The practice of hospital medicine is rapidly changing. Higher-acuity patients are being admitted to hospitals already struggling with capacity, and hospitalists are being instructed to pay attention to length of stay, improve their documentation and billing, and participate in initiatives to improve hospital throughput, all while delivering high-quality patient care.

As hospitalists and SHM members who are also physician advisors, we have a unique understanding of these pressures. In this article, we answer common questions we receive from hospitalists regarding utilization management, care coordination, clinical documentation, and CMS regulations.
 

Why do physician advisors exist, and what do they do?

A physician advisor is hired by the hospital to act as a liaison between the hospital administration, clinical staff, and support personnel in order to ensure regulatory compliance, advise physicians on medical necessity, and assist hospital leadership in meeting overall organizational goals related to the efficient utilization of health care services.¹

Given their deep knowledge of hospital systems and processes, and ability to collaborate and teach, hospitalists are well-positioned to serve in this capacity. Our primary goal as physician advisors is to help physicians continue to focus on the parts of medicine they enjoy – clinical care, education, quality improvement, research etc. – by helping to demystify complex regulatory requirements and by creating streamlined processes to make following these requirements easier.
 

Why does this matter?

We understand that regulatory and hospital systems issues such as patient class determination, appropriate clinical documentation, and hospital throughput and capacity management can feel tedious, and sometimes overwhelming, to busy hospitalists. While it is easy to attribute these problems solely to hospitals’ desire for increased revenue, these issues directly impact the quality of care we provide to their patients.

In addition, our entire financial system is predicated on appropriate health care resource utilization, financial reimbursement, demonstration of medical acuity, and our impact on the care of a patient. Thus, our ability to advocate for our patients and for ourselves is directly connected with this endeavor. Developing a working knowledge of regulatory and systems issues allows hospitalists to be more engaged in leadership and negotiations and allows us to advocate for resources we deem most important.
 

Why are clinical documentation integrity teams so important?

Accurately and specifically describing how sick your patients are helps ensure that hospitals are reimbursed appropriately, coded data is accurate for research purposes, quality metrics are attributed correctly, and patients receive the correct diagnoses.

Clarification of documentation and/or addressing “clinical validity” of a given diagnosis (e.g., acute hypoxic respiratory failure requires both hypoxia and respiratory distress) may support an increase or result in a decrease in hospital reimbursement. For example, if the reason for a patient’s admission is renal failure, renal failure with true acute hypoxic respiratory failure will be reimbursed at a rate 40% higher than renal failure without the documentation of other conditions that reflect how ill the patient really is. The patient with acute hypoxic respiratory failure (or other major comorbid condition) is genuinely sicker, thus requiring more time (length of stay) and resources (deserved higher reimbursement).
 

What is the two-midnight rule, and why does it matter?

In October of 2013, the Centers for Medicare & Medicaid Services initiated the two-midnight rule, which states a Medicare patient can be an “inpatient” class if the admitting provider determines that 1) the patient requires medically necessary care which cannot be provided outside the hospital and 2) the patient is expected to stay at least 2 midnights in the hospital.

If, at the time of admission, an admitting provider thinks it is likely that the patient may be discharged prior to 2 midnights, then outpatient care with “observation” designation is appropriate. Incorrect patient class assignment may result in significant adverse consequences for hospitals, including improper patient billing, decreased hospital reimbursement, substantial risk for external auditing, violation of Medicare conditions of participation, and even loss of accreditation.
 

Who can I talk to if I have a question about a patient’s class? What should I do if I disagree with the class assigned to my patient?

The Utilization Management team typically consists of nurses and physician advisors specifically trained in UM. This team functions as a liaison between providers and payers (particularly Medicare and Medicaid) regarding medical necessity, appropriateness of care received, and efficiency of health care services.

When it comes to discussions about patient class, start by learning more about why the determination was made. The most common reason for patient class disagreements is simply that the documentation does not reflect the severity of illness or accurately reflect the care the patient is receiving. Your documentation should communicate that your patient needs services that only the hospital can provide, and/or they need monitoring that must be done in the hospital to meet the medical necessity criteria that CMS requires for a patient to be “inpatient” class.

If you disagree with a determination provided by the UM nurse and/or physician advisor, then the case will be presented to the hospital UM committee for further review. Two physicians from the UM committee must review the case and provide their own determinations of patient status, and whichever admission determination has two votes is the one that is appropriate.
 

How do I talk to patients about class determinations?

As media coverage continues about the two-midnight rule and the impact this has on patients, providers should expect more questions about class determination from their patients.

An AARP Bulletin article from 2012 advised patients to “ask [their] own doctor whether observation status is justified … and if not ask him or her to call the hospital to explain the medical reasons why they should be admitted as inpatient.”² Patients should be informed that providers understand the implications of patient class determinations and are making these decisions as outlined by CMS.

We recommend informing patients that the decision about whether a patient is “inpatient” or “outpatient with observation” class is complex and involves taking into consideration a patient’s medical history, the severity of their current medical condition, need for diagnostic testing, and degree of health resource utilization, as well as a provider’s medical opinion of the risk of an adverse event occurring.
 

Is it true that observation patients receive higher hospital bills?

It is a common misperception that a designation of “observation” class means that a patient’s medical bill will be higher than “inpatient” class. In 2016, CMS changed the way observation class patients are billed so that, in most scenarios, patients do not receive a higher hospital bill when placed in “observation” class.

How do I approach a denial from a payer?

Commercial payers review all hospitalizations for medical necessity and appropriateness of care received during a patient’s hospitalization. If you receive notice that all or part of your patient’s hospital stay was denied coverage, you have the option of discussing the case with the medical director of the insurance company – this is called a peer-to-peer discussion.

We recommend reviewing the patient’s case and your documentation of the care you provided prior to the peer to peer, especially since these denials may come weeks to months after you have cared for the patient. Begin your conversation by learning why the insurance company denied coverage of the stay and then provide an accurate portrayal of the acuity of illness of the patient, and the resources your hospital used in caring for them. Consider consulting with your hospital’s physician advisor for other high-yield tips.
 

How can care management help with ‘nonmedical’ hospitalizations?

Care managers are your allies for all patients, especially those with complex discharge needs. Often patients admitted for “nonmedical” reasons do not have the ability to discharge to a skilled nursing facility, long-term care facility, or home due to lack of insurance coverage or resources and/or assistance. Care managers can help you creatively problem solve and coordinate care. Physician advisors are your allies in helping create system-level interventions that might avert some of these “nonmedical” admissions. Consider involving both care managers and physician advisors early in the admission to help navigate social complexities.

How can hospitalists get involved?

According to CMS, the decision on “whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital … can typically be made in less than 48 hours, usually in less than 24 hours.”³ In reality, this is not black and white. The “2 midnights” has brought a host of new challenges for hospitals, hospitalists, and patients to navigate. The Society of Hospital Medicine released an Observation White Paper in 2017 challenging the status quo and proposing comprehensive observation reform.⁴

We encourage hospital medicine providers to more routinely engage with their institutional physician advisors and consider joining the SHM Public Policy Committee to become more involved in advocacy, and/or consider becoming a physician advisor.
 

Dr. Singh is physician advisor for Utilization & CM in the division of hospital medicine at the University of Colorado at Denver, Aurora. Dr. Patel is a hospitalist and assistant professor of medicine at the university. Dr. Anoff is director of clinical operations and director of nights for the Hospital Medicine Group at the University of Colorado at Denver. Dr. Stella is a hospitalist at Denver Health and Hospital Authority and an associate professor of medicine at the university.

References

1. What is a physician advisor? 2017 Oct 9.

2. Barry P. Medicare: Inpatient or outpatient. AARP Bulletin. 2012 Oct.

3. Goldberg TH. The long-term and post-acute care continuum. WV Med J. 2014 Nov-Dec;10(6):24-30.

4. Society of Hospital Medicine Public Policy Committee. The hospital observation care problem. Perspectives and solutions from the Society of Hospital Medicine. 2017 Sep.

The practice of hospital medicine is rapidly changing. Higher-acuity patients are being admitted to hospitals already struggling with capacity, and hospitalists are being instructed to pay attention to length of stay, improve their documentation and billing, and participate in initiatives to improve hospital throughput, all while delivering high-quality patient care.

As hospitalists and SHM members who are also physician advisors, we have a unique understanding of these pressures. In this article, we answer common questions we receive from hospitalists regarding utilization management, care coordination, clinical documentation, and CMS regulations.
 

Why do physician advisors exist, and what do they do?

A physician advisor is hired by the hospital to act as a liaison between the hospital administration, clinical staff, and support personnel in order to ensure regulatory compliance, advise physicians on medical necessity, and assist hospital leadership in meeting overall organizational goals related to the efficient utilization of health care services.¹

Given their deep knowledge of hospital systems and processes, and ability to collaborate and teach, hospitalists are well-positioned to serve in this capacity. Our primary goal as physician advisors is to help physicians continue to focus on the parts of medicine they enjoy – clinical care, education, quality improvement, research etc. – by helping to demystify complex regulatory requirements and by creating streamlined processes to make following these requirements easier.
 

Why does this matter?

We understand that regulatory and hospital systems issues such as patient class determination, appropriate clinical documentation, and hospital throughput and capacity management can feel tedious, and sometimes overwhelming, to busy hospitalists. While it is easy to attribute these problems solely to hospitals’ desire for increased revenue, these issues directly impact the quality of care we provide to their patients.

In addition, our entire financial system is predicated on appropriate health care resource utilization, financial reimbursement, demonstration of medical acuity, and our impact on the care of a patient. Thus, our ability to advocate for our patients and for ourselves is directly connected with this endeavor. Developing a working knowledge of regulatory and systems issues allows hospitalists to be more engaged in leadership and negotiations and allows us to advocate for resources we deem most important.
 

Why are clinical documentation integrity teams so important?

Accurately and specifically describing how sick your patients are helps ensure that hospitals are reimbursed appropriately, coded data is accurate for research purposes, quality metrics are attributed correctly, and patients receive the correct diagnoses.

Clarification of documentation and/or addressing “clinical validity” of a given diagnosis (e.g., acute hypoxic respiratory failure requires both hypoxia and respiratory distress) may support an increase or result in a decrease in hospital reimbursement. For example, if the reason for a patient’s admission is renal failure, renal failure with true acute hypoxic respiratory failure will be reimbursed at a rate 40% higher than renal failure without the documentation of other conditions that reflect how ill the patient really is. The patient with acute hypoxic respiratory failure (or other major comorbid condition) is genuinely sicker, thus requiring more time (length of stay) and resources (deserved higher reimbursement).
 

What is the two-midnight rule, and why does it matter?

In October of 2013, the Centers for Medicare & Medicaid Services initiated the two-midnight rule, which states a Medicare patient can be an “inpatient” class if the admitting provider determines that 1) the patient requires medically necessary care which cannot be provided outside the hospital and 2) the patient is expected to stay at least 2 midnights in the hospital.

If, at the time of admission, an admitting provider thinks it is likely that the patient may be discharged prior to 2 midnights, then outpatient care with “observation” designation is appropriate. Incorrect patient class assignment may result in significant adverse consequences for hospitals, including improper patient billing, decreased hospital reimbursement, substantial risk for external auditing, violation of Medicare conditions of participation, and even loss of accreditation.
 

Who can I talk to if I have a question about a patient’s class? What should I do if I disagree with the class assigned to my patient?

The Utilization Management team typically consists of nurses and physician advisors specifically trained in UM. This team functions as a liaison between providers and payers (particularly Medicare and Medicaid) regarding medical necessity, appropriateness of care received, and efficiency of health care services.

When it comes to discussions about patient class, start by learning more about why the determination was made. The most common reason for patient class disagreements is simply that the documentation does not reflect the severity of illness or accurately reflect the care the patient is receiving. Your documentation should communicate that your patient needs services that only the hospital can provide, and/or they need monitoring that must be done in the hospital to meet the medical necessity criteria that CMS requires for a patient to be “inpatient” class.

If you disagree with a determination provided by the UM nurse and/or physician advisor, then the case will be presented to the hospital UM committee for further review. Two physicians from the UM committee must review the case and provide their own determinations of patient status, and whichever admission determination has two votes is the one that is appropriate.
 

