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Incorporating self-care, wellness into routines can prevent doctors’ burnout
Gradually, we are emerging from the chaos, isolation, and anxiety of COVID-19. As the Centers for Disease Control and Prevention adjusts its recommendations and vaccinations become more widely available, our communities are beginning to return to normalcy. We are encouraged to put aside our masks if vaccinated and rejoin society, to venture out with less hesitancy and anxiety. As family and friends reunite, memories of confusion, frustration, and fear are beginning to fade to black. Despite the prevailing belief that we should move on, look forward, and remember the past to safeguard our future, remnants of the pandemic remain.
Unvaccinated individuals, notably children under the age of 12, are quite significant in number. The use of telehealth is now standard practice.
For several years, we were warned about the looming “mental health crisis.” The past year has demonstrated that a crisis no longer looms – it has arrived. Our patients can reveal the vulnerability COVID-19 has wrought – from the devastation of lives lost, supply shortages, loss of employment and financial stability – to a lack of access to computers and thereby, the risk of educational decline. Those factors, coupled with isolation and uncertainty about the future, have led to an influx of individuals with anxiety, depression, and other mood disorders seeking mental health treatment.
Doctors, others suffering
As result of a medical culture guided by the sacred oath to which care, compassion, and dedication held as true in ancient Greece as it does today, the focus centers on those around us – while signs of our own weariness are waved away as “a bad day.” Even though several support groups are readily available to offer a listening ear and mental health physicians who focus on the treatment of health care professionals are becoming more ubiquitous, the vestiges of past doctrine remain.
In this modern age of medical training, there is often as much sacrifice as there is attainment of knowledge. This philosophy is so ingrained that throughout training and practice one may come across colleagues experiencing an abundance of guilt when leave is needed for personal reasons. We are quick to recommend such steps for our patients, family, and friends, but hesitant to consider such for ourselves. Yet, of all the lessons this past year has wrought, the importance of mental health and self-care cannot be overstated. This raises the question:
It is vital to accept our humanity as something not to repair, treat, or overcome but to understand. There is strength and power in vulnerability. If we do not perceive and validate this process within ourselves, how can we do so for others? In other words, the oxygen mask must be placed on us first before we can place it on anyone else – patients or otherwise.
Chiefly and above all else, the importance of identifying individual signs of stress is essential. Where do you hold tension? Are you prone to GI distress or headaches when taxed? Do you tend toward irritability, apathy, or exhaustion?
Once this is determined, it is important to assess your stress on a numerical scale, such as those used for pain. Are you a 5 or an 8? Finally, are there identifiable triggers or reliable alleviators? Is there a time of day or day of the week that is most difficult to manage? Can you anticipate potential stressors? Understanding your triggers, listening to your body, and practicing the language of self is the first step toward wellness.
Following introspection and observation, the next step is inventory. Take stock of your reserves. What replenishes? What depletes? What brings joy? What brings dread? Are there certain activities that mitigate stress? If so, how much time do they entail? Identify your number on a scale and associate that number with specific strategies or techniques. Remember that decompression for a 6 might be excessive for a 4. Furthermore, what is the duration of these feelings? Chronic stressors may incur gradual change verses sudden impact if acute. Through identifying personal signs, devising and using a scale, as well as escalating or de-escalating factors, individuals become more in tune with their bodies and therefore, more likely to intervene before burnout takes hold.
With this process well integrated, one can now consider stylized approaches for stress management. For example, those inclined toward mindfulness practices may find yoga, meditation, and relaxation exercises beneficial. Others may thrive on positive affirmations, gratitude, and thankfulness. While some might find relief in physical activity, be it strenuous or casual, the creative arts might appeal to those who find joy in painting, writing, or doing crafts. In addition, baking, reading, dancing, and/or listening to music might help lift stress.
Along with those discoveries, or in some cases, rediscoveries, basic needs such as dietary habits and nutrition, hydration, and sleep are vital toward emotional regulation, physiological homeostasis, and stress modulation. Remember HALT: Hungry, Angry, Lonely, Tired, Too hot, Too cold, Sad or Stressed. Those strategies are meant to guide self-care and highlight the importance of allowing time for self-awareness. Imagine yourself as if you are meeting a new patient. Establish rapport, identify symptoms, and explore options for treatment. When we give time to ourselves, we can give time more freely to others. With this in mind, try following the 5-minute wellness check that I formulated:
1. How am I feeling? What am I feeling?
2. Assess HALTS.
3. Identify the number on your scale.
4. Methods of quick de-escalation:
- Designate and schedule personal time.
- Write down daily goals.
- Repeat positive affirmations or write down words of gratitude.
- Use deep breathing exercises.
- Stretch or take a brief walk.
- Engage in mindfulness practices, such as meditation.
Once we develop a habit of monitoring, assessing, and practicing self-care, the process becomes more efficient and effective. Think of the way a seasoned attending can manage workflow with ease, compared with an intern. Recognizing signs and using these strategies routinely can become a quick daily measure of well-being.
Dr. Thomas is a board-certified adult psychiatrist with interests in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. Dr. Thomas has no conflicts of interest.
Gradually, we are emerging from the chaos, isolation, and anxiety of COVID-19. As the Centers for Disease Control and Prevention adjusts its recommendations and vaccinations become more widely available, our communities are beginning to return to normalcy. We are encouraged to put aside our masks if vaccinated and rejoin society, to venture out with less hesitancy and anxiety. As family and friends reunite, memories of confusion, frustration, and fear are beginning to fade to black. Despite the prevailing belief that we should move on, look forward, and remember the past to safeguard our future, remnants of the pandemic remain.
Unvaccinated individuals, notably children under the age of 12, are quite significant in number. The use of telehealth is now standard practice.
For several years, we were warned about the looming “mental health crisis.” The past year has demonstrated that a crisis no longer looms – it has arrived. Our patients can reveal the vulnerability COVID-19 has wrought – from the devastation of lives lost, supply shortages, loss of employment and financial stability – to a lack of access to computers and thereby, the risk of educational decline. Those factors, coupled with isolation and uncertainty about the future, have led to an influx of individuals with anxiety, depression, and other mood disorders seeking mental health treatment.
Doctors, others suffering
As result of a medical culture guided by the sacred oath to which care, compassion, and dedication held as true in ancient Greece as it does today, the focus centers on those around us – while signs of our own weariness are waved away as “a bad day.” Even though several support groups are readily available to offer a listening ear and mental health physicians who focus on the treatment of health care professionals are becoming more ubiquitous, the vestiges of past doctrine remain.
In this modern age of medical training, there is often as much sacrifice as there is attainment of knowledge. This philosophy is so ingrained that throughout training and practice one may come across colleagues experiencing an abundance of guilt when leave is needed for personal reasons. We are quick to recommend such steps for our patients, family, and friends, but hesitant to consider such for ourselves. Yet, of all the lessons this past year has wrought, the importance of mental health and self-care cannot be overstated. This raises the question:
It is vital to accept our humanity as something not to repair, treat, or overcome but to understand. There is strength and power in vulnerability. If we do not perceive and validate this process within ourselves, how can we do so for others? In other words, the oxygen mask must be placed on us first before we can place it on anyone else – patients or otherwise.
Chiefly and above all else, the importance of identifying individual signs of stress is essential. Where do you hold tension? Are you prone to GI distress or headaches when taxed? Do you tend toward irritability, apathy, or exhaustion?
Once this is determined, it is important to assess your stress on a numerical scale, such as those used for pain. Are you a 5 or an 8? Finally, are there identifiable triggers or reliable alleviators? Is there a time of day or day of the week that is most difficult to manage? Can you anticipate potential stressors? Understanding your triggers, listening to your body, and practicing the language of self is the first step toward wellness.
Following introspection and observation, the next step is inventory. Take stock of your reserves. What replenishes? What depletes? What brings joy? What brings dread? Are there certain activities that mitigate stress? If so, how much time do they entail? Identify your number on a scale and associate that number with specific strategies or techniques. Remember that decompression for a 6 might be excessive for a 4. Furthermore, what is the duration of these feelings? Chronic stressors may incur gradual change verses sudden impact if acute. Through identifying personal signs, devising and using a scale, as well as escalating or de-escalating factors, individuals become more in tune with their bodies and therefore, more likely to intervene before burnout takes hold.
With this process well integrated, one can now consider stylized approaches for stress management. For example, those inclined toward mindfulness practices may find yoga, meditation, and relaxation exercises beneficial. Others may thrive on positive affirmations, gratitude, and thankfulness. While some might find relief in physical activity, be it strenuous or casual, the creative arts might appeal to those who find joy in painting, writing, or doing crafts. In addition, baking, reading, dancing, and/or listening to music might help lift stress.
Along with those discoveries, or in some cases, rediscoveries, basic needs such as dietary habits and nutrition, hydration, and sleep are vital toward emotional regulation, physiological homeostasis, and stress modulation. Remember HALT: Hungry, Angry, Lonely, Tired, Too hot, Too cold, Sad or Stressed. Those strategies are meant to guide self-care and highlight the importance of allowing time for self-awareness. Imagine yourself as if you are meeting a new patient. Establish rapport, identify symptoms, and explore options for treatment. When we give time to ourselves, we can give time more freely to others. With this in mind, try following the 5-minute wellness check that I formulated:
1. How am I feeling? What am I feeling?
2. Assess HALTS.
3. Identify the number on your scale.
4. Methods of quick de-escalation:
- Designate and schedule personal time.
- Write down daily goals.
- Repeat positive affirmations or write down words of gratitude.
- Use deep breathing exercises.
- Stretch or take a brief walk.
- Engage in mindfulness practices, such as meditation.
Once we develop a habit of monitoring, assessing, and practicing self-care, the process becomes more efficient and effective. Think of the way a seasoned attending can manage workflow with ease, compared with an intern. Recognizing signs and using these strategies routinely can become a quick daily measure of well-being.
Dr. Thomas is a board-certified adult psychiatrist with interests in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. Dr. Thomas has no conflicts of interest.
Gradually, we are emerging from the chaos, isolation, and anxiety of COVID-19. As the Centers for Disease Control and Prevention adjusts its recommendations and vaccinations become more widely available, our communities are beginning to return to normalcy. We are encouraged to put aside our masks if vaccinated and rejoin society, to venture out with less hesitancy and anxiety. As family and friends reunite, memories of confusion, frustration, and fear are beginning to fade to black. Despite the prevailing belief that we should move on, look forward, and remember the past to safeguard our future, remnants of the pandemic remain.
Unvaccinated individuals, notably children under the age of 12, are quite significant in number. The use of telehealth is now standard practice.
For several years, we were warned about the looming “mental health crisis.” The past year has demonstrated that a crisis no longer looms – it has arrived. Our patients can reveal the vulnerability COVID-19 has wrought – from the devastation of lives lost, supply shortages, loss of employment and financial stability – to a lack of access to computers and thereby, the risk of educational decline. Those factors, coupled with isolation and uncertainty about the future, have led to an influx of individuals with anxiety, depression, and other mood disorders seeking mental health treatment.
Doctors, others suffering
As result of a medical culture guided by the sacred oath to which care, compassion, and dedication held as true in ancient Greece as it does today, the focus centers on those around us – while signs of our own weariness are waved away as “a bad day.” Even though several support groups are readily available to offer a listening ear and mental health physicians who focus on the treatment of health care professionals are becoming more ubiquitous, the vestiges of past doctrine remain.
In this modern age of medical training, there is often as much sacrifice as there is attainment of knowledge. This philosophy is so ingrained that throughout training and practice one may come across colleagues experiencing an abundance of guilt when leave is needed for personal reasons. We are quick to recommend such steps for our patients, family, and friends, but hesitant to consider such for ourselves. Yet, of all the lessons this past year has wrought, the importance of mental health and self-care cannot be overstated. This raises the question:
It is vital to accept our humanity as something not to repair, treat, or overcome but to understand. There is strength and power in vulnerability. If we do not perceive and validate this process within ourselves, how can we do so for others? In other words, the oxygen mask must be placed on us first before we can place it on anyone else – patients or otherwise.
Chiefly and above all else, the importance of identifying individual signs of stress is essential. Where do you hold tension? Are you prone to GI distress or headaches when taxed? Do you tend toward irritability, apathy, or exhaustion?
Once this is determined, it is important to assess your stress on a numerical scale, such as those used for pain. Are you a 5 or an 8? Finally, are there identifiable triggers or reliable alleviators? Is there a time of day or day of the week that is most difficult to manage? Can you anticipate potential stressors? Understanding your triggers, listening to your body, and practicing the language of self is the first step toward wellness.
Following introspection and observation, the next step is inventory. Take stock of your reserves. What replenishes? What depletes? What brings joy? What brings dread? Are there certain activities that mitigate stress? If so, how much time do they entail? Identify your number on a scale and associate that number with specific strategies or techniques. Remember that decompression for a 6 might be excessive for a 4. Furthermore, what is the duration of these feelings? Chronic stressors may incur gradual change verses sudden impact if acute. Through identifying personal signs, devising and using a scale, as well as escalating or de-escalating factors, individuals become more in tune with their bodies and therefore, more likely to intervene before burnout takes hold.
With this process well integrated, one can now consider stylized approaches for stress management. For example, those inclined toward mindfulness practices may find yoga, meditation, and relaxation exercises beneficial. Others may thrive on positive affirmations, gratitude, and thankfulness. While some might find relief in physical activity, be it strenuous or casual, the creative arts might appeal to those who find joy in painting, writing, or doing crafts. In addition, baking, reading, dancing, and/or listening to music might help lift stress.
Along with those discoveries, or in some cases, rediscoveries, basic needs such as dietary habits and nutrition, hydration, and sleep are vital toward emotional regulation, physiological homeostasis, and stress modulation. Remember HALT: Hungry, Angry, Lonely, Tired, Too hot, Too cold, Sad or Stressed. Those strategies are meant to guide self-care and highlight the importance of allowing time for self-awareness. Imagine yourself as if you are meeting a new patient. Establish rapport, identify symptoms, and explore options for treatment. When we give time to ourselves, we can give time more freely to others. With this in mind, try following the 5-minute wellness check that I formulated:
1. How am I feeling? What am I feeling?
2. Assess HALTS.
3. Identify the number on your scale.
4. Methods of quick de-escalation:
- Designate and schedule personal time.
