MIAMI – Pearls for providers of photodynamic therapy (PDT) include tips on skin preparation, eye protection, and use of three new codes to maximize reimbursement. Also trending in medical dermatology are best practices for intralesional injections of 5-FU to treat the often challenging isomorphic squamous cell carcinomas (SCCs) or keratoacanthomas on the lower leg, as well as use of neoadjuvant hedgehog inhibitors to shrink large skin cancer lesions, according to Glenn David Goldman, MD.

“This talk is about what you can do medically as a dermatologic surgeon,” Dr. Goldman said at the Orlando Dermatology Aesthetic and Clinical Conference.
 

Use new billing codes for photodynamic therapy

There are now three new PDT billing codes. “Make sure your coders are using these properly. They are active now, and if you don’t use them, you won’t get paid properly,” said Dr. Goldman, professor and medical director of dermatology at the University of Vermont, Burlington. Specifically, 96567 is for standard PDT applied by staff; 96573 is for PDT applied by a physician; and 96574 is for PDT and curettage performed by a physician.

“Be involved, don’t delegate,” Dr. Goldman added. “If you do, you will get paid half as much as you used to, which means you will lose money on every single patient you treat.”

What type of PDT physicians choose to use in their practice remains controversial. “Do you do short-contact PDT, do you do daylight PDT? We’ve gone back and forth in our practice,” Dr. Goldman said. “I’m not impressed with daylight PDT. I know this is at odds with some of the people here, but at least in Vermont, it doesn’t work very well.”

The way PDT was described in the original trials (a photosensitizer applied in the office followed by PDT) “works the best, with one caveat,” Dr. Goldman said. The caveat is that dermatologists should aim for a PDT clearance that approaches the efficacy of 5-fluorouracil (5-FU). “If you can get to that – which is difficult by the way – I think your patients will really appreciate this.”

An additional PDT pearl Dr. Goldman shared involves skin preparation: the use of acetone to defat the skin, even in patients with very thick lesions. Apply acetone with gauze to the site for 5 minutes and “all of that hyperkeratosis just wipes away,” curette off any residual hyperkeratosis – and consider a ring anesthetic block to control pain for the patient with severe disease, he advised.

Another tip is to forgo the goggles that come with most PDT kits. Instead, purchase smaller, disposable laser eye shields for PDT patients, Dr. Goldman said. “They work better. You can get closer to the eye … and they are more comfortable for the patient.”

Dr. Goldman’s practice is providing more PDT and much less 5-FU for patient convenience. “I believe if someone is willing to go through 3 weeks of 5-FU or 12-16 weeks of imiquimod, they get the best results. However, most people don’t want to do that if they can sit in front of a light for 15 minutes.”
 

Consider intralesional injections for SCCs and KAs on the legs

An ongoing challenge in medical dermatology is preventing rapid recurrence of SCCs and/or keratoacanthomas (KAs) near sites of previous excision on the legs. “We all see this quite a bit. Often you get lesions on the leg, you cut them out, and they come right back” close to the excision site, Dr. Goldman said.

He does not recommend methotrexate injections for these lesions. “Methotrexate does not work. It doesn’t hurt, but I’ve injected methotrexate into squamous cell carcinomas many times and they’ve never gone away.” In contrast, 5-FU “works incredibly well. They go away, I’ve had tremendous success. This has changed the way we treat these lesions.” 5-FU is inexpensive and can be obtained from oncology pharmacies. One caveat is 5-FU injections can be painful and patients require anesthesia prior to injection.

Using a 25-gauge or 27-gauge needle, Dr. Goldman injects 5-FU “exactly as I would a hypertrophic scar. I inject a squamous cell carcinoma carefully and ‘expand’ the tumor.” He typically injects a lesion every 2 weeks until it resolves completely, which typically takes two or three sessions.

“I want to emphasize that that’s really true about intralesional 5-FU for those KAs and scars on the legs,” said session moderator James Spencer, MD, a dermatologist in private practice in St. Petersburg, Florida. “Otherwise, you’re just chasing your tail trying to cut them out. You’ll do much better with the intralesional 5-FU; it’s easy to get, it’s affordable, it comes as 50 mg/mL … just keep it in the office.”
 

A recommended role for hedgehog inhibitors

Hedgehog inhibitors work best as neoadjuvant therapy to shrink large skin cancer tumors prior to excision, Dr. Goldman said. “Hedgehog inhibitors don’t cure anything … except for rare cases of small basal cell carcinomas.” For most lesions, however, the strategy is not curative.

“I don’t believe in hedgehog inhibitors for things that are readily resectable. We use them to shrink things down,” he added.

Dr. Goldman recommended treating patients with neoadjuvant hedgehog inhibitors to achieve the maximum tumor shrinking effect. Adverse effects tend to develop slowly over time, typically after a 6-week “grace period.” Nighttime leg muscle cramps, loss of taste, hair loss, and weight loss can occur. Also, electrolyte imbalances can occur, particularly in older patients with renal clearance issues. When the patient can no longer reasonably tolerate the adverse effects, which is usually the case, “then you do the surgery,” Dr. Goldman said.

“The benefits of neoadjuvant hedgehog inhibitors include predictable shrinkage of tumors,” and manufacturers have been helpful with financial issues, he noted.

Dr. Goldman had no relevant financial disclosures. Dr. Spencer has served on the speakers bureau for Genentech and Leo Pharma.

MIAMI – Pearls for providers of photodynamic therapy (PDT) include tips on skin preparation, eye protection, and use of three new codes to maximize reimbursement. Also trending in medical dermatology are best practices for intralesional injections of 5-FU to treat the often challenging isomorphic squamous cell carcinomas (SCCs) or keratoacanthomas on the lower leg, as well as use of neoadjuvant hedgehog inhibitors to shrink large skin cancer lesions, according to Glenn David Goldman, MD.

“This talk is about what you can do medically as a dermatologic surgeon,” Dr. Goldman said at the Orlando Dermatology Aesthetic and Clinical Conference.
 

Use new billing codes for photodynamic therapy

There are now three new PDT billing codes. “Make sure your coders are using these properly. They are active now, and if you don’t use them, you won’t get paid properly,” said Dr. Goldman, professor and medical director of dermatology at the University of Vermont, Burlington. Specifically, 96567 is for standard PDT applied by staff; 96573 is for PDT applied by a physician; and 96574 is for PDT and curettage performed by a physician.

“Be involved, don’t delegate,” Dr. Goldman added. “If you do, you will get paid half as much as you used to, which means you will lose money on every single patient you treat.”

What type of PDT physicians choose to use in their practice remains controversial. “Do you do short-contact PDT, do you do daylight PDT? We’ve gone back and forth in our practice,” Dr. Goldman said. “I’m not impressed with daylight PDT. I know this is at odds with some of the people here, but at least in Vermont, it doesn’t work very well.”

The way PDT was described in the original trials (a photosensitizer applied in the office followed by PDT) “works the best, with one caveat,” Dr. Goldman said. The caveat is that dermatologists should aim for a PDT clearance that approaches the efficacy of 5-fluorouracil (5-FU). “If you can get to that – which is difficult by the way – I think your patients will really appreciate this.”

An additional PDT pearl Dr. Goldman shared involves skin preparation: the use of acetone to defat the skin, even in patients with very thick lesions. Apply acetone with gauze to the site for 5 minutes and “all of that hyperkeratosis just wipes away,” curette off any residual hyperkeratosis – and consider a ring anesthetic block to control pain for the patient with severe disease, he advised.

Another tip is to forgo the goggles that come with most PDT kits. Instead, purchase smaller, disposable laser eye shields for PDT patients, Dr. Goldman said. “They work better. You can get closer to the eye … and they are more comfortable for the patient.”

Dr. Goldman’s practice is providing more PDT and much less 5-FU for patient convenience. “I believe if someone is willing to go through 3 weeks of 5-FU or 12-16 weeks of imiquimod, they get the best results. However, most people don’t want to do that if they can sit in front of a light for 15 minutes.”
 

Consider intralesional injections for SCCs and KAs on the legs

An ongoing challenge in medical dermatology is preventing rapid recurrence of SCCs and/or keratoacanthomas (KAs) near sites of previous excision on the legs. “We all see this quite a bit. Often you get lesions on the leg, you cut them out, and they come right back” close to the excision site, Dr. Goldman said.

He does not recommend methotrexate injections for these lesions. “Methotrexate does not work. It doesn’t hurt, but I’ve injected methotrexate into squamous cell carcinomas many times and they’ve never gone away.” In contrast, 5-FU “works incredibly well. They go away, I’ve had tremendous success. This has changed the way we treat these lesions.” 5-FU is inexpensive and can be obtained from oncology pharmacies. One caveat is 5-FU injections can be painful and patients require anesthesia prior to injection.

