Thadeo Catacutan, MD, sat in a ballroom at the Gaylord Resort & Convention Center in National Harbor, Md., on a sunny spring day at HM13, just thinking about his future after spending seven years as a hospitalist at Cleveland Clinic. He wondered if additional training in business administration would provide him with the advancement opportunities and professional fulfillment he sought.

“It’s been hard to determine what I really want to do,” he said. “After seven years, is this the peak? Are there other opportunities?

“I realize that if you are not going to specialize, you have to go into a leadership career track,” he said. “Some would say you can just be a clinician, but in the long term, I don’t think that is a sustainable path. You will just burn out.”

Dr. Catacutan isn’t the only one concerned. Nearly 200 physicians joined him for an HM13 breakout session titled “Career Tracks for Hospitalists.” The session provided attendees two viewpoints on career advancement: the executive pathway and the hospital leadership pathway. And although the session’s speakers demonstrated distinct routes to senior positions, there’s a shared path for each, including:

• Weighing choices carefully. The reasons for seeking a new career path are personal and not the same for everyone. Keep that in mind.
• Thinking about return on investment. Physicians should consider what they’re getting for their effort, whether that’s the cost of an advanced degree or the value of time spent volunteering on a hospital committee.
• Contemplating what you like about your job. When considering a career move, remember the adage that the grass is always greener.

“The way you get to take on leadership opportunities is by acceptance,” said session moderator Michael Guthrie, MD, MBA, executive in residence at the University of Colorado. “Say ‘yes.’ Say ‘I’m curious’ or ‘How can I make a contribution?’ You will stumble. You will make mistakes. You will be clumsy. … But it is that process that teaches you what you need to know.”

Path: Advanced Training

Michael Ruhlen, MD, MHCM, FACHE, SFHM, said he needed to know how to communicate better with the administrators he regularly met with to discuss his pediatric hospitalist program.

“I found that I wasn’t always speaking the same language when I talked to administrators about the value that hospitalists brought to their individual institutions,” he said. “No matter how hard I tried, I could always walk into a room with a master’s-prepared administrator who could absolutely prove to me that my hospitalist program would cost them far more money than it would ever be worth—and they simply could not afford it.”

To address what he calls a “knowledge deficit,” Dr. Ruhlen earned his master’s degree in health-care management from the Harvard School of Public Health in Boston. Armed with new business acumen, he rose to vice president of medical affairs at Toledo Children’s Hospital in Ohio, and even served as interim president for a short time before he became vice president and chief medical officer of Carolina HealthCare Systems in Charlotte, N.C.

“Communications, public speaking, and change management was a very big component of what we were taught,” he added, “as well as performance improvement, which is where my career has drifted.”

Dr. Ruhlen said hospitalists are perfectly positioned for leadership roles in hospitals. He also said that “institutions led by physicians appear to have better performance metrics” and that physicians “owe it to our patients to try to take back medicine.”

One thing Dr. Ruhlen wished medical training would address better is population health, a topic he became “enamored” with in business school. “It’s a very interesting body of work, interesting body of language,” he said. “I think it will be critically important as we move into a realm of significant health reform.”

Path: Quality Expertise

Greg Maynard, MD, MSC, SFHM, took a different route to hospital leadership. He didn’t seek an advanced degree in business and hasn’t bounced from one job to another climbing the corporate ladder. Instead, he’s devoted his time and energy to quality improvement (QI) as clinical professor of medicine in the division of hospital medicine at the University of California at San Diego.

Dr. Maynard encouraged hospitalists to consider becoming experts in hospital quality and patient safety, a path that has led him to national recognition. “You won’t get bored,” he said. “Your career will find you.”

Dr. Maynard, who serves as senior vice president of SHM’s Center for Healthcare Improvement and Innovation, said every QI project “seems to have its time,” and he warned hospitalists that dealing with frustration is part of the job description.

“Some projects I initiated didn’t get off the ground, no matter why I did it,” he explained. “For example, transitions of care—when we started looking at it, nobody in the hospital cared. The administrators didn’t care about discharge summaries or teachback communication strategies. They only cared when readmissions came in focus.”

He and his team needed to learn to “satisfy ourselves” and change what they could change as hospitalists. The hard part, he said, was being patient.

“We knew it was coming; we just had to wait and not get rankled,” he added. “I had to learn to not take things personally. Be patient and wait for the opportunity.”

Dr. Maynard advised hospitalists to learn to “say no, or ‘I would love to but I just can’t.’” He also said hospitalists should not be afraid to ask for help.

Return on Investment

Dr. Guthrie, who received his MBA nearly 40 years ago, said times have changed and business schools have adapted to a new economic landscape. Opportunities for physicians to receive advanced training are much greater now, with physicians earning advanced degrees in public health and health administration, as well as MBAs.

Many of the top schools offer work-friendly course schedules, including night and weekend courses and plenty of online options. Some, such as the University of Massachusetts, offer a 100% online MBA program.

Listen to Dr. Guthrie discuss his path to hospital leadership and how business schools have adapted for physicians.

Still, he warned hospitalists to consider their goals along with the time, energy, and financial commitment that post-graduate work requires.

“The investment is huge,” he said.

It’s exactly what Dr. Catacutan is contemplating. Should he go back to school, pursue leadership within the walls of his hospital and executive courses like SHM’s Leadership Academy, or should he be satisfied as a full-time clinician?

“Is it really worth my time, especially with family and kids?” he asked rhetorically. “It’s a personal decision.” TH

Richard Quinn is a freelance writer in New Jersey.

Thadeo Catacutan, MD, sat in a ballroom at the Gaylord Resort & Convention Center in National Harbor, Md., on a sunny spring day at HM13, just thinking about his future after spending seven years as a hospitalist at Cleveland Clinic. He wondered if additional training in business administration would provide him with the advancement opportunities and professional fulfillment he sought.

“It’s been hard to determine what I really want to do,” he said. “After seven years, is this the peak? Are there other opportunities?

“I realize that if you are not going to specialize, you have to go into a leadership career track,” he said. “Some would say you can just be a clinician, but in the long term, I don’t think that is a sustainable path. You will just burn out.”

Dr. Catacutan isn’t the only one concerned. Nearly 200 physicians joined him for an HM13 breakout session titled “Career Tracks for Hospitalists.” The session provided attendees two viewpoints on career advancement: the executive pathway and the hospital leadership pathway. And although the session’s speakers demonstrated distinct routes to senior positions, there’s a shared path for each, including:

• Weighing choices carefully. The reasons for seeking a new career path are personal and not the same for everyone. Keep that in mind.
• Thinking about return on investment. Physicians should consider what they’re getting for their effort, whether that’s the cost of an advanced degree or the value of time spent volunteering on a hospital committee.
• Contemplating what you like about your job. When considering a career move, remember the adage that the grass is always greener.