How do I talk to patients about class determinations?

As media coverage continues about the two-midnight rule and the impact this has on patients, providers should expect more questions about class determination from their patients.

An AARP Bulletin article from 2012 advised patients to “ask [their] own doctor whether observation status is justified … and if not ask him or her to call the hospital to explain the medical reasons why they should be admitted as inpatient.”² Patients should be informed that providers understand the implications of patient class determinations and are making these decisions as outlined by CMS.

We recommend informing patients that the decision about whether a patient is “inpatient” or “outpatient with observation” class is complex and involves taking into consideration a patient’s medical history, the severity of their current medical condition, need for diagnostic testing, and degree of health resource utilization, as well as a provider’s medical opinion of the risk of an adverse event occurring.
 

Is it true that observation patients receive higher hospital bills?

It is a common misperception that a designation of “observation” class means that a patient’s medical bill will be higher than “inpatient” class. In 2016, CMS changed the way observation class patients are billed so that, in most scenarios, patients do not receive a higher hospital bill when placed in “observation” class.

How do I approach a denial from a payer?

Commercial payers review all hospitalizations for medical necessity and appropriateness of care received during a patient’s hospitalization. If you receive notice that all or part of your patient’s hospital stay was denied coverage, you have the option of discussing the case with the medical director of the insurance company – this is called a peer-to-peer discussion.

We recommend reviewing the patient’s case and your documentation of the care you provided prior to the peer to peer, especially since these denials may come weeks to months after you have cared for the patient. Begin your conversation by learning why the insurance company denied coverage of the stay and then provide an accurate portrayal of the acuity of illness of the patient, and the resources your hospital used in caring for them. Consider consulting with your hospital’s physician advisor for other high-yield tips.
 

How can care management help with ‘nonmedical’ hospitalizations?

Care managers are your allies for all patients, especially those with complex discharge needs. Often patients admitted for “nonmedical” reasons do not have the ability to discharge to a skilled nursing facility, long-term care facility, or home due to lack of insurance coverage or resources and/or assistance. Care managers can help you creatively problem solve and coordinate care. Physician advisors are your allies in helping create system-level interventions that might avert some of these “nonmedical” admissions. Consider involving both care managers and physician advisors early in the admission to help navigate social complexities.

How can hospitalists get involved?

According to CMS, the decision on “whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital … can typically be made in less than 48 hours, usually in less than 24 hours.”³ In reality, this is not black and white. The “2 midnights” has brought a host of new challenges for hospitals, hospitalists, and patients to navigate. The Society of Hospital Medicine released an Observation White Paper in 2017 challenging the status quo and proposing comprehensive observation reform.⁴

We encourage hospital medicine providers to more routinely engage with their institutional physician advisors and consider joining the SHM Public Policy Committee to become more involved in advocacy, and/or consider becoming a physician advisor.
 

Dr. Singh is physician advisor for Utilization & CM in the division of hospital medicine at the University of Colorado at Denver, Aurora. Dr. Patel is a hospitalist and assistant professor of medicine at the university. Dr. Anoff is director of clinical operations and director of nights for the Hospital Medicine Group at the University of Colorado at Denver. Dr. Stella is a hospitalist at Denver Health and Hospital Authority and an associate professor of medicine at the university.

References

1. What is a physician advisor? 2017 Oct 9.

2. Barry P. Medicare: Inpatient or outpatient. AARP Bulletin. 2012 Oct.

3. Goldberg TH. The long-term and post-acute care continuum. WV Med J. 2014 Nov-Dec;10(6):24-30.

4. Society of Hospital Medicine Public Policy Committee. The hospital observation care problem. Perspectives and solutions from the Society of Hospital Medicine. 2017 Sep.

The practice of hospital medicine is rapidly changing. Higher-acuity patients are being admitted to hospitals already struggling with capacity, and hospitalists are being instructed to pay attention to length of stay, improve their documentation and billing, and participate in initiatives to improve hospital throughput, all while delivering high-quality patient care.

As hospitalists and SHM members who are also physician advisors, we have a unique understanding of these pressures. In this article, we answer common questions we receive from hospitalists regarding utilization management, care coordination, clinical documentation, and CMS regulations.
 

Why do physician advisors exist, and what do they do?

A physician advisor is hired by the hospital to act as a liaison between the hospital administration, clinical staff, and support personnel in order to ensure regulatory compliance, advise physicians on medical necessity, and assist hospital leadership in meeting overall organizational goals related to the efficient utilization of health care services.¹

Given their deep knowledge of hospital systems and processes, and ability to collaborate and teach, hospitalists are well-positioned to serve in this capacity. Our primary goal as physician advisors is to help physicians continue to focus on the parts of medicine they enjoy – clinical care, education, quality improvement, research etc. – by helping to demystify complex regulatory requirements and by creating streamlined processes to make following these requirements easier.
 

Why does this matter?

We understand that regulatory and hospital systems issues such as patient class determination, appropriate clinical documentation, and hospital throughput and capacity management can feel tedious, and sometimes overwhelming, to busy hospitalists. While it is easy to attribute these problems solely to hospitals’ desire for increased revenue, these issues directly impact the quality of care we provide to their patients.

In addition, our entire financial system is predicated on appropriate health care resource utilization, financial reimbursement, demonstration of medical acuity, and our impact on the care of a patient. Thus, our ability to advocate for our patients and for ourselves is directly connected with this endeavor. Developing a working knowledge of regulatory and systems issues allows hospitalists to be more engaged in leadership and negotiations and allows us to advocate for resources we deem most important.
 

Why are clinical documentation integrity teams so important?

Accurately and specifically describing how sick your patients are helps ensure that hospitals are reimbursed appropriately, coded data is accurate for research purposes, quality metrics are attributed correctly, and patients receive the correct diagnoses.

Clarification of documentation and/or addressing “clinical validity” of a given diagnosis (e.g., acute hypoxic respiratory failure requires both hypoxia and respiratory distress) may support an increase or result in a decrease in hospital reimbursement. For example, if the reason for a patient’s admission is renal failure, renal failure with true acute hypoxic respiratory failure will be reimbursed at a rate 40% higher than renal failure without the documentation of other conditions that reflect how ill the patient really is. The patient with acute hypoxic respiratory failure (or other major comorbid condition) is genuinely sicker, thus requiring more time (length of stay) and resources (deserved higher reimbursement).
 

What is the two-midnight rule, and why does it matter?

In October of 2013, the Centers for Medicare & Medicaid Services initiated the two-midnight rule, which states a Medicare patient can be an “inpatient” class if the admitting provider determines that 1) the patient requires medically necessary care which cannot be provided outside the hospital and 2) the patient is expected to stay at least 2 midnights in the hospital.

If, at the time of admission, an admitting provider thinks it is likely that the patient may be discharged prior to 2 midnights, then outpatient care with “observation” designation is appropriate. Incorrect patient class assignment may result in significant adverse consequences for hospitals, including improper patient billing, decreased hospital reimbursement, substantial risk for external auditing, violation of Medicare conditions of participation, and even loss of accreditation.
 

Who can I talk to if I have a question about a patient’s class? What should I do if I disagree with the class assigned to my patient?

The Utilization Management team typically consists of nurses and physician advisors specifically trained in UM. This team functions as a liaison between providers and payers (particularly Medicare and Medicaid) regarding medical necessity, appropriateness of care received, and efficiency of health care services.

When it comes to discussions about patient class, start by learning more about why the determination was made. The most common reason for patient class disagreements is simply that the documentation does not reflect the severity of illness or accurately reflect the care the patient is receiving. Your documentation should communicate that your patient needs services that only the hospital can provide, and/or they need monitoring that must be done in the hospital to meet the medical necessity criteria that CMS requires for a patient to be “inpatient” class.

If you disagree with a determination provided by the UM nurse and/or physician advisor, then the case will be presented to the hospital UM committee for further review. Two physicians from the UM committee must review the case and provide their own determinations of patient status, and whichever admission determination has two votes is the one that is appropriate.
 

How do I talk to patients about class determinations?

As media coverage continues about the two-midnight rule and the impact this has on patients, providers should expect more questions about class determination from their patients.

An AARP Bulletin article from 2012 advised patients to “ask [their] own doctor whether observation status is justified … and if not ask him or her to call the hospital to explain the medical reasons why they should be admitted as inpatient.”² Patients should be informed that providers understand the implications of patient class determinations and are making these decisions as outlined by CMS.

We recommend informing patients that the decision about whether a patient is “inpatient” or “outpatient with observation” class is complex and involves taking into consideration a patient’s medical history, the severity of their current medical condition, need for diagnostic testing, and degree of health resource utilization, as well as a provider’s medical opinion of the risk of an adverse event occurring.
 

Is it true that observation patients receive higher hospital bills?

It is a common misperception that a designation of “observation” class means that a patient’s medical bill will be higher than “inpatient” class. In 2016, CMS changed the way observation class patients are billed so that, in most scenarios, patients do not receive a higher hospital bill when placed in “observation” class.

How do I approach a denial from a payer?

Commercial payers review all hospitalizations for medical necessity and appropriateness of care received during a patient’s hospitalization. If you receive notice that all or part of your patient’s hospital stay was denied coverage, you have the option of discussing the case with the medical director of the insurance company – this is called a peer-to-peer discussion.

We recommend reviewing the patient’s case and your documentation of the care you provided prior to the peer to peer, especially since these denials may come weeks to months after you have cared for the patient. Begin your conversation by learning why the insurance company denied coverage of the stay and then provide an accurate portrayal of the acuity of illness of the patient, and the resources your hospital used in caring for them. Consider consulting with your hospital’s physician advisor for other high-yield tips.
 

How can care management help with ‘nonmedical’ hospitalizations?

Care managers are your allies for all patients, especially those with complex discharge needs. Often patients admitted for “nonmedical” reasons do not have the ability to discharge to a skilled nursing facility, long-term care facility, or home due to lack of insurance coverage or resources and/or assistance. Care managers can help you creatively problem solve and coordinate care. Physician advisors are your allies in helping create system-level interventions that might avert some of these “nonmedical” admissions. Consider involving both care managers and physician advisors early in the admission to help navigate social complexities.

How can hospitalists get involved?

According to CMS, the decision on “whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital … can typically be made in less than 48 hours, usually in less than 24 hours.”³ In reality, this is not black and white. The “2 midnights” has brought a host of new challenges for hospitals, hospitalists, and patients to navigate. The Society of Hospital Medicine released an Observation White Paper in 2017 challenging the status quo and proposing comprehensive observation reform.⁴

We encourage hospital medicine providers to more routinely engage with their institutional physician advisors and consider joining the SHM Public Policy Committee to become more involved in advocacy, and/or consider becoming a physician advisor.
 

Dr. Singh is physician advisor for Utilization & CM in the division of hospital medicine at the University of Colorado at Denver, Aurora. Dr. Patel is a hospitalist and assistant professor of medicine at the university. Dr. Anoff is director of clinical operations and director of nights for the Hospital Medicine Group at the University of Colorado at Denver. Dr. Stella is a hospitalist at Denver Health and Hospital Authority and an associate professor of medicine at the university.

References

1. What is a physician advisor? 2017 Oct 9.

2. Barry P. Medicare: Inpatient or outpatient. AARP Bulletin. 2012 Oct.

3. Goldberg TH. The long-term and post-acute care continuum. WV Med J. 2014 Nov-Dec;10(6):24-30.

4. Society of Hospital Medicine Public Policy Committee. The hospital observation care problem. Perspectives and solutions from the Society of Hospital Medicine. 2017 Sep.

The new vascular surgery training protocol may not reflect what is currently occurring in practice for peripheral artery occlusive disease, and may warrant further investigation, according to a study performed by John Phair, MD, and his colleagues.

© danr13/iStockphoto

“Peripheral arterial occlusive disease constitutes a substantial portion of clinical practice in vascular surgery and, as such, trainees must graduate with proficiency in endovascular and open procedures to become capable vascular surgeons,” they stated, but the new paradigm does not appear to be reflecting that reality.

