Higher reliance on electronic health records (EHRs) in ambulatory oncology practice was significantly associated with reduced safety actions among oncology nurses and prescribers, according to results of a statewide survey.

“The purpose of this study was to investigate the degree to which EHRs, satisfaction with technology, and clinician communication enable a safety culture in ambulatory oncology treatment settings,” wrote Minal R. Patel, PhD, MPH, of the University of Michigan, Ann Arbor, and colleagues. The report is published in the Journal of Oncology Practice.

The researchers conducted a statewide survey of 297 oncology nurses and prescribers in 29 ambulatory oncology practices in Michigan. They obtained quantitative data for May to October 2017 from clinician surveys and practice logs at these clinical sites.

The study methodology was built by use of the sociotechnical framework, which examined how EHR technologies influenced the safe administration of chemotherapy.

Eligible survey participants included physicians, nurses, physician assistants, and nurse practitioners who cared for adult patients receiving infusion treatments for cancer.

A total of 438 clinicians were recruited and confirmed to be eligible, and 297 (68%) completed a survey.

After analysis, the researchers found that higher reliance on electronic health records in practice was associated with reduced safety scores (P less than .001). The mean safety score was reported to be 5.3 (standard deviation, 1.1; practice-level range, 4.9-5.4).

In an opposite manner, increased satisfaction with technology and better-quality communication were associated with higher safety actions.

The researchers acknowledged a key limitation of the study was cross-sectional design. As a result, confounding factors could influence the findings.

“Careful attention to technology adoption and updates coupled with high-quality communication skills across clinicians are promising strategies to administer high-risk treatments safely in ambulatory oncology settings,” they concluded.

The study was supported by grant funding from the Agency for Healthcare Research and Quality and the National Cancer Institute. No conflicts of interest were reported.

SOURCE: Patel MR et al. J Oncol Pract. 2019 Apr 22. doi: 10.1200/JOP.18.00507.

Higher reliance on electronic health records (EHRs) in ambulatory oncology practice was significantly associated with reduced safety actions among oncology nurses and prescribers, according to results of a statewide survey.

“The purpose of this study was to investigate the degree to which EHRs, satisfaction with technology, and clinician communication enable a safety culture in ambulatory oncology treatment settings,” wrote Minal R. Patel, PhD, MPH, of the University of Michigan, Ann Arbor, and colleagues. The report is published in the Journal of Oncology Practice.

The researchers conducted a statewide survey of 297 oncology nurses and prescribers in 29 ambulatory oncology practices in Michigan. They obtained quantitative data for May to October 2017 from clinician surveys and practice logs at these clinical sites.

The study methodology was built by use of the sociotechnical framework, which examined how EHR technologies influenced the safe administration of chemotherapy.

Eligible survey participants included physicians, nurses, physician assistants, and nurse practitioners who cared for adult patients receiving infusion treatments for cancer.

A total of 438 clinicians were recruited and confirmed to be eligible, and 297 (68%) completed a survey.

After analysis, the researchers found that higher reliance on electronic health records in practice was associated with reduced safety scores (P less than .001). The mean safety score was reported to be 5.3 (standard deviation, 1.1; practice-level range, 4.9-5.4).

In an opposite manner, increased satisfaction with technology and better-quality communication were associated with higher safety actions.

The researchers acknowledged a key limitation of the study was cross-sectional design. As a result, confounding factors could influence the findings.

“Careful attention to technology adoption and updates coupled with high-quality communication skills across clinicians are promising strategies to administer high-risk treatments safely in ambulatory oncology settings,” they concluded.

The study was supported by grant funding from the Agency for Healthcare Research and Quality and the National Cancer Institute. No conflicts of interest were reported.

SOURCE: Patel MR et al. J Oncol Pract. 2019 Apr 22. doi: 10.1200/JOP.18.00507.

Higher reliance on electronic health records (EHRs) in ambulatory oncology practice was significantly associated with reduced safety actions among oncology nurses and prescribers, according to results of a statewide survey.

“The purpose of this study was to investigate the degree to which EHRs, satisfaction with technology, and clinician communication enable a safety culture in ambulatory oncology treatment settings,” wrote Minal R. Patel, PhD, MPH, of the University of Michigan, Ann Arbor, and colleagues. The report is published in the Journal of Oncology Practice.

The researchers conducted a statewide survey of 297 oncology nurses and prescribers in 29 ambulatory oncology practices in Michigan. They obtained quantitative data for May to October 2017 from clinician surveys and practice logs at these clinical sites.

The study methodology was built by use of the sociotechnical framework, which examined how EHR technologies influenced the safe administration of chemotherapy.

Eligible survey participants included physicians, nurses, physician assistants, and nurse practitioners who cared for adult patients receiving infusion treatments for cancer.

A total of 438 clinicians were recruited and confirmed to be eligible, and 297 (68%) completed a survey.

After analysis, the researchers found that higher reliance on electronic health records in practice was associated with reduced safety scores (P less than .001). The mean safety score was reported to be 5.3 (standard deviation, 1.1; practice-level range, 4.9-5.4).

In an opposite manner, increased satisfaction with technology and better-quality communication were associated with higher safety actions.

The researchers acknowledged a key limitation of the study was cross-sectional design. As a result, confounding factors could influence the findings.

“Careful attention to technology adoption and updates coupled with high-quality communication skills across clinicians are promising strategies to administer high-risk treatments safely in ambulatory oncology settings,” they concluded.

The study was supported by grant funding from the Agency for Healthcare Research and Quality and the National Cancer Institute. No conflicts of interest were reported.

SOURCE: Patel MR et al. J Oncol Pract. 2019 Apr 22. doi: 10.1200/JOP.18.00507.

Two federal judges have temporarily barred the Trump administration from making changes to the Title X program that would restrict funding from clinics that provide abortion counseling or that refer patients for abortion services.

jsmith/iStockphoto

U.S. District Judge Stanley Bastian for the District of Eastern Washington on April 25 approved a temporary nationwide ban against the program changes in response to legal a challenge by Washington state. The same day, U.S. District Judge for the District of Oregon Michael J. McShane also preliminarily barred the restrictions from taking effect in response to a legal challenge by the American Medical Association and the Planned Parenthood Federation of America.

Judge McShane called the program restrictions “arbitrary and capricious,” and wrote that the rules ignore comprehensive, ethical, and evidence-based health care, and impermissibly interfere with the patient-doctor relationship. Judge Bastian agreed, writing in his order that the plaintiffs have demonstrated that the restrictions violate the central purpose of Title X, which is to equalize access to comprehensive, evidence-based, and voluntary family planning.

“Plaintiffs have demonstrated they are likely to suffer irreparable harm in the absence of a preliminary injunction by presenting facts and argument that the final rule may or likely will: seriously disrupt or destroy the existing network of Title X providers in both the State of Washington and throughout the entire nation,” Judge Bastian wrote in his order.

Changes to the Title X program – scheduled to take effect May 3 – would have made health clinics ineligible for Title X funding if they offer, promote, or support abortion as a method of family planning. Title X grants generally go to health centers that provide reproductive health care – such as STD-testing, cancer screenings, and contraception – to low-income families. Under the rule, the government would withdraw financial assistance to clinics if they allow counseling or referrals associated with abortion, regardless of whether the money is used for other health care services.

HHS officials said that the final rule will provide for clear financial and physical separation between Title X and non–Title X activities, reduce confusion on the part of Title X clinics and the public about permissible Title X activities, and improve program transparency by requiring more complete reporting by grantees about their partnerships with referral agencies.

Two federal judges have temporarily barred the Trump administration from making changes to the Title X program that would restrict funding from clinics that provide abortion counseling or that refer patients for abortion services.

jsmith/iStockphoto

U.S. District Judge Stanley Bastian for the District of Eastern Washington on April 25 approved a temporary nationwide ban against the program changes in response to legal a challenge by Washington state. The same day, U.S. District Judge for the District of Oregon Michael J. McShane also preliminarily barred the restrictions from taking effect in response to a legal challenge by the American Medical Association and the Planned Parenthood Federation of America.

Judge McShane called the program restrictions “arbitrary and capricious,” and wrote that the rules ignore comprehensive, ethical, and evidence-based health care, and impermissibly interfere with the patient-doctor relationship. Judge Bastian agreed, writing in his order that the plaintiffs have demonstrated that the restrictions violate the central purpose of Title X, which is to equalize access to comprehensive, evidence-based, and voluntary family planning.

“Plaintiffs have demonstrated they are likely to suffer irreparable harm in the absence of a preliminary injunction by presenting facts and argument that the final rule may or likely will: seriously disrupt or destroy the existing network of Title X providers in both the State of Washington and throughout the entire nation,” Judge Bastian wrote in his order.

Changes to the Title X program – scheduled to take effect May 3 – would have made health clinics ineligible for Title X funding if they offer, promote, or support abortion as a method of family planning. Title X grants generally go to health centers that provide reproductive health care – such as STD-testing, cancer screenings, and contraception – to low-income families. Under the rule, the government would withdraw financial assistance to clinics if they allow counseling or referrals associated with abortion, regardless of whether the money is used for other health care services.

HHS officials said that the final rule will provide for clear financial and physical separation between Title X and non–Title X activities, reduce confusion on the part of Title X clinics and the public about permissible Title X activities, and improve program transparency by requiring more complete reporting by grantees about their partnerships with referral agencies.

Two federal judges have temporarily barred the Trump administration from making changes to the Title X program that would restrict funding from clinics that provide abortion counseling or that refer patients for abortion services.

jsmith/iStockphoto

U.S. District Judge Stanley Bastian for the District of Eastern Washington on April 25 approved a temporary nationwide ban against the program changes in response to legal a challenge by Washington state. The same day, U.S. District Judge for the District of Oregon Michael J. McShane also preliminarily barred the restrictions from taking effect in response to a legal challenge by the American Medical Association and the Planned Parenthood Federation of America.

Judge McShane called the program restrictions “arbitrary and capricious,” and wrote that the rules ignore comprehensive, ethical, and evidence-based health care, and impermissibly interfere with the patient-doctor relationship. Judge Bastian agreed, writing in his order that the plaintiffs have demonstrated that the restrictions violate the central purpose of Title X, which is to equalize access to comprehensive, evidence-based, and voluntary family planning.

“Plaintiffs have demonstrated they are likely to suffer irreparable harm in the absence of a preliminary injunction by presenting facts and argument that the final rule may or likely will: seriously disrupt or destroy the existing network of Title X providers in both the State of Washington and throughout the entire nation,” Judge Bastian wrote in his order.

Changes to the Title X program – scheduled to take effect May 3 – would have made health clinics ineligible for Title X funding if they offer, promote, or support abortion as a method of family planning. Title X grants generally go to health centers that provide reproductive health care – such as STD-testing, cancer screenings, and contraception – to low-income families. Under the rule, the government would withdraw financial assistance to clinics if they allow counseling or referrals associated with abortion, regardless of whether the money is used for other health care services.

