Federal Practitioner

Even though younger patients with metastatic colorectal cancer (CRC) tend to be fitter and receive more intensive treatment compared with older patients, overall survival (OS) and progression-free survival (PFS) are remarkably similar between the two groups, according to a large phase 3 randomized trial.

“Colorectal cancer is on track to be the leading cause of cancer death in patients 20 to 49 by the year 2040, so it is important to understand survival in this population,” lead author Marla Lipsyc-Sharf, MD, Young-Onset Colorectal Cancer Center, Dana-Farber Cancer Center, Boston, said in an interview. “The most important point for oncologists to take away from our study is that the survival of young-onset colorectal cancer does not seem to be different from that in older patients.”

Previous studies comparing survival in younger versus older patients with metastatic CRC have yielded conflicting results. Dr. Lipsyc-Sharf and colleagues set out to clarify the literature in their large randomized study, published online on Oct. 12 in the Journal of the National Cancer Institute.

Dr. Lipsyc-Sharf and colleagues enrolled 2,326 eligible patients in the Cancer and Leukemia Group B (CALGB)/SWOG 80405 (Alliance) trial to evaluate the efficacy of chemotherapy plus a biologic to treat metastatic CRC. Slightly over 22% of participants (514 patients) were under age 50 at study enrollment, with a median age of 44.3 years vs. 62.5 in those patients older than 50.

The primary outcome was OS and secondary outcomes included PFS, defined as time from study entry until disease progression or death from any cause. At a follow-up of 6 years, median OS was 27.07 months in the young CRC cohort compared with 26.12 months in the older CRC cohort.

Similarly, median PFS in both younger and older cohorts was virtually identical at 10.87 months versus 10.55 months, respectively. Patients younger than age 35 did have a shorter median OS of 21.95 months and PFS of 9.33 months compared with 26.12 months and 10.55 months, respectively, for those 50 and older, but neither difference was significant.

The similar OS between the younger and older patients with metastatic CRC is “particularly interesting,” the authors noted, given that younger patients should, in theory, have done better than their older peers. Younger patients tend to have better overall health (less diabetes, greater physical activity), have more left-sided CRC, (which is associated with a better prognosis), and receive more intensive therapy.

“It’s not clear at this time why the young-onset CRC patients – despite having these more favorable characteristics – did not have improved survival compared to older patients,” Dr. Lipsyc-Sharf said.  

The authors suggest that this similar survival may be because younger patients tend to be diagnosed at more advanced stages, due to differences in underlying tumor biology, or due to other unknown factors. However, “additional investigation into the tumor biology, clinical characteristics, and optimal treatment of patients with [early onset] CRC is essential,” the authors concluded.

The work was supported by the National Cancer Institute of the National Institutes of Health and, in part, by Bristol Myers Squibb, Genentech, Pfizer, and Sanofi. Dr. Lipsyc-Sharf has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Even though younger patients with metastatic colorectal cancer (CRC) tend to be fitter and receive more intensive treatment compared with older patients, overall survival (OS) and progression-free survival (PFS) are remarkably similar between the two groups, according to a large phase 3 randomized trial.

“Colorectal cancer is on track to be the leading cause of cancer death in patients 20 to 49 by the year 2040, so it is important to understand survival in this population,” lead author Marla Lipsyc-Sharf, MD, Young-Onset Colorectal Cancer Center, Dana-Farber Cancer Center, Boston, said in an interview. “The most important point for oncologists to take away from our study is that the survival of young-onset colorectal cancer does not seem to be different from that in older patients.”

Previous studies comparing survival in younger versus older patients with metastatic CRC have yielded conflicting results. Dr. Lipsyc-Sharf and colleagues set out to clarify the literature in their large randomized study, published online on Oct. 12 in the Journal of the National Cancer Institute.

Dr. Lipsyc-Sharf and colleagues enrolled 2,326 eligible patients in the Cancer and Leukemia Group B (CALGB)/SWOG 80405 (Alliance) trial to evaluate the efficacy of chemotherapy plus a biologic to treat metastatic CRC. Slightly over 22% of participants (514 patients) were under age 50 at study enrollment, with a median age of 44.3 years vs. 62.5 in those patients older than 50.

The primary outcome was OS and secondary outcomes included PFS, defined as time from study entry until disease progression or death from any cause. At a follow-up of 6 years, median OS was 27.07 months in the young CRC cohort compared with 26.12 months in the older CRC cohort.

Similarly, median PFS in both younger and older cohorts was virtually identical at 10.87 months versus 10.55 months, respectively. Patients younger than age 35 did have a shorter median OS of 21.95 months and PFS of 9.33 months compared with 26.12 months and 10.55 months, respectively, for those 50 and older, but neither difference was significant.

The similar OS between the younger and older patients with metastatic CRC is “particularly interesting,” the authors noted, given that younger patients should, in theory, have done better than their older peers. Younger patients tend to have better overall health (less diabetes, greater physical activity), have more left-sided CRC, (which is associated with a better prognosis), and receive more intensive therapy.

“It’s not clear at this time why the young-onset CRC patients – despite having these more favorable characteristics – did not have improved survival compared to older patients,” Dr. Lipsyc-Sharf said.  

The authors suggest that this similar survival may be because younger patients tend to be diagnosed at more advanced stages, due to differences in underlying tumor biology, or due to other unknown factors. However, “additional investigation into the tumor biology, clinical characteristics, and optimal treatment of patients with [early onset] CRC is essential,” the authors concluded.

The work was supported by the National Cancer Institute of the National Institutes of Health and, in part, by Bristol Myers Squibb, Genentech, Pfizer, and Sanofi. Dr. Lipsyc-Sharf has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Even though younger patients with metastatic colorectal cancer (CRC) tend to be fitter and receive more intensive treatment compared with older patients, overall survival (OS) and progression-free survival (PFS) are remarkably similar between the two groups, according to a large phase 3 randomized trial.

“Colorectal cancer is on track to be the leading cause of cancer death in patients 20 to 49 by the year 2040, so it is important to understand survival in this population,” lead author Marla Lipsyc-Sharf, MD, Young-Onset Colorectal Cancer Center, Dana-Farber Cancer Center, Boston, said in an interview. “The most important point for oncologists to take away from our study is that the survival of young-onset colorectal cancer does not seem to be different from that in older patients.”

Previous studies comparing survival in younger versus older patients with metastatic CRC have yielded conflicting results. Dr. Lipsyc-Sharf and colleagues set out to clarify the literature in their large randomized study, published online on Oct. 12 in the Journal of the National Cancer Institute.

Dr. Lipsyc-Sharf and colleagues enrolled 2,326 eligible patients in the Cancer and Leukemia Group B (CALGB)/SWOG 80405 (Alliance) trial to evaluate the efficacy of chemotherapy plus a biologic to treat metastatic CRC. Slightly over 22% of participants (514 patients) were under age 50 at study enrollment, with a median age of 44.3 years vs. 62.5 in those patients older than 50.

The primary outcome was OS and secondary outcomes included PFS, defined as time from study entry until disease progression or death from any cause. At a follow-up of 6 years, median OS was 27.07 months in the young CRC cohort compared with 26.12 months in the older CRC cohort.

Similarly, median PFS in both younger and older cohorts was virtually identical at 10.87 months versus 10.55 months, respectively. Patients younger than age 35 did have a shorter median OS of 21.95 months and PFS of 9.33 months compared with 26.12 months and 10.55 months, respectively, for those 50 and older, but neither difference was significant.

The similar OS between the younger and older patients with metastatic CRC is “particularly interesting,” the authors noted, given that younger patients should, in theory, have done better than their older peers. Younger patients tend to have better overall health (less diabetes, greater physical activity), have more left-sided CRC, (which is associated with a better prognosis), and receive more intensive therapy.

“It’s not clear at this time why the young-onset CRC patients – despite having these more favorable characteristics – did not have improved survival compared to older patients,” Dr. Lipsyc-Sharf said.  

The authors suggest that this similar survival may be because younger patients tend to be diagnosed at more advanced stages, due to differences in underlying tumor biology, or due to other unknown factors. However, “additional investigation into the tumor biology, clinical characteristics, and optimal treatment of patients with [early onset] CRC is essential,” the authors concluded.

The work was supported by the National Cancer Institute of the National Institutes of Health and, in part, by Bristol Myers Squibb, Genentech, Pfizer, and Sanofi. Dr. Lipsyc-Sharf has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Adding lithium to usual care does not decrease the risk of suicide-related events in those with major depressive disorder (MDD) or bipolar disorder (BD) who have survived a recent suicidal event, new research shows.

The results of a randomized, double-blind, placebo-controlled trial in veterans showed no apparent advantage of the drug in preventing self-injury, suicide attempts, or urgent hospitalization to prevent suicide.

“Lithium is an important therapy for bipolar disorders and depression subsets. Our study indicates that, in patients who are actively followed and treated in a system of care that the VA provides, simply adding lithium to their existing management, including medications, is unlikely to be effective for preventing a broad range of suicide-related events,” study investigator Ryan Ferguson, MPH, ScD, Boston Cooperative Studies Coordinating Center, VA Boston Healthcare System, told this news organization.

The study was published online JAMA Psychiatry.
 

Surprising findings

The results were somewhat surprising, Dr. Ferguson added. “Lithium showed little or no effect in our study, compared to observational data and results from previous trials. Many clinicians and practice guidelines had assumed that lithium was an effective agent in preventing suicide,” he said.

However, the authors of an accompanying editorial urge caution in concluding that lithium has no antisuicidal effects.

This “rigorously designed and conducted trial has much to teach but cannot be taken as evidence that lithium treatment is ineffective regarding suicidal risk,” write Ross Baldessarini, MD, and Leonardo Tondo, MD, department of psychiatry, Harvard Medical School, Boston.

Study participants were veterans with MDD or BD receiving care at one of 29 Veterans Administration medical centers who survived a recent suicide-related event. In addition to usual care, they were randomly assigned to receive oral extended-release lithium carbonate starting at 600 mg/day or matching placebo for 52 weeks.

The primary outcome was time to the first repeated suicide-related event, including suicide attempts, interrupted attempts, hospitalizations specifically to prevent suicide, and deaths from suicide.

The trial was stopped for futility after 519 veterans (mean age, 42.8 years; 84% male) were randomly assigned to receive lithium (n = 255) or placebo (n = 264). At 3 months, mean lithium concentrations were 0.54 mEq/L for patients with BD and 0.46 mEq/L for those with MDD.

There was no significant difference in the primary outcome (hazard ratio, 1.10; 95% confidence interval, 0.77-1.55; P = .61).

A total of 127 participants (24.5%) had suicide-related outcomes – 65 in the lithium group and 62 in the placebo group. One death occurred in the lithium group and three in the placebo group. There were no unanticipated drug-related safety concerns.
 

Caveats, cautionary notes

The researchers note that the study did not reach its original recruitment goal. “One of the barriers to recruitment was the perception of many of the clinicians caring for potential participants that the effectiveness of lithium was already established; in fact, this perception was supported by the VA/U.S. Department of Defense Clinical Practice Guideline,” they point out.

They also note that most veterans in the study had depression rather than BD, which is the most common indication for lithium use. Most also had substance use disorders, posttraumatic stress disorder, or both, which could influence outcomes.

As a result of small numbers, it wasn’t possible to evaluate outcomes for patients with BD, test whether outcomes differed among patients with BD and MDD, or assess whether comorbidities attenuated the effects of lithium.

The study’s protocol increased participants’ contacts with the VA, which also may have affected outcomes, the researchers note.

In addition, high rates of attrition and low rates of substantial adherence to lithium meant only about half (48.1%) of the study population achieved target serum lithium concentrations.

Editorial writers Dr. Baldessarini and Dr. Tondo note that the low circulating concentrations of lithium and the fact that adherence to assigned treatment was considered adequate in only 17% of participants are key limitations of the study.

“In general, controlled treatment trials aimed at detecting suicide preventive effects are difficult to design, perform, and interpret,” they point out.

Evidence supporting an antisuicidal effect of lithium treatment includes nearly three dozen observational trials that have shown fewer suicides or attempts with lithium treatment, as well as “marked, temporary” increases in suicidal behavior soon after stopping lithium treatment.

Dr. Baldessarini and Dr. Tondo note the current findings “cannot be taken as evidence that lithium lacks antisuicidal effects. An ironic final note is that recruiting participants to such trials may be made difficult by an evidently prevalent belief that the question of antisuicidal effects of lithium is already settled, which it certainly is not,” they write.

Dr. Ferguson “agrees that more work needs to be done to understand the antisuicidal effect of lithium.

The study received financial and material support from a grant from the Cooperative Studies Program, Office of Research and Development, U.S. Department of Veterans Affairs. Dr. Ferguson has disclosed no relevant financial relationships. A complete list of author disclosures is available with the original article.

Dr. Baldessarini and Dr. Tondo have disclosed no relevant financial relationships. Their editorial was supported by grants from the Bruce J. Anderson Foundation, the McLean Private Donors Fund for Psychiatric Research, and the Aretaeus Foundation of Rome.

A version of this article first appeared on Medscape.com.

Adding lithium to usual care does not decrease the risk of suicide-related events in those with major depressive disorder (MDD) or bipolar disorder (BD) who have survived a recent suicidal event, new research shows.

The results of a randomized, double-blind, placebo-controlled trial in veterans showed no apparent advantage of the drug in preventing self-injury, suicide attempts, or urgent hospitalization to prevent suicide.

“Lithium is an important therapy for bipolar disorders and depression subsets. Our study indicates that, in patients who are actively followed and treated in a system of care that the VA provides, simply adding lithium to their existing management, including medications, is unlikely to be effective for preventing a broad range of suicide-related events,” study investigator Ryan Ferguson, MPH, ScD, Boston Cooperative Studies Coordinating Center, VA Boston Healthcare System, told this news organization.

The study was published online JAMA Psychiatry.
 

Surprising findings

The results were somewhat surprising, Dr. Ferguson added. “Lithium showed little or no effect in our study, compared to observational data and results from previous trials. Many clinicians and practice guidelines had assumed that lithium was an effective agent in preventing suicide,” he said.

However, the authors of an accompanying editorial urge caution in concluding that lithium has no antisuicidal effects.

This “rigorously designed and conducted trial has much to teach but cannot be taken as evidence that lithium treatment is ineffective regarding suicidal risk,” write Ross Baldessarini, MD, and Leonardo Tondo, MD, department of psychiatry, Harvard Medical School, Boston.

Study participants were veterans with MDD or BD receiving care at one of 29 Veterans Administration medical centers who survived a recent suicide-related event. In addition to usual care, they were randomly assigned to receive oral extended-release lithium carbonate starting at 600 mg/day or matching placebo for 52 weeks.

The primary outcome was time to the first repeated suicide-related event, including suicide attempts, interrupted attempts, hospitalizations specifically to prevent suicide, and deaths from suicide.

The trial was stopped for futility after 519 veterans (mean age, 42.8 years; 84% male) were randomly assigned to receive lithium (n = 255) or placebo (n = 264). At 3 months, mean lithium concentrations were 0.54 mEq/L for patients with BD and 0.46 mEq/L for those with MDD.

There was no significant difference in the primary outcome (hazard ratio, 1.10; 95% confidence interval, 0.77-1.55; P = .61).

A total of 127 participants (24.5%) had suicide-related outcomes – 65 in the lithium group and 62 in the placebo group. One death occurred in the lithium group and three in the placebo group. There were no unanticipated drug-related safety concerns.
 

Caveats, cautionary notes

The researchers note that the study did not reach its original recruitment goal. “One of the barriers to recruitment was the perception of many of the clinicians caring for potential participants that the effectiveness of lithium was already established; in fact, this perception was supported by the VA/U.S. Department of Defense Clinical Practice Guideline,” they point out.

They also note that most veterans in the study had depression rather than BD, which is the most common indication for lithium use. Most also had substance use disorders, posttraumatic stress disorder, or both, which could influence outcomes.