- Write down daily goals.
- Repeat positive affirmations or write down words of gratitude.
- Use deep breathing exercises.
- Stretch or take a brief walk.
- Engage in mindfulness practices, such as meditation.
Once we develop a habit of monitoring, assessing, and practicing self-care, the process becomes more efficient and effective. Think of the way a seasoned attending can manage workflow with ease, compared with an intern. Recognizing signs and using these strategies routinely can become a quick daily measure of well-being.
Dr. Thomas is a board-certified adult psychiatrist with interests in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. Dr. Thomas has no conflicts of interest.
AMA acknowledges medical education racism of past, vows better future
The report received overwhelming support at the House of Delegates, the AMA’s legislative policy making body, during an online meeting held June 13.
The Council on Medical Education’s report recommends that the AMA acknowledge the harm caused by the Flexner Report, which was issued in 1910 and has since shaped medical education. The Flexner Report caused harm not only to historically Black medical schools, but also to physician workforce diversity and to the clinical outcomes of minority and marginalized patients, according to the medical education advisory body.
The council also recommended conducting a study on medical education with a focus on health equity and racial justice, improving diversity among healthcare workers, and fixing inequitable outcomes from minorities and marginalized patient populations.
The report comes on the heels of the resignation of JAMA editor-in-chief Howard Bauchner, MD, and another high-ranking editor following a February podcast on systemic racism in medicine. The AMA has since released a strategic plan addressing racism and health inequity that has divided membership.
Flexner Report’s effect on physician diversity
The Council on Medical Education’s report observed that as a result of the Flexner Report’s recommendations, 89 medical schools, including 5 of the 7 existing medical schools training Black physicians, were closed because they didn’t meet the report’s standards. In addition, the report created a limited role for Black physicians while “hint[ing] that Black physicians possessed less potential and ability than their White counterparts,” read the Council’s report.
In addition to consigning the role of the Black physician to “educating the [Black] race to know and to practice fundamental hygienic principles,” the Flexner Report also observed that “a well-taught negro sanitarian will be immensely useful,” per the Council’s report.
The impact of the closure of medical schools training Black physicians was dramatic. According to the Council’s report, in 1964, 93% of medical students in the United States were men and 97% of those students were non-Hispanic White.
Today, 56% of physicians identify as White, 17% as Asian, 6% as Hispanic, and 5% as Black or African American, per the Association of American Medical Colleges; nearly 14% of active physicians didn’t report their race in the survey. By means of contrast, the U.S. population in 2019 was 60% White, 19% Latino/Hispanic, 13% Black or African American, and 6% Asian American, according to the Brookings Institute.
Abraham Flexner, who wrote the Flexner Report, is often referred to as the “father of modern medical education,” according to the AAMC. In November, the AAMC observed that the Flexner Report contained racist and sexist ideas and that his work contributed to the closure of historically Black medical schools. Both statements were included in AAMC’s announcement about the removal of Flexner’s name from its most prestigious award. As of January, the award is now called the AAMC Award for Excellence in Medical Education.
Pathway programs can increase diversity
Pathway programs, which leverage targeted milestones along the journey to becoming a physician in order to increase diversity, were an area of focus in the council’s report. These programs “can exert a meaningful, positive effect on student outcomes and increase diversity across various levels of educational settings,” according to its report.
Centers of Excellence, which provides grants for mentorship and training programs, is one of many pathway programs. During the 2018-2019 academic year, Centers of Excellence supported more than 1,300 trainees – 99% of them were underrepresented minorities and 64% came from financially or educationally disadvantaged backgrounds. In 2006, federal funding was cut to these programs and the number of Centers of Excellence fell.
Still, the report cites the passage of federal funding in 2020 of $50 million for public institutions of higher education that train physicians; educational institutions in states with a projected primary care shortage in 2025 are given priority in the grant-funding process.
AMA council’s report garners support from delegates
Delegates voiced overwhelming support of the council’s report during the June 13 meeting. Lou Edje, MD, a Perrysburgh, Ohio–based family physician, voiced strong support for the council’s report, in particular its recommendations that recognize the harm caused by the Flexner Report. Dr. Edje observed that the Flexner Report, with its elimination of five of seven Black medical schools, “[set] back admissions of Black students into medicine by 50 years.”
“Empathy is what we are called to have as physicians. I implore you to simply substitute your ethnicity into these quotes to help understand the historic need for health equity in medicine today. This CME report is part of the antidote to Flexner. We support [it] fully,” concluded Dr. Edje, who spoke for the Great Lakes States Coalition of the AMA.
Rohan Khazanchi, a medical student at the University of Nebraska, Omaha, and a member of the council, said, “Our broad attempt with this report was twofold: to fill gaps in AMA policy with evidence-based recommendations which could improve diversity in our health workforce and, second, to enhance our organization’s vision for truth, reconciliation, and healing to redress the historic marginalization of minoritized physicians in medicine.”
According to an AMA spokesperson, the House of Delegates will vote on this and other policies this week, after which the policies are considered final.
A version of this article first appeared on Medscape.com.
The report received overwhelming support at the House of Delegates, the AMA’s legislative policy making body, during an online meeting held June 13.
The Council on Medical Education’s report recommends that the AMA acknowledge the harm caused by the Flexner Report, which was issued in 1910 and has since shaped medical education. The Flexner Report caused harm not only to historically Black medical schools, but also to physician workforce diversity and to the clinical outcomes of minority and marginalized patients, according to the medical education advisory body.
The council also recommended conducting a study on medical education with a focus on health equity and racial justice, improving diversity among healthcare workers, and fixing inequitable outcomes from minorities and marginalized patient populations.
The report comes on the heels of the resignation of JAMA editor-in-chief Howard Bauchner, MD, and another high-ranking editor following a February podcast on systemic racism in medicine. The AMA has since released a strategic plan addressing racism and health inequity that has divided membership.
Flexner Report’s effect on physician diversity
The Council on Medical Education’s report observed that as a result of the Flexner Report’s recommendations, 89 medical schools, including 5 of the 7 existing medical schools training Black physicians, were closed because they didn’t meet the report’s standards. In addition, the report created a limited role for Black physicians while “hint[ing] that Black physicians possessed less potential and ability than their White counterparts,” read the Council’s report.
In addition to consigning the role of the Black physician to “educating the [Black] race to know and to practice fundamental hygienic principles,” the Flexner Report also observed that “a well-taught negro sanitarian will be immensely useful,” per the Council’s report.
The impact of the closure of medical schools training Black physicians was dramatic. According to the Council’s report, in 1964, 93% of medical students in the United States were men and 97% of those students were non-Hispanic White.
Today, 56% of physicians identify as White, 17% as Asian, 6% as Hispanic, and 5% as Black or African American, per the Association of American Medical Colleges; nearly 14% of active physicians didn’t report their race in the survey. By means of contrast, the U.S. population in 2019 was 60% White, 19% Latino/Hispanic, 13% Black or African American, and 6% Asian American, according to the Brookings Institute.
Abraham Flexner, who wrote the Flexner Report, is often referred to as the “father of modern medical education,” according to the AAMC. In November, the AAMC observed that the Flexner Report contained racist and sexist ideas and that his work contributed to the closure of historically Black medical schools. Both statements were included in AAMC’s announcement about the removal of Flexner’s name from its most prestigious award. As of January, the award is now called the AAMC Award for Excellence in Medical Education.
Pathway programs can increase diversity
Pathway programs, which leverage targeted milestones along the journey to becoming a physician in order to increase diversity, were an area of focus in the council’s report. These programs “can exert a meaningful, positive effect on student outcomes and increase diversity across various levels of educational settings,” according to its report.
Centers of Excellence, which provides grants for mentorship and training programs, is one of many pathway programs. During the 2018-2019 academic year, Centers of Excellence supported more than 1,300 trainees – 99% of them were underrepresented minorities and 64% came from financially or educationally disadvantaged backgrounds. In 2006, federal funding was cut to these programs and the number of Centers of Excellence fell.
Still, the report cites the passage of federal funding in 2020 of $50 million for public institutions of higher education that train physicians; educational institutions in states with a projected primary care shortage in 2025 are given priority in the grant-funding process.
AMA council’s report garners support from delegates
Delegates voiced overwhelming support of the council’s report during the June 13 meeting. Lou Edje, MD, a Perrysburgh, Ohio–based family physician, voiced strong support for the council’s report, in particular its recommendations that recognize the harm caused by the Flexner Report. Dr. Edje observed that the Flexner Report, with its elimination of five of seven Black medical schools, “[set] back admissions of Black students into medicine by 50 years.”
“Empathy is what we are called to have as physicians. I implore you to simply substitute your ethnicity into these quotes to help understand the historic need for health equity in medicine today. This CME report is part of the antidote to Flexner. We support [it] fully,” concluded Dr. Edje, who spoke for the Great Lakes States Coalition of the AMA.
Rohan Khazanchi, a medical student at the University of Nebraska, Omaha, and a member of the council, said, “Our broad attempt with this report was twofold: to fill gaps in AMA policy with evidence-based recommendations which could improve diversity in our health workforce and, second, to enhance our organization’s vision for truth, reconciliation, and healing to redress the historic marginalization of minoritized physicians in medicine.”
According to an AMA spokesperson, the House of Delegates will vote on this and other policies this week, after which the policies are considered final.
A version of this article first appeared on Medscape.com.
The report received overwhelming support at the House of Delegates, the AMA’s legislative policy making body, during an online meeting held June 13.
The Council on Medical Education’s report recommends that the AMA acknowledge the harm caused by the Flexner Report, which was issued in 1910 and has since shaped medical education. The Flexner Report caused harm not only to historically Black medical schools, but also to physician workforce diversity and to the clinical outcomes of minority and marginalized patients, according to the medical education advisory body.
The council also recommended conducting a study on medical education with a focus on health equity and racial justice, improving diversity among healthcare workers, and fixing inequitable outcomes from minorities and marginalized patient populations.
The report comes on the heels of the resignation of JAMA editor-in-chief Howard Bauchner, MD, and another high-ranking editor following a February podcast on systemic racism in medicine. The AMA has since released a strategic plan addressing racism and health inequity that has divided membership.
Flexner Report’s effect on physician diversity
The Council on Medical Education’s report observed that as a result of the Flexner Report’s recommendations, 89 medical schools, including 5 of the 7 existing medical schools training Black physicians, were closed because they didn’t meet the report’s standards. In addition, the report created a limited role for Black physicians while “hint[ing] that Black physicians possessed less potential and ability than their White counterparts,” read the Council’s report.
In addition to consigning the role of the Black physician to “educating the [Black] race to know and to practice fundamental hygienic principles,” the Flexner Report also observed that “a well-taught negro sanitarian will be immensely useful,” per the Council’s report.
The impact of the closure of medical schools training Black physicians was dramatic. According to the Council’s report, in 1964, 93% of medical students in the United States were men and 97% of those students were non-Hispanic White.
Today, 56% of physicians identify as White, 17% as Asian, 6% as Hispanic, and 5% as Black or African American, per the Association of American Medical Colleges; nearly 14% of active physicians didn’t report their race in the survey. By means of contrast, the U.S. population in 2019 was 60% White, 19% Latino/Hispanic, 13% Black or African American, and 6% Asian American, according to the Brookings Institute.
Abraham Flexner, who wrote the Flexner Report, is often referred to as the “father of modern medical education,” according to the AAMC. In November, the AAMC observed that the Flexner Report contained racist and sexist ideas and that his work contributed to the closure of historically Black medical schools. Both statements were included in AAMC’s announcement about the removal of Flexner’s name from its most prestigious award. As of January, the award is now called the AAMC Award for Excellence in Medical Education.
Pathway programs can increase diversity
Pathway programs, which leverage targeted milestones along the journey to becoming a physician in order to increase diversity, were an area of focus in the council’s report. These programs “can exert a meaningful, positive effect on student outcomes and increase diversity across various levels of educational settings,” according to its report.
Centers of Excellence, which provides grants for mentorship and training programs, is one of many pathway programs. During the 2018-2019 academic year, Centers of Excellence supported more than 1,300 trainees – 99% of them were underrepresented minorities and 64% came from financially or educationally disadvantaged backgrounds. In 2006, federal funding was cut to these programs and the number of Centers of Excellence fell.
Still, the report cites the passage of federal funding in 2020 of $50 million for public institutions of higher education that train physicians; educational institutions in states with a projected primary care shortage in 2025 are given priority in the grant-funding process.
AMA council’s report garners support from delegates
Delegates voiced overwhelming support of the council’s report during the June 13 meeting. Lou Edje, MD, a Perrysburgh, Ohio–based family physician, voiced strong support for the council’s report, in particular its recommendations that recognize the harm caused by the Flexner Report. Dr. Edje observed that the Flexner Report, with its elimination of five of seven Black medical schools, “[set] back admissions of Black students into medicine by 50 years.”
“Empathy is what we are called to have as physicians. I implore you to simply substitute your ethnicity into these quotes to help understand the historic need for health equity in medicine today. This CME report is part of the antidote to Flexner. We support [it] fully,” concluded Dr. Edje, who spoke for the Great Lakes States Coalition of the AMA.
Rohan Khazanchi, a medical student at the University of Nebraska, Omaha, and a member of the council, said, “Our broad attempt with this report was twofold: to fill gaps in AMA policy with evidence-based recommendations which could improve diversity in our health workforce and, second, to enhance our organization’s vision for truth, reconciliation, and healing to redress the historic marginalization of minoritized physicians in medicine.”
According to an AMA spokesperson, the House of Delegates will vote on this and other policies this week, after which the policies are considered final.
A version of this article first appeared on Medscape.com.
AMA: ‘Excited delirium’ not a legitimate medical diagnosis
Current evidence does not support use of “excited delirium” or “excited delirium syndrome” as a medical diagnosis, the American Medical Association said June 14, and the term should not be used unless clear diagnostic criteria are validated.
