Mixed Topics

New guidelines from the American Academy of Dermatology strongly recommend the use of either 5-fluorouracil (5-FU) or imiquimod for the field treatment of actinic keratosis (AK). They also conditionally recommend the use of photodynamic therapy (PDT) and diclofenac for the treatment of AK, both individually and as part of combination therapy regimens.

Those are two of 18 recommendations made by 14 members of the multidisciplinary work group that convened to assemble the AAD’s first-ever guidelines on the management of AKs, which were published online April 2 in the Journal of the American Academy of Dermatology. The group, cochaired by Daniel B. Eisen, MD, professor of clinical dermatology at the University of California, Davis, and Todd E. Schlesinger, MD, medical director of the Dermatology and Laser Center of Charleston, S.C., conducted a systematic review to address five clinical questions on the management of AKs in adults. The questions were: What are the efficacy, effectiveness, and adverse effects of surgical and chemical peel treatments for AK; of topically applied agents for AK; of energy devices and other miscellaneous treatments for AK; and of combination therapy for the treatment of AK? And what are the special considerations to be taken into account when treating AK in immunocompromised individuals?

Next, the work group applied the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach for assessing the certainty of the evidence and formulating and grading clinical recommendations based on relevant randomized trials in the medical literature.

“As a participant in the work group, I was impressed by the level of care and detail and the involvement of relevant stakeholders, including a patient advocate, as well as having the draft guidelines go out to the AAD membership at large, and evaluating every comment that came in,” Maryam Asgari, MD, MPH, professor of dermatology at Harvard University, Boston, said in an interview. “The academy sought stakeholder and leadership input in revising and revamping the guidelines. The AAD also made sure the work group had minimal conflicts of interest by requiring that the majority of experts convened did not have relevant financial conflicts of interest. That might not be the case in a publication such as a systematic review, where no threshold for financial conflict of interest for coauthorship is set.”

Of the 18 recommendations the work group made for patients with AKs, only four were ranked as “strong” based on the evidence reviewed, while the rest were ranked as “conditional.”

The strong recommendations include the use of UV protection, field treatment with 5-FU, field treatment with imiquimod, and the use of cryosurgery.

The first four conditional recommendations for patients with AKs include the use of diclofenac, treatment with cryosurgery over CO₂ laser ablation, aminolevulinic acid (ALA)–red-light PDT, and 1- to 4-hour 5-ALA incubation time to enhance complete clearance with red-light PDT. The work group also conditionally recommends ALA-daylight PDT as less painful than but equally effective as ALA–red-light PDT.

In the clinical experience of Catherine M. DiGiorgio, MD, who was not involved in the guidelines, daylight PDT with ALA is a viable, cost-effective option. “Patients can come into the office, apply the ALA and then they go outside for 2 hours – not in direct sunlight but in a shady area,” Dr. DiGiorgio, a dermatologist who practices at the Boston Center for Facial Rejuvenation, said in an interview. “That’s a cost-effective treatment for patients who perhaps can’t afford some of the chemotherapy creams. I don’t think we’ve adopted ALA-daylight PDT here in the U.S. very much.”

The work group noted that topical 1% tirbanibulin ointment, a novel microtubule inhibitor, was approved for treatment of AKs on the face and scalp by the Food and Drug Administration after the guidelines had been put together.

Several trials of combination therapy were included in the review of evidence, prompting several recommendations. For example, the work group conditionally recommends combined 5-FU cream and cryosurgery over cryosurgery alone, based on moderate-quality evidence and conditionally recommends combined imiquimod and cryosurgery over cryosurgery alone based on low-quality evidence. In addition, the work group conditionally recommends against the use of 3% diclofenac in addition to cryosurgery, favoring cryosurgery alone based on low-quality evidence, and conditionally recommends against the use of imiquimod typically after ALA–blue-light PDT, based on moderate-quality data.

“The additional treatment with imiquimod was thought to add both expense and burden to the patient, which negates much of the perceived convenience of using PDT as a stand-alone treatment modality and which is not mitigated by the modest increase in lesion reduction,” the authors wrote.

The guidelines emphasize the importance of shared decision-making between patients and clinicians on the choice of therapy, a point that resonates with Dr. DiGiorgio. Success of a treatment can depend on whether a patient is willing to go through with it, she said. “Some patients don’t want to do a therapeutic topical like 5-FU. They prefer to come in and have cryotherapy done. Others prefer to not come in and have the cream at home and treat themselves.”

Assembling the guidelines exposed certain gaps in research, according to the work group. Of the 18 recommendations, seven were based on low-quality evidence, and there were not enough data to make guidelines for the treatment of AKs in immunocompromised individuals.

“I can’t tell you the number of times we in the committee sat back and said, ‘we need to have a randomized trial that looks at this, or compares this to that head on,’” Dr. Asgari said. Such limitations “give researchers direction for where the areas of study need to go to help us answer some of these management conundrums.”

She added that the new guidelines “give clinicians a leg to stand on” when an insurer pushes back on a recommended treatment for AK. “It gives you a way to have dialogue with insurers if you’re prescribing some of these treatments.”

The guidelines authors write that there is “strong theoretic rationale for the treatment of AK to prevent skin cancers” but acknowledge that only a few studies in the review “report the incidence of skin cancer as an outcome measure or have sufficient follow-up to viably measure carcinoma development.” In addition, “more long-term research is needed to validate our current understanding of skin cancer progression from AKs to keratinocyte carcinoma.”

Dr. DiGiorgio thinks about this differently. “I think treatment of AKs does prevent skin cancers,” she said. “We call them precancers as we’re treating our patients because we know a certain percentage of them can develop into skin cancers over time.”

The study was funded by internal funds from the AAD. Dr. Asgari disclosed that she serves as an investigator for Pfizer. Several of the other authors reported having financial disclosures.

Dr. DiGiorgio reported having no financial disclosures.

New guidelines from the American Academy of Dermatology strongly recommend the use of either 5-fluorouracil (5-FU) or imiquimod for the field treatment of actinic keratosis (AK). They also conditionally recommend the use of photodynamic therapy (PDT) and diclofenac for the treatment of AK, both individually and as part of combination therapy regimens.

Those are two of 18 recommendations made by 14 members of the multidisciplinary work group that convened to assemble the AAD’s first-ever guidelines on the management of AKs, which were published online April 2 in the Journal of the American Academy of Dermatology. The group, cochaired by Daniel B. Eisen, MD, professor of clinical dermatology at the University of California, Davis, and Todd E. Schlesinger, MD, medical director of the Dermatology and Laser Center of Charleston, S.C., conducted a systematic review to address five clinical questions on the management of AKs in adults. The questions were: What are the efficacy, effectiveness, and adverse effects of surgical and chemical peel treatments for AK; of topically applied agents for AK; of energy devices and other miscellaneous treatments for AK; and of combination therapy for the treatment of AK? And what are the special considerations to be taken into account when treating AK in immunocompromised individuals?

Next, the work group applied the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach for assessing the certainty of the evidence and formulating and grading clinical recommendations based on relevant randomized trials in the medical literature.

“As a participant in the work group, I was impressed by the level of care and detail and the involvement of relevant stakeholders, including a patient advocate, as well as having the draft guidelines go out to the AAD membership at large, and evaluating every comment that came in,” Maryam Asgari, MD, MPH, professor of dermatology at Harvard University, Boston, said in an interview. “The academy sought stakeholder and leadership input in revising and revamping the guidelines. The AAD also made sure the work group had minimal conflicts of interest by requiring that the majority of experts convened did not have relevant financial conflicts of interest. That might not be the case in a publication such as a systematic review, where no threshold for financial conflict of interest for coauthorship is set.”

Of the 18 recommendations the work group made for patients with AKs, only four were ranked as “strong” based on the evidence reviewed, while the rest were ranked as “conditional.”

The strong recommendations include the use of UV protection, field treatment with 5-FU, field treatment with imiquimod, and the use of cryosurgery.

