SAN ANTONIO – Prescription opioid abuse has continued declining since 2011, but opioids remain far more commonly abused than other prescription drugs, including gabapentin and pregabalin, new research shows.

“Both gabapentin and pregabalin are abused but at rates that are 6-56 times less frequent than for opioid analgesics,” wrote Kofi Asomaning, DSci, of Pfizer, and associates at Pfizer and Denver Health’s Rocky Mountain Poison and Drug Center.

“Gabapentin is generally more frequently abused than pregabalin,” they reported in a research poster at the annual meeting of the College on Problems of Drug Dependence.

The researchers analyzed data from the RADARS System Survey of Non-Medical Use of Prescription Drugs Program (NMURx), the RADARS System Treatment Center Programs Combined, and the American Association of Poison Control Centers National Poison Data System (NPDS).

All those use self-reported data. The first is a confidential, anonymous web-based survey used to estimate population-level prevalence, and the second surveys patients with opioid use disorder entering treatment. The NPDS tracks all cases reported to poison control centers nationally.


Analysis of the NMURx data revealed similar lifetime abuse prevalence rates for gabapentin and pregabalin at 0.4%, several magnitudes lower than the 5.3% rate identified with opioids.

Gabapentin, however, had higher rates of abuse in the past month in the Treatment Center Programs Combined. For the third to fourth quarter of 2017, 0.12 per 100,000 population reportedly abused gabapentin, compared with 0.01 per 100,000 for pregabalin. The rate for past-month abuse of opioids was 0.79 per 100,000.

A similar pattern for the same quarter emerged from the NPDS data: Rate of gabapentin abuse was 0.06 per 100,000, rate for pregabalin was 0.01 per 100,000, and rate for opioids was 0.40 per 100,000.

Both pregabalin and opioids were predominantly ingested, though a very small amount of each was inhaled and a similarly small amount of opioids was injected. Data on exposure route for gabapentin were not provided, though it was used more frequently than pregabalin.

The research was funded by Pfizer. The RADARS system is owned by Denver Health and Hospital Authority under the Colorado state government. RADARS receives some funding from pharmaceutical industry subscriptions. Dr. Asomaning and Diane L. Martire, MD, MPH, are Pfizer employees who have financial interests with Pfizer.

SAN ANTONIO – Prescription opioid abuse has continued declining since 2011, but opioids remain far more commonly abused than other prescription drugs, including gabapentin and pregabalin, new research shows.

“Both gabapentin and pregabalin are abused but at rates that are 6-56 times less frequent than for opioid analgesics,” wrote Kofi Asomaning, DSci, of Pfizer, and associates at Pfizer and Denver Health’s Rocky Mountain Poison and Drug Center.

“Gabapentin is generally more frequently abused than pregabalin,” they reported in a research poster at the annual meeting of the College on Problems of Drug Dependence.

The researchers analyzed data from the RADARS System Survey of Non-Medical Use of Prescription Drugs Program (NMURx), the RADARS System Treatment Center Programs Combined, and the American Association of Poison Control Centers National Poison Data System (NPDS).

All those use self-reported data. The first is a confidential, anonymous web-based survey used to estimate population-level prevalence, and the second surveys patients with opioid use disorder entering treatment. The NPDS tracks all cases reported to poison control centers nationally.


Analysis of the NMURx data revealed similar lifetime abuse prevalence rates for gabapentin and pregabalin at 0.4%, several magnitudes lower than the 5.3% rate identified with opioids.

Gabapentin, however, had higher rates of abuse in the past month in the Treatment Center Programs Combined. For the third to fourth quarter of 2017, 0.12 per 100,000 population reportedly abused gabapentin, compared with 0.01 per 100,000 for pregabalin. The rate for past-month abuse of opioids was 0.79 per 100,000.

A similar pattern for the same quarter emerged from the NPDS data: Rate of gabapentin abuse was 0.06 per 100,000, rate for pregabalin was 0.01 per 100,000, and rate for opioids was 0.40 per 100,000.

Both pregabalin and opioids were predominantly ingested, though a very small amount of each was inhaled and a similarly small amount of opioids was injected. Data on exposure route for gabapentin were not provided, though it was used more frequently than pregabalin.

The research was funded by Pfizer. The RADARS system is owned by Denver Health and Hospital Authority under the Colorado state government. RADARS receives some funding from pharmaceutical industry subscriptions. Dr. Asomaning and Diane L. Martire, MD, MPH, are Pfizer employees who have financial interests with Pfizer.

SAN ANTONIO – Prescription opioid abuse has continued declining since 2011, but opioids remain far more commonly abused than other prescription drugs, including gabapentin and pregabalin, new research shows.

“Both gabapentin and pregabalin are abused but at rates that are 6-56 times less frequent than for opioid analgesics,” wrote Kofi Asomaning, DSci, of Pfizer, and associates at Pfizer and Denver Health’s Rocky Mountain Poison and Drug Center.

“Gabapentin is generally more frequently abused than pregabalin,” they reported in a research poster at the annual meeting of the College on Problems of Drug Dependence.

The researchers analyzed data from the RADARS System Survey of Non-Medical Use of Prescription Drugs Program (NMURx), the RADARS System Treatment Center Programs Combined, and the American Association of Poison Control Centers National Poison Data System (NPDS).

All those use self-reported data. The first is a confidential, anonymous web-based survey used to estimate population-level prevalence, and the second surveys patients with opioid use disorder entering treatment. The NPDS tracks all cases reported to poison control centers nationally.


Analysis of the NMURx data revealed similar lifetime abuse prevalence rates for gabapentin and pregabalin at 0.4%, several magnitudes lower than the 5.3% rate identified with opioids.

Gabapentin, however, had higher rates of abuse in the past month in the Treatment Center Programs Combined. For the third to fourth quarter of 2017, 0.12 per 100,000 population reportedly abused gabapentin, compared with 0.01 per 100,000 for pregabalin. The rate for past-month abuse of opioids was 0.79 per 100,000.

A similar pattern for the same quarter emerged from the NPDS data: Rate of gabapentin abuse was 0.06 per 100,000, rate for pregabalin was 0.01 per 100,000, and rate for opioids was 0.40 per 100,000.

Both pregabalin and opioids were predominantly ingested, though a very small amount of each was inhaled and a similarly small amount of opioids was injected. Data on exposure route for gabapentin were not provided, though it was used more frequently than pregabalin.

The research was funded by Pfizer. The RADARS system is owned by Denver Health and Hospital Authority under the Colorado state government. RADARS receives some funding from pharmaceutical industry subscriptions. Dr. Asomaning and Diane L. Martire, MD, MPH, are Pfizer employees who have financial interests with Pfizer.

Anticoagulant use to prevent ischemic strokes in patients with atrial fibrillation (AF) continues to be one of the most challenging decisions facing patients and their physicians, in large part due to significant patient-to-patient variation in both AF-related stroke risk and anticoagulant-associated hemorrhage risk. Now, add a layer of complexity—.how should one approach anticoagulant use following an adverse event such as an acute upper gastrointestinal (GI) hemorrhage? On the one side, the risk of ischemic stroke, and on the other, the risk of recurrent bleeding, either of which can lead to death or disability. Making this decision requires humility, clinical acumen, shared decision-making, and data.

Data on this subject are sparse.^1,2 Observational studies show that patients who restart anticoagulants after GI hemorrhage experience fewer ischemic strokes. These studies also show that patients who restart anticoagulant therapy are healthier than those who do not—in measurable ways and, importantly, in unmeasurable ways. Thus far, observational studies have not sufficiently dealt with confounding by indication; that is, patients who restart anticoagulants are fundamentally different than patients who do not.

In this issue of the Journal of Hospital Medicine^®, Pappas et al. focus on the optimal timing of resuming oral anticoagulation in patients who have sustained acute upper GI bleeds while receiving oral anticoagulation for AF.³ They use a microsimulation modeling approach to address this question, by creating a synthetic population of patients reflective of age, gender, and comorbidities in a United States population of patients with AF. Using data from epidemiologic studies that describe the risk of rebleeding, hemorrhagic complications, and ischemic stroke as well as the quality of life associated with each of these events, the authors have constructed a decision analytic model to determine the optimal day to restart anticoagulation. This modeling approach mitigates confounding by indication, a limitation of observational studies. They report that the optimal day to restart anticoagulant therapy is in the range of 32-51 days. As one would predict, when using direct-acting anticoagulants and for patients with high stroke risk, the investigators find that restarting therapy earlier is associated with greater benefit. These findings help to untangle a knot of risk and benefits facing patients with AF following an acute GI hemorrhage.

Interpreting the results relies on an understanding of the strengths and weaknesses of simulation modeling and the data used in the analysis. Like any research method, the devil is in the details. Stitching together event rates and outcomes from multiple studies, the results of a simulation model are only as good as the studies the model draws from. In particular, assumptions regarding the time-dependent decline in rebleeding risk are a critical component of determining the optimal time to resume anticoagulation. The authors had to make multiple assumptions to project the 24-hour risk of rebleeding determined from the Rockall score to estimate the risk of rebleeding over the next days to months.⁴ Consequently, the results are likely overly precise. Practically, 30-50 days or four to eight weeks may better reflect the precision of the study findings.

Results on optimal timing of resuming anticoagulation therapy are most applicable for patients when the decision to restart anticoagulants has already been made. We part ways with the authors in their conclusion that these results confirm that anticoagulants should be restarted. There are multiple appropriate reasons why anticoagulant therapy should not be restarted following an acute upper GI hemorrhage. For example, in observational studies, patients not restarted on anticoagulant therapy were more likely to have a history of falls and to have had severe bleeds.¹ Furthermore, patients who do not restart therapy are more likely to die in follow-up. It is tempting to use this fact to support restarting anticoagulants. However, when the causes of death are examined, the vast majority of deaths were unrelated to thrombosis or hemorrhage.² Patients with AF are older and have multiple comorbidities and life-limiting conditions. Accordingly, the results of this study are better used to engage patients in shared decision-making and contextualized in the broader picture of patients’ health and goals.⁵

Restarting anticoagulants after a GI hemorrhage is a difficult and high-stakes clinical decision. The study by Pappas et al. uses a simulation model to advance our understanding about the optimal timing to restart anticoagulants. By integrating the dynamic risk of ischemic stroke and recurrent hemorrhage following GI hemorrhage, they estimate the maximal benefit when anticoagulants are restarted between 30 days and 50 days after hemorrhage. The results of their analysis are best used to inform timing among patients where the decision to restart anticoagulants has already been made. The analysis also provides a useful starting point for shared decision-making by highlighting that the optimal net benefit is influenced by patient-to-patient variation in the underlying AF-related stroke risk and anticoagulant-associated rebleeding risk.

Disclosures: Dr. Shah has nothing to disclose. Dr. Eckman reports grants from Heart Rhythm Society/Boehringer-Ingelheim and grants from Bristol-Myers Squibb/Pfizer Education Consortium, outside the submitted work.

Anticoagulant use to prevent ischemic strokes in patients with atrial fibrillation (AF) continues to be one of the most challenging decisions facing patients and their physicians, in large part due to significant patient-to-patient variation in both AF-related stroke risk and anticoagulant-associated hemorrhage risk. Now, add a layer of complexity—.how should one approach anticoagulant use following an adverse event such as an acute upper gastrointestinal (GI) hemorrhage? On the one side, the risk of ischemic stroke, and on the other, the risk of recurrent bleeding, either of which can lead to death or disability. Making this decision requires humility, clinical acumen, shared decision-making, and data.

Data on this subject are sparse.^1,2 Observational studies show that patients who restart anticoagulants after GI hemorrhage experience fewer ischemic strokes. These studies also show that patients who restart anticoagulant therapy are healthier than those who do not—in measurable ways and, importantly, in unmeasurable ways. Thus far, observational studies have not sufficiently dealt with confounding by indication; that is, patients who restart anticoagulants are fundamentally different than patients who do not.

In this issue of the Journal of Hospital Medicine^®, Pappas et al. focus on the optimal timing of resuming oral anticoagulation in patients who have sustained acute upper GI bleeds while receiving oral anticoagulation for AF.³ They use a microsimulation modeling approach to address this question, by creating a synthetic population of patients reflective of age, gender, and comorbidities in a United States population of patients with AF. Using data from epidemiologic studies that describe the risk of rebleeding, hemorrhagic complications, and ischemic stroke as well as the quality of life associated with each of these events, the authors have constructed a decision analytic model to determine the optimal day to restart anticoagulation. This modeling approach mitigates confounding by indication, a limitation of observational studies. They report that the optimal day to restart anticoagulant therapy is in the range of 32-51 days. As one would predict, when using direct-acting anticoagulants and for patients with high stroke risk, the investigators find that restarting therapy earlier is associated with greater benefit. These findings help to untangle a knot of risk and benefits facing patients with AF following an acute GI hemorrhage.