HHS officials said that the final rule will provide for clear financial and physical separation between Title X and non–Title X activities, reduce confusion on the part of Title X clinics and the public about permissible Title X activities, and improve program transparency by requiring more complete reporting by grantees about their partnerships with referral agencies.

Care of the cancer patient is complex and expensive. During 2001-2011, medical spending to treat cancer increased from $56.8 billion to $88.3 billion in the United States. During this time, ambulatory expenditures for care and treatment increased while inpatient hospital expenditures decreased.^1,2 Treatments for cancer have advanced, but costs do not correlate with outcomes. Advanced payment models aimed at ensuring high quality while lowering costs may be the vehicle to help mitigate the financial burden of cancer treatment on patients and society at large.

Courtesy Dr. Sameer Mahesh

Oncology Care Model

The Center for Medicare and Medicaid Innovation designed the Oncology Care Model (OCM), which allows practices and payers in the United States to partner with the Centers for Medicare & Medicaid Services. The goal of the OCM is to provide high quality, highly coordinated cancer care at the same or lower cost. Practice partnerships with the CMS involve payment arrangements that include financial and performance accountability for episodes of cancer care surrounding chemotherapy delivery to patients.³

Practices that have been selected by the CMS have attested to providing a number of enhanced services from 24/7 patient access to an appropriate clinician who can access medical records to having a documented care plan for every patient.⁴

Payment methodology

An episode of care is defined as a 6-month period that starts at the time of chemotherapy administration. In addition to the standard fee-for-service payment, practices have the ability to earn two other types of payments during an oncology episode.

The per-beneficiary Monthly Enhanced Oncology Services payment is $960 for the entire episode but is paid to practices at $160 per month.

Practices have the potential to earn additional performance-based payments (PBP) based on the difference in cost between the projected and actual cost of the episode. The PBP also incorporates performance on quality metrics, based on Medicare claims and other information submitted by the practice. For example, claims-based measures include hospital, emergency department (ED), and hospice utilization.

To participate in the OCM, practices must choose either a one-sided or two-sided risk model. In the one-sided risk model, practices take on no downside risk but need to achieve a greater reduction in expenditures (4% below the benchmark price). In the two-side risk model, practices need only to reduce expenditures by 2.75% below the benchmark price. But if they fail to meet their savings goals, they must pay the difference to the CMS. The recoupment is capped at 20% of the benchmark amount.
 

Feedback reports

The CMS sends quarterly feedback reports that contain information on practice demographics, outcomes, expenditures, chemotherapy use, and patient satisfaction. The outcomes include the mortality rate for Medicare beneficiaries treated at the practice, compared with other practices nationally. In addition, the reports include end-of-life metrics and patient satisfaction, as well as details of expenditures on drugs, hospital use, imaging and laboratory services, and a description of chemotherapy usage.

These reports can be a helpful tool for measuring your own use of services, as well as benchmarking it against national figures.
 

Practice modifications

According to CMS feedback reports, the cost of care per beneficiary per month has increased across all practices since the inception of the OCM. However, there are practices that have been successful in reducing cost of care without negatively affecting mortality.

Drugs, hospital, and ED visits, along with imaging and laboratory evaluation, account for 75% of the cost. Some strategies to reduce expenditure involve targeting those areas.

Consider prescribing drugs conservatively without affecting outcomes. For instance, bisphosphonates for bone metastasis can be given every 12 weeks instead of 4 weeks.⁵ Similarly, adjuvant chemotherapy can be given for 3 months, instead of 6 months in appropriate stage 3 colon cancer patients.⁶

Another potential opportunity for savings is the judicious use of pertuzumab in early-stage breast cancer patients.⁷ These are all evidence-based recommendations with potential for cost savings. Clinical pathways can aid in this process, but physician buy-in is imperative.

In terms of imaging, avoid PET scans when they will not affect your clinical decision making, avoid staging scans in early-stage breast and prostate cancer patients, and avoid surveillance scans among early-stage breast cancer and lymphoma patients. The Choosing Wisely campaign can help guide some of these decisions.⁸

Another area where good care meets cost effective care is in the early engagement of palliative care. Several studies have shown that early involvement of palliative care improves survival and quality of life.^9,10 Palliative care involvement also decreases the emotional burden for patients and oncologists. Appropriate symptom control, particularly of pain, decreases hospitalizations during treatment.

Investing in a robust supportive care team – financial advocates, social work, nutrition, behavioral health, as well as various community services – can help reduce the financial, physical, and emotional distress levels for patients. All of these services ultimately lead to reduced hospitalizations.¹¹ The Monthly Enhanced Oncology Services payment can be put toward these expenses.

Care teams working at the highest level of competence and license can also save time and money. Consider using registered nurses to implement triage pathways to assess side effects and symptom management, or using nurse practitioners, registered nurses, and physician assistants for same-day appointments and to assess symptoms rather than referring patients to the emergency department.

Avoid the ED and hospitalizations by using the infusion center to provide hydration and blood transfusions in a timely fashion.

Telemedicine can be used for symptom management as well as leveraging supportive care services.

Cost for cancer care is very difficult to sustain. The OCM provides early insights into expenditures, challenges, and opportunities. Practices should use this information to build infrastructure and provide high quality, cost-effective care. Value-based cancer care should be the overarching goal for oncology practices and health care organizations.
 

Dr. Mahesh is the director of hematology-oncology and program director of the Oncology Care Model at Summa Health in Akron, Ohio.
 

References

1. Siegel RL et al. Cancer statistics, 2018. CA Cancer J Clin. 2018 Jan;68(1):7-30.

2. Medical Expenditure Panel Survey, Statistical Brief #443. 2014 Jun.

3. CMS: Oncology Care Model.

4. CMS: OCM Frequently Asked Questions.

5. Himelstein AL et al. Effect of longer-interval vs. standard dosing of zoledronic acid on skeletal events in patients with bone metastases. JAMA. 2017 Jan 3;317(1):48-58.

6. Grothey A et al. Duration of adjuvant chemotherapy for stage III colon cancer. N Engl J Med. 2018;378(13):1177-88.

7. Von Minckwitz G et al. Adjuvant pertuzumab and trastuzumab in early HER2-positive breast cancer. N Engl J Med. 2017;377(2):122-31.

8. American Society of Clinical Oncology: Ten Things Physician and Patients Should Question.

9. Temel JS et al. Early palliative care for patients with metastatic non–small cell lung cancer. N Engl J Med. 2010;363(8):733-42.

10. Blayney DW et al. Critical lessons from high-value oncology practices. JAMA Oncol. 2018 Feb 1;4(2):164-71.

11. Sherman DE. Transforming practices through the oncology care model: financial toxicity and counseling. J Oncol Pract. 2017 Aug;13(8):519-22.

Care of the cancer patient is complex and expensive. During 2001-2011, medical spending to treat cancer increased from $56.8 billion to $88.3 billion in the United States. During this time, ambulatory expenditures for care and treatment increased while inpatient hospital expenditures decreased.^1,2 Treatments for cancer have advanced, but costs do not correlate with outcomes. Advanced payment models aimed at ensuring high quality while lowering costs may be the vehicle to help mitigate the financial burden of cancer treatment on patients and society at large.

Courtesy Dr. Sameer Mahesh

Oncology Care Model

The Center for Medicare and Medicaid Innovation designed the Oncology Care Model (OCM), which allows practices and payers in the United States to partner with the Centers for Medicare & Medicaid Services. The goal of the OCM is to provide high quality, highly coordinated cancer care at the same or lower cost. Practice partnerships with the CMS involve payment arrangements that include financial and performance accountability for episodes of cancer care surrounding chemotherapy delivery to patients.³

Practices that have been selected by the CMS have attested to providing a number of enhanced services from 24/7 patient access to an appropriate clinician who can access medical records to having a documented care plan for every patient.⁴

Payment methodology

An episode of care is defined as a 6-month period that starts at the time of chemotherapy administration. In addition to the standard fee-for-service payment, practices have the ability to earn two other types of payments during an oncology episode.

The per-beneficiary Monthly Enhanced Oncology Services payment is $960 for the entire episode but is paid to practices at $160 per month.

Practices have the potential to earn additional performance-based payments (PBP) based on the difference in cost between the projected and actual cost of the episode. The PBP also incorporates performance on quality metrics, based on Medicare claims and other information submitted by the practice. For example, claims-based measures include hospital, emergency department (ED), and hospice utilization.

To participate in the OCM, practices must choose either a one-sided or two-sided risk model. In the one-sided risk model, practices take on no downside risk but need to achieve a greater reduction in expenditures (4% below the benchmark price). In the two-side risk model, practices need only to reduce expenditures by 2.75% below the benchmark price. But if they fail to meet their savings goals, they must pay the difference to the CMS. The recoupment is capped at 20% of the benchmark amount.
 

Feedback reports

The CMS sends quarterly feedback reports that contain information on practice demographics, outcomes, expenditures, chemotherapy use, and patient satisfaction. The outcomes include the mortality rate for Medicare beneficiaries treated at the practice, compared with other practices nationally. In addition, the reports include end-of-life metrics and patient satisfaction, as well as details of expenditures on drugs, hospital use, imaging and laboratory services, and a description of chemotherapy usage.

These reports can be a helpful tool for measuring your own use of services, as well as benchmarking it against national figures.
 

Practice modifications

According to CMS feedback reports, the cost of care per beneficiary per month has increased across all practices since the inception of the OCM. However, there are practices that have been successful in reducing cost of care without negatively affecting mortality.

Drugs, hospital, and ED visits, along with imaging and laboratory evaluation, account for 75% of the cost. Some strategies to reduce expenditure involve targeting those areas.

Consider prescribing drugs conservatively without affecting outcomes. For instance, bisphosphonates for bone metastasis can be given every 12 weeks instead of 4 weeks.⁵ Similarly, adjuvant chemotherapy can be given for 3 months, instead of 6 months in appropriate stage 3 colon cancer patients.⁶

Another potential opportunity for savings is the judicious use of pertuzumab in early-stage breast cancer patients.⁷ These are all evidence-based recommendations with potential for cost savings. Clinical pathways can aid in this process, but physician buy-in is imperative.

In terms of imaging, avoid PET scans when they will not affect your clinical decision making, avoid staging scans in early-stage breast and prostate cancer patients, and avoid surveillance scans among early-stage breast cancer and lymphoma patients. The Choosing Wisely campaign can help guide some of these decisions.⁸

Another area where good care meets cost effective care is in the early engagement of palliative care. Several studies have shown that early involvement of palliative care improves survival and quality of life.^9,10 Palliative care involvement also decreases the emotional burden for patients and oncologists. Appropriate symptom control, particularly of pain, decreases hospitalizations during treatment.

