the profession altogether.

“That can have a huge impact in a time when we need many more health care providers to care for this exploding population,” Dr. Altman said. It can also negatively influence the patient-provider relationship, potentially affecting the quantity and safety of care delivered, she explained.

But there are ways to address moral distress, she said.

“We’re not going to eradicate it because we will never eradicate critical care or end-of-life care, and those are the causes that lead to moral distress,” Dr. Altman said. “But what we can do, and what the research is now focusing on, is concentrate on improving our work environment, and help people recognize that they’re experiencing moral distress before it gets to burnout … or mitigating moral distress when it occurs.”

Those improvements include fostering both a positive ethical environment, with ethics education, an ethics committee, and on-site ethics experts, and a healthy work environment with collaboration and skillful communication.

Research has shown that “a higher ethical work environment is correlated with a decrease in moral distress frequency,” Dr. Altman said. And structured communication processes should focus on the goals of care, she said. More formal programs may include moral distress workshops, a moral distress consult service, an ethics consult service, and distress debriefings, during which a facilitator leads providers in a structured, collaborative discussion about a distressing event that has occurred.

AUSTIN, TEX. – Mass shootings make up only a tiny percentage of annual gun violence deaths in the United States, but they capture the attention of the nation – and of media that do not always accurately represent their context.

Experts tend to identify the first modern U.S. mass shooting event as the University of Texas Tower shooting in Austin by Charles Whitman in 1966, Corina Freitas, MD, said at the annual meeting of the American Academy of Psychiatry and the Law.

But two previous incidents preceded Whitman’s: Howard Unruh’s 12-minute killing spree in his neighborhood in Camden, N.J., in 1949, and Andrew Kehoe’s 1927 series of bombings that killed 43 people in the Bath School disaster in Michigan. Studies of these events and the hundreds since have led to a better understanding of what motivates mass shooters (or bombers in Kehoe’s case) and how to potentially identify them and prevent such events, said Dr. Freitas, of the department of psychiatry and behavioral sciences at George Washington University in Washington.

Dr. Freitas provided an overview of mass shooting history in the United States before Karen B. Rosenbaum, MD, clinical assistant professor at New York University and clinical instructor at New York Presbyterian–Weill Cornell Medical Center, spoke about the social, political, and legal implications of the intersection between mental illness and mass shootings.

She began by explaining how the FBI’s definition of mass shootings has changed from “four or more people at one location within one event” in 2005 to its redefinition in 2012-2013 to “three or more killings in a single incident and in a place of public use.”

Mass shootings usually are not impulse kills, Dr. Freitas said, noting that 77% of shooters plan their shooting for at least a week, and 46% of people spend about a week preparing. The perpetrators are potentially recognizable, typically displaying four to five concerning behaviors up to 1 year before the shooting, such as talking about their plans or purchasing supplies. But only a minority of people who observe these behaviors ever speak up about them or take any actions, she said.

The most common driver of shooters is feeling aggrieved (44%), followed by anger and social alienation, but they also display numerous other psychosocial characteristics, such as self-esteem issues, paranoia, narcissism, depression, and suicidality.

“Almost half of them are suicidal, and they actually proclaim it up to 1 year ahead of the shooting,” Dr. Freitas said. “We could catch them if we paid more attention to that.”

Mass killers tend to fall into three categories, as classified by psychiatrist Park Dietz, MD, in 1986:

• Family annihilators, such as George Banks, are typically depressed, paranoid, suicidal older males who might be intoxicated at the time of their attack. Banks shot 13 people, including 5 of his own children and 2 other children and their mothers, in Pennsylvania in 1982.
• Pseudocommandos, such as Charles Whitman, are usually preoccupied with firearms and plan heavily. “They usually end up killing themselves by cop,” Dr. Freitas said.
• Set-and-run killers, the rarest type, include perpetrators like Kehoe; their method of killing gives them an escape (though Kehoe blew himself up as well).

But mental illness is not a major feature of mass killers: Only about a quarter of mass shooters have a diagnosed mental illness, and the illness might not necessarily be related to their crime. Of that quarter, about 75% of mass shooters had a mood disorder, 25% had an anxiety disorder,19% had psychosis, and 1% had the developmental condition, such as autism spectrum disorder.

Yet, as mass shootings have dramatically increased, mental illness has become inextricably associated with these events in the media and popular opinion, Dr. Rosenbaum said. There have been 74 school shootings since the Newtown, Conn., tragedy, and mental illness is repeatedly brought up as a contributor, she said.

A 2014 study that analyzed 25% of a random sample of news stories from 1997 to 2012 on serious mental illness and gun violence (before Newtown) found that most of the coverage occurred after mass shootings and “ ‘dangerous people’ with serious mental illness were more likely to be mentioned than ‘dangerous weapons’ as a cause of gun violence” (Am J Public Health. 2014 Mar;104[3]:406-13).

Yet this association does not reflect reality, Dr. Rosenbaum said. One meta-analysis found that prevention of one stranger homicide by someone with psychosis would require detaining 35,000 people with schizophrenia who had been judged as being at high risk for violence (Schizophr Bull. 2011 May;37[3]:572-9).

Further, the relationship between violence and mental illness is not simple. Complex historical factors are usually involved, including past violence, juvenile detection, physical abuse, substance abuse, age, parental arrest record, and life circumstances – such as a recent divorce, unemployment, or victimization.

The greater danger of a person with mental illness is the harm they will do to themselves, research shows. A study of 255 recently discharged psychiatric patients and 490 matched community residents found that the patients were no more likely to perpetuate violence than were the community members, but they were significantly more likely to report being suicidal (Int J Law Psychiatry. 2018 Jan-Feb;56:44-9).

Rather than mental illness, what is associated with violence is substance use and access to weapons, Dr. Rosenbaum said.

“The United States is one of only three countries in the world with a constitutionally protected right to own firearms,” Dr. Rosenbaum said, citing a 2017 study by John S. Rozel, MD, and Edward P. Mulvey, PhD, (Annu Rev Clin Psychol. 2017 May 8;13:445-9). And the United States has few restrictions on that right. With more than 350 million privately owned firearms – approximately 30% of all privately owned firearms in the world – the U.S. population exceeds all other countries in both per capita and absolute gun ownership.

And research shows that guns don’t make a country safer: Guns per capita are significantly correlated with firearm-related deaths; mental illness is only of borderline significance (Am J Med. 2013 Oct;126[10]:873-6).

Substance use – including use of cocaine, hallucinogens, methamphetamine, ecstasy, and prescription medications – has a stronger correlation with gun-carrying and gun-related behaviors (Inj Prev. 2017 Dec; 23[6]:383-7 and Epidemiol Rev. 2016;38[1]:46-61). Both acute and chronic alcohol misuse also are linked to firearm ownership and violence toward others and one’s self (Prev Med. 2015 Oct;79:15-21).

Yet public misperceptions of mental illness as a contributor to violence persists, research shows (Aust N Z J Psychiatry. 2014 Aug;48[8]:764-71), further stigmatizing people with psychiatric conditions and potentially reducing the likelihood of their seeking treatment. Politicians contribute to these misperceptions; an example is House Speaker Paul Ryan’s comment after the Parkland, Fla., school shooting: “Mental health is often a big problem underlying these tragedies.”

“The media sensationalizes violent crimes committed by people with mental illness, especially after mass shooting, and this societal bias contributes to the stigma that leads to decreased treatment seeking and discrimination,” Dr. Rosenbaum said, citing research from Mohit Varshney, MD, and his associates (J Epidemiol Community Health. 2016 Mar;70[3]:223-5). “It is important to dissociate the concept of mental illness from dangerousness.”

AUSTIN, TEX. – Mass shootings make up only a tiny percentage of annual gun violence deaths in the United States, but they capture the attention of the nation – and of media that do not always accurately represent their context.

Experts tend to identify the first modern U.S. mass shooting event as the University of Texas Tower shooting in Austin by Charles Whitman in 1966, Corina Freitas, MD, said at the annual meeting of the American Academy of Psychiatry and the Law.

But two previous incidents preceded Whitman’s: Howard Unruh’s 12-minute killing spree in his neighborhood in Camden, N.J., in 1949, and Andrew Kehoe’s 1927 series of bombings that killed 43 people in the Bath School disaster in Michigan. Studies of these events and the hundreds since have led to a better understanding of what motivates mass shooters (or bombers in Kehoe’s case) and how to potentially identify them and prevent such events, said Dr. Freitas, of the department of psychiatry and behavioral sciences at George Washington University in Washington.

Dr. Freitas provided an overview of mass shooting history in the United States before Karen B. Rosenbaum, MD, clinical assistant professor at New York University and clinical instructor at New York Presbyterian–Weill Cornell Medical Center, spoke about the social, political, and legal implications of the intersection between mental illness and mass shootings.

She began by explaining how the FBI’s definition of mass shootings has changed from “four or more people at one location within one event” in 2005 to its redefinition in 2012-2013 to “three or more killings in a single incident and in a place of public use.”

Mass shootings usually are not impulse kills, Dr. Freitas said, noting that 77% of shooters plan their shooting for at least a week, and 46% of people spend about a week preparing. The perpetrators are potentially recognizable, typically displaying four to five concerning behaviors up to 1 year before the shooting, such as talking about their plans or purchasing supplies. But only a minority of people who observe these behaviors ever speak up about them or take any actions, she said.

The most common driver of shooters is feeling aggrieved (44%), followed by anger and social alienation, but they also display numerous other psychosocial characteristics, such as self-esteem issues, paranoia, narcissism, depression, and suicidality.

“Almost half of them are suicidal, and they actually proclaim it up to 1 year ahead of the shooting,” Dr. Freitas said. “We could catch them if we paid more attention to that.”

Mass killers tend to fall into three categories, as classified by psychiatrist Park Dietz, MD, in 1986:

• Family annihilators, such as George Banks, are typically depressed, paranoid, suicidal older males who might be intoxicated at the time of their attack. Banks shot 13 people, including 5 of his own children and 2 other children and their mothers, in Pennsylvania in 1982.
• Pseudocommandos, such as Charles Whitman, are usually preoccupied with firearms and plan heavily. “They usually end up killing themselves by cop,” Dr. Freitas said.
• Set-and-run killers, the rarest type, include perpetrators like Kehoe; their method of killing gives them an escape (though Kehoe blew himself up as well).

But mental illness is not a major feature of mass killers: Only about a quarter of mass shooters have a diagnosed mental illness, and the illness might not necessarily be related to their crime. Of that quarter, about 75% of mass shooters had a mood disorder, 25% had an anxiety disorder,19% had psychosis, and 1% had the developmental condition, such as autism spectrum disorder.

Yet, as mass shootings have dramatically increased, mental illness has become inextricably associated with these events in the media and popular opinion, Dr. Rosenbaum said. There have been 74 school shootings since the Newtown, Conn., tragedy, and mental illness is repeatedly brought up as a contributor, she said.

A 2014 study that analyzed 25% of a random sample of news stories from 1997 to 2012 on serious mental illness and gun violence (before Newtown) found that most of the coverage occurred after mass shootings and “ ‘dangerous people’ with serious mental illness were more likely to be mentioned than ‘dangerous weapons’ as a cause of gun violence” (Am J Public Health. 2014 Mar;104[3]:406-13).

Yet this association does not reflect reality, Dr. Rosenbaum said. One meta-analysis found that prevention of one stranger homicide by someone with psychosis would require detaining 35,000 people with schizophrenia who had been judged as being at high risk for violence (Schizophr Bull. 2011 May;37[3]:572-9).

Further, the relationship between violence and mental illness is not simple. Complex historical factors are usually involved, including past violence, juvenile detection, physical abuse, substance abuse, age, parental arrest record, and life circumstances – such as a recent divorce, unemployment, or victimization.

The greater danger of a person with mental illness is the harm they will do to themselves, research shows. A study of 255 recently discharged psychiatric patients and 490 matched community residents found that the patients were no more likely to perpetuate violence than were the community members, but they were significantly more likely to report being suicidal (Int J Law Psychiatry. 2018 Jan-Feb;56:44-9).

Rather than mental illness, what is associated with violence is substance use and access to weapons, Dr. Rosenbaum said.

“The United States is one of only three countries in the world with a constitutionally protected right to own firearms,” Dr. Rosenbaum said, citing a 2017 study by John S. Rozel, MD, and Edward P. Mulvey, PhD, (Annu Rev Clin Psychol. 2017 May 8;13:445-9). And the United States has few restrictions on that right. With more than 350 million privately owned firearms – approximately 30% of all privately owned firearms in the world – the U.S. population exceeds all other countries in both per capita and absolute gun ownership.

And research shows that guns don’t make a country safer: Guns per capita are significantly correlated with firearm-related deaths; mental illness is only of borderline significance (Am J Med. 2013 Oct;126[10]:873-6).

Substance use – including use of cocaine, hallucinogens, methamphetamine, ecstasy, and prescription medications – has a stronger correlation with gun-carrying and gun-related behaviors (Inj Prev. 2017 Dec; 23[6]:383-7 and Epidemiol Rev. 2016;38[1]:46-61). Both acute and chronic alcohol misuse also are linked to firearm ownership and violence toward others and one’s self (Prev Med. 2015 Oct;79:15-21).

Yet public misperceptions of mental illness as a contributor to violence persists, research shows (Aust N Z J Psychiatry. 2014 Aug;48[8]:764-71), further stigmatizing people with psychiatric conditions and potentially reducing the likelihood of their seeking treatment. Politicians contribute to these misperceptions; an example is House Speaker Paul Ryan’s comment after the Parkland, Fla., school shooting: “Mental health is often a big problem underlying these tragedies.”

“The media sensationalizes violent crimes committed by people with mental illness, especially after mass shooting, and this societal bias contributes to the stigma that leads to decreased treatment seeking and discrimination,” Dr. Rosenbaum said, citing research from Mohit Varshney, MD, and his associates (J Epidemiol Community Health. 2016 Mar;70[3]:223-5). “It is important to dissociate the concept of mental illness from dangerousness.”

AUSTIN, TEX. – Mass shootings make up only a tiny percentage of annual gun violence deaths in the United States, but they capture the attention of the nation – and of media that do not always accurately represent their context.

Experts tend to identify the first modern U.S. mass shooting event as the University of Texas Tower shooting in Austin by Charles Whitman in 1966, Corina Freitas, MD, said at the annual meeting of the American Academy of Psychiatry and the Law.