Interpreting the results relies on an understanding of the strengths and weaknesses of simulation modeling and the data used in the analysis. Like any research method, the devil is in the details. Stitching together event rates and outcomes from multiple studies, the results of a simulation model are only as good as the studies the model draws from. In particular, assumptions regarding the time-dependent decline in rebleeding risk are a critical component of determining the optimal time to resume anticoagulation. The authors had to make multiple assumptions to project the 24-hour risk of rebleeding determined from the Rockall score to estimate the risk of rebleeding over the next days to months.⁴ Consequently, the results are likely overly precise. Practically, 30-50 days or four to eight weeks may better reflect the precision of the study findings.

Results on optimal timing of resuming anticoagulation therapy are most applicable for patients when the decision to restart anticoagulants has already been made. We part ways with the authors in their conclusion that these results confirm that anticoagulants should be restarted. There are multiple appropriate reasons why anticoagulant therapy should not be restarted following an acute upper GI hemorrhage. For example, in observational studies, patients not restarted on anticoagulant therapy were more likely to have a history of falls and to have had severe bleeds.¹ Furthermore, patients who do not restart therapy are more likely to die in follow-up. It is tempting to use this fact to support restarting anticoagulants. However, when the causes of death are examined, the vast majority of deaths were unrelated to thrombosis or hemorrhage.² Patients with AF are older and have multiple comorbidities and life-limiting conditions. Accordingly, the results of this study are better used to engage patients in shared decision-making and contextualized in the broader picture of patients’ health and goals.⁵

Restarting anticoagulants after a GI hemorrhage is a difficult and high-stakes clinical decision. The study by Pappas et al. uses a simulation model to advance our understanding about the optimal timing to restart anticoagulants. By integrating the dynamic risk of ischemic stroke and recurrent hemorrhage following GI hemorrhage, they estimate the maximal benefit when anticoagulants are restarted between 30 days and 50 days after hemorrhage. The results of their analysis are best used to inform timing among patients where the decision to restart anticoagulants has already been made. The analysis also provides a useful starting point for shared decision-making by highlighting that the optimal net benefit is influenced by patient-to-patient variation in the underlying AF-related stroke risk and anticoagulant-associated rebleeding risk.

Disclosures: Dr. Shah has nothing to disclose. Dr. Eckman reports grants from Heart Rhythm Society/Boehringer-Ingelheim and grants from Bristol-Myers Squibb/Pfizer Education Consortium, outside the submitted work.

Anticoagulant use to prevent ischemic strokes in patients with atrial fibrillation (AF) continues to be one of the most challenging decisions facing patients and their physicians, in large part due to significant patient-to-patient variation in both AF-related stroke risk and anticoagulant-associated hemorrhage risk. Now, add a layer of complexity—.how should one approach anticoagulant use following an adverse event such as an acute upper gastrointestinal (GI) hemorrhage? On the one side, the risk of ischemic stroke, and on the other, the risk of recurrent bleeding, either of which can lead to death or disability. Making this decision requires humility, clinical acumen, shared decision-making, and data.

Data on this subject are sparse.^1,2 Observational studies show that patients who restart anticoagulants after GI hemorrhage experience fewer ischemic strokes. These studies also show that patients who restart anticoagulant therapy are healthier than those who do not—in measurable ways and, importantly, in unmeasurable ways. Thus far, observational studies have not sufficiently dealt with confounding by indication; that is, patients who restart anticoagulants are fundamentally different than patients who do not.

In this issue of the Journal of Hospital Medicine^®, Pappas et al. focus on the optimal timing of resuming oral anticoagulation in patients who have sustained acute upper GI bleeds while receiving oral anticoagulation for AF.³ They use a microsimulation modeling approach to address this question, by creating a synthetic population of patients reflective of age, gender, and comorbidities in a United States population of patients with AF. Using data from epidemiologic studies that describe the risk of rebleeding, hemorrhagic complications, and ischemic stroke as well as the quality of life associated with each of these events, the authors have constructed a decision analytic model to determine the optimal day to restart anticoagulation. This modeling approach mitigates confounding by indication, a limitation of observational studies. They report that the optimal day to restart anticoagulant therapy is in the range of 32-51 days. As one would predict, when using direct-acting anticoagulants and for patients with high stroke risk, the investigators find that restarting therapy earlier is associated with greater benefit. These findings help to untangle a knot of risk and benefits facing patients with AF following an acute GI hemorrhage.

Interpreting the results relies on an understanding of the strengths and weaknesses of simulation modeling and the data used in the analysis. Like any research method, the devil is in the details. Stitching together event rates and outcomes from multiple studies, the results of a simulation model are only as good as the studies the model draws from. In particular, assumptions regarding the time-dependent decline in rebleeding risk are a critical component of determining the optimal time to resume anticoagulation. The authors had to make multiple assumptions to project the 24-hour risk of rebleeding determined from the Rockall score to estimate the risk of rebleeding over the next days to months.⁴ Consequently, the results are likely overly precise. Practically, 30-50 days or four to eight weeks may better reflect the precision of the study findings.

Results on optimal timing of resuming anticoagulation therapy are most applicable for patients when the decision to restart anticoagulants has already been made. We part ways with the authors in their conclusion that these results confirm that anticoagulants should be restarted. There are multiple appropriate reasons why anticoagulant therapy should not be restarted following an acute upper GI hemorrhage. For example, in observational studies, patients not restarted on anticoagulant therapy were more likely to have a history of falls and to have had severe bleeds.¹ Furthermore, patients who do not restart therapy are more likely to die in follow-up. It is tempting to use this fact to support restarting anticoagulants. However, when the causes of death are examined, the vast majority of deaths were unrelated to thrombosis or hemorrhage.² Patients with AF are older and have multiple comorbidities and life-limiting conditions. Accordingly, the results of this study are better used to engage patients in shared decision-making and contextualized in the broader picture of patients’ health and goals.⁵

Restarting anticoagulants after a GI hemorrhage is a difficult and high-stakes clinical decision. The study by Pappas et al. uses a simulation model to advance our understanding about the optimal timing to restart anticoagulants. By integrating the dynamic risk of ischemic stroke and recurrent hemorrhage following GI hemorrhage, they estimate the maximal benefit when anticoagulants are restarted between 30 days and 50 days after hemorrhage. The results of their analysis are best used to inform timing among patients where the decision to restart anticoagulants has already been made. The analysis also provides a useful starting point for shared decision-making by highlighting that the optimal net benefit is influenced by patient-to-patient variation in the underlying AF-related stroke risk and anticoagulant-associated rebleeding risk.

Disclosures: Dr. Shah has nothing to disclose. Dr. Eckman reports grants from Heart Rhythm Society/Boehringer-Ingelheim and grants from Bristol-Myers Squibb/Pfizer Education Consortium, outside the submitted work.

MADRID – The first consensus recommendations for the identification and management of interstitial lung disease (ILD) in patients with systemic sclerosis (SSc) place particular emphasis on routine screening in all systemic sclerosis patients for early detection, monitoring, and, when warranted, treatment, Anna-Maria Hoffmann-Vold, MD, PhD, reported at the European Congress of Rheumatology.

“Everyone with systemic sclerosis needs to be screened because this is the most important risk factor for ILD,” said Dr. Hoffmann-Vold, a clinical scientist in the division of rheumatology at the University of Oslo and head of scleroderma research at Oslo University Hospital.

Although the frequency of screening is not specified based on the opinion that this should be based on risk factors and other clinical characteristics, there was unanimous agreement that lung function tests do not represent an adequate screening tool or method for assessing ILD severity. Rather, the recommendations make clear that lung function studies are adjunctive to high-resolution computed tomography (HRCT).

“HRCT is the primary tool for evaluating ILD, but there was 100% agreement that assessment should include more than one measure, including lung function tests and clinical assessment,” Dr. Hoffmann-Vold reported.

There was a strong opinion that the numerous potential biomarkers described for ILD, although promising, are not yet ready for clinical use.

In developing these new recommendations, 95 potential statements were considered by the panel of 27 rheumatologists, pulmonologists, and others with experience in this field. A Delphi process was used for members of the panel to identify areas of agreement to produce consensus statements.

The result has been more than 50 statements issued in six major domains. These include statements on risk factors, appropriate methodology for diagnosis and severity assessment, when to initiate therapy, and when and how to initiate treatment escalation.

“We want to increase clinician awareness and provide standardized guidance for evaluating patients for the presence and medical management of ILD-SSc,” Dr. Hoffmann-Vold explained.

ILD occurs in about half of all patients with systemic sclerosis. Among these, approximately one out of three will experience lung disease progression. Although these high prevalence rates are well recognized and associated with high morbidity and mortality, Dr. Hoffmann-Vold said that there has been uncertainty about how to screen systemic sclerosis patients for ILD and what steps to take when it was found. It is this uncertainty that prompted the present initiative.

The consensus recommendations are an initial step to guide clinicians, but Dr. Hoffmann-Vold noted that the many statements are based on expert opinion, suggesting more studies are needed to compare strategies for objective severity grading and prediction of which patients are most at risk for ILD progression.

“There are still huge knowledge gaps we need to fill,” she stated. Still, she believes these recommendations represent progress in this field. While they are likely “to increase the standard of care” for those who develop ILD-SSc, they also have identified where to concentrate further research.

Dr. Hoffmann-Vold reported financial relationships with Actelion, Boehringer Ingelheim, and GlaxoSmithKline.

SOURCE: Hoffmann-Vold A-M et al. Ann Rheum Dis. Jun 2019;78(Suppl 2):104, Abstract OPO064, doi: 10.1136/annrheumdis-2019-eular.3225.

MADRID – The first consensus recommendations for the identification and management of interstitial lung disease (ILD) in patients with systemic sclerosis (SSc) place particular emphasis on routine screening in all systemic sclerosis patients for early detection, monitoring, and, when warranted, treatment, Anna-Maria Hoffmann-Vold, MD, PhD, reported at the European Congress of Rheumatology.

“Everyone with systemic sclerosis needs to be screened because this is the most important risk factor for ILD,” said Dr. Hoffmann-Vold, a clinical scientist in the division of rheumatology at the University of Oslo and head of scleroderma research at Oslo University Hospital.

Although the frequency of screening is not specified based on the opinion that this should be based on risk factors and other clinical characteristics, there was unanimous agreement that lung function tests do not represent an adequate screening tool or method for assessing ILD severity. Rather, the recommendations make clear that lung function studies are adjunctive to high-resolution computed tomography (HRCT).

“HRCT is the primary tool for evaluating ILD, but there was 100% agreement that assessment should include more than one measure, including lung function tests and clinical assessment,” Dr. Hoffmann-Vold reported.

There was a strong opinion that the numerous potential biomarkers described for ILD, although promising, are not yet ready for clinical use.

In developing these new recommendations, 95 potential statements were considered by the panel of 27 rheumatologists, pulmonologists, and others with experience in this field. A Delphi process was used for members of the panel to identify areas of agreement to produce consensus statements.

The result has been more than 50 statements issued in six major domains. These include statements on risk factors, appropriate methodology for diagnosis and severity assessment, when to initiate therapy, and when and how to initiate treatment escalation.

“We want to increase clinician awareness and provide standardized guidance for evaluating patients for the presence and medical management of ILD-SSc,” Dr. Hoffmann-Vold explained.

ILD occurs in about half of all patients with systemic sclerosis. Among these, approximately one out of three will experience lung disease progression. Although these high prevalence rates are well recognized and associated with high morbidity and mortality, Dr. Hoffmann-Vold said that there has been uncertainty about how to screen systemic sclerosis patients for ILD and what steps to take when it was found. It is this uncertainty that prompted the present initiative.

The consensus recommendations are an initial step to guide clinicians, but Dr. Hoffmann-Vold noted that the many statements are based on expert opinion, suggesting more studies are needed to compare strategies for objective severity grading and prediction of which patients are most at risk for ILD progression.

“There are still huge knowledge gaps we need to fill,” she stated. Still, she believes these recommendations represent progress in this field. While they are likely “to increase the standard of care” for those who develop ILD-SSc, they also have identified where to concentrate further research.

Dr. Hoffmann-Vold reported financial relationships with Actelion, Boehringer Ingelheim, and GlaxoSmithKline.

SOURCE: Hoffmann-Vold A-M et al. Ann Rheum Dis. Jun 2019;78(Suppl 2):104, Abstract OPO064, doi: 10.1136/annrheumdis-2019-eular.3225.