Investing in a robust supportive care team – financial advocates, social work, nutrition, behavioral health, as well as various community services – can help reduce the financial, physical, and emotional distress levels for patients. All of these services ultimately lead to reduced hospitalizations.¹¹ The Monthly Enhanced Oncology Services payment can be put toward these expenses.

Care teams working at the highest level of competence and license can also save time and money. Consider using registered nurses to implement triage pathways to assess side effects and symptom management, or using nurse practitioners, registered nurses, and physician assistants for same-day appointments and to assess symptoms rather than referring patients to the emergency department.

Avoid the ED and hospitalizations by using the infusion center to provide hydration and blood transfusions in a timely fashion.

Telemedicine can be used for symptom management as well as leveraging supportive care services.

Cost for cancer care is very difficult to sustain. The OCM provides early insights into expenditures, challenges, and opportunities. Practices should use this information to build infrastructure and provide high quality, cost-effective care. Value-based cancer care should be the overarching goal for oncology practices and health care organizations.
 

Dr. Mahesh is the director of hematology-oncology and program director of the Oncology Care Model at Summa Health in Akron, Ohio.
 

References

1. Siegel RL et al. Cancer statistics, 2018. CA Cancer J Clin. 2018 Jan;68(1):7-30.

2. Medical Expenditure Panel Survey, Statistical Brief #443. 2014 Jun.

3. CMS: Oncology Care Model.

4. CMS: OCM Frequently Asked Questions.

5. Himelstein AL et al. Effect of longer-interval vs. standard dosing of zoledronic acid on skeletal events in patients with bone metastases. JAMA. 2017 Jan 3;317(1):48-58.

6. Grothey A et al. Duration of adjuvant chemotherapy for stage III colon cancer. N Engl J Med. 2018;378(13):1177-88.

7. Von Minckwitz G et al. Adjuvant pertuzumab and trastuzumab in early HER2-positive breast cancer. N Engl J Med. 2017;377(2):122-31.

8. American Society of Clinical Oncology: Ten Things Physician and Patients Should Question.

9. Temel JS et al. Early palliative care for patients with metastatic non–small cell lung cancer. N Engl J Med. 2010;363(8):733-42.

10. Blayney DW et al. Critical lessons from high-value oncology practices. JAMA Oncol. 2018 Feb 1;4(2):164-71.

11. Sherman DE. Transforming practices through the oncology care model: financial toxicity and counseling. J Oncol Pract. 2017 Aug;13(8):519-22.

Care of the cancer patient is complex and expensive. During 2001-2011, medical spending to treat cancer increased from $56.8 billion to $88.3 billion in the United States. During this time, ambulatory expenditures for care and treatment increased while inpatient hospital expenditures decreased.^1,2 Treatments for cancer have advanced, but costs do not correlate with outcomes. Advanced payment models aimed at ensuring high quality while lowering costs may be the vehicle to help mitigate the financial burden of cancer treatment on patients and society at large.

Courtesy Dr. Sameer Mahesh

Oncology Care Model

The Center for Medicare and Medicaid Innovation designed the Oncology Care Model (OCM), which allows practices and payers in the United States to partner with the Centers for Medicare & Medicaid Services. The goal of the OCM is to provide high quality, highly coordinated cancer care at the same or lower cost. Practice partnerships with the CMS involve payment arrangements that include financial and performance accountability for episodes of cancer care surrounding chemotherapy delivery to patients.³

Practices that have been selected by the CMS have attested to providing a number of enhanced services from 24/7 patient access to an appropriate clinician who can access medical records to having a documented care plan for every patient.⁴

Payment methodology

An episode of care is defined as a 6-month period that starts at the time of chemotherapy administration. In addition to the standard fee-for-service payment, practices have the ability to earn two other types of payments during an oncology episode.

The per-beneficiary Monthly Enhanced Oncology Services payment is $960 for the entire episode but is paid to practices at $160 per month.

Practices have the potential to earn additional performance-based payments (PBP) based on the difference in cost between the projected and actual cost of the episode. The PBP also incorporates performance on quality metrics, based on Medicare claims and other information submitted by the practice. For example, claims-based measures include hospital, emergency department (ED), and hospice utilization.

To participate in the OCM, practices must choose either a one-sided or two-sided risk model. In the one-sided risk model, practices take on no downside risk but need to achieve a greater reduction in expenditures (4% below the benchmark price). In the two-side risk model, practices need only to reduce expenditures by 2.75% below the benchmark price. But if they fail to meet their savings goals, they must pay the difference to the CMS. The recoupment is capped at 20% of the benchmark amount.
 

Feedback reports

The CMS sends quarterly feedback reports that contain information on practice demographics, outcomes, expenditures, chemotherapy use, and patient satisfaction. The outcomes include the mortality rate for Medicare beneficiaries treated at the practice, compared with other practices nationally. In addition, the reports include end-of-life metrics and patient satisfaction, as well as details of expenditures on drugs, hospital use, imaging and laboratory services, and a description of chemotherapy usage.

These reports can be a helpful tool for measuring your own use of services, as well as benchmarking it against national figures.
 

Practice modifications

According to CMS feedback reports, the cost of care per beneficiary per month has increased across all practices since the inception of the OCM. However, there are practices that have been successful in reducing cost of care without negatively affecting mortality.

Drugs, hospital, and ED visits, along with imaging and laboratory evaluation, account for 75% of the cost. Some strategies to reduce expenditure involve targeting those areas.

Consider prescribing drugs conservatively without affecting outcomes. For instance, bisphosphonates for bone metastasis can be given every 12 weeks instead of 4 weeks.⁵ Similarly, adjuvant chemotherapy can be given for 3 months, instead of 6 months in appropriate stage 3 colon cancer patients.⁶

Another potential opportunity for savings is the judicious use of pertuzumab in early-stage breast cancer patients.⁷ These are all evidence-based recommendations with potential for cost savings. Clinical pathways can aid in this process, but physician buy-in is imperative.

In terms of imaging, avoid PET scans when they will not affect your clinical decision making, avoid staging scans in early-stage breast and prostate cancer patients, and avoid surveillance scans among early-stage breast cancer and lymphoma patients. The Choosing Wisely campaign can help guide some of these decisions.⁸

Another area where good care meets cost effective care is in the early engagement of palliative care. Several studies have shown that early involvement of palliative care improves survival and quality of life.^9,10 Palliative care involvement also decreases the emotional burden for patients and oncologists. Appropriate symptom control, particularly of pain, decreases hospitalizations during treatment.

Investing in a robust supportive care team – financial advocates, social work, nutrition, behavioral health, as well as various community services – can help reduce the financial, physical, and emotional distress levels for patients. All of these services ultimately lead to reduced hospitalizations.¹¹ The Monthly Enhanced Oncology Services payment can be put toward these expenses.

Care teams working at the highest level of competence and license can also save time and money. Consider using registered nurses to implement triage pathways to assess side effects and symptom management, or using nurse practitioners, registered nurses, and physician assistants for same-day appointments and to assess symptoms rather than referring patients to the emergency department.

Avoid the ED and hospitalizations by using the infusion center to provide hydration and blood transfusions in a timely fashion.

Telemedicine can be used for symptom management as well as leveraging supportive care services.

Cost for cancer care is very difficult to sustain. The OCM provides early insights into expenditures, challenges, and opportunities. Practices should use this information to build infrastructure and provide high quality, cost-effective care. Value-based cancer care should be the overarching goal for oncology practices and health care organizations.
 

Dr. Mahesh is the director of hematology-oncology and program director of the Oncology Care Model at Summa Health in Akron, Ohio.
 

References

1. Siegel RL et al. Cancer statistics, 2018. CA Cancer J Clin. 2018 Jan;68(1):7-30.

2. Medical Expenditure Panel Survey, Statistical Brief #443. 2014 Jun.

3. CMS: Oncology Care Model.

4. CMS: OCM Frequently Asked Questions.

5. Himelstein AL et al. Effect of longer-interval vs. standard dosing of zoledronic acid on skeletal events in patients with bone metastases. JAMA. 2017 Jan 3;317(1):48-58.

6. Grothey A et al. Duration of adjuvant chemotherapy for stage III colon cancer. N Engl J Med. 2018;378(13):1177-88.

7. Von Minckwitz G et al. Adjuvant pertuzumab and trastuzumab in early HER2-positive breast cancer. N Engl J Med. 2017;377(2):122-31.

8. American Society of Clinical Oncology: Ten Things Physician and Patients Should Question.

9. Temel JS et al. Early palliative care for patients with metastatic non–small cell lung cancer. N Engl J Med. 2010;363(8):733-42.

10. Blayney DW et al. Critical lessons from high-value oncology practices. JAMA Oncol. 2018 Feb 1;4(2):164-71.

11. Sherman DE. Transforming practices through the oncology care model: financial toxicity and counseling. J Oncol Pract. 2017 Aug;13(8):519-22.

On March 23 and 24, AGA and the European Society of Neurogastroenterology and Motility (ESNM) gathered 350+ international clinicians and researchers to network and discuss the latest evidence on the interaction between diet, nutrition and the gut microbiome at the 2019 Gut Microbiota for Health World Summit.

Twenty-three novel abstracts were presented as posters at the meeting. The abstracts covered topics ranging from probiotics to diet to potential microbiome-driven treatments for GI disorders.

Below are some key takeaways (as shared on Twitter) from the meeting. Stay tuned for more news and resources from the 2019 Gut Microbiota for Health World Summit, including an official meeting report in Gastroenterology, on-demand presentation recordings, video clips, and more.



“Excess zinc supplementation can change the gut #microbiota and increase risk AND severity of #cdiff infection, says @joeyzacks #GMFH2019 @cdiffFoundation” — Dr. Caterina Oneto (@caterina_oneto)



“You need a #dietitian for low #FODMAP diet education to ensure the patient consumes a nutritionally adequate diet. @MagnusSimren #GMFH2019” — Kate Scarlata, RDN (@KateScarlata_RD)



“Patients with cirrhosis have increased bacteremia, blood LPS levels and intestinal permeability. This background has led to study the role of gut microbiota in liver disease #GMFH2019” — GutMicrobiota Health (@GMFHx)



“Much anticipated talk on #probiotics happening now at #GMFH2019 led by AGA’s probiotics experts @KashyapPurna & Geoffrey Preidis. This work will culminate in a new AGA guideline on using probiotics in clinical practice. Additional data will be presented at #DDW19” — AGA (@AmerGastroAssn)



“Eric Martens: while a low fibre diet may not drive inflammation in the short term, it may increase disease risk in the long term, due to changes in microbiota & mucus degrading bacteria! #GMFH2019” — Andrea Hardy RD (@AndreaHardyRD)



View additional Twitter coverage of the meeting: #GMFH2019.
 

