BOSTON – The number of cases of meningitis caused by tuberculosis has fallen dramatically in the United States in recent decades as TB itself has become less common, according to findings from a study presented at the annual meeting of the American Academy of Neurology.

However, these findings from patient hospitalizations during 1993-2013 in the Nationwide Inpatient Sample database also indicate that neurologic complications from TB meningitis are on the rise.

The findings suggest that neurologists need to become involved whenever a patient with TB shows signs of neurologic problems, said study lead author Alexander E. Merkler, MD, of Cornell University, New York, in an interview. “They’re at high risk, and some complications can be life threatening.”

Zerbor/Thinkstock

• Hydrocephalus, from 2.3% (95% confidence interval, 0.5%-4.2%) to 5.4% (95% CI, 2.3%-10.0%).

• Seizure, from 2.9% (95% CI, 0.3%-5.4%) to 14.1% (95% CI, 7.3%-21.0%).

• Stroke, from 2.9% (95% CI, 0.6%-5.3%) to 13.0% (95% CI, 6.3%-19.8%).

• Vision and hearing impairment, from 8.2% (95% CI, 4.8%-11.6%) to 10.9% (95% CI, 4.1%-17.6%), and from 1.1% (95% CI, 0.0%-2.3%) to 3.3% (95% CI, 0.0%-6.9%), respectively.

Dr. Merkler said it’s not clear why these rates are going up, but it may be because patients have more complications as a result of living longer. Another theory is that a form of drug-resistant TB is boosting the level of these complications, Dr. Merkler said, but he’s skeptical of that idea: “I don’t know why drug resistance would lead to more neurological complications.”

The study was funded by the National Institute of Neurological Disorders and Stroke and the Michael Goldberg Stroke Research Fund. Dr. Merkler reported no relevant financial disclosures.

BOSTON – The number of cases of meningitis caused by tuberculosis has fallen dramatically in the United States in recent decades as TB itself has become less common, according to findings from a study presented at the annual meeting of the American Academy of Neurology.

However, these findings from patient hospitalizations during 1993-2013 in the Nationwide Inpatient Sample database also indicate that neurologic complications from TB meningitis are on the rise.

The findings suggest that neurologists need to become involved whenever a patient with TB shows signs of neurologic problems, said study lead author Alexander E. Merkler, MD, of Cornell University, New York, in an interview. “They’re at high risk, and some complications can be life threatening.”

Zerbor/Thinkstock

• Hydrocephalus, from 2.3% (95% confidence interval, 0.5%-4.2%) to 5.4% (95% CI, 2.3%-10.0%).

• Seizure, from 2.9% (95% CI, 0.3%-5.4%) to 14.1% (95% CI, 7.3%-21.0%).

• Stroke, from 2.9% (95% CI, 0.6%-5.3%) to 13.0% (95% CI, 6.3%-19.8%).

• Vision and hearing impairment, from 8.2% (95% CI, 4.8%-11.6%) to 10.9% (95% CI, 4.1%-17.6%), and from 1.1% (95% CI, 0.0%-2.3%) to 3.3% (95% CI, 0.0%-6.9%), respectively.

Dr. Merkler said it’s not clear why these rates are going up, but it may be because patients have more complications as a result of living longer. Another theory is that a form of drug-resistant TB is boosting the level of these complications, Dr. Merkler said, but he’s skeptical of that idea: “I don’t know why drug resistance would lead to more neurological complications.”

The study was funded by the National Institute of Neurological Disorders and Stroke and the Michael Goldberg Stroke Research Fund. Dr. Merkler reported no relevant financial disclosures.

BOSTON – The number of cases of meningitis caused by tuberculosis has fallen dramatically in the United States in recent decades as TB itself has become less common, according to findings from a study presented at the annual meeting of the American Academy of Neurology.

However, these findings from patient hospitalizations during 1993-2013 in the Nationwide Inpatient Sample database also indicate that neurologic complications from TB meningitis are on the rise.

The findings suggest that neurologists need to become involved whenever a patient with TB shows signs of neurologic problems, said study lead author Alexander E. Merkler, MD, of Cornell University, New York, in an interview. “They’re at high risk, and some complications can be life threatening.”

Zerbor/Thinkstock

• Hydrocephalus, from 2.3% (95% confidence interval, 0.5%-4.2%) to 5.4% (95% CI, 2.3%-10.0%).

• Seizure, from 2.9% (95% CI, 0.3%-5.4%) to 14.1% (95% CI, 7.3%-21.0%).

• Stroke, from 2.9% (95% CI, 0.6%-5.3%) to 13.0% (95% CI, 6.3%-19.8%).

• Vision and hearing impairment, from 8.2% (95% CI, 4.8%-11.6%) to 10.9% (95% CI, 4.1%-17.6%), and from 1.1% (95% CI, 0.0%-2.3%) to 3.3% (95% CI, 0.0%-6.9%), respectively.

Dr. Merkler said it’s not clear why these rates are going up, but it may be because patients have more complications as a result of living longer. Another theory is that a form of drug-resistant TB is boosting the level of these complications, Dr. Merkler said, but he’s skeptical of that idea: “I don’t know why drug resistance would lead to more neurological complications.”

The study was funded by the National Institute of Neurological Disorders and Stroke and the Michael Goldberg Stroke Research Fund. Dr. Merkler reported no relevant financial disclosures.

Communication among healthcare professionals is essential for high-quality patient care. However, communication is difficult in hospitals because of heavy workloads, rapidly evolving plans of care, and geographic dispersion of team members. When hospital-based professionals are not in the same place at the same time, they rely on technology to communicate. Pagers have historically been used to support communication in hospitals, but are limited in their capabilities. Several recent small studies have shown that some physicians have started using standard text messaging on smartphones for patient care–related (PCR) messages.^1-3 Although potentially enhancing clinician efficiency, use of standard text messaging for PCR messages raises concern about security risks related to transmission of protected health information. Addressing these concerns are emerging secure mobile messaging applications designed for PCR communication. Although recent studies suggest these applications are well received by users, the adoption rate is largely unknown.^4,5

We conducted a study to see if there was a shift in use of hospital-based communication technologies under way. We surveyed a national sample of hospital-based clinicians to characterize current use of communication technologies, assess potential risks and perceptions related to use of standard text messaging for PCR messages, and characterize the adoption of secure mobile messaging applications designed for PCR communication.

Study Design

The study was a cross-sectional survey of hospitalists—physicians and advanced practice providers whose primary professional focus is care of hospitalized patients. We studied hospitalists because of their role in coordinating care for complex medical patients and because prior studies identified communication as a major component of their work.^6,7 The Northwestern University Institutional Review Board deemed this study exempt.

Survey Instrument

Four investigators (Drs. O’Leary, Liebovitz, Wu, and Reddy) with expertise in interprofessional communication and information technology created a draft survey based in part on results of prior studies assessing clinicians’ use of smartphones and standard text messaging for PCR communication.^1,3 In the first section of the survey, we asked respondents which technologies were provided by their organization and which technologies they used for PCR communication. In the second section, we asked respondents about their use and perceptions of standard text messaging for PCR communication. In the third section, we asked about implementation and adoption of secure mobile messaging applications at their hospital. In the fourth and final section, we asked for demographic information.

We randomly selected 8 attendees of the 2015 Midwest Hospital Medicine Conference and invited them to participate in a focus group that would review a paper version of the draft survey and recommend revisions. Using the group’s feedback, we revised the ordinal response scale for questions related to standard text messaging and made other minor edits. We then created an Internet-based version of the survey and pilot-tested it with 8 hospitalists from 4 diverse hospitalist groups within the Northwestern Medicine Health System. We made additional minor edits based on pilot-test feedback.

Sampling Strategy

We used the largest hospitalist database maintained by the Society of Hospital Medicine (SHM). This database includes information on more than 28,000 individuals, representing SHM members and nonmembers who had participated in organizational events. In addition to clinically active hospitalists, the database includes non-hospitalists and clinically inactive hospitalists. We used this database to try to capture the largest possible number of potentially eligible hospitalists.

Survey Administration

We administered the survey in collaboration with SHM staff. E-mails that included a link to the survey on the Survey Monkey website were sent by SHM staff to individuals within the database. These e-mails were sent through Real Magnet, an e-mail marketing platform⁸ that allowed the SHM staff to determine the number of individuals who received and opened the e-mail and the number who clicked on the survey link. To try to promote participation, we offered respondents the chance to enter a lottery to win one of four $50 gift certificates. The initial e-mail was sent in April 2016, a reminder in May 2016, and a final reminder in July 2016.

Data Analysis

We calculated descriptive statistics of participants’ demographic characteristics. We estimated nonresponse bias by comparing demographic characteristics across waves of respondents using analysis of variance, t tests, and χ² tests. This method is based on the finding that characteristics of late respondents often resemble those of nonrespondents.⁹ We collapsed response categories for communication technologies to simplify interpretation. For example, numeric pagers, alphanumeric pagers, and 2-way pagers were collapsed into a pagers category. We used t tests and χ² tests to assess for associations between receipt of standard text messages for PCR communication and respondents’ age, sex, race, professional type, hospital size, practice location, and hospital teaching status. Similarly, we used t tests and χ² tests to explore associations between implementation of secure mobile messaging application and respondents’ age, sex, race, professional type, hospital size, practice location, and hospital teaching status. All statistical analyses were performed with Stata Release 11.2 (StataCorp).