MADRID – The first consensus recommendations for the identification and management of interstitial lung disease (ILD) in patients with systemic sclerosis (SSc) place particular emphasis on routine screening in all systemic sclerosis patients for early detection, monitoring, and, when warranted, treatment, Anna-Maria Hoffmann-Vold, MD, PhD, reported at the European Congress of Rheumatology.

“Everyone with systemic sclerosis needs to be screened because this is the most important risk factor for ILD,” said Dr. Hoffmann-Vold, a clinical scientist in the division of rheumatology at the University of Oslo and head of scleroderma research at Oslo University Hospital.

Although the frequency of screening is not specified based on the opinion that this should be based on risk factors and other clinical characteristics, there was unanimous agreement that lung function tests do not represent an adequate screening tool or method for assessing ILD severity. Rather, the recommendations make clear that lung function studies are adjunctive to high-resolution computed tomography (HRCT).

“HRCT is the primary tool for evaluating ILD, but there was 100% agreement that assessment should include more than one measure, including lung function tests and clinical assessment,” Dr. Hoffmann-Vold reported.

There was a strong opinion that the numerous potential biomarkers described for ILD, although promising, are not yet ready for clinical use.

In developing these new recommendations, 95 potential statements were considered by the panel of 27 rheumatologists, pulmonologists, and others with experience in this field. A Delphi process was used for members of the panel to identify areas of agreement to produce consensus statements.

The result has been more than 50 statements issued in six major domains. These include statements on risk factors, appropriate methodology for diagnosis and severity assessment, when to initiate therapy, and when and how to initiate treatment escalation.

“We want to increase clinician awareness and provide standardized guidance for evaluating patients for the presence and medical management of ILD-SSc,” Dr. Hoffmann-Vold explained.

ILD occurs in about half of all patients with systemic sclerosis. Among these, approximately one out of three will experience lung disease progression. Although these high prevalence rates are well recognized and associated with high morbidity and mortality, Dr. Hoffmann-Vold said that there has been uncertainty about how to screen systemic sclerosis patients for ILD and what steps to take when it was found. It is this uncertainty that prompted the present initiative.

The consensus recommendations are an initial step to guide clinicians, but Dr. Hoffmann-Vold noted that the many statements are based on expert opinion, suggesting more studies are needed to compare strategies for objective severity grading and prediction of which patients are most at risk for ILD progression.

“There are still huge knowledge gaps we need to fill,” she stated. Still, she believes these recommendations represent progress in this field. While they are likely “to increase the standard of care” for those who develop ILD-SSc, they also have identified where to concentrate further research.

Dr. Hoffmann-Vold reported financial relationships with Actelion, Boehringer Ingelheim, and GlaxoSmithKline.

SOURCE: Hoffmann-Vold A-M et al. Ann Rheum Dis. Jun 2019;78(Suppl 2):104, Abstract OPO064, doi: 10.1136/annrheumdis-2019-eular.3225.

CHICAGO – Tumor protein 53 (TP53) mutation, fibroblast growth factor receptor 1 (FGFR1) amplification, and tumor purity in plasma each predict early progression on palbociclib and/or fulvestrant in patients with advanced estrogen receptor–positive (ER+) breast cancer, according to genomic analyses of PALOMA-3 trial data.

Sharon Worcester/MDedge News

Overall, the presence of one or more of these genomic changes identified 131 out of 310 patients from the phase 3 trial who had baseline samples available, Ben O’Leary, MBBS, said at the annual meeting of the American Society of Clinical Oncology.

“So, a significant minority of patients – 42.3% – potentially who fall into a more poor-prognosis group,” said Dr. O’Leary of the Institute of Cancer Research at the Royal Marsden Hospital in London.

The findings suggest that a “liquid biopsy” at the start of treatment could identify patients at risk for progression.

The PALOMA-3 trial randomized 521 patients with ER+, human epidermal growth factor receptor 2 (HER2)–negative advanced breast cancer who had previously progressed on endocrine therapy 2:1 to CDK4/CDK6 inhibition with palbociclib plus fulvestrant (P+F) or placebo plus fulvestrant (F), and it showed that adding palbociclib significantly improved progression-free survival (PFS) (N Engl J Med. Jul 16 2015;373:209-19).

For the current analysis, the investigators assessed circulating tumor DNA (ctDNA) in baseline plasma samples from 459 study participants in an effort to identify genomic biomarkers for progression, to examine the association between baseline tumor fraction and clinical outcome, and to explore differences in predictive markers by treatment arm. A custom amplicon-sequencing analysis was performed to look for mutations in 17 different relevant genes, and another was used to estimate tumor fraction by looking at about 800 common germline single-nucleotide polymorphisms and to assess copy-number gain in the amplification status in 11 different genes, Dr. O’Leary said.


Results for mutations and circulating nucleic acids were available in 203 and 107 patients from the P+F and F groups, respectively, and on multivariable analysis of all 310 patients (including palbociclib as a variable in the model and with ctDNA fraction as a continuous variable), higher baseline tumor purity in plasma was associated with highly significantly worse PFS (HR 1.2 per 10% increase in purity), and baseline TP53 mutation and FGFR1 amplification each were associated with significantly shorter PFS (HRs, 1.8 and 2.9, respectively).

“[It is] very important to note ... that we did look specifically for interaction between our genomic changes and treatment, and we didn’t find any evidence of a significant interaction, so these genomic markers [are] prognostic rather than predictive in terms of the two treatment arms of the trial,” he said.

A survival analysis showed a median PFS of 3.7 vs. 12.7 months in patients with vs. without TP53 mutation in the P+F arm, and 1.8 vs. 5.4 months, respectively, in the F arm, with similar HRs of 2.0 and 2.3 in the arms, respectively.

“Even in the [P+F] arm, you see almost half of the patients with a TP53 mutation ... have relapsed by 2 months, the earliest clinical assessment in the trial,” he noted.

For FGFR1, the PFS was 3.9 vs. 12 months with vs. without amplification in the P+F arms, and 1.8 vs. 5.8 months, respectively in th F arm, with HRs of 3.4 and 3.6, respectively.

These findings are notable because markers of early progression on endocrine therapy in combination with CDK4/6 inhibitors remain limited – despite the key role of these combinations in treating ER+ advanced breast cancer, Dr. O’Leary explained.

“Although many patients derive a great deal of benefit from these combinations, there are a subset of patients who will relapse relatively early, and ... we don’t have an established means of identifying those patients at the present,” he said. “From the technical perspective, liquid biopsies have emerged in recent years as a promising means of genotyping patients’ cancers from circulating tumor DNA, and in addition, the overall level of circulating tumor DNA – the fractional purity – has been associated with poor prognosis, specifically in the triple-negative breast cancer setting.”

The results, which require independent validation, could potentially inform future clinical trials of CDK4/6 inhibitor combinations in advanced ER+ breast cancer to identify a high-risk group of patients who require escalation of therapy, he concluded.

Dr. O’Leary reported receiving research funding from Pfizer to his institution.

SOURCE: O’Leary B et al. ASCO 2019, Abstract 1010.

CHICAGO – Tumor protein 53 (TP53) mutation, fibroblast growth factor receptor 1 (FGFR1) amplification, and tumor purity in plasma each predict early progression on palbociclib and/or fulvestrant in patients with advanced estrogen receptor–positive (ER+) breast cancer, according to genomic analyses of PALOMA-3 trial data.

Sharon Worcester/MDedge News

Overall, the presence of one or more of these genomic changes identified 131 out of 310 patients from the phase 3 trial who had baseline samples available, Ben O’Leary, MBBS, said at the annual meeting of the American Society of Clinical Oncology.

“So, a significant minority of patients – 42.3% – potentially who fall into a more poor-prognosis group,” said Dr. O’Leary of the Institute of Cancer Research at the Royal Marsden Hospital in London.

The findings suggest that a “liquid biopsy” at the start of treatment could identify patients at risk for progression.

The PALOMA-3 trial randomized 521 patients with ER+, human epidermal growth factor receptor 2 (HER2)–negative advanced breast cancer who had previously progressed on endocrine therapy 2:1 to CDK4/CDK6 inhibition with palbociclib plus fulvestrant (P+F) or placebo plus fulvestrant (F), and it showed that adding palbociclib significantly improved progression-free survival (PFS) (N Engl J Med. Jul 16 2015;373:209-19).

For the current analysis, the investigators assessed circulating tumor DNA (ctDNA) in baseline plasma samples from 459 study participants in an effort to identify genomic biomarkers for progression, to examine the association between baseline tumor fraction and clinical outcome, and to explore differences in predictive markers by treatment arm. A custom amplicon-sequencing analysis was performed to look for mutations in 17 different relevant genes, and another was used to estimate tumor fraction by looking at about 800 common germline single-nucleotide polymorphisms and to assess copy-number gain in the amplification status in 11 different genes, Dr. O’Leary said.


Results for mutations and circulating nucleic acids were available in 203 and 107 patients from the P+F and F groups, respectively, and on multivariable analysis of all 310 patients (including palbociclib as a variable in the model and with ctDNA fraction as a continuous variable), higher baseline tumor purity in plasma was associated with highly significantly worse PFS (HR 1.2 per 10% increase in purity), and baseline TP53 mutation and FGFR1 amplification each were associated with significantly shorter PFS (HRs, 1.8 and 2.9, respectively).

“[It is] very important to note ... that we did look specifically for interaction between our genomic changes and treatment, and we didn’t find any evidence of a significant interaction, so these genomic markers [are] prognostic rather than predictive in terms of the two treatment arms of the trial,” he said.

A survival analysis showed a median PFS of 3.7 vs. 12.7 months in patients with vs. without TP53 mutation in the P+F arm, and 1.8 vs. 5.4 months, respectively, in the F arm, with similar HRs of 2.0 and 2.3 in the arms, respectively.

“Even in the [P+F] arm, you see almost half of the patients with a TP53 mutation ... have relapsed by 2 months, the earliest clinical assessment in the trial,” he noted.

For FGFR1, the PFS was 3.9 vs. 12 months with vs. without amplification in the P+F arms, and 1.8 vs. 5.8 months, respectively in th F arm, with HRs of 3.4 and 3.6, respectively.

These findings are notable because markers of early progression on endocrine therapy in combination with CDK4/6 inhibitors remain limited – despite the key role of these combinations in treating ER+ advanced breast cancer, Dr. O’Leary explained.

“Although many patients derive a great deal of benefit from these combinations, there are a subset of patients who will relapse relatively early, and ... we don’t have an established means of identifying those patients at the present,” he said. “From the technical perspective, liquid biopsies have emerged in recent years as a promising means of genotyping patients’ cancers from circulating tumor DNA, and in addition, the overall level of circulating tumor DNA – the fractional purity – has been associated with poor prognosis, specifically in the triple-negative breast cancer setting.”

The results, which require independent validation, could potentially inform future clinical trials of CDK4/6 inhibitor combinations in advanced ER+ breast cancer to identify a high-risk group of patients who require escalation of therapy, he concluded.

Dr. O’Leary reported receiving research funding from Pfizer to his institution.

SOURCE: O’Leary B et al. ASCO 2019, Abstract 1010.

CHICAGO – Tumor protein 53 (TP53) mutation, fibroblast growth factor receptor 1 (FGFR1) amplification, and tumor purity in plasma each predict early progression on palbociclib and/or fulvestrant in patients with advanced estrogen receptor–positive (ER+) breast cancer, according to genomic analyses of PALOMA-3 trial data.

Sharon Worcester/MDedge News

Overall, the presence of one or more of these genomic changes identified 131 out of 310 patients from the phase 3 trial who had baseline samples available, Ben O’Leary, MBBS, said at the annual meeting of the American Society of Clinical Oncology.

“So, a significant minority of patients – 42.3% – potentially who fall into a more poor-prognosis group,” said Dr. O’Leary of the Institute of Cancer Research at the Royal Marsden Hospital in London.

The findings suggest that a “liquid biopsy” at the start of treatment could identify patients at risk for progression.

The PALOMA-3 trial randomized 521 patients with ER+, human epidermal growth factor receptor 2 (HER2)–negative advanced breast cancer who had previously progressed on endocrine therapy 2:1 to CDK4/CDK6 inhibition with palbociclib plus fulvestrant (P+F) or placebo plus fulvestrant (F), and it showed that adding palbociclib significantly improved progression-free survival (PFS) (N Engl J Med. Jul 16 2015;373:209-19).

For the current analysis, the investigators assessed circulating tumor DNA (ctDNA) in baseline plasma samples from 459 study participants in an effort to identify genomic biomarkers for progression, to examine the association between baseline tumor fraction and clinical outcome, and to explore differences in predictive markers by treatment arm. A custom amplicon-sequencing analysis was performed to look for mutations in 17 different relevant genes, and another was used to estimate tumor fraction by looking at about 800 common germline single-nucleotide polymorphisms and to assess copy-number gain in the amplification status in 11 different genes, Dr. O’Leary said.


