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How family medicine has changed over the past half century
From my residency training graduation date, June 1978, many changes to the family medicine specialty have occurred. These are not due to certification requirements but to the dilution of physician control in health care.
The need to provide more affordable health care by insurance companies while maintaining quality prompted more changes. Additionally, employer-based decisions to change insurance plans, since they were the payer for employer-based health insurance, sometimes yearly, prompted mandatory changes in health insurance.
To achieve hospital-based goals and cost containment the advent and use of hospitalists and the expanded use of physician extenders emerged. While I have some support for these changes, they have redefined elements of the Folsom report, which concluded that every American should have a personal physician to care for them and help integrate them into the health care system.
Changes in the health care delivery system and insurance companies’ need to contain costs, while expanding preventative medicine, coupled with a decreasing number of trained family medicine physicians, represents the background of some of the changes in family medicine over the past 50 years. Managed health care, I believe, was certainly part of the answer to implementing the following recommendation of the Folsom report: every American should have a physician-manager for their health care.
Despite the continual output of new family physicians, a shortage of physicians trained in this specialty remained. Advances in health care, which lengthened life expectancy and the fact that most health insurance companies required its members to name a primary care physician expanded the population requiring primary health care services. This only exacerbated the shortage of family physicians and lowered earning power for doctors practicing family medicine, and it created greater professional demands on family physicians, compared with those in other, more limited-scope specialties. The primary care physician shortage needed to be addressed, prompting a redefinition in the traditional nurse practitioner role.
The expansion of nurse practitioners and physician assistants’ roles
The nursing profession began training advanced-placement nurses and instituted a Doctor of Nurse Practitioner degree. At the same time physician assistants, a program that began while I was a resident, had a further role expansion, including training confined to a single specialty area of medicine. These roles were expanded by state legislators who added them to the list of primary care providers, in some locations, permitting independent practice and placing the physician assistant under the state medical boards and the nurse practitioner and Doctor of Nurse Practitioners under the nursing boards, for expanded regulations and the implementation of the new provider requirements for licensure.
The effects of insurance companies on primary care physicians and patients
When I started practicing medicine the physician was truly the manager of a person’s health care. With the advent of managed health care, that has changed. Physicians are no longer the managers; an uninvited marriage between physician, physician extender, insurance company, employer, and patient jointly controls health care.
Patients are opting for less care at the cheapest price based on incentives driven by cost and abetted by insurance companies and employers. The cost of medications has increased and provider services, coupled with medication and specialty costs have nearly priced many beyond their economic limits to pay. As a result, the patient is not always as committed as their provider to meeting the metrics of their insurance company, especially if that is increasing their out-of-pocket cost.
In addition to usual services, the primary care physician is required to demonstrate the adequacy of services provided through meeting certain practice quality metrics for nearly all insurance carriers, including Medicare and Medicaid. Because meeting these metrics carries a significant economic incentive many practices are retaining fewer noncompliant patients and have opted to bolster their bottom line with the more complaint. This adversely impacts the delivery of primary care to a significant portion of the population.
Patients that reside in poorer neighborhoods, rural areas, as well the marginalized compose a significant portion of many primary care provider’s practices and make up a significant percentage of noncompliant patients. Recognizing that the primary care physician’s overhead is high, coupled with the amount of financial and personal resources put into place to meet metrics, it costs much more to care for the marginalized, poor, and rural populations than easier-to-care for patient groups. This creates a disparity in health care.
A study that revisited the Folsom report concluded that “the 21st century primary care physician must be a true public health professional, forming partnerships and assisting data sharing with community organizations to facilitate healthy changes.” These observations have redefined primary care. This type of medicine is no longer tied to a physician; it is tied to a fairly expensive team of providers, which includes a nurse manager, physician, physician extender, social worker, and in some cases, a pharmacist. The days of mostly solo practitioners are waning and the days of the traditional family medicine residency training requires continuous nuancing, to accommodate the expanded list of practice-related responsibilities assigned to the family doctor.
Low reimbursements rates and high office overhead
The last change I have observed in the practice of family medicine over the past 50 years is a decline in the ratio of reimbursement rate for services to practice expenses. Many practitioners opt out of Medicaid or have certainly curtailed the number of Medicaid recipients on their panel because of its unacceptably low reimbursement rates combined with their high office overhead. The requirements for organizing community resources, including nursing agencies and church and community groups, carry no reimbursement for time invested. The primary care provider is responsible and evaluated on patient outcomes despite the noncompliant behavior of the patient.
What is the future of the primary care physician or provider?
The factors that determine this answer lie in what will be required of the provider and the role of the insurance company in assisting the provider of services. Insurance companies have a responsibility because they receive money to pay for metrics while remaining profitable. They must be brought into the success formula and assist the provider in order for the latter to survive. Currently the primary care provider, in an abundance of caution, is required to seek more specialty services, which drives up the cost of health care. Instead, the insurance company should allow the primary care provider to direct the health care and stop being the manager, approving or disapproving services. In summary, much has happened in family medicine over the past 50 years. The ongoing personal doctor-patient relationship has turned into a doctor-patient-insurance company relationship. The introduction of the third party has created an economic incentive for the physician to meet practice metrics, which sometimes, from the patient’s economic perspective, creates economic hardship.
Some patients enlist a primary care physician in name only but continue to drive their health care by the older model, thanks to the advent of the urgent care centers. These patients see participating in the crisis-care model as resulting in lower out-of-pocket costs. Insurance companies should enlist patient support by expanding their patient education to include the benefits of health, the benefits of meeting quality metrics by their physician, and the necessity of maintaining a compliant doctor-patient relationship. Just as they offer incentives to the primary care practitioner for meeting quality metrics incentives should be offered to those patients that meet quality metrics as well.
In the 21st century, a new model of health care emerged, which includes a primary care practitioner, nurse manager-educator, social worker, and a pharmacist. To deliver quality health care one person can’t be responsible for this burden and do it effectively. Many family practice residencies already use this model and most likely advise their graduates to seek employment where this model exists. Additionally, I am sure that family practice residencies are continually nuanced to achieve the teaching mantra required for successful postgraduate employment and good patient outcomes.
What is the future of family medicine?
The family medicine specialty is represented by a practice that looks at outcome metrics primarily without an incentive for helping the marginalized, poor, homeless, and displaced members of our society.
Urban family medicine, much like what I have practiced in this my 43rd year, is different. My practice community includes every segment of society and my approach lies in the improvement of outcomes from all that I serve. It is my impression that the future of family medicine education must include all members of our society and train residents to effectively care for all, irrespective of economic status, and evolve ways to improve the health outcomes for all.
The federal government, through reimbursement and incentive programs, needs to include such efforts in the model of care for these individuals to reduce the expense burden on the practitioner achieving better practice success and less burnout.
Dr. Betton practices family medicine in Little Rock, Ark. He also serves on the editorial advisory board of Family Practice News.
From my residency training graduation date, June 1978, many changes to the family medicine specialty have occurred. These are not due to certification requirements but to the dilution of physician control in health care.
The need to provide more affordable health care by insurance companies while maintaining quality prompted more changes. Additionally, employer-based decisions to change insurance plans, since they were the payer for employer-based health insurance, sometimes yearly, prompted mandatory changes in health insurance.
To achieve hospital-based goals and cost containment the advent and use of hospitalists and the expanded use of physician extenders emerged. While I have some support for these changes, they have redefined elements of the Folsom report, which concluded that every American should have a personal physician to care for them and help integrate them into the health care system.
Changes in the health care delivery system and insurance companies’ need to contain costs, while expanding preventative medicine, coupled with a decreasing number of trained family medicine physicians, represents the background of some of the changes in family medicine over the past 50 years. Managed health care, I believe, was certainly part of the answer to implementing the following recommendation of the Folsom report: every American should have a physician-manager for their health care.
Despite the continual output of new family physicians, a shortage of physicians trained in this specialty remained. Advances in health care, which lengthened life expectancy and the fact that most health insurance companies required its members to name a primary care physician expanded the population requiring primary health care services. This only exacerbated the shortage of family physicians and lowered earning power for doctors practicing family medicine, and it created greater professional demands on family physicians, compared with those in other, more limited-scope specialties. The primary care physician shortage needed to be addressed, prompting a redefinition in the traditional nurse practitioner role.
The expansion of nurse practitioners and physician assistants’ roles
The nursing profession began training advanced-placement nurses and instituted a Doctor of Nurse Practitioner degree. At the same time physician assistants, a program that began while I was a resident, had a further role expansion, including training confined to a single specialty area of medicine. These roles were expanded by state legislators who added them to the list of primary care providers, in some locations, permitting independent practice and placing the physician assistant under the state medical boards and the nurse practitioner and Doctor of Nurse Practitioners under the nursing boards, for expanded regulations and the implementation of the new provider requirements for licensure.
The effects of insurance companies on primary care physicians and patients
When I started practicing medicine the physician was truly the manager of a person’s health care. With the advent of managed health care, that has changed. Physicians are no longer the managers; an uninvited marriage between physician, physician extender, insurance company, employer, and patient jointly controls health care.
Patients are opting for less care at the cheapest price based on incentives driven by cost and abetted by insurance companies and employers. The cost of medications has increased and provider services, coupled with medication and specialty costs have nearly priced many beyond their economic limits to pay. As a result, the patient is not always as committed as their provider to meeting the metrics of their insurance company, especially if that is increasing their out-of-pocket cost.
In addition to usual services, the primary care physician is required to demonstrate the adequacy of services provided through meeting certain practice quality metrics for nearly all insurance carriers, including Medicare and Medicaid. Because meeting these metrics carries a significant economic incentive many practices are retaining fewer noncompliant patients and have opted to bolster their bottom line with the more complaint. This adversely impacts the delivery of primary care to a significant portion of the population.
Patients that reside in poorer neighborhoods, rural areas, as well the marginalized compose a significant portion of many primary care provider’s practices and make up a significant percentage of noncompliant patients. Recognizing that the primary care physician’s overhead is high, coupled with the amount of financial and personal resources put into place to meet metrics, it costs much more to care for the marginalized, poor, and rural populations than easier-to-care for patient groups. This creates a disparity in health care.
A study that revisited the Folsom report concluded that “the 21st century primary care physician must be a true public health professional, forming partnerships and assisting data sharing with community organizations to facilitate healthy changes.” These observations have redefined primary care. This type of medicine is no longer tied to a physician; it is tied to a fairly expensive team of providers, which includes a nurse manager, physician, physician extender, social worker, and in some cases, a pharmacist. The days of mostly solo practitioners are waning and the days of the traditional family medicine residency training requires continuous nuancing, to accommodate the expanded list of practice-related responsibilities assigned to the family doctor.
Low reimbursements rates and high office overhead
The last change I have observed in the practice of family medicine over the past 50 years is a decline in the ratio of reimbursement rate for services to practice expenses. Many practitioners opt out of Medicaid or have certainly curtailed the number of Medicaid recipients on their panel because of its unacceptably low reimbursement rates combined with their high office overhead. The requirements for organizing community resources, including nursing agencies and church and community groups, carry no reimbursement for time invested. The primary care provider is responsible and evaluated on patient outcomes despite the noncompliant behavior of the patient.
What is the future of the primary care physician or provider?
The factors that determine this answer lie in what will be required of the provider and the role of the insurance company in assisting the provider of services. Insurance companies have a responsibility because they receive money to pay for metrics while remaining profitable. They must be brought into the success formula and assist the provider in order for the latter to survive. Currently the primary care provider, in an abundance of caution, is required to seek more specialty services, which drives up the cost of health care. Instead, the insurance company should allow the primary care provider to direct the health care and stop being the manager, approving or disapproving services. In summary, much has happened in family medicine over the past 50 years. The ongoing personal doctor-patient relationship has turned into a doctor-patient-insurance company relationship. The introduction of the third party has created an economic incentive for the physician to meet practice metrics, which sometimes, from the patient’s economic perspective, creates economic hardship.
Some patients enlist a primary care physician in name only but continue to drive their health care by the older model, thanks to the advent of the urgent care centers. These patients see participating in the crisis-care model as resulting in lower out-of-pocket costs. Insurance companies should enlist patient support by expanding their patient education to include the benefits of health, the benefits of meeting quality metrics by their physician, and the necessity of maintaining a compliant doctor-patient relationship. Just as they offer incentives to the primary care practitioner for meeting quality metrics incentives should be offered to those patients that meet quality metrics as well.
In the 21st century, a new model of health care emerged, which includes a primary care practitioner, nurse manager-educator, social worker, and a pharmacist. To deliver quality health care one person can’t be responsible for this burden and do it effectively. Many family practice residencies already use this model and most likely advise their graduates to seek employment where this model exists. Additionally, I am sure that family practice residencies are continually nuanced to achieve the teaching mantra required for successful postgraduate employment and good patient outcomes.
What is the future of family medicine?
The family medicine specialty is represented by a practice that looks at outcome metrics primarily without an incentive for helping the marginalized, poor, homeless, and displaced members of our society.
Urban family medicine, much like what I have practiced in this my 43rd year, is different. My practice community includes every segment of society and my approach lies in the improvement of outcomes from all that I serve. It is my impression that the future of family medicine education must include all members of our society and train residents to effectively care for all, irrespective of economic status, and evolve ways to improve the health outcomes for all.
The federal government, through reimbursement and incentive programs, needs to include such efforts in the model of care for these individuals to reduce the expense burden on the practitioner achieving better practice success and less burnout.
Dr. Betton practices family medicine in Little Rock, Ark. He also serves on the editorial advisory board of Family Practice News.
From my residency training graduation date, June 1978, many changes to the family medicine specialty have occurred. These are not due to certification requirements but to the dilution of physician control in health care.
The need to provide more affordable health care by insurance companies while maintaining quality prompted more changes. Additionally, employer-based decisions to change insurance plans, since they were the payer for employer-based health insurance, sometimes yearly, prompted mandatory changes in health insurance.
To achieve hospital-based goals and cost containment the advent and use of hospitalists and the expanded use of physician extenders emerged. While I have some support for these changes, they have redefined elements of the Folsom report, which concluded that every American should have a personal physician to care for them and help integrate them into the health care system.
Changes in the health care delivery system and insurance companies’ need to contain costs, while expanding preventative medicine, coupled with a decreasing number of trained family medicine physicians, represents the background of some of the changes in family medicine over the past 50 years. Managed health care, I believe, was certainly part of the answer to implementing the following recommendation of the Folsom report: every American should have a physician-manager for their health care.
Despite the continual output of new family physicians, a shortage of physicians trained in this specialty remained. Advances in health care, which lengthened life expectancy and the fact that most health insurance companies required its members to name a primary care physician expanded the population requiring primary health care services. This only exacerbated the shortage of family physicians and lowered earning power for doctors practicing family medicine, and it created greater professional demands on family physicians, compared with those in other, more limited-scope specialties. The primary care physician shortage needed to be addressed, prompting a redefinition in the traditional nurse practitioner role.
The expansion of nurse practitioners and physician assistants’ roles
The nursing profession began training advanced-placement nurses and instituted a Doctor of Nurse Practitioner degree. At the same time physician assistants, a program that began while I was a resident, had a further role expansion, including training confined to a single specialty area of medicine. These roles were expanded by state legislators who added them to the list of primary care providers, in some locations, permitting independent practice and placing the physician assistant under the state medical boards and the nurse practitioner and Doctor of Nurse Practitioners under the nursing boards, for expanded regulations and the implementation of the new provider requirements for licensure.
The effects of insurance companies on primary care physicians and patients
When I started practicing medicine the physician was truly the manager of a person’s health care. With the advent of managed health care, that has changed. Physicians are no longer the managers; an uninvited marriage between physician, physician extender, insurance company, employer, and patient jointly controls health care.
Patients are opting for less care at the cheapest price based on incentives driven by cost and abetted by insurance companies and employers. The cost of medications has increased and provider services, coupled with medication and specialty costs have nearly priced many beyond their economic limits to pay. As a result, the patient is not always as committed as their provider to meeting the metrics of their insurance company, especially if that is increasing their out-of-pocket cost.
In addition to usual services, the primary care physician is required to demonstrate the adequacy of services provided through meeting certain practice quality metrics for nearly all insurance carriers, including Medicare and Medicaid. Because meeting these metrics carries a significant economic incentive many practices are retaining fewer noncompliant patients and have opted to bolster their bottom line with the more complaint. This adversely impacts the delivery of primary care to a significant portion of the population.
Patients that reside in poorer neighborhoods, rural areas, as well the marginalized compose a significant portion of many primary care provider’s practices and make up a significant percentage of noncompliant patients. Recognizing that the primary care physician’s overhead is high, coupled with the amount of financial and personal resources put into place to meet metrics, it costs much more to care for the marginalized, poor, and rural populations than easier-to-care for patient groups. This creates a disparity in health care.
A study that revisited the Folsom report concluded that “the 21st century primary care physician must be a true public health professional, forming partnerships and assisting data sharing with community organizations to facilitate healthy changes.” These observations have redefined primary care. This type of medicine is no longer tied to a physician; it is tied to a fairly expensive team of providers, which includes a nurse manager, physician, physician extender, social worker, and in some cases, a pharmacist. The days of mostly solo practitioners are waning and the days of the traditional family medicine residency training requires continuous nuancing, to accommodate the expanded list of practice-related responsibilities assigned to the family doctor.
Low reimbursements rates and high office overhead
The last change I have observed in the practice of family medicine over the past 50 years is a decline in the ratio of reimbursement rate for services to practice expenses. Many practitioners opt out of Medicaid or have certainly curtailed the number of Medicaid recipients on their panel because of its unacceptably low reimbursement rates combined with their high office overhead. The requirements for organizing community resources, including nursing agencies and church and community groups, carry no reimbursement for time invested. The primary care provider is responsible and evaluated on patient outcomes despite the noncompliant behavior of the patient.
What is the future of the primary care physician or provider?
The factors that determine this answer lie in what will be required of the provider and the role of the insurance company in assisting the provider of services. Insurance companies have a responsibility because they receive money to pay for metrics while remaining profitable. They must be brought into the success formula and assist the provider in order for the latter to survive. Currently the primary care provider, in an abundance of caution, is required to seek more specialty services, which drives up the cost of health care. Instead, the insurance company should allow the primary care provider to direct the health care and stop being the manager, approving or disapproving services. In summary, much has happened in family medicine over the past 50 years. The ongoing personal doctor-patient relationship has turned into a doctor-patient-insurance company relationship. The introduction of the third party has created an economic incentive for the physician to meet practice metrics, which sometimes, from the patient’s economic perspective, creates economic hardship.
Some patients enlist a primary care physician in name only but continue to drive their health care by the older model, thanks to the advent of the urgent care centers. These patients see participating in the crisis-care model as resulting in lower out-of-pocket costs. Insurance companies should enlist patient support by expanding their patient education to include the benefits of health, the benefits of meeting quality metrics by their physician, and the necessity of maintaining a compliant doctor-patient relationship. Just as they offer incentives to the primary care practitioner for meeting quality metrics incentives should be offered to those patients that meet quality metrics as well.
In the 21st century, a new model of health care emerged, which includes a primary care practitioner, nurse manager-educator, social worker, and a pharmacist. To deliver quality health care one person can’t be responsible for this burden and do it effectively. Many family practice residencies already use this model and most likely advise their graduates to seek employment where this model exists. Additionally, I am sure that family practice residencies are continually nuanced to achieve the teaching mantra required for successful postgraduate employment and good patient outcomes.
What is the future of family medicine?
The family medicine specialty is represented by a practice that looks at outcome metrics primarily without an incentive for helping the marginalized, poor, homeless, and displaced members of our society.
Urban family medicine, much like what I have practiced in this my 43rd year, is different. My practice community includes every segment of society and my approach lies in the improvement of outcomes from all that I serve. It is my impression that the future of family medicine education must include all members of our society and train residents to effectively care for all, irrespective of economic status, and evolve ways to improve the health outcomes for all.
The federal government, through reimbursement and incentive programs, needs to include such efforts in the model of care for these individuals to reduce the expense burden on the practitioner achieving better practice success and less burnout.
Dr. Betton practices family medicine in Little Rock, Ark. He also serves on the editorial advisory board of Family Practice News.
1 in 3 on levothyroxine take meds that interfere with thyroid tests
, potentially compromising treatment decisions, new research shows.
“We know from previous studies that thyroid hormone use is common in older adults and that there are a multitude of medications that can interfere with thyroid function tests in different ways,” senior author Maria Papaleontiou, MD, told Medscape Medical News.
“However, to our knowledge, the extent of concurrent use of thyroid hormone and interfering medications in older adults, age 65 years and older, has not been previously explored,” added Dr. Papaleontiou, of the Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor.
The findings were presented as a poster during virtual ENDO 2021, the Endocrine Society’s annual meeting.
Commenting on the study, Thanh Duc Hoang, DO, an endocrinologist with the Walter Reed National Military Medical Center, in Bethesda, Md., said: “It is important for clinicians to be aware of various interactions and interferences of medications affecting the accuracy of thyroid function tests.”
“If patients are not able to discontinue the medications shortly before the bloodwork, the clinicians may consider ordering different thyroid tests or assays that avoid the interferences,” he told Medscape Medical News.
32% of patients taking meds that could interfere with tests
In evaluating data on 538,137 patients treated with thyroid hormones from the Corporate Data Warehouse of the Veterans Health Administration, spanning 2004-2017, first author Rachel Beeson, MD, and colleagues with the University of Michigan found most patients in the study were men (96.5%), White (77.1%), and had two or more comorbidities (62.6%).
Of this total, 170,261 (31.6%) patients treated with thyroid hormones, over a median follow-up of 56 months, were taking at least one drug that could potentially interfere with thyroid function tests.
Among the drugs with potential thyroid test interference, about 28% of patients were taking prednisone or prednisolone, 8% were taking amiodarone, and 1.42% were taking phenytoin. Other reported drugs that could potentially interfere included carbamazepine (0.91%), phenobarbital (0.15%), lithium (0.40%), and tamoxifen (0.11%).