Participant Characteristics

Overall, the survey link was sent to 28,870 e-mail addresses. Addresses for which e-mails were undeliverable or for which the e-mail was never opened were excluded, yielding a total of 5,786 eligible respondents in the sample. After rejecting 42 clinically inactive individuals, 70 individuals who responded to only the initial item, and 27 duplicates, a total of 620 participant surveys were included in the final analysis. The adjusted response rate was 11.0%.

As shown in Table 1, mean (SD) respondent age was 42.9 (10.0) years, nearly half of the respondents were female, nearly a third were of nonwhite race, an overwhelming majority were physicians, and workplaces were in a variety of hospital settings. The sample size used to calculate demographic characteristics varied from 538 to 549 because of missing data for these items. We found no significant differences in demographic characteristics of respondents across the 3 survey waves, suggesting a lack of survey response bias (Supplemental Table).

Provision and Use of Communication Technologies for PCR Communication

Pagers were provided to the majority of respondents by their hospitals (79.8%, 495/620). Other devices were provided much less frequently, with 21.0% (130/620) reporting their organization provided a smartphone, 20.2% (125/620) a mobile phone, and 4.4% (27/620) a hands-free communication device. Organizations provided no device to 8.2% (51/620) of respondents and an “other” device to 5.5% (34/620).

An overwhelming majority used multiple technologies to receive PCR communication, with 17.7% (110/620) of respondents indicating use of 2 technologies, 22.7% (141/620) use of 3 technologies, and 49.4% (306/620) use of more than 3 technologies. The distribution of the most common ways respondents received PCR communication is shown in Table 2. Pagers were the most common form of technology, with 49.0% (304/620) indicating this was the primary way they received PCR communication. Being called on a mobile phone provided by the organization was the second most common form of receiving PCR communication (11.0%, 68/620), followed by standard text messaging (9.5%, 59/620) and mobile secure messaging using an application approved by the organization (9.0%, 56/620).

Participants’ Experiences With Standard Text Messaging for PCR Communication

Participants’ experiences with standard text messaging for PCR communication are summarized in Table 3. Overall, 65.1% (369/ 567) of respondents reported receiving standard text messages for PCR communication at least once per week when on clinical duty, and 52.9% (300/567) received standard text messages at least once per day.

Overall, 21.5% (122/567) of respondents received standard text messages that included individually identifiable information at least once per day, and 41.3% (234/567) received messages that included some identifiable information (eg, patient initials, room number) at least once per day. About one-fifth of respondents (21.0%, 119/567) indicated receiving standard text messages for urgent clinical issues at least once per day. Receipt of standard text messages for a patient for whom the respondent was no longer providing care, delays in receipt of messages, messages missed because smartphones were set to vibrate, and receipt of messages when not on clinical duty occurred, but less frequently. We found no significant associations between receipt of PCR standard text messages once or more per day and respondents’ age, sex, race, professional type, hospital size, or hospital teaching status. A higher percentage of respondents in the South (63.2%, 96/152) and West (57.9%, 70/121) reported receipt of at least 1 PCR standard text message per day, compared with respondents in the Northeast (51.9%, 54/104), Midwest (45.2%, 61/135), and other (25.0%, 4/16) (P = 0.003).

Senders of PCR standard text messages. Of respondents who received standard text messages for PCR communication at least once per week, a majority reported receiving messages from physicians in the same specialty (88.6%, 327/369) and from physicians in other specialties (71.3%, 263/369). A minority of respondents reported receiving messages from nurses (35.0%, 129/369), social workers (30.6%, 113/369), and pharmacists (27.9%, 103/369).

Perceptions among users. Of respondents who received standard text messages for PCR communication at least once per week, an overwhelming majority agreed or strongly agreed that use of standard text messaging allowed them to provide better care (81.7%, 295/361) and made them more efficient (87.3%, 315/361). A majority also agreed or strongly agreed that standard text messaging posed a risk to the privacy and confidentiality of patient information (56.4%, 203/360), and nearly a third indicated that standard text messaging posed a risk to the timely receipt of messages by the correct individual (27.6%, 100/362). Overall, a large majority agreed or strongly agreed that the benefits of using standard text messaging for PCR communication outweighed the risks (85.0%, 306/360).

Adoption of Organization-Approved Secure Mobile Messaging Applications

Participants’ reported adoption of organization-approved secure mobile messaging applications is shown in the Figure. About one-fourth (26.6%, 146/549) of respondents reported that their organization had implemented a secure messaging application and that some clinicians were using it, whereas relatively few (7.3%, 40/549) reported that their organization had implemented an application that was being used by most clinicians. A substantial portion of respondents (21.3%, 117/549) were not sure whether their organization was planning to implement a secure mobile messaging application for PCR communication. We found no significant associations between partial or nearly full implementation of a secure mobile messaging application and respondents’ age, sex, race, professional type, hospital size, or practice location. A lower percentage of respondents in major teaching hospitals (28.0%, 67/239) reported partial or nearly full implementation of a secure mobile messaging application, compared with respondents from teaching hospitals (39.6%, 74/187) and nonteaching hospitals (39.2%, 40/102) (P = 0.02).

We found that pagers were the technology most commonly used by hospital-based clinicians, but also that a majority have used standard text messaging for PCR communication, and that relatively few hospitals had fully implemented secure mobile messaging applications. Our findings reveal a wide range of technology use and suggest an evolution to support communication among healthcare professionals.

The persistence of pagers as the technology most commonly provided by hospitals and used by clinicians for communication is noteworthy in that pagers are limited in their capabilities, typically not allowing a response to the message sender or the ability to forward a message, and often not allowing the ability to send messages to multiple recipients. The continued heavy use of pagers may be explained by their relatively low cost, especially compared with investment in new technologies, and reliable receipt of messages, even in areas with no cell phone service or WiFi signal. Furthermore, hospitals’ providing pagers allows for oversight, directory creation, and the potential for integration into other information systems. In 2 recent studies, inpatient paging communication was evaluated in depth. Carlile et al.¹⁰ found that the majority of pages requested a response, requiring an interruption in physician workflow to initiate a callback. Kummerow Broman et al.¹¹ similarly found that a majority of pages requested a callback; they also found a high volume of nonurgent messages. With pager use, a high volume of messages, many of which require a response but are nonurgent, makes for a highly interruptive workflow.

That more than half of our hospital-based clinicians received standard text messages for PCR communication once or more per day is consistent with other, smaller studies. Kuhlmann et al.¹ surveyed 97 pediatric hospitalists and found that a majority sent and received work-related text messages. Prochaska et al.² surveyed 131 residents and found that standard text messaging was the communication method preferred by the majority of residents. Similar to these studies, our study found that receipt of standard text messages that included protected health information was fairly common. However, we identified additional risks related to standard text messaging. One-fifth of our respondents received standard text messages for urgent clinical issues once or more per day, and many respondents reported occasional receipt of messages regarding a patient for whom they were no longer providing care and receipt of messages when not on clinical duty. The usual inability to automate forwarding of standard text messages to another clinician creates the potential for clinically important messages to be delayed or missed. These risks have not been reported in the literature, and we think healthcare systems may not be fully aware of them. Our findings suggest that many clinicians have migrated from pagers to standard text messaging for the enhanced efficiency, and they perceive that the benefit of improved efficiency outweighs the risks to protected health information and the delay in receipt of clinically important messages by the correct individual.

Secure mobile messaging applications seem to address the limitations of both pagers and standard text messaging. Secure mobile messaging applications typically allow message response, message forwarding, multiple recipients, directory creation, the potential to create escalation schemes for nonresponse, and integration with other information systems, including electronic health records. Although several hospitals have developed their own systems,^4,12,13 most hospitals likely will purchase a vendor-based system. We found that a minority of hospitals had implemented a secure messaging application, and even fewer had most of their clinicians using it. Although little research has been conducted on these applications, studies suggest they are well received by users.^4,5 Given that paging communication studies have found a large portion of pages are sent by nurses and other non-physician team members, secure mobile messaging applications should allow for direct message exchange with all professionals caring for a patient.^10,11 Furthermore, hospitals will need to ensure adequate cell phone and WiFi signal strength throughout their facilities to ensure reliable and timely delivery of messages.

Our study had several limitations. We used a large database to conduct a national survey but had a low response rate and some drop-off of responses within surveys. Our sample reflected respondent diversity, and our analyses of demographic characteristics found no significant differences across survey response waves. Unfortunately, we did not have nonrespondents’ characteristics and therefore could not compare them with respondents’. It is possible that nonrespondents may have had different practices related to use of communication technology, especially in light of the fact that the survey was conducted by e-mail. However, given our finding that use of standard text messaging was comparable to that in other studies,^1,2 and given the similarity of respondents’ characteristics across response waves, our findings likely were not affected by nonresponse bias.⁹ Last, we used a survey that had not been validated. However, this survey was created by experts in interprofessional collaboration and information technology, was informed by prior studies, and was iteratively refined during pretesting and pilot testing.

Pagers remain the technology most commonly used by hospital-based clinicians, but a majority also use standard text messaging for PCR communication, and relatively few hospitals have fully implemented secure mobile messaging applications. The wide range of technologies used suggests an evolution of methods to support communication among healthcare professionals. An optimized system will improve communication efficiency while ensuring the security of their patients’ information and the timely receipt of that information by the intended clinician.