The researchers compared case volume for 0 + 5 integrated vascular surgery residents (IVSR) in the chief and junior years with their 5 + 2 fellowship counterparts (VSF) for the treatment of peripheral arterial occlusive disease. An aggregate of 887 residents and fellows from 137 programs were identified. From 2012 to 2018, VSFs performed significantly more total peripheral procedures than IVSR surgeon chiefs in the treatment of peripheral arterial occlusive disease, with VSFs consistently performing 1.7-fold (P less than .001) and 1.6-fold (P less than .001) more total peripheral cases than their integrated vascular surgery residents chief and junior counterparts, respectively. When stratified by anatomic location, VSFs were found to have performed more peripheral arterial procedures in the aortoiliac, femoropopliteal, and infrapopliteal arteries, compared with IVSR chiefs, and they also performed more total peripheral procedures than IVSR surgeon juniors, the authors reported online in the journal Surgery (2019 E-pub; doi/10.1016/j.surg.2019.02.021).

“Although both training paradigms offer operative experiences that meet criteria for graduation, it seems that VSFs currently perform more endovascular and open cases than their IVSR counterparts for peripheral arterial occlusive disease during the final phase of training. These findings may be contradictory to current thinking regarding the vascular surgery training paradigms,” the researchers concluded.

There were no disclosures reported.

[email protected]

SOURCE: Phari J et al. Surgery 2019 E-pub; doi/10.1016/j.surg.2019.02.021).

The new vascular surgery training protocol may not reflect what is currently occurring in practice for peripheral artery occlusive disease, and may warrant further investigation, according to a study performed by John Phair, MD, and his colleagues.

© danr13/iStockphoto

“Peripheral arterial occlusive disease constitutes a substantial portion of clinical practice in vascular surgery and, as such, trainees must graduate with proficiency in endovascular and open procedures to become capable vascular surgeons,” they stated, but the new paradigm does not appear to be reflecting that reality.

The researchers compared case volume for 0 + 5 integrated vascular surgery residents (IVSR) in the chief and junior years with their 5 + 2 fellowship counterparts (VSF) for the treatment of peripheral arterial occlusive disease. An aggregate of 887 residents and fellows from 137 programs were identified. From 2012 to 2018, VSFs performed significantly more total peripheral procedures than IVSR surgeon chiefs in the treatment of peripheral arterial occlusive disease, with VSFs consistently performing 1.7-fold (P less than .001) and 1.6-fold (P less than .001) more total peripheral cases than their integrated vascular surgery residents chief and junior counterparts, respectively. When stratified by anatomic location, VSFs were found to have performed more peripheral arterial procedures in the aortoiliac, femoropopliteal, and infrapopliteal arteries, compared with IVSR chiefs, and they also performed more total peripheral procedures than IVSR surgeon juniors, the authors reported online in the journal Surgery (2019 E-pub; doi/10.1016/j.surg.2019.02.021).

“Although both training paradigms offer operative experiences that meet criteria for graduation, it seems that VSFs currently perform more endovascular and open cases than their IVSR counterparts for peripheral arterial occlusive disease during the final phase of training. These findings may be contradictory to current thinking regarding the vascular surgery training paradigms,” the researchers concluded.

There were no disclosures reported.

[email protected]

SOURCE: Phari J et al. Surgery 2019 E-pub; doi/10.1016/j.surg.2019.02.021).

The new vascular surgery training protocol may not reflect what is currently occurring in practice for peripheral artery occlusive disease, and may warrant further investigation, according to a study performed by John Phair, MD, and his colleagues.

© danr13/iStockphoto

“Peripheral arterial occlusive disease constitutes a substantial portion of clinical practice in vascular surgery and, as such, trainees must graduate with proficiency in endovascular and open procedures to become capable vascular surgeons,” they stated, but the new paradigm does not appear to be reflecting that reality.

The researchers compared case volume for 0 + 5 integrated vascular surgery residents (IVSR) in the chief and junior years with their 5 + 2 fellowship counterparts (VSF) for the treatment of peripheral arterial occlusive disease. An aggregate of 887 residents and fellows from 137 programs were identified. From 2012 to 2018, VSFs performed significantly more total peripheral procedures than IVSR surgeon chiefs in the treatment of peripheral arterial occlusive disease, with VSFs consistently performing 1.7-fold (P less than .001) and 1.6-fold (P less than .001) more total peripheral cases than their integrated vascular surgery residents chief and junior counterparts, respectively. When stratified by anatomic location, VSFs were found to have performed more peripheral arterial procedures in the aortoiliac, femoropopliteal, and infrapopliteal arteries, compared with IVSR chiefs, and they also performed more total peripheral procedures than IVSR surgeon juniors, the authors reported online in the journal Surgery (2019 E-pub; doi/10.1016/j.surg.2019.02.021).

“Although both training paradigms offer operative experiences that meet criteria for graduation, it seems that VSFs currently perform more endovascular and open cases than their IVSR counterparts for peripheral arterial occlusive disease during the final phase of training. These findings may be contradictory to current thinking regarding the vascular surgery training paradigms,” the researchers concluded.

There were no disclosures reported.

[email protected]

SOURCE: Phari J et al. Surgery 2019 E-pub; doi/10.1016/j.surg.2019.02.021).

For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.



May 18-21, 2019

Digestive Disease Week® (DDW) 2018 – San Diego, CA
DDW is the world’s leading educational forum for academicians, clinicians, researchers, students, and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery, and related fields. Whether you work in patient care, research, education or administration, the DDW program offers something for you. DDW is cosponsored by AGA, AASLD, ASGE, and SSAT.

• May 18, 8:15 a.m.–5:30 p.m.; May 19, 8:30 a.m.–12:35 p.m.
  2019 AGA Postgraduate Course
  The AGA Institute’s flagship live educational offering and premier CME activity, the AGA Postgraduate Course, is a one-and-a-half-day multitopic course covering recent clinical advances that affect how care is delivered. This live CME activity is eligible for Maintenance of Certification (MOC) points. Saturday afternoon’s case-based breakout sessions incorporate new learning-style formats for greater audience-speaker engagement. AGA member trainees and early career GIs receive discounted pricing for this cour
• May 19, 2–3 p.m.
  AGA Networking Hour
  This event is open to all DDW trainee and early career GI attendees and provides a casual atmosphere to network with peers. You can also meet the AGA Trainee & Early Career Committee, participate in an advocacy initiative, and learn more about all that AGA has to offer for fellows and early career GIs. This networking event will take place in the DDW Trainee and Early Career Lounge, Sails Pavilion (San Diego Convention Center). Light refreshments will be served.
• May 20, 10–11:30 a.m.
  Introduction to GI Practice: A Trainee Boot Camp
  Trainees and early-career GIs interested in or going into private practice should attend this symposium for key tips and insights from experts for a successful career. Learn about the business of private practice GI, how to start and grow your practice, and most importantly, how to find the perfect fit for you. A “must-not-miss ‘insider tips’ session.” This activity has been approved for 1.5 AMA PRA Category 1 Credits™.
• May 20, 1:30–5:30 p.m.
  AGA Board Review Course
  This session, designed around content from the newly released DDSEP^® 9, serves as a primer for third-year fellows preparing for the board exam as well as a review course for others wanting to test their knowledge. Attendees will be provided with real-time feedback on their readiness to take the board exams and will also receive exclusive access to discounts on DDSEP to further prepare. This live CME activity is eligible for MOC points. This activity has been approved for 4 AMA PRA Category 1 Credits^™.
• May 20, 2-3:30 p.m.
  Advancing Clinical Practice: GI Fellow-Directed Quality-Improvement Projects
  This trainee-focused session will showcase selected abstracts from GI fellows based on quality improvement with a state-of-the-art lecture. Attendees will learn about practical examples of successful quality-improvement projects for integration into their day-to-day work lives. This session also will provide guidance on how to develop a quality-improvement project and will target a specific need in the GI training program curriculum of addressing the development of quality-improvement requirements within training programs. This activity has been approved for 1.5 AMA PRA Category 1 Credits™.

• May 20, 4-5:30 p.m.
  GI in the Digital Age
  Social media is becoming a major part of our daily activities at both the social and professional levels. The session will provide attendees with a comprehensive review on the use of social media to build personal brand, interact with other colleagues and with patients. Experts presenting in the session also will discuss tips improve efficiency and safety when working with electronic health records (EHRs). This activity has been approved for 1.5 AMA PRA Category 1 Credits™.

May 18, 2019, 6-8 p.m.
Digestive Health Physicians Association® and The New Gastroenterologist Networking Reception
After a full day of DDW sessions, join the Digestive Health Physicians Association (DHPA) and AGA’s The New Gastroenterologist to relax and network with independent GI physicians from across the nation. This event will take place in the Elevation Room at the Hilton San Diego Bayfront.

May 18-21, 2019, 7:30 a.m.–6 p.m.
Trainee and Early Career Lounge
This space is dedicated to trainee and young GI attendees. Come meet and network with peers from around the world over a cup of coffee. Information will be available from each of the sponsoring societies, in addition to trainee-specific programming tips at DDW.

May 21, 2019, 8-9:30 a.m.
2019 AGA Academy of Educators Plenary Session: Achieving Competence Through Learner-Engaged Teaching Methods
Join your peers to improve your teaching skills with systems and strategies from expert faculty leaders. This session is held in conjunction with DDW 2019. A portion of time will also be dedicated to endoscopy education tools and presentations from the 2018 academy grants recipients.

UPCOMING EVENTS

May 15, 2019
Coding and Reimbursement Solutions by McVey Associates Inc.
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding and compliance changes.
Harrisburg, PA

May 15-16; June 19-20; September 18-19; October 9-10, 2019
Two-Day, In-Depth Coding and Billing Seminar
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates Inc.
San Diego, CA (May 15-16); Nashville, TN (June 19-20); Atlanta, GA (Sept. 18-19); Las Vegas, NV (Oct. 9-10)

Aug. 9-10, 2019
2019 Freston Conference: Food at the Intersection of Gut Health and Disease
GI clinicians and allied health professionals are increasingly focused on how nutrients influence GI physiology and how diet can promote sound gut health. In response to this growing body of knowledge, the 2019 James W. Freston Conference: Food at the Intersection of Gut Health and Disease, will examine how nutrition management therapies can combat GI disorders such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and celiac disease and how diet supports improvement across the care continuum.
Chicago

Aug. 9-11, 2019
2019 Principles of GI for the NP and PA
The Principles of Gastroenterology for the Nurse Practitioner and Physician Assistant (NPPA) is the medical industry’s premiere course guiding and enabling nurse practitioners and physician assistants in the intricacies of identifying, treating, and managing GI disorders. Designed and taught by expert clinicians and advanced practice providers, NPPA provides the latest insights, knowledge, and research on how to improve GI patient care. Attendees will leave with stronger diagnostic and therapeutic skills, a more robust professional network, and an enhanced value for their practices.
Chicago
 

AWARDS APPLICATION DEADLINES

AGA-Gastric Cancer Foundation Ben Feinstein Memorial Research Scholar Award in Gastric Cancer
This award provides $100,000 per year for 3 years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate, or equivalent) working toward an independent career in gastric cancer research. Research involving precancerous lesions will be considered if relevance to gastric cancer is explicitly outlined.
Application opens: June 3, 2019

For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.



May 18-21, 2019

Digestive Disease Week® (DDW) 2018 – San Diego, CA
DDW is the world’s leading educational forum for academicians, clinicians, researchers, students, and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery, and related fields. Whether you work in patient care, research, education or administration, the DDW program offers something for you. DDW is cosponsored by AGA, AASLD, ASGE, and SSAT.