Multivariate analysis showed that characteristics associated with those most likely to have concurrent medication use included non-Whites (OR, 1.18 vs Whites), Hispanic ethnicity (OR 1.11 vs non-Hispanic), female sex (OR 1.12 vs males), and presence of comorbidities (eg, Charlson-Deyo comorbidity score ≥ 2, OR, 2.47 vs score of 0).
Meanwhile, older patients age 85 years and over had a lower likelihood of concurrent medications interfering with thyroid tests (OR, 0.47 vs age 65-74 years).
The findings are concerning given the wide use of levothyroxine to treat hypothyroidism, which is the most widely prescribed drug in the United States.
“Our findings not only highlight the complexity of thyroid hormone management in older adults in the context of polypharmacy and multimorbidity, but they also draw attention to vulnerable groups for this practice, which included female patients, non-Whites, patients of Hispanic ethnicity, and patients with comorbidities,” Dr. Papaleontiou said.
Nature of interference possibilities varies
Medications or supplements can interfere with thyroid function tests in a variety of ways, she explained. “Some medications could lead to a decrease in the absorption of levothyroxine, others may affect how well the pill dissolves.”
In addition, certain medications can affect the circulation of thyroid hormone in the blood and how it binds with proteins, or they can lead to decreasing thyroid hormone levels due to a variety of interactions.
And in contrast, “What is even more challenging is that some medications or supplements may appear to affect thyroid function based on lab tests when in reality they don’t actually affect thyroid function and may lead to dose adjustments unnecessarily,” Dr. Papaleontiou noted.
Recommendations to counter interference
Current recommendations to try to counter the effects of polypharmacy on thyroid treatment include advising patients to take thyroid hormones on an empty stomach at least 30-60 minutes prior to eating for optimal absorption.
If the patient is taking medications known to interfere with absorption of thyroid hormones, the recommendation is to space those out by at least 4 hours.
“The big challenge in older adults is that many of them do experience polypharmacy, being at risk for multiple drug-drug interactions,” Dr. Papaleontiou said.
“Physicians and patients should be vigilant and communicate closely every time there is initiation of a new medication or supplement to consider whether there may be interference.”
The authors have reported no relevant financial relationships. Dr. Hoang has reported being a speaker for Acella Pharmaceuticals.
A version of this article first appeared on Medscape.com.
, potentially compromising treatment decisions, new research shows.
“We know from previous studies that thyroid hormone use is common in older adults and that there are a multitude of medications that can interfere with thyroid function tests in different ways,” senior author Maria Papaleontiou, MD, told Medscape Medical News.
“However, to our knowledge, the extent of concurrent use of thyroid hormone and interfering medications in older adults, age 65 years and older, has not been previously explored,” added Dr. Papaleontiou, of the Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor.
The findings were presented as a poster during virtual ENDO 2021, the Endocrine Society’s annual meeting.
Commenting on the study, Thanh Duc Hoang, DO, an endocrinologist with the Walter Reed National Military Medical Center, in Bethesda, Md., said: “It is important for clinicians to be aware of various interactions and interferences of medications affecting the accuracy of thyroid function tests.”
“If patients are not able to discontinue the medications shortly before the bloodwork, the clinicians may consider ordering different thyroid tests or assays that avoid the interferences,” he told Medscape Medical News.
32% of patients taking meds that could interfere with tests
In evaluating data on 538,137 patients treated with thyroid hormones from the Corporate Data Warehouse of the Veterans Health Administration, spanning 2004-2017, first author Rachel Beeson, MD, and colleagues with the University of Michigan found most patients in the study were men (96.5%), White (77.1%), and had two or more comorbidities (62.6%).
Of this total, 170,261 (31.6%) patients treated with thyroid hormones, over a median follow-up of 56 months, were taking at least one drug that could potentially interfere with thyroid function tests.
Among the drugs with potential thyroid test interference, about 28% of patients were taking prednisone or prednisolone, 8% were taking amiodarone, and 1.42% were taking phenytoin. Other reported drugs that could potentially interfere included carbamazepine (0.91%), phenobarbital (0.15%), lithium (0.40%), and tamoxifen (0.11%).
Multivariate analysis showed that characteristics associated with those most likely to have concurrent medication use included non-Whites (OR, 1.18 vs Whites), Hispanic ethnicity (OR 1.11 vs non-Hispanic), female sex (OR 1.12 vs males), and presence of comorbidities (eg, Charlson-Deyo comorbidity score ≥ 2, OR, 2.47 vs score of 0).
Meanwhile, older patients age 85 years and over had a lower likelihood of concurrent medications interfering with thyroid tests (OR, 0.47 vs age 65-74 years).
The findings are concerning given the wide use of levothyroxine to treat hypothyroidism, which is the most widely prescribed drug in the United States.
“Our findings not only highlight the complexity of thyroid hormone management in older adults in the context of polypharmacy and multimorbidity, but they also draw attention to vulnerable groups for this practice, which included female patients, non-Whites, patients of Hispanic ethnicity, and patients with comorbidities,” Dr. Papaleontiou said.
Nature of interference possibilities varies
Medications or supplements can interfere with thyroid function tests in a variety of ways, she explained. “Some medications could lead to a decrease in the absorption of levothyroxine, others may affect how well the pill dissolves.”
In addition, certain medications can affect the circulation of thyroid hormone in the blood and how it binds with proteins, or they can lead to decreasing thyroid hormone levels due to a variety of interactions.
And in contrast, “What is even more challenging is that some medications or supplements may appear to affect thyroid function based on lab tests when in reality they don’t actually affect thyroid function and may lead to dose adjustments unnecessarily,” Dr. Papaleontiou noted.
Recommendations to counter interference
Current recommendations to try to counter the effects of polypharmacy on thyroid treatment include advising patients to take thyroid hormones on an empty stomach at least 30-60 minutes prior to eating for optimal absorption.
If the patient is taking medications known to interfere with absorption of thyroid hormones, the recommendation is to space those out by at least 4 hours.
“The big challenge in older adults is that many of them do experience polypharmacy, being at risk for multiple drug-drug interactions,” Dr. Papaleontiou said.
“Physicians and patients should be vigilant and communicate closely every time there is initiation of a new medication or supplement to consider whether there may be interference.”
The authors have reported no relevant financial relationships. Dr. Hoang has reported being a speaker for Acella Pharmaceuticals.
A version of this article first appeared on Medscape.com.
, potentially compromising treatment decisions, new research shows.
“We know from previous studies that thyroid hormone use is common in older adults and that there are a multitude of medications that can interfere with thyroid function tests in different ways,” senior author Maria Papaleontiou, MD, told Medscape Medical News.
“However, to our knowledge, the extent of concurrent use of thyroid hormone and interfering medications in older adults, age 65 years and older, has not been previously explored,” added Dr. Papaleontiou, of the Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor.
The findings were presented as a poster during virtual ENDO 2021, the Endocrine Society’s annual meeting.
Commenting on the study, Thanh Duc Hoang, DO, an endocrinologist with the Walter Reed National Military Medical Center, in Bethesda, Md., said: “It is important for clinicians to be aware of various interactions and interferences of medications affecting the accuracy of thyroid function tests.”
“If patients are not able to discontinue the medications shortly before the bloodwork, the clinicians may consider ordering different thyroid tests or assays that avoid the interferences,” he told Medscape Medical News.
32% of patients taking meds that could interfere with tests
In evaluating data on 538,137 patients treated with thyroid hormones from the Corporate Data Warehouse of the Veterans Health Administration, spanning 2004-2017, first author Rachel Beeson, MD, and colleagues with the University of Michigan found most patients in the study were men (96.5%), White (77.1%), and had two or more comorbidities (62.6%).
Of this total, 170,261 (31.6%) patients treated with thyroid hormones, over a median follow-up of 56 months, were taking at least one drug that could potentially interfere with thyroid function tests.
Among the drugs with potential thyroid test interference, about 28% of patients were taking prednisone or prednisolone, 8% were taking amiodarone, and 1.42% were taking phenytoin. Other reported drugs that could potentially interfere included carbamazepine (0.91%), phenobarbital (0.15%), lithium (0.40%), and tamoxifen (0.11%).
Multivariate analysis showed that characteristics associated with those most likely to have concurrent medication use included non-Whites (OR, 1.18 vs Whites), Hispanic ethnicity (OR 1.11 vs non-Hispanic), female sex (OR 1.12 vs males), and presence of comorbidities (eg, Charlson-Deyo comorbidity score ≥ 2, OR, 2.47 vs score of 0).
Meanwhile, older patients age 85 years and over had a lower likelihood of concurrent medications interfering with thyroid tests (OR, 0.47 vs age 65-74 years).
The findings are concerning given the wide use of levothyroxine to treat hypothyroidism, which is the most widely prescribed drug in the United States.
“Our findings not only highlight the complexity of thyroid hormone management in older adults in the context of polypharmacy and multimorbidity, but they also draw attention to vulnerable groups for this practice, which included female patients, non-Whites, patients of Hispanic ethnicity, and patients with comorbidities,” Dr. Papaleontiou said.
Nature of interference possibilities varies
Medications or supplements can interfere with thyroid function tests in a variety of ways, she explained. “Some medications could lead to a decrease in the absorption of levothyroxine, others may affect how well the pill dissolves.”
In addition, certain medications can affect the circulation of thyroid hormone in the blood and how it binds with proteins, or they can lead to decreasing thyroid hormone levels due to a variety of interactions.
And in contrast, “What is even more challenging is that some medications or supplements may appear to affect thyroid function based on lab tests when in reality they don’t actually affect thyroid function and may lead to dose adjustments unnecessarily,” Dr. Papaleontiou noted.
Recommendations to counter interference
Current recommendations to try to counter the effects of polypharmacy on thyroid treatment include advising patients to take thyroid hormones on an empty stomach at least 30-60 minutes prior to eating for optimal absorption.
If the patient is taking medications known to interfere with absorption of thyroid hormones, the recommendation is to space those out by at least 4 hours.
“The big challenge in older adults is that many of them do experience polypharmacy, being at risk for multiple drug-drug interactions,” Dr. Papaleontiou said.
“Physicians and patients should be vigilant and communicate closely every time there is initiation of a new medication or supplement to consider whether there may be interference.”
The authors have reported no relevant financial relationships. Dr. Hoang has reported being a speaker for Acella Pharmaceuticals.
A version of this article first appeared on Medscape.com.
Imaging alternative to AVS could boost detection of primary aldosteronism
A noninvasive imaging method for identifying whether the source of a patient’s primary aldosteronism is from unilateral or bilateral adrenal adenomas worked as well as the standard method, invasive adrenal vein sampling, in a head-to-head comparison with 143 patients.
This noninvasive alternative, which also does not require the substantial technical expertise that AVS demands, should make assessment of adenoma laterality in patients with primary aldosteronism (PA) much more widely available and accessible, predicted Dr. Wu, a researcher at Queen Mary University of London.
“It will allow more places to do this, and I think it will definitely allow more patients to be diagnosed” with PA from a unilateral source. AVS “is a real bottleneck,” she said. “We hope metomidate, or molecular imaging using other selective radiotracers, will enable many more patients to be diagnosed and appropriately managed.” Creating new diagnostic options for patients with PA and potentially increasing the number of these patients who are surgical candidates “is the aim of this study.”
Patients with PA develop a curable form of hypertension if their excess aldosterone can be neutralized with a mineralocorticoid receptor antagonist (MRA), or even more definitively by surgical removal of the adrenal aldosteronoma generating the hormonal excess as long as the adenoma is unilateral. Conventional imaging of the adrenals with CT or MRI has proven unreliable for identifying adrenal nodules noninvasively, which has made the invasive and technically challenging standard option of AVS the only game in town.
But some endocrinologists caution that the results from this one study do not suffice to make 11C-metomidate-based PET-CT imaging a widely used alternative.
‘This is a first step.’
“This study is a first step. It will take lots more data for endocrinologists to buy into a scan over AVS,” commented David A. D’Alessio, MD, professor and chief of the division of endocrinology and metabolism at Duke University in Durham, N.C.
But Dr. D’Alessio also acknowledged the clear benefits from a safe and effective alternative to AVS.
“A reliable, less invasive, and less technical means of lateralizing excess aldosterone production would increase the number of people [with a unilateral PA source] going to surgery. The reality is that, if you are not a patient at the Mayo Clinic . . .or the National Institutes of Health, then AVS is a bit of crap shoot” that is very operator and institution dependent for its accuracy, Dr. D’Alessio said in an interview.
Metomidate specifically binds to key enzymes of the adrenal corticosteroid biosynthetic pathway, making it a precise targeting agent for a radioactive tag as documented almost a decade ago. One limitation is that this radiotracer labeling of metomidate has a 20-minute half life, which means it must be produced on site, thereby making the technology out of reach for locations that can’t set up this capability.
MATCHing imaging against AVS
To test the clinical utility of metomidate-based PET-CT directly against AVS, Dr. Wu and her associates enrolled 143 adults with confirmed PA and hypertension at two centers in London and one in Cambridge, England. The MATCH study cohort averaged 53 years of age; two-thirds were men, 58% were White, and 30% were Black. Their median blood pressure was 147/91 mm Hg, and they were maintained on a median of two antihypertensive drugs.
The researchers assessed every patient with both the imaging method and AVS, performed in random order and blindly scored. They then began each patient on a 1-month regimen with an MRA (usually spironolactone but eplerenone [Inspra] was also an option) to test the responsiveness of each patient’s hypertension to this drug class and to gauge their likely response to adrenalectomy. After the MRA test, the researchers assessed the lateralization tests and determined that 78 patients were appropriate candidates for unilateral adrenalectomy while the remaining 65 patients were not and continued on the MRA regimen. They recommended surgery if patients were clear positives by AVS, by PET-CT imaging, or both.
The study had four primary outcomes to assess the ability of the two diagnostic methods to predict the success of surgery based on four increasingly stringent postsurgical criteria calculated in hierarchical sequence: Partial or complete biochemical success, complete biochemical success, partial or complete clinical success (partial meaning any significant reduction in blood pressure), or complete clinical success (systolic pressure reduced to less than 135 mm Hg). Only one of the 78 patients treated with surgery failed to achieve at least a partial biochemical response.
For each of the four metrics, 11C-metomidate PET-CT produced point estimates of diagnostic accuracy that consistently edged out AVS. While these advantages were not large enough to meet the prespecified threshold for proving superiority, they comfortably showed the noninferiority of this imaging method compared with AVS.
For example, the PET-CT method had 43.6% accuracy for predicting a clinical cure, compared with 39.7% accuracy for AVS. For complete biochemical cure, imaging had 68.8% accuracy, compared with 62.3% for AVS, Dr. Wu reported.
Another notable finding from the study was how strongly a robust blood pressure response to spironolactone predicted the clinical outcome from surgery. Patients whose systolic blood pressure fell below 135 mm Hg on MRA treatment had a nearly 18-fold higher rate of achieving a complete clinical cure following surgery compared with patients who did not have as dramatic a blood pressure response to MRA treatment.
Woefully low rates of PA assessment
But regardless of the success that PET-CT imaging has for identifying surgical candidates, the first step is to identify patients with PA, a diagnosis that’s woefully underperformed worldwide. One example: A separate report at ENDO 2021 retrospectively reviewed nearly 12,000 patients with hypertension and an indication of PA, such as treatment-resistant hypertension or early-onset hypertension, and managed at either of two university outpatient clinics in Michigan during 2010-2019. The report documented that 3% underwent PA assessment.
Diagnosis of patients with PA “is a major problem,” noted Dr. D’Alessio. “I think of PA as an underdiagnosed and undertreated condition, with a huge impact on morbidity and mortality. Any advance in this area is likely to be useful.” But, he added, “I’m dubious whether this [new imaging approach] will increase diagnosis of PA.” What’s needed is “getting more primary care physicians to do more screening” for PA among their patients with hypertension and a suggestion of a PA cause.
“Surgical cures are glamorous, but medical management is also very effective, and we have good, inexpensive drugs to do this,” the MRAs, Dr. D’Alessio said.
The study received no commercial funding. Dr. Wu and her coauthors had no disclosures. Dr. D’Alessio has been a speaker on behalf of Novo Nordisk, a consultant to Intarcia and Lilly, and has received research funding from Lilly and Merck.
A noninvasive imaging method for identifying whether the source of a patient’s primary aldosteronism is from unilateral or bilateral adrenal adenomas worked as well as the standard method, invasive adrenal vein sampling, in a head-to-head comparison with 143 patients.
This noninvasive alternative, which also does not require the substantial technical expertise that AVS demands, should make assessment of adenoma laterality in patients with primary aldosteronism (PA) much more widely available and accessible, predicted Dr. Wu, a researcher at Queen Mary University of London.
“It will allow more places to do this, and I think it will definitely allow more patients to be diagnosed” with PA from a unilateral source. AVS “is a real bottleneck,” she said. “We hope metomidate, or molecular imaging using other selective radiotracers, will enable many more patients to be diagnosed and appropriately managed.” Creating new diagnostic options for patients with PA and potentially increasing the number of these patients who are surgical candidates “is the aim of this study.”
Patients with PA develop a curable form of hypertension if their excess aldosterone can be neutralized with a mineralocorticoid receptor antagonist (MRA), or even more definitively by surgical removal of the adrenal aldosteronoma generating the hormonal excess as long as the adenoma is unilateral. Conventional imaging of the adrenals with CT or MRI has proven unreliable for identifying adrenal nodules noninvasively, which has made the invasive and technically challenging standard option of AVS the only game in town.
But some endocrinologists caution that the results from this one study do not suffice to make 11C-metomidate-based PET-CT imaging a widely used alternative.
‘This is a first step.’
“This study is a first step. It will take lots more data for endocrinologists to buy into a scan over AVS,” commented David A. D’Alessio, MD, professor and chief of the division of endocrinology and metabolism at Duke University in Durham, N.C.
But Dr. D’Alessio also acknowledged the clear benefits from a safe and effective alternative to AVS.
“A reliable, less invasive, and less technical means of lateralizing excess aldosterone production would increase the number of people [with a unilateral PA source] going to surgery. The reality is that, if you are not a patient at the Mayo Clinic . . .or the National Institutes of Health, then AVS is a bit of crap shoot” that is very operator and institution dependent for its accuracy, Dr. D’Alessio said in an interview.
Metomidate specifically binds to key enzymes of the adrenal corticosteroid biosynthetic pathway, making it a precise targeting agent for a radioactive tag as documented almost a decade ago. One limitation is that this radiotracer labeling of metomidate has a 20-minute half life, which means it must be produced on site, thereby making the technology out of reach for locations that can’t set up this capability.
MATCHing imaging against AVS
To test the clinical utility of metomidate-based PET-CT directly against AVS, Dr. Wu and her associates enrolled 143 adults with confirmed PA and hypertension at two centers in London and one in Cambridge, England. The MATCH study cohort averaged 53 years of age; two-thirds were men, 58% were White, and 30% were Black. Their median blood pressure was 147/91 mm Hg, and they were maintained on a median of two antihypertensive drugs.
The researchers assessed every patient with both the imaging method and AVS, performed in random order and blindly scored. They then began each patient on a 1-month regimen with an MRA (usually spironolactone but eplerenone [Inspra] was also an option) to test the responsiveness of each patient’s hypertension to this drug class and to gauge their likely response to adrenalectomy. After the MRA test, the researchers assessed the lateralization tests and determined that 78 patients were appropriate candidates for unilateral adrenalectomy while the remaining 65 patients were not and continued on the MRA regimen. They recommended surgery if patients were clear positives by AVS, by PET-CT imaging, or both.
The study had four primary outcomes to assess the ability of the two diagnostic methods to predict the success of surgery based on four increasingly stringent postsurgical criteria calculated in hierarchical sequence: Partial or complete biochemical success, complete biochemical success, partial or complete clinical success (partial meaning any significant reduction in blood pressure), or complete clinical success (systolic pressure reduced to less than 135 mm Hg). Only one of the 78 patients treated with surgery failed to achieve at least a partial biochemical response.
For each of the four metrics, 11C-metomidate PET-CT produced point estimates of diagnostic accuracy that consistently edged out AVS. While these advantages were not large enough to meet the prespecified threshold for proving superiority, they comfortably showed the noninferiority of this imaging method compared with AVS.
For example, the PET-CT method had 43.6% accuracy for predicting a clinical cure, compared with 39.7% accuracy for AVS. For complete biochemical cure, imaging had 68.8% accuracy, compared with 62.3% for AVS, Dr. Wu reported.
Another notable finding from the study was how strongly a robust blood pressure response to spironolactone predicted the clinical outcome from surgery. Patients whose systolic blood pressure fell below 135 mm Hg on MRA treatment had a nearly 18-fold higher rate of achieving a complete clinical cure following surgery compared with patients who did not have as dramatic a blood pressure response to MRA treatment.
Woefully low rates of PA assessment
But regardless of the success that PET-CT imaging has for identifying surgical candidates, the first step is to identify patients with PA, a diagnosis that’s woefully underperformed worldwide. One example: A separate report at ENDO 2021 retrospectively reviewed nearly 12,000 patients with hypertension and an indication of PA, such as treatment-resistant hypertension or early-onset hypertension, and managed at either of two university outpatient clinics in Michigan during 2010-2019. The report documented that 3% underwent PA assessment.
Diagnosis of patients with PA “is a major problem,” noted Dr. D’Alessio. “I think of PA as an underdiagnosed and undertreated condition, with a huge impact on morbidity and mortality. Any advance in this area is likely to be useful.” But, he added, “I’m dubious whether this [new imaging approach] will increase diagnosis of PA.” What’s needed is “getting more primary care physicians to do more screening” for PA among their patients with hypertension and a suggestion of a PA cause.
“Surgical cures are glamorous, but medical management is also very effective, and we have good, inexpensive drugs to do this,” the MRAs, Dr. D’Alessio said.
The study received no commercial funding. Dr. Wu and her coauthors had no disclosures. Dr. D’Alessio has been a speaker on behalf of Novo Nordisk, a consultant to Intarcia and Lilly, and has received research funding from Lilly and Merck.
A noninvasive imaging method for identifying whether the source of a patient’s primary aldosteronism is from unilateral or bilateral adrenal adenomas worked as well as the standard method, invasive adrenal vein sampling, in a head-to-head comparison with 143 patients.