But two previous incidents preceded Whitman’s: Howard Unruh’s 12-minute killing spree in his neighborhood in Camden, N.J., in 1949, and Andrew Kehoe’s 1927 series of bombings that killed 43 people in the Bath School disaster in Michigan. Studies of these events and the hundreds since have led to a better understanding of what motivates mass shooters (or bombers in Kehoe’s case) and how to potentially identify them and prevent such events, said Dr. Freitas, of the department of psychiatry and behavioral sciences at George Washington University in Washington.

Dr. Freitas provided an overview of mass shooting history in the United States before Karen B. Rosenbaum, MD, clinical assistant professor at New York University and clinical instructor at New York Presbyterian–Weill Cornell Medical Center, spoke about the social, political, and legal implications of the intersection between mental illness and mass shootings.

She began by explaining how the FBI’s definition of mass shootings has changed from “four or more people at one location within one event” in 2005 to its redefinition in 2012-2013 to “three or more killings in a single incident and in a place of public use.”

Mass shootings usually are not impulse kills, Dr. Freitas said, noting that 77% of shooters plan their shooting for at least a week, and 46% of people spend about a week preparing. The perpetrators are potentially recognizable, typically displaying four to five concerning behaviors up to 1 year before the shooting, such as talking about their plans or purchasing supplies. But only a minority of people who observe these behaviors ever speak up about them or take any actions, she said.

The most common driver of shooters is feeling aggrieved (44%), followed by anger and social alienation, but they also display numerous other psychosocial characteristics, such as self-esteem issues, paranoia, narcissism, depression, and suicidality.

“Almost half of them are suicidal, and they actually proclaim it up to 1 year ahead of the shooting,” Dr. Freitas said. “We could catch them if we paid more attention to that.”

Mass killers tend to fall into three categories, as classified by psychiatrist Park Dietz, MD, in 1986:

• Family annihilators, such as George Banks, are typically depressed, paranoid, suicidal older males who might be intoxicated at the time of their attack. Banks shot 13 people, including 5 of his own children and 2 other children and their mothers, in Pennsylvania in 1982.
• Pseudocommandos, such as Charles Whitman, are usually preoccupied with firearms and plan heavily. “They usually end up killing themselves by cop,” Dr. Freitas said.
• Set-and-run killers, the rarest type, include perpetrators like Kehoe; their method of killing gives them an escape (though Kehoe blew himself up as well).

But mental illness is not a major feature of mass killers: Only about a quarter of mass shooters have a diagnosed mental illness, and the illness might not necessarily be related to their crime. Of that quarter, about 75% of mass shooters had a mood disorder, 25% had an anxiety disorder,19% had psychosis, and 1% had the developmental condition, such as autism spectrum disorder.

Yet, as mass shootings have dramatically increased, mental illness has become inextricably associated with these events in the media and popular opinion, Dr. Rosenbaum said. There have been 74 school shootings since the Newtown, Conn., tragedy, and mental illness is repeatedly brought up as a contributor, she said.

A 2014 study that analyzed 25% of a random sample of news stories from 1997 to 2012 on serious mental illness and gun violence (before Newtown) found that most of the coverage occurred after mass shootings and “ ‘dangerous people’ with serious mental illness were more likely to be mentioned than ‘dangerous weapons’ as a cause of gun violence” (Am J Public Health. 2014 Mar;104[3]:406-13).

Yet this association does not reflect reality, Dr. Rosenbaum said. One meta-analysis found that prevention of one stranger homicide by someone with psychosis would require detaining 35,000 people with schizophrenia who had been judged as being at high risk for violence (Schizophr Bull. 2011 May;37[3]:572-9).

Further, the relationship between violence and mental illness is not simple. Complex historical factors are usually involved, including past violence, juvenile detection, physical abuse, substance abuse, age, parental arrest record, and life circumstances – such as a recent divorce, unemployment, or victimization.

The greater danger of a person with mental illness is the harm they will do to themselves, research shows. A study of 255 recently discharged psychiatric patients and 490 matched community residents found that the patients were no more likely to perpetuate violence than were the community members, but they were significantly more likely to report being suicidal (Int J Law Psychiatry. 2018 Jan-Feb;56:44-9).

Rather than mental illness, what is associated with violence is substance use and access to weapons, Dr. Rosenbaum said.

“The United States is one of only three countries in the world with a constitutionally protected right to own firearms,” Dr. Rosenbaum said, citing a 2017 study by John S. Rozel, MD, and Edward P. Mulvey, PhD, (Annu Rev Clin Psychol. 2017 May 8;13:445-9). And the United States has few restrictions on that right. With more than 350 million privately owned firearms – approximately 30% of all privately owned firearms in the world – the U.S. population exceeds all other countries in both per capita and absolute gun ownership.

And research shows that guns don’t make a country safer: Guns per capita are significantly correlated with firearm-related deaths; mental illness is only of borderline significance (Am J Med. 2013 Oct;126[10]:873-6).

Substance use – including use of cocaine, hallucinogens, methamphetamine, ecstasy, and prescription medications – has a stronger correlation with gun-carrying and gun-related behaviors (Inj Prev. 2017 Dec; 23[6]:383-7 and Epidemiol Rev. 2016;38[1]:46-61). Both acute and chronic alcohol misuse also are linked to firearm ownership and violence toward others and one’s self (Prev Med. 2015 Oct;79:15-21).

Yet public misperceptions of mental illness as a contributor to violence persists, research shows (Aust N Z J Psychiatry. 2014 Aug;48[8]:764-71), further stigmatizing people with psychiatric conditions and potentially reducing the likelihood of their seeking treatment. Politicians contribute to these misperceptions; an example is House Speaker Paul Ryan’s comment after the Parkland, Fla., school shooting: “Mental health is often a big problem underlying these tragedies.”

“The media sensationalizes violent crimes committed by people with mental illness, especially after mass shooting, and this societal bias contributes to the stigma that leads to decreased treatment seeking and discrimination,” Dr. Rosenbaum said, citing research from Mohit Varshney, MD, and his associates (J Epidemiol Community Health. 2016 Mar;70[3]:223-5). “It is important to dissociate the concept of mental illness from dangerousness.”

SAN ANTONIO – Obstructive sleep apnea (OSA) in children is associated with an abnormal metabolic profile, but not with body mass index (BMI), according to new research.

Tara Haelle/MDedge News

“Screening for metabolic dysfunction in obese children with obstructive sleep apnea can help identify those at risk for cardiovascular complications,” Kanika Mathur, MD, of the Albert Einstein College of Medicine and the Children’s Hospital at Montefiore, both in New York, told attendees at the annual meeting of the American College of Chest Physicians. Dr. Mathur explained that no consensus currently exists regarding routine cardiac evaluation of children with OSA.

“The American Academy of Pediatrics does not mention any sort of cardiac evaluation in children with OSA while the most recent guidelines from the American Heart Association and the American Thoracic Society recommend echocardiographic evaluation in children with severe obstructive sleep apnea, specifically to evaluate for pulmonary hypertension and right ventricular dysfunction,” Dr. Mathur told attendees.

OSA’s association with obesity, diabetes, and hypertension is well established in adults. It is an independent risk factor for coronary artery disease, heart failure, stroke and atrial fibrillation, and research has suggested OSA treatment can reduce cardiovascular risk in adults, Dr. Mathur explained, but little data on children exist. She and her colleagues set out to understand the relationship of OSA in children with various measures of cardiovascular and metabolic health.

“Despite similar degrees of obesity and systemic blood pressure, pediatric patients with OSA had significantly higher diastolic blood pressure, heart rate, and abnormal metabolic profile, including elevated alanine transaminase, aspartate transaminase, triglycerides and hemoglobin A_1c,” they found.

Their study included patients aged 3-21 years with a BMI of at least the 95th percentile who had undergone sleep study and an echocardiogram at the Children’s Hospital at Montefiore between November 2016 and November 2017.

They excluded those with comorbidities related to cardiovascular morbidity: heart disease, neuromuscular disease, sickle cell disease, rheumatologic diseases, significant cranial facial abnormalities, tracheostomy, and any lung disease. However, 7% of the patients had trisomy 21.

Among the 81 children who met their criteria, 37 were male and 44 were female, with an average age of 14 years old and a mean BMI of 39.4 kg/m² (mean BMI z score of 2.22). Most of the patients (53.1%) had severe OSA (apnea-hypopnea index of at least 10), 21% had moderate OSA (AHI 5-9.9), 12.3% had mild OSA (AHI 2-4.9), and 13.6% did not have OSA. The median AHI of the children was 10.3.

Among all the children, “about half had elevated systolic blood pressure, which is already a risk factor for cardiovascular morbidity,” Mathur reported.

BMI, BMI z score, systolic blood pressure z score, oxygen saturation and cholesterol (overall and both HDL and LDL cholesterol levels) did not significantly differ between children who had OSA and those who did not, but diastolic blood pressure and heart rate did. Those with OSA had a diastolic blood pressure of 65 mm Hg, compared with 58 mm Hg without OSA (P = .008). Heart rate was 89 bpm in the children with OSA, compared with 78 bpm in those without (P = .004).

The children with OSA also showed higher mean levels of several other metabolic biomarkers:

• Alanine transaminase: 26 U/L with OSA vs. 18 U/L without (P = .01).
• Aspartate transaminase: 23 U/L with OSA vs. 18 U/L without (P = .03).
• Triglycerides: 138 mg/dL with OSA vs 84 mg/dL without (P = .004).
• Hemoglobin A_1c: 6.2% with OSA vs. 5.4% without (P = .002).

Children with and without OSA did not have any significant differences in left atrial indexed volume, left ventricular volume, left ventricular ejection fraction, or left ventricular mass (measured by M-mode or 5/6 area length formula). Though research has shown these measures to differ in adults with and without OSA, evidence on echocardiographic changes in children has been conflicting, Dr. Mathur noted.

The researchers also conducted subanalyses according to OSA severity, but BMI, BMI Z-score, systolic or diastolic blood pressure Z-score, heart rate and oxygen saturation did not differ between those with mild OSA vs those with moderate or severe OSA. No differences in echocardiographic measurements existed between these subgroups, either.

However, children with moderate to severe OSA did have higher alanine transaminase (27 U/L with moderate to severe vs. 17 U/L with mild OSA; P = .005) and higher triglycerides (148 vs 74; P = .001).

“Certainly we need further evaluation to see the efficacy of obstructive sleep apnea therapies on metabolic dysfunction and whether weight loss needs to be an adjunct therapy for these patients,” Dr. Mathur told attendees. She also noted the need to define the role of echocardiography in managing children with OSA.

The study had several limitations, including its retrospective cross-sectional nature at a single center and its small sample size.

Andrew D. Bowser/MDedge News

“Additionally, we have a wide variety of ages, which could represent different pathophysiology of the associated metabolic dysfunction in these patients,” Mathur said. “There is an inherent difficulty to performing echocardiograms in a very obese population as well.”

Both the moderators of the pediatrics section, Christopher Carroll, MD, FCCP, of Connecticut Children’s Medical Center in Hartford, and Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital in Columbus, Ohio, were impressed with the research. Dr. Carroll called it a “very elegant” study, and Dr. Sheikh noted the need for these studies in pediatrics “so that we don’t have to rely on grown-up data,” which may or may not generalize to children.

SOURCE: CHEST 2018. https://journal.chestnet.org/article/S0012-3692(18)31935-4/fulltext

SAN ANTONIO – Obstructive sleep apnea (OSA) in children is associated with an abnormal metabolic profile, but not with body mass index (BMI), according to new research.

Tara Haelle/MDedge News

“Screening for metabolic dysfunction in obese children with obstructive sleep apnea can help identify those at risk for cardiovascular complications,” Kanika Mathur, MD, of the Albert Einstein College of Medicine and the Children’s Hospital at Montefiore, both in New York, told attendees at the annual meeting of the American College of Chest Physicians. Dr. Mathur explained that no consensus currently exists regarding routine cardiac evaluation of children with OSA.

“The American Academy of Pediatrics does not mention any sort of cardiac evaluation in children with OSA while the most recent guidelines from the American Heart Association and the American Thoracic Society recommend echocardiographic evaluation in children with severe obstructive sleep apnea, specifically to evaluate for pulmonary hypertension and right ventricular dysfunction,” Dr. Mathur told attendees.

OSA’s association with obesity, diabetes, and hypertension is well established in adults. It is an independent risk factor for coronary artery disease, heart failure, stroke and atrial fibrillation, and research has suggested OSA treatment can reduce cardiovascular risk in adults, Dr. Mathur explained, but little data on children exist. She and her colleagues set out to understand the relationship of OSA in children with various measures of cardiovascular and metabolic health.

“Despite similar degrees of obesity and systemic blood pressure, pediatric patients with OSA had significantly higher diastolic blood pressure, heart rate, and abnormal metabolic profile, including elevated alanine transaminase, aspartate transaminase, triglycerides and hemoglobin A_1c,” they found.

Their study included patients aged 3-21 years with a BMI of at least the 95th percentile who had undergone sleep study and an echocardiogram at the Children’s Hospital at Montefiore between November 2016 and November 2017.

They excluded those with comorbidities related to cardiovascular morbidity: heart disease, neuromuscular disease, sickle cell disease, rheumatologic diseases, significant cranial facial abnormalities, tracheostomy, and any lung disease. However, 7% of the patients had trisomy 21.

Among the 81 children who met their criteria, 37 were male and 44 were female, with an average age of 14 years old and a mean BMI of 39.4 kg/m² (mean BMI z score of 2.22). Most of the patients (53.1%) had severe OSA (apnea-hypopnea index of at least 10), 21% had moderate OSA (AHI 5-9.9), 12.3% had mild OSA (AHI 2-4.9), and 13.6% did not have OSA. The median AHI of the children was 10.3.

Among all the children, “about half had elevated systolic blood pressure, which is already a risk factor for cardiovascular morbidity,” Mathur reported.

BMI, BMI z score, systolic blood pressure z score, oxygen saturation and cholesterol (overall and both HDL and LDL cholesterol levels) did not significantly differ between children who had OSA and those who did not, but diastolic blood pressure and heart rate did. Those with OSA had a diastolic blood pressure of 65 mm Hg, compared with 58 mm Hg without OSA (P = .008). Heart rate was 89 bpm in the children with OSA, compared with 78 bpm in those without (P = .004).