The first four conditional recommendations for patients with AKs include the use of diclofenac, treatment with cryosurgery over CO₂ laser ablation, aminolevulinic acid (ALA)–red-light PDT, and 1- to 4-hour 5-ALA incubation time to enhance complete clearance with red-light PDT. The work group also conditionally recommends ALA-daylight PDT as less painful than but equally effective as ALA–red-light PDT.

In the clinical experience of Catherine M. DiGiorgio, MD, who was not involved in the guidelines, daylight PDT with ALA is a viable, cost-effective option. “Patients can come into the office, apply the ALA and then they go outside for 2 hours – not in direct sunlight but in a shady area,” Dr. DiGiorgio, a dermatologist who practices at the Boston Center for Facial Rejuvenation, said in an interview. “That’s a cost-effective treatment for patients who perhaps can’t afford some of the chemotherapy creams. I don’t think we’ve adopted ALA-daylight PDT here in the U.S. very much.”

The work group noted that topical 1% tirbanibulin ointment, a novel microtubule inhibitor, was approved for treatment of AKs on the face and scalp by the Food and Drug Administration after the guidelines had been put together.

Several trials of combination therapy were included in the review of evidence, prompting several recommendations. For example, the work group conditionally recommends combined 5-FU cream and cryosurgery over cryosurgery alone, based on moderate-quality evidence and conditionally recommends combined imiquimod and cryosurgery over cryosurgery alone based on low-quality evidence. In addition, the work group conditionally recommends against the use of 3% diclofenac in addition to cryosurgery, favoring cryosurgery alone based on low-quality evidence, and conditionally recommends against the use of imiquimod typically after ALA–blue-light PDT, based on moderate-quality data.

“The additional treatment with imiquimod was thought to add both expense and burden to the patient, which negates much of the perceived convenience of using PDT as a stand-alone treatment modality and which is not mitigated by the modest increase in lesion reduction,” the authors wrote.

The guidelines emphasize the importance of shared decision-making between patients and clinicians on the choice of therapy, a point that resonates with Dr. DiGiorgio. Success of a treatment can depend on whether a patient is willing to go through with it, she said. “Some patients don’t want to do a therapeutic topical like 5-FU. They prefer to come in and have cryotherapy done. Others prefer to not come in and have the cream at home and treat themselves.”

Assembling the guidelines exposed certain gaps in research, according to the work group. Of the 18 recommendations, seven were based on low-quality evidence, and there were not enough data to make guidelines for the treatment of AKs in immunocompromised individuals.

“I can’t tell you the number of times we in the committee sat back and said, ‘we need to have a randomized trial that looks at this, or compares this to that head on,’” Dr. Asgari said. Such limitations “give researchers direction for where the areas of study need to go to help us answer some of these management conundrums.”

She added that the new guidelines “give clinicians a leg to stand on” when an insurer pushes back on a recommended treatment for AK. “It gives you a way to have dialogue with insurers if you’re prescribing some of these treatments.”

The guidelines authors write that there is “strong theoretic rationale for the treatment of AK to prevent skin cancers” but acknowledge that only a few studies in the review “report the incidence of skin cancer as an outcome measure or have sufficient follow-up to viably measure carcinoma development.” In addition, “more long-term research is needed to validate our current understanding of skin cancer progression from AKs to keratinocyte carcinoma.”

Dr. DiGiorgio thinks about this differently. “I think treatment of AKs does prevent skin cancers,” she said. “We call them precancers as we’re treating our patients because we know a certain percentage of them can develop into skin cancers over time.”

The study was funded by internal funds from the AAD. Dr. Asgari disclosed that she serves as an investigator for Pfizer. Several of the other authors reported having financial disclosures.

Dr. DiGiorgio reported having no financial disclosures.

New guidelines from the American Academy of Dermatology strongly recommend the use of either 5-fluorouracil (5-FU) or imiquimod for the field treatment of actinic keratosis (AK). They also conditionally recommend the use of photodynamic therapy (PDT) and diclofenac for the treatment of AK, both individually and as part of combination therapy regimens.

Those are two of 18 recommendations made by 14 members of the multidisciplinary work group that convened to assemble the AAD’s first-ever guidelines on the management of AKs, which were published online April 2 in the Journal of the American Academy of Dermatology. The group, cochaired by Daniel B. Eisen, MD, professor of clinical dermatology at the University of California, Davis, and Todd E. Schlesinger, MD, medical director of the Dermatology and Laser Center of Charleston, S.C., conducted a systematic review to address five clinical questions on the management of AKs in adults. The questions were: What are the efficacy, effectiveness, and adverse effects of surgical and chemical peel treatments for AK; of topically applied agents for AK; of energy devices and other miscellaneous treatments for AK; and of combination therapy for the treatment of AK? And what are the special considerations to be taken into account when treating AK in immunocompromised individuals?

Next, the work group applied the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach for assessing the certainty of the evidence and formulating and grading clinical recommendations based on relevant randomized trials in the medical literature.

“As a participant in the work group, I was impressed by the level of care and detail and the involvement of relevant stakeholders, including a patient advocate, as well as having the draft guidelines go out to the AAD membership at large, and evaluating every comment that came in,” Maryam Asgari, MD, MPH, professor of dermatology at Harvard University, Boston, said in an interview. “The academy sought stakeholder and leadership input in revising and revamping the guidelines. The AAD also made sure the work group had minimal conflicts of interest by requiring that the majority of experts convened did not have relevant financial conflicts of interest. That might not be the case in a publication such as a systematic review, where no threshold for financial conflict of interest for coauthorship is set.”

Of the 18 recommendations the work group made for patients with AKs, only four were ranked as “strong” based on the evidence reviewed, while the rest were ranked as “conditional.”

The strong recommendations include the use of UV protection, field treatment with 5-FU, field treatment with imiquimod, and the use of cryosurgery.

The first four conditional recommendations for patients with AKs include the use of diclofenac, treatment with cryosurgery over CO₂ laser ablation, aminolevulinic acid (ALA)–red-light PDT, and 1- to 4-hour 5-ALA incubation time to enhance complete clearance with red-light PDT. The work group also conditionally recommends ALA-daylight PDT as less painful than but equally effective as ALA–red-light PDT.

In the clinical experience of Catherine M. DiGiorgio, MD, who was not involved in the guidelines, daylight PDT with ALA is a viable, cost-effective option. “Patients can come into the office, apply the ALA and then they go outside for 2 hours – not in direct sunlight but in a shady area,” Dr. DiGiorgio, a dermatologist who practices at the Boston Center for Facial Rejuvenation, said in an interview. “That’s a cost-effective treatment for patients who perhaps can’t afford some of the chemotherapy creams. I don’t think we’ve adopted ALA-daylight PDT here in the U.S. very much.”

The work group noted that topical 1% tirbanibulin ointment, a novel microtubule inhibitor, was approved for treatment of AKs on the face and scalp by the Food and Drug Administration after the guidelines had been put together.

Several trials of combination therapy were included in the review of evidence, prompting several recommendations. For example, the work group conditionally recommends combined 5-FU cream and cryosurgery over cryosurgery alone, based on moderate-quality evidence and conditionally recommends combined imiquimod and cryosurgery over cryosurgery alone based on low-quality evidence. In addition, the work group conditionally recommends against the use of 3% diclofenac in addition to cryosurgery, favoring cryosurgery alone based on low-quality evidence, and conditionally recommends against the use of imiquimod typically after ALA–blue-light PDT, based on moderate-quality data.

“The additional treatment with imiquimod was thought to add both expense and burden to the patient, which negates much of the perceived convenience of using PDT as a stand-alone treatment modality and which is not mitigated by the modest increase in lesion reduction,” the authors wrote.

The guidelines emphasize the importance of shared decision-making between patients and clinicians on the choice of therapy, a point that resonates with Dr. DiGiorgio. Success of a treatment can depend on whether a patient is willing to go through with it, she said. “Some patients don’t want to do a therapeutic topical like 5-FU. They prefer to come in and have cryotherapy done. Others prefer to not come in and have the cream at home and treat themselves.”