Results for mutations and circulating nucleic acids were available in 203 and 107 patients from the P+F and F groups, respectively, and on multivariable analysis of all 310 patients (including palbociclib as a variable in the model and with ctDNA fraction as a continuous variable), higher baseline tumor purity in plasma was associated with highly significantly worse PFS (HR 1.2 per 10% increase in purity), and baseline TP53 mutation and FGFR1 amplification each were associated with significantly shorter PFS (HRs, 1.8 and 2.9, respectively).

“[It is] very important to note ... that we did look specifically for interaction between our genomic changes and treatment, and we didn’t find any evidence of a significant interaction, so these genomic markers [are] prognostic rather than predictive in terms of the two treatment arms of the trial,” he said.

A survival analysis showed a median PFS of 3.7 vs. 12.7 months in patients with vs. without TP53 mutation in the P+F arm, and 1.8 vs. 5.4 months, respectively, in the F arm, with similar HRs of 2.0 and 2.3 in the arms, respectively.

“Even in the [P+F] arm, you see almost half of the patients with a TP53 mutation ... have relapsed by 2 months, the earliest clinical assessment in the trial,” he noted.

For FGFR1, the PFS was 3.9 vs. 12 months with vs. without amplification in the P+F arms, and 1.8 vs. 5.8 months, respectively in th F arm, with HRs of 3.4 and 3.6, respectively.

These findings are notable because markers of early progression on endocrine therapy in combination with CDK4/6 inhibitors remain limited – despite the key role of these combinations in treating ER+ advanced breast cancer, Dr. O’Leary explained.

“Although many patients derive a great deal of benefit from these combinations, there are a subset of patients who will relapse relatively early, and ... we don’t have an established means of identifying those patients at the present,” he said. “From the technical perspective, liquid biopsies have emerged in recent years as a promising means of genotyping patients’ cancers from circulating tumor DNA, and in addition, the overall level of circulating tumor DNA – the fractional purity – has been associated with poor prognosis, specifically in the triple-negative breast cancer setting.”

The results, which require independent validation, could potentially inform future clinical trials of CDK4/6 inhibitor combinations in advanced ER+ breast cancer to identify a high-risk group of patients who require escalation of therapy, he concluded.

Dr. O’Leary reported receiving research funding from Pfizer to his institution.

SOURCE: O’Leary B et al. ASCO 2019, Abstract 1010.

The inability to be in two places at one time makes VAM On Demand an essential component of the Vascular Annual Meeting.

ISerg Creative/Getty Images

VAM on Demand lets people review — in depth and on their own timeline —sessions they attended and “attend” electronically the ones they couldn’t in person. VAM on Demand will include hundreds of individual presentations, with accompanying PowerPoint slides and audio. Select video sessions will be available.

The fee is $199 for attendees after the meeting ends. (Non-attendees may purchase VAM on Demand for $499.) All purchasers receive unlimited access, plus downloads to the library, for up to one year. Access begins several weeks after VAM ends and will be available on the SVS website vascular.org.

Contact [email protected] with questions.




 

The inability to be in two places at one time makes VAM On Demand an essential component of the Vascular Annual Meeting.

ISerg Creative/Getty Images

VAM on Demand lets people review — in depth and on their own timeline —sessions they attended and “attend” electronically the ones they couldn’t in person. VAM on Demand will include hundreds of individual presentations, with accompanying PowerPoint slides and audio. Select video sessions will be available.

The fee is $199 for attendees after the meeting ends. (Non-attendees may purchase VAM on Demand for $499.) All purchasers receive unlimited access, plus downloads to the library, for up to one year. Access begins several weeks after VAM ends and will be available on the SVS website vascular.org.

Contact [email protected] with questions.




 

The inability to be in two places at one time makes VAM On Demand an essential component of the Vascular Annual Meeting.

ISerg Creative/Getty Images

VAM on Demand lets people review — in depth and on their own timeline —sessions they attended and “attend” electronically the ones they couldn’t in person. VAM on Demand will include hundreds of individual presentations, with accompanying PowerPoint slides and audio. Select video sessions will be available.

The fee is $199 for attendees after the meeting ends. (Non-attendees may purchase VAM on Demand for $499.) All purchasers receive unlimited access, plus downloads to the library, for up to one year. Access begins several weeks after VAM ends and will be available on the SVS website vascular.org.

Contact [email protected] with questions.




 

During my medical training and fellowship, I often heard that my education was not preparing me for the real world. After 3 years of internal medicine training with limited exposure to the outpatient arena and 3-4 years of specialty gastroenterology, hepatology, and advanced procedure training, you’ve probably heard the same thing. If you’ve chosen private practice, the thought of building a practice and establishing referrals probably seems daunting. It doesn’t have to be. Most gastroenterologists who enter private practice have felt this way early on, and our experiences can help you navigate some of the major factors that influence clinical practice to build a thriving career in gastroenterology.

Conduct research on referrals

Once you’ve decided to join a practice, do some research about local dynamics between large hospital systems and private practice. Community clinical practice is unique and varies by region, location, and how the practice is set up. GIs working in rural, low-access areas face different challenges than those working in urban areas near major health care systems. In rural, low-access areas, some physicians have long wait lists for office appointments and procedures.

In urban settings, there may be a larger population of patients but more competition from hospital systems and other practices. In this case, you’ll have to figure out where most of the referrals come from and why – is it the group’s overall reputation or are there physicians in the practice with a highly needed specialty?

Determine if your specialty training can be a differentiator in your market. If you are multilingual and there is a large patient population that speaks the language(s) in which you are fluent, this can be a great way to bring new patients into a practice. This is especially true if there aren’t many (or any) physicians in the practice who are multilingual.

Meet with local physicians in health care systems. Make a connection with hospitalists, referring physicians, ED physicians, advanced practitioners, and surgeons while covering inpatient service. Volunteer for teaching activities – including for nursing staff, who are a great referral source.

Figure out what opportunities exist to have direct interactions with patients, such as health fairs. If possible, it might be smart to invest in marketing directly to patients in your community as well. Leverage opportunities provided by awareness months – such as providing patients with information about cancer screening – to establish a referral basis.

Medical practice is complex and at times can be confusing until you’ve practiced in a given location for some time. Look internally to learn about the community. It’s always a good idea to learn from those who have been practicing in the community for a long time. Don’t hesitate to ask questions and make suggestions, even if they seem naive. Develop relationships with staff members and gain their trust. Establishing a clear understanding of your specialty with your colleagues and staff also can be a good way to find referrals.

Learn the internal process

Schedules during early months are usually filled with urgent patients. Make yourself available for overflow referrals to other established physicians within the practice and for hospital discharge follow-ups. Reading through the charts of these patients can help you understand the various styles of other doctors and can help you familiarize yourself with referring physicians.

This also will help to clarify the process of how a patient moves through the system – from the time patients call the office to when they check out. This includes navigating through procedures, results reporting, and the recall system. While it will be hard to master all aspects of a practice right away, processes within practices are well established, and it is important for you to have a good understanding of how they function.

Focus on patient care and satisfaction

Learning internal processes also can be useful in increasing patient satisfaction, an important quality outcome indicator. As you’re starting out, keep the following things in mind that can help put your patients at ease and increase satisfaction.

• Understand how to communicate what a patient should expect when being seen. Being at ease with the process helps garner trust and confidence.
• Call patients the next day to check on their symptoms.
• Relay results personally. Make connections with family member(s).
• Remember that cultural competency is important. Do everything you can to ensure you’re meeting the social, cultural, and linguistic needs of patients in your community.
• Above all – continue to provide personalized and thorough care. Word of mouth is the best form of referral and is time tested.

Continue to grow

As you begin to understand the dynamics of local practice, it’s important to establish where you fit into the practice and start differentiating your expertise. Here are some ideas and suggestions for how you can continue to expand your patient base.

• Differentiate and establish a subspecialty within your practice: Motility, inflammatory bowel disease, Clostridium difficile/fecal microbiota transplantation, liver diseases, Celiac disease, and medical weight-loss programs are just a few.
• Establish connections with local medical societies as well as hospital and state committees. This is a great way to connect with other physicians of various specialties. If you have a specialty unique to the area, it may help establish a clear referral line.
• Establish a consistent conversation with referring physicians – get to know them and keep direct lines of communication, such as having their cell phone numbers.
• Look for public speaking engagements that reach patients directly. These are organized mostly through patient-based organization and foundations.
• Increase your reach through the local media and through social media platforms like Facebook, Instagram, and Twitter.

At this point, you should have plenty of patients to keep you busy, which could lead to other challenges in managing your various responsibilities and obligations. A key factor at this stage to help reduce stress is to lean on the effective and efficient support system your practice should have in place. Educating medical assistants or nurses on the most common GI diseases and conditions can help reduce the time involved in communicating results. Practice management software and patient portals can help create efficiencies to handle the increasing number of patient visits.

Remember, creating a referral process and patient base as a new gastroenterologist doesn’t have to be daunting. If you follow these tips, you’ll be on your way to establishing yourself within the community. No doubt you will have the same success as many physicians in my group and in the groups of my colleagues in the Digestive Health Physicians Association. And once you’re established, it will be your turn to help the next generation of physicians who want to enter private practice and thrive – so that independent community GI care remains strong well into the future.

Dr. Alaparthi is the director of committee operations at the Gastroenterology Center of Connecticut and serves as chair of the communications committee for the Digestive Health Physicians Association.

During my medical training and fellowship, I often heard that my education was not preparing me for the real world. After 3 years of internal medicine training with limited exposure to the outpatient arena and 3-4 years of specialty gastroenterology, hepatology, and advanced procedure training, you’ve probably heard the same thing. If you’ve chosen private practice, the thought of building a practice and establishing referrals probably seems daunting. It doesn’t have to be. Most gastroenterologists who enter private practice have felt this way early on, and our experiences can help you navigate some of the major factors that influence clinical practice to build a thriving career in gastroenterology.

Conduct research on referrals

Once you’ve decided to join a practice, do some research about local dynamics between large hospital systems and private practice. Community clinical practice is unique and varies by region, location, and how the practice is set up. GIs working in rural, low-access areas face different challenges than those working in urban areas near major health care systems. In rural, low-access areas, some physicians have long wait lists for office appointments and procedures.

In urban settings, there may be a larger population of patients but more competition from hospital systems and other practices. In this case, you’ll have to figure out where most of the referrals come from and why – is it the group’s overall reputation or are there physicians in the practice with a highly needed specialty?

Determine if your specialty training can be a differentiator in your market. If you are multilingual and there is a large patient population that speaks the language(s) in which you are fluent, this can be a great way to bring new patients into a practice. This is especially true if there aren’t many (or any) physicians in the practice who are multilingual.

Meet with local physicians in health care systems. Make a connection with hospitalists, referring physicians, ED physicians, advanced practitioners, and surgeons while covering inpatient service. Volunteer for teaching activities – including for nursing staff, who are a great referral source.

Figure out what opportunities exist to have direct interactions with patients, such as health fairs. If possible, it might be smart to invest in marketing directly to patients in your community as well. Leverage opportunities provided by awareness months – such as providing patients with information about cancer screening – to establish a referral basis.

Medical practice is complex and at times can be confusing until you’ve practiced in a given location for some time. Look internally to learn about the community. It’s always a good idea to learn from those who have been practicing in the community for a long time. Don’t hesitate to ask questions and make suggestions, even if they seem naive. Develop relationships with staff members and gain their trust. Establishing a clear understanding of your specialty with your colleagues and staff also can be a good way to find referrals.

Learn the internal process

Schedules during early months are usually filled with urgent patients. Make yourself available for overflow referrals to other established physicians within the practice and for hospital discharge follow-ups. Reading through the charts of these patients can help you understand the various styles of other doctors and can help you familiarize yourself with referring physicians.

This also will help to clarify the process of how a patient moves through the system – from the time patients call the office to when they check out. This includes navigating through procedures, results reporting, and the recall system. While it will be hard to master all aspects of a practice right away, processes within practices are well established, and it is important for you to have a good understanding of how they function.

Focus on patient care and satisfaction

Learning internal processes also can be useful in increasing patient satisfaction, an important quality outcome indicator. As you’re starting out, keep the following things in mind that can help put your patients at ease and increase satisfaction.

• Understand how to communicate what a patient should expect when being seen. Being at ease with the process helps garner trust and confidence.
• Call patients the next day to check on their symptoms.
• Relay results personally. Make connections with family member(s).
• Remember that cultural competency is important. Do everything you can to ensure you’re meeting the social, cultural, and linguistic needs of patients in your community.
• Above all – continue to provide personalized and thorough care. Word of mouth is the best form of referral and is time tested.

