Federal Practitioner

Final results from the landmark SPRINT study confirm that aggressive blood pressure (BP) management, targeting a systolic blood pressure (SBP) below 120 mm Hg, significantly reduces the risk for heart disease, stroke, and death from these diseases, as well as death from all causes.

The results include data on some outcome events from the trial that had yet to be adjudicated when the primary analysis was released in 2015, as well as posttrial observational follow-up data collected through July 2016.

The data confirm and enhance the earlier findings and show that “lower is better” when it comes to blood pressure, primary investigator Cora E. Lewis, MD, professor and chair, department of epidemiology, University of Alabama at Birmingham, said in an interview.

Final results of the Systolic Blood Pressure Intervention Trial (SPRINT) were published in the May 20 issue of the New England Journal of Medicine.

For the trial, researchers enrolled 9,361 adults 50 years and older with a SBP between 130 and 180 mm Hg who were at increased risk for cardiovascular disease (CVD) but did not have a history of diabetes or stroke. Patients were randomly assigned to an intensive treatment target (SBP < 120 mm Hg) or a standard treatment target (SBP < 140 mm Hg).

In the final analysis, the rate of the primary outcome was 1.77% per year in the intensive-treatment group and 2.40% per year in the standard-treatment group (hazard ratio [HR], 0.73; 95% confidence interval [CR], 0.63-0.86; P < .001), similar to the earlier SPRINT findings.

All-cause mortality was 1.06% per year in the intensive-treatment group and 1.41% per year in the standard-treatment group (HR, 0.75; 95% CI, 0.61-0.92; P = .006), again similar to the previous findings.

“These results were highly statistically significant. It is remarkable in a trial powered for a composite CVD outcome to obtain a significant benefit for total mortality,” Dr. Lewis said.

She noted that one criticism of the initial SPRINT results was that, for the components of the primary outcome, only heart failure and death due to CVD were significantly lower in the intensively treated group.

“Heart failure can be difficult to diagnose from records in a clinical trial, and the critiques were that this was shaky evidence, given that more participants treated to less than 120 were on diuretics, which could decrease swelling, a key symptom of heart failure,” she explained.

“In these final results, SPRINT found that risk of myocardial infarction, heart failure, and death from CVD were significantly lower in the group treated to less than 120, and risk of the primary outcome, excluding heart failure, was still significantly lower in the more intensively treated group,” she noted.

After the trial phase ended, blood pressure treatment was returned to the participants’ usual source of medical care and the trial treatment goals were no longer pursued. SPRINT continued to collect data on the outcomes through July 2016. During this time, SBP rose 6.9 mm Hg in the intensive-treatment group and 2.6 mm Hg in the standard-treatment group.

“Putting all the data together from the trial phase and the phase after randomized interventions had been stopped, there was still a significant benefit for the more intensive treatment on the primary outcome and on death from all causes,” Dr. Lewis said.

In addition, a separate new analysis based on all the data showed significantly fewer first and recurrent primary outcome events with intensive treatment than with standard treatment (435 vs. 552; HR, 0.78; 95% CI, 0.69-0.89; P < .001).
 

Manageable risk

The pattern of safety events in the final analysis was similar to the 2015 report. In the intervention period, rates of serious adverse events overall did not differ significantly between the groups. However, rates of hypotension, electrolyte abnormalities, syncope (none leading to injurious falls), and acute kidney injury were higher in the intensive-treatment group.

As in other SPRINT reports, “acute kidney injury safety events were generally mild and there was nearly complete recovery of kidney function within 1 year,” Dr. Lewis said. “This and other analyses we have published indicate this is probably a hemodynamic effect.”

“Intensive treatment can be well tolerated and is generally safe with proper patient selection and monitoring. There are advantages to intensive therapy, and some risks, but I don’t think the risks are such that we should just throw the idea of more intensive treatment out the window,” Dr. Lewis said.

Reached for comment, Carlos G. Santos-Gallego, MD, from the Icahn School of Medicine at Mount Sinai in New York, said there has been “controversy” over whether intensive blood pressure control targeting systolic to below 120 mm Hg is beneficial.

“The original SPRINT trial is incredibly important, in that it conclusively demonstrated that among patients with hypertension and increased cardiovascular risk, targeting systolic blood pressure to below 120 mm Hg resulted in lower rates of adverse cardiovascular events and, importantly, all-cause mortality," compared with the conventional target of 140 mm Hg, he said in an interview.

“This final report of the SPRINT trial basically consolidates, confirms, and corroborates the original SPRINT data,” he noted. However, the final data are “more robust, with additional primary outcome events and all events having been adjudicated by a central committee, and there is an additional observation period of 1 extra year in which the treatment has been discontinued,” he said.

“Over time, we are becoming more and more certain that lower is better with blood pressure. We still have a long way to go, but the cardiology community is slowly becoming more intense in our treatment of blood pressure for our patients,” Dr. Santos-Gallego said.

The potential adverse effects of intensive blood pressure control are “very manageable,” he added.

Support for SPRINT was provided by the National Institutes of Health. Full disclosures for authors are available in the original article. Dr. Santos-Gallego has no relevant disclosures.

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

Final results from the landmark SPRINT study confirm that aggressive blood pressure (BP) management, targeting a systolic blood pressure (SBP) below 120 mm Hg, significantly reduces the risk for heart disease, stroke, and death from these diseases, as well as death from all causes.

The results include data on some outcome events from the trial that had yet to be adjudicated when the primary analysis was released in 2015, as well as posttrial observational follow-up data collected through July 2016.

The data confirm and enhance the earlier findings and show that “lower is better” when it comes to blood pressure, primary investigator Cora E. Lewis, MD, professor and chair, department of epidemiology, University of Alabama at Birmingham, said in an interview.

Final results of the Systolic Blood Pressure Intervention Trial (SPRINT) were published in the May 20 issue of the New England Journal of Medicine.

For the trial, researchers enrolled 9,361 adults 50 years and older with a SBP between 130 and 180 mm Hg who were at increased risk for cardiovascular disease (CVD) but did not have a history of diabetes or stroke. Patients were randomly assigned to an intensive treatment target (SBP < 120 mm Hg) or a standard treatment target (SBP < 140 mm Hg).

In the final analysis, the rate of the primary outcome was 1.77% per year in the intensive-treatment group and 2.40% per year in the standard-treatment group (hazard ratio [HR], 0.73; 95% confidence interval [CR], 0.63-0.86; P < .001), similar to the earlier SPRINT findings.

All-cause mortality was 1.06% per year in the intensive-treatment group and 1.41% per year in the standard-treatment group (HR, 0.75; 95% CI, 0.61-0.92; P = .006), again similar to the previous findings.

“These results were highly statistically significant. It is remarkable in a trial powered for a composite CVD outcome to obtain a significant benefit for total mortality,” Dr. Lewis said.

She noted that one criticism of the initial SPRINT results was that, for the components of the primary outcome, only heart failure and death due to CVD were significantly lower in the intensively treated group.

“Heart failure can be difficult to diagnose from records in a clinical trial, and the critiques were that this was shaky evidence, given that more participants treated to less than 120 were on diuretics, which could decrease swelling, a key symptom of heart failure,” she explained.

“In these final results, SPRINT found that risk of myocardial infarction, heart failure, and death from CVD were significantly lower in the group treated to less than 120, and risk of the primary outcome, excluding heart failure, was still significantly lower in the more intensively treated group,” she noted.

After the trial phase ended, blood pressure treatment was returned to the participants’ usual source of medical care and the trial treatment goals were no longer pursued. SPRINT continued to collect data on the outcomes through July 2016. During this time, SBP rose 6.9 mm Hg in the intensive-treatment group and 2.6 mm Hg in the standard-treatment group.

“Putting all the data together from the trial phase and the phase after randomized interventions had been stopped, there was still a significant benefit for the more intensive treatment on the primary outcome and on death from all causes,” Dr. Lewis said.

In addition, a separate new analysis based on all the data showed significantly fewer first and recurrent primary outcome events with intensive treatment than with standard treatment (435 vs. 552; HR, 0.78; 95% CI, 0.69-0.89; P < .001).
 

Manageable risk

The pattern of safety events in the final analysis was similar to the 2015 report. In the intervention period, rates of serious adverse events overall did not differ significantly between the groups. However, rates of hypotension, electrolyte abnormalities, syncope (none leading to injurious falls), and acute kidney injury were higher in the intensive-treatment group.

As in other SPRINT reports, “acute kidney injury safety events were generally mild and there was nearly complete recovery of kidney function within 1 year,” Dr. Lewis said. “This and other analyses we have published indicate this is probably a hemodynamic effect.”

“Intensive treatment can be well tolerated and is generally safe with proper patient selection and monitoring. There are advantages to intensive therapy, and some risks, but I don’t think the risks are such that we should just throw the idea of more intensive treatment out the window,” Dr. Lewis said.

Reached for comment, Carlos G. Santos-Gallego, MD, from the Icahn School of Medicine at Mount Sinai in New York, said there has been “controversy” over whether intensive blood pressure control targeting systolic to below 120 mm Hg is beneficial.

“The original SPRINT trial is incredibly important, in that it conclusively demonstrated that among patients with hypertension and increased cardiovascular risk, targeting systolic blood pressure to below 120 mm Hg resulted in lower rates of adverse cardiovascular events and, importantly, all-cause mortality," compared with the conventional target of 140 mm Hg, he said in an interview.

“This final report of the SPRINT trial basically consolidates, confirms, and corroborates the original SPRINT data,” he noted. However, the final data are “more robust, with additional primary outcome events and all events having been adjudicated by a central committee, and there is an additional observation period of 1 extra year in which the treatment has been discontinued,” he said.

“Over time, we are becoming more and more certain that lower is better with blood pressure. We still have a long way to go, but the cardiology community is slowly becoming more intense in our treatment of blood pressure for our patients,” Dr. Santos-Gallego said.

The potential adverse effects of intensive blood pressure control are “very manageable,” he added.

Support for SPRINT was provided by the National Institutes of Health. Full disclosures for authors are available in the original article. Dr. Santos-Gallego has no relevant disclosures.

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

Final results from the landmark SPRINT study confirm that aggressive blood pressure (BP) management, targeting a systolic blood pressure (SBP) below 120 mm Hg, significantly reduces the risk for heart disease, stroke, and death from these diseases, as well as death from all causes.

The results include data on some outcome events from the trial that had yet to be adjudicated when the primary analysis was released in 2015, as well as posttrial observational follow-up data collected through July 2016.

The data confirm and enhance the earlier findings and show that “lower is better” when it comes to blood pressure, primary investigator Cora E. Lewis, MD, professor and chair, department of epidemiology, University of Alabama at Birmingham, said in an interview.

Final results of the Systolic Blood Pressure Intervention Trial (SPRINT) were published in the May 20 issue of the New England Journal of Medicine.

For the trial, researchers enrolled 9,361 adults 50 years and older with a SBP between 130 and 180 mm Hg who were at increased risk for cardiovascular disease (CVD) but did not have a history of diabetes or stroke. Patients were randomly assigned to an intensive treatment target (SBP < 120 mm Hg) or a standard treatment target (SBP < 140 mm Hg).

In the final analysis, the rate of the primary outcome was 1.77% per year in the intensive-treatment group and 2.40% per year in the standard-treatment group (hazard ratio [HR], 0.73; 95% confidence interval [CR], 0.63-0.86; P < .001), similar to the earlier SPRINT findings.

All-cause mortality was 1.06% per year in the intensive-treatment group and 1.41% per year in the standard-treatment group (HR, 0.75; 95% CI, 0.61-0.92; P = .006), again similar to the previous findings.

“These results were highly statistically significant. It is remarkable in a trial powered for a composite CVD outcome to obtain a significant benefit for total mortality,” Dr. Lewis said.

She noted that one criticism of the initial SPRINT results was that, for the components of the primary outcome, only heart failure and death due to CVD were significantly lower in the intensively treated group.

“Heart failure can be difficult to diagnose from records in a clinical trial, and the critiques were that this was shaky evidence, given that more participants treated to less than 120 were on diuretics, which could decrease swelling, a key symptom of heart failure,” she explained.

“In these final results, SPRINT found that risk of myocardial infarction, heart failure, and death from CVD were significantly lower in the group treated to less than 120, and risk of the primary outcome, excluding heart failure, was still significantly lower in the more intensively treated group,” she noted.

After the trial phase ended, blood pressure treatment was returned to the participants’ usual source of medical care and the trial treatment goals were no longer pursued. SPRINT continued to collect data on the outcomes through July 2016. During this time, SBP rose 6.9 mm Hg in the intensive-treatment group and 2.6 mm Hg in the standard-treatment group.

“Putting all the data together from the trial phase and the phase after randomized interventions had been stopped, there was still a significant benefit for the more intensive treatment on the primary outcome and on death from all causes,” Dr. Lewis said.

In addition, a separate new analysis based on all the data showed significantly fewer first and recurrent primary outcome events with intensive treatment than with standard treatment (435 vs. 552; HR, 0.78; 95% CI, 0.69-0.89; P < .001).
 

Manageable risk

The pattern of safety events in the final analysis was similar to the 2015 report. In the intervention period, rates of serious adverse events overall did not differ significantly between the groups. However, rates of hypotension, electrolyte abnormalities, syncope (none leading to injurious falls), and acute kidney injury were higher in the intensive-treatment group.

As in other SPRINT reports, “acute kidney injury safety events were generally mild and there was nearly complete recovery of kidney function within 1 year,” Dr. Lewis said. “This and other analyses we have published indicate this is probably a hemodynamic effect.”

