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Inpatient prenatal yoga found feasible for high-risk women
AT ACOG 2017
SAN DIEGO – Inpatient prenatal yoga is a feasible and acceptable intervention for high-risk women admitted to the hospital, results from a single-center study suggested.
“We know that outside of obstetrics, yoga is beneficial to stress relief, musculoskeletal pain, and sleep quality,” Veronica Demtchouk, MD, said in an interview at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “Inpatient high-risk obstetrics patients have very limited physical activity that they feel is safe to do.”
In an effort to investigate the feasibility of establishing an inpatient prenatal yoga program, the researchers recruited 40 women with anticipated admission to the antepartum service for at least 72 hours and who received medical clearance from their primary obstetrician. One of the medical center’s nurse practitioners, who is also a certified yoga instructor, taught a 30-minute prenatal yoga session once a week in a waiting room.
“It was a large enough space; we moved away the furniture and did the yoga sessions there,” Dr. Demtchouk said.
Study participants completed a questionnaire after each yoga session and at hospital discharge, while 14 nurses completed questionnaires regarding patient care and patient satisfaction. Of the 40 patients, 16 completed one or more yoga sessions; 24 did not participate because of scheduling conflicts with ultrasound or fetal testing, change in clinical status, lack of interest on the day of the session, and delivery or discharge prior to the yoga session.
Of the 16 study participants, 8 reported a decreased level of stress, 4 reported better sleep, 4 reported applying the yoga techniques outside of class, and 3 reported decreased pain/discomfort.
“Not a single woman complained or was displeased with the yoga sessions,” Dr. Demtchouk said. “The biggest challenge was the timing of the yoga session. It was just once a week, which limited the number of women who could attend.”
Of the 14 nurses who completed questionnaires, all viewed yoga as beneficial to their patients, none found it disruptive to providing patient care, and all indicated they would recommend an inpatient prenatal yoga program to other hospitals with an antepartum service.
“I think having several sessions throughout the week is essential for having adequate patient participation,” Dr. Demtchouk added. “It’s essential to have the nurses on board with it.”
She reported having no relevant financial disclosures.
AT ACOG 2017
SAN DIEGO – Inpatient prenatal yoga is a feasible and acceptable intervention for high-risk women admitted to the hospital, results from a single-center study suggested.
“We know that outside of obstetrics, yoga is beneficial to stress relief, musculoskeletal pain, and sleep quality,” Veronica Demtchouk, MD, said in an interview at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “Inpatient high-risk obstetrics patients have very limited physical activity that they feel is safe to do.”
In an effort to investigate the feasibility of establishing an inpatient prenatal yoga program, the researchers recruited 40 women with anticipated admission to the antepartum service for at least 72 hours and who received medical clearance from their primary obstetrician. One of the medical center’s nurse practitioners, who is also a certified yoga instructor, taught a 30-minute prenatal yoga session once a week in a waiting room.
“It was a large enough space; we moved away the furniture and did the yoga sessions there,” Dr. Demtchouk said.
Study participants completed a questionnaire after each yoga session and at hospital discharge, while 14 nurses completed questionnaires regarding patient care and patient satisfaction. Of the 40 patients, 16 completed one or more yoga sessions; 24 did not participate because of scheduling conflicts with ultrasound or fetal testing, change in clinical status, lack of interest on the day of the session, and delivery or discharge prior to the yoga session.
Of the 16 study participants, 8 reported a decreased level of stress, 4 reported better sleep, 4 reported applying the yoga techniques outside of class, and 3 reported decreased pain/discomfort.
“Not a single woman complained or was displeased with the yoga sessions,” Dr. Demtchouk said. “The biggest challenge was the timing of the yoga session. It was just once a week, which limited the number of women who could attend.”
Of the 14 nurses who completed questionnaires, all viewed yoga as beneficial to their patients, none found it disruptive to providing patient care, and all indicated they would recommend an inpatient prenatal yoga program to other hospitals with an antepartum service.
“I think having several sessions throughout the week is essential for having adequate patient participation,” Dr. Demtchouk added. “It’s essential to have the nurses on board with it.”
She reported having no relevant financial disclosures.
AT ACOG 2017
SAN DIEGO – Inpatient prenatal yoga is a feasible and acceptable intervention for high-risk women admitted to the hospital, results from a single-center study suggested.
“We know that outside of obstetrics, yoga is beneficial to stress relief, musculoskeletal pain, and sleep quality,” Veronica Demtchouk, MD, said in an interview at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “Inpatient high-risk obstetrics patients have very limited physical activity that they feel is safe to do.”