Assembling the guidelines exposed certain gaps in research, according to the work group. Of the 18 recommendations, seven were based on low-quality evidence, and there were not enough data to make guidelines for the treatment of AKs in immunocompromised individuals.

“I can’t tell you the number of times we in the committee sat back and said, ‘we need to have a randomized trial that looks at this, or compares this to that head on,’” Dr. Asgari said. Such limitations “give researchers direction for where the areas of study need to go to help us answer some of these management conundrums.”

She added that the new guidelines “give clinicians a leg to stand on” when an insurer pushes back on a recommended treatment for AK. “It gives you a way to have dialogue with insurers if you’re prescribing some of these treatments.”

The guidelines authors write that there is “strong theoretic rationale for the treatment of AK to prevent skin cancers” but acknowledge that only a few studies in the review “report the incidence of skin cancer as an outcome measure or have sufficient follow-up to viably measure carcinoma development.” In addition, “more long-term research is needed to validate our current understanding of skin cancer progression from AKs to keratinocyte carcinoma.”

Dr. DiGiorgio thinks about this differently. “I think treatment of AKs does prevent skin cancers,” she said. “We call them precancers as we’re treating our patients because we know a certain percentage of them can develop into skin cancers over time.”

The study was funded by internal funds from the AAD. Dr. Asgari disclosed that she serves as an investigator for Pfizer. Several of the other authors reported having financial disclosures.

Dr. DiGiorgio reported having no financial disclosures.

Click here for the Friday issue of the SHM Converge Daily News newsletter.

Click here for the Friday issue of the SHM Converge Daily News newsletter.

Click here for the Friday issue of the SHM Converge Daily News newsletter.

While the COVID-19 pandemic has generated anxiety and confusion in medicine, one thing should bring a sense of clarity to hospitalists: They’re needed now more than ever.

Larry Wellikson, MD, MHM, the former, longtime CEO of the Society of Hospital Medicine, in a May 6 keynote speech at SHM Converge, the annual conference of the Society of Hospital Medicine, said the COVID-19 era has underscored the singular importance of the specialty.

“I think one thing that this recent pandemic has emphasized is just how important and vital hospitalists are to the United States’ health care system,” Dr. Wellikson said. “The response to the acute care needs in this pandemic would have been impossible in the health care system that existed before hospitalists. And so this is something that we should understand and appreciate.”

The “upheaval” experienced in hospital medicine continues a trend of change that will go on, both in the corporate health care landscape and in the role that hospitalists play in providing care, he said. Insurers have been merging and looking to consolidate. Hospital medicine companies have been merging, and “newfangled bedfellows” have been a trend, such as CVS stepping beyond its pharmacy role into an expanded health care role, Cigna buying Express Scripts, and an Amazon-Berkshire Hathaway-J.P. Morgan health care partnership that ultimately did not pan out, although that hasn’t ended Amazon’s presence in health care.

“You may not realize it, but Amazon is currently one of the largest hospital supply-chain companies,” Dr. Wellikson said. “They’re attempting to become a major pharmacy benefits manager and will only further enter into health care and into our personal and professional lives.”

New models of care point to the way of the future, he said. Mount Sinai’s continuing success with its Hospital at Home program – which involves an acute care nurse and team assigned to a patient in the home – introduces a concept that will be adopted more broadly, because of its cost savings and good outcomes, he said. Mergers of hospital systems, leading to excess hospital capacity, has given rise to what he calls “ED-plus,” or using formerly full-service hospitals as more focused centers – providing emergency, obstetrician, cardiology, x-ray, or orthopedics care, or whatever is needed in a given community.

An increasing focus on population health rather than procedures plays into the strengths of hospitalists, Dr. Wellikson said, and the need for their skills will continue to deepen.

When changes in reimbursement began about 4 years ago, specialties such as cardiology entered into new contracts with hospitals, but the facilities began to notice that many of the services – such as initial heart failure and chest pain management – can be provided by hospitalists.

“They’re signing fewer cardiologists and needing therefore to hire more hospitalists,” he said.

To keep readmissions low and subsequent costs down, hospitalists will continue to handle the first few postdischarge visits with patients, he said. This is crucial in bundled payment systems.

“Most of the savings in those systems comes from being very efficient in the initial postdischarge portion of people’s care,” Dr. Wellikson said.

At the same time, hospitalists are not in “unlimited supply.”

“I think every hospital medicine group should be assessing and working on improving their clinicians’ well-being,” he said. “We need to ration somewhat, so we’re deploying hospitalists for the things that only we can do.” He predicted that hospitalists will be required to work in the electronic medical record less frequently, with this task handled by others.

Dr. Wellikson also called on the specialty to continue to expand its racial and ethnic diversity so that it reflects the patient population it serves.

“We’re looking to create pathways to leadership for everyone and not just a tokenism moving forward,” he said.

The basic strengths of hospital medicine – its flexibility, professional culture, and youth – leave it well prepared for all of these changes, he said.

“There is a bright future and hospitalists are right in the middle of this – we’re not going to be marginalized or on the periphery,” Dr. Wellikson said. “If I had one message for all of you, I would say be relevant and add value and you will not only survive, but thrive.”
 

RIV winners announced

The winners of the 2021 RIV competition were also announced at the May 6 general session of Converge. There were two winners in each of the three categories, as follows:

RESEARCH
Overall: “Suboptimal Communication During Inter-Hospital Transfer,” Stephanie Mueller, MD, MPH, SFHM

Trainee: “Mentorship in Pediatric Hospital Medicine: A Survey of Division Directors,” Brandon Palmer, MD

INNOVATIONS
Overall: “Leveraging Artificial Intelligence for a Team-Based Approach to Advance Care Planning,” Ron Li, MD

Trainee: “A Trainee-Designed Initiative Reshapes Communication for Hospital Medicine Patients During COVID-19,” Smitha Ganeshan, MD, MBA

CLINICAL VIGNETTES
Adults: “Holy Spontaneous Heparin-Induced Thrombocytopenia,” Min Hwang

Pediatrics: “The Great Pretender: A Tale of Two Systems,” Shivani Desai, MD

While the COVID-19 pandemic has generated anxiety and confusion in medicine, one thing should bring a sense of clarity to hospitalists: They’re needed now more than ever.

Larry Wellikson, MD, MHM, the former, longtime CEO of the Society of Hospital Medicine, in a May 6 keynote speech at SHM Converge, the annual conference of the Society of Hospital Medicine, said the COVID-19 era has underscored the singular importance of the specialty.

“I think one thing that this recent pandemic has emphasized is just how important and vital hospitalists are to the United States’ health care system,” Dr. Wellikson said. “The response to the acute care needs in this pandemic would have been impossible in the health care system that existed before hospitalists. And so this is something that we should understand and appreciate.”

The “upheaval” experienced in hospital medicine continues a trend of change that will go on, both in the corporate health care landscape and in the role that hospitalists play in providing care, he said. Insurers have been merging and looking to consolidate. Hospital medicine companies have been merging, and “newfangled bedfellows” have been a trend, such as CVS stepping beyond its pharmacy role into an expanded health care role, Cigna buying Express Scripts, and an Amazon-Berkshire Hathaway-J.P. Morgan health care partnership that ultimately did not pan out, although that hasn’t ended Amazon’s presence in health care.

“You may not realize it, but Amazon is currently one of the largest hospital supply-chain companies,” Dr. Wellikson said. “They’re attempting to become a major pharmacy benefits manager and will only further enter into health care and into our personal and professional lives.”

New models of care point to the way of the future, he said. Mount Sinai’s continuing success with its Hospital at Home program – which involves an acute care nurse and team assigned to a patient in the home – introduces a concept that will be adopted more broadly, because of its cost savings and good outcomes, he said. Mergers of hospital systems, leading to excess hospital capacity, has given rise to what he calls “ED-plus,” or using formerly full-service hospitals as more focused centers – providing emergency, obstetrician, cardiology, x-ray, or orthopedics care, or whatever is needed in a given community.