As a result of small numbers, it wasn’t possible to evaluate outcomes for patients with BD, test whether outcomes differed among patients with BD and MDD, or assess whether comorbidities attenuated the effects of lithium.

The study’s protocol increased participants’ contacts with the VA, which also may have affected outcomes, the researchers note.

In addition, high rates of attrition and low rates of substantial adherence to lithium meant only about half (48.1%) of the study population achieved target serum lithium concentrations.

Editorial writers Dr. Baldessarini and Dr. Tondo note that the low circulating concentrations of lithium and the fact that adherence to assigned treatment was considered adequate in only 17% of participants are key limitations of the study.

“In general, controlled treatment trials aimed at detecting suicide preventive effects are difficult to design, perform, and interpret,” they point out.

Evidence supporting an antisuicidal effect of lithium treatment includes nearly three dozen observational trials that have shown fewer suicides or attempts with lithium treatment, as well as “marked, temporary” increases in suicidal behavior soon after stopping lithium treatment.

Dr. Baldessarini and Dr. Tondo note the current findings “cannot be taken as evidence that lithium lacks antisuicidal effects. An ironic final note is that recruiting participants to such trials may be made difficult by an evidently prevalent belief that the question of antisuicidal effects of lithium is already settled, which it certainly is not,” they write.

Dr. Ferguson “agrees that more work needs to be done to understand the antisuicidal effect of lithium.

The study received financial and material support from a grant from the Cooperative Studies Program, Office of Research and Development, U.S. Department of Veterans Affairs. Dr. Ferguson has disclosed no relevant financial relationships. A complete list of author disclosures is available with the original article.

Dr. Baldessarini and Dr. Tondo have disclosed no relevant financial relationships. Their editorial was supported by grants from the Bruce J. Anderson Foundation, the McLean Private Donors Fund for Psychiatric Research, and the Aretaeus Foundation of Rome.

A version of this article first appeared on Medscape.com.

Adding lithium to usual care does not decrease the risk of suicide-related events in those with major depressive disorder (MDD) or bipolar disorder (BD) who have survived a recent suicidal event, new research shows.

The results of a randomized, double-blind, placebo-controlled trial in veterans showed no apparent advantage of the drug in preventing self-injury, suicide attempts, or urgent hospitalization to prevent suicide.

“Lithium is an important therapy for bipolar disorders and depression subsets. Our study indicates that, in patients who are actively followed and treated in a system of care that the VA provides, simply adding lithium to their existing management, including medications, is unlikely to be effective for preventing a broad range of suicide-related events,” study investigator Ryan Ferguson, MPH, ScD, Boston Cooperative Studies Coordinating Center, VA Boston Healthcare System, told this news organization.

The study was published online JAMA Psychiatry.
 

Surprising findings

The results were somewhat surprising, Dr. Ferguson added. “Lithium showed little or no effect in our study, compared to observational data and results from previous trials. Many clinicians and practice guidelines had assumed that lithium was an effective agent in preventing suicide,” he said.

However, the authors of an accompanying editorial urge caution in concluding that lithium has no antisuicidal effects.

This “rigorously designed and conducted trial has much to teach but cannot be taken as evidence that lithium treatment is ineffective regarding suicidal risk,” write Ross Baldessarini, MD, and Leonardo Tondo, MD, department of psychiatry, Harvard Medical School, Boston.

Study participants were veterans with MDD or BD receiving care at one of 29 Veterans Administration medical centers who survived a recent suicide-related event. In addition to usual care, they were randomly assigned to receive oral extended-release lithium carbonate starting at 600 mg/day or matching placebo for 52 weeks.

The primary outcome was time to the first repeated suicide-related event, including suicide attempts, interrupted attempts, hospitalizations specifically to prevent suicide, and deaths from suicide.

The trial was stopped for futility after 519 veterans (mean age, 42.8 years; 84% male) were randomly assigned to receive lithium (n = 255) or placebo (n = 264). At 3 months, mean lithium concentrations were 0.54 mEq/L for patients with BD and 0.46 mEq/L for those with MDD.

There was no significant difference in the primary outcome (hazard ratio, 1.10; 95% confidence interval, 0.77-1.55; P = .61).

A total of 127 participants (24.5%) had suicide-related outcomes – 65 in the lithium group and 62 in the placebo group. One death occurred in the lithium group and three in the placebo group. There were no unanticipated drug-related safety concerns.
 

Caveats, cautionary notes

The researchers note that the study did not reach its original recruitment goal. “One of the barriers to recruitment was the perception of many of the clinicians caring for potential participants that the effectiveness of lithium was already established; in fact, this perception was supported by the VA/U.S. Department of Defense Clinical Practice Guideline,” they point out.

They also note that most veterans in the study had depression rather than BD, which is the most common indication for lithium use. Most also had substance use disorders, posttraumatic stress disorder, or both, which could influence outcomes.

As a result of small numbers, it wasn’t possible to evaluate outcomes for patients with BD, test whether outcomes differed among patients with BD and MDD, or assess whether comorbidities attenuated the effects of lithium.

The study’s protocol increased participants’ contacts with the VA, which also may have affected outcomes, the researchers note.

In addition, high rates of attrition and low rates of substantial adherence to lithium meant only about half (48.1%) of the study population achieved target serum lithium concentrations.

Editorial writers Dr. Baldessarini and Dr. Tondo note that the low circulating concentrations of lithium and the fact that adherence to assigned treatment was considered adequate in only 17% of participants are key limitations of the study.

“In general, controlled treatment trials aimed at detecting suicide preventive effects are difficult to design, perform, and interpret,” they point out.

Evidence supporting an antisuicidal effect of lithium treatment includes nearly three dozen observational trials that have shown fewer suicides or attempts with lithium treatment, as well as “marked, temporary” increases in suicidal behavior soon after stopping lithium treatment.

Dr. Baldessarini and Dr. Tondo note the current findings “cannot be taken as evidence that lithium lacks antisuicidal effects. An ironic final note is that recruiting participants to such trials may be made difficult by an evidently prevalent belief that the question of antisuicidal effects of lithium is already settled, which it certainly is not,” they write.

Dr. Ferguson “agrees that more work needs to be done to understand the antisuicidal effect of lithium.

The study received financial and material support from a grant from the Cooperative Studies Program, Office of Research and Development, U.S. Department of Veterans Affairs. Dr. Ferguson has disclosed no relevant financial relationships. A complete list of author disclosures is available with the original article.

Dr. Baldessarini and Dr. Tondo have disclosed no relevant financial relationships. Their editorial was supported by grants from the Bruce J. Anderson Foundation, the McLean Private Donors Fund for Psychiatric Research, and the Aretaeus Foundation of Rome.

A version of this article first appeared on Medscape.com.

A federal jury found William R. Bauer, 84, of Port Clinton, Ohio, guilty of prescribing powerful controlled substances, including opioids, to patients without medical necessity and outside the usual course of medical practice.

Dr. Bauer, a neurologist with over 50 years of experience, was convicted of 76 counts of distribution of controlled substances and 25 counts of healthcare fraud. According to television station WTOL, a federal indictment from 2019 listed 270 charges against the physician.

Federal officials claim that through his practice in Bellevue, Ohio, Dr. Bauer repeatedly prescribed controlled substances, including oxycodone, fentanyl, morphine, and tramadol, outside the usual course of professional practice and without legitimate medical purpose. The charges focused on 14 of his patients, to whom he prescribed high doses of opioids and other controlled substances without medical necessity. He also prescribed dangerous drug combinations. He ignored patients’ signs of addiction and abuse, such as early requests for refills, claims that medications had been lost, and claims that family members were stealing pills.

Dr. Bauer was also convicted of healthcare fraud for regularly administering epidural injections and trigger-point injections without medical necessity. Because these injections failed to meet the procedural requirements, they were rendered ineffective and were fraudulently billed to insurers. Dr. Bauer’s illegal prescriptions resulted in insurers paying for these medically unnecessary controlled substances.

Evidence at trial indicated that between January 2007 and August 16, 2019, Dr. Bauer prescribed controlled substances outside the usual course of medical practice and for illegitimate medical purposes. Insurers paid for these medically unnecessary controlled substances as well.

He will be sentenced at a later date.
 

Lab pays $1.2 million to resolve allegations of false claims for drug testing

Bluewater Toxicology, LLC, a clinical laboratory in Mount Washington, Ky., has agreed to pay $1.2 million to resolve civil allegations that it violated the False Claims Act.

The U.S. Department of Justice alleged three issues relating to claims for urine drug testing services that Bluewater submitted to Medicare, Kentucky Medicaid, Indiana Medicaid, TRICARE, and CHAMPVA. First, Bluewater submitted claims in which it misrepresented the number of drug classes it tested. Bluewater claimed it conducted definitive urine drug tests of 22 or more drug classes. In truth, Bluewater tested for fewer than 22 drug classes and secured reimbursement for drug tests that it did not conduct.

Second, Bluewater submitted certain claims without sufficient documentation to support the physician’s intent to order the test that was billed. In this way Bluewater obtained further unwarranted reimbursements.

Finally, Bluewater billed Medicare for specimen validity testing, a quality control process used to analyze a urine specimen to ensure that it has not been diluted or adulterated. Since January 2014, Medicare’s guidance has stated that specimen validity testing should not be separately billed to Medicare, but Bluewater did so anyway.
 

Home care company owner pays $1 million in Medicare fraud restitution

Richard Wennerberg, 72, of Grantham, N.H., pleaded guilty and was sentenced to two counts of class B felony Medicaid fraud, according to the New Hampshire Department of Justice.

Mr. Wennerberg is the owner of Alternative Care @ Home, LLC, a company licensed to provide in-home personal care services to Medicaid beneficiaries. He also pleaded guilty to a third charge of Medicaid fraud, through which Alternative Care @ Home, LLC, will be excluded from future participation in federal healthcare programs.

According to New Hampshire officials, Mr. Wennerberg submitted claims for reimbursement for in-home, personal care services that were never provided. Wennerberg billed Medicaid up to the maximum hours allowed under certain clients’ service authorizations, knowing that his employees did not provide care for all of those hours. He would use the difference to reimburse some caregivers for mileage.

Mr. Wennerberg will serve 1 year in state prison and will pay $1 million in restitution.
 

North Carolina wins two “Operation Root Canal” settlements

North Carolina Attorney General Josh Stein announced two separate civil settlements with ProHealth Dental Inc and Henry W. Davis, Jr, DDS, as part of Operation Root Canal, an ongoing effort to find and stop healthcare fraud among dental practitioners. The settlements, totaling $75,000, resolve allegations of the submission of false claims to the North Carolina Medicaid program.

In Operation Root Canal, the state Medicaid investigations department reviews billing practices for a wide variety of dental services, including dental cleanings, use of nitrous oxide, repetitive restorations on the same tooth, palliative care, and upcoding of patient examinations. In total, the operation has netted more than $7 million for the state.

The recent settlement relates to a prior criminal plea the attorney general’s Medicaid Investigations Division obtained involving Mr. Christian Ekberg, of Maryland, who was sentenced to 18 months in prison for healthcare fraud and was ordered to pay $173,870.12 to the North Carolina Medicaid Fund in restitution. Ekberg was an officer and minority shareholder of ProHealth Dental, a company that entered into a practice management agreement with Henry W. Davis, Jr, DDS., a North Carolina dentist and Medicaid practitioner who provided dental services to patients living in skilled nursing facilities throughout North Carolina. ProHealth Dental would provide professional management services to Dr. Davis, including submitting Medicaid claims. The company submitted claims for dental services that Dr. Davis did not perform on Medicaid recipients.

A version of this article first appeared on Medscape.com.

A federal jury found William R. Bauer, 84, of Port Clinton, Ohio, guilty of prescribing powerful controlled substances, including opioids, to patients without medical necessity and outside the usual course of medical practice.

Dr. Bauer, a neurologist with over 50 years of experience, was convicted of 76 counts of distribution of controlled substances and 25 counts of healthcare fraud. According to television station WTOL, a federal indictment from 2019 listed 270 charges against the physician.

Federal officials claim that through his practice in Bellevue, Ohio, Dr. Bauer repeatedly prescribed controlled substances, including oxycodone, fentanyl, morphine, and tramadol, outside the usual course of professional practice and without legitimate medical purpose. The charges focused on 14 of his patients, to whom he prescribed high doses of opioids and other controlled substances without medical necessity. He also prescribed dangerous drug combinations. He ignored patients’ signs of addiction and abuse, such as early requests for refills, claims that medications had been lost, and claims that family members were stealing pills.

Dr. Bauer was also convicted of healthcare fraud for regularly administering epidural injections and trigger-point injections without medical necessity. Because these injections failed to meet the procedural requirements, they were rendered ineffective and were fraudulently billed to insurers. Dr. Bauer’s illegal prescriptions resulted in insurers paying for these medically unnecessary controlled substances.

Evidence at trial indicated that between January 2007 and August 16, 2019, Dr. Bauer prescribed controlled substances outside the usual course of medical practice and for illegitimate medical purposes. Insurers paid for these medically unnecessary controlled substances as well.

He will be sentenced at a later date.
 

Lab pays $1.2 million to resolve allegations of false claims for drug testing

Bluewater Toxicology, LLC, a clinical laboratory in Mount Washington, Ky., has agreed to pay $1.2 million to resolve civil allegations that it violated the False Claims Act.

The U.S. Department of Justice alleged three issues relating to claims for urine drug testing services that Bluewater submitted to Medicare, Kentucky Medicaid, Indiana Medicaid, TRICARE, and CHAMPVA. First, Bluewater submitted claims in which it misrepresented the number of drug classes it tested. Bluewater claimed it conducted definitive urine drug tests of 22 or more drug classes. In truth, Bluewater tested for fewer than 22 drug classes and secured reimbursement for drug tests that it did not conduct.

Second, Bluewater submitted certain claims without sufficient documentation to support the physician’s intent to order the test that was billed. In this way Bluewater obtained further unwarranted reimbursements.

Finally, Bluewater billed Medicare for specimen validity testing, a quality control process used to analyze a urine specimen to ensure that it has not been diluted or adulterated. Since January 2014, Medicare’s guidance has stated that specimen validity testing should not be separately billed to Medicare, but Bluewater did so anyway.
 

Home care company owner pays $1 million in Medicare fraud restitution

Richard Wennerberg, 72, of Grantham, N.H., pleaded guilty and was sentenced to two counts of class B felony Medicaid fraud, according to the New Hampshire Department of Justice.

Mr. Wennerberg is the owner of Alternative Care @ Home, LLC, a company licensed to provide in-home personal care services to Medicaid beneficiaries. He also pleaded guilty to a third charge of Medicaid fraud, through which Alternative Care @ Home, LLC, will be excluded from future participation in federal healthcare programs.

According to New Hampshire officials, Mr. Wennerberg submitted claims for reimbursement for in-home, personal care services that were never provided. Wennerberg billed Medicaid up to the maximum hours allowed under certain clients’ service authorizations, knowing that his employees did not provide care for all of those hours. He would use the difference to reimburse some caregivers for mileage.

Mr. Wennerberg will serve 1 year in state prison and will pay $1 million in restitution.
 

North Carolina wins two “Operation Root Canal” settlements

North Carolina Attorney General Josh Stein announced two separate civil settlements with ProHealth Dental Inc and Henry W. Davis, Jr, DDS, as part of Operation Root Canal, an ongoing effort to find and stop healthcare fraud among dental practitioners. The settlements, totaling $75,000, resolve allegations of the submission of false claims to the North Carolina Medicaid program.

In Operation Root Canal, the state Medicaid investigations department reviews billing practices for a wide variety of dental services, including dental cleanings, use of nitrous oxide, repetitive restorations on the same tooth, palliative care, and upcoding of patient examinations. In total, the operation has netted more than $7 million for the state.