“The way you get to take on leadership opportunities is by acceptance,” said session moderator Michael Guthrie, MD, MBA, executive in residence at the University of Colorado. “Say ‘yes.’ Say ‘I’m curious’ or ‘How can I make a contribution?’ You will stumble. You will make mistakes. You will be clumsy. … But it is that process that teaches you what you need to know.”

Path: Advanced Training

Michael Ruhlen, MD, MHCM, FACHE, SFHM, said he needed to know how to communicate better with the administrators he regularly met with to discuss his pediatric hospitalist program.

“I found that I wasn’t always speaking the same language when I talked to administrators about the value that hospitalists brought to their individual institutions,” he said. “No matter how hard I tried, I could always walk into a room with a master’s-prepared administrator who could absolutely prove to me that my hospitalist program would cost them far more money than it would ever be worth—and they simply could not afford it.”

To address what he calls a “knowledge deficit,” Dr. Ruhlen earned his master’s degree in health-care management from the Harvard School of Public Health in Boston. Armed with new business acumen, he rose to vice president of medical affairs at Toledo Children’s Hospital in Ohio, and even served as interim president for a short time before he became vice president and chief medical officer of Carolina HealthCare Systems in Charlotte, N.C.

“Communications, public speaking, and change management was a very big component of what we were taught,” he added, “as well as performance improvement, which is where my career has drifted.”

Dr. Ruhlen said hospitalists are perfectly positioned for leadership roles in hospitals. He also said that “institutions led by physicians appear to have better performance metrics” and that physicians “owe it to our patients to try to take back medicine.”

One thing Dr. Ruhlen wished medical training would address better is population health, a topic he became “enamored” with in business school. “It’s a very interesting body of work, interesting body of language,” he said. “I think it will be critically important as we move into a realm of significant health reform.”

Path: Quality Expertise

Greg Maynard, MD, MSC, SFHM, took a different route to hospital leadership. He didn’t seek an advanced degree in business and hasn’t bounced from one job to another climbing the corporate ladder. Instead, he’s devoted his time and energy to quality improvement (QI) as clinical professor of medicine in the division of hospital medicine at the University of California at San Diego.

Dr. Maynard encouraged hospitalists to consider becoming experts in hospital quality and patient safety, a path that has led him to national recognition. “You won’t get bored,” he said. “Your career will find you.”

Dr. Maynard, who serves as senior vice president of SHM’s Center for Healthcare Improvement and Innovation, said every QI project “seems to have its time,” and he warned hospitalists that dealing with frustration is part of the job description.

“Some projects I initiated didn’t get off the ground, no matter why I did it,” he explained. “For example, transitions of care—when we started looking at it, nobody in the hospital cared. The administrators didn’t care about discharge summaries or teachback communication strategies. They only cared when readmissions came in focus.”

He and his team needed to learn to “satisfy ourselves” and change what they could change as hospitalists. The hard part, he said, was being patient.

“We knew it was coming; we just had to wait and not get rankled,” he added. “I had to learn to not take things personally. Be patient and wait for the opportunity.”

Dr. Maynard advised hospitalists to learn to “say no, or ‘I would love to but I just can’t.’” He also said hospitalists should not be afraid to ask for help.

Return on Investment

Dr. Guthrie, who received his MBA nearly 40 years ago, said times have changed and business schools have adapted to a new economic landscape. Opportunities for physicians to receive advanced training are much greater now, with physicians earning advanced degrees in public health and health administration, as well as MBAs.

Many of the top schools offer work-friendly course schedules, including night and weekend courses and plenty of online options. Some, such as the University of Massachusetts, offer a 100% online MBA program.

Listen to Dr. Guthrie discuss his path to hospital leadership and how business schools have adapted for physicians.

Still, he warned hospitalists to consider their goals along with the time, energy, and financial commitment that post-graduate work requires.

“The investment is huge,” he said.

It’s exactly what Dr. Catacutan is contemplating. Should he go back to school, pursue leadership within the walls of his hospital and executive courses like SHM’s Leadership Academy, or should he be satisfied as a full-time clinician?

“Is it really worth my time, especially with family and kids?” he asked rhetorically. “It’s a personal decision.” TH

Richard Quinn is a freelance writer in New Jersey.

Thadeo Catacutan, MD, sat in a ballroom at the Gaylord Resort & Convention Center in National Harbor, Md., on a sunny spring day at HM13, just thinking about his future after spending seven years as a hospitalist at Cleveland Clinic. He wondered if additional training in business administration would provide him with the advancement opportunities and professional fulfillment he sought.

“It’s been hard to determine what I really want to do,” he said. “After seven years, is this the peak? Are there other opportunities?

“I realize that if you are not going to specialize, you have to go into a leadership career track,” he said. “Some would say you can just be a clinician, but in the long term, I don’t think that is a sustainable path. You will just burn out.”

Dr. Catacutan isn’t the only one concerned. Nearly 200 physicians joined him for an HM13 breakout session titled “Career Tracks for Hospitalists.” The session provided attendees two viewpoints on career advancement: the executive pathway and the hospital leadership pathway. And although the session’s speakers demonstrated distinct routes to senior positions, there’s a shared path for each, including:

• Weighing choices carefully. The reasons for seeking a new career path are personal and not the same for everyone. Keep that in mind.
• Thinking about return on investment. Physicians should consider what they’re getting for their effort, whether that’s the cost of an advanced degree or the value of time spent volunteering on a hospital committee.
• Contemplating what you like about your job. When considering a career move, remember the adage that the grass is always greener.

“The way you get to take on leadership opportunities is by acceptance,” said session moderator Michael Guthrie, MD, MBA, executive in residence at the University of Colorado. “Say ‘yes.’ Say ‘I’m curious’ or ‘How can I make a contribution?’ You will stumble. You will make mistakes. You will be clumsy. … But it is that process that teaches you what you need to know.”

Path: Advanced Training

Michael Ruhlen, MD, MHCM, FACHE, SFHM, said he needed to know how to communicate better with the administrators he regularly met with to discuss his pediatric hospitalist program.

“I found that I wasn’t always speaking the same language when I talked to administrators about the value that hospitalists brought to their individual institutions,” he said. “No matter how hard I tried, I could always walk into a room with a master’s-prepared administrator who could absolutely prove to me that my hospitalist program would cost them far more money than it would ever be worth—and they simply could not afford it.”

To address what he calls a “knowledge deficit,” Dr. Ruhlen earned his master’s degree in health-care management from the Harvard School of Public Health in Boston. Armed with new business acumen, he rose to vice president of medical affairs at Toledo Children’s Hospital in Ohio, and even served as interim president for a short time before he became vice president and chief medical officer of Carolina HealthCare Systems in Charlotte, N.C.