An increasing focus on population health rather than procedures plays into the strengths of hospitalists, Dr. Wellikson said, and the need for their skills will continue to deepen.

When changes in reimbursement began about 4 years ago, specialties such as cardiology entered into new contracts with hospitals, but the facilities began to notice that many of the services – such as initial heart failure and chest pain management – can be provided by hospitalists.

“They’re signing fewer cardiologists and needing therefore to hire more hospitalists,” he said.

To keep readmissions low and subsequent costs down, hospitalists will continue to handle the first few postdischarge visits with patients, he said. This is crucial in bundled payment systems.

“Most of the savings in those systems comes from being very efficient in the initial postdischarge portion of people’s care,” Dr. Wellikson said.

At the same time, hospitalists are not in “unlimited supply.”

“I think every hospital medicine group should be assessing and working on improving their clinicians’ well-being,” he said. “We need to ration somewhat, so we’re deploying hospitalists for the things that only we can do.” He predicted that hospitalists will be required to work in the electronic medical record less frequently, with this task handled by others.

Dr. Wellikson also called on the specialty to continue to expand its racial and ethnic diversity so that it reflects the patient population it serves.

“We’re looking to create pathways to leadership for everyone and not just a tokenism moving forward,” he said.

The basic strengths of hospital medicine – its flexibility, professional culture, and youth – leave it well prepared for all of these changes, he said.

“There is a bright future and hospitalists are right in the middle of this – we’re not going to be marginalized or on the periphery,” Dr. Wellikson said. “If I had one message for all of you, I would say be relevant and add value and you will not only survive, but thrive.”
 

RIV winners announced

The winners of the 2021 RIV competition were also announced at the May 6 general session of Converge. There were two winners in each of the three categories, as follows:

RESEARCH
Overall: “Suboptimal Communication During Inter-Hospital Transfer,” Stephanie Mueller, MD, MPH, SFHM

Trainee: “Mentorship in Pediatric Hospital Medicine: A Survey of Division Directors,” Brandon Palmer, MD

INNOVATIONS
Overall: “Leveraging Artificial Intelligence for a Team-Based Approach to Advance Care Planning,” Ron Li, MD

Trainee: “A Trainee-Designed Initiative Reshapes Communication for Hospital Medicine Patients During COVID-19,” Smitha Ganeshan, MD, MBA

CLINICAL VIGNETTES
Adults: “Holy Spontaneous Heparin-Induced Thrombocytopenia,” Min Hwang

Pediatrics: “The Great Pretender: A Tale of Two Systems,” Shivani Desai, MD

While the COVID-19 pandemic has generated anxiety and confusion in medicine, one thing should bring a sense of clarity to hospitalists: They’re needed now more than ever.

Larry Wellikson, MD, MHM, the former, longtime CEO of the Society of Hospital Medicine, in a May 6 keynote speech at SHM Converge, the annual conference of the Society of Hospital Medicine, said the COVID-19 era has underscored the singular importance of the specialty.

“I think one thing that this recent pandemic has emphasized is just how important and vital hospitalists are to the United States’ health care system,” Dr. Wellikson said. “The response to the acute care needs in this pandemic would have been impossible in the health care system that existed before hospitalists. And so this is something that we should understand and appreciate.”

The “upheaval” experienced in hospital medicine continues a trend of change that will go on, both in the corporate health care landscape and in the role that hospitalists play in providing care, he said. Insurers have been merging and looking to consolidate. Hospital medicine companies have been merging, and “newfangled bedfellows” have been a trend, such as CVS stepping beyond its pharmacy role into an expanded health care role, Cigna buying Express Scripts, and an Amazon-Berkshire Hathaway-J.P. Morgan health care partnership that ultimately did not pan out, although that hasn’t ended Amazon’s presence in health care.

“You may not realize it, but Amazon is currently one of the largest hospital supply-chain companies,” Dr. Wellikson said. “They’re attempting to become a major pharmacy benefits manager and will only further enter into health care and into our personal and professional lives.”

New models of care point to the way of the future, he said. Mount Sinai’s continuing success with its Hospital at Home program – which involves an acute care nurse and team assigned to a patient in the home – introduces a concept that will be adopted more broadly, because of its cost savings and good outcomes, he said. Mergers of hospital systems, leading to excess hospital capacity, has given rise to what he calls “ED-plus,” or using formerly full-service hospitals as more focused centers – providing emergency, obstetrician, cardiology, x-ray, or orthopedics care, or whatever is needed in a given community.

An increasing focus on population health rather than procedures plays into the strengths of hospitalists, Dr. Wellikson said, and the need for their skills will continue to deepen.

When changes in reimbursement began about 4 years ago, specialties such as cardiology entered into new contracts with hospitals, but the facilities began to notice that many of the services – such as initial heart failure and chest pain management – can be provided by hospitalists.

“They’re signing fewer cardiologists and needing therefore to hire more hospitalists,” he said.

To keep readmissions low and subsequent costs down, hospitalists will continue to handle the first few postdischarge visits with patients, he said. This is crucial in bundled payment systems.

“Most of the savings in those systems comes from being very efficient in the initial postdischarge portion of people’s care,” Dr. Wellikson said.

At the same time, hospitalists are not in “unlimited supply.”

“I think every hospital medicine group should be assessing and working on improving their clinicians’ well-being,” he said. “We need to ration somewhat, so we’re deploying hospitalists for the things that only we can do.” He predicted that hospitalists will be required to work in the electronic medical record less frequently, with this task handled by others.

Dr. Wellikson also called on the specialty to continue to expand its racial and ethnic diversity so that it reflects the patient population it serves.

“We’re looking to create pathways to leadership for everyone and not just a tokenism moving forward,” he said.

The basic strengths of hospital medicine – its flexibility, professional culture, and youth – leave it well prepared for all of these changes, he said.

“There is a bright future and hospitalists are right in the middle of this – we’re not going to be marginalized or on the periphery,” Dr. Wellikson said. “If I had one message for all of you, I would say be relevant and add value and you will not only survive, but thrive.”
 

RIV winners announced

The winners of the 2021 RIV competition were also announced at the May 6 general session of Converge. There were two winners in each of the three categories, as follows:

RESEARCH
Overall: “Suboptimal Communication During Inter-Hospital Transfer,” Stephanie Mueller, MD, MPH, SFHM

Trainee: “Mentorship in Pediatric Hospital Medicine: A Survey of Division Directors,” Brandon Palmer, MD

INNOVATIONS
Overall: “Leveraging Artificial Intelligence for a Team-Based Approach to Advance Care Planning,” Ron Li, MD

Trainee: “A Trainee-Designed Initiative Reshapes Communication for Hospital Medicine Patients During COVID-19,” Smitha Ganeshan, MD, MBA

CLINICAL VIGNETTES
Adults: “Holy Spontaneous Heparin-Induced Thrombocytopenia,” Min Hwang

Pediatrics: “The Great Pretender: A Tale of Two Systems,” Shivani Desai, MD

Although the COVID-19 pandemic put telehealth on fast forward, more than one third of patients in the United States engaged with telehealth services before February 2020, according to Ameet Doshi, MD, and Chrisanne Timpe, MD, of HealthPartners in Bloomington, Minn.

Broadly speaking, telehealth is “using virtual tools to evaluate, manage, and care for our patients, regardless of where they are located,” Dr. Doshi said during a May 6 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

The entirety of telehealth includes remote ways to meet almost any patient demand, he said. Some common health terms are used interchangeably, but some use telehealth as a broad term for electronic health care services, while telemedicine may refer specifically to remote patient care, he said.

Telemedicine allows flexibility of delivering patient care in inpatient, outpatient, or at-home settings, said Dr. Doshi. To illustrate the current application of telemedicine, he used an example of a 25-bed critical access hospital serving a growing regional population in which outpatient volume is expanding and ambulatory care services are being added. In this example, inpatient volume is growing, but not enough to support an inpatient consult service, but telehealth access to specialists such as cardiology would be useful in this case, he said.