The term is disproportionately applied to people of color, “for whom inappropriate and excessive pharmacotherapy continues to be the norm instead of behavioral deescalation,” the report by the AMA’s Council on Science and Public Health stated, and is therefore indicative of systemic racism.
That conclusion was one of many included in CSAPH Report 2, which was adopted June 14 at the special meeting of the AMA House of Delegates.
The AMA also opposes “use of sedative/hypnotic and dissociative agents, including ketamine, as a pharmacologic intervention for agitated individuals in the out-of-hospital setting, when done solely for a law enforcement purpose.”
Medications typically used for restraint include dissociative ketamine, benzodiazepine sedatives such as midazolam, and antipsychotic medications including olanzapine or haloperidol, alone or in combination.
Kenneth Certa, MD, from the American Psychiatric Association, speaking on behalf of the section council on psychiatry, said in a reference committee hearing: “We have been very concerned over the years with the development of the inexact diagnosis of ‘agitated delirium’ or ‘excited delirium,’ especially after having had a number of individuals, more than what’s reported in the press, die by the use of ketamine in the field for this inexact diagnosis.”
Tamaan Osbourne-Roberts, MD, a delegate and CSAPH member, said the diagnosis lacks scientific evidence and is “disproportionately applied to otherwise healthy Black men in their mid-30s and these men are most likely to die from resulting first-responder actions.”
Dr. Osbourne-Roberts testified that deescalation training should be more widely used and that crisis intervention team models in which behavioral health specialists are first deployed to respond to behavioral health emergencies should be more prevalent.
Andrew Rudawsky, MD, an assistant medical director of two emergency departments and delegate from Ohio, speaking as an individual, testified: “I can tell you from first-hand experience that ‘excited delirium’ is very real. These acutely ill, unstable patients have an emergency medical condition best cared for by an emergency medicine physician.”
The report recognizes that drugs used outside a hospital setting by nonphysicians come with significant risks, particularly for those with underlying conditions and in terms of drug–drug interactions.
“I completely agree that medicine should not be practiced by law enforcement,” Dr. Rudawsky said. “I’m gravely concerned by the legal ramifications of stating that this condition doesn’t exist.”
He said he is optimistic that the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be updated to include “excited delirium.”
in medical and mental health emergencies in local communities.
Additionally, the report urges that “administration of any pharmacologic treatments in the out-of-hospital setting be done equitably, in an evidence-based, antiracist, and stigma-free way.”
The report calls on law enforcement and frontline emergency medical service personnel, who are a part of the “dual response” in emergency situations, to engage in training overseen by EMS medical directors. “The training should minimally include deescalation techniques and the appropriate use of pharmacologic intervention for agitated individuals in the out-of-hospital setting,” the report states.
Recommendation on oversight draws controversy
Several commenters were emergency physicians and medical directors who expressed concern that investigation of potential cases of inappropriate pharmacologic intervention would be overseen by nonphysicians.
The CSAPH authors write that independent investigators are appropriate, whereas those in emergency medicine say EMS medical directors should lead oversight.
Stephen Epstein, MD, chair of the section council on emergency medicine, speaking on behalf of the section council, had moved for referral of the portion of the report that deals with oversight of EMS.
“We’re concerned that recommendation 6, by calling for independent investigators, would put nonphysicians in the position of supervising the practice of medicine of a board-approved specialty. This would set an unfortunate precedent for our AMA,” he said.
Dr. Epstein also said the American College of Emergency Physicians will soon release a report on “excited delirium,” which will add key information for debating the issue.
He added that a new report on the safety of ketamine in out-of-hospital use was published just last week in the Annals of Emergency Medicine. The authors reviewed more than 11,000 cases of the pharmacologic intervention over the past 2 years.
“We believe this information may add substantively to the recommendation in this report,” Dr. Epstein said.
Recommendation 6 was referred to the AMA Board for a decision, but the rest of the report was overwhelmingly adopted.
Dr. Certa, Dr. Osbourne-Roberts, Dr. Rudawsky, and Dr. Epstein have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Current evidence does not support use of “excited delirium” or “excited delirium syndrome” as a medical diagnosis, the American Medical Association said June 14, and the term should not be used unless clear diagnostic criteria are validated.
The term is disproportionately applied to people of color, “for whom inappropriate and excessive pharmacotherapy continues to be the norm instead of behavioral deescalation,” the report by the AMA’s Council on Science and Public Health stated, and is therefore indicative of systemic racism.
That conclusion was one of many included in CSAPH Report 2, which was adopted June 14 at the special meeting of the AMA House of Delegates.
The AMA also opposes “use of sedative/hypnotic and dissociative agents, including ketamine, as a pharmacologic intervention for agitated individuals in the out-of-hospital setting, when done solely for a law enforcement purpose.”
Medications typically used for restraint include dissociative ketamine, benzodiazepine sedatives such as midazolam, and antipsychotic medications including olanzapine or haloperidol, alone or in combination.
Kenneth Certa, MD, from the American Psychiatric Association, speaking on behalf of the section council on psychiatry, said in a reference committee hearing: “We have been very concerned over the years with the development of the inexact diagnosis of ‘agitated delirium’ or ‘excited delirium,’ especially after having had a number of individuals, more than what’s reported in the press, die by the use of ketamine in the field for this inexact diagnosis.”
Tamaan Osbourne-Roberts, MD, a delegate and CSAPH member, said the diagnosis lacks scientific evidence and is “disproportionately applied to otherwise healthy Black men in their mid-30s and these men are most likely to die from resulting first-responder actions.”
Dr. Osbourne-Roberts testified that deescalation training should be more widely used and that crisis intervention team models in which behavioral health specialists are first deployed to respond to behavioral health emergencies should be more prevalent.
Andrew Rudawsky, MD, an assistant medical director of two emergency departments and delegate from Ohio, speaking as an individual, testified: “I can tell you from first-hand experience that ‘excited delirium’ is very real. These acutely ill, unstable patients have an emergency medical condition best cared for by an emergency medicine physician.”
The report recognizes that drugs used outside a hospital setting by nonphysicians come with significant risks, particularly for those with underlying conditions and in terms of drug–drug interactions.
“I completely agree that medicine should not be practiced by law enforcement,” Dr. Rudawsky said. “I’m gravely concerned by the legal ramifications of stating that this condition doesn’t exist.”
He said he is optimistic that the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be updated to include “excited delirium.”
in medical and mental health emergencies in local communities.
Additionally, the report urges that “administration of any pharmacologic treatments in the out-of-hospital setting be done equitably, in an evidence-based, antiracist, and stigma-free way.”
The report calls on law enforcement and frontline emergency medical service personnel, who are a part of the “dual response” in emergency situations, to engage in training overseen by EMS medical directors. “The training should minimally include deescalation techniques and the appropriate use of pharmacologic intervention for agitated individuals in the out-of-hospital setting,” the report states.
Recommendation on oversight draws controversy
Several commenters were emergency physicians and medical directors who expressed concern that investigation of potential cases of inappropriate pharmacologic intervention would be overseen by nonphysicians.
The CSAPH authors write that independent investigators are appropriate, whereas those in emergency medicine say EMS medical directors should lead oversight.
Stephen Epstein, MD, chair of the section council on emergency medicine, speaking on behalf of the section council, had moved for referral of the portion of the report that deals with oversight of EMS.
“We’re concerned that recommendation 6, by calling for independent investigators, would put nonphysicians in the position of supervising the practice of medicine of a board-approved specialty. This would set an unfortunate precedent for our AMA,” he said.
Dr. Epstein also said the American College of Emergency Physicians will soon release a report on “excited delirium,” which will add key information for debating the issue.
He added that a new report on the safety of ketamine in out-of-hospital use was published just last week in the Annals of Emergency Medicine. The authors reviewed more than 11,000 cases of the pharmacologic intervention over the past 2 years.
“We believe this information may add substantively to the recommendation in this report,” Dr. Epstein said.
Recommendation 6 was referred to the AMA Board for a decision, but the rest of the report was overwhelmingly adopted.
Dr. Certa, Dr. Osbourne-Roberts, Dr. Rudawsky, and Dr. Epstein have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Current evidence does not support use of “excited delirium” or “excited delirium syndrome” as a medical diagnosis, the American Medical Association said June 14, and the term should not be used unless clear diagnostic criteria are validated.
The term is disproportionately applied to people of color, “for whom inappropriate and excessive pharmacotherapy continues to be the norm instead of behavioral deescalation,” the report by the AMA’s Council on Science and Public Health stated, and is therefore indicative of systemic racism.
That conclusion was one of many included in CSAPH Report 2, which was adopted June 14 at the special meeting of the AMA House of Delegates.
The AMA also opposes “use of sedative/hypnotic and dissociative agents, including ketamine, as a pharmacologic intervention for agitated individuals in the out-of-hospital setting, when done solely for a law enforcement purpose.”
Medications typically used for restraint include dissociative ketamine, benzodiazepine sedatives such as midazolam, and antipsychotic medications including olanzapine or haloperidol, alone or in combination.
Kenneth Certa, MD, from the American Psychiatric Association, speaking on behalf of the section council on psychiatry, said in a reference committee hearing: “We have been very concerned over the years with the development of the inexact diagnosis of ‘agitated delirium’ or ‘excited delirium,’ especially after having had a number of individuals, more than what’s reported in the press, die by the use of ketamine in the field for this inexact diagnosis.”
Tamaan Osbourne-Roberts, MD, a delegate and CSAPH member, said the diagnosis lacks scientific evidence and is “disproportionately applied to otherwise healthy Black men in their mid-30s and these men are most likely to die from resulting first-responder actions.”
Dr. Osbourne-Roberts testified that deescalation training should be more widely used and that crisis intervention team models in which behavioral health specialists are first deployed to respond to behavioral health emergencies should be more prevalent.
Andrew Rudawsky, MD, an assistant medical director of two emergency departments and delegate from Ohio, speaking as an individual, testified: “I can tell you from first-hand experience that ‘excited delirium’ is very real. These acutely ill, unstable patients have an emergency medical condition best cared for by an emergency medicine physician.”
The report recognizes that drugs used outside a hospital setting by nonphysicians come with significant risks, particularly for those with underlying conditions and in terms of drug–drug interactions.
“I completely agree that medicine should not be practiced by law enforcement,” Dr. Rudawsky said. “I’m gravely concerned by the legal ramifications of stating that this condition doesn’t exist.”
He said he is optimistic that the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be updated to include “excited delirium.”
in medical and mental health emergencies in local communities.
Additionally, the report urges that “administration of any pharmacologic treatments in the out-of-hospital setting be done equitably, in an evidence-based, antiracist, and stigma-free way.”
The report calls on law enforcement and frontline emergency medical service personnel, who are a part of the “dual response” in emergency situations, to engage in training overseen by EMS medical directors. “The training should minimally include deescalation techniques and the appropriate use of pharmacologic intervention for agitated individuals in the out-of-hospital setting,” the report states.
Recommendation on oversight draws controversy
Several commenters were emergency physicians and medical directors who expressed concern that investigation of potential cases of inappropriate pharmacologic intervention would be overseen by nonphysicians.
The CSAPH authors write that independent investigators are appropriate, whereas those in emergency medicine say EMS medical directors should lead oversight.
Stephen Epstein, MD, chair of the section council on emergency medicine, speaking on behalf of the section council, had moved for referral of the portion of the report that deals with oversight of EMS.
“We’re concerned that recommendation 6, by calling for independent investigators, would put nonphysicians in the position of supervising the practice of medicine of a board-approved specialty. This would set an unfortunate precedent for our AMA,” he said.
Dr. Epstein also said the American College of Emergency Physicians will soon release a report on “excited delirium,” which will add key information for debating the issue.
He added that a new report on the safety of ketamine in out-of-hospital use was published just last week in the Annals of Emergency Medicine. The authors reviewed more than 11,000 cases of the pharmacologic intervention over the past 2 years.
“We believe this information may add substantively to the recommendation in this report,” Dr. Epstein said.
Recommendation 6 was referred to the AMA Board for a decision, but the rest of the report was overwhelmingly adopted.
Dr. Certa, Dr. Osbourne-Roberts, Dr. Rudawsky, and Dr. Epstein have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Inpatient care for HS higher for Black and Hispanic patients
National Inpatient Sample.
The differences occurred despite Black and Hispanic patients being younger at the time of admission than White patients, and may reflect increased disease severity and management challenges in these patients with skin of color, Nishadh Sutaria, BS, a medical student at Tufts University, Boston, said at the annual Skin of Color Society symposium. “They may also reflect social inequities in access to dermatologists, with racial and ethnic minorities using inpatient services in lieu of outpatient care.”
Mr. Sutaria and coinvestigators, led by Shawn Kwatra, MD, of Johns Hopkins University, Baltimore, identified 8,040 HS admissions for White patients, 16,490 Black patients, and 2,405 for Hispanic patients during the 5-year period.
Black and Hispanic patients were significantly younger than White patients, with a mean age of 38.1 years and 35 years, respectively, compared with 42 years for White patients (P < .001 in each case). Compared with White patients, Black patients had more procedures (2.03 vs. 1.84, P = .006), a longer length of stay (5.82 days vs. 4.97 days, P = .001), and higher cost of care ($46,119 vs. $39,862, P = .010). Compared with White patients, Hispanic patients had higher cost of care ($52,334 vs. $39,862, P = .004).
“In these models, Black patients stayed almost a full day longer and accrued a charge of $8,000 more than White patients, and Hispanic patients stayed about a half-day longer and accrued a charge of almost $15,000 more than White patients,” Mr. Sutaria said.
In a multilinear regression analysis adjusting for age, sex, and insurance type, Black race correlated with more procedures, higher length of stay, and higher cost of care, and Hispanic ethnicity with more procedures and higher cost of care.
Prior research has shown that Black patients may be disproportionately affected by HS. A 2017 analysis of electronic health record data for tens of millions of patients nationally, for instance, showed an incidence of HS that was over 2.5 times greater in Blacks than Whites. And a recent analysis of electronic data in Wisconsin for patients with an HS diagnosis and 3 or more encounters for the disease showed that Blacks are more likely to have HS that is Hurley Stage 3, the most severe type.