[email protected]

On March 23 and 24, AGA and the European Society of Neurogastroenterology and Motility (ESNM) gathered 350+ international clinicians and researchers to network and discuss the latest evidence on the interaction between diet, nutrition and the gut microbiome at the 2019 Gut Microbiota for Health World Summit.

Twenty-three novel abstracts were presented as posters at the meeting. The abstracts covered topics ranging from probiotics to diet to potential microbiome-driven treatments for GI disorders.

Below are some key takeaways (as shared on Twitter) from the meeting. Stay tuned for more news and resources from the 2019 Gut Microbiota for Health World Summit, including an official meeting report in Gastroenterology, on-demand presentation recordings, video clips, and more.



“Excess zinc supplementation can change the gut #microbiota and increase risk AND severity of #cdiff infection, says @joeyzacks #GMFH2019 @cdiffFoundation” — Dr. Caterina Oneto (@caterina_oneto)



“You need a #dietitian for low #FODMAP diet education to ensure the patient consumes a nutritionally adequate diet. @MagnusSimren #GMFH2019” — Kate Scarlata, RDN (@KateScarlata_RD)



“Patients with cirrhosis have increased bacteremia, blood LPS levels and intestinal permeability. This background has led to study the role of gut microbiota in liver disease #GMFH2019” — GutMicrobiota Health (@GMFHx)



“Much anticipated talk on #probiotics happening now at #GMFH2019 led by AGA’s probiotics experts @KashyapPurna & Geoffrey Preidis. This work will culminate in a new AGA guideline on using probiotics in clinical practice. Additional data will be presented at #DDW19” — AGA (@AmerGastroAssn)



“Eric Martens: while a low fibre diet may not drive inflammation in the short term, it may increase disease risk in the long term, due to changes in microbiota & mucus degrading bacteria! #GMFH2019” — Andrea Hardy RD (@AndreaHardyRD)



View additional Twitter coverage of the meeting: #GMFH2019.
 

[email protected]

On March 23 and 24, AGA and the European Society of Neurogastroenterology and Motility (ESNM) gathered 350+ international clinicians and researchers to network and discuss the latest evidence on the interaction between diet, nutrition and the gut microbiome at the 2019 Gut Microbiota for Health World Summit.

Twenty-three novel abstracts were presented as posters at the meeting. The abstracts covered topics ranging from probiotics to diet to potential microbiome-driven treatments for GI disorders.

Below are some key takeaways (as shared on Twitter) from the meeting. Stay tuned for more news and resources from the 2019 Gut Microbiota for Health World Summit, including an official meeting report in Gastroenterology, on-demand presentation recordings, video clips, and more.



“Excess zinc supplementation can change the gut #microbiota and increase risk AND severity of #cdiff infection, says @joeyzacks #GMFH2019 @cdiffFoundation” — Dr. Caterina Oneto (@caterina_oneto)



“You need a #dietitian for low #FODMAP diet education to ensure the patient consumes a nutritionally adequate diet. @MagnusSimren #GMFH2019” — Kate Scarlata, RDN (@KateScarlata_RD)



“Patients with cirrhosis have increased bacteremia, blood LPS levels and intestinal permeability. This background has led to study the role of gut microbiota in liver disease #GMFH2019” — GutMicrobiota Health (@GMFHx)



“Much anticipated talk on #probiotics happening now at #GMFH2019 led by AGA’s probiotics experts @KashyapPurna & Geoffrey Preidis. This work will culminate in a new AGA guideline on using probiotics in clinical practice. Additional data will be presented at #DDW19” — AGA (@AmerGastroAssn)



“Eric Martens: while a low fibre diet may not drive inflammation in the short term, it may increase disease risk in the long term, due to changes in microbiota & mucus degrading bacteria! #GMFH2019” — Andrea Hardy RD (@AndreaHardyRD)



View additional Twitter coverage of the meeting: #GMFH2019.
 

[email protected]

The AGA Research Foundation offers its flagship grant, the AGA Research Scholar Award, to the most promising early career investigators. Kyle Staller, MD, MPH, an assistant professor of medicine at Harvard Medical School in Boston, is no exception. We’re thrilled to highlight Dr. Staller – a 2016 AGA Research Scholar Award winner — as our AGA Research Foundation researcher of the month.

The Staller lab’s AGA-funded project is specifically focused on the risk factors for fecal incontinence, which have not been well studied. One in 10 women over age 80 suffer from this debilitating condition. Dr. Staller looked at the lifestyles and dietary factors of female study participants in research databases to determine whether they were predisposed to developing fecal incontinence beyond the usual risk factors such as childbirth, which can cause injury to the pelvic floor, and diabetes. Dr. Staller believes that understanding and modifying risk factors could decrease the chance, or even prevent, women from developing this condition.

With his AGA Research Foundation grant, Dr. Staller found that consuming dietary fiber in higher quantities, and increasing moderate exercise up to a point, lowered the risk of developing fecal incontinence. “This tells us that not only is fiber healthy but also preventative to fecal incontinence,” he said.

Dr. Staller says that he became interested in this area of study after patients, who were getting excited about their impending retirement or enjoying their retirement years, developed this life-altering condition. His compassion for his patients inspired him to study the factors leading to fecal incontinence, which will likely become more prevalent as the U.S. population ages.

Dr. Staller is using the baseline data from his AGA Research Foundation grant to support his application for a 5-year NIH grant designed to help young investigators learn new research skills to further their careers.

Read more and get to know Dr. Staller by visiting https://www.gastro.org/news/meet-a-rising-star-in-fecal-incontinence-research.



Help AGA build a community of investigators through the AGA Research Foundation.

Your donation to the AGA Research Foundation can fund future success stories by keeping young scientists working to advance our understanding of digestive diseases. Donate today at www.gastro.org/donateonline.

[email protected]

The AGA Research Foundation offers its flagship grant, the AGA Research Scholar Award, to the most promising early career investigators. Kyle Staller, MD, MPH, an assistant professor of medicine at Harvard Medical School in Boston, is no exception. We’re thrilled to highlight Dr. Staller – a 2016 AGA Research Scholar Award winner — as our AGA Research Foundation researcher of the month.

The Staller lab’s AGA-funded project is specifically focused on the risk factors for fecal incontinence, which have not been well studied. One in 10 women over age 80 suffer from this debilitating condition. Dr. Staller looked at the lifestyles and dietary factors of female study participants in research databases to determine whether they were predisposed to developing fecal incontinence beyond the usual risk factors such as childbirth, which can cause injury to the pelvic floor, and diabetes. Dr. Staller believes that understanding and modifying risk factors could decrease the chance, or even prevent, women from developing this condition.

With his AGA Research Foundation grant, Dr. Staller found that consuming dietary fiber in higher quantities, and increasing moderate exercise up to a point, lowered the risk of developing fecal incontinence. “This tells us that not only is fiber healthy but also preventative to fecal incontinence,” he said.

Dr. Staller says that he became interested in this area of study after patients, who were getting excited about their impending retirement or enjoying their retirement years, developed this life-altering condition. His compassion for his patients inspired him to study the factors leading to fecal incontinence, which will likely become more prevalent as the U.S. population ages.

Dr. Staller is using the baseline data from his AGA Research Foundation grant to support his application for a 5-year NIH grant designed to help young investigators learn new research skills to further their careers.

Read more and get to know Dr. Staller by visiting https://www.gastro.org/news/meet-a-rising-star-in-fecal-incontinence-research.



Help AGA build a community of investigators through the AGA Research Foundation.

Your donation to the AGA Research Foundation can fund future success stories by keeping young scientists working to advance our understanding of digestive diseases. Donate today at www.gastro.org/donateonline.

[email protected]

The AGA Research Foundation offers its flagship grant, the AGA Research Scholar Award, to the most promising early career investigators. Kyle Staller, MD, MPH, an assistant professor of medicine at Harvard Medical School in Boston, is no exception. We’re thrilled to highlight Dr. Staller – a 2016 AGA Research Scholar Award winner — as our AGA Research Foundation researcher of the month.

The Staller lab’s AGA-funded project is specifically focused on the risk factors for fecal incontinence, which have not been well studied. One in 10 women over age 80 suffer from this debilitating condition. Dr. Staller looked at the lifestyles and dietary factors of female study participants in research databases to determine whether they were predisposed to developing fecal incontinence beyond the usual risk factors such as childbirth, which can cause injury to the pelvic floor, and diabetes. Dr. Staller believes that understanding and modifying risk factors could decrease the chance, or even prevent, women from developing this condition.

With his AGA Research Foundation grant, Dr. Staller found that consuming dietary fiber in higher quantities, and increasing moderate exercise up to a point, lowered the risk of developing fecal incontinence. “This tells us that not only is fiber healthy but also preventative to fecal incontinence,” he said.

Dr. Staller says that he became interested in this area of study after patients, who were getting excited about their impending retirement or enjoying their retirement years, developed this life-altering condition. His compassion for his patients inspired him to study the factors leading to fecal incontinence, which will likely become more prevalent as the U.S. population ages.

Dr. Staller is using the baseline data from his AGA Research Foundation grant to support his application for a 5-year NIH grant designed to help young investigators learn new research skills to further their careers.

Read more and get to know Dr. Staller by visiting https://www.gastro.org/news/meet-a-rising-star-in-fecal-incontinence-research.



Help AGA build a community of investigators through the AGA Research Foundation.

Your donation to the AGA Research Foundation can fund future success stories by keeping young scientists working to advance our understanding of digestive diseases. Donate today at www.gastro.org/donateonline.

[email protected]

Rates of a potentially deadly overlap between use of nonprescribed fentanyl and use of either cocaine or methamphetamine have been increasing, a cross-sectional study of 1 million urine drug tests shows.

Leah LaRue, PharmD, of Millennium Health in San Diego, and colleagues performed the study, which sampled 1 million urine drug tests submitted by health care professionals “as part of routine care” during Jan. 1, 2013–Sept. 30, 2018. They isolated tests that were positive for either cocaine or methamphetamine – but not positive for both – and then determined how many in each group were also positive for nonprescribed fentanyl. Their analyses showed that the rate of cocaine-positive tests that also were positive for nonprescribed fentanyl increased from 0.9% in 2013 (n = 84; 95% confidence interval, 0.7%-1.1%) to 17.6% in 2018 (n = 427; 95% CI, 16.1%-19.1%), an increase of 1,850% (P less than .001). The rate of methamphetamine-positive tests that also were positive for nonprescribed fentanyl also started at 0.9% in 2013 (n = 29; 95% CI, 0.6%-1.2%) but rose to 7.9% in 2018 (n = 344; 95% CI, 7.1%-8.7%, a 798% increase (P less than .001). The study was published in JAMA Network Open.