“Intensive treatment can be well tolerated and is generally safe with proper patient selection and monitoring. There are advantages to intensive therapy, and some risks, but I don’t think the risks are such that we should just throw the idea of more intensive treatment out the window,” Dr. Lewis said.

Reached for comment, Carlos G. Santos-Gallego, MD, from the Icahn School of Medicine at Mount Sinai in New York, said there has been “controversy” over whether intensive blood pressure control targeting systolic to below 120 mm Hg is beneficial.

“The original SPRINT trial is incredibly important, in that it conclusively demonstrated that among patients with hypertension and increased cardiovascular risk, targeting systolic blood pressure to below 120 mm Hg resulted in lower rates of adverse cardiovascular events and, importantly, all-cause mortality," compared with the conventional target of 140 mm Hg, he said in an interview.

“This final report of the SPRINT trial basically consolidates, confirms, and corroborates the original SPRINT data,” he noted. However, the final data are “more robust, with additional primary outcome events and all events having been adjudicated by a central committee, and there is an additional observation period of 1 extra year in which the treatment has been discontinued,” he said.

“Over time, we are becoming more and more certain that lower is better with blood pressure. We still have a long way to go, but the cardiology community is slowly becoming more intense in our treatment of blood pressure for our patients,” Dr. Santos-Gallego said.

The potential adverse effects of intensive blood pressure control are “very manageable,” he added.

Support for SPRINT was provided by the National Institutes of Health. Full disclosures for authors are available in the original article. Dr. Santos-Gallego has no relevant disclosures.

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

Federal Practitioner Supplement: Advances in Hematology and Oncology

• Impact of an Oral Antineoplastic Renewal Clinic
• Implementing Comprehensive Geriatric Assessments for Oncology Patients
• Radiation Toxicity and Survival in Patients with Presumed Early-Stage NCSLC
• Screening High-Risk Women Veterans for Breast Cancer
• Standardizing the Discharge Process for Inpatient Hem/Onc
• Massive Retroperitoneal Liposarcoma Masquerading as Meralgia Paresthetica
• Delayed Coronary Vasospasm in Metastatic Gastric Cancer

THIS ISSUE WAS PRODUCED IN COLLABORATION WITH AVAHO

Federal Practitioner Supplement: Advances in Hematology and Oncology

• Impact of an Oral Antineoplastic Renewal Clinic
• Implementing Comprehensive Geriatric Assessments for Oncology Patients
• Radiation Toxicity and Survival in Patients with Presumed Early-Stage NCSLC
• Screening High-Risk Women Veterans for Breast Cancer
• Standardizing the Discharge Process for Inpatient Hem/Onc
• Massive Retroperitoneal Liposarcoma Masquerading as Meralgia Paresthetica
• Delayed Coronary Vasospasm in Metastatic Gastric Cancer

THIS ISSUE WAS PRODUCED IN COLLABORATION WITH AVAHO

Federal Practitioner Supplement: Advances in Hematology and Oncology

• Impact of an Oral Antineoplastic Renewal Clinic
• Implementing Comprehensive Geriatric Assessments for Oncology Patients
• Radiation Toxicity and Survival in Patients with Presumed Early-Stage NCSLC
• Screening High-Risk Women Veterans for Breast Cancer
• Standardizing the Discharge Process for Inpatient Hem/Onc
• Massive Retroperitoneal Liposarcoma Masquerading as Meralgia Paresthetica
• Delayed Coronary Vasospasm in Metastatic Gastric Cancer

THIS ISSUE WAS PRODUCED IN COLLABORATION WITH AVAHO

The U.S. Department of Health and Human Services will inject billions of dollars into programs designed to address mental health and substance use disorders, including $3 billion released to states as of May 18, said federal officials.

The American Rescue Plan, a COVID-relief package signed into law in March, contained the money, which will be divided equally between the Community Mental Health Services Block Grant Program and the Substance Abuse Prevention and Treatment Block Grant Program, said Tom Coderre, Acting Assistant Secretary for Mental Health and Substance Use, in a call with reporters.

The award amounts will vary by state.

The mental health program helps states and territories provide services for children with serious emotional issues and adults with serious mental illness.

The substance use program provides money to plan, implement, and evaluate prevention, intervention, treatment, and recovery services.

‘A huge step forward’

The American Psychiatric Association welcomed the new money and the return of the council.

“In the wake of the pandemic an unprecedented, and as of yet untold, number of Americans are faced with mental health and substance use disorders, particularly in communities impacted by structural racism,” said APA President Vivian Pender, MD, in a statement. “With the creation of this Council and this investment in mental health, the administration is taking a huge step forward.” 

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

The U.S. Department of Health and Human Services will inject billions of dollars into programs designed to address mental health and substance use disorders, including $3 billion released to states as of May 18, said federal officials.

The American Rescue Plan, a COVID-relief package signed into law in March, contained the money, which will be divided equally between the Community Mental Health Services Block Grant Program and the Substance Abuse Prevention and Treatment Block Grant Program, said Tom Coderre, Acting Assistant Secretary for Mental Health and Substance Use, in a call with reporters.

The award amounts will vary by state.

The mental health program helps states and territories provide services for children with serious emotional issues and adults with serious mental illness.

The substance use program provides money to plan, implement, and evaluate prevention, intervention, treatment, and recovery services.

‘A huge step forward’

The American Psychiatric Association welcomed the new money and the return of the council.

“In the wake of the pandemic an unprecedented, and as of yet untold, number of Americans are faced with mental health and substance use disorders, particularly in communities impacted by structural racism,” said APA President Vivian Pender, MD, in a statement. “With the creation of this Council and this investment in mental health, the administration is taking a huge step forward.” 

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

The U.S. Department of Health and Human Services will inject billions of dollars into programs designed to address mental health and substance use disorders, including $3 billion released to states as of May 18, said federal officials.

The American Rescue Plan, a COVID-relief package signed into law in March, contained the money, which will be divided equally between the Community Mental Health Services Block Grant Program and the Substance Abuse Prevention and Treatment Block Grant Program, said Tom Coderre, Acting Assistant Secretary for Mental Health and Substance Use, in a call with reporters.

The award amounts will vary by state.

The mental health program helps states and territories provide services for children with serious emotional issues and adults with serious mental illness.

The substance use program provides money to plan, implement, and evaluate prevention, intervention, treatment, and recovery services.

‘A huge step forward’

The American Psychiatric Association welcomed the new money and the return of the council.

“In the wake of the pandemic an unprecedented, and as of yet untold, number of Americans are faced with mental health and substance use disorders, particularly in communities impacted by structural racism,” said APA President Vivian Pender, MD, in a statement. “With the creation of this Council and this investment in mental health, the administration is taking a huge step forward.” 

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

As bleeding disorders are increasingly recognized as a national health priority, hematologists are focusing on how the patient-centered medical home – a widely accepted concept in primary care and in some specialties – can improve outcomes and quality life for their patients.

Courtesy of Dr. Shapiro

The patient-centered medical home is a model of health care delivery in which patients receive comprehensive, accessible care that is fully integrated across all providers and elements of a healthcare system.¹ The concept emerged in the 1960s among pediatricians seeking to better coordinate care for children with complex medical needs. Since then, the patient-centered medical home has become a globally recognized standard – not only in primary care, but also in specialties such as endocrinology, oncology, and geriatric medicine. The movement to establish medical homes for patients with bleeding disorders is more recent and is receiving national attention.

Why a medical home?

The advent of prophylactic therapies for bleeding disorders has vastly improved the outlook for many patients compared to just a few decades ago. However, treatment options remain limited, and patients who have severe disease or complications – such as an inadequate treatment response or the development of inhibitory antibodies to replacement clotting factors – are at risk for recurrent breakthrough bleeding that can lead to synovitis and ultimately culminate in progressive, irreversible joint damage. The resulting pain and limitation of motion greatly compromises patients’ quality of life across physical, psychological, and social domains, undermines their ability to live and work independently, and greatly increases treatment costs.^2-4 Family members, too, face high stress and lower quality of life when they struggle to obtain and manage treatment while caring for loved ones with bleeding disorders.⁵

For patients with bleeding disorders, a patient-centered medical home can help address or surmount these challenges, said Amy Shapiro, MD, medical director of the Indiana Hemophilia and Thrombosis Center in Indianapolis, Ind., which was the first hemophilia treatment center in the country to be formally certified as a medical home.

Dr. Shapiro explained that a patient-centered medical home leverages the care of an integrated multidisciplinary team to help optimize therapies and patient outcomes across all domains of life. She sees the medical home concept as a natural fit for patients with bleeding disorders, given the complexity of their needs and the number of specialties involved. “When you have hemophilia, you don’t just need a hematologist to manage your care. You need nurses, physical therapists, and social workers. You need coordinated care for genetic counseling. You also need to coordinate dental hygiene and surgical interventions, if these are required. Patients need nutrition counseling, and they may need assistance with education or career options if too many days are missed from work or school. Patients or their families may need counseling on choosing the right insurance program so they don’t choose a plan that may create more hardships for them because of their chronic disorder.”

Meeting these needs requires the help of an integrated care team, which many individuals with bleeding disorders lack. “If you are just out there in the community and you have medical issues that need to be dealt with, often the individuals themselves have to coordinate their own care, including their medications and their appointments with different specialists,” said Dr. Shapiro. “For example, a care provider may tell a patient that they need a physical therapist and give them some names, and then the patient has to take it from there and not only find the provider, but also determine if their insurance provides coverage.”

A medical home takes a completely different approach, she explained. “At my center, when we say you need a physical therapist, we have a physical therapist on staff. Our therapist provides an assessment and determines the need for ongoing PT and whether that can be done at home with a plan and intermittent oversight, or whether the patient needs a referral, and whether the person the patient is referred to needs education on how to provide PT for someone with hemophilia. A medical home provides all this in one place. It is a place where patients know they will receive either direct services, or support to shepherd their care and outcomes, and oversight of that support as well.”

Few studies have directly assessed the medical home model in the setting of bleeding disorders, but a number have evaluated the impact of integrated care, a more general term for the practice of coordinating multidisciplinary care to improve access and outcomes while eliminating redundancies and unnecessary costs. In a recent systematic review and meta-analysis of 27 nonrandomized studies of patients with hemophilia, integrated care was linked to lower mortality, fewer emergency room visits and hospitalizations, shorter lengths of stay in the hospital, and fewer missed days of school and work.⁶ Such findings, combined with promising outcomes data from studies of patient-centered medical homes in other disease settings, suggest that the patient-centered medical home can significantly benefit patients with bleeding disorders and their families and caregivers.
 

Creating a medical home

Establishing a patient-centered medical home can be challenging, involving a plethora of stakeholders and a considerable investment of time, energy, and resources. Organizations such as the National Committee for Quality Assurance and the Accreditation Association for Ambulatory Health Care have formal certification programs to help ensure that an inpatient or outpatient center that calls itself a medical home truly is one.^7-8

The certification process requires centers to document activities in areas such as patients’ rights and responsibilities, administration and governance, patient and care team relationships, clinical records and other health information, and quality, comprehensiveness, continuity, and accessibility.⁷ Achieving certification is rigorous, often requiring centers to document compliance with more than 100 policies, procedures, and standards.

For the Indiana Hemophilia and Thrombosis Center, becoming certified as a medical home “was a multiyear process and an ongoing process,” said Dr. Shapiro. “It involves documentation of quality improvement initiatives, obtaining input from patients to document their satisfaction, and looking at all types of systems within our center and how we integrate care so that all those systems function together. It’s a difficult process, but treatment centers are a medical home for patients with bleeding disorders, and this is an effort to provide some documentation on a national level of how we’re doing everything that we are doing.”

She noted that the process of obtaining medical home certification may require an even higher level of commitment if a bleeding disorder (hemophilia) treatment center is embedded in a university or academic medical center. In this case, more stakeholders are involved, and more hoops may need to be jumped through to implement processes that meet medical home standards while still adhering to any requirements at the organizational level.

Certification programs for patient-centered medical homes are not designed around specific disorders or diseases, but a closer look at their compliance metrics underscores how medical homes can benefit patients with bleeding disorders. For example, to receive medical home certification from the Accreditation Association for Ambulatory Health Care, a center needs to be able to document that patients’ care is not transferred without first making arrangements with a receiving health care provider, that the quality improvement programs are peer-led, and that these programs assess and address diverse measures of clinical performance, cost-effectiveness, and administrative functioning.^7-9

Medical homes, the NHPCC, and Healthy People 2030

Creating patient-centered medical homes for patients with bleeding disorders is now a quality improvement objective of the National Hemophilia Program Coordinating Center, or NHPCC. Established in 2012 and funded by the federal Health Resources and Services Administration, the NHPCC partners with the eight regional hemophilia networks and more than 140 federally funded hemophilia treatment centers across the United States to identify gaps, standardize and improve access to care, and share and promote best practices for the treatment and management of blood disorders.¹⁰

In the United States, receiving care in a hemophilia treatment center (which, despite its name, typically offers care for other disorders such as von Willebrand disease) has been linked to lower mortality and fewer hospitalizations related to bleeding complications.¹¹ To continue to improve on these outcomes, the NHPCC, regional networks, and hemophilia treatment centers are prioritizing medical homes and ranking their establishments alongside core objectives such as bettering patient and family engagement and improving the transition from pediatric to adult care.¹²

As part of this quality improvement work, the NHPCC, regional leadership, and hemophilia treatment centers meet regularly to identify needs and priorities, plan programs, and ensure that each center is meeting the goals and objectives set out by its federal grant.¹³ Such partnerships help improve and integrate care within a coordinated national framework, Dr. Shapiro said. “We all are charged with this same mission,” she added. “That doesn’t mean that every treatment center looks exactly the same, has the same number of staff, or does everything the same way, but we all have the same mission, and we know what that is. That is the work of the NHPCC, to determine and document that and help level and improve care throughout the country.”