Increased severity “has not been explicitly shown in Hispanic patients,” Dr. Kwatra said in an interview, “[but] there is a strong relationship between obesity/metabolic syndrome with HS. Because Hispanic patients have higher rates of obesity and metabolic syndrome, it’s [thought] that they may have more severe HS.”
HS patients with skin of color are underrepresented in clinical trials, he said. “Severe HS can be difficult to treat because there are few effective treatments,” he said, noting that adalimumab is the only Food and Drug Administration–approved therapy.
The National Inpatient Sample is a publicly available, all-payer inpatient care database developed for the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project.
Mr. Sutaria is a dermatology research fellow working under the guidance of Dr. Kwatra.
National Inpatient Sample.
The differences occurred despite Black and Hispanic patients being younger at the time of admission than White patients, and may reflect increased disease severity and management challenges in these patients with skin of color, Nishadh Sutaria, BS, a medical student at Tufts University, Boston, said at the annual Skin of Color Society symposium. “They may also reflect social inequities in access to dermatologists, with racial and ethnic minorities using inpatient services in lieu of outpatient care.”
Mr. Sutaria and coinvestigators, led by Shawn Kwatra, MD, of Johns Hopkins University, Baltimore, identified 8,040 HS admissions for White patients, 16,490 Black patients, and 2,405 for Hispanic patients during the 5-year period.
Black and Hispanic patients were significantly younger than White patients, with a mean age of 38.1 years and 35 years, respectively, compared with 42 years for White patients (P < .001 in each case). Compared with White patients, Black patients had more procedures (2.03 vs. 1.84, P = .006), a longer length of stay (5.82 days vs. 4.97 days, P = .001), and higher cost of care ($46,119 vs. $39,862, P = .010). Compared with White patients, Hispanic patients had higher cost of care ($52,334 vs. $39,862, P = .004).
“In these models, Black patients stayed almost a full day longer and accrued a charge of $8,000 more than White patients, and Hispanic patients stayed about a half-day longer and accrued a charge of almost $15,000 more than White patients,” Mr. Sutaria said.
In a multilinear regression analysis adjusting for age, sex, and insurance type, Black race correlated with more procedures, higher length of stay, and higher cost of care, and Hispanic ethnicity with more procedures and higher cost of care.
Prior research has shown that Black patients may be disproportionately affected by HS. A 2017 analysis of electronic health record data for tens of millions of patients nationally, for instance, showed an incidence of HS that was over 2.5 times greater in Blacks than Whites. And a recent analysis of electronic data in Wisconsin for patients with an HS diagnosis and 3 or more encounters for the disease showed that Blacks are more likely to have HS that is Hurley Stage 3, the most severe type.
Increased severity “has not been explicitly shown in Hispanic patients,” Dr. Kwatra said in an interview, “[but] there is a strong relationship between obesity/metabolic syndrome with HS. Because Hispanic patients have higher rates of obesity and metabolic syndrome, it’s [thought] that they may have more severe HS.”
HS patients with skin of color are underrepresented in clinical trials, he said. “Severe HS can be difficult to treat because there are few effective treatments,” he said, noting that adalimumab is the only Food and Drug Administration–approved therapy.
The National Inpatient Sample is a publicly available, all-payer inpatient care database developed for the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project.
Mr. Sutaria is a dermatology research fellow working under the guidance of Dr. Kwatra.
National Inpatient Sample.
The differences occurred despite Black and Hispanic patients being younger at the time of admission than White patients, and may reflect increased disease severity and management challenges in these patients with skin of color, Nishadh Sutaria, BS, a medical student at Tufts University, Boston, said at the annual Skin of Color Society symposium. “They may also reflect social inequities in access to dermatologists, with racial and ethnic minorities using inpatient services in lieu of outpatient care.”
Mr. Sutaria and coinvestigators, led by Shawn Kwatra, MD, of Johns Hopkins University, Baltimore, identified 8,040 HS admissions for White patients, 16,490 Black patients, and 2,405 for Hispanic patients during the 5-year period.
Black and Hispanic patients were significantly younger than White patients, with a mean age of 38.1 years and 35 years, respectively, compared with 42 years for White patients (P < .001 in each case). Compared with White patients, Black patients had more procedures (2.03 vs. 1.84, P = .006), a longer length of stay (5.82 days vs. 4.97 days, P = .001), and higher cost of care ($46,119 vs. $39,862, P = .010). Compared with White patients, Hispanic patients had higher cost of care ($52,334 vs. $39,862, P = .004).
“In these models, Black patients stayed almost a full day longer and accrued a charge of $8,000 more than White patients, and Hispanic patients stayed about a half-day longer and accrued a charge of almost $15,000 more than White patients,” Mr. Sutaria said.
In a multilinear regression analysis adjusting for age, sex, and insurance type, Black race correlated with more procedures, higher length of stay, and higher cost of care, and Hispanic ethnicity with more procedures and higher cost of care.
Prior research has shown that Black patients may be disproportionately affected by HS. A 2017 analysis of electronic health record data for tens of millions of patients nationally, for instance, showed an incidence of HS that was over 2.5 times greater in Blacks than Whites. And a recent analysis of electronic data in Wisconsin for patients with an HS diagnosis and 3 or more encounters for the disease showed that Blacks are more likely to have HS that is Hurley Stage 3, the most severe type.
Increased severity “has not been explicitly shown in Hispanic patients,” Dr. Kwatra said in an interview, “[but] there is a strong relationship between obesity/metabolic syndrome with HS. Because Hispanic patients have higher rates of obesity and metabolic syndrome, it’s [thought] that they may have more severe HS.”
HS patients with skin of color are underrepresented in clinical trials, he said. “Severe HS can be difficult to treat because there are few effective treatments,” he said, noting that adalimumab is the only Food and Drug Administration–approved therapy.
The National Inpatient Sample is a publicly available, all-payer inpatient care database developed for the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project.
Mr. Sutaria is a dermatology research fellow working under the guidance of Dr. Kwatra.
FROM SOC SOCIETY 2021
Minnesota named best place to practice in 2021
For physicians who are just starting out or thinking about moving, the “Land of 10,000 Lakes” could be the land of opportunity, according to a recent Medscape analysis.
In a ranking of the 50 states, Minnesota “claimed top marks for livability, low incidence of adverse actions against doctors, and the performance of its health system,” Shelly Reese wrote in Medscape’s “Best & Worst Places to Practice 2021.”
Minnesota is below average where it’s good to be below average – share of physicians reporting burnout and/or depression – but above average in the share of physicians who say they’re “very happy” outside of work, Medscape said in the annual report.
and adverse actions and a high level of livability. Third place went to Washington (called the most livable state in the country by U.S. News and World Report), fourth to Colorado (physicians happy at and outside of work, high retention rate for residents), and fifth to Utah (low crime rate, high quality of life), Medscape said.
At the bottom of the list for 2021 is West Virginia, where physicians “may confront a bevy of challenges” in the form of low livability, a high rate of adverse actions, and relatively high malpractice payouts, Ms. Reese noted in the report.
State number 49 is Louisiana, where livability is low, malpractice payouts are high, and more than half of physicians say that they’re burned out and/or depressed. New Mexico is 48th (very high rate of adverse actions, poor resident retention), Nevada is 47th (low marks for avoidable hospital use and disparity in care), and Rhode Island is 46th (high malpractice payouts, low physician compensation), Medscape said.
Continuing with the group-of-five theme, America’s three most populous states finished in the top half of the ranking – California 16th, Texas 11th, and Florida 21st – but New York and Pennsylvania, numbers four and five by population size, did not.
The rankings are based on states’ performance in 10 different measures, three of which were sourced from Medscape surveys – happiness at work, happiness outside of work, and burnout/depression – and seven from other organizations: adverse actions against physicians, malpractice payouts, compensation (adjusted for cost of living), overall health, health system performance, overall livability, resident retention.
For physicians who are just starting out or thinking about moving, the “Land of 10,000 Lakes” could be the land of opportunity, according to a recent Medscape analysis.
In a ranking of the 50 states, Minnesota “claimed top marks for livability, low incidence of adverse actions against doctors, and the performance of its health system,” Shelly Reese wrote in Medscape’s “Best & Worst Places to Practice 2021.”
Minnesota is below average where it’s good to be below average – share of physicians reporting burnout and/or depression – but above average in the share of physicians who say they’re “very happy” outside of work, Medscape said in the annual report.
and adverse actions and a high level of livability. Third place went to Washington (called the most livable state in the country by U.S. News and World Report), fourth to Colorado (physicians happy at and outside of work, high retention rate for residents), and fifth to Utah (low crime rate, high quality of life), Medscape said.
At the bottom of the list for 2021 is West Virginia, where physicians “may confront a bevy of challenges” in the form of low livability, a high rate of adverse actions, and relatively high malpractice payouts, Ms. Reese noted in the report.
State number 49 is Louisiana, where livability is low, malpractice payouts are high, and more than half of physicians say that they’re burned out and/or depressed. New Mexico is 48th (very high rate of adverse actions, poor resident retention), Nevada is 47th (low marks for avoidable hospital use and disparity in care), and Rhode Island is 46th (high malpractice payouts, low physician compensation), Medscape said.
Continuing with the group-of-five theme, America’s three most populous states finished in the top half of the ranking – California 16th, Texas 11th, and Florida 21st – but New York and Pennsylvania, numbers four and five by population size, did not.
The rankings are based on states’ performance in 10 different measures, three of which were sourced from Medscape surveys – happiness at work, happiness outside of work, and burnout/depression – and seven from other organizations: adverse actions against physicians, malpractice payouts, compensation (adjusted for cost of living), overall health, health system performance, overall livability, resident retention.
For physicians who are just starting out or thinking about moving, the “Land of 10,000 Lakes” could be the land of opportunity, according to a recent Medscape analysis.
In a ranking of the 50 states, Minnesota “claimed top marks for livability, low incidence of adverse actions against doctors, and the performance of its health system,” Shelly Reese wrote in Medscape’s “Best & Worst Places to Practice 2021.”
Minnesota is below average where it’s good to be below average – share of physicians reporting burnout and/or depression – but above average in the share of physicians who say they’re “very happy” outside of work, Medscape said in the annual report.
and adverse actions and a high level of livability. Third place went to Washington (called the most livable state in the country by U.S. News and World Report), fourth to Colorado (physicians happy at and outside of work, high retention rate for residents), and fifth to Utah (low crime rate, high quality of life), Medscape said.
At the bottom of the list for 2021 is West Virginia, where physicians “may confront a bevy of challenges” in the form of low livability, a high rate of adverse actions, and relatively high malpractice payouts, Ms. Reese noted in the report.
State number 49 is Louisiana, where livability is low, malpractice payouts are high, and more than half of physicians say that they’re burned out and/or depressed. New Mexico is 48th (very high rate of adverse actions, poor resident retention), Nevada is 47th (low marks for avoidable hospital use and disparity in care), and Rhode Island is 46th (high malpractice payouts, low physician compensation), Medscape said.
Continuing with the group-of-five theme, America’s three most populous states finished in the top half of the ranking – California 16th, Texas 11th, and Florida 21st – but New York and Pennsylvania, numbers four and five by population size, did not.
The rankings are based on states’ performance in 10 different measures, three of which were sourced from Medscape surveys – happiness at work, happiness outside of work, and burnout/depression – and seven from other organizations: adverse actions against physicians, malpractice payouts, compensation (adjusted for cost of living), overall health, health system performance, overall livability, resident retention.
U.S. News releases Best Children’s Hospitals list, with changes
Released June 15, the 2021-2022 rankings, which acknowledge 50 U.S. centers for delivering exceptional care in several specialties, also give the Massachusetts hospital the top spot in 4 of 10 pediatric specialties assessed: nephrology, neurology and neurosurgery, pulmonology and lung surgery, and urology.
Children’s Hospital of Philadelphia retains second spot in the annually updated list, and Texas Children’s Hospital, in Houston, moves up a rung to third place, bumping Cincinnati Children’s Hospital Medical Center from third to fourth place. Children’s Hospital Los Angeles comes in at no. 5.
The remaining top 10 placements, in descending order, are as follows:
Children’s Hospital Colorado in Aurora; Children’s National Hospital in Washington; Nationwide Children’s Hospital in Columbus, Ohio; UPMS Children’s Hospital of Pittsburgh; and Lucile Packard Children’s Hospital Stanford (Calif.).
New regional rankings
This year’s edition offers something new, adding rankings within states and multiple-state rankings within seven regions to facilitate choice. “The Best Children’s Hospitals rankings have always highlighted hospitals that excel in specialized care,” said Ben Harder, chief of health analysis and managing editor at U.S. News, in a press release. “Now, this year’s new state and regional rankings can help families identify conveniently located hospitals capable of meeting their child’s needs. As the pandemic continues to affect travel, finding high-quality care close to home has never been more important.”
Across the seven regions, the top-ranked institutions are as follows:
- Mid-Atlantic – Children’s Hospital of Philadelphia.
- Midwest – Cincinnati Children’s Hospital Medical Center.
- New England – Boston Children’s Hospital.
- Pacific – Children’s Hospital Los Angeles.
- Rocky Mountains – Children’s Hospital Colorado.
- Southeast – Children’s Healthcare of Atlanta and Monroe Carell Jr. Children’s Hospital of Vanderbilt, in Nashville, Tenn.
- Southwest – Texas Children’s Hospital.
Specialties
Boston Children’s not only topped the overall list but also led in four specialties. For the other six specialties that were ranked, the top hospitals on the honor roll are as follows:
- Cancer – Children’s Hospital of Philadelphia.
- Cardiology and heart surgery – Texas Children’s Hospital.
- Diabetes and endocrinology – Children’s Hospital of Philadelphia.
- Gastroenterology and gastrointestinal surgery – Children’s Hospital Colorado.
- Neonatology – Children’s National Hospital.
- Orthopedics – Children’s Hospital of Philadelphia.