Hospitalist telehealth means “being able to provide services to changing patient populations regardless of location; we can bring services to where patients are,” said Dr. Doshi.

Benefits of telehealth to patients include less travel and easier access to care, benefits to clinicians include expanding services at lower financial costs, he said.
 

COVID-19 challenges and opportunities

The COVID-19 pandemic presented both challenges and opportunities for telehealth, Dr. Doshi said. One opportunity was the sudden broad acceptance of virtual care out of necessity and concern for patient and staff safety, and to preserve the use of personal protective equipment, he said. In addition, a loosening of regulatory and financial pressures allowed more institutions to expand and initiate telehealth services.

Challenges included technological limitations and, in some cases, the need to develop a telehealth infrastructure from scratch, Dr. Doshi explained. Concerns also remain regarding how telehealth will evolve in the post-pandemic future, he said.

In the meantime, Medicare data show the impact of the pandemic on telehealth services, said Dr. Doshi. A telehealth waiver issued in March 2020 led to an increase in virtual encounters, and Medicare data show approximately 25 million virtual Medicare encounters between March 2020 and October 2020, representing a 3,000% increase from the same period in 2019, he said.

“Telehealth is here to stay, so the questions are how to craft a hospitalist telehealth program and provide essential patient care,” he said.

Dr. Timpe shared some examples of the evolution of telehealth care during the pandemic, including a case of an asymptomatic but frail patient with diabetes, dementia, and coronary artery disease undergoing outpatient care for a foot infection. The patient presented to an emergency department but refused to be hospitalized because of family concerns about patient isolation (no visitors were allowed at the time) and the concerns about COVID-19 infection.

The need to help treat acutely ill patients such as this patient while avoiding hospital admission during and after the pandemic continues to lead to the development of telehealth programs, Dr. Timpe said. She shared details of the Hospital@Home program developed by her organization, Health Partners. The program is designed to treat acutely ill people in the home, if possible, and avoid the need for hospital admission. Patients receive daily medical management from a hospitalist and care from staff, including registered nurses and community paramedics. Services include provision of IV medications and fluids, but the staff also conduct labs and imaging services, Dr. Timpe said.

Conditions that the program has managed at patients’ homes include pneumonia, COPD, asthma, bronchitis, flu, COVID-19, congestive heart failure, cellulitis, and urinary tract infections, said Dr. Timpe.

“We do not accept people into the program who have treatment needs that can only be met in a hospital,” such as the need for blood products, vasopressor support, telemetry, or positive pressure support, she noted.

Between November 2019 and February 15, 2021, the Hospital@Home program has provided services to 132 patients for a total of 287 visits. The program has averted 50 emergency department visits and 40 hospitalizations, and shorted hospital stays in 57 cases, she noted.

Hospitalists are suited for telehealth for several reasons, including the ability to triage acutely ill patients, familiarity with resource utilization, and expertise in management of complex medical care, said Dr. Timpe.
 

Looking ahead

Dr. Doshi emphasized several ongoing issues regarding the future of telemedicine, primarily the need for standardized regulation and reimbursement; reduction of health equity disparity and attention to technological barriers (including access and technology literacy); and identification of the next frontiers in telehealth.

Research on the impact and effectiveness of telehealth is limited, but growing, and next frontiers might include making patients more active participants in telehealth via patient-operated kits, or the option of an open telemedicine marketplace, in which patients can select providers from across the country, he said. No matter where telehealth leads in the future, “we need to make sure we have a positive patient outcome,” he concluded.

Dr. Doshi and Dr. Timpe had no financial conflicts to disclose.

Although the COVID-19 pandemic put telehealth on fast forward, more than one third of patients in the United States engaged with telehealth services before February 2020, according to Ameet Doshi, MD, and Chrisanne Timpe, MD, of HealthPartners in Bloomington, Minn.

Broadly speaking, telehealth is “using virtual tools to evaluate, manage, and care for our patients, regardless of where they are located,” Dr. Doshi said during a May 6 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

The entirety of telehealth includes remote ways to meet almost any patient demand, he said. Some common health terms are used interchangeably, but some use telehealth as a broad term for electronic health care services, while telemedicine may refer specifically to remote patient care, he said.

Telemedicine allows flexibility of delivering patient care in inpatient, outpatient, or at-home settings, said Dr. Doshi. To illustrate the current application of telemedicine, he used an example of a 25-bed critical access hospital serving a growing regional population in which outpatient volume is expanding and ambulatory care services are being added. In this example, inpatient volume is growing, but not enough to support an inpatient consult service, but telehealth access to specialists such as cardiology would be useful in this case, he said.

Hospitalist telehealth means “being able to provide services to changing patient populations regardless of location; we can bring services to where patients are,” said Dr. Doshi.

Benefits of telehealth to patients include less travel and easier access to care, benefits to clinicians include expanding services at lower financial costs, he said.
 

COVID-19 challenges and opportunities

The COVID-19 pandemic presented both challenges and opportunities for telehealth, Dr. Doshi said. One opportunity was the sudden broad acceptance of virtual care out of necessity and concern for patient and staff safety, and to preserve the use of personal protective equipment, he said. In addition, a loosening of regulatory and financial pressures allowed more institutions to expand and initiate telehealth services.

Challenges included technological limitations and, in some cases, the need to develop a telehealth infrastructure from scratch, Dr. Doshi explained. Concerns also remain regarding how telehealth will evolve in the post-pandemic future, he said.

In the meantime, Medicare data show the impact of the pandemic on telehealth services, said Dr. Doshi. A telehealth waiver issued in March 2020 led to an increase in virtual encounters, and Medicare data show approximately 25 million virtual Medicare encounters between March 2020 and October 2020, representing a 3,000% increase from the same period in 2019, he said.

“Telehealth is here to stay, so the questions are how to craft a hospitalist telehealth program and provide essential patient care,” he said.

Dr. Timpe shared some examples of the evolution of telehealth care during the pandemic, including a case of an asymptomatic but frail patient with diabetes, dementia, and coronary artery disease undergoing outpatient care for a foot infection. The patient presented to an emergency department but refused to be hospitalized because of family concerns about patient isolation (no visitors were allowed at the time) and the concerns about COVID-19 infection.

The need to help treat acutely ill patients such as this patient while avoiding hospital admission during and after the pandemic continues to lead to the development of telehealth programs, Dr. Timpe said. She shared details of the Hospital@Home program developed by her organization, Health Partners. The program is designed to treat acutely ill people in the home, if possible, and avoid the need for hospital admission. Patients receive daily medical management from a hospitalist and care from staff, including registered nurses and community paramedics. Services include provision of IV medications and fluids, but the staff also conduct labs and imaging services, Dr. Timpe said.

Conditions that the program has managed at patients’ homes include pneumonia, COPD, asthma, bronchitis, flu, COVID-19, congestive heart failure, cellulitis, and urinary tract infections, said Dr. Timpe.

“We do not accept people into the program who have treatment needs that can only be met in a hospital,” such as the need for blood products, vasopressor support, telemetry, or positive pressure support, she noted.

Between November 2019 and February 15, 2021, the Hospital@Home program has provided services to 132 patients for a total of 287 visits. The program has averted 50 emergency department visits and 40 hospitalizations, and shorted hospital stays in 57 cases, she noted.

Hospitalists are suited for telehealth for several reasons, including the ability to triage acutely ill patients, familiarity with resource utilization, and expertise in management of complex medical care, said Dr. Timpe.
 

Looking ahead

Dr. Doshi emphasized several ongoing issues regarding the future of telemedicine, primarily the need for standardized regulation and reimbursement; reduction of health equity disparity and attention to technological barriers (including access and technology literacy); and identification of the next frontiers in telehealth.

Research on the impact and effectiveness of telehealth is limited, but growing, and next frontiers might include making patients more active participants in telehealth via patient-operated kits, or the option of an open telemedicine marketplace, in which patients can select providers from across the country, he said. No matter where telehealth leads in the future, “we need to make sure we have a positive patient outcome,” he concluded.