The NHPCC also engages other stakeholders, including consumer agencies and professional organizations. Recent achievements have included a first-ever national patient needs assessment, a tandem technical needs assessment of hemophilia treatment centers, an educational outreach program for genetic counselors, a webinar on transitioning care for adolescents, a national survey of the federal 340B Drug Pricing Program, and a survey of minority patients to identify and characterize problems such as language and insurance barriers, the lack of culturally appropriate educational materials on blood disorders, and difficulties getting transportation to treatment centers or educational programs.¹⁴

In part because of this advocacy work, the U.S. Department of Health and Human Services recently included hemophilia for the first time in Healthy People, its evidence-based set of decade-long objectives aimed at improving the health of all Americans. In Healthy People 2030, the specific objective for hemophilia is to reduce the proportion of patients with severe disease who experience more than four joint bleeds per year to 13.3% (the current estimate is 16.9%).¹⁵

For Healthy People to prioritize hemophilia for the first time alongside much more common conditions such as diabetes and heart disease reflects the challenges of managing bleeding disorders and the efforts by the NHPCC and other stakeholders to raise awareness about current needs. To track progress in meeting the Healthy People 2030 objective, the NHPCC will work with federal partners to analyze patient-level data gathered through the Centers for Disease Control’s Community Counts Registry for Bleeding Disorders Surveillance program, which collects data from hemophilia treatment centers across the United States and includes patients with all levels of disease severity.

“The inclusion of bleeding disorders in Healthy People 2030 is really very significant,” said Dr. Shapiro. “These are disorders that affect less than 200,000 Americans, which is the definition of a rare disease in this context. To have hemophilia considered as a national priority is very important, not only for hemophilia, but also for other rare diseases that may in the future also be considered as being as of national importance in this way.”
 

References

1. Rodriguez-Saldana J. 2019. The Patient-Centered Medical Home, Primary Care, and Diabetes. In: Rodriguez-Saldana J. (eds) The Diabetes Textbook. Springer, Cham.

2. J Comorb. 2011;1:51-59.

3. Eur J Haematol. 2018 Apr;100 Suppl 1:5-13.

4. Blood. 2003;102(7):2358-63.

5. Haemophilia. 2014 Jul;20(4):541-9.

6. Haemophilia. 2016;22(Suppl 3):31-40.

7. AAAHC. Medical Home.

8. NCQA. Patient-centered medical home (PCMH).

9. AAAHC, 2013. Medical Home On-Site Certification Handbook.

10. Centers for Disease Control and Prevention. HTC Population Profile.

11. Blood Transfus. 2014;12 Suppl 3(Suppl 3):e542-e548.

12. American Thrombosis and Hemostasis Network.

13. The Great Lakes Regional Hemophilia Network.

14. American Thrombosis and Hemostasis Network. What the NHPCC does.

15. U.S. Department of Health and Human Services. Healthy People 2030: Blood Disorders.

As bleeding disorders are increasingly recognized as a national health priority, hematologists are focusing on how the patient-centered medical home – a widely accepted concept in primary care and in some specialties – can improve outcomes and quality life for their patients.

Courtesy of Dr. Shapiro

The patient-centered medical home is a model of health care delivery in which patients receive comprehensive, accessible care that is fully integrated across all providers and elements of a healthcare system.¹ The concept emerged in the 1960s among pediatricians seeking to better coordinate care for children with complex medical needs. Since then, the patient-centered medical home has become a globally recognized standard – not only in primary care, but also in specialties such as endocrinology, oncology, and geriatric medicine. The movement to establish medical homes for patients with bleeding disorders is more recent and is receiving national attention.

Why a medical home?

The advent of prophylactic therapies for bleeding disorders has vastly improved the outlook for many patients compared to just a few decades ago. However, treatment options remain limited, and patients who have severe disease or complications – such as an inadequate treatment response or the development of inhibitory antibodies to replacement clotting factors – are at risk for recurrent breakthrough bleeding that can lead to synovitis and ultimately culminate in progressive, irreversible joint damage. The resulting pain and limitation of motion greatly compromises patients’ quality of life across physical, psychological, and social domains, undermines their ability to live and work independently, and greatly increases treatment costs.^2-4 Family members, too, face high stress and lower quality of life when they struggle to obtain and manage treatment while caring for loved ones with bleeding disorders.⁵

For patients with bleeding disorders, a patient-centered medical home can help address or surmount these challenges, said Amy Shapiro, MD, medical director of the Indiana Hemophilia and Thrombosis Center in Indianapolis, Ind., which was the first hemophilia treatment center in the country to be formally certified as a medical home.

Dr. Shapiro explained that a patient-centered medical home leverages the care of an integrated multidisciplinary team to help optimize therapies and patient outcomes across all domains of life. She sees the medical home concept as a natural fit for patients with bleeding disorders, given the complexity of their needs and the number of specialties involved. “When you have hemophilia, you don’t just need a hematologist to manage your care. You need nurses, physical therapists, and social workers. You need coordinated care for genetic counseling. You also need to coordinate dental hygiene and surgical interventions, if these are required. Patients need nutrition counseling, and they may need assistance with education or career options if too many days are missed from work or school. Patients or their families may need counseling on choosing the right insurance program so they don’t choose a plan that may create more hardships for them because of their chronic disorder.”

Meeting these needs requires the help of an integrated care team, which many individuals with bleeding disorders lack. “If you are just out there in the community and you have medical issues that need to be dealt with, often the individuals themselves have to coordinate their own care, including their medications and their appointments with different specialists,” said Dr. Shapiro. “For example, a care provider may tell a patient that they need a physical therapist and give them some names, and then the patient has to take it from there and not only find the provider, but also determine if their insurance provides coverage.”

A medical home takes a completely different approach, she explained. “At my center, when we say you need a physical therapist, we have a physical therapist on staff. Our therapist provides an assessment and determines the need for ongoing PT and whether that can be done at home with a plan and intermittent oversight, or whether the patient needs a referral, and whether the person the patient is referred to needs education on how to provide PT for someone with hemophilia. A medical home provides all this in one place. It is a place where patients know they will receive either direct services, or support to shepherd their care and outcomes, and oversight of that support as well.”

Few studies have directly assessed the medical home model in the setting of bleeding disorders, but a number have evaluated the impact of integrated care, a more general term for the practice of coordinating multidisciplinary care to improve access and outcomes while eliminating redundancies and unnecessary costs. In a recent systematic review and meta-analysis of 27 nonrandomized studies of patients with hemophilia, integrated care was linked to lower mortality, fewer emergency room visits and hospitalizations, shorter lengths of stay in the hospital, and fewer missed days of school and work.⁶ Such findings, combined with promising outcomes data from studies of patient-centered medical homes in other disease settings, suggest that the patient-centered medical home can significantly benefit patients with bleeding disorders and their families and caregivers.
 

Creating a medical home

Establishing a patient-centered medical home can be challenging, involving a plethora of stakeholders and a considerable investment of time, energy, and resources. Organizations such as the National Committee for Quality Assurance and the Accreditation Association for Ambulatory Health Care have formal certification programs to help ensure that an inpatient or outpatient center that calls itself a medical home truly is one.^7-8

The certification process requires centers to document activities in areas such as patients’ rights and responsibilities, administration and governance, patient and care team relationships, clinical records and other health information, and quality, comprehensiveness, continuity, and accessibility.⁷ Achieving certification is rigorous, often requiring centers to document compliance with more than 100 policies, procedures, and standards.

For the Indiana Hemophilia and Thrombosis Center, becoming certified as a medical home “was a multiyear process and an ongoing process,” said Dr. Shapiro. “It involves documentation of quality improvement initiatives, obtaining input from patients to document their satisfaction, and looking at all types of systems within our center and how we integrate care so that all those systems function together. It’s a difficult process, but treatment centers are a medical home for patients with bleeding disorders, and this is an effort to provide some documentation on a national level of how we’re doing everything that we are doing.”

She noted that the process of obtaining medical home certification may require an even higher level of commitment if a bleeding disorder (hemophilia) treatment center is embedded in a university or academic medical center. In this case, more stakeholders are involved, and more hoops may need to be jumped through to implement processes that meet medical home standards while still adhering to any requirements at the organizational level.

Certification programs for patient-centered medical homes are not designed around specific disorders or diseases, but a closer look at their compliance metrics underscores how medical homes can benefit patients with bleeding disorders. For example, to receive medical home certification from the Accreditation Association for Ambulatory Health Care, a center needs to be able to document that patients’ care is not transferred without first making arrangements with a receiving health care provider, that the quality improvement programs are peer-led, and that these programs assess and address diverse measures of clinical performance, cost-effectiveness, and administrative functioning.^7-9

Medical homes, the NHPCC, and Healthy People 2030

Creating patient-centered medical homes for patients with bleeding disorders is now a quality improvement objective of the National Hemophilia Program Coordinating Center, or NHPCC. Established in 2012 and funded by the federal Health Resources and Services Administration, the NHPCC partners with the eight regional hemophilia networks and more than 140 federally funded hemophilia treatment centers across the United States to identify gaps, standardize and improve access to care, and share and promote best practices for the treatment and management of blood disorders.¹⁰

In the United States, receiving care in a hemophilia treatment center (which, despite its name, typically offers care for other disorders such as von Willebrand disease) has been linked to lower mortality and fewer hospitalizations related to bleeding complications.¹¹ To continue to improve on these outcomes, the NHPCC, regional networks, and hemophilia treatment centers are prioritizing medical homes and ranking their establishments alongside core objectives such as bettering patient and family engagement and improving the transition from pediatric to adult care.¹²

As part of this quality improvement work, the NHPCC, regional leadership, and hemophilia treatment centers meet regularly to identify needs and priorities, plan programs, and ensure that each center is meeting the goals and objectives set out by its federal grant.¹³ Such partnerships help improve and integrate care within a coordinated national framework, Dr. Shapiro said. “We all are charged with this same mission,” she added. “That doesn’t mean that every treatment center looks exactly the same, has the same number of staff, or does everything the same way, but we all have the same mission, and we know what that is. That is the work of the NHPCC, to determine and document that and help level and improve care throughout the country.”

The NHPCC also engages other stakeholders, including consumer agencies and professional organizations. Recent achievements have included a first-ever national patient needs assessment, a tandem technical needs assessment of hemophilia treatment centers, an educational outreach program for genetic counselors, a webinar on transitioning care for adolescents, a national survey of the federal 340B Drug Pricing Program, and a survey of minority patients to identify and characterize problems such as language and insurance barriers, the lack of culturally appropriate educational materials on blood disorders, and difficulties getting transportation to treatment centers or educational programs.¹⁴

In part because of this advocacy work, the U.S. Department of Health and Human Services recently included hemophilia for the first time in Healthy People, its evidence-based set of decade-long objectives aimed at improving the health of all Americans. In Healthy People 2030, the specific objective for hemophilia is to reduce the proportion of patients with severe disease who experience more than four joint bleeds per year to 13.3% (the current estimate is 16.9%).¹⁵

For Healthy People to prioritize hemophilia for the first time alongside much more common conditions such as diabetes and heart disease reflects the challenges of managing bleeding disorders and the efforts by the NHPCC and other stakeholders to raise awareness about current needs. To track progress in meeting the Healthy People 2030 objective, the NHPCC will work with federal partners to analyze patient-level data gathered through the Centers for Disease Control’s Community Counts Registry for Bleeding Disorders Surveillance program, which collects data from hemophilia treatment centers across the United States and includes patients with all levels of disease severity.

“The inclusion of bleeding disorders in Healthy People 2030 is really very significant,” said Dr. Shapiro. “These are disorders that affect less than 200,000 Americans, which is the definition of a rare disease in this context. To have hemophilia considered as a national priority is very important, not only for hemophilia, but also for other rare diseases that may in the future also be considered as being as of national importance in this way.”
 

References

1. Rodriguez-Saldana J. 2019. The Patient-Centered Medical Home, Primary Care, and Diabetes. In: Rodriguez-Saldana J. (eds) The Diabetes Textbook. Springer, Cham.

2. J Comorb. 2011;1:51-59.

3. Eur J Haematol. 2018 Apr;100 Suppl 1:5-13.

4. Blood. 2003;102(7):2358-63.

5. Haemophilia. 2014 Jul;20(4):541-9.

6. Haemophilia. 2016;22(Suppl 3):31-40.

7. AAAHC. Medical Home.

8. NCQA. Patient-centered medical home (PCMH).

9. AAAHC, 2013. Medical Home On-Site Certification Handbook.

10. Centers for Disease Control and Prevention. HTC Population Profile.

11. Blood Transfus. 2014;12 Suppl 3(Suppl 3):e542-e548.

12. American Thrombosis and Hemostasis Network.

13. The Great Lakes Regional Hemophilia Network.

14. American Thrombosis and Hemostasis Network. What the NHPCC does.

15. U.S. Department of Health and Human Services. Healthy People 2030: Blood Disorders.

As bleeding disorders are increasingly recognized as a national health priority, hematologists are focusing on how the patient-centered medical home – a widely accepted concept in primary care and in some specialties – can improve outcomes and quality life for their patients.