“Communications, public speaking, and change management was a very big component of what we were taught,” he added, “as well as performance improvement, which is where my career has drifted.”

Dr. Ruhlen said hospitalists are perfectly positioned for leadership roles in hospitals. He also said that “institutions led by physicians appear to have better performance metrics” and that physicians “owe it to our patients to try to take back medicine.”

One thing Dr. Ruhlen wished medical training would address better is population health, a topic he became “enamored” with in business school. “It’s a very interesting body of work, interesting body of language,” he said. “I think it will be critically important as we move into a realm of significant health reform.”

Path: Quality Expertise

Greg Maynard, MD, MSC, SFHM, took a different route to hospital leadership. He didn’t seek an advanced degree in business and hasn’t bounced from one job to another climbing the corporate ladder. Instead, he’s devoted his time and energy to quality improvement (QI) as clinical professor of medicine in the division of hospital medicine at the University of California at San Diego.

Dr. Maynard encouraged hospitalists to consider becoming experts in hospital quality and patient safety, a path that has led him to national recognition. “You won’t get bored,” he said. “Your career will find you.”

Dr. Maynard, who serves as senior vice president of SHM’s Center for Healthcare Improvement and Innovation, said every QI project “seems to have its time,” and he warned hospitalists that dealing with frustration is part of the job description.

“Some projects I initiated didn’t get off the ground, no matter why I did it,” he explained. “For example, transitions of care—when we started looking at it, nobody in the hospital cared. The administrators didn’t care about discharge summaries or teachback communication strategies. They only cared when readmissions came in focus.”

He and his team needed to learn to “satisfy ourselves” and change what they could change as hospitalists. The hard part, he said, was being patient.

“We knew it was coming; we just had to wait and not get rankled,” he added. “I had to learn to not take things personally. Be patient and wait for the opportunity.”

Dr. Maynard advised hospitalists to learn to “say no, or ‘I would love to but I just can’t.’” He also said hospitalists should not be afraid to ask for help.

Return on Investment

Dr. Guthrie, who received his MBA nearly 40 years ago, said times have changed and business schools have adapted to a new economic landscape. Opportunities for physicians to receive advanced training are much greater now, with physicians earning advanced degrees in public health and health administration, as well as MBAs.

Many of the top schools offer work-friendly course schedules, including night and weekend courses and plenty of online options. Some, such as the University of Massachusetts, offer a 100% online MBA program.

Listen to Dr. Guthrie discuss his path to hospital leadership and how business schools have adapted for physicians.

Still, he warned hospitalists to consider their goals along with the time, energy, and financial commitment that post-graduate work requires.

“The investment is huge,” he said.

It’s exactly what Dr. Catacutan is contemplating. Should he go back to school, pursue leadership within the walls of his hospital and executive courses like SHM’s Leadership Academy, or should he be satisfied as a full-time clinician?

“Is it really worth my time, especially with family and kids?” he asked rhetorically. “It’s a personal decision.” TH

Richard Quinn is a freelance writer in New Jersey.

CHICAGO – Routine surveillance imaging does not improve clinical outcomes in patients with classic Hodgkin disease who are in first complete remission and it sharply increases costs, researchers reported at the annual meeting of the American Society of Clinical Oncology.

The team, led by Dr. Sai Ravi Pingali, retrospectively reviewed the charts of 241 adult patients who achieved a complete remission after first-line therapy.

In 68%, the treating physicians’ planned approach was routine surveillance imaging, which consisted of radiologic imaging with scans every few months, plus clinical exams and laboratory testing. In the other 32%, the planned approach was clinical surveillance, meaning that radiologic imaging was performed only if concerning signs or symptoms occurred.

The two groups had statistically indistinguishable overall survival, and in both groups, all patients experiencing relapse successfully achieved a second complete remission with salvage therapy.

In the routinely imaged group, scanning increased costs by nearly $20,000 per patient and by almost $600,000 per each relapse detected. In addition, patients were exposed to the associated radiation.

"We were unable to detect an overall survival benefit associated with routine surveillance imaging, although I have to acknowledge that our study was limited in power given the small number of deaths and relapses," commented Dr. Pingali, an oncologist with the Medical College of Wisconsin Affiliated Hospitals in Milwaukee.

"Relapses in both ... groups were effectively salvaged with autologous stem cell transplantation, arguing against a critical advantage of detection of asymptomatic relapse. Also, we need to keep in mind that the costs associated with routine surveillance imaging are significant, and it is also associated with potential risks, both in terms of radiation exposure and unnecessary work-up," he added.

"We do not feel that potential risks and costs without overall survival benefit or any other clinical benefit justify the practice of routine surveillance imaging in classical Hodgkin lymphoma patients who have achieved a complete remission after first-line therapy. We recommend that such patients be followed clinically," Dr. Pingali concluded.

Invited discussant Dr. Leo Gordon of Northwestern University in Chicago, agreed that accumulating data argue against routine imaging for surveillance in this context and noted that insurers will likely not continue to cover scans having no proven benefit. The data should prompt a revision of guidelines and reeducation of clinicians and patients, he said.

"For translational researchers and investigators and academics, I think we need to convince journal reviewers that a manuscript is acceptable if scans are not so frequent. And for industry trials, I think we need to discuss with the Food and Drug Administration the endpoint of progression-free survival and that those endpoints may not only be driven by scans but by more mundane parameters," he said—namely, the history and physical examination.

But session comoderator Dr. Gilles A. Salles of Hospices Civils de Lyon, Université Claude Bernard, France, expressed reservations, noting that the study did not provide information on how patients were allocated to groups and the time frame of relapse.

"It may be different whether relapses occur early, in the first year, or they occur later, and that may have some implications for the surveillance," he said. "I understand that you and many others jumped over the idea that we should immediately stop. A few people may think that we need more solid data, despite the provocative and quality data that were presented, to really make this jump in clinical practice. That’s my personal opinion."

Dr. Pingali and his team retrospectively reviewed the charts of adult patients who received a new diagnosis of classical Hodgkin lymphoma between 2000 and 2010 at three institutions, achieved complete remission after first-line therapy and had at least 2 years of follow-up.

The routine surveillance imaging and clinical surveillance groups had similar demographic and disease characteristics, Dr. Pingali reported. The former were significantly more likely to have received ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, and dacarbazine) and less likely to have received the Stanford V regimen as first-line therapy, and they were significantly less likely to have received radiation therapy.

With a median duration of follow-up of about 4 years, the groups did not differ significantly with respect to overall survival. "When we look at the 5-year time point, when typically the surveillance CT scans are discontinued, the curves are pretty much superimposable," he pointed out.