This noninvasive alternative, which also does not require the substantial technical expertise that AVS demands, should make assessment of adenoma laterality in patients with primary aldosteronism (PA) much more widely available and accessible, predicted Dr. Wu, a researcher at Queen Mary University of London.
“It will allow more places to do this, and I think it will definitely allow more patients to be diagnosed” with PA from a unilateral source. AVS “is a real bottleneck,” she said. “We hope metomidate, or molecular imaging using other selective radiotracers, will enable many more patients to be diagnosed and appropriately managed.” Creating new diagnostic options for patients with PA and potentially increasing the number of these patients who are surgical candidates “is the aim of this study.”
Patients with PA develop a curable form of hypertension if their excess aldosterone can be neutralized with a mineralocorticoid receptor antagonist (MRA), or even more definitively by surgical removal of the adrenal aldosteronoma generating the hormonal excess as long as the adenoma is unilateral. Conventional imaging of the adrenals with CT or MRI has proven unreliable for identifying adrenal nodules noninvasively, which has made the invasive and technically challenging standard option of AVS the only game in town.
But some endocrinologists caution that the results from this one study do not suffice to make 11C-metomidate-based PET-CT imaging a widely used alternative.
‘This is a first step.’
“This study is a first step. It will take lots more data for endocrinologists to buy into a scan over AVS,” commented David A. D’Alessio, MD, professor and chief of the division of endocrinology and metabolism at Duke University in Durham, N.C.
But Dr. D’Alessio also acknowledged the clear benefits from a safe and effective alternative to AVS.
“A reliable, less invasive, and less technical means of lateralizing excess aldosterone production would increase the number of people [with a unilateral PA source] going to surgery. The reality is that, if you are not a patient at the Mayo Clinic . . .or the National Institutes of Health, then AVS is a bit of crap shoot” that is very operator and institution dependent for its accuracy, Dr. D’Alessio said in an interview.
Metomidate specifically binds to key enzymes of the adrenal corticosteroid biosynthetic pathway, making it a precise targeting agent for a radioactive tag as documented almost a decade ago. One limitation is that this radiotracer labeling of metomidate has a 20-minute half life, which means it must be produced on site, thereby making the technology out of reach for locations that can’t set up this capability.
MATCHing imaging against AVS
To test the clinical utility of metomidate-based PET-CT directly against AVS, Dr. Wu and her associates enrolled 143 adults with confirmed PA and hypertension at two centers in London and one in Cambridge, England. The MATCH study cohort averaged 53 years of age; two-thirds were men, 58% were White, and 30% were Black. Their median blood pressure was 147/91 mm Hg, and they were maintained on a median of two antihypertensive drugs.
The researchers assessed every patient with both the imaging method and AVS, performed in random order and blindly scored. They then began each patient on a 1-month regimen with an MRA (usually spironolactone but eplerenone [Inspra] was also an option) to test the responsiveness of each patient’s hypertension to this drug class and to gauge their likely response to adrenalectomy. After the MRA test, the researchers assessed the lateralization tests and determined that 78 patients were appropriate candidates for unilateral adrenalectomy while the remaining 65 patients were not and continued on the MRA regimen. They recommended surgery if patients were clear positives by AVS, by PET-CT imaging, or both.
The study had four primary outcomes to assess the ability of the two diagnostic methods to predict the success of surgery based on four increasingly stringent postsurgical criteria calculated in hierarchical sequence: Partial or complete biochemical success, complete biochemical success, partial or complete clinical success (partial meaning any significant reduction in blood pressure), or complete clinical success (systolic pressure reduced to less than 135 mm Hg). Only one of the 78 patients treated with surgery failed to achieve at least a partial biochemical response.
For each of the four metrics, 11C-metomidate PET-CT produced point estimates of diagnostic accuracy that consistently edged out AVS. While these advantages were not large enough to meet the prespecified threshold for proving superiority, they comfortably showed the noninferiority of this imaging method compared with AVS.
For example, the PET-CT method had 43.6% accuracy for predicting a clinical cure, compared with 39.7% accuracy for AVS. For complete biochemical cure, imaging had 68.8% accuracy, compared with 62.3% for AVS, Dr. Wu reported.
Another notable finding from the study was how strongly a robust blood pressure response to spironolactone predicted the clinical outcome from surgery. Patients whose systolic blood pressure fell below 135 mm Hg on MRA treatment had a nearly 18-fold higher rate of achieving a complete clinical cure following surgery compared with patients who did not have as dramatic a blood pressure response to MRA treatment.
Woefully low rates of PA assessment
But regardless of the success that PET-CT imaging has for identifying surgical candidates, the first step is to identify patients with PA, a diagnosis that’s woefully underperformed worldwide. One example: A separate report at ENDO 2021 retrospectively reviewed nearly 12,000 patients with hypertension and an indication of PA, such as treatment-resistant hypertension or early-onset hypertension, and managed at either of two university outpatient clinics in Michigan during 2010-2019. The report documented that 3% underwent PA assessment.
Diagnosis of patients with PA “is a major problem,” noted Dr. D’Alessio. “I think of PA as an underdiagnosed and undertreated condition, with a huge impact on morbidity and mortality. Any advance in this area is likely to be useful.” But, he added, “I’m dubious whether this [new imaging approach] will increase diagnosis of PA.” What’s needed is “getting more primary care physicians to do more screening” for PA among their patients with hypertension and a suggestion of a PA cause.
“Surgical cures are glamorous, but medical management is also very effective, and we have good, inexpensive drugs to do this,” the MRAs, Dr. D’Alessio said.
The study received no commercial funding. Dr. Wu and her coauthors had no disclosures. Dr. D’Alessio has been a speaker on behalf of Novo Nordisk, a consultant to Intarcia and Lilly, and has received research funding from Lilly and Merck.
FROM ENDO 2021
When to not go with your gut: Modern approaches to abdominal wall pain
Abdominal pain is a commonly seen presenting concern in gastroenterology clinics. Establishing a diagnosis effectively and efficiently can be challenging given the broad differential. Abdominal wall pain is an often-overlooked diagnosis but accounts for up to 30% of cases of chronic abdominal pain1 and up to 10% of patients with chronic idiopathic abdominal pain seen in gastroenterology practices.2 Trigger point injection in the office can be both diagnostic and therapeutic.
The prevalence of chronic abdominal wall pain is highest in the fifth and sixth decades, and it is four times more likely to occur in women than in men. Common comorbid conditions include obesity, gastroesophageal reflux disease, irritable bowel syndrome, and fibromyalgia.3 Abdominal wall pain is often sharp or burning due to somatic innervation of the abdominal wall supplied by the anterior branches of thoracic intercostal nerves (T7 to T11). Abdominal wall pain may originate from entrapment of these nerves.2 Potential causes of entrapment include disruption of insulating fat, localized edema and distension, and scar tissue or fibrosis from prior surgical procedures.3 Symptoms are typically exacerbated with any actions or activities that engage the abdominal wall such as twisting or turning, and pain often improves with rest.
The classic physical exam finding for abdominal wall pain is a positive Carnett sign. This is determined via palpation of the point of maximal tenderness. First, this is done with a single finger while the patient’s abdominal wall is relaxed. The same point is then palpated again while the patient engages their abdominal muscles, most commonly while the patient to performs a “sit up” or lifts their legs off the exam table. Exacerbation of pain with these maneuvers indicates a positive test and suggests the abdominal wall as the underlying etiology.
While performing the maneuver for determining Carnett sign is a simple test in the traditional office visit, the COVID-19 pandemic has led to a burgeoning proportion of telehealth visits, limiting the physician’s ability to perform a direct physical exam. Fortunately, the maneuvers required when testing for Carnett sign are simple enough that a clinician can guide a patient step-by-step on how to perform the test. Ideally, if a family member or friend is available to serve as the clinician’s hands, the test can be performed with ease while directly visualizing proper technique. Sample videos of how the test is performed are readily available on the Internet for patients to view (the authors suggest screening the video yourself before providing a link to patients). The sensitivity and specificity of Carnett sign are very high (>70%) and even better when there is no apparent hernia.1
Management
Trigger point injections with local anesthetic can be both diagnostic and therapeutic in patients with abdominal wall pain. An immediate reduction of pain by at least 50% with injection at the site of maximal tenderness strongly supports the diagnosis of abdominal wall pain.1 Patients should first be thoroughly counseled on potential side effects of local corticosteroid injection to include risk of infection, bleeding, pain, skin hypopigmentation, or thinning and fat atrophy. Repeat injections are rarely needed, and any additional injection should be performed after at least 3 months. Additional adjunct therapies include nonsteroidal anti-inflammatory medications, topical therapies such as lidocaine, and neuroleptic agents such as gabapentin.4 One previously described trigger point injection technique, involves a mix of triamcinolone and lidocaine injected at the point of maximal tenderness.5 This technique is easy to perform in clinic and has minimal risks.
Conclusion
Abdominal wall pain is a common, yet often-overlooked, condition that can be diagnosed with a good clinical history and physical exam. A simple in-office trigger point injection can confirm the diagnosis and offer durable relief for most patients. A shift to virtual medicine does not need to a barrier to diagnosis, particularly in the attentive patient.
Dr. Park is a fellow in the gastroenterology service in the Department of Internal Medicine at Naval Medical Center San Diego and an assistant professor in the department of medicine of the Uniformed Services University in Bethesda, Md. Dr. Singla is a gastroenterologist at Capital Digestive Care in Silver Spring, Md., and an associate professor in the department of medicine at the Uniformed Services University. The authors have no conflicts of interest.
References
1. Glissen Brown JR et al. J Clin Gastroenterol. 2016;50(10):828-35.
2. Srinivasan R, Greenbaum DS. Am J Gastroenterol. 2002;97(4):824-30.
3. Kambox AK et al. Mayo Clin Proc. 2019;94(1):139-44.
4. Scheltinga MR, Roumen RM. Hernia. 2018;22(3):507-16.
5. Singla M, Laczek JT. Am J Gastroenterol. 2020 May;115(5):645-7.
Abdominal pain is a commonly seen presenting concern in gastroenterology clinics. Establishing a diagnosis effectively and efficiently can be challenging given the broad differential. Abdominal wall pain is an often-overlooked diagnosis but accounts for up to 30% of cases of chronic abdominal pain1 and up to 10% of patients with chronic idiopathic abdominal pain seen in gastroenterology practices.2 Trigger point injection in the office can be both diagnostic and therapeutic.
The prevalence of chronic abdominal wall pain is highest in the fifth and sixth decades, and it is four times more likely to occur in women than in men. Common comorbid conditions include obesity, gastroesophageal reflux disease, irritable bowel syndrome, and fibromyalgia.3 Abdominal wall pain is often sharp or burning due to somatic innervation of the abdominal wall supplied by the anterior branches of thoracic intercostal nerves (T7 to T11). Abdominal wall pain may originate from entrapment of these nerves.2 Potential causes of entrapment include disruption of insulating fat, localized edema and distension, and scar tissue or fibrosis from prior surgical procedures.3 Symptoms are typically exacerbated with any actions or activities that engage the abdominal wall such as twisting or turning, and pain often improves with rest.
The classic physical exam finding for abdominal wall pain is a positive Carnett sign. This is determined via palpation of the point of maximal tenderness. First, this is done with a single finger while the patient’s abdominal wall is relaxed. The same point is then palpated again while the patient engages their abdominal muscles, most commonly while the patient to performs a “sit up” or lifts their legs off the exam table. Exacerbation of pain with these maneuvers indicates a positive test and suggests the abdominal wall as the underlying etiology.
While performing the maneuver for determining Carnett sign is a simple test in the traditional office visit, the COVID-19 pandemic has led to a burgeoning proportion of telehealth visits, limiting the physician’s ability to perform a direct physical exam. Fortunately, the maneuvers required when testing for Carnett sign are simple enough that a clinician can guide a patient step-by-step on how to perform the test. Ideally, if a family member or friend is available to serve as the clinician’s hands, the test can be performed with ease while directly visualizing proper technique. Sample videos of how the test is performed are readily available on the Internet for patients to view (the authors suggest screening the video yourself before providing a link to patients). The sensitivity and specificity of Carnett sign are very high (>70%) and even better when there is no apparent hernia.1
Management
Trigger point injections with local anesthetic can be both diagnostic and therapeutic in patients with abdominal wall pain. An immediate reduction of pain by at least 50% with injection at the site of maximal tenderness strongly supports the diagnosis of abdominal wall pain.1 Patients should first be thoroughly counseled on potential side effects of local corticosteroid injection to include risk of infection, bleeding, pain, skin hypopigmentation, or thinning and fat atrophy. Repeat injections are rarely needed, and any additional injection should be performed after at least 3 months. Additional adjunct therapies include nonsteroidal anti-inflammatory medications, topical therapies such as lidocaine, and neuroleptic agents such as gabapentin.4 One previously described trigger point injection technique, involves a mix of triamcinolone and lidocaine injected at the point of maximal tenderness.5 This technique is easy to perform in clinic and has minimal risks.
Conclusion
Abdominal wall pain is a common, yet often-overlooked, condition that can be diagnosed with a good clinical history and physical exam. A simple in-office trigger point injection can confirm the diagnosis and offer durable relief for most patients. A shift to virtual medicine does not need to a barrier to diagnosis, particularly in the attentive patient.
Dr. Park is a fellow in the gastroenterology service in the Department of Internal Medicine at Naval Medical Center San Diego and an assistant professor in the department of medicine of the Uniformed Services University in Bethesda, Md. Dr. Singla is a gastroenterologist at Capital Digestive Care in Silver Spring, Md., and an associate professor in the department of medicine at the Uniformed Services University. The authors have no conflicts of interest.
References
1. Glissen Brown JR et al. J Clin Gastroenterol. 2016;50(10):828-35.
2. Srinivasan R, Greenbaum DS. Am J Gastroenterol. 2002;97(4):824-30.
3. Kambox AK et al. Mayo Clin Proc. 2019;94(1):139-44.
4. Scheltinga MR, Roumen RM. Hernia. 2018;22(3):507-16.
5. Singla M, Laczek JT. Am J Gastroenterol. 2020 May;115(5):645-7.
Abdominal pain is a commonly seen presenting concern in gastroenterology clinics. Establishing a diagnosis effectively and efficiently can be challenging given the broad differential. Abdominal wall pain is an often-overlooked diagnosis but accounts for up to 30% of cases of chronic abdominal pain1 and up to 10% of patients with chronic idiopathic abdominal pain seen in gastroenterology practices.2 Trigger point injection in the office can be both diagnostic and therapeutic.
The prevalence of chronic abdominal wall pain is highest in the fifth and sixth decades, and it is four times more likely to occur in women than in men. Common comorbid conditions include obesity, gastroesophageal reflux disease, irritable bowel syndrome, and fibromyalgia.3 Abdominal wall pain is often sharp or burning due to somatic innervation of the abdominal wall supplied by the anterior branches of thoracic intercostal nerves (T7 to T11). Abdominal wall pain may originate from entrapment of these nerves.2 Potential causes of entrapment include disruption of insulating fat, localized edema and distension, and scar tissue or fibrosis from prior surgical procedures.3 Symptoms are typically exacerbated with any actions or activities that engage the abdominal wall such as twisting or turning, and pain often improves with rest.
The classic physical exam finding for abdominal wall pain is a positive Carnett sign. This is determined via palpation of the point of maximal tenderness. First, this is done with a single finger while the patient’s abdominal wall is relaxed. The same point is then palpated again while the patient engages their abdominal muscles, most commonly while the patient to performs a “sit up” or lifts their legs off the exam table. Exacerbation of pain with these maneuvers indicates a positive test and suggests the abdominal wall as the underlying etiology.
While performing the maneuver for determining Carnett sign is a simple test in the traditional office visit, the COVID-19 pandemic has led to a burgeoning proportion of telehealth visits, limiting the physician’s ability to perform a direct physical exam. Fortunately, the maneuvers required when testing for Carnett sign are simple enough that a clinician can guide a patient step-by-step on how to perform the test. Ideally, if a family member or friend is available to serve as the clinician’s hands, the test can be performed with ease while directly visualizing proper technique. Sample videos of how the test is performed are readily available on the Internet for patients to view (the authors suggest screening the video yourself before providing a link to patients). The sensitivity and specificity of Carnett sign are very high (>70%) and even better when there is no apparent hernia.1
Management
Trigger point injections with local anesthetic can be both diagnostic and therapeutic in patients with abdominal wall pain. An immediate reduction of pain by at least 50% with injection at the site of maximal tenderness strongly supports the diagnosis of abdominal wall pain.1 Patients should first be thoroughly counseled on potential side effects of local corticosteroid injection to include risk of infection, bleeding, pain, skin hypopigmentation, or thinning and fat atrophy. Repeat injections are rarely needed, and any additional injection should be performed after at least 3 months. Additional adjunct therapies include nonsteroidal anti-inflammatory medications, topical therapies such as lidocaine, and neuroleptic agents such as gabapentin.4 One previously described trigger point injection technique, involves a mix of triamcinolone and lidocaine injected at the point of maximal tenderness.5 This technique is easy to perform in clinic and has minimal risks.
Conclusion
Abdominal wall pain is a common, yet often-overlooked, condition that can be diagnosed with a good clinical history and physical exam. A simple in-office trigger point injection can confirm the diagnosis and offer durable relief for most patients. A shift to virtual medicine does not need to a barrier to diagnosis, particularly in the attentive patient.
Dr. Park is a fellow in the gastroenterology service in the Department of Internal Medicine at Naval Medical Center San Diego and an assistant professor in the department of medicine of the Uniformed Services University in Bethesda, Md. Dr. Singla is a gastroenterologist at Capital Digestive Care in Silver Spring, Md., and an associate professor in the department of medicine at the Uniformed Services University. The authors have no conflicts of interest.
References
1. Glissen Brown JR et al. J Clin Gastroenterol. 2016;50(10):828-35.
2. Srinivasan R, Greenbaum DS. Am J Gastroenterol. 2002;97(4):824-30.
3. Kambox AK et al. Mayo Clin Proc. 2019;94(1):139-44.
4. Scheltinga MR, Roumen RM. Hernia. 2018;22(3):507-16.
5. Singla M, Laczek JT. Am J Gastroenterol. 2020 May;115(5):645-7.
Advocating in a pandemic: A fellow’s perspective on AGA Advocacy Day
Gastroenterology fellowship is an exercise in balance. You are learning your way around different parts of the gastrointestinal tract, both cerebrally and anatomically. You are continuously taking care of patients, in the hospital and in the clinic. You attend all kinds of conferences, didactics, and webinars. And though the hours are long, the work is worth seeing a smile from even one patient for whom you have made a tangible difference in health care. Though these moments are priceless, how often they happen is often limited by access to care, health care disparities, and systemic injustice. Fighting for each one of our patients and their health is difficult for even the most seasoned physician. Training during the middle of a pandemic has brought health care disparities to the forefront; delays in colorectal cancer screening and postponements of nonurgent procedures will have downstream impacts. It was with these thoughts in mind that I decided to participate in AGA (American Gastroenterological Association) Advocacy Day in September 2020 as a gastroenterology fellow.
After close to 20 years of in-person Advocacy Days, the AGA decided to take its advocacy efforts to a virtual platform in the fall of 2020. The country remained in the throes of the worst pandemic it had seen in over a century, and social distancing efforts necessitated a different venue than previous years. This year’s online platform was designed to let individuals involved in gastroenterology health care join each other and discuss policies germane to our patients and our profession.
I have to confess that I did not have significant legislative experience, and I signed up for the virtual Advocacy Day with a sense of slight trepidation. Would I be prepared to talk to experts in the field? What did I know about health care policy on the granular level? How could I get across my message cogently and successfully? All I really knew was that I wanted to get engaged with a group of gastroenterologists early on in my career who were not only vociferous advocates for their patients at the bedside, but who were also able to actively support policy changes that would bring about systemic change.
As it turned out, I had nothing to worry about. This advocacy experience was designed for gastroenterology clinical providers to be able to talk intelligently about topics they knew well – research funding, colonoscopy costs, and different levels of therapy for patients with inflammatory bowel disease, among others. To provide an overview of public policy issues, the AGA prepared a legislative briefing book that allowed us to take a deep dive into these topics. I remember reviewing the issue briefs in detail, understanding that I did not need to be an expert but that familiarity with the issues would be a key component of having a successful meeting. I also completed an online advocacy training module that gave me insight into how and why I could advocate for my profession as a future gastroenterologist. Based on our congressional district and state, we were divided into groups of congressional advocates who would speak to specific congressional staff members. During our meetings, we had legislative staff available to help us navigate the finer points of public policy. Each member of my group chose a topic that was personally relevant to them. Throughout our sessions, we shared personal stories, dove in and out of virtual meeting rooms, and made sure we were clear in what we were advocating for.
As a second-year gastroenterology fellow working at the National Institutes of Health, I chose to focus on digestive diseases research funding for the research community. I talked to the congressional staff members about a patient I had seen earlier that year. He was a man in his mid-30s who was diagnosed with hepatitis C more than 10 years ago and was told, at the time of his diagnosis, that there were no good treatments for him. He had resigned himself to that fact until I saw him in my office and spoke to him about the remarkable advances in liver disease treatment that were made over the past few years. I talked to him about how Hepatitis C was a disease that could now be cured – the relief on his face was clear and only reaffirmed in me the understanding that research in digestive diseases has improved the health of our nation’s population through sustained research efforts in gastrointestinal cancers and other life-altering illnesses.
So what did I take away from this adventure in advocacy? Our role as gastroenterologists can go beyond treating one patient in one office in one hospital system at a time. We can effect change by addressing policies that we know are hurting our patients and their health. The learning curve is made much easier under the excellence of the AGA advocacy staff, who takes the time to gather resources and educate us on the specifics of relevant legislative policies, as well as of the congressional members with whom we are speaking. Our advice was sought after because, after years of training, we were the experts in this field. I was proud to have joined this grassroots network of engaged members to speak to our lawmakers. I can only imagine, in the years to come, how wonderful it would be to do this in person in our nation’s capital.
Dr. Asif is a gastroenterology fellow working with the University of Maryland and National Institutes of Health. He has no conflicts of interest to disclose.