Continue to grow

As you begin to understand the dynamics of local practice, it’s important to establish where you fit into the practice and start differentiating your expertise. Here are some ideas and suggestions for how you can continue to expand your patient base.

• Differentiate and establish a subspecialty within your practice: Motility, inflammatory bowel disease, Clostridium difficile/fecal microbiota transplantation, liver diseases, Celiac disease, and medical weight-loss programs are just a few.
• Establish connections with local medical societies as well as hospital and state committees. This is a great way to connect with other physicians of various specialties. If you have a specialty unique to the area, it may help establish a clear referral line.
• Establish a consistent conversation with referring physicians – get to know them and keep direct lines of communication, such as having their cell phone numbers.
• Look for public speaking engagements that reach patients directly. These are organized mostly through patient-based organization and foundations.
• Increase your reach through the local media and through social media platforms like Facebook, Instagram, and Twitter.

At this point, you should have plenty of patients to keep you busy, which could lead to other challenges in managing your various responsibilities and obligations. A key factor at this stage to help reduce stress is to lean on the effective and efficient support system your practice should have in place. Educating medical assistants or nurses on the most common GI diseases and conditions can help reduce the time involved in communicating results. Practice management software and patient portals can help create efficiencies to handle the increasing number of patient visits.

Remember, creating a referral process and patient base as a new gastroenterologist doesn’t have to be daunting. If you follow these tips, you’ll be on your way to establishing yourself within the community. No doubt you will have the same success as many physicians in my group and in the groups of my colleagues in the Digestive Health Physicians Association. And once you’re established, it will be your turn to help the next generation of physicians who want to enter private practice and thrive – so that independent community GI care remains strong well into the future.

Dr. Alaparthi is the director of committee operations at the Gastroenterology Center of Connecticut and serves as chair of the communications committee for the Digestive Health Physicians Association.

During my medical training and fellowship, I often heard that my education was not preparing me for the real world. After 3 years of internal medicine training with limited exposure to the outpatient arena and 3-4 years of specialty gastroenterology, hepatology, and advanced procedure training, you’ve probably heard the same thing. If you’ve chosen private practice, the thought of building a practice and establishing referrals probably seems daunting. It doesn’t have to be. Most gastroenterologists who enter private practice have felt this way early on, and our experiences can help you navigate some of the major factors that influence clinical practice to build a thriving career in gastroenterology.

Conduct research on referrals

Once you’ve decided to join a practice, do some research about local dynamics between large hospital systems and private practice. Community clinical practice is unique and varies by region, location, and how the practice is set up. GIs working in rural, low-access areas face different challenges than those working in urban areas near major health care systems. In rural, low-access areas, some physicians have long wait lists for office appointments and procedures.

In urban settings, there may be a larger population of patients but more competition from hospital systems and other practices. In this case, you’ll have to figure out where most of the referrals come from and why – is it the group’s overall reputation or are there physicians in the practice with a highly needed specialty?

Determine if your specialty training can be a differentiator in your market. If you are multilingual and there is a large patient population that speaks the language(s) in which you are fluent, this can be a great way to bring new patients into a practice. This is especially true if there aren’t many (or any) physicians in the practice who are multilingual.

Meet with local physicians in health care systems. Make a connection with hospitalists, referring physicians, ED physicians, advanced practitioners, and surgeons while covering inpatient service. Volunteer for teaching activities – including for nursing staff, who are a great referral source.

Figure out what opportunities exist to have direct interactions with patients, such as health fairs. If possible, it might be smart to invest in marketing directly to patients in your community as well. Leverage opportunities provided by awareness months – such as providing patients with information about cancer screening – to establish a referral basis.

Medical practice is complex and at times can be confusing until you’ve practiced in a given location for some time. Look internally to learn about the community. It’s always a good idea to learn from those who have been practicing in the community for a long time. Don’t hesitate to ask questions and make suggestions, even if they seem naive. Develop relationships with staff members and gain their trust. Establishing a clear understanding of your specialty with your colleagues and staff also can be a good way to find referrals.

Learn the internal process

Schedules during early months are usually filled with urgent patients. Make yourself available for overflow referrals to other established physicians within the practice and for hospital discharge follow-ups. Reading through the charts of these patients can help you understand the various styles of other doctors and can help you familiarize yourself with referring physicians.

This also will help to clarify the process of how a patient moves through the system – from the time patients call the office to when they check out. This includes navigating through procedures, results reporting, and the recall system. While it will be hard to master all aspects of a practice right away, processes within practices are well established, and it is important for you to have a good understanding of how they function.

Focus on patient care and satisfaction

Learning internal processes also can be useful in increasing patient satisfaction, an important quality outcome indicator. As you’re starting out, keep the following things in mind that can help put your patients at ease and increase satisfaction.

• Understand how to communicate what a patient should expect when being seen. Being at ease with the process helps garner trust and confidence.
• Call patients the next day to check on their symptoms.
• Relay results personally. Make connections with family member(s).
• Remember that cultural competency is important. Do everything you can to ensure you’re meeting the social, cultural, and linguistic needs of patients in your community.
• Above all – continue to provide personalized and thorough care. Word of mouth is the best form of referral and is time tested.

Continue to grow

As you begin to understand the dynamics of local practice, it’s important to establish where you fit into the practice and start differentiating your expertise. Here are some ideas and suggestions for how you can continue to expand your patient base.

• Differentiate and establish a subspecialty within your practice: Motility, inflammatory bowel disease, Clostridium difficile/fecal microbiota transplantation, liver diseases, Celiac disease, and medical weight-loss programs are just a few.
• Establish connections with local medical societies as well as hospital and state committees. This is a great way to connect with other physicians of various specialties. If you have a specialty unique to the area, it may help establish a clear referral line.
• Establish a consistent conversation with referring physicians – get to know them and keep direct lines of communication, such as having their cell phone numbers.
• Look for public speaking engagements that reach patients directly. These are organized mostly through patient-based organization and foundations.
• Increase your reach through the local media and through social media platforms like Facebook, Instagram, and Twitter.

At this point, you should have plenty of patients to keep you busy, which could lead to other challenges in managing your various responsibilities and obligations. A key factor at this stage to help reduce stress is to lean on the effective and efficient support system your practice should have in place. Educating medical assistants or nurses on the most common GI diseases and conditions can help reduce the time involved in communicating results. Practice management software and patient portals can help create efficiencies to handle the increasing number of patient visits.

Remember, creating a referral process and patient base as a new gastroenterologist doesn’t have to be daunting. If you follow these tips, you’ll be on your way to establishing yourself within the community. No doubt you will have the same success as many physicians in my group and in the groups of my colleagues in the Digestive Health Physicians Association. And once you’re established, it will be your turn to help the next generation of physicians who want to enter private practice and thrive – so that independent community GI care remains strong well into the future.

Dr. Alaparthi is the director of committee operations at the Gastroenterology Center of Connecticut and serves as chair of the communications committee for the Digestive Health Physicians Association.

Physician registrants can get a big boost in collecting required Continuing Medical Education (CME) and Maintenance of Certification (MOC) self-assessment credits at the Vascular Annual Meeting.

The Society for Vascular Surgery is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. SVS has designated the 2019 Vascular Annual Meeting for a maximum of 30 AMA PRA Category 1 Credits™.

Physicians should claim only the credits commensurate with the extent of their participation in the activity.

Full credit is not available for attendance at two sessions occurring simultaneously.

A number of sessions also permit earning of MOC credits.

Participants may claim credits beginning Wednesday, June 12. Credits must be claimed by Dec. 31, 2019. 

Physician registrants can get a big boost in collecting required Continuing Medical Education (CME) and Maintenance of Certification (MOC) self-assessment credits at the Vascular Annual Meeting.

The Society for Vascular Surgery is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. SVS has designated the 2019 Vascular Annual Meeting for a maximum of 30 AMA PRA Category 1 Credits™.

Physicians should claim only the credits commensurate with the extent of their participation in the activity.

Full credit is not available for attendance at two sessions occurring simultaneously.

A number of sessions also permit earning of MOC credits.

Participants may claim credits beginning Wednesday, June 12. Credits must be claimed by Dec. 31, 2019. 

Physician registrants can get a big boost in collecting required Continuing Medical Education (CME) and Maintenance of Certification (MOC) self-assessment credits at the Vascular Annual Meeting.

The Society for Vascular Surgery is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. SVS has designated the 2019 Vascular Annual Meeting for a maximum of 30 AMA PRA Category 1 Credits™.

Physicians should claim only the credits commensurate with the extent of their participation in the activity.

Full credit is not available for attendance at two sessions occurring simultaneously.

A number of sessions also permit earning of MOC credits.

Participants may claim credits beginning Wednesday, June 12. Credits must be claimed by Dec. 31, 2019. 

A tradition at the Vascular Annual Meeting, the E. Stanley Crawford Critical Issues Forum is organized by the incoming SVS President and devotes itself to assessing and discussing particular challenges currently facing the society. This year’s Forum focused on how vascular surgeons could use evidence-based medicine to develop tools to improve outcomes, reduce costs, and ensure appropriate utilization of resources.

Nationwide Photographers

Session moderator and organizer Kim J. Hodgson, MD, SVS president-elect and chair of the division of vascular surgery at Southern Illinois University School of Medicine, outlined the problem in his introductory presentation “Why Good Outcomes Are No Longer Good Enough.”

He pointed out how there are several driving forces influencing the inappropriate use of medical procedures, resulting in diminished quality of outcomes and increased costs of health care: These comprise incorrect evaluation, incorrect treatment and planning, and improper motivation. The first two factors can be improved through education and development and promulgation of evidence-based medical practices, but the last is correctable only through enforced regulation and peer-review. This has become increasingly more difficult as procedures move from the hospital to outpatient centers, where the profit motive for performing inappropriate procedures, and the means to satisfy it, are increasingly more tempting.

He emphasized how SVS has tools such as the Vascular Quality Initiative and its registries to provide evidence-based input on the appropriateness of procedures and whether an institution is matching up to its peers in providing appropriate patient care. The importance of the VQI was also stressed by the majority of the Crawford Forum speakers.

“Unfortunately, like it or not, the reality is that some degree of regulation is inevitable, and if we don’t step up and regulate ourselves, there are plenty of other people willing to do it for us. I would say that we let the bureaucrats develop our EHRs, and you know how that worked out. So, I think it is incumbent upon us to be able to regulate ourselves.”

Dr. Hodgson turned over the discussion to Arlene Seid, MD, MPH, medical director of the quality assurance office within the Pennsylvania Department of Health. Her presentation, “The Government’s Perspective on When & Where Endovascular Interventions Should Be Performed,” detailed how her department recently became concerned about an increase in the volume of endovascular procedures, and complications thereof, mainly in outpatient settings. The department also raised questions about the procedures and discussed whether reimbursement via programs such as Medicaid should be ceased.

She pointed out how federal regulations from the Centers for Medicare & Medicaid Services (CMS) only regulate through payments and their choice of procedures to be reimbursed, the vast majority of other regulations are established at the state level and vary widely from state to state. And at the state level, such as hers, there was great difficulty finding trustworthy expert opinion, and she added how organizations like the SVS could be of tremendous use in providing guidance in developing regulations.

Nationwide Photographers

As an example she used Ambulatory Surgical Centers, which are defined differently from state to state and vary widely in their requirements for licensing. The state’s job is made much simpler, and more effective, when expert organizations like the SVS can provide certification programs as a firm foundation for basing such licensing efforts.

She also suggested that if individuals have problems with or disagree with state regulations, they must become knowledgeable as to what level of state organization is involved, and ideally enlist the help of groups such as SVS to provide the expert justification for change.

A tradition at the Vascular Annual Meeting, the E. Stanley Crawford Critical Issues Forum is organized by the incoming SVS President and devotes itself to assessing and discussing particular challenges currently facing the society. This year’s Forum focused on how vascular surgeons could use evidence-based medicine to develop tools to improve outcomes, reduce costs, and ensure appropriate utilization of resources.

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Session moderator and organizer Kim J. Hodgson, MD, SVS president-elect and chair of the division of vascular surgery at Southern Illinois University School of Medicine, outlined the problem in his introductory presentation “Why Good Outcomes Are No Longer Good Enough.”

He pointed out how there are several driving forces influencing the inappropriate use of medical procedures, resulting in diminished quality of outcomes and increased costs of health care: These comprise incorrect evaluation, incorrect treatment and planning, and improper motivation. The first two factors can be improved through education and development and promulgation of evidence-based medical practices, but the last is correctable only through enforced regulation and peer-review. This has become increasingly more difficult as procedures move from the hospital to outpatient centers, where the profit motive for performing inappropriate procedures, and the means to satisfy it, are increasingly more tempting.