The children with OSA also showed higher mean levels of several other metabolic biomarkers:

• Alanine transaminase: 26 U/L with OSA vs. 18 U/L without (P = .01).
• Aspartate transaminase: 23 U/L with OSA vs. 18 U/L without (P = .03).
• Triglycerides: 138 mg/dL with OSA vs 84 mg/dL without (P = .004).
• Hemoglobin A_1c: 6.2% with OSA vs. 5.4% without (P = .002).

Children with and without OSA did not have any significant differences in left atrial indexed volume, left ventricular volume, left ventricular ejection fraction, or left ventricular mass (measured by M-mode or 5/6 area length formula). Though research has shown these measures to differ in adults with and without OSA, evidence on echocardiographic changes in children has been conflicting, Dr. Mathur noted.

The researchers also conducted subanalyses according to OSA severity, but BMI, BMI Z-score, systolic or diastolic blood pressure Z-score, heart rate and oxygen saturation did not differ between those with mild OSA vs those with moderate or severe OSA. No differences in echocardiographic measurements existed between these subgroups, either.

However, children with moderate to severe OSA did have higher alanine transaminase (27 U/L with moderate to severe vs. 17 U/L with mild OSA; P = .005) and higher triglycerides (148 vs 74; P = .001).

“Certainly we need further evaluation to see the efficacy of obstructive sleep apnea therapies on metabolic dysfunction and whether weight loss needs to be an adjunct therapy for these patients,” Dr. Mathur told attendees. She also noted the need to define the role of echocardiography in managing children with OSA.

The study had several limitations, including its retrospective cross-sectional nature at a single center and its small sample size.

Andrew D. Bowser/MDedge News

“Additionally, we have a wide variety of ages, which could represent different pathophysiology of the associated metabolic dysfunction in these patients,” Mathur said. “There is an inherent difficulty to performing echocardiograms in a very obese population as well.”

Both the moderators of the pediatrics section, Christopher Carroll, MD, FCCP, of Connecticut Children’s Medical Center in Hartford, and Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital in Columbus, Ohio, were impressed with the research. Dr. Carroll called it a “very elegant” study, and Dr. Sheikh noted the need for these studies in pediatrics “so that we don’t have to rely on grown-up data,” which may or may not generalize to children.

SOURCE: CHEST 2018. https://journal.chestnet.org/article/S0012-3692(18)31935-4/fulltext

SAN ANTONIO – Obstructive sleep apnea (OSA) in children is associated with an abnormal metabolic profile, but not with body mass index (BMI), according to new research.

Tara Haelle/MDedge News

“Screening for metabolic dysfunction in obese children with obstructive sleep apnea can help identify those at risk for cardiovascular complications,” Kanika Mathur, MD, of the Albert Einstein College of Medicine and the Children’s Hospital at Montefiore, both in New York, told attendees at the annual meeting of the American College of Chest Physicians. Dr. Mathur explained that no consensus currently exists regarding routine cardiac evaluation of children with OSA.

“The American Academy of Pediatrics does not mention any sort of cardiac evaluation in children with OSA while the most recent guidelines from the American Heart Association and the American Thoracic Society recommend echocardiographic evaluation in children with severe obstructive sleep apnea, specifically to evaluate for pulmonary hypertension and right ventricular dysfunction,” Dr. Mathur told attendees.

OSA’s association with obesity, diabetes, and hypertension is well established in adults. It is an independent risk factor for coronary artery disease, heart failure, stroke and atrial fibrillation, and research has suggested OSA treatment can reduce cardiovascular risk in adults, Dr. Mathur explained, but little data on children exist. She and her colleagues set out to understand the relationship of OSA in children with various measures of cardiovascular and metabolic health.

“Despite similar degrees of obesity and systemic blood pressure, pediatric patients with OSA had significantly higher diastolic blood pressure, heart rate, and abnormal metabolic profile, including elevated alanine transaminase, aspartate transaminase, triglycerides and hemoglobin A_1c,” they found.

Their study included patients aged 3-21 years with a BMI of at least the 95th percentile who had undergone sleep study and an echocardiogram at the Children’s Hospital at Montefiore between November 2016 and November 2017.

They excluded those with comorbidities related to cardiovascular morbidity: heart disease, neuromuscular disease, sickle cell disease, rheumatologic diseases, significant cranial facial abnormalities, tracheostomy, and any lung disease. However, 7% of the patients had trisomy 21.

Among the 81 children who met their criteria, 37 were male and 44 were female, with an average age of 14 years old and a mean BMI of 39.4 kg/m² (mean BMI z score of 2.22). Most of the patients (53.1%) had severe OSA (apnea-hypopnea index of at least 10), 21% had moderate OSA (AHI 5-9.9), 12.3% had mild OSA (AHI 2-4.9), and 13.6% did not have OSA. The median AHI of the children was 10.3.

Among all the children, “about half had elevated systolic blood pressure, which is already a risk factor for cardiovascular morbidity,” Mathur reported.

BMI, BMI z score, systolic blood pressure z score, oxygen saturation and cholesterol (overall and both HDL and LDL cholesterol levels) did not significantly differ between children who had OSA and those who did not, but diastolic blood pressure and heart rate did. Those with OSA had a diastolic blood pressure of 65 mm Hg, compared with 58 mm Hg without OSA (P = .008). Heart rate was 89 bpm in the children with OSA, compared with 78 bpm in those without (P = .004).

The children with OSA also showed higher mean levels of several other metabolic biomarkers:

• Alanine transaminase: 26 U/L with OSA vs. 18 U/L without (P = .01).
• Aspartate transaminase: 23 U/L with OSA vs. 18 U/L without (P = .03).
• Triglycerides: 138 mg/dL with OSA vs 84 mg/dL without (P = .004).
• Hemoglobin A_1c: 6.2% with OSA vs. 5.4% without (P = .002).

Children with and without OSA did not have any significant differences in left atrial indexed volume, left ventricular volume, left ventricular ejection fraction, or left ventricular mass (measured by M-mode or 5/6 area length formula). Though research has shown these measures to differ in adults with and without OSA, evidence on echocardiographic changes in children has been conflicting, Dr. Mathur noted.

The researchers also conducted subanalyses according to OSA severity, but BMI, BMI Z-score, systolic or diastolic blood pressure Z-score, heart rate and oxygen saturation did not differ between those with mild OSA vs those with moderate or severe OSA. No differences in echocardiographic measurements existed between these subgroups, either.

However, children with moderate to severe OSA did have higher alanine transaminase (27 U/L with moderate to severe vs. 17 U/L with mild OSA; P = .005) and higher triglycerides (148 vs 74; P = .001).

“Certainly we need further evaluation to see the efficacy of obstructive sleep apnea therapies on metabolic dysfunction and whether weight loss needs to be an adjunct therapy for these patients,” Dr. Mathur told attendees. She also noted the need to define the role of echocardiography in managing children with OSA.

The study had several limitations, including its retrospective cross-sectional nature at a single center and its small sample size.

Andrew D. Bowser/MDedge News

“Additionally, we have a wide variety of ages, which could represent different pathophysiology of the associated metabolic dysfunction in these patients,” Mathur said. “There is an inherent difficulty to performing echocardiograms in a very obese population as well.”

Both the moderators of the pediatrics section, Christopher Carroll, MD, FCCP, of Connecticut Children’s Medical Center in Hartford, and Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital in Columbus, Ohio, were impressed with the research. Dr. Carroll called it a “very elegant” study, and Dr. Sheikh noted the need for these studies in pediatrics “so that we don’t have to rely on grown-up data,” which may or may not generalize to children.

SOURCE: CHEST 2018. https://journal.chestnet.org/article/S0012-3692(18)31935-4/fulltext

SAN ANTONIO – Women in medicine have made great strides in cracking the glass ceiling, but it’s not shattered yet, said Stephanie M. Levine, MD, FCCP, the incoming president of CHEST.

At a session on women in medicine at the annual meeting of the American College of Chest Physicians, Dr. Levine discussed the challenges of breaking through the metaphorical invisible barrier. The “glass ceiling” refers to multiple ways in which women lack equality with men in medicine: leadership roles, positions and titles, progress in academic medicine, gaps in salaries and compensation, and overall gender parity in specialties.

For example, according to data from the American Association of Medical Colleges for 2017-2018, women comprise 50% of medical school graduates but only 34% of the physician workforce and 22% of leadership roles. Women are 13% less likely to be promoted to professor. They receive salaries an average 21% lower than those of their male peers, said Dr. Levine, professor of medicine and director of the pulmonary/critical care fellowship program at the University of Texas, San Antonio.

Disparities exist particularly within specialties and subspecialties, she said. Women make 85% of what men earn in primary care but, in the specialties, only 75% of what men earn. Among active fellow trainees in the areas of medicine most represented by CHEST, one-third (32%) of critical care physicians and less than a third (29%) of pulmonary physicians are female.
 

Why the lag in specialty parity?

The reasons for these disparities are complex, Dr. Levine argued, but the problem is not insurmountable. They begin, in a sense, with the problem itself: When there are fewer mentors, role models, sponsors, and leaders, and less overall representation of women in the first place, it is harder for women to advance.

One male audience member, for example, asked how his department could recruit more women, because most turned down interviews despite the fact that more women than men were being invited. “How many women are in your leadership?” Dr. Levine asked. He acknowledged that there were none – and therein lies the likely problem. Applicants are looking for female representation in leadership.

Gender bias and discrimination certainly play a role among peers, leadership, and even patients. Patients referring to female physicians by their first names and asking questions such as “Are you my nurse?” are subtle but cutting examples of the ways in which they reveal implicit bias and reinforce gender stereotypes, Dr. Levine said to weary nods of agreement among the attendees.

Implicit, unconscious bias is also built into the culture of a place and the way things have always been done. Lack of equity in salary, space to work, support, and promotion all compound one another. Work-life integration challenges often do not favor women. Studies have shown that in the hiring process, CVs with female names do not receive as much attention as do CVs with male names, Dr. Levine noted.

Some of the challenges lie with the way women themselves do or do not advocate for themselves. Research has long shown that women do not negotiate as well – or at all – compared with men. Women tend to be less aggressive in seeking higher compensation and leadership roles, possibly because of existing implicit bias against female assertiveness in general.

The catch-22 is that being more assertive or direct can lead others to interpret a woman as being rude or brusk, as one audience member noted when she described how colleagues perceive her simple, direct tone as seeming “upset.”

Conscious bias remains alive and well: The stereotypes that women are caretakers and men are take-charge dominators persist and can reinforce gender disparities in leadership roles.

Women also must make calculations and trade-offs between their academic promotion clocks and their biologic clocks, Dr. Levine explained.

“The 30s are great for both academic and biologic productivity,” she told attendees. The typical age for a person’s first National Institutes of Health Research Project grant (R01) is in the early 40s.
 

How to improve gender equality

Women bring diverse skills and perspectives to the table, Dr. Levine explained. Women tend to have stronger collaborative skills and greater compassion and empathy, for example. They tend to be less hierarchal and better at mentoring and empowerment, she said.

There are many ways to poke more cracks in the ceiling, starting with diversity and inclusion officers who make it a priority to focus on parity. Formal programs can educate staff and colleagues about implicit bias so that they might more easily recognize it when it kicks in, and training for gatekeepers can lead to more proportional hiring of women at every level.

Institutions should review their policies – salary inequities, diversity in promotion, processes for selecting leaders – and set formal interventional goals that are then evaluated in honest, documented annual reviews.

Some of these policies should address work-life balance as well: Offering part-time and flexible work options during early child-rearing years helps not only mothers, but also fathers who are now taking a more active role in parenting. Slowing or prorating the promotion clock can help those building families, and shifting meetings away from times such as 7:00 a.m. and 6:00 p.m. allow mothers and fathers alike to get their kids to and from school and attend children’s events.

Sponsorship of women is an important strategy in breaking the glass ceiling, Dr. Levine said. Sponsors can support women with untapped leadership potential and do the necessary networking and introductions that help make that advance happen. And it must be done by sponsors with power and influence, including men, Dr. Levine said.

Men can play important roles in promoting gender parity by suggesting women for key roles, leadership positions, and committees and also notifying women of upcoming opportunities, such as editorial board spots and other hot jobs. For women who aspire to be leaders, men can seek to convey leadership skills that may be needed to chair committees and other groups. Search committees need to expand beyond looking for “token women,” she said.

Dr. Levine illustrated her address with her own story. She described how many of these strategies had helped her career and how many male supervisors, mentors, and colleagues helped her, including introducing her to other male leaders who then offered her opportunities to contribute to the American College of Chest Physicians. She ran for CHEST president twice before being elected on her third run in September. She is the fifth woman to lead CHEST.

“Don’t give up,” she encouraged women in the audience, telling them to advocate for themselves and to encourage, mentor, and sponsor their female fellows and junior faculty.

“This will result in closing the gaps and will help women achieve leadership roles and competitive salaries as well as work-life integration,” Dr. Levine said.

SAN ANTONIO – Women in medicine have made great strides in cracking the glass ceiling, but it’s not shattered yet, said Stephanie M. Levine, MD, FCCP, the incoming president of CHEST.

At a session on women in medicine at the annual meeting of the American College of Chest Physicians, Dr. Levine discussed the challenges of breaking through the metaphorical invisible barrier. The “glass ceiling” refers to multiple ways in which women lack equality with men in medicine: leadership roles, positions and titles, progress in academic medicine, gaps in salaries and compensation, and overall gender parity in specialties.

For example, according to data from the American Association of Medical Colleges for 2017-2018, women comprise 50% of medical school graduates but only 34% of the physician workforce and 22% of leadership roles. Women are 13% less likely to be promoted to professor. They receive salaries an average 21% lower than those of their male peers, said Dr. Levine, professor of medicine and director of the pulmonary/critical care fellowship program at the University of Texas, San Antonio.

Disparities exist particularly within specialties and subspecialties, she said. Women make 85% of what men earn in primary care but, in the specialties, only 75% of what men earn. Among active fellow trainees in the areas of medicine most represented by CHEST, one-third (32%) of critical care physicians and less than a third (29%) of pulmonary physicians are female.
 

Why the lag in specialty parity?

The reasons for these disparities are complex, Dr. Levine argued, but the problem is not insurmountable. They begin, in a sense, with the problem itself: When there are fewer mentors, role models, sponsors, and leaders, and less overall representation of women in the first place, it is harder for women to advance.