Gastroenterology fellowship is an exercise in balance. You are learning your way around different parts of the gastrointestinal tract, both cerebrally and anatomically. You are continuously taking care of patients, in the hospital and in the clinic. You attend all kinds of conferences, didactics, and webinars. And though the hours are long, the work is worth seeing a smile from even one patient for whom you have made a tangible difference in health care. Though these moments are priceless, how often they happen is often limited by access to care, health care disparities, and systemic injustice. Fighting for each one of our patients and their health is difficult for even the most seasoned physician. Training during the middle of a pandemic has brought health care disparities to the forefront; delays in colorectal cancer screening and postponements of nonurgent procedures will have downstream impacts. It was with these thoughts in mind that I decided to participate in AGA (American Gastroenterological Association) Advocacy Day in September 2020 as a gastroenterology fellow.
After close to 20 years of in-person Advocacy Days, the AGA decided to take its advocacy efforts to a virtual platform in the fall of 2020. The country remained in the throes of the worst pandemic it had seen in over a century, and social distancing efforts necessitated a different venue than previous years. This year’s online platform was designed to let individuals involved in gastroenterology health care join each other and discuss policies germane to our patients and our profession.
I have to confess that I did not have significant legislative experience, and I signed up for the virtual Advocacy Day with a sense of slight trepidation. Would I be prepared to talk to experts in the field? What did I know about health care policy on the granular level? How could I get across my message cogently and successfully? All I really knew was that I wanted to get engaged with a group of gastroenterologists early on in my career who were not only vociferous advocates for their patients at the bedside, but who were also able to actively support policy changes that would bring about systemic change.
As it turned out, I had nothing to worry about. This advocacy experience was designed for gastroenterology clinical providers to be able to talk intelligently about topics they knew well – research funding, colonoscopy costs, and different levels of therapy for patients with inflammatory bowel disease, among others. To provide an overview of public policy issues, the AGA prepared a legislative briefing book that allowed us to take a deep dive into these topics. I remember reviewing the issue briefs in detail, understanding that I did not need to be an expert but that familiarity with the issues would be a key component of having a successful meeting. I also completed an online advocacy training module that gave me insight into how and why I could advocate for my profession as a future gastroenterologist. Based on our congressional district and state, we were divided into groups of congressional advocates who would speak to specific congressional staff members. During our meetings, we had legislative staff available to help us navigate the finer points of public policy. Each member of my group chose a topic that was personally relevant to them. Throughout our sessions, we shared personal stories, dove in and out of virtual meeting rooms, and made sure we were clear in what we were advocating for.
As a second-year gastroenterology fellow working at the National Institutes of Health, I chose to focus on digestive diseases research funding for the research community. I talked to the congressional staff members about a patient I had seen earlier that year. He was a man in his mid-30s who was diagnosed with hepatitis C more than 10 years ago and was told, at the time of his diagnosis, that there were no good treatments for him. He had resigned himself to that fact until I saw him in my office and spoke to him about the remarkable advances in liver disease treatment that were made over the past few years. I talked to him about how Hepatitis C was a disease that could now be cured – the relief on his face was clear and only reaffirmed in me the understanding that research in digestive diseases has improved the health of our nation’s population through sustained research efforts in gastrointestinal cancers and other life-altering illnesses.
So what did I take away from this adventure in advocacy? Our role as gastroenterologists can go beyond treating one patient in one office in one hospital system at a time. We can effect change by addressing policies that we know are hurting our patients and their health. The learning curve is made much easier under the excellence of the AGA advocacy staff, who takes the time to gather resources and educate us on the specifics of relevant legislative policies, as well as of the congressional members with whom we are speaking. Our advice was sought after because, after years of training, we were the experts in this field. I was proud to have joined this grassroots network of engaged members to speak to our lawmakers. I can only imagine, in the years to come, how wonderful it would be to do this in person in our nation’s capital.
Dr. Asif is a gastroenterology fellow working with the University of Maryland and National Institutes of Health. He has no conflicts of interest to disclose.
Gastroenterology fellowship is an exercise in balance. You are learning your way around different parts of the gastrointestinal tract, both cerebrally and anatomically. You are continuously taking care of patients, in the hospital and in the clinic. You attend all kinds of conferences, didactics, and webinars. And though the hours are long, the work is worth seeing a smile from even one patient for whom you have made a tangible difference in health care. Though these moments are priceless, how often they happen is often limited by access to care, health care disparities, and systemic injustice. Fighting for each one of our patients and their health is difficult for even the most seasoned physician. Training during the middle of a pandemic has brought health care disparities to the forefront; delays in colorectal cancer screening and postponements of nonurgent procedures will have downstream impacts. It was with these thoughts in mind that I decided to participate in AGA (American Gastroenterological Association) Advocacy Day in September 2020 as a gastroenterology fellow.
After close to 20 years of in-person Advocacy Days, the AGA decided to take its advocacy efforts to a virtual platform in the fall of 2020. The country remained in the throes of the worst pandemic it had seen in over a century, and social distancing efforts necessitated a different venue than previous years. This year’s online platform was designed to let individuals involved in gastroenterology health care join each other and discuss policies germane to our patients and our profession.
I have to confess that I did not have significant legislative experience, and I signed up for the virtual Advocacy Day with a sense of slight trepidation. Would I be prepared to talk to experts in the field? What did I know about health care policy on the granular level? How could I get across my message cogently and successfully? All I really knew was that I wanted to get engaged with a group of gastroenterologists early on in my career who were not only vociferous advocates for their patients at the bedside, but who were also able to actively support policy changes that would bring about systemic change.
As it turned out, I had nothing to worry about. This advocacy experience was designed for gastroenterology clinical providers to be able to talk intelligently about topics they knew well – research funding, colonoscopy costs, and different levels of therapy for patients with inflammatory bowel disease, among others. To provide an overview of public policy issues, the AGA prepared a legislative briefing book that allowed us to take a deep dive into these topics. I remember reviewing the issue briefs in detail, understanding that I did not need to be an expert but that familiarity with the issues would be a key component of having a successful meeting. I also completed an online advocacy training module that gave me insight into how and why I could advocate for my profession as a future gastroenterologist. Based on our congressional district and state, we were divided into groups of congressional advocates who would speak to specific congressional staff members. During our meetings, we had legislative staff available to help us navigate the finer points of public policy. Each member of my group chose a topic that was personally relevant to them. Throughout our sessions, we shared personal stories, dove in and out of virtual meeting rooms, and made sure we were clear in what we were advocating for.
As a second-year gastroenterology fellow working at the National Institutes of Health, I chose to focus on digestive diseases research funding for the research community. I talked to the congressional staff members about a patient I had seen earlier that year. He was a man in his mid-30s who was diagnosed with hepatitis C more than 10 years ago and was told, at the time of his diagnosis, that there were no good treatments for him. He had resigned himself to that fact until I saw him in my office and spoke to him about the remarkable advances in liver disease treatment that were made over the past few years. I talked to him about how Hepatitis C was a disease that could now be cured – the relief on his face was clear and only reaffirmed in me the understanding that research in digestive diseases has improved the health of our nation’s population through sustained research efforts in gastrointestinal cancers and other life-altering illnesses.
So what did I take away from this adventure in advocacy? Our role as gastroenterologists can go beyond treating one patient in one office in one hospital system at a time. We can effect change by addressing policies that we know are hurting our patients and their health. The learning curve is made much easier under the excellence of the AGA advocacy staff, who takes the time to gather resources and educate us on the specifics of relevant legislative policies, as well as of the congressional members with whom we are speaking. Our advice was sought after because, after years of training, we were the experts in this field. I was proud to have joined this grassroots network of engaged members to speak to our lawmakers. I can only imagine, in the years to come, how wonderful it would be to do this in person in our nation’s capital.
Dr. Asif is a gastroenterology fellow working with the University of Maryland and National Institutes of Health. He has no conflicts of interest to disclose.
New guidelines dispel myths about COVID-19 treatment
Recommendations, as well as conspiracy theories about COVID-19, have changed at distressing rates over the past year. No disease has ever been more politicized, or more polarizing.
Experts, as well as the least educated, take a stand on what they believe is the most important way to prevent and treat this virus.
Just recently, a study was published revealing that ivermectin is not effective as a COVID-19 treatment while people continue to claim it works. It has never been more important for doctors, and especially family physicians, to have accurate and updated guidelines.
The NIH and CDC have been publishing recommendations and guidelines for the prevention and treatment of COVID-19 since the start of the pandemic. Like any new disease, these have been changing to keep up as new knowledge related to the disease becomes available.
NIH updates treatment guidelines
A recent update to the NIH COVID-19 treatment guidelines was published on March 5, 2021. While the complete guidelines are quite extensive, spanning over 200 pages, it’s most important to understand the most recent updates in them.
Since preventative medicine is an integral part of primary care, it is important to note that no medications have been advised to prevent infection with COVID-19. In fact, taking drugs for pre-exposure prophylaxis (PrEp) is not recommended even in the highest-risk patients, such as health care workers.
In the updated guidelines, tocilizumab in a single IV dose of 8 mg/kg up to a maximum of 800 mg can be given only in combination with dexamethasone (or equivalent corticosteroid) in certain hospitalized patients exhibiting rapid respiratory decompensation. These patients include recently hospitalized patients who have been admitted to the ICU within the previous 24 hours and now require mechanical ventilation or high-flow oxygen via nasal cannula. Those not in the ICU who require rapidly increasing oxygen levels and have significantly increased levels of inflammatory markers should also receive this therapy. In the new guidance, the NIH recommends treating other hospitalized patients who require oxygen with remdesivir, remdesivir + dexamethasone, or dexamethasone alone.
In outpatients, those who have mild to moderate infection and are at increased risk of developing severe disease and/or hospitalization can be treated with bamlanivimab 700 mg + etesevimab 1,400 mg. This should be started as soon as possible after a confirmed diagnosis and within 10 days of symptom onset, according to the NIH recommendations. There is no evidence to support its use in patients hospitalized because of infection. However, it can be used in patients hospitalized for other reasons who have mild to moderate infection, but should be reserved – because of limited supply – for those with the highest risk of complications.
Hydroxychloroquine and casirivimab + imdevimab
One medication that has been touted in the media as a tool to treat COVID-19 has been hydroxychloroquine. Past guidelines recommended against this medication as a treatment because it lacked efficacy and posed risks for no therapeutic benefit. The most recent guidelines also recommend against the use of hydroxychloroquine for pre- and postexposure prophylaxis.
Casirivimab + imdevimab has been another talked about therapy. However, current guidelines recommend against its use in hospitalized patients. In addition, it is advised that hospitalized patients be enrolled in a clinical trial to receive it.
Since the pandemic began, the world has seen more than 120 million infections and more than 2 million deaths. Family physicians have a vital role to play as we are often the first ones patients turn to for treatment and advice. It is imperative we stay current with the guidelines and follow the most recent updates as research data are published.
Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].
Recommendations, as well as conspiracy theories about COVID-19, have changed at distressing rates over the past year. No disease has ever been more politicized, or more polarizing.
Experts, as well as the least educated, take a stand on what they believe is the most important way to prevent and treat this virus.
Just recently, a study was published revealing that ivermectin is not effective as a COVID-19 treatment while people continue to claim it works. It has never been more important for doctors, and especially family physicians, to have accurate and updated guidelines.
The NIH and CDC have been publishing recommendations and guidelines for the prevention and treatment of COVID-19 since the start of the pandemic. Like any new disease, these have been changing to keep up as new knowledge related to the disease becomes available.
NIH updates treatment guidelines
A recent update to the NIH COVID-19 treatment guidelines was published on March 5, 2021. While the complete guidelines are quite extensive, spanning over 200 pages, it’s most important to understand the most recent updates in them.
Since preventative medicine is an integral part of primary care, it is important to note that no medications have been advised to prevent infection with COVID-19. In fact, taking drugs for pre-exposure prophylaxis (PrEp) is not recommended even in the highest-risk patients, such as health care workers.
In the updated guidelines, tocilizumab in a single IV dose of 8 mg/kg up to a maximum of 800 mg can be given only in combination with dexamethasone (or equivalent corticosteroid) in certain hospitalized patients exhibiting rapid respiratory decompensation. These patients include recently hospitalized patients who have been admitted to the ICU within the previous 24 hours and now require mechanical ventilation or high-flow oxygen via nasal cannula. Those not in the ICU who require rapidly increasing oxygen levels and have significantly increased levels of inflammatory markers should also receive this therapy. In the new guidance, the NIH recommends treating other hospitalized patients who require oxygen with remdesivir, remdesivir + dexamethasone, or dexamethasone alone.
In outpatients, those who have mild to moderate infection and are at increased risk of developing severe disease and/or hospitalization can be treated with bamlanivimab 700 mg + etesevimab 1,400 mg. This should be started as soon as possible after a confirmed diagnosis and within 10 days of symptom onset, according to the NIH recommendations. There is no evidence to support its use in patients hospitalized because of infection. However, it can be used in patients hospitalized for other reasons who have mild to moderate infection, but should be reserved – because of limited supply – for those with the highest risk of complications.
Hydroxychloroquine and casirivimab + imdevimab
One medication that has been touted in the media as a tool to treat COVID-19 has been hydroxychloroquine. Past guidelines recommended against this medication as a treatment because it lacked efficacy and posed risks for no therapeutic benefit. The most recent guidelines also recommend against the use of hydroxychloroquine for pre- and postexposure prophylaxis.
Casirivimab + imdevimab has been another talked about therapy. However, current guidelines recommend against its use in hospitalized patients. In addition, it is advised that hospitalized patients be enrolled in a clinical trial to receive it.
Since the pandemic began, the world has seen more than 120 million infections and more than 2 million deaths. Family physicians have a vital role to play as we are often the first ones patients turn to for treatment and advice. It is imperative we stay current with the guidelines and follow the most recent updates as research data are published.
Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].
Recommendations, as well as conspiracy theories about COVID-19, have changed at distressing rates over the past year. No disease has ever been more politicized, or more polarizing.
Experts, as well as the least educated, take a stand on what they believe is the most important way to prevent and treat this virus.
Just recently, a study was published revealing that ivermectin is not effective as a COVID-19 treatment while people continue to claim it works. It has never been more important for doctors, and especially family physicians, to have accurate and updated guidelines.
The NIH and CDC have been publishing recommendations and guidelines for the prevention and treatment of COVID-19 since the start of the pandemic. Like any new disease, these have been changing to keep up as new knowledge related to the disease becomes available.
NIH updates treatment guidelines
A recent update to the NIH COVID-19 treatment guidelines was published on March 5, 2021. While the complete guidelines are quite extensive, spanning over 200 pages, it’s most important to understand the most recent updates in them.
Since preventative medicine is an integral part of primary care, it is important to note that no medications have been advised to prevent infection with COVID-19. In fact, taking drugs for pre-exposure prophylaxis (PrEp) is not recommended even in the highest-risk patients, such as health care workers.
In the updated guidelines, tocilizumab in a single IV dose of 8 mg/kg up to a maximum of 800 mg can be given only in combination with dexamethasone (or equivalent corticosteroid) in certain hospitalized patients exhibiting rapid respiratory decompensation. These patients include recently hospitalized patients who have been admitted to the ICU within the previous 24 hours and now require mechanical ventilation or high-flow oxygen via nasal cannula. Those not in the ICU who require rapidly increasing oxygen levels and have significantly increased levels of inflammatory markers should also receive this therapy. In the new guidance, the NIH recommends treating other hospitalized patients who require oxygen with remdesivir, remdesivir + dexamethasone, or dexamethasone alone.
In outpatients, those who have mild to moderate infection and are at increased risk of developing severe disease and/or hospitalization can be treated with bamlanivimab 700 mg + etesevimab 1,400 mg. This should be started as soon as possible after a confirmed diagnosis and within 10 days of symptom onset, according to the NIH recommendations. There is no evidence to support its use in patients hospitalized because of infection. However, it can be used in patients hospitalized for other reasons who have mild to moderate infection, but should be reserved – because of limited supply – for those with the highest risk of complications.
Hydroxychloroquine and casirivimab + imdevimab
One medication that has been touted in the media as a tool to treat COVID-19 has been hydroxychloroquine. Past guidelines recommended against this medication as a treatment because it lacked efficacy and posed risks for no therapeutic benefit. The most recent guidelines also recommend against the use of hydroxychloroquine for pre- and postexposure prophylaxis.
Casirivimab + imdevimab has been another talked about therapy. However, current guidelines recommend against its use in hospitalized patients. In addition, it is advised that hospitalized patients be enrolled in a clinical trial to receive it.
Since the pandemic began, the world has seen more than 120 million infections and more than 2 million deaths. Family physicians have a vital role to play as we are often the first ones patients turn to for treatment and advice. It is imperative we stay current with the guidelines and follow the most recent updates as research data are published.
Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].
Climate change: Dermatologists address impact on health, and mobilize to increase awareness
Climate change will increasingly affect the distribution and frequency of insect-borne diseases, cutaneous leishmaniasis, skin cancer, fungal diseases, and a host of other illnesses that have cutaneous manifestations or involve the skin – and dermatologists are being urged to be ready to diagnose clinical findings, counsel patients about risk mitigation, and decrease the carbon footprint of their practices and medical organizations.
“Climate change is not a far-off threat but an urgent health issue,” Misha Rosenbach, MD, associate professor of dermatology at the University of Pennsylvania, Philadelphia, wrote in an editorial with coauthor Mary Sun, a student at Icahn School of Medicine at Mount Sinai, New York. It was first published online in the British Journal of Dermatology last year, titled, “The climate emergency: Why should dermatologists care and how can they act?”.
. Some of the 150-plus members of the ERG have been writing about the dermatologic impacts of climate change – including content that filled the January issue of the International Journal of Women’s Dermatology – and speaking about the issues.
A session at the AAD’s virtual annual meeting in April will address climate change and dermatology – the second such session at an annual meeting – and the first two of three planned virtual symposia led by Dr. Rosenbach and his colleagues, have been hosted by the Association of Professors of Dermatology. The ERG encouraged the AAD’s adoption of a position statement in 2018 about climate change and dermatology and its membership in the Medical Society Consortium on Climate and Health.
“There’s been a lot of conversation in the medical community about the health effects of climate change, but most people leave out the skin,” said Mary L. Williams, MD, clinical professor of dermatology at the University of California, San Francisco, who is a cofounder and coleader with Dr. Rosenbach of the climate change ERG.
“That’s interesting because the skin is the most environmental of all our organs. Of course it will be impacted by all that’s going on,” she said. “We want to bring the dermatologic community and the wider medical community along with us [in appreciating and acting on this knowledge].”
Changing disease patterns
Dr. Rosenbach did not think much about how climate change could affect his patients and his clinical practice until he saw a severe case of hand, foot, and mouth disease in a hospitalized adult in Philadelphia about 10 years ago.
A presentation of the case at an infectious disease conference spurred discussion of how the preceding winters had been warmer and of correlations reported by researchers in China between the incidence of hand, foot, and mouth disease – historically a mild infection in children – and average temperature and other meteorological factors. “I knew about climate change, but I never knew we’d see different diseases in our clinical practice, or old diseases affecting new hosts,” Dr. Rosenbach said in an interview.
He pored over the literature to deepen his understanding of climate change science and the impact of climate change on medicine, and found an “emerging focus” on climate change in some medical journals, but “very little in dermatology.” In collaboration with Benjamin Kaffenberger, MD, a dermatologist at The Ohio State University, and colleagues, including an entomologist, Dr. Rosenbach wrote a review of publications relating to climate change and skin disease in North America.
Published in 2017 in the Journal of the American Academy of Dermatology, the review details how bacteria, viruses, fungi, and parasites are responding to changing weather patterns in North America, and why dermatologists should be able to recognize changing patterns of disease. Globalization plays a role in changing disease and vector patterns, but “climate change allows expansion of the natural range of pathogens, hosts, reservoirs, and vectors that allow diseases to appear in immunologically naive populations,” they wrote.
Patterns of infectious diseases with cutaneous manifestations are already changing. The geographic range of coccidioidomycosis, or valley fever, for instance, “has basically doubled in the Southwest U.S., extending up the entire West Coast,” Dr. Rosenbach said, as the result of longer dry seasons and more frequent wind storms that aerosolize the mycosis-causing, soil-dwelling fungal spores.
Lyme disease and associated tick-borne infections continue to expand northward as Ixodes tick vectors move and breed “exactly in sync with a warming world,” Dr. Rosenbach said. “We’re seeing Lyme in Philadelphia in February, whereas in the past we may not have seen it until May ... There are derms in Maine [whose patients have Lyme disease] who may never have seen a case before, and derms in Canada who are making diagnoses of Lyme [for the first time].”
And locally acquired cases of dengue are being reported in Hawaii, Texas, and Florida – and even North Carolina, according to a review of infectious diseases with cutaneous manifestations in the issue of the International Journal of Women’s Dermatology dedicated to climate change. As with Ixodes ticks, which transmit Lyme disease, rising temperatures lead to longer breeding seasons for Aedes mosquitoes, which transmit dengue. Increased endemicity of dengue is concerning because severe illness is significantly more likely in individuals previously infected with a different serotype.
“Dermatologists should be ready to identify and diagnose these mosquito-borne diseases that we think of as occurring in Central America or tropical regions,” Dr. Rosenbach said. “In my children’s lifetime there will be tropical diseases in New York, Philadelphia, Boston and other such places.”
In his articles and talks, Dr. Rosenbach lays out the science of climate change – for instance, the change in average global temperatures above preindustrial levels (an approximate 1° C rise) , the threshold beyond which the Earth will become less hospitable (1.5° C of warming according to United Nation’s Intergovernmental Panel on Climate Change), the current projections for future warming (an increase of about 3° Celsius by 2100), and the “gold-standard” level of scientific certainty that climate change is human-caused.
Mathematical climate modeling, he emphasized in the interview, can accurately project changes in infection rates. Researchers predicted 10 years ago in a published paper, for instance, that based on global warming patterns, the sand fly vector responsible for cutaneous leishmaniasis would live in the Southern United States and cause endemic infections within 10 years.
And in 2018, Dr. Rosenbach said, a paper in JAMA Dermatology described how more than half – 59% – of the cases of cutaneous leishmaniasis diagnosed in Texas were endemic, all occurring in people with no prior travel outside the United States.