He emphasized how SVS has tools such as the Vascular Quality Initiative and its registries to provide evidence-based input on the appropriateness of procedures and whether an institution is matching up to its peers in providing appropriate patient care. The importance of the VQI was also stressed by the majority of the Crawford Forum speakers.

“Unfortunately, like it or not, the reality is that some degree of regulation is inevitable, and if we don’t step up and regulate ourselves, there are plenty of other people willing to do it for us. I would say that we let the bureaucrats develop our EHRs, and you know how that worked out. So, I think it is incumbent upon us to be able to regulate ourselves.”

Dr. Hodgson turned over the discussion to Arlene Seid, MD, MPH, medical director of the quality assurance office within the Pennsylvania Department of Health. Her presentation, “The Government’s Perspective on When & Where Endovascular Interventions Should Be Performed,” detailed how her department recently became concerned about an increase in the volume of endovascular procedures, and complications thereof, mainly in outpatient settings. The department also raised questions about the procedures and discussed whether reimbursement via programs such as Medicaid should be ceased.

She pointed out how federal regulations from the Centers for Medicare & Medicaid Services (CMS) only regulate through payments and their choice of procedures to be reimbursed, the vast majority of other regulations are established at the state level and vary widely from state to state. And at the state level, such as hers, there was great difficulty finding trustworthy expert opinion, and she added how organizations like the SVS could be of tremendous use in providing guidance in developing regulations.

Nationwide Photographers

As an example she used Ambulatory Surgical Centers, which are defined differently from state to state and vary widely in their requirements for licensing. The state’s job is made much simpler, and more effective, when expert organizations like the SVS can provide certification programs as a firm foundation for basing such licensing efforts.

She also suggested that if individuals have problems with or disagree with state regulations, they must become knowledgeable as to what level of state organization is involved, and ideally enlist the help of groups such as SVS to provide the expert justification for change.

A tradition at the Vascular Annual Meeting, the E. Stanley Crawford Critical Issues Forum is organized by the incoming SVS President and devotes itself to assessing and discussing particular challenges currently facing the society. This year’s Forum focused on how vascular surgeons could use evidence-based medicine to develop tools to improve outcomes, reduce costs, and ensure appropriate utilization of resources.

Nationwide Photographers

Session moderator and organizer Kim J. Hodgson, MD, SVS president-elect and chair of the division of vascular surgery at Southern Illinois University School of Medicine, outlined the problem in his introductory presentation “Why Good Outcomes Are No Longer Good Enough.”

He pointed out how there are several driving forces influencing the inappropriate use of medical procedures, resulting in diminished quality of outcomes and increased costs of health care: These comprise incorrect evaluation, incorrect treatment and planning, and improper motivation. The first two factors can be improved through education and development and promulgation of evidence-based medical practices, but the last is correctable only through enforced regulation and peer-review. This has become increasingly more difficult as procedures move from the hospital to outpatient centers, where the profit motive for performing inappropriate procedures, and the means to satisfy it, are increasingly more tempting.

He emphasized how SVS has tools such as the Vascular Quality Initiative and its registries to provide evidence-based input on the appropriateness of procedures and whether an institution is matching up to its peers in providing appropriate patient care. The importance of the VQI was also stressed by the majority of the Crawford Forum speakers.

“Unfortunately, like it or not, the reality is that some degree of regulation is inevitable, and if we don’t step up and regulate ourselves, there are plenty of other people willing to do it for us. I would say that we let the bureaucrats develop our EHRs, and you know how that worked out. So, I think it is incumbent upon us to be able to regulate ourselves.”

Dr. Hodgson turned over the discussion to Arlene Seid, MD, MPH, medical director of the quality assurance office within the Pennsylvania Department of Health. Her presentation, “The Government’s Perspective on When & Where Endovascular Interventions Should Be Performed,” detailed how her department recently became concerned about an increase in the volume of endovascular procedures, and complications thereof, mainly in outpatient settings. The department also raised questions about the procedures and discussed whether reimbursement via programs such as Medicaid should be ceased.

She pointed out how federal regulations from the Centers for Medicare & Medicaid Services (CMS) only regulate through payments and their choice of procedures to be reimbursed, the vast majority of other regulations are established at the state level and vary widely from state to state. And at the state level, such as hers, there was great difficulty finding trustworthy expert opinion, and she added how organizations like the SVS could be of tremendous use in providing guidance in developing regulations.

Nationwide Photographers

As an example she used Ambulatory Surgical Centers, which are defined differently from state to state and vary widely in their requirements for licensing. The state’s job is made much simpler, and more effective, when expert organizations like the SVS can provide certification programs as a firm foundation for basing such licensing efforts.

She also suggested that if individuals have problems with or disagree with state regulations, they must become knowledgeable as to what level of state organization is involved, and ideally enlist the help of groups such as SVS to provide the expert justification for change.

MADRID – The musculoskeletal complications of checkpoint inhibitors therapy are sometimes described as RA like, but a detailed analysis of a consecutive series of patients presented at the European Congress of Rheumatology produced the conclusion that the phenotypic expression is unique.

“These manifestations do not necessarily include synovial involvement, so their description as a rheumatoid arthritis–like presentation is not accurate. Rather, our findings suggest the pathology is something completely different and completely new,” said Alexandra Filippopoulou, MD, a rheumatology resident at the University of Patras (Greece).

This comment was based on a prospective study evaluating musculoskeletal complications in patients treated with checkpoint inhibitors over a recent 2-year period. Of the 130 consecutive patients who received a checkpoint inhibitor in the study period, 10 (7.7%) complained of joint pain and were determined to have an inflammatory complication.

The median time to development of musculoskeletal symptoms in this mostly male patient series was 2.5 months. The site of cancer was lung in four, bladder in three, kidney in two, and skin in one. Nivolumab (Opdivo) was the most common checkpoint inhibitor used, but others were represented.

MRI studies were conducted in 8 of the 10 patients. Overall, the MRI studies showed more myofascial than synovial involvement, but Dr. Filippopoulou described three distinct patterns.

In four patients, there was prominent periarticular involvement marked by diffuse swelling in the hands, feet, knees, or a combination of these joints. Synovitis, when observed, was mild, but myositis and fasciitis were common in adjacent tissues.

In three patients with a chief complaint of knee pain, myofasciitis was prominent in the surrounding muscles. Again, synovitis, when observed, was mild. It was unclear whether a partial tear of the quadriceps tendon observed in one patient was checkpoint inhibitor related.

In a third pattern, shared by three other patients, synovitis was prominent, but so was myositis in adjacent muscles. In two of these patients, the inflammatory activity was confined to the hands; in the third, both the knees and the ankle were also involved.


Regardless of these patterns of inflammation, “almost all of these patients continued to show good range of motion, which is not something that is commonly seen in patients with rheumatoid arthritis,” Dr. Filippopoulou observed.

Overall, the joint pain tended to be mild to moderate. They all responded well to low-dose glucocorticoids or analgesics without need to discontinue the anticancer therapy, Dr. Filippopoulou reported.

Not least interesting of the findings, 50% of the patients with musculoskeletal adverse events had a favorable response to the checkpoint inhibitor therapy, compared with just 12.5% of patients without these complaints, a difference that reached statistical significance (P = .0016), according to Dr. Filippopoulou. This observation is consistent with a study published last year that also associated immune-related adverse events with a greater likelihood of an anticancer response (Ann Rheumatic Dis. 2018;77:393-8).

“This is an interesting finding, but the theory that musculoskeletal adverse events predict a better response to checkpoint inhibitor therapy needs to be proven,” she said.

A larger case series is needed to better characterize joint inflammation associated with checkpoint inhibitors, but Dr. Filippopoulou concluded from her series that these adverse events are not accurately described as RA like. Rather, the phenotypic expression appears to be unique, not fully resembling any other joint pathology.

Dr. Filippopoulou reported no potential conflicts of interest.

SOURCE: Filippopoulou A et al. Ann Rheum Dis. Jun 2019;78 (Suppl 2):251. Abstract OP0335. doi: 10.1136/annrheumdis-2019-eular.5029.

MADRID – The musculoskeletal complications of checkpoint inhibitors therapy are sometimes described as RA like, but a detailed analysis of a consecutive series of patients presented at the European Congress of Rheumatology produced the conclusion that the phenotypic expression is unique.

“These manifestations do not necessarily include synovial involvement, so their description as a rheumatoid arthritis–like presentation is not accurate. Rather, our findings suggest the pathology is something completely different and completely new,” said Alexandra Filippopoulou, MD, a rheumatology resident at the University of Patras (Greece).

This comment was based on a prospective study evaluating musculoskeletal complications in patients treated with checkpoint inhibitors over a recent 2-year period. Of the 130 consecutive patients who received a checkpoint inhibitor in the study period, 10 (7.7%) complained of joint pain and were determined to have an inflammatory complication.

The median time to development of musculoskeletal symptoms in this mostly male patient series was 2.5 months. The site of cancer was lung in four, bladder in three, kidney in two, and skin in one. Nivolumab (Opdivo) was the most common checkpoint inhibitor used, but others were represented.

MRI studies were conducted in 8 of the 10 patients. Overall, the MRI studies showed more myofascial than synovial involvement, but Dr. Filippopoulou described three distinct patterns.

In four patients, there was prominent periarticular involvement marked by diffuse swelling in the hands, feet, knees, or a combination of these joints. Synovitis, when observed, was mild, but myositis and fasciitis were common in adjacent tissues.

In three patients with a chief complaint of knee pain, myofasciitis was prominent in the surrounding muscles. Again, synovitis, when observed, was mild. It was unclear whether a partial tear of the quadriceps tendon observed in one patient was checkpoint inhibitor related.

In a third pattern, shared by three other patients, synovitis was prominent, but so was myositis in adjacent muscles. In two of these patients, the inflammatory activity was confined to the hands; in the third, both the knees and the ankle were also involved.


Regardless of these patterns of inflammation, “almost all of these patients continued to show good range of motion, which is not something that is commonly seen in patients with rheumatoid arthritis,” Dr. Filippopoulou observed.

Overall, the joint pain tended to be mild to moderate. They all responded well to low-dose glucocorticoids or analgesics without need to discontinue the anticancer therapy, Dr. Filippopoulou reported.

Not least interesting of the findings, 50% of the patients with musculoskeletal adverse events had a favorable response to the checkpoint inhibitor therapy, compared with just 12.5% of patients without these complaints, a difference that reached statistical significance (P = .0016), according to Dr. Filippopoulou. This observation is consistent with a study published last year that also associated immune-related adverse events with a greater likelihood of an anticancer response (Ann Rheumatic Dis. 2018;77:393-8).

“This is an interesting finding, but the theory that musculoskeletal adverse events predict a better response to checkpoint inhibitor therapy needs to be proven,” she said.

A larger case series is needed to better characterize joint inflammation associated with checkpoint inhibitors, but Dr. Filippopoulou concluded from her series that these adverse events are not accurately described as RA like. Rather, the phenotypic expression appears to be unique, not fully resembling any other joint pathology.

Dr. Filippopoulou reported no potential conflicts of interest.

SOURCE: Filippopoulou A et al. Ann Rheum Dis. Jun 2019;78 (Suppl 2):251. Abstract OP0335. doi: 10.1136/annrheumdis-2019-eular.5029.

MADRID – The musculoskeletal complications of checkpoint inhibitors therapy are sometimes described as RA like, but a detailed analysis of a consecutive series of patients presented at the European Congress of Rheumatology produced the conclusion that the phenotypic expression is unique.

“These manifestations do not necessarily include synovial involvement, so their description as a rheumatoid arthritis–like presentation is not accurate. Rather, our findings suggest the pathology is something completely different and completely new,” said Alexandra Filippopoulou, MD, a rheumatology resident at the University of Patras (Greece).

This comment was based on a prospective study evaluating musculoskeletal complications in patients treated with checkpoint inhibitors over a recent 2-year period. Of the 130 consecutive patients who received a checkpoint inhibitor in the study period, 10 (7.7%) complained of joint pain and were determined to have an inflammatory complication.

The median time to development of musculoskeletal symptoms in this mostly male patient series was 2.5 months. The site of cancer was lung in four, bladder in three, kidney in two, and skin in one. Nivolumab (Opdivo) was the most common checkpoint inhibitor used, but others were represented.

MRI studies were conducted in 8 of the 10 patients. Overall, the MRI studies showed more myofascial than synovial involvement, but Dr. Filippopoulou described three distinct patterns.