There were five deaths in the routine surveillance imaging group, one of which was from relapsed disease; the other deaths were from cancer, heart failure, hip fracture, and myelodysplastic syndrome. There were four deaths in the clinical surveillance group: two were from non-Hodgkin lymphoma and two from unknown causes while the patient was in confirmed remission.

All of the six patients in the routinely imaged group and all of the five patients in the clinically followed group experiencing a relapse achieved another complete remission with second-line therapy.

The mean number of scans received was 1.14 in the clinical surveillance group – usually the scan performed after first-line treatment to confirm remission, according to Dr. Pingali – and 4.25 in the routine surveillance imaging group. The ratio of scans to detected relapses was 18 vs. 124.

The extra charges incurred from scans using the routine surveillance imaging approach were $18,896/patient and $593,698/relapse.

"It is important to note that this does not include additional costs from the work-up of the false-positive scans and also the wages lost," he noted.

Dr. Pingali disclosed no relevant conflicts of interest. Dr. Gordon disclosed that he receives honoraria from Genentech and research funding from Millennium and Pharmacyclics. Dr. Salles disclosed serving as an advisor or consultant for Calistoga Pharmaceuticals, Celgene; Genentech, Janssen Pharmaceutica, and Roche. He has served as a speaker or a member of a speakers bureau and has received grants for clinical research from Celgene and Roche.

CHICAGO – Routine surveillance imaging does not improve clinical outcomes in patients with classic Hodgkin disease who are in first complete remission and it sharply increases costs, researchers reported at the annual meeting of the American Society of Clinical Oncology.

The team, led by Dr. Sai Ravi Pingali, retrospectively reviewed the charts of 241 adult patients who achieved a complete remission after first-line therapy.

In 68%, the treating physicians’ planned approach was routine surveillance imaging, which consisted of radiologic imaging with scans every few months, plus clinical exams and laboratory testing. In the other 32%, the planned approach was clinical surveillance, meaning that radiologic imaging was performed only if concerning signs or symptoms occurred.

The two groups had statistically indistinguishable overall survival, and in both groups, all patients experiencing relapse successfully achieved a second complete remission with salvage therapy.

In the routinely imaged group, scanning increased costs by nearly $20,000 per patient and by almost $600,000 per each relapse detected. In addition, patients were exposed to the associated radiation.

"We were unable to detect an overall survival benefit associated with routine surveillance imaging, although I have to acknowledge that our study was limited in power given the small number of deaths and relapses," commented Dr. Pingali, an oncologist with the Medical College of Wisconsin Affiliated Hospitals in Milwaukee.

"Relapses in both ... groups were effectively salvaged with autologous stem cell transplantation, arguing against a critical advantage of detection of asymptomatic relapse. Also, we need to keep in mind that the costs associated with routine surveillance imaging are significant, and it is also associated with potential risks, both in terms of radiation exposure and unnecessary work-up," he added.

"We do not feel that potential risks and costs without overall survival benefit or any other clinical benefit justify the practice of routine surveillance imaging in classical Hodgkin lymphoma patients who have achieved a complete remission after first-line therapy. We recommend that such patients be followed clinically," Dr. Pingali concluded.

Invited discussant Dr. Leo Gordon of Northwestern University in Chicago, agreed that accumulating data argue against routine imaging for surveillance in this context and noted that insurers will likely not continue to cover scans having no proven benefit. The data should prompt a revision of guidelines and reeducation of clinicians and patients, he said.

"For translational researchers and investigators and academics, I think we need to convince journal reviewers that a manuscript is acceptable if scans are not so frequent. And for industry trials, I think we need to discuss with the Food and Drug Administration the endpoint of progression-free survival and that those endpoints may not only be driven by scans but by more mundane parameters," he said—namely, the history and physical examination.

But session comoderator Dr. Gilles A. Salles of Hospices Civils de Lyon, Université Claude Bernard, France, expressed reservations, noting that the study did not provide information on how patients were allocated to groups and the time frame of relapse.

"It may be different whether relapses occur early, in the first year, or they occur later, and that may have some implications for the surveillance," he said. "I understand that you and many others jumped over the idea that we should immediately stop. A few people may think that we need more solid data, despite the provocative and quality data that were presented, to really make this jump in clinical practice. That’s my personal opinion."

Dr. Pingali and his team retrospectively reviewed the charts of adult patients who received a new diagnosis of classical Hodgkin lymphoma between 2000 and 2010 at three institutions, achieved complete remission after first-line therapy and had at least 2 years of follow-up.

The routine surveillance imaging and clinical surveillance groups had similar demographic and disease characteristics, Dr. Pingali reported. The former were significantly more likely to have received ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, and dacarbazine) and less likely to have received the Stanford V regimen as first-line therapy, and they were significantly less likely to have received radiation therapy.

With a median duration of follow-up of about 4 years, the groups did not differ significantly with respect to overall survival. "When we look at the 5-year time point, when typically the surveillance CT scans are discontinued, the curves are pretty much superimposable," he pointed out.

There were five deaths in the routine surveillance imaging group, one of which was from relapsed disease; the other deaths were from cancer, heart failure, hip fracture, and myelodysplastic syndrome. There were four deaths in the clinical surveillance group: two were from non-Hodgkin lymphoma and two from unknown causes while the patient was in confirmed remission.

All of the six patients in the routinely imaged group and all of the five patients in the clinically followed group experiencing a relapse achieved another complete remission with second-line therapy.

The mean number of scans received was 1.14 in the clinical surveillance group – usually the scan performed after first-line treatment to confirm remission, according to Dr. Pingali – and 4.25 in the routine surveillance imaging group. The ratio of scans to detected relapses was 18 vs. 124.

The extra charges incurred from scans using the routine surveillance imaging approach were $18,896/patient and $593,698/relapse.

"It is important to note that this does not include additional costs from the work-up of the false-positive scans and also the wages lost," he noted.

Dr. Pingali disclosed no relevant conflicts of interest. Dr. Gordon disclosed that he receives honoraria from Genentech and research funding from Millennium and Pharmacyclics. Dr. Salles disclosed serving as an advisor or consultant for Calistoga Pharmaceuticals, Celgene; Genentech, Janssen Pharmaceutica, and Roche. He has served as a speaker or a member of a speakers bureau and has received grants for clinical research from Celgene and Roche.

CHICAGO – Routine surveillance imaging does not improve clinical outcomes in patients with classic Hodgkin disease who are in first complete remission and it sharply increases costs, researchers reported at the annual meeting of the American Society of Clinical Oncology.

The team, led by Dr. Sai Ravi Pingali, retrospectively reviewed the charts of 241 adult patients who achieved a complete remission after first-line therapy.