Courtesy of Dr. Shapiro

The patient-centered medical home is a model of health care delivery in which patients receive comprehensive, accessible care that is fully integrated across all providers and elements of a healthcare system.¹ The concept emerged in the 1960s among pediatricians seeking to better coordinate care for children with complex medical needs. Since then, the patient-centered medical home has become a globally recognized standard – not only in primary care, but also in specialties such as endocrinology, oncology, and geriatric medicine. The movement to establish medical homes for patients with bleeding disorders is more recent and is receiving national attention.

Why a medical home?

The advent of prophylactic therapies for bleeding disorders has vastly improved the outlook for many patients compared to just a few decades ago. However, treatment options remain limited, and patients who have severe disease or complications – such as an inadequate treatment response or the development of inhibitory antibodies to replacement clotting factors – are at risk for recurrent breakthrough bleeding that can lead to synovitis and ultimately culminate in progressive, irreversible joint damage. The resulting pain and limitation of motion greatly compromises patients’ quality of life across physical, psychological, and social domains, undermines their ability to live and work independently, and greatly increases treatment costs.^2-4 Family members, too, face high stress and lower quality of life when they struggle to obtain and manage treatment while caring for loved ones with bleeding disorders.⁵

For patients with bleeding disorders, a patient-centered medical home can help address or surmount these challenges, said Amy Shapiro, MD, medical director of the Indiana Hemophilia and Thrombosis Center in Indianapolis, Ind., which was the first hemophilia treatment center in the country to be formally certified as a medical home.

Dr. Shapiro explained that a patient-centered medical home leverages the care of an integrated multidisciplinary team to help optimize therapies and patient outcomes across all domains of life. She sees the medical home concept as a natural fit for patients with bleeding disorders, given the complexity of their needs and the number of specialties involved. “When you have hemophilia, you don’t just need a hematologist to manage your care. You need nurses, physical therapists, and social workers. You need coordinated care for genetic counseling. You also need to coordinate dental hygiene and surgical interventions, if these are required. Patients need nutrition counseling, and they may need assistance with education or career options if too many days are missed from work or school. Patients or their families may need counseling on choosing the right insurance program so they don’t choose a plan that may create more hardships for them because of their chronic disorder.”

Meeting these needs requires the help of an integrated care team, which many individuals with bleeding disorders lack. “If you are just out there in the community and you have medical issues that need to be dealt with, often the individuals themselves have to coordinate their own care, including their medications and their appointments with different specialists,” said Dr. Shapiro. “For example, a care provider may tell a patient that they need a physical therapist and give them some names, and then the patient has to take it from there and not only find the provider, but also determine if their insurance provides coverage.”

A medical home takes a completely different approach, she explained. “At my center, when we say you need a physical therapist, we have a physical therapist on staff. Our therapist provides an assessment and determines the need for ongoing PT and whether that can be done at home with a plan and intermittent oversight, or whether the patient needs a referral, and whether the person the patient is referred to needs education on how to provide PT for someone with hemophilia. A medical home provides all this in one place. It is a place where patients know they will receive either direct services, or support to shepherd their care and outcomes, and oversight of that support as well.”

Few studies have directly assessed the medical home model in the setting of bleeding disorders, but a number have evaluated the impact of integrated care, a more general term for the practice of coordinating multidisciplinary care to improve access and outcomes while eliminating redundancies and unnecessary costs. In a recent systematic review and meta-analysis of 27 nonrandomized studies of patients with hemophilia, integrated care was linked to lower mortality, fewer emergency room visits and hospitalizations, shorter lengths of stay in the hospital, and fewer missed days of school and work.⁶ Such findings, combined with promising outcomes data from studies of patient-centered medical homes in other disease settings, suggest that the patient-centered medical home can significantly benefit patients with bleeding disorders and their families and caregivers.
 

Creating a medical home

Establishing a patient-centered medical home can be challenging, involving a plethora of stakeholders and a considerable investment of time, energy, and resources. Organizations such as the National Committee for Quality Assurance and the Accreditation Association for Ambulatory Health Care have formal certification programs to help ensure that an inpatient or outpatient center that calls itself a medical home truly is one.^7-8

The certification process requires centers to document activities in areas such as patients’ rights and responsibilities, administration and governance, patient and care team relationships, clinical records and other health information, and quality, comprehensiveness, continuity, and accessibility.⁷ Achieving certification is rigorous, often requiring centers to document compliance with more than 100 policies, procedures, and standards.

For the Indiana Hemophilia and Thrombosis Center, becoming certified as a medical home “was a multiyear process and an ongoing process,” said Dr. Shapiro. “It involves documentation of quality improvement initiatives, obtaining input from patients to document their satisfaction, and looking at all types of systems within our center and how we integrate care so that all those systems function together. It’s a difficult process, but treatment centers are a medical home for patients with bleeding disorders, and this is an effort to provide some documentation on a national level of how we’re doing everything that we are doing.”

She noted that the process of obtaining medical home certification may require an even higher level of commitment if a bleeding disorder (hemophilia) treatment center is embedded in a university or academic medical center. In this case, more stakeholders are involved, and more hoops may need to be jumped through to implement processes that meet medical home standards while still adhering to any requirements at the organizational level.

Certification programs for patient-centered medical homes are not designed around specific disorders or diseases, but a closer look at their compliance metrics underscores how medical homes can benefit patients with bleeding disorders. For example, to receive medical home certification from the Accreditation Association for Ambulatory Health Care, a center needs to be able to document that patients’ care is not transferred without first making arrangements with a receiving health care provider, that the quality improvement programs are peer-led, and that these programs assess and address diverse measures of clinical performance, cost-effectiveness, and administrative functioning.^7-9

Medical homes, the NHPCC, and Healthy People 2030

Creating patient-centered medical homes for patients with bleeding disorders is now a quality improvement objective of the National Hemophilia Program Coordinating Center, or NHPCC. Established in 2012 and funded by the federal Health Resources and Services Administration, the NHPCC partners with the eight regional hemophilia networks and more than 140 federally funded hemophilia treatment centers across the United States to identify gaps, standardize and improve access to care, and share and promote best practices for the treatment and management of blood disorders.¹⁰

In the United States, receiving care in a hemophilia treatment center (which, despite its name, typically offers care for other disorders such as von Willebrand disease) has been linked to lower mortality and fewer hospitalizations related to bleeding complications.¹¹ To continue to improve on these outcomes, the NHPCC, regional networks, and hemophilia treatment centers are prioritizing medical homes and ranking their establishments alongside core objectives such as bettering patient and family engagement and improving the transition from pediatric to adult care.¹²

As part of this quality improvement work, the NHPCC, regional leadership, and hemophilia treatment centers meet regularly to identify needs and priorities, plan programs, and ensure that each center is meeting the goals and objectives set out by its federal grant.¹³ Such partnerships help improve and integrate care within a coordinated national framework, Dr. Shapiro said. “We all are charged with this same mission,” she added. “That doesn’t mean that every treatment center looks exactly the same, has the same number of staff, or does everything the same way, but we all have the same mission, and we know what that is. That is the work of the NHPCC, to determine and document that and help level and improve care throughout the country.”

The NHPCC also engages other stakeholders, including consumer agencies and professional organizations. Recent achievements have included a first-ever national patient needs assessment, a tandem technical needs assessment of hemophilia treatment centers, an educational outreach program for genetic counselors, a webinar on transitioning care for adolescents, a national survey of the federal 340B Drug Pricing Program, and a survey of minority patients to identify and characterize problems such as language and insurance barriers, the lack of culturally appropriate educational materials on blood disorders, and difficulties getting transportation to treatment centers or educational programs.¹⁴

In part because of this advocacy work, the U.S. Department of Health and Human Services recently included hemophilia for the first time in Healthy People, its evidence-based set of decade-long objectives aimed at improving the health of all Americans. In Healthy People 2030, the specific objective for hemophilia is to reduce the proportion of patients with severe disease who experience more than four joint bleeds per year to 13.3% (the current estimate is 16.9%).¹⁵

For Healthy People to prioritize hemophilia for the first time alongside much more common conditions such as diabetes and heart disease reflects the challenges of managing bleeding disorders and the efforts by the NHPCC and other stakeholders to raise awareness about current needs. To track progress in meeting the Healthy People 2030 objective, the NHPCC will work with federal partners to analyze patient-level data gathered through the Centers for Disease Control’s Community Counts Registry for Bleeding Disorders Surveillance program, which collects data from hemophilia treatment centers across the United States and includes patients with all levels of disease severity.

“The inclusion of bleeding disorders in Healthy People 2030 is really very significant,” said Dr. Shapiro. “These are disorders that affect less than 200,000 Americans, which is the definition of a rare disease in this context. To have hemophilia considered as a national priority is very important, not only for hemophilia, but also for other rare diseases that may in the future also be considered as being as of national importance in this way.”
 

References

1. Rodriguez-Saldana J. 2019. The Patient-Centered Medical Home, Primary Care, and Diabetes. In: Rodriguez-Saldana J. (eds) The Diabetes Textbook. Springer, Cham.

2. J Comorb. 2011;1:51-59.

3. Eur J Haematol. 2018 Apr;100 Suppl 1:5-13.

4. Blood. 2003;102(7):2358-63.

5. Haemophilia. 2014 Jul;20(4):541-9.

6. Haemophilia. 2016;22(Suppl 3):31-40.

7. AAAHC. Medical Home.

8. NCQA. Patient-centered medical home (PCMH).

9. AAAHC, 2013. Medical Home On-Site Certification Handbook.

10. Centers for Disease Control and Prevention. HTC Population Profile.

11. Blood Transfus. 2014;12 Suppl 3(Suppl 3):e542-e548.

12. American Thrombosis and Hemostasis Network.

13. The Great Lakes Regional Hemophilia Network.

14. American Thrombosis and Hemostasis Network. What the NHPCC does.

15. U.S. Department of Health and Human Services. Healthy People 2030: Blood Disorders.

Sex-specific differences in the severity of symptoms and prevalence of comorbidities in patients with chronic obstructive pulmonary disease (COPD) may point to different criteria for diagnosing cardiac comorbidities in women and men, a retrospective analysis suggests.

Among 2,046 patients in the German COSYCONET (COPD and Systemic Consequences–Comorbidities Net) cohort, most functional parameters and comorbidities and several items on the COPD Assessment Test (CAT) differed significantly between men and women.

In addition, there were sex-specific differences in the association between symptoms and cardiac disease, Franziska C. Trudzinski, MD, from the University of Heidelberg (Germany), and colleagues reported.

(Note: Although the authors used the term “gender” to distinguish male from female, this news organization has used the term “sex” in this article to refer to biological attributes of individual patients rather than personal identity.)

“[Sex]-specific differences in COPD comprised not only differences in the level of symptoms, comorbidities, and functional alterations but also differences in their mutual relationships. This was reflected in different sets of predictors for cardiac disease,” they wrote in a thematic poster presented at the American Thoracic Society’s virtual international conference.
 

GOLD standard

The investigators conducted an analysis of data on 795 women and 1,251 men with GOLD (Global Initiative for Chronic Obstructive Lung Disease) class 1-3 disease from the COSYCONET COPD cohort.

They looked at the patients’ clinical history, comorbidities, lung function, CAT scores, and modified Medical Research Council (mMRC) dyspnea score.

The authors used multivariate regression analysis to model potential sex-related differences in the relationship between symptoms in general and CAT items in particular, and the pattern of comorbidities and functional alterations.

They also performed logistic regression analyses to identify predictors for cardiac disease, defined as myocardial infarction, heart failure, or coronary artery disease. The analyses were controlled for age, body mass index (BMI), smoking status, mMRC, CAT items, and z scores of forced expiratory volume in 1 second/forced vital capacity ratio.

The investigators found significant differences between men and women for most functional parameters and comorbidities, and for CAT items of cough (item 1), phlegm (item 2), and energy (item 8; P < .05 for all comparisons).

In logistic regression analysis, predictors for cardiac disease in men were energy (CAT item 8), mMRC score, smoking status, BMI, age, and spirometric lung function.

In women, however, only age was significantly predictive for cardiac disease.

“Our findings give hints how diagnostic information might be used differently in men and women,” Dr. Trudzinski and colleagues wrote.
 

Reassuring data

David Mannino, MD, medical director of the COPD Foundation, who was not involved in the study, said in an interview that sex differences in COPD presentation and severity are common.

“In general, men and women report symptoms differently. For example, women don’t report a whole lot of chronic bronchitis and phlegm, although they may have it,” he said, “whereas men may report less dyspnea. It varies, but in general we know that men and women, even with the same type of disease, report symptoms differently.”

Comorbidities also differ between the sexes, he noted. Women more frequently have osteoporosis, and men more frequently have heart disease, as borne out in the study. The prevalence of heart disease among patients in the study was approximately 2.5 times higher in men than women.

“It’s reassuring, because what we’re seeing is similar to what we’ve seen in other [studies] with regards to comorbidities,” he said.

The study was sponsored by Philipps University Marburg Medical Center, Germany. The authors and Dr. Mannino have reported no relevant financial relationships.

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

Sex-specific differences in the severity of symptoms and prevalence of comorbidities in patients with chronic obstructive pulmonary disease (COPD) may point to different criteria for diagnosing cardiac comorbidities in women and men, a retrospective analysis suggests.

Among 2,046 patients in the German COSYCONET (COPD and Systemic Consequences–Comorbidities Net) cohort, most functional parameters and comorbidities and several items on the COPD Assessment Test (CAT) differed significantly between men and women.

In addition, there were sex-specific differences in the association between symptoms and cardiac disease, Franziska C. Trudzinski, MD, from the University of Heidelberg (Germany), and colleagues reported.