The investigators suggested two explanations for these increases: intentional combination of drugs for “speedball effects” of combining stimulants and depressants and/or unintentional exposure on the part of users through contamination of substances. There have been increases in both cocaine-related and methamphetamine-related deaths, and the investigators of this study suspect these increases could be explained in part by overlap with opioids such as fentanyl. Part of the overdose risk inherent in these combinations is that, as the stimulant wears off, the fentanyl increasingly depresses the respiratory system, according to investigators; alternatively, opioid-naive stimulant users might be exposed to high levels of fentanyl with no opioid tolerance, which also can lead to overdose.

The study’s limitations include how samples were submitted – by health care professionals as part of routine care – and the possibility that individuals’ list of prescribed medications could have been incomplete or inaccurate such that the presence of prescribed fentanyl was counted as nonprescribed.

“The combination of nonprescribed fentanyl with cocaine or methamphetamine places an individual at increased risk of overdose,” they concluded. “Clinicians treating these individuals, and the individuals themselves, should be aware of this risk. Additionally, efforts should be made to educate the public about this risk and about overdose prevention.”

[email protected]

SOURCE: LaRue L et al. JAMA Netw Open. 2019 Apr 26. doi: 10.1001/jamanetworkopen.2019.2851.

Rates of a potentially deadly overlap between use of nonprescribed fentanyl and use of either cocaine or methamphetamine have been increasing, a cross-sectional study of 1 million urine drug tests shows.

Leah LaRue, PharmD, of Millennium Health in San Diego, and colleagues performed the study, which sampled 1 million urine drug tests submitted by health care professionals “as part of routine care” during Jan. 1, 2013–Sept. 30, 2018. They isolated tests that were positive for either cocaine or methamphetamine – but not positive for both – and then determined how many in each group were also positive for nonprescribed fentanyl. Their analyses showed that the rate of cocaine-positive tests that also were positive for nonprescribed fentanyl increased from 0.9% in 2013 (n = 84; 95% confidence interval, 0.7%-1.1%) to 17.6% in 2018 (n = 427; 95% CI, 16.1%-19.1%), an increase of 1,850% (P less than .001). The rate of methamphetamine-positive tests that also were positive for nonprescribed fentanyl also started at 0.9% in 2013 (n = 29; 95% CI, 0.6%-1.2%) but rose to 7.9% in 2018 (n = 344; 95% CI, 7.1%-8.7%, a 798% increase (P less than .001). The study was published in JAMA Network Open.

The investigators suggested two explanations for these increases: intentional combination of drugs for “speedball effects” of combining stimulants and depressants and/or unintentional exposure on the part of users through contamination of substances. There have been increases in both cocaine-related and methamphetamine-related deaths, and the investigators of this study suspect these increases could be explained in part by overlap with opioids such as fentanyl. Part of the overdose risk inherent in these combinations is that, as the stimulant wears off, the fentanyl increasingly depresses the respiratory system, according to investigators; alternatively, opioid-naive stimulant users might be exposed to high levels of fentanyl with no opioid tolerance, which also can lead to overdose.

The study’s limitations include how samples were submitted – by health care professionals as part of routine care – and the possibility that individuals’ list of prescribed medications could have been incomplete or inaccurate such that the presence of prescribed fentanyl was counted as nonprescribed.

“The combination of nonprescribed fentanyl with cocaine or methamphetamine places an individual at increased risk of overdose,” they concluded. “Clinicians treating these individuals, and the individuals themselves, should be aware of this risk. Additionally, efforts should be made to educate the public about this risk and about overdose prevention.”

[email protected]

SOURCE: LaRue L et al. JAMA Netw Open. 2019 Apr 26. doi: 10.1001/jamanetworkopen.2019.2851.

Rates of a potentially deadly overlap between use of nonprescribed fentanyl and use of either cocaine or methamphetamine have been increasing, a cross-sectional study of 1 million urine drug tests shows.

Leah LaRue, PharmD, of Millennium Health in San Diego, and colleagues performed the study, which sampled 1 million urine drug tests submitted by health care professionals “as part of routine care” during Jan. 1, 2013–Sept. 30, 2018. They isolated tests that were positive for either cocaine or methamphetamine – but not positive for both – and then determined how many in each group were also positive for nonprescribed fentanyl. Their analyses showed that the rate of cocaine-positive tests that also were positive for nonprescribed fentanyl increased from 0.9% in 2013 (n = 84; 95% confidence interval, 0.7%-1.1%) to 17.6% in 2018 (n = 427; 95% CI, 16.1%-19.1%), an increase of 1,850% (P less than .001). The rate of methamphetamine-positive tests that also were positive for nonprescribed fentanyl also started at 0.9% in 2013 (n = 29; 95% CI, 0.6%-1.2%) but rose to 7.9% in 2018 (n = 344; 95% CI, 7.1%-8.7%, a 798% increase (P less than .001). The study was published in JAMA Network Open.

The investigators suggested two explanations for these increases: intentional combination of drugs for “speedball effects” of combining stimulants and depressants and/or unintentional exposure on the part of users through contamination of substances. There have been increases in both cocaine-related and methamphetamine-related deaths, and the investigators of this study suspect these increases could be explained in part by overlap with opioids such as fentanyl. Part of the overdose risk inherent in these combinations is that, as the stimulant wears off, the fentanyl increasingly depresses the respiratory system, according to investigators; alternatively, opioid-naive stimulant users might be exposed to high levels of fentanyl with no opioid tolerance, which also can lead to overdose.

The study’s limitations include how samples were submitted – by health care professionals as part of routine care – and the possibility that individuals’ list of prescribed medications could have been incomplete or inaccurate such that the presence of prescribed fentanyl was counted as nonprescribed.

“The combination of nonprescribed fentanyl with cocaine or methamphetamine places an individual at increased risk of overdose,” they concluded. “Clinicians treating these individuals, and the individuals themselves, should be aware of this risk. Additionally, efforts should be made to educate the public about this risk and about overdose prevention.”

[email protected]

SOURCE: LaRue L et al. JAMA Netw Open. 2019 Apr 26. doi: 10.1001/jamanetworkopen.2019.2851.

For patients with relapsed/refractory chronic lymphocytic leukemia (CLL), long-term treatment with the phosphoinositol 3-kinase inhibitor idelalisib appears safe and effective, according to investigators.

Final results from a phase 3 trial confirmed survival advantages when idelalisib is used in combination with rituximab, reported lead author Jeff P. Sharman, MD, of Willamette Valley Cancer Institute and Research Center in Springfield, Ore., and colleagues.

During follow-up, which exceeded 5 years in some patients, no new idelalisib-related adverse events were encountered, supporting the safety of long-term use, the investigators noted. The report is in the Journal of Clinical Oncology.

This study was “pivotal” for treating elderly patients with relapsed CLL, the investigators wrote, as these patients previously had few treatment options beyond supportive or palliative care.

Earlier results from the study showed that adding idelalisib to rituximab raised overall response rates from about 15.5% to 83.6% and median progression-free survival from 6.5 months to 19.4 months, resulting in “significantly better clinical outcomes compared with those seen with rituximab alone,” leading to approval by the Food and Drug Administration.

During the primary study, 110 patients received a combination of idelalisib and rituximab, while 108 patients received rituximab and placebo. The median patient age was 71 years, with a median of three lines of prior therapy. The present analysis focused on the 110 patients in the combination group who received at least one dose of idelalisib, whether or not they elected to participate in the extension phase.

After a median follow-up of 18 months, ranging from 0.3 months to 67.6 months, the overall response rate was 85.5% and the median progression-free survival was 20.3 months, both of which are similar to earlier findings. Median overall survival was 40.6 months.

With a median duration of exposure of 16.2 months, the safety analysis revealed no new idelalisib-related adverse events.

However, the investigators pointed out that prolonged therapy often led to diarrhea, which ultimately occurred in about half of patients (46.4%). Roughly equal amounts of patients experienced grade 2 (17.3%) or grade 3 or greater diarrhea (16.4%). In cases of grade 3 or greater diarrhea, steroid therapy was recommended, typically resulting in symptom resolution within 2 weeks; however, “there were insufficient numbers of patients to determine if steroid therapy affected the duration of symptoms,” the investigators wrote.

“The longer-term data presented here confirm the previously reported efficacy of targeting PI3K with idelalisib in patients with relapsed/refractory CLL and support the use of [idelalisib and rituximab] in this patient population with careful management of potential [adverse events],” they wrote.

Gilead Sciences funded the study. Dr. Sharman reported financial relationships with Gilead and other companies.

SOURCE: Sharman JP et al. J Clin Oncol. 2019 Apr 17. doi: 10.1200/JCO.18.01460.

For patients with relapsed/refractory chronic lymphocytic leukemia (CLL), long-term treatment with the phosphoinositol 3-kinase inhibitor idelalisib appears safe and effective, according to investigators.

Final results from a phase 3 trial confirmed survival advantages when idelalisib is used in combination with rituximab, reported lead author Jeff P. Sharman, MD, of Willamette Valley Cancer Institute and Research Center in Springfield, Ore., and colleagues.

During follow-up, which exceeded 5 years in some patients, no new idelalisib-related adverse events were encountered, supporting the safety of long-term use, the investigators noted. The report is in the Journal of Clinical Oncology.

This study was “pivotal” for treating elderly patients with relapsed CLL, the investigators wrote, as these patients previously had few treatment options beyond supportive or palliative care.

Earlier results from the study showed that adding idelalisib to rituximab raised overall response rates from about 15.5% to 83.6% and median progression-free survival from 6.5 months to 19.4 months, resulting in “significantly better clinical outcomes compared with those seen with rituximab alone,” leading to approval by the Food and Drug Administration.

During the primary study, 110 patients received a combination of idelalisib and rituximab, while 108 patients received rituximab and placebo. The median patient age was 71 years, with a median of three lines of prior therapy. The present analysis focused on the 110 patients in the combination group who received at least one dose of idelalisib, whether or not they elected to participate in the extension phase.

After a median follow-up of 18 months, ranging from 0.3 months to 67.6 months, the overall response rate was 85.5% and the median progression-free survival was 20.3 months, both of which are similar to earlier findings. Median overall survival was 40.6 months.

With a median duration of exposure of 16.2 months, the safety analysis revealed no new idelalisib-related adverse events.

However, the investigators pointed out that prolonged therapy often led to diarrhea, which ultimately occurred in about half of patients (46.4%). Roughly equal amounts of patients experienced grade 2 (17.3%) or grade 3 or greater diarrhea (16.4%). In cases of grade 3 or greater diarrhea, steroid therapy was recommended, typically resulting in symptom resolution within 2 weeks; however, “there were insufficient numbers of patients to determine if steroid therapy affected the duration of symptoms,” the investigators wrote.

“The longer-term data presented here confirm the previously reported efficacy of targeting PI3K with idelalisib in patients with relapsed/refractory CLL and support the use of [idelalisib and rituximab] in this patient population with careful management of potential [adverse events],” they wrote.