Acknowledgment

The authors thank the Society of Hospital Medicine and the society staff who helped administer the survey, especially Mr. Ethan Gray.

Disclosure

Nothing to report.

Communication among healthcare professionals is essential for high-quality patient care. However, communication is difficult in hospitals because of heavy workloads, rapidly evolving plans of care, and geographic dispersion of team members. When hospital-based professionals are not in the same place at the same time, they rely on technology to communicate. Pagers have historically been used to support communication in hospitals, but are limited in their capabilities. Several recent small studies have shown that some physicians have started using standard text messaging on smartphones for patient care–related (PCR) messages.^1-3 Although potentially enhancing clinician efficiency, use of standard text messaging for PCR messages raises concern about security risks related to transmission of protected health information. Addressing these concerns are emerging secure mobile messaging applications designed for PCR communication. Although recent studies suggest these applications are well received by users, the adoption rate is largely unknown.^4,5

We conducted a study to see if there was a shift in use of hospital-based communication technologies under way. We surveyed a national sample of hospital-based clinicians to characterize current use of communication technologies, assess potential risks and perceptions related to use of standard text messaging for PCR messages, and characterize the adoption of secure mobile messaging applications designed for PCR communication.

Study Design

The study was a cross-sectional survey of hospitalists—physicians and advanced practice providers whose primary professional focus is care of hospitalized patients. We studied hospitalists because of their role in coordinating care for complex medical patients and because prior studies identified communication as a major component of their work.^6,7 The Northwestern University Institutional Review Board deemed this study exempt.

Survey Instrument

Four investigators (Drs. O’Leary, Liebovitz, Wu, and Reddy) with expertise in interprofessional communication and information technology created a draft survey based in part on results of prior studies assessing clinicians’ use of smartphones and standard text messaging for PCR communication.^1,3 In the first section of the survey, we asked respondents which technologies were provided by their organization and which technologies they used for PCR communication. In the second section, we asked respondents about their use and perceptions of standard text messaging for PCR communication. In the third section, we asked about implementation and adoption of secure mobile messaging applications at their hospital. In the fourth and final section, we asked for demographic information.

We randomly selected 8 attendees of the 2015 Midwest Hospital Medicine Conference and invited them to participate in a focus group that would review a paper version of the draft survey and recommend revisions. Using the group’s feedback, we revised the ordinal response scale for questions related to standard text messaging and made other minor edits. We then created an Internet-based version of the survey and pilot-tested it with 8 hospitalists from 4 diverse hospitalist groups within the Northwestern Medicine Health System. We made additional minor edits based on pilot-test feedback.

Sampling Strategy

We used the largest hospitalist database maintained by the Society of Hospital Medicine (SHM). This database includes information on more than 28,000 individuals, representing SHM members and nonmembers who had participated in organizational events. In addition to clinically active hospitalists, the database includes non-hospitalists and clinically inactive hospitalists. We used this database to try to capture the largest possible number of potentially eligible hospitalists.

Survey Administration

We administered the survey in collaboration with SHM staff. E-mails that included a link to the survey on the Survey Monkey website were sent by SHM staff to individuals within the database. These e-mails were sent through Real Magnet, an e-mail marketing platform⁸ that allowed the SHM staff to determine the number of individuals who received and opened the e-mail and the number who clicked on the survey link. To try to promote participation, we offered respondents the chance to enter a lottery to win one of four $50 gift certificates. The initial e-mail was sent in April 2016, a reminder in May 2016, and a final reminder in July 2016.

Data Analysis

We calculated descriptive statistics of participants’ demographic characteristics. We estimated nonresponse bias by comparing demographic characteristics across waves of respondents using analysis of variance, t tests, and χ² tests. This method is based on the finding that characteristics of late respondents often resemble those of nonrespondents.⁹ We collapsed response categories for communication technologies to simplify interpretation. For example, numeric pagers, alphanumeric pagers, and 2-way pagers were collapsed into a pagers category. We used t tests and χ² tests to assess for associations between receipt of standard text messages for PCR communication and respondents’ age, sex, race, professional type, hospital size, practice location, and hospital teaching status. Similarly, we used t tests and χ² tests to explore associations between implementation of secure mobile messaging application and respondents’ age, sex, race, professional type, hospital size, practice location, and hospital teaching status. All statistical analyses were performed with Stata Release 11.2 (StataCorp).

Participant Characteristics

Overall, the survey link was sent to 28,870 e-mail addresses. Addresses for which e-mails were undeliverable or for which the e-mail was never opened were excluded, yielding a total of 5,786 eligible respondents in the sample. After rejecting 42 clinically inactive individuals, 70 individuals who responded to only the initial item, and 27 duplicates, a total of 620 participant surveys were included in the final analysis. The adjusted response rate was 11.0%.

As shown in Table 1, mean (SD) respondent age was 42.9 (10.0) years, nearly half of the respondents were female, nearly a third were of nonwhite race, an overwhelming majority were physicians, and workplaces were in a variety of hospital settings. The sample size used to calculate demographic characteristics varied from 538 to 549 because of missing data for these items. We found no significant differences in demographic characteristics of respondents across the 3 survey waves, suggesting a lack of survey response bias (Supplemental Table).

Provision and Use of Communication Technologies for PCR Communication

Pagers were provided to the majority of respondents by their hospitals (79.8%, 495/620). Other devices were provided much less frequently, with 21.0% (130/620) reporting their organization provided a smartphone, 20.2% (125/620) a mobile phone, and 4.4% (27/620) a hands-free communication device. Organizations provided no device to 8.2% (51/620) of respondents and an “other” device to 5.5% (34/620).

An overwhelming majority used multiple technologies to receive PCR communication, with 17.7% (110/620) of respondents indicating use of 2 technologies, 22.7% (141/620) use of 3 technologies, and 49.4% (306/620) use of more than 3 technologies. The distribution of the most common ways respondents received PCR communication is shown in Table 2. Pagers were the most common form of technology, with 49.0% (304/620) indicating this was the primary way they received PCR communication. Being called on a mobile phone provided by the organization was the second most common form of receiving PCR communication (11.0%, 68/620), followed by standard text messaging (9.5%, 59/620) and mobile secure messaging using an application approved by the organization (9.0%, 56/620).

Participants’ Experiences With Standard Text Messaging for PCR Communication

Participants’ experiences with standard text messaging for PCR communication are summarized in Table 3. Overall, 65.1% (369/ 567) of respondents reported receiving standard text messages for PCR communication at least once per week when on clinical duty, and 52.9% (300/567) received standard text messages at least once per day.

Overall, 21.5% (122/567) of respondents received standard text messages that included individually identifiable information at least once per day, and 41.3% (234/567) received messages that included some identifiable information (eg, patient initials, room number) at least once per day. About one-fifth of respondents (21.0%, 119/567) indicated receiving standard text messages for urgent clinical issues at least once per day. Receipt of standard text messages for a patient for whom the respondent was no longer providing care, delays in receipt of messages, messages missed because smartphones were set to vibrate, and receipt of messages when not on clinical duty occurred, but less frequently. We found no significant associations between receipt of PCR standard text messages once or more per day and respondents’ age, sex, race, professional type, hospital size, or hospital teaching status. A higher percentage of respondents in the South (63.2%, 96/152) and West (57.9%, 70/121) reported receipt of at least 1 PCR standard text message per day, compared with respondents in the Northeast (51.9%, 54/104), Midwest (45.2%, 61/135), and other (25.0%, 4/16) (P = 0.003).

Senders of PCR standard text messages. Of respondents who received standard text messages for PCR communication at least once per week, a majority reported receiving messages from physicians in the same specialty (88.6%, 327/369) and from physicians in other specialties (71.3%, 263/369). A minority of respondents reported receiving messages from nurses (35.0%, 129/369), social workers (30.6%, 113/369), and pharmacists (27.9%, 103/369).

Perceptions among users. Of respondents who received standard text messages for PCR communication at least once per week, an overwhelming majority agreed or strongly agreed that use of standard text messaging allowed them to provide better care (81.7%, 295/361) and made them more efficient (87.3%, 315/361). A majority also agreed or strongly agreed that standard text messaging posed a risk to the privacy and confidentiality of patient information (56.4%, 203/360), and nearly a third indicated that standard text messaging posed a risk to the timely receipt of messages by the correct individual (27.6%, 100/362). Overall, a large majority agreed or strongly agreed that the benefits of using standard text messaging for PCR communication outweighed the risks (85.0%, 306/360).

Adoption of Organization-Approved Secure Mobile Messaging Applications

Participants’ reported adoption of organization-approved secure mobile messaging applications is shown in the Figure. About one-fourth (26.6%, 146/549) of respondents reported that their organization had implemented a secure messaging application and that some clinicians were using it, whereas relatively few (7.3%, 40/549) reported that their organization had implemented an application that was being used by most clinicians. A substantial portion of respondents (21.3%, 117/549) were not sure whether their organization was planning to implement a secure mobile messaging application for PCR communication. We found no significant associations between partial or nearly full implementation of a secure mobile messaging application and respondents’ age, sex, race, professional type, hospital size, or practice location. A lower percentage of respondents in major teaching hospitals (28.0%, 67/239) reported partial or nearly full implementation of a secure mobile messaging application, compared with respondents from teaching hospitals (39.6%, 74/187) and nonteaching hospitals (39.2%, 40/102) (P = 0.02).