In 68%, the treating physicians’ planned approach was routine surveillance imaging, which consisted of radiologic imaging with scans every few months, plus clinical exams and laboratory testing. In the other 32%, the planned approach was clinical surveillance, meaning that radiologic imaging was performed only if concerning signs or symptoms occurred.

The two groups had statistically indistinguishable overall survival, and in both groups, all patients experiencing relapse successfully achieved a second complete remission with salvage therapy.

In the routinely imaged group, scanning increased costs by nearly $20,000 per patient and by almost $600,000 per each relapse detected. In addition, patients were exposed to the associated radiation.

"We were unable to detect an overall survival benefit associated with routine surveillance imaging, although I have to acknowledge that our study was limited in power given the small number of deaths and relapses," commented Dr. Pingali, an oncologist with the Medical College of Wisconsin Affiliated Hospitals in Milwaukee.

"Relapses in both ... groups were effectively salvaged with autologous stem cell transplantation, arguing against a critical advantage of detection of asymptomatic relapse. Also, we need to keep in mind that the costs associated with routine surveillance imaging are significant, and it is also associated with potential risks, both in terms of radiation exposure and unnecessary work-up," he added.

"We do not feel that potential risks and costs without overall survival benefit or any other clinical benefit justify the practice of routine surveillance imaging in classical Hodgkin lymphoma patients who have achieved a complete remission after first-line therapy. We recommend that such patients be followed clinically," Dr. Pingali concluded.

Invited discussant Dr. Leo Gordon of Northwestern University in Chicago, agreed that accumulating data argue against routine imaging for surveillance in this context and noted that insurers will likely not continue to cover scans having no proven benefit. The data should prompt a revision of guidelines and reeducation of clinicians and patients, he said.

"For translational researchers and investigators and academics, I think we need to convince journal reviewers that a manuscript is acceptable if scans are not so frequent. And for industry trials, I think we need to discuss with the Food and Drug Administration the endpoint of progression-free survival and that those endpoints may not only be driven by scans but by more mundane parameters," he said—namely, the history and physical examination.

But session comoderator Dr. Gilles A. Salles of Hospices Civils de Lyon, Université Claude Bernard, France, expressed reservations, noting that the study did not provide information on how patients were allocated to groups and the time frame of relapse.

"It may be different whether relapses occur early, in the first year, or they occur later, and that may have some implications for the surveillance," he said. "I understand that you and many others jumped over the idea that we should immediately stop. A few people may think that we need more solid data, despite the provocative and quality data that were presented, to really make this jump in clinical practice. That’s my personal opinion."

Dr. Pingali and his team retrospectively reviewed the charts of adult patients who received a new diagnosis of classical Hodgkin lymphoma between 2000 and 2010 at three institutions, achieved complete remission after first-line therapy and had at least 2 years of follow-up.

The routine surveillance imaging and clinical surveillance groups had similar demographic and disease characteristics, Dr. Pingali reported. The former were significantly more likely to have received ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, and dacarbazine) and less likely to have received the Stanford V regimen as first-line therapy, and they were significantly less likely to have received radiation therapy.

With a median duration of follow-up of about 4 years, the groups did not differ significantly with respect to overall survival. "When we look at the 5-year time point, when typically the surveillance CT scans are discontinued, the curves are pretty much superimposable," he pointed out.

There were five deaths in the routine surveillance imaging group, one of which was from relapsed disease; the other deaths were from cancer, heart failure, hip fracture, and myelodysplastic syndrome. There were four deaths in the clinical surveillance group: two were from non-Hodgkin lymphoma and two from unknown causes while the patient was in confirmed remission.

All of the six patients in the routinely imaged group and all of the five patients in the clinically followed group experiencing a relapse achieved another complete remission with second-line therapy.

The mean number of scans received was 1.14 in the clinical surveillance group – usually the scan performed after first-line treatment to confirm remission, according to Dr. Pingali – and 4.25 in the routine surveillance imaging group. The ratio of scans to detected relapses was 18 vs. 124.

The extra charges incurred from scans using the routine surveillance imaging approach were $18,896/patient and $593,698/relapse.

"It is important to note that this does not include additional costs from the work-up of the false-positive scans and also the wages lost," he noted.

Dr. Pingali disclosed no relevant conflicts of interest. Dr. Gordon disclosed that he receives honoraria from Genentech and research funding from Millennium and Pharmacyclics. Dr. Salles disclosed serving as an advisor or consultant for Calistoga Pharmaceuticals, Celgene; Genentech, Janssen Pharmaceutica, and Roche. He has served as a speaker or a member of a speakers bureau and has received grants for clinical research from Celgene and Roche.

Photo by Piotr Bodzek

AMSTERDAM—A recombinant factor IX Fc fusion protein (rFIXFc) can control bleeding among hemophilia B patients undergoing major surgery, according to data from the B-LONG study presented at ISTH 2013.

The goal of the phase 3 B-LONG study was to evaluate the safety, efficacy, and pharmacokinetics (PK) of rFIXFc among male patients with hemophilia B.

Previously released data from the study suggested rFIXFc can safely prevent bleeding in these patients, and the product stays in the body more than twice as long as the recombinant factor IX therapy BeneFIX.

At ISTH 2013, Jerry Powell, MD, of the University of California at Davis, presented an analysis of B-LONG data that demonstrated rFIXFc’s effects among hemophilia B patients who underwent major surgery (e-Poster PA 2.07-4).

The B-LONG study was sponsored by Biogen Idec and Sobi, the companies developing rFIXFc (also known as eftrenonacog alfa) as Alprolix.

The study included 123 male subjects with severe hemophilia B (≤2 IU/dL [2%] endogenous FIX). Patients were 12 years of age or older They had no current or previous FIX inhibitors and a history of 100 or more documented prior exposure days to FIX products.

Patients received rFIXFc in 1 of 4 treatment arms:

1. Weekly prophylaxis starting at 50 IU/kg, with PK-driven dose adjustments  (n=63)
2. Individualized interval prophylaxis starting at 100 IU/kg every 10 days, with PK-driven interval adjustments (n=29)
3. On-demand treatment at 20 IU/kg to 100 IU/kg (n=27)
4. Perioperative management (n=12, including 8 from arms 1-3).

The patients who required major surgery were placed in arm 4. Investigators and surgeons decided upon treatment for these patients based on considerations of their rFIXFc PK profile, the type of planned surgery, and the patients’ clinical status.

The 12 patients underwent a total of 14 major surgeries, including arthroscopic meniscectomy of knee (n=1), arthroscopic ankle fusion (n=1), knee replacements (n=5), and other (n=7).

The investigators/surgeons rated hemostasis as “excellent” in 13 of the surgeries and “good” for 1 procedure.