• May 18, 8:15 a.m.–5:30 p.m.; May 19, 8:30 a.m.–12:35 p.m.
  2019 AGA Postgraduate Course
  The AGA Institute’s flagship live educational offering and premier CME activity, the AGA Postgraduate Course, is a one-and-a-half-day multitopic course covering recent clinical advances that affect how care is delivered. This live CME activity is eligible for Maintenance of Certification (MOC) points. Saturday afternoon’s case-based breakout sessions incorporate new learning-style formats for greater audience-speaker engagement. AGA member trainees and early career GIs receive discounted pricing for this cour
• May 19, 2–3 p.m.
  AGA Networking Hour
  This event is open to all DDW trainee and early career GI attendees and provides a casual atmosphere to network with peers. You can also meet the AGA Trainee & Early Career Committee, participate in an advocacy initiative, and learn more about all that AGA has to offer for fellows and early career GIs. This networking event will take place in the DDW Trainee and Early Career Lounge, Sails Pavilion (San Diego Convention Center). Light refreshments will be served.
• May 20, 10–11:30 a.m.
  Introduction to GI Practice: A Trainee Boot Camp
  Trainees and early-career GIs interested in or going into private practice should attend this symposium for key tips and insights from experts for a successful career. Learn about the business of private practice GI, how to start and grow your practice, and most importantly, how to find the perfect fit for you. A “must-not-miss ‘insider tips’ session.” This activity has been approved for 1.5 AMA PRA Category 1 Credits™.
• May 20, 1:30–5:30 p.m.
  AGA Board Review Course
  This session, designed around content from the newly released DDSEP^® 9, serves as a primer for third-year fellows preparing for the board exam as well as a review course for others wanting to test their knowledge. Attendees will be provided with real-time feedback on their readiness to take the board exams and will also receive exclusive access to discounts on DDSEP to further prepare. This live CME activity is eligible for MOC points. This activity has been approved for 4 AMA PRA Category 1 Credits^™.
• May 20, 2-3:30 p.m.
  Advancing Clinical Practice: GI Fellow-Directed Quality-Improvement Projects
  This trainee-focused session will showcase selected abstracts from GI fellows based on quality improvement with a state-of-the-art lecture. Attendees will learn about practical examples of successful quality-improvement projects for integration into their day-to-day work lives. This session also will provide guidance on how to develop a quality-improvement project and will target a specific need in the GI training program curriculum of addressing the development of quality-improvement requirements within training programs. This activity has been approved for 1.5 AMA PRA Category 1 Credits™.

• May 20, 4-5:30 p.m.
  GI in the Digital Age
  Social media is becoming a major part of our daily activities at both the social and professional levels. The session will provide attendees with a comprehensive review on the use of social media to build personal brand, interact with other colleagues and with patients. Experts presenting in the session also will discuss tips improve efficiency and safety when working with electronic health records (EHRs). This activity has been approved for 1.5 AMA PRA Category 1 Credits™.

May 18, 2019, 6-8 p.m.
Digestive Health Physicians Association® and The New Gastroenterologist Networking Reception
After a full day of DDW sessions, join the Digestive Health Physicians Association (DHPA) and AGA’s The New Gastroenterologist to relax and network with independent GI physicians from across the nation. This event will take place in the Elevation Room at the Hilton San Diego Bayfront.

May 18-21, 2019, 7:30 a.m.–6 p.m.
Trainee and Early Career Lounge
This space is dedicated to trainee and young GI attendees. Come meet and network with peers from around the world over a cup of coffee. Information will be available from each of the sponsoring societies, in addition to trainee-specific programming tips at DDW.

May 21, 2019, 8-9:30 a.m.
2019 AGA Academy of Educators Plenary Session: Achieving Competence Through Learner-Engaged Teaching Methods
Join your peers to improve your teaching skills with systems and strategies from expert faculty leaders. This session is held in conjunction with DDW 2019. A portion of time will also be dedicated to endoscopy education tools and presentations from the 2018 academy grants recipients.

UPCOMING EVENTS

May 15, 2019
Coding and Reimbursement Solutions by McVey Associates Inc.
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding and compliance changes.
Harrisburg, PA

May 15-16; June 19-20; September 18-19; October 9-10, 2019
Two-Day, In-Depth Coding and Billing Seminar
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates Inc.
San Diego, CA (May 15-16); Nashville, TN (June 19-20); Atlanta, GA (Sept. 18-19); Las Vegas, NV (Oct. 9-10)

Aug. 9-10, 2019
2019 Freston Conference: Food at the Intersection of Gut Health and Disease
GI clinicians and allied health professionals are increasingly focused on how nutrients influence GI physiology and how diet can promote sound gut health. In response to this growing body of knowledge, the 2019 James W. Freston Conference: Food at the Intersection of Gut Health and Disease, will examine how nutrition management therapies can combat GI disorders such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and celiac disease and how diet supports improvement across the care continuum.
Chicago

Aug. 9-11, 2019
2019 Principles of GI for the NP and PA
The Principles of Gastroenterology for the Nurse Practitioner and Physician Assistant (NPPA) is the medical industry’s premiere course guiding and enabling nurse practitioners and physician assistants in the intricacies of identifying, treating, and managing GI disorders. Designed and taught by expert clinicians and advanced practice providers, NPPA provides the latest insights, knowledge, and research on how to improve GI patient care. Attendees will leave with stronger diagnostic and therapeutic skills, a more robust professional network, and an enhanced value for their practices.
Chicago
 

AWARDS APPLICATION DEADLINES

AGA-Gastric Cancer Foundation Ben Feinstein Memorial Research Scholar Award in Gastric Cancer
This award provides $100,000 per year for 3 years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate, or equivalent) working toward an independent career in gastric cancer research. Research involving precancerous lesions will be considered if relevance to gastric cancer is explicitly outlined.
Application opens: June 3, 2019

For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.



May 18-21, 2019

Digestive Disease Week® (DDW) 2018 – San Diego, CA
DDW is the world’s leading educational forum for academicians, clinicians, researchers, students, and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery, and related fields. Whether you work in patient care, research, education or administration, the DDW program offers something for you. DDW is cosponsored by AGA, AASLD, ASGE, and SSAT.

• May 18, 8:15 a.m.–5:30 p.m.; May 19, 8:30 a.m.–12:35 p.m.
  2019 AGA Postgraduate Course
  The AGA Institute’s flagship live educational offering and premier CME activity, the AGA Postgraduate Course, is a one-and-a-half-day multitopic course covering recent clinical advances that affect how care is delivered. This live CME activity is eligible for Maintenance of Certification (MOC) points. Saturday afternoon’s case-based breakout sessions incorporate new learning-style formats for greater audience-speaker engagement. AGA member trainees and early career GIs receive discounted pricing for this cour
• May 19, 2–3 p.m.
  AGA Networking Hour
  This event is open to all DDW trainee and early career GI attendees and provides a casual atmosphere to network with peers. You can also meet the AGA Trainee & Early Career Committee, participate in an advocacy initiative, and learn more about all that AGA has to offer for fellows and early career GIs. This networking event will take place in the DDW Trainee and Early Career Lounge, Sails Pavilion (San Diego Convention Center). Light refreshments will be served.
• May 20, 10–11:30 a.m.
  Introduction to GI Practice: A Trainee Boot Camp
  Trainees and early-career GIs interested in or going into private practice should attend this symposium for key tips and insights from experts for a successful career. Learn about the business of private practice GI, how to start and grow your practice, and most importantly, how to find the perfect fit for you. A “must-not-miss ‘insider tips’ session.” This activity has been approved for 1.5 AMA PRA Category 1 Credits™.
• May 20, 1:30–5:30 p.m.
  AGA Board Review Course
  This session, designed around content from the newly released DDSEP^® 9, serves as a primer for third-year fellows preparing for the board exam as well as a review course for others wanting to test their knowledge. Attendees will be provided with real-time feedback on their readiness to take the board exams and will also receive exclusive access to discounts on DDSEP to further prepare. This live CME activity is eligible for MOC points. This activity has been approved for 4 AMA PRA Category 1 Credits^™.
• May 20, 2-3:30 p.m.
  Advancing Clinical Practice: GI Fellow-Directed Quality-Improvement Projects
  This trainee-focused session will showcase selected abstracts from GI fellows based on quality improvement with a state-of-the-art lecture. Attendees will learn about practical examples of successful quality-improvement projects for integration into their day-to-day work lives. This session also will provide guidance on how to develop a quality-improvement project and will target a specific need in the GI training program curriculum of addressing the development of quality-improvement requirements within training programs. This activity has been approved for 1.5 AMA PRA Category 1 Credits™.

• May 20, 4-5:30 p.m.
  GI in the Digital Age
  Social media is becoming a major part of our daily activities at both the social and professional levels. The session will provide attendees with a comprehensive review on the use of social media to build personal brand, interact with other colleagues and with patients. Experts presenting in the session also will discuss tips improve efficiency and safety when working with electronic health records (EHRs). This activity has been approved for 1.5 AMA PRA Category 1 Credits™.

May 18, 2019, 6-8 p.m.
Digestive Health Physicians Association® and The New Gastroenterologist Networking Reception
After a full day of DDW sessions, join the Digestive Health Physicians Association (DHPA) and AGA’s The New Gastroenterologist to relax and network with independent GI physicians from across the nation. This event will take place in the Elevation Room at the Hilton San Diego Bayfront.

May 18-21, 2019, 7:30 a.m.–6 p.m.
Trainee and Early Career Lounge
This space is dedicated to trainee and young GI attendees. Come meet and network with peers from around the world over a cup of coffee. Information will be available from each of the sponsoring societies, in addition to trainee-specific programming tips at DDW.

May 21, 2019, 8-9:30 a.m.
2019 AGA Academy of Educators Plenary Session: Achieving Competence Through Learner-Engaged Teaching Methods
Join your peers to improve your teaching skills with systems and strategies from expert faculty leaders. This session is held in conjunction with DDW 2019. A portion of time will also be dedicated to endoscopy education tools and presentations from the 2018 academy grants recipients.

UPCOMING EVENTS

May 15, 2019
Coding and Reimbursement Solutions by McVey Associates Inc.
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding and compliance changes.
Harrisburg, PA

May 15-16; June 19-20; September 18-19; October 9-10, 2019
Two-Day, In-Depth Coding and Billing Seminar
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates Inc.
San Diego, CA (May 15-16); Nashville, TN (June 19-20); Atlanta, GA (Sept. 18-19); Las Vegas, NV (Oct. 9-10)

Aug. 9-10, 2019
2019 Freston Conference: Food at the Intersection of Gut Health and Disease
GI clinicians and allied health professionals are increasingly focused on how nutrients influence GI physiology and how diet can promote sound gut health. In response to this growing body of knowledge, the 2019 James W. Freston Conference: Food at the Intersection of Gut Health and Disease, will examine how nutrition management therapies can combat GI disorders such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and celiac disease and how diet supports improvement across the care continuum.
Chicago

Aug. 9-11, 2019
2019 Principles of GI for the NP and PA
The Principles of Gastroenterology for the Nurse Practitioner and Physician Assistant (NPPA) is the medical industry’s premiere course guiding and enabling nurse practitioners and physician assistants in the intricacies of identifying, treating, and managing GI disorders. Designed and taught by expert clinicians and advanced practice providers, NPPA provides the latest insights, knowledge, and research on how to improve GI patient care. Attendees will leave with stronger diagnostic and therapeutic skills, a more robust professional network, and an enhanced value for their practices.
Chicago
 

AWARDS APPLICATION DEADLINES

AGA-Gastric Cancer Foundation Ben Feinstein Memorial Research Scholar Award in Gastric Cancer
This award provides $100,000 per year for 3 years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate, or equivalent) working toward an independent career in gastric cancer research. Research involving precancerous lesions will be considered if relevance to gastric cancer is explicitly outlined.
Application opens: June 3, 2019

GLASGOW – Many patients receiving tyrosine kinase inhibitors (TKIs) are taking complementary therapies or eating foods that interfere with TKI metabolism, based on results of a British survey of patients with chronic myeloid leukemia.

©Ls9907/Thinkstockphotos.com

About one out of three patients with chronic myeloid leukemia (CML) reported taking complementary medicines, according to lead author David Sparksman, MD, of Norfolk and Norwich (England) University Hospital, and his colleagues.

Only a minority of patients were aware of the potential for dietary interactions with TKIs. However, even knowing the potential risk, about a quarter of patients still didn’t exclude these foods from their diets.

“These worrying results are unlikely to be confined to patients with CML,” the investigators wrote in an abstract presented at the annual meeting of the British Society for Haematology. “TKIs are used in the treatment of many other haematological malignancies.”