For the past 15 years, the objective of the rankings has been to offer a starting point for parents in making decisions about the best place to take very sick children for high-quality care. The editors of the rankings acknowledge that considerations of travel costs and insurance coverage are other factors to consider.
Helpful for families
The rankings are helpful for families, according to Joe W. St. Geme, III, MD, Children’s Hospital of Philadelphia’s physician-in-chief and chair of its department of pediatrics. “Some parents, especially those coming from outside an area, find them useful when deciding on care away from home,” he told this news organization. “Most types of pediatric care are available in the community, but sometimes a child has an unusual disease or complex disease for which local care is not available.”
Dr. St. Geme said the new regional rankings may be useful in helping parents decide where to bring a child for care that is closer to where they live.
A top ranking from U.S. News is just one indication of a hospital›s overall performance, according to Angela Lorts, MD, MBA, director of the Ventricular Assist Device Program, at Cincinnati Children’s Hospital Medical Center.
“Parents seeking care for their child should use the data to ask questions and understand the limitations,” she told this news organization. “Rankings are only based on a small subset of the children we care for. Many of the metrics may not pertain to their child and may not reflect the care they will receive.”
In her view, ranking will not give parents all the information they need about medical care and outcomes for specific conditions.
Hospital reaction
Hospitals can use the rankings to target improvements, says Dr. St. Geme. “These rankings can provide an opportunity for some benchmarking, to see what other institutions are doing and how they’re able to deliver care. They can serve as a source of ideas and can influence planning,” he said.
He cautioned that the data are not as complete as they could be. “A number of services are not included, and we try to keep that in mind,” he said.
Rankings may also affect recruitment, Dr. St. Geme added, because higher-ranked institutions may find it easier to attract sought-after clinicians and investigators in needed areas.
Another sphere of influence is philanthropy and fund raising. “People are much more likely to consider making both small and large donations to a high-ranked institution,” said J. Howard Smart, MD, chair of pediatrics at Sharp Rees-Stealy Medical Group and chair-elect of the physician leadership council at Sharp Mary Birch Hospital for Women and Newborns in San Diego.
Dr. St. Geme agrees. “Philanthropists are interested in making investments where they feel they’re a sure bet, and rankings may indicate a sure bet. But their impact on government funding and grant support is probably less.”
Ultimately, however, some families may not have lot of choice in where to go when their children are sick, Dr. Smart said. “And people probably don’t choose a location to live in based on nearby children’s hospitals the way they do for schools,” he said.
What about hospitals that continue to rank much lower on the 50-institution list – excellent though they must be to make it onto the honor roll. “To be on the list but not to have risen in rank in recent years might be a disappointment,” said Dr. St. Geme. “But it might also motivate a hospital to think about making internal investments in order to strengthen a particular service. And it may motivate nonranked hospitals to improve care in order to break into the list.”
Dr. Lorts points out that the annual survey process requires hospitals to track the clinical outcomes of a subset of patients, which may lead to improvement in these areas. It also requires data collection on structure and process, which drives needs assessments of select hospital areas. “But ideally, all hospitals would be tracking important outcomes, benchmarking to peer hospitals, and improving where needed without the U.S. News incentive,” she said.
This year’s data, compiled by research and consulting firm RTI International, derive from feedback on more than 1,200 questions provided by 118 responding institutions. Details on each hospital on the list and the methodology used in the analysis are available on U.S. News & World Report’s website.
A version of this article first appeared on Medscape.com.
Released June 15, the 2021-2022 rankings, which acknowledge 50 U.S. centers for delivering exceptional care in several specialties, also give the Massachusetts hospital the top spot in 4 of 10 pediatric specialties assessed: nephrology, neurology and neurosurgery, pulmonology and lung surgery, and urology.
Children’s Hospital of Philadelphia retains second spot in the annually updated list, and Texas Children’s Hospital, in Houston, moves up a rung to third place, bumping Cincinnati Children’s Hospital Medical Center from third to fourth place. Children’s Hospital Los Angeles comes in at no. 5.
The remaining top 10 placements, in descending order, are as follows:
Children’s Hospital Colorado in Aurora; Children’s National Hospital in Washington; Nationwide Children’s Hospital in Columbus, Ohio; UPMS Children’s Hospital of Pittsburgh; and Lucile Packard Children’s Hospital Stanford (Calif.).
New regional rankings
This year’s edition offers something new, adding rankings within states and multiple-state rankings within seven regions to facilitate choice. “The Best Children’s Hospitals rankings have always highlighted hospitals that excel in specialized care,” said Ben Harder, chief of health analysis and managing editor at U.S. News, in a press release. “Now, this year’s new state and regional rankings can help families identify conveniently located hospitals capable of meeting their child’s needs. As the pandemic continues to affect travel, finding high-quality care close to home has never been more important.”
Across the seven regions, the top-ranked institutions are as follows:
- Mid-Atlantic – Children’s Hospital of Philadelphia.
- Midwest – Cincinnati Children’s Hospital Medical Center.
- New England – Boston Children’s Hospital.
- Pacific – Children’s Hospital Los Angeles.
- Rocky Mountains – Children’s Hospital Colorado.
- Southeast – Children’s Healthcare of Atlanta and Monroe Carell Jr. Children’s Hospital of Vanderbilt, in Nashville, Tenn.
- Southwest – Texas Children’s Hospital.
Specialties
Boston Children’s not only topped the overall list but also led in four specialties. For the other six specialties that were ranked, the top hospitals on the honor roll are as follows:
- Cancer – Children’s Hospital of Philadelphia.
- Cardiology and heart surgery – Texas Children’s Hospital.
- Diabetes and endocrinology – Children’s Hospital of Philadelphia.
- Gastroenterology and gastrointestinal surgery – Children’s Hospital Colorado.
- Neonatology – Children’s National Hospital.
- Orthopedics – Children’s Hospital of Philadelphia.
For the past 15 years, the objective of the rankings has been to offer a starting point for parents in making decisions about the best place to take very sick children for high-quality care. The editors of the rankings acknowledge that considerations of travel costs and insurance coverage are other factors to consider.
Helpful for families
The rankings are helpful for families, according to Joe W. St. Geme, III, MD, Children’s Hospital of Philadelphia’s physician-in-chief and chair of its department of pediatrics. “Some parents, especially those coming from outside an area, find them useful when deciding on care away from home,” he told this news organization. “Most types of pediatric care are available in the community, but sometimes a child has an unusual disease or complex disease for which local care is not available.”
Dr. St. Geme said the new regional rankings may be useful in helping parents decide where to bring a child for care that is closer to where they live.
A top ranking from U.S. News is just one indication of a hospital›s overall performance, according to Angela Lorts, MD, MBA, director of the Ventricular Assist Device Program, at Cincinnati Children’s Hospital Medical Center.
“Parents seeking care for their child should use the data to ask questions and understand the limitations,” she told this news organization. “Rankings are only based on a small subset of the children we care for. Many of the metrics may not pertain to their child and may not reflect the care they will receive.”
In her view, ranking will not give parents all the information they need about medical care and outcomes for specific conditions.
Hospital reaction
Hospitals can use the rankings to target improvements, says Dr. St. Geme. “These rankings can provide an opportunity for some benchmarking, to see what other institutions are doing and how they’re able to deliver care. They can serve as a source of ideas and can influence planning,” he said.
He cautioned that the data are not as complete as they could be. “A number of services are not included, and we try to keep that in mind,” he said.
Rankings may also affect recruitment, Dr. St. Geme added, because higher-ranked institutions may find it easier to attract sought-after clinicians and investigators in needed areas.
Another sphere of influence is philanthropy and fund raising. “People are much more likely to consider making both small and large donations to a high-ranked institution,” said J. Howard Smart, MD, chair of pediatrics at Sharp Rees-Stealy Medical Group and chair-elect of the physician leadership council at Sharp Mary Birch Hospital for Women and Newborns in San Diego.
Dr. St. Geme agrees. “Philanthropists are interested in making investments where they feel they’re a sure bet, and rankings may indicate a sure bet. But their impact on government funding and grant support is probably less.”
Ultimately, however, some families may not have lot of choice in where to go when their children are sick, Dr. Smart said. “And people probably don’t choose a location to live in based on nearby children’s hospitals the way they do for schools,” he said.
What about hospitals that continue to rank much lower on the 50-institution list – excellent though they must be to make it onto the honor roll. “To be on the list but not to have risen in rank in recent years might be a disappointment,” said Dr. St. Geme. “But it might also motivate a hospital to think about making internal investments in order to strengthen a particular service. And it may motivate nonranked hospitals to improve care in order to break into the list.”
Dr. Lorts points out that the annual survey process requires hospitals to track the clinical outcomes of a subset of patients, which may lead to improvement in these areas. It also requires data collection on structure and process, which drives needs assessments of select hospital areas. “But ideally, all hospitals would be tracking important outcomes, benchmarking to peer hospitals, and improving where needed without the U.S. News incentive,” she said.
This year’s data, compiled by research and consulting firm RTI International, derive from feedback on more than 1,200 questions provided by 118 responding institutions. Details on each hospital on the list and the methodology used in the analysis are available on U.S. News & World Report’s website.
A version of this article first appeared on Medscape.com.
Released June 15, the 2021-2022 rankings, which acknowledge 50 U.S. centers for delivering exceptional care in several specialties, also give the Massachusetts hospital the top spot in 4 of 10 pediatric specialties assessed: nephrology, neurology and neurosurgery, pulmonology and lung surgery, and urology.
Children’s Hospital of Philadelphia retains second spot in the annually updated list, and Texas Children’s Hospital, in Houston, moves up a rung to third place, bumping Cincinnati Children’s Hospital Medical Center from third to fourth place. Children’s Hospital Los Angeles comes in at no. 5.
The remaining top 10 placements, in descending order, are as follows:
Children’s Hospital Colorado in Aurora; Children’s National Hospital in Washington; Nationwide Children’s Hospital in Columbus, Ohio; UPMS Children’s Hospital of Pittsburgh; and Lucile Packard Children’s Hospital Stanford (Calif.).
New regional rankings
This year’s edition offers something new, adding rankings within states and multiple-state rankings within seven regions to facilitate choice. “The Best Children’s Hospitals rankings have always highlighted hospitals that excel in specialized care,” said Ben Harder, chief of health analysis and managing editor at U.S. News, in a press release. “Now, this year’s new state and regional rankings can help families identify conveniently located hospitals capable of meeting their child’s needs. As the pandemic continues to affect travel, finding high-quality care close to home has never been more important.”
Across the seven regions, the top-ranked institutions are as follows:
- Mid-Atlantic – Children’s Hospital of Philadelphia.
- Midwest – Cincinnati Children’s Hospital Medical Center.
- New England – Boston Children’s Hospital.
- Pacific – Children’s Hospital Los Angeles.
- Rocky Mountains – Children’s Hospital Colorado.
- Southeast – Children’s Healthcare of Atlanta and Monroe Carell Jr. Children’s Hospital of Vanderbilt, in Nashville, Tenn.
- Southwest – Texas Children’s Hospital.
Specialties
Boston Children’s not only topped the overall list but also led in four specialties. For the other six specialties that were ranked, the top hospitals on the honor roll are as follows:
- Cancer – Children’s Hospital of Philadelphia.
- Cardiology and heart surgery – Texas Children’s Hospital.
- Diabetes and endocrinology – Children’s Hospital of Philadelphia.
- Gastroenterology and gastrointestinal surgery – Children’s Hospital Colorado.
- Neonatology – Children’s National Hospital.
- Orthopedics – Children’s Hospital of Philadelphia.
For the past 15 years, the objective of the rankings has been to offer a starting point for parents in making decisions about the best place to take very sick children for high-quality care. The editors of the rankings acknowledge that considerations of travel costs and insurance coverage are other factors to consider.
Helpful for families
The rankings are helpful for families, according to Joe W. St. Geme, III, MD, Children’s Hospital of Philadelphia’s physician-in-chief and chair of its department of pediatrics. “Some parents, especially those coming from outside an area, find them useful when deciding on care away from home,” he told this news organization. “Most types of pediatric care are available in the community, but sometimes a child has an unusual disease or complex disease for which local care is not available.”
Dr. St. Geme said the new regional rankings may be useful in helping parents decide where to bring a child for care that is closer to where they live.
A top ranking from U.S. News is just one indication of a hospital›s overall performance, according to Angela Lorts, MD, MBA, director of the Ventricular Assist Device Program, at Cincinnati Children’s Hospital Medical Center.
“Parents seeking care for their child should use the data to ask questions and understand the limitations,” she told this news organization. “Rankings are only based on a small subset of the children we care for. Many of the metrics may not pertain to their child and may not reflect the care they will receive.”
In her view, ranking will not give parents all the information they need about medical care and outcomes for specific conditions.
Hospital reaction
Hospitals can use the rankings to target improvements, says Dr. St. Geme. “These rankings can provide an opportunity for some benchmarking, to see what other institutions are doing and how they’re able to deliver care. They can serve as a source of ideas and can influence planning,” he said.
He cautioned that the data are not as complete as they could be. “A number of services are not included, and we try to keep that in mind,” he said.
Rankings may also affect recruitment, Dr. St. Geme added, because higher-ranked institutions may find it easier to attract sought-after clinicians and investigators in needed areas.
Another sphere of influence is philanthropy and fund raising. “People are much more likely to consider making both small and large donations to a high-ranked institution,” said J. Howard Smart, MD, chair of pediatrics at Sharp Rees-Stealy Medical Group and chair-elect of the physician leadership council at Sharp Mary Birch Hospital for Women and Newborns in San Diego.
Dr. St. Geme agrees. “Philanthropists are interested in making investments where they feel they’re a sure bet, and rankings may indicate a sure bet. But their impact on government funding and grant support is probably less.”
Ultimately, however, some families may not have lot of choice in where to go when their children are sick, Dr. Smart said. “And people probably don’t choose a location to live in based on nearby children’s hospitals the way they do for schools,” he said.