In four patients, there was prominent periarticular involvement marked by diffuse swelling in the hands, feet, knees, or a combination of these joints. Synovitis, when observed, was mild, but myositis and fasciitis were common in adjacent tissues.

In three patients with a chief complaint of knee pain, myofasciitis was prominent in the surrounding muscles. Again, synovitis, when observed, was mild. It was unclear whether a partial tear of the quadriceps tendon observed in one patient was checkpoint inhibitor related.

In a third pattern, shared by three other patients, synovitis was prominent, but so was myositis in adjacent muscles. In two of these patients, the inflammatory activity was confined to the hands; in the third, both the knees and the ankle were also involved.


Regardless of these patterns of inflammation, “almost all of these patients continued to show good range of motion, which is not something that is commonly seen in patients with rheumatoid arthritis,” Dr. Filippopoulou observed.

Overall, the joint pain tended to be mild to moderate. They all responded well to low-dose glucocorticoids or analgesics without need to discontinue the anticancer therapy, Dr. Filippopoulou reported.

Not least interesting of the findings, 50% of the patients with musculoskeletal adverse events had a favorable response to the checkpoint inhibitor therapy, compared with just 12.5% of patients without these complaints, a difference that reached statistical significance (P = .0016), according to Dr. Filippopoulou. This observation is consistent with a study published last year that also associated immune-related adverse events with a greater likelihood of an anticancer response (Ann Rheumatic Dis. 2018;77:393-8).

“This is an interesting finding, but the theory that musculoskeletal adverse events predict a better response to checkpoint inhibitor therapy needs to be proven,” she said.

A larger case series is needed to better characterize joint inflammation associated with checkpoint inhibitors, but Dr. Filippopoulou concluded from her series that these adverse events are not accurately described as RA like. Rather, the phenotypic expression appears to be unique, not fully resembling any other joint pathology.

Dr. Filippopoulou reported no potential conflicts of interest.

SOURCE: Filippopoulou A et al. Ann Rheum Dis. Jun 2019;78 (Suppl 2):251. Abstract OP0335. doi: 10.1136/annrheumdis-2019-eular.5029.

After 30 years in a traditional family medicine practice, Jesse Hsieh, MD, was ready for a change.

Alicia Gallegos/MDedge News

Data entry and insurance paperwork had drastically reduced his time with patients, and practicing medicine was no longer enjoyable or meaningful, said Dr. Hsieh of Granger, Ind.

“I felt very strongly that we were not delivering the kind of care that could be the best for the patient,” he said. “I explored other ways I could continue to practice the way I wanted; spend time with patients, teach them about things, and not spend so much time with regulatory paperwork and insurance.”

The answer for Dr. Hsieh was direct primary care (DPC), a model that cuts out insurance and centers on unlimited physician access for a flat, membership fee. For $2,500 a year, Dr. Hsieh’s patients can schedule visits as often as they like and communicate with him as the need arises by phone, text, or email.

For Dr. Hsieh, the model allows for a more manageable panel size, ample time to spend with patients, and the ability to make a greater impact on their health.

“I’m practicing the way I did 30 years ago,” Dr. Hsieh said. “I’m spending more time with people, I can call the patient myself about their labs and results and take their questions. I spend a lot more time educating the patient.”

Dr. Hsieh is one of a growing number of physicians moving to direct primary care. In 2009, about 100 practices were providing direct primary care, according to Jay Keese, executive director for the Direct Primary Care Coalition. Today, about 1,000 practices in 48 states provide direct primary care to more than 300,000 patients.

A direct primary care practice can be designed in different ways, but most opt out of insurance and offer a flat fee to patients for all primary care provided, said James A. Ellzy, MD, a family physician in Washington who serves on the American Academy of Family Physicians (AAFP) board of directors. A smaller number of practices operate a hybrid structure that includes both direct patients and fee-for-service patients.

About 3% of AAFP members are currently practicing direct primary care, and another 1% are currently converting, according to the AAFP 2018 Practice Profile Survey.

Nationally, about a third of survey respondents said they were learning about or considering a conversion to direct primary care, while another third said they were unfamiliar with the concept. The AAFP is working to educate physicians about the model, including holding an annual DPC summit.

But the move to direct primary care isn’t a sure bet. Success requires significant preparation, marketing, and structuring, experts say.

“There [can be] challenges in building a practice from scratch after you’ve had a fee-for-service practice,” Mr. Keese said. “If you’ve had a panel size of 2,500 or 3,000, and you’re looking at filling in 600 to 800 patients, it can take some time, which can cause some economic stress. But I think most people who go into direct primary care are excited and never look back.


 

Preparing for transition

When Rob Lamberts, MD, left his traditional practice in 2012, there were few leaders in direct primary care and not many resources available.

“I ended up just kind of figuring it out myself,” said Dr. Lamberts, an internist based in Augusta, Ga. “Over the past 6 1/2 years, I’ve built the practice to about 800 patients.”

Today, Dr. Lamberts is highly satisfied with his work and is helping local colleagues set up similar practices. He charges patients between $35 and $70 a month, depending on age, and offers a family fee between $150 and $175 for up to five members. Services include: extended physician access, office visits, discounted in-house labs, and discounted medications dispensed from his office.

“The amount of paperwork I have to do is substantially less,” Dr. Lamberts said. “My income is at least the same, if not a little more. My quality of life is tons better, and the quality of care is so much better.

Before making the jump to direct primary care, do your research and talk to other doctors about their experiences, Dr. Lamberts advised.

One important consideration is what type of direct primary care design to choose – the direct-to-consumer route or the direct-to-employer road. The first model targets patients as members, while the latter contracts with employers to provide services to their employees.

“There has been a surge in amount of interest in direct primary care to employers,” said Michael Tetreault, editor in chief for the DPC Journal, a news source that conducts data analytics on concierge medicine and DPC practices.

Reader surveys conducted by the DPC Journal found that a growing number of DPC physicians are looking to partner with local employers. Of 141 DPC physicians in 2019, 52% expressed an interest in employer partnerships, up from 35% in 2015, according to data provided by Mr. Tetreault.

One example of such growth is Nextera Healthcare, a network that started out with a handful of physicians about 10 years ago and now has more than 50, according to CEO and founder Clint Flanagan, MD.

The network contracts with employers across Colorado and eight other states to provide direct primary care services to their employees. Once affiliated, Nextera operates the marketing, sales, accounting, legal, and development side of the business. Most Nextera physicians have an average of 15 years practice experience, Dr. Flanagan said. Physicians receive most of the monthly revenue generated by their patients; Nextera retains a portion. Dr. Flanagan declined to specify the exact percentage retained.
 

Attracting patients, starting strong

For Dr. Hsieh, being well known in his community and having built a reputation as a family physician contributed to his success in direct primary care. In addition to taking on leadership roles in the health care community over the years, Dr. Hsieh regularly offers perspective for local media regarding medical topics, plays in a popular band at charity events, and teaches courses at two major universities in the area.

“When starting out in this practice, you really have to have built a reputation in town,” said Dr. Hsieh. “In this city, we’ve already had people try direct primary care who have failed because they came out of residency or people didn’t know who they were. You really have to have had a reputation of quality and service and patients should know about you.”

In many cases, physicians can bring their patients with them into direct primary care practice; however, some may not be able to based on their prior employment contract. Dr. Hsieh, for example, could not speak about his new practice or market the business until the day after he left his former practice, he said.

Dr. Lamberts said about 200 of his former patients initially followed him to direct primary care and another 100 have joined since. Before departing his former office, he gave a presentation to his patients about the direct primary care model and what the structure entailed.

Making patients aware of direct primary care and how it works is a top challenge to the model, Dr. Ellzy of the AAFP said. Some patients incorrectly believe that DPC covers all health services including hospitalizations and surgeries. Many DPC patients still carry insurance for hospitalizations as well as specialist visits.

“Part of it is understanding what direct primary care is and isn’t as you move from an insurance basis,” Dr. Ellzy said. “A lot of it is patient education, That’s one of the biggest issues.”
 

Strong team, alternate mindset

Putting in place an efficient, dedicated staff is also key to establishing a fruitful DPC practice, Dr. Hsieh noted. He credits his practice director, Jami Feitz, with keeping things running smoothly through patient education and advocacy. Ms. Feitz aids patients in navigating specialist visits, medication access issues, and payment.

“You can have the best business plan, you can have the best economics, you can even have the best reputation in town, but if you don’t have someone to run the logistics of your practice, you’re sunk,” Dr. Hsieh said. “As soon as you walk out of the exam room, that patient is going into that fragmented, complicated health care system. They need someone experienced with the special skills to help them through that process”

Dr. Lamberts adds that of all the shifts necessary for a prosperous direct primary care practice, a different mindset is among the most important for physicians.

“It’s a big change in philosophy,” he said. “You suddenly are focused on keeping patients away from the office rather than having a full office. You’re focused on keeping people well, rather than benefiting from people getting sick. That’s a challenge to lose the mindset and to suddenly celebrate if you have a day that’s not very busy or your office is empty. That’s a good thing.”
 

Direct primary care by the numbers

A 2018 survey by AAFP of 148 direct primary care physicians reveals how doctors are structuring their practices.

• 80% charge a fee to patients and do not bill any third-party payer.
• 14% engage with one or more third-party payers.
• 54% are male.
• 56% are greater than 15 years post residency.
• 20% are less than 7 years post residency.
• 72% of practices have been in operation less than 3 years.
• 11% of practices have been in operation less than 1 year.
• 54% of practices started from scratch.
• 34% of practices were converted from an existing practice.
• 57% of practices have employer-based contracts.
• 29% of practices are interested in employer-based contracts.
• 58% of practices supplement their income through other practice opportunities.
• 345 patients is the average panel size.
• 596 is the average target panel size.
• 91% of physicians would promote the model to others.

SOURCE: The American Academy of Family Physicians

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After 30 years in a traditional family medicine practice, Jesse Hsieh, MD, was ready for a change.

Alicia Gallegos/MDedge News

Data entry and insurance paperwork had drastically reduced his time with patients, and practicing medicine was no longer enjoyable or meaningful, said Dr. Hsieh of Granger, Ind.

“I felt very strongly that we were not delivering the kind of care that could be the best for the patient,” he said. “I explored other ways I could continue to practice the way I wanted; spend time with patients, teach them about things, and not spend so much time with regulatory paperwork and insurance.”

The answer for Dr. Hsieh was direct primary care (DPC), a model that cuts out insurance and centers on unlimited physician access for a flat, membership fee. For $2,500 a year, Dr. Hsieh’s patients can schedule visits as often as they like and communicate with him as the need arises by phone, text, or email.

For Dr. Hsieh, the model allows for a more manageable panel size, ample time to spend with patients, and the ability to make a greater impact on their health.

“I’m practicing the way I did 30 years ago,” Dr. Hsieh said. “I’m spending more time with people, I can call the patient myself about their labs and results and take their questions. I spend a lot more time educating the patient.”

Dr. Hsieh is one of a growing number of physicians moving to direct primary care. In 2009, about 100 practices were providing direct primary care, according to Jay Keese, executive director for the Direct Primary Care Coalition. Today, about 1,000 practices in 48 states provide direct primary care to more than 300,000 patients.

A direct primary care practice can be designed in different ways, but most opt out of insurance and offer a flat fee to patients for all primary care provided, said James A. Ellzy, MD, a family physician in Washington who serves on the American Academy of Family Physicians (AAFP) board of directors. A smaller number of practices operate a hybrid structure that includes both direct patients and fee-for-service patients.

About 3% of AAFP members are currently practicing direct primary care, and another 1% are currently converting, according to the AAFP 2018 Practice Profile Survey.

Nationally, about a third of survey respondents said they were learning about or considering a conversion to direct primary care, while another third said they were unfamiliar with the concept. The AAFP is working to educate physicians about the model, including holding an annual DPC summit.

But the move to direct primary care isn’t a sure bet. Success requires significant preparation, marketing, and structuring, experts say.

“There [can be] challenges in building a practice from scratch after you’ve had a fee-for-service practice,” Mr. Keese said. “If you’ve had a panel size of 2,500 or 3,000, and you’re looking at filling in 600 to 800 patients, it can take some time, which can cause some economic stress. But I think most people who go into direct primary care are excited and never look back.


 

Preparing for transition

When Rob Lamberts, MD, left his traditional practice in 2012, there were few leaders in direct primary care and not many resources available.

“I ended up just kind of figuring it out myself,” said Dr. Lamberts, an internist based in Augusta, Ga. “Over the past 6 1/2 years, I’ve built the practice to about 800 patients.”