One male audience member, for example, asked how his department could recruit more women, because most turned down interviews despite the fact that more women than men were being invited. “How many women are in your leadership?” Dr. Levine asked. He acknowledged that there were none – and therein lies the likely problem. Applicants are looking for female representation in leadership.

Gender bias and discrimination certainly play a role among peers, leadership, and even patients. Patients referring to female physicians by their first names and asking questions such as “Are you my nurse?” are subtle but cutting examples of the ways in which they reveal implicit bias and reinforce gender stereotypes, Dr. Levine said to weary nods of agreement among the attendees.

Implicit, unconscious bias is also built into the culture of a place and the way things have always been done. Lack of equity in salary, space to work, support, and promotion all compound one another. Work-life integration challenges often do not favor women. Studies have shown that in the hiring process, CVs with female names do not receive as much attention as do CVs with male names, Dr. Levine noted.

Some of the challenges lie with the way women themselves do or do not advocate for themselves. Research has long shown that women do not negotiate as well – or at all – compared with men. Women tend to be less aggressive in seeking higher compensation and leadership roles, possibly because of existing implicit bias against female assertiveness in general.

The catch-22 is that being more assertive or direct can lead others to interpret a woman as being rude or brusk, as one audience member noted when she described how colleagues perceive her simple, direct tone as seeming “upset.”

Conscious bias remains alive and well: The stereotypes that women are caretakers and men are take-charge dominators persist and can reinforce gender disparities in leadership roles.

Women also must make calculations and trade-offs between their academic promotion clocks and their biologic clocks, Dr. Levine explained.

“The 30s are great for both academic and biologic productivity,” she told attendees. The typical age for a person’s first National Institutes of Health Research Project grant (R01) is in the early 40s.
 

How to improve gender equality

Women bring diverse skills and perspectives to the table, Dr. Levine explained. Women tend to have stronger collaborative skills and greater compassion and empathy, for example. They tend to be less hierarchal and better at mentoring and empowerment, she said.

There are many ways to poke more cracks in the ceiling, starting with diversity and inclusion officers who make it a priority to focus on parity. Formal programs can educate staff and colleagues about implicit bias so that they might more easily recognize it when it kicks in, and training for gatekeepers can lead to more proportional hiring of women at every level.

Institutions should review their policies – salary inequities, diversity in promotion, processes for selecting leaders – and set formal interventional goals that are then evaluated in honest, documented annual reviews.

Some of these policies should address work-life balance as well: Offering part-time and flexible work options during early child-rearing years helps not only mothers, but also fathers who are now taking a more active role in parenting. Slowing or prorating the promotion clock can help those building families, and shifting meetings away from times such as 7:00 a.m. and 6:00 p.m. allow mothers and fathers alike to get their kids to and from school and attend children’s events.

Sponsorship of women is an important strategy in breaking the glass ceiling, Dr. Levine said. Sponsors can support women with untapped leadership potential and do the necessary networking and introductions that help make that advance happen. And it must be done by sponsors with power and influence, including men, Dr. Levine said.

Men can play important roles in promoting gender parity by suggesting women for key roles, leadership positions, and committees and also notifying women of upcoming opportunities, such as editorial board spots and other hot jobs. For women who aspire to be leaders, men can seek to convey leadership skills that may be needed to chair committees and other groups. Search committees need to expand beyond looking for “token women,” she said.

Dr. Levine illustrated her address with her own story. She described how many of these strategies had helped her career and how many male supervisors, mentors, and colleagues helped her, including introducing her to other male leaders who then offered her opportunities to contribute to the American College of Chest Physicians. She ran for CHEST president twice before being elected on her third run in September. She is the fifth woman to lead CHEST.

“Don’t give up,” she encouraged women in the audience, telling them to advocate for themselves and to encourage, mentor, and sponsor their female fellows and junior faculty.

“This will result in closing the gaps and will help women achieve leadership roles and competitive salaries as well as work-life integration,” Dr. Levine said.

SAN ANTONIO – Women in medicine have made great strides in cracking the glass ceiling, but it’s not shattered yet, said Stephanie M. Levine, MD, FCCP, the incoming president of CHEST.

At a session on women in medicine at the annual meeting of the American College of Chest Physicians, Dr. Levine discussed the challenges of breaking through the metaphorical invisible barrier. The “glass ceiling” refers to multiple ways in which women lack equality with men in medicine: leadership roles, positions and titles, progress in academic medicine, gaps in salaries and compensation, and overall gender parity in specialties.

For example, according to data from the American Association of Medical Colleges for 2017-2018, women comprise 50% of medical school graduates but only 34% of the physician workforce and 22% of leadership roles. Women are 13% less likely to be promoted to professor. They receive salaries an average 21% lower than those of their male peers, said Dr. Levine, professor of medicine and director of the pulmonary/critical care fellowship program at the University of Texas, San Antonio.

Disparities exist particularly within specialties and subspecialties, she said. Women make 85% of what men earn in primary care but, in the specialties, only 75% of what men earn. Among active fellow trainees in the areas of medicine most represented by CHEST, one-third (32%) of critical care physicians and less than a third (29%) of pulmonary physicians are female.
 

Why the lag in specialty parity?

The reasons for these disparities are complex, Dr. Levine argued, but the problem is not insurmountable. They begin, in a sense, with the problem itself: When there are fewer mentors, role models, sponsors, and leaders, and less overall representation of women in the first place, it is harder for women to advance.

One male audience member, for example, asked how his department could recruit more women, because most turned down interviews despite the fact that more women than men were being invited. “How many women are in your leadership?” Dr. Levine asked. He acknowledged that there were none – and therein lies the likely problem. Applicants are looking for female representation in leadership.

Gender bias and discrimination certainly play a role among peers, leadership, and even patients. Patients referring to female physicians by their first names and asking questions such as “Are you my nurse?” are subtle but cutting examples of the ways in which they reveal implicit bias and reinforce gender stereotypes, Dr. Levine said to weary nods of agreement among the attendees.

Implicit, unconscious bias is also built into the culture of a place and the way things have always been done. Lack of equity in salary, space to work, support, and promotion all compound one another. Work-life integration challenges often do not favor women. Studies have shown that in the hiring process, CVs with female names do not receive as much attention as do CVs with male names, Dr. Levine noted.

Some of the challenges lie with the way women themselves do or do not advocate for themselves. Research has long shown that women do not negotiate as well – or at all – compared with men. Women tend to be less aggressive in seeking higher compensation and leadership roles, possibly because of existing implicit bias against female assertiveness in general.

The catch-22 is that being more assertive or direct can lead others to interpret a woman as being rude or brusk, as one audience member noted when she described how colleagues perceive her simple, direct tone as seeming “upset.”

Conscious bias remains alive and well: The stereotypes that women are caretakers and men are take-charge dominators persist and can reinforce gender disparities in leadership roles.

Women also must make calculations and trade-offs between their academic promotion clocks and their biologic clocks, Dr. Levine explained.

“The 30s are great for both academic and biologic productivity,” she told attendees. The typical age for a person’s first National Institutes of Health Research Project grant (R01) is in the early 40s.
 

How to improve gender equality

Women bring diverse skills and perspectives to the table, Dr. Levine explained. Women tend to have stronger collaborative skills and greater compassion and empathy, for example. They tend to be less hierarchal and better at mentoring and empowerment, she said.

There are many ways to poke more cracks in the ceiling, starting with diversity and inclusion officers who make it a priority to focus on parity. Formal programs can educate staff and colleagues about implicit bias so that they might more easily recognize it when it kicks in, and training for gatekeepers can lead to more proportional hiring of women at every level.

Institutions should review their policies – salary inequities, diversity in promotion, processes for selecting leaders – and set formal interventional goals that are then evaluated in honest, documented annual reviews.

Some of these policies should address work-life balance as well: Offering part-time and flexible work options during early child-rearing years helps not only mothers, but also fathers who are now taking a more active role in parenting. Slowing or prorating the promotion clock can help those building families, and shifting meetings away from times such as 7:00 a.m. and 6:00 p.m. allow mothers and fathers alike to get their kids to and from school and attend children’s events.

Sponsorship of women is an important strategy in breaking the glass ceiling, Dr. Levine said. Sponsors can support women with untapped leadership potential and do the necessary networking and introductions that help make that advance happen. And it must be done by sponsors with power and influence, including men, Dr. Levine said.

Men can play important roles in promoting gender parity by suggesting women for key roles, leadership positions, and committees and also notifying women of upcoming opportunities, such as editorial board spots and other hot jobs. For women who aspire to be leaders, men can seek to convey leadership skills that may be needed to chair committees and other groups. Search committees need to expand beyond looking for “token women,” she said.

Dr. Levine illustrated her address with her own story. She described how many of these strategies had helped her career and how many male supervisors, mentors, and colleagues helped her, including introducing her to other male leaders who then offered her opportunities to contribute to the American College of Chest Physicians. She ran for CHEST president twice before being elected on her third run in September. She is the fifth woman to lead CHEST.

“Don’t give up,” she encouraged women in the audience, telling them to advocate for themselves and to encourage, mentor, and sponsor their female fellows and junior faculty.

“This will result in closing the gaps and will help women achieve leadership roles and competitive salaries as well as work-life integration,” Dr. Levine said.

SAN ANTONIO – Two-thirds of U.S. adults with COPD or asthma are making multiple errors in using their metered-dose inhalers (MDIs), according to new research. About half of patients failed to inhale slowly and deeply to ensure they received the appropriate dose, and about 40% of patients failed to hold their breath for 5-10 seconds afterward so that the medication made its way to their lungs, the findings show.

“There’s a need to educate patients on proper inhalation technique to optimize the appropriate delivery of medication,” Maryam Navaie, DrPH, of Advance Health Solutions in New York told attendees at the annual meeting of the American College of Chest Physicians. She also urged practitioners to think more carefully about what devices to prescribe to patients based on their own personal attributes.

“Nebulizer devices may be a better consideration for patients who have difficulty performing the necessary steps required by handheld inhalers,” Dr. Navaie said.

She and fellow researchers conducted a systematic review to gain more insights into the errors and difficulties experienced by U.S. adults using MDIs for COPD or asthma. They combed through PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar databases for English language studies about MDI-related errors in U.S. adult COPD or asthma patients published between January 2003 and February 2017.

The researchers included only randomized controlled trials and cross-sectional and observational studies, and they excluded studies with combined error rates across multiple devices so they could better parse out the data. They also used baseline rates only in studies that involved an intervention to reduce errors.

The researchers defined the proportion of overall MDI errors as “the percentage of patients who made errors in equal to or greater than 20% of inhalation steps.” They computed pooled estimates and created forest plots for both overall errors and for errors according to each step in using an MDI.

The eight studies they identified involved 1,221 patients, with ages ranging from a mean 48 to 82 years, 53% of whom were female. Nearly two-thirds of the patients had COPD (63.6%) while 36.4% had asthma. Most of the devices studied were MDIs alone (68.8%), while 31.2% included a spacer.

The pooled weighted average revealed a 66.5% error rate, that is, two-thirds of all the patients were making at least two errors during the 10 steps involved in using their device. The researchers then used individual error rates data in five studies to calculate the overall error rate for each step in using MDIs. The most common error, made by 73.8% of people in those five studies, was failing to attach the inhaler to the spacer. In addition, 68.7% of patients were failing to exhale fully and away from the inhaler before inhaling, and 47.8% were inhaling too fast instead of inhaling deeply.

“So these [findings] actually give you [some specific] ideas of how we could help improve patients’ ability to use the device properly,” Dr. Navaie told attendees, adding that these data can inform patient education needs and interventions.

Based on the data from those five studies, the error rates for all 10 steps to using an MDI were as follows:

• Failed to shake inhaler before use (37.9%).
• Failed to attach inhaler to spacer (73.8%).
• Failed to exhale fully and away from inhaler before inhalation (68.7%).
• Failed to place mouthpiece between teeth and sealed lips (7.4%).
• Failed to actuate once during inhalation (24.4%).
• Inhalation too fast, not deep (47.8%).
• Failed to hold breath for 5-10 seconds (40.1%).
• Failed to remove the inhaler/spacer from mouth (11.3%).
• Failed to exhale after inhalation (33.2%).
• Failed to repeat steps for second puff (36.7%).

Dr. Navaie also noted the investigators were surprised to learn that physicians themselves sometimes make several of these errors in explaining to patients how to use their devices.

“I think for the reps and other people who go out and visit doctors, it’s important to think about making sure the clinicians are using the devices properly,” Dr. Navaie said. She pointed out the potential for patients to forget steps between visits.

“One of the things a lot of our clinicians and key opinion leaders told us during the course of this study is that you shouldn’t just educate the patient at the time you are scripting the device but repeatedly because patients forget,” she said. She recommended having patients demonstrate their use of the device at each visit. If patients continue to struggle, it may be worth considering other therapies, such as a nebulizer, for patients unable to regularly use their devices correctly.

The meta-analysis was limited by the sparse research available in general on MDI errors in the U.S. adult population, so the data on error rates for each individual step may not be broadly generalizable. The studies also did not distinguish between rates among users with asthma vs. users with COPD. Further, too few data exist on associations between MDI errors and health outcomes to have a clear picture of the clinical implications of regularly making multiple errors in MDI use.

Dr. Navaie is employed by Advance Health Solutions, which received Sunovion Pharmaceuticals funding for the study.

SOURCE: Navaie M et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.705.

SAN ANTONIO – Two-thirds of U.S. adults with COPD or asthma are making multiple errors in using their metered-dose inhalers (MDIs), according to new research. About half of patients failed to inhale slowly and deeply to ensure they received the appropriate dose, and about 40% of patients failed to hold their breath for 5-10 seconds afterward so that the medication made its way to their lungs, the findings show.

“There’s a need to educate patients on proper inhalation technique to optimize the appropriate delivery of medication,” Maryam Navaie, DrPH, of Advance Health Solutions in New York told attendees at the annual meeting of the American College of Chest Physicians. She also urged practitioners to think more carefully about what devices to prescribe to patients based on their own personal attributes.

“Nebulizer devices may be a better consideration for patients who have difficulty performing the necessary steps required by handheld inhalers,” Dr. Navaie said.

She and fellow researchers conducted a systematic review to gain more insights into the errors and difficulties experienced by U.S. adults using MDIs for COPD or asthma. They combed through PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar databases for English language studies about MDI-related errors in U.S. adult COPD or asthma patients published between January 2003 and February 2017.

