SAN FRANCISCO – SGLT2 inhibitors did a better job than GLP-1 receptor agonists at preventing heart failure hospitalizations in elderly patients with type 2 diabetes, but at the cost of more strokes, myocardial infarctions, and deaths among those without preexisting cardiovascular disease, according to Harvard University investigators.

Using Medicare claims data and propensity scoring, they matched 43,609 elderly patients who started a sodium-glucose cotransporter 2 (SGLT2) inhibitor for type 2 diabetes, 77% of whom were taking canagliflozin (Invokana), to 43,609 who started a glucagonlike peptide–1 (GLP-1)–receptor agonist, 60% of whom were taking liraglutide (Victoza).

Patients were paired by age, comorbidities, diabetes severity, and dozens of other variables, more than 120 in all. The data window ran from April 2013 through December 2016.

The idea was to compare the drugs directly in order to help clinicians decide which class to choose for older patients as second-line therapy, an important consideration at a time when there’s not much guidance specifically for the elderly, and manufacturers are issuing dueling placebo-controlled trials.

Both classes have shown cardiovascular benefits, but studies were mostly in younger people with preexisting cardiovascular disease (CVD). “The comparative impact of these agents in the older population has not yet been established,” lead investigator Elisabetta Patorno, MD, DrPH, of Harvard University, Boston, said at the annual scientific sessions of the American Diabetes Association.

General themes are emerging from Dr. Patorno’s work; it seems that deciding between the two classes has a lot to do with whether the main concern is heart failure or cardiovascular events. Even so, she said, it’s too early to incorporate the observations into guidelines. The analysis is ongoing, and there are plans to compare impacts on renal disease and other problems.

In the meantime, she and her colleagues found that initiating an SGLT2 inhibitor versus a GLP-1 receptor agonist in the elderly was associated with a 34% decreased risk of heart failure hospitalization (2.5 fewer hospitalizations per 1,000 patient years), with an even larger drop among people who had preexisting CVD.

There was, however, a 41% increased risk of lower limb amputations (0.8 more events per 1,000 patient years) and a 62% increase in diabetic ketoacidosis (DKA, 1 more event), problems previously associated with the class.

Results were comparable – fewer heart failure hospitalizations but more amputations and DKA – when SGLT2 initiation was compared to initiation with dipeptidyl peptidase-4 (DPP-4) inhibitors, another second-line option for type 2 diabetes that includes sitagliptin (Januvia), among others.

There was a 25% increased relative risk of the composite primary outcome of myocardial infarction, stroke, and all-cause mortality when patients without baseline CVD were started on an SGLT2 inhibitor instead of a GLP-1 receptor agonist (3.7 more events per 1,000 patient years). There was no increased risk among patients who already had CVD.

SGLT2 initiation actually had a protective effect, compared with dipeptidyl peptidase-4 inhibitors, with a 23% decreased risk of the composite outcome (6.5 fewer events) among patients both with and without baseline CVD. The findings were all statistically significant.

The average age in the study was 71.5 years; 45% of the subjects were men; 40% had a history of cardiovascular disease; and 60% were on metformin and 24% on insulin at study entry.

The work was funded by the National Institutes of Health. Dr. Patorno disclosed research grants form Boehringer Ingelheim and GlaxoSmithKline. Other investigators reported relationships with numerous pharmaceutical companies.

[email protected]

SAN FRANCISCO – SGLT2 inhibitors did a better job than GLP-1 receptor agonists at preventing heart failure hospitalizations in elderly patients with type 2 diabetes, but at the cost of more strokes, myocardial infarctions, and deaths among those without preexisting cardiovascular disease, according to Harvard University investigators.

Using Medicare claims data and propensity scoring, they matched 43,609 elderly patients who started a sodium-glucose cotransporter 2 (SGLT2) inhibitor for type 2 diabetes, 77% of whom were taking canagliflozin (Invokana), to 43,609 who started a glucagonlike peptide–1 (GLP-1)–receptor agonist, 60% of whom were taking liraglutide (Victoza).

Patients were paired by age, comorbidities, diabetes severity, and dozens of other variables, more than 120 in all. The data window ran from April 2013 through December 2016.

The idea was to compare the drugs directly in order to help clinicians decide which class to choose for older patients as second-line therapy, an important consideration at a time when there’s not much guidance specifically for the elderly, and manufacturers are issuing dueling placebo-controlled trials.

Both classes have shown cardiovascular benefits, but studies were mostly in younger people with preexisting cardiovascular disease (CVD). “The comparative impact of these agents in the older population has not yet been established,” lead investigator Elisabetta Patorno, MD, DrPH, of Harvard University, Boston, said at the annual scientific sessions of the American Diabetes Association.

General themes are emerging from Dr. Patorno’s work; it seems that deciding between the two classes has a lot to do with whether the main concern is heart failure or cardiovascular events. Even so, she said, it’s too early to incorporate the observations into guidelines. The analysis is ongoing, and there are plans to compare impacts on renal disease and other problems.

In the meantime, she and her colleagues found that initiating an SGLT2 inhibitor versus a GLP-1 receptor agonist in the elderly was associated with a 34% decreased risk of heart failure hospitalization (2.5 fewer hospitalizations per 1,000 patient years), with an even larger drop among people who had preexisting CVD.

There was, however, a 41% increased risk of lower limb amputations (0.8 more events per 1,000 patient years) and a 62% increase in diabetic ketoacidosis (DKA, 1 more event), problems previously associated with the class.

Results were comparable – fewer heart failure hospitalizations but more amputations and DKA – when SGLT2 initiation was compared to initiation with dipeptidyl peptidase-4 (DPP-4) inhibitors, another second-line option for type 2 diabetes that includes sitagliptin (Januvia), among others.

There was a 25% increased relative risk of the composite primary outcome of myocardial infarction, stroke, and all-cause mortality when patients without baseline CVD were started on an SGLT2 inhibitor instead of a GLP-1 receptor agonist (3.7 more events per 1,000 patient years). There was no increased risk among patients who already had CVD.

SGLT2 initiation actually had a protective effect, compared with dipeptidyl peptidase-4 inhibitors, with a 23% decreased risk of the composite outcome (6.5 fewer events) among patients both with and without baseline CVD. The findings were all statistically significant.

The average age in the study was 71.5 years; 45% of the subjects were men; 40% had a history of cardiovascular disease; and 60% were on metformin and 24% on insulin at study entry.

The work was funded by the National Institutes of Health. Dr. Patorno disclosed research grants form Boehringer Ingelheim and GlaxoSmithKline. Other investigators reported relationships with numerous pharmaceutical companies.

[email protected]

SAN FRANCISCO – SGLT2 inhibitors did a better job than GLP-1 receptor agonists at preventing heart failure hospitalizations in elderly patients with type 2 diabetes, but at the cost of more strokes, myocardial infarctions, and deaths among those without preexisting cardiovascular disease, according to Harvard University investigators.

Using Medicare claims data and propensity scoring, they matched 43,609 elderly patients who started a sodium-glucose cotransporter 2 (SGLT2) inhibitor for type 2 diabetes, 77% of whom were taking canagliflozin (Invokana), to 43,609 who started a glucagonlike peptide–1 (GLP-1)–receptor agonist, 60% of whom were taking liraglutide (Victoza).

Patients were paired by age, comorbidities, diabetes severity, and dozens of other variables, more than 120 in all. The data window ran from April 2013 through December 2016.

The idea was to compare the drugs directly in order to help clinicians decide which class to choose for older patients as second-line therapy, an important consideration at a time when there’s not much guidance specifically for the elderly, and manufacturers are issuing dueling placebo-controlled trials.

Both classes have shown cardiovascular benefits, but studies were mostly in younger people with preexisting cardiovascular disease (CVD). “The comparative impact of these agents in the older population has not yet been established,” lead investigator Elisabetta Patorno, MD, DrPH, of Harvard University, Boston, said at the annual scientific sessions of the American Diabetes Association.

General themes are emerging from Dr. Patorno’s work; it seems that deciding between the two classes has a lot to do with whether the main concern is heart failure or cardiovascular events. Even so, she said, it’s too early to incorporate the observations into guidelines. The analysis is ongoing, and there are plans to compare impacts on renal disease and other problems.

In the meantime, she and her colleagues found that initiating an SGLT2 inhibitor versus a GLP-1 receptor agonist in the elderly was associated with a 34% decreased risk of heart failure hospitalization (2.5 fewer hospitalizations per 1,000 patient years), with an even larger drop among people who had preexisting CVD.

There was, however, a 41% increased risk of lower limb amputations (0.8 more events per 1,000 patient years) and a 62% increase in diabetic ketoacidosis (DKA, 1 more event), problems previously associated with the class.

Results were comparable – fewer heart failure hospitalizations but more amputations and DKA – when SGLT2 initiation was compared to initiation with dipeptidyl peptidase-4 (DPP-4) inhibitors, another second-line option for type 2 diabetes that includes sitagliptin (Januvia), among others.

There was a 25% increased relative risk of the composite primary outcome of myocardial infarction, stroke, and all-cause mortality when patients without baseline CVD were started on an SGLT2 inhibitor instead of a GLP-1 receptor agonist (3.7 more events per 1,000 patient years). There was no increased risk among patients who already had CVD.

SGLT2 initiation actually had a protective effect, compared with dipeptidyl peptidase-4 inhibitors, with a 23% decreased risk of the composite outcome (6.5 fewer events) among patients both with and without baseline CVD. The findings were all statistically significant.

The average age in the study was 71.5 years; 45% of the subjects were men; 40% had a history of cardiovascular disease; and 60% were on metformin and 24% on insulin at study entry.

The work was funded by the National Institutes of Health. Dr. Patorno disclosed research grants form Boehringer Ingelheim and GlaxoSmithKline. Other investigators reported relationships with numerous pharmaceutical companies.

[email protected]

Since the inception of hospital medicine more than 2 decades ago, the total number of hospitalists has rapidly increased to more than 60,000. The Society of Hospital Medicine’s State of Hospital Medicine Report (SoHM), published biennially, captures new changes in our growing field and sheds light on current practice trends.

Among its findings, the 2018 SoHM Report reassuringly reveals that financial support from hospitals to hospital medicine groups (HMGs) continues to climb, even in the setting of rising health care costs and ongoing budget pressure.

The median amount of financial support per full-time equivalent (FTE) physician for HMGs serving adults was $176,658, according to the 2018 SoHM Report, which is up 12% from the 2016 median of $157,535. While there is no correlation between group sizes and the amount of financial support per FTE physician, there are significant differences across regions, with HMGs in the Midwest garnering the highest median support, at $193,121 per FTE physician.

The report also reveals big differences by employment model. For example, private multispecialty and primary care medical groups receive much less financial support ($58,396 per FTE physician) than HMGs employed by hospitals. This likely signifies that their main source of revenue is from professional service fees. Regardless of the types of employment models, past surveys have reported more than 95% of HMGs receive support from their hospitals to help cover expenses.