What about hospitals that continue to rank much lower on the 50-institution list – excellent though they must be to make it onto the honor roll. “To be on the list but not to have risen in rank in recent years might be a disappointment,” said Dr. St. Geme. “But it might also motivate a hospital to think about making internal investments in order to strengthen a particular service. And it may motivate nonranked hospitals to improve care in order to break into the list.”
Dr. Lorts points out that the annual survey process requires hospitals to track the clinical outcomes of a subset of patients, which may lead to improvement in these areas. It also requires data collection on structure and process, which drives needs assessments of select hospital areas. “But ideally, all hospitals would be tracking important outcomes, benchmarking to peer hospitals, and improving where needed without the U.S. News incentive,” she said.
This year’s data, compiled by research and consulting firm RTI International, derive from feedback on more than 1,200 questions provided by 118 responding institutions. Details on each hospital on the list and the methodology used in the analysis are available on U.S. News & World Report’s website.
A version of this article first appeared on Medscape.com.
Bariatric surgery tied to fewer HFpEF hospitalizations
Patients who underwent metabolic and bariatric surgery had fewer than half the number of hospitalizations for both acute and chronic episodes of heart failure with preserved ejection fraction (HFpEF) in a retrospective analysis of more than 2 million Americans collected in a national database.
In a multivariate analysis that adjusted for several variables patients without a history of bariatric surgery had three- to fivefold more hospitalizations for acute events involving HFpEF, and more than double the rate of hospitalizations for chronic HFpEF events, David R. Funes, MD, said at the annual meeting of the American Society for Metabolic and Bariatric Surgery.
While this analysis has the limitations of being retrospective, observational, and entirely reliant on procedure codes to define medical histories and outcomes, it had the advantage of using a large database designed to represent the U.S. adult population, said Dr. Funes, a bariatric surgeon at the Cleveland Clinic in Weston, Fla.
HFpEF effects could ‘extend’ surgery’s use
The report “adds an important article to the literature where there is a true void in trying to discern the effect of bariatric surgery on HFpEF,” commented Tammy L. Kindel, MD, PhD, director of the bariatric surgery program at the Medical College of Wisconsin, Milwaukee, and designated discussant for the report. “Minimal studies [up to now] demonstrate that weight loss in any form can modify diastolic dysfunction in patients with HFpEF. Studies that investigate the impact of bariatric surgery on clinical outcomes in patients with HFpEF are probably the most important for extending use of metabolic surgery,” Dr. Kindel said.
She added that “one of the most difficult parts of studying HFpEF” is making a firm diagnosis that often involves excluding other potential causes. She also questioned Dr. Funes about his confidence that his analysis correctly identified patients only with HFpEF. Dr. Funes replied that the diagnostic codes his team used allowed for a clear distinction between patients identified with HFpEF and those with heart failure with reduced ejection fraction, but he also admitted that his study’s complete reliance on these codes introduced a limitation to the analysis.
Including patients with diastolic dysfunction as well as HFpEF
The study used data collected during 2010-2015 by the National Inpatient Sample, run by the U.S. Department of Health & Human Services in a case-control analysis that included 296,041 patients who had undergone some form of bariatric surgery and 2,004,804 people with no history of bariatric surgery selected as controls on the basis of their obesity.
The absolute numbers showed that, during the observation period, the incidence of acute HFpEF hospitalizations was 0.19% among those with prior bariatric surgery and 0.86% among those with no surgery, and the incidence of chronic heart failure hospitalizations was 0.01% among people with prior bariatric surgery and 0.05% among those without prior surgery. Dr. Funes said. He noted that, during the period studied patients, with HFpEF were usually identified as having diastolic heart failure, an older name for the same disease.
In multivariate analyses that adjusted for age, sex, race, hypertension, diabetes, smoking, and coronary artery disease, people without prior bariatric surgery and with hypertension had a 2.8-fold increased rate of acute hospitalizations for HFpEF, while those without hypertension or prior bariatric surgery had a 5.2-fold increased rate. In addition, control patients, regardless of hypertension status, had a 2.9-fold increased rate of hospitalizations for chronic HFpEF events. All these differences were statistically significant.
Dr. Funes also reported results from additional analyses that focused on a roughly 68,000-patient subgroup of those included in the study who had a history of coronary artery disease, including about 62,000 with no prior bariatric surgery and nearly 6,000 people with prior bariatric surgery. In a multivariate analysis of this subgroup, people without prior bariatric surgery had a 2.65-fold increased rate of hospitalization for a HFpEF event (either acute or chronic), compared with those who had undergone bariatric surgery.
Dr. Funes and associates and Dr. Kindel had no relevant disclosures.
Patients who underwent metabolic and bariatric surgery had fewer than half the number of hospitalizations for both acute and chronic episodes of heart failure with preserved ejection fraction (HFpEF) in a retrospective analysis of more than 2 million Americans collected in a national database.
In a multivariate analysis that adjusted for several variables patients without a history of bariatric surgery had three- to fivefold more hospitalizations for acute events involving HFpEF, and more than double the rate of hospitalizations for chronic HFpEF events, David R. Funes, MD, said at the annual meeting of the American Society for Metabolic and Bariatric Surgery.
While this analysis has the limitations of being retrospective, observational, and entirely reliant on procedure codes to define medical histories and outcomes, it had the advantage of using a large database designed to represent the U.S. adult population, said Dr. Funes, a bariatric surgeon at the Cleveland Clinic in Weston, Fla.
HFpEF effects could ‘extend’ surgery’s use
The report “adds an important article to the literature where there is a true void in trying to discern the effect of bariatric surgery on HFpEF,” commented Tammy L. Kindel, MD, PhD, director of the bariatric surgery program at the Medical College of Wisconsin, Milwaukee, and designated discussant for the report. “Minimal studies [up to now] demonstrate that weight loss in any form can modify diastolic dysfunction in patients with HFpEF. Studies that investigate the impact of bariatric surgery on clinical outcomes in patients with HFpEF are probably the most important for extending use of metabolic surgery,” Dr. Kindel said.
She added that “one of the most difficult parts of studying HFpEF” is making a firm diagnosis that often involves excluding other potential causes. She also questioned Dr. Funes about his confidence that his analysis correctly identified patients only with HFpEF. Dr. Funes replied that the diagnostic codes his team used allowed for a clear distinction between patients identified with HFpEF and those with heart failure with reduced ejection fraction, but he also admitted that his study’s complete reliance on these codes introduced a limitation to the analysis.
Including patients with diastolic dysfunction as well as HFpEF
The study used data collected during 2010-2015 by the National Inpatient Sample, run by the U.S. Department of Health & Human Services in a case-control analysis that included 296,041 patients who had undergone some form of bariatric surgery and 2,004,804 people with no history of bariatric surgery selected as controls on the basis of their obesity.
The absolute numbers showed that, during the observation period, the incidence of acute HFpEF hospitalizations was 0.19% among those with prior bariatric surgery and 0.86% among those with no surgery, and the incidence of chronic heart failure hospitalizations was 0.01% among people with prior bariatric surgery and 0.05% among those without prior surgery. Dr. Funes said. He noted that, during the period studied patients, with HFpEF were usually identified as having diastolic heart failure, an older name for the same disease.
In multivariate analyses that adjusted for age, sex, race, hypertension, diabetes, smoking, and coronary artery disease, people without prior bariatric surgery and with hypertension had a 2.8-fold increased rate of acute hospitalizations for HFpEF, while those without hypertension or prior bariatric surgery had a 5.2-fold increased rate. In addition, control patients, regardless of hypertension status, had a 2.9-fold increased rate of hospitalizations for chronic HFpEF events. All these differences were statistically significant.
Dr. Funes also reported results from additional analyses that focused on a roughly 68,000-patient subgroup of those included in the study who had a history of coronary artery disease, including about 62,000 with no prior bariatric surgery and nearly 6,000 people with prior bariatric surgery. In a multivariate analysis of this subgroup, people without prior bariatric surgery had a 2.65-fold increased rate of hospitalization for a HFpEF event (either acute or chronic), compared with those who had undergone bariatric surgery.
Dr. Funes and associates and Dr. Kindel had no relevant disclosures.
Patients who underwent metabolic and bariatric surgery had fewer than half the number of hospitalizations for both acute and chronic episodes of heart failure with preserved ejection fraction (HFpEF) in a retrospective analysis of more than 2 million Americans collected in a national database.
In a multivariate analysis that adjusted for several variables patients without a history of bariatric surgery had three- to fivefold more hospitalizations for acute events involving HFpEF, and more than double the rate of hospitalizations for chronic HFpEF events, David R. Funes, MD, said at the annual meeting of the American Society for Metabolic and Bariatric Surgery.
While this analysis has the limitations of being retrospective, observational, and entirely reliant on procedure codes to define medical histories and outcomes, it had the advantage of using a large database designed to represent the U.S. adult population, said Dr. Funes, a bariatric surgeon at the Cleveland Clinic in Weston, Fla.
HFpEF effects could ‘extend’ surgery’s use
The report “adds an important article to the literature where there is a true void in trying to discern the effect of bariatric surgery on HFpEF,” commented Tammy L. Kindel, MD, PhD, director of the bariatric surgery program at the Medical College of Wisconsin, Milwaukee, and designated discussant for the report. “Minimal studies [up to now] demonstrate that weight loss in any form can modify diastolic dysfunction in patients with HFpEF. Studies that investigate the impact of bariatric surgery on clinical outcomes in patients with HFpEF are probably the most important for extending use of metabolic surgery,” Dr. Kindel said.
She added that “one of the most difficult parts of studying HFpEF” is making a firm diagnosis that often involves excluding other potential causes. She also questioned Dr. Funes about his confidence that his analysis correctly identified patients only with HFpEF. Dr. Funes replied that the diagnostic codes his team used allowed for a clear distinction between patients identified with HFpEF and those with heart failure with reduced ejection fraction, but he also admitted that his study’s complete reliance on these codes introduced a limitation to the analysis.
Including patients with diastolic dysfunction as well as HFpEF
The study used data collected during 2010-2015 by the National Inpatient Sample, run by the U.S. Department of Health & Human Services in a case-control analysis that included 296,041 patients who had undergone some form of bariatric surgery and 2,004,804 people with no history of bariatric surgery selected as controls on the basis of their obesity.
The absolute numbers showed that, during the observation period, the incidence of acute HFpEF hospitalizations was 0.19% among those with prior bariatric surgery and 0.86% among those with no surgery, and the incidence of chronic heart failure hospitalizations was 0.01% among people with prior bariatric surgery and 0.05% among those without prior surgery. Dr. Funes said. He noted that, during the period studied patients, with HFpEF were usually identified as having diastolic heart failure, an older name for the same disease.
In multivariate analyses that adjusted for age, sex, race, hypertension, diabetes, smoking, and coronary artery disease, people without prior bariatric surgery and with hypertension had a 2.8-fold increased rate of acute hospitalizations for HFpEF, while those without hypertension or prior bariatric surgery had a 5.2-fold increased rate. In addition, control patients, regardless of hypertension status, had a 2.9-fold increased rate of hospitalizations for chronic HFpEF events. All these differences were statistically significant.
Dr. Funes also reported results from additional analyses that focused on a roughly 68,000-patient subgroup of those included in the study who had a history of coronary artery disease, including about 62,000 with no prior bariatric surgery and nearly 6,000 people with prior bariatric surgery. In a multivariate analysis of this subgroup, people without prior bariatric surgery had a 2.65-fold increased rate of hospitalization for a HFpEF event (either acute or chronic), compared with those who had undergone bariatric surgery.
Dr. Funes and associates and Dr. Kindel had no relevant disclosures.
FROM ASMBS 2021
Simple risk assessment predicts post-PCI ischemic events
A patient’s risk for ischemic events, but not bleeding, after percutaneous coronary intervention (PCI) can be predicted simply based on whether they have one or more guideline-based standardized risk criteria, a large-scale real-world analysis suggests.
Haoyu Wang, MD, and colleagues showed that having at least one high-risk feature, as outlined in the 2018 European Society of Cardiology and European Association for Cardiothoracic Surgery (ESC/EACTS) Guidelines on Myocardial Revascularization, was associated with an increased risk for target vessel failure by 48% and for a patient-oriented composite outcome by 44%.
Moreover, they showed that implantation of at least three stents and the presence of diabetes and diffuse multivessel disease were the only high-risk features from the guidelines that were independent predictors of the two outcomes.
The study of more than 10,000 PCI patients also showed that determining whether patients were at high bleeding risk (HBR) did not modify their ischemic risk.
This, said Dr. Wang, from the National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, underscores the importance of applying the high ischemic risk (HIR) criteria from the ESC/EACTS guidelines when tailoring dual antiplatelet therapy (DAPT).
The research was presented at the European Atherosclerosis Society 2021 Virtual Congress on June 2, and published online in the Journal of Atherosclerosis and Thrombosis.
Dr. Wang told theheart.org | Medscape Cardiology that they conducted the study to determine which – HIR or HBR – is “most important to balance when treating patients undergoing PCI and then having dual antiplatelet therapy.”
The results showed that when patients have both a HIR and HBR, it is the ESC/EACTS guideline HIR criteria that have “a higher impact” than the bleeding risk, and that this can be “used to guide our choice of the duration of dual anti-platelet therapy.”
“Maybe we can extend, or use more potent, P2Y12 inhibitors” in those situations, he said.
S. Lale Tokgözoglu, MD, PhD, professor of cardiology, Hacettepe University, Ankara, Turkey, who was not involved in the study, said the HIR assessment “performed well,” adding that the HBR score might have been expected to attenuate its “prognostic advantage.”
She told this news organization that the results “are interesting since previous observations have suggested that Asian patients may be more prone to medication side effects and bleeding.”
These findings emphasize the importance of assessing HIR in daily PCI practice and confirm that it “performs well in different populations in real life,” added Dr. Tokgözoglu, a former president of the EAS.
The ESC/EACTS guidelines aimed to standardize the definition of HIR, Dr. Wang said during the presentation.
They set out 10 high-risk features for ischemic events for patients undergoing revascularization, which included patient medical history, comorbid conditions, and the characteristics of the PCI procedure.