The researchers included only randomized controlled trials and cross-sectional and observational studies, and they excluded studies with combined error rates across multiple devices so they could better parse out the data. They also used baseline rates only in studies that involved an intervention to reduce errors.

The researchers defined the proportion of overall MDI errors as “the percentage of patients who made errors in equal to or greater than 20% of inhalation steps.” They computed pooled estimates and created forest plots for both overall errors and for errors according to each step in using an MDI.

The eight studies they identified involved 1,221 patients, with ages ranging from a mean 48 to 82 years, 53% of whom were female. Nearly two-thirds of the patients had COPD (63.6%) while 36.4% had asthma. Most of the devices studied were MDIs alone (68.8%), while 31.2% included a spacer.

The pooled weighted average revealed a 66.5% error rate, that is, two-thirds of all the patients were making at least two errors during the 10 steps involved in using their device. The researchers then used individual error rates data in five studies to calculate the overall error rate for each step in using MDIs. The most common error, made by 73.8% of people in those five studies, was failing to attach the inhaler to the spacer. In addition, 68.7% of patients were failing to exhale fully and away from the inhaler before inhaling, and 47.8% were inhaling too fast instead of inhaling deeply.

“So these [findings] actually give you [some specific] ideas of how we could help improve patients’ ability to use the device properly,” Dr. Navaie told attendees, adding that these data can inform patient education needs and interventions.

Based on the data from those five studies, the error rates for all 10 steps to using an MDI were as follows:

• Failed to shake inhaler before use (37.9%).
• Failed to attach inhaler to spacer (73.8%).
• Failed to exhale fully and away from inhaler before inhalation (68.7%).
• Failed to place mouthpiece between teeth and sealed lips (7.4%).
• Failed to actuate once during inhalation (24.4%).
• Inhalation too fast, not deep (47.8%).
• Failed to hold breath for 5-10 seconds (40.1%).
• Failed to remove the inhaler/spacer from mouth (11.3%).
• Failed to exhale after inhalation (33.2%).
• Failed to repeat steps for second puff (36.7%).

Dr. Navaie also noted the investigators were surprised to learn that physicians themselves sometimes make several of these errors in explaining to patients how to use their devices.

“I think for the reps and other people who go out and visit doctors, it’s important to think about making sure the clinicians are using the devices properly,” Dr. Navaie said. She pointed out the potential for patients to forget steps between visits.

“One of the things a lot of our clinicians and key opinion leaders told us during the course of this study is that you shouldn’t just educate the patient at the time you are scripting the device but repeatedly because patients forget,” she said. She recommended having patients demonstrate their use of the device at each visit. If patients continue to struggle, it may be worth considering other therapies, such as a nebulizer, for patients unable to regularly use their devices correctly.

The meta-analysis was limited by the sparse research available in general on MDI errors in the U.S. adult population, so the data on error rates for each individual step may not be broadly generalizable. The studies also did not distinguish between rates among users with asthma vs. users with COPD. Further, too few data exist on associations between MDI errors and health outcomes to have a clear picture of the clinical implications of regularly making multiple errors in MDI use.

Dr. Navaie is employed by Advance Health Solutions, which received Sunovion Pharmaceuticals funding for the study.

SOURCE: Navaie M et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.705.

SAN ANTONIO – Two-thirds of U.S. adults with COPD or asthma are making multiple errors in using their metered-dose inhalers (MDIs), according to new research. About half of patients failed to inhale slowly and deeply to ensure they received the appropriate dose, and about 40% of patients failed to hold their breath for 5-10 seconds afterward so that the medication made its way to their lungs, the findings show.

“There’s a need to educate patients on proper inhalation technique to optimize the appropriate delivery of medication,” Maryam Navaie, DrPH, of Advance Health Solutions in New York told attendees at the annual meeting of the American College of Chest Physicians. She also urged practitioners to think more carefully about what devices to prescribe to patients based on their own personal attributes.

“Nebulizer devices may be a better consideration for patients who have difficulty performing the necessary steps required by handheld inhalers,” Dr. Navaie said.

She and fellow researchers conducted a systematic review to gain more insights into the errors and difficulties experienced by U.S. adults using MDIs for COPD or asthma. They combed through PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar databases for English language studies about MDI-related errors in U.S. adult COPD or asthma patients published between January 2003 and February 2017.

The researchers included only randomized controlled trials and cross-sectional and observational studies, and they excluded studies with combined error rates across multiple devices so they could better parse out the data. They also used baseline rates only in studies that involved an intervention to reduce errors.

The researchers defined the proportion of overall MDI errors as “the percentage of patients who made errors in equal to or greater than 20% of inhalation steps.” They computed pooled estimates and created forest plots for both overall errors and for errors according to each step in using an MDI.

The eight studies they identified involved 1,221 patients, with ages ranging from a mean 48 to 82 years, 53% of whom were female. Nearly two-thirds of the patients had COPD (63.6%) while 36.4% had asthma. Most of the devices studied were MDIs alone (68.8%), while 31.2% included a spacer.

The pooled weighted average revealed a 66.5% error rate, that is, two-thirds of all the patients were making at least two errors during the 10 steps involved in using their device. The researchers then used individual error rates data in five studies to calculate the overall error rate for each step in using MDIs. The most common error, made by 73.8% of people in those five studies, was failing to attach the inhaler to the spacer. In addition, 68.7% of patients were failing to exhale fully and away from the inhaler before inhaling, and 47.8% were inhaling too fast instead of inhaling deeply.

“So these [findings] actually give you [some specific] ideas of how we could help improve patients’ ability to use the device properly,” Dr. Navaie told attendees, adding that these data can inform patient education needs and interventions.

Based on the data from those five studies, the error rates for all 10 steps to using an MDI were as follows:

• Failed to shake inhaler before use (37.9%).
• Failed to attach inhaler to spacer (73.8%).
• Failed to exhale fully and away from inhaler before inhalation (68.7%).
• Failed to place mouthpiece between teeth and sealed lips (7.4%).
• Failed to actuate once during inhalation (24.4%).
• Inhalation too fast, not deep (47.8%).
• Failed to hold breath for 5-10 seconds (40.1%).
• Failed to remove the inhaler/spacer from mouth (11.3%).
• Failed to exhale after inhalation (33.2%).
• Failed to repeat steps for second puff (36.7%).

Dr. Navaie also noted the investigators were surprised to learn that physicians themselves sometimes make several of these errors in explaining to patients how to use their devices.

“I think for the reps and other people who go out and visit doctors, it’s important to think about making sure the clinicians are using the devices properly,” Dr. Navaie said. She pointed out the potential for patients to forget steps between visits.

“One of the things a lot of our clinicians and key opinion leaders told us during the course of this study is that you shouldn’t just educate the patient at the time you are scripting the device but repeatedly because patients forget,” she said. She recommended having patients demonstrate their use of the device at each visit. If patients continue to struggle, it may be worth considering other therapies, such as a nebulizer, for patients unable to regularly use their devices correctly.

The meta-analysis was limited by the sparse research available in general on MDI errors in the U.S. adult population, so the data on error rates for each individual step may not be broadly generalizable. The studies also did not distinguish between rates among users with asthma vs. users with COPD. Further, too few data exist on associations between MDI errors and health outcomes to have a clear picture of the clinical implications of regularly making multiple errors in MDI use.

Dr. Navaie is employed by Advance Health Solutions, which received Sunovion Pharmaceuticals funding for the study.

SOURCE: Navaie M et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.705.

CHICAGO – Diagnosing the cause of vaginal itching, which can have a significant negative impact on a woman’s quality of life, can be particularly difficult for multiple reasons, according to Rachel Kornik, MD, of the departments of dermatology and obstetrics and gynecology at the University of Wisconsin, Madison.

“The anatomy is really challenging in this area, and there’s a broad differential. Often there’s more than one thing happening,” Dr. Kornik said during a session on diagnosing and managing genital pruritus in women at the American Academy of Dermatology summer meeting. Like hair loss, vaginal pruritus is also very emotionally distressing.

“Patients are very anxious when they have all this itching,” she said. “It has an impact on personal relationships. Some patients find it difficult to talk about because it’s a taboo subject, so we have to make them comfortable.”

Dr. Kornik showed a chart of the many conditions that cause vaginal or vulvar pruritus, falling within a variety of categories: inflammatory, neoplastic, infections, infestations, environmental, neuropathic, and hormonal. But she focused her presentation primarily on the most common causes: contact dermatitis, lichen sclerosus, and lichen simplex chronicus.

Contact dermatitis

The most common factors that contribute to contact dermatitis are friction, hygiene practices, unique body exposures (such as body fluids and menstrual and personal care products), and occlusion/maceration, which facilitates penetration of external agents. Estrogen deficiency may also play a role.

Taking a thorough history from the patient is key to finding out possible causes. Dr. Kornik provided a list of common irritants to consider.

• Hygiene-related irritants, such as frequent washing and the use of soaps, wash cloths, loofahs, wipes, bath oil, bubbles, and water.
• Laundry products, such as fabric softeners or dryer sheets.
• Menstrual products, such as panty liners, pads, and scents or additives for retaining moisture.
• Over-the-counter itch products, such as those containing benzocaine.
• Medications, such as alcohol-based creams and gels, trichloroacetic acid, fluorouracil (Efudex), imiquimod, and topical antifungals.
• Heat-related irritants, such as use of hair dryers and heating pads.
• Body fluids, including urine, feces, menstrual blood, sweat, semen, and excessive discharge.

It’s also important to consider whether there is an allergic cause. “Contact dermatitis and allergic dermatitis can look very similar both clinically and histologically, and patients can even have them both at the same time,” Dr. Kornik said. “So really, patch testing is essential sometimes to identify a true allergic contact dermatitis.”

She cited a study that identified the top five most common allergens as fragrance mixes, balsam of Peru, benzocaine, terconazole, and quaternium-15 (a formaldehyde-releasing preservative) (Dermatitis. 2013 Mar-Apr;24(2):64-72).

“If somebody’s coming into your office and they have vulvar itching for any reason, the No. 1 thing is making sure that they eliminate and not use any products with fragrances,” Dr. Kornik said. “It’s also important to note that over time, industries’ use of preservatives does change, the concentrations change, and so we may see more emerging allergens or different ones over time.”

The causative allergens are rarely consumed orally, but they may be ectopic, such as shampoo or nail polish.

“What I’ve learned over the years in treating patients with vulvar itching is that they don’t always think to tell you about everything they are applying,” Dr. Kornik said. “You have to ask specific questions. Are you using any wipes or using any lubricants? What is the type and brand of menstrual pad you’re using?”

Patients might also think they can eliminate the cause of irritation by changing products, but “there are cross reactants in many preservatives and fragrances in many products, so they might not eliminate exposure, and intermittent exposures can lead to chronic dermatitis,” she pointed out.

One example is wipes: Some women may use them only periodically, such as after a yoga class, and not think of this as a possibility or realize that wipes could perpetuate chronic dermatitis.

Research has also found that it’s very common for patients with allergic contact dermatitis to have a concomitant vulvar diagnosis. In one study, more than half of patients had another condition, the most common of which was lichen sclerosus. Others included simplex chronicus, atopic dermatitis, condyloma acuminatum, psoriasis, and Paget disease.

Therefore, if patients are not responding as expected, it’s important to consider that the condition is multifactorial “and consider allergic contact dermatitis in addition to whatever other underlying dermatosis they have,” Dr. Kornik said.

Lichen sclerosus

Prevalence of the scarring disorder lichen sclerosus ranges from 1.7% to 3% in the research literature and pathogenesis is likely multifactorial.

“It’s a very frustrating condition for patients and for physicians because we don’t know exactly what causes it, but it definitely has a predilection for the vulva area, and it affects women of all ages,” she said. “I also think it’s more common than we think.”

Loss of normal anatomical structures are a key feature, so physicians need to know their anatomy well to look for what’s not there. Lichen sclerosus involves modified mucous membranes and the perianal area, and it may spread to the crural folds and upper thighs. Symptoms can include periclitoral edema, white patches, pale skin, textural changes (such as wrinkling, waxiness, or hyperkeratosis), fissures, melanosis, and sometimes ulcerations or erosions from scratching.

There is no standardized treatment for lichen sclerosus. Research suggests using a high potency topical steroid treatment daily until skin texture normalizes, which can take anywhere from 6 weeks to 5 months, depending on severity, Dr. Kornik said. Few data are available for management if topical steroids do not work, she added.*

If dealing with recalcitrant disease, she recommends first checking the patients’ compliance and then considering alternative diagnoses or secondary conditions. Do patch testing, rule out contact dermatitis, and rebiopsy if needed. Other options are to add tacrolimus ointment, offer intralesional triamcinolone, consider a systemic agent (acitretin, methotrexate, or possibly hydroxychloroquine), or try laser or photodynamic therapy. She emphasizes the importance of demonstrating to the patient where to apply ointment, since they may not be applying to the right areas.*

Lichen simplex chronicus

Lichen simplex chronicus is a clinical description of the result of chronic rubbing and scratching. It might be triggered by something that has now resolved or be linked to other itching conditions, but clinicians need to consider the possibility of neuropathic itch as well.

Features of lichen simplex chronicus can include bilateral or unilateral involvement of the labia majora, erythematous plaques with lichenification, hyper- or hypopigmentation, or angulated excoriations and hypertrophy of labia caused by thickened skin, though the signs may be subtle, she said.

Treatment requires management of the skin problem itself – the underlying cause of the itch – as well as the behavioral component. Topical steroids are first line, plus an antihistamine at night as needed to stop the scratching. If those are insufficient, the next treatments to consider are intralesional triamcinolone (Kenalog), tacrolimus ointment, topical or oral doxepin, mirtazapine, or even selective serotonin reuptake inhibitors.

Women using topical steroids should also be aware of the possible side effects, including atrophy, infections, and allergic contact dermatitis if the steroid itself or the cream it’s in is an allergen. If stinging or burning occurs, switch to a steroid without propylene glycol, she added.

If no changes occur in the skin, clinicians may have to consider the existence of neuropathic pruritus diagnosis, an injury or dysfunction along the afferent itch pathway. Burning is more common with this neuropathy, but itching can occur too.