Dr. Williams’ devotion to climate change and dermatology and to the climate change ERG was inspired in large part by Dr. Rosenbach’s 2017 paper in JAAD. She had long been concerned about climate change, she said, but “the review article was really the impetus for me to think, this is really within my specialty.”
Extreme weather events, and the climate-driven migration expected to increasingly occur, have clear relevance to dermatology, Dr. Williams said. “Often, the most vexing problems that people have when they’re forced out of their homes ... are dermatologic,” she said, like infections from contaminated waters after flooding and the spread of scabies and other communicable diseases due to crowding and unsanitary conditions.
But there are other less obvious ramifications of a changing climate that affect dermatology. Dr. Williams has delved into the literature on heat-related illness, for instance, and found that most research has been in the realm of sports medicine and military health. “Most of us don’t treat serious heat-related illnesses, but our skin is responsible for keeping us cool and there’s an important role for dermatologists to play in knowing how the skin does that and who is at risk for heat illness because the skin is unable to do the full job,” she said.
Research is needed to identify which medications can interfere with the skin’s thermoregulatory responses and put patients at risk, she noted. “And a lot of the work on sweat gland physiology is probably 30 years old now. We should bring to bear contemporary research techniques.”
Dermatology is also “in the early stages of understanding the role that air pollution plays in skin disease,” Dr. Williams said. “Most of the medical literature focuses on the effects of pollution on the lungs and in cardiovascular disease.”
There is evidence linking small particulate matter found in wood smoke and other air pollutants to exacerbations of atopic dermatitis and other inflammatory skin conditions, she noted, but mechanisms need to be explored and health disparities examined. “While we know that there are health disparities in terms of [exposure to] pollution and respiratory illness, we have no idea if this is the case with our skin diseases like atopic dermatitis,” said Dr. Williams.
In general, according to the AAD position statement, low-income and minority communities, in addition to the very young and the very old, “are and will continue to be disproportionately affected by climate change.”
Education and the carbon footprint
Viewing climate change as a social determinant of health (SDH ) – and integrating it into medical training as such – is a topic of active discussion. At UCSF, Sarah J. Coates, MD, a fellow in pediatric dermatology, is working with colleagues to integrate climate change into formal resident education. “We know that climate change affects housing, food security, migration ... and certain populations are and will be especially vulnerable,” she said in an interview. “The effects of climate change fit squarely into the social determinant of health curriculum that we’re building here.”
Dr. Coates began to appreciate the link between climate and infectious diseases – a topic she now writes and speaks about – when she saw several patients with coccidioidomycosis as a dermatology resident at UCSF and learned that the cases represented an epidemic in the Central Valley “resulting from several years of drought.”
Her medical school and residency training were otherwise devoid of any discussion of climate change. At UCSF and nearby Stanford (Calif.) University, this is no longer the case, she and Dr. Williams said. “The medical students here have been quite active and are requesting education,” noted Dr. Williams. “The desire to know more is coming from the bottom.”
Mary E. Maloney, MD, professor of medicine and director of dermatologic surgery at the University of Massachusetts, Worcester, sees the same interest from physicians-in-training in the Boston area. They want education about climate science, the impact of climate changes on health and risk mitigation, and ways to reduce medicine’s carbon footprint. “We need to teach them and charge them to lead in their communities,” she said in an interview.
Dr. Maloney joined the AAD’s climate change resource group soon after its inception, having realized the urgency of climate change and feeling that she needed “to get passionate and not just do small things.” As a Mohs surgeon, she expects an “explosion” of skin cancer as temperatures and sun exposure continue to increase.
She urges dermatologists to work to decrease the carbon footprint of their practices and to advocate for local hospitals and other clinical institutions to do so. On the AAD website, members now have free access to tools provided by the nonprofit organization My Green Doctor for outpatient offices to lighten their carbon footprints in a cost-effective – or even cost-saving – manner.
Dr. Maloney’s institution has moved to automated lighting systems and the use of LED lights, she said, and has encouraged ride sharing (prior to the pandemic) and computer switch-offs at night. And in her practice, she and a colleague have been working to reduce the purchasing and use of disposable plastics.
Educating patients about the effects of climate change on the health of their skin is another of the missions listed in the AAD’s position statement, and it’s something that Dr. Coates is currently researching. “It seems similar to talking about other social determinants of health,” she said. “Saying to a patient, for instance, ‘we’ve had some really terrible wildfires lately. They’re getting worse as the seasons go on and we know that’s because of climate change. How do you think your current rash relates to the current air quality? How you think the air quality affects your skin?’ ”
Dr. Rosenbach emphasizes that physicians are a broadly trusted group. “I’d tell a patient, ‘you’re the fourth patient I’ve seen with Lyme – we think that’s because it’s been a warmer year due to climate change,’” he said. “I don’t think that bringing up climate change has ever been a source of friction.”
Climate change will increasingly affect the distribution and frequency of insect-borne diseases, cutaneous leishmaniasis, skin cancer, fungal diseases, and a host of other illnesses that have cutaneous manifestations or involve the skin – and dermatologists are being urged to be ready to diagnose clinical findings, counsel patients about risk mitigation, and decrease the carbon footprint of their practices and medical organizations.
“Climate change is not a far-off threat but an urgent health issue,” Misha Rosenbach, MD, associate professor of dermatology at the University of Pennsylvania, Philadelphia, wrote in an editorial with coauthor Mary Sun, a student at Icahn School of Medicine at Mount Sinai, New York. It was first published online in the British Journal of Dermatology last year, titled, “The climate emergency: Why should dermatologists care and how can they act?”.
. Some of the 150-plus members of the ERG have been writing about the dermatologic impacts of climate change – including content that filled the January issue of the International Journal of Women’s Dermatology – and speaking about the issues.
A session at the AAD’s virtual annual meeting in April will address climate change and dermatology – the second such session at an annual meeting – and the first two of three planned virtual symposia led by Dr. Rosenbach and his colleagues, have been hosted by the Association of Professors of Dermatology. The ERG encouraged the AAD’s adoption of a position statement in 2018 about climate change and dermatology and its membership in the Medical Society Consortium on Climate and Health.
“There’s been a lot of conversation in the medical community about the health effects of climate change, but most people leave out the skin,” said Mary L. Williams, MD, clinical professor of dermatology at the University of California, San Francisco, who is a cofounder and coleader with Dr. Rosenbach of the climate change ERG.
“That’s interesting because the skin is the most environmental of all our organs. Of course it will be impacted by all that’s going on,” she said. “We want to bring the dermatologic community and the wider medical community along with us [in appreciating and acting on this knowledge].”
Changing disease patterns
Dr. Rosenbach did not think much about how climate change could affect his patients and his clinical practice until he saw a severe case of hand, foot, and mouth disease in a hospitalized adult in Philadelphia about 10 years ago.
A presentation of the case at an infectious disease conference spurred discussion of how the preceding winters had been warmer and of correlations reported by researchers in China between the incidence of hand, foot, and mouth disease – historically a mild infection in children – and average temperature and other meteorological factors. “I knew about climate change, but I never knew we’d see different diseases in our clinical practice, or old diseases affecting new hosts,” Dr. Rosenbach said in an interview.
He pored over the literature to deepen his understanding of climate change science and the impact of climate change on medicine, and found an “emerging focus” on climate change in some medical journals, but “very little in dermatology.” In collaboration with Benjamin Kaffenberger, MD, a dermatologist at The Ohio State University, and colleagues, including an entomologist, Dr. Rosenbach wrote a review of publications relating to climate change and skin disease in North America.
Published in 2017 in the Journal of the American Academy of Dermatology, the review details how bacteria, viruses, fungi, and parasites are responding to changing weather patterns in North America, and why dermatologists should be able to recognize changing patterns of disease. Globalization plays a role in changing disease and vector patterns, but “climate change allows expansion of the natural range of pathogens, hosts, reservoirs, and vectors that allow diseases to appear in immunologically naive populations,” they wrote.
Patterns of infectious diseases with cutaneous manifestations are already changing. The geographic range of coccidioidomycosis, or valley fever, for instance, “has basically doubled in the Southwest U.S., extending up the entire West Coast,” Dr. Rosenbach said, as the result of longer dry seasons and more frequent wind storms that aerosolize the mycosis-causing, soil-dwelling fungal spores.
Lyme disease and associated tick-borne infections continue to expand northward as Ixodes tick vectors move and breed “exactly in sync with a warming world,” Dr. Rosenbach said. “We’re seeing Lyme in Philadelphia in February, whereas in the past we may not have seen it until May ... There are derms in Maine [whose patients have Lyme disease] who may never have seen a case before, and derms in Canada who are making diagnoses of Lyme [for the first time].”
And locally acquired cases of dengue are being reported in Hawaii, Texas, and Florida – and even North Carolina, according to a review of infectious diseases with cutaneous manifestations in the issue of the International Journal of Women’s Dermatology dedicated to climate change. As with Ixodes ticks, which transmit Lyme disease, rising temperatures lead to longer breeding seasons for Aedes mosquitoes, which transmit dengue. Increased endemicity of dengue is concerning because severe illness is significantly more likely in individuals previously infected with a different serotype.
“Dermatologists should be ready to identify and diagnose these mosquito-borne diseases that we think of as occurring in Central America or tropical regions,” Dr. Rosenbach said. “In my children’s lifetime there will be tropical diseases in New York, Philadelphia, Boston and other such places.”
In his articles and talks, Dr. Rosenbach lays out the science of climate change – for instance, the change in average global temperatures above preindustrial levels (an approximate 1° C rise) , the threshold beyond which the Earth will become less hospitable (1.5° C of warming according to United Nation’s Intergovernmental Panel on Climate Change), the current projections for future warming (an increase of about 3° Celsius by 2100), and the “gold-standard” level of scientific certainty that climate change is human-caused.
Mathematical climate modeling, he emphasized in the interview, can accurately project changes in infection rates. Researchers predicted 10 years ago in a published paper, for instance, that based on global warming patterns, the sand fly vector responsible for cutaneous leishmaniasis would live in the Southern United States and cause endemic infections within 10 years.
And in 2018, Dr. Rosenbach said, a paper in JAMA Dermatology described how more than half – 59% – of the cases of cutaneous leishmaniasis diagnosed in Texas were endemic, all occurring in people with no prior travel outside the United States.
Dr. Williams’ devotion to climate change and dermatology and to the climate change ERG was inspired in large part by Dr. Rosenbach’s 2017 paper in JAAD. She had long been concerned about climate change, she said, but “the review article was really the impetus for me to think, this is really within my specialty.”
Extreme weather events, and the climate-driven migration expected to increasingly occur, have clear relevance to dermatology, Dr. Williams said. “Often, the most vexing problems that people have when they’re forced out of their homes ... are dermatologic,” she said, like infections from contaminated waters after flooding and the spread of scabies and other communicable diseases due to crowding and unsanitary conditions.
But there are other less obvious ramifications of a changing climate that affect dermatology. Dr. Williams has delved into the literature on heat-related illness, for instance, and found that most research has been in the realm of sports medicine and military health. “Most of us don’t treat serious heat-related illnesses, but our skin is responsible for keeping us cool and there’s an important role for dermatologists to play in knowing how the skin does that and who is at risk for heat illness because the skin is unable to do the full job,” she said.
Research is needed to identify which medications can interfere with the skin’s thermoregulatory responses and put patients at risk, she noted. “And a lot of the work on sweat gland physiology is probably 30 years old now. We should bring to bear contemporary research techniques.”
Dermatology is also “in the early stages of understanding the role that air pollution plays in skin disease,” Dr. Williams said. “Most of the medical literature focuses on the effects of pollution on the lungs and in cardiovascular disease.”
There is evidence linking small particulate matter found in wood smoke and other air pollutants to exacerbations of atopic dermatitis and other inflammatory skin conditions, she noted, but mechanisms need to be explored and health disparities examined. “While we know that there are health disparities in terms of [exposure to] pollution and respiratory illness, we have no idea if this is the case with our skin diseases like atopic dermatitis,” said Dr. Williams.
In general, according to the AAD position statement, low-income and minority communities, in addition to the very young and the very old, “are and will continue to be disproportionately affected by climate change.”
Education and the carbon footprint
Viewing climate change as a social determinant of health (SDH ) – and integrating it into medical training as such – is a topic of active discussion. At UCSF, Sarah J. Coates, MD, a fellow in pediatric dermatology, is working with colleagues to integrate climate change into formal resident education. “We know that climate change affects housing, food security, migration ... and certain populations are and will be especially vulnerable,” she said in an interview. “The effects of climate change fit squarely into the social determinant of health curriculum that we’re building here.”
Dr. Coates began to appreciate the link between climate and infectious diseases – a topic she now writes and speaks about – when she saw several patients with coccidioidomycosis as a dermatology resident at UCSF and learned that the cases represented an epidemic in the Central Valley “resulting from several years of drought.”
Her medical school and residency training were otherwise devoid of any discussion of climate change. At UCSF and nearby Stanford (Calif.) University, this is no longer the case, she and Dr. Williams said. “The medical students here have been quite active and are requesting education,” noted Dr. Williams. “The desire to know more is coming from the bottom.”
Mary E. Maloney, MD, professor of medicine and director of dermatologic surgery at the University of Massachusetts, Worcester, sees the same interest from physicians-in-training in the Boston area. They want education about climate science, the impact of climate changes on health and risk mitigation, and ways to reduce medicine’s carbon footprint. “We need to teach them and charge them to lead in their communities,” she said in an interview.
Dr. Maloney joined the AAD’s climate change resource group soon after its inception, having realized the urgency of climate change and feeling that she needed “to get passionate and not just do small things.” As a Mohs surgeon, she expects an “explosion” of skin cancer as temperatures and sun exposure continue to increase.
She urges dermatologists to work to decrease the carbon footprint of their practices and to advocate for local hospitals and other clinical institutions to do so. On the AAD website, members now have free access to tools provided by the nonprofit organization My Green Doctor for outpatient offices to lighten their carbon footprints in a cost-effective – or even cost-saving – manner.
Dr. Maloney’s institution has moved to automated lighting systems and the use of LED lights, she said, and has encouraged ride sharing (prior to the pandemic) and computer switch-offs at night. And in her practice, she and a colleague have been working to reduce the purchasing and use of disposable plastics.
Educating patients about the effects of climate change on the health of their skin is another of the missions listed in the AAD’s position statement, and it’s something that Dr. Coates is currently researching. “It seems similar to talking about other social determinants of health,” she said. “Saying to a patient, for instance, ‘we’ve had some really terrible wildfires lately. They’re getting worse as the seasons go on and we know that’s because of climate change. How do you think your current rash relates to the current air quality? How you think the air quality affects your skin?’ ”
Dr. Rosenbach emphasizes that physicians are a broadly trusted group. “I’d tell a patient, ‘you’re the fourth patient I’ve seen with Lyme – we think that’s because it’s been a warmer year due to climate change,’” he said. “I don’t think that bringing up climate change has ever been a source of friction.”
Climate change will increasingly affect the distribution and frequency of insect-borne diseases, cutaneous leishmaniasis, skin cancer, fungal diseases, and a host of other illnesses that have cutaneous manifestations or involve the skin – and dermatologists are being urged to be ready to diagnose clinical findings, counsel patients about risk mitigation, and decrease the carbon footprint of their practices and medical organizations.
“Climate change is not a far-off threat but an urgent health issue,” Misha Rosenbach, MD, associate professor of dermatology at the University of Pennsylvania, Philadelphia, wrote in an editorial with coauthor Mary Sun, a student at Icahn School of Medicine at Mount Sinai, New York. It was first published online in the British Journal of Dermatology last year, titled, “The climate emergency: Why should dermatologists care and how can they act?”.
. Some of the 150-plus members of the ERG have been writing about the dermatologic impacts of climate change – including content that filled the January issue of the International Journal of Women’s Dermatology – and speaking about the issues.
A session at the AAD’s virtual annual meeting in April will address climate change and dermatology – the second such session at an annual meeting – and the first two of three planned virtual symposia led by Dr. Rosenbach and his colleagues, have been hosted by the Association of Professors of Dermatology. The ERG encouraged the AAD’s adoption of a position statement in 2018 about climate change and dermatology and its membership in the Medical Society Consortium on Climate and Health.
“There’s been a lot of conversation in the medical community about the health effects of climate change, but most people leave out the skin,” said Mary L. Williams, MD, clinical professor of dermatology at the University of California, San Francisco, who is a cofounder and coleader with Dr. Rosenbach of the climate change ERG.
“That’s interesting because the skin is the most environmental of all our organs. Of course it will be impacted by all that’s going on,” she said. “We want to bring the dermatologic community and the wider medical community along with us [in appreciating and acting on this knowledge].”
Changing disease patterns
Dr. Rosenbach did not think much about how climate change could affect his patients and his clinical practice until he saw a severe case of hand, foot, and mouth disease in a hospitalized adult in Philadelphia about 10 years ago.
A presentation of the case at an infectious disease conference spurred discussion of how the preceding winters had been warmer and of correlations reported by researchers in China between the incidence of hand, foot, and mouth disease – historically a mild infection in children – and average temperature and other meteorological factors. “I knew about climate change, but I never knew we’d see different diseases in our clinical practice, or old diseases affecting new hosts,” Dr. Rosenbach said in an interview.
He pored over the literature to deepen his understanding of climate change science and the impact of climate change on medicine, and found an “emerging focus” on climate change in some medical journals, but “very little in dermatology.” In collaboration with Benjamin Kaffenberger, MD, a dermatologist at The Ohio State University, and colleagues, including an entomologist, Dr. Rosenbach wrote a review of publications relating to climate change and skin disease in North America.
Published in 2017 in the Journal of the American Academy of Dermatology, the review details how bacteria, viruses, fungi, and parasites are responding to changing weather patterns in North America, and why dermatologists should be able to recognize changing patterns of disease. Globalization plays a role in changing disease and vector patterns, but “climate change allows expansion of the natural range of pathogens, hosts, reservoirs, and vectors that allow diseases to appear in immunologically naive populations,” they wrote.
Patterns of infectious diseases with cutaneous manifestations are already changing. The geographic range of coccidioidomycosis, or valley fever, for instance, “has basically doubled in the Southwest U.S., extending up the entire West Coast,” Dr. Rosenbach said, as the result of longer dry seasons and more frequent wind storms that aerosolize the mycosis-causing, soil-dwelling fungal spores.
Lyme disease and associated tick-borne infections continue to expand northward as Ixodes tick vectors move and breed “exactly in sync with a warming world,” Dr. Rosenbach said. “We’re seeing Lyme in Philadelphia in February, whereas in the past we may not have seen it until May ... There are derms in Maine [whose patients have Lyme disease] who may never have seen a case before, and derms in Canada who are making diagnoses of Lyme [for the first time].”
And locally acquired cases of dengue are being reported in Hawaii, Texas, and Florida – and even North Carolina, according to a review of infectious diseases with cutaneous manifestations in the issue of the International Journal of Women’s Dermatology dedicated to climate change. As with Ixodes ticks, which transmit Lyme disease, rising temperatures lead to longer breeding seasons for Aedes mosquitoes, which transmit dengue. Increased endemicity of dengue is concerning because severe illness is significantly more likely in individuals previously infected with a different serotype.
“Dermatologists should be ready to identify and diagnose these mosquito-borne diseases that we think of as occurring in Central America or tropical regions,” Dr. Rosenbach said. “In my children’s lifetime there will be tropical diseases in New York, Philadelphia, Boston and other such places.”
In his articles and talks, Dr. Rosenbach lays out the science of climate change – for instance, the change in average global temperatures above preindustrial levels (an approximate 1° C rise) , the threshold beyond which the Earth will become less hospitable (1.5° C of warming according to United Nation’s Intergovernmental Panel on Climate Change), the current projections for future warming (an increase of about 3° Celsius by 2100), and the “gold-standard” level of scientific certainty that climate change is human-caused.
Mathematical climate modeling, he emphasized in the interview, can accurately project changes in infection rates. Researchers predicted 10 years ago in a published paper, for instance, that based on global warming patterns, the sand fly vector responsible for cutaneous leishmaniasis would live in the Southern United States and cause endemic infections within 10 years.
And in 2018, Dr. Rosenbach said, a paper in JAMA Dermatology described how more than half – 59% – of the cases of cutaneous leishmaniasis diagnosed in Texas were endemic, all occurring in people with no prior travel outside the United States.
Dr. Williams’ devotion to climate change and dermatology and to the climate change ERG was inspired in large part by Dr. Rosenbach’s 2017 paper in JAAD. She had long been concerned about climate change, she said, but “the review article was really the impetus for me to think, this is really within my specialty.”
Extreme weather events, and the climate-driven migration expected to increasingly occur, have clear relevance to dermatology, Dr. Williams said. “Often, the most vexing problems that people have when they’re forced out of their homes ... are dermatologic,” she said, like infections from contaminated waters after flooding and the spread of scabies and other communicable diseases due to crowding and unsanitary conditions.
But there are other less obvious ramifications of a changing climate that affect dermatology. Dr. Williams has delved into the literature on heat-related illness, for instance, and found that most research has been in the realm of sports medicine and military health. “Most of us don’t treat serious heat-related illnesses, but our skin is responsible for keeping us cool and there’s an important role for dermatologists to play in knowing how the skin does that and who is at risk for heat illness because the skin is unable to do the full job,” she said.
Research is needed to identify which medications can interfere with the skin’s thermoregulatory responses and put patients at risk, she noted. “And a lot of the work on sweat gland physiology is probably 30 years old now. We should bring to bear contemporary research techniques.”
Dermatology is also “in the early stages of understanding the role that air pollution plays in skin disease,” Dr. Williams said. “Most of the medical literature focuses on the effects of pollution on the lungs and in cardiovascular disease.”
There is evidence linking small particulate matter found in wood smoke and other air pollutants to exacerbations of atopic dermatitis and other inflammatory skin conditions, she noted, but mechanisms need to be explored and health disparities examined. “While we know that there are health disparities in terms of [exposure to] pollution and respiratory illness, we have no idea if this is the case with our skin diseases like atopic dermatitis,” said Dr. Williams.