The median estimated blood loss was 65.5 mL (range, 0.0 to 300.0 mL) during surgery and 0.0 mL (range, 0.0 to 500 mL) after surgery. None of the patients required blood transfusions during surgery, but 2 patients received transfusions postoperatively.

In most of the surgeries—85.7%—patients required a single injection of rFIXFc to maintain hemostasis during the operation. The median dose was 90.9 IU/kg per injection.

Most patients required 1 to 2 injections of rFIXFc the day before and the day of surgery. And most patients required 2 to 3 injections from days 1 to 3 after surgery. So the median rFIXFc consumption was 146.1 IU/kg on the day of surgery, 164.6 IU/kg from days 1 to 3 after surgery, and 277.1 IU/kg for days 4 to 14 after surgery.

A majority of patients—83.3% (10/12)—experienced 1 or more adverse events related to treatment. Three patients experienced 6 adverse events, but these were resolved, and investigators said they were unrelated to rFIXFc treatment.

Additional analyses of B-LONG data were presented at ISTH 2013, including an analysis of rFIXFc in the treatment of bleeding episodes and a PK analysis of rFIXFc.

Photo by Piotr Bodzek

AMSTERDAM—A recombinant factor IX Fc fusion protein (rFIXFc) can control bleeding among hemophilia B patients undergoing major surgery, according to data from the B-LONG study presented at ISTH 2013.

The goal of the phase 3 B-LONG study was to evaluate the safety, efficacy, and pharmacokinetics (PK) of rFIXFc among male patients with hemophilia B.

Previously released data from the study suggested rFIXFc can safely prevent bleeding in these patients, and the product stays in the body more than twice as long as the recombinant factor IX therapy BeneFIX.

At ISTH 2013, Jerry Powell, MD, of the University of California at Davis, presented an analysis of B-LONG data that demonstrated rFIXFc’s effects among hemophilia B patients who underwent major surgery (e-Poster PA 2.07-4).

The B-LONG study was sponsored by Biogen Idec and Sobi, the companies developing rFIXFc (also known as eftrenonacog alfa) as Alprolix.

The study included 123 male subjects with severe hemophilia B (≤2 IU/dL [2%] endogenous FIX). Patients were 12 years of age or older They had no current or previous FIX inhibitors and a history of 100 or more documented prior exposure days to FIX products.

Patients received rFIXFc in 1 of 4 treatment arms:

1. Weekly prophylaxis starting at 50 IU/kg, with PK-driven dose adjustments  (n=63)
2. Individualized interval prophylaxis starting at 100 IU/kg every 10 days, with PK-driven interval adjustments (n=29)
3. On-demand treatment at 20 IU/kg to 100 IU/kg (n=27)
4. Perioperative management (n=12, including 8 from arms 1-3).

The patients who required major surgery were placed in arm 4. Investigators and surgeons decided upon treatment for these patients based on considerations of their rFIXFc PK profile, the type of planned surgery, and the patients’ clinical status.

The 12 patients underwent a total of 14 major surgeries, including arthroscopic meniscectomy of knee (n=1), arthroscopic ankle fusion (n=1), knee replacements (n=5), and other (n=7).

The investigators/surgeons rated hemostasis as “excellent” in 13 of the surgeries and “good” for 1 procedure.

The median estimated blood loss was 65.5 mL (range, 0.0 to 300.0 mL) during surgery and 0.0 mL (range, 0.0 to 500 mL) after surgery. None of the patients required blood transfusions during surgery, but 2 patients received transfusions postoperatively.

In most of the surgeries—85.7%—patients required a single injection of rFIXFc to maintain hemostasis during the operation. The median dose was 90.9 IU/kg per injection.

Most patients required 1 to 2 injections of rFIXFc the day before and the day of surgery. And most patients required 2 to 3 injections from days 1 to 3 after surgery. So the median rFIXFc consumption was 146.1 IU/kg on the day of surgery, 164.6 IU/kg from days 1 to 3 after surgery, and 277.1 IU/kg for days 4 to 14 after surgery.

A majority of patients—83.3% (10/12)—experienced 1 or more adverse events related to treatment. Three patients experienced 6 adverse events, but these were resolved, and investigators said they were unrelated to rFIXFc treatment.

Additional analyses of B-LONG data were presented at ISTH 2013, including an analysis of rFIXFc in the treatment of bleeding episodes and a PK analysis of rFIXFc.

Photo by Piotr Bodzek

AMSTERDAM—A recombinant factor IX Fc fusion protein (rFIXFc) can control bleeding among hemophilia B patients undergoing major surgery, according to data from the B-LONG study presented at ISTH 2013.

The goal of the phase 3 B-LONG study was to evaluate the safety, efficacy, and pharmacokinetics (PK) of rFIXFc among male patients with hemophilia B.

Previously released data from the study suggested rFIXFc can safely prevent bleeding in these patients, and the product stays in the body more than twice as long as the recombinant factor IX therapy BeneFIX.

At ISTH 2013, Jerry Powell, MD, of the University of California at Davis, presented an analysis of B-LONG data that demonstrated rFIXFc’s effects among hemophilia B patients who underwent major surgery (e-Poster PA 2.07-4).

The B-LONG study was sponsored by Biogen Idec and Sobi, the companies developing rFIXFc (also known as eftrenonacog alfa) as Alprolix.

The study included 123 male subjects with severe hemophilia B (≤2 IU/dL [2%] endogenous FIX). Patients were 12 years of age or older They had no current or previous FIX inhibitors and a history of 100 or more documented prior exposure days to FIX products.

Patients received rFIXFc in 1 of 4 treatment arms:

1. Weekly prophylaxis starting at 50 IU/kg, with PK-driven dose adjustments  (n=63)
2. Individualized interval prophylaxis starting at 100 IU/kg every 10 days, with PK-driven interval adjustments (n=29)
3. On-demand treatment at 20 IU/kg to 100 IU/kg (n=27)
4. Perioperative management (n=12, including 8 from arms 1-3).

The patients who required major surgery were placed in arm 4. Investigators and surgeons decided upon treatment for these patients based on considerations of their rFIXFc PK profile, the type of planned surgery, and the patients’ clinical status.

The 12 patients underwent a total of 14 major surgeries, including arthroscopic meniscectomy of knee (n=1), arthroscopic ankle fusion (n=1), knee replacements (n=5), and other (n=7).

The investigators/surgeons rated hemostasis as “excellent” in 13 of the surgeries and “good” for 1 procedure.

The median estimated blood loss was 65.5 mL (range, 0.0 to 300.0 mL) during surgery and 0.0 mL (range, 0.0 to 500 mL) after surgery. None of the patients required blood transfusions during surgery, but 2 patients received transfusions postoperatively.