Although the goals of the criteria are to inform decision-making and stimulate research, Dr. Wang said that their “prevalence and prognostic association with clinical outcomes are yet to be established in real-world PCI practice.”
Alongside, the Predicting Bleeding Complication in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) score was developed to predict out-of-hospital bleeding in patients receiving DAPT after stent implantation.
Although a PRECISE-DAPT score of at least 25 constitutes a patient at high bleeding risk, Dr. Wang pointed out that such patients are typically also at risk for ischemic events after PCI, and it is “unclear” whether being at HBR modifies this risk.
To investigate further, they used the prospective, real-world Fuwai PCI registry to collate an all-comer patient population with unselected use of drug-eluting stents at the National Center for Cardiovascular Diseases at Fuwai Hospital.
They excluded individuals who were treated with balloon angioplasty alone, bioresorbable scaffolds, or bare metal stents, leaving a total population of 10,167 patients who were treated in 2013.
In that cohort, 5,149 patients (50.6%) met at least one risk criterion from the ESC/EACTS guidelines (HIR patients) and 5,018 (49.4%) met none of the risk criteria (non-HIR patients).
The most common criteria were implantation of at least three stents (23.5%); total stent length greater than 60 mm (20.2%); diffuse multivessel disease, especially in diabetic patients (18.5%); and a history of ST-segment elevation myocardial infarction (13.9%).
HIR patients were significantly older than non-HIR patients (average age, 58.86 vs. 57.77 years; P < .001), were more likely to have diabetes mellitus (42.6% vs. 16.9%; P < .001); and were more likely to have already had a myocardial infarction (32.2% vs. 5.2%; P < .001).
HIR patients also had higher average PRECISE-ADAPT scores than those without HIR (11.22 vs. 9.94; P < .001), and were conversely less likely to have the left anterior descending artery as the target vessel than non-HIR patients (86.0% vs. 94.6%; P < .001).
Cox regression analysis taking into account a range of patient and clinical factors revealed that HIR patients were significantly more likely than their non-HIR counterparts to experience target vessel failure (hazard ratio, 1.48; 95% confidence interval, 1.25-1.74; P < .001).
They were also significantly more likely to have a patient-oriented composite outcome, defined as all-cause death, any myocardial infarction, or any revascularization (HR, 1.44; 95% CI, 1.28-1.63; P < .001).
There was also a significantly higher risk for cardiac death in HIR than in non-HIR patients (HR, 1.95; 95% CI, 1.16-3.29; P = .012).
However, there was no significant association between HIR status and clinically relevant bleeding (HR, 0.84; 95% CI, 0.66-1.06; P = .143).
When the researchers looked at individual ischemic risk features, they found that, on fully adjusted analyses, only two were independent predictors of target vessel failure and the patient-oriented composite outcome.
Having at least three stents implanted was significantly associated with target vessel failure (HR, 1.36; 95% CI, 1.02-1.80; P = .038), and borderline significantly associated with the patient oriented composite outcome (HR, 1.23; 95% CI, 1.00-1.53; P = .056).
Diffuse multivessel disease, especially in diabetic patients, was significantly associated with both target vessel failure (HR, 1.24; 95% CI, 1.02-1.51; P = .035) and with the patient-oriented composite outcome (HR, 1.20; 95% CI, 1.04-1.39; P = .012).
Neither risk feature was significantly associated with clinically relevant bleeding, Dr. Wang noted.
Stratifying the patients by HBR status, the team found that rates of target vessel failure, the patient-oriented composite outcome, cardiac death, myocardial infarction, and definite/probable stent thrombosis were higher in patients with both HIR and HBR than those with neither HIR nor HBR (P < .001).
Further stratifying patients by PRECISE-ADAPT scores – 10 or less indicating very low risk, 11-17 indicating low risk, 18-24 indicating moderate risk, and at least 25 indicating high risk – showed that HIR features had a consistent effect on ischemic and bleeding outcomes, regardless of bleeding risk.
No funding declared. No relevant financial relationships declared.
A version of this article first appeared on Medscape.com.
A patient’s risk for ischemic events, but not bleeding, after percutaneous coronary intervention (PCI) can be predicted simply based on whether they have one or more guideline-based standardized risk criteria, a large-scale real-world analysis suggests.
Haoyu Wang, MD, and colleagues showed that having at least one high-risk feature, as outlined in the 2018 European Society of Cardiology and European Association for Cardiothoracic Surgery (ESC/EACTS) Guidelines on Myocardial Revascularization, was associated with an increased risk for target vessel failure by 48% and for a patient-oriented composite outcome by 44%.
Moreover, they showed that implantation of at least three stents and the presence of diabetes and diffuse multivessel disease were the only high-risk features from the guidelines that were independent predictors of the two outcomes.
The study of more than 10,000 PCI patients also showed that determining whether patients were at high bleeding risk (HBR) did not modify their ischemic risk.
This, said Dr. Wang, from the National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, underscores the importance of applying the high ischemic risk (HIR) criteria from the ESC/EACTS guidelines when tailoring dual antiplatelet therapy (DAPT).
The research was presented at the European Atherosclerosis Society 2021 Virtual Congress on June 2, and published online in the Journal of Atherosclerosis and Thrombosis.
Dr. Wang told theheart.org | Medscape Cardiology that they conducted the study to determine which – HIR or HBR – is “most important to balance when treating patients undergoing PCI and then having dual antiplatelet therapy.”
The results showed that when patients have both a HIR and HBR, it is the ESC/EACTS guideline HIR criteria that have “a higher impact” than the bleeding risk, and that this can be “used to guide our choice of the duration of dual anti-platelet therapy.”
“Maybe we can extend, or use more potent, P2Y12 inhibitors” in those situations, he said.
S. Lale Tokgözoglu, MD, PhD, professor of cardiology, Hacettepe University, Ankara, Turkey, who was not involved in the study, said the HIR assessment “performed well,” adding that the HBR score might have been expected to attenuate its “prognostic advantage.”
She told this news organization that the results “are interesting since previous observations have suggested that Asian patients may be more prone to medication side effects and bleeding.”
These findings emphasize the importance of assessing HIR in daily PCI practice and confirm that it “performs well in different populations in real life,” added Dr. Tokgözoglu, a former president of the EAS.
The ESC/EACTS guidelines aimed to standardize the definition of HIR, Dr. Wang said during the presentation.
They set out 10 high-risk features for ischemic events for patients undergoing revascularization, which included patient medical history, comorbid conditions, and the characteristics of the PCI procedure.
Although the goals of the criteria are to inform decision-making and stimulate research, Dr. Wang said that their “prevalence and prognostic association with clinical outcomes are yet to be established in real-world PCI practice.”
Alongside, the Predicting Bleeding Complication in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) score was developed to predict out-of-hospital bleeding in patients receiving DAPT after stent implantation.
Although a PRECISE-DAPT score of at least 25 constitutes a patient at high bleeding risk, Dr. Wang pointed out that such patients are typically also at risk for ischemic events after PCI, and it is “unclear” whether being at HBR modifies this risk.
To investigate further, they used the prospective, real-world Fuwai PCI registry to collate an all-comer patient population with unselected use of drug-eluting stents at the National Center for Cardiovascular Diseases at Fuwai Hospital.
They excluded individuals who were treated with balloon angioplasty alone, bioresorbable scaffolds, or bare metal stents, leaving a total population of 10,167 patients who were treated in 2013.
In that cohort, 5,149 patients (50.6%) met at least one risk criterion from the ESC/EACTS guidelines (HIR patients) and 5,018 (49.4%) met none of the risk criteria (non-HIR patients).
The most common criteria were implantation of at least three stents (23.5%); total stent length greater than 60 mm (20.2%); diffuse multivessel disease, especially in diabetic patients (18.5%); and a history of ST-segment elevation myocardial infarction (13.9%).
HIR patients were significantly older than non-HIR patients (average age, 58.86 vs. 57.77 years; P < .001), were more likely to have diabetes mellitus (42.6% vs. 16.9%; P < .001); and were more likely to have already had a myocardial infarction (32.2% vs. 5.2%; P < .001).
HIR patients also had higher average PRECISE-ADAPT scores than those without HIR (11.22 vs. 9.94; P < .001), and were conversely less likely to have the left anterior descending artery as the target vessel than non-HIR patients (86.0% vs. 94.6%; P < .001).
Cox regression analysis taking into account a range of patient and clinical factors revealed that HIR patients were significantly more likely than their non-HIR counterparts to experience target vessel failure (hazard ratio, 1.48; 95% confidence interval, 1.25-1.74; P < .001).
They were also significantly more likely to have a patient-oriented composite outcome, defined as all-cause death, any myocardial infarction, or any revascularization (HR, 1.44; 95% CI, 1.28-1.63; P < .001).
There was also a significantly higher risk for cardiac death in HIR than in non-HIR patients (HR, 1.95; 95% CI, 1.16-3.29; P = .012).
However, there was no significant association between HIR status and clinically relevant bleeding (HR, 0.84; 95% CI, 0.66-1.06; P = .143).
When the researchers looked at individual ischemic risk features, they found that, on fully adjusted analyses, only two were independent predictors of target vessel failure and the patient-oriented composite outcome.
Having at least three stents implanted was significantly associated with target vessel failure (HR, 1.36; 95% CI, 1.02-1.80; P = .038), and borderline significantly associated with the patient oriented composite outcome (HR, 1.23; 95% CI, 1.00-1.53; P = .056).
Diffuse multivessel disease, especially in diabetic patients, was significantly associated with both target vessel failure (HR, 1.24; 95% CI, 1.02-1.51; P = .035) and with the patient-oriented composite outcome (HR, 1.20; 95% CI, 1.04-1.39; P = .012).
Neither risk feature was significantly associated with clinically relevant bleeding, Dr. Wang noted.
Stratifying the patients by HBR status, the team found that rates of target vessel failure, the patient-oriented composite outcome, cardiac death, myocardial infarction, and definite/probable stent thrombosis were higher in patients with both HIR and HBR than those with neither HIR nor HBR (P < .001).
Further stratifying patients by PRECISE-ADAPT scores – 10 or less indicating very low risk, 11-17 indicating low risk, 18-24 indicating moderate risk, and at least 25 indicating high risk – showed that HIR features had a consistent effect on ischemic and bleeding outcomes, regardless of bleeding risk.
No funding declared. No relevant financial relationships declared.
A version of this article first appeared on Medscape.com.
A patient’s risk for ischemic events, but not bleeding, after percutaneous coronary intervention (PCI) can be predicted simply based on whether they have one or more guideline-based standardized risk criteria, a large-scale real-world analysis suggests.
Haoyu Wang, MD, and colleagues showed that having at least one high-risk feature, as outlined in the 2018 European Society of Cardiology and European Association for Cardiothoracic Surgery (ESC/EACTS) Guidelines on Myocardial Revascularization, was associated with an increased risk for target vessel failure by 48% and for a patient-oriented composite outcome by 44%.
Moreover, they showed that implantation of at least three stents and the presence of diabetes and diffuse multivessel disease were the only high-risk features from the guidelines that were independent predictors of the two outcomes.
The study of more than 10,000 PCI patients also showed that determining whether patients were at high bleeding risk (HBR) did not modify their ischemic risk.
This, said Dr. Wang, from the National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, underscores the importance of applying the high ischemic risk (HIR) criteria from the ESC/EACTS guidelines when tailoring dual antiplatelet therapy (DAPT).
The research was presented at the European Atherosclerosis Society 2021 Virtual Congress on June 2, and published online in the Journal of Atherosclerosis and Thrombosis.
Dr. Wang told theheart.org | Medscape Cardiology that they conducted the study to determine which – HIR or HBR – is “most important to balance when treating patients undergoing PCI and then having dual antiplatelet therapy.”
The results showed that when patients have both a HIR and HBR, it is the ESC/EACTS guideline HIR criteria that have “a higher impact” than the bleeding risk, and that this can be “used to guide our choice of the duration of dual anti-platelet therapy.”
“Maybe we can extend, or use more potent, P2Y12 inhibitors” in those situations, he said.
S. Lale Tokgözoglu, MD, PhD, professor of cardiology, Hacettepe University, Ankara, Turkey, who was not involved in the study, said the HIR assessment “performed well,” adding that the HBR score might have been expected to attenuate its “prognostic advantage.”
She told this news organization that the results “are interesting since previous observations have suggested that Asian patients may be more prone to medication side effects and bleeding.”
These findings emphasize the importance of assessing HIR in daily PCI practice and confirm that it “performs well in different populations in real life,” added Dr. Tokgözoglu, a former president of the EAS.
The ESC/EACTS guidelines aimed to standardize the definition of HIR, Dr. Wang said during the presentation.
They set out 10 high-risk features for ischemic events for patients undergoing revascularization, which included patient medical history, comorbid conditions, and the characteristics of the PCI procedure.
Although the goals of the criteria are to inform decision-making and stimulate research, Dr. Wang said that their “prevalence and prognostic association with clinical outcomes are yet to be established in real-world PCI practice.”
Alongside, the Predicting Bleeding Complication in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) score was developed to predict out-of-hospital bleeding in patients receiving DAPT after stent implantation.
Although a PRECISE-DAPT score of at least 25 constitutes a patient at high bleeding risk, Dr. Wang pointed out that such patients are typically also at risk for ischemic events after PCI, and it is “unclear” whether being at HBR modifies this risk.
To investigate further, they used the prospective, real-world Fuwai PCI registry to collate an all-comer patient population with unselected use of drug-eluting stents at the National Center for Cardiovascular Diseases at Fuwai Hospital.
They excluded individuals who were treated with balloon angioplasty alone, bioresorbable scaffolds, or bare metal stents, leaving a total population of 10,167 patients who were treated in 2013.
In that cohort, 5,149 patients (50.6%) met at least one risk criterion from the ESC/EACTS guidelines (HIR patients) and 5,018 (49.4%) met none of the risk criteria (non-HIR patients).
The most common criteria were implantation of at least three stents (23.5%); total stent length greater than 60 mm (20.2%); diffuse multivessel disease, especially in diabetic patients (18.5%); and a history of ST-segment elevation myocardial infarction (13.9%).