Today, Dr. Lamberts is highly satisfied with his work and is helping local colleagues set up similar practices. He charges patients between $35 and $70 a month, depending on age, and offers a family fee between $150 and $175 for up to five members. Services include: extended physician access, office visits, discounted in-house labs, and discounted medications dispensed from his office.

“The amount of paperwork I have to do is substantially less,” Dr. Lamberts said. “My income is at least the same, if not a little more. My quality of life is tons better, and the quality of care is so much better.

Before making the jump to direct primary care, do your research and talk to other doctors about their experiences, Dr. Lamberts advised.

One important consideration is what type of direct primary care design to choose – the direct-to-consumer route or the direct-to-employer road. The first model targets patients as members, while the latter contracts with employers to provide services to their employees.

“There has been a surge in amount of interest in direct primary care to employers,” said Michael Tetreault, editor in chief for the DPC Journal, a news source that conducts data analytics on concierge medicine and DPC practices.

Reader surveys conducted by the DPC Journal found that a growing number of DPC physicians are looking to partner with local employers. Of 141 DPC physicians in 2019, 52% expressed an interest in employer partnerships, up from 35% in 2015, according to data provided by Mr. Tetreault.

One example of such growth is Nextera Healthcare, a network that started out with a handful of physicians about 10 years ago and now has more than 50, according to CEO and founder Clint Flanagan, MD.

The network contracts with employers across Colorado and eight other states to provide direct primary care services to their employees. Once affiliated, Nextera operates the marketing, sales, accounting, legal, and development side of the business. Most Nextera physicians have an average of 15 years practice experience, Dr. Flanagan said. Physicians receive most of the monthly revenue generated by their patients; Nextera retains a portion. Dr. Flanagan declined to specify the exact percentage retained.
 

Attracting patients, starting strong

For Dr. Hsieh, being well known in his community and having built a reputation as a family physician contributed to his success in direct primary care. In addition to taking on leadership roles in the health care community over the years, Dr. Hsieh regularly offers perspective for local media regarding medical topics, plays in a popular band at charity events, and teaches courses at two major universities in the area.

“When starting out in this practice, you really have to have built a reputation in town,” said Dr. Hsieh. “In this city, we’ve already had people try direct primary care who have failed because they came out of residency or people didn’t know who they were. You really have to have had a reputation of quality and service and patients should know about you.”

In many cases, physicians can bring their patients with them into direct primary care practice; however, some may not be able to based on their prior employment contract. Dr. Hsieh, for example, could not speak about his new practice or market the business until the day after he left his former practice, he said.

Dr. Lamberts said about 200 of his former patients initially followed him to direct primary care and another 100 have joined since. Before departing his former office, he gave a presentation to his patients about the direct primary care model and what the structure entailed.

Making patients aware of direct primary care and how it works is a top challenge to the model, Dr. Ellzy of the AAFP said. Some patients incorrectly believe that DPC covers all health services including hospitalizations and surgeries. Many DPC patients still carry insurance for hospitalizations as well as specialist visits.

“Part of it is understanding what direct primary care is and isn’t as you move from an insurance basis,” Dr. Ellzy said. “A lot of it is patient education, That’s one of the biggest issues.”
 

Strong team, alternate mindset

Putting in place an efficient, dedicated staff is also key to establishing a fruitful DPC practice, Dr. Hsieh noted. He credits his practice director, Jami Feitz, with keeping things running smoothly through patient education and advocacy. Ms. Feitz aids patients in navigating specialist visits, medication access issues, and payment.

“You can have the best business plan, you can have the best economics, you can even have the best reputation in town, but if you don’t have someone to run the logistics of your practice, you’re sunk,” Dr. Hsieh said. “As soon as you walk out of the exam room, that patient is going into that fragmented, complicated health care system. They need someone experienced with the special skills to help them through that process”

Dr. Lamberts adds that of all the shifts necessary for a prosperous direct primary care practice, a different mindset is among the most important for physicians.

“It’s a big change in philosophy,” he said. “You suddenly are focused on keeping patients away from the office rather than having a full office. You’re focused on keeping people well, rather than benefiting from people getting sick. That’s a challenge to lose the mindset and to suddenly celebrate if you have a day that’s not very busy or your office is empty. That’s a good thing.”
 

Direct primary care by the numbers

A 2018 survey by AAFP of 148 direct primary care physicians reveals how doctors are structuring their practices.

• 80% charge a fee to patients and do not bill any third-party payer.
• 14% engage with one or more third-party payers.
• 54% are male.
• 56% are greater than 15 years post residency.
• 20% are less than 7 years post residency.
• 72% of practices have been in operation less than 3 years.
• 11% of practices have been in operation less than 1 year.
• 54% of practices started from scratch.
• 34% of practices were converted from an existing practice.
• 57% of practices have employer-based contracts.
• 29% of practices are interested in employer-based contracts.
• 58% of practices supplement their income through other practice opportunities.
• 345 patients is the average panel size.
• 596 is the average target panel size.
• 91% of physicians would promote the model to others.

SOURCE: The American Academy of Family Physicians

[email protected]

After 30 years in a traditional family medicine practice, Jesse Hsieh, MD, was ready for a change.

Alicia Gallegos/MDedge News

Data entry and insurance paperwork had drastically reduced his time with patients, and practicing medicine was no longer enjoyable or meaningful, said Dr. Hsieh of Granger, Ind.

“I felt very strongly that we were not delivering the kind of care that could be the best for the patient,” he said. “I explored other ways I could continue to practice the way I wanted; spend time with patients, teach them about things, and not spend so much time with regulatory paperwork and insurance.”

The answer for Dr. Hsieh was direct primary care (DPC), a model that cuts out insurance and centers on unlimited physician access for a flat, membership fee. For $2,500 a year, Dr. Hsieh’s patients can schedule visits as often as they like and communicate with him as the need arises by phone, text, or email.

For Dr. Hsieh, the model allows for a more manageable panel size, ample time to spend with patients, and the ability to make a greater impact on their health.

“I’m practicing the way I did 30 years ago,” Dr. Hsieh said. “I’m spending more time with people, I can call the patient myself about their labs and results and take their questions. I spend a lot more time educating the patient.”

Dr. Hsieh is one of a growing number of physicians moving to direct primary care. In 2009, about 100 practices were providing direct primary care, according to Jay Keese, executive director for the Direct Primary Care Coalition. Today, about 1,000 practices in 48 states provide direct primary care to more than 300,000 patients.

A direct primary care practice can be designed in different ways, but most opt out of insurance and offer a flat fee to patients for all primary care provided, said James A. Ellzy, MD, a family physician in Washington who serves on the American Academy of Family Physicians (AAFP) board of directors. A smaller number of practices operate a hybrid structure that includes both direct patients and fee-for-service patients.

About 3% of AAFP members are currently practicing direct primary care, and another 1% are currently converting, according to the AAFP 2018 Practice Profile Survey.

Nationally, about a third of survey respondents said they were learning about or considering a conversion to direct primary care, while another third said they were unfamiliar with the concept. The AAFP is working to educate physicians about the model, including holding an annual DPC summit.

But the move to direct primary care isn’t a sure bet. Success requires significant preparation, marketing, and structuring, experts say.

“There [can be] challenges in building a practice from scratch after you’ve had a fee-for-service practice,” Mr. Keese said. “If you’ve had a panel size of 2,500 or 3,000, and you’re looking at filling in 600 to 800 patients, it can take some time, which can cause some economic stress. But I think most people who go into direct primary care are excited and never look back.


 

Preparing for transition

When Rob Lamberts, MD, left his traditional practice in 2012, there were few leaders in direct primary care and not many resources available.

“I ended up just kind of figuring it out myself,” said Dr. Lamberts, an internist based in Augusta, Ga. “Over the past 6 1/2 years, I’ve built the practice to about 800 patients.”

Today, Dr. Lamberts is highly satisfied with his work and is helping local colleagues set up similar practices. He charges patients between $35 and $70 a month, depending on age, and offers a family fee between $150 and $175 for up to five members. Services include: extended physician access, office visits, discounted in-house labs, and discounted medications dispensed from his office.

“The amount of paperwork I have to do is substantially less,” Dr. Lamberts said. “My income is at least the same, if not a little more. My quality of life is tons better, and the quality of care is so much better.

Before making the jump to direct primary care, do your research and talk to other doctors about their experiences, Dr. Lamberts advised.

One important consideration is what type of direct primary care design to choose – the direct-to-consumer route or the direct-to-employer road. The first model targets patients as members, while the latter contracts with employers to provide services to their employees.

“There has been a surge in amount of interest in direct primary care to employers,” said Michael Tetreault, editor in chief for the DPC Journal, a news source that conducts data analytics on concierge medicine and DPC practices.

Reader surveys conducted by the DPC Journal found that a growing number of DPC physicians are looking to partner with local employers. Of 141 DPC physicians in 2019, 52% expressed an interest in employer partnerships, up from 35% in 2015, according to data provided by Mr. Tetreault.

One example of such growth is Nextera Healthcare, a network that started out with a handful of physicians about 10 years ago and now has more than 50, according to CEO and founder Clint Flanagan, MD.

The network contracts with employers across Colorado and eight other states to provide direct primary care services to their employees. Once affiliated, Nextera operates the marketing, sales, accounting, legal, and development side of the business. Most Nextera physicians have an average of 15 years practice experience, Dr. Flanagan said. Physicians receive most of the monthly revenue generated by their patients; Nextera retains a portion. Dr. Flanagan declined to specify the exact percentage retained.
 

Attracting patients, starting strong

For Dr. Hsieh, being well known in his community and having built a reputation as a family physician contributed to his success in direct primary care. In addition to taking on leadership roles in the health care community over the years, Dr. Hsieh regularly offers perspective for local media regarding medical topics, plays in a popular band at charity events, and teaches courses at two major universities in the area.

“When starting out in this practice, you really have to have built a reputation in town,” said Dr. Hsieh. “In this city, we’ve already had people try direct primary care who have failed because they came out of residency or people didn’t know who they were. You really have to have had a reputation of quality and service and patients should know about you.”

In many cases, physicians can bring their patients with them into direct primary care practice; however, some may not be able to based on their prior employment contract. Dr. Hsieh, for example, could not speak about his new practice or market the business until the day after he left his former practice, he said.

Dr. Lamberts said about 200 of his former patients initially followed him to direct primary care and another 100 have joined since. Before departing his former office, he gave a presentation to his patients about the direct primary care model and what the structure entailed.

Making patients aware of direct primary care and how it works is a top challenge to the model, Dr. Ellzy of the AAFP said. Some patients incorrectly believe that DPC covers all health services including hospitalizations and surgeries. Many DPC patients still carry insurance for hospitalizations as well as specialist visits.

“Part of it is understanding what direct primary care is and isn’t as you move from an insurance basis,” Dr. Ellzy said. “A lot of it is patient education, That’s one of the biggest issues.”
 

Strong team, alternate mindset

Putting in place an efficient, dedicated staff is also key to establishing a fruitful DPC practice, Dr. Hsieh noted. He credits his practice director, Jami Feitz, with keeping things running smoothly through patient education and advocacy. Ms. Feitz aids patients in navigating specialist visits, medication access issues, and payment.

“You can have the best business plan, you can have the best economics, you can even have the best reputation in town, but if you don’t have someone to run the logistics of your practice, you’re sunk,” Dr. Hsieh said. “As soon as you walk out of the exam room, that patient is going into that fragmented, complicated health care system. They need someone experienced with the special skills to help them through that process”

Dr. Lamberts adds that of all the shifts necessary for a prosperous direct primary care practice, a different mindset is among the most important for physicians.

“It’s a big change in philosophy,” he said. “You suddenly are focused on keeping patients away from the office rather than having a full office. You’re focused on keeping people well, rather than benefiting from people getting sick. That’s a challenge to lose the mindset and to suddenly celebrate if you have a day that’s not very busy or your office is empty. That’s a good thing.”
 

Direct primary care by the numbers

A 2018 survey by AAFP of 148 direct primary care physicians reveals how doctors are structuring their practices.

• 80% charge a fee to patients and do not bill any third-party payer.
• 14% engage with one or more third-party payers.
• 54% are male.
• 56% are greater than 15 years post residency.
• 20% are less than 7 years post residency.
• 72% of practices have been in operation less than 3 years.
• 11% of practices have been in operation less than 1 year.
• 54% of practices started from scratch.
• 34% of practices were converted from an existing practice.
• 57% of practices have employer-based contracts.
• 29% of practices are interested in employer-based contracts.
• 58% of practices supplement their income through other practice opportunities.
• 345 patients is the average panel size.
• 596 is the average target panel size.
• 91% of physicians would promote the model to others.

SOURCE: The American Academy of Family Physicians

[email protected]