Using a 25-gauge or 27-gauge needle, Dr. Goldman injects 5-FU “exactly as I would a hypertrophic scar. I inject a squamous cell carcinoma carefully and ‘expand’ the tumor.” He typically injects a lesion every 2 weeks until it resolves completely, which typically takes two or three sessions.

“I want to emphasize that that’s really true about intralesional 5-FU for those KAs and scars on the legs,” said session moderator James Spencer, MD, a dermatologist in private practice in St. Petersburg, Florida. “Otherwise, you’re just chasing your tail trying to cut them out. You’ll do much better with the intralesional 5-FU; it’s easy to get, it’s affordable, it comes as 50 mg/mL … just keep it in the office.”
 

A recommended role for hedgehog inhibitors

Hedgehog inhibitors work best as neoadjuvant therapy to shrink large skin cancer tumors prior to excision, Dr. Goldman said. “Hedgehog inhibitors don’t cure anything … except for rare cases of small basal cell carcinomas.” For most lesions, however, the strategy is not curative.

“I don’t believe in hedgehog inhibitors for things that are readily resectable. We use them to shrink things down,” he added.

Dr. Goldman recommended treating patients with neoadjuvant hedgehog inhibitors to achieve the maximum tumor shrinking effect. Adverse effects tend to develop slowly over time, typically after a 6-week “grace period.” Nighttime leg muscle cramps, loss of taste, hair loss, and weight loss can occur. Also, electrolyte imbalances can occur, particularly in older patients with renal clearance issues. When the patient can no longer reasonably tolerate the adverse effects, which is usually the case, “then you do the surgery,” Dr. Goldman said.

“The benefits of neoadjuvant hedgehog inhibitors include predictable shrinkage of tumors,” and manufacturers have been helpful with financial issues, he noted.

Dr. Goldman had no relevant financial disclosures. Dr. Spencer has served on the speakers bureau for Genentech and Leo Pharma.

MIAMI – Pearls for providers of photodynamic therapy (PDT) include tips on skin preparation, eye protection, and use of three new codes to maximize reimbursement. Also trending in medical dermatology are best practices for intralesional injections of 5-FU to treat the often challenging isomorphic squamous cell carcinomas (SCCs) or keratoacanthomas on the lower leg, as well as use of neoadjuvant hedgehog inhibitors to shrink large skin cancer lesions, according to Glenn David Goldman, MD.

“This talk is about what you can do medically as a dermatologic surgeon,” Dr. Goldman said at the Orlando Dermatology Aesthetic and Clinical Conference.
 

Use new billing codes for photodynamic therapy

There are now three new PDT billing codes. “Make sure your coders are using these properly. They are active now, and if you don’t use them, you won’t get paid properly,” said Dr. Goldman, professor and medical director of dermatology at the University of Vermont, Burlington. Specifically, 96567 is for standard PDT applied by staff; 96573 is for PDT applied by a physician; and 96574 is for PDT and curettage performed by a physician.

“Be involved, don’t delegate,” Dr. Goldman added. “If you do, you will get paid half as much as you used to, which means you will lose money on every single patient you treat.”

What type of PDT physicians choose to use in their practice remains controversial. “Do you do short-contact PDT, do you do daylight PDT? We’ve gone back and forth in our practice,” Dr. Goldman said. “I’m not impressed with daylight PDT. I know this is at odds with some of the people here, but at least in Vermont, it doesn’t work very well.”

The way PDT was described in the original trials (a photosensitizer applied in the office followed by PDT) “works the best, with one caveat,” Dr. Goldman said. The caveat is that dermatologists should aim for a PDT clearance that approaches the efficacy of 5-fluorouracil (5-FU). “If you can get to that – which is difficult by the way – I think your patients will really appreciate this.”

An additional PDT pearl Dr. Goldman shared involves skin preparation: the use of acetone to defat the skin, even in patients with very thick lesions. Apply acetone with gauze to the site for 5 minutes and “all of that hyperkeratosis just wipes away,” curette off any residual hyperkeratosis – and consider a ring anesthetic block to control pain for the patient with severe disease, he advised.

Another tip is to forgo the goggles that come with most PDT kits. Instead, purchase smaller, disposable laser eye shields for PDT patients, Dr. Goldman said. “They work better. You can get closer to the eye … and they are more comfortable for the patient.”

Dr. Goldman’s practice is providing more PDT and much less 5-FU for patient convenience. “I believe if someone is willing to go through 3 weeks of 5-FU or 12-16 weeks of imiquimod, they get the best results. However, most people don’t want to do that if they can sit in front of a light for 15 minutes.”
 

Consider intralesional injections for SCCs and KAs on the legs

An ongoing challenge in medical dermatology is preventing rapid recurrence of SCCs and/or keratoacanthomas (KAs) near sites of previous excision on the legs. “We all see this quite a bit. Often you get lesions on the leg, you cut them out, and they come right back” close to the excision site, Dr. Goldman said.

He does not recommend methotrexate injections for these lesions. “Methotrexate does not work. It doesn’t hurt, but I’ve injected methotrexate into squamous cell carcinomas many times and they’ve never gone away.” In contrast, 5-FU “works incredibly well. They go away, I’ve had tremendous success. This has changed the way we treat these lesions.” 5-FU is inexpensive and can be obtained from oncology pharmacies. One caveat is 5-FU injections can be painful and patients require anesthesia prior to injection.

Using a 25-gauge or 27-gauge needle, Dr. Goldman injects 5-FU “exactly as I would a hypertrophic scar. I inject a squamous cell carcinoma carefully and ‘expand’ the tumor.” He typically injects a lesion every 2 weeks until it resolves completely, which typically takes two or three sessions.

“I want to emphasize that that’s really true about intralesional 5-FU for those KAs and scars on the legs,” said session moderator James Spencer, MD, a dermatologist in private practice in St. Petersburg, Florida. “Otherwise, you’re just chasing your tail trying to cut them out. You’ll do much better with the intralesional 5-FU; it’s easy to get, it’s affordable, it comes as 50 mg/mL … just keep it in the office.”
 

A recommended role for hedgehog inhibitors

Hedgehog inhibitors work best as neoadjuvant therapy to shrink large skin cancer tumors prior to excision, Dr. Goldman said. “Hedgehog inhibitors don’t cure anything … except for rare cases of small basal cell carcinomas.” For most lesions, however, the strategy is not curative.

“I don’t believe in hedgehog inhibitors for things that are readily resectable. We use them to shrink things down,” he added.

Dr. Goldman recommended treating patients with neoadjuvant hedgehog inhibitors to achieve the maximum tumor shrinking effect. Adverse effects tend to develop slowly over time, typically after a 6-week “grace period.” Nighttime leg muscle cramps, loss of taste, hair loss, and weight loss can occur. Also, electrolyte imbalances can occur, particularly in older patients with renal clearance issues. When the patient can no longer reasonably tolerate the adverse effects, which is usually the case, “then you do the surgery,” Dr. Goldman said.

“The benefits of neoadjuvant hedgehog inhibitors include predictable shrinkage of tumors,” and manufacturers have been helpful with financial issues, he noted.

Dr. Goldman had no relevant financial disclosures. Dr. Spencer has served on the speakers bureau for Genentech and Leo Pharma.

A randomized clinical trial will compare two techniques for achieving extraperitoneal space during hernia surgery.

The Telescopic Dissection vs. Balloon Dissection During Laparoscopic TEP Inguinal Hernia Repair trial aims to determine whether these techniques are comparable in operative times, early postoperative pain scores, surgical complications, and rate of hernia recurrence. The Spacemaker Balloon Dissector will be used for the trial.

[email protected]

SOURCE: Clinical Trial NCT03276871.

A randomized clinical trial will compare two techniques for achieving extraperitoneal space during hernia surgery.

The Telescopic Dissection vs. Balloon Dissection During Laparoscopic TEP Inguinal Hernia Repair trial aims to determine whether these techniques are comparable in operative times, early postoperative pain scores, surgical complications, and rate of hernia recurrence. The Spacemaker Balloon Dissector will be used for the trial.

[email protected]

SOURCE: Clinical Trial NCT03276871.

A randomized clinical trial will compare two techniques for achieving extraperitoneal space during hernia surgery.

The Telescopic Dissection vs. Balloon Dissection During Laparoscopic TEP Inguinal Hernia Repair trial aims to determine whether these techniques are comparable in operative times, early postoperative pain scores, surgical complications, and rate of hernia recurrence. The Spacemaker Balloon Dissector will be used for the trial.

[email protected]

SOURCE: Clinical Trial NCT03276871.

ATLANTA – An intriguing link between the sex steroid hormonal milieu and platelet mitochondria has potential implications for reducing thrombosis risk.

The link, which involves a mitochondrial protein known as optic atrophy 1 (OPA1), appears to play a role in the regulation of thrombosis, and provides a possible explanation for the marked differences in cardiovascular risks between men and women, according to E. Dale Abel, MD, chair of the department of internal medicine, and director of the Fraternal Order of Eagles Diabetes Research Center at the University of Iowa, Iowa City.