Other issues include symptoms that worsen with sitting and pain that worsens throughout the day. Causes can include childbirth, surgery, pelvic trauma, infection, and chemoradiation, and diagnosis requires imaging to rule out other possible causes. Treatment involves pelvic floor physical therapy, pudendal nerve block, or gabapentin.

Dr. Kornik wrapped up with a reminder that vulvar itch is often multifactorial, so clinicians need to chip away at the potential causes – sometimes with cultures, scrapes, and biopsies as needed.

She reported no financial disclosures.

Correction, 10/26/18: Dr. Kornik's treatment recommendations for lichen sclerosus were misstated.

CHICAGO – Diagnosing the cause of vaginal itching, which can have a significant negative impact on a woman’s quality of life, can be particularly difficult for multiple reasons, according to Rachel Kornik, MD, of the departments of dermatology and obstetrics and gynecology at the University of Wisconsin, Madison.

“The anatomy is really challenging in this area, and there’s a broad differential. Often there’s more than one thing happening,” Dr. Kornik said during a session on diagnosing and managing genital pruritus in women at the American Academy of Dermatology summer meeting. Like hair loss, vaginal pruritus is also very emotionally distressing.

“Patients are very anxious when they have all this itching,” she said. “It has an impact on personal relationships. Some patients find it difficult to talk about because it’s a taboo subject, so we have to make them comfortable.”

Dr. Kornik showed a chart of the many conditions that cause vaginal or vulvar pruritus, falling within a variety of categories: inflammatory, neoplastic, infections, infestations, environmental, neuropathic, and hormonal. But she focused her presentation primarily on the most common causes: contact dermatitis, lichen sclerosus, and lichen simplex chronicus.

Contact dermatitis

The most common factors that contribute to contact dermatitis are friction, hygiene practices, unique body exposures (such as body fluids and menstrual and personal care products), and occlusion/maceration, which facilitates penetration of external agents. Estrogen deficiency may also play a role.

Taking a thorough history from the patient is key to finding out possible causes. Dr. Kornik provided a list of common irritants to consider.

• Hygiene-related irritants, such as frequent washing and the use of soaps, wash cloths, loofahs, wipes, bath oil, bubbles, and water.
• Laundry products, such as fabric softeners or dryer sheets.
• Menstrual products, such as panty liners, pads, and scents or additives for retaining moisture.
• Over-the-counter itch products, such as those containing benzocaine.
• Medications, such as alcohol-based creams and gels, trichloroacetic acid, fluorouracil (Efudex), imiquimod, and topical antifungals.
• Heat-related irritants, such as use of hair dryers and heating pads.
• Body fluids, including urine, feces, menstrual blood, sweat, semen, and excessive discharge.

It’s also important to consider whether there is an allergic cause. “Contact dermatitis and allergic dermatitis can look very similar both clinically and histologically, and patients can even have them both at the same time,” Dr. Kornik said. “So really, patch testing is essential sometimes to identify a true allergic contact dermatitis.”

She cited a study that identified the top five most common allergens as fragrance mixes, balsam of Peru, benzocaine, terconazole, and quaternium-15 (a formaldehyde-releasing preservative) (Dermatitis. 2013 Mar-Apr;24(2):64-72).

“If somebody’s coming into your office and they have vulvar itching for any reason, the No. 1 thing is making sure that they eliminate and not use any products with fragrances,” Dr. Kornik said. “It’s also important to note that over time, industries’ use of preservatives does change, the concentrations change, and so we may see more emerging allergens or different ones over time.”

The causative allergens are rarely consumed orally, but they may be ectopic, such as shampoo or nail polish.

“What I’ve learned over the years in treating patients with vulvar itching is that they don’t always think to tell you about everything they are applying,” Dr. Kornik said. “You have to ask specific questions. Are you using any wipes or using any lubricants? What is the type and brand of menstrual pad you’re using?”

Patients might also think they can eliminate the cause of irritation by changing products, but “there are cross reactants in many preservatives and fragrances in many products, so they might not eliminate exposure, and intermittent exposures can lead to chronic dermatitis,” she pointed out.

One example is wipes: Some women may use them only periodically, such as after a yoga class, and not think of this as a possibility or realize that wipes could perpetuate chronic dermatitis.

Research has also found that it’s very common for patients with allergic contact dermatitis to have a concomitant vulvar diagnosis. In one study, more than half of patients had another condition, the most common of which was lichen sclerosus. Others included simplex chronicus, atopic dermatitis, condyloma acuminatum, psoriasis, and Paget disease.

Therefore, if patients are not responding as expected, it’s important to consider that the condition is multifactorial “and consider allergic contact dermatitis in addition to whatever other underlying dermatosis they have,” Dr. Kornik said.

Lichen sclerosus

Prevalence of the scarring disorder lichen sclerosus ranges from 1.7% to 3% in the research literature and pathogenesis is likely multifactorial.

“It’s a very frustrating condition for patients and for physicians because we don’t know exactly what causes it, but it definitely has a predilection for the vulva area, and it affects women of all ages,” she said. “I also think it’s more common than we think.”

Loss of normal anatomical structures are a key feature, so physicians need to know their anatomy well to look for what’s not there. Lichen sclerosus involves modified mucous membranes and the perianal area, and it may spread to the crural folds and upper thighs. Symptoms can include periclitoral edema, white patches, pale skin, textural changes (such as wrinkling, waxiness, or hyperkeratosis), fissures, melanosis, and sometimes ulcerations or erosions from scratching.

There is no standardized treatment for lichen sclerosus. Research suggests using a high potency topical steroid treatment daily until skin texture normalizes, which can take anywhere from 6 weeks to 5 months, depending on severity, Dr. Kornik said. Few data are available for management if topical steroids do not work, she added.*

If dealing with recalcitrant disease, she recommends first checking the patients’ compliance and then considering alternative diagnoses or secondary conditions. Do patch testing, rule out contact dermatitis, and rebiopsy if needed. Other options are to add tacrolimus ointment, offer intralesional triamcinolone, consider a systemic agent (acitretin, methotrexate, or possibly hydroxychloroquine), or try laser or photodynamic therapy. She emphasizes the importance of demonstrating to the patient where to apply ointment, since they may not be applying to the right areas.*

Lichen simplex chronicus

Lichen simplex chronicus is a clinical description of the result of chronic rubbing and scratching. It might be triggered by something that has now resolved or be linked to other itching conditions, but clinicians need to consider the possibility of neuropathic itch as well.

Features of lichen simplex chronicus can include bilateral or unilateral involvement of the labia majora, erythematous plaques with lichenification, hyper- or hypopigmentation, or angulated excoriations and hypertrophy of labia caused by thickened skin, though the signs may be subtle, she said.

Treatment requires management of the skin problem itself – the underlying cause of the itch – as well as the behavioral component. Topical steroids are first line, plus an antihistamine at night as needed to stop the scratching. If those are insufficient, the next treatments to consider are intralesional triamcinolone (Kenalog), tacrolimus ointment, topical or oral doxepin, mirtazapine, or even selective serotonin reuptake inhibitors.

Women using topical steroids should also be aware of the possible side effects, including atrophy, infections, and allergic contact dermatitis if the steroid itself or the cream it’s in is an allergen. If stinging or burning occurs, switch to a steroid without propylene glycol, she added.

If no changes occur in the skin, clinicians may have to consider the existence of neuropathic pruritus diagnosis, an injury or dysfunction along the afferent itch pathway. Burning is more common with this neuropathy, but itching can occur too.

Other issues include symptoms that worsen with sitting and pain that worsens throughout the day. Causes can include childbirth, surgery, pelvic trauma, infection, and chemoradiation, and diagnosis requires imaging to rule out other possible causes. Treatment involves pelvic floor physical therapy, pudendal nerve block, or gabapentin.

Dr. Kornik wrapped up with a reminder that vulvar itch is often multifactorial, so clinicians need to chip away at the potential causes – sometimes with cultures, scrapes, and biopsies as needed.

She reported no financial disclosures.

Correction, 10/26/18: Dr. Kornik's treatment recommendations for lichen sclerosus were misstated.

CHICAGO – Diagnosing the cause of vaginal itching, which can have a significant negative impact on a woman’s quality of life, can be particularly difficult for multiple reasons, according to Rachel Kornik, MD, of the departments of dermatology and obstetrics and gynecology at the University of Wisconsin, Madison.

“The anatomy is really challenging in this area, and there’s a broad differential. Often there’s more than one thing happening,” Dr. Kornik said during a session on diagnosing and managing genital pruritus in women at the American Academy of Dermatology summer meeting. Like hair loss, vaginal pruritus is also very emotionally distressing.

“Patients are very anxious when they have all this itching,” she said. “It has an impact on personal relationships. Some patients find it difficult to talk about because it’s a taboo subject, so we have to make them comfortable.”

Dr. Kornik showed a chart of the many conditions that cause vaginal or vulvar pruritus, falling within a variety of categories: inflammatory, neoplastic, infections, infestations, environmental, neuropathic, and hormonal. But she focused her presentation primarily on the most common causes: contact dermatitis, lichen sclerosus, and lichen simplex chronicus.

Contact dermatitis

The most common factors that contribute to contact dermatitis are friction, hygiene practices, unique body exposures (such as body fluids and menstrual and personal care products), and occlusion/maceration, which facilitates penetration of external agents. Estrogen deficiency may also play a role.

Taking a thorough history from the patient is key to finding out possible causes. Dr. Kornik provided a list of common irritants to consider.

• Hygiene-related irritants, such as frequent washing and the use of soaps, wash cloths, loofahs, wipes, bath oil, bubbles, and water.
• Laundry products, such as fabric softeners or dryer sheets.
• Menstrual products, such as panty liners, pads, and scents or additives for retaining moisture.
• Over-the-counter itch products, such as those containing benzocaine.
• Medications, such as alcohol-based creams and gels, trichloroacetic acid, fluorouracil (Efudex), imiquimod, and topical antifungals.
• Heat-related irritants, such as use of hair dryers and heating pads.
• Body fluids, including urine, feces, menstrual blood, sweat, semen, and excessive discharge.

It’s also important to consider whether there is an allergic cause. “Contact dermatitis and allergic dermatitis can look very similar both clinically and histologically, and patients can even have them both at the same time,” Dr. Kornik said. “So really, patch testing is essential sometimes to identify a true allergic contact dermatitis.”

She cited a study that identified the top five most common allergens as fragrance mixes, balsam of Peru, benzocaine, terconazole, and quaternium-15 (a formaldehyde-releasing preservative) (Dermatitis. 2013 Mar-Apr;24(2):64-72).

“If somebody’s coming into your office and they have vulvar itching for any reason, the No. 1 thing is making sure that they eliminate and not use any products with fragrances,” Dr. Kornik said. “It’s also important to note that over time, industries’ use of preservatives does change, the concentrations change, and so we may see more emerging allergens or different ones over time.”

The causative allergens are rarely consumed orally, but they may be ectopic, such as shampoo or nail polish.

“What I’ve learned over the years in treating patients with vulvar itching is that they don’t always think to tell you about everything they are applying,” Dr. Kornik said. “You have to ask specific questions. Are you using any wipes or using any lubricants? What is the type and brand of menstrual pad you’re using?”

Patients might also think they can eliminate the cause of irritation by changing products, but “there are cross reactants in many preservatives and fragrances in many products, so they might not eliminate exposure, and intermittent exposures can lead to chronic dermatitis,” she pointed out.

One example is wipes: Some women may use them only periodically, such as after a yoga class, and not think of this as a possibility or realize that wipes could perpetuate chronic dermatitis.

Research has also found that it’s very common for patients with allergic contact dermatitis to have a concomitant vulvar diagnosis. In one study, more than half of patients had another condition, the most common of which was lichen sclerosus. Others included simplex chronicus, atopic dermatitis, condyloma acuminatum, psoriasis, and Paget disease.

Therefore, if patients are not responding as expected, it’s important to consider that the condition is multifactorial “and consider allergic contact dermatitis in addition to whatever other underlying dermatosis they have,” Dr. Kornik said.

Lichen sclerosus

Prevalence of the scarring disorder lichen sclerosus ranges from 1.7% to 3% in the research literature and pathogenesis is likely multifactorial.

“It’s a very frustrating condition for patients and for physicians because we don’t know exactly what causes it, but it definitely has a predilection for the vulva area, and it affects women of all ages,” she said. “I also think it’s more common than we think.”

Loss of normal anatomical structures are a key feature, so physicians need to know their anatomy well to look for what’s not there. Lichen sclerosus involves modified mucous membranes and the perianal area, and it may spread to the crural folds and upper thighs. Symptoms can include periclitoral edema, white patches, pale skin, textural changes (such as wrinkling, waxiness, or hyperkeratosis), fissures, melanosis, and sometimes ulcerations or erosions from scratching.

There is no standardized treatment for lichen sclerosus. Research suggests using a high potency topical steroid treatment daily until skin texture normalizes, which can take anywhere from 6 weeks to 5 months, depending on severity, Dr. Kornik said. Few data are available for management if topical steroids do not work, she added.*

If dealing with recalcitrant disease, she recommends first checking the patients’ compliance and then considering alternative diagnoses or secondary conditions. Do patch testing, rule out contact dermatitis, and rebiopsy if needed. Other options are to add tacrolimus ointment, offer intralesional triamcinolone, consider a systemic agent (acitretin, methotrexate, or possibly hydroxychloroquine), or try laser or photodynamic therapy. She emphasizes the importance of demonstrating to the patient where to apply ointment, since they may not be applying to the right areas.*

Lichen simplex chronicus

Lichen simplex chronicus is a clinical description of the result of chronic rubbing and scratching. It might be triggered by something that has now resolved or be linked to other itching conditions, but clinicians need to consider the possibility of neuropathic itch as well.

Features of lichen simplex chronicus can include bilateral or unilateral involvement of the labia majora, erythematous plaques with lichenification, hyper- or hypopigmentation, or angulated excoriations and hypertrophy of labia caused by thickened skin, though the signs may be subtle, she said.

Treatment requires management of the skin problem itself – the underlying cause of the itch – as well as the behavioral component. Topical steroids are first line, plus an antihistamine at night as needed to stop the scratching. If those are insufficient, the next treatments to consider are intralesional triamcinolone (Kenalog), tacrolimus ointment, topical or oral doxepin, mirtazapine, or even selective serotonin reuptake inhibitors.

Women using topical steroids should also be aware of the possible side effects, including atrophy, infections, and allergic contact dermatitis if the steroid itself or the cream it’s in is an allergen. If stinging or burning occurs, switch to a steroid without propylene glycol, she added.