In general, according to the AAD position statement, low-income and minority communities, in addition to the very young and the very old, “are and will continue to be disproportionately affected by climate change.”
Education and the carbon footprint
Viewing climate change as a social determinant of health (SDH ) – and integrating it into medical training as such – is a topic of active discussion. At UCSF, Sarah J. Coates, MD, a fellow in pediatric dermatology, is working with colleagues to integrate climate change into formal resident education. “We know that climate change affects housing, food security, migration ... and certain populations are and will be especially vulnerable,” she said in an interview. “The effects of climate change fit squarely into the social determinant of health curriculum that we’re building here.”
Dr. Coates began to appreciate the link between climate and infectious diseases – a topic she now writes and speaks about – when she saw several patients with coccidioidomycosis as a dermatology resident at UCSF and learned that the cases represented an epidemic in the Central Valley “resulting from several years of drought.”
Her medical school and residency training were otherwise devoid of any discussion of climate change. At UCSF and nearby Stanford (Calif.) University, this is no longer the case, she and Dr. Williams said. “The medical students here have been quite active and are requesting education,” noted Dr. Williams. “The desire to know more is coming from the bottom.”
Mary E. Maloney, MD, professor of medicine and director of dermatologic surgery at the University of Massachusetts, Worcester, sees the same interest from physicians-in-training in the Boston area. They want education about climate science, the impact of climate changes on health and risk mitigation, and ways to reduce medicine’s carbon footprint. “We need to teach them and charge them to lead in their communities,” she said in an interview.
Dr. Maloney joined the AAD’s climate change resource group soon after its inception, having realized the urgency of climate change and feeling that she needed “to get passionate and not just do small things.” As a Mohs surgeon, she expects an “explosion” of skin cancer as temperatures and sun exposure continue to increase.
She urges dermatologists to work to decrease the carbon footprint of their practices and to advocate for local hospitals and other clinical institutions to do so. On the AAD website, members now have free access to tools provided by the nonprofit organization My Green Doctor for outpatient offices to lighten their carbon footprints in a cost-effective – or even cost-saving – manner.
Dr. Maloney’s institution has moved to automated lighting systems and the use of LED lights, she said, and has encouraged ride sharing (prior to the pandemic) and computer switch-offs at night. And in her practice, she and a colleague have been working to reduce the purchasing and use of disposable plastics.
Educating patients about the effects of climate change on the health of their skin is another of the missions listed in the AAD’s position statement, and it’s something that Dr. Coates is currently researching. “It seems similar to talking about other social determinants of health,” she said. “Saying to a patient, for instance, ‘we’ve had some really terrible wildfires lately. They’re getting worse as the seasons go on and we know that’s because of climate change. How do you think your current rash relates to the current air quality? How you think the air quality affects your skin?’ ”
Dr. Rosenbach emphasizes that physicians are a broadly trusted group. “I’d tell a patient, ‘you’re the fourth patient I’ve seen with Lyme – we think that’s because it’s been a warmer year due to climate change,’” he said. “I don’t think that bringing up climate change has ever been a source of friction.”
SNP chips deemed ‘extremely unreliable’ for identifying rare variants
In fact, SNP chips are “extremely unreliable for genotyping very rare pathogenic variants,” and a positive result for such a variant “is more likely to be wrong than right,” researchers reported in the BMJ.
The authors explained that SNP chips are “DNA microarrays that test genetic variation at many hundreds of thousands of specific locations across the genome.” Although SNP chips have proven accurate in identifying common variants, past reports have suggested that SNP chips perform poorly for genotyping rare variants.
To gain more insight, Caroline Wright, PhD, of the University of Exeter (England) and colleagues conducted a large study.
The researchers analyzed data on 49,908 people from the UK Biobank who had SNP chip and next-generation sequencing results, as well as an additional 21 people who purchased consumer genetic tests and shared their data online via the Personal Genome Project.
The researchers compared the SNP chip and sequencing results. They also selected rare pathogenic variants in BRCA1 and BRCA2 for detailed analysis of clinically actionable variants in the UK Biobank, and they assessed BRCA-related cancers in participants using cancer registry data.
Largest evaluation of SNP chips
SNP chips performed well for common variants, the researchers found. Sensitivity, specificity, positive-predictive value, and negative-predictive value all exceeded 99% for 108,574 common variants.
For rare variants, SNP chips performed poorly, with a positive-predictive value of 16% for variants with a frequency below 0.001% in the UK Biobank.
“The study provides the largest evaluation of the performance of SNP chips for genotyping genetic variants at different frequencies in the population, particularly focusing on very rare variants,” Dr. Wright said. “The biggest surprise was how poorly the SNP chips we evaluated performed for rare variants.”
Dr. Wright noted that there is an inherent problem built into using SNP chip technology to genotype very rare variants.
“The SNP chip technology relies on clustering data from multiple individuals in order to determine what genotype each individual has at a specific position in their genome,” Dr. Wright explained. “Although this method works very well for common variants, the rarer the variant, the harder it is to distinguish from experimental noise.”
False positives and cancer: ‘Don’t trust the results’
The researchers found that, for rare BRCA variants (frequency below 0.01%), SNP chips had a sensitivity of 34.6%, specificity of 98.3%, negative-predictive value of 99.9%, and positive-predictive value of 4.2%.
Rates of BRCA-related cancers in patients with positive SNP chip results were similar to rates in age-matched control subjects because “the vast majority of variants were false positives,” the researchers noted.
“If these variants are incorrectly genotyped – that is, false positives detected – a woman could be offered screening or even prophylactic surgery inappropriately when she is more likely to be at population background risk [for BRCA-related cancers],” Dr. Wright said.
“For very-rare-disease–causing genetic variants, don’t trust the results from SNP chips; for example, those from direct-to-consumer genetic tests. Never use them to guide clinical action without diagnostic validation,” she added.
Heather Hampel, a genetic counselor and researcher at the Ohio State University Comprehensive Cancer Center in Columbus, agreed.
“Positive results on SNP-based tests need to be confirmed by medical-grade genetic testing using a sequencing technology,” she said. “Negative results on an SNP- based test cannot be considered to rule out mutations in BRCA1/2 or other cancer-susceptibility genes, so individuals with strong personal and family histories of cancer should be seen by a genetic counselor to consider medical-grade genetic testing using a sequencing technology.”
Practicing oncologists can trust patients’ prior germline genetic test results if the testing was performed in a cancer genetics clinic, which uses sequencing-based technologies, Ms. Hampel noted.
“If the test was performed before 2013, there are likely new genes that have been discovered for which their patient was not tested, and repeat testing may be warranted,” Ms. Hampel said. “A referral to a cancer genetic counselor would be appropriate.”
Ms. Hampel disclosed relationships with Genome Medical, GI OnDemand, Invitae Genetics, and Promega. Dr. Wright and her coauthors disclosed no conflicts of interest. The group’s research was conducted using the UK Biobank and the University of Exeter High-Performance Computing, with funding from the Wellcome Trust and the National Institute for Health Research.
In fact, SNP chips are “extremely unreliable for genotyping very rare pathogenic variants,” and a positive result for such a variant “is more likely to be wrong than right,” researchers reported in the BMJ.
The authors explained that SNP chips are “DNA microarrays that test genetic variation at many hundreds of thousands of specific locations across the genome.” Although SNP chips have proven accurate in identifying common variants, past reports have suggested that SNP chips perform poorly for genotyping rare variants.
To gain more insight, Caroline Wright, PhD, of the University of Exeter (England) and colleagues conducted a large study.
The researchers analyzed data on 49,908 people from the UK Biobank who had SNP chip and next-generation sequencing results, as well as an additional 21 people who purchased consumer genetic tests and shared their data online via the Personal Genome Project.
The researchers compared the SNP chip and sequencing results. They also selected rare pathogenic variants in BRCA1 and BRCA2 for detailed analysis of clinically actionable variants in the UK Biobank, and they assessed BRCA-related cancers in participants using cancer registry data.
Largest evaluation of SNP chips
SNP chips performed well for common variants, the researchers found. Sensitivity, specificity, positive-predictive value, and negative-predictive value all exceeded 99% for 108,574 common variants.
For rare variants, SNP chips performed poorly, with a positive-predictive value of 16% for variants with a frequency below 0.001% in the UK Biobank.
“The study provides the largest evaluation of the performance of SNP chips for genotyping genetic variants at different frequencies in the population, particularly focusing on very rare variants,” Dr. Wright said. “The biggest surprise was how poorly the SNP chips we evaluated performed for rare variants.”
Dr. Wright noted that there is an inherent problem built into using SNP chip technology to genotype very rare variants.
“The SNP chip technology relies on clustering data from multiple individuals in order to determine what genotype each individual has at a specific position in their genome,” Dr. Wright explained. “Although this method works very well for common variants, the rarer the variant, the harder it is to distinguish from experimental noise.”
False positives and cancer: ‘Don’t trust the results’
The researchers found that, for rare BRCA variants (frequency below 0.01%), SNP chips had a sensitivity of 34.6%, specificity of 98.3%, negative-predictive value of 99.9%, and positive-predictive value of 4.2%.
Rates of BRCA-related cancers in patients with positive SNP chip results were similar to rates in age-matched control subjects because “the vast majority of variants were false positives,” the researchers noted.
“If these variants are incorrectly genotyped – that is, false positives detected – a woman could be offered screening or even prophylactic surgery inappropriately when she is more likely to be at population background risk [for BRCA-related cancers],” Dr. Wright said.
“For very-rare-disease–causing genetic variants, don’t trust the results from SNP chips; for example, those from direct-to-consumer genetic tests. Never use them to guide clinical action without diagnostic validation,” she added.
Heather Hampel, a genetic counselor and researcher at the Ohio State University Comprehensive Cancer Center in Columbus, agreed.
“Positive results on SNP-based tests need to be confirmed by medical-grade genetic testing using a sequencing technology,” she said. “Negative results on an SNP- based test cannot be considered to rule out mutations in BRCA1/2 or other cancer-susceptibility genes, so individuals with strong personal and family histories of cancer should be seen by a genetic counselor to consider medical-grade genetic testing using a sequencing technology.”
Practicing oncologists can trust patients’ prior germline genetic test results if the testing was performed in a cancer genetics clinic, which uses sequencing-based technologies, Ms. Hampel noted.
“If the test was performed before 2013, there are likely new genes that have been discovered for which their patient was not tested, and repeat testing may be warranted,” Ms. Hampel said. “A referral to a cancer genetic counselor would be appropriate.”
Ms. Hampel disclosed relationships with Genome Medical, GI OnDemand, Invitae Genetics, and Promega. Dr. Wright and her coauthors disclosed no conflicts of interest. The group’s research was conducted using the UK Biobank and the University of Exeter High-Performance Computing, with funding from the Wellcome Trust and the National Institute for Health Research.
In fact, SNP chips are “extremely unreliable for genotyping very rare pathogenic variants,” and a positive result for such a variant “is more likely to be wrong than right,” researchers reported in the BMJ.
The authors explained that SNP chips are “DNA microarrays that test genetic variation at many hundreds of thousands of specific locations across the genome.” Although SNP chips have proven accurate in identifying common variants, past reports have suggested that SNP chips perform poorly for genotyping rare variants.
To gain more insight, Caroline Wright, PhD, of the University of Exeter (England) and colleagues conducted a large study.
The researchers analyzed data on 49,908 people from the UK Biobank who had SNP chip and next-generation sequencing results, as well as an additional 21 people who purchased consumer genetic tests and shared their data online via the Personal Genome Project.
The researchers compared the SNP chip and sequencing results. They also selected rare pathogenic variants in BRCA1 and BRCA2 for detailed analysis of clinically actionable variants in the UK Biobank, and they assessed BRCA-related cancers in participants using cancer registry data.
Largest evaluation of SNP chips
SNP chips performed well for common variants, the researchers found. Sensitivity, specificity, positive-predictive value, and negative-predictive value all exceeded 99% for 108,574 common variants.
For rare variants, SNP chips performed poorly, with a positive-predictive value of 16% for variants with a frequency below 0.001% in the UK Biobank.
“The study provides the largest evaluation of the performance of SNP chips for genotyping genetic variants at different frequencies in the population, particularly focusing on very rare variants,” Dr. Wright said. “The biggest surprise was how poorly the SNP chips we evaluated performed for rare variants.”
Dr. Wright noted that there is an inherent problem built into using SNP chip technology to genotype very rare variants.
“The SNP chip technology relies on clustering data from multiple individuals in order to determine what genotype each individual has at a specific position in their genome,” Dr. Wright explained. “Although this method works very well for common variants, the rarer the variant, the harder it is to distinguish from experimental noise.”
False positives and cancer: ‘Don’t trust the results’
The researchers found that, for rare BRCA variants (frequency below 0.01%), SNP chips had a sensitivity of 34.6%, specificity of 98.3%, negative-predictive value of 99.9%, and positive-predictive value of 4.2%.
Rates of BRCA-related cancers in patients with positive SNP chip results were similar to rates in age-matched control subjects because “the vast majority of variants were false positives,” the researchers noted.
“If these variants are incorrectly genotyped – that is, false positives detected – a woman could be offered screening or even prophylactic surgery inappropriately when she is more likely to be at population background risk [for BRCA-related cancers],” Dr. Wright said.
“For very-rare-disease–causing genetic variants, don’t trust the results from SNP chips; for example, those from direct-to-consumer genetic tests. Never use them to guide clinical action without diagnostic validation,” she added.
Heather Hampel, a genetic counselor and researcher at the Ohio State University Comprehensive Cancer Center in Columbus, agreed.
“Positive results on SNP-based tests need to be confirmed by medical-grade genetic testing using a sequencing technology,” she said. “Negative results on an SNP- based test cannot be considered to rule out mutations in BRCA1/2 or other cancer-susceptibility genes, so individuals with strong personal and family histories of cancer should be seen by a genetic counselor to consider medical-grade genetic testing using a sequencing technology.”
Practicing oncologists can trust patients’ prior germline genetic test results if the testing was performed in a cancer genetics clinic, which uses sequencing-based technologies, Ms. Hampel noted.
“If the test was performed before 2013, there are likely new genes that have been discovered for which their patient was not tested, and repeat testing may be warranted,” Ms. Hampel said. “A referral to a cancer genetic counselor would be appropriate.”
Ms. Hampel disclosed relationships with Genome Medical, GI OnDemand, Invitae Genetics, and Promega. Dr. Wright and her coauthors disclosed no conflicts of interest. The group’s research was conducted using the UK Biobank and the University of Exeter High-Performance Computing, with funding from the Wellcome Trust and the National Institute for Health Research.
FROM BMJ
The skill set of the ‘pluripotent’ hospitalist
Editor’s note: National Hospitalist Day occurs the first Thursday in March annually, and serves to celebrate the fastest growing specialty in modern medicine and hospitalists’ enduring contributions to the evolving health care landscape. On National Hospitalist Day in 2021, SHM convened a virtual roundtable with a diverse group of hospitalists to discuss skill set, wellness, and other key issues for hospitalists. To listen to the entire roundtable discussion, visit this Explore The Space podcast episode.
A hospitalist isn’t just a physician who happens to work in a hospital. They are medical professionals with a robust skill set that they use both inside and outside the hospital setting. But what skill sets do hospitalists need to become successful in their careers? And what skill sets does a “pluripotent” hospitalist need in their armamentarium?
These were the issues discussed by participants of a virtual roundtable discussion on National Hospitalist Day – March 4, 2021 – as part of a joint effort of the Society of Hospital Medicine and the Explore the Space podcast.
Maylyn S. Martinez, MD, clinician-researcher and clinical associate at the University of Chicago, sees her hospitalist and research skill sets as two “buckets” of skills she can sort through, with diagnostic, knowledge-based care coordination, and interpersonal skills as lanes where she can focus and improve. “I’m always trying to work in, and sharpen, and find ways to get better at something in each of those every day,” she said.
For Anika Kumar, MD, FHM, pediatric editor of the Hospitalist and clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine, much of her work is focused on problem solving. “I approach that as: ‘How do I come up with my differential diagnosis, and how do I diagnose the patient?’ I think that the lanes are a little bit different, but there is some overlap.”
Adaptability is another important part of the skill set for the hospitalist, Ndidi Unaka, MD, MEd, associate professor in the division of hospital medicine at Cincinnati Children’s Hospital Medical Center, said during the discussion. “I think we all really value teamwork, and we take on the role of being the coordinator and making sure things are getting done in a seamless and thoughtful manner. Communicating with families, communicating with our research team, communicating with primary care physicians. I think that is something we’re very used to doing, and I think we do it well. I think we don’t shy away from difficult conversations with consultants. And I think that’s what makes being a hospitalist so amazing.”
Achieving wellness as a hospitalist
Another topic discussed during the roundtable was “comprehensive care for the hospitalist” and how they can achieve a sense of wellness for themselves. Gurpreet Dhaliwal, MD, clinician-educator and professor of medicine at the University of California, San Francisco, said long-term satisfaction in one’s career is less about compensation and more about autonomy, mastery, and purpose.
“Autonomy is shrinking a little bit in health care. But if we connect to our purpose – ‘what are we doing here and how do we connect?’ – it’s either learning about patients and their stories, being with a team of people that you work with, that really builds that purpose,” he said.
Regarding mastery, there’s “tremendous joy if you’re in an environment where people value your mastery, whether it is working in a team or communicating or diagnosing or doing a procedure. If you think of setting up the work environment and those things are in place, I think a lot of wellness can actually happen at work, even though another component, of course, is balancing your life outside of work,” Dr. Dhaliwal said.
This may seem out of reach during COVID-19, but wellness is still achievable during the pandemic, Dr. Martinez said. Her time is spent 75% as a researcher and 25% as a clinician, which is her ideal balance. “I enjoy doing my research, doing my own statistics and writing grants and just learning about this problem that I’ve developed an interest in,” she said. “I just think that’s an important piece for people to focus on as far as health care for the hospitalist, is that there’s no no-one-size-fits-all, that’s for sure.”
Dr. Kumar noted that her clinical time gives her energy for nonclinical work. “I love my clinical time. It’s one of my favorite things that I do,” she said. Although she is tired at the end of the week, “I feel like I am not only giving back to my patients and my team, but I’m also giving back to myself and reminding myself why it is I do what I do every day,” she said.
Wellness for Dr. Unaka meant remembering what drew her to medicine. “It was definitely the opportunity to build strong relationships with patients and families,” she said. While these encounters can sometimes be heavy and stay with a hospitalist, “the fact that we’re in it with them is something that gives a lot of us purpose. I think that when I reflect on all of those things, I’m so happy that I’m in the role that I am.”
Unique skills during COVID-19
Mark Shapiro, MD, hospitalist and host of the roundtable and the Explore the Space podcast, also asked the panelists what skills they unexpectedly leveraged during the pandemic. Communication – with colleagues and with the community they serve – was a universal answer among the panelists.
“I learned – really from seeing some of our senior leaders here do it so well – the importance of being visible, particularly at a time when people were not together and more isolated,” Dr. Unaka said. “I think being able to be visible when you can, in order to deliver really complicated or tough news or communicate about uncertainty, for instance. Being here for our residents – many of our interns moved here sight unseen. I think they needed to feel like they had some sense of normalcy and a sense of community. I really learned how important it was to be visible, and available, and how important the little things mattered.”
Dr. Martinez said that worrying about her patients with COVID-19 in the hospital and the uncertainty around the disease kept her up at night. “I think we always have a hard time leaving work at work and getting a good night’s sleep. I just could not let go of worrying about these patients and having terrible insomnia, trying to leave work at work and I couldn’t – even after they were discharged.”
Dr. Shapiro said the skill he most needed to work on during the pandemic was his courage. “I remember the first time I took care of COVID patients. I was scared. I have no problems saying that out loud. That was a scary experience.”
The demeanor of the nurses on his unit, who had already seen patients with COVID-19, helped ground him during those moments and gave him the courage to move forward. “They’d already been doing it and they were the same. Same affect, same jokes, same everything,” he said. “That actually really helped, and I’ve leaned on that every time I’ve been back on our COVID service.”
Importance of mental health
The COVID-19 pandemic has also shined a light on the importance of mental health. “I think it is important to acknowledge that as hospitalists who have been out on the bleeding edge for a year, mental health is critically important, and we know that we face shortages in that space for the public at large and also for our profession,” Dr. Shapiro said.
When asked about what mental health and self-care looks like for her, Dr. Kumar referenced the need for exercise, meditation, and yoga. “My mental health was better knowing that the people closest to me – whether they be colleagues or friends or family – their mental health was also in a good place and they were also in a good place. And that helped to build me up,” she said.
Dr. Unaka called attention to the stigma around mental health, particularly among physicians, and the lack of resources to address the issue. “It’s a real problem,” she said. “I think it’s at a point where we as a profession need to advocate on behalf of each other and on behalf of our trainees. And honestly, I think we need to view mental health as just ‘health’ and stop separating it out in order for us to move to a place where people feel like they can access what they need without feeling shame about it.”
Editor’s note: National Hospitalist Day occurs the first Thursday in March annually, and serves to celebrate the fastest growing specialty in modern medicine and hospitalists’ enduring contributions to the evolving health care landscape. On National Hospitalist Day in 2021, SHM convened a virtual roundtable with a diverse group of hospitalists to discuss skill set, wellness, and other key issues for hospitalists. To listen to the entire roundtable discussion, visit this Explore The Space podcast episode.
A hospitalist isn’t just a physician who happens to work in a hospital. They are medical professionals with a robust skill set that they use both inside and outside the hospital setting. But what skill sets do hospitalists need to become successful in their careers? And what skill sets does a “pluripotent” hospitalist need in their armamentarium?
These were the issues discussed by participants of a virtual roundtable discussion on National Hospitalist Day – March 4, 2021 – as part of a joint effort of the Society of Hospital Medicine and the Explore the Space podcast.
Maylyn S. Martinez, MD, clinician-researcher and clinical associate at the University of Chicago, sees her hospitalist and research skill sets as two “buckets” of skills she can sort through, with diagnostic, knowledge-based care coordination, and interpersonal skills as lanes where she can focus and improve. “I’m always trying to work in, and sharpen, and find ways to get better at something in each of those every day,” she said.