The findings could lead to risk-stratification strategies and the identification of therapeutic targets, Dr. Abel said in an interview.

Courtesy Dr. E. Dale Abel

“If we understand that, we may be in a position to stratify these women based on thrombosis risk in the setting of estrogen exposure. I think the other thing that will come out of the work, as we begin to understand the mechanisms for this relationship, is the identification of targets that we could therapeutically modulate to reduce this risk,” he added.

Eventually, as more is learned about the mechanisms that underlie the relationship between OPA1 and platelet activation, the findings might also lead to new approaches for reducing the risk of thrombosis in men, he noted.

Dr. Abel and Dr. Weyrich reported having no relevant financial disclosures.

[email protected]

ATLANTA – An intriguing link between the sex steroid hormonal milieu and platelet mitochondria has potential implications for reducing thrombosis risk.

The link, which involves a mitochondrial protein known as optic atrophy 1 (OPA1), appears to play a role in the regulation of thrombosis, and provides a possible explanation for the marked differences in cardiovascular risks between men and women, according to E. Dale Abel, MD, chair of the department of internal medicine, and director of the Fraternal Order of Eagles Diabetes Research Center at the University of Iowa, Iowa City.

The findings could lead to risk-stratification strategies and the identification of therapeutic targets, Dr. Abel said in an interview.

Courtesy Dr. E. Dale Abel

“If we understand that, we may be in a position to stratify these women based on thrombosis risk in the setting of estrogen exposure. I think the other thing that will come out of the work, as we begin to understand the mechanisms for this relationship, is the identification of targets that we could therapeutically modulate to reduce this risk,” he added.

Eventually, as more is learned about the mechanisms that underlie the relationship between OPA1 and platelet activation, the findings might also lead to new approaches for reducing the risk of thrombosis in men, he noted.

Dr. Abel and Dr. Weyrich reported having no relevant financial disclosures.

[email protected]

ATLANTA – An intriguing link between the sex steroid hormonal milieu and platelet mitochondria has potential implications for reducing thrombosis risk.

The link, which involves a mitochondrial protein known as optic atrophy 1 (OPA1), appears to play a role in the regulation of thrombosis, and provides a possible explanation for the marked differences in cardiovascular risks between men and women, according to E. Dale Abel, MD, chair of the department of internal medicine, and director of the Fraternal Order of Eagles Diabetes Research Center at the University of Iowa, Iowa City.

The findings could lead to risk-stratification strategies and the identification of therapeutic targets, Dr. Abel said in an interview.

Courtesy Dr. E. Dale Abel

“If we understand that, we may be in a position to stratify these women based on thrombosis risk in the setting of estrogen exposure. I think the other thing that will come out of the work, as we begin to understand the mechanisms for this relationship, is the identification of targets that we could therapeutically modulate to reduce this risk,” he added.

Eventually, as more is learned about the mechanisms that underlie the relationship between OPA1 and platelet activation, the findings might also lead to new approaches for reducing the risk of thrombosis in men, he noted.

Dr. Abel and Dr. Weyrich reported having no relevant financial disclosures.

[email protected]

LAS VEGAS – Male gender and white race rank among epidemiologic risk factors that predict which inflammatory bowel disease (IBD) patients go on to develop nonmelanoma skin cancer, a large national analysis showed.

“Some studies have shown that patients with IBD may be at increased risk for nonmelanoma skin cancer (NMSC) because of the immunomodulators that they take for the management of their disease,” Zubair Khan, MD, said in an interview at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “But these are mostly small, single-center studies.” In an effort to determine the epidemiology of NMSC in patients hospitalized with IBD, Dr. Khan, associate chief resident in the internal medicine department at the University of Toledo (Ohio) Medical Center and his associates analyzed the National Inpatient Sample (NIS) database for all subjects who had a primary or secondary discharge diagnosis of IBD during 2002-2014. Next, they used ICD-9 codes to identify the rate of NMSC in this population.

Doug Brunk/Frontline Medical News

*This story was updated on 3/26.

[email protected]

SOURCE: Khan Z et al. Crohn’s & Colitis Congress, Poster 209.

LAS VEGAS – Male gender and white race rank among epidemiologic risk factors that predict which inflammatory bowel disease (IBD) patients go on to develop nonmelanoma skin cancer, a large national analysis showed.

“Some studies have shown that patients with IBD may be at increased risk for nonmelanoma skin cancer (NMSC) because of the immunomodulators that they take for the management of their disease,” Zubair Khan, MD, said in an interview at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “But these are mostly small, single-center studies.” In an effort to determine the epidemiology of NMSC in patients hospitalized with IBD, Dr. Khan, associate chief resident in the internal medicine department at the University of Toledo (Ohio) Medical Center and his associates analyzed the National Inpatient Sample (NIS) database for all subjects who had a primary or secondary discharge diagnosis of IBD during 2002-2014. Next, they used ICD-9 codes to identify the rate of NMSC in this population.

Doug Brunk/Frontline Medical News

*This story was updated on 3/26.

[email protected]

SOURCE: Khan Z et al. Crohn’s & Colitis Congress, Poster 209.

LAS VEGAS – Male gender and white race rank among epidemiologic risk factors that predict which inflammatory bowel disease (IBD) patients go on to develop nonmelanoma skin cancer, a large national analysis showed.

“Some studies have shown that patients with IBD may be at increased risk for nonmelanoma skin cancer (NMSC) because of the immunomodulators that they take for the management of their disease,” Zubair Khan, MD, said in an interview at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “But these are mostly small, single-center studies.” In an effort to determine the epidemiology of NMSC in patients hospitalized with IBD, Dr. Khan, associate chief resident in the internal medicine department at the University of Toledo (Ohio) Medical Center and his associates analyzed the National Inpatient Sample (NIS) database for all subjects who had a primary or secondary discharge diagnosis of IBD during 2002-2014. Next, they used ICD-9 codes to identify the rate of NMSC in this population.

Doug Brunk/Frontline Medical News

*This story was updated on 3/26.

[email protected]

SOURCE: Khan Z et al. Crohn’s & Colitis Congress, Poster 209.

LOS ANGELES – For every 10 of your adult patients with type 2 diabetes, three are likely to have moderate to severe liver fibrosis, according to Kenneth Cusi, MD, FACP, FACE.

“If in the last 10 patients, you didn’t diagnose anybody with fibrosis, you probably missed it,” he said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “The question is, How are we going to tackle this problem? My academic goal is that we incorporate screening for NASH [nonalcoholic steatohepatitis], or for fibrosis more specifically, in the same way we do for retinopathy or nephropathy, because we do have a way to treat it.”

Doug Brunk/Frontline Medical News

[email protected]

LOS ANGELES – For every 10 of your adult patients with type 2 diabetes, three are likely to have moderate to severe liver fibrosis, according to Kenneth Cusi, MD, FACP, FACE.

“If in the last 10 patients, you didn’t diagnose anybody with fibrosis, you probably missed it,” he said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “The question is, How are we going to tackle this problem? My academic goal is that we incorporate screening for NASH [nonalcoholic steatohepatitis], or for fibrosis more specifically, in the same way we do for retinopathy or nephropathy, because we do have a way to treat it.”

Doug Brunk/Frontline Medical News

[email protected]

LOS ANGELES – For every 10 of your adult patients with type 2 diabetes, three are likely to have moderate to severe liver fibrosis, according to Kenneth Cusi, MD, FACP, FACE.

“If in the last 10 patients, you didn’t diagnose anybody with fibrosis, you probably missed it,” he said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “The question is, How are we going to tackle this problem? My academic goal is that we incorporate screening for NASH [nonalcoholic steatohepatitis], or for fibrosis more specifically, in the same way we do for retinopathy or nephropathy, because we do have a way to treat it.”

Doug Brunk/Frontline Medical News

[email protected]

“This is an emerging disease that you’re all going to see in your practices this year. You’ve got to know what to do with these patients. Get to them early,” one expert warns. 

To learn about this important development and more, click on the link above for today's four-minute medical news update.

“This is an emerging disease that you’re all going to see in your practices this year. You’ve got to know what to do with these patients. Get to them early,” one expert warns. 

To learn about this important development and more, click on the link above for today's four-minute medical news update.

“This is an emerging disease that you’re all going to see in your practices this year. You’ve got to know what to do with these patients. Get to them early,” one expert warns. 

To learn about this important development and more, click on the link above for today's four-minute medical news update.

Female surgeons were less likely than were male surgeons to be full professors in 2014, according to an analysis that adjusted for a number of “factors known to influence academic rank independently of sex.”