The median amount of financial support per FTE provider (including nurse practitioners, physician assistants, and locum tenens) was $134,300, which represents a 3.3% decrease, compared with the 2016 SoHM Report. For the first time, the 2018 SoHM also collected data on financial support per “work relative value unit” (wRVU) in addition to support per FTE physician and support per FTE provider. HMGs and their hospitals can use support per wRVU data to evaluate the support per unit of work, regardless of who (whether it is a physician, an advanced practice provider, and/or others) performed that work.

The median amount of financial support per wRVU for HMGs serving adults in 2018 was $41.92, with academic HMGs reporting a higher amount ($45.81) than nonacademic HMGs ($41.28). It will be interesting to track these numbers over time.

One of the most intriguing findings from the SHM’s 2018 SoHM Report is that financial support has risen despite relatively flat professional fee productivity (see Figure 1). Productivity, calculated as work relative value units (wRVUs) per physician declined slightly from 4,252 in 2016 to 4,147 in 2018.

There may be a few reasons why wRVUs per physician has remained relatively unchanged over the years. Many hospitals emphasize quality of care above provider productivity. The volume-to-value shift in theory serves as a means to reduce hospital-associated complications, length of stay, and readmission rates, thereby avoiding penalties and saving the overall costs for the hospitals in the long run.

Hospitalists involved in quality improvement projects and other essential nonclinical work perform tasks that are rarely captured in the wRVU metric. Improving patient experience, one of the Triple Aim components, necessitates extra time and effort, which also are nonbillable. In addition, increasing productivity can be challenging, a double-edged sword that may further escalate burnout and turnover rates. The static productivity may portend that it has leveled off or hit the ceiling in spite of ongoing efforts to improve efficacy.

In my view, the decision to invest in hospitalists for their contributions and dedications should not be determined based on a single metric such as wRVUs per physician. Hospitalist work on quality improvements; patient safety; efficiency, from direct bedside patient care to nonclinical efforts; teaching; research; involvements in various committees; administrative tasks; and leadership roles in improving health care systems are immeasurable. These are the reasons that most hospitals chose to adopt the hospitalist model and continue to support it. In fact, demand for hospitalists still outstrips supply, as evidenced by more than half of the hospital medicine groups with unfilled positions and an overall high turnover rate per 2018 SoHM data.

Although hospitalists are needed for the value that they provide, they should not take the status quo for granted. Instead, in return for the favorable financial support and in appreciation of being valued, hospitalists have a responsibility to prove that they are the right group chosen to do the work and help achieve their hospital’s mission and goals.

Dr. Vuong is a hospitalist at HealthPartners Medical Group in St Paul, Minn., and an assistant professor of medicine at the University of Minnesota. He is a member of SHM’s Practice Analysis Committee.

References

Afsar N. Looking into the Future and Making History. Hospitalist. 2019;23(1):31.

Beresford L. The State of Hospital Medicine in 2018. Hospitalist. 2019;23(1):1-11.

FitzGerald S. Not a Time for Modesty. Oct. 2009. Retrieved from https://acphospitalist.org/archives/2009/10/value.htm.

Watcher RM et al. Zero to 50,000 – The 20th Anniversary of the Hospitalist. N Eng J Med. 2016. 375(11):1009-11.

Since the inception of hospital medicine more than 2 decades ago, the total number of hospitalists has rapidly increased to more than 60,000. The Society of Hospital Medicine’s State of Hospital Medicine Report (SoHM), published biennially, captures new changes in our growing field and sheds light on current practice trends.

Among its findings, the 2018 SoHM Report reassuringly reveals that financial support from hospitals to hospital medicine groups (HMGs) continues to climb, even in the setting of rising health care costs and ongoing budget pressure.

The median amount of financial support per full-time equivalent (FTE) physician for HMGs serving adults was $176,658, according to the 2018 SoHM Report, which is up 12% from the 2016 median of $157,535. While there is no correlation between group sizes and the amount of financial support per FTE physician, there are significant differences across regions, with HMGs in the Midwest garnering the highest median support, at $193,121 per FTE physician.

The report also reveals big differences by employment model. For example, private multispecialty and primary care medical groups receive much less financial support ($58,396 per FTE physician) than HMGs employed by hospitals. This likely signifies that their main source of revenue is from professional service fees. Regardless of the types of employment models, past surveys have reported more than 95% of HMGs receive support from their hospitals to help cover expenses.

The median amount of financial support per FTE provider (including nurse practitioners, physician assistants, and locum tenens) was $134,300, which represents a 3.3% decrease, compared with the 2016 SoHM Report. For the first time, the 2018 SoHM also collected data on financial support per “work relative value unit” (wRVU) in addition to support per FTE physician and support per FTE provider. HMGs and their hospitals can use support per wRVU data to evaluate the support per unit of work, regardless of who (whether it is a physician, an advanced practice provider, and/or others) performed that work.

The median amount of financial support per wRVU for HMGs serving adults in 2018 was $41.92, with academic HMGs reporting a higher amount ($45.81) than nonacademic HMGs ($41.28). It will be interesting to track these numbers over time.

One of the most intriguing findings from the SHM’s 2018 SoHM Report is that financial support has risen despite relatively flat professional fee productivity (see Figure 1). Productivity, calculated as work relative value units (wRVUs) per physician declined slightly from 4,252 in 2016 to 4,147 in 2018.

There may be a few reasons why wRVUs per physician has remained relatively unchanged over the years. Many hospitals emphasize quality of care above provider productivity. The volume-to-value shift in theory serves as a means to reduce hospital-associated complications, length of stay, and readmission rates, thereby avoiding penalties and saving the overall costs for the hospitals in the long run.

Hospitalists involved in quality improvement projects and other essential nonclinical work perform tasks that are rarely captured in the wRVU metric. Improving patient experience, one of the Triple Aim components, necessitates extra time and effort, which also are nonbillable. In addition, increasing productivity can be challenging, a double-edged sword that may further escalate burnout and turnover rates. The static productivity may portend that it has leveled off or hit the ceiling in spite of ongoing efforts to improve efficacy.

In my view, the decision to invest in hospitalists for their contributions and dedications should not be determined based on a single metric such as wRVUs per physician. Hospitalist work on quality improvements; patient safety; efficiency, from direct bedside patient care to nonclinical efforts; teaching; research; involvements in various committees; administrative tasks; and leadership roles in improving health care systems are immeasurable. These are the reasons that most hospitals chose to adopt the hospitalist model and continue to support it. In fact, demand for hospitalists still outstrips supply, as evidenced by more than half of the hospital medicine groups with unfilled positions and an overall high turnover rate per 2018 SoHM data.

Although hospitalists are needed for the value that they provide, they should not take the status quo for granted. Instead, in return for the favorable financial support and in appreciation of being valued, hospitalists have a responsibility to prove that they are the right group chosen to do the work and help achieve their hospital’s mission and goals.

Dr. Vuong is a hospitalist at HealthPartners Medical Group in St Paul, Minn., and an assistant professor of medicine at the University of Minnesota. He is a member of SHM’s Practice Analysis Committee.

References

Afsar N. Looking into the Future and Making History. Hospitalist. 2019;23(1):31.

Beresford L. The State of Hospital Medicine in 2018. Hospitalist. 2019;23(1):1-11.

FitzGerald S. Not a Time for Modesty. Oct. 2009. Retrieved from https://acphospitalist.org/archives/2009/10/value.htm.

Watcher RM et al. Zero to 50,000 – The 20th Anniversary of the Hospitalist. N Eng J Med. 2016. 375(11):1009-11.

Since the inception of hospital medicine more than 2 decades ago, the total number of hospitalists has rapidly increased to more than 60,000. The Society of Hospital Medicine’s State of Hospital Medicine Report (SoHM), published biennially, captures new changes in our growing field and sheds light on current practice trends.

Among its findings, the 2018 SoHM Report reassuringly reveals that financial support from hospitals to hospital medicine groups (HMGs) continues to climb, even in the setting of rising health care costs and ongoing budget pressure.

The median amount of financial support per full-time equivalent (FTE) physician for HMGs serving adults was $176,658, according to the 2018 SoHM Report, which is up 12% from the 2016 median of $157,535. While there is no correlation between group sizes and the amount of financial support per FTE physician, there are significant differences across regions, with HMGs in the Midwest garnering the highest median support, at $193,121 per FTE physician.

The report also reveals big differences by employment model. For example, private multispecialty and primary care medical groups receive much less financial support ($58,396 per FTE physician) than HMGs employed by hospitals. This likely signifies that their main source of revenue is from professional service fees. Regardless of the types of employment models, past surveys have reported more than 95% of HMGs receive support from their hospitals to help cover expenses.

The median amount of financial support per FTE provider (including nurse practitioners, physician assistants, and locum tenens) was $134,300, which represents a 3.3% decrease, compared with the 2016 SoHM Report. For the first time, the 2018 SoHM also collected data on financial support per “work relative value unit” (wRVU) in addition to support per FTE physician and support per FTE provider. HMGs and their hospitals can use support per wRVU data to evaluate the support per unit of work, regardless of who (whether it is a physician, an advanced practice provider, and/or others) performed that work.

The median amount of financial support per wRVU for HMGs serving adults in 2018 was $41.92, with academic HMGs reporting a higher amount ($45.81) than nonacademic HMGs ($41.28). It will be interesting to track these numbers over time.

One of the most intriguing findings from the SHM’s 2018 SoHM Report is that financial support has risen despite relatively flat professional fee productivity (see Figure 1). Productivity, calculated as work relative value units (wRVUs) per physician declined slightly from 4,252 in 2016 to 4,147 in 2018.

There may be a few reasons why wRVUs per physician has remained relatively unchanged over the years. Many hospitals emphasize quality of care above provider productivity. The volume-to-value shift in theory serves as a means to reduce hospital-associated complications, length of stay, and readmission rates, thereby avoiding penalties and saving the overall costs for the hospitals in the long run.

Hospitalists involved in quality improvement projects and other essential nonclinical work perform tasks that are rarely captured in the wRVU metric. Improving patient experience, one of the Triple Aim components, necessitates extra time and effort, which also are nonbillable. In addition, increasing productivity can be challenging, a double-edged sword that may further escalate burnout and turnover rates. The static productivity may portend that it has leveled off or hit the ceiling in spite of ongoing efforts to improve efficacy.

In my view, the decision to invest in hospitalists for their contributions and dedications should not be determined based on a single metric such as wRVUs per physician. Hospitalist work on quality improvements; patient safety; efficiency, from direct bedside patient care to nonclinical efforts; teaching; research; involvements in various committees; administrative tasks; and leadership roles in improving health care systems are immeasurable. These are the reasons that most hospitals chose to adopt the hospitalist model and continue to support it. In fact, demand for hospitalists still outstrips supply, as evidenced by more than half of the hospital medicine groups with unfilled positions and an overall high turnover rate per 2018 SoHM data.