(Note: Although the authors used the term “gender” to distinguish male from female, this news organization has used the term “sex” in this article to refer to biological attributes of individual patients rather than personal identity.)

“[Sex]-specific differences in COPD comprised not only differences in the level of symptoms, comorbidities, and functional alterations but also differences in their mutual relationships. This was reflected in different sets of predictors for cardiac disease,” they wrote in a thematic poster presented at the American Thoracic Society’s virtual international conference.
 

GOLD standard

The investigators conducted an analysis of data on 795 women and 1,251 men with GOLD (Global Initiative for Chronic Obstructive Lung Disease) class 1-3 disease from the COSYCONET COPD cohort.

They looked at the patients’ clinical history, comorbidities, lung function, CAT scores, and modified Medical Research Council (mMRC) dyspnea score.

The authors used multivariate regression analysis to model potential sex-related differences in the relationship between symptoms in general and CAT items in particular, and the pattern of comorbidities and functional alterations.

They also performed logistic regression analyses to identify predictors for cardiac disease, defined as myocardial infarction, heart failure, or coronary artery disease. The analyses were controlled for age, body mass index (BMI), smoking status, mMRC, CAT items, and z scores of forced expiratory volume in 1 second/forced vital capacity ratio.

The investigators found significant differences between men and women for most functional parameters and comorbidities, and for CAT items of cough (item 1), phlegm (item 2), and energy (item 8; P < .05 for all comparisons).

In logistic regression analysis, predictors for cardiac disease in men were energy (CAT item 8), mMRC score, smoking status, BMI, age, and spirometric lung function.

In women, however, only age was significantly predictive for cardiac disease.

“Our findings give hints how diagnostic information might be used differently in men and women,” Dr. Trudzinski and colleagues wrote.
 

Reassuring data

David Mannino, MD, medical director of the COPD Foundation, who was not involved in the study, said in an interview that sex differences in COPD presentation and severity are common.

“In general, men and women report symptoms differently. For example, women don’t report a whole lot of chronic bronchitis and phlegm, although they may have it,” he said, “whereas men may report less dyspnea. It varies, but in general we know that men and women, even with the same type of disease, report symptoms differently.”

Comorbidities also differ between the sexes, he noted. Women more frequently have osteoporosis, and men more frequently have heart disease, as borne out in the study. The prevalence of heart disease among patients in the study was approximately 2.5 times higher in men than women.

“It’s reassuring, because what we’re seeing is similar to what we’ve seen in other [studies] with regards to comorbidities,” he said.

The study was sponsored by Philipps University Marburg Medical Center, Germany. The authors and Dr. Mannino have reported no relevant financial relationships.

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

Sex-specific differences in the severity of symptoms and prevalence of comorbidities in patients with chronic obstructive pulmonary disease (COPD) may point to different criteria for diagnosing cardiac comorbidities in women and men, a retrospective analysis suggests.

Among 2,046 patients in the German COSYCONET (COPD and Systemic Consequences–Comorbidities Net) cohort, most functional parameters and comorbidities and several items on the COPD Assessment Test (CAT) differed significantly between men and women.

In addition, there were sex-specific differences in the association between symptoms and cardiac disease, Franziska C. Trudzinski, MD, from the University of Heidelberg (Germany), and colleagues reported.

(Note: Although the authors used the term “gender” to distinguish male from female, this news organization has used the term “sex” in this article to refer to biological attributes of individual patients rather than personal identity.)

“[Sex]-specific differences in COPD comprised not only differences in the level of symptoms, comorbidities, and functional alterations but also differences in their mutual relationships. This was reflected in different sets of predictors for cardiac disease,” they wrote in a thematic poster presented at the American Thoracic Society’s virtual international conference.
 

GOLD standard

The investigators conducted an analysis of data on 795 women and 1,251 men with GOLD (Global Initiative for Chronic Obstructive Lung Disease) class 1-3 disease from the COSYCONET COPD cohort.

They looked at the patients’ clinical history, comorbidities, lung function, CAT scores, and modified Medical Research Council (mMRC) dyspnea score.

The authors used multivariate regression analysis to model potential sex-related differences in the relationship between symptoms in general and CAT items in particular, and the pattern of comorbidities and functional alterations.

They also performed logistic regression analyses to identify predictors for cardiac disease, defined as myocardial infarction, heart failure, or coronary artery disease. The analyses were controlled for age, body mass index (BMI), smoking status, mMRC, CAT items, and z scores of forced expiratory volume in 1 second/forced vital capacity ratio.

The investigators found significant differences between men and women for most functional parameters and comorbidities, and for CAT items of cough (item 1), phlegm (item 2), and energy (item 8; P < .05 for all comparisons).

In logistic regression analysis, predictors for cardiac disease in men were energy (CAT item 8), mMRC score, smoking status, BMI, age, and spirometric lung function.

In women, however, only age was significantly predictive for cardiac disease.

“Our findings give hints how diagnostic information might be used differently in men and women,” Dr. Trudzinski and colleagues wrote.
 

Reassuring data

David Mannino, MD, medical director of the COPD Foundation, who was not involved in the study, said in an interview that sex differences in COPD presentation and severity are common.

“In general, men and women report symptoms differently. For example, women don’t report a whole lot of chronic bronchitis and phlegm, although they may have it,” he said, “whereas men may report less dyspnea. It varies, but in general we know that men and women, even with the same type of disease, report symptoms differently.”

Comorbidities also differ between the sexes, he noted. Women more frequently have osteoporosis, and men more frequently have heart disease, as borne out in the study. The prevalence of heart disease among patients in the study was approximately 2.5 times higher in men than women.

“It’s reassuring, because what we’re seeing is similar to what we’ve seen in other [studies] with regards to comorbidities,” he said.

The study was sponsored by Philipps University Marburg Medical Center, Germany. The authors and Dr. Mannino have reported no relevant financial relationships.

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

Sigmund Freud said, “Out of your vulnerabilities will come greatest strength.” What exactly did Dr. Freud mean by this?

Many aspects of mental health treatment include cognitive restructuring, behavioral changes, emotion processing, and setting boundaries. These are all critical aspects of treatment, but what about kindness and compassion?

We often forget that kindness requires us to be vulnerable and take a risk at times. Being kind to others is not always easy, and it is not always an automatic reaction. Vulnerability often involves risk, but the outcomes often outweigh fear.

Dr. Freud was highlighting that being kind, open, and honest will often result in strong character and resilience. In turn, it will help others. Psychology and psychiatry have proved time and time again that empathy, compassion, and kindness have numerous benefits for mental and physical health for both the giver and the receiver.

From a biological perspective, we know that acts of kindness signal the brain to release serotonin and dopamine, known as “feel good transmitters,” and endorphins, which in turn lessen pain, depression, and anxiety. According to Waguih W. Ishak, MD, a psychiatrist affiliated with Cedars-Sinai in Los Angeles,¹ in addition to boosting oxytocin and dopamine, being kind can increase serotonin, a neurotransmitter that helps regulate mood. Kindness and compassion have been shown to release oxytocin, known as the “love hormone,” which increases self-esteem, trust, connection, and optimism. Oxytocin also reduces blood pressure and has been dubbed the “cardioprotective” hormone. According to Kelli Harding, MD, MPH, a psychiatrist affiliated with Columbia University in New York,² kindness can extend the lifespan. Research from Emory University in Atlanta has shown that, when an individual is kind to another, the brain’s reward centers light up – resulting in a “helper’s high.” Thus, kindness is self-reinforcing.³

Kindness leads to a greater sense of connection to others and a lessening in feelings of isolation. Small acts of kindness build up compassion in oneself. Research indicates that kindness doesn’t just positively affect the giver and receiver but can also benefit onlookers. An article in Psychology Today,⁴ suggests that those who witness acts of kindness are also more likely to “pay it forward,” resulting in a domino effect. Along these same lines, altruistic people, specifically those who engage in charitable donations, expressed higher levels of overall happiness according to a 2010 Harvard Business School survey.⁵

“You can’t pour from an empty cup” is a trendy quote making its way around social media. Before we can be kind and compassionate to others, we must first be kind and compassionate to ourselves. In today’s world, productivity and pressure-filled environments consume us daily. We often find ourselves skipping meals, forgetting to connect with loved ones, missing breaks, and even neglecting our sleep. It is virtually impossible to care for others when we are depleted ourselves. Sometimes not prioritizing ourselves can result in collateral damage. We may become short-tempered, irritable, moody, and overwhelmed. At this point kindness, compassion, and empathy toward others are likely to be absent. Once we replenish ourselves, by taking time off, indulging in a nice meal, exercising, we are more likely to respond as opposed to react, ask others about themselves, and engage in overall positive interactions throughout our day. Kindness is best fostered by being kind to ourselves to sustain our own well-being and by being kind to others in order to maintain the cycle. For clinicians who have been pushed to respond to various aspects of the COVID-19 pandemic, self-care has never been more important.

COVID-19 has been difficult for everyone, particularly the elderly and vulnerable populations. However, kindness has proved to be an overwhelming response as many businesses and individuals have taken to volunteering time and resources for those in need. Even big corporations have chipped in. For example, Lyft and Uber – in a partnership with the White House – are now offering free rides to vaccine sites, and several local businesses have donated personal protective equipment to hospitals and assisted living facilities.

Kindness and empathy are ever present in the field of mental health, medicine, and substance use treatment. The very act of caring for another involves kindness. In medicine, empathy has been defined as “an emotional experience between an observer and a subject in which the observer, based on visual and auditory cues, identifies and transiently experiences the subject’s emotional state.”⁶

As mental health professionals, we receive empathy training early on in our schooling – increasingly so over the last decade. Research has indicated that trusting relationships between clinicians and patients result in optimal care. Evidence-based communication styles are being widely implemented. This entails using nonjudgmental language, open-ended questions, and active listening skills, for example. In addition, the mental health professionals have our conscious and unconscious judgments. If empathy training is provided, we can learn to acknowledge our biases and mitigate them. Lastly, empathy training has been proven to assist with destigmatization, increase in treatment seeking, and overall better outcomes.

Substance use treatment, which often focuses on cognition and behavior changing, boundaries, and family dynamics, also requires support and kindness. Although it is not an empirically based “treatment,” Alcoholics Anonymous (AA) has used kindness for decades.

Step 12 of AA’s 12-step program, which was developed by two people with alcohol use disorder in 1935 in Akron, Ohio, is as follows: “Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.”

Once AA members are on solid ground with their sobriety, they are urged to help others in their recovery. This process provides many benefits. When individuals are concerned about someone else, they are less focused on themselves. This helps the individuals in recovery to decrease their rumination and “get out of themselves.” It also allows for the AA member to be kind and helpful to an individual who is suffering, thereby expressing kindness, compassion, and empathy. This act of “paying it forward” produces a domino effect that has withstood the test of time as evidenced by the ever-growing fellowship of Alcoholics Anonymous.

Several small acts of kindness can help us as clinicians and our patients:

1. Practice self-care.

2. Take a half day off from your practice.

3. Give staff a half day off.

4. Call a family member or friend and ask them how they are doing. Then engage in active listening and refrain from giving advice.

5. Donate to a homeless shelter or volunteer your time at a charity.

6. Give a stranger a compliment.

7. Surprise someone with a small gift.

8. Send a loved one a letter instead of a text.

9. Pick up litter.

10. Acknowledge family and friends who gave you extra support during the pandemic.

11. Take baked goods to your office.

12. Help a neighbor with groceries.

13. Leave a generous tip.

14. Play soft music in your office.

In conclusion, kindness, empathy, and compassion are vital concepts that are not just fluffy theories. They have vast mental, physical, and social benefits for us and our patients.
 

References

1. Cedars-Sinai staff. The Science of Kindness. 2019 Feb 13. Cedars-Sinai blog.

2. Harding K. The Rabbit Effect: Live Longer, Happier, and Healthier with the Groundbreaking Science of Kindness. Atria Books, 2019.

3. Ritvo E. BeKindr. Momosa Publishing, 2017.

4. Svoboda E. “Pay it Forward.” Psychology Today. Last reviewed 2016 Jun 9.

5. Aknin LB et al. “Prosocial spending and well-being: Cross-Cultural Evidence for a Psychological Universal.” Harvard Business School. Working Paper 11-038. 2010.

6. Hirsch EM. AMA J Ethics. Virtual Mentor. 2007;9(6):423-7.

Dr. Haji is a licensed clinical psychologist specializing in psychodiagnostic assessment, forensic assessment, dual diagnosis, serious and persistent mental illness, depression, anxiety, personality disorders, and substance abuse treatment. She practices in Miami and has no conflicts of interest.

Sigmund Freud said, “Out of your vulnerabilities will come greatest strength.” What exactly did Dr. Freud mean by this?

Many aspects of mental health treatment include cognitive restructuring, behavioral changes, emotion processing, and setting boundaries. These are all critical aspects of treatment, but what about kindness and compassion?

We often forget that kindness requires us to be vulnerable and take a risk at times. Being kind to others is not always easy, and it is not always an automatic reaction. Vulnerability often involves risk, but the outcomes often outweigh fear.

Dr. Freud was highlighting that being kind, open, and honest will often result in strong character and resilience. In turn, it will help others. Psychology and psychiatry have proved time and time again that empathy, compassion, and kindness have numerous benefits for mental and physical health for both the giver and the receiver.