The overall odds ratio for female surgeons to be full professors, compared with men, was 0.76, after adjustment for such factors as age, years since residency, subspecialty, total publications, and clinical trial participation. “This methodological rigor is a central and unique strength of this analysis and bolsters the validity of the study findings,” wrote Daniel M. Blumenthal, MD, of Massachusetts General Hospital and Harvard Medical School, Boston, and his associates. The report was published in Annals of Surgery (2018 Jan 12. doi: 10.1097/SLA.0000000000002662).

Differences favoring men were seen in eight of the nine subspecialties included in the study, with vascular surgery being the exception (adjusted odds ratio, 1.63). Of the other eight, however, only in general surgery (adjusted odds ratio, 0.68) was the difference significant, the investigators said.

Another factor included in the analysis was the research ranking of the medical schools. There was no significant sex disparity for faculty members at medical schools ranked in the top 20 by U.S. News & World Report (adjusted odds ratio, 1.03), but schools outside the top 20 had an adjusted odds ratio (AOR) of 0.65 for women, compared with men. Geographically speaking, the largest disadvantage for female surgeons among the four main census divisions was in the Northeast (AOR, 0.52), with the West generating relative equality (AOR, 1.02) and the South (AOR, 0.83) and the Midwest (AOR, 0.87) in between, they reported.

Dr. Blumenthal and his associates used a cross-sectional database maintained by Doximity, an online networking company. The analysis included data for 11,549 surgeons with faculty appointments in 2014: 3,080 were full professors (7% were women), 2,931 were associate professors (13.8% were women), and 5,538 were assistant professors (19.4% were women).

Dr. Blumenthal reported research funding from a fellowship at Harvard. The investigators declared no conflict of interests.

[email protected]

SOURCE: Blumenthal DM et al. Ann Surg. 2018 Jan 12. doi: 10.1097/SLA.0000000000002662.

Female surgeons were less likely than were male surgeons to be full professors in 2014, according to an analysis that adjusted for a number of “factors known to influence academic rank independently of sex.”

The overall odds ratio for female surgeons to be full professors, compared with men, was 0.76, after adjustment for such factors as age, years since residency, subspecialty, total publications, and clinical trial participation. “This methodological rigor is a central and unique strength of this analysis and bolsters the validity of the study findings,” wrote Daniel M. Blumenthal, MD, of Massachusetts General Hospital and Harvard Medical School, Boston, and his associates. The report was published in Annals of Surgery (2018 Jan 12. doi: 10.1097/SLA.0000000000002662).

Differences favoring men were seen in eight of the nine subspecialties included in the study, with vascular surgery being the exception (adjusted odds ratio, 1.63). Of the other eight, however, only in general surgery (adjusted odds ratio, 0.68) was the difference significant, the investigators said.

Another factor included in the analysis was the research ranking of the medical schools. There was no significant sex disparity for faculty members at medical schools ranked in the top 20 by U.S. News & World Report (adjusted odds ratio, 1.03), but schools outside the top 20 had an adjusted odds ratio (AOR) of 0.65 for women, compared with men. Geographically speaking, the largest disadvantage for female surgeons among the four main census divisions was in the Northeast (AOR, 0.52), with the West generating relative equality (AOR, 1.02) and the South (AOR, 0.83) and the Midwest (AOR, 0.87) in between, they reported.

Dr. Blumenthal and his associates used a cross-sectional database maintained by Doximity, an online networking company. The analysis included data for 11,549 surgeons with faculty appointments in 2014: 3,080 were full professors (7% were women), 2,931 were associate professors (13.8% were women), and 5,538 were assistant professors (19.4% were women).

Dr. Blumenthal reported research funding from a fellowship at Harvard. The investigators declared no conflict of interests.

[email protected]

SOURCE: Blumenthal DM et al. Ann Surg. 2018 Jan 12. doi: 10.1097/SLA.0000000000002662.

Female surgeons were less likely than were male surgeons to be full professors in 2014, according to an analysis that adjusted for a number of “factors known to influence academic rank independently of sex.”

The overall odds ratio for female surgeons to be full professors, compared with men, was 0.76, after adjustment for such factors as age, years since residency, subspecialty, total publications, and clinical trial participation. “This methodological rigor is a central and unique strength of this analysis and bolsters the validity of the study findings,” wrote Daniel M. Blumenthal, MD, of Massachusetts General Hospital and Harvard Medical School, Boston, and his associates. The report was published in Annals of Surgery (2018 Jan 12. doi: 10.1097/SLA.0000000000002662).

Differences favoring men were seen in eight of the nine subspecialties included in the study, with vascular surgery being the exception (adjusted odds ratio, 1.63). Of the other eight, however, only in general surgery (adjusted odds ratio, 0.68) was the difference significant, the investigators said.

Another factor included in the analysis was the research ranking of the medical schools. There was no significant sex disparity for faculty members at medical schools ranked in the top 20 by U.S. News & World Report (adjusted odds ratio, 1.03), but schools outside the top 20 had an adjusted odds ratio (AOR) of 0.65 for women, compared with men. Geographically speaking, the largest disadvantage for female surgeons among the four main census divisions was in the Northeast (AOR, 0.52), with the West generating relative equality (AOR, 1.02) and the South (AOR, 0.83) and the Midwest (AOR, 0.87) in between, they reported.

Dr. Blumenthal and his associates used a cross-sectional database maintained by Doximity, an online networking company. The analysis included data for 11,549 surgeons with faculty appointments in 2014: 3,080 were full professors (7% were women), 2,931 were associate professors (13.8% were women), and 5,538 were assistant professors (19.4% were women).

Dr. Blumenthal reported research funding from a fellowship at Harvard. The investigators declared no conflict of interests.

[email protected]

SOURCE: Blumenthal DM et al. Ann Surg. 2018 Jan 12. doi: 10.1097/SLA.0000000000002662.

The FDA is launching a new website to get critical updates about antibiotics and antifungals out faster to health care professionals to help them make more informed prescribing decisions. The site will provide “direct and timely access” to information about when bacterial or fungal infections are likely to respond to a specific drug.

“When you are treating critically ill patients, you want as much information as possible about the pathogen…and the susceptibility of that pathogen to various treatment,” said FDA Commissioner Scott Gottlieb, MD. Under the old approach, he said, updating each drug’s individual labeling took too long. Only after the revised drug labeling was approved could a drug or device manufacturer update testing criteria and labeling for the latest antimicrobial susceptibility test results. Each drug and device labeling had to be updated whenever criteria changed.

The new tool will allow the FDA to simultaneously provide updates multiple drugs that have the same active ingredient and share that information transparently via a dedicated web page.

The FDA is launching a new website to get critical updates about antibiotics and antifungals out faster to health care professionals to help them make more informed prescribing decisions. The site will provide “direct and timely access” to information about when bacterial or fungal infections are likely to respond to a specific drug.

“When you are treating critically ill patients, you want as much information as possible about the pathogen…and the susceptibility of that pathogen to various treatment,” said FDA Commissioner Scott Gottlieb, MD. Under the old approach, he said, updating each drug’s individual labeling took too long. Only after the revised drug labeling was approved could a drug or device manufacturer update testing criteria and labeling for the latest antimicrobial susceptibility test results. Each drug and device labeling had to be updated whenever criteria changed.

The new tool will allow the FDA to simultaneously provide updates multiple drugs that have the same active ingredient and share that information transparently via a dedicated web page.

The FDA is launching a new website to get critical updates about antibiotics and antifungals out faster to health care professionals to help them make more informed prescribing decisions. The site will provide “direct and timely access” to information about when bacterial or fungal infections are likely to respond to a specific drug.

“When you are treating critically ill patients, you want as much information as possible about the pathogen…and the susceptibility of that pathogen to various treatment,” said FDA Commissioner Scott Gottlieb, MD. Under the old approach, he said, updating each drug’s individual labeling took too long. Only after the revised drug labeling was approved could a drug or device manufacturer update testing criteria and labeling for the latest antimicrobial susceptibility test results. Each drug and device labeling had to be updated whenever criteria changed.

The new tool will allow the FDA to simultaneously provide updates multiple drugs that have the same active ingredient and share that information transparently via a dedicated web page.

As Assistant Deputy Under Secretary of Health Quality, Safety and Value, Shereef Elnahal, MD led VA efforts to improve the quality of care and to find, develop, and expand successful local programs through the Diffusion of Excellence initiative. More recently, he helped to develop new performance metrics for VA facilities and to increase transparency to veterans about wait times and quality. Federal Practitioner recently asked Dr. Elnahal to discuss these initiatives.

Improving the Veteran Experience

Federal Practitioner. Last year, VA launched accesstocare.va.gov to provide the public access to performance, wait time, and other data. What was the rationale for creating the website?

Shereef Elnahal, MD. The rationale, which directly aligns with the top priorities outlined by VA Secretary David J. Shulkin, MD, was simple: If we provide veterans with an easy-to-use tool that lets them see data on wait times and quality, they’ll be able to make informed decisions about where and when they receive their health care.