Gilead Sciences funded the study. Dr. Sharman reported financial relationships with Gilead and other companies.

SOURCE: Sharman JP et al. J Clin Oncol. 2019 Apr 17. doi: 10.1200/JCO.18.01460.

For patients with relapsed/refractory chronic lymphocytic leukemia (CLL), long-term treatment with the phosphoinositol 3-kinase inhibitor idelalisib appears safe and effective, according to investigators.

Final results from a phase 3 trial confirmed survival advantages when idelalisib is used in combination with rituximab, reported lead author Jeff P. Sharman, MD, of Willamette Valley Cancer Institute and Research Center in Springfield, Ore., and colleagues.

During follow-up, which exceeded 5 years in some patients, no new idelalisib-related adverse events were encountered, supporting the safety of long-term use, the investigators noted. The report is in the Journal of Clinical Oncology.

This study was “pivotal” for treating elderly patients with relapsed CLL, the investigators wrote, as these patients previously had few treatment options beyond supportive or palliative care.

Earlier results from the study showed that adding idelalisib to rituximab raised overall response rates from about 15.5% to 83.6% and median progression-free survival from 6.5 months to 19.4 months, resulting in “significantly better clinical outcomes compared with those seen with rituximab alone,” leading to approval by the Food and Drug Administration.

During the primary study, 110 patients received a combination of idelalisib and rituximab, while 108 patients received rituximab and placebo. The median patient age was 71 years, with a median of three lines of prior therapy. The present analysis focused on the 110 patients in the combination group who received at least one dose of idelalisib, whether or not they elected to participate in the extension phase.

After a median follow-up of 18 months, ranging from 0.3 months to 67.6 months, the overall response rate was 85.5% and the median progression-free survival was 20.3 months, both of which are similar to earlier findings. Median overall survival was 40.6 months.

With a median duration of exposure of 16.2 months, the safety analysis revealed no new idelalisib-related adverse events.

However, the investigators pointed out that prolonged therapy often led to diarrhea, which ultimately occurred in about half of patients (46.4%). Roughly equal amounts of patients experienced grade 2 (17.3%) or grade 3 or greater diarrhea (16.4%). In cases of grade 3 or greater diarrhea, steroid therapy was recommended, typically resulting in symptom resolution within 2 weeks; however, “there were insufficient numbers of patients to determine if steroid therapy affected the duration of symptoms,” the investigators wrote.

“The longer-term data presented here confirm the previously reported efficacy of targeting PI3K with idelalisib in patients with relapsed/refractory CLL and support the use of [idelalisib and rituximab] in this patient population with careful management of potential [adverse events],” they wrote.

Gilead Sciences funded the study. Dr. Sharman reported financial relationships with Gilead and other companies.

SOURCE: Sharman JP et al. J Clin Oncol. 2019 Apr 17. doi: 10.1200/JCO.18.01460.

Although nutrition therapy is pivotal in the management of patients with diabetes or prediabetes, there’s no one correct eating pattern appropriate for all patients, according to a consensus report from an expert panel convened by the American Diabetes Association.

A one-size-fits-all eating plan would be an unrealistic expectation, given the diversity of cultural issues, personal preferences, comorbidities, and other factors that are unique to individual patients with diabetes or prediabetes, according to the report, which was published in Diabetes Care.

Instead, authors of the report outlined nine different eating patterns, along with the evidence supporting their use and their reported benefits in patients with diabetes or prediabetes.

The report reflects a commitment to developing evidence-based guidelines that are “achievable and meet people where they are” to formulate individualized nutrition plans, William T. Cefalu, MD, chief scientific, medical, and mission officer for the ADA, said in a statement.

“The importance of this consensus also lies in the fact it was authored by a group of experts who are extremely knowledgeable about numerous eating patterns, including vegan, vegetarian, and low carb,” Dr. Cefalu added.

The expert panel of 14 individuals included registered dietitians, diabetes educators, endocrinologists, a primary care physician, and a patient advocate who all answered a national call for experts, according to the ADA.

The panel reviewed more than 600 nutrition manuscripts published between 2014 and 2018 to develop the new consensus statement, which updates the ADA 2014 position statement on nutrition therapy for adults with diabetes and has been incorporated into the association’s Standards of Medical Care in Diabetes–2019 supplement as a living standards update.

All adults with type 1 or 2 diabetes should be referred to individualized, diabetes-focused medical nutrition therapy, the panel members wrote in their report.

There is no evidence suggesting an ideal percentage of calories from carbohydrate, protein, and fat in patients with prediabetes or diabetes, so macronutrient distribution should also be individualized, according to the panel.

Likewise, a variety of eating patterns are acceptable for managing diabetes, according to the report, which describes evidence for eating patterns including Mediterranean, vegetarian or vegan, low fat and very low fat, low carbohydrate and very low carbohydrate, and paleo, as well as the Dietary Approaches to Stop Hypertension diet and the Department of Agriculture Dietary Guidelines for Americans.

Not all diets have the same level of evidence, however. For prevention of prediabetes or type 2 diabetes, for example, the most robust research is available for Mediterranean-style, low-fat, and low-carbohydrate eating patterns, the panel said.

Until there’s better comparative evidence between eating patterns, health care providers should concentrate on several key factors common to a number of the eating patterns, such as limiting sugars and refined grains, emphasizing nonstarchy vegetables, and choosing whole foods over processed foods, the experts wrote.

Consensus panel participants reported disclosures with the ADA, the National Institutes of Health, the Academy of Nutrition and Dietetics, the American Medical Group Association, the University of Michigan, Novo Nordisk, Merck, Amgen, Gilead, BOYDSense, Janssen, Sanofi, Pfizer, Sunstar Foundation, New England Dairy and Dairy Farmer, the National Dairy Council, Kowa Company, and dietdoctor.com.

SOURCE: Evert AB et al. Diabetes Care. 2019 Apr 18. doi: 10.2337/dci19-0014.

Although nutrition therapy is pivotal in the management of patients with diabetes or prediabetes, there’s no one correct eating pattern appropriate for all patients, according to a consensus report from an expert panel convened by the American Diabetes Association.

A one-size-fits-all eating plan would be an unrealistic expectation, given the diversity of cultural issues, personal preferences, comorbidities, and other factors that are unique to individual patients with diabetes or prediabetes, according to the report, which was published in Diabetes Care.

Instead, authors of the report outlined nine different eating patterns, along with the evidence supporting their use and their reported benefits in patients with diabetes or prediabetes.

The report reflects a commitment to developing evidence-based guidelines that are “achievable and meet people where they are” to formulate individualized nutrition plans, William T. Cefalu, MD, chief scientific, medical, and mission officer for the ADA, said in a statement.

“The importance of this consensus also lies in the fact it was authored by a group of experts who are extremely knowledgeable about numerous eating patterns, including vegan, vegetarian, and low carb,” Dr. Cefalu added.

The expert panel of 14 individuals included registered dietitians, diabetes educators, endocrinologists, a primary care physician, and a patient advocate who all answered a national call for experts, according to the ADA.

The panel reviewed more than 600 nutrition manuscripts published between 2014 and 2018 to develop the new consensus statement, which updates the ADA 2014 position statement on nutrition therapy for adults with diabetes and has been incorporated into the association’s Standards of Medical Care in Diabetes–2019 supplement as a living standards update.

All adults with type 1 or 2 diabetes should be referred to individualized, diabetes-focused medical nutrition therapy, the panel members wrote in their report.

There is no evidence suggesting an ideal percentage of calories from carbohydrate, protein, and fat in patients with prediabetes or diabetes, so macronutrient distribution should also be individualized, according to the panel.

Likewise, a variety of eating patterns are acceptable for managing diabetes, according to the report, which describes evidence for eating patterns including Mediterranean, vegetarian or vegan, low fat and very low fat, low carbohydrate and very low carbohydrate, and paleo, as well as the Dietary Approaches to Stop Hypertension diet and the Department of Agriculture Dietary Guidelines for Americans.

Not all diets have the same level of evidence, however. For prevention of prediabetes or type 2 diabetes, for example, the most robust research is available for Mediterranean-style, low-fat, and low-carbohydrate eating patterns, the panel said.

Until there’s better comparative evidence between eating patterns, health care providers should concentrate on several key factors common to a number of the eating patterns, such as limiting sugars and refined grains, emphasizing nonstarchy vegetables, and choosing whole foods over processed foods, the experts wrote.

Consensus panel participants reported disclosures with the ADA, the National Institutes of Health, the Academy of Nutrition and Dietetics, the American Medical Group Association, the University of Michigan, Novo Nordisk, Merck, Amgen, Gilead, BOYDSense, Janssen, Sanofi, Pfizer, Sunstar Foundation, New England Dairy and Dairy Farmer, the National Dairy Council, Kowa Company, and dietdoctor.com.

SOURCE: Evert AB et al. Diabetes Care. 2019 Apr 18. doi: 10.2337/dci19-0014.

Although nutrition therapy is pivotal in the management of patients with diabetes or prediabetes, there’s no one correct eating pattern appropriate for all patients, according to a consensus report from an expert panel convened by the American Diabetes Association.

A one-size-fits-all eating plan would be an unrealistic expectation, given the diversity of cultural issues, personal preferences, comorbidities, and other factors that are unique to individual patients with diabetes or prediabetes, according to the report, which was published in Diabetes Care.

Instead, authors of the report outlined nine different eating patterns, along with the evidence supporting their use and their reported benefits in patients with diabetes or prediabetes.

The report reflects a commitment to developing evidence-based guidelines that are “achievable and meet people where they are” to formulate individualized nutrition plans, William T. Cefalu, MD, chief scientific, medical, and mission officer for the ADA, said in a statement.

“The importance of this consensus also lies in the fact it was authored by a group of experts who are extremely knowledgeable about numerous eating patterns, including vegan, vegetarian, and low carb,” Dr. Cefalu added.

The expert panel of 14 individuals included registered dietitians, diabetes educators, endocrinologists, a primary care physician, and a patient advocate who all answered a national call for experts, according to the ADA.

The panel reviewed more than 600 nutrition manuscripts published between 2014 and 2018 to develop the new consensus statement, which updates the ADA 2014 position statement on nutrition therapy for adults with diabetes and has been incorporated into the association’s Standards of Medical Care in Diabetes–2019 supplement as a living standards update.

All adults with type 1 or 2 diabetes should be referred to individualized, diabetes-focused medical nutrition therapy, the panel members wrote in their report.

There is no evidence suggesting an ideal percentage of calories from carbohydrate, protein, and fat in patients with prediabetes or diabetes, so macronutrient distribution should also be individualized, according to the panel.