The recent settlement relates to a prior criminal plea the attorney general’s Medicaid Investigations Division obtained involving Mr. Christian Ekberg, of Maryland, who was sentenced to 18 months in prison for healthcare fraud and was ordered to pay $173,870.12 to the North Carolina Medicaid Fund in restitution. Ekberg was an officer and minority shareholder of ProHealth Dental, a company that entered into a practice management agreement with Henry W. Davis, Jr, DDS., a North Carolina dentist and Medicaid practitioner who provided dental services to patients living in skilled nursing facilities throughout North Carolina. ProHealth Dental would provide professional management services to Dr. Davis, including submitting Medicaid claims. The company submitted claims for dental services that Dr. Davis did not perform on Medicaid recipients.

A version of this article first appeared on Medscape.com.

A federal jury found William R. Bauer, 84, of Port Clinton, Ohio, guilty of prescribing powerful controlled substances, including opioids, to patients without medical necessity and outside the usual course of medical practice.

Dr. Bauer, a neurologist with over 50 years of experience, was convicted of 76 counts of distribution of controlled substances and 25 counts of healthcare fraud. According to television station WTOL, a federal indictment from 2019 listed 270 charges against the physician.

Federal officials claim that through his practice in Bellevue, Ohio, Dr. Bauer repeatedly prescribed controlled substances, including oxycodone, fentanyl, morphine, and tramadol, outside the usual course of professional practice and without legitimate medical purpose. The charges focused on 14 of his patients, to whom he prescribed high doses of opioids and other controlled substances without medical necessity. He also prescribed dangerous drug combinations. He ignored patients’ signs of addiction and abuse, such as early requests for refills, claims that medications had been lost, and claims that family members were stealing pills.

Dr. Bauer was also convicted of healthcare fraud for regularly administering epidural injections and trigger-point injections without medical necessity. Because these injections failed to meet the procedural requirements, they were rendered ineffective and were fraudulently billed to insurers. Dr. Bauer’s illegal prescriptions resulted in insurers paying for these medically unnecessary controlled substances.

Evidence at trial indicated that between January 2007 and August 16, 2019, Dr. Bauer prescribed controlled substances outside the usual course of medical practice and for illegitimate medical purposes. Insurers paid for these medically unnecessary controlled substances as well.

He will be sentenced at a later date.
 

Lab pays $1.2 million to resolve allegations of false claims for drug testing

Bluewater Toxicology, LLC, a clinical laboratory in Mount Washington, Ky., has agreed to pay $1.2 million to resolve civil allegations that it violated the False Claims Act.

The U.S. Department of Justice alleged three issues relating to claims for urine drug testing services that Bluewater submitted to Medicare, Kentucky Medicaid, Indiana Medicaid, TRICARE, and CHAMPVA. First, Bluewater submitted claims in which it misrepresented the number of drug classes it tested. Bluewater claimed it conducted definitive urine drug tests of 22 or more drug classes. In truth, Bluewater tested for fewer than 22 drug classes and secured reimbursement for drug tests that it did not conduct.

Second, Bluewater submitted certain claims without sufficient documentation to support the physician’s intent to order the test that was billed. In this way Bluewater obtained further unwarranted reimbursements.

Finally, Bluewater billed Medicare for specimen validity testing, a quality control process used to analyze a urine specimen to ensure that it has not been diluted or adulterated. Since January 2014, Medicare’s guidance has stated that specimen validity testing should not be separately billed to Medicare, but Bluewater did so anyway.
 

Home care company owner pays $1 million in Medicare fraud restitution

Richard Wennerberg, 72, of Grantham, N.H., pleaded guilty and was sentenced to two counts of class B felony Medicaid fraud, according to the New Hampshire Department of Justice.

Mr. Wennerberg is the owner of Alternative Care @ Home, LLC, a company licensed to provide in-home personal care services to Medicaid beneficiaries. He also pleaded guilty to a third charge of Medicaid fraud, through which Alternative Care @ Home, LLC, will be excluded from future participation in federal healthcare programs.

According to New Hampshire officials, Mr. Wennerberg submitted claims for reimbursement for in-home, personal care services that were never provided. Wennerberg billed Medicaid up to the maximum hours allowed under certain clients’ service authorizations, knowing that his employees did not provide care for all of those hours. He would use the difference to reimburse some caregivers for mileage.

Mr. Wennerberg will serve 1 year in state prison and will pay $1 million in restitution.
 

North Carolina wins two “Operation Root Canal” settlements

North Carolina Attorney General Josh Stein announced two separate civil settlements with ProHealth Dental Inc and Henry W. Davis, Jr, DDS, as part of Operation Root Canal, an ongoing effort to find and stop healthcare fraud among dental practitioners. The settlements, totaling $75,000, resolve allegations of the submission of false claims to the North Carolina Medicaid program.

In Operation Root Canal, the state Medicaid investigations department reviews billing practices for a wide variety of dental services, including dental cleanings, use of nitrous oxide, repetitive restorations on the same tooth, palliative care, and upcoding of patient examinations. In total, the operation has netted more than $7 million for the state.

The recent settlement relates to a prior criminal plea the attorney general’s Medicaid Investigations Division obtained involving Mr. Christian Ekberg, of Maryland, who was sentenced to 18 months in prison for healthcare fraud and was ordered to pay $173,870.12 to the North Carolina Medicaid Fund in restitution. Ekberg was an officer and minority shareholder of ProHealth Dental, a company that entered into a practice management agreement with Henry W. Davis, Jr, DDS., a North Carolina dentist and Medicaid practitioner who provided dental services to patients living in skilled nursing facilities throughout North Carolina. ProHealth Dental would provide professional management services to Dr. Davis, including submitting Medicaid claims. The company submitted claims for dental services that Dr. Davis did not perform on Medicaid recipients.

A version of this article first appeared on Medscape.com.

Roughly 5% of adults with type 2 diabetes achieve remission of their disease, often unbeknownst to the patient and without aggressive weight-loss interventions, according to a new analysis of data from more than 160,000 people in a national diabetes registry in Scotland.

“One of our key new findings is that a reasonably large proportion of people [with type 2 diabetes] were able to achieve remission in routine care, without undergoing bariatric surgery and prior to the introduction of very-low-calorie interventions in routine care,” said Mireille Captieux, MBChB, lead author of the report, in an interview.

The findings “support previous reports that weight loss is associated with type 2 diabetes remission,” said Dr. Captieux, a diabetes researcher at the University of Edinburgh (Scotland).

In her analysis, two of the strongest correlates of remission related to weight loss.

First, a history of bariatric surgery, which included a scant 488 people (0.3% of the study cohort), was associated with a 13-fold increase in the rate of remission, compared with those who did not undergo bariatric surgery. Second, weight loss of 15 kg (33 lb) or more at the time of remission detection in 2019, in comparison with their weight at initial diabetes diagnosis, was linked with a greater than fourfold increase in the rate of remission, compared with those who did not have this amount of weight loss.

But “even losing a small amount of weight increased the chances of remission,” highlights Dr. Captieux. “This finding offers a counterbalance to the pessimistic assumption that almost all people find it very difficult to lose weight.”
 

Hopeful message, but which people achieve diabetes remission?

“What’s encouraging here is that you have people who probably did not do anything radical, and yet they went into remission. The next step is to find out who these people are and what they did to go into remission,” commented Julia Lawton, PhD, a professor of health and social science at the University of Edinburgh whose research focuses on how patients with diabetes manage their disorder.

“If we can understand who the patients are who can achieve remission without taking extreme measures, it could help people in the health professions get beyond their presumptions about who is, or is not, a good candidate for achieving diabetes remission,” said Dr. Lawton, who was not involved with the study.

The message from this study is “very hopeful,” Dr. Lawton said in an interview. “How can we make this opportunity [for diabetes remission] available to more people? What can we learn from these patients that we could then apply to other patients?”

Dr. Captieux agrees. Given her findings, an important next step is to find out more about the population in remission to better understand “their perspectives on the challenges and benefits of supporting weight loss.

“Obesity is a complex issue, and therefore weight loss interventions that target individual actions and behaviors are much more likely to be effective if they are accompanied by multiple interventions at different levels,” Dr. Captieux said.

In addition, “more evidence is needed to assess the sustainability of diabetes remission and the effect of different durations of remission for a clinically relevant definition.”
 

Duration, definition of diabetes remission

Dr. Captieux noted that the new international consensus definition of type 2 diabetes remission – which specifies a minimum 3-month duration of glycemic control to qualify as remission – means that people with diabetes “may frequently oscillate” between remission and active disease.

This makes it important to better define the effect of duration of diabetes remission regarding various diabetes complications.

Another issue raised by the new findings is the importance of distinguishing people who lose weight because of a healthier diet and increased activity from those who lose weight because of chronic illness or frailty that’s followed by long-term adverse outcomes.

If these two populations are not distinguished in an observational cohort study – such as the one run by Dr. Captieux and her associates – then the people with chronic illness might appear to have worse outcomes following diabetes remission.

Dr. Captieux and her coauthors used data collected in the Scottish Care Information–Diabetes registry, which includes almost all people diagnosed with diabetes in Scotland. They focused on people with diabetes who had first been diagnosed with diabetes during 2004-2018, who were at least 30 years old at the time of their initial diagnosis, and who had received care in the national health system during 2019.

This yielded a study cohort of 162,316 people, of whom 7,710 (4.8%) were identified by the researchers as being in remission in 2019.

Patients in remission were defined as those whose hemoglobin A1c level was less than 6.5% at their index reading in 2019 and whose A1c level could be documented as being lower than 6.5% for at least 1 year prior to the 2019 measurement.

In a primary logistic regression analysis, the authors identified five variables that were significantly linked with remission: age of at least 65 years (the association was even stronger for age older than 75 years), a lower A1c level at the time of initial diabetes diagnosis, weight loss, prior bariatric surgery, and no prior treatment with a glucose-lowering therapy.

The strongest association was with having had no prior treatment with a glucose-lowering therapy in 2019. People who met this criterion were nearly 15 times more likely to be in remission in 2019, compared with those who had received at least one of these agents.

The study received no commercial funding. Dr. Captieux and Dr. Lawton have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Roughly 5% of adults with type 2 diabetes achieve remission of their disease, often unbeknownst to the patient and without aggressive weight-loss interventions, according to a new analysis of data from more than 160,000 people in a national diabetes registry in Scotland.

“One of our key new findings is that a reasonably large proportion of people [with type 2 diabetes] were able to achieve remission in routine care, without undergoing bariatric surgery and prior to the introduction of very-low-calorie interventions in routine care,” said Mireille Captieux, MBChB, lead author of the report, in an interview.

The findings “support previous reports that weight loss is associated with type 2 diabetes remission,” said Dr. Captieux, a diabetes researcher at the University of Edinburgh (Scotland).

In her analysis, two of the strongest correlates of remission related to weight loss.

First, a history of bariatric surgery, which included a scant 488 people (0.3% of the study cohort), was associated with a 13-fold increase in the rate of remission, compared with those who did not undergo bariatric surgery. Second, weight loss of 15 kg (33 lb) or more at the time of remission detection in 2019, in comparison with their weight at initial diabetes diagnosis, was linked with a greater than fourfold increase in the rate of remission, compared with those who did not have this amount of weight loss.

But “even losing a small amount of weight increased the chances of remission,” highlights Dr. Captieux. “This finding offers a counterbalance to the pessimistic assumption that almost all people find it very difficult to lose weight.”
 

Hopeful message, but which people achieve diabetes remission?

“What’s encouraging here is that you have people who probably did not do anything radical, and yet they went into remission. The next step is to find out who these people are and what they did to go into remission,” commented Julia Lawton, PhD, a professor of health and social science at the University of Edinburgh whose research focuses on how patients with diabetes manage their disorder.

“If we can understand who the patients are who can achieve remission without taking extreme measures, it could help people in the health professions get beyond their presumptions about who is, or is not, a good candidate for achieving diabetes remission,” said Dr. Lawton, who was not involved with the study.

The message from this study is “very hopeful,” Dr. Lawton said in an interview. “How can we make this opportunity [for diabetes remission] available to more people? What can we learn from these patients that we could then apply to other patients?”

Dr. Captieux agrees. Given her findings, an important next step is to find out more about the population in remission to better understand “their perspectives on the challenges and benefits of supporting weight loss.

“Obesity is a complex issue, and therefore weight loss interventions that target individual actions and behaviors are much more likely to be effective if they are accompanied by multiple interventions at different levels,” Dr. Captieux said.

In addition, “more evidence is needed to assess the sustainability of diabetes remission and the effect of different durations of remission for a clinically relevant definition.”
 

Duration, definition of diabetes remission

Dr. Captieux noted that the new international consensus definition of type 2 diabetes remission – which specifies a minimum 3-month duration of glycemic control to qualify as remission – means that people with diabetes “may frequently oscillate” between remission and active disease.

This makes it important to better define the effect of duration of diabetes remission regarding various diabetes complications.

Another issue raised by the new findings is the importance of distinguishing people who lose weight because of a healthier diet and increased activity from those who lose weight because of chronic illness or frailty that’s followed by long-term adverse outcomes.

If these two populations are not distinguished in an observational cohort study – such as the one run by Dr. Captieux and her associates – then the people with chronic illness might appear to have worse outcomes following diabetes remission.

Dr. Captieux and her coauthors used data collected in the Scottish Care Information–Diabetes registry, which includes almost all people diagnosed with diabetes in Scotland. They focused on people with diabetes who had first been diagnosed with diabetes during 2004-2018, who were at least 30 years old at the time of their initial diagnosis, and who had received care in the national health system during 2019.

This yielded a study cohort of 162,316 people, of whom 7,710 (4.8%) were identified by the researchers as being in remission in 2019.

Patients in remission were defined as those whose hemoglobin A1c level was less than 6.5% at their index reading in 2019 and whose A1c level could be documented as being lower than 6.5% for at least 1 year prior to the 2019 measurement.

In a primary logistic regression analysis, the authors identified five variables that were significantly linked with remission: age of at least 65 years (the association was even stronger for age older than 75 years), a lower A1c level at the time of initial diabetes diagnosis, weight loss, prior bariatric surgery, and no prior treatment with a glucose-lowering therapy.

The strongest association was with having had no prior treatment with a glucose-lowering therapy in 2019. People who met this criterion were nearly 15 times more likely to be in remission in 2019, compared with those who had received at least one of these agents.

The study received no commercial funding. Dr. Captieux and Dr. Lawton have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Roughly 5% of adults with type 2 diabetes achieve remission of their disease, often unbeknownst to the patient and without aggressive weight-loss interventions, according to a new analysis of data from more than 160,000 people in a national diabetes registry in Scotland.

“One of our key new findings is that a reasonably large proportion of people [with type 2 diabetes] were able to achieve remission in routine care, without undergoing bariatric surgery and prior to the introduction of very-low-calorie interventions in routine care,” said Mireille Captieux, MBChB, lead author of the report, in an interview.

The findings “support previous reports that weight loss is associated with type 2 diabetes remission,” said Dr. Captieux, a diabetes researcher at the University of Edinburgh (Scotland).

In her analysis, two of the strongest correlates of remission related to weight loss.

First, a history of bariatric surgery, which included a scant 488 people (0.3% of the study cohort), was associated with a 13-fold increase in the rate of remission, compared with those who did not undergo bariatric surgery. Second, weight loss of 15 kg (33 lb) or more at the time of remission detection in 2019, in comparison with their weight at initial diabetes diagnosis, was linked with a greater than fourfold increase in the rate of remission, compared with those who did not have this amount of weight loss.

But “even losing a small amount of weight increased the chances of remission,” highlights Dr. Captieux. “This finding offers a counterbalance to the pessimistic assumption that almost all people find it very difficult to lose weight.”
 

Hopeful message, but which people achieve diabetes remission?

“What’s encouraging here is that you have people who probably did not do anything radical, and yet they went into remission. The next step is to find out who these people are and what they did to go into remission,” commented Julia Lawton, PhD, a professor of health and social science at the University of Edinburgh whose research focuses on how patients with diabetes manage their disorder.

“If we can understand who the patients are who can achieve remission without taking extreme measures, it could help people in the health professions get beyond their presumptions about who is, or is not, a good candidate for achieving diabetes remission,” said Dr. Lawton, who was not involved with the study.