Secretary Shulkin has underscored the importance of improving the timeliness of VA health care services while simultaneously empowering veterans through transparency of information. This website provides a vital tool for realizing his vision.

Federal Practitioner. What types of data and tools are currently included on the site and what would you like to include in the future?

Dr. Elnahal. Right now, veterans can find information about wait times, quality of care, as well as other veterans’ experiences at local VA facilities. They also can compare quality of care provided by VA medical centers with that of local private hospitals. In addition, we recently added a feature whereby veterans can see if a local VA facility is better, worse, or the same as the regional average wait time of private sector clinics.

For example, if you’re a veteran and want to find out how quickly you can get an appointment with a primary care provider in your area, you simply visit www.accesstocare.va.gov and click the box “How Quickly Can My VA Facility See Me?” You’ll then be directed to a page that asks whether you want to find out about wait times at individual facilities or learn about facilities with same-day access. By clicking the former, you’ll be taken to a screen that includes a map and a few drop-down menus. From there, you can query the system in several ways, including “How soon can I get an appointment at the facility closest to me?” in which case the site will display a list of facilities in your area, with the closest facility listed first, along with wait times. Or you can ask “How soon can I get an appointment at a nearby facility?” in which case, the system will list facilities in your area displayed according to wait time, with the shortest wait time listed first. No other health care system that we know of provides this level of transparency.

Finally, last October, we also added a new feature, “Our Providers,” which provides information on more than 40,000 full-time and part-time VA health care providers. By visiting www.accesstocare.va.gov/ourproviders, veterans and their families can search practitioners by state, VA facility name, occupation, gender, and the service line to which the practitioner is assigned.

Federal Practitioner. What feedback have you received on accesstocare.va.gov from veterans and veterans groups?

Dr. Elnahal. The response has been overwhelmingly positive, both in terms of what veterans and Veterans Service Organizations (VSOs) have told us, and what we’ve seen in the news. For example, I read a story quoting an Arizona Veterans of Foreign Wars senior vice commander who said “That’s the thing about transparency. You can talk about it and promise it, but putting yourself out there online and making it available for everyone to use is a whole other story. That’s being pretty transparent.”¹

I should note, though, that our desire for feedback didn’t end with the site’s launch. We want veterans and VSOs to continue advising us on ways to improve the site. On the website itself, you can find a section that allows you to give feedback, and we encourage veterans and their family members to do so.

Quality of Care

Federal Practitioner. What metrics are you using internally to measure and improve the quality of VA performance and health care?

Dr. Elnahal. We mainly use metrics that are already reported by private sector hospitals and clinics, such as Medicare core metrics, patient experience surveys, and those that are administered by the National Committee for Quality Assurance (NCQA).

Federal Practitioner. How are central office, VISN, or facility leadership using these metrics?

Dr. Elnahal. Each of these levels of management look at their specific purview, identify areas where they are falling behind the rest of the system or the private sector, and focus their resources on improving those specific areas. At the national level, the main focus right now is on those facilities that Secretary Shulkin has identified as “high risk” so that we can make sure they are on a fast path to improvement. We cannot afford to wait on improving these facilities, and Secretary Shulkin has asked us to focus our resources on the areas that need it most. I think it’s also important to note that we’ve been working to create a standard structure for quality (and safety) governance. Through this structure, which includes boards and committees at every level of VHA, we’re supporting front-line improvement teams that focus on quality of care in particular clinical service lines. We’re also leveraging these front-line teams to promote rapid sharing of best practices across the entire enterprise.

Federal Practitioner. How important is employee engagement and employee satisfaction to VA quality improvement?

Dr. Elnahal. Employee engagement and satisfaction are integral to quality improvement and are high priorities at VA. One factor that makes VA especially unique, even among other federal departments and agencies, is that our workforce truly is mission driven. VA employees are typically not paid quite as highly as health care workers in the private sector and are often asked to do jobs that are more difficult. Our veterans need and deserve the highest quality of care, and for service-related conditions, that can be quite complex. The people who choose to work for VA are invested in the mission, and about one-third of them are veterans themselves.

In addition, VA measures employee satisfaction more consistently and robustly than do most other health care institutions. Every year, a survey called the All-Employee Survey is released to every employee in VHA, and detailed questions are asked about how folks are feeling about their work environment, supervisors, you name it. We play close attention to these results across the organization—happier, engaged employees are more likely to provide the best service they can to veterans, which is why we care so much about this issue.

Federal Practitioner. Do you have any insight based on these metrics on the VA’s recent progress in improving access and quality of care?

In a recent analysis of 15 large metropolitan areas, we found that VA facility outpatient access has improved by 6 days on average between 2014 and 2017, while wait times in the private sector increased by 6 days on average. Wait times have improved in 11 of the 15 metropolitan areas. The number of unique patients seen and the volume of encounters nationally increased substantially between FY14 and FY17 for all 4 analyzed specialties: cardiology, dermatology, primary care and orthopedics.

For example, in cardiology the number of unique patients seen increased by 12%, and the volume of encounters increased by 19%. This progress is further illustrated by our improvement in our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data. VA has had incremental improvements annually in access according to reported HCAHPS scores for primary care and specialty care appointments, both urgent and routine care. The percentage of patients who believe “I ‘always’ got an appointment for care needed right away/routine care,” has been improving, on average, 1.3% annually since 2014.

In terms of care quality, several reports have been published in recent years that show high levels of performance in standard metrics for quality and patient safety, and in most, VA exceeds the private sector’s performance. VA continues to strive for the highest possible quality of care that we can provide.

Diffusion of Excellence

Federal Practitioner. How has the Diffusion of Excellence (DoE) program grown from its inception?

Dr. Elnahal. Since 2015, when we launched the initiative, the program has grown considerably both in size as well as in the diversity of best practices put forward.

Federal Practitioner. Does this initiative play into the larger efforts to improve transparency and quality of care?

Dr. Elnahal. Absolutely. Every cycle, categories of best practices are aligned seamlessly with the priorities of the moment. For example, suicide prevention and controlling the opioid epidemic were just some of the priorities we focused on this past year, because they are what the organization has been focused on at large. Quality and patient safety—perennial priorities of VHA—are always reflected in our solicitation of best practices.

Federal Practitioner. Can you identify/describe a few successful DoE programs that exemplify VA employees’ commitment to improving quality of care?

Dr. Elnahal. One example that springs to mind is the Home-based Mental Health Evaluation, or HOME, a program that bridges the gap in mental health care recently discharged rural veterans’ experience. In VISN 16, the program reduced psychiatric rehospitalizations by nearly 50% and the average length of a hospital stay by 41% by having staff meet with hospitalized veterans; complete a home visit within 1 week after the patient is discharged; and maintain weekly phone contact until the veteran starts outpatient mental health services.

Another example is a program developed by staff at the North Florida/South Georgia Veterans Health Care System in Gainesville, which helped reduce wait times in the hospital’s cardiology clinic. This best practice encourages physicians to review individual requests for consultations with specialists. They are asked to triage the requests to determine whether a face-to-face encounter is needed, if the request can be handled either at a local outpatient clinic or electronically, or whether the doctor needs more information before deciding what to do. In 1 year, this process reduced wait times in Gainesville’s cardiology clinic by 46%, to about 10 days.

Another Boston VA project is the development of a screening and transfer process for patients who want to be detoxified from substances to which they have become addicted. The facility’s psychosomatic medicine service team uses an algorithm for screenings and transfers that embeds available literature on the subject and a multidisciplinary consensus into an order set for electronic consultations. This results in an evidence-based, multidisciplinary, and technologic approach to the transfer process.

Federal Practitioner. Do you see DoE as a laboratory for quality of care improvement that could expand beyond the VA?

Dr. Elnahal. Absolutely. In fact, I recently coauthored, with Secretary Shulkin and Deputy Under Secretary for Health Carolyn Clancy, a commentary  that provided a how-to for private sector systems to replicate our efforts.² In that commentary, we identified four distinct phases of diffusing best practices across health care systems: Identify promising practices, recruit champions, replicate; and establish consistency, standardize, and sustain.

As Assistant Deputy Under Secretary of Health Quality, Safety and Value, Shereef Elnahal, MD led VA efforts to improve the quality of care and to find, develop, and expand successful local programs through the Diffusion of Excellence initiative. More recently, he helped to develop new performance metrics for VA facilities and to increase transparency to veterans about wait times and quality. Federal Practitioner recently asked Dr. Elnahal to discuss these initiatives.

Improving the Veteran Experience

Federal Practitioner. Last year, VA launched accesstocare.va.gov to provide the public access to performance, wait time, and other data. What was the rationale for creating the website?

Shereef Elnahal, MD. The rationale, which directly aligns with the top priorities outlined by VA Secretary David J. Shulkin, MD, was simple: If we provide veterans with an easy-to-use tool that lets them see data on wait times and quality, they’ll be able to make informed decisions about where and when they receive their health care.