We found that pagers were the technology most commonly used by hospital-based clinicians, but also that a majority have used standard text messaging for PCR communication, and that relatively few hospitals had fully implemented secure mobile messaging applications. Our findings reveal a wide range of technology use and suggest an evolution to support communication among healthcare professionals.

The persistence of pagers as the technology most commonly provided by hospitals and used by clinicians for communication is noteworthy in that pagers are limited in their capabilities, typically not allowing a response to the message sender or the ability to forward a message, and often not allowing the ability to send messages to multiple recipients. The continued heavy use of pagers may be explained by their relatively low cost, especially compared with investment in new technologies, and reliable receipt of messages, even in areas with no cell phone service or WiFi signal. Furthermore, hospitals’ providing pagers allows for oversight, directory creation, and the potential for integration into other information systems. In 2 recent studies, inpatient paging communication was evaluated in depth. Carlile et al.¹⁰ found that the majority of pages requested a response, requiring an interruption in physician workflow to initiate a callback. Kummerow Broman et al.¹¹ similarly found that a majority of pages requested a callback; they also found a high volume of nonurgent messages. With pager use, a high volume of messages, many of which require a response but are nonurgent, makes for a highly interruptive workflow.

That more than half of our hospital-based clinicians received standard text messages for PCR communication once or more per day is consistent with other, smaller studies. Kuhlmann et al.¹ surveyed 97 pediatric hospitalists and found that a majority sent and received work-related text messages. Prochaska et al.² surveyed 131 residents and found that standard text messaging was the communication method preferred by the majority of residents. Similar to these studies, our study found that receipt of standard text messages that included protected health information was fairly common. However, we identified additional risks related to standard text messaging. One-fifth of our respondents received standard text messages for urgent clinical issues once or more per day, and many respondents reported occasional receipt of messages regarding a patient for whom they were no longer providing care and receipt of messages when not on clinical duty. The usual inability to automate forwarding of standard text messages to another clinician creates the potential for clinically important messages to be delayed or missed. These risks have not been reported in the literature, and we think healthcare systems may not be fully aware of them. Our findings suggest that many clinicians have migrated from pagers to standard text messaging for the enhanced efficiency, and they perceive that the benefit of improved efficiency outweighs the risks to protected health information and the delay in receipt of clinically important messages by the correct individual.

Secure mobile messaging applications seem to address the limitations of both pagers and standard text messaging. Secure mobile messaging applications typically allow message response, message forwarding, multiple recipients, directory creation, the potential to create escalation schemes for nonresponse, and integration with other information systems, including electronic health records. Although several hospitals have developed their own systems,^4,12,13 most hospitals likely will purchase a vendor-based system. We found that a minority of hospitals had implemented a secure messaging application, and even fewer had most of their clinicians using it. Although little research has been conducted on these applications, studies suggest they are well received by users.^4,5 Given that paging communication studies have found a large portion of pages are sent by nurses and other non-physician team members, secure mobile messaging applications should allow for direct message exchange with all professionals caring for a patient.^10,11 Furthermore, hospitals will need to ensure adequate cell phone and WiFi signal strength throughout their facilities to ensure reliable and timely delivery of messages.

Our study had several limitations. We used a large database to conduct a national survey but had a low response rate and some drop-off of responses within surveys. Our sample reflected respondent diversity, and our analyses of demographic characteristics found no significant differences across survey response waves. Unfortunately, we did not have nonrespondents’ characteristics and therefore could not compare them with respondents’. It is possible that nonrespondents may have had different practices related to use of communication technology, especially in light of the fact that the survey was conducted by e-mail. However, given our finding that use of standard text messaging was comparable to that in other studies,^1,2 and given the similarity of respondents’ characteristics across response waves, our findings likely were not affected by nonresponse bias.⁹ Last, we used a survey that had not been validated. However, this survey was created by experts in interprofessional collaboration and information technology, was informed by prior studies, and was iteratively refined during pretesting and pilot testing.

Pagers remain the technology most commonly used by hospital-based clinicians, but a majority also use standard text messaging for PCR communication, and relatively few hospitals have fully implemented secure mobile messaging applications. The wide range of technologies used suggests an evolution of methods to support communication among healthcare professionals. An optimized system will improve communication efficiency while ensuring the security of their patients’ information and the timely receipt of that information by the intended clinician.

Acknowledgment

The authors thank the Society of Hospital Medicine and the society staff who helped administer the survey, especially Mr. Ethan Gray.

Disclosure

Nothing to report.

Communication among healthcare professionals is essential for high-quality patient care. However, communication is difficult in hospitals because of heavy workloads, rapidly evolving plans of care, and geographic dispersion of team members. When hospital-based professionals are not in the same place at the same time, they rely on technology to communicate. Pagers have historically been used to support communication in hospitals, but are limited in their capabilities. Several recent small studies have shown that some physicians have started using standard text messaging on smartphones for patient care–related (PCR) messages.^1-3 Although potentially enhancing clinician efficiency, use of standard text messaging for PCR messages raises concern about security risks related to transmission of protected health information. Addressing these concerns are emerging secure mobile messaging applications designed for PCR communication. Although recent studies suggest these applications are well received by users, the adoption rate is largely unknown.^4,5

We conducted a study to see if there was a shift in use of hospital-based communication technologies under way. We surveyed a national sample of hospital-based clinicians to characterize current use of communication technologies, assess potential risks and perceptions related to use of standard text messaging for PCR messages, and characterize the adoption of secure mobile messaging applications designed for PCR communication.

Study Design

The study was a cross-sectional survey of hospitalists—physicians and advanced practice providers whose primary professional focus is care of hospitalized patients. We studied hospitalists because of their role in coordinating care for complex medical patients and because prior studies identified communication as a major component of their work.^6,7 The Northwestern University Institutional Review Board deemed this study exempt.

Survey Instrument

Four investigators (Drs. O’Leary, Liebovitz, Wu, and Reddy) with expertise in interprofessional communication and information technology created a draft survey based in part on results of prior studies assessing clinicians’ use of smartphones and standard text messaging for PCR communication.^1,3 In the first section of the survey, we asked respondents which technologies were provided by their organization and which technologies they used for PCR communication. In the second section, we asked respondents about their use and perceptions of standard text messaging for PCR communication. In the third section, we asked about implementation and adoption of secure mobile messaging applications at their hospital. In the fourth and final section, we asked for demographic information.

We randomly selected 8 attendees of the 2015 Midwest Hospital Medicine Conference and invited them to participate in a focus group that would review a paper version of the draft survey and recommend revisions. Using the group’s feedback, we revised the ordinal response scale for questions related to standard text messaging and made other minor edits. We then created an Internet-based version of the survey and pilot-tested it with 8 hospitalists from 4 diverse hospitalist groups within the Northwestern Medicine Health System. We made additional minor edits based on pilot-test feedback.

Sampling Strategy

We used the largest hospitalist database maintained by the Society of Hospital Medicine (SHM). This database includes information on more than 28,000 individuals, representing SHM members and nonmembers who had participated in organizational events. In addition to clinically active hospitalists, the database includes non-hospitalists and clinically inactive hospitalists. We used this database to try to capture the largest possible number of potentially eligible hospitalists.

Survey Administration

We administered the survey in collaboration with SHM staff. E-mails that included a link to the survey on the Survey Monkey website were sent by SHM staff to individuals within the database. These e-mails were sent through Real Magnet, an e-mail marketing platform⁸ that allowed the SHM staff to determine the number of individuals who received and opened the e-mail and the number who clicked on the survey link. To try to promote participation, we offered respondents the chance to enter a lottery to win one of four $50 gift certificates. The initial e-mail was sent in April 2016, a reminder in May 2016, and a final reminder in July 2016.

Data Analysis

We calculated descriptive statistics of participants’ demographic characteristics. We estimated nonresponse bias by comparing demographic characteristics across waves of respondents using analysis of variance, t tests, and χ² tests. This method is based on the finding that characteristics of late respondents often resemble those of nonrespondents.⁹ We collapsed response categories for communication technologies to simplify interpretation. For example, numeric pagers, alphanumeric pagers, and 2-way pagers were collapsed into a pagers category. We used t tests and χ² tests to assess for associations between receipt of standard text messages for PCR communication and respondents’ age, sex, race, professional type, hospital size, practice location, and hospital teaching status. Similarly, we used t tests and χ² tests to explore associations between implementation of secure mobile messaging application and respondents’ age, sex, race, professional type, hospital size, practice location, and hospital teaching status. All statistical analyses were performed with Stata Release 11.2 (StataCorp).

Participant Characteristics

Overall, the survey link was sent to 28,870 e-mail addresses. Addresses for which e-mails were undeliverable or for which the e-mail was never opened were excluded, yielding a total of 5,786 eligible respondents in the sample. After rejecting 42 clinically inactive individuals, 70 individuals who responded to only the initial item, and 27 duplicates, a total of 620 participant surveys were included in the final analysis. The adjusted response rate was 11.0%.

As shown in Table 1, mean (SD) respondent age was 42.9 (10.0) years, nearly half of the respondents were female, nearly a third were of nonwhite race, an overwhelming majority were physicians, and workplaces were in a variety of hospital settings. The sample size used to calculate demographic characteristics varied from 538 to 549 because of missing data for these items. We found no significant differences in demographic characteristics of respondents across the 3 survey waves, suggesting a lack of survey response bias (Supplemental Table).