The message from this study is “very hopeful,” Dr. Lawton said in an interview. “How can we make this opportunity [for diabetes remission] available to more people? What can we learn from these patients that we could then apply to other patients?”

Dr. Captieux agrees. Given her findings, an important next step is to find out more about the population in remission to better understand “their perspectives on the challenges and benefits of supporting weight loss.

“Obesity is a complex issue, and therefore weight loss interventions that target individual actions and behaviors are much more likely to be effective if they are accompanied by multiple interventions at different levels,” Dr. Captieux said.

In addition, “more evidence is needed to assess the sustainability of diabetes remission and the effect of different durations of remission for a clinically relevant definition.”
 

Duration, definition of diabetes remission

Dr. Captieux noted that the new international consensus definition of type 2 diabetes remission – which specifies a minimum 3-month duration of glycemic control to qualify as remission – means that people with diabetes “may frequently oscillate” between remission and active disease.

This makes it important to better define the effect of duration of diabetes remission regarding various diabetes complications.

Another issue raised by the new findings is the importance of distinguishing people who lose weight because of a healthier diet and increased activity from those who lose weight because of chronic illness or frailty that’s followed by long-term adverse outcomes.

If these two populations are not distinguished in an observational cohort study – such as the one run by Dr. Captieux and her associates – then the people with chronic illness might appear to have worse outcomes following diabetes remission.

Dr. Captieux and her coauthors used data collected in the Scottish Care Information–Diabetes registry, which includes almost all people diagnosed with diabetes in Scotland. They focused on people with diabetes who had first been diagnosed with diabetes during 2004-2018, who were at least 30 years old at the time of their initial diagnosis, and who had received care in the national health system during 2019.

This yielded a study cohort of 162,316 people, of whom 7,710 (4.8%) were identified by the researchers as being in remission in 2019.

Patients in remission were defined as those whose hemoglobin A1c level was less than 6.5% at their index reading in 2019 and whose A1c level could be documented as being lower than 6.5% for at least 1 year prior to the 2019 measurement.

In a primary logistic regression analysis, the authors identified five variables that were significantly linked with remission: age of at least 65 years (the association was even stronger for age older than 75 years), a lower A1c level at the time of initial diabetes diagnosis, weight loss, prior bariatric surgery, and no prior treatment with a glucose-lowering therapy.

The strongest association was with having had no prior treatment with a glucose-lowering therapy in 2019. People who met this criterion were nearly 15 times more likely to be in remission in 2019, compared with those who had received at least one of these agents.

The study received no commercial funding. Dr. Captieux and Dr. Lawton have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Health experts are warning the United States could be headed for another COVID-19 surge just as we enter the holiday season, following a massive new wave of infections in Europe – a troubling pattern seen throughout the pandemic.

Eighteen months into the global health crisis that has killed 5.1 million people worldwide including more than 767,000 Americans, Europe has become the epicenter of the global health crisis once again.

And some infectious disease specialists say the United States may be next.

“It’s déjà vu, yet again,” says Eric Topol, M.D., founder and director of the Scripps Research Translational Institute. In a new analysis published in The Guardian, the professor of molecular medicine argues that it’s “wishful thinking” for U.S. authorities to believe the nation is “immune” to what’s happening in Europe.

Dr. Topol is also editor-in-chief of Medscape, MDedge’s sister site for medical professionals.

Three times over the past 18 months coronavirus surges in the United States followed similar spikes in Europe, where COVID-19 deaths grew by 10% this month.

Dr. Topol argues another wave may be in store for the states, as European countries implement new lockdowns. COVID-19 spikes are hitting some regions of the continent hard, including areas with high vaccination rates and strict control measures.

Eastern Europe and Russia, where vaccination rates are low, have experienced the worst of it. But even western countries, such as Germany, Austria and the United Kingdom, are reporting some of the highest daily infection figures in the world today.

Countries are responding in increasingly drastic ways.

In Russia, President Vladimir Putin ordered tens of thousands of workers to stay home earlier this month.

In the Dutch city of Utrecht, traditional Christmas celebrations have been canceled as the country is headed for a partial lockdown.

Austria announced a 20-day lockdown beginning Nov. 22 and on Nov. 19 leaders there announced that all 9 million residents will be required to be vaccinated by February. Leaders there are telling unvaccinated individuals to stay at home and out of restaurants, cafes, and other shops in hard-hit regions of the country.

And in Germany, where daily new-infection rates now stand at 50,000, officials have introduced stricter mask mandates and made proof of vaccination or past infection mandatory for entry to many venues. Berlin is also eyeing proposals to shut down the city’s traditional Christmas markets while authorities in Cologne have already called off holiday celebrations, after the ceremonial head of festivities tested positive for COVID-19. Bavaria canceled its popular Christmas markets and will order lockdowns in particularly vulnerable districts, while unvaccinated people will face serious restrictions on where they can go.

Former FDA Commissioner Scott Gottlieb, MD, says what’s happening across the European continent is troubling.

But he also believes it’s possible the United States may be better prepared to head off a similar surge this time around, with increased testing, vaccination and new therapies such as monoclonal antibodies, and antiviral therapeutics.

“Germany’s challenges are [a] caution to [the] world, the COVID pandemic isn’t over globally, won’t be for long time,” he says. “But [the] U.S. is further along than many other countries, in part because we already suffered more spread, in part because we’re making progress on vaccines, therapeutics, testing.”

Other experts agree the United States may not be as vulnerable to another wave of COVID-19 in coming weeks but have stopped short of suggesting we’re out of the woods.

“I don’t think that what we’re seeing in Europe necessarily means that we’re in for a huge surge of serious illness and death the way that we saw last year here in the states,” says David Dowdy, MD, PhD, an associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health and a general internist with Baltimore Medical Services.

“But I think anyone who says that they can predict the course of the pandemic for the next few months or few years has been proven wrong in the past and will probably be proven wrong in the future,” Dr. Dowdy says. “None of us knows the future of this pandemic, but I do think that we are in for an increase of cases, not necessarily of deaths and serious illness.”
 

Looking back, and forward

What’s happening in Europe today mirrors past COVID-19 spikes that presaged big upticks in cases, hospitalizations, and deaths in the United States.

When the pandemic first hit Europe in March 2020, then-President Donald Trump downplayed the threat of the virus despite the warnings of his own advisors and independent public health experts who said COVID-19 could have dire impacts without an aggressive federal action plan.

By late spring the United States had become the epicenter of the pandemic, when case totals eclipsed those of other countries and New York City became a hot zone, according to data compiled by the Johns Hopkins Coronavirus Resource Center. Over the summer, spread of the disease slowed in New York, after tough control measures were instituted, but steadily increased in other states.

Then, later in the year, the Alpha variant of the virus took hold in the United Kingdom and the United States was again unprepared. By winter, the number of cases accelerated in every state in a major second surge that kept millions of Americans from traveling and gathering for the winter holidays.

With the rollout of COVID vaccines last December, cases in the United States – and in many parts of the world – began to fall. Some experts even suggested we’d turned a corner on the pandemic.

But then, last spring and summer, the Delta variant popped up in India and spread to the United Kingdom in a third major wave of COVID. Once again, the United States was unprepared, with 4 in 10 Americans refusing the vaccine and even some vaccinated individuals succumbing to breakthrough Delta infections.

The resulting Delta surge swept the country, preventing many businesses and schools from fully reopening and stressing hospitals in some areas of the country – particularly southern states – with new influxes of COVID-19 patients.

Now, Europe is facing another rise in COVID, with about 350 cases per 100,000 people and many countries hitting new record highs.
 

What’s driving the European resurgence?

So, what’s behind the new COVID-19 wave in Europe and what might it mean for the United States?

Shaun Truelove, PhD, an infectious disease epidemiologist and faculty member of the Johns Hopkins School of Public Health, says experts are examining several likely factors:

Waning immunity from the vaccines. Data from Johns Hopkins shows infections rising in nations with lower vaccination rates.

The impact of the Delta variant, which is three times more transmissible than the original virus and can even sicken some vaccinated individuals.

The spread of COVID-19 among teens and children; the easing of precautions (such as masking and social distancing); differences in the types of vaccines used in European nations and the United States.

“These are all possibilities,” says Dr. Truelove. “There are so many factors and so it’s difficult to pinpoint exactly what’s driving it and what effect each of those things might be having.”

As a result, it’s difficult to predict and prepare for what might lie ahead for the United States, he says.

“There’s a ton of uncertainty and we’re trying to understand what’s going to happen here over the next 6 months,” he says.

Even so, Dr. Truelove adds that what’s happening overseas might not be “super predictive” of a new wave of COVID in the United States.

For one thing, he says, the Pfizer and Moderna vaccines, the two mRNA vaccines used predominantly in the United States, are far more effective – 94-95% – than the Oxford/AstraZeneca COVID shot (63%) widely administered across Europe.

Secondly, European countries have imposed much stronger and stricter control measures throughout the pandemic than the United States. That might actually be driving the new surges because fewer unvaccinated people have been exposed to the virus, which means they have lower “natural immunity” from prior COVID infection.

Dr. Truelove explains: “Stronger and stricter control measures … have the consequence of leaving a lot more susceptible individuals in the population, [because] the stronger the controls, the fewer people get infected. And so, you have more individuals remaining in the population who are more susceptible and at risk of getting infected in the future.”

By contrast, he notes, a “large chunk” of the United States has not put strict lockdowns in place.

“So, what we’ve seen over the past couple months with the Delta wave is that in a lot of those states with lower vaccination coverage and lower controls this virus has really burned through a lot of the susceptible population. As a result, we’re seeing the curves coming down and what really looks like a lot of the built-up immunity in these states, especially southern states.”

But whether these differences will be enough for the United States to dodge another COVID-19 bullet this winter is uncertain.

“I don’t want to say that the [Europe] surge is NOT a predictor of what might come in the U.S., because I think that it very well could be,” Dr. Truelove says. “And so, people need to be aware of that, and be cautious and be sure get their vaccines and everything else.

“But I’m hopeful that because of some of the differences that maybe we’ll have a little bit of a different situation.”
 

The takeaway: How best to prepare?

Dr. Dowdy agrees that Europe’s current troubles might not necessarily mean a major new winter surge in the United States.

But he also points out that cases are beginning to head up again in New England, the Midwest, and other regions of the country that are just experiencing the first chill of winter.

“After reaching a low point about 3 weeks ago, cases due to COVID-19 have started to rise again in the United States,” he says. “Cases were falling consistently until mid-October, but over the last 3 weeks, cases have started to rise again in most states.

“Cases in Eastern and Central Europe have more than doubled during that time, meaning that the possibility of a winter surge here is very real.”

Even so, Dr. Dowdy believes the rising rates of vaccination could limit the number of Americans who will be hospitalized with severe disease or die this winter.

Still, he warns against being too optimistic, as Americans travel and get together for the winter holidays.

None of us knows the future of this pandemic, but I do think that we are in for an increase of cases, not necessarily of deaths and serious illness, Dr. Dowdy says.”

The upshot?

“People need to realize that it’s not quite over,” Dr. Truelove says. “We still have a substantial amount of infection in our country. We’re still above 200 cases per million [and] 500,000 incident cases per week or so. That’s a lot of death and a lot of hospitalizations. So, we still have to be concerned and do our best to reduce transmission … by wearing masks, getting vaccinated, getting a booster shot, and getting your children vaccinated.”

Johns Hopkins social and behavioral scientist Rupali Limaye, PhD, MPH, adds that while COVID vaccines have been a “game changer” in the pandemic, more than a third of Americans have yet to receive one.

“That’s really what we need to be messaging around -- that people can still get COVID, there can still be breakthrough infections,” says Dr. Limaye, a health communications scholar. “But the great news is if you have been vaccinated, you are very much less likely, I think it’s 12 times, to be hospitalized or have severe COVID compared to those that are un-vaccinated.”

Dr. Topol agrees, adding: “Now is the time for the U.S. to heed the European signal for the first time, to pull out all the stops. Promote primary vaccination and boosters like there’s no tomorrow. Aggressively counter the pervasive misinformation and disinformation. Accelerate and expand the vaccine mandates ...

“Instead of succumbing to yet another major rise in cases and their sequelae, this is a chance for America to finally rise to the occasion, showing an ability to lead and execute.”

A version of this article first appeared on WebMD.com.

Health experts are warning the United States could be headed for another COVID-19 surge just as we enter the holiday season, following a massive new wave of infections in Europe – a troubling pattern seen throughout the pandemic.

Eighteen months into the global health crisis that has killed 5.1 million people worldwide including more than 767,000 Americans, Europe has become the epicenter of the global health crisis once again.

And some infectious disease specialists say the United States may be next.

“It’s déjà vu, yet again,” says Eric Topol, M.D., founder and director of the Scripps Research Translational Institute. In a new analysis published in The Guardian, the professor of molecular medicine argues that it’s “wishful thinking” for U.S. authorities to believe the nation is “immune” to what’s happening in Europe.

Dr. Topol is also editor-in-chief of Medscape, MDedge’s sister site for medical professionals.

Three times over the past 18 months coronavirus surges in the United States followed similar spikes in Europe, where COVID-19 deaths grew by 10% this month.

Dr. Topol argues another wave may be in store for the states, as European countries implement new lockdowns. COVID-19 spikes are hitting some regions of the continent hard, including areas with high vaccination rates and strict control measures.

Eastern Europe and Russia, where vaccination rates are low, have experienced the worst of it. But even western countries, such as Germany, Austria and the United Kingdom, are reporting some of the highest daily infection figures in the world today.

Countries are responding in increasingly drastic ways.

In Russia, President Vladimir Putin ordered tens of thousands of workers to stay home earlier this month.

In the Dutch city of Utrecht, traditional Christmas celebrations have been canceled as the country is headed for a partial lockdown.

Austria announced a 20-day lockdown beginning Nov. 22 and on Nov. 19 leaders there announced that all 9 million residents will be required to be vaccinated by February. Leaders there are telling unvaccinated individuals to stay at home and out of restaurants, cafes, and other shops in hard-hit regions of the country.

And in Germany, where daily new-infection rates now stand at 50,000, officials have introduced stricter mask mandates and made proof of vaccination or past infection mandatory for entry to many venues. Berlin is also eyeing proposals to shut down the city’s traditional Christmas markets while authorities in Cologne have already called off holiday celebrations, after the ceremonial head of festivities tested positive for COVID-19. Bavaria canceled its popular Christmas markets and will order lockdowns in particularly vulnerable districts, while unvaccinated people will face serious restrictions on where they can go.

Former FDA Commissioner Scott Gottlieb, MD, says what’s happening across the European continent is troubling.

But he also believes it’s possible the United States may be better prepared to head off a similar surge this time around, with increased testing, vaccination and new therapies such as monoclonal antibodies, and antiviral therapeutics.

“Germany’s challenges are [a] caution to [the] world, the COVID pandemic isn’t over globally, won’t be for long time,” he says. “But [the] U.S. is further along than many other countries, in part because we already suffered more spread, in part because we’re making progress on vaccines, therapeutics, testing.”

Other experts agree the United States may not be as vulnerable to another wave of COVID-19 in coming weeks but have stopped short of suggesting we’re out of the woods.

“I don’t think that what we’re seeing in Europe necessarily means that we’re in for a huge surge of serious illness and death the way that we saw last year here in the states,” says David Dowdy, MD, PhD, an associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health and a general internist with Baltimore Medical Services.

“But I think anyone who says that they can predict the course of the pandemic for the next few months or few years has been proven wrong in the past and will probably be proven wrong in the future,” Dr. Dowdy says. “None of us knows the future of this pandemic, but I do think that we are in for an increase of cases, not necessarily of deaths and serious illness.”
 

Looking back, and forward

What’s happening in Europe today mirrors past COVID-19 spikes that presaged big upticks in cases, hospitalizations, and deaths in the United States.

When the pandemic first hit Europe in March 2020, then-President Donald Trump downplayed the threat of the virus despite the warnings of his own advisors and independent public health experts who said COVID-19 could have dire impacts without an aggressive federal action plan.