From a biological perspective, we know that acts of kindness signal the brain to release serotonin and dopamine, known as “feel good transmitters,” and endorphins, which in turn lessen pain, depression, and anxiety. According to Waguih W. Ishak, MD, a psychiatrist affiliated with Cedars-Sinai in Los Angeles,¹ in addition to boosting oxytocin and dopamine, being kind can increase serotonin, a neurotransmitter that helps regulate mood. Kindness and compassion have been shown to release oxytocin, known as the “love hormone,” which increases self-esteem, trust, connection, and optimism. Oxytocin also reduces blood pressure and has been dubbed the “cardioprotective” hormone. According to Kelli Harding, MD, MPH, a psychiatrist affiliated with Columbia University in New York,² kindness can extend the lifespan. Research from Emory University in Atlanta has shown that, when an individual is kind to another, the brain’s reward centers light up – resulting in a “helper’s high.” Thus, kindness is self-reinforcing.³

Kindness leads to a greater sense of connection to others and a lessening in feelings of isolation. Small acts of kindness build up compassion in oneself. Research indicates that kindness doesn’t just positively affect the giver and receiver but can also benefit onlookers. An article in Psychology Today,⁴ suggests that those who witness acts of kindness are also more likely to “pay it forward,” resulting in a domino effect. Along these same lines, altruistic people, specifically those who engage in charitable donations, expressed higher levels of overall happiness according to a 2010 Harvard Business School survey.⁵

“You can’t pour from an empty cup” is a trendy quote making its way around social media. Before we can be kind and compassionate to others, we must first be kind and compassionate to ourselves. In today’s world, productivity and pressure-filled environments consume us daily. We often find ourselves skipping meals, forgetting to connect with loved ones, missing breaks, and even neglecting our sleep. It is virtually impossible to care for others when we are depleted ourselves. Sometimes not prioritizing ourselves can result in collateral damage. We may become short-tempered, irritable, moody, and overwhelmed. At this point kindness, compassion, and empathy toward others are likely to be absent. Once we replenish ourselves, by taking time off, indulging in a nice meal, exercising, we are more likely to respond as opposed to react, ask others about themselves, and engage in overall positive interactions throughout our day. Kindness is best fostered by being kind to ourselves to sustain our own well-being and by being kind to others in order to maintain the cycle. For clinicians who have been pushed to respond to various aspects of the COVID-19 pandemic, self-care has never been more important.

COVID-19 has been difficult for everyone, particularly the elderly and vulnerable populations. However, kindness has proved to be an overwhelming response as many businesses and individuals have taken to volunteering time and resources for those in need. Even big corporations have chipped in. For example, Lyft and Uber – in a partnership with the White House – are now offering free rides to vaccine sites, and several local businesses have donated personal protective equipment to hospitals and assisted living facilities.

Kindness and empathy are ever present in the field of mental health, medicine, and substance use treatment. The very act of caring for another involves kindness. In medicine, empathy has been defined as “an emotional experience between an observer and a subject in which the observer, based on visual and auditory cues, identifies and transiently experiences the subject’s emotional state.”⁶

As mental health professionals, we receive empathy training early on in our schooling – increasingly so over the last decade. Research has indicated that trusting relationships between clinicians and patients result in optimal care. Evidence-based communication styles are being widely implemented. This entails using nonjudgmental language, open-ended questions, and active listening skills, for example. In addition, the mental health professionals have our conscious and unconscious judgments. If empathy training is provided, we can learn to acknowledge our biases and mitigate them. Lastly, empathy training has been proven to assist with destigmatization, increase in treatment seeking, and overall better outcomes.

Substance use treatment, which often focuses on cognition and behavior changing, boundaries, and family dynamics, also requires support and kindness. Although it is not an empirically based “treatment,” Alcoholics Anonymous (AA) has used kindness for decades.

Step 12 of AA’s 12-step program, which was developed by two people with alcohol use disorder in 1935 in Akron, Ohio, is as follows: “Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.”

Once AA members are on solid ground with their sobriety, they are urged to help others in their recovery. This process provides many benefits. When individuals are concerned about someone else, they are less focused on themselves. This helps the individuals in recovery to decrease their rumination and “get out of themselves.” It also allows for the AA member to be kind and helpful to an individual who is suffering, thereby expressing kindness, compassion, and empathy. This act of “paying it forward” produces a domino effect that has withstood the test of time as evidenced by the ever-growing fellowship of Alcoholics Anonymous.

Several small acts of kindness can help us as clinicians and our patients:

1. Practice self-care.

2. Take a half day off from your practice.

3. Give staff a half day off.

4. Call a family member or friend and ask them how they are doing. Then engage in active listening and refrain from giving advice.

5. Donate to a homeless shelter or volunteer your time at a charity.

6. Give a stranger a compliment.

7. Surprise someone with a small gift.

8. Send a loved one a letter instead of a text.

9. Pick up litter.

10. Acknowledge family and friends who gave you extra support during the pandemic.

11. Take baked goods to your office.

12. Help a neighbor with groceries.

13. Leave a generous tip.

14. Play soft music in your office.

In conclusion, kindness, empathy, and compassion are vital concepts that are not just fluffy theories. They have vast mental, physical, and social benefits for us and our patients.
 

References

1. Cedars-Sinai staff. The Science of Kindness. 2019 Feb 13. Cedars-Sinai blog.

2. Harding K. The Rabbit Effect: Live Longer, Happier, and Healthier with the Groundbreaking Science of Kindness. Atria Books, 2019.

3. Ritvo E. BeKindr. Momosa Publishing, 2017.

4. Svoboda E. “Pay it Forward.” Psychology Today. Last reviewed 2016 Jun 9.

5. Aknin LB et al. “Prosocial spending and well-being: Cross-Cultural Evidence for a Psychological Universal.” Harvard Business School. Working Paper 11-038. 2010.

6. Hirsch EM. AMA J Ethics. Virtual Mentor. 2007;9(6):423-7.

Dr. Haji is a licensed clinical psychologist specializing in psychodiagnostic assessment, forensic assessment, dual diagnosis, serious and persistent mental illness, depression, anxiety, personality disorders, and substance abuse treatment. She practices in Miami and has no conflicts of interest.

Sigmund Freud said, “Out of your vulnerabilities will come greatest strength.” What exactly did Dr. Freud mean by this?

Many aspects of mental health treatment include cognitive restructuring, behavioral changes, emotion processing, and setting boundaries. These are all critical aspects of treatment, but what about kindness and compassion?

We often forget that kindness requires us to be vulnerable and take a risk at times. Being kind to others is not always easy, and it is not always an automatic reaction. Vulnerability often involves risk, but the outcomes often outweigh fear.

Dr. Freud was highlighting that being kind, open, and honest will often result in strong character and resilience. In turn, it will help others. Psychology and psychiatry have proved time and time again that empathy, compassion, and kindness have numerous benefits for mental and physical health for both the giver and the receiver.

From a biological perspective, we know that acts of kindness signal the brain to release serotonin and dopamine, known as “feel good transmitters,” and endorphins, which in turn lessen pain, depression, and anxiety. According to Waguih W. Ishak, MD, a psychiatrist affiliated with Cedars-Sinai in Los Angeles,¹ in addition to boosting oxytocin and dopamine, being kind can increase serotonin, a neurotransmitter that helps regulate mood. Kindness and compassion have been shown to release oxytocin, known as the “love hormone,” which increases self-esteem, trust, connection, and optimism. Oxytocin also reduces blood pressure and has been dubbed the “cardioprotective” hormone. According to Kelli Harding, MD, MPH, a psychiatrist affiliated with Columbia University in New York,² kindness can extend the lifespan. Research from Emory University in Atlanta has shown that, when an individual is kind to another, the brain’s reward centers light up – resulting in a “helper’s high.” Thus, kindness is self-reinforcing.³

Kindness leads to a greater sense of connection to others and a lessening in feelings of isolation. Small acts of kindness build up compassion in oneself. Research indicates that kindness doesn’t just positively affect the giver and receiver but can also benefit onlookers. An article in Psychology Today,⁴ suggests that those who witness acts of kindness are also more likely to “pay it forward,” resulting in a domino effect. Along these same lines, altruistic people, specifically those who engage in charitable donations, expressed higher levels of overall happiness according to a 2010 Harvard Business School survey.⁵

“You can’t pour from an empty cup” is a trendy quote making its way around social media. Before we can be kind and compassionate to others, we must first be kind and compassionate to ourselves. In today’s world, productivity and pressure-filled environments consume us daily. We often find ourselves skipping meals, forgetting to connect with loved ones, missing breaks, and even neglecting our sleep. It is virtually impossible to care for others when we are depleted ourselves. Sometimes not prioritizing ourselves can result in collateral damage. We may become short-tempered, irritable, moody, and overwhelmed. At this point kindness, compassion, and empathy toward others are likely to be absent. Once we replenish ourselves, by taking time off, indulging in a nice meal, exercising, we are more likely to respond as opposed to react, ask others about themselves, and engage in overall positive interactions throughout our day. Kindness is best fostered by being kind to ourselves to sustain our own well-being and by being kind to others in order to maintain the cycle. For clinicians who have been pushed to respond to various aspects of the COVID-19 pandemic, self-care has never been more important.

COVID-19 has been difficult for everyone, particularly the elderly and vulnerable populations. However, kindness has proved to be an overwhelming response as many businesses and individuals have taken to volunteering time and resources for those in need. Even big corporations have chipped in. For example, Lyft and Uber – in a partnership with the White House – are now offering free rides to vaccine sites, and several local businesses have donated personal protective equipment to hospitals and assisted living facilities.

Kindness and empathy are ever present in the field of mental health, medicine, and substance use treatment. The very act of caring for another involves kindness. In medicine, empathy has been defined as “an emotional experience between an observer and a subject in which the observer, based on visual and auditory cues, identifies and transiently experiences the subject’s emotional state.”⁶

As mental health professionals, we receive empathy training early on in our schooling – increasingly so over the last decade. Research has indicated that trusting relationships between clinicians and patients result in optimal care. Evidence-based communication styles are being widely implemented. This entails using nonjudgmental language, open-ended questions, and active listening skills, for example. In addition, the mental health professionals have our conscious and unconscious judgments. If empathy training is provided, we can learn to acknowledge our biases and mitigate them. Lastly, empathy training has been proven to assist with destigmatization, increase in treatment seeking, and overall better outcomes.

Substance use treatment, which often focuses on cognition and behavior changing, boundaries, and family dynamics, also requires support and kindness. Although it is not an empirically based “treatment,” Alcoholics Anonymous (AA) has used kindness for decades.

Step 12 of AA’s 12-step program, which was developed by two people with alcohol use disorder in 1935 in Akron, Ohio, is as follows: “Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.”

Once AA members are on solid ground with their sobriety, they are urged to help others in their recovery. This process provides many benefits. When individuals are concerned about someone else, they are less focused on themselves. This helps the individuals in recovery to decrease their rumination and “get out of themselves.” It also allows for the AA member to be kind and helpful to an individual who is suffering, thereby expressing kindness, compassion, and empathy. This act of “paying it forward” produces a domino effect that has withstood the test of time as evidenced by the ever-growing fellowship of Alcoholics Anonymous.

Several small acts of kindness can help us as clinicians and our patients:

1. Practice self-care.

2. Take a half day off from your practice.

3. Give staff a half day off.

4. Call a family member or friend and ask them how they are doing. Then engage in active listening and refrain from giving advice.

5. Donate to a homeless shelter or volunteer your time at a charity.

6. Give a stranger a compliment.

7. Surprise someone with a small gift.

8. Send a loved one a letter instead of a text.

9. Pick up litter.

10. Acknowledge family and friends who gave you extra support during the pandemic.

11. Take baked goods to your office.

12. Help a neighbor with groceries.

13. Leave a generous tip.

14. Play soft music in your office.

In conclusion, kindness, empathy, and compassion are vital concepts that are not just fluffy theories. They have vast mental, physical, and social benefits for us and our patients.
 

References

1. Cedars-Sinai staff. The Science of Kindness. 2019 Feb 13. Cedars-Sinai blog.

2. Harding K. The Rabbit Effect: Live Longer, Happier, and Healthier with the Groundbreaking Science of Kindness. Atria Books, 2019.

3. Ritvo E. BeKindr. Momosa Publishing, 2017.

4. Svoboda E. “Pay it Forward.” Psychology Today. Last reviewed 2016 Jun 9.

5. Aknin LB et al. “Prosocial spending and well-being: Cross-Cultural Evidence for a Psychological Universal.” Harvard Business School. Working Paper 11-038. 2010.

6. Hirsch EM. AMA J Ethics. Virtual Mentor. 2007;9(6):423-7.

Dr. Haji is a licensed clinical psychologist specializing in psychodiagnostic assessment, forensic assessment, dual diagnosis, serious and persistent mental illness, depression, anxiety, personality disorders, and substance abuse treatment. She practices in Miami and has no conflicts of interest.

A 75-year-old man with Parkinson’s disease has had three falls over the past 4 weeks. He has been compliant with his Parkinson’s treatment. Which of the following options would most help decrease his fall risk?

A. Vitamin D supplementation

B. Vitamin B₁₂ supplementation

C. Calcium supplementation

D. Tai chi

Falls are a catastrophic problem in our elderly population, and are especially common in patients with Parkinson’s disease.

There has been recent evidence that vitamin D supplementation is not helpful in preventing falls in most community-dwelling older adults. Bolland and colleagues performed a meta-analysis of 81 randomized, controlled trials and found that vitamin D supplementation does not prevent fractures or falls.¹ They found no difference or benefit in high-dose versus low-dose vitamin D supplementation.

The U.S. Preventive Services Task Force recommends against vitamin D supplementation for the purpose of preventing falls in community-dwelling adults over the age of 65.² The same USPSTF report recommends exercise intervention, as having the strongest evidence for fall prevention in community-dwelling adults age 65 or older who are at risk for falls.
 