Although hospitalists are needed for the value that they provide, they should not take the status quo for granted. Instead, in return for the favorable financial support and in appreciation of being valued, hospitalists have a responsibility to prove that they are the right group chosen to do the work and help achieve their hospital’s mission and goals.

Dr. Vuong is a hospitalist at HealthPartners Medical Group in St Paul, Minn., and an assistant professor of medicine at the University of Minnesota. He is a member of SHM’s Practice Analysis Committee.

References

Afsar N. Looking into the Future and Making History. Hospitalist. 2019;23(1):31.

Beresford L. The State of Hospital Medicine in 2018. Hospitalist. 2019;23(1):1-11.

FitzGerald S. Not a Time for Modesty. Oct. 2009. Retrieved from https://acphospitalist.org/archives/2009/10/value.htm.

Watcher RM et al. Zero to 50,000 – The 20th Anniversary of the Hospitalist. N Eng J Med. 2016. 375(11):1009-11.

While most Republicans used their time at the House Ways & Means Committee hearing on Medicare-for-all to trash the concept, one rogue member criticized the hearing as simply misguided.

Courtesy YouTube

“We are living a time of disruption,” Rep. David Schweikert (R-Ariz) said. “There is incredible technology that is about to crash the price of health care if this committee particularly is willing to challenge and do something that’s incredibly uncomfortable for those of us in elective office, and that is look incumbent providers, business, insurers, systems in the face and say ‘it’s time for the revolution.’

“Are we willing to talk to our hospitals, talk to our providers, talk to technology, talk to the FDA [Food and Drug Administration], and have the honest discussion that this is about to become your primary care physician,” he said, raising a smartphone in his hand. “We will be healthier because it is individualized to us instead of what is going here in the discussion of a collectivization of a system that is already pretty crappy.”

He cited the recent Medicare Trustees Report showing that the hospital insurance trust fund (Medicare Part A) is 6.5 years from insolvency. “I don’t know why this hearing isn’t about Medicare itself and protecting Medicare itself instead of nationalization of health care. ... So defending the current system is absurd for all of us.”

The partisan nature of the June 12 hearing was clear.

Republican committee members focused their questioning on Grace-Marie Turner, president of the conservative Galen Institute and an outspoken opponent of Medicare-for-all. Less attention was paid to witnesses who offered alternatives to achieving greater health care coverage for the population.

Ranking member Kevin Brady (R-Texas) set the tone in his opening statement: “While our American health care system does have real problems, we should focus on improving what’s working and to fix what’s broken, rather than starting over with a massive new socialized medicine scheme that will leave many families worse off,” he said.

He noted that the federal government is on the cusp of yet another shutdown after three shutdowns in 2018. “The federal government can’t even keep its doors open. Can you really trust Washington with your life-and-death health care decisions? Make no mistake, Medicare-for-all guts quality health care in favor of delays and long waiting lines. It gives Washington politicians unlimited control over your health care. It cancels good quality health care plans for millions of workers, children, and the elderly and is so costly – tens of trillions of dollars – it will bankrupt America.”

Ms. Turner was regularly called upon to back up these talking points, using an analysis of a specific legislative proposal (H.R. 1384), in which she noted that under that specific Medicare-for-all bill, “Washington would be deciding what benefits people are eligible to receive. It will be deciding how much providers will be paid, so yes, it significantly limits choices of individuals and we see this, of course, in other countries as well.”

And while Republicans were using the testimony of Ms. Turner to back up their agenda, no one queried Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and president emeritus and senior fellow at the Institute for Healthcare Improvement, who testified in support of a Medicare-for-all program – that the true impact of any universal coverage plan is dependent upon the program’s design.

One common GOP criticism throughout the hearing was that there would be a 40% reduction in pay to physicians and hospitals because the higher payments rates from private insurers that currently help offset lower payments from Medicare and Medicaid would be lost.

“The rhetoric we are hearing about 40% cuts is not necessary,” Dr. Berwick testified. “We can have sensible payment under an expanded Medicare system. That’s rhetoric, not fact. That’s in the design.”

[email protected]

While most Republicans used their time at the House Ways & Means Committee hearing on Medicare-for-all to trash the concept, one rogue member criticized the hearing as simply misguided.

Courtesy YouTube

“We are living a time of disruption,” Rep. David Schweikert (R-Ariz) said. “There is incredible technology that is about to crash the price of health care if this committee particularly is willing to challenge and do something that’s incredibly uncomfortable for those of us in elective office, and that is look incumbent providers, business, insurers, systems in the face and say ‘it’s time for the revolution.’

“Are we willing to talk to our hospitals, talk to our providers, talk to technology, talk to the FDA [Food and Drug Administration], and have the honest discussion that this is about to become your primary care physician,” he said, raising a smartphone in his hand. “We will be healthier because it is individualized to us instead of what is going here in the discussion of a collectivization of a system that is already pretty crappy.”

He cited the recent Medicare Trustees Report showing that the hospital insurance trust fund (Medicare Part A) is 6.5 years from insolvency. “I don’t know why this hearing isn’t about Medicare itself and protecting Medicare itself instead of nationalization of health care. ... So defending the current system is absurd for all of us.”

The partisan nature of the June 12 hearing was clear.

Republican committee members focused their questioning on Grace-Marie Turner, president of the conservative Galen Institute and an outspoken opponent of Medicare-for-all. Less attention was paid to witnesses who offered alternatives to achieving greater health care coverage for the population.

Ranking member Kevin Brady (R-Texas) set the tone in his opening statement: “While our American health care system does have real problems, we should focus on improving what’s working and to fix what’s broken, rather than starting over with a massive new socialized medicine scheme that will leave many families worse off,” he said.

He noted that the federal government is on the cusp of yet another shutdown after three shutdowns in 2018. “The federal government can’t even keep its doors open. Can you really trust Washington with your life-and-death health care decisions? Make no mistake, Medicare-for-all guts quality health care in favor of delays and long waiting lines. It gives Washington politicians unlimited control over your health care. It cancels good quality health care plans for millions of workers, children, and the elderly and is so costly – tens of trillions of dollars – it will bankrupt America.”

Ms. Turner was regularly called upon to back up these talking points, using an analysis of a specific legislative proposal (H.R. 1384), in which she noted that under that specific Medicare-for-all bill, “Washington would be deciding what benefits people are eligible to receive. It will be deciding how much providers will be paid, so yes, it significantly limits choices of individuals and we see this, of course, in other countries as well.”

And while Republicans were using the testimony of Ms. Turner to back up their agenda, no one queried Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and president emeritus and senior fellow at the Institute for Healthcare Improvement, who testified in support of a Medicare-for-all program – that the true impact of any universal coverage plan is dependent upon the program’s design.

One common GOP criticism throughout the hearing was that there would be a 40% reduction in pay to physicians and hospitals because the higher payments rates from private insurers that currently help offset lower payments from Medicare and Medicaid would be lost.

“The rhetoric we are hearing about 40% cuts is not necessary,” Dr. Berwick testified. “We can have sensible payment under an expanded Medicare system. That’s rhetoric, not fact. That’s in the design.”

[email protected]

While most Republicans used their time at the House Ways & Means Committee hearing on Medicare-for-all to trash the concept, one rogue member criticized the hearing as simply misguided.

Courtesy YouTube

“We are living a time of disruption,” Rep. David Schweikert (R-Ariz) said. “There is incredible technology that is about to crash the price of health care if this committee particularly is willing to challenge and do something that’s incredibly uncomfortable for those of us in elective office, and that is look incumbent providers, business, insurers, systems in the face and say ‘it’s time for the revolution.’

“Are we willing to talk to our hospitals, talk to our providers, talk to technology, talk to the FDA [Food and Drug Administration], and have the honest discussion that this is about to become your primary care physician,” he said, raising a smartphone in his hand. “We will be healthier because it is individualized to us instead of what is going here in the discussion of a collectivization of a system that is already pretty crappy.”

He cited the recent Medicare Trustees Report showing that the hospital insurance trust fund (Medicare Part A) is 6.5 years from insolvency. “I don’t know why this hearing isn’t about Medicare itself and protecting Medicare itself instead of nationalization of health care. ... So defending the current system is absurd for all of us.”

The partisan nature of the June 12 hearing was clear.

Republican committee members focused their questioning on Grace-Marie Turner, president of the conservative Galen Institute and an outspoken opponent of Medicare-for-all. Less attention was paid to witnesses who offered alternatives to achieving greater health care coverage for the population.

Ranking member Kevin Brady (R-Texas) set the tone in his opening statement: “While our American health care system does have real problems, we should focus on improving what’s working and to fix what’s broken, rather than starting over with a massive new socialized medicine scheme that will leave many families worse off,” he said.

He noted that the federal government is on the cusp of yet another shutdown after three shutdowns in 2018. “The federal government can’t even keep its doors open. Can you really trust Washington with your life-and-death health care decisions? Make no mistake, Medicare-for-all guts quality health care in favor of delays and long waiting lines. It gives Washington politicians unlimited control over your health care. It cancels good quality health care plans for millions of workers, children, and the elderly and is so costly – tens of trillions of dollars – it will bankrupt America.”

Ms. Turner was regularly called upon to back up these talking points, using an analysis of a specific legislative proposal (H.R. 1384), in which she noted that under that specific Medicare-for-all bill, “Washington would be deciding what benefits people are eligible to receive. It will be deciding how much providers will be paid, so yes, it significantly limits choices of individuals and we see this, of course, in other countries as well.”

And while Republicans were using the testimony of Ms. Turner to back up their agenda, no one queried Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and president emeritus and senior fellow at the Institute for Healthcare Improvement, who testified in support of a Medicare-for-all program – that the true impact of any universal coverage plan is dependent upon the program’s design.

One common GOP criticism throughout the hearing was that there would be a 40% reduction in pay to physicians and hospitals because the higher payments rates from private insurers that currently help offset lower payments from Medicare and Medicaid would be lost.

“The rhetoric we are hearing about 40% cuts is not necessary,” Dr. Berwick testified. “We can have sensible payment under an expanded Medicare system. That’s rhetoric, not fact. That’s in the design.”

[email protected]

MILAN – A teletriage approach significantly reduced the waiting time for underserved patients to see dermatologists in a specialty outreach clinic, and optimized primary care physicians’ care of nonreferred patients, Cory Simpson, MD, PhD, reported at the World Congress of Dermatology.

Kari Oakes/MDedge News

With implementation of teledermatology, patient wait times for specialist input dropped from 13.9 days to 1.6 days (P less than .00001).

By allowing dermatologists to evaluate photographs of lesions and perform their own triage of referrals from primary care physicians (PCPs), the teletriage pilot program reduced the number of patients for whom dermatology consults were deemed necessary and also allowed optimal management for the nonreferred patients, said Dr. Simpson, of the University of Pennsylvania, Philadelphia.