Because TKIs are metabolized by cytochrome P450 enzymes, inhibition of these enzymes by complementary therapies and foods may alter metabolism, and therefore, safety and efficacy of TKIs, according to the investigators.

“Use of complementary medicines and belief in their effectiveness is common,” the investigators wrote. “In a recent YouGov poll, 51% of those asked believed herbal medicine to be an effective treatment for illness.”

To investigate the prevalence of these beliefs and practices in a subset of cancer patients, the investigators identified 78 patients with CML undergoing follow-up at Norfolk and Norwich University Hospital. The median age of patients was 60 years. Eleven patients were excluded because they were not receiving a TKI and 6 patients declined to participate, leaving 61 patients in the final survey group.

Of these respondents, 41% had considered taking a complementary therapy and 34% were actively doing so. Further questioning revealed that about half of the patients taking a complementary medicine (52%) were taking a drug with known potential to interact with their TKI. Of these 11 patients, 5 were taking a complementary drug that would reduce serum concentrations of their TKI, potentially making it less effective. Conversely, six patients were taking a complementary drug that would increase serum concentrations, potentially increasing the risk of TKI side effects.

About 39% of respondents were aware of possible dietary interactions with TKIs, such as grapefruit. “Surprisingly,” the investigators said, 25% of patients with this knowledge still included such foods in their diet.

Dietary questioning revealed that among the patients who were unaware of food interactions, 67% were consuming foods that interact with TKIs.

Considering these results, the investigators offered some advice on patient communication and management.

“The use of complementary medicine should be discussed with all patients when starting TKIs and written information given to patients should highlight the potential dangers posed by substances which many patients currently regard as harmless,” thy wrote. “Since most patients will remain on treatment for many years, re-discussion about food and drug interactions should take place periodically to remind them of the potential risks.”

The investigators reported having no conflicts of interest.

GLASGOW – Many patients receiving tyrosine kinase inhibitors (TKIs) are taking complementary therapies or eating foods that interfere with TKI metabolism, based on results of a British survey of patients with chronic myeloid leukemia.

©Ls9907/Thinkstockphotos.com

About one out of three patients with chronic myeloid leukemia (CML) reported taking complementary medicines, according to lead author David Sparksman, MD, of Norfolk and Norwich (England) University Hospital, and his colleagues.

Only a minority of patients were aware of the potential for dietary interactions with TKIs. However, even knowing the potential risk, about a quarter of patients still didn’t exclude these foods from their diets.

“These worrying results are unlikely to be confined to patients with CML,” the investigators wrote in an abstract presented at the annual meeting of the British Society for Haematology. “TKIs are used in the treatment of many other haematological malignancies.”

Because TKIs are metabolized by cytochrome P450 enzymes, inhibition of these enzymes by complementary therapies and foods may alter metabolism, and therefore, safety and efficacy of TKIs, according to the investigators.

“Use of complementary medicines and belief in their effectiveness is common,” the investigators wrote. “In a recent YouGov poll, 51% of those asked believed herbal medicine to be an effective treatment for illness.”

To investigate the prevalence of these beliefs and practices in a subset of cancer patients, the investigators identified 78 patients with CML undergoing follow-up at Norfolk and Norwich University Hospital. The median age of patients was 60 years. Eleven patients were excluded because they were not receiving a TKI and 6 patients declined to participate, leaving 61 patients in the final survey group.

Of these respondents, 41% had considered taking a complementary therapy and 34% were actively doing so. Further questioning revealed that about half of the patients taking a complementary medicine (52%) were taking a drug with known potential to interact with their TKI. Of these 11 patients, 5 were taking a complementary drug that would reduce serum concentrations of their TKI, potentially making it less effective. Conversely, six patients were taking a complementary drug that would increase serum concentrations, potentially increasing the risk of TKI side effects.

About 39% of respondents were aware of possible dietary interactions with TKIs, such as grapefruit. “Surprisingly,” the investigators said, 25% of patients with this knowledge still included such foods in their diet.

Dietary questioning revealed that among the patients who were unaware of food interactions, 67% were consuming foods that interact with TKIs.

Considering these results, the investigators offered some advice on patient communication and management.

“The use of complementary medicine should be discussed with all patients when starting TKIs and written information given to patients should highlight the potential dangers posed by substances which many patients currently regard as harmless,” thy wrote. “Since most patients will remain on treatment for many years, re-discussion about food and drug interactions should take place periodically to remind them of the potential risks.”

The investigators reported having no conflicts of interest.

GLASGOW – Many patients receiving tyrosine kinase inhibitors (TKIs) are taking complementary therapies or eating foods that interfere with TKI metabolism, based on results of a British survey of patients with chronic myeloid leukemia.

©Ls9907/Thinkstockphotos.com

About one out of three patients with chronic myeloid leukemia (CML) reported taking complementary medicines, according to lead author David Sparksman, MD, of Norfolk and Norwich (England) University Hospital, and his colleagues.

Only a minority of patients were aware of the potential for dietary interactions with TKIs. However, even knowing the potential risk, about a quarter of patients still didn’t exclude these foods from their diets.

“These worrying results are unlikely to be confined to patients with CML,” the investigators wrote in an abstract presented at the annual meeting of the British Society for Haematology. “TKIs are used in the treatment of many other haematological malignancies.”

Because TKIs are metabolized by cytochrome P450 enzymes, inhibition of these enzymes by complementary therapies and foods may alter metabolism, and therefore, safety and efficacy of TKIs, according to the investigators.

“Use of complementary medicines and belief in their effectiveness is common,” the investigators wrote. “In a recent YouGov poll, 51% of those asked believed herbal medicine to be an effective treatment for illness.”

To investigate the prevalence of these beliefs and practices in a subset of cancer patients, the investigators identified 78 patients with CML undergoing follow-up at Norfolk and Norwich University Hospital. The median age of patients was 60 years. Eleven patients were excluded because they were not receiving a TKI and 6 patients declined to participate, leaving 61 patients in the final survey group.

Of these respondents, 41% had considered taking a complementary therapy and 34% were actively doing so. Further questioning revealed that about half of the patients taking a complementary medicine (52%) were taking a drug with known potential to interact with their TKI. Of these 11 patients, 5 were taking a complementary drug that would reduce serum concentrations of their TKI, potentially making it less effective. Conversely, six patients were taking a complementary drug that would increase serum concentrations, potentially increasing the risk of TKI side effects.

About 39% of respondents were aware of possible dietary interactions with TKIs, such as grapefruit. “Surprisingly,” the investigators said, 25% of patients with this knowledge still included such foods in their diet.

Dietary questioning revealed that among the patients who were unaware of food interactions, 67% were consuming foods that interact with TKIs.

Considering these results, the investigators offered some advice on patient communication and management.

“The use of complementary medicine should be discussed with all patients when starting TKIs and written information given to patients should highlight the potential dangers posed by substances which many patients currently regard as harmless,” thy wrote. “Since most patients will remain on treatment for many years, re-discussion about food and drug interactions should take place periodically to remind them of the potential risks.”

The investigators reported having no conflicts of interest.

MILWAUKEE – More than 40% of white physician trainees demonstrated racial bias in medical decision making about treatment of low back pain, as did 31% of nonwhite trainees. However, just 6% of white residents and fellows, and 10% of the nonwhite residents and fellows, reported that patient race had factored into their treatment decisions in a virtual patient task.

The 444 medical residents and fellows who participated viewed video vignettes presenting 12 virtual patients who presented with low back pain, wrote Alexis Grant of Indiana University–Purdue University Indianapolis and her colleagues. In a poster presentation at the scientific meeting of the American Pain Society, Ms. Grant, a doctoral student in clinical psychology, and her collaborators explained that participants agreed to view a series of 12 videos of virtual patients.

The videos presented male and female virtual patients who were black or white and who had jobs associated with low or high socioeconomic status (SES). Information in text vignettes accompanying the videos included occupation, pain etiology, physical exam findings, and pain intensity by self-report.

After viewing the videos and reading the vignettes, participating clinicians were asked to use a 0-100 visual analog scale to report their likelihood of referring patients to a pain specialist or to physical therapy and of recommending opioid or nonopioid analgesia.

“Next, they rated the degree to which they considered different sources of patient information when making treatment decision,” Ms. Grant and her coauthors wrote. Statistical analysis “examined the extent to which providers demonstrated statistically reliable treatment differences across patient race and SES.” These findings were compared with how clinicians reported they used patient race and SES in decision making.

Demonstrated race-based decision making occurred for 41% of white and 31% of nonwhite clinicians. About two-thirds of providers (67.3%) were white, and of the remainder, 26.3% were Asian, 4.4% were classified as “other,” and 2.1% were black. The respondents were aged a mean 29.7 years, and were 42.3% female.

In addition, Ms. Grant and her coauthors estimated provider SES by asking about parental SES, dividing respondents into low (less than $38,000), medium ($38,000-$75,000), and high (greater than $75,000) SES categories.

Demonstrated bias based on socioeconomic status was common, and similar across levels of provider SES, at 41%, 43%, and 38% for low, medium, and high SES residents and fellows, respectively. However, the disconnect between reported and demonstrated bias that was seen with race was not seen with SES bias, with 43%-48% of providers in each SES group reporting that they had factored patient SES into their treatment decision making.

“These results suggest that providers have low awareness of making different pain treatment decisions” for black patients, compared with decision making for white patients, Ms. Grant and her colleagues wrote. “Decision-making awareness did not substantially differ across provider race or SES.” She and her collaborators called for more research into whether raising awareness about demonstrated racial bias in decision making can improve both racial and socioeconomic gaps in pain care.

The authors reported funding from the National Institutes of Health. They reported no conflicts of interest.

[email protected]

MILWAUKEE – More than 40% of white physician trainees demonstrated racial bias in medical decision making about treatment of low back pain, as did 31% of nonwhite trainees. However, just 6% of white residents and fellows, and 10% of the nonwhite residents and fellows, reported that patient race had factored into their treatment decisions in a virtual patient task.

The 444 medical residents and fellows who participated viewed video vignettes presenting 12 virtual patients who presented with low back pain, wrote Alexis Grant of Indiana University–Purdue University Indianapolis and her colleagues. In a poster presentation at the scientific meeting of the American Pain Society, Ms. Grant, a doctoral student in clinical psychology, and her collaborators explained that participants agreed to view a series of 12 videos of virtual patients.

The videos presented male and female virtual patients who were black or white and who had jobs associated with low or high socioeconomic status (SES). Information in text vignettes accompanying the videos included occupation, pain etiology, physical exam findings, and pain intensity by self-report.

After viewing the videos and reading the vignettes, participating clinicians were asked to use a 0-100 visual analog scale to report their likelihood of referring patients to a pain specialist or to physical therapy and of recommending opioid or nonopioid analgesia.

“Next, they rated the degree to which they considered different sources of patient information when making treatment decision,” Ms. Grant and her coauthors wrote. Statistical analysis “examined the extent to which providers demonstrated statistically reliable treatment differences across patient race and SES.” These findings were compared with how clinicians reported they used patient race and SES in decision making.

Demonstrated race-based decision making occurred for 41% of white and 31% of nonwhite clinicians. About two-thirds of providers (67.3%) were white, and of the remainder, 26.3% were Asian, 4.4% were classified as “other,” and 2.1% were black. The respondents were aged a mean 29.7 years, and were 42.3% female.

In addition, Ms. Grant and her coauthors estimated provider SES by asking about parental SES, dividing respondents into low (less than $38,000), medium ($38,000-$75,000), and high (greater than $75,000) SES categories.

Demonstrated bias based on socioeconomic status was common, and similar across levels of provider SES, at 41%, 43%, and 38% for low, medium, and high SES residents and fellows, respectively. However, the disconnect between reported and demonstrated bias that was seen with race was not seen with SES bias, with 43%-48% of providers in each SES group reporting that they had factored patient SES into their treatment decision making.

“These results suggest that providers have low awareness of making different pain treatment decisions” for black patients, compared with decision making for white patients, Ms. Grant and her colleagues wrote. “Decision-making awareness did not substantially differ across provider race or SES.” She and her collaborators called for more research into whether raising awareness about demonstrated racial bias in decision making can improve both racial and socioeconomic gaps in pain care.