The benefits of tai chi

Tai chi with it’s emphasis on balance, strength training as well as stress reduction is an excellent option for older adults.

Lui and colleagues performed a meta-analyses of five randomized, controlled trials (355 patients) of tai chi in patients with Parkinson disease.³ Tai chi significantly decreased fall rates (odds ratio, 0.47; 95% confidence interval, 0.30-0.74; P = .001) and significantly improved balance and functional mobility (P < .001) in people with Parkinson disease, compared with no training.

Tai chi can also help prevent falls in a more general population of elderly patients. Lomas-Vega and colleagues performed a meta-analysis of 10 high-quality studies that met inclusion criteria evaluating tai chi for fall prevention.⁴ Fall risk was reduced over short-term follow-up (incident rate ratio, 0.57; 95% CI, 0.46-0.70) and a small protective effect was seen over long-term follow-up (IRR, 0.87; 95% CI, 0.77-0.98).

Pearl: Consider tai chi in your elderly patients with fall risk to increase their balance and reduce risks of falls.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Bolland MJ et al. Lancet Diabetes Endocrinol. 2018;6(11):847.

2. U.S. Preventive Services Task Force. JAMA. 2018;319(16):1696.

3. Liu HH et al. Parkinsons Dis. 2019 Feb 21;2019:9626934

4. Lomas-Vega R et al. J Am Geriatr Soc. 2017;65(9):2037.

A 75-year-old man with Parkinson’s disease has had three falls over the past 4 weeks. He has been compliant with his Parkinson’s treatment. Which of the following options would most help decrease his fall risk?

A. Vitamin D supplementation

B. Vitamin B₁₂ supplementation

C. Calcium supplementation

D. Tai chi

Falls are a catastrophic problem in our elderly population, and are especially common in patients with Parkinson’s disease.

There has been recent evidence that vitamin D supplementation is not helpful in preventing falls in most community-dwelling older adults. Bolland and colleagues performed a meta-analysis of 81 randomized, controlled trials and found that vitamin D supplementation does not prevent fractures or falls.¹ They found no difference or benefit in high-dose versus low-dose vitamin D supplementation.

The U.S. Preventive Services Task Force recommends against vitamin D supplementation for the purpose of preventing falls in community-dwelling adults over the age of 65.² The same USPSTF report recommends exercise intervention, as having the strongest evidence for fall prevention in community-dwelling adults age 65 or older who are at risk for falls.
 

The benefits of tai chi

Tai chi with it’s emphasis on balance, strength training as well as stress reduction is an excellent option for older adults.

Lui and colleagues performed a meta-analyses of five randomized, controlled trials (355 patients) of tai chi in patients with Parkinson disease.³ Tai chi significantly decreased fall rates (odds ratio, 0.47; 95% confidence interval, 0.30-0.74; P = .001) and significantly improved balance and functional mobility (P < .001) in people with Parkinson disease, compared with no training.

Tai chi can also help prevent falls in a more general population of elderly patients. Lomas-Vega and colleagues performed a meta-analysis of 10 high-quality studies that met inclusion criteria evaluating tai chi for fall prevention.⁴ Fall risk was reduced over short-term follow-up (incident rate ratio, 0.57; 95% CI, 0.46-0.70) and a small protective effect was seen over long-term follow-up (IRR, 0.87; 95% CI, 0.77-0.98).

Pearl: Consider tai chi in your elderly patients with fall risk to increase their balance and reduce risks of falls.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Bolland MJ et al. Lancet Diabetes Endocrinol. 2018;6(11):847.

2. U.S. Preventive Services Task Force. JAMA. 2018;319(16):1696.

3. Liu HH et al. Parkinsons Dis. 2019 Feb 21;2019:9626934

4. Lomas-Vega R et al. J Am Geriatr Soc. 2017;65(9):2037.

A 75-year-old man with Parkinson’s disease has had three falls over the past 4 weeks. He has been compliant with his Parkinson’s treatment. Which of the following options would most help decrease his fall risk?

A. Vitamin D supplementation

B. Vitamin B₁₂ supplementation

C. Calcium supplementation

D. Tai chi

Falls are a catastrophic problem in our elderly population, and are especially common in patients with Parkinson’s disease.

There has been recent evidence that vitamin D supplementation is not helpful in preventing falls in most community-dwelling older adults. Bolland and colleagues performed a meta-analysis of 81 randomized, controlled trials and found that vitamin D supplementation does not prevent fractures or falls.¹ They found no difference or benefit in high-dose versus low-dose vitamin D supplementation.

The U.S. Preventive Services Task Force recommends against vitamin D supplementation for the purpose of preventing falls in community-dwelling adults over the age of 65.² The same USPSTF report recommends exercise intervention, as having the strongest evidence for fall prevention in community-dwelling adults age 65 or older who are at risk for falls.
 

The benefits of tai chi

Tai chi with it’s emphasis on balance, strength training as well as stress reduction is an excellent option for older adults.

Lui and colleagues performed a meta-analyses of five randomized, controlled trials (355 patients) of tai chi in patients with Parkinson disease.³ Tai chi significantly decreased fall rates (odds ratio, 0.47; 95% confidence interval, 0.30-0.74; P = .001) and significantly improved balance and functional mobility (P < .001) in people with Parkinson disease, compared with no training.

Tai chi can also help prevent falls in a more general population of elderly patients. Lomas-Vega and colleagues performed a meta-analysis of 10 high-quality studies that met inclusion criteria evaluating tai chi for fall prevention.⁴ Fall risk was reduced over short-term follow-up (incident rate ratio, 0.57; 95% CI, 0.46-0.70) and a small protective effect was seen over long-term follow-up (IRR, 0.87; 95% CI, 0.77-0.98).

Pearl: Consider tai chi in your elderly patients with fall risk to increase their balance and reduce risks of falls.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Bolland MJ et al. Lancet Diabetes Endocrinol. 2018;6(11):847.

2. U.S. Preventive Services Task Force. JAMA. 2018;319(16):1696.

3. Liu HH et al. Parkinsons Dis. 2019 Feb 21;2019:9626934

4. Lomas-Vega R et al. J Am Geriatr Soc. 2017;65(9):2037.

As the number of patients struggling with lingering effects of COVID-19 grows, much of the diagnosis and symptom management will fall on primary care, experts say.

“It could be as many as 5% to 10% who are still having symptoms at 12 weeks. Those numbers are higher if you’re talking about patients who had been hospitalized with COVID-19,” Russ Phillips, MD, director of the Center for Primary Care at Harvard Medical School, Boston, said in an interview.

A recent study from the Centers for Disease Control and Prevention and Kaiser Permanente Georgia found that among 3,171 nonhospitalized adult patients with COVID-19, 69% had one or more outpatient visits 28 to 180 days after the diagnosis. Two-thirds had a visit for a new primary diagnosis, and about one-third had a new specialist visit. Symptom diagnoses included cough, shortness of breath, chest or throat pain, and fatigue.

These visits have come while cases of acute COVID continue to occur, and there has been an increase in patients returning to primary care after avoiding it while the pandemic surged. For these patients, delay in seeking care has often led a worsening of chronic conditions.

Dr. Phillips pointed to a shortcoming in primary care that will need to be addressed with regard to long-COVID: “We don’t have good systems to follow patients and their symptoms over time.”

Long-COVID will require that kind of care, but current payment systems don’t support proactively reaching out to patients to track them over time, he noted.

“We do a good job of identifying these issues for patients who come in, but it’s the patients who don’t that we worry about the most,” he said.

Dr. Phillips provided examples of the kind of management plans needed to improve outcomes for patients with long-COVID. In anticoagulation clinics, patients who receive blood thinners are monitored closely, and in mental health care, patients with depression are linked with social workers and are monitored regularly.

“Around COVID, those management plans are in their infancy,” he said.

John Brooks, MD, chief medical officer for the CDC’s COVID-19 response, testified in a congressional hearing at the end of April that interim guidance concerning protocols for long-COVID in primary care are forthcoming. He also noted that the CDC is working closely with the Centers for Medicare & Medicaid Services to develop medical coding for long-COVID.

In the meantime, Dr. Phillips said, one strategy is to have patients self-monitor their condition and relay results to primary care physicians electronically.

As an example, Dr. Phillips described a patient with long-COVID who was receiving supplemental oxygen and who wanted to resume her exercise regimen.

She checked her own oxygen saturation levels before and during exercise and reported the levels every few days through their patient portal.

“Very slowly we were able to cut down on her oxygen and increase her exercise capacity until she no longer needed oxygen and could go back to her usual activities of daily living,” he said.

Nurse practitioners, social workers, and other nonphysician care team members may be increasingly relied upon to provide care for long-COVID patients as well, he said.

Additionally, telehealth, which is currently reimbursed the same way as in-person visits are, enables easier access for checking in with patients, he said.
 

Empathy and listening needed

Sabrina Assoumou, MD, MPH, assistant professor of medicine at Boston University, told this news organization that it will be crucial to address health care disparities as long-COVID cases mount.

COVID disproportionately affects communities of color, and it stands to reason that this will be the case for long-COVID as well, she said. Diversifying the workforce will be vital, inasmuch as diagnosis may depend on how well a physician listens to patients as they describe their symptoms, continued Dr. Assoumou, whose primary care practice centers on HIV patients.

The symptoms of long-COVID are vague, she explained, and include brain fog, fatigue, and shortness of breath, and it takes longer to diagnose than many conditions.

Dr. Assoumou said some people were never tested for COVID and never received a diagnosis, yet they are now experiencing the extended effects.

“Long-COVID will force us to go back to the basics – like really listening to our patients,” she said. “We’re definitely going to need to be more empathetic.”
 

No large influx yet

Charles Vega, MD, health sciences clinical professor of family medicine at the University of California, Irvine, said he is skeptical that the primary care system will be overwhelmed with long-COVID cases.

Dr. Vega is a family physician working in the largest safety net clinic in Orange County, California. About 90% of his patients are LatinX, a population disproportionately burdened by COVID, yet he hasn’t seen a surge in long-COVID cases.

He said that may be because patients know there isn’t a treatment for long-COVID. They are well connected through online forums such as Body Politic COVID-19 Support Group and may not feel they need to see a doctor.

“It wasn’t scientists finding [long-COVID], it was patients who developed this disease model themselves,” he said. “That’s where most of the data sharing is.”

Yet, for long-COVID patients who do need care, primary care is the best home for them, Dr. Vega said.

He said the most common symptoms he sees are fatigue and poor activity tolerance. “They get winded going to the bathroom,” he said.

The most difficult symptom is dyspnea, he said. Patients describe being breathless, but it’s not bad enough to qualify for supplemental oxygen.

“Being breathless is a pretty desperate thing and hurts quality of life,” he said.

Most patients describe general malaise.

Care for long-COVID will require medical care and mental health care, Dr. Vega notes. Primary care is already set up to screen and to coordinate care with the appropriate provider.

“I think there’s a role for specialists, but primary care has to be involved,” he said.

Dr. Phillips, Dr. Assoumou, and Dr. Vega report no relevant financial relationships.

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

As the number of patients struggling with lingering effects of COVID-19 grows, much of the diagnosis and symptom management will fall on primary care, experts say.

“It could be as many as 5% to 10% who are still having symptoms at 12 weeks. Those numbers are higher if you’re talking about patients who had been hospitalized with COVID-19,” Russ Phillips, MD, director of the Center for Primary Care at Harvard Medical School, Boston, said in an interview.

A recent study from the Centers for Disease Control and Prevention and Kaiser Permanente Georgia found that among 3,171 nonhospitalized adult patients with COVID-19, 69% had one or more outpatient visits 28 to 180 days after the diagnosis. Two-thirds had a visit for a new primary diagnosis, and about one-third had a new specialist visit. Symptom diagnoses included cough, shortness of breath, chest or throat pain, and fatigue.

These visits have come while cases of acute COVID continue to occur, and there has been an increase in patients returning to primary care after avoiding it while the pandemic surged. For these patients, delay in seeking care has often led a worsening of chronic conditions.

Dr. Phillips pointed to a shortcoming in primary care that will need to be addressed with regard to long-COVID: “We don’t have good systems to follow patients and their symptoms over time.”

Long-COVID will require that kind of care, but current payment systems don’t support proactively reaching out to patients to track them over time, he noted.

“We do a good job of identifying these issues for patients who come in, but it’s the patients who don’t that we worry about the most,” he said.

Dr. Phillips provided examples of the kind of management plans needed to improve outcomes for patients with long-COVID. In anticoagulation clinics, patients who receive blood thinners are monitored closely, and in mental health care, patients with depression are linked with social workers and are monitored regularly.

“Around COVID, those management plans are in their infancy,” he said.

John Brooks, MD, chief medical officer for the CDC’s COVID-19 response, testified in a congressional hearing at the end of April that interim guidance concerning protocols for long-COVID in primary care are forthcoming. He also noted that the CDC is working closely with the Centers for Medicare & Medicaid Services to develop medical coding for long-COVID.

In the meantime, Dr. Phillips said, one strategy is to have patients self-monitor their condition and relay results to primary care physicians electronically.

As an example, Dr. Phillips described a patient with long-COVID who was receiving supplemental oxygen and who wanted to resume her exercise regimen.

She checked her own oxygen saturation levels before and during exercise and reported the levels every few days through their patient portal.

“Very slowly we were able to cut down on her oxygen and increase her exercise capacity until she no longer needed oxygen and could go back to her usual activities of daily living,” he said.