In an effort to investigate the feasibility of establishing an inpatient prenatal yoga program, the researchers recruited 40 women with anticipated admission to the antepartum service for at least 72 hours and who received medical clearance from their primary obstetrician. One of the medical center’s nurse practitioners, who is also a certified yoga instructor, taught a 30-minute prenatal yoga session once a week in a waiting room.
“It was a large enough space; we moved away the furniture and did the yoga sessions there,” Dr. Demtchouk said.
Study participants completed a questionnaire after each yoga session and at hospital discharge, while 14 nurses completed questionnaires regarding patient care and patient satisfaction. Of the 40 patients, 16 completed one or more yoga sessions; 24 did not participate because of scheduling conflicts with ultrasound or fetal testing, change in clinical status, lack of interest on the day of the session, and delivery or discharge prior to the yoga session.
Of the 16 study participants, 8 reported a decreased level of stress, 4 reported better sleep, 4 reported applying the yoga techniques outside of class, and 3 reported decreased pain/discomfort.
“Not a single woman complained or was displeased with the yoga sessions,” Dr. Demtchouk said. “The biggest challenge was the timing of the yoga session. It was just once a week, which limited the number of women who could attend.”
Of the 14 nurses who completed questionnaires, all viewed yoga as beneficial to their patients, none found it disruptive to providing patient care, and all indicated they would recommend an inpatient prenatal yoga program to other hospitals with an antepartum service.
“I think having several sessions throughout the week is essential for having adequate patient participation,” Dr. Demtchouk added. “It’s essential to have the nurses on board with it.”
She reported having no relevant financial disclosures.
Key clinical point:
Major finding: Of the 16 study participants, 8 reported a decreased level of stress, 4 reported better sleep, 4 reported applying the yoga techniques outside of class, and 3 reported decreased pain/discomfort.
Data source: A feasibility study of 16 hospitalized high-risk pregnant women.
Disclosures: Dr. Demtchouk reported having no relevant financial disclosures.
AAP advises against giving fruit juice to children under 1 year
according to a 2017 policy statement by the American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition and the Committee on Nutrition.
In addition, no more than 4 ounces of fruit juice per day should be given to toddlers aged 1-3 years, and no more than 4-6 ounces to children aged 4-6 years. For children aged 7-18 years, fruit juice intake should be limited to 8 ounces (Pediatrics. 2017 Jun;139[6]:e20170967).
In fact, the AAP recommends that human milk be the only nutrient for infants up to 6 months of age, or a prepared infant formula for mothers who cannot breastfeed or choose not to breastfeed their infants. In a study of 168 children aged either 2 years or 5 years, consumption of 12 fluid ounces or more per day of fruit juice was associated with short stature and with obesity (Pediatrics. 1997 Jan;99[1]:15-22).
If toddlers are given fruit juice, it should be in a cup rather that a bottle, sippy cup, or box of juice that they can carry around for long periods. Also, infants and toddlers should not be put to bed with a bottle of fruit juice, according to the statement. Prolonged exposure of the teeth to the sugars in juice can result in dental caries.
Fruit juice is sometime erroneously used instead of oral electrolyte solutions to rehydrate infants and young children with gastroenteritis or diarrhea, but the high carbohydrate content of fruit juice “may exceed the intestine’s ability to absorb carbohydrate, resulting in carbohydrate malabsorption. Carbohydrate malabsorption causes osmotic diarrhea, increasing the severity of the diarrhea already present,” according to the statement. Also, if fruit juice is used to replace fluid losses in infants, it may cause hyponatremia.
There are several medical conditions in which it is prudent to determine how much fruit juice is being consumed:
- Overnutrition or undernutrition.
- Chronic diarrhea, excessive flatulence, abdominal pain, and bloating.
- Dental caries.
- Poor or excessive weight gain.
Fruit juice is viewed by parents as nutritious, but toddlers and young children should be encouraged to eat whole fruit instead.
“We know that excessive fruit juice can lead to excessive weight gain and tooth decay,” coauthor Steven A. Abrams, MD, of the University of Texas, Austin, said in a press release. “Pediatricians have a lot of information to share with families on how to provide the proper balance of fresh fruit within their child’s diet.”
The authors said they had no relevant financial conflicts.
The AAP’s new policy statement regarding limiting juice consumption has potential to make a big difference in the prevention of two largely preventable diseases – obesity and dental caries. Recognizing that obesity and dental caries are silent epidemics in the United States, and that overconsumption of sugar is a common risk factor for both of these diseases, the AAP’s new policy statement is overdue. Fruit juice has as much sugar as soda drinks, yet parents feel it is a healthy drink alternative because juice comes from fruit. Parents often introduce juice to their children at a very young age and serve them more juice than is needed. Also, young children commonly consume juice in a sippy cup or bottle, which can lead to dental decay, because the frequent sipping of the juice fuels the acid-producing bacteria that contribute to enamel erosion.