Secretary Shulkin has underscored the importance of improving the timeliness of VA health care services while simultaneously empowering veterans through transparency of information. This website provides a vital tool for realizing his vision.

Federal Practitioner. What types of data and tools are currently included on the site and what would you like to include in the future?

Dr. Elnahal. Right now, veterans can find information about wait times, quality of care, as well as other veterans’ experiences at local VA facilities. They also can compare quality of care provided by VA medical centers with that of local private hospitals. In addition, we recently added a feature whereby veterans can see if a local VA facility is better, worse, or the same as the regional average wait time of private sector clinics.

For example, if you’re a veteran and want to find out how quickly you can get an appointment with a primary care provider in your area, you simply visit www.accesstocare.va.gov and click the box “How Quickly Can My VA Facility See Me?” You’ll then be directed to a page that asks whether you want to find out about wait times at individual facilities or learn about facilities with same-day access. By clicking the former, you’ll be taken to a screen that includes a map and a few drop-down menus. From there, you can query the system in several ways, including “How soon can I get an appointment at the facility closest to me?” in which case the site will display a list of facilities in your area, with the closest facility listed first, along with wait times. Or you can ask “How soon can I get an appointment at a nearby facility?” in which case, the system will list facilities in your area displayed according to wait time, with the shortest wait time listed first. No other health care system that we know of provides this level of transparency.

Finally, last October, we also added a new feature, “Our Providers,” which provides information on more than 40,000 full-time and part-time VA health care providers. By visiting www.accesstocare.va.gov/ourproviders, veterans and their families can search practitioners by state, VA facility name, occupation, gender, and the service line to which the practitioner is assigned.

Federal Practitioner. What feedback have you received on accesstocare.va.gov from veterans and veterans groups?

Dr. Elnahal. The response has been overwhelmingly positive, both in terms of what veterans and Veterans Service Organizations (VSOs) have told us, and what we’ve seen in the news. For example, I read a story quoting an Arizona Veterans of Foreign Wars senior vice commander who said “That’s the thing about transparency. You can talk about it and promise it, but putting yourself out there online and making it available for everyone to use is a whole other story. That’s being pretty transparent.”¹

I should note, though, that our desire for feedback didn’t end with the site’s launch. We want veterans and VSOs to continue advising us on ways to improve the site. On the website itself, you can find a section that allows you to give feedback, and we encourage veterans and their family members to do so.

Quality of Care

Federal Practitioner. What metrics are you using internally to measure and improve the quality of VA performance and health care?

Dr. Elnahal. We mainly use metrics that are already reported by private sector hospitals and clinics, such as Medicare core metrics, patient experience surveys, and those that are administered by the National Committee for Quality Assurance (NCQA).

Federal Practitioner. How are central office, VISN, or facility leadership using these metrics?

Dr. Elnahal. Each of these levels of management look at their specific purview, identify areas where they are falling behind the rest of the system or the private sector, and focus their resources on improving those specific areas. At the national level, the main focus right now is on those facilities that Secretary Shulkin has identified as “high risk” so that we can make sure they are on a fast path to improvement. We cannot afford to wait on improving these facilities, and Secretary Shulkin has asked us to focus our resources on the areas that need it most. I think it’s also important to note that we’ve been working to create a standard structure for quality (and safety) governance. Through this structure, which includes boards and committees at every level of VHA, we’re supporting front-line improvement teams that focus on quality of care in particular clinical service lines. We’re also leveraging these front-line teams to promote rapid sharing of best practices across the entire enterprise.

Federal Practitioner. How important is employee engagement and employee satisfaction to VA quality improvement?

Dr. Elnahal. Employee engagement and satisfaction are integral to quality improvement and are high priorities at VA. One factor that makes VA especially unique, even among other federal departments and agencies, is that our workforce truly is mission driven. VA employees are typically not paid quite as highly as health care workers in the private sector and are often asked to do jobs that are more difficult. Our veterans need and deserve the highest quality of care, and for service-related conditions, that can be quite complex. The people who choose to work for VA are invested in the mission, and about one-third of them are veterans themselves.

In addition, VA measures employee satisfaction more consistently and robustly than do most other health care institutions. Every year, a survey called the All-Employee Survey is released to every employee in VHA, and detailed questions are asked about how folks are feeling about their work environment, supervisors, you name it. We play close attention to these results across the organization—happier, engaged employees are more likely to provide the best service they can to veterans, which is why we care so much about this issue.

Federal Practitioner. Do you have any insight based on these metrics on the VA’s recent progress in improving access and quality of care?

In a recent analysis of 15 large metropolitan areas, we found that VA facility outpatient access has improved by 6 days on average between 2014 and 2017, while wait times in the private sector increased by 6 days on average. Wait times have improved in 11 of the 15 metropolitan areas. The number of unique patients seen and the volume of encounters nationally increased substantially between FY14 and FY17 for all 4 analyzed specialties: cardiology, dermatology, primary care and orthopedics.

For example, in cardiology the number of unique patients seen increased by 12%, and the volume of encounters increased by 19%. This progress is further illustrated by our improvement in our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data. VA has had incremental improvements annually in access according to reported HCAHPS scores for primary care and specialty care appointments, both urgent and routine care. The percentage of patients who believe “I ‘always’ got an appointment for care needed right away/routine care,” has been improving, on average, 1.3% annually since 2014.

In terms of care quality, several reports have been published in recent years that show high levels of performance in standard metrics for quality and patient safety, and in most, VA exceeds the private sector’s performance. VA continues to strive for the highest possible quality of care that we can provide.

Diffusion of Excellence

Federal Practitioner. How has the Diffusion of Excellence (DoE) program grown from its inception?

Dr. Elnahal. Since 2015, when we launched the initiative, the program has grown considerably both in size as well as in the diversity of best practices put forward.

Federal Practitioner. Does this initiative play into the larger efforts to improve transparency and quality of care?

Dr. Elnahal. Absolutely. Every cycle, categories of best practices are aligned seamlessly with the priorities of the moment. For example, suicide prevention and controlling the opioid epidemic were just some of the priorities we focused on this past year, because they are what the organization has been focused on at large. Quality and patient safety—perennial priorities of VHA—are always reflected in our solicitation of best practices.

Federal Practitioner. Can you identify/describe a few successful DoE programs that exemplify VA employees’ commitment to improving quality of care?

Dr. Elnahal. One example that springs to mind is the Home-based Mental Health Evaluation, or HOME, a program that bridges the gap in mental health care recently discharged rural veterans’ experience. In VISN 16, the program reduced psychiatric rehospitalizations by nearly 50% and the average length of a hospital stay by 41% by having staff meet with hospitalized veterans; complete a home visit within 1 week after the patient is discharged; and maintain weekly phone contact until the veteran starts outpatient mental health services.

Another example is a program developed by staff at the North Florida/South Georgia Veterans Health Care System in Gainesville, which helped reduce wait times in the hospital’s cardiology clinic. This best practice encourages physicians to review individual requests for consultations with specialists. They are asked to triage the requests to determine whether a face-to-face encounter is needed, if the request can be handled either at a local outpatient clinic or electronically, or whether the doctor needs more information before deciding what to do. In 1 year, this process reduced wait times in Gainesville’s cardiology clinic by 46%, to about 10 days.

Another Boston VA project is the development of a screening and transfer process for patients who want to be detoxified from substances to which they have become addicted. The facility’s psychosomatic medicine service team uses an algorithm for screenings and transfers that embeds available literature on the subject and a multidisciplinary consensus into an order set for electronic consultations. This results in an evidence-based, multidisciplinary, and technologic approach to the transfer process.

Federal Practitioner. Do you see DoE as a laboratory for quality of care improvement that could expand beyond the VA?

Dr. Elnahal. Absolutely. In fact, I recently coauthored, with Secretary Shulkin and Deputy Under Secretary for Health Carolyn Clancy, a commentary  that provided a how-to for private sector systems to replicate our efforts.² In that commentary, we identified four distinct phases of diffusing best practices across health care systems: Identify promising practices, recruit champions, replicate; and establish consistency, standardize, and sustain.

As Assistant Deputy Under Secretary of Health Quality, Safety and Value, Shereef Elnahal, MD led VA efforts to improve the quality of care and to find, develop, and expand successful local programs through the Diffusion of Excellence initiative. More recently, he helped to develop new performance metrics for VA facilities and to increase transparency to veterans about wait times and quality. Federal Practitioner recently asked Dr. Elnahal to discuss these initiatives.

Improving the Veteran Experience

Federal Practitioner. Last year, VA launched accesstocare.va.gov to provide the public access to performance, wait time, and other data. What was the rationale for creating the website?

Shereef Elnahal, MD. The rationale, which directly aligns with the top priorities outlined by VA Secretary David J. Shulkin, MD, was simple: If we provide veterans with an easy-to-use tool that lets them see data on wait times and quality, they’ll be able to make informed decisions about where and when they receive their health care.