Provision and Use of Communication Technologies for PCR Communication

Pagers were provided to the majority of respondents by their hospitals (79.8%, 495/620). Other devices were provided much less frequently, with 21.0% (130/620) reporting their organization provided a smartphone, 20.2% (125/620) a mobile phone, and 4.4% (27/620) a hands-free communication device. Organizations provided no device to 8.2% (51/620) of respondents and an “other” device to 5.5% (34/620).

An overwhelming majority used multiple technologies to receive PCR communication, with 17.7% (110/620) of respondents indicating use of 2 technologies, 22.7% (141/620) use of 3 technologies, and 49.4% (306/620) use of more than 3 technologies. The distribution of the most common ways respondents received PCR communication is shown in Table 2. Pagers were the most common form of technology, with 49.0% (304/620) indicating this was the primary way they received PCR communication. Being called on a mobile phone provided by the organization was the second most common form of receiving PCR communication (11.0%, 68/620), followed by standard text messaging (9.5%, 59/620) and mobile secure messaging using an application approved by the organization (9.0%, 56/620).

Participants’ Experiences With Standard Text Messaging for PCR Communication

Participants’ experiences with standard text messaging for PCR communication are summarized in Table 3. Overall, 65.1% (369/ 567) of respondents reported receiving standard text messages for PCR communication at least once per week when on clinical duty, and 52.9% (300/567) received standard text messages at least once per day.

Overall, 21.5% (122/567) of respondents received standard text messages that included individually identifiable information at least once per day, and 41.3% (234/567) received messages that included some identifiable information (eg, patient initials, room number) at least once per day. About one-fifth of respondents (21.0%, 119/567) indicated receiving standard text messages for urgent clinical issues at least once per day. Receipt of standard text messages for a patient for whom the respondent was no longer providing care, delays in receipt of messages, messages missed because smartphones were set to vibrate, and receipt of messages when not on clinical duty occurred, but less frequently. We found no significant associations between receipt of PCR standard text messages once or more per day and respondents’ age, sex, race, professional type, hospital size, or hospital teaching status. A higher percentage of respondents in the South (63.2%, 96/152) and West (57.9%, 70/121) reported receipt of at least 1 PCR standard text message per day, compared with respondents in the Northeast (51.9%, 54/104), Midwest (45.2%, 61/135), and other (25.0%, 4/16) (P = 0.003).

Senders of PCR standard text messages. Of respondents who received standard text messages for PCR communication at least once per week, a majority reported receiving messages from physicians in the same specialty (88.6%, 327/369) and from physicians in other specialties (71.3%, 263/369). A minority of respondents reported receiving messages from nurses (35.0%, 129/369), social workers (30.6%, 113/369), and pharmacists (27.9%, 103/369).

Perceptions among users. Of respondents who received standard text messages for PCR communication at least once per week, an overwhelming majority agreed or strongly agreed that use of standard text messaging allowed them to provide better care (81.7%, 295/361) and made them more efficient (87.3%, 315/361). A majority also agreed or strongly agreed that standard text messaging posed a risk to the privacy and confidentiality of patient information (56.4%, 203/360), and nearly a third indicated that standard text messaging posed a risk to the timely receipt of messages by the correct individual (27.6%, 100/362). Overall, a large majority agreed or strongly agreed that the benefits of using standard text messaging for PCR communication outweighed the risks (85.0%, 306/360).

Adoption of Organization-Approved Secure Mobile Messaging Applications

Participants’ reported adoption of organization-approved secure mobile messaging applications is shown in the Figure. About one-fourth (26.6%, 146/549) of respondents reported that their organization had implemented a secure messaging application and that some clinicians were using it, whereas relatively few (7.3%, 40/549) reported that their organization had implemented an application that was being used by most clinicians. A substantial portion of respondents (21.3%, 117/549) were not sure whether their organization was planning to implement a secure mobile messaging application for PCR communication. We found no significant associations between partial or nearly full implementation of a secure mobile messaging application and respondents’ age, sex, race, professional type, hospital size, or practice location. A lower percentage of respondents in major teaching hospitals (28.0%, 67/239) reported partial or nearly full implementation of a secure mobile messaging application, compared with respondents from teaching hospitals (39.6%, 74/187) and nonteaching hospitals (39.2%, 40/102) (P = 0.02).

We found that pagers were the technology most commonly used by hospital-based clinicians, but also that a majority have used standard text messaging for PCR communication, and that relatively few hospitals had fully implemented secure mobile messaging applications. Our findings reveal a wide range of technology use and suggest an evolution to support communication among healthcare professionals.

The persistence of pagers as the technology most commonly provided by hospitals and used by clinicians for communication is noteworthy in that pagers are limited in their capabilities, typically not allowing a response to the message sender or the ability to forward a message, and often not allowing the ability to send messages to multiple recipients. The continued heavy use of pagers may be explained by their relatively low cost, especially compared with investment in new technologies, and reliable receipt of messages, even in areas with no cell phone service or WiFi signal. Furthermore, hospitals’ providing pagers allows for oversight, directory creation, and the potential for integration into other information systems. In 2 recent studies, inpatient paging communication was evaluated in depth. Carlile et al.¹⁰ found that the majority of pages requested a response, requiring an interruption in physician workflow to initiate a callback. Kummerow Broman et al.¹¹ similarly found that a majority of pages requested a callback; they also found a high volume of nonurgent messages. With pager use, a high volume of messages, many of which require a response but are nonurgent, makes for a highly interruptive workflow.

That more than half of our hospital-based clinicians received standard text messages for PCR communication once or more per day is consistent with other, smaller studies. Kuhlmann et al.¹ surveyed 97 pediatric hospitalists and found that a majority sent and received work-related text messages. Prochaska et al.² surveyed 131 residents and found that standard text messaging was the communication method preferred by the majority of residents. Similar to these studies, our study found that receipt of standard text messages that included protected health information was fairly common. However, we identified additional risks related to standard text messaging. One-fifth of our respondents received standard text messages for urgent clinical issues once or more per day, and many respondents reported occasional receipt of messages regarding a patient for whom they were no longer providing care and receipt of messages when not on clinical duty. The usual inability to automate forwarding of standard text messages to another clinician creates the potential for clinically important messages to be delayed or missed. These risks have not been reported in the literature, and we think healthcare systems may not be fully aware of them. Our findings suggest that many clinicians have migrated from pagers to standard text messaging for the enhanced efficiency, and they perceive that the benefit of improved efficiency outweighs the risks to protected health information and the delay in receipt of clinically important messages by the correct individual.

Secure mobile messaging applications seem to address the limitations of both pagers and standard text messaging. Secure mobile messaging applications typically allow message response, message forwarding, multiple recipients, directory creation, the potential to create escalation schemes for nonresponse, and integration with other information systems, including electronic health records. Although several hospitals have developed their own systems,^4,12,13 most hospitals likely will purchase a vendor-based system. We found that a minority of hospitals had implemented a secure messaging application, and even fewer had most of their clinicians using it. Although little research has been conducted on these applications, studies suggest they are well received by users.^4,5 Given that paging communication studies have found a large portion of pages are sent by nurses and other non-physician team members, secure mobile messaging applications should allow for direct message exchange with all professionals caring for a patient.^10,11 Furthermore, hospitals will need to ensure adequate cell phone and WiFi signal strength throughout their facilities to ensure reliable and timely delivery of messages.

Our study had several limitations. We used a large database to conduct a national survey but had a low response rate and some drop-off of responses within surveys. Our sample reflected respondent diversity, and our analyses of demographic characteristics found no significant differences across survey response waves. Unfortunately, we did not have nonrespondents’ characteristics and therefore could not compare them with respondents’. It is possible that nonrespondents may have had different practices related to use of communication technology, especially in light of the fact that the survey was conducted by e-mail. However, given our finding that use of standard text messaging was comparable to that in other studies,^1,2 and given the similarity of respondents’ characteristics across response waves, our findings likely were not affected by nonresponse bias.⁹ Last, we used a survey that had not been validated. However, this survey was created by experts in interprofessional collaboration and information technology, was informed by prior studies, and was iteratively refined during pretesting and pilot testing.

Pagers remain the technology most commonly used by hospital-based clinicians, but a majority also use standard text messaging for PCR communication, and relatively few hospitals have fully implemented secure mobile messaging applications. The wide range of technologies used suggests an evolution of methods to support communication among healthcare professionals. An optimized system will improve communication efficiency while ensuring the security of their patients’ information and the timely receipt of that information by the intended clinician.

Acknowledgment

The authors thank the Society of Hospital Medicine and the society staff who helped administer the survey, especially Mr. Ethan Gray.

Disclosure

Nothing to report.

The more vaccines children get at any one office visit between the ages of 4 and 6 years, the more fearful they are of needles later on and the less likely they are to start human papillomavirus vaccine (HPV) as adolescents, according to an investigation of 120 children.

Shot-stacking between ages 4 and 6 years is not uncommon, especially if children might not be back in the office any time soon. Although it’s convenient and often better reimbursed to give all the recommended 4- to 6-year-old shots – MMR, DTaP, varicella, IPV, and maybe flu and hepatitis B vaccines – in one visit, the investigators found a hidden cost.

M. Alexander Otto/Frontline Medical News

[email protected]

The more vaccines children get at any one office visit between the ages of 4 and 6 years, the more fearful they are of needles later on and the less likely they are to start human papillomavirus vaccine (HPV) as adolescents, according to an investigation of 120 children.