The authors reported funding from the National Institutes of Health. They reported no conflicts of interest.

[email protected]

MILWAUKEE – More than 40% of white physician trainees demonstrated racial bias in medical decision making about treatment of low back pain, as did 31% of nonwhite trainees. However, just 6% of white residents and fellows, and 10% of the nonwhite residents and fellows, reported that patient race had factored into their treatment decisions in a virtual patient task.

The 444 medical residents and fellows who participated viewed video vignettes presenting 12 virtual patients who presented with low back pain, wrote Alexis Grant of Indiana University–Purdue University Indianapolis and her colleagues. In a poster presentation at the scientific meeting of the American Pain Society, Ms. Grant, a doctoral student in clinical psychology, and her collaborators explained that participants agreed to view a series of 12 videos of virtual patients.

The videos presented male and female virtual patients who were black or white and who had jobs associated with low or high socioeconomic status (SES). Information in text vignettes accompanying the videos included occupation, pain etiology, physical exam findings, and pain intensity by self-report.

After viewing the videos and reading the vignettes, participating clinicians were asked to use a 0-100 visual analog scale to report their likelihood of referring patients to a pain specialist or to physical therapy and of recommending opioid or nonopioid analgesia.

“Next, they rated the degree to which they considered different sources of patient information when making treatment decision,” Ms. Grant and her coauthors wrote. Statistical analysis “examined the extent to which providers demonstrated statistically reliable treatment differences across patient race and SES.” These findings were compared with how clinicians reported they used patient race and SES in decision making.

Demonstrated race-based decision making occurred for 41% of white and 31% of nonwhite clinicians. About two-thirds of providers (67.3%) were white, and of the remainder, 26.3% were Asian, 4.4% were classified as “other,” and 2.1% were black. The respondents were aged a mean 29.7 years, and were 42.3% female.

In addition, Ms. Grant and her coauthors estimated provider SES by asking about parental SES, dividing respondents into low (less than $38,000), medium ($38,000-$75,000), and high (greater than $75,000) SES categories.

Demonstrated bias based on socioeconomic status was common, and similar across levels of provider SES, at 41%, 43%, and 38% for low, medium, and high SES residents and fellows, respectively. However, the disconnect between reported and demonstrated bias that was seen with race was not seen with SES bias, with 43%-48% of providers in each SES group reporting that they had factored patient SES into their treatment decision making.

“These results suggest that providers have low awareness of making different pain treatment decisions” for black patients, compared with decision making for white patients, Ms. Grant and her colleagues wrote. “Decision-making awareness did not substantially differ across provider race or SES.” She and her collaborators called for more research into whether raising awareness about demonstrated racial bias in decision making can improve both racial and socioeconomic gaps in pain care.

The authors reported funding from the National Institutes of Health. They reported no conflicts of interest.

[email protected]

WASHINGTON – Smartphone applications that provide advice to people about their skin lesions may provide misleading information that could result in not seeking care from a dermatologist, Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

Even with disclaimers, there are people who want a “quick and easy answer,” and these apps can provide misleading information that “can lead them down a wrong diagnostic pathway,” said Dr. Chen, professor of dermatology and director of the teledermatology service at Emory University, Atlanta. Users not only include lower income or uninsured patients, but busy, high-powered executives.

Apps focused on photo storage are used to help patients track lesions for changes, with some apps dedicated to total body mole mapping. However, while these apps may empower patients to perform regular self skin checks, there is a question of whether they are HIPAA secure, Dr. Chen said. Another issue is that the many different app choices on the market may make it difficult for providers to keep up with which app a particular patient is using, she added. “If you have 10 different patients coming in with 10 different apps, it’s going to be really hard for you to learn all of those and be able to manipulate that easily, especially in the 15-minute slot.”

Smartphone and tablet apps that offer reminders to perform monthly skin checks or apply sunscreen when outdoors are plentiful. Dr. Chen noted that, while the efficacy of these apps are not known, they are similar to less high-tech technology like alarms or calendar reminders. “[They] are really kind of neat and fun. It’s kind of boring to just get a reminder, and you tune it out if you get a reminder on your calendars, so this may be a new way to help people,” she said.


Wearables also track users’ sun exposure, and range from a UV sensor on the thumb that measures sun exposure over a period of months to clip-on wearables and temporary tattoos that tell users when to apply or reapply sunscreen. Some devices allow entry of an individual’s Fitzpatrick skin type and can detect temperature and humidity, she noted.

Risk-calculating apps use images taken from smartphone cameras to determine the risk of melanoma, using algorithms that consider color and pattern recognition, but these apps are not as accurate as dermatologists, she said. In a study published in 2013, the app that sent images directly to a dermatologist was the most effective, compared with apps that relied on an automated algorithm to analyze the images (JAMA Dermatol. 2013 Apr;149[4]:422-6).

One of the conclusions the authors made was that feedback was slow for the one that required the image be sent to a dermatologist. “As opposed to just a minute and spitting out the result, it took 24 hours. My argument is 24 hours is still a lot faster than if you tried to call and get an appointment with a dermatologist,” Dr. Chen commented.

One step above teledermatology is teledermoscopy, or using a mobile, smartphone-attached device to send images to a dermatologist over a secure cloud service for review. “Most of us would agree that it would just take too long to do a live video with a patient,” Dr. Chen pointed out. “They may as well just come in anyway. It’ll take you 40 minutes to be able to take a look at that mole on the video, but to do it in a store-and-forward format can be quite efficient.”

However, she noted that one barrier to entry for teledermoscopy is defining the type of service, such as whether apps will offer provider-to-provider or patient-to-provider services. “That is fraught with its own details and issues, especially with photo quality.”


Another barrier, reimbursement from Centers for Medicare & Medicaid Services for teledermatology, is “the real sticking point,” Dr. Chen continued. Under a 2019 CMS Final Rule, telemedicine is only covered if the patient is already established within the practice, and reimbursement for Healthcare Common Procedure Coding System codes G2010 and G2012 relating to telemedicine ranges between $12 and $14.

Based on her back-of-the-envelope calculation, she added, “I would have to see 180 patients in a half-day session by this method in order to generate my salary, and that would just be impossible.”

Dr. Chen said that teledermatology is the “way of the future” and hopes the CMS Final Rule is reconsidered so the technology can be used to help solve some of the growing issues in the dermatology field. “There’s no way we can meet the demands of an increasingly aging population by an in-person brick and mortar sort of paradigm,” she said, noting that, even in an urban setting, it can be difficult to see a dermatologist.

Dr. Chen reports relationships with BioPharmX, Dermecular Therapeutics, Leo Pharma, Phoenix Tissue Repair, Trevi Therapeutics, and Unilever.

WASHINGTON – Smartphone applications that provide advice to people about their skin lesions may provide misleading information that could result in not seeking care from a dermatologist, Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

Even with disclaimers, there are people who want a “quick and easy answer,” and these apps can provide misleading information that “can lead them down a wrong diagnostic pathway,” said Dr. Chen, professor of dermatology and director of the teledermatology service at Emory University, Atlanta. Users not only include lower income or uninsured patients, but busy, high-powered executives.

Apps focused on photo storage are used to help patients track lesions for changes, with some apps dedicated to total body mole mapping. However, while these apps may empower patients to perform regular self skin checks, there is a question of whether they are HIPAA secure, Dr. Chen said. Another issue is that the many different app choices on the market may make it difficult for providers to keep up with which app a particular patient is using, she added. “If you have 10 different patients coming in with 10 different apps, it’s going to be really hard for you to learn all of those and be able to manipulate that easily, especially in the 15-minute slot.”

Smartphone and tablet apps that offer reminders to perform monthly skin checks or apply sunscreen when outdoors are plentiful. Dr. Chen noted that, while the efficacy of these apps are not known, they are similar to less high-tech technology like alarms or calendar reminders. “[They] are really kind of neat and fun. It’s kind of boring to just get a reminder, and you tune it out if you get a reminder on your calendars, so this may be a new way to help people,” she said.


Wearables also track users’ sun exposure, and range from a UV sensor on the thumb that measures sun exposure over a period of months to clip-on wearables and temporary tattoos that tell users when to apply or reapply sunscreen. Some devices allow entry of an individual’s Fitzpatrick skin type and can detect temperature and humidity, she noted.

Risk-calculating apps use images taken from smartphone cameras to determine the risk of melanoma, using algorithms that consider color and pattern recognition, but these apps are not as accurate as dermatologists, she said. In a study published in 2013, the app that sent images directly to a dermatologist was the most effective, compared with apps that relied on an automated algorithm to analyze the images (JAMA Dermatol. 2013 Apr;149[4]:422-6).

One of the conclusions the authors made was that feedback was slow for the one that required the image be sent to a dermatologist. “As opposed to just a minute and spitting out the result, it took 24 hours. My argument is 24 hours is still a lot faster than if you tried to call and get an appointment with a dermatologist,” Dr. Chen commented.

One step above teledermatology is teledermoscopy, or using a mobile, smartphone-attached device to send images to a dermatologist over a secure cloud service for review. “Most of us would agree that it would just take too long to do a live video with a patient,” Dr. Chen pointed out. “They may as well just come in anyway. It’ll take you 40 minutes to be able to take a look at that mole on the video, but to do it in a store-and-forward format can be quite efficient.”

However, she noted that one barrier to entry for teledermoscopy is defining the type of service, such as whether apps will offer provider-to-provider or patient-to-provider services. “That is fraught with its own details and issues, especially with photo quality.”


Another barrier, reimbursement from Centers for Medicare & Medicaid Services for teledermatology, is “the real sticking point,” Dr. Chen continued. Under a 2019 CMS Final Rule, telemedicine is only covered if the patient is already established within the practice, and reimbursement for Healthcare Common Procedure Coding System codes G2010 and G2012 relating to telemedicine ranges between $12 and $14.

Based on her back-of-the-envelope calculation, she added, “I would have to see 180 patients in a half-day session by this method in order to generate my salary, and that would just be impossible.”

Dr. Chen said that teledermatology is the “way of the future” and hopes the CMS Final Rule is reconsidered so the technology can be used to help solve some of the growing issues in the dermatology field. “There’s no way we can meet the demands of an increasingly aging population by an in-person brick and mortar sort of paradigm,” she said, noting that, even in an urban setting, it can be difficult to see a dermatologist.

Dr. Chen reports relationships with BioPharmX, Dermecular Therapeutics, Leo Pharma, Phoenix Tissue Repair, Trevi Therapeutics, and Unilever.

WASHINGTON – Smartphone applications that provide advice to people about their skin lesions may provide misleading information that could result in not seeking care from a dermatologist, Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

Even with disclaimers, there are people who want a “quick and easy answer,” and these apps can provide misleading information that “can lead them down a wrong diagnostic pathway,” said Dr. Chen, professor of dermatology and director of the teledermatology service at Emory University, Atlanta. Users not only include lower income or uninsured patients, but busy, high-powered executives.

Apps focused on photo storage are used to help patients track lesions for changes, with some apps dedicated to total body mole mapping. However, while these apps may empower patients to perform regular self skin checks, there is a question of whether they are HIPAA secure, Dr. Chen said. Another issue is that the many different app choices on the market may make it difficult for providers to keep up with which app a particular patient is using, she added. “If you have 10 different patients coming in with 10 different apps, it’s going to be really hard for you to learn all of those and be able to manipulate that easily, especially in the 15-minute slot.”

Smartphone and tablet apps that offer reminders to perform monthly skin checks or apply sunscreen when outdoors are plentiful. Dr. Chen noted that, while the efficacy of these apps are not known, they are similar to less high-tech technology like alarms or calendar reminders. “[They] are really kind of neat and fun. It’s kind of boring to just get a reminder, and you tune it out if you get a reminder on your calendars, so this may be a new way to help people,” she said.


Wearables also track users’ sun exposure, and range from a UV sensor on the thumb that measures sun exposure over a period of months to clip-on wearables and temporary tattoos that tell users when to apply or reapply sunscreen. Some devices allow entry of an individual’s Fitzpatrick skin type and can detect temperature and humidity, she noted.