Dr. Doshi and Dr. Timpe had no financial conflicts to disclose.

Although the COVID-19 pandemic put telehealth on fast forward, more than one third of patients in the United States engaged with telehealth services before February 2020, according to Ameet Doshi, MD, and Chrisanne Timpe, MD, of HealthPartners in Bloomington, Minn.

Broadly speaking, telehealth is “using virtual tools to evaluate, manage, and care for our patients, regardless of where they are located,” Dr. Doshi said during a May 6 session at SHM Converge, the annual conference of the Society of Hospital Medicine.

The entirety of telehealth includes remote ways to meet almost any patient demand, he said. Some common health terms are used interchangeably, but some use telehealth as a broad term for electronic health care services, while telemedicine may refer specifically to remote patient care, he said.

Telemedicine allows flexibility of delivering patient care in inpatient, outpatient, or at-home settings, said Dr. Doshi. To illustrate the current application of telemedicine, he used an example of a 25-bed critical access hospital serving a growing regional population in which outpatient volume is expanding and ambulatory care services are being added. In this example, inpatient volume is growing, but not enough to support an inpatient consult service, but telehealth access to specialists such as cardiology would be useful in this case, he said.

Hospitalist telehealth means “being able to provide services to changing patient populations regardless of location; we can bring services to where patients are,” said Dr. Doshi.

Benefits of telehealth to patients include less travel and easier access to care, benefits to clinicians include expanding services at lower financial costs, he said.
 

COVID-19 challenges and opportunities

The COVID-19 pandemic presented both challenges and opportunities for telehealth, Dr. Doshi said. One opportunity was the sudden broad acceptance of virtual care out of necessity and concern for patient and staff safety, and to preserve the use of personal protective equipment, he said. In addition, a loosening of regulatory and financial pressures allowed more institutions to expand and initiate telehealth services.

Challenges included technological limitations and, in some cases, the need to develop a telehealth infrastructure from scratch, Dr. Doshi explained. Concerns also remain regarding how telehealth will evolve in the post-pandemic future, he said.

In the meantime, Medicare data show the impact of the pandemic on telehealth services, said Dr. Doshi. A telehealth waiver issued in March 2020 led to an increase in virtual encounters, and Medicare data show approximately 25 million virtual Medicare encounters between March 2020 and October 2020, representing a 3,000% increase from the same period in 2019, he said.

“Telehealth is here to stay, so the questions are how to craft a hospitalist telehealth program and provide essential patient care,” he said.

Dr. Timpe shared some examples of the evolution of telehealth care during the pandemic, including a case of an asymptomatic but frail patient with diabetes, dementia, and coronary artery disease undergoing outpatient care for a foot infection. The patient presented to an emergency department but refused to be hospitalized because of family concerns about patient isolation (no visitors were allowed at the time) and the concerns about COVID-19 infection.

The need to help treat acutely ill patients such as this patient while avoiding hospital admission during and after the pandemic continues to lead to the development of telehealth programs, Dr. Timpe said. She shared details of the Hospital@Home program developed by her organization, Health Partners. The program is designed to treat acutely ill people in the home, if possible, and avoid the need for hospital admission. Patients receive daily medical management from a hospitalist and care from staff, including registered nurses and community paramedics. Services include provision of IV medications and fluids, but the staff also conduct labs and imaging services, Dr. Timpe said.

Conditions that the program has managed at patients’ homes include pneumonia, COPD, asthma, bronchitis, flu, COVID-19, congestive heart failure, cellulitis, and urinary tract infections, said Dr. Timpe.

“We do not accept people into the program who have treatment needs that can only be met in a hospital,” such as the need for blood products, vasopressor support, telemetry, or positive pressure support, she noted.

Between November 2019 and February 15, 2021, the Hospital@Home program has provided services to 132 patients for a total of 287 visits. The program has averted 50 emergency department visits and 40 hospitalizations, and shorted hospital stays in 57 cases, she noted.

Hospitalists are suited for telehealth for several reasons, including the ability to triage acutely ill patients, familiarity with resource utilization, and expertise in management of complex medical care, said Dr. Timpe.
 

Looking ahead

Dr. Doshi emphasized several ongoing issues regarding the future of telemedicine, primarily the need for standardized regulation and reimbursement; reduction of health equity disparity and attention to technological barriers (including access and technology literacy); and identification of the next frontiers in telehealth.

Research on the impact and effectiveness of telehealth is limited, but growing, and next frontiers might include making patients more active participants in telehealth via patient-operated kits, or the option of an open telemedicine marketplace, in which patients can select providers from across the country, he said. No matter where telehealth leads in the future, “we need to make sure we have a positive patient outcome,” he concluded.

Dr. Doshi and Dr. Timpe had no financial conflicts to disclose.

When caring for older adults with multiple chronic conditions, prioritizing patient goals is more effective and efficient than trying to address each condition in isolation, said Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and Public Health and chief of geriatrics at Yale University, New Haven, Conn.

During a virtual presentation at the American College of Physicians annual Internal Medicine meeting, the gerontologist noted that primary care providers face a number of challenges when managing elderly patients with multimorbidity. These challenges include a lack of representative data in clinical trials, conflicting guideline recommendations, patient nonadherence, and decreased benefit from therapies due to competing conditions, she said.

“Trying to follow multiple guidelines can result in unintentional harms to these people with multiple conditions,” Dr. Tinetti said. She gave examples of the wide-ranging goals patients can have.

“Some [patients] will maximize the focus on function, regardless of how long they are likely to live,” Dr. Tinetti said. “Others will say symptom burden management is most important to them. And others will say they want to live as long as possible, and survival is most important, even if that means a reduction in their function. These individuals also vary in the care they are willing and able to receive to achieve the outcomes that matter most to them.”

For these reasons, Dr. Tinetti recommended patient priorities care, which she and her colleagues have been developing and implementing over the past 5-6 years.

“If the benefits and harms of addressing each condition in isolation is of uncertain benefit and potentially burdensome to both clinician and patient, and we know that patients vary in their health priorities ... then what else would you want to focus on in your 20-minute visit ... except each patient’s priorities?” Dr. Tinetti asked. “This is one solution to the challenge.”


 

What is patient priorities care?

Patient priorities care is a multidisciplinary, cyclical approach to clinical decision-making composed of three steps, Dr. Tinetti explained. First, a clinician identifies the patient’s health priorities. Second, this information is transmitted to comanaging providers, who decide which of their respective treatments are consistent with the patient’s priorities. And third, those decisions are disseminated to everyone involved in the patient’s care, both within and outside of the health care system, allowing all care providers to align with the patient’s priorities, she noted.

“Each person does that from their own expertise,” Dr. Tinetti said. “The social worker will do something different than the cardiologist, the physical therapist, the endocrinologist – but everybody is aiming at the same outcome – the patient’s priorities.”

In 2019, Dr. Tinetti led a nonrandomized clinical trial to test the feasibility of patient priorities care. The study involved 366 older adults with multimorbidity, among whom 203 received usual care, while 163 received this type of care. Patients in the latter group were twice as likely to have medications stopped, and significantly less likely to have self-management tasks added and diagnostic tests ordered.
 

How electronic health records can help

In an interview, Dr. Tinetti suggested that comanaging physicians communicate through electronic health records (EHRs), first to ensure that all care providers understand a patient’s goals, then to determine if recommended therapies align with those goals.

“It would be a little bit of a culture change to do that,” Dr. Tinetti said, “but the technology is there and it isn’t too terribly time consuming.”

She went on to suggest that primary care providers are typically best suited to coordinate this process; however, if a patient receives the majority of their care from a particular specialist, then that clinician may be the most suitable coordinator.
 

Systemic obstacles and solutions

According to Cynthia Boyd, MD, interim director of the division of geriatric medicine and gerontology, Johns Hopkins University, Baltimore, clinicians may encounter obstacles when implementing patient priorities care.