Shot-stacking between ages 4 and 6 years is not uncommon, especially if children might not be back in the office any time soon. Although it’s convenient and often better reimbursed to give all the recommended 4- to 6-year-old shots – MMR, DTaP, varicella, IPV, and maybe flu and hepatitis B vaccines – in one visit, the investigators found a hidden cost.

M. Alexander Otto/Frontline Medical News

[email protected]

The more vaccines children get at any one office visit between the ages of 4 and 6 years, the more fearful they are of needles later on and the less likely they are to start human papillomavirus vaccine (HPV) as adolescents, according to an investigation of 120 children.

Shot-stacking between ages 4 and 6 years is not uncommon, especially if children might not be back in the office any time soon. Although it’s convenient and often better reimbursed to give all the recommended 4- to 6-year-old shots – MMR, DTaP, varicella, IPV, and maybe flu and hepatitis B vaccines – in one visit, the investigators found a hidden cost.

M. Alexander Otto/Frontline Medical News

[email protected]

MADRID – A nurse-led program successfully increased the uptake of pneumococcal vaccination among patients with chronic inflammatory rheumatic diseases in a single-center study.

From the start to the end of a 4-month evaluation period, the rate of vaccination of at-risk patients increased from 17.1% (13/76) to 77.6% (59/76; P less than .001).

Sara Freeman/Frontline Medical News

MADRID – A nurse-led program successfully increased the uptake of pneumococcal vaccination among patients with chronic inflammatory rheumatic diseases in a single-center study.

From the start to the end of a 4-month evaluation period, the rate of vaccination of at-risk patients increased from 17.1% (13/76) to 77.6% (59/76; P less than .001).

Sara Freeman/Frontline Medical News

MADRID – A nurse-led program successfully increased the uptake of pneumococcal vaccination among patients with chronic inflammatory rheumatic diseases in a single-center study.

From the start to the end of a 4-month evaluation period, the rate of vaccination of at-risk patients increased from 17.1% (13/76) to 77.6% (59/76; P less than .001).

Sara Freeman/Frontline Medical News

MADRID – Cases of invasive meningococcal disease in English 1 year olds dropped fourfold in the first year after the multicomponent group B meningococcal (MenB) vaccine (4CMenB, Bexsero) was added to the national infant immunization list, Shamez Ladhani, MD, Ph.D, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“In 1 year olds, we have seen a significant decrease in the number of cases, compared with the number of cases predicted. I suspect the vaccine effectiveness is close to 94% against meningococcal group B,” said Dr. Ladhani of Public Health England, London.

[email protected]

MADRID – Cases of invasive meningococcal disease in English 1 year olds dropped fourfold in the first year after the multicomponent group B meningococcal (MenB) vaccine (4CMenB, Bexsero) was added to the national infant immunization list, Shamez Ladhani, MD, Ph.D, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“In 1 year olds, we have seen a significant decrease in the number of cases, compared with the number of cases predicted. I suspect the vaccine effectiveness is close to 94% against meningococcal group B,” said Dr. Ladhani of Public Health England, London.

[email protected]

MADRID – Cases of invasive meningococcal disease in English 1 year olds dropped fourfold in the first year after the multicomponent group B meningococcal (MenB) vaccine (4CMenB, Bexsero) was added to the national infant immunization list, Shamez Ladhani, MD, Ph.D, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“In 1 year olds, we have seen a significant decrease in the number of cases, compared with the number of cases predicted. I suspect the vaccine effectiveness is close to 94% against meningococcal group B,” said Dr. Ladhani of Public Health England, London.

[email protected]

MADRID – A new Finnish study raises a provocative question: Is transient tachypnea of the newborn really transient?

Transient tachypnea of the newborn (TTN) has traditionally been viewed as a benign, self-limited condition involving 1-3 days of respiratory distress. But data from Finland’s comprehensive national health registries indicate that TTN in term babies is associated with significantly increased risk of subsequent bronchiolitis during infancy, Otto Helve, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“This association suggests similar pathogenic mechanisms in transient tachypnea of the newborn and bronchiolitis. We suggest that an intrinsic defect in sodium ion–driven pulmonary fluid transport may predispose to clinically significant bronchiolitis during the first year of life,” said Dr. Helve, a pediatrician at the National Institute for Health and Welfare, Helsinki, and the University of Helsinki.

Of more than 1 million term babies born in Finland during 1996-2015, 17,569 were diagnosed with TTN. During the same period, 40,338 infants were hospitalized with a diagnosis of bronchiolitis attributable to respiratory syncytial virus infection.

In a multivariate analysis adjusted for birth year, gender, delivery method, gestational age, and parity, TTN was independently associated with a 1.2-fold increased risk of bronchiolitis during the first year of life.

Dr. Helve reported having no financial conflicts of interest regarding his study.

[email protected]

MADRID – A new Finnish study raises a provocative question: Is transient tachypnea of the newborn really transient?

Transient tachypnea of the newborn (TTN) has traditionally been viewed as a benign, self-limited condition involving 1-3 days of respiratory distress. But data from Finland’s comprehensive national health registries indicate that TTN in term babies is associated with significantly increased risk of subsequent bronchiolitis during infancy, Otto Helve, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“This association suggests similar pathogenic mechanisms in transient tachypnea of the newborn and bronchiolitis. We suggest that an intrinsic defect in sodium ion–driven pulmonary fluid transport may predispose to clinically significant bronchiolitis during the first year of life,” said Dr. Helve, a pediatrician at the National Institute for Health and Welfare, Helsinki, and the University of Helsinki.

Of more than 1 million term babies born in Finland during 1996-2015, 17,569 were diagnosed with TTN. During the same period, 40,338 infants were hospitalized with a diagnosis of bronchiolitis attributable to respiratory syncytial virus infection.

In a multivariate analysis adjusted for birth year, gender, delivery method, gestational age, and parity, TTN was independently associated with a 1.2-fold increased risk of bronchiolitis during the first year of life.

Dr. Helve reported having no financial conflicts of interest regarding his study.

[email protected]

MADRID – A new Finnish study raises a provocative question: Is transient tachypnea of the newborn really transient?

Transient tachypnea of the newborn (TTN) has traditionally been viewed as a benign, self-limited condition involving 1-3 days of respiratory distress. But data from Finland’s comprehensive national health registries indicate that TTN in term babies is associated with significantly increased risk of subsequent bronchiolitis during infancy, Otto Helve, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“This association suggests similar pathogenic mechanisms in transient tachypnea of the newborn and bronchiolitis. We suggest that an intrinsic defect in sodium ion–driven pulmonary fluid transport may predispose to clinically significant bronchiolitis during the first year of life,” said Dr. Helve, a pediatrician at the National Institute for Health and Welfare, Helsinki, and the University of Helsinki.

Of more than 1 million term babies born in Finland during 1996-2015, 17,569 were diagnosed with TTN. During the same period, 40,338 infants were hospitalized with a diagnosis of bronchiolitis attributable to respiratory syncytial virus infection.

In a multivariate analysis adjusted for birth year, gender, delivery method, gestational age, and parity, TTN was independently associated with a 1.2-fold increased risk of bronchiolitis during the first year of life.

Dr. Helve reported having no financial conflicts of interest regarding his study.

[email protected]

Results of a longitudinal study have confirmed that the recently established EULAR definition of arthralgia suspicious for progression to rheumatoid arthritis can help to distinguish patients who are at highest risk for progression from those who do not progress to RA.

Patients clinically suspected of arthralgia who met the definition for arthralgia suspicious for progression to RA displayed an increased risk for arthritis development, compared with patients who did not meet the EULAR definition (hazard ratio, 2.1; 95% confidence interval, 0.9-4.7). The approach had a sensitivity of 83% and positive predictive value of 30%, study head Annette van der Helm–van Mil, MD, reported at the European Congress of Rheumatology in Madrid.

Results of a longitudinal study have confirmed that the recently established EULAR definition of arthralgia suspicious for progression to rheumatoid arthritis can help to distinguish patients who are at highest risk for progression from those who do not progress to RA.

Patients clinically suspected of arthralgia who met the definition for arthralgia suspicious for progression to RA displayed an increased risk for arthritis development, compared with patients who did not meet the EULAR definition (hazard ratio, 2.1; 95% confidence interval, 0.9-4.7). The approach had a sensitivity of 83% and positive predictive value of 30%, study head Annette van der Helm–van Mil, MD, reported at the European Congress of Rheumatology in Madrid.

Results of a longitudinal study have confirmed that the recently established EULAR definition of arthralgia suspicious for progression to rheumatoid arthritis can help to distinguish patients who are at highest risk for progression from those who do not progress to RA.

Patients clinically suspected of arthralgia who met the definition for arthralgia suspicious for progression to RA displayed an increased risk for arthritis development, compared with patients who did not meet the EULAR definition (hazard ratio, 2.1; 95% confidence interval, 0.9-4.7). The approach had a sensitivity of 83% and positive predictive value of 30%, study head Annette van der Helm–van Mil, MD, reported at the European Congress of Rheumatology in Madrid.

CHICAGO – The clear advantage goes to the second-generation tyrosine kinase inhibitor in a new trial comparing dacomitinib to gefitinib for advanced non–small cell lung cancer.