Risk-calculating apps use images taken from smartphone cameras to determine the risk of melanoma, using algorithms that consider color and pattern recognition, but these apps are not as accurate as dermatologists, she said. In a study published in 2013, the app that sent images directly to a dermatologist was the most effective, compared with apps that relied on an automated algorithm to analyze the images (JAMA Dermatol. 2013 Apr;149[4]:422-6).

One of the conclusions the authors made was that feedback was slow for the one that required the image be sent to a dermatologist. “As opposed to just a minute and spitting out the result, it took 24 hours. My argument is 24 hours is still a lot faster than if you tried to call and get an appointment with a dermatologist,” Dr. Chen commented.

One step above teledermatology is teledermoscopy, or using a mobile, smartphone-attached device to send images to a dermatologist over a secure cloud service for review. “Most of us would agree that it would just take too long to do a live video with a patient,” Dr. Chen pointed out. “They may as well just come in anyway. It’ll take you 40 minutes to be able to take a look at that mole on the video, but to do it in a store-and-forward format can be quite efficient.”

However, she noted that one barrier to entry for teledermoscopy is defining the type of service, such as whether apps will offer provider-to-provider or patient-to-provider services. “That is fraught with its own details and issues, especially with photo quality.”


Another barrier, reimbursement from Centers for Medicare & Medicaid Services for teledermatology, is “the real sticking point,” Dr. Chen continued. Under a 2019 CMS Final Rule, telemedicine is only covered if the patient is already established within the practice, and reimbursement for Healthcare Common Procedure Coding System codes G2010 and G2012 relating to telemedicine ranges between $12 and $14.

Based on her back-of-the-envelope calculation, she added, “I would have to see 180 patients in a half-day session by this method in order to generate my salary, and that would just be impossible.”

Dr. Chen said that teledermatology is the “way of the future” and hopes the CMS Final Rule is reconsidered so the technology can be used to help solve some of the growing issues in the dermatology field. “There’s no way we can meet the demands of an increasingly aging population by an in-person brick and mortar sort of paradigm,” she said, noting that, even in an urban setting, it can be difficult to see a dermatologist.

Dr. Chen reports relationships with BioPharmX, Dermecular Therapeutics, Leo Pharma, Phoenix Tissue Repair, Trevi Therapeutics, and Unilever.

The ankle-brachial index (ABI) is a poor indicator of patient-centered and clinician-based evaluations of functional status in patients with intermittent claudication, according to the results of PORTRAIT, a prospective observational study of patients with newly diagnosed or an exacerbation of nonlimb-threatening peripheral arterial disease (PAD).

PORTRAIT studied 1,251 patients with intermittent claudication enrolled at 16 sites. Researchers studied the correlation of ABI values and Rutherford symptom classification with PAD-specific health status as measured by the Peripheral Artery Questionnaire (PAQ).

ABI values were categorized as mild (greater than 0.80), moderate (0.40-0.79), and severe (less than 0.40). Spearman rank correlation coefficients were calculated between raw ABI values and PAQ scores and between the Rutherford classification and PAQ scores.

ABI explained only 0.1%-2.1% of the variation in PAQ scores and the Rutherford classification had stronger but still modest associations with PAQ scores, according to the researchers.

“This large study of IC patients found that the PAQ offers a unique and complementary

measure of disease burden that is not captured by physiologic or clinician-observed classifications. The findings from this study highlight the clinical complexity of PAD

and the difficulty in using common hemodynamic and symptom measures to classify the impact of this disease on patients’ health status,” the researchers concluded.

Several authors reported serving as consultant for and/or receiving grants from various device and pharmaceutical companies involved with PAD. The senior author. owns the copyright to the Peripheral Artery Questionnaire that formed the basis for the study.

[email protected]

SOURCE: Johnston A et al. J Vasc Surg. 2018;69(3):906-12.

The ankle-brachial index (ABI) is a poor indicator of patient-centered and clinician-based evaluations of functional status in patients with intermittent claudication, according to the results of PORTRAIT, a prospective observational study of patients with newly diagnosed or an exacerbation of nonlimb-threatening peripheral arterial disease (PAD).

PORTRAIT studied 1,251 patients with intermittent claudication enrolled at 16 sites. Researchers studied the correlation of ABI values and Rutherford symptom classification with PAD-specific health status as measured by the Peripheral Artery Questionnaire (PAQ).

ABI values were categorized as mild (greater than 0.80), moderate (0.40-0.79), and severe (less than 0.40). Spearman rank correlation coefficients were calculated between raw ABI values and PAQ scores and between the Rutherford classification and PAQ scores.

ABI explained only 0.1%-2.1% of the variation in PAQ scores and the Rutherford classification had stronger but still modest associations with PAQ scores, according to the researchers.

“This large study of IC patients found that the PAQ offers a unique and complementary

measure of disease burden that is not captured by physiologic or clinician-observed classifications. The findings from this study highlight the clinical complexity of PAD

and the difficulty in using common hemodynamic and symptom measures to classify the impact of this disease on patients’ health status,” the researchers concluded.

Several authors reported serving as consultant for and/or receiving grants from various device and pharmaceutical companies involved with PAD. The senior author. owns the copyright to the Peripheral Artery Questionnaire that formed the basis for the study.

[email protected]

SOURCE: Johnston A et al. J Vasc Surg. 2018;69(3):906-12.

The ankle-brachial index (ABI) is a poor indicator of patient-centered and clinician-based evaluations of functional status in patients with intermittent claudication, according to the results of PORTRAIT, a prospective observational study of patients with newly diagnosed or an exacerbation of nonlimb-threatening peripheral arterial disease (PAD).

PORTRAIT studied 1,251 patients with intermittent claudication enrolled at 16 sites. Researchers studied the correlation of ABI values and Rutherford symptom classification with PAD-specific health status as measured by the Peripheral Artery Questionnaire (PAQ).

ABI values were categorized as mild (greater than 0.80), moderate (0.40-0.79), and severe (less than 0.40). Spearman rank correlation coefficients were calculated between raw ABI values and PAQ scores and between the Rutherford classification and PAQ scores.

ABI explained only 0.1%-2.1% of the variation in PAQ scores and the Rutherford classification had stronger but still modest associations with PAQ scores, according to the researchers.

“This large study of IC patients found that the PAQ offers a unique and complementary

measure of disease burden that is not captured by physiologic or clinician-observed classifications. The findings from this study highlight the clinical complexity of PAD

and the difficulty in using common hemodynamic and symptom measures to classify the impact of this disease on patients’ health status,” the researchers concluded.

Several authors reported serving as consultant for and/or receiving grants from various device and pharmaceutical companies involved with PAD. The senior author. owns the copyright to the Peripheral Artery Questionnaire that formed the basis for the study.

[email protected]

SOURCE: Johnston A et al. J Vasc Surg. 2018;69(3):906-12.

Mitochondrial damage and iron accumulation from hepatitis C virus are linked to the development of hepatocellular carcinoma (HCC), according to an extensive literature review.

E.H. Cook, Jr./CDC

Although the mechanisms underlying the hepatocellular carcinoma development are not fully understood, it is known that oxidative stress exists to a greater degree in hepatitis C virus (HCV) infection, compared with other inflammatory liver diseases. Such stress has been proposed as a major mechanism of liver injury in patients with chronic HCV, the authors reported in Free Radical Biology and Medicine.

Patients with HCV have significant hepatocellular mitochondrial alterations, and iron accumulation is also a well-known characteristic in patients with chronic HCV. Such alterations in mitochondria and iron accumulation are closely related to oxidative stress, since the mitochondria are the main site of reactive oxygen species generation, and iron produces hydroxy radicals via the Fenton reaction, according to the review.

“The greatest concern is whether mitochondrial damage and iron metabolic dysregulation persist even after HCV eradication and to what extent such pathological conditions affect the development of HCC. Determining the molecular signaling that underlies the mitophagy induced by iron depletion is another topic of interest and is expected to lead to potential therapeutic approaches for multiple diseases,” the researchers concluded.

Support was from the Research Program on Hepatitis from the Japan Agency for Medical Research and Development. The authors reported no disclosures.

[email protected]

SOURCE: Keisuke H et al. Free Radic Biol Med. 2019;133:193-9.

Mitochondrial damage and iron accumulation from hepatitis C virus are linked to the development of hepatocellular carcinoma (HCC), according to an extensive literature review.

E.H. Cook, Jr./CDC

Although the mechanisms underlying the hepatocellular carcinoma development are not fully understood, it is known that oxidative stress exists to a greater degree in hepatitis C virus (HCV) infection, compared with other inflammatory liver diseases. Such stress has been proposed as a major mechanism of liver injury in patients with chronic HCV, the authors reported in Free Radical Biology and Medicine.

Patients with HCV have significant hepatocellular mitochondrial alterations, and iron accumulation is also a well-known characteristic in patients with chronic HCV. Such alterations in mitochondria and iron accumulation are closely related to oxidative stress, since the mitochondria are the main site of reactive oxygen species generation, and iron produces hydroxy radicals via the Fenton reaction, according to the review.

“The greatest concern is whether mitochondrial damage and iron metabolic dysregulation persist even after HCV eradication and to what extent such pathological conditions affect the development of HCC. Determining the molecular signaling that underlies the mitophagy induced by iron depletion is another topic of interest and is expected to lead to potential therapeutic approaches for multiple diseases,” the researchers concluded.

Support was from the Research Program on Hepatitis from the Japan Agency for Medical Research and Development. The authors reported no disclosures.

[email protected]

SOURCE: Keisuke H et al. Free Radic Biol Med. 2019;133:193-9.

Mitochondrial damage and iron accumulation from hepatitis C virus are linked to the development of hepatocellular carcinoma (HCC), according to an extensive literature review.

E.H. Cook, Jr./CDC

Although the mechanisms underlying the hepatocellular carcinoma development are not fully understood, it is known that oxidative stress exists to a greater degree in hepatitis C virus (HCV) infection, compared with other inflammatory liver diseases. Such stress has been proposed as a major mechanism of liver injury in patients with chronic HCV, the authors reported in Free Radical Biology and Medicine.

Patients with HCV have significant hepatocellular mitochondrial alterations, and iron accumulation is also a well-known characteristic in patients with chronic HCV. Such alterations in mitochondria and iron accumulation are closely related to oxidative stress, since the mitochondria are the main site of reactive oxygen species generation, and iron produces hydroxy radicals via the Fenton reaction, according to the review.

“The greatest concern is whether mitochondrial damage and iron metabolic dysregulation persist even after HCV eradication and to what extent such pathological conditions affect the development of HCC. Determining the molecular signaling that underlies the mitophagy induced by iron depletion is another topic of interest and is expected to lead to potential therapeutic approaches for multiple diseases,” the researchers concluded.

Support was from the Research Program on Hepatitis from the Japan Agency for Medical Research and Development. The authors reported no disclosures.

[email protected]

SOURCE: Keisuke H et al. Free Radic Biol Med. 2019;133:193-9.

Over two-thirds of sudden unexpected infant deaths classified as accidental suffocation were attributed to airway obstruction by soft bedding, according to research published in Pediatrics.

FamVeld/Thinkstock

Alexa B. Erck Lambert, MPH, of DB Consulting Group in Silver Spring, Md., and her associates conducted an analysis of 1,812 cases of sudden unexpected infant death (SUID) in children aged 1 year or less included in a Centers for Disease Control and Prevention registry. Of those 1,812 SUID cases, 250 (14%) were classified as accidental suffocation.

Airway obstruction by soft bedding was by far the most common mechanism of accidental suffocation, contributing to death in 69% of cases. Overlay was attributed in 19% of cases and wedging was attributed in 12%. The median age for soft bedding, overlay, and wedging death was 3 months, 2 months, and 6 months, respectively. The majority of cases were male (55%), born after at least 37 weeks’ gestation (81%), non-Hispanic white or African American (74%), and insured by Medicaid (70%).

In deaths attributed to soft bedding, 49% occurred while the infant was in an adult bed, 92% occurred while the infant was in a nonsupine position, and 34% occurred while a blanket was obstructing the airway. While infants aged 5-11 months were twice as likely to have had a blanket obstructing their airway as infants aged 0-4 months (55% vs. 27%), younger infants were twice as likely to have had a pillow or couch cushion obstructing their airway (25% vs. 11%).