If no changes occur in the skin, clinicians may have to consider the existence of neuropathic pruritus diagnosis, an injury or dysfunction along the afferent itch pathway. Burning is more common with this neuropathy, but itching can occur too.

Other issues include symptoms that worsen with sitting and pain that worsens throughout the day. Causes can include childbirth, surgery, pelvic trauma, infection, and chemoradiation, and diagnosis requires imaging to rule out other possible causes. Treatment involves pelvic floor physical therapy, pudendal nerve block, or gabapentin.

Dr. Kornik wrapped up with a reminder that vulvar itch is often multifactorial, so clinicians need to chip away at the potential causes – sometimes with cultures, scrapes, and biopsies as needed.

She reported no financial disclosures.

Correction, 10/26/18: Dr. Kornik's treatment recommendations for lichen sclerosus were misstated.

DALLAS – With the approaching midterm elections and Congress’ relative silence on health care policy this year, new health care legislation is unlikely in the immediate foreseeable future. But that does not mean the door to federal changes in health care policy is completely closed, according to Robert S. Saunders, PhD, of the Duke–Margolis Center for Health Policy, Durham, N.C.

It’s simply more likely to come from the new leadership at the Department of Health & Human Services including Secretary Alex Azar, Center for Medicare & Medicaid Services Administrator Seema Verma, and Center for Medicare & Medicaid Innovation Director Adam Boehler. In his keynote address for the American Gastroenterological Association’s Partners in Value meeting, Dr. Saunders gave attendees an overview of the current landscape in Washington and what they might expect in the coming months.

“Assuming congressional gridlock continues, HHS is a primary outlet for policy,” Dr. Saunders said, also noting CMMI’s pledge to make value-based payment a priority.

Broadly speaking, six goals comprise the current administration’s future vision within CMS, Dr. Saunders said. CMS has been encouraging payment reform innovation and benefit flexibility in Medicare Advantage and promoting private sector leadership with payment reform.

Three other goals include using CMMI to increase alternative payment model availability to specialists, expanding patients’ access to their own health data, and adding more outcomes measures but reducing the total number of measures.

• CMS is also collecting information on how it might reform the Stark Law to streamline value-based payment (VBP) arrangements or establish a mechanism for direct provider contracting.

Dr. Saunders highlighted two health policy developments already announced. First, CMS will continue to offer bundled payment options through the Bundled Payments for Care Improvement Advanced initiative, Dr. Saunders said. That program presents opportunities related to treatment of GI hemorrhage, GI obstruction, and most liver disorders (excepting cancer, cirrhosis, and alcoholic hepatitis).

Then, CMS is proposing several changes to existing programs, though it remains to be seen how those will develop. One of those is the proposed modification of the Accountable Care Organization program to shorten the period ACOs can spend in upside risk, thereby pushing for more downside risk taking. Instead of having 6 years in upside risk getting 50% of savings, the proposed Pathways to Success would reduce that period to 2 years of upside risk, after which the ACOs would be responsible for shared losses in adddition to potentially receiving savings.

Another proposed change is to make payments sites neutral so that Medicare clinical visits are charged the same regardless of whether they occur at a doctor’s office or in a hospital outpatient setting. Currently, hospital outpatient visits are reimbursed at a higher amount than are those in private physicians offices.

Finally, a new proposed rule would collapse payments for evaluation and management services into two tiers, which would apply only to office and outpatient E/M codes.

But it’s not clear yet how hard CMS will push for implementation of these changes. For example, the proposed rule on E/M policy is the most significant push so far to reduce documentation from this administration, Dr. Saunders said, but medical groups, particularly specialists, oppose the rule because they argue it incentivizes short, repeat visits.

The three probable scenarios are that CMS moves forward with the new rule, that CMS scales back and retains the existing system, or that the “medical community pushes for an alternative to E/M with a framework that rewards doctors for their time,” Dr. Saunders said. The final rule, likely to come down by November, will also offer some insight into how forcefully CMS will promote its agenda, according to Dr. Saunders.

Hearing these points “helps confirm that we are all headed toward this value-based world, and so we should start to ready our practices in the way that we internally compensate physicians and the way we engage with patients toward that value-based world,” Michael Weinstein, MD, president of the Digestive Health Physicians Association, said in an interview following the keynote.

But Dr. Weinstein expressed skepticism about CMS’ power to alter regulations sufficiently to really move forward into value-based care more broadly. He pointed out the various obstacles in the private sector that simply require legislative fixes, such as Stark Law modernization; increased transparency on price, outcomes, and quality measures; and interoperability between systems; among others.

“You have to keep knocking CMS to make the changes, but if CMS makes changes, it only makes changes for Medicare,” Dr. Weinstein said. Many states have laws requiring commercial carriers to follow the same federal rules that are set up for Medicare, but those are not universal and remain limited in scope.

Dr. Saunders also discussed the Physician-Focused Payment Model Technical Advisory Committee (PTAC), created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to review new options for alternative payment models.

Since beginning to accept submissions in December 2016, PTAC has reviewed two GI models in 2017: Project Sonar and a comprehensive colonoscopy APM. Project Sonar focuses on creation of an IBD/Crohn’s medical home. Despite reservations about proprietary technology and about the evidence on Project Sonar, PTAC has recommended the program for further testing. The comprehensive colonoscopy APM, however, was withdrawn after preliminary reviews because the PTAC was concerned the proposal “was too reliant on site-of-service shift and wanted more information on how it would lead to better integrated care,” Dr. Saunders explained.

Though PTAC’s existence led to hope early on that it might stimulate the creation of APMs and help them spread, the reality has been much shakier.

“CMS has not implemented any of the models PTAC has approved for use, and CMS has also not yet created a formal pathway for limited testing,” Dr. Saunders said. That has left members uncertain about the future.

DALLAS – With the approaching midterm elections and Congress’ relative silence on health care policy this year, new health care legislation is unlikely in the immediate foreseeable future. But that does not mean the door to federal changes in health care policy is completely closed, according to Robert S. Saunders, PhD, of the Duke–Margolis Center for Health Policy, Durham, N.C.

It’s simply more likely to come from the new leadership at the Department of Health & Human Services including Secretary Alex Azar, Center for Medicare & Medicaid Services Administrator Seema Verma, and Center for Medicare & Medicaid Innovation Director Adam Boehler. In his keynote address for the American Gastroenterological Association’s Partners in Value meeting, Dr. Saunders gave attendees an overview of the current landscape in Washington and what they might expect in the coming months.

“Assuming congressional gridlock continues, HHS is a primary outlet for policy,” Dr. Saunders said, also noting CMMI’s pledge to make value-based payment a priority.

Broadly speaking, six goals comprise the current administration’s future vision within CMS, Dr. Saunders said. CMS has been encouraging payment reform innovation and benefit flexibility in Medicare Advantage and promoting private sector leadership with payment reform.

Three other goals include using CMMI to increase alternative payment model availability to specialists, expanding patients’ access to their own health data, and adding more outcomes measures but reducing the total number of measures.

• CMS is also collecting information on how it might reform the Stark Law to streamline value-based payment (VBP) arrangements or establish a mechanism for direct provider contracting.

Dr. Saunders highlighted two health policy developments already announced. First, CMS will continue to offer bundled payment options through the Bundled Payments for Care Improvement Advanced initiative, Dr. Saunders said. That program presents opportunities related to treatment of GI hemorrhage, GI obstruction, and most liver disorders (excepting cancer, cirrhosis, and alcoholic hepatitis).

Then, CMS is proposing several changes to existing programs, though it remains to be seen how those will develop. One of those is the proposed modification of the Accountable Care Organization program to shorten the period ACOs can spend in upside risk, thereby pushing for more downside risk taking. Instead of having 6 years in upside risk getting 50% of savings, the proposed Pathways to Success would reduce that period to 2 years of upside risk, after which the ACOs would be responsible for shared losses in adddition to potentially receiving savings.

Another proposed change is to make payments sites neutral so that Medicare clinical visits are charged the same regardless of whether they occur at a doctor’s office or in a hospital outpatient setting. Currently, hospital outpatient visits are reimbursed at a higher amount than are those in private physicians offices.

Finally, a new proposed rule would collapse payments for evaluation and management services into two tiers, which would apply only to office and outpatient E/M codes.

But it’s not clear yet how hard CMS will push for implementation of these changes. For example, the proposed rule on E/M policy is the most significant push so far to reduce documentation from this administration, Dr. Saunders said, but medical groups, particularly specialists, oppose the rule because they argue it incentivizes short, repeat visits.

The three probable scenarios are that CMS moves forward with the new rule, that CMS scales back and retains the existing system, or that the “medical community pushes for an alternative to E/M with a framework that rewards doctors for their time,” Dr. Saunders said. The final rule, likely to come down by November, will also offer some insight into how forcefully CMS will promote its agenda, according to Dr. Saunders.

Hearing these points “helps confirm that we are all headed toward this value-based world, and so we should start to ready our practices in the way that we internally compensate physicians and the way we engage with patients toward that value-based world,” Michael Weinstein, MD, president of the Digestive Health Physicians Association, said in an interview following the keynote.

But Dr. Weinstein expressed skepticism about CMS’ power to alter regulations sufficiently to really move forward into value-based care more broadly. He pointed out the various obstacles in the private sector that simply require legislative fixes, such as Stark Law modernization; increased transparency on price, outcomes, and quality measures; and interoperability between systems; among others.

“You have to keep knocking CMS to make the changes, but if CMS makes changes, it only makes changes for Medicare,” Dr. Weinstein said. Many states have laws requiring commercial carriers to follow the same federal rules that are set up for Medicare, but those are not universal and remain limited in scope.

Dr. Saunders also discussed the Physician-Focused Payment Model Technical Advisory Committee (PTAC), created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to review new options for alternative payment models.

Since beginning to accept submissions in December 2016, PTAC has reviewed two GI models in 2017: Project Sonar and a comprehensive colonoscopy APM. Project Sonar focuses on creation of an IBD/Crohn’s medical home. Despite reservations about proprietary technology and about the evidence on Project Sonar, PTAC has recommended the program for further testing. The comprehensive colonoscopy APM, however, was withdrawn after preliminary reviews because the PTAC was concerned the proposal “was too reliant on site-of-service shift and wanted more information on how it would lead to better integrated care,” Dr. Saunders explained.

Though PTAC’s existence led to hope early on that it might stimulate the creation of APMs and help them spread, the reality has been much shakier.

“CMS has not implemented any of the models PTAC has approved for use, and CMS has also not yet created a formal pathway for limited testing,” Dr. Saunders said. That has left members uncertain about the future.

DALLAS – With the approaching midterm elections and Congress’ relative silence on health care policy this year, new health care legislation is unlikely in the immediate foreseeable future. But that does not mean the door to federal changes in health care policy is completely closed, according to Robert S. Saunders, PhD, of the Duke–Margolis Center for Health Policy, Durham, N.C.

It’s simply more likely to come from the new leadership at the Department of Health & Human Services including Secretary Alex Azar, Center for Medicare & Medicaid Services Administrator Seema Verma, and Center for Medicare & Medicaid Innovation Director Adam Boehler. In his keynote address for the American Gastroenterological Association’s Partners in Value meeting, Dr. Saunders gave attendees an overview of the current landscape in Washington and what they might expect in the coming months.

“Assuming congressional gridlock continues, HHS is a primary outlet for policy,” Dr. Saunders said, also noting CMMI’s pledge to make value-based payment a priority.

Broadly speaking, six goals comprise the current administration’s future vision within CMS, Dr. Saunders said. CMS has been encouraging payment reform innovation and benefit flexibility in Medicare Advantage and promoting private sector leadership with payment reform.

Three other goals include using CMMI to increase alternative payment model availability to specialists, expanding patients’ access to their own health data, and adding more outcomes measures but reducing the total number of measures.

• CMS is also collecting information on how it might reform the Stark Law to streamline value-based payment (VBP) arrangements or establish a mechanism for direct provider contracting.

Dr. Saunders highlighted two health policy developments already announced. First, CMS will continue to offer bundled payment options through the Bundled Payments for Care Improvement Advanced initiative, Dr. Saunders said. That program presents opportunities related to treatment of GI hemorrhage, GI obstruction, and most liver disorders (excepting cancer, cirrhosis, and alcoholic hepatitis).

Then, CMS is proposing several changes to existing programs, though it remains to be seen how those will develop. One of those is the proposed modification of the Accountable Care Organization program to shorten the period ACOs can spend in upside risk, thereby pushing for more downside risk taking. Instead of having 6 years in upside risk getting 50% of savings, the proposed Pathways to Success would reduce that period to 2 years of upside risk, after which the ACOs would be responsible for shared losses in adddition to potentially receiving savings.

Another proposed change is to make payments sites neutral so that Medicare clinical visits are charged the same regardless of whether they occur at a doctor’s office or in a hospital outpatient setting. Currently, hospital outpatient visits are reimbursed at a higher amount than are those in private physicians offices.

Finally, a new proposed rule would collapse payments for evaluation and management services into two tiers, which would apply only to office and outpatient E/M codes.

But it’s not clear yet how hard CMS will push for implementation of these changes. For example, the proposed rule on E/M policy is the most significant push so far to reduce documentation from this administration, Dr. Saunders said, but medical groups, particularly specialists, oppose the rule because they argue it incentivizes short, repeat visits.

The three probable scenarios are that CMS moves forward with the new rule, that CMS scales back and retains the existing system, or that the “medical community pushes for an alternative to E/M with a framework that rewards doctors for their time,” Dr. Saunders said. The final rule, likely to come down by November, will also offer some insight into how forcefully CMS will promote its agenda, according to Dr. Saunders.

Hearing these points “helps confirm that we are all headed toward this value-based world, and so we should start to ready our practices in the way that we internally compensate physicians and the way we engage with patients toward that value-based world,” Michael Weinstein, MD, president of the Digestive Health Physicians Association, said in an interview following the keynote.

But Dr. Weinstein expressed skepticism about CMS’ power to alter regulations sufficiently to really move forward into value-based care more broadly. He pointed out the various obstacles in the private sector that simply require legislative fixes, such as Stark Law modernization; increased transparency on price, outcomes, and quality measures; and interoperability between systems; among others.