In most of the surgeries—85.7%—patients required a single injection of rFIXFc to maintain hemostasis during the operation. The median dose was 90.9 IU/kg per injection.

Most patients required 1 to 2 injections of rFIXFc the day before and the day of surgery. And most patients required 2 to 3 injections from days 1 to 3 after surgery. So the median rFIXFc consumption was 146.1 IU/kg on the day of surgery, 164.6 IU/kg from days 1 to 3 after surgery, and 277.1 IU/kg for days 4 to 14 after surgery.

A majority of patients—83.3% (10/12)—experienced 1 or more adverse events related to treatment. Three patients experienced 6 adverse events, but these were resolved, and investigators said they were unrelated to rFIXFc treatment.

Additional analyses of B-LONG data were presented at ISTH 2013, including an analysis of rFIXFc in the treatment of bleeding episodes and a PK analysis of rFIXFc.

Many oncologists remember the storied history of homoharringtonine (HHT) and wonder whatever happened to it. HHT showed initial promise for myeloid leukemias, particularly for chronic myelogenous leukemia (CML) where it seemed to induce more cytogenetic remissions than did interferon alpha.1 Unfortunately for HHT investigators, but fortunately for everybody else, these studies coincided with those being done with imatinib. The phenomenal introduction of imatinib contributed to the shelving of HHT in the mid to late 1990s.2 As is often the case, though, imatinib is not perfect. Some patients with CML develop resistance and approximately half of these do so through the acquisition of binding site mutations. One mutation in particular, T315I, rendered patients with CML resistant to all available tyrosine kinase inhibitors (TKI). In the meantime, a semisynthetic version of HHT, omacetaxine mepesuccinate, was developed. With the help of partners in industry, investigators at MD Anderson Cancer Center initiated new studies of omacetaxine in TKI resistant CML patients. Among 62 CML patients with a T315I mutation, complete hematologic response was achieved in 77% with median response duration of 9.1 months.3 Further, cytogenetic response was also achieved in a portion of patients, complete in 16%. These data prompted application for approval by the Food and Drug Administration, but were rejected for lack of a standardized test for T315I mutations. The additional data presented in the Community Translations article on page 194 formed the basis of a second application, this time for an indication in patients with CML resistant to 2 or more TKIs.

Many oncologists remember the storied history of homoharringtonine (HHT) and wonder whatever happened to it. HHT showed initial promise for myeloid leukemias, particularly for chronic myelogenous leukemia (CML) where it seemed to induce more cytogenetic remissions than did interferon alpha.1 Unfortunately for HHT investigators, but fortunately for everybody else, these studies coincided with those being done with imatinib. The phenomenal introduction of imatinib contributed to the shelving of HHT in the mid to late 1990s.2 As is often the case, though, imatinib is not perfect. Some patients with CML develop resistance and approximately half of these do so through the acquisition of binding site mutations. One mutation in particular, T315I, rendered patients with CML resistant to all available tyrosine kinase inhibitors (TKI). In the meantime, a semisynthetic version of HHT, omacetaxine mepesuccinate, was developed. With the help of partners in industry, investigators at MD Anderson Cancer Center initiated new studies of omacetaxine in TKI resistant CML patients. Among 62 CML patients with a T315I mutation, complete hematologic response was achieved in 77% with median response duration of 9.1 months.3 Further, cytogenetic response was also achieved in a portion of patients, complete in 16%. These data prompted application for approval by the Food and Drug Administration, but were rejected for lack of a standardized test for T315I mutations. The additional data presented in the Community Translations article on page 194 formed the basis of a second application, this time for an indication in patients with CML resistant to 2 or more TKIs.

Many oncologists remember the storied history of homoharringtonine (HHT) and wonder whatever happened to it. HHT showed initial promise for myeloid leukemias, particularly for chronic myelogenous leukemia (CML) where it seemed to induce more cytogenetic remissions than did interferon alpha.1 Unfortunately for HHT investigators, but fortunately for everybody else, these studies coincided with those being done with imatinib. The phenomenal introduction of imatinib contributed to the shelving of HHT in the mid to late 1990s.2 As is often the case, though, imatinib is not perfect. Some patients with CML develop resistance and approximately half of these do so through the acquisition of binding site mutations. One mutation in particular, T315I, rendered patients with CML resistant to all available tyrosine kinase inhibitors (TKI). In the meantime, a semisynthetic version of HHT, omacetaxine mepesuccinate, was developed. With the help of partners in industry, investigators at MD Anderson Cancer Center initiated new studies of omacetaxine in TKI resistant CML patients. Among 62 CML patients with a T315I mutation, complete hematologic response was achieved in 77% with median response duration of 9.1 months.3 Further, cytogenetic response was also achieved in a portion of patients, complete in 16%. These data prompted application for approval by the Food and Drug Administration, but were rejected for lack of a standardized test for T315I mutations. The additional data presented in the Community Translations article on page 194 formed the basis of a second application, this time for an indication in patients with CML resistant to 2 or more TKIs.

With this issue of COMMUNITY ONCOLOGY, memories of this year’s annual meeting of the American Society of Clinical Oncology in Chicago are starting to fade, but we are still trying to make sense of the wealth of data that was presented there. I found a number of the presentations particularly noteworthy and some of the findings likely to have an impact on how we practice. The aTTom trial1 by a group of British researchers was presented at the plenary session and dovetailed nicely with the ATLAS trial² findings that were presented at last year’s San Antonio Breast Cancer Symposium. Both trials examined 5 and 10 years of adjuvant tamoxifen in women with early stage, hormone-positive breast cancer, and findings from both trials showed reductions in recurrence, breast cancer mortality, and overall mortality in women who remained on tamoxifen to year 10. Two presentations examined frequency of scanning in Hodgkin and non-Hodgkin lymphoma and both groups of researchers concluded what many of us have often suspected – that we overscan, and that clinical surveillance is an adequate strategy for detecting recurrence. One study showed that most diffuse large B-cell lymphoma relapses were found by detection of symptoms during a physical exam, lab abnormalities, or even the patients themselves, and that routine surveillance scans did not add much to the detection of relapse.³ Findings from a second study showed that routine surveillance did not result in any survival advantage in patients with classical Hodgkin lymphoma who had achieved complete remission.⁴