When caring for older adults with multiple chronic conditions, prioritizing patient goals is more effective and efficient than trying to address each condition in isolation, said Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and Public Health and chief of geriatrics at Yale University, New Haven, Conn.

During a virtual presentation at the American College of Physicians annual Internal Medicine meeting, the gerontologist noted that primary care providers face a number of challenges when managing elderly patients with multimorbidity. These challenges include a lack of representative data in clinical trials, conflicting guideline recommendations, patient nonadherence, and decreased benefit from therapies due to competing conditions, she said.

“Trying to follow multiple guidelines can result in unintentional harms to these people with multiple conditions,” Dr. Tinetti said. She gave examples of the wide-ranging goals patients can have.

“Some [patients] will maximize the focus on function, regardless of how long they are likely to live,” Dr. Tinetti said. “Others will say symptom burden management is most important to them. And others will say they want to live as long as possible, and survival is most important, even if that means a reduction in their function. These individuals also vary in the care they are willing and able to receive to achieve the outcomes that matter most to them.”

For these reasons, Dr. Tinetti recommended patient priorities care, which she and her colleagues have been developing and implementing over the past 5-6 years.

“If the benefits and harms of addressing each condition in isolation is of uncertain benefit and potentially burdensome to both clinician and patient, and we know that patients vary in their health priorities ... then what else would you want to focus on in your 20-minute visit ... except each patient’s priorities?” Dr. Tinetti asked. “This is one solution to the challenge.”


 

What is patient priorities care?

Patient priorities care is a multidisciplinary, cyclical approach to clinical decision-making composed of three steps, Dr. Tinetti explained. First, a clinician identifies the patient’s health priorities. Second, this information is transmitted to comanaging providers, who decide which of their respective treatments are consistent with the patient’s priorities. And third, those decisions are disseminated to everyone involved in the patient’s care, both within and outside of the health care system, allowing all care providers to align with the patient’s priorities, she noted.

“Each person does that from their own expertise,” Dr. Tinetti said. “The social worker will do something different than the cardiologist, the physical therapist, the endocrinologist – but everybody is aiming at the same outcome – the patient’s priorities.”

In 2019, Dr. Tinetti led a nonrandomized clinical trial to test the feasibility of patient priorities care. The study involved 366 older adults with multimorbidity, among whom 203 received usual care, while 163 received this type of care. Patients in the latter group were twice as likely to have medications stopped, and significantly less likely to have self-management tasks added and diagnostic tests ordered.
 

How electronic health records can help

In an interview, Dr. Tinetti suggested that comanaging physicians communicate through electronic health records (EHRs), first to ensure that all care providers understand a patient’s goals, then to determine if recommended therapies align with those goals.

“It would be a little bit of a culture change to do that,” Dr. Tinetti said, “but the technology is there and it isn’t too terribly time consuming.”

She went on to suggest that primary care providers are typically best suited to coordinate this process; however, if a patient receives the majority of their care from a particular specialist, then that clinician may be the most suitable coordinator.
 

Systemic obstacles and solutions

According to Cynthia Boyd, MD, interim director of the division of geriatric medicine and gerontology, Johns Hopkins University, Baltimore, clinicians may encounter obstacles when implementing patient priorities care.

When caring for older adults with multiple chronic conditions, prioritizing patient goals is more effective and efficient than trying to address each condition in isolation, said Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and Public Health and chief of geriatrics at Yale University, New Haven, Conn.

During a virtual presentation at the American College of Physicians annual Internal Medicine meeting, the gerontologist noted that primary care providers face a number of challenges when managing elderly patients with multimorbidity. These challenges include a lack of representative data in clinical trials, conflicting guideline recommendations, patient nonadherence, and decreased benefit from therapies due to competing conditions, she said.

“Trying to follow multiple guidelines can result in unintentional harms to these people with multiple conditions,” Dr. Tinetti said. She gave examples of the wide-ranging goals patients can have.

“Some [patients] will maximize the focus on function, regardless of how long they are likely to live,” Dr. Tinetti said. “Others will say symptom burden management is most important to them. And others will say they want to live as long as possible, and survival is most important, even if that means a reduction in their function. These individuals also vary in the care they are willing and able to receive to achieve the outcomes that matter most to them.”

For these reasons, Dr. Tinetti recommended patient priorities care, which she and her colleagues have been developing and implementing over the past 5-6 years.

“If the benefits and harms of addressing each condition in isolation is of uncertain benefit and potentially burdensome to both clinician and patient, and we know that patients vary in their health priorities ... then what else would you want to focus on in your 20-minute visit ... except each patient’s priorities?” Dr. Tinetti asked. “This is one solution to the challenge.”


 

What is patient priorities care?

Patient priorities care is a multidisciplinary, cyclical approach to clinical decision-making composed of three steps, Dr. Tinetti explained. First, a clinician identifies the patient’s health priorities. Second, this information is transmitted to comanaging providers, who decide which of their respective treatments are consistent with the patient’s priorities. And third, those decisions are disseminated to everyone involved in the patient’s care, both within and outside of the health care system, allowing all care providers to align with the patient’s priorities, she noted.

“Each person does that from their own expertise,” Dr. Tinetti said. “The social worker will do something different than the cardiologist, the physical therapist, the endocrinologist – but everybody is aiming at the same outcome – the patient’s priorities.”

In 2019, Dr. Tinetti led a nonrandomized clinical trial to test the feasibility of patient priorities care. The study involved 366 older adults with multimorbidity, among whom 203 received usual care, while 163 received this type of care. Patients in the latter group were twice as likely to have medications stopped, and significantly less likely to have self-management tasks added and diagnostic tests ordered.
 

How electronic health records can help

In an interview, Dr. Tinetti suggested that comanaging physicians communicate through electronic health records (EHRs), first to ensure that all care providers understand a patient’s goals, then to determine if recommended therapies align with those goals.

“It would be a little bit of a culture change to do that,” Dr. Tinetti said, “but the technology is there and it isn’t too terribly time consuming.”

She went on to suggest that primary care providers are typically best suited to coordinate this process; however, if a patient receives the majority of their care from a particular specialist, then that clinician may be the most suitable coordinator.
 

Systemic obstacles and solutions

According to Cynthia Boyd, MD, interim director of the division of geriatric medicine and gerontology, Johns Hopkins University, Baltimore, clinicians may encounter obstacles when implementing patient priorities care.

Click here for the Thursday issue of the SHM Converge Daily News newsletter.

Click here for the Thursday issue of the SHM Converge Daily News newsletter.

Click here for the Thursday issue of the SHM Converge Daily News newsletter.

Click here for the Wednesday issue of the SHM Converge Daily News newsletter.

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Click here for the Wednesday issue of the SHM Converge Daily News newsletter.

To the Editor:

Levamisole is a veterinary anthelmintic drug with immunomodulating properties that was once approved by the US Food and Drug Administration for the treatment of various conditions, including autoimmune diseases, cancer, pediatric kidney disease, and chronic infections.^1-4 Levamisole was banned in 2000 after reports of associated agranulocytosis and a characteristic painful purpuric vasculitis.^4,5 Despite the ban, its use persists due to its increasing incorporation as an adulterant in cocaine, presumably for its dopaminergic properties that potentiate psychotropic effects.⁶ In 2009, the Drug Enforcement Administration reported that 69% of seized cocaine in the United States contains this chemical, with an average concentration of 10%.⁵ Levamisole-induced vasculopathy (LIV) typically resolves following the cessation of cocaine without further treatment necessary. We present a fatal case of LIV to emphasize that early recognition and discontinuation of the offending agent could be lifesaving.

A 40-year-old woman with a history of cocaine abuse was admitted with tender, reticular, purpuric, and erythematous patches and plaques on the lower extremities with areas of necrosis (Figure 1). The lesions had been present intermittently for 6 months. She tried topical mupirocin and oral amoxicillin clavulanate without improvement. She also described polyarthralgia in the hands, but the remainder of the review of symptoms and physical examination was negative.