In a randomized, open-label phase III trial designed as a head-to-head comparison of the two drugs for the first-line treatment of advanced non–small cell lung cancer (NSCLC), “the blinded, independent review showed that we have a median progression-free survival (PFS) of 14.7 months versus 9.2 months,” said first author Tony Mok, MD, professor and chair of the department of clinical oncology at the Chinese University of Hong Kong. This PFS rate, he said, “is among the highest of randomized phase III trials in the first-line setting.”

Two years into the study, those taking dacomitinib had triple the PFS rate of those on gefitinib (30.6% versus 9.6%). The overall hazard ratio (HR) for PFS with dacomitinib compared to gefitinib was 0.59 (95% confidence interval [CI], 0.47-0.74, P less than .0001).

A previous single-arm phase II trial of the drug, ARCHER 2017, showed a response rate of 75.6% and a median PFS of 18.2 months for patients with NSCLC and an EGFR-activating mutation.

“Based on these data, we thought it was likely that we could have a hypothesis for dacomitinib to be superior to gefitinib, a first-generation TKI [tyrosine kinase inhibitor], in terms of progression-free survival,” Dr. Mok said in a press conference at the annual meeting of the American Society of Clinical Oncology. Dacomitinib is a second-generation TKI.

Patients in the new study, ARCHER 1050, had advanced NSCLC with EGFR-activating mutations and no prior systemic treatment for their advanced disease. In addition, patients had good performance status, could not have had prior TKI exposure, and could not have CNS metastases. This last exclusion, explained Dr. Mok, was because investigators were uncertain about dacomitinib’s CNS penetration at the time of study design, and because gefitinib may also not be the best therapeutic choice for CNS metastases.

Patients were randomized 1:1 to receive either dacomitinib 45 mg orally daily (n = 227), or gefitinib 250 mg orally daily (n = 225). Patients were stratified by whether or not they were ethnically Asian, and by whether they had EGFR mutation of exon 19 or exon 21. Patients were balanced in terms of age, gender, ethnicity, smoking, and performance status between arms. About 75% of the patients were Asian, and 65% were nonsmokers.

The international study enrolled patients from 71 centers in Asia and Europe. At the time of the data cutoff, investigators saw PFS events totaling 59.9% in the dacomitinib arm and 79.6% in the gefitinib arm. Patients were followed for PFS for a median of 22.1 months. “We have relatively mature data,” said Dr. Mok, except for overall survival, with only 36.9% of events occurring at the time of the data cutoff.

The primary endpoint in the open-label trial was PFS in the intention-to-treat population, as assessed by an independent, blinded reviewer. Dr. Mok said that the study was powered to see at least 256 PFS events, and to see an improvement in PFS for dacomitinib that equated to an HR of no more than 0.667. This would translate to median PFS for dacomitinib of 14.3 months versus 9.5 months for gefitinib, values Dr. Mok said were “reasonable.” And, he pointed out, the study results fell almost exactly in line with these predictions, though the actual HR was a bit lower than predicted.

An analysis of PFS by subgroup, also conducted by independent review, found that dacomitinib was favored for all subgroups except for non-Asian patients, for whom the HR was 0.89 but did not reach statistical significance. Since these patients made up about one-fourth of the study population, said Dr. Mok, small sample size was a potential issue. “But we have to ask ourselves the question, do they really perform worse than the Asians, if they have a response?”

To attempt to answer this question, the investigators performed an exploratory analysis of the 72 non-Asian patients who had responded to therapy. Among this group, they saw data similar to that of the overall group, with an HR of 0.547 (95% CI, 0.321-0.933, P less than .0123).

Secondary endpoints included investigator-assessed PFS, overall survival, objective response rate, duration of response, quality of life, and safety assessments.

Objective response rates were similar between arms, at 74.9% for dacomitinib and 71.6% for gefitinib (P = .3883). However, the median duration of response was significantly longer for those on dacomitinib (14.8 versus 8.3 months, P less than .0001).

“This may be best explained by looking into the depth of the response,” said Dr. Mok. Patient-level data showed that dacomitinib patients had a larger reduction in target lesion size; “this may reflect a more potent inhibition of EGFR,” he said.

With the more potent inhibition, however, came more frequent grade 3 adverse events involving diarrhea, dermatitis, stomatitis, and paronychia for those on dacomitinib; however, noted Dr. Mok, serious transaminase elevations were more common in the gefitinib group. “There is no new signal” for concerning toxicity, he said. Dose reductions were more common in dacomitinib than in gefitinib (66.1% versus 18%), but there are two tiers of dose reductions permissible with dacomitinib, giving some flexibility.

Dr. Mok reported financial relationships with multiple pharmaceutical companies, including Pfizer and SFJ Pharmaceuticals, which sponsored the study.

[email protected]

On Twitter @karioakes

CHICAGO – The clear advantage goes to the second-generation tyrosine kinase inhibitor in a new trial comparing dacomitinib to gefitinib for advanced non–small cell lung cancer.

In a randomized, open-label phase III trial designed as a head-to-head comparison of the two drugs for the first-line treatment of advanced non–small cell lung cancer (NSCLC), “the blinded, independent review showed that we have a median progression-free survival (PFS) of 14.7 months versus 9.2 months,” said first author Tony Mok, MD, professor and chair of the department of clinical oncology at the Chinese University of Hong Kong. This PFS rate, he said, “is among the highest of randomized phase III trials in the first-line setting.”

Two years into the study, those taking dacomitinib had triple the PFS rate of those on gefitinib (30.6% versus 9.6%). The overall hazard ratio (HR) for PFS with dacomitinib compared to gefitinib was 0.59 (95% confidence interval [CI], 0.47-0.74, P less than .0001).

A previous single-arm phase II trial of the drug, ARCHER 2017, showed a response rate of 75.6% and a median PFS of 18.2 months for patients with NSCLC and an EGFR-activating mutation.

“Based on these data, we thought it was likely that we could have a hypothesis for dacomitinib to be superior to gefitinib, a first-generation TKI [tyrosine kinase inhibitor], in terms of progression-free survival,” Dr. Mok said in a press conference at the annual meeting of the American Society of Clinical Oncology. Dacomitinib is a second-generation TKI.

Patients in the new study, ARCHER 1050, had advanced NSCLC with EGFR-activating mutations and no prior systemic treatment for their advanced disease. In addition, patients had good performance status, could not have had prior TKI exposure, and could not have CNS metastases. This last exclusion, explained Dr. Mok, was because investigators were uncertain about dacomitinib’s CNS penetration at the time of study design, and because gefitinib may also not be the best therapeutic choice for CNS metastases.

Patients were randomized 1:1 to receive either dacomitinib 45 mg orally daily (n = 227), or gefitinib 250 mg orally daily (n = 225). Patients were stratified by whether or not they were ethnically Asian, and by whether they had EGFR mutation of exon 19 or exon 21. Patients were balanced in terms of age, gender, ethnicity, smoking, and performance status between arms. About 75% of the patients were Asian, and 65% were nonsmokers.

The international study enrolled patients from 71 centers in Asia and Europe. At the time of the data cutoff, investigators saw PFS events totaling 59.9% in the dacomitinib arm and 79.6% in the gefitinib arm. Patients were followed for PFS for a median of 22.1 months. “We have relatively mature data,” said Dr. Mok, except for overall survival, with only 36.9% of events occurring at the time of the data cutoff.

The primary endpoint in the open-label trial was PFS in the intention-to-treat population, as assessed by an independent, blinded reviewer. Dr. Mok said that the study was powered to see at least 256 PFS events, and to see an improvement in PFS for dacomitinib that equated to an HR of no more than 0.667. This would translate to median PFS for dacomitinib of 14.3 months versus 9.5 months for gefitinib, values Dr. Mok said were “reasonable.” And, he pointed out, the study results fell almost exactly in line with these predictions, though the actual HR was a bit lower than predicted.

An analysis of PFS by subgroup, also conducted by independent review, found that dacomitinib was favored for all subgroups except for non-Asian patients, for whom the HR was 0.89 but did not reach statistical significance. Since these patients made up about one-fourth of the study population, said Dr. Mok, small sample size was a potential issue. “But we have to ask ourselves the question, do they really perform worse than the Asians, if they have a response?”

To attempt to answer this question, the investigators performed an exploratory analysis of the 72 non-Asian patients who had responded to therapy. Among this group, they saw data similar to that of the overall group, with an HR of 0.547 (95% CI, 0.321-0.933, P less than .0123).

Secondary endpoints included investigator-assessed PFS, overall survival, objective response rate, duration of response, quality of life, and safety assessments.

Objective response rates were similar between arms, at 74.9% for dacomitinib and 71.6% for gefitinib (P = .3883). However, the median duration of response was significantly longer for those on dacomitinib (14.8 versus 8.3 months, P less than .0001).

“This may be best explained by looking into the depth of the response,” said Dr. Mok. Patient-level data showed that dacomitinib patients had a larger reduction in target lesion size; “this may reflect a more potent inhibition of EGFR,” he said.

With the more potent inhibition, however, came more frequent grade 3 adverse events involving diarrhea, dermatitis, stomatitis, and paronychia for those on dacomitinib; however, noted Dr. Mok, serious transaminase elevations were more common in the gefitinib group. “There is no new signal” for concerning toxicity, he said. Dose reductions were more common in dacomitinib than in gefitinib (66.1% versus 18%), but there are two tiers of dose reductions permissible with dacomitinib, giving some flexibility.