With this issue of COMMUNITY ONCOLOGY, memories of this year’s annual meeting of the American Society of Clinical Oncology in Chicago are starting to fade, but we are still trying to make sense of the wealth of data that was presented there. I found a number of the presentations particularly noteworthy and some of the findings likely to have an impact on how we practice. The aTTom trial1 by a group of British researchers was presented at the plenary session and dovetailed nicely with the ATLAS trial² findings that were presented at last year’s San Antonio Breast Cancer Symposium. Both trials examined 5 and 10 years of adjuvant tamoxifen in women with early stage, hormone-positive breast cancer, and findings from both trials showed reductions in recurrence, breast cancer mortality, and overall mortality in women who remained on tamoxifen to year 10. Two presentations examined frequency of scanning in Hodgkin and non-Hodgkin lymphoma and both groups of researchers concluded what many of us have often suspected – that we overscan, and that clinical surveillance is an adequate strategy for detecting recurrence. One study showed that most diffuse large B-cell lymphoma relapses were found by detection of symptoms during a physical exam, lab abnormalities, or even the patients themselves, and that routine surveillance scans did not add much to the detection of relapse.³ Findings from a second study showed that routine surveillance did not result in any survival advantage in patients with classical Hodgkin lymphoma who had achieved complete remission.⁴

With this issue of COMMUNITY ONCOLOGY, memories of this year’s annual meeting of the American Society of Clinical Oncology in Chicago are starting to fade, but we are still trying to make sense of the wealth of data that was presented there. I found a number of the presentations particularly noteworthy and some of the findings likely to have an impact on how we practice. The aTTom trial1 by a group of British researchers was presented at the plenary session and dovetailed nicely with the ATLAS trial² findings that were presented at last year’s San Antonio Breast Cancer Symposium. Both trials examined 5 and 10 years of adjuvant tamoxifen in women with early stage, hormone-positive breast cancer, and findings from both trials showed reductions in recurrence, breast cancer mortality, and overall mortality in women who remained on tamoxifen to year 10. Two presentations examined frequency of scanning in Hodgkin and non-Hodgkin lymphoma and both groups of researchers concluded what many of us have often suspected – that we overscan, and that clinical surveillance is an adequate strategy for detecting recurrence. One study showed that most diffuse large B-cell lymphoma relapses were found by detection of symptoms during a physical exam, lab abnormalities, or even the patients themselves, and that routine surveillance scans did not add much to the detection of relapse.³ Findings from a second study showed that routine surveillance did not result in any survival advantage in patients with classical Hodgkin lymphoma who had achieved complete remission.⁴

A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

The Center for Medicare & Medicaid Innovation's Rick Gilfillan, MD, will be leaving at the end of June, just as the organization prepares to start accepting round-two grant applications for up to $1 billion in Health Care Innovation Awards. Replacing him as acting director will be Patrick Conway, MD, MSc, FAAP, SFHM, a practicing pediatric hospitalist, former director of hospital medicine at Cincinnati Children's Hospital, and HM13 keynote speaker.

Dr. Conway will continue in his current role as CMS' chief medical officer.

"We applaud Patrick Conway's appointment to the Center for Medicare & Medicaid Innovation," says SHM President Eric Howell, MD, SFHM. "His work, compassion, and vision are tremendous validations of the hospitalist model as both a change agent and as a career path. Patients across the country will be the true beneficiaries of his new work.

"Hospitalists should continue to look toward the CMS Innovation Center as a leader in transforming healthcare."

The center was created by the 2010 Affordable Care Act to offer solutions to healthcare cost and delivery problems. Its first round of 107 innovations awards, averaging $8.4 million each over three years, was announced in 2012 and included several that focused on preventing hospitalizations, avoidable rehospitalizations, and ED visits. One award went to David Meltzer, MD, PhD, FHM, of the University of Chicago to test a model in which the same doctor would see selected high-risk patients both in and out of the hospital.

Round two "provides hospitalists—who have an exceptionally broad perspective—with a unique opportunity to share new approaches to delivering the best patient care at an affordable cost," Dr. Conway told The Hospitalist.

Visit our website for more information on CMS Innovation Center initiatives.

The Center for Medicare & Medicaid Innovation's Rick Gilfillan, MD, will be leaving at the end of June, just as the organization prepares to start accepting round-two grant applications for up to $1 billion in Health Care Innovation Awards. Replacing him as acting director will be Patrick Conway, MD, MSc, FAAP, SFHM, a practicing pediatric hospitalist, former director of hospital medicine at Cincinnati Children's Hospital, and HM13 keynote speaker.

Dr. Conway will continue in his current role as CMS' chief medical officer.

"We applaud Patrick Conway's appointment to the Center for Medicare & Medicaid Innovation," says SHM President Eric Howell, MD, SFHM. "His work, compassion, and vision are tremendous validations of the hospitalist model as both a change agent and as a career path. Patients across the country will be the true beneficiaries of his new work.

"Hospitalists should continue to look toward the CMS Innovation Center as a leader in transforming healthcare."

The center was created by the 2010 Affordable Care Act to offer solutions to healthcare cost and delivery problems. Its first round of 107 innovations awards, averaging $8.4 million each over three years, was announced in 2012 and included several that focused on preventing hospitalizations, avoidable rehospitalizations, and ED visits. One award went to David Meltzer, MD, PhD, FHM, of the University of Chicago to test a model in which the same doctor would see selected high-risk patients both in and out of the hospital.

Round two "provides hospitalists—who have an exceptionally broad perspective—with a unique opportunity to share new approaches to delivering the best patient care at an affordable cost," Dr. Conway told The Hospitalist.

Visit our website for more information on CMS Innovation Center initiatives.

The Center for Medicare & Medicaid Innovation's Rick Gilfillan, MD, will be leaving at the end of June, just as the organization prepares to start accepting round-two grant applications for up to $1 billion in Health Care Innovation Awards. Replacing him as acting director will be Patrick Conway, MD, MSc, FAAP, SFHM, a practicing pediatric hospitalist, former director of hospital medicine at Cincinnati Children's Hospital, and HM13 keynote speaker.

Dr. Conway will continue in his current role as CMS' chief medical officer.

"We applaud Patrick Conway's appointment to the Center for Medicare & Medicaid Innovation," says SHM President Eric Howell, MD, SFHM. "His work, compassion, and vision are tremendous validations of the hospitalist model as both a change agent and as a career path. Patients across the country will be the true beneficiaries of his new work.

"Hospitalists should continue to look toward the CMS Innovation Center as a leader in transforming healthcare."

The center was created by the 2010 Affordable Care Act to offer solutions to healthcare cost and delivery problems. Its first round of 107 innovations awards, averaging $8.4 million each over three years, was announced in 2012 and included several that focused on preventing hospitalizations, avoidable rehospitalizations, and ED visits. One award went to David Meltzer, MD, PhD, FHM, of the University of Chicago to test a model in which the same doctor would see selected high-risk patients both in and out of the hospital.

Round two "provides hospitalists—who have an exceptionally broad perspective—with a unique opportunity to share new approaches to delivering the best patient care at an affordable cost," Dr. Conway told The Hospitalist.

Visit our website for more information on CMS Innovation Center initiatives.