“Teledermatology has the potential to increase access to dermatologist-level care, especially for underserved patients,” he commented. “It allows us to educate primary care physicians in resource-limited settings, and it also allows us to avoid suboptimal care of skin disease by nonspecialists – especially the more judicious use of antimicrobial agents and corticosteroids.”

Dr. Simpson explained to the international audience that, for many in the United States, access to a dermatologist requires a lengthy wait that can extend to months.

In Philadelphia, University of Pennsylvania dermatology residents and attending physicians volunteer in an outreach program that serves an uninsured population of primarily Latino immigrants. Operating 1 or 2 evenings a month, the medical and surgical dermatology clinics can accommodate from 8-12 appointments per clinic.

The clinic had been overwhelmed with referrals from PCPs, but Dr. Simpson and his colleagues realized that many of the conditions they were seeing – verruca vulgaris, hand dermatitis, and psoriasis, for example – did not necessarily need a face-to-face dermatologic evaluation.

The AccessDerm app, available at no cost by the American Academy of Dermatology, allows PCPs and dermatologists to communicate and collaborate. “This is a store-and-forward program, meaning the primary physician takes the photos and sends them to an off-site dermatologist who can then review them at his or her convenience,” Dr. Simpson said. “It’s a smartphone-based app, so actually, while I was at this conference, even though I’m thousands of miles from Philadelphia, I got through three consults this morning on my smartphone. It’s a very convenient way to be a volunteer.”

The consultation is between the PCP and the dermatologist, he added. “It’s the dermatologist talking to the PCP, and the patient receives the care recommendations from their primary doctor – so there’s no direct communication with the patient.”

Using the app, PCPs photographed skin lesions and completed simple history and physical exam modules within the app. Then, Dr. Simpson and his dermatology colleagues reviewed the photos and pertinent information.

If diagnostic uncertainty persisted after the teledermatology review, or if Dr. Simpson and his colleagues judged that a procedure such as a biopsy or lesion destruction was required, then the patient was scheduled for an appointment, with an interim plan put in place. Otherwise, patients were managed by teledermatology alone.

Of the 131 patients involved in the pilot study, 48 (37%) were female; the average patient age was 31.7 years (range, 1-92 years).

About 40% of patients were seen for inflammatory conditions, and another 20% for nonpigmented neoplasms. Almost 18% were seen for infectious reasons, with the remainder divided between pigmented neoplasms, hair disorders, and other conditions.

It turned out, said Dr. Simpson, that about two-thirds (65%) of the teletriage consultations ended in a definitive plan not requiring a face-to-face dermatology appointment. About a quarter (23%) were deferred to an in-person dermatology appointment, and the remaining 12% had an interim plan while more information was gathered.

Of the 32 neoplasms addressed by the teletriage strategy, 21 (66%) were deferred to an in-person visit. By contrast, 24 of the 95 non–neoplastic teletriage encounters were deferred to an in-person visit (P less than .001).

Overall, the strategy opened up 18% more appointment slots for new patients, Dr. Simpson said.

As part of the teletriage process, PCPs provided their proposed plan of care before receiving a dermatologist’s advice. When comparing the PCP’s plan to the dermatologist’s final plan, he and his colleagues found that there was a complete change of plan for three-quarters of visits (76%). A partial change happened 14% of the time, and only one in ten patients had no change in treatment plan as a result of the teledermatology consult. “This indicates again that specialist input matters,” he noted.

“This also gives us an opportunity to educate primary care physicians,” Dr. Simpson said, pointing out that in replies, he and his dermatologist colleagues included information about common diagnoses, including first-line treatments and “worrisome features they should be thinking about.”

He and his collaborators found that proper treatment would have been provided 30% of the time without a teledermatology consult, but that patients would have been undertreated 27% of the time. Overtreatment would have occurred at a rate of 11%, and care would have been unnecessarily delayed for about one in four patients. Unnecessary ED visits were averted for 6% of patients with the teletriage approach.

Examples of undertreatment included use of a weak topical steroid, missing infections or the need for referral, and using a suboptimal acne regimen. On the other hand, Dr. Simpson said, overtreatment with unnecessary antibiotics, antifungals, and antivirals also was averted; on some occasions, the PCP plan for an oral corticosteroid or an overly potent topical steroid was shifted to a more appropriate plan by teledermatology.

In sum, said Dr. Simpson, “teletriage via AccessDerm allowed us to reduce by tenfold the wait time for specialist input in dermatology cases. We were able to remove almost two-thirds of people from the queue ... waiting for dermatology appointments, which was very helpful to our clinic.”

And most importantly, he added, “this allowed us to allocate the limited number of in-person appointments that we had at this volunteer clinic to those that were more complicated cases.”

Dr. Simpson reported that he had no relevant disclosures. The project was funded by Penn Medicine and the American Academy of Dermatology.

[email protected]

MILAN – A teletriage approach significantly reduced the waiting time for underserved patients to see dermatologists in a specialty outreach clinic, and optimized primary care physicians’ care of nonreferred patients, Cory Simpson, MD, PhD, reported at the World Congress of Dermatology.

Kari Oakes/MDedge News

With implementation of teledermatology, patient wait times for specialist input dropped from 13.9 days to 1.6 days (P less than .00001).

By allowing dermatologists to evaluate photographs of lesions and perform their own triage of referrals from primary care physicians (PCPs), the teletriage pilot program reduced the number of patients for whom dermatology consults were deemed necessary and also allowed optimal management for the nonreferred patients, said Dr. Simpson, of the University of Pennsylvania, Philadelphia.

“Teledermatology has the potential to increase access to dermatologist-level care, especially for underserved patients,” he commented. “It allows us to educate primary care physicians in resource-limited settings, and it also allows us to avoid suboptimal care of skin disease by nonspecialists – especially the more judicious use of antimicrobial agents and corticosteroids.”

Dr. Simpson explained to the international audience that, for many in the United States, access to a dermatologist requires a lengthy wait that can extend to months.

In Philadelphia, University of Pennsylvania dermatology residents and attending physicians volunteer in an outreach program that serves an uninsured population of primarily Latino immigrants. Operating 1 or 2 evenings a month, the medical and surgical dermatology clinics can accommodate from 8-12 appointments per clinic.

The clinic had been overwhelmed with referrals from PCPs, but Dr. Simpson and his colleagues realized that many of the conditions they were seeing – verruca vulgaris, hand dermatitis, and psoriasis, for example – did not necessarily need a face-to-face dermatologic evaluation.

The AccessDerm app, available at no cost by the American Academy of Dermatology, allows PCPs and dermatologists to communicate and collaborate. “This is a store-and-forward program, meaning the primary physician takes the photos and sends them to an off-site dermatologist who can then review them at his or her convenience,” Dr. Simpson said. “It’s a smartphone-based app, so actually, while I was at this conference, even though I’m thousands of miles from Philadelphia, I got through three consults this morning on my smartphone. It’s a very convenient way to be a volunteer.”

The consultation is between the PCP and the dermatologist, he added. “It’s the dermatologist talking to the PCP, and the patient receives the care recommendations from their primary doctor – so there’s no direct communication with the patient.”

Using the app, PCPs photographed skin lesions and completed simple history and physical exam modules within the app. Then, Dr. Simpson and his dermatology colleagues reviewed the photos and pertinent information.

If diagnostic uncertainty persisted after the teledermatology review, or if Dr. Simpson and his colleagues judged that a procedure such as a biopsy or lesion destruction was required, then the patient was scheduled for an appointment, with an interim plan put in place. Otherwise, patients were managed by teledermatology alone.

Of the 131 patients involved in the pilot study, 48 (37%) were female; the average patient age was 31.7 years (range, 1-92 years).

About 40% of patients were seen for inflammatory conditions, and another 20% for nonpigmented neoplasms. Almost 18% were seen for infectious reasons, with the remainder divided between pigmented neoplasms, hair disorders, and other conditions.

It turned out, said Dr. Simpson, that about two-thirds (65%) of the teletriage consultations ended in a definitive plan not requiring a face-to-face dermatology appointment. About a quarter (23%) were deferred to an in-person dermatology appointment, and the remaining 12% had an interim plan while more information was gathered.

Of the 32 neoplasms addressed by the teletriage strategy, 21 (66%) were deferred to an in-person visit. By contrast, 24 of the 95 non–neoplastic teletriage encounters were deferred to an in-person visit (P less than .001).

Overall, the strategy opened up 18% more appointment slots for new patients, Dr. Simpson said.

As part of the teletriage process, PCPs provided their proposed plan of care before receiving a dermatologist’s advice. When comparing the PCP’s plan to the dermatologist’s final plan, he and his colleagues found that there was a complete change of plan for three-quarters of visits (76%). A partial change happened 14% of the time, and only one in ten patients had no change in treatment plan as a result of the teledermatology consult. “This indicates again that specialist input matters,” he noted.

“This also gives us an opportunity to educate primary care physicians,” Dr. Simpson said, pointing out that in replies, he and his dermatologist colleagues included information about common diagnoses, including first-line treatments and “worrisome features they should be thinking about.”

He and his collaborators found that proper treatment would have been provided 30% of the time without a teledermatology consult, but that patients would have been undertreated 27% of the time. Overtreatment would have occurred at a rate of 11%, and care would have been unnecessarily delayed for about one in four patients. Unnecessary ED visits were averted for 6% of patients with the teletriage approach.

Examples of undertreatment included use of a weak topical steroid, missing infections or the need for referral, and using a suboptimal acne regimen. On the other hand, Dr. Simpson said, overtreatment with unnecessary antibiotics, antifungals, and antivirals also was averted; on some occasions, the PCP plan for an oral corticosteroid or an overly potent topical steroid was shifted to a more appropriate plan by teledermatology.

In sum, said Dr. Simpson, “teletriage via AccessDerm allowed us to reduce by tenfold the wait time for specialist input in dermatology cases. We were able to remove almost two-thirds of people from the queue ... waiting for dermatology appointments, which was very helpful to our clinic.”

And most importantly, he added, “this allowed us to allocate the limited number of in-person appointments that we had at this volunteer clinic to those that were more complicated cases.”

Dr. Simpson reported that he had no relevant disclosures. The project was funded by Penn Medicine and the American Academy of Dermatology.

[email protected]

MILAN – A teletriage approach significantly reduced the waiting time for underserved patients to see dermatologists in a specialty outreach clinic, and optimized primary care physicians’ care of nonreferred patients, Cory Simpson, MD, PhD, reported at the World Congress of Dermatology.

Kari Oakes/MDedge News

With implementation of teledermatology, patient wait times for specialist input dropped from 13.9 days to 1.6 days (P less than .00001).

By allowing dermatologists to evaluate photographs of lesions and perform their own triage of referrals from primary care physicians (PCPs), the teletriage pilot program reduced the number of patients for whom dermatology consults were deemed necessary and also allowed optimal management for the nonreferred patients, said Dr. Simpson, of the University of Pennsylvania, Philadelphia.