The pathogenesis of LIV is not completely understood, but it is thought to be an immune complex–mediated process based on immunofluorescence studies in the skin.^13,14 Classic pathologic findings include multiple fibrin thrombi within small vessels in the superficial and deep dermis, leukocytoclastic vasculitis of small vessels consisting of fibrinoid necrosis of the vessel wall, extravasated erythrocytes, karyorrhectic debris, and angiocentric inflammation.¹⁴ Direct immunofluorescence is not routinely performed but most commonly demonstrates deposition of IgA, IgM, and C3.^14,15

Levamisole-induced vasculopathy usually resolves upon cessation of cocaine use without long-term sequelae. Steroids have been used as treatment of prominent vasculitis with variable success; however, immunosuppressive effects should be closely monitored, especially with inpatients with concurrent granulocytopenia. Broad-spectrum antibiotics have been used in cases with fever and agranulocytosis. Cutaneous lesions typically disappear within 2 to 3 weeks, and serologic markers resolve within 2 to 10 months. Recurrent use of cocaine generally results in recurrent neutropenia and skin eruptions, supporting the causal role. Our patient’s recurrent prolonged cocaine use with vasculopathy was assumed to be the source of the necrotizing fasciitis that led to a cascade of sepsis, rapidly progressing multiorgan failure, and ultimate demise.

Presentation of a purpuric vasculopathy, with or without associated neutropenia and positive autoantibodies, should prompt the consideration of levamisole-contaminated cocaine use in the clinician’s differential. Although the patient may initially deny cocaine use, it is important to keep this diagnosis in mind when the clinical picture fits, and urine toxicology screen should be ordered when there is question. Physicians and patients should be wary of potential complications, even death. Early recognition and discontinuation of the offending agent could be lifesaving.

To the Editor:

Levamisole is a veterinary anthelmintic drug with immunomodulating properties that was once approved by the US Food and Drug Administration for the treatment of various conditions, including autoimmune diseases, cancer, pediatric kidney disease, and chronic infections.^1-4 Levamisole was banned in 2000 after reports of associated agranulocytosis and a characteristic painful purpuric vasculitis.^4,5 Despite the ban, its use persists due to its increasing incorporation as an adulterant in cocaine, presumably for its dopaminergic properties that potentiate psychotropic effects.⁶ In 2009, the Drug Enforcement Administration reported that 69% of seized cocaine in the United States contains this chemical, with an average concentration of 10%.⁵ Levamisole-induced vasculopathy (LIV) typically resolves following the cessation of cocaine without further treatment necessary. We present a fatal case of LIV to emphasize that early recognition and discontinuation of the offending agent could be lifesaving.

A 40-year-old woman with a history of cocaine abuse was admitted with tender, reticular, purpuric, and erythematous patches and plaques on the lower extremities with areas of necrosis (Figure 1). The lesions had been present intermittently for 6 months. She tried topical mupirocin and oral amoxicillin clavulanate without improvement. She also described polyarthralgia in the hands, but the remainder of the review of symptoms and physical examination was negative.

The pathogenesis of LIV is not completely understood, but it is thought to be an immune complex–mediated process based on immunofluorescence studies in the skin.^13,14 Classic pathologic findings include multiple fibrin thrombi within small vessels in the superficial and deep dermis, leukocytoclastic vasculitis of small vessels consisting of fibrinoid necrosis of the vessel wall, extravasated erythrocytes, karyorrhectic debris, and angiocentric inflammation.¹⁴ Direct immunofluorescence is not routinely performed but most commonly demonstrates deposition of IgA, IgM, and C3.^14,15

Levamisole-induced vasculopathy usually resolves upon cessation of cocaine use without long-term sequelae. Steroids have been used as treatment of prominent vasculitis with variable success; however, immunosuppressive effects should be closely monitored, especially with inpatients with concurrent granulocytopenia. Broad-spectrum antibiotics have been used in cases with fever and agranulocytosis. Cutaneous lesions typically disappear within 2 to 3 weeks, and serologic markers resolve within 2 to 10 months. Recurrent use of cocaine generally results in recurrent neutropenia and skin eruptions, supporting the causal role. Our patient’s recurrent prolonged cocaine use with vasculopathy was assumed to be the source of the necrotizing fasciitis that led to a cascade of sepsis, rapidly progressing multiorgan failure, and ultimate demise.

Presentation of a purpuric vasculopathy, with or without associated neutropenia and positive autoantibodies, should prompt the consideration of levamisole-contaminated cocaine use in the clinician’s differential. Although the patient may initially deny cocaine use, it is important to keep this diagnosis in mind when the clinical picture fits, and urine toxicology screen should be ordered when there is question. Physicians and patients should be wary of potential complications, even death. Early recognition and discontinuation of the offending agent could be lifesaving.

To the Editor:

Levamisole is a veterinary anthelmintic drug with immunomodulating properties that was once approved by the US Food and Drug Administration for the treatment of various conditions, including autoimmune diseases, cancer, pediatric kidney disease, and chronic infections.^1-4 Levamisole was banned in 2000 after reports of associated agranulocytosis and a characteristic painful purpuric vasculitis.^4,5 Despite the ban, its use persists due to its increasing incorporation as an adulterant in cocaine, presumably for its dopaminergic properties that potentiate psychotropic effects.⁶ In 2009, the Drug Enforcement Administration reported that 69% of seized cocaine in the United States contains this chemical, with an average concentration of 10%.⁵ Levamisole-induced vasculopathy (LIV) typically resolves following the cessation of cocaine without further treatment necessary. We present a fatal case of LIV to emphasize that early recognition and discontinuation of the offending agent could be lifesaving.

A 40-year-old woman with a history of cocaine abuse was admitted with tender, reticular, purpuric, and erythematous patches and plaques on the lower extremities with areas of necrosis (Figure 1). The lesions had been present intermittently for 6 months. She tried topical mupirocin and oral amoxicillin clavulanate without improvement. She also described polyarthralgia in the hands, but the remainder of the review of symptoms and physical examination was negative.

The pathogenesis of LIV is not completely understood, but it is thought to be an immune complex–mediated process based on immunofluorescence studies in the skin.^13,14 Classic pathologic findings include multiple fibrin thrombi within small vessels in the superficial and deep dermis, leukocytoclastic vasculitis of small vessels consisting of fibrinoid necrosis of the vessel wall, extravasated erythrocytes, karyorrhectic debris, and angiocentric inflammation.¹⁴ Direct immunofluorescence is not routinely performed but most commonly demonstrates deposition of IgA, IgM, and C3.^14,15

Levamisole-induced vasculopathy usually resolves upon cessation of cocaine use without long-term sequelae. Steroids have been used as treatment of prominent vasculitis with variable success; however, immunosuppressive effects should be closely monitored, especially with inpatients with concurrent granulocytopenia. Broad-spectrum antibiotics have been used in cases with fever and agranulocytosis. Cutaneous lesions typically disappear within 2 to 3 weeks, and serologic markers resolve within 2 to 10 months. Recurrent use of cocaine generally results in recurrent neutropenia and skin eruptions, supporting the causal role. Our patient’s recurrent prolonged cocaine use with vasculopathy was assumed to be the source of the necrotizing fasciitis that led to a cascade of sepsis, rapidly progressing multiorgan failure, and ultimate demise.

Presentation of a purpuric vasculopathy, with or without associated neutropenia and positive autoantibodies, should prompt the consideration of levamisole-contaminated cocaine use in the clinician’s differential. Although the patient may initially deny cocaine use, it is important to keep this diagnosis in mind when the clinical picture fits, and urine toxicology screen should be ordered when there is question. Physicians and patients should be wary of potential complications, even death. Early recognition and discontinuation of the offending agent could be lifesaving.

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.

Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.

He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.

Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.

Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.

While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.

“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.

Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.

There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.

Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”

Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.

He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.

Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.

Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.

Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”

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

Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.

Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.

He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.

Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.

Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.

While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.

“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.

Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.

There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.

Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”

Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.

He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.

Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.

Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.

Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”

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

Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.

Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.

He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.

Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.

Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.

While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.

“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.

Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.

There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.

Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”

Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.

He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.

Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.

Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.

Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”

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