Likewise, a variety of eating patterns are acceptable for managing diabetes, according to the report, which describes evidence for eating patterns including Mediterranean, vegetarian or vegan, low fat and very low fat, low carbohydrate and very low carbohydrate, and paleo, as well as the Dietary Approaches to Stop Hypertension diet and the Department of Agriculture Dietary Guidelines for Americans.

Not all diets have the same level of evidence, however. For prevention of prediabetes or type 2 diabetes, for example, the most robust research is available for Mediterranean-style, low-fat, and low-carbohydrate eating patterns, the panel said.

Until there’s better comparative evidence between eating patterns, health care providers should concentrate on several key factors common to a number of the eating patterns, such as limiting sugars and refined grains, emphasizing nonstarchy vegetables, and choosing whole foods over processed foods, the experts wrote.

Consensus panel participants reported disclosures with the ADA, the National Institutes of Health, the Academy of Nutrition and Dietetics, the American Medical Group Association, the University of Michigan, Novo Nordisk, Merck, Amgen, Gilead, BOYDSense, Janssen, Sanofi, Pfizer, Sunstar Foundation, New England Dairy and Dairy Farmer, the National Dairy Council, Kowa Company, and dietdoctor.com.

SOURCE: Evert AB et al. Diabetes Care. 2019 Apr 18. doi: 10.2337/dci19-0014.

The Food and Drug Administration has approved a topical combination of corticosteroid halobetasol propionate (0.01%) and the topical retinoid, tazarotene (0.045%), in a lotion formulation, for the treatment of plaque psoriasis in adults, the manufacturer announced on April 25.

A press release from the manufacturer, Ortho Dermatologics, summarized the results of two phase 3 studies that compared treatment with the combination product, in 418 adults with moderate to severe plaque psoriasis. At week 8, the proportion of patients who had achieved treatment success – defined as at least a two-grade improvement in Investigator Global Assessment score and a score of “clear” or “almost clear” – was 36% and 45% in the treatment groups, compared with 7% and 13% of those on vehicle, respectively (P less than .001 for both).

The release also refers to a phase 2 study of 212 patients, which found that the combination treatment was more effective in treating plaque psoriasis than was either component separately (J Drugs Dermatol. 2017 Mar 1;16[1]:197-204). By week 8, 52.5% of patients treated with the combination lotion had shown treatment success – compared with 33.3% of those treated with halobetasol, 18.6% of those treated with tazarotene, and 9.7% of those treated with vehicle (P = .033).

Common treatment-related adverse events included treatment site reactions, such as irritation, pain, itching, and folliculitis. Treatment may cause birth defects if used during pregnancy, so a negative pregnancy test should be obtained before treatment begins and effective birth control should be used during treatment.

It will be marketed under the trade name Duobrii and is priced at $825 for a 100-gram tube, according to the press release.

[email protected]

The Food and Drug Administration has approved a topical combination of corticosteroid halobetasol propionate (0.01%) and the topical retinoid, tazarotene (0.045%), in a lotion formulation, for the treatment of plaque psoriasis in adults, the manufacturer announced on April 25.

A press release from the manufacturer, Ortho Dermatologics, summarized the results of two phase 3 studies that compared treatment with the combination product, in 418 adults with moderate to severe plaque psoriasis. At week 8, the proportion of patients who had achieved treatment success – defined as at least a two-grade improvement in Investigator Global Assessment score and a score of “clear” or “almost clear” – was 36% and 45% in the treatment groups, compared with 7% and 13% of those on vehicle, respectively (P less than .001 for both).

The release also refers to a phase 2 study of 212 patients, which found that the combination treatment was more effective in treating plaque psoriasis than was either component separately (J Drugs Dermatol. 2017 Mar 1;16[1]:197-204). By week 8, 52.5% of patients treated with the combination lotion had shown treatment success – compared with 33.3% of those treated with halobetasol, 18.6% of those treated with tazarotene, and 9.7% of those treated with vehicle (P = .033).

Common treatment-related adverse events included treatment site reactions, such as irritation, pain, itching, and folliculitis. Treatment may cause birth defects if used during pregnancy, so a negative pregnancy test should be obtained before treatment begins and effective birth control should be used during treatment.

It will be marketed under the trade name Duobrii and is priced at $825 for a 100-gram tube, according to the press release.

[email protected]

The Food and Drug Administration has approved a topical combination of corticosteroid halobetasol propionate (0.01%) and the topical retinoid, tazarotene (0.045%), in a lotion formulation, for the treatment of plaque psoriasis in adults, the manufacturer announced on April 25.

A press release from the manufacturer, Ortho Dermatologics, summarized the results of two phase 3 studies that compared treatment with the combination product, in 418 adults with moderate to severe plaque psoriasis. At week 8, the proportion of patients who had achieved treatment success – defined as at least a two-grade improvement in Investigator Global Assessment score and a score of “clear” or “almost clear” – was 36% and 45% in the treatment groups, compared with 7% and 13% of those on vehicle, respectively (P less than .001 for both).

The release also refers to a phase 2 study of 212 patients, which found that the combination treatment was more effective in treating plaque psoriasis than was either component separately (J Drugs Dermatol. 2017 Mar 1;16[1]:197-204). By week 8, 52.5% of patients treated with the combination lotion had shown treatment success – compared with 33.3% of those treated with halobetasol, 18.6% of those treated with tazarotene, and 9.7% of those treated with vehicle (P = .033).

Common treatment-related adverse events included treatment site reactions, such as irritation, pain, itching, and folliculitis. Treatment may cause birth defects if used during pregnancy, so a negative pregnancy test should be obtained before treatment begins and effective birth control should be used during treatment.

It will be marketed under the trade name Duobrii and is priced at $825 for a 100-gram tube, according to the press release.

[email protected]

Losing a patient to suicide is one of the most difficult and painful experiences a psychiatrist will face. In addition to concern for the patient and his or her family, psychiatrists may experience thoughts of responsibility and what they could have done to prevent the suicide. Although often trained in helping patients address grief, psychiatrists may not be as comfortable processing their own grief after the loss of a patient to suicide.

On April 24, MDedge Psychiatry hosted a conversation on Twitter to help psychiatrists examine some of their own feelings about losing patients in this way. Two psychiatrists – Dinah Miller, MD, and Eric Plakun, MD – responded to questions on this topic.

Dr. Miller is the author of numerous books and articles, including “Committed: The Battle Over Involuntary Care” (Baltimore: Johns Hopkins University Press, 2016), which she wrote with Dr. Annette Hanson, and a piece in the New England Journal of Medicine about her own experience with the death of a patient to suicide. She has a private practice in Baltimore and is affiliated with Johns Hopkins University there. Dr. Plakun is the medical director and CEO of the Austen Riggs Center based in Stockbridge, Mass., a “Top 10” U.S. News and World Report “Best Hospital” in psychiatry. He also serves on the board of trustees of the American Psychiatric Association representing New England and Eastern Canada, and was the founding leader of the APA Psychotherapy Caucus. Dr. Plakun is a board-certified psychiatrist, psychoanalyst, former member of the Harvard Medical School clinical faculty, and author of more than 50 publications.

Some of the conversation focused on the impact of patient suicide on young doctors. “I tell the residents: Never Worry Alone,” Dr. Miller wrote. “When in doubt, get supervision, curbside consult, formal paid supervision, or send the patient for a second opinion. Have friends.”

Dr. Miller also wrote that these kinds of losses are difficult for experienced doctors, but “just awful when you’re just starting out. A young psychiatrist I knew lost two patients early on in her career. Hang in there – sending support.”

“The impact on trainees is often major and enduring,” Dr. Plakun wrote. “Questioning whether one wants to do such work is not unusual.”

The following is an edited version of the discussion.
 

Question: Have you ever lost a patient to suicide?

Dr. Plakun: This is an important subject and worth bringing to wider discussion. Thirty-eight percent of clinicians experience a significant reaction to this kind of loss.

Dr. Miller: I spent decades worrying that a patient might die by suicide. The reality was more troubling to me than I imagined. It left me more hesitant, less trusting of both the patients and myself. Not always, just at moments. The work we do is hard.

Dr. Plakun: Not one I was working with, but several after we terminated. And it has happened to patients I admitted to Austen Riggs during 35 years as director of admissions.

Dr. Miller: You know, I was struck by the fact that we have no formal way to approach this ... the APA info is for residents. This was part of why I wrote the NEJM piece, to open the conversation.
 

Question: How do you think the loss of your patient changed your approach to psychiatry?

Dr. Miller: One of the things I’ve heard is that recovering from this tremendous loss helps doctors/therapists to know that others have had a rough time, and that this isn’t weird or odd, and that they are not alone.

Question: How did the loss change you?

Dr. Miller: I did not feel a sense of “blame.” I imagine that would have made it much more difficult. An internist wrote to me discussing how he’d dismissed a patient’s chest pain and the patient died – there are so many layers of complexity here. So many different stories.

Dr. Plakun: I think the impact on us is great because in suicide the deceased is both victim and perpetrator of murder, while we have tried to empathize with both sides.

Dr. Miller: I imagine everyone feels some distress, some emotional response. It’s hard to imagine that a doctor or therapist would hear a patient under their care died of any cause and would feel nothing.

Closing observations

Dr. Plakun: If you lose a patient to suicide, seek consultation and support from a trusted colleague. Remember that isolation will be part of the problem, not the solution. Remember to call your insurance carrier for consultation regarding risk-management issues.

Dr. Miller: I think this topic is difficult for docs/therapists to listen to. It’s hard to sit with a friend/colleague’s pain.

Dr. Plakun: Meeting with family is an issue. The primary purpose of such meetings is to meet their needs – not your own. Help them deal with a traumatic loss causing powerful and complicated feelings. If it helps you, that’s a bonus rather than the goal of the meeting.

References

Miller D. When a patient dies by suicide –The physician’s silent sorrow. (N Engl J Med. 2019 Jan 24;380:311-3).

Plakun EM. Psychotherapy with suicidal patients, Part 1: Expert consensus recommendations. (J Psychiatr Prac. 2018 Nov;249[6]:420-3).

Plakun EM and Jane G. Tillman. Responding to clinicians after loss of a patient to suicide. Directions in Psychiatry. 2005 Oct.

Connect with Dr. Miller on Twitter at @shrinkrapdinah and with Dr. Plakun at @EricPlakunMD. And look for #MDedgeChats to find the complete conversation on Twitter. Dr. Miller and Dr. Plakun will be joining Lorenzo Norris, MD, and Jane Tillman, PhD, for a discussion of this topic from noon to 1 p.m. on Monday, May 20, at the American Psychiatric Association annual meeting in San Francisco for a live recording of the MDedge Psychcast. Join them at booth 1518!

Also, as in past years, Dr. Plakun will join Dr. Tillman to offer a workshop at the APA meeting called “Responding to the Impact of Suicide on Clinicians.” The workshop (session ID: 1054) will be held on Sunday, May 19, 10 a.m. – 11:30 a.m., in Room 153, upper mezzanine, Moscone South.
 