“Teledermatology has the potential to increase access to dermatologist-level care, especially for underserved patients,” he commented. “It allows us to educate primary care physicians in resource-limited settings, and it also allows us to avoid suboptimal care of skin disease by nonspecialists – especially the more judicious use of antimicrobial agents and corticosteroids.”

Dr. Simpson explained to the international audience that, for many in the United States, access to a dermatologist requires a lengthy wait that can extend to months.

In Philadelphia, University of Pennsylvania dermatology residents and attending physicians volunteer in an outreach program that serves an uninsured population of primarily Latino immigrants. Operating 1 or 2 evenings a month, the medical and surgical dermatology clinics can accommodate from 8-12 appointments per clinic.

The clinic had been overwhelmed with referrals from PCPs, but Dr. Simpson and his colleagues realized that many of the conditions they were seeing – verruca vulgaris, hand dermatitis, and psoriasis, for example – did not necessarily need a face-to-face dermatologic evaluation.

The AccessDerm app, available at no cost by the American Academy of Dermatology, allows PCPs and dermatologists to communicate and collaborate. “This is a store-and-forward program, meaning the primary physician takes the photos and sends them to an off-site dermatologist who can then review them at his or her convenience,” Dr. Simpson said. “It’s a smartphone-based app, so actually, while I was at this conference, even though I’m thousands of miles from Philadelphia, I got through three consults this morning on my smartphone. It’s a very convenient way to be a volunteer.”

The consultation is between the PCP and the dermatologist, he added. “It’s the dermatologist talking to the PCP, and the patient receives the care recommendations from their primary doctor – so there’s no direct communication with the patient.”

Using the app, PCPs photographed skin lesions and completed simple history and physical exam modules within the app. Then, Dr. Simpson and his dermatology colleagues reviewed the photos and pertinent information.

If diagnostic uncertainty persisted after the teledermatology review, or if Dr. Simpson and his colleagues judged that a procedure such as a biopsy or lesion destruction was required, then the patient was scheduled for an appointment, with an interim plan put in place. Otherwise, patients were managed by teledermatology alone.

Of the 131 patients involved in the pilot study, 48 (37%) were female; the average patient age was 31.7 years (range, 1-92 years).

About 40% of patients were seen for inflammatory conditions, and another 20% for nonpigmented neoplasms. Almost 18% were seen for infectious reasons, with the remainder divided between pigmented neoplasms, hair disorders, and other conditions.

It turned out, said Dr. Simpson, that about two-thirds (65%) of the teletriage consultations ended in a definitive plan not requiring a face-to-face dermatology appointment. About a quarter (23%) were deferred to an in-person dermatology appointment, and the remaining 12% had an interim plan while more information was gathered.

Of the 32 neoplasms addressed by the teletriage strategy, 21 (66%) were deferred to an in-person visit. By contrast, 24 of the 95 non–neoplastic teletriage encounters were deferred to an in-person visit (P less than .001).

Overall, the strategy opened up 18% more appointment slots for new patients, Dr. Simpson said.

As part of the teletriage process, PCPs provided their proposed plan of care before receiving a dermatologist’s advice. When comparing the PCP’s plan to the dermatologist’s final plan, he and his colleagues found that there was a complete change of plan for three-quarters of visits (76%). A partial change happened 14% of the time, and only one in ten patients had no change in treatment plan as a result of the teledermatology consult. “This indicates again that specialist input matters,” he noted.

“This also gives us an opportunity to educate primary care physicians,” Dr. Simpson said, pointing out that in replies, he and his dermatologist colleagues included information about common diagnoses, including first-line treatments and “worrisome features they should be thinking about.”

He and his collaborators found that proper treatment would have been provided 30% of the time without a teledermatology consult, but that patients would have been undertreated 27% of the time. Overtreatment would have occurred at a rate of 11%, and care would have been unnecessarily delayed for about one in four patients. Unnecessary ED visits were averted for 6% of patients with the teletriage approach.

Examples of undertreatment included use of a weak topical steroid, missing infections or the need for referral, and using a suboptimal acne regimen. On the other hand, Dr. Simpson said, overtreatment with unnecessary antibiotics, antifungals, and antivirals also was averted; on some occasions, the PCP plan for an oral corticosteroid or an overly potent topical steroid was shifted to a more appropriate plan by teledermatology.

In sum, said Dr. Simpson, “teletriage via AccessDerm allowed us to reduce by tenfold the wait time for specialist input in dermatology cases. We were able to remove almost two-thirds of people from the queue ... waiting for dermatology appointments, which was very helpful to our clinic.”

And most importantly, he added, “this allowed us to allocate the limited number of in-person appointments that we had at this volunteer clinic to those that were more complicated cases.”

Dr. Simpson reported that he had no relevant disclosures. The project was funded by Penn Medicine and the American Academy of Dermatology.

[email protected]

MILAN – A checkpoint inhibitor given with or without targeted therapy resulted in robust response rates in patients with advanced basal cell carcinoma, according to an investigator in a recent proof-of-concept study.

The side effect profile for the progressive death 1 (PD-1) inhibitor pembrolizumab (Keytruda), plus or minus the hedgehog pathway inhibitor vismodegib (Erivedge), was “not out of range” with what’s been observed in other cancer types, said Anne Lynn S. Chang, MD, a medical dermatologist at Stanford (Calif.) University.

Taken together, these safety and efficacy results suggest pembrolizumab could prove useful for patients with advanced basal cell carcinomas, Dr. Chang said in an oral presentation at the World Congress of Dermatology.

Unexpectedly, dual therapy with pembrolizumab and vismodegib was not clearly superior to pembrolizumab alone, though the two arms are not directly comparable in this nonrandomized, investigator-initiated study, according to Dr. Chang.

“That was a surprise for us, but this is a subjective and a small study,” she told attendees at the conference.

There is currently a multi-institutional clinical trial underway to evaluate another PD-1 inhibitor, cemiplimab, in patients with advanced basal cell carcinoma previously treated with a hedgehog pathway inhibitor, she said.

While a large fraction of basal cell carcinomas are cured by resection, those that are locally advanced or metastatic to lymph nodes or distant organs are challenging to manage. Hedgehog pathway inhibitors, which include vismodegib and sonidegib, are the only Food and Drug Administration–approved drug class in this setting, but more than half of patients do not have a response to treatment, and another 20% or so will initially respond but develop resistance, Dr. Chang said.

Other treatments that have been tried in advanced basal cell carcinomas include taxanes, platinum-based agents, 5-fluorouracil, and everolimus, but their efficacy is unclear, according to Dr. Chang, because of a lack of systematic studies.

Investigators thought PD-1 inhibitors might be promising in basal cell carcinoma for a few reasons, Dr. Chang said. In particular, PD-1 inhibitor treatment response has been linked to mutational burden and PD–ligand 1 expression, and advanced basal cell carcinomas have the largest mutational burden of all human cancers, a large proportion of which express PD-L1.

There are multiple case reports in the literature suggesting that advanced basal cell carcinoma is responsive to PD-1 inhibitors, she added.

In the study, nine patients received 200 mg infusion of pembrolizumab every 3 weeks, and seven received the pembrolizumab infusions plus oral vismodegib 150 mg per day.

The pembrolizumab monotherapy group included patients who had tumor progression on vismodegib, did not tolerate vismodegib, or had contraindications to vismodegib. The pembrolizumab-vismodegib regimen was used in patients who had prior stable or partial responses to hedgehog pathway inhibitors.

The overall response rate was 38%, or 6 of 16 patients, with a 70% probability of 1-year progression-free survival and 94% probability of 1-year overall survival, Dr. Chang reported.

The results did not make the case that pembrolizumab and vismodegib was superior to pembrolizumab alone, though as Dr. Chang noted, the numbers of patients were small. Response rates were 29% (two of seven patients) in the combination arm and 44% (four of nine patients) in the monotherapy arm.

There were 24 immune-related adverse events in the trial; the most serious was hyponatremia, which was reversible, according to Dr. Chang. The overall rates of grade 3-4 adverse events were 22% for pembrolizumab monotherapy and 17% for dual therapy.

A report on the study has also been published in the Journal of the American Academy of Dermatology.

Funding for the study was provided by Merck. Dr. Chang reported serving as a clinical investigator and advisory board member for studies sponsored by Genentech-Roche, Merck, Novartis, and Regeneron.
 

MILAN – A checkpoint inhibitor given with or without targeted therapy resulted in robust response rates in patients with advanced basal cell carcinoma, according to an investigator in a recent proof-of-concept study.

The side effect profile for the progressive death 1 (PD-1) inhibitor pembrolizumab (Keytruda), plus or minus the hedgehog pathway inhibitor vismodegib (Erivedge), was “not out of range” with what’s been observed in other cancer types, said Anne Lynn S. Chang, MD, a medical dermatologist at Stanford (Calif.) University.

Taken together, these safety and efficacy results suggest pembrolizumab could prove useful for patients with advanced basal cell carcinomas, Dr. Chang said in an oral presentation at the World Congress of Dermatology.

Unexpectedly, dual therapy with pembrolizumab and vismodegib was not clearly superior to pembrolizumab alone, though the two arms are not directly comparable in this nonrandomized, investigator-initiated study, according to Dr. Chang.

“That was a surprise for us, but this is a subjective and a small study,” she told attendees at the conference.

There is currently a multi-institutional clinical trial underway to evaluate another PD-1 inhibitor, cemiplimab, in patients with advanced basal cell carcinoma previously treated with a hedgehog pathway inhibitor, she said.

While a large fraction of basal cell carcinomas are cured by resection, those that are locally advanced or metastatic to lymph nodes or distant organs are challenging to manage. Hedgehog pathway inhibitors, which include vismodegib and sonidegib, are the only Food and Drug Administration–approved drug class in this setting, but more than half of patients do not have a response to treatment, and another 20% or so will initially respond but develop resistance, Dr. Chang said.

Other treatments that have been tried in advanced basal cell carcinomas include taxanes, platinum-based agents, 5-fluorouracil, and everolimus, but their efficacy is unclear, according to Dr. Chang, because of a lack of systematic studies.

Investigators thought PD-1 inhibitors might be promising in basal cell carcinoma for a few reasons, Dr. Chang said. In particular, PD-1 inhibitor treatment response has been linked to mutational burden and PD–ligand 1 expression, and advanced basal cell carcinomas have the largest mutational burden of all human cancers, a large proportion of which express PD-L1.

There are multiple case reports in the literature suggesting that advanced basal cell carcinoma is responsive to PD-1 inhibitors, she added.

In the study, nine patients received 200 mg infusion of pembrolizumab every 3 weeks, and seven received the pembrolizumab infusions plus oral vismodegib 150 mg per day.

The pembrolizumab monotherapy group included patients who had tumor progression on vismodegib, did not tolerate vismodegib, or had contraindications to vismodegib. The pembrolizumab-vismodegib regimen was used in patients who had prior stable or partial responses to hedgehog pathway inhibitors.