“You have to keep knocking CMS to make the changes, but if CMS makes changes, it only makes changes for Medicare,” Dr. Weinstein said. Many states have laws requiring commercial carriers to follow the same federal rules that are set up for Medicare, but those are not universal and remain limited in scope.

Dr. Saunders also discussed the Physician-Focused Payment Model Technical Advisory Committee (PTAC), created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to review new options for alternative payment models.

Since beginning to accept submissions in December 2016, PTAC has reviewed two GI models in 2017: Project Sonar and a comprehensive colonoscopy APM. Project Sonar focuses on creation of an IBD/Crohn’s medical home. Despite reservations about proprietary technology and about the evidence on Project Sonar, PTAC has recommended the program for further testing. The comprehensive colonoscopy APM, however, was withdrawn after preliminary reviews because the PTAC was concerned the proposal “was too reliant on site-of-service shift and wanted more information on how it would lead to better integrated care,” Dr. Saunders explained.

Though PTAC’s existence led to hope early on that it might stimulate the creation of APMs and help them spread, the reality has been much shakier.

“CMS has not implemented any of the models PTAC has approved for use, and CMS has also not yet created a formal pathway for limited testing,” Dr. Saunders said. That has left members uncertain about the future.

SAN ANTONIO – Unplanned readmissions declined among tracheostomy/ventilator-dependent children whose discharge process involved a pulmonary nurse practitioner to coordinate continuity of care, a study of more than 70 patients has found.

Tara Haelle/MDedge News

Despite an increase over time in the rate of discharges, readmissions fell, Sarah Barry, CRNP, of Children’s Hospital of Philadelphia (CHOP), said at the annual meeting of the American College of Chest Physicians.

“The technology-dependent pediatric population who is going home with tracheostomy and ventilator dependence is at risk for hospital readmission, and having an advanced practice provider in a continuity role promotes adherence to our standards of practice and improves transition to home,” Ms. Barry said in an interview.

She noted previous research showing that 40% of 109 home mechanical ventilation patients discharged between 2003 and 2009 had unplanned readmissions, 28% of which occurred within the first month after discharge.

Nearly two thirds (64%) of those readmissions were related to a pulmonary and/or tracheostomy problem. That study also found that changes in condition management 1 week before discharge, such as medications, ventilator settings, or feeding regimens, was associated with unplanned readmission.

That research “makes us ask ourselves if our readmissions are avoidable and what can we do to get these kids home safe and to keep them home,” Ms. Barry told attendees, adding that CHOP was unhappy with their readmission rates.

“Kids were often not making it to their first pulmonary appointment, and it was a burden for these families,” she said. “We questioned whether or not having a nurse practitioner in a role to promote adherence to our standards would have a positive impact on our unplanned route.”

They evaluated the effect of such an NP on unplanned readmissions among tracheostomy/ventilator-supported children. The NP’s role was to track patients, mostly from the progressive care unit, who required a tracheostomy and ventilator and were expected to be discharged home or to a long-term care facility. The NP provided continuity for medical management and coordinated care at discharge.

“We also do not make changes for 2 weeks before discharge so that we can focus on all the other coordination that goes into getting these kids home,” Ms. Barry said.

She reviewed the patients’ electronic charts to record time to scheduled follow-up visit, days until hospital readmission, admitting diagnosis at readmission, and length of stay after readmission. With consideration for the time needed for transition into this new process, the population studied was assessed within three cohorts.

The first cohort comprised the 22 children discharged between April 2016 and March 2017, the full year before a pulmonary NP began coordinating the discharge process. These patients averaged 1.8 discharges per month with an initial follow-up of 2-12 weeks.

Just over a quarter (27%) of the first cohort were readmitted before their scheduled follow-up, ranging from 2 to 25 days after discharge. Five percent were readmitted within a week of discharge, and 27% were readmitted within a month; their average length of stay was 13 days after readmission. Most (83%) of these discharges were respiratory related while the other 17% were gastrointestinal related.

The second cohort involved the 11 patients discharged between April 2017 and August 2017, the first 5 months after a pulmonary NP began overseeing the discharge readiness process.

“We chose 5 months because it took about 5months for me to develop my own protocols and standards of practice,” Ms. Barry explained.

An average 2.2 discharges occurred monthly with 2-8 weeks of initial postdischarge follow-up. Though nearly half these children (45%) were readmitted before their scheduled follow-up, their length of stay was shorter, an average of 11 days.

Readmission within a week after discharge occurred among 27% of the children, and 45% of them were readmitted within a month of discharge. Sixty percent of these patients were readmitted for respiratory issues, compared with 40% with GI issues.

The third cohort included all 38 patients discharged from September 2017 to August 2018, the year after a pulmonary NP had become fully established in the continuity role, with an average 3.2 discharges occurred per month. Readmission rates were considerably lower: Eighteen percent of patients were readmitted before their scheduled follow-up appointment, which ranged from 1 to 13 weeks after discharge.

Five percent were readmitted within a week of discharge, and 24% were readmitted within a month, ranging from 1 to 26 days post discharge. But length of stay was shorter still at an average of 9 days.

The reasons for readmission varied more in this cohort: While 56% were respiratory related, 22% were related to fever, and 11% were related to neurodevelopment concerns or social reasons, such as necessary involvement of social services.

Ms. Barry’s colleague, Howard B. Panitch, MD, also on the staff of CHOP, noted during the discussion that the NP’s role is invaluable in “keeping the inpatient teams honest.

“She reminds her colleagues in critical care that you can’t make that ventilator change when on your way out the door or very close to discharge.”

Ms. Barry had no disclosures. No external funding was noted.

SOURCE: Barry S et al. CHEST 2018 Oct. doi: 10.1016/j.chest.2018.08.743.

SAN ANTONIO – Unplanned readmissions declined among tracheostomy/ventilator-dependent children whose discharge process involved a pulmonary nurse practitioner to coordinate continuity of care, a study of more than 70 patients has found.

Tara Haelle/MDedge News

Despite an increase over time in the rate of discharges, readmissions fell, Sarah Barry, CRNP, of Children’s Hospital of Philadelphia (CHOP), said at the annual meeting of the American College of Chest Physicians.

“The technology-dependent pediatric population who is going home with tracheostomy and ventilator dependence is at risk for hospital readmission, and having an advanced practice provider in a continuity role promotes adherence to our standards of practice and improves transition to home,” Ms. Barry said in an interview.

She noted previous research showing that 40% of 109 home mechanical ventilation patients discharged between 2003 and 2009 had unplanned readmissions, 28% of which occurred within the first month after discharge.

Nearly two thirds (64%) of those readmissions were related to a pulmonary and/or tracheostomy problem. That study also found that changes in condition management 1 week before discharge, such as medications, ventilator settings, or feeding regimens, was associated with unplanned readmission.

That research “makes us ask ourselves if our readmissions are avoidable and what can we do to get these kids home safe and to keep them home,” Ms. Barry told attendees, adding that CHOP was unhappy with their readmission rates.

“Kids were often not making it to their first pulmonary appointment, and it was a burden for these families,” she said. “We questioned whether or not having a nurse practitioner in a role to promote adherence to our standards would have a positive impact on our unplanned route.”

They evaluated the effect of such an NP on unplanned readmissions among tracheostomy/ventilator-supported children. The NP’s role was to track patients, mostly from the progressive care unit, who required a tracheostomy and ventilator and were expected to be discharged home or to a long-term care facility. The NP provided continuity for medical management and coordinated care at discharge.

“We also do not make changes for 2 weeks before discharge so that we can focus on all the other coordination that goes into getting these kids home,” Ms. Barry said.

She reviewed the patients’ electronic charts to record time to scheduled follow-up visit, days until hospital readmission, admitting diagnosis at readmission, and length of stay after readmission. With consideration for the time needed for transition into this new process, the population studied was assessed within three cohorts.

The first cohort comprised the 22 children discharged between April 2016 and March 2017, the full year before a pulmonary NP began coordinating the discharge process. These patients averaged 1.8 discharges per month with an initial follow-up of 2-12 weeks.

Just over a quarter (27%) of the first cohort were readmitted before their scheduled follow-up, ranging from 2 to 25 days after discharge. Five percent were readmitted within a week of discharge, and 27% were readmitted within a month; their average length of stay was 13 days after readmission. Most (83%) of these discharges were respiratory related while the other 17% were gastrointestinal related.

The second cohort involved the 11 patients discharged between April 2017 and August 2017, the first 5 months after a pulmonary NP began overseeing the discharge readiness process.

“We chose 5 months because it took about 5months for me to develop my own protocols and standards of practice,” Ms. Barry explained.

An average 2.2 discharges occurred monthly with 2-8 weeks of initial postdischarge follow-up. Though nearly half these children (45%) were readmitted before their scheduled follow-up, their length of stay was shorter, an average of 11 days.

Readmission within a week after discharge occurred among 27% of the children, and 45% of them were readmitted within a month of discharge. Sixty percent of these patients were readmitted for respiratory issues, compared with 40% with GI issues.

The third cohort included all 38 patients discharged from September 2017 to August 2018, the year after a pulmonary NP had become fully established in the continuity role, with an average 3.2 discharges occurred per month. Readmission rates were considerably lower: Eighteen percent of patients were readmitted before their scheduled follow-up appointment, which ranged from 1 to 13 weeks after discharge.

Five percent were readmitted within a week of discharge, and 24% were readmitted within a month, ranging from 1 to 26 days post discharge. But length of stay was shorter still at an average of 9 days.

The reasons for readmission varied more in this cohort: While 56% were respiratory related, 22% were related to fever, and 11% were related to neurodevelopment concerns or social reasons, such as necessary involvement of social services.

Ms. Barry’s colleague, Howard B. Panitch, MD, also on the staff of CHOP, noted during the discussion that the NP’s role is invaluable in “keeping the inpatient teams honest.

“She reminds her colleagues in critical care that you can’t make that ventilator change when on your way out the door or very close to discharge.”

Ms. Barry had no disclosures. No external funding was noted.

SOURCE: Barry S et al. CHEST 2018 Oct. doi: 10.1016/j.chest.2018.08.743.

SAN ANTONIO – Unplanned readmissions declined among tracheostomy/ventilator-dependent children whose discharge process involved a pulmonary nurse practitioner to coordinate continuity of care, a study of more than 70 patients has found.

Tara Haelle/MDedge News

Despite an increase over time in the rate of discharges, readmissions fell, Sarah Barry, CRNP, of Children’s Hospital of Philadelphia (CHOP), said at the annual meeting of the American College of Chest Physicians.

“The technology-dependent pediatric population who is going home with tracheostomy and ventilator dependence is at risk for hospital readmission, and having an advanced practice provider in a continuity role promotes adherence to our standards of practice and improves transition to home,” Ms. Barry said in an interview.

She noted previous research showing that 40% of 109 home mechanical ventilation patients discharged between 2003 and 2009 had unplanned readmissions, 28% of which occurred within the first month after discharge.

Nearly two thirds (64%) of those readmissions were related to a pulmonary and/or tracheostomy problem. That study also found that changes in condition management 1 week before discharge, such as medications, ventilator settings, or feeding regimens, was associated with unplanned readmission.

That research “makes us ask ourselves if our readmissions are avoidable and what can we do to get these kids home safe and to keep them home,” Ms. Barry told attendees, adding that CHOP was unhappy with their readmission rates.

“Kids were often not making it to their first pulmonary appointment, and it was a burden for these families,” she said. “We questioned whether or not having a nurse practitioner in a role to promote adherence to our standards would have a positive impact on our unplanned route.”

They evaluated the effect of such an NP on unplanned readmissions among tracheostomy/ventilator-supported children. The NP’s role was to track patients, mostly from the progressive care unit, who required a tracheostomy and ventilator and were expected to be discharged home or to a long-term care facility. The NP provided continuity for medical management and coordinated care at discharge.

“We also do not make changes for 2 weeks before discharge so that we can focus on all the other coordination that goes into getting these kids home,” Ms. Barry said.

She reviewed the patients’ electronic charts to record time to scheduled follow-up visit, days until hospital readmission, admitting diagnosis at readmission, and length of stay after readmission. With consideration for the time needed for transition into this new process, the population studied was assessed within three cohorts.

The first cohort comprised the 22 children discharged between April 2016 and March 2017, the full year before a pulmonary NP began coordinating the discharge process. These patients averaged 1.8 discharges per month with an initial follow-up of 2-12 weeks.

Just over a quarter (27%) of the first cohort were readmitted before their scheduled follow-up, ranging from 2 to 25 days after discharge. Five percent were readmitted within a week of discharge, and 27% were readmitted within a month; their average length of stay was 13 days after readmission. Most (83%) of these discharges were respiratory related while the other 17% were gastrointestinal related.

The second cohort involved the 11 patients discharged between April 2017 and August 2017, the first 5 months after a pulmonary NP began overseeing the discharge readiness process.

“We chose 5 months because it took about 5months for me to develop my own protocols and standards of practice,” Ms. Barry explained.

An average 2.2 discharges occurred monthly with 2-8 weeks of initial postdischarge follow-up. Though nearly half these children (45%) were readmitted before their scheduled follow-up, their length of stay was shorter, an average of 11 days.

Readmission within a week after discharge occurred among 27% of the children, and 45% of them were readmitted within a month of discharge. Sixty percent of these patients were readmitted for respiratory issues, compared with 40% with GI issues.

The third cohort included all 38 patients discharged from September 2017 to August 2018, the year after a pulmonary NP had become fully established in the continuity role, with an average 3.2 discharges occurred per month. Readmission rates were considerably lower: Eighteen percent of patients were readmitted before their scheduled follow-up appointment, which ranged from 1 to 13 weeks after discharge.

Five percent were readmitted within a week of discharge, and 24% were readmitted within a month, ranging from 1 to 26 days post discharge. But length of stay was shorter still at an average of 9 days.

The reasons for readmission varied more in this cohort: While 56% were respiratory related, 22% were related to fever, and 11% were related to neurodevelopment concerns or social reasons, such as necessary involvement of social services.

Ms. Barry’s colleague, Howard B. Panitch, MD, also on the staff of CHOP, noted during the discussion that the NP’s role is invaluable in “keeping the inpatient teams honest.

“She reminds her colleagues in critical care that you can’t make that ventilator change when on your way out the door or very close to discharge.”

Ms. Barry had no disclosures. No external funding was noted.

SOURCE: Barry S et al. CHEST 2018 Oct. doi: 10.1016/j.chest.2018.08.743.