Of the 51 overlay deaths, 71% occurred in an adult’s bed, 51% were found nonsupine, and 41% were found in a bed with more than one adult. Most deaths were attributed to neck or chest compression, rather than nose or mouth obstruction. Of the 33 wedging deaths, 45% were sharing a sleep surface and 73% were in an adult bed; the most common objects the infant was wedged between were a mattress and wall.

“The safest place for infants to sleep is on their backs, on an unshared sleep surface, in a crib or bassinet in the caregivers’ room, and without soft bedding in their sleep area,” the investigators wrote. “Improving our understanding of the characteristics and risk factors ... of suffocation deaths by mechanism of airway obstruction can inform the development of more targeted strategies to prevent these injuries and deaths.”

The authors reported no potential conflicts of interest. Ms. Erck Lambert was supported by a contract her employer and the Centers for Disease Control and Prevention. Meghan Faulkner’s agency also received funds from the Centers for Disease Control and Prevention.

[email protected]

SOURCE: Erck Lambert AB et al. Pediatrics. 2019 Apr 22. doi: 10.1542/peds.2018-3408.

Over two-thirds of sudden unexpected infant deaths classified as accidental suffocation were attributed to airway obstruction by soft bedding, according to research published in Pediatrics.

FamVeld/Thinkstock

Alexa B. Erck Lambert, MPH, of DB Consulting Group in Silver Spring, Md., and her associates conducted an analysis of 1,812 cases of sudden unexpected infant death (SUID) in children aged 1 year or less included in a Centers for Disease Control and Prevention registry. Of those 1,812 SUID cases, 250 (14%) were classified as accidental suffocation.

Airway obstruction by soft bedding was by far the most common mechanism of accidental suffocation, contributing to death in 69% of cases. Overlay was attributed in 19% of cases and wedging was attributed in 12%. The median age for soft bedding, overlay, and wedging death was 3 months, 2 months, and 6 months, respectively. The majority of cases were male (55%), born after at least 37 weeks’ gestation (81%), non-Hispanic white or African American (74%), and insured by Medicaid (70%).

In deaths attributed to soft bedding, 49% occurred while the infant was in an adult bed, 92% occurred while the infant was in a nonsupine position, and 34% occurred while a blanket was obstructing the airway. While infants aged 5-11 months were twice as likely to have had a blanket obstructing their airway as infants aged 0-4 months (55% vs. 27%), younger infants were twice as likely to have had a pillow or couch cushion obstructing their airway (25% vs. 11%).

Of the 51 overlay deaths, 71% occurred in an adult’s bed, 51% were found nonsupine, and 41% were found in a bed with more than one adult. Most deaths were attributed to neck or chest compression, rather than nose or mouth obstruction. Of the 33 wedging deaths, 45% were sharing a sleep surface and 73% were in an adult bed; the most common objects the infant was wedged between were a mattress and wall.

“The safest place for infants to sleep is on their backs, on an unshared sleep surface, in a crib or bassinet in the caregivers’ room, and without soft bedding in their sleep area,” the investigators wrote. “Improving our understanding of the characteristics and risk factors ... of suffocation deaths by mechanism of airway obstruction can inform the development of more targeted strategies to prevent these injuries and deaths.”

The authors reported no potential conflicts of interest. Ms. Erck Lambert was supported by a contract her employer and the Centers for Disease Control and Prevention. Meghan Faulkner’s agency also received funds from the Centers for Disease Control and Prevention.

[email protected]

SOURCE: Erck Lambert AB et al. Pediatrics. 2019 Apr 22. doi: 10.1542/peds.2018-3408.

Over two-thirds of sudden unexpected infant deaths classified as accidental suffocation were attributed to airway obstruction by soft bedding, according to research published in Pediatrics.

FamVeld/Thinkstock

Alexa B. Erck Lambert, MPH, of DB Consulting Group in Silver Spring, Md., and her associates conducted an analysis of 1,812 cases of sudden unexpected infant death (SUID) in children aged 1 year or less included in a Centers for Disease Control and Prevention registry. Of those 1,812 SUID cases, 250 (14%) were classified as accidental suffocation.

Airway obstruction by soft bedding was by far the most common mechanism of accidental suffocation, contributing to death in 69% of cases. Overlay was attributed in 19% of cases and wedging was attributed in 12%. The median age for soft bedding, overlay, and wedging death was 3 months, 2 months, and 6 months, respectively. The majority of cases were male (55%), born after at least 37 weeks’ gestation (81%), non-Hispanic white or African American (74%), and insured by Medicaid (70%).

In deaths attributed to soft bedding, 49% occurred while the infant was in an adult bed, 92% occurred while the infant was in a nonsupine position, and 34% occurred while a blanket was obstructing the airway. While infants aged 5-11 months were twice as likely to have had a blanket obstructing their airway as infants aged 0-4 months (55% vs. 27%), younger infants were twice as likely to have had a pillow or couch cushion obstructing their airway (25% vs. 11%).

Of the 51 overlay deaths, 71% occurred in an adult’s bed, 51% were found nonsupine, and 41% were found in a bed with more than one adult. Most deaths were attributed to neck or chest compression, rather than nose or mouth obstruction. Of the 33 wedging deaths, 45% were sharing a sleep surface and 73% were in an adult bed; the most common objects the infant was wedged between were a mattress and wall.

“The safest place for infants to sleep is on their backs, on an unshared sleep surface, in a crib or bassinet in the caregivers’ room, and without soft bedding in their sleep area,” the investigators wrote. “Improving our understanding of the characteristics and risk factors ... of suffocation deaths by mechanism of airway obstruction can inform the development of more targeted strategies to prevent these injuries and deaths.”

The authors reported no potential conflicts of interest. Ms. Erck Lambert was supported by a contract her employer and the Centers for Disease Control and Prevention. Meghan Faulkner’s agency also received funds from the Centers for Disease Control and Prevention.

[email protected]

SOURCE: Erck Lambert AB et al. Pediatrics. 2019 Apr 22. doi: 10.1542/peds.2018-3408.

Employee wellness programs (EWPs) have a good track record, with plenty of affirmative research showing benefits: lowered stress levels, fewer sick days, reduced absenteeism, health care savings. Studies have found that for every dollar spent on an EWP, medical costs fall by $3 to $6. Moreover, studies have found that organizations that invest in EWPs have higher rates of employee satisfaction, morale, and retention.

But does one size of EWP fit all needs? Not according to researchers from Northern Arizona University. They studied factors that go in to successful EWPs and suggest that geography should play a big part in decision making: from whether to have an EWP to what it should offer. Take Houston, Texas, for instance, where influenza lasts longer than in most other places. Geographic and climatologic variables, the researchers say, like those necessitate “tailored wellness responses,” such as spending more money on outreach and educational programs to make sure people are prepared for seasonal outbreaks.

The researchers endorse the idea of “individualism in city preferences”—that is, that cities maximize their wellness offerings by taking advantage of the characteristics of the spaces, cultures, and lifestyles unique to them. The researchers note that cities with high incidence of obesity, such as Memphis, Tennessee, and Louisville, Kentucky, tend to put more money into weight-loss programs. Cities with more elderly workers, like Phoenix, Arizona, and Jacksonville, Florida, have “robust programs” for managing chronic diseases associated with age. Stress management may be a priority in impoverished areas. Similarly, EWPs need to factor in geography to make sure the programs meet local needs. Some cities have more and longer days with sunshine: How much of the year can people be active outside? Some have farmland nearby: EWPs can encourage eating healthy locally sourced foods. It is significant, the researchers say, that EWPs in “lower obesity” regions have a proportionately higher intake of activities associated with the outdoors.

Geography is only one consideration among many, the researchers emphasize. City leadership and commitment and incentive structures lead to recreational investments and investments in healthy-living infrastructures, which in turn, lead to higher livability rankings and quality-of-life indexes, workforce productivity, and attracting new business. Those lead to more community involvement, cohesion, and reduced reliance on public health care facilities. And ultimately, the researchers say, the components of a successful EWP all lead to a positive impact on health and longevity.

Employee wellness programs (EWPs) have a good track record, with plenty of affirmative research showing benefits: lowered stress levels, fewer sick days, reduced absenteeism, health care savings. Studies have found that for every dollar spent on an EWP, medical costs fall by $3 to $6. Moreover, studies have found that organizations that invest in EWPs have higher rates of employee satisfaction, morale, and retention.

But does one size of EWP fit all needs? Not according to researchers from Northern Arizona University. They studied factors that go in to successful EWPs and suggest that geography should play a big part in decision making: from whether to have an EWP to what it should offer. Take Houston, Texas, for instance, where influenza lasts longer than in most other places. Geographic and climatologic variables, the researchers say, like those necessitate “tailored wellness responses,” such as spending more money on outreach and educational programs to make sure people are prepared for seasonal outbreaks.

The researchers endorse the idea of “individualism in city preferences”—that is, that cities maximize their wellness offerings by taking advantage of the characteristics of the spaces, cultures, and lifestyles unique to them. The researchers note that cities with high incidence of obesity, such as Memphis, Tennessee, and Louisville, Kentucky, tend to put more money into weight-loss programs. Cities with more elderly workers, like Phoenix, Arizona, and Jacksonville, Florida, have “robust programs” for managing chronic diseases associated with age. Stress management may be a priority in impoverished areas. Similarly, EWPs need to factor in geography to make sure the programs meet local needs. Some cities have more and longer days with sunshine: How much of the year can people be active outside? Some have farmland nearby: EWPs can encourage eating healthy locally sourced foods. It is significant, the researchers say, that EWPs in “lower obesity” regions have a proportionately higher intake of activities associated with the outdoors.

Geography is only one consideration among many, the researchers emphasize. City leadership and commitment and incentive structures lead to recreational investments and investments in healthy-living infrastructures, which in turn, lead to higher livability rankings and quality-of-life indexes, workforce productivity, and attracting new business. Those lead to more community involvement, cohesion, and reduced reliance on public health care facilities. And ultimately, the researchers say, the components of a successful EWP all lead to a positive impact on health and longevity.

Employee wellness programs (EWPs) have a good track record, with plenty of affirmative research showing benefits: lowered stress levels, fewer sick days, reduced absenteeism, health care savings. Studies have found that for every dollar spent on an EWP, medical costs fall by $3 to $6. Moreover, studies have found that organizations that invest in EWPs have higher rates of employee satisfaction, morale, and retention.

But does one size of EWP fit all needs? Not according to researchers from Northern Arizona University. They studied factors that go in to successful EWPs and suggest that geography should play a big part in decision making: from whether to have an EWP to what it should offer. Take Houston, Texas, for instance, where influenza lasts longer than in most other places. Geographic and climatologic variables, the researchers say, like those necessitate “tailored wellness responses,” such as spending more money on outreach and educational programs to make sure people are prepared for seasonal outbreaks.

The researchers endorse the idea of “individualism in city preferences”—that is, that cities maximize their wellness offerings by taking advantage of the characteristics of the spaces, cultures, and lifestyles unique to them. The researchers note that cities with high incidence of obesity, such as Memphis, Tennessee, and Louisville, Kentucky, tend to put more money into weight-loss programs. Cities with more elderly workers, like Phoenix, Arizona, and Jacksonville, Florida, have “robust programs” for managing chronic diseases associated with age. Stress management may be a priority in impoverished areas. Similarly, EWPs need to factor in geography to make sure the programs meet local needs. Some cities have more and longer days with sunshine: How much of the year can people be active outside? Some have farmland nearby: EWPs can encourage eating healthy locally sourced foods. It is significant, the researchers say, that EWPs in “lower obesity” regions have a proportionately higher intake of activities associated with the outdoors.

Geography is only one consideration among many, the researchers emphasize. City leadership and commitment and incentive structures lead to recreational investments and investments in healthy-living infrastructures, which in turn, lead to higher livability rankings and quality-of-life indexes, workforce productivity, and attracting new business. Those lead to more community involvement, cohesion, and reduced reliance on public health care facilities. And ultimately, the researchers say, the components of a successful EWP all lead to a positive impact on health and longevity.