The overall response rate was 38%, or 6 of 16 patients, with a 70% probability of 1-year progression-free survival and 94% probability of 1-year overall survival, Dr. Chang reported.

The results did not make the case that pembrolizumab and vismodegib was superior to pembrolizumab alone, though as Dr. Chang noted, the numbers of patients were small. Response rates were 29% (two of seven patients) in the combination arm and 44% (four of nine patients) in the monotherapy arm.

There were 24 immune-related adverse events in the trial; the most serious was hyponatremia, which was reversible, according to Dr. Chang. The overall rates of grade 3-4 adverse events were 22% for pembrolizumab monotherapy and 17% for dual therapy.

A report on the study has also been published in the Journal of the American Academy of Dermatology.

Funding for the study was provided by Merck. Dr. Chang reported serving as a clinical investigator and advisory board member for studies sponsored by Genentech-Roche, Merck, Novartis, and Regeneron.
 

MILAN – A checkpoint inhibitor given with or without targeted therapy resulted in robust response rates in patients with advanced basal cell carcinoma, according to an investigator in a recent proof-of-concept study.

The side effect profile for the progressive death 1 (PD-1) inhibitor pembrolizumab (Keytruda), plus or minus the hedgehog pathway inhibitor vismodegib (Erivedge), was “not out of range” with what’s been observed in other cancer types, said Anne Lynn S. Chang, MD, a medical dermatologist at Stanford (Calif.) University.

Taken together, these safety and efficacy results suggest pembrolizumab could prove useful for patients with advanced basal cell carcinomas, Dr. Chang said in an oral presentation at the World Congress of Dermatology.

Unexpectedly, dual therapy with pembrolizumab and vismodegib was not clearly superior to pembrolizumab alone, though the two arms are not directly comparable in this nonrandomized, investigator-initiated study, according to Dr. Chang.

“That was a surprise for us, but this is a subjective and a small study,” she told attendees at the conference.

There is currently a multi-institutional clinical trial underway to evaluate another PD-1 inhibitor, cemiplimab, in patients with advanced basal cell carcinoma previously treated with a hedgehog pathway inhibitor, she said.

While a large fraction of basal cell carcinomas are cured by resection, those that are locally advanced or metastatic to lymph nodes or distant organs are challenging to manage. Hedgehog pathway inhibitors, which include vismodegib and sonidegib, are the only Food and Drug Administration–approved drug class in this setting, but more than half of patients do not have a response to treatment, and another 20% or so will initially respond but develop resistance, Dr. Chang said.

Other treatments that have been tried in advanced basal cell carcinomas include taxanes, platinum-based agents, 5-fluorouracil, and everolimus, but their efficacy is unclear, according to Dr. Chang, because of a lack of systematic studies.

Investigators thought PD-1 inhibitors might be promising in basal cell carcinoma for a few reasons, Dr. Chang said. In particular, PD-1 inhibitor treatment response has been linked to mutational burden and PD–ligand 1 expression, and advanced basal cell carcinomas have the largest mutational burden of all human cancers, a large proportion of which express PD-L1.

There are multiple case reports in the literature suggesting that advanced basal cell carcinoma is responsive to PD-1 inhibitors, she added.

In the study, nine patients received 200 mg infusion of pembrolizumab every 3 weeks, and seven received the pembrolizumab infusions plus oral vismodegib 150 mg per day.

The pembrolizumab monotherapy group included patients who had tumor progression on vismodegib, did not tolerate vismodegib, or had contraindications to vismodegib. The pembrolizumab-vismodegib regimen was used in patients who had prior stable or partial responses to hedgehog pathway inhibitors.

The overall response rate was 38%, or 6 of 16 patients, with a 70% probability of 1-year progression-free survival and 94% probability of 1-year overall survival, Dr. Chang reported.

The results did not make the case that pembrolizumab and vismodegib was superior to pembrolizumab alone, though as Dr. Chang noted, the numbers of patients were small. Response rates were 29% (two of seven patients) in the combination arm and 44% (four of nine patients) in the monotherapy arm.

There were 24 immune-related adverse events in the trial; the most serious was hyponatremia, which was reversible, according to Dr. Chang. The overall rates of grade 3-4 adverse events were 22% for pembrolizumab monotherapy and 17% for dual therapy.

A report on the study has also been published in the Journal of the American Academy of Dermatology.

Funding for the study was provided by Merck. Dr. Chang reported serving as a clinical investigator and advisory board member for studies sponsored by Genentech-Roche, Merck, Novartis, and Regeneron.
 

Forty percent of Americans say that they would be more likely to spend an hour a day improving their health if they got paid to do it, according to a survey by UnitedHealthcare.

More than half (54%) of the 1,006 respondents said that they didn’t need a financial incentive to get that much exercise, but 21% said that $1-$3 a day would be necessary and 19% said that they would need $4-$5 per day, the company said in its 2019 Wellness Checkup Survey.

Women were more likely than men to say that they needed an incentive (42% vs. 36%). Among age-related subgroups, there was a clear progression from youngest to oldest: The youngest age group (18-34 years, 47%) and youngest generation (Millennials, 46%) in the study were the most likely to require an incentive, while the oldest age group (65 years and older, 30%) and generation (Baby Boomers, 31%) were the least likely, UnitedHealthcare said.

A majority (57%) of respondents said that it was important – either very important (19%) or somewhat important (38%) – for a fitness routine to have a social component, either in-person or virtual. Almost two-thirds of respondents expressed support for wearable fitness-tracking devices: 42% would use one if it was provided by their employer, and 22% said that they already had one, the survey results show.

“This year employers are expected to invest an average of more than $3.6 million on their respective well-being programs, and over 60% of employees are interested in engaging in these initiatives. [This] survey provides insights that we hope can be helpful to enhance the design and implementation of well-being programs, which may help improve employees’ health, reduce absenteeism, and curb care costs,” Rebecca Madsen, UnitedHealthcare’s chief consumer officer, said in the company’s written statement.

The survey was conducted April 11-15, 2019, and the margin of error was plus or minus 3.1%.

[email protected]

Forty percent of Americans say that they would be more likely to spend an hour a day improving their health if they got paid to do it, according to a survey by UnitedHealthcare.

More than half (54%) of the 1,006 respondents said that they didn’t need a financial incentive to get that much exercise, but 21% said that $1-$3 a day would be necessary and 19% said that they would need $4-$5 per day, the company said in its 2019 Wellness Checkup Survey.

Women were more likely than men to say that they needed an incentive (42% vs. 36%). Among age-related subgroups, there was a clear progression from youngest to oldest: The youngest age group (18-34 years, 47%) and youngest generation (Millennials, 46%) in the study were the most likely to require an incentive, while the oldest age group (65 years and older, 30%) and generation (Baby Boomers, 31%) were the least likely, UnitedHealthcare said.

A majority (57%) of respondents said that it was important – either very important (19%) or somewhat important (38%) – for a fitness routine to have a social component, either in-person or virtual. Almost two-thirds of respondents expressed support for wearable fitness-tracking devices: 42% would use one if it was provided by their employer, and 22% said that they already had one, the survey results show.

“This year employers are expected to invest an average of more than $3.6 million on their respective well-being programs, and over 60% of employees are interested in engaging in these initiatives. [This] survey provides insights that we hope can be helpful to enhance the design and implementation of well-being programs, which may help improve employees’ health, reduce absenteeism, and curb care costs,” Rebecca Madsen, UnitedHealthcare’s chief consumer officer, said in the company’s written statement.

The survey was conducted April 11-15, 2019, and the margin of error was plus or minus 3.1%.

[email protected]

Forty percent of Americans say that they would be more likely to spend an hour a day improving their health if they got paid to do it, according to a survey by UnitedHealthcare.

More than half (54%) of the 1,006 respondents said that they didn’t need a financial incentive to get that much exercise, but 21% said that $1-$3 a day would be necessary and 19% said that they would need $4-$5 per day, the company said in its 2019 Wellness Checkup Survey.

Women were more likely than men to say that they needed an incentive (42% vs. 36%). Among age-related subgroups, there was a clear progression from youngest to oldest: The youngest age group (18-34 years, 47%) and youngest generation (Millennials, 46%) in the study were the most likely to require an incentive, while the oldest age group (65 years and older, 30%) and generation (Baby Boomers, 31%) were the least likely, UnitedHealthcare said.

A majority (57%) of respondents said that it was important – either very important (19%) or somewhat important (38%) – for a fitness routine to have a social component, either in-person or virtual. Almost two-thirds of respondents expressed support for wearable fitness-tracking devices: 42% would use one if it was provided by their employer, and 22% said that they already had one, the survey results show.

“This year employers are expected to invest an average of more than $3.6 million on their respective well-being programs, and over 60% of employees are interested in engaging in these initiatives. [This] survey provides insights that we hope can be helpful to enhance the design and implementation of well-being programs, which may help improve employees’ health, reduce absenteeism, and curb care costs,” Rebecca Madsen, UnitedHealthcare’s chief consumer officer, said in the company’s written statement.

The survey was conducted April 11-15, 2019, and the margin of error was plus or minus 3.1%.

[email protected]

Using eosinophil levels to guide steroid treatment in patients with chronic obstructive pulmonary disease (COPD) was found to be noninferior to standard treatment in terms of the number of days out of hospital and alive, new research has found.

Writing in the Lancet Respiratory Medicine, researchers reported the outcomes of a multicenter, controlled, open-label trial comparing eosinophil-guided and standard therapy with systemic corticosteroids in 318 patients with COPD.

Pradeesh Sivapalan, MD, of the respiratory medicine section of Herlev and Gentofte Hospital at the University of Copenhagen, and coauthors wrote that eosinophilic inflammation had been seen in 20%-40% of patients with acute exacerbations of COPD. Patients with higher eosinophilic blood counts were at increased risk of acute exacerbations but were also more likely to benefit from corticosteroid treatment.

In the eosinophil-guided therapy arm of the study, 159 patients received 80 mg of intravenous methylprednisolone on day 1, then from the second day were treated with 37.5 mg of prednisolone oral tablet daily ­– up to 4 days – only on days when their blood eosinophil count was at least 0.3 x 10^⁹ cells/L. In the control arm, 159 patients also received 80 mg of intravenous methylprednisolone on day 1, followed by 37.5 mg of prednisolone tablets daily for 4 days.

After 14 days, there were no significant differences between the two groups for mean days alive and out of hospital.

There were 12 more cases of readmission with COPD, including three fatalities, in the eosinophil-guided group within the first month. However the authors said these differences were not statistically significant, but “because the study was not powered to detect differences in this absolute risk range, we cannot rule out that this was an actual harm effect from the interventional strategy.”

The eosinophil-guided therapy group did show more than a 50% reduction in the median duration of systemic corticosteroid therapy, which was 2 days in the eosinophil-guided group, compared with 5 days in the control group (P less than .0001), and the differences between the two groups remained significant at days 30 and 90.