Secretary Shulkin has underscored the importance of improving the timeliness of VA health care services while simultaneously empowering veterans through transparency of information. This website provides a vital tool for realizing his vision.

Federal Practitioner. What types of data and tools are currently included on the site and what would you like to include in the future?

Dr. Elnahal. Right now, veterans can find information about wait times, quality of care, as well as other veterans’ experiences at local VA facilities. They also can compare quality of care provided by VA medical centers with that of local private hospitals. In addition, we recently added a feature whereby veterans can see if a local VA facility is better, worse, or the same as the regional average wait time of private sector clinics.

For example, if you’re a veteran and want to find out how quickly you can get an appointment with a primary care provider in your area, you simply visit www.accesstocare.va.gov and click the box “How Quickly Can My VA Facility See Me?” You’ll then be directed to a page that asks whether you want to find out about wait times at individual facilities or learn about facilities with same-day access. By clicking the former, you’ll be taken to a screen that includes a map and a few drop-down menus. From there, you can query the system in several ways, including “How soon can I get an appointment at the facility closest to me?” in which case the site will display a list of facilities in your area, with the closest facility listed first, along with wait times. Or you can ask “How soon can I get an appointment at a nearby facility?” in which case, the system will list facilities in your area displayed according to wait time, with the shortest wait time listed first. No other health care system that we know of provides this level of transparency.

Finally, last October, we also added a new feature, “Our Providers,” which provides information on more than 40,000 full-time and part-time VA health care providers. By visiting www.accesstocare.va.gov/ourproviders, veterans and their families can search practitioners by state, VA facility name, occupation, gender, and the service line to which the practitioner is assigned.

Federal Practitioner. What feedback have you received on accesstocare.va.gov from veterans and veterans groups?

Dr. Elnahal. The response has been overwhelmingly positive, both in terms of what veterans and Veterans Service Organizations (VSOs) have told us, and what we’ve seen in the news. For example, I read a story quoting an Arizona Veterans of Foreign Wars senior vice commander who said “That’s the thing about transparency. You can talk about it and promise it, but putting yourself out there online and making it available for everyone to use is a whole other story. That’s being pretty transparent.”¹

I should note, though, that our desire for feedback didn’t end with the site’s launch. We want veterans and VSOs to continue advising us on ways to improve the site. On the website itself, you can find a section that allows you to give feedback, and we encourage veterans and their family members to do so.

Quality of Care

Federal Practitioner. What metrics are you using internally to measure and improve the quality of VA performance and health care?

Dr. Elnahal. We mainly use metrics that are already reported by private sector hospitals and clinics, such as Medicare core metrics, patient experience surveys, and those that are administered by the National Committee for Quality Assurance (NCQA).

Federal Practitioner. How are central office, VISN, or facility leadership using these metrics?

Dr. Elnahal. Each of these levels of management look at their specific purview, identify areas where they are falling behind the rest of the system or the private sector, and focus their resources on improving those specific areas. At the national level, the main focus right now is on those facilities that Secretary Shulkin has identified as “high risk” so that we can make sure they are on a fast path to improvement. We cannot afford to wait on improving these facilities, and Secretary Shulkin has asked us to focus our resources on the areas that need it most. I think it’s also important to note that we’ve been working to create a standard structure for quality (and safety) governance. Through this structure, which includes boards and committees at every level of VHA, we’re supporting front-line improvement teams that focus on quality of care in particular clinical service lines. We’re also leveraging these front-line teams to promote rapid sharing of best practices across the entire enterprise.

Federal Practitioner. How important is employee engagement and employee satisfaction to VA quality improvement?

Dr. Elnahal. Employee engagement and satisfaction are integral to quality improvement and are high priorities at VA. One factor that makes VA especially unique, even among other federal departments and agencies, is that our workforce truly is mission driven. VA employees are typically not paid quite as highly as health care workers in the private sector and are often asked to do jobs that are more difficult. Our veterans need and deserve the highest quality of care, and for service-related conditions, that can be quite complex. The people who choose to work for VA are invested in the mission, and about one-third of them are veterans themselves.

In addition, VA measures employee satisfaction more consistently and robustly than do most other health care institutions. Every year, a survey called the All-Employee Survey is released to every employee in VHA, and detailed questions are asked about how folks are feeling about their work environment, supervisors, you name it. We play close attention to these results across the organization—happier, engaged employees are more likely to provide the best service they can to veterans, which is why we care so much about this issue.

Federal Practitioner. Do you have any insight based on these metrics on the VA’s recent progress in improving access and quality of care?

In a recent analysis of 15 large metropolitan areas, we found that VA facility outpatient access has improved by 6 days on average between 2014 and 2017, while wait times in the private sector increased by 6 days on average. Wait times have improved in 11 of the 15 metropolitan areas. The number of unique patients seen and the volume of encounters nationally increased substantially between FY14 and FY17 for all 4 analyzed specialties: cardiology, dermatology, primary care and orthopedics.

For example, in cardiology the number of unique patients seen increased by 12%, and the volume of encounters increased by 19%. This progress is further illustrated by our improvement in our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data. VA has had incremental improvements annually in access according to reported HCAHPS scores for primary care and specialty care appointments, both urgent and routine care. The percentage of patients who believe “I ‘always’ got an appointment for care needed right away/routine care,” has been improving, on average, 1.3% annually since 2014.

In terms of care quality, several reports have been published in recent years that show high levels of performance in standard metrics for quality and patient safety, and in most, VA exceeds the private sector’s performance. VA continues to strive for the highest possible quality of care that we can provide.

Diffusion of Excellence

Federal Practitioner. How has the Diffusion of Excellence (DoE) program grown from its inception?

Dr. Elnahal. Since 2015, when we launched the initiative, the program has grown considerably both in size as well as in the diversity of best practices put forward.

Federal Practitioner. Does this initiative play into the larger efforts to improve transparency and quality of care?

Dr. Elnahal. Absolutely. Every cycle, categories of best practices are aligned seamlessly with the priorities of the moment. For example, suicide prevention and controlling the opioid epidemic were just some of the priorities we focused on this past year, because they are what the organization has been focused on at large. Quality and patient safety—perennial priorities of VHA—are always reflected in our solicitation of best practices.

Federal Practitioner. Can you identify/describe a few successful DoE programs that exemplify VA employees’ commitment to improving quality of care?

Dr. Elnahal. One example that springs to mind is the Home-based Mental Health Evaluation, or HOME, a program that bridges the gap in mental health care recently discharged rural veterans’ experience. In VISN 16, the program reduced psychiatric rehospitalizations by nearly 50% and the average length of a hospital stay by 41% by having staff meet with hospitalized veterans; complete a home visit within 1 week after the patient is discharged; and maintain weekly phone contact until the veteran starts outpatient mental health services.

Another example is a program developed by staff at the North Florida/South Georgia Veterans Health Care System in Gainesville, which helped reduce wait times in the hospital’s cardiology clinic. This best practice encourages physicians to review individual requests for consultations with specialists. They are asked to triage the requests to determine whether a face-to-face encounter is needed, if the request can be handled either at a local outpatient clinic or electronically, or whether the doctor needs more information before deciding what to do. In 1 year, this process reduced wait times in Gainesville’s cardiology clinic by 46%, to about 10 days.

Another Boston VA project is the development of a screening and transfer process for patients who want to be detoxified from substances to which they have become addicted. The facility’s psychosomatic medicine service team uses an algorithm for screenings and transfers that embeds available literature on the subject and a multidisciplinary consensus into an order set for electronic consultations. This results in an evidence-based, multidisciplinary, and technologic approach to the transfer process.

Federal Practitioner. Do you see DoE as a laboratory for quality of care improvement that could expand beyond the VA?

Dr. Elnahal. Absolutely. In fact, I recently coauthored, with Secretary Shulkin and Deputy Under Secretary for Health Carolyn Clancy, a commentary  that provided a how-to for private sector systems to replicate our efforts.² In that commentary, we identified four distinct phases of diffusing best practices across health care systems: Identify promising practices, recruit champions, replicate; and establish consistency, standardize, and sustain.

Antihemophilic factor

Researchers have observed a low inhibitor rate in previously untreated patients (PUPs) with severe hemophilia A who received treatment with Octanate®.

The study included 51 PUPs who received octanate, a plasma-derived, von Willebrand factor-stabilized coagulation factor VIII (FVIII) concentrate.

Five of these patients (9.8%) developed FVIII inhibitors, all of whom were receiving on-demand treatment.

The hemostatic efficacy of octanate was rated as “excellent” for 99.6% of all infusions, and tolerability was rated “very good” for 99.98% of infusions.

“We are very excited by the low inhibitor rates and the excellent efficacy and tolerability achieved with octanate® in this particularly challenging patient population,” said Larisa Belyanskaya, head of IBU Haematology at Octapharma AG, the company marketing octanate.