Nurse practitioners, social workers, and other nonphysician care team members may be increasingly relied upon to provide care for long-COVID patients as well, he said.

Additionally, telehealth, which is currently reimbursed the same way as in-person visits are, enables easier access for checking in with patients, he said.
 

Empathy and listening needed

Sabrina Assoumou, MD, MPH, assistant professor of medicine at Boston University, told this news organization that it will be crucial to address health care disparities as long-COVID cases mount.

COVID disproportionately affects communities of color, and it stands to reason that this will be the case for long-COVID as well, she said. Diversifying the workforce will be vital, inasmuch as diagnosis may depend on how well a physician listens to patients as they describe their symptoms, continued Dr. Assoumou, whose primary care practice centers on HIV patients.

The symptoms of long-COVID are vague, she explained, and include brain fog, fatigue, and shortness of breath, and it takes longer to diagnose than many conditions.

Dr. Assoumou said some people were never tested for COVID and never received a diagnosis, yet they are now experiencing the extended effects.

“Long-COVID will force us to go back to the basics – like really listening to our patients,” she said. “We’re definitely going to need to be more empathetic.”
 

No large influx yet

Charles Vega, MD, health sciences clinical professor of family medicine at the University of California, Irvine, said he is skeptical that the primary care system will be overwhelmed with long-COVID cases.

Dr. Vega is a family physician working in the largest safety net clinic in Orange County, California. About 90% of his patients are LatinX, a population disproportionately burdened by COVID, yet he hasn’t seen a surge in long-COVID cases.

He said that may be because patients know there isn’t a treatment for long-COVID. They are well connected through online forums such as Body Politic COVID-19 Support Group and may not feel they need to see a doctor.

“It wasn’t scientists finding [long-COVID], it was patients who developed this disease model themselves,” he said. “That’s where most of the data sharing is.”

Yet, for long-COVID patients who do need care, primary care is the best home for them, Dr. Vega said.

He said the most common symptoms he sees are fatigue and poor activity tolerance. “They get winded going to the bathroom,” he said.

The most difficult symptom is dyspnea, he said. Patients describe being breathless, but it’s not bad enough to qualify for supplemental oxygen.

“Being breathless is a pretty desperate thing and hurts quality of life,” he said.

Most patients describe general malaise.

Care for long-COVID will require medical care and mental health care, Dr. Vega notes. Primary care is already set up to screen and to coordinate care with the appropriate provider.

“I think there’s a role for specialists, but primary care has to be involved,” he said.

Dr. Phillips, Dr. Assoumou, and Dr. Vega report no relevant financial relationships.

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

As the number of patients struggling with lingering effects of COVID-19 grows, much of the diagnosis and symptom management will fall on primary care, experts say.

“It could be as many as 5% to 10% who are still having symptoms at 12 weeks. Those numbers are higher if you’re talking about patients who had been hospitalized with COVID-19,” Russ Phillips, MD, director of the Center for Primary Care at Harvard Medical School, Boston, said in an interview.

A recent study from the Centers for Disease Control and Prevention and Kaiser Permanente Georgia found that among 3,171 nonhospitalized adult patients with COVID-19, 69% had one or more outpatient visits 28 to 180 days after the diagnosis. Two-thirds had a visit for a new primary diagnosis, and about one-third had a new specialist visit. Symptom diagnoses included cough, shortness of breath, chest or throat pain, and fatigue.

These visits have come while cases of acute COVID continue to occur, and there has been an increase in patients returning to primary care after avoiding it while the pandemic surged. For these patients, delay in seeking care has often led a worsening of chronic conditions.

Dr. Phillips pointed to a shortcoming in primary care that will need to be addressed with regard to long-COVID: “We don’t have good systems to follow patients and their symptoms over time.”

Long-COVID will require that kind of care, but current payment systems don’t support proactively reaching out to patients to track them over time, he noted.

“We do a good job of identifying these issues for patients who come in, but it’s the patients who don’t that we worry about the most,” he said.

Dr. Phillips provided examples of the kind of management plans needed to improve outcomes for patients with long-COVID. In anticoagulation clinics, patients who receive blood thinners are monitored closely, and in mental health care, patients with depression are linked with social workers and are monitored regularly.

“Around COVID, those management plans are in their infancy,” he said.

John Brooks, MD, chief medical officer for the CDC’s COVID-19 response, testified in a congressional hearing at the end of April that interim guidance concerning protocols for long-COVID in primary care are forthcoming. He also noted that the CDC is working closely with the Centers for Medicare & Medicaid Services to develop medical coding for long-COVID.

In the meantime, Dr. Phillips said, one strategy is to have patients self-monitor their condition and relay results to primary care physicians electronically.

As an example, Dr. Phillips described a patient with long-COVID who was receiving supplemental oxygen and who wanted to resume her exercise regimen.

She checked her own oxygen saturation levels before and during exercise and reported the levels every few days through their patient portal.

“Very slowly we were able to cut down on her oxygen and increase her exercise capacity until she no longer needed oxygen and could go back to her usual activities of daily living,” he said.

Nurse practitioners, social workers, and other nonphysician care team members may be increasingly relied upon to provide care for long-COVID patients as well, he said.

Additionally, telehealth, which is currently reimbursed the same way as in-person visits are, enables easier access for checking in with patients, he said.
 

Empathy and listening needed

Sabrina Assoumou, MD, MPH, assistant professor of medicine at Boston University, told this news organization that it will be crucial to address health care disparities as long-COVID cases mount.

COVID disproportionately affects communities of color, and it stands to reason that this will be the case for long-COVID as well, she said. Diversifying the workforce will be vital, inasmuch as diagnosis may depend on how well a physician listens to patients as they describe their symptoms, continued Dr. Assoumou, whose primary care practice centers on HIV patients.

The symptoms of long-COVID are vague, she explained, and include brain fog, fatigue, and shortness of breath, and it takes longer to diagnose than many conditions.

Dr. Assoumou said some people were never tested for COVID and never received a diagnosis, yet they are now experiencing the extended effects.

“Long-COVID will force us to go back to the basics – like really listening to our patients,” she said. “We’re definitely going to need to be more empathetic.”
 

No large influx yet

Charles Vega, MD, health sciences clinical professor of family medicine at the University of California, Irvine, said he is skeptical that the primary care system will be overwhelmed with long-COVID cases.

Dr. Vega is a family physician working in the largest safety net clinic in Orange County, California. About 90% of his patients are LatinX, a population disproportionately burdened by COVID, yet he hasn’t seen a surge in long-COVID cases.

He said that may be because patients know there isn’t a treatment for long-COVID. They are well connected through online forums such as Body Politic COVID-19 Support Group and may not feel they need to see a doctor.

“It wasn’t scientists finding [long-COVID], it was patients who developed this disease model themselves,” he said. “That’s where most of the data sharing is.”

Yet, for long-COVID patients who do need care, primary care is the best home for them, Dr. Vega said.

He said the most common symptoms he sees are fatigue and poor activity tolerance. “They get winded going to the bathroom,” he said.

The most difficult symptom is dyspnea, he said. Patients describe being breathless, but it’s not bad enough to qualify for supplemental oxygen.

“Being breathless is a pretty desperate thing and hurts quality of life,” he said.

Most patients describe general malaise.

Care for long-COVID will require medical care and mental health care, Dr. Vega notes. Primary care is already set up to screen and to coordinate care with the appropriate provider.

“I think there’s a role for specialists, but primary care has to be involved,” he said.

Dr. Phillips, Dr. Assoumou, and Dr. Vega report no relevant financial relationships.

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

Although use of some herbal and dietary supplements show statistically greater weight loss compared with placebo, it is not sufficient to benefit health, according to the joint findings of two systematic reviews, which are the first to comprehensively include all available herbal and dietary supplements for weight loss for over 15 years.

Sally Kubetin/MDedge News

“There is currently insufficient evidence to recommend any of the supplements we included in our reviews for weight loss,” stressed lead author Erica Bessell, a PhD candidate from the University of Sydney.

She added that some products with promising results warrant further investigation in well-conducted randomized controlled trials (RCTs) to determine their efficacy and safety.

But, overall, she would like to see a reduction in the number of products on the market without evidence to support their efficacy, “because, as we found, many of the products currently marketed for weight loss just do not work.

“Herbal and dietary supplements might seem like a quick-fix solution to weight problems, but people need to be aware of how little we actually know about them,” she said in an interview. “We would recommend that people trying to lose weight should save their money and seek out evidence-based care instead,” she emphasized.

The research was presented as two posters at this year’s online European Congress on Obesity (ECO). The meeting was presented by the European Association for the Study of Obesity.
 

Herbal and dietary supplement industry booming

Supplements for weight loss are growing in popularity, sustaining a rapidly expanding business sector globally. In the United States, the herbal and dietary supplements industry was estimated to be worth USD $41 billion in 2020, with 15% of Americans having tried a weight loss supplement in their efforts to shed pounds.

In light of this, Ms. Bessell said it is increasingly important to ensure supplements are efficacious and safe: “The popularity of these products underscores the urgency of conducting larger, more rigorous studies to have reasonable assurance of their safety and effectiveness for weight loss.”

Commenting on the study and the wider issues related to the surge in uptake of herbal and dietary supplements, Susan Arentz, PhD, said the evidence is similar to that for other complex interventions that people attempt for weight loss, including for example exercise, in that it is heterogeneous and low quality.

“One outstanding limitation for herbal medicine was the failure of trialists to validate the contents of interventions. Given the chemical variability of plants grown and harvested in different conditions, and the presence of pharmaceuticals and heavy metals found in some supplements ... future investigations of standardized herbal supplements and RCTs of higher methodological quality are needed,” remarked Dr. Arentz, a board member of the Australasian Integrative Medicine Association and researcher at Western Sydney University.

“Also, further RCTs are warranted due to the consumer preferences for natural treatments, especially in health settings with predominant use of traditional medicines and practices,” said Dr. Arentz.   
 

One review for herbal supplements, one for organic compounds

To accommodate the large number of trials investigating supplements for weight loss, the researchers conducted two systematic reviews, together representing 121 randomized placebo-controlled trials. One of the reviews investigated herbal supplements, and the other examined supplements with isolated organic compounds for example, specific fibers or lipids.  

Many of the included trials had been published in the last decade and had not been previously included in an up-to-date systematic review.

Ms. Bessell added that many studies often had a small sample size or were poorly designed, with insufficient information on the composition of supplements, and often featured little data on long-term effectiveness.

The two reviews primarily analyzed efficacy, not safety, because many of the studies did not report adverse effects.

The first review, published last year in Diabetes, Obesity and Metabolism, looked at 54 placebo-controlled randomized trials up to August 2018 on the effect of herbal supplements on weight loss . The study included 4,331 individuals aged 16 years or older who were overweight or obese. To be clinically meaningful, a weight loss of at least 2.5 kg was required over a period of, most often, 12 weeks or less.

Herbal supplements included in the analysis included green tea, Garcinia cambogia and mangosteen (tropical fruits), white kidney bean, ephedra (a stimulant that increases metabolism), African mango, yerba mate (herbal tea made from the leaves and twigs of the Ilex paraguariensis plant), veld grape (commonly used in Indian traditional medicine), licorice root, and East Indian Globe Thistle (used in Ayurvedic medicine).

The second review analyzed 67 randomized trials up to December 2019 that compared the effect of dietary supplements containing naturally occurring isolated organic compounds to placebo for weight loss in 5,194 individuals aged 16 years or older who were overweight or obese.

Meta-analyses were conducted for chitosan, glucomannan, conjugated linoleic acid, and fructans comparing the mean weight difference post intervention between participants receiving the dietary supplement and those on placebo.
 

No clinically significant results

Commenting on the overall results, Ms. Bessell said: “Though most supplements were safe for use in the short term, very few were found to produce clinically meaningful weight loss. Those that were found to result in clinically meaningful weight loss had only been investigated in one or two trials, so we need more research.”

The first review on herbal supplements found that only Phaseolus vulgaris (white kidney bean) resulted in significant weight loss compared with placebo, with an average weight difference of 1.61 kg (3.5 pounds). The result was not clinically meaningful, however.

For isolated organic compounds, significant weight differences compared with placebo were seen for chitosan, with a mean difference of 1.84 kg (4 pounds), glucomannan at 1.27 kg (2.8 pounds), and conjugated linoleic acid at 1.08 kg (2.4 pounds).

Again, none of these findings met the criteria for clinical significance (weight loss of 2.5 kg [5.5 pounds] or more).

In addition, some combination preparations containing African mango, veld grape, East Indian Globe Thistle, and mangosteen showed promising results with a mean weight difference of 1.85 kg (4 pounds), but were investigated in three or fewer trials, often with poor research methodology or reporting, and the findings should be interpreted with caution, the researchers noted.

Other dietary supplements, including modified cellulose – a plant fiber that expands in the stomach to induce a feeling of fullness – and blood orange juice extract, also showed encouraging results but were investigated in one trial and need more evidence before they can be recommended for weight loss, Ms. Bessell added.

She pointed out that some supplements are banned in some countries, such as ephedra (an extract from the plant Ephedra sinica). “This supplement is already banned in many countries because of the risk of serious adverse effects. The possibility of drug interactions may also be present with some other supplements, so health professionals and consumers should be aware of this.”

The isolated organic compounds supplements review was published in the International Journal of Obesity to coincide with the ECO 2021 conference.

Ms. Bessell has declared no relevant conflicts of interests. Dr. Arentz reviewed the systematic review of RCTs of herbal medicine supplements for weight loss published in Diabetes, Obesity and Metabolism.
 

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