For Anika Kumar, MD, FHM, pediatric editor of the Hospitalist and clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine, much of her work is focused on problem solving. “I approach that as: ‘How do I come up with my differential diagnosis, and how do I diagnose the patient?’ I think that the lanes are a little bit different, but there is some overlap.”
Adaptability is another important part of the skill set for the hospitalist, Ndidi Unaka, MD, MEd, associate professor in the division of hospital medicine at Cincinnati Children’s Hospital Medical Center, said during the discussion. “I think we all really value teamwork, and we take on the role of being the coordinator and making sure things are getting done in a seamless and thoughtful manner. Communicating with families, communicating with our research team, communicating with primary care physicians. I think that is something we’re very used to doing, and I think we do it well. I think we don’t shy away from difficult conversations with consultants. And I think that’s what makes being a hospitalist so amazing.”
Achieving wellness as a hospitalist
Another topic discussed during the roundtable was “comprehensive care for the hospitalist” and how they can achieve a sense of wellness for themselves. Gurpreet Dhaliwal, MD, clinician-educator and professor of medicine at the University of California, San Francisco, said long-term satisfaction in one’s career is less about compensation and more about autonomy, mastery, and purpose.
“Autonomy is shrinking a little bit in health care. But if we connect to our purpose – ‘what are we doing here and how do we connect?’ – it’s either learning about patients and their stories, being with a team of people that you work with, that really builds that purpose,” he said.
Regarding mastery, there’s “tremendous joy if you’re in an environment where people value your mastery, whether it is working in a team or communicating or diagnosing or doing a procedure. If you think of setting up the work environment and those things are in place, I think a lot of wellness can actually happen at work, even though another component, of course, is balancing your life outside of work,” Dr. Dhaliwal said.
This may seem out of reach during COVID-19, but wellness is still achievable during the pandemic, Dr. Martinez said. Her time is spent 75% as a researcher and 25% as a clinician, which is her ideal balance. “I enjoy doing my research, doing my own statistics and writing grants and just learning about this problem that I’ve developed an interest in,” she said. “I just think that’s an important piece for people to focus on as far as health care for the hospitalist, is that there’s no no-one-size-fits-all, that’s for sure.”
Dr. Kumar noted that her clinical time gives her energy for nonclinical work. “I love my clinical time. It’s one of my favorite things that I do,” she said. Although she is tired at the end of the week, “I feel like I am not only giving back to my patients and my team, but I’m also giving back to myself and reminding myself why it is I do what I do every day,” she said.
Wellness for Dr. Unaka meant remembering what drew her to medicine. “It was definitely the opportunity to build strong relationships with patients and families,” she said. While these encounters can sometimes be heavy and stay with a hospitalist, “the fact that we’re in it with them is something that gives a lot of us purpose. I think that when I reflect on all of those things, I’m so happy that I’m in the role that I am.”
Unique skills during COVID-19
Mark Shapiro, MD, hospitalist and host of the roundtable and the Explore the Space podcast, also asked the panelists what skills they unexpectedly leveraged during the pandemic. Communication – with colleagues and with the community they serve – was a universal answer among the panelists.
“I learned – really from seeing some of our senior leaders here do it so well – the importance of being visible, particularly at a time when people were not together and more isolated,” Dr. Unaka said. “I think being able to be visible when you can, in order to deliver really complicated or tough news or communicate about uncertainty, for instance. Being here for our residents – many of our interns moved here sight unseen. I think they needed to feel like they had some sense of normalcy and a sense of community. I really learned how important it was to be visible, and available, and how important the little things mattered.”
Dr. Martinez said that worrying about her patients with COVID-19 in the hospital and the uncertainty around the disease kept her up at night. “I think we always have a hard time leaving work at work and getting a good night’s sleep. I just could not let go of worrying about these patients and having terrible insomnia, trying to leave work at work and I couldn’t – even after they were discharged.”
Dr. Shapiro said the skill he most needed to work on during the pandemic was his courage. “I remember the first time I took care of COVID patients. I was scared. I have no problems saying that out loud. That was a scary experience.”
The demeanor of the nurses on his unit, who had already seen patients with COVID-19, helped ground him during those moments and gave him the courage to move forward. “They’d already been doing it and they were the same. Same affect, same jokes, same everything,” he said. “That actually really helped, and I’ve leaned on that every time I’ve been back on our COVID service.”
Importance of mental health
The COVID-19 pandemic has also shined a light on the importance of mental health. “I think it is important to acknowledge that as hospitalists who have been out on the bleeding edge for a year, mental health is critically important, and we know that we face shortages in that space for the public at large and also for our profession,” Dr. Shapiro said.
When asked about what mental health and self-care looks like for her, Dr. Kumar referenced the need for exercise, meditation, and yoga. “My mental health was better knowing that the people closest to me – whether they be colleagues or friends or family – their mental health was also in a good place and they were also in a good place. And that helped to build me up,” she said.
Dr. Unaka called attention to the stigma around mental health, particularly among physicians, and the lack of resources to address the issue. “It’s a real problem,” she said. “I think it’s at a point where we as a profession need to advocate on behalf of each other and on behalf of our trainees. And honestly, I think we need to view mental health as just ‘health’ and stop separating it out in order for us to move to a place where people feel like they can access what they need without feeling shame about it.”
Editor’s note: National Hospitalist Day occurs the first Thursday in March annually, and serves to celebrate the fastest growing specialty in modern medicine and hospitalists’ enduring contributions to the evolving health care landscape. On National Hospitalist Day in 2021, SHM convened a virtual roundtable with a diverse group of hospitalists to discuss skill set, wellness, and other key issues for hospitalists. To listen to the entire roundtable discussion, visit this Explore The Space podcast episode.
A hospitalist isn’t just a physician who happens to work in a hospital. They are medical professionals with a robust skill set that they use both inside and outside the hospital setting. But what skill sets do hospitalists need to become successful in their careers? And what skill sets does a “pluripotent” hospitalist need in their armamentarium?
These were the issues discussed by participants of a virtual roundtable discussion on National Hospitalist Day – March 4, 2021 – as part of a joint effort of the Society of Hospital Medicine and the Explore the Space podcast.
Maylyn S. Martinez, MD, clinician-researcher and clinical associate at the University of Chicago, sees her hospitalist and research skill sets as two “buckets” of skills she can sort through, with diagnostic, knowledge-based care coordination, and interpersonal skills as lanes where she can focus and improve. “I’m always trying to work in, and sharpen, and find ways to get better at something in each of those every day,” she said.
For Anika Kumar, MD, FHM, pediatric editor of the Hospitalist and clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine, much of her work is focused on problem solving. “I approach that as: ‘How do I come up with my differential diagnosis, and how do I diagnose the patient?’ I think that the lanes are a little bit different, but there is some overlap.”
Adaptability is another important part of the skill set for the hospitalist, Ndidi Unaka, MD, MEd, associate professor in the division of hospital medicine at Cincinnati Children’s Hospital Medical Center, said during the discussion. “I think we all really value teamwork, and we take on the role of being the coordinator and making sure things are getting done in a seamless and thoughtful manner. Communicating with families, communicating with our research team, communicating with primary care physicians. I think that is something we’re very used to doing, and I think we do it well. I think we don’t shy away from difficult conversations with consultants. And I think that’s what makes being a hospitalist so amazing.”
Achieving wellness as a hospitalist
Another topic discussed during the roundtable was “comprehensive care for the hospitalist” and how they can achieve a sense of wellness for themselves. Gurpreet Dhaliwal, MD, clinician-educator and professor of medicine at the University of California, San Francisco, said long-term satisfaction in one’s career is less about compensation and more about autonomy, mastery, and purpose.
“Autonomy is shrinking a little bit in health care. But if we connect to our purpose – ‘what are we doing here and how do we connect?’ – it’s either learning about patients and their stories, being with a team of people that you work with, that really builds that purpose,” he said.
Regarding mastery, there’s “tremendous joy if you’re in an environment where people value your mastery, whether it is working in a team or communicating or diagnosing or doing a procedure. If you think of setting up the work environment and those things are in place, I think a lot of wellness can actually happen at work, even though another component, of course, is balancing your life outside of work,” Dr. Dhaliwal said.
This may seem out of reach during COVID-19, but wellness is still achievable during the pandemic, Dr. Martinez said. Her time is spent 75% as a researcher and 25% as a clinician, which is her ideal balance. “I enjoy doing my research, doing my own statistics and writing grants and just learning about this problem that I’ve developed an interest in,” she said. “I just think that’s an important piece for people to focus on as far as health care for the hospitalist, is that there’s no no-one-size-fits-all, that’s for sure.”
Dr. Kumar noted that her clinical time gives her energy for nonclinical work. “I love my clinical time. It’s one of my favorite things that I do,” she said. Although she is tired at the end of the week, “I feel like I am not only giving back to my patients and my team, but I’m also giving back to myself and reminding myself why it is I do what I do every day,” she said.
Wellness for Dr. Unaka meant remembering what drew her to medicine. “It was definitely the opportunity to build strong relationships with patients and families,” she said. While these encounters can sometimes be heavy and stay with a hospitalist, “the fact that we’re in it with them is something that gives a lot of us purpose. I think that when I reflect on all of those things, I’m so happy that I’m in the role that I am.”
Unique skills during COVID-19
Mark Shapiro, MD, hospitalist and host of the roundtable and the Explore the Space podcast, also asked the panelists what skills they unexpectedly leveraged during the pandemic. Communication – with colleagues and with the community they serve – was a universal answer among the panelists.
“I learned – really from seeing some of our senior leaders here do it so well – the importance of being visible, particularly at a time when people were not together and more isolated,” Dr. Unaka said. “I think being able to be visible when you can, in order to deliver really complicated or tough news or communicate about uncertainty, for instance. Being here for our residents – many of our interns moved here sight unseen. I think they needed to feel like they had some sense of normalcy and a sense of community. I really learned how important it was to be visible, and available, and how important the little things mattered.”
Dr. Martinez said that worrying about her patients with COVID-19 in the hospital and the uncertainty around the disease kept her up at night. “I think we always have a hard time leaving work at work and getting a good night’s sleep. I just could not let go of worrying about these patients and having terrible insomnia, trying to leave work at work and I couldn’t – even after they were discharged.”
Dr. Shapiro said the skill he most needed to work on during the pandemic was his courage. “I remember the first time I took care of COVID patients. I was scared. I have no problems saying that out loud. That was a scary experience.”
The demeanor of the nurses on his unit, who had already seen patients with COVID-19, helped ground him during those moments and gave him the courage to move forward. “They’d already been doing it and they were the same. Same affect, same jokes, same everything,” he said. “That actually really helped, and I’ve leaned on that every time I’ve been back on our COVID service.”
Importance of mental health
The COVID-19 pandemic has also shined a light on the importance of mental health. “I think it is important to acknowledge that as hospitalists who have been out on the bleeding edge for a year, mental health is critically important, and we know that we face shortages in that space for the public at large and also for our profession,” Dr. Shapiro said.
When asked about what mental health and self-care looks like for her, Dr. Kumar referenced the need for exercise, meditation, and yoga. “My mental health was better knowing that the people closest to me – whether they be colleagues or friends or family – their mental health was also in a good place and they were also in a good place. And that helped to build me up,” she said.
Dr. Unaka called attention to the stigma around mental health, particularly among physicians, and the lack of resources to address the issue. “It’s a real problem,” she said. “I think it’s at a point where we as a profession need to advocate on behalf of each other and on behalf of our trainees. And honestly, I think we need to view mental health as just ‘health’ and stop separating it out in order for us to move to a place where people feel like they can access what they need without feeling shame about it.”
Virtual is the new real
Why did we fall short on maximizing telehealth’s value in the COVID-19 pandemic?
The COVID-19 pandemic catalyzed the transformation of Internet-based, remotely accessible innovative technologies. Internet-based customer service delivery technology was rapidly adopted and utilized by several services industries, but health care systems in most of the countries across the world faced unique challenges in adopting the technology for the delivery of health care services. The health care ecosystem of the United States was not immune to such challenges, and several significant barriers surfaced while the pandemic was underway.
Complexly structured, fragmented, unprepared, and overly burnt-out health systems in the United States arguably have fallen short of maximizing the value of telehealth in delivering safe, easily accessible, comprehensive, and cost-effective health care services. In this essay, we examine the reasons for such a suboptimal performance and discuss a few important strategies that may be useful in maximizing the value of telehealth value in several, appropriate health care services.
Hospitals and telehealth
Are hospitalists preparing ourselves “not to see” patients in a hospital-based health care delivery setting? If you have not yet started yet, now may be the right time! Yes, a certain percentage of doctor-patient encounters in hospital settings will remain virtual forever.
A well-established telehealth infrastructure is rarely found in most U.S. hospitals, although the COVID-19 pandemic has unexpectedly boosted the rapid growth of telehealth in the country.1 Public health emergency declarations in the United States in the face of the COVID-19 crisis have facilitated two important initiatives to restore health care delivery amidst formal and informal lockdowns that brought states to a grinding halt. These extend from expansion of virtual services, including telehealth, virtual check-ins, and e-visits, to the decision by the Department of Health & Human Services Office of Civil Rights to exercise enforcement discretion and waive penalties for the use of relatively inexpensive, non–public-facing mobile and other audiovisual technology tools.2
Hospital-based care in the United States taps nearly 33% of national health expenditure. An additional 30% of national health expenditure that is related to physicians, prescriptions, and other facilities is indirectly influenced by care delivered at health care facilities.3 Studies show that about 20% of ED visits could potentially be avoided via virtual urgent care offerings.4 A rapidly changing health care ecosystem is proving formidable for most hospital systems, and a test for their resilience and agility. Not just the implementation of telehealth is challenging, but getting it right is the key success factor.
Hospital-based telehealth
Expansion of telehealth coverage by the Centers for Medicare & Medicaid Services and most commercial payers did not quite ride the pandemic-induced momentum across the care continuum. Hospitals are lagging far behind ambulatory care in implementing telehealth. As illustrated in the “4-T Matrix” (see graphic) we would like to examine four key reasons for such a sluggish initial uptake and try to propose four important strategies that may help us to maximize the value created by telehealth technologies.
1. Timing
The health care system has always lagged far behind other service industries in terms of technology adaptation. Because of the unique nature of health care services, face-to-face interaction supersedes all other forms of communication. A rapidly evolving pandemic was not matched by simultaneous technology education for patients and providers. The enormous choice of hard-to-navigate telehealth tools; time and labor-intensive implementation; and uncertainty around payer, policy, and regulatory expectations might have precluded providers from the rapid adoption of telehealth in the hospital setting. Patients’ specific characteristics, such as the absence of technology-centered education, information, age, comorbidities, lack of technical literacy, and dependency on caregivers contributed to the suboptimal response from patients and families.
Deploying simple, ubiquitous, user-friendly, and technologically less challenging telehealth solutions may be a better approach to increase the adoption of such solutions by providers and patients. Hospitals need to develop and distribute telehealth user guides in all possible modes of communication. Provider-centric in-service sessions, workshops, and live support by “superuser teams” often work well in reducing end-user resistance.
2. Technical
Current electronic medical records vary widely in their features and offerings, and their ability to interact with third-party software and platforms. Dissatisfaction of end users with EMRs is well known, as is their likely relationship to burnout. Recent research continues to show a strong relationship between EMR usability and the odds of burnout among physicians.5 In the current climate, administrators and health informaticists have the responsibility to avoid adding increased burdens to end users.
Another issue is the limited connectivity in many remote/rural areas that would impact implementation of telehealth platforms. Studies indicate that 33% of rural Americans lack access to high-speed broadband Internet to support video visits.6 The recent successful implementation of telehealth across 530 providers in 75 ambulatory practices operated by Munson Healthcare, a rural health system in northern Michigan, sheds light on the technology’s enormous potential in providing safe access to rural populations.6,7
Privacy and safety of patient data is of paramount importance. According to a national poll on healthy aging by the University of Michigan in May 2019, targeting older adults, 47% of survey responders expressed difficulty using technology and 49% of survey responders were concerned about privacy.8 Use of certification and other tools offered by the Office of the National Coordinator for Health Information Technology would help reassure users, and the ability to capture and share images between providers would be of immense benefit in facilitating e-consults.
The need of the hour is redesigned work flow, to help providers adopt and use virtual care/telehealth efficiently. Work flow redesign must be coupled with technological advances to allow seamless integration of third-party telehealth platforms into existing EMR systems or built directly into EMRs. Use of quality metrics and analytical tools specific to telehealth would help measure the technology’s impact on patient care, outcomes, and end-user/provider experience.
3. Teams and training
Outcomes of health care interventions are often determined by the effectiveness of teams. Irrespective of how robust health care systems may have been initially, rapidly spreading infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and patients to a breaking point.5 Decentralized, uncoordinated, and siloed efforts by individual teams across the care continuum were contributing factors for the partial success of telehealth care delivery pathways. The hospital systems with telehealth-ready teams at the start of the COVID-19 pandemic were so rare that the knowledge and technical training opportunities for innovators grew severalfold during the pandemic.
As per the American Medical Association, telehealth success is massively dependent on building the right team. Core, leadership, advisory, and implementation teams comprised of clinical representatives, end users, administrative personnel, executive members of the organization, technical experts, and payment/policy experts should be put together before implementing a telehealth strategy.9 Seamless integration of hospital-based care with ambulatory care via a telehealth platform is only complete when care managers are trained and deployed to fulfill the needs of a diverse group of patients. Deriving overall value from telehealth is only possible when there is a skill development, training and mentoring team put in place.
4. Thinking
In most U.S. hospitals, inpatient health care is equally distributed between nonprocedure and procedure-based services. Hospitals resorted to suspension of nonemergent procedures to mitigate the risk of spreading COVID-19. This was further compounded by many patients’ self-selection to defer care, an abrupt reduction in the influx of patients from the referral base because of suboptimally operating ambulatory care services, leading to low hospital occupancy.
Hospitals across the nation have gone through a massive short-term financial crunch and unfavorable cash-flow forecast, which prompted a paradoxical work-force reduction. While some argue that it may be akin to strategic myopia, the authors believed that such a response is strategically imperative to keep the hospital afloat. It is reasonable to attribute the paucity of innovation to constrained resources, and health systems are simply staying overly optimistic about “weathering the storm” and reverting soon to “business as usual.” The technological framework necessary for deploying a telehealth solution often comes with a price. Financially challenged hospital systems rarely exercise any capital-intensive activities. By contrast, telehealth adoption by ambulatory care can result in quicker resumption of patient care in community settings. A lack of operational and infrastructure synchrony between ambulatory and in-hospital systems has failed to capture telehealth-driven inpatient volume. For example, direct admissions from ambulatory telehealth referrals was a missed opportunity in several places. Referrals for labs, diagnostic tests, and other allied services could have helped hospitals offset their fixed costs. Similarly, work flows related to discharge and postdischarge follow up rarely embrace telehealth tools or telehealth care pathways. A brisk change in the health care ecosystem is partly responsible for this.
Digital strategy needs to be incorporated into business strategy. For the reasons already discussed, telehealth technology is not a “nice to have” anymore, but a “must have.” At present, providers are of the opinion that about 20% of their patient services can be delivered via a telehealth platform. Similar trends are observed among patients, as a new modality of access to care is increasingly beneficial to them. Telehealth must be incorporated in standardized hospital work flows. Use of telehealth for preoperative clearance will greatly minimize same-day surgery cancellations. Given the potential shortage in resources, telehealth adoption for inpatient consultations will help systems conserve personal protective equipment, minimize the risk of staff exposure to COVID-19, and improve efficiency.
Digital strategy also prompts the reengineering of care delivery.10 Excessive and unused physical capacity can be converted into digital care hubs. Health maintenance, prevention, health promotion, health education, and chronic disease management not only can serve a variety of patient groups but can also help address the “last-mile problem” in health care. A successful digital strategy usually has three important components – Commitment: Hospital leadership is committed to include digital transformation as a strategic objective; Cost: Digital strategy is added as a line item in the budget; and Control: Measurable metrics are put in place to monitor the performance, impact, and influence of the digital strategy.
Conclusion
For decades, most U.S. health systems occupied the periphery of technological transformation when compared to the rest of the service industry. While most health systems took a heroic approach to the adoption of telehealth during COVID-19, despite being unprepared, the need for a systematic telehealth deployment is far from being adequately fulfilled. The COVID-19 pandemic brought permanent changes to several business disciplines globally. Given the impact of the pandemic on the health and overall wellbeing of American society, the U.S. health care industry must leave no stone unturned in its quest for transformation.
Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark, and is cofounder/president of SHM’s Arkansas chapter. Dr. Prasad is medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He is cochair of SHM’s IT Special Interest Group, sits on the HQPS committee, and is president of SHM’s Wisconsin chapter. Dr. Palabindala is the medical director, utilization management, and physician advisory services at the University of Mississippi Medical Center and an associate professor of medicine and academic hospitalist at the University of Mississippi, both in Jackson.
References
1. Finnegan M. “Telehealth booms amid COVID-19 crisis.” Computerworld. 2020 Apr 27. www.computerworld.com/article/3540315/telehealth-booms-amid-covid-19-crisis-virtual-care-is-here-to-stay.html. Accessed 2020 Sep 12.
2. Department of Health & Human Services. “OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.” 2020 Mar 17. www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html. Accessed 2020 Sep 12.
3. National Center for Health Statistics. “Health Expenditures.” www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed 2020 Sep 12.
4. Bestsennyy O et al. “Telehealth: A post–COVID-19 reality?” McKinsey & Company. 2020 May 29. www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality. Accessed 2020 Sep 12.
5. Melnick ER et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among U.S. Physicians. Mayo Clin Proc. 2020 March;95(3):476-87.
6. Hirko KA et al. Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. J Am Med Inform Assoc. 2020 Nov;27(11):1816-8. .
7. American Academy of Family Physicians. “Study Examines Telehealth, Rural Disparities in Pandemic.” 2020 July 30. www.aafp.org/news/practice-professional-issues/20200730ruraltelehealth.html. Accessed 2020 Dec 15.