“The tested strategy was successful in reducing the exposure to systemic corticosteroids, but we cannot exclude the possibility that a more aggressive algorithm, such as a single dose of systemic corticosteroid, might have been more effective,” the authors wrote.

At the 90-day follow-up, there were no differences in the number of infections requiring antibiotic treatment, nor in dyspepsia, ulcer complications, or initiation of new proton-pump inhibitor treatment.

The study was supported by the Danish Regions Medical Fund and the Danish Council for Independent Research. Two authors declared personal fees from pharmaceutical companies outside the submitted work. No other conflicts were declared.

SOURCE: Sivapalan P et al. Lancet Respir Med. 2019, May 20. doi: 10.1016/S2213-2600(19)30176-6.

Using eosinophil levels to guide steroid treatment in patients with chronic obstructive pulmonary disease (COPD) was found to be noninferior to standard treatment in terms of the number of days out of hospital and alive, new research has found.

Writing in the Lancet Respiratory Medicine, researchers reported the outcomes of a multicenter, controlled, open-label trial comparing eosinophil-guided and standard therapy with systemic corticosteroids in 318 patients with COPD.

Pradeesh Sivapalan, MD, of the respiratory medicine section of Herlev and Gentofte Hospital at the University of Copenhagen, and coauthors wrote that eosinophilic inflammation had been seen in 20%-40% of patients with acute exacerbations of COPD. Patients with higher eosinophilic blood counts were at increased risk of acute exacerbations but were also more likely to benefit from corticosteroid treatment.

In the eosinophil-guided therapy arm of the study, 159 patients received 80 mg of intravenous methylprednisolone on day 1, then from the second day were treated with 37.5 mg of prednisolone oral tablet daily ­– up to 4 days – only on days when their blood eosinophil count was at least 0.3 x 10^⁹ cells/L. In the control arm, 159 patients also received 80 mg of intravenous methylprednisolone on day 1, followed by 37.5 mg of prednisolone tablets daily for 4 days.

After 14 days, there were no significant differences between the two groups for mean days alive and out of hospital.

There were 12 more cases of readmission with COPD, including three fatalities, in the eosinophil-guided group within the first month. However the authors said these differences were not statistically significant, but “because the study was not powered to detect differences in this absolute risk range, we cannot rule out that this was an actual harm effect from the interventional strategy.”

The eosinophil-guided therapy group did show more than a 50% reduction in the median duration of systemic corticosteroid therapy, which was 2 days in the eosinophil-guided group, compared with 5 days in the control group (P less than .0001), and the differences between the two groups remained significant at days 30 and 90.

“The tested strategy was successful in reducing the exposure to systemic corticosteroids, but we cannot exclude the possibility that a more aggressive algorithm, such as a single dose of systemic corticosteroid, might have been more effective,” the authors wrote.

At the 90-day follow-up, there were no differences in the number of infections requiring antibiotic treatment, nor in dyspepsia, ulcer complications, or initiation of new proton-pump inhibitor treatment.

The study was supported by the Danish Regions Medical Fund and the Danish Council for Independent Research. Two authors declared personal fees from pharmaceutical companies outside the submitted work. No other conflicts were declared.

SOURCE: Sivapalan P et al. Lancet Respir Med. 2019, May 20. doi: 10.1016/S2213-2600(19)30176-6.

Using eosinophil levels to guide steroid treatment in patients with chronic obstructive pulmonary disease (COPD) was found to be noninferior to standard treatment in terms of the number of days out of hospital and alive, new research has found.

Writing in the Lancet Respiratory Medicine, researchers reported the outcomes of a multicenter, controlled, open-label trial comparing eosinophil-guided and standard therapy with systemic corticosteroids in 318 patients with COPD.

Pradeesh Sivapalan, MD, of the respiratory medicine section of Herlev and Gentofte Hospital at the University of Copenhagen, and coauthors wrote that eosinophilic inflammation had been seen in 20%-40% of patients with acute exacerbations of COPD. Patients with higher eosinophilic blood counts were at increased risk of acute exacerbations but were also more likely to benefit from corticosteroid treatment.

In the eosinophil-guided therapy arm of the study, 159 patients received 80 mg of intravenous methylprednisolone on day 1, then from the second day were treated with 37.5 mg of prednisolone oral tablet daily ­– up to 4 days – only on days when their blood eosinophil count was at least 0.3 x 10^⁹ cells/L. In the control arm, 159 patients also received 80 mg of intravenous methylprednisolone on day 1, followed by 37.5 mg of prednisolone tablets daily for 4 days.

After 14 days, there were no significant differences between the two groups for mean days alive and out of hospital.

There were 12 more cases of readmission with COPD, including three fatalities, in the eosinophil-guided group within the first month. However the authors said these differences were not statistically significant, but “because the study was not powered to detect differences in this absolute risk range, we cannot rule out that this was an actual harm effect from the interventional strategy.”

The eosinophil-guided therapy group did show more than a 50% reduction in the median duration of systemic corticosteroid therapy, which was 2 days in the eosinophil-guided group, compared with 5 days in the control group (P less than .0001), and the differences between the two groups remained significant at days 30 and 90.

“The tested strategy was successful in reducing the exposure to systemic corticosteroids, but we cannot exclude the possibility that a more aggressive algorithm, such as a single dose of systemic corticosteroid, might have been more effective,” the authors wrote.

At the 90-day follow-up, there were no differences in the number of infections requiring antibiotic treatment, nor in dyspepsia, ulcer complications, or initiation of new proton-pump inhibitor treatment.

The study was supported by the Danish Regions Medical Fund and the Danish Council for Independent Research. Two authors declared personal fees from pharmaceutical companies outside the submitted work. No other conflicts were declared.

SOURCE: Sivapalan P et al. Lancet Respir Med. 2019, May 20. doi: 10.1016/S2213-2600(19)30176-6.

The Firearm Safety Among Children and Teens (FACTS) Consortium issued a research agenda with the goal of preventing pediatric firearm injuries and death.

Kateywhat/ThinkStock

The 26 research agenda items from FACTS, which span across the broad topic areas of epidemiology, surveillance, and risk and protective factors; primary, secondary, and cross-cutting protective factors; policy-related issues; and data-enhancement priorities, were published in JAMA Pediatrics.

“Firearms are the second leading cause of death among children and adolescents aged 1 to 18 years in the United States and responsible for more than 2,570 deaths and nearly 12,000 nonfatal injuries requiring emergency department treatment in 2017,” said Rebecca Cunningham, MD, of the University of Michigan, Ann Arbor, and colleagues who are members of the FACTS Consortium.

“Pediatric firearm injuries result from a range of causes, including the unintentional discharge of a firearm, self-inflicted wounds, or the escalation of interpersonal violence,” they continued. “Nearly 265 million firearms are in civilian hands in the United States, and a 44% increase in pediatric firearm mortality rate has been documented during the past 5 years.”

The FACTS Consortium defined an agenda “to serve as a guide for future research efforts to decrease pediatric death and injury.”

Some of the research agenda items include the following:

• Understanding epidemiologic trends and how demographic factors are associated with fatal and nonfatal outcomes.
• The long-term cost associated with pediatric firearm outcomes.
• The effectiveness of health care–focused primary prevention strategies for children, adolescents, and their families to reduce firearm outcomes.
• Examination of health care–based interventions for children and adolescents who have experienced or witnessed a firearm injury to prevent (or reduce) subsequent firearm outcomes including firearm injury recidivism and mental health, socioemotional, and educational outcomes.

“It is an excellent list, and I think it was very thoughtful to come out with a research agenda for firearm safety for kids,” Marlene Melzer-Lange, MD, chair of the American Academy of Pediatrics subcommittee on violence prevention, said in an interview. “The thing that’s been lacking nationally has been funding for firearm injury prevention, both for children and adults, and to have something focused specifically on children – because children have the biggest chance of living the longest – is really important.”

She described the research agenda as being “comprehensive” and didn’t see anything that stood out as missing from the list, although the big issue that remains is getting funding for the research now that an agenda has been outlined.

And getting that is not going to be easy.

“I think it’s going to take some political will of the people and particularly of our legislators ... to allow the [Centers for Disease Control and Prevention] to provide funding” said Dr. Melzer-Lange, an attending emergency department physician at Children’s Hospital of Wisconsin, Milwaukee, adding that AAP has long been asking for such funding. “It’s going [to come down to] the legislators [having] enough guts to actually put the funding in and not be afraid of external groups that might ask them not to do that.”

She remains optimistic and hopeful that the legislators are going to look at it and will eventually say that this is an crisis and will take more action beyond just talking about it.

Dr. Melzer-Lange also emphasized that this is about firearm safety and not firearm control, especially for children and teenagers.

All authors reported receiving grants from National Institutes of Health/National Institute of Child Health and Human Development.

[email protected]

SOURCE: Cunningham RM et al. JAMA Pediatrics. 2019. doi: 10.1001/jamapediatrics.2019.1494.

The Firearm Safety Among Children and Teens (FACTS) Consortium issued a research agenda with the goal of preventing pediatric firearm injuries and death.

Kateywhat/ThinkStock

The 26 research agenda items from FACTS, which span across the broad topic areas of epidemiology, surveillance, and risk and protective factors; primary, secondary, and cross-cutting protective factors; policy-related issues; and data-enhancement priorities, were published in JAMA Pediatrics.

“Firearms are the second leading cause of death among children and adolescents aged 1 to 18 years in the United States and responsible for more than 2,570 deaths and nearly 12,000 nonfatal injuries requiring emergency department treatment in 2017,” said Rebecca Cunningham, MD, of the University of Michigan, Ann Arbor, and colleagues who are members of the FACTS Consortium.

“Pediatric firearm injuries result from a range of causes, including the unintentional discharge of a firearm, self-inflicted wounds, or the escalation of interpersonal violence,” they continued. “Nearly 265 million firearms are in civilian hands in the United States, and a 44% increase in pediatric firearm mortality rate has been documented during the past 5 years.”

The FACTS Consortium defined an agenda “to serve as a guide for future research efforts to decrease pediatric death and injury.”

Some of the research agenda items include the following:

• Understanding epidemiologic trends and how demographic factors are associated with fatal and nonfatal outcomes.
• The long-term cost associated with pediatric firearm outcomes.
• The effectiveness of health care–focused primary prevention strategies for children, adolescents, and their families to reduce firearm outcomes.
• Examination of health care–based interventions for children and adolescents who have experienced or witnessed a firearm injury to prevent (or reduce) subsequent firearm outcomes including firearm injury recidivism and mental health, socioemotional, and educational outcomes.

“It is an excellent list, and I think it was very thoughtful to come out with a research agenda for firearm safety for kids,” Marlene Melzer-Lange, MD, chair of the American Academy of Pediatrics subcommittee on violence prevention, said in an interview. “The thing that’s been lacking nationally has been funding for firearm injury prevention, both for children and adults, and to have something focused specifically on children – because children have the biggest chance of living the longest – is really important.”