Octapharma sponsored this study, the results of which were published in Haemophilia.

The study enrolled 51 Caucasian males with previously untreated, severe hemophilia A. They had a median age at study entry of 7.7 months (range, 0.1 months to 67.3 months).

Patients received octanate, either prophylactically or on-demand, for 100 exposure days (EDs) or 5 years, whichever came first.

There were a mean of 136.33 (±246.3) EDs, and the mean dose of octanate was 38.4 (±28.6) IU/kg/ED. Most patients (78.4%) had at least 100 EDs. The total number of EDs was 6953.

Prophylaxis accounted for 3027 EDs, immune tolerance induction for 1869 EDs, treatment of bleeds for 1817 EDs, surgical procedures for 149 EDs, and in vivo recovery assessments for 106 EDs.

Inhibitors

Five patients developed FVIII inhibitors, 4 of which were high titer and 1 low titer.

In 3 cases, the inhibitors were considered clinically relevant. In the other 2 cases, the inhibitors disappeared without a change in dose or treatment frequency.

All inhibitors developed during on-demand treatment, and all 4 high-titer inhibitors developed within the first 20 EDs.

All patients who developed inhibitors had major F8 gene defects (intron 22 inversions or large deletions of exons 7-12) that are associated with a high risk of inhibitor development.

Efficacy

The hemostatic efficacy of octanate was rated as “excellent” in 99.6% of infusions (n=4700), “good” in 0.3% (n=15), and “moderate” in 0.02% (n=1).

Most bleeds resolved within 1 day of treatment (81.2%) or within 2 days (14.3%).

Efficacy was rated as “excellent” for all but 1 of the 2611 prophylactic infusions. One was rated as “good.”

For treatment of bleeds, efficacy was rated as “excellent” for 99.2% of infusions (n=1809), “good” for 0.8% (n=14), and “moderate” for 0.05% (n=1).

There were 23 evaluable surgical procedures in 19 patients. The efficacy of octanate was rated as “excellent” in all cases (201 infusions).

Safety

There were 260 treatment-emergent adverse events (AEs) in 45 patients (88.2%). Seventy-eight of these AEs were serious.

Twenty-one AEs were considered probably or possibly related to octanate—asymptomatic parvovirus B19 seroconversions (n=16) and FVIII inhibitor development (n=5). These were classified as serious AEs according to the study protocol.

The tolerability of octanate was considered “very good” in 99.98% of infusions (n=8674) and “good” in 0.02% (n=2).

Antihemophilic factor

Researchers have observed a low inhibitor rate in previously untreated patients (PUPs) with severe hemophilia A who received treatment with Octanate®.

The study included 51 PUPs who received octanate, a plasma-derived, von Willebrand factor-stabilized coagulation factor VIII (FVIII) concentrate.

Five of these patients (9.8%) developed FVIII inhibitors, all of whom were receiving on-demand treatment.

The hemostatic efficacy of octanate was rated as “excellent” for 99.6% of all infusions, and tolerability was rated “very good” for 99.98% of infusions.

“We are very excited by the low inhibitor rates and the excellent efficacy and tolerability achieved with octanate® in this particularly challenging patient population,” said Larisa Belyanskaya, head of IBU Haematology at Octapharma AG, the company marketing octanate.

Octapharma sponsored this study, the results of which were published in Haemophilia.

The study enrolled 51 Caucasian males with previously untreated, severe hemophilia A. They had a median age at study entry of 7.7 months (range, 0.1 months to 67.3 months).

Patients received octanate, either prophylactically or on-demand, for 100 exposure days (EDs) or 5 years, whichever came first.

There were a mean of 136.33 (±246.3) EDs, and the mean dose of octanate was 38.4 (±28.6) IU/kg/ED. Most patients (78.4%) had at least 100 EDs. The total number of EDs was 6953.

Prophylaxis accounted for 3027 EDs, immune tolerance induction for 1869 EDs, treatment of bleeds for 1817 EDs, surgical procedures for 149 EDs, and in vivo recovery assessments for 106 EDs.

Inhibitors

Five patients developed FVIII inhibitors, 4 of which were high titer and 1 low titer.

In 3 cases, the inhibitors were considered clinically relevant. In the other 2 cases, the inhibitors disappeared without a change in dose or treatment frequency.

All inhibitors developed during on-demand treatment, and all 4 high-titer inhibitors developed within the first 20 EDs.

All patients who developed inhibitors had major F8 gene defects (intron 22 inversions or large deletions of exons 7-12) that are associated with a high risk of inhibitor development.

Efficacy

The hemostatic efficacy of octanate was rated as “excellent” in 99.6% of infusions (n=4700), “good” in 0.3% (n=15), and “moderate” in 0.02% (n=1).

Most bleeds resolved within 1 day of treatment (81.2%) or within 2 days (14.3%).

Efficacy was rated as “excellent” for all but 1 of the 2611 prophylactic infusions. One was rated as “good.”

For treatment of bleeds, efficacy was rated as “excellent” for 99.2% of infusions (n=1809), “good” for 0.8% (n=14), and “moderate” for 0.05% (n=1).

There were 23 evaluable surgical procedures in 19 patients. The efficacy of octanate was rated as “excellent” in all cases (201 infusions).

Safety

There were 260 treatment-emergent adverse events (AEs) in 45 patients (88.2%). Seventy-eight of these AEs were serious.

Twenty-one AEs were considered probably or possibly related to octanate—asymptomatic parvovirus B19 seroconversions (n=16) and FVIII inhibitor development (n=5). These were classified as serious AEs according to the study protocol.

The tolerability of octanate was considered “very good” in 99.98% of infusions (n=8674) and “good” in 0.02% (n=2).

Antihemophilic factor

Researchers have observed a low inhibitor rate in previously untreated patients (PUPs) with severe hemophilia A who received treatment with Octanate®.

The study included 51 PUPs who received octanate, a plasma-derived, von Willebrand factor-stabilized coagulation factor VIII (FVIII) concentrate.

Five of these patients (9.8%) developed FVIII inhibitors, all of whom were receiving on-demand treatment.

The hemostatic efficacy of octanate was rated as “excellent” for 99.6% of all infusions, and tolerability was rated “very good” for 99.98% of infusions.

“We are very excited by the low inhibitor rates and the excellent efficacy and tolerability achieved with octanate® in this particularly challenging patient population,” said Larisa Belyanskaya, head of IBU Haematology at Octapharma AG, the company marketing octanate.

Octapharma sponsored this study, the results of which were published in Haemophilia.

The study enrolled 51 Caucasian males with previously untreated, severe hemophilia A. They had a median age at study entry of 7.7 months (range, 0.1 months to 67.3 months).

Patients received octanate, either prophylactically or on-demand, for 100 exposure days (EDs) or 5 years, whichever came first.

There were a mean of 136.33 (±246.3) EDs, and the mean dose of octanate was 38.4 (±28.6) IU/kg/ED. Most patients (78.4%) had at least 100 EDs. The total number of EDs was 6953.

Prophylaxis accounted for 3027 EDs, immune tolerance induction for 1869 EDs, treatment of bleeds for 1817 EDs, surgical procedures for 149 EDs, and in vivo recovery assessments for 106 EDs.

Inhibitors

Five patients developed FVIII inhibitors, 4 of which were high titer and 1 low titer.

In 3 cases, the inhibitors were considered clinically relevant. In the other 2 cases, the inhibitors disappeared without a change in dose or treatment frequency.

All inhibitors developed during on-demand treatment, and all 4 high-titer inhibitors developed within the first 20 EDs.

All patients who developed inhibitors had major F8 gene defects (intron 22 inversions or large deletions of exons 7-12) that are associated with a high risk of inhibitor development.

Efficacy

The hemostatic efficacy of octanate was rated as “excellent” in 99.6% of infusions (n=4700), “good” in 0.3% (n=15), and “moderate” in 0.02% (n=1).

Most bleeds resolved within 1 day of treatment (81.2%) or within 2 days (14.3%).

Efficacy was rated as “excellent” for all but 1 of the 2611 prophylactic infusions. One was rated as “good.”

For treatment of bleeds, efficacy was rated as “excellent” for 99.2% of infusions (n=1809), “good” for 0.8% (n=14), and “moderate” for 0.05% (n=1).

There were 23 evaluable surgical procedures in 19 patients. The efficacy of octanate was rated as “excellent” in all cases (201 infusions).

Safety

There were 260 treatment-emergent adverse events (AEs) in 45 patients (88.2%). Seventy-eight of these AEs were serious.

Twenty-one AEs were considered probably or possibly related to octanate—asymptomatic parvovirus B19 seroconversions (n=16) and FVIII inhibitor development (n=5). These were classified as serious AEs according to the study protocol.

The tolerability of octanate was considered “very good” in 99.98% of infusions (n=8674) and “good” in 0.02% (n=2).