By late spring the United States had become the epicenter of the pandemic, when case totals eclipsed those of other countries and New York City became a hot zone, according to data compiled by the Johns Hopkins Coronavirus Resource Center. Over the summer, spread of the disease slowed in New York, after tough control measures were instituted, but steadily increased in other states.

Then, later in the year, the Alpha variant of the virus took hold in the United Kingdom and the United States was again unprepared. By winter, the number of cases accelerated in every state in a major second surge that kept millions of Americans from traveling and gathering for the winter holidays.

With the rollout of COVID vaccines last December, cases in the United States – and in many parts of the world – began to fall. Some experts even suggested we’d turned a corner on the pandemic.

But then, last spring and summer, the Delta variant popped up in India and spread to the United Kingdom in a third major wave of COVID. Once again, the United States was unprepared, with 4 in 10 Americans refusing the vaccine and even some vaccinated individuals succumbing to breakthrough Delta infections.

The resulting Delta surge swept the country, preventing many businesses and schools from fully reopening and stressing hospitals in some areas of the country – particularly southern states – with new influxes of COVID-19 patients.

Now, Europe is facing another rise in COVID, with about 350 cases per 100,000 people and many countries hitting new record highs.
 

What’s driving the European resurgence?

So, what’s behind the new COVID-19 wave in Europe and what might it mean for the United States?

Shaun Truelove, PhD, an infectious disease epidemiologist and faculty member of the Johns Hopkins School of Public Health, says experts are examining several likely factors:

Waning immunity from the vaccines. Data from Johns Hopkins shows infections rising in nations with lower vaccination rates.

The impact of the Delta variant, which is three times more transmissible than the original virus and can even sicken some vaccinated individuals.

The spread of COVID-19 among teens and children; the easing of precautions (such as masking and social distancing); differences in the types of vaccines used in European nations and the United States.

“These are all possibilities,” says Dr. Truelove. “There are so many factors and so it’s difficult to pinpoint exactly what’s driving it and what effect each of those things might be having.”

As a result, it’s difficult to predict and prepare for what might lie ahead for the United States, he says.

“There’s a ton of uncertainty and we’re trying to understand what’s going to happen here over the next 6 months,” he says.

Even so, Dr. Truelove adds that what’s happening overseas might not be “super predictive” of a new wave of COVID in the United States.

For one thing, he says, the Pfizer and Moderna vaccines, the two mRNA vaccines used predominantly in the United States, are far more effective – 94-95% – than the Oxford/AstraZeneca COVID shot (63%) widely administered across Europe.

Secondly, European countries have imposed much stronger and stricter control measures throughout the pandemic than the United States. That might actually be driving the new surges because fewer unvaccinated people have been exposed to the virus, which means they have lower “natural immunity” from prior COVID infection.

Dr. Truelove explains: “Stronger and stricter control measures … have the consequence of leaving a lot more susceptible individuals in the population, [because] the stronger the controls, the fewer people get infected. And so, you have more individuals remaining in the population who are more susceptible and at risk of getting infected in the future.”

By contrast, he notes, a “large chunk” of the United States has not put strict lockdowns in place.

“So, what we’ve seen over the past couple months with the Delta wave is that in a lot of those states with lower vaccination coverage and lower controls this virus has really burned through a lot of the susceptible population. As a result, we’re seeing the curves coming down and what really looks like a lot of the built-up immunity in these states, especially southern states.”

But whether these differences will be enough for the United States to dodge another COVID-19 bullet this winter is uncertain.

“I don’t want to say that the [Europe] surge is NOT a predictor of what might come in the U.S., because I think that it very well could be,” Dr. Truelove says. “And so, people need to be aware of that, and be cautious and be sure get their vaccines and everything else.

“But I’m hopeful that because of some of the differences that maybe we’ll have a little bit of a different situation.”
 

The takeaway: How best to prepare?

Dr. Dowdy agrees that Europe’s current troubles might not necessarily mean a major new winter surge in the United States.

But he also points out that cases are beginning to head up again in New England, the Midwest, and other regions of the country that are just experiencing the first chill of winter.

“After reaching a low point about 3 weeks ago, cases due to COVID-19 have started to rise again in the United States,” he says. “Cases were falling consistently until mid-October, but over the last 3 weeks, cases have started to rise again in most states.

“Cases in Eastern and Central Europe have more than doubled during that time, meaning that the possibility of a winter surge here is very real.”

Even so, Dr. Dowdy believes the rising rates of vaccination could limit the number of Americans who will be hospitalized with severe disease or die this winter.

Still, he warns against being too optimistic, as Americans travel and get together for the winter holidays.

None of us knows the future of this pandemic, but I do think that we are in for an increase of cases, not necessarily of deaths and serious illness, Dr. Dowdy says.”

The upshot?

“People need to realize that it’s not quite over,” Dr. Truelove says. “We still have a substantial amount of infection in our country. We’re still above 200 cases per million [and] 500,000 incident cases per week or so. That’s a lot of death and a lot of hospitalizations. So, we still have to be concerned and do our best to reduce transmission … by wearing masks, getting vaccinated, getting a booster shot, and getting your children vaccinated.”

Johns Hopkins social and behavioral scientist Rupali Limaye, PhD, MPH, adds that while COVID vaccines have been a “game changer” in the pandemic, more than a third of Americans have yet to receive one.

“That’s really what we need to be messaging around -- that people can still get COVID, there can still be breakthrough infections,” says Dr. Limaye, a health communications scholar. “But the great news is if you have been vaccinated, you are very much less likely, I think it’s 12 times, to be hospitalized or have severe COVID compared to those that are un-vaccinated.”

Dr. Topol agrees, adding: “Now is the time for the U.S. to heed the European signal for the first time, to pull out all the stops. Promote primary vaccination and boosters like there’s no tomorrow. Aggressively counter the pervasive misinformation and disinformation. Accelerate and expand the vaccine mandates ...

“Instead of succumbing to yet another major rise in cases and their sequelae, this is a chance for America to finally rise to the occasion, showing an ability to lead and execute.”

A version of this article first appeared on WebMD.com.

Health experts are warning the United States could be headed for another COVID-19 surge just as we enter the holiday season, following a massive new wave of infections in Europe – a troubling pattern seen throughout the pandemic.

Eighteen months into the global health crisis that has killed 5.1 million people worldwide including more than 767,000 Americans, Europe has become the epicenter of the global health crisis once again.

And some infectious disease specialists say the United States may be next.

“It’s déjà vu, yet again,” says Eric Topol, M.D., founder and director of the Scripps Research Translational Institute. In a new analysis published in The Guardian, the professor of molecular medicine argues that it’s “wishful thinking” for U.S. authorities to believe the nation is “immune” to what’s happening in Europe.

Dr. Topol is also editor-in-chief of Medscape, MDedge’s sister site for medical professionals.

Three times over the past 18 months coronavirus surges in the United States followed similar spikes in Europe, where COVID-19 deaths grew by 10% this month.

Dr. Topol argues another wave may be in store for the states, as European countries implement new lockdowns. COVID-19 spikes are hitting some regions of the continent hard, including areas with high vaccination rates and strict control measures.

Eastern Europe and Russia, where vaccination rates are low, have experienced the worst of it. But even western countries, such as Germany, Austria and the United Kingdom, are reporting some of the highest daily infection figures in the world today.

Countries are responding in increasingly drastic ways.

In Russia, President Vladimir Putin ordered tens of thousands of workers to stay home earlier this month.

In the Dutch city of Utrecht, traditional Christmas celebrations have been canceled as the country is headed for a partial lockdown.

Austria announced a 20-day lockdown beginning Nov. 22 and on Nov. 19 leaders there announced that all 9 million residents will be required to be vaccinated by February. Leaders there are telling unvaccinated individuals to stay at home and out of restaurants, cafes, and other shops in hard-hit regions of the country.

And in Germany, where daily new-infection rates now stand at 50,000, officials have introduced stricter mask mandates and made proof of vaccination or past infection mandatory for entry to many venues. Berlin is also eyeing proposals to shut down the city’s traditional Christmas markets while authorities in Cologne have already called off holiday celebrations, after the ceremonial head of festivities tested positive for COVID-19. Bavaria canceled its popular Christmas markets and will order lockdowns in particularly vulnerable districts, while unvaccinated people will face serious restrictions on where they can go.

Former FDA Commissioner Scott Gottlieb, MD, says what’s happening across the European continent is troubling.

But he also believes it’s possible the United States may be better prepared to head off a similar surge this time around, with increased testing, vaccination and new therapies such as monoclonal antibodies, and antiviral therapeutics.

“Germany’s challenges are [a] caution to [the] world, the COVID pandemic isn’t over globally, won’t be for long time,” he says. “But [the] U.S. is further along than many other countries, in part because we already suffered more spread, in part because we’re making progress on vaccines, therapeutics, testing.”

Other experts agree the United States may not be as vulnerable to another wave of COVID-19 in coming weeks but have stopped short of suggesting we’re out of the woods.

“I don’t think that what we’re seeing in Europe necessarily means that we’re in for a huge surge of serious illness and death the way that we saw last year here in the states,” says David Dowdy, MD, PhD, an associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health and a general internist with Baltimore Medical Services.

“But I think anyone who says that they can predict the course of the pandemic for the next few months or few years has been proven wrong in the past and will probably be proven wrong in the future,” Dr. Dowdy says. “None of us knows the future of this pandemic, but I do think that we are in for an increase of cases, not necessarily of deaths and serious illness.”
 

Looking back, and forward

What’s happening in Europe today mirrors past COVID-19 spikes that presaged big upticks in cases, hospitalizations, and deaths in the United States.

When the pandemic first hit Europe in March 2020, then-President Donald Trump downplayed the threat of the virus despite the warnings of his own advisors and independent public health experts who said COVID-19 could have dire impacts without an aggressive federal action plan.

By late spring the United States had become the epicenter of the pandemic, when case totals eclipsed those of other countries and New York City became a hot zone, according to data compiled by the Johns Hopkins Coronavirus Resource Center. Over the summer, spread of the disease slowed in New York, after tough control measures were instituted, but steadily increased in other states.

Then, later in the year, the Alpha variant of the virus took hold in the United Kingdom and the United States was again unprepared. By winter, the number of cases accelerated in every state in a major second surge that kept millions of Americans from traveling and gathering for the winter holidays.

With the rollout of COVID vaccines last December, cases in the United States – and in many parts of the world – began to fall. Some experts even suggested we’d turned a corner on the pandemic.

But then, last spring and summer, the Delta variant popped up in India and spread to the United Kingdom in a third major wave of COVID. Once again, the United States was unprepared, with 4 in 10 Americans refusing the vaccine and even some vaccinated individuals succumbing to breakthrough Delta infections.

The resulting Delta surge swept the country, preventing many businesses and schools from fully reopening and stressing hospitals in some areas of the country – particularly southern states – with new influxes of COVID-19 patients.

Now, Europe is facing another rise in COVID, with about 350 cases per 100,000 people and many countries hitting new record highs.
 

What’s driving the European resurgence?

So, what’s behind the new COVID-19 wave in Europe and what might it mean for the United States?

Shaun Truelove, PhD, an infectious disease epidemiologist and faculty member of the Johns Hopkins School of Public Health, says experts are examining several likely factors:

Waning immunity from the vaccines. Data from Johns Hopkins shows infections rising in nations with lower vaccination rates.

The impact of the Delta variant, which is three times more transmissible than the original virus and can even sicken some vaccinated individuals.

The spread of COVID-19 among teens and children; the easing of precautions (such as masking and social distancing); differences in the types of vaccines used in European nations and the United States.

“These are all possibilities,” says Dr. Truelove. “There are so many factors and so it’s difficult to pinpoint exactly what’s driving it and what effect each of those things might be having.”

As a result, it’s difficult to predict and prepare for what might lie ahead for the United States, he says.

“There’s a ton of uncertainty and we’re trying to understand what’s going to happen here over the next 6 months,” he says.

Even so, Dr. Truelove adds that what’s happening overseas might not be “super predictive” of a new wave of COVID in the United States.

For one thing, he says, the Pfizer and Moderna vaccines, the two mRNA vaccines used predominantly in the United States, are far more effective – 94-95% – than the Oxford/AstraZeneca COVID shot (63%) widely administered across Europe.

Secondly, European countries have imposed much stronger and stricter control measures throughout the pandemic than the United States. That might actually be driving the new surges because fewer unvaccinated people have been exposed to the virus, which means they have lower “natural immunity” from prior COVID infection.

Dr. Truelove explains: “Stronger and stricter control measures … have the consequence of leaving a lot more susceptible individuals in the population, [because] the stronger the controls, the fewer people get infected. And so, you have more individuals remaining in the population who are more susceptible and at risk of getting infected in the future.”

By contrast, he notes, a “large chunk” of the United States has not put strict lockdowns in place.

“So, what we’ve seen over the past couple months with the Delta wave is that in a lot of those states with lower vaccination coverage and lower controls this virus has really burned through a lot of the susceptible population. As a result, we’re seeing the curves coming down and what really looks like a lot of the built-up immunity in these states, especially southern states.”

But whether these differences will be enough for the United States to dodge another COVID-19 bullet this winter is uncertain.

“I don’t want to say that the [Europe] surge is NOT a predictor of what might come in the U.S., because I think that it very well could be,” Dr. Truelove says. “And so, people need to be aware of that, and be cautious and be sure get their vaccines and everything else.

“But I’m hopeful that because of some of the differences that maybe we’ll have a little bit of a different situation.”
 

The takeaway: How best to prepare?

Dr. Dowdy agrees that Europe’s current troubles might not necessarily mean a major new winter surge in the United States.

But he also points out that cases are beginning to head up again in New England, the Midwest, and other regions of the country that are just experiencing the first chill of winter.

“After reaching a low point about 3 weeks ago, cases due to COVID-19 have started to rise again in the United States,” he says. “Cases were falling consistently until mid-October, but over the last 3 weeks, cases have started to rise again in most states.

“Cases in Eastern and Central Europe have more than doubled during that time, meaning that the possibility of a winter surge here is very real.”

Even so, Dr. Dowdy believes the rising rates of vaccination could limit the number of Americans who will be hospitalized with severe disease or die this winter.

Still, he warns against being too optimistic, as Americans travel and get together for the winter holidays.

None of us knows the future of this pandemic, but I do think that we are in for an increase of cases, not necessarily of deaths and serious illness, Dr. Dowdy says.”

The upshot?

“People need to realize that it’s not quite over,” Dr. Truelove says. “We still have a substantial amount of infection in our country. We’re still above 200 cases per million [and] 500,000 incident cases per week or so. That’s a lot of death and a lot of hospitalizations. So, we still have to be concerned and do our best to reduce transmission … by wearing masks, getting vaccinated, getting a booster shot, and getting your children vaccinated.”

Johns Hopkins social and behavioral scientist Rupali Limaye, PhD, MPH, adds that while COVID vaccines have been a “game changer” in the pandemic, more than a third of Americans have yet to receive one.

“That’s really what we need to be messaging around -- that people can still get COVID, there can still be breakthrough infections,” says Dr. Limaye, a health communications scholar. “But the great news is if you have been vaccinated, you are very much less likely, I think it’s 12 times, to be hospitalized or have severe COVID compared to those that are un-vaccinated.”

Dr. Topol agrees, adding: “Now is the time for the U.S. to heed the European signal for the first time, to pull out all the stops. Promote primary vaccination and boosters like there’s no tomorrow. Aggressively counter the pervasive misinformation and disinformation. Accelerate and expand the vaccine mandates ...

“Instead of succumbing to yet another major rise in cases and their sequelae, this is a chance for America to finally rise to the occasion, showing an ability to lead and execute.”

A version of this article first appeared on WebMD.com.

Over the past 2 years, the COVID-19 pandemic has caused numerous disruptions in health care, including in global HIV/AIDS services. But new data presented at the Association of Nurses in AIDS Care (ANAC) 2021 Annual Meeting suggest that practitioners quickly adapted to challenges posed by the pandemic, and care and prevention services around the world have begun to return to prepandemic levels.