She described the research agenda as being “comprehensive” and didn’t see anything that stood out as missing from the list, although the big issue that remains is getting funding for the research now that an agenda has been outlined.

And getting that is not going to be easy.

“I think it’s going to take some political will of the people and particularly of our legislators ... to allow the [Centers for Disease Control and Prevention] to provide funding” said Dr. Melzer-Lange, an attending emergency department physician at Children’s Hospital of Wisconsin, Milwaukee, adding that AAP has long been asking for such funding. “It’s going [to come down to] the legislators [having] enough guts to actually put the funding in and not be afraid of external groups that might ask them not to do that.”

She remains optimistic and hopeful that the legislators are going to look at it and will eventually say that this is an crisis and will take more action beyond just talking about it.

Dr. Melzer-Lange also emphasized that this is about firearm safety and not firearm control, especially for children and teenagers.

All authors reported receiving grants from National Institutes of Health/National Institute of Child Health and Human Development.

[email protected]

SOURCE: Cunningham RM et al. JAMA Pediatrics. 2019. doi: 10.1001/jamapediatrics.2019.1494.

The Firearm Safety Among Children and Teens (FACTS) Consortium issued a research agenda with the goal of preventing pediatric firearm injuries and death.

Kateywhat/ThinkStock

The 26 research agenda items from FACTS, which span across the broad topic areas of epidemiology, surveillance, and risk and protective factors; primary, secondary, and cross-cutting protective factors; policy-related issues; and data-enhancement priorities, were published in JAMA Pediatrics.

“Firearms are the second leading cause of death among children and adolescents aged 1 to 18 years in the United States and responsible for more than 2,570 deaths and nearly 12,000 nonfatal injuries requiring emergency department treatment in 2017,” said Rebecca Cunningham, MD, of the University of Michigan, Ann Arbor, and colleagues who are members of the FACTS Consortium.

“Pediatric firearm injuries result from a range of causes, including the unintentional discharge of a firearm, self-inflicted wounds, or the escalation of interpersonal violence,” they continued. “Nearly 265 million firearms are in civilian hands in the United States, and a 44% increase in pediatric firearm mortality rate has been documented during the past 5 years.”

The FACTS Consortium defined an agenda “to serve as a guide for future research efforts to decrease pediatric death and injury.”

Some of the research agenda items include the following:

• Understanding epidemiologic trends and how demographic factors are associated with fatal and nonfatal outcomes.
• The long-term cost associated with pediatric firearm outcomes.
• The effectiveness of health care–focused primary prevention strategies for children, adolescents, and their families to reduce firearm outcomes.
• Examination of health care–based interventions for children and adolescents who have experienced or witnessed a firearm injury to prevent (or reduce) subsequent firearm outcomes including firearm injury recidivism and mental health, socioemotional, and educational outcomes.

“It is an excellent list, and I think it was very thoughtful to come out with a research agenda for firearm safety for kids,” Marlene Melzer-Lange, MD, chair of the American Academy of Pediatrics subcommittee on violence prevention, said in an interview. “The thing that’s been lacking nationally has been funding for firearm injury prevention, both for children and adults, and to have something focused specifically on children – because children have the biggest chance of living the longest – is really important.”

She described the research agenda as being “comprehensive” and didn’t see anything that stood out as missing from the list, although the big issue that remains is getting funding for the research now that an agenda has been outlined.

And getting that is not going to be easy.

“I think it’s going to take some political will of the people and particularly of our legislators ... to allow the [Centers for Disease Control and Prevention] to provide funding” said Dr. Melzer-Lange, an attending emergency department physician at Children’s Hospital of Wisconsin, Milwaukee, adding that AAP has long been asking for such funding. “It’s going [to come down to] the legislators [having] enough guts to actually put the funding in and not be afraid of external groups that might ask them not to do that.”

She remains optimistic and hopeful that the legislators are going to look at it and will eventually say that this is an crisis and will take more action beyond just talking about it.

Dr. Melzer-Lange also emphasized that this is about firearm safety and not firearm control, especially for children and teenagers.

All authors reported receiving grants from National Institutes of Health/National Institute of Child Health and Human Development.

[email protected]

SOURCE: Cunningham RM et al. JAMA Pediatrics. 2019. doi: 10.1001/jamapediatrics.2019.1494.

SAN ANTONIO – Key determinants of no-show rates to a sleep clinic include being a new patient and lacking health insurance coverage, results from a single-center study showed.

Doug Brunk/MDedge News

“There are lots of people with sleep problems,” one of the study’s authors, Alvan Nzewuihe, MD, said in an interview at the annual meeting of the Associated Professional Sleep Societies. “However, we have to identify these patients to be able to help them. If they don’t come to the sleep clinic [for assessment], we are going nowhere.”

In an effort to better understand determinants of no-show rates among sleep clinics, Dr. Nzewuihe and colleagues performed a 10-month, retrospective chart review of 2,532 patients scheduled at Saint Louis University’s SLUCare Sleep Disorders Center during the months of July and October 2017 and April 2018. A no-show was determined if the patient failed to show up at their scheduled appointment on time or if they canceled their appointment. The researchers used multivariable logistic regression to determine which factors were independently associated with no-show rates.

Dr. Nzewuihe, a sleep medicine physician at the university, reported that the overall no-show rate during the study period was 21.2% and did not change with age, sex, or appointment factors such as time of day, day of week, or season of the year. Significant determinants of no-show rates included being a new patient (39.1% vs. 28.8% among established patients; P less than .0001) and having no health insurance (47.5% vs. public 28.3% vs private 24.2%; P less than .0001). Multivariate logistic regression confirmed the associations. New patients were 1.96 times more likely to not show up to the sleep clinic, compared with established patients, while patients with no health insurance coverage were 1.55 times more likely to not show up, compared with those with public health insurance.

The researchers wrote in their poster abstract, “Patients who are new to the clinic or have no insurance coverage have a higher odds of not showing up to their appointment and delaying their care. Efforts to prioritize high-risk patients of nonadherence will help contribute to better care and outcomes. Further studies are needed to develop methods to decrease no-show rates once high-risk appointments have been identified.”

Dr. Nzewuihe acknowledged certain limitations of the study, including its retrospective design and the fact that other possible contributing factors were not evaluated such as literacy level, employment status, and length of time between appointment booking and appointment date. The study’s first author was Julie Sahrmann, DO. The researchers reported having no financial disclosures.

[email protected]

SOURCE: Sahrmann J et al. Sleep 2019, Abstract 0965.

SAN ANTONIO – Key determinants of no-show rates to a sleep clinic include being a new patient and lacking health insurance coverage, results from a single-center study showed.

Doug Brunk/MDedge News

“There are lots of people with sleep problems,” one of the study’s authors, Alvan Nzewuihe, MD, said in an interview at the annual meeting of the Associated Professional Sleep Societies. “However, we have to identify these patients to be able to help them. If they don’t come to the sleep clinic [for assessment], we are going nowhere.”

In an effort to better understand determinants of no-show rates among sleep clinics, Dr. Nzewuihe and colleagues performed a 10-month, retrospective chart review of 2,532 patients scheduled at Saint Louis University’s SLUCare Sleep Disorders Center during the months of July and October 2017 and April 2018. A no-show was determined if the patient failed to show up at their scheduled appointment on time or if they canceled their appointment. The researchers used multivariable logistic regression to determine which factors were independently associated with no-show rates.

Dr. Nzewuihe, a sleep medicine physician at the university, reported that the overall no-show rate during the study period was 21.2% and did not change with age, sex, or appointment factors such as time of day, day of week, or season of the year. Significant determinants of no-show rates included being a new patient (39.1% vs. 28.8% among established patients; P less than .0001) and having no health insurance (47.5% vs. public 28.3% vs private 24.2%; P less than .0001). Multivariate logistic regression confirmed the associations. New patients were 1.96 times more likely to not show up to the sleep clinic, compared with established patients, while patients with no health insurance coverage were 1.55 times more likely to not show up, compared with those with public health insurance.

The researchers wrote in their poster abstract, “Patients who are new to the clinic or have no insurance coverage have a higher odds of not showing up to their appointment and delaying their care. Efforts to prioritize high-risk patients of nonadherence will help contribute to better care and outcomes. Further studies are needed to develop methods to decrease no-show rates once high-risk appointments have been identified.”

Dr. Nzewuihe acknowledged certain limitations of the study, including its retrospective design and the fact that other possible contributing factors were not evaluated such as literacy level, employment status, and length of time between appointment booking and appointment date. The study’s first author was Julie Sahrmann, DO. The researchers reported having no financial disclosures.

[email protected]

SOURCE: Sahrmann J et al. Sleep 2019, Abstract 0965.

SAN ANTONIO – Key determinants of no-show rates to a sleep clinic include being a new patient and lacking health insurance coverage, results from a single-center study showed.

Doug Brunk/MDedge News

“There are lots of people with sleep problems,” one of the study’s authors, Alvan Nzewuihe, MD, said in an interview at the annual meeting of the Associated Professional Sleep Societies. “However, we have to identify these patients to be able to help them. If they don’t come to the sleep clinic [for assessment], we are going nowhere.”

In an effort to better understand determinants of no-show rates among sleep clinics, Dr. Nzewuihe and colleagues performed a 10-month, retrospective chart review of 2,532 patients scheduled at Saint Louis University’s SLUCare Sleep Disorders Center during the months of July and October 2017 and April 2018. A no-show was determined if the patient failed to show up at their scheduled appointment on time or if they canceled their appointment. The researchers used multivariable logistic regression to determine which factors were independently associated with no-show rates.

Dr. Nzewuihe, a sleep medicine physician at the university, reported that the overall no-show rate during the study period was 21.2% and did not change with age, sex, or appointment factors such as time of day, day of week, or season of the year. Significant determinants of no-show rates included being a new patient (39.1% vs. 28.8% among established patients; P less than .0001) and having no health insurance (47.5% vs. public 28.3% vs private 24.2%; P less than .0001). Multivariate logistic regression confirmed the associations. New patients were 1.96 times more likely to not show up to the sleep clinic, compared with established patients, while patients with no health insurance coverage were 1.55 times more likely to not show up, compared with those with public health insurance.

The researchers wrote in their poster abstract, “Patients who are new to the clinic or have no insurance coverage have a higher odds of not showing up to their appointment and delaying their care. Efforts to prioritize high-risk patients of nonadherence will help contribute to better care and outcomes. Further studies are needed to develop methods to decrease no-show rates once high-risk appointments have been identified.”

Dr. Nzewuihe acknowledged certain limitations of the study, including its retrospective design and the fact that other possible contributing factors were not evaluated such as literacy level, employment status, and length of time between appointment booking and appointment date. The study’s first author was Julie Sahrmann, DO. The researchers reported having no financial disclosures.

[email protected]

SOURCE: Sahrmann J et al. Sleep 2019, Abstract 0965.