HIR patients were significantly older than non-HIR patients (average age, 58.86 vs. 57.77 years; P < .001), were more likely to have diabetes mellitus (42.6% vs. 16.9%; P < .001); and were more likely to have already had a myocardial infarction (32.2% vs. 5.2%; P < .001).
HIR patients also had higher average PRECISE-ADAPT scores than those without HIR (11.22 vs. 9.94; P < .001), and were conversely less likely to have the left anterior descending artery as the target vessel than non-HIR patients (86.0% vs. 94.6%; P < .001).
Cox regression analysis taking into account a range of patient and clinical factors revealed that HIR patients were significantly more likely than their non-HIR counterparts to experience target vessel failure (hazard ratio, 1.48; 95% confidence interval, 1.25-1.74; P < .001).
They were also significantly more likely to have a patient-oriented composite outcome, defined as all-cause death, any myocardial infarction, or any revascularization (HR, 1.44; 95% CI, 1.28-1.63; P < .001).
There was also a significantly higher risk for cardiac death in HIR than in non-HIR patients (HR, 1.95; 95% CI, 1.16-3.29; P = .012).
However, there was no significant association between HIR status and clinically relevant bleeding (HR, 0.84; 95% CI, 0.66-1.06; P = .143).
When the researchers looked at individual ischemic risk features, they found that, on fully adjusted analyses, only two were independent predictors of target vessel failure and the patient-oriented composite outcome.
Having at least three stents implanted was significantly associated with target vessel failure (HR, 1.36; 95% CI, 1.02-1.80; P = .038), and borderline significantly associated with the patient oriented composite outcome (HR, 1.23; 95% CI, 1.00-1.53; P = .056).
Diffuse multivessel disease, especially in diabetic patients, was significantly associated with both target vessel failure (HR, 1.24; 95% CI, 1.02-1.51; P = .035) and with the patient-oriented composite outcome (HR, 1.20; 95% CI, 1.04-1.39; P = .012).
Neither risk feature was significantly associated with clinically relevant bleeding, Dr. Wang noted.
Stratifying the patients by HBR status, the team found that rates of target vessel failure, the patient-oriented composite outcome, cardiac death, myocardial infarction, and definite/probable stent thrombosis were higher in patients with both HIR and HBR than those with neither HIR nor HBR (P < .001).
Further stratifying patients by PRECISE-ADAPT scores – 10 or less indicating very low risk, 11-17 indicating low risk, 18-24 indicating moderate risk, and at least 25 indicating high risk – showed that HIR features had a consistent effect on ischemic and bleeding outcomes, regardless of bleeding risk.
No funding declared. No relevant financial relationships declared.
A version of this article first appeared on Medscape.com.
FDA: More metformin extended-release tablets recalled
Two lots of metformin HCl extended-release tablets have been recalled by Viona Pharmaceuticals because unacceptable levels of nitrosodimethylamine (NDMA), a likely carcinogen, were found in the 750-mg tablets.
According to a June 11 alert from the Food and Drug Administration, the affected lot numbers are M915601 and M915602.
This generic product was made by Cadila Healthcare, Ahmedabad, India, in November 2019 with an expiration date of October 2021, and distributed throughout the United States. The pill is white to off-white, capsule-shaped, uncoated tablets, debossed with “Z”, “C” on one side and “20” on the other side.
No adverse events related to the lots involved in the recall have been reported, the FDA said. It also recommends that clinicians continue to prescribe metformin when clinically appropriate.
In late 2019, the FDA announced it had become aware of NDMA in some metformin products in other countries. The agency immediately began testing to determine whether the metformin in the U.S. supply was at risk, as part of the ongoing investigation into nitrosamine impurities across medication types, which included recalls of hypertension and heartburn medications within the past 3 years.
In February 2020, the FDA reported that they hadn’t found NDMA levels that exceeded the acceptable daily intake. But starting in May 2020, voluntary recalls by, numerous manufacturers have been announced as levels of the compound exceeded that cutoff.
Two lots of metformin HCl extended-release tablets have been recalled by Viona Pharmaceuticals because unacceptable levels of nitrosodimethylamine (NDMA), a likely carcinogen, were found in the 750-mg tablets.
According to a June 11 alert from the Food and Drug Administration, the affected lot numbers are M915601 and M915602.
This generic product was made by Cadila Healthcare, Ahmedabad, India, in November 2019 with an expiration date of October 2021, and distributed throughout the United States. The pill is white to off-white, capsule-shaped, uncoated tablets, debossed with “Z”, “C” on one side and “20” on the other side.
No adverse events related to the lots involved in the recall have been reported, the FDA said. It also recommends that clinicians continue to prescribe metformin when clinically appropriate.
In late 2019, the FDA announced it had become aware of NDMA in some metformin products in other countries. The agency immediately began testing to determine whether the metformin in the U.S. supply was at risk, as part of the ongoing investigation into nitrosamine impurities across medication types, which included recalls of hypertension and heartburn medications within the past 3 years.
In February 2020, the FDA reported that they hadn’t found NDMA levels that exceeded the acceptable daily intake. But starting in May 2020, voluntary recalls by, numerous manufacturers have been announced as levels of the compound exceeded that cutoff.
Two lots of metformin HCl extended-release tablets have been recalled by Viona Pharmaceuticals because unacceptable levels of nitrosodimethylamine (NDMA), a likely carcinogen, were found in the 750-mg tablets.
According to a June 11 alert from the Food and Drug Administration, the affected lot numbers are M915601 and M915602.
This generic product was made by Cadila Healthcare, Ahmedabad, India, in November 2019 with an expiration date of October 2021, and distributed throughout the United States. The pill is white to off-white, capsule-shaped, uncoated tablets, debossed with “Z”, “C” on one side and “20” on the other side.
No adverse events related to the lots involved in the recall have been reported, the FDA said. It also recommends that clinicians continue to prescribe metformin when clinically appropriate.
In late 2019, the FDA announced it had become aware of NDMA in some metformin products in other countries. The agency immediately began testing to determine whether the metformin in the U.S. supply was at risk, as part of the ongoing investigation into nitrosamine impurities across medication types, which included recalls of hypertension and heartburn medications within the past 3 years.
In February 2020, the FDA reported that they hadn’t found NDMA levels that exceeded the acceptable daily intake. But starting in May 2020, voluntary recalls by, numerous manufacturers have been announced as levels of the compound exceeded that cutoff.
FROM THE FOOD AND DRUG ADMINISTRATION
Judge tosses hospital staff suit over vaccine mandate
A federal judge in Texas has dismissed a lawsuit from 117 Houston Methodist Hospital workers who refused to get a COVID-19 vaccine and said it was illegal to require them to do so.
In the ruling issued June 12, U.S. District Judge Lynn Hughes upheld the hospital’s policy and said the vaccination requirement didn’t break any federal laws.
“This is not coercion,” Judge Hughes wrote in the ruling.
“Methodist is trying to do their business of saving lives without giving them the COVID-19 virus,” he wrote. “It is a choice made to keep staff, patients, and their families safer.”
In April, the Houston Methodist Hospital system announced a policy that required employees to be vaccinated by June 7 or request an exemption. After the deadline, 178 of 26,000 employees refused to get inoculated and were placed on suspension without pay. The employees said the vaccine was unsafe and “experimental.” In his ruling, Judge Hughes said their claim was false and irrelevant.
“Texas law only protects employees from being terminated for refusing to commit an act carrying criminal penalties to the worker,” he wrote. “Receiving a COVID-19 vaccination is not an illegal act, and it carries no criminal penalties.”
He denounced the “press-release style of the complaint” and the comparison of the hospital’s vaccine policy to forced experimentation by the Nazis against Jewish people during the Holocaust.
“Equating the injection requirement to medical experimentation in concentration camps is reprehensible,” he wrote. “Nazi doctors conducted medical experiments on victims that caused pain, mutilation, permanent disability, and in many cases, death.”
Judge Hughes also said that employees can “freely choose” to accept or refuse a COVID-19 vaccine. If they refuse, they “simply need to work somewhere else,” he wrote.
“If a worker refuses an assignment, changed office, earlier start time, or other directive, he may be properly fired,” Judge Hughes said. “Every employment includes limits on the worker’s behavior in exchange for his remuneration. This is all part of the bargain.”
The ruling could set a precedent for similar COVID-19 vaccine lawsuits across the country, NPR reported. Houston Methodist was one of the first hospitals to require staff to be vaccinated. After the ruling on June 12, the hospital system wrote in a statement that it was “pleased and reassured” that Judge Hughes dismissed a “frivolous lawsuit.”
The hospital system will begin to terminate the 178 employees who were suspended if they don’t get a vaccine by June 21.
Jennifer Bridges, a nurse who has led the campaign against the vaccine policy, said she and the other plaintiffs will appeal the decision, according to KHOU.
“We’re OK with this decision. We are appealing. This will be taken all the way to the Supreme Court,” she told the news station. “This is far from over. This is literally only the beginning.”
A version of this article first appeared on WebMD.com.
A federal judge in Texas has dismissed a lawsuit from 117 Houston Methodist Hospital workers who refused to get a COVID-19 vaccine and said it was illegal to require them to do so.
In the ruling issued June 12, U.S. District Judge Lynn Hughes upheld the hospital’s policy and said the vaccination requirement didn’t break any federal laws.
“This is not coercion,” Judge Hughes wrote in the ruling.
“Methodist is trying to do their business of saving lives without giving them the COVID-19 virus,” he wrote. “It is a choice made to keep staff, patients, and their families safer.”
In April, the Houston Methodist Hospital system announced a policy that required employees to be vaccinated by June 7 or request an exemption. After the deadline, 178 of 26,000 employees refused to get inoculated and were placed on suspension without pay. The employees said the vaccine was unsafe and “experimental.” In his ruling, Judge Hughes said their claim was false and irrelevant.
“Texas law only protects employees from being terminated for refusing to commit an act carrying criminal penalties to the worker,” he wrote. “Receiving a COVID-19 vaccination is not an illegal act, and it carries no criminal penalties.”
He denounced the “press-release style of the complaint” and the comparison of the hospital’s vaccine policy to forced experimentation by the Nazis against Jewish people during the Holocaust.
“Equating the injection requirement to medical experimentation in concentration camps is reprehensible,” he wrote. “Nazi doctors conducted medical experiments on victims that caused pain, mutilation, permanent disability, and in many cases, death.”
Judge Hughes also said that employees can “freely choose” to accept or refuse a COVID-19 vaccine. If they refuse, they “simply need to work somewhere else,” he wrote.
“If a worker refuses an assignment, changed office, earlier start time, or other directive, he may be properly fired,” Judge Hughes said. “Every employment includes limits on the worker’s behavior in exchange for his remuneration. This is all part of the bargain.”
The ruling could set a precedent for similar COVID-19 vaccine lawsuits across the country, NPR reported. Houston Methodist was one of the first hospitals to require staff to be vaccinated. After the ruling on June 12, the hospital system wrote in a statement that it was “pleased and reassured” that Judge Hughes dismissed a “frivolous lawsuit.”
The hospital system will begin to terminate the 178 employees who were suspended if they don’t get a vaccine by June 21.
Jennifer Bridges, a nurse who has led the campaign against the vaccine policy, said she and the other plaintiffs will appeal the decision, according to KHOU.
“We’re OK with this decision. We are appealing. This will be taken all the way to the Supreme Court,” she told the news station. “This is far from over. This is literally only the beginning.”
A version of this article first appeared on WebMD.com.
A federal judge in Texas has dismissed a lawsuit from 117 Houston Methodist Hospital workers who refused to get a COVID-19 vaccine and said it was illegal to require them to do so.
In the ruling issued June 12, U.S. District Judge Lynn Hughes upheld the hospital’s policy and said the vaccination requirement didn’t break any federal laws.
“This is not coercion,” Judge Hughes wrote in the ruling.
“Methodist is trying to do their business of saving lives without giving them the COVID-19 virus,” he wrote. “It is a choice made to keep staff, patients, and their families safer.”
In April, the Houston Methodist Hospital system announced a policy that required employees to be vaccinated by June 7 or request an exemption. After the deadline, 178 of 26,000 employees refused to get inoculated and were placed on suspension without pay. The employees said the vaccine was unsafe and “experimental.” In his ruling, Judge Hughes said their claim was false and irrelevant.
“Texas law only protects employees from being terminated for refusing to commit an act carrying criminal penalties to the worker,” he wrote. “Receiving a COVID-19 vaccination is not an illegal act, and it carries no criminal penalties.”
He denounced the “press-release style of the complaint” and the comparison of the hospital’s vaccine policy to forced experimentation by the Nazis against Jewish people during the Holocaust.
“Equating the injection requirement to medical experimentation in concentration camps is reprehensible,” he wrote. “Nazi doctors conducted medical experiments on victims that caused pain, mutilation, permanent disability, and in many cases, death.”
Judge Hughes also said that employees can “freely choose” to accept or refuse a COVID-19 vaccine. If they refuse, they “simply need to work somewhere else,” he wrote.
“If a worker refuses an assignment, changed office, earlier start time, or other directive, he may be properly fired,” Judge Hughes said. “Every employment includes limits on the worker’s behavior in exchange for his remuneration. This is all part of the bargain.”
The ruling could set a precedent for similar COVID-19 vaccine lawsuits across the country, NPR reported. Houston Methodist was one of the first hospitals to require staff to be vaccinated. After the ruling on June 12, the hospital system wrote in a statement that it was “pleased and reassured” that Judge Hughes dismissed a “frivolous lawsuit.”
The hospital system will begin to terminate the 178 employees who were suspended if they don’t get a vaccine by June 21.
Jennifer Bridges, a nurse who has led the campaign against the vaccine policy, said she and the other plaintiffs will appeal the decision, according to KHOU.
“We’re OK with this decision. We are appealing. This will be taken all the way to the Supreme Court,” she told the news station. “This is far from over. This is literally only the beginning.”
A version of this article first appeared on WebMD.com.