These rebounding numbers “show how resilient the HIV system can be,” Jennifer Kates, PhD, senior vice president and director of global health and HIV policy at the Kaiser Family Foundation (KFF), said in an interview. She presented the data during her ANAC plenary talk on Nov. 11. Dr. Kates noted that continued recovery relies on improving global access to and delivery of COVID-19 vaccines. “If we do not have control of COVID, we are going to see endless cycles of impact,” she said during her talk.
 

COVID-19 and HIV services

Although there was concern that the pandemic could disrupt access to antiretrovirals, the Global Fund previously reported a nearly 9% increase in people receiving antiretroviral therapy (ART) from 2019 to 2020. HIV prevention and testing did take a hit: There was a 22% decrease in testing for HIV and an 11% decline in the number of people receiving HIV prevention services over that period.

New data from the President’s Emergency Plan for AIDS Relief (PEPFAR) showed similar trends. Consistent with the Global Fund’s findings, a KFF analysis of PEPFAR data found that the number of people receiving ART grew in 2020, climbing from 16.0 million in the first quarter (Q1) of 2020 to 17.4 million by the end of the year. The most recent data from PEPFAR suggest that the number had climbed to 18.4 million by September 2021.

However, there was a 24% decrease in the number of newly enrolled individuals receiving ART from Q2 to Q3 in 2020. It dipped from 669,436 to 509,509. There was a similar decrease in the number of people being tested for HIV, dropping 25% from an estimated 16,700 to 12,500 from Q2 to Q3. But by the end of the year, both measurements had rebounded: New enrollments in ART grew 31%, and HIV testing grew nearly 41% compared to Q3.

The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program, which is focused on adolescent girls and young women, saw a dip in preexposure prophylaxis (PrEP) and other preventive services in Q4 2020, but numbers surpassed prepandemic levels by June 2021.

PEPFAR helped speed recovery, Dr. Kates said, by providing guidance on COVID-19 protocols to the field and implementing innovations, such as accelerated 3- and 6-month medication dispensing, virtual platforms, and decentralized drug delivery. In addition, the U.S. Congress allocated $3.8 billion in emergency funding in fiscal year 2021 to help mitigate the effects of COVID-19 on HIV and AIDS care.
 

Longer-term outcomes still unclear

Although these numbers are encouraging, some of the effects of COVID-19 on the HIV epidemic are still unknown – in particular, whether these documented dips in preventive services will translate to an increase in new infections. This will not be clear until a year or 2 from now, Dr. Kates noted. Increased use of ART as well as an increase in some behaviors associated with the pandemic, such as decreased social contact, are factors that mitigate an increase in the rate of infections, she said, but “how that all is going to play out we don’t know for sure.”

Other conference attendees expressed anxiety about the possibility of an increase in the rate of infections. “I’m waiting for the other shoe to drop, as it were,” Barb Cardell, training and technical assistance director at Positive Women’s Network–USA, in Oakland, Calif., said in an interview. The Positive Women’s Network is a national organization of women living with HIV. “Starting late in 2019, we have been cautioning public health officials in states and federally that there will likely be an uptick in HIV diagnosis as we return to whatever ‘normal’ looks like these days,” Ms. Cardell noted, adding, “We have all heard stories of folks that had an exposure and weren’t able to access PrEP during the pandemic and hence seroconverted.”

Kara McGee, associate clinical professor at Duke University School of Nursing, Durham, N.C., shared similar sentiments. “Many people at risk of acquiring HIV had trouble accessing testing and prevention prior to the pandemic, and service interruptions due to the COVID-19 pandemic have only worsened access – especially in rural areas,” she told this news organization.

Need for equitable vaccine access

For HIV services to continue to rebound, COVID-19 vaccination needs to be made a priority globally, Dr. Kates said. But data suggest lower-income countries are being left behind. In high-income countries, 65% of the population has been fully vaccinated, compared to 2% of people in the lowest-income countries. A KFF analysis projected that at the current rates of vaccination, these disparities will widen over time. COVID-19 testing rates in lower-income countries also lag. In high-income countries, 740 tests per 100,000 individuals are conducted daily; in low-income countries, that rate is 13 daily tests per 100,000 people. Until we can achieve more equitable access globally, the documented recovery of HIV is “precarious,” Dr. Kates said.

Ms. McGee agreed with Dr. Kates and was surprised by the extent of global inequities in the COVID-19 response. She said these issues should be a focus for the HIV health care community moving forward. “I think there are lot of us who have worked in the HIV field for many years – both domestically and internationally – who did not fully grasp the global disparities and need to consider how we can advocate for more equal access and distribution,” she said.

A version of this article first appeared on Medscape.com.

Over the past 2 years, the COVID-19 pandemic has caused numerous disruptions in health care, including in global HIV/AIDS services. But new data presented at the Association of Nurses in AIDS Care (ANAC) 2021 Annual Meeting suggest that practitioners quickly adapted to challenges posed by the pandemic, and care and prevention services around the world have begun to return to prepandemic levels.

These rebounding numbers “show how resilient the HIV system can be,” Jennifer Kates, PhD, senior vice president and director of global health and HIV policy at the Kaiser Family Foundation (KFF), said in an interview. She presented the data during her ANAC plenary talk on Nov. 11. Dr. Kates noted that continued recovery relies on improving global access to and delivery of COVID-19 vaccines. “If we do not have control of COVID, we are going to see endless cycles of impact,” she said during her talk.
 

COVID-19 and HIV services

Although there was concern that the pandemic could disrupt access to antiretrovirals, the Global Fund previously reported a nearly 9% increase in people receiving antiretroviral therapy (ART) from 2019 to 2020. HIV prevention and testing did take a hit: There was a 22% decrease in testing for HIV and an 11% decline in the number of people receiving HIV prevention services over that period.

New data from the President’s Emergency Plan for AIDS Relief (PEPFAR) showed similar trends. Consistent with the Global Fund’s findings, a KFF analysis of PEPFAR data found that the number of people receiving ART grew in 2020, climbing from 16.0 million in the first quarter (Q1) of 2020 to 17.4 million by the end of the year. The most recent data from PEPFAR suggest that the number had climbed to 18.4 million by September 2021.

However, there was a 24% decrease in the number of newly enrolled individuals receiving ART from Q2 to Q3 in 2020. It dipped from 669,436 to 509,509. There was a similar decrease in the number of people being tested for HIV, dropping 25% from an estimated 16,700 to 12,500 from Q2 to Q3. But by the end of the year, both measurements had rebounded: New enrollments in ART grew 31%, and HIV testing grew nearly 41% compared to Q3.

The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program, which is focused on adolescent girls and young women, saw a dip in preexposure prophylaxis (PrEP) and other preventive services in Q4 2020, but numbers surpassed prepandemic levels by June 2021.

PEPFAR helped speed recovery, Dr. Kates said, by providing guidance on COVID-19 protocols to the field and implementing innovations, such as accelerated 3- and 6-month medication dispensing, virtual platforms, and decentralized drug delivery. In addition, the U.S. Congress allocated $3.8 billion in emergency funding in fiscal year 2021 to help mitigate the effects of COVID-19 on HIV and AIDS care.
 

Longer-term outcomes still unclear

Although these numbers are encouraging, some of the effects of COVID-19 on the HIV epidemic are still unknown – in particular, whether these documented dips in preventive services will translate to an increase in new infections. This will not be clear until a year or 2 from now, Dr. Kates noted. Increased use of ART as well as an increase in some behaviors associated with the pandemic, such as decreased social contact, are factors that mitigate an increase in the rate of infections, she said, but “how that all is going to play out we don’t know for sure.”

Other conference attendees expressed anxiety about the possibility of an increase in the rate of infections. “I’m waiting for the other shoe to drop, as it were,” Barb Cardell, training and technical assistance director at Positive Women’s Network–USA, in Oakland, Calif., said in an interview. The Positive Women’s Network is a national organization of women living with HIV. “Starting late in 2019, we have been cautioning public health officials in states and federally that there will likely be an uptick in HIV diagnosis as we return to whatever ‘normal’ looks like these days,” Ms. Cardell noted, adding, “We have all heard stories of folks that had an exposure and weren’t able to access PrEP during the pandemic and hence seroconverted.”

Kara McGee, associate clinical professor at Duke University School of Nursing, Durham, N.C., shared similar sentiments. “Many people at risk of acquiring HIV had trouble accessing testing and prevention prior to the pandemic, and service interruptions due to the COVID-19 pandemic have only worsened access – especially in rural areas,” she told this news organization.

Need for equitable vaccine access

For HIV services to continue to rebound, COVID-19 vaccination needs to be made a priority globally, Dr. Kates said. But data suggest lower-income countries are being left behind. In high-income countries, 65% of the population has been fully vaccinated, compared to 2% of people in the lowest-income countries. A KFF analysis projected that at the current rates of vaccination, these disparities will widen over time. COVID-19 testing rates in lower-income countries also lag. In high-income countries, 740 tests per 100,000 individuals are conducted daily; in low-income countries, that rate is 13 daily tests per 100,000 people. Until we can achieve more equitable access globally, the documented recovery of HIV is “precarious,” Dr. Kates said.

Ms. McGee agreed with Dr. Kates and was surprised by the extent of global inequities in the COVID-19 response. She said these issues should be a focus for the HIV health care community moving forward. “I think there are lot of us who have worked in the HIV field for many years – both domestically and internationally – who did not fully grasp the global disparities and need to consider how we can advocate for more equal access and distribution,” she said.

A version of this article first appeared on Medscape.com.

Over the past 2 years, the COVID-19 pandemic has caused numerous disruptions in health care, including in global HIV/AIDS services. But new data presented at the Association of Nurses in AIDS Care (ANAC) 2021 Annual Meeting suggest that practitioners quickly adapted to challenges posed by the pandemic, and care and prevention services around the world have begun to return to prepandemic levels.

These rebounding numbers “show how resilient the HIV system can be,” Jennifer Kates, PhD, senior vice president and director of global health and HIV policy at the Kaiser Family Foundation (KFF), said in an interview. She presented the data during her ANAC plenary talk on Nov. 11. Dr. Kates noted that continued recovery relies on improving global access to and delivery of COVID-19 vaccines. “If we do not have control of COVID, we are going to see endless cycles of impact,” she said during her talk.
 

COVID-19 and HIV services

Although there was concern that the pandemic could disrupt access to antiretrovirals, the Global Fund previously reported a nearly 9% increase in people receiving antiretroviral therapy (ART) from 2019 to 2020. HIV prevention and testing did take a hit: There was a 22% decrease in testing for HIV and an 11% decline in the number of people receiving HIV prevention services over that period.

New data from the President’s Emergency Plan for AIDS Relief (PEPFAR) showed similar trends. Consistent with the Global Fund’s findings, a KFF analysis of PEPFAR data found that the number of people receiving ART grew in 2020, climbing from 16.0 million in the first quarter (Q1) of 2020 to 17.4 million by the end of the year. The most recent data from PEPFAR suggest that the number had climbed to 18.4 million by September 2021.

However, there was a 24% decrease in the number of newly enrolled individuals receiving ART from Q2 to Q3 in 2020. It dipped from 669,436 to 509,509. There was a similar decrease in the number of people being tested for HIV, dropping 25% from an estimated 16,700 to 12,500 from Q2 to Q3. But by the end of the year, both measurements had rebounded: New enrollments in ART grew 31%, and HIV testing grew nearly 41% compared to Q3.

The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program, which is focused on adolescent girls and young women, saw a dip in preexposure prophylaxis (PrEP) and other preventive services in Q4 2020, but numbers surpassed prepandemic levels by June 2021.

PEPFAR helped speed recovery, Dr. Kates said, by providing guidance on COVID-19 protocols to the field and implementing innovations, such as accelerated 3- and 6-month medication dispensing, virtual platforms, and decentralized drug delivery. In addition, the U.S. Congress allocated $3.8 billion in emergency funding in fiscal year 2021 to help mitigate the effects of COVID-19 on HIV and AIDS care.
 

Longer-term outcomes still unclear

Although these numbers are encouraging, some of the effects of COVID-19 on the HIV epidemic are still unknown – in particular, whether these documented dips in preventive services will translate to an increase in new infections. This will not be clear until a year or 2 from now, Dr. Kates noted. Increased use of ART as well as an increase in some behaviors associated with the pandemic, such as decreased social contact, are factors that mitigate an increase in the rate of infections, she said, but “how that all is going to play out we don’t know for sure.”

Other conference attendees expressed anxiety about the possibility of an increase in the rate of infections. “I’m waiting for the other shoe to drop, as it were,” Barb Cardell, training and technical assistance director at Positive Women’s Network–USA, in Oakland, Calif., said in an interview. The Positive Women’s Network is a national organization of women living with HIV. “Starting late in 2019, we have been cautioning public health officials in states and federally that there will likely be an uptick in HIV diagnosis as we return to whatever ‘normal’ looks like these days,” Ms. Cardell noted, adding, “We have all heard stories of folks that had an exposure and weren’t able to access PrEP during the pandemic and hence seroconverted.”

Kara McGee, associate clinical professor at Duke University School of Nursing, Durham, N.C., shared similar sentiments. “Many people at risk of acquiring HIV had trouble accessing testing and prevention prior to the pandemic, and service interruptions due to the COVID-19 pandemic have only worsened access – especially in rural areas,” she told this news organization.

Need for equitable vaccine access

For HIV services to continue to rebound, COVID-19 vaccination needs to be made a priority globally, Dr. Kates said. But data suggest lower-income countries are being left behind. In high-income countries, 65% of the population has been fully vaccinated, compared to 2% of people in the lowest-income countries. A KFF analysis projected that at the current rates of vaccination, these disparities will widen over time. COVID-19 testing rates in lower-income countries also lag. In high-income countries, 740 tests per 100,000 individuals are conducted daily; in low-income countries, that rate is 13 daily tests per 100,000 people. Until we can achieve more equitable access globally, the documented recovery of HIV is “precarious,” Dr. Kates said.

Ms. McGee agreed with Dr. Kates and was surprised by the extent of global inequities in the COVID-19 response. She said these issues should be a focus for the HIV health care community moving forward. “I think there are lot of us who have worked in the HIV field for many years – both domestically and internationally – who did not fully grasp the global disparities and need to consider how we can advocate for more equal access and distribution,” she said.

A version of this article first appeared on Medscape.com.

Federal health officials have outlined a five-part plan to improve and protect the mental health and well-being of America’s health care workers (HCWs) and create sustainable change for the next generation of HCWs.

“It’s long past time for us to care for the people who care for all of us and address burnout in our health care workers,” U.S. Surgeon General Vivek H. Murthy, MD, MBA, said during a webinar hosted by the National Institute for Occupational Safety and Health, part of the U.S. Centers for Disease Control and Prevention.

“My hope is that, going forward, we will be able to embark on this journey together to create a health care system, a health care environment, a country where we can not only provide extraordinary care to all those who need it, but where we can take good care of those who have sacrificed so much and make sure that they are well,” Dr. Murthy said.
 

Burnout is not selective

There are 20 million HCWs in the United States, and no one is immune from burnout, said NIOSH Director John Howard, MD.

He noted that from June through Sept. of 2020 – the height of the COVID-19 pandemic – 93% of HCWs experienced some degree of stress, with 22% reporting moderate depression and post-traumatic stress disorder.

Looking at subsets of HCWs, a recent survey showed that one in five nurses contemplated leaving the profession because of insufficient staffing, intensity of workload, emotional and physical toll of the job, and lack of support, Dr. Howard noted.

Physician burnout was a significant issue even before the pandemic, with about 79% of physicians reporting burnout. In the fall of 2020, 69% reported depression and “a very alarming figure” of 13% reported having thoughts of suicide, Dr. Howard said.

Women in health care jobs are especially vulnerable to burnout; 76% of health care jobs are held by women and 64% of physicians that feel burned-out are women, according to federal data. 

“We have significant work to do in shoring up the safety and health of women in health care,” Dr. Howard said.