Losing a patient to suicide is one of the most difficult and painful experiences a psychiatrist will face. In addition to concern for the patient and his or her family, psychiatrists may experience thoughts of responsibility and what they could have done to prevent the suicide. Although often trained in helping patients address grief, psychiatrists may not be as comfortable processing their own grief after the loss of a patient to suicide.

On April 24, MDedge Psychiatry hosted a conversation on Twitter to help psychiatrists examine some of their own feelings about losing patients in this way. Two psychiatrists – Dinah Miller, MD, and Eric Plakun, MD – responded to questions on this topic.

Dr. Miller is the author of numerous books and articles, including “Committed: The Battle Over Involuntary Care” (Baltimore: Johns Hopkins University Press, 2016), which she wrote with Dr. Annette Hanson, and a piece in the New England Journal of Medicine about her own experience with the death of a patient to suicide. She has a private practice in Baltimore and is affiliated with Johns Hopkins University there. Dr. Plakun is the medical director and CEO of the Austen Riggs Center based in Stockbridge, Mass., a “Top 10” U.S. News and World Report “Best Hospital” in psychiatry. He also serves on the board of trustees of the American Psychiatric Association representing New England and Eastern Canada, and was the founding leader of the APA Psychotherapy Caucus. Dr. Plakun is a board-certified psychiatrist, psychoanalyst, former member of the Harvard Medical School clinical faculty, and author of more than 50 publications.

Some of the conversation focused on the impact of patient suicide on young doctors. “I tell the residents: Never Worry Alone,” Dr. Miller wrote. “When in doubt, get supervision, curbside consult, formal paid supervision, or send the patient for a second opinion. Have friends.”

Dr. Miller also wrote that these kinds of losses are difficult for experienced doctors, but “just awful when you’re just starting out. A young psychiatrist I knew lost two patients early on in her career. Hang in there – sending support.”

“The impact on trainees is often major and enduring,” Dr. Plakun wrote. “Questioning whether one wants to do such work is not unusual.”

The following is an edited version of the discussion.
 

Question: Have you ever lost a patient to suicide?

Dr. Plakun: This is an important subject and worth bringing to wider discussion. Thirty-eight percent of clinicians experience a significant reaction to this kind of loss.

Dr. Miller: I spent decades worrying that a patient might die by suicide. The reality was more troubling to me than I imagined. It left me more hesitant, less trusting of both the patients and myself. Not always, just at moments. The work we do is hard.

Dr. Plakun: Not one I was working with, but several after we terminated. And it has happened to patients I admitted to Austen Riggs during 35 years as director of admissions.

Dr. Miller: You know, I was struck by the fact that we have no formal way to approach this ... the APA info is for residents. This was part of why I wrote the NEJM piece, to open the conversation.
 

Question: How do you think the loss of your patient changed your approach to psychiatry?

Dr. Miller: One of the things I’ve heard is that recovering from this tremendous loss helps doctors/therapists to know that others have had a rough time, and that this isn’t weird or odd, and that they are not alone.

Question: How did the loss change you?

Dr. Miller: I did not feel a sense of “blame.” I imagine that would have made it much more difficult. An internist wrote to me discussing how he’d dismissed a patient’s chest pain and the patient died – there are so many layers of complexity here. So many different stories.

Dr. Plakun: I think the impact on us is great because in suicide the deceased is both victim and perpetrator of murder, while we have tried to empathize with both sides.

Dr. Miller: I imagine everyone feels some distress, some emotional response. It’s hard to imagine that a doctor or therapist would hear a patient under their care died of any cause and would feel nothing.

Closing observations

Dr. Plakun: If you lose a patient to suicide, seek consultation and support from a trusted colleague. Remember that isolation will be part of the problem, not the solution. Remember to call your insurance carrier for consultation regarding risk-management issues.

Dr. Miller: I think this topic is difficult for docs/therapists to listen to. It’s hard to sit with a friend/colleague’s pain.

Dr. Plakun: Meeting with family is an issue. The primary purpose of such meetings is to meet their needs – not your own. Help them deal with a traumatic loss causing powerful and complicated feelings. If it helps you, that’s a bonus rather than the goal of the meeting.

References

Miller D. When a patient dies by suicide –The physician’s silent sorrow. (N Engl J Med. 2019 Jan 24;380:311-3).

Plakun EM. Psychotherapy with suicidal patients, Part 1: Expert consensus recommendations. (J Psychiatr Prac. 2018 Nov;249[6]:420-3).

Plakun EM and Jane G. Tillman. Responding to clinicians after loss of a patient to suicide. Directions in Psychiatry. 2005 Oct.

Connect with Dr. Miller on Twitter at @shrinkrapdinah and with Dr. Plakun at @EricPlakunMD. And look for #MDedgeChats to find the complete conversation on Twitter. Dr. Miller and Dr. Plakun will be joining Lorenzo Norris, MD, and Jane Tillman, PhD, for a discussion of this topic from noon to 1 p.m. on Monday, May 20, at the American Psychiatric Association annual meeting in San Francisco for a live recording of the MDedge Psychcast. Join them at booth 1518!

Also, as in past years, Dr. Plakun will join Dr. Tillman to offer a workshop at the APA meeting called “Responding to the Impact of Suicide on Clinicians.” The workshop (session ID: 1054) will be held on Sunday, May 19, 10 a.m. – 11:30 a.m., in Room 153, upper mezzanine, Moscone South.
 

Losing a patient to suicide is one of the most difficult and painful experiences a psychiatrist will face. In addition to concern for the patient and his or her family, psychiatrists may experience thoughts of responsibility and what they could have done to prevent the suicide. Although often trained in helping patients address grief, psychiatrists may not be as comfortable processing their own grief after the loss of a patient to suicide.

On April 24, MDedge Psychiatry hosted a conversation on Twitter to help psychiatrists examine some of their own feelings about losing patients in this way. Two psychiatrists – Dinah Miller, MD, and Eric Plakun, MD – responded to questions on this topic.

Dr. Miller is the author of numerous books and articles, including “Committed: The Battle Over Involuntary Care” (Baltimore: Johns Hopkins University Press, 2016), which she wrote with Dr. Annette Hanson, and a piece in the New England Journal of Medicine about her own experience with the death of a patient to suicide. She has a private practice in Baltimore and is affiliated with Johns Hopkins University there. Dr. Plakun is the medical director and CEO of the Austen Riggs Center based in Stockbridge, Mass., a “Top 10” U.S. News and World Report “Best Hospital” in psychiatry. He also serves on the board of trustees of the American Psychiatric Association representing New England and Eastern Canada, and was the founding leader of the APA Psychotherapy Caucus. Dr. Plakun is a board-certified psychiatrist, psychoanalyst, former member of the Harvard Medical School clinical faculty, and author of more than 50 publications.

Some of the conversation focused on the impact of patient suicide on young doctors. “I tell the residents: Never Worry Alone,” Dr. Miller wrote. “When in doubt, get supervision, curbside consult, formal paid supervision, or send the patient for a second opinion. Have friends.”

Dr. Miller also wrote that these kinds of losses are difficult for experienced doctors, but “just awful when you’re just starting out. A young psychiatrist I knew lost two patients early on in her career. Hang in there – sending support.”

“The impact on trainees is often major and enduring,” Dr. Plakun wrote. “Questioning whether one wants to do such work is not unusual.”

The following is an edited version of the discussion.
 

Question: Have you ever lost a patient to suicide?

Dr. Plakun: This is an important subject and worth bringing to wider discussion. Thirty-eight percent of clinicians experience a significant reaction to this kind of loss.

Dr. Miller: I spent decades worrying that a patient might die by suicide. The reality was more troubling to me than I imagined. It left me more hesitant, less trusting of both the patients and myself. Not always, just at moments. The work we do is hard.

Dr. Plakun: Not one I was working with, but several after we terminated. And it has happened to patients I admitted to Austen Riggs during 35 years as director of admissions.

Dr. Miller: You know, I was struck by the fact that we have no formal way to approach this ... the APA info is for residents. This was part of why I wrote the NEJM piece, to open the conversation.
 

Question: How do you think the loss of your patient changed your approach to psychiatry?

Dr. Miller: One of the things I’ve heard is that recovering from this tremendous loss helps doctors/therapists to know that others have had a rough time, and that this isn’t weird or odd, and that they are not alone.

Question: How did the loss change you?

Dr. Miller: I did not feel a sense of “blame.” I imagine that would have made it much more difficult. An internist wrote to me discussing how he’d dismissed a patient’s chest pain and the patient died – there are so many layers of complexity here. So many different stories.

Dr. Plakun: I think the impact on us is great because in suicide the deceased is both victim and perpetrator of murder, while we have tried to empathize with both sides.

Dr. Miller: I imagine everyone feels some distress, some emotional response. It’s hard to imagine that a doctor or therapist would hear a patient under their care died of any cause and would feel nothing.

Closing observations

Dr. Plakun: If you lose a patient to suicide, seek consultation and support from a trusted colleague. Remember that isolation will be part of the problem, not the solution. Remember to call your insurance carrier for consultation regarding risk-management issues.

Dr. Miller: I think this topic is difficult for docs/therapists to listen to. It’s hard to sit with a friend/colleague’s pain.

Dr. Plakun: Meeting with family is an issue. The primary purpose of such meetings is to meet their needs – not your own. Help them deal with a traumatic loss causing powerful and complicated feelings. If it helps you, that’s a bonus rather than the goal of the meeting.

References

Miller D. When a patient dies by suicide –The physician’s silent sorrow. (N Engl J Med. 2019 Jan 24;380:311-3).

Plakun EM. Psychotherapy with suicidal patients, Part 1: Expert consensus recommendations. (J Psychiatr Prac. 2018 Nov;249[6]:420-3).

Plakun EM and Jane G. Tillman. Responding to clinicians after loss of a patient to suicide. Directions in Psychiatry. 2005 Oct.

Connect with Dr. Miller on Twitter at @shrinkrapdinah and with Dr. Plakun at @EricPlakunMD. And look for #MDedgeChats to find the complete conversation on Twitter. Dr. Miller and Dr. Plakun will be joining Lorenzo Norris, MD, and Jane Tillman, PhD, for a discussion of this topic from noon to 1 p.m. on Monday, May 20, at the American Psychiatric Association annual meeting in San Francisco for a live recording of the MDedge Psychcast. Join them at booth 1518!

Also, as in past years, Dr. Plakun will join Dr. Tillman to offer a workshop at the APA meeting called “Responding to the Impact of Suicide on Clinicians.” The workshop (session ID: 1054) will be held on Sunday, May 19, 10 a.m. – 11:30 a.m., in Room 153, upper mezzanine, Moscone South.