8. Kurlander J et al. “Virtual Visits: Telehealth and Older Adults.” National Poll on Healthy Aging. 2019 Oct. hdl.handle.net/2027.42/151376.
9. American Medical Association. Telehealth Implementation Playbook. 2019. www.ama-assn.org/system/files/2020-04/ama-telehealth-implementation-playbook.pdf.
10. Smith AC et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020 Jun;26(5):309-13.
Why did we fall short on maximizing telehealth’s value in the COVID-19 pandemic?
Why did we fall short on maximizing telehealth’s value in the COVID-19 pandemic?
The COVID-19 pandemic catalyzed the transformation of Internet-based, remotely accessible innovative technologies. Internet-based customer service delivery technology was rapidly adopted and utilized by several services industries, but health care systems in most of the countries across the world faced unique challenges in adopting the technology for the delivery of health care services. The health care ecosystem of the United States was not immune to such challenges, and several significant barriers surfaced while the pandemic was underway.
Complexly structured, fragmented, unprepared, and overly burnt-out health systems in the United States arguably have fallen short of maximizing the value of telehealth in delivering safe, easily accessible, comprehensive, and cost-effective health care services. In this essay, we examine the reasons for such a suboptimal performance and discuss a few important strategies that may be useful in maximizing the value of telehealth value in several, appropriate health care services.
Hospitals and telehealth
Are hospitalists preparing ourselves “not to see” patients in a hospital-based health care delivery setting? If you have not yet started yet, now may be the right time! Yes, a certain percentage of doctor-patient encounters in hospital settings will remain virtual forever.
A well-established telehealth infrastructure is rarely found in most U.S. hospitals, although the COVID-19 pandemic has unexpectedly boosted the rapid growth of telehealth in the country.1 Public health emergency declarations in the United States in the face of the COVID-19 crisis have facilitated two important initiatives to restore health care delivery amidst formal and informal lockdowns that brought states to a grinding halt. These extend from expansion of virtual services, including telehealth, virtual check-ins, and e-visits, to the decision by the Department of Health & Human Services Office of Civil Rights to exercise enforcement discretion and waive penalties for the use of relatively inexpensive, non–public-facing mobile and other audiovisual technology tools.2
Hospital-based care in the United States taps nearly 33% of national health expenditure. An additional 30% of national health expenditure that is related to physicians, prescriptions, and other facilities is indirectly influenced by care delivered at health care facilities.3 Studies show that about 20% of ED visits could potentially be avoided via virtual urgent care offerings.4 A rapidly changing health care ecosystem is proving formidable for most hospital systems, and a test for their resilience and agility. Not just the implementation of telehealth is challenging, but getting it right is the key success factor.
Hospital-based telehealth
Expansion of telehealth coverage by the Centers for Medicare & Medicaid Services and most commercial payers did not quite ride the pandemic-induced momentum across the care continuum. Hospitals are lagging far behind ambulatory care in implementing telehealth. As illustrated in the “4-T Matrix” (see graphic) we would like to examine four key reasons for such a sluggish initial uptake and try to propose four important strategies that may help us to maximize the value created by telehealth technologies.
1. Timing
The health care system has always lagged far behind other service industries in terms of technology adaptation. Because of the unique nature of health care services, face-to-face interaction supersedes all other forms of communication. A rapidly evolving pandemic was not matched by simultaneous technology education for patients and providers. The enormous choice of hard-to-navigate telehealth tools; time and labor-intensive implementation; and uncertainty around payer, policy, and regulatory expectations might have precluded providers from the rapid adoption of telehealth in the hospital setting. Patients’ specific characteristics, such as the absence of technology-centered education, information, age, comorbidities, lack of technical literacy, and dependency on caregivers contributed to the suboptimal response from patients and families.
Deploying simple, ubiquitous, user-friendly, and technologically less challenging telehealth solutions may be a better approach to increase the adoption of such solutions by providers and patients. Hospitals need to develop and distribute telehealth user guides in all possible modes of communication. Provider-centric in-service sessions, workshops, and live support by “superuser teams” often work well in reducing end-user resistance.
2. Technical
Current electronic medical records vary widely in their features and offerings, and their ability to interact with third-party software and platforms. Dissatisfaction of end users with EMRs is well known, as is their likely relationship to burnout. Recent research continues to show a strong relationship between EMR usability and the odds of burnout among physicians.5 In the current climate, administrators and health informaticists have the responsibility to avoid adding increased burdens to end users.
Another issue is the limited connectivity in many remote/rural areas that would impact implementation of telehealth platforms. Studies indicate that 33% of rural Americans lack access to high-speed broadband Internet to support video visits.6 The recent successful implementation of telehealth across 530 providers in 75 ambulatory practices operated by Munson Healthcare, a rural health system in northern Michigan, sheds light on the technology’s enormous potential in providing safe access to rural populations.6,7
Privacy and safety of patient data is of paramount importance. According to a national poll on healthy aging by the University of Michigan in May 2019, targeting older adults, 47% of survey responders expressed difficulty using technology and 49% of survey responders were concerned about privacy.8 Use of certification and other tools offered by the Office of the National Coordinator for Health Information Technology would help reassure users, and the ability to capture and share images between providers would be of immense benefit in facilitating e-consults.
The need of the hour is redesigned work flow, to help providers adopt and use virtual care/telehealth efficiently. Work flow redesign must be coupled with technological advances to allow seamless integration of third-party telehealth platforms into existing EMR systems or built directly into EMRs. Use of quality metrics and analytical tools specific to telehealth would help measure the technology’s impact on patient care, outcomes, and end-user/provider experience.
3. Teams and training
Outcomes of health care interventions are often determined by the effectiveness of teams. Irrespective of how robust health care systems may have been initially, rapidly spreading infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and patients to a breaking point.5 Decentralized, uncoordinated, and siloed efforts by individual teams across the care continuum were contributing factors for the partial success of telehealth care delivery pathways. The hospital systems with telehealth-ready teams at the start of the COVID-19 pandemic were so rare that the knowledge and technical training opportunities for innovators grew severalfold during the pandemic.
As per the American Medical Association, telehealth success is massively dependent on building the right team. Core, leadership, advisory, and implementation teams comprised of clinical representatives, end users, administrative personnel, executive members of the organization, technical experts, and payment/policy experts should be put together before implementing a telehealth strategy.9 Seamless integration of hospital-based care with ambulatory care via a telehealth platform is only complete when care managers are trained and deployed to fulfill the needs of a diverse group of patients. Deriving overall value from telehealth is only possible when there is a skill development, training and mentoring team put in place.
4. Thinking
In most U.S. hospitals, inpatient health care is equally distributed between nonprocedure and procedure-based services. Hospitals resorted to suspension of nonemergent procedures to mitigate the risk of spreading COVID-19. This was further compounded by many patients’ self-selection to defer care, an abrupt reduction in the influx of patients from the referral base because of suboptimally operating ambulatory care services, leading to low hospital occupancy.
Hospitals across the nation have gone through a massive short-term financial crunch and unfavorable cash-flow forecast, which prompted a paradoxical work-force reduction. While some argue that it may be akin to strategic myopia, the authors believed that such a response is strategically imperative to keep the hospital afloat. It is reasonable to attribute the paucity of innovation to constrained resources, and health systems are simply staying overly optimistic about “weathering the storm” and reverting soon to “business as usual.” The technological framework necessary for deploying a telehealth solution often comes with a price. Financially challenged hospital systems rarely exercise any capital-intensive activities. By contrast, telehealth adoption by ambulatory care can result in quicker resumption of patient care in community settings. A lack of operational and infrastructure synchrony between ambulatory and in-hospital systems has failed to capture telehealth-driven inpatient volume. For example, direct admissions from ambulatory telehealth referrals was a missed opportunity in several places. Referrals for labs, diagnostic tests, and other allied services could have helped hospitals offset their fixed costs. Similarly, work flows related to discharge and postdischarge follow up rarely embrace telehealth tools or telehealth care pathways. A brisk change in the health care ecosystem is partly responsible for this.
Digital strategy needs to be incorporated into business strategy. For the reasons already discussed, telehealth technology is not a “nice to have” anymore, but a “must have.” At present, providers are of the opinion that about 20% of their patient services can be delivered via a telehealth platform. Similar trends are observed among patients, as a new modality of access to care is increasingly beneficial to them. Telehealth must be incorporated in standardized hospital work flows. Use of telehealth for preoperative clearance will greatly minimize same-day surgery cancellations. Given the potential shortage in resources, telehealth adoption for inpatient consultations will help systems conserve personal protective equipment, minimize the risk of staff exposure to COVID-19, and improve efficiency.
Digital strategy also prompts the reengineering of care delivery.10 Excessive and unused physical capacity can be converted into digital care hubs. Health maintenance, prevention, health promotion, health education, and chronic disease management not only can serve a variety of patient groups but can also help address the “last-mile problem” in health care. A successful digital strategy usually has three important components – Commitment: Hospital leadership is committed to include digital transformation as a strategic objective; Cost: Digital strategy is added as a line item in the budget; and Control: Measurable metrics are put in place to monitor the performance, impact, and influence of the digital strategy.
Conclusion
For decades, most U.S. health systems occupied the periphery of technological transformation when compared to the rest of the service industry. While most health systems took a heroic approach to the adoption of telehealth during COVID-19, despite being unprepared, the need for a systematic telehealth deployment is far from being adequately fulfilled. The COVID-19 pandemic brought permanent changes to several business disciplines globally. Given the impact of the pandemic on the health and overall wellbeing of American society, the U.S. health care industry must leave no stone unturned in its quest for transformation.
Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark, and is cofounder/president of SHM’s Arkansas chapter. Dr. Prasad is medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He is cochair of SHM’s IT Special Interest Group, sits on the HQPS committee, and is president of SHM’s Wisconsin chapter. Dr. Palabindala is the medical director, utilization management, and physician advisory services at the University of Mississippi Medical Center and an associate professor of medicine and academic hospitalist at the University of Mississippi, both in Jackson.
References
1. Finnegan M. “Telehealth booms amid COVID-19 crisis.” Computerworld. 2020 Apr 27. www.computerworld.com/article/3540315/telehealth-booms-amid-covid-19-crisis-virtual-care-is-here-to-stay.html. Accessed 2020 Sep 12.
2. Department of Health & Human Services. “OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.” 2020 Mar 17. www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html. Accessed 2020 Sep 12.
3. National Center for Health Statistics. “Health Expenditures.” www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed 2020 Sep 12.
4. Bestsennyy O et al. “Telehealth: A post–COVID-19 reality?” McKinsey & Company. 2020 May 29. www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality. Accessed 2020 Sep 12.
5. Melnick ER et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among U.S. Physicians. Mayo Clin Proc. 2020 March;95(3):476-87.
6. Hirko KA et al. Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. J Am Med Inform Assoc. 2020 Nov;27(11):1816-8. .
7. American Academy of Family Physicians. “Study Examines Telehealth, Rural Disparities in Pandemic.” 2020 July 30. www.aafp.org/news/practice-professional-issues/20200730ruraltelehealth.html. Accessed 2020 Dec 15.
8. Kurlander J et al. “Virtual Visits: Telehealth and Older Adults.” National Poll on Healthy Aging. 2019 Oct. hdl.handle.net/2027.42/151376.
9. American Medical Association. Telehealth Implementation Playbook. 2019. www.ama-assn.org/system/files/2020-04/ama-telehealth-implementation-playbook.pdf.
10. Smith AC et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020 Jun;26(5):309-13.
The COVID-19 pandemic catalyzed the transformation of Internet-based, remotely accessible innovative technologies. Internet-based customer service delivery technology was rapidly adopted and utilized by several services industries, but health care systems in most of the countries across the world faced unique challenges in adopting the technology for the delivery of health care services. The health care ecosystem of the United States was not immune to such challenges, and several significant barriers surfaced while the pandemic was underway.
Complexly structured, fragmented, unprepared, and overly burnt-out health systems in the United States arguably have fallen short of maximizing the value of telehealth in delivering safe, easily accessible, comprehensive, and cost-effective health care services. In this essay, we examine the reasons for such a suboptimal performance and discuss a few important strategies that may be useful in maximizing the value of telehealth value in several, appropriate health care services.
Hospitals and telehealth
Are hospitalists preparing ourselves “not to see” patients in a hospital-based health care delivery setting? If you have not yet started yet, now may be the right time! Yes, a certain percentage of doctor-patient encounters in hospital settings will remain virtual forever.
A well-established telehealth infrastructure is rarely found in most U.S. hospitals, although the COVID-19 pandemic has unexpectedly boosted the rapid growth of telehealth in the country.1 Public health emergency declarations in the United States in the face of the COVID-19 crisis have facilitated two important initiatives to restore health care delivery amidst formal and informal lockdowns that brought states to a grinding halt. These extend from expansion of virtual services, including telehealth, virtual check-ins, and e-visits, to the decision by the Department of Health & Human Services Office of Civil Rights to exercise enforcement discretion and waive penalties for the use of relatively inexpensive, non–public-facing mobile and other audiovisual technology tools.2
Hospital-based care in the United States taps nearly 33% of national health expenditure. An additional 30% of national health expenditure that is related to physicians, prescriptions, and other facilities is indirectly influenced by care delivered at health care facilities.3 Studies show that about 20% of ED visits could potentially be avoided via virtual urgent care offerings.4 A rapidly changing health care ecosystem is proving formidable for most hospital systems, and a test for their resilience and agility. Not just the implementation of telehealth is challenging, but getting it right is the key success factor.
Hospital-based telehealth
Expansion of telehealth coverage by the Centers for Medicare & Medicaid Services and most commercial payers did not quite ride the pandemic-induced momentum across the care continuum. Hospitals are lagging far behind ambulatory care in implementing telehealth. As illustrated in the “4-T Matrix” (see graphic) we would like to examine four key reasons for such a sluggish initial uptake and try to propose four important strategies that may help us to maximize the value created by telehealth technologies.
1. Timing
The health care system has always lagged far behind other service industries in terms of technology adaptation. Because of the unique nature of health care services, face-to-face interaction supersedes all other forms of communication. A rapidly evolving pandemic was not matched by simultaneous technology education for patients and providers. The enormous choice of hard-to-navigate telehealth tools; time and labor-intensive implementation; and uncertainty around payer, policy, and regulatory expectations might have precluded providers from the rapid adoption of telehealth in the hospital setting. Patients’ specific characteristics, such as the absence of technology-centered education, information, age, comorbidities, lack of technical literacy, and dependency on caregivers contributed to the suboptimal response from patients and families.
Deploying simple, ubiquitous, user-friendly, and technologically less challenging telehealth solutions may be a better approach to increase the adoption of such solutions by providers and patients. Hospitals need to develop and distribute telehealth user guides in all possible modes of communication. Provider-centric in-service sessions, workshops, and live support by “superuser teams” often work well in reducing end-user resistance.
2. Technical
Current electronic medical records vary widely in their features and offerings, and their ability to interact with third-party software and platforms. Dissatisfaction of end users with EMRs is well known, as is their likely relationship to burnout. Recent research continues to show a strong relationship between EMR usability and the odds of burnout among physicians.5 In the current climate, administrators and health informaticists have the responsibility to avoid adding increased burdens to end users.
Another issue is the limited connectivity in many remote/rural areas that would impact implementation of telehealth platforms. Studies indicate that 33% of rural Americans lack access to high-speed broadband Internet to support video visits.6 The recent successful implementation of telehealth across 530 providers in 75 ambulatory practices operated by Munson Healthcare, a rural health system in northern Michigan, sheds light on the technology’s enormous potential in providing safe access to rural populations.6,7
Privacy and safety of patient data is of paramount importance. According to a national poll on healthy aging by the University of Michigan in May 2019, targeting older adults, 47% of survey responders expressed difficulty using technology and 49% of survey responders were concerned about privacy.8 Use of certification and other tools offered by the Office of the National Coordinator for Health Information Technology would help reassure users, and the ability to capture and share images between providers would be of immense benefit in facilitating e-consults.
The need of the hour is redesigned work flow, to help providers adopt and use virtual care/telehealth efficiently. Work flow redesign must be coupled with technological advances to allow seamless integration of third-party telehealth platforms into existing EMR systems or built directly into EMRs. Use of quality metrics and analytical tools specific to telehealth would help measure the technology’s impact on patient care, outcomes, and end-user/provider experience.
3. Teams and training
Outcomes of health care interventions are often determined by the effectiveness of teams. Irrespective of how robust health care systems may have been initially, rapidly spreading infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and patients to a breaking point.5 Decentralized, uncoordinated, and siloed efforts by individual teams across the care continuum were contributing factors for the partial success of telehealth care delivery pathways. The hospital systems with telehealth-ready teams at the start of the COVID-19 pandemic were so rare that the knowledge and technical training opportunities for innovators grew severalfold during the pandemic.
As per the American Medical Association, telehealth success is massively dependent on building the right team. Core, leadership, advisory, and implementation teams comprised of clinical representatives, end users, administrative personnel, executive members of the organization, technical experts, and payment/policy experts should be put together before implementing a telehealth strategy.9 Seamless integration of hospital-based care with ambulatory care via a telehealth platform is only complete when care managers are trained and deployed to fulfill the needs of a diverse group of patients. Deriving overall value from telehealth is only possible when there is a skill development, training and mentoring team put in place.
4. Thinking
In most U.S. hospitals, inpatient health care is equally distributed between nonprocedure and procedure-based services. Hospitals resorted to suspension of nonemergent procedures to mitigate the risk of spreading COVID-19. This was further compounded by many patients’ self-selection to defer care, an abrupt reduction in the influx of patients from the referral base because of suboptimally operating ambulatory care services, leading to low hospital occupancy.
Hospitals across the nation have gone through a massive short-term financial crunch and unfavorable cash-flow forecast, which prompted a paradoxical work-force reduction. While some argue that it may be akin to strategic myopia, the authors believed that such a response is strategically imperative to keep the hospital afloat. It is reasonable to attribute the paucity of innovation to constrained resources, and health systems are simply staying overly optimistic about “weathering the storm” and reverting soon to “business as usual.” The technological framework necessary for deploying a telehealth solution often comes with a price. Financially challenged hospital systems rarely exercise any capital-intensive activities. By contrast, telehealth adoption by ambulatory care can result in quicker resumption of patient care in community settings. A lack of operational and infrastructure synchrony between ambulatory and in-hospital systems has failed to capture telehealth-driven inpatient volume. For example, direct admissions from ambulatory telehealth referrals was a missed opportunity in several places. Referrals for labs, diagnostic tests, and other allied services could have helped hospitals offset their fixed costs. Similarly, work flows related to discharge and postdischarge follow up rarely embrace telehealth tools or telehealth care pathways. A brisk change in the health care ecosystem is partly responsible for this.
Digital strategy needs to be incorporated into business strategy. For the reasons already discussed, telehealth technology is not a “nice to have” anymore, but a “must have.” At present, providers are of the opinion that about 20% of their patient services can be delivered via a telehealth platform. Similar trends are observed among patients, as a new modality of access to care is increasingly beneficial to them. Telehealth must be incorporated in standardized hospital work flows. Use of telehealth for preoperative clearance will greatly minimize same-day surgery cancellations. Given the potential shortage in resources, telehealth adoption for inpatient consultations will help systems conserve personal protective equipment, minimize the risk of staff exposure to COVID-19, and improve efficiency.
Digital strategy also prompts the reengineering of care delivery.10 Excessive and unused physical capacity can be converted into digital care hubs. Health maintenance, prevention, health promotion, health education, and chronic disease management not only can serve a variety of patient groups but can also help address the “last-mile problem” in health care. A successful digital strategy usually has three important components – Commitment: Hospital leadership is committed to include digital transformation as a strategic objective; Cost: Digital strategy is added as a line item in the budget; and Control: Measurable metrics are put in place to monitor the performance, impact, and influence of the digital strategy.
Conclusion
For decades, most U.S. health systems occupied the periphery of technological transformation when compared to the rest of the service industry. While most health systems took a heroic approach to the adoption of telehealth during COVID-19, despite being unprepared, the need for a systematic telehealth deployment is far from being adequately fulfilled. The COVID-19 pandemic brought permanent changes to several business disciplines globally. Given the impact of the pandemic on the health and overall wellbeing of American society, the U.S. health care industry must leave no stone unturned in its quest for transformation.
Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark, and is cofounder/president of SHM’s Arkansas chapter. Dr. Prasad is medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He is cochair of SHM’s IT Special Interest Group, sits on the HQPS committee, and is president of SHM’s Wisconsin chapter. Dr. Palabindala is the medical director, utilization management, and physician advisory services at the University of Mississippi Medical Center and an associate professor of medicine and academic hospitalist at the University of Mississippi, both in Jackson.
References
1. Finnegan M. “Telehealth booms amid COVID-19 crisis.” Computerworld. 2020 Apr 27. www.computerworld.com/article/3540315/telehealth-booms-amid-covid-19-crisis-virtual-care-is-here-to-stay.html. Accessed 2020 Sep 12.
2. Department of Health & Human Services. “OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.” 2020 Mar 17. www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html. Accessed 2020 Sep 12.
3. National Center for Health Statistics. “Health Expenditures.” www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed 2020 Sep 12.
4. Bestsennyy O et al. “Telehealth: A post–COVID-19 reality?” McKinsey & Company. 2020 May 29. www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality. Accessed 2020 Sep 12.
5. Melnick ER et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among U.S. Physicians. Mayo Clin Proc. 2020 March;95(3):476-87.
6. Hirko KA et al. Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. J Am Med Inform Assoc. 2020 Nov;27(11):1816-8. .
7. American Academy of Family Physicians. “Study Examines Telehealth, Rural Disparities in Pandemic.” 2020 July 30. www.aafp.org/news/practice-professional-issues/20200730ruraltelehealth.html. Accessed 2020 Dec 15.
8. Kurlander J et al. “Virtual Visits: Telehealth and Older Adults.” National Poll on Healthy Aging. 2019 Oct. hdl.handle.net/2027.42/151376.
9. American Medical Association. Telehealth Implementation Playbook. 2019. www.ama-assn.org/system/files/2020-04/ama-telehealth-implementation-playbook.pdf.
10. Smith AC et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020 Jun;26(5):309-13.