Mental health is also suffering among local and state public health workers. In a recent CDC survey of 26,000 of these workers, 53% reported symptoms of at least one mental health condition in the past 2 weeks.

“That is really an alarming proportion of public health workers who are as vital and essential as nurses and doctors are in our health care system,” Dr. Howard said.
 

Primary prevention approach

To tackle the burnout crisis, NIOSH plans to:

• Take a deep dive into understanding the personal, social, and economic burdens HCWs face on a daily basis.
• Assimilate the evidence and create a repository of best practices, resources, and interventions.
• Partner with key stakeholders, including the American Hospital Association, the American Nurses Association, National Nurses United, the Joint Commission.
• Identify and adapt tools for the health care workplace that emphasize stress reduction.

NIOSH also plans to “generate awareness through a national, multidimensional social marketing campaign to get the word out about stress so health care workers don’t feel so alone,” Dr. Howard said.

This five-part plan takes a primary prevention approach to identifying and eliminating risk factors for burnout and stress, he added.

Secondary prevention, “when damage has already been done and you’re trying to save a health care worker who is suffering from a mental health issue, that’s a lot harder than taking a good look at what you can do to organizational practices that lead to health care workers’ stress and burnout,” Dr. Howard said.

A version of this article first appeared on Medscape.com.

Federal health officials have outlined a five-part plan to improve and protect the mental health and well-being of America’s health care workers (HCWs) and create sustainable change for the next generation of HCWs.

“It’s long past time for us to care for the people who care for all of us and address burnout in our health care workers,” U.S. Surgeon General Vivek H. Murthy, MD, MBA, said during a webinar hosted by the National Institute for Occupational Safety and Health, part of the U.S. Centers for Disease Control and Prevention.

“My hope is that, going forward, we will be able to embark on this journey together to create a health care system, a health care environment, a country where we can not only provide extraordinary care to all those who need it, but where we can take good care of those who have sacrificed so much and make sure that they are well,” Dr. Murthy said.
 

Burnout is not selective

There are 20 million HCWs in the United States, and no one is immune from burnout, said NIOSH Director John Howard, MD.

He noted that from June through Sept. of 2020 – the height of the COVID-19 pandemic – 93% of HCWs experienced some degree of stress, with 22% reporting moderate depression and post-traumatic stress disorder.

Looking at subsets of HCWs, a recent survey showed that one in five nurses contemplated leaving the profession because of insufficient staffing, intensity of workload, emotional and physical toll of the job, and lack of support, Dr. Howard noted.

Physician burnout was a significant issue even before the pandemic, with about 79% of physicians reporting burnout. In the fall of 2020, 69% reported depression and “a very alarming figure” of 13% reported having thoughts of suicide, Dr. Howard said.

Women in health care jobs are especially vulnerable to burnout; 76% of health care jobs are held by women and 64% of physicians that feel burned-out are women, according to federal data. 

“We have significant work to do in shoring up the safety and health of women in health care,” Dr. Howard said.

Mental health is also suffering among local and state public health workers. In a recent CDC survey of 26,000 of these workers, 53% reported symptoms of at least one mental health condition in the past 2 weeks.

“That is really an alarming proportion of public health workers who are as vital and essential as nurses and doctors are in our health care system,” Dr. Howard said.
 

Primary prevention approach

To tackle the burnout crisis, NIOSH plans to:

• Take a deep dive into understanding the personal, social, and economic burdens HCWs face on a daily basis.
• Assimilate the evidence and create a repository of best practices, resources, and interventions.
• Partner with key stakeholders, including the American Hospital Association, the American Nurses Association, National Nurses United, the Joint Commission.
• Identify and adapt tools for the health care workplace that emphasize stress reduction.

NIOSH also plans to “generate awareness through a national, multidimensional social marketing campaign to get the word out about stress so health care workers don’t feel so alone,” Dr. Howard said.

This five-part plan takes a primary prevention approach to identifying and eliminating risk factors for burnout and stress, he added.

Secondary prevention, “when damage has already been done and you’re trying to save a health care worker who is suffering from a mental health issue, that’s a lot harder than taking a good look at what you can do to organizational practices that lead to health care workers’ stress and burnout,” Dr. Howard said.

A version of this article first appeared on Medscape.com.

Federal health officials have outlined a five-part plan to improve and protect the mental health and well-being of America’s health care workers (HCWs) and create sustainable change for the next generation of HCWs.

“It’s long past time for us to care for the people who care for all of us and address burnout in our health care workers,” U.S. Surgeon General Vivek H. Murthy, MD, MBA, said during a webinar hosted by the National Institute for Occupational Safety and Health, part of the U.S. Centers for Disease Control and Prevention.

“My hope is that, going forward, we will be able to embark on this journey together to create a health care system, a health care environment, a country where we can not only provide extraordinary care to all those who need it, but where we can take good care of those who have sacrificed so much and make sure that they are well,” Dr. Murthy said.
 

Burnout is not selective

There are 20 million HCWs in the United States, and no one is immune from burnout, said NIOSH Director John Howard, MD.

He noted that from June through Sept. of 2020 – the height of the COVID-19 pandemic – 93% of HCWs experienced some degree of stress, with 22% reporting moderate depression and post-traumatic stress disorder.

Looking at subsets of HCWs, a recent survey showed that one in five nurses contemplated leaving the profession because of insufficient staffing, intensity of workload, emotional and physical toll of the job, and lack of support, Dr. Howard noted.

Physician burnout was a significant issue even before the pandemic, with about 79% of physicians reporting burnout. In the fall of 2020, 69% reported depression and “a very alarming figure” of 13% reported having thoughts of suicide, Dr. Howard said.

Women in health care jobs are especially vulnerable to burnout; 76% of health care jobs are held by women and 64% of physicians that feel burned-out are women, according to federal data. 

“We have significant work to do in shoring up the safety and health of women in health care,” Dr. Howard said.

Mental health is also suffering among local and state public health workers. In a recent CDC survey of 26,000 of these workers, 53% reported symptoms of at least one mental health condition in the past 2 weeks.

“That is really an alarming proportion of public health workers who are as vital and essential as nurses and doctors are in our health care system,” Dr. Howard said.
 

Primary prevention approach

To tackle the burnout crisis, NIOSH plans to:

• Take a deep dive into understanding the personal, social, and economic burdens HCWs face on a daily basis.
• Assimilate the evidence and create a repository of best practices, resources, and interventions.
• Partner with key stakeholders, including the American Hospital Association, the American Nurses Association, National Nurses United, the Joint Commission.
• Identify and adapt tools for the health care workplace that emphasize stress reduction.

NIOSH also plans to “generate awareness through a national, multidimensional social marketing campaign to get the word out about stress so health care workers don’t feel so alone,” Dr. Howard said.

This five-part plan takes a primary prevention approach to identifying and eliminating risk factors for burnout and stress, he added.

Secondary prevention, “when damage has already been done and you’re trying to save a health care worker who is suffering from a mental health issue, that’s a lot harder than taking a good look at what you can do to organizational practices that lead to health care workers’ stress and burnout,” Dr. Howard said.

A version of this article first appeared on Medscape.com.

I remember a conversation I had at the end of my training with an older psychiatrist who was closing his practice. I was very excited to finally be a psychiatrist, and therefore a bit shocked that someone would voluntarily end a career I was just beginning. After all, psychiatry is a field where people can practice with flexibility, and a private practice is not an all-or-none endeavor.

“Dinah,” this gentleman said to me, sensing my dismay, “I’m 74. I’m allowed to retire.”

Like many retired psychiatrists, this one continued to come to grand rounds every Monday, dressed in a suit, which was followed by lunch with friends in the dining room. He continued to be involved in professional activities and lived to be 96.

Another dear friend practiced psychiatry until she entered hospice after a 2-year battle with cancer. Others have whittled down their practices, hanging on to a few hours of patient care along with supervision, teaching, and involvement with professional organizations.

In discussing retirement with some of my peers, it’s become immediately clear that each psychiatrist approaches this decision – and how they choose to live after it’s made – with a unique set of concerns and goals.
 

Fatigued by bureaucracy

Robin Weiss, MD, is in the process of “shrinking” her private practice. She is quick to say she is not retiring, but planning to scale back to 1 day a week starting next summer.

“I want to work less so I have more time for my grandchildren, friends, and travel, and to finally write more.” She also hopes to improve her ping-pong game and exercise habits.

“I’m so tired of prior authorizations, and the one day a week of patients I’ve been committed to feels just about right.”

During the pandemic, Dr. Weiss relinquished her office and she plans to continue with a virtual practice, which allows her more flexibility in terms of where she is physically located.

“The pandemic didn’t influence my decision to scale back, but it did play a role in deciding to give up my office,” she said.

A decision precipitated by medical reasons

Stephen Warres, MD, is a child and adolescent psychiatrist in Maryland who fully retired from practice in June 2021. He started scaling back a few years ago, when he had to give up his office because the building was undergoing renovations.

“I was seeing some patients from my home, but for 2 years I had been working 1 or 2 weekends a month at the Baltimore city jail, and I thought of that as my final act. It was a setting I had never worked in, and I left there 4 months before the pandemic started.”

Dr. Warres noted that his decision to retire was propelled by his diagnosis of Parkinson’s disease at the end of 2019.

“So far I only have a resting tremor, but this is an illness in which cognitive decline is a possibility.”
 

The emotional roller-coaster that can await

Dr. Warres said a myriad of emotions come with retirement, beginning with a sense of guilt.

“Why am I leaving when others practice longer? I read about a psychiatrist in California who was still practicing when he died at 102. And the last patient whom I saw when I left practice was a man I started treating just 2 days after I started residency in 1976! When I told him I would be retiring, he found a new psychiatrist who is 82 years old.”

This was followed, he said, by a sense of shame.

“My father was a radiologist and he retired at 76, the same age that I am now, but he volunteered 2 days a week for the state attorney’s office until he was 92, and I’m not doing that.”

What Dr. Warres is choosing to do instead is indulge his many interests, including reading; writing; and practicing on the instrument he’s recently taken up, the harmonium.

This cascade of emotions led to one that was arguably more pleasurable: a sense of immense relief.

“When I got my first request after retirement for a prior authorization, I felt jubilant, like I wanted to throw a party! I felt like I had been walking with a backpack full of weights, and only after the weights were removed did I realize how much lighter it was.

“I loved doing psychotherapy, but more and more psychiatry was not what I had signed up for. I’m relieved that I no longer have to keep up with psychopharmacology. In a way, the Parkinson’s diagnosis sealed the deal. I felt that it gave me license, like a get out of jail card, to retire.”

But even this sense of palpable relief hasn’t closed the cycle of emotions Dr. Warres is experiencing over his retirement.

“You know, the more relieved I am, the more guilt I feel.”
 

As intellectually adventurous as ever

Marshal Folstein, MD, of Miami retired over a decade ago after a long academic career at Johns Hopkins University, Baltimore, and as chairman of psychiatry at Tufts University, Boston. His Facebook profile states: “Leading the quiet life of a retired professor.”

He said retirement was an easy decision for he and his wife Susan, herself a former academic psychiatrist, which allowed them to immediately change gears.

“At the beginning, we traveled a bit. I wanted to continue with music, so I took flute lessons, and then I played flute in my synagogue, so now I have recently retired from that. I spend my time reading Talmud and the Bible and I keep asking questions. I found a new group of people, some are physicians, and we study and argue. I just turned 80 and I’m intellectually busy and happy.”

The retirement coach

Barbara Fowler, PhD, is a lifespan services consultant at Johns Hopkins who works with faculty and staff getting ready to retire. She said that the university has methods in place to make this decision less jarring.

“The school of medicine has a faculty transition plan that lets people cut back over a set period of time while still keeping benefits. It gives doctors a way to wind up their research and clinical responsibilities, and this is negotiated on an individual level.”

When she’s discussing with someone the possibility of retirement, Dr. Fowler likes to begin by asking them to define what exactly they mean by that word.

“The stereotyped concept is that someone stops what they are doing completely and spends their time playing golf or canasta,” she said. “But the baby boomers are redefining that. Physicians often continue to see some patients or participate in professional organizations. Some people are happy to stop doing the work they have done for years and go do something different, whereas others are interested in scaling back on work activities while adding new ones.”
 

Timing it right

So, when should psychiatrists retire? The most obvious time to reconsider is when the doctor is no longer able to perform work-related obligations owing to physical or cognitive limitations.

Financial constraints are another factor that comes into play. How necessary is it to work to pay the bills?

“When the kids are out of college and the mortgage is paid off, then there may be the financial means to reconceptualize work life and how you want to rebuild it,” Dr. Fowler said. “Because whether or not people are getting paid, they want to be productive.”

For some, this may come in the form of working in a reduced capacity. Certain practices are more amenable to part-time work or a gradual decrease in hours. A private practice may allow for more control than a position with an institution where an employee may have to continue working full time or not at all.

For others, that productivity might be measured in pursuing their own interests or assisting with family members who need their help. Grandchildren can be an important factor, especially if they live at a distance or childcare is needed. These issues became all the more salient when the pandemic shuttered day care centers and schools, and people limited contact with those outside their households.

Retirement for all physicians is wrapped in issues of identity; for those who have not cultivated other interests, retirement can be a huge loss with no clear path forward. And in an environment where there is a psychiatrist shortage, health care workers are deemed heroes, and human distress is mounting, retirement may come with mixed feelings of guilt, even when the psychiatrist wants a change and is ready for the next chapter. Finally, for those who have launched programs or research projects, there may be the fear that there is no one else who can or will carry on, and that all will be lost.

Yet these considerations focus on the negative, whereas Dr. Fowler said she likes to frame retirement in a positive light. “The key is having more choices; looking for activities that inspire passion; and asking, how can you live your best life?”

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. A version of this article first appeared on Medscape.com.

I remember a conversation I had at the end of my training with an older psychiatrist who was closing his practice. I was very excited to finally be a psychiatrist, and therefore a bit shocked that someone would voluntarily end a career I was just beginning. After all, psychiatry is a field where people can practice with flexibility, and a private practice is not an all-or-none endeavor.

“Dinah,” this gentleman said to me, sensing my dismay, “I’m 74. I’m allowed to retire.”

Like many retired psychiatrists, this one continued to come to grand rounds every Monday, dressed in a suit, which was followed by lunch with friends in the dining room. He continued to be involved in professional activities and lived to be 96.

Another dear friend practiced psychiatry until she entered hospice after a 2-year battle with cancer. Others have whittled down their practices, hanging on to a few hours of patient care along with supervision, teaching, and involvement with professional organizations.

In discussing retirement with some of my peers, it’s become immediately clear that each psychiatrist approaches this decision – and how they choose to live after it’s made – with a unique set of concerns and goals.
 

Fatigued by bureaucracy

Robin Weiss, MD, is in the process of “shrinking” her private practice. She is quick to say she is not retiring, but planning to scale back to 1 day a week starting next summer.

“I want to work less so I have more time for my grandchildren, friends, and travel, and to finally write more.” She also hopes to improve her ping-pong game and exercise habits.

“I’m so tired of prior authorizations, and the one day a week of patients I’ve been committed to feels just about right.”

During the pandemic, Dr. Weiss relinquished her office and she plans to continue with a virtual practice, which allows her more flexibility in terms of where she is physically located.

“The pandemic didn’t influence my decision to scale back, but it did play a role in deciding to give up my office,” she said.

A decision precipitated by medical reasons

Stephen Warres, MD, is a child and adolescent psychiatrist in Maryland who fully retired from practice in June 2021. He started scaling back a few years ago, when he had to give up his office because the building was undergoing renovations.

“I was seeing some patients from my home, but for 2 years I had been working 1 or 2 weekends a month at the Baltimore city jail, and I thought of that as my final act. It was a setting I had never worked in, and I left there 4 months before the pandemic started.”

Dr. Warres noted that his decision to retire was propelled by his diagnosis of Parkinson’s disease at the end of 2019.

“So far I only have a resting tremor, but this is an illness in which cognitive decline is a possibility.”
 

The emotional roller-coaster that can await

Dr. Warres said a myriad of emotions come with retirement, beginning with a sense of guilt.