Dr. Mok reported financial relationships with multiple pharmaceutical companies, including Pfizer and SFJ Pharmaceuticals, which sponsored the study.

[email protected]

On Twitter @karioakes

CHICAGO – The clear advantage goes to the second-generation tyrosine kinase inhibitor in a new trial comparing dacomitinib to gefitinib for advanced non–small cell lung cancer.

In a randomized, open-label phase III trial designed as a head-to-head comparison of the two drugs for the first-line treatment of advanced non–small cell lung cancer (NSCLC), “the blinded, independent review showed that we have a median progression-free survival (PFS) of 14.7 months versus 9.2 months,” said first author Tony Mok, MD, professor and chair of the department of clinical oncology at the Chinese University of Hong Kong. This PFS rate, he said, “is among the highest of randomized phase III trials in the first-line setting.”

Two years into the study, those taking dacomitinib had triple the PFS rate of those on gefitinib (30.6% versus 9.6%). The overall hazard ratio (HR) for PFS with dacomitinib compared to gefitinib was 0.59 (95% confidence interval [CI], 0.47-0.74, P less than .0001).

A previous single-arm phase II trial of the drug, ARCHER 2017, showed a response rate of 75.6% and a median PFS of 18.2 months for patients with NSCLC and an EGFR-activating mutation.

“Based on these data, we thought it was likely that we could have a hypothesis for dacomitinib to be superior to gefitinib, a first-generation TKI [tyrosine kinase inhibitor], in terms of progression-free survival,” Dr. Mok said in a press conference at the annual meeting of the American Society of Clinical Oncology. Dacomitinib is a second-generation TKI.

Patients in the new study, ARCHER 1050, had advanced NSCLC with EGFR-activating mutations and no prior systemic treatment for their advanced disease. In addition, patients had good performance status, could not have had prior TKI exposure, and could not have CNS metastases. This last exclusion, explained Dr. Mok, was because investigators were uncertain about dacomitinib’s CNS penetration at the time of study design, and because gefitinib may also not be the best therapeutic choice for CNS metastases.

Patients were randomized 1:1 to receive either dacomitinib 45 mg orally daily (n = 227), or gefitinib 250 mg orally daily (n = 225). Patients were stratified by whether or not they were ethnically Asian, and by whether they had EGFR mutation of exon 19 or exon 21. Patients were balanced in terms of age, gender, ethnicity, smoking, and performance status between arms. About 75% of the patients were Asian, and 65% were nonsmokers.

The international study enrolled patients from 71 centers in Asia and Europe. At the time of the data cutoff, investigators saw PFS events totaling 59.9% in the dacomitinib arm and 79.6% in the gefitinib arm. Patients were followed for PFS for a median of 22.1 months. “We have relatively mature data,” said Dr. Mok, except for overall survival, with only 36.9% of events occurring at the time of the data cutoff.

The primary endpoint in the open-label trial was PFS in the intention-to-treat population, as assessed by an independent, blinded reviewer. Dr. Mok said that the study was powered to see at least 256 PFS events, and to see an improvement in PFS for dacomitinib that equated to an HR of no more than 0.667. This would translate to median PFS for dacomitinib of 14.3 months versus 9.5 months for gefitinib, values Dr. Mok said were “reasonable.” And, he pointed out, the study results fell almost exactly in line with these predictions, though the actual HR was a bit lower than predicted.

An analysis of PFS by subgroup, also conducted by independent review, found that dacomitinib was favored for all subgroups except for non-Asian patients, for whom the HR was 0.89 but did not reach statistical significance. Since these patients made up about one-fourth of the study population, said Dr. Mok, small sample size was a potential issue. “But we have to ask ourselves the question, do they really perform worse than the Asians, if they have a response?”

To attempt to answer this question, the investigators performed an exploratory analysis of the 72 non-Asian patients who had responded to therapy. Among this group, they saw data similar to that of the overall group, with an HR of 0.547 (95% CI, 0.321-0.933, P less than .0123).

Secondary endpoints included investigator-assessed PFS, overall survival, objective response rate, duration of response, quality of life, and safety assessments.

Objective response rates were similar between arms, at 74.9% for dacomitinib and 71.6% for gefitinib (P = .3883). However, the median duration of response was significantly longer for those on dacomitinib (14.8 versus 8.3 months, P less than .0001).

“This may be best explained by looking into the depth of the response,” said Dr. Mok. Patient-level data showed that dacomitinib patients had a larger reduction in target lesion size; “this may reflect a more potent inhibition of EGFR,” he said.

With the more potent inhibition, however, came more frequent grade 3 adverse events involving diarrhea, dermatitis, stomatitis, and paronychia for those on dacomitinib; however, noted Dr. Mok, serious transaminase elevations were more common in the gefitinib group. “There is no new signal” for concerning toxicity, he said. Dose reductions were more common in dacomitinib than in gefitinib (66.1% versus 18%), but there are two tiers of dose reductions permissible with dacomitinib, giving some flexibility.

Dr. Mok reported financial relationships with multiple pharmaceutical companies, including Pfizer and SFJ Pharmaceuticals, which sponsored the study.

[email protected]

On Twitter @karioakes

MADRID – When it comes to patients with rheumatoid arthritis who are responding inadequately to methotrexate therapy, results of the Oral Rheumatoid Arthritis triaL (ORAL) Strategy study suggest that adding the Janus kinase inhibitor tofacitinib is just as effective as adding the tumor necrosis factor inhibitor adalimumab.

At 6 months’ follow-up, 46% of patients randomized to tofacitinib (Xeljanz) plus methotrexate met the trial’s primary endpoint of an American College of Rheumatology response of at least 50% (ACR50), compared with 44% of those who were given adalimumab (Humira) plus methotrexate. This result met the trial’s prespecified criteria for noninferiority. An ACR50 response means that there was at least 50% improvement in tender or swollen joint counts as well as a 50% improvement in at least three of the other five criteria (acute phase reactant, such as erythrocyte sedimentation rate; patient assessment; physician assessment; pain scale; and disability/functional questionnaire).

EULAR2017 - Streaming.hr

MADRID – When it comes to patients with rheumatoid arthritis who are responding inadequately to methotrexate therapy, results of the Oral Rheumatoid Arthritis triaL (ORAL) Strategy study suggest that adding the Janus kinase inhibitor tofacitinib is just as effective as adding the tumor necrosis factor inhibitor adalimumab.

At 6 months’ follow-up, 46% of patients randomized to tofacitinib (Xeljanz) plus methotrexate met the trial’s primary endpoint of an American College of Rheumatology response of at least 50% (ACR50), compared with 44% of those who were given adalimumab (Humira) plus methotrexate. This result met the trial’s prespecified criteria for noninferiority. An ACR50 response means that there was at least 50% improvement in tender or swollen joint counts as well as a 50% improvement in at least three of the other five criteria (acute phase reactant, such as erythrocyte sedimentation rate; patient assessment; physician assessment; pain scale; and disability/functional questionnaire).

EULAR2017 - Streaming.hr

MADRID – When it comes to patients with rheumatoid arthritis who are responding inadequately to methotrexate therapy, results of the Oral Rheumatoid Arthritis triaL (ORAL) Strategy study suggest that adding the Janus kinase inhibitor tofacitinib is just as effective as adding the tumor necrosis factor inhibitor adalimumab.

At 6 months’ follow-up, 46% of patients randomized to tofacitinib (Xeljanz) plus methotrexate met the trial’s primary endpoint of an American College of Rheumatology response of at least 50% (ACR50), compared with 44% of those who were given adalimumab (Humira) plus methotrexate. This result met the trial’s prespecified criteria for noninferiority. An ACR50 response means that there was at least 50% improvement in tender or swollen joint counts as well as a 50% improvement in at least three of the other five criteria (acute phase reactant, such as erythrocyte sedimentation rate; patient assessment; physician assessment; pain scale; and disability/functional questionnaire).

EULAR2017 - Streaming.hr

SAN FRANCISCO – International adoptions today almost exclusively involve children with special needs, and domestic adoptions are far more likely to involve children exposed prenatally to marijuana, opiates, or another drug, Lisa Prock, MD, MPH, found in a study.

“Pediatric health care providers reviewing referrals for adoption should be knowledgeable about the changing demographics of this population and the long-term implications of prenatal substance exposure, given increasing opiate and marijuana use nationally,” said Dr. Prock of Boston Children’s Hospital.

SAN FRANCISCO – International adoptions today almost exclusively involve children with special needs, and domestic adoptions are far more likely to involve children exposed prenatally to marijuana, opiates, or another drug, Lisa Prock, MD, MPH, found in a study.

“Pediatric health care providers reviewing referrals for adoption should be knowledgeable about the changing demographics of this population and the long-term implications of prenatal substance exposure, given increasing opiate and marijuana use nationally,” said Dr. Prock of Boston Children’s Hospital.

SAN FRANCISCO – International adoptions today almost exclusively involve children with special needs, and domestic adoptions are far more likely to involve children exposed prenatally to marijuana, opiates, or another drug, Lisa Prock, MD, MPH, found in a study.

“Pediatric health care providers reviewing referrals for adoption should be knowledgeable about the changing demographics of this population and the long-term implications of prenatal substance exposure, given increasing opiate and marijuana use nationally,” said Dr. Prock of Boston Children’s Hospital.