“Why am I leaving when others practice longer? I read about a psychiatrist in California who was still practicing when he died at 102. And the last patient whom I saw when I left practice was a man I started treating just 2 days after I started residency in 1976! When I told him I would be retiring, he found a new psychiatrist who is 82 years old.”

This was followed, he said, by a sense of shame.

“My father was a radiologist and he retired at 76, the same age that I am now, but he volunteered 2 days a week for the state attorney’s office until he was 92, and I’m not doing that.”

What Dr. Warres is choosing to do instead is indulge his many interests, including reading; writing; and practicing on the instrument he’s recently taken up, the harmonium.

This cascade of emotions led to one that was arguably more pleasurable: a sense of immense relief.

“When I got my first request after retirement for a prior authorization, I felt jubilant, like I wanted to throw a party! I felt like I had been walking with a backpack full of weights, and only after the weights were removed did I realize how much lighter it was.

“I loved doing psychotherapy, but more and more psychiatry was not what I had signed up for. I’m relieved that I no longer have to keep up with psychopharmacology. In a way, the Parkinson’s diagnosis sealed the deal. I felt that it gave me license, like a get out of jail card, to retire.”

But even this sense of palpable relief hasn’t closed the cycle of emotions Dr. Warres is experiencing over his retirement.

“You know, the more relieved I am, the more guilt I feel.”
 

As intellectually adventurous as ever

Marshal Folstein, MD, of Miami retired over a decade ago after a long academic career at Johns Hopkins University, Baltimore, and as chairman of psychiatry at Tufts University, Boston. His Facebook profile states: “Leading the quiet life of a retired professor.”

He said retirement was an easy decision for he and his wife Susan, herself a former academic psychiatrist, which allowed them to immediately change gears.

“At the beginning, we traveled a bit. I wanted to continue with music, so I took flute lessons, and then I played flute in my synagogue, so now I have recently retired from that. I spend my time reading Talmud and the Bible and I keep asking questions. I found a new group of people, some are physicians, and we study and argue. I just turned 80 and I’m intellectually busy and happy.”

The retirement coach

Barbara Fowler, PhD, is a lifespan services consultant at Johns Hopkins who works with faculty and staff getting ready to retire. She said that the university has methods in place to make this decision less jarring.

“The school of medicine has a faculty transition plan that lets people cut back over a set period of time while still keeping benefits. It gives doctors a way to wind up their research and clinical responsibilities, and this is negotiated on an individual level.”

When she’s discussing with someone the possibility of retirement, Dr. Fowler likes to begin by asking them to define what exactly they mean by that word.

“The stereotyped concept is that someone stops what they are doing completely and spends their time playing golf or canasta,” she said. “But the baby boomers are redefining that. Physicians often continue to see some patients or participate in professional organizations. Some people are happy to stop doing the work they have done for years and go do something different, whereas others are interested in scaling back on work activities while adding new ones.”
 

Timing it right

So, when should psychiatrists retire? The most obvious time to reconsider is when the doctor is no longer able to perform work-related obligations owing to physical or cognitive limitations.

Financial constraints are another factor that comes into play. How necessary is it to work to pay the bills?

“When the kids are out of college and the mortgage is paid off, then there may be the financial means to reconceptualize work life and how you want to rebuild it,” Dr. Fowler said. “Because whether or not people are getting paid, they want to be productive.”

For some, this may come in the form of working in a reduced capacity. Certain practices are more amenable to part-time work or a gradual decrease in hours. A private practice may allow for more control than a position with an institution where an employee may have to continue working full time or not at all.

For others, that productivity might be measured in pursuing their own interests or assisting with family members who need their help. Grandchildren can be an important factor, especially if they live at a distance or childcare is needed. These issues became all the more salient when the pandemic shuttered day care centers and schools, and people limited contact with those outside their households.

Retirement for all physicians is wrapped in issues of identity; for those who have not cultivated other interests, retirement can be a huge loss with no clear path forward. And in an environment where there is a psychiatrist shortage, health care workers are deemed heroes, and human distress is mounting, retirement may come with mixed feelings of guilt, even when the psychiatrist wants a change and is ready for the next chapter. Finally, for those who have launched programs or research projects, there may be the fear that there is no one else who can or will carry on, and that all will be lost.

Yet these considerations focus on the negative, whereas Dr. Fowler said she likes to frame retirement in a positive light. “The key is having more choices; looking for activities that inspire passion; and asking, how can you live your best life?”

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. A version of this article first appeared on Medscape.com.

I remember a conversation I had at the end of my training with an older psychiatrist who was closing his practice. I was very excited to finally be a psychiatrist, and therefore a bit shocked that someone would voluntarily end a career I was just beginning. After all, psychiatry is a field where people can practice with flexibility, and a private practice is not an all-or-none endeavor.

“Dinah,” this gentleman said to me, sensing my dismay, “I’m 74. I’m allowed to retire.”

Like many retired psychiatrists, this one continued to come to grand rounds every Monday, dressed in a suit, which was followed by lunch with friends in the dining room. He continued to be involved in professional activities and lived to be 96.

Another dear friend practiced psychiatry until she entered hospice after a 2-year battle with cancer. Others have whittled down their practices, hanging on to a few hours of patient care along with supervision, teaching, and involvement with professional organizations.

In discussing retirement with some of my peers, it’s become immediately clear that each psychiatrist approaches this decision – and how they choose to live after it’s made – with a unique set of concerns and goals.
 

Fatigued by bureaucracy

Robin Weiss, MD, is in the process of “shrinking” her private practice. She is quick to say she is not retiring, but planning to scale back to 1 day a week starting next summer.

“I want to work less so I have more time for my grandchildren, friends, and travel, and to finally write more.” She also hopes to improve her ping-pong game and exercise habits.

“I’m so tired of prior authorizations, and the one day a week of patients I’ve been committed to feels just about right.”

During the pandemic, Dr. Weiss relinquished her office and she plans to continue with a virtual practice, which allows her more flexibility in terms of where she is physically located.

“The pandemic didn’t influence my decision to scale back, but it did play a role in deciding to give up my office,” she said.

A decision precipitated by medical reasons

Stephen Warres, MD, is a child and adolescent psychiatrist in Maryland who fully retired from practice in June 2021. He started scaling back a few years ago, when he had to give up his office because the building was undergoing renovations.

“I was seeing some patients from my home, but for 2 years I had been working 1 or 2 weekends a month at the Baltimore city jail, and I thought of that as my final act. It was a setting I had never worked in, and I left there 4 months before the pandemic started.”

Dr. Warres noted that his decision to retire was propelled by his diagnosis of Parkinson’s disease at the end of 2019.

“So far I only have a resting tremor, but this is an illness in which cognitive decline is a possibility.”
 

The emotional roller-coaster that can await

Dr. Warres said a myriad of emotions come with retirement, beginning with a sense of guilt.

“Why am I leaving when others practice longer? I read about a psychiatrist in California who was still practicing when he died at 102. And the last patient whom I saw when I left practice was a man I started treating just 2 days after I started residency in 1976! When I told him I would be retiring, he found a new psychiatrist who is 82 years old.”

This was followed, he said, by a sense of shame.

“My father was a radiologist and he retired at 76, the same age that I am now, but he volunteered 2 days a week for the state attorney’s office until he was 92, and I’m not doing that.”

What Dr. Warres is choosing to do instead is indulge his many interests, including reading; writing; and practicing on the instrument he’s recently taken up, the harmonium.

This cascade of emotions led to one that was arguably more pleasurable: a sense of immense relief.

“When I got my first request after retirement for a prior authorization, I felt jubilant, like I wanted to throw a party! I felt like I had been walking with a backpack full of weights, and only after the weights were removed did I realize how much lighter it was.

“I loved doing psychotherapy, but more and more psychiatry was not what I had signed up for. I’m relieved that I no longer have to keep up with psychopharmacology. In a way, the Parkinson’s diagnosis sealed the deal. I felt that it gave me license, like a get out of jail card, to retire.”

But even this sense of palpable relief hasn’t closed the cycle of emotions Dr. Warres is experiencing over his retirement.

“You know, the more relieved I am, the more guilt I feel.”
 

As intellectually adventurous as ever

Marshal Folstein, MD, of Miami retired over a decade ago after a long academic career at Johns Hopkins University, Baltimore, and as chairman of psychiatry at Tufts University, Boston. His Facebook profile states: “Leading the quiet life of a retired professor.”

He said retirement was an easy decision for he and his wife Susan, herself a former academic psychiatrist, which allowed them to immediately change gears.

“At the beginning, we traveled a bit. I wanted to continue with music, so I took flute lessons, and then I played flute in my synagogue, so now I have recently retired from that. I spend my time reading Talmud and the Bible and I keep asking questions. I found a new group of people, some are physicians, and we study and argue. I just turned 80 and I’m intellectually busy and happy.”

The retirement coach

Barbara Fowler, PhD, is a lifespan services consultant at Johns Hopkins who works with faculty and staff getting ready to retire. She said that the university has methods in place to make this decision less jarring.

“The school of medicine has a faculty transition plan that lets people cut back over a set period of time while still keeping benefits. It gives doctors a way to wind up their research and clinical responsibilities, and this is negotiated on an individual level.”

When she’s discussing with someone the possibility of retirement, Dr. Fowler likes to begin by asking them to define what exactly they mean by that word.

“The stereotyped concept is that someone stops what they are doing completely and spends their time playing golf or canasta,” she said. “But the baby boomers are redefining that. Physicians often continue to see some patients or participate in professional organizations. Some people are happy to stop doing the work they have done for years and go do something different, whereas others are interested in scaling back on work activities while adding new ones.”
 

Timing it right

So, when should psychiatrists retire? The most obvious time to reconsider is when the doctor is no longer able to perform work-related obligations owing to physical or cognitive limitations.

Financial constraints are another factor that comes into play. How necessary is it to work to pay the bills?

“When the kids are out of college and the mortgage is paid off, then there may be the financial means to reconceptualize work life and how you want to rebuild it,” Dr. Fowler said. “Because whether or not people are getting paid, they want to be productive.”

For some, this may come in the form of working in a reduced capacity. Certain practices are more amenable to part-time work or a gradual decrease in hours. A private practice may allow for more control than a position with an institution where an employee may have to continue working full time or not at all.

For others, that productivity might be measured in pursuing their own interests or assisting with family members who need their help. Grandchildren can be an important factor, especially if they live at a distance or childcare is needed. These issues became all the more salient when the pandemic shuttered day care centers and schools, and people limited contact with those outside their households.

Retirement for all physicians is wrapped in issues of identity; for those who have not cultivated other interests, retirement can be a huge loss with no clear path forward. And in an environment where there is a psychiatrist shortage, health care workers are deemed heroes, and human distress is mounting, retirement may come with mixed feelings of guilt, even when the psychiatrist wants a change and is ready for the next chapter. Finally, for those who have launched programs or research projects, there may be the fear that there is no one else who can or will carry on, and that all will be lost.

Yet these considerations focus on the negative, whereas Dr. Fowler said she likes to frame retirement in a positive light. “The key is having more choices; looking for activities that inspire passion; and asking, how can you live your best life?”

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. A version of this article first appeared on Medscape.com.

Medical practices will likely have to confront a doctor at some point who treats staff badly or is too impaired to practice safely. Knowing what to say and do can lead to a positive outcome for the physician involved and the organization.

Misbehaving and impaired physicians put their organizations at risk, which can lead to malpractice/patient injury lawsuits, labor law and harassment claims, and a damaged reputation through negative social media reviews, said Debra Phairas, MBA, president of Practice and Liability Consultants LLC, at the annual meeting of the Medical Group Management Association (MGMA) .

“Verbal harassment or bullying claims can result in large dollar awards against the organizations that knew about the behavior and did nothing to stop it. Organizations can be sued for that,” says Ms. Phairas.

She recalls a doctor who called a female doctor “an entitled bitch” and the administrator “incompetent” in front of other staff. “He would pick on one department manager at every meeting and humiliate them in front of the others,” says Ms. Phairas.

After working with a human resources (HR) attorney and conducting independent reviews, they used a strategy Ms. Phairas calls her “3 C’s” for dealing with disruptive doctors.
 

Confront, correct, and/or counsel

The three C’s can work individually or together, depending on the doctor’s situation. Confronting a physician can start with an informal discussion; correcting can involve seeking a written apology that directly addresses the problem or sending a letter of admonition; and coaching or counseling can be offered. If the doctor resists those efforts, practice administrators can issue a final letter of warning and then suspend or terminate the physician, says Ms. Phairas.

Sometimes having a conversation with a disruptive doctor about the risks and consequences is enough to change the offending behavior, says Ms. Phairas.

She recalled being asked by a medical group to meet with a physician who she says was “snapping the bra straps of medical assistants in the hall — everyone there was horrified. I told him that’s not appropriate, that he was placing everyone at risk and they will terminate him if he didn’t stop. I asked for his commitment to stop, and he agreed,” says Ms. Phairas.

She also recommends implementing these strategies to prevent and deal with disruptive physicians:

• Implement a code of conduct and share it during interviews;
• Have zero tolerance policies and procedures for documenting behavior;
• Get advice from a good employment attorney;
• Implement written performance improvement plans;
• Provide resources to change the behavior;
• Follow through with suspension and termination; and
• Add to shareholder agreements a clause stating that partners/shareholders can gently ask or insist that the physician obtain counseling or help.

Getting impaired doctors help

Doctors can be impaired through substance abuse, a serious medical illness, mental illness, or age-related deterioration.

Life events such as divorce or the death of a spouse, child, or a physician partner can affect a doctor’s mental health. “In those cases, you need to have the courage to say you’re really depressed and we all agree you need to get help,” says Ms. Phairas.

She recalls one occasion in which a practice administration staff member could not locate a doctor whose patients were waiting to be seen. “He was so devastated from his divorce that he had crawled into a ball beneath his desk. She had to coax him out and tell him that they were worried about him and he needed to get help.”

Another reason doctors may not be performing well may be because of an undiagnosed medical illness. Doctors in an orthopedic group were mad at another partner who had slowed down and couldn’t help pay the expenses. “They were ready to terminate him when he went to the doctor and learned he had colon cancer,” says Ms. Phairas.

Ms. Phairas recommends that practices update their partner shareholder agreements regularly with the following:

• Include “fit for duty” examinations, especially after age 65.
• Insist that a physician be evaluated by a doctor outside the practice. The doctor may be one that they agree upon or one chosen by the local medical society president.
• Include in the agreement the clause, “Partners and employees will be subject to review for impairment due to matters including but not limited to age-related, physical, or mental conditions.”
• Establish a voting mechanism for terminating a physician.

Aging doctors who won’t retire

Some doctors have retired early because of COVID, whereas others are staying on because they are feeling financial pressures — they lost a lot of money last year and need to make up for it, says Ms. Phairas.

She warned that administrators have to be careful in dealing with older doctors because of age discrimination laws.

Doctors may not notice they are declining mentally until it becomes a problem. Ms. Phairas recalls an internist senior partner who started behaving erratically when he was 78 years old. “He wrote himself a $25,000 check from the organization’s funds without telling his partners, left a patient he should have been watching and she fell over and sued the practice, and the staff started noticing that he was forgetting or not doing things,” says Ms. Phairas.

She sought guidance from a good HR attorney and involved a malpractice attorney. She then met with the senior partner. “I reminded him of his Hippocratic Oath that he took when he became a doctor and told him that his actions were harming patients. I pleaded with him that it was time to retire. He didn’t.”

Because this physician wouldn’t retire, the practice referred to their updated shareholder agreement, which stated that they could insist that the physician undergo a neuropsychiatric assessment from a certified specialist. He didn’t pass the evaluation, which then provided evidence of his declining cognitive skills.

“All the doctors, myself, and the HR attorney talked to him about this and laid out all the facts. It was hard to say these things, but he listened and left. We went through the termination process to protect the practice and avoid litigation. The malpractice insurer also refused to renew his policy,” says Ms. Phairas.

A version of this article first appeared on Medscape.com.