As pediatricians, my colleagues and I are challenged to help children maintain a healthy weight and healthy mouths, and we have long battled the early introduction and overconsumption of juice. Medical and dental health care professionals, along with public health programs, can rally around this new policy statement.
Patricia Braun, MD, is a professor of pediatrics at the University of Colorado, Denver, and a practicing pediatrician at Denver Health. She had no conflicts of interest.
The AAP’s new policy statement regarding limiting juice consumption has potential to make a big difference in the prevention of two largely preventable diseases – obesity and dental caries. Recognizing that obesity and dental caries are silent epidemics in the United States, and that overconsumption of sugar is a common risk factor for both of these diseases, the AAP’s new policy statement is overdue. Fruit juice has as much sugar as soda drinks, yet parents feel it is a healthy drink alternative because juice comes from fruit. Parents often introduce juice to their children at a very young age and serve them more juice than is needed. Also, young children commonly consume juice in a sippy cup or bottle, which can lead to dental decay, because the frequent sipping of the juice fuels the acid-producing bacteria that contribute to enamel erosion.
As pediatricians, my colleagues and I are challenged to help children maintain a healthy weight and healthy mouths, and we have long battled the early introduction and overconsumption of juice. Medical and dental health care professionals, along with public health programs, can rally around this new policy statement.
Patricia Braun, MD, is a professor of pediatrics at the University of Colorado, Denver, and a practicing pediatrician at Denver Health. She had no conflicts of interest.
The AAP’s new policy statement regarding limiting juice consumption has potential to make a big difference in the prevention of two largely preventable diseases – obesity and dental caries. Recognizing that obesity and dental caries are silent epidemics in the United States, and that overconsumption of sugar is a common risk factor for both of these diseases, the AAP’s new policy statement is overdue. Fruit juice has as much sugar as soda drinks, yet parents feel it is a healthy drink alternative because juice comes from fruit. Parents often introduce juice to their children at a very young age and serve them more juice than is needed. Also, young children commonly consume juice in a sippy cup or bottle, which can lead to dental decay, because the frequent sipping of the juice fuels the acid-producing bacteria that contribute to enamel erosion.
As pediatricians, my colleagues and I are challenged to help children maintain a healthy weight and healthy mouths, and we have long battled the early introduction and overconsumption of juice. Medical and dental health care professionals, along with public health programs, can rally around this new policy statement.
Patricia Braun, MD, is a professor of pediatrics at the University of Colorado, Denver, and a practicing pediatrician at Denver Health. She had no conflicts of interest.
according to a 2017 policy statement by the American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition and the Committee on Nutrition.
In addition, no more than 4 ounces of fruit juice per day should be given to toddlers aged 1-3 years, and no more than 4-6 ounces to children aged 4-6 years. For children aged 7-18 years, fruit juice intake should be limited to 8 ounces (Pediatrics. 2017 Jun;139[6]:e20170967).
In fact, the AAP recommends that human milk be the only nutrient for infants up to 6 months of age, or a prepared infant formula for mothers who cannot breastfeed or choose not to breastfeed their infants. In a study of 168 children aged either 2 years or 5 years, consumption of 12 fluid ounces or more per day of fruit juice was associated with short stature and with obesity (Pediatrics. 1997 Jan;99[1]:15-22).
If toddlers are given fruit juice, it should be in a cup rather that a bottle, sippy cup, or box of juice that they can carry around for long periods. Also, infants and toddlers should not be put to bed with a bottle of fruit juice, according to the statement. Prolonged exposure of the teeth to the sugars in juice can result in dental caries.
Fruit juice is sometime erroneously used instead of oral electrolyte solutions to rehydrate infants and young children with gastroenteritis or diarrhea, but the high carbohydrate content of fruit juice “may exceed the intestine’s ability to absorb carbohydrate, resulting in carbohydrate malabsorption. Carbohydrate malabsorption causes osmotic diarrhea, increasing the severity of the diarrhea already present,” according to the statement. Also, if fruit juice is used to replace fluid losses in infants, it may cause hyponatremia.
There are several medical conditions in which it is prudent to determine how much fruit juice is being consumed:
- Overnutrition or undernutrition.
- Chronic diarrhea, excessive flatulence, abdominal pain, and bloating.
- Dental caries.
- Poor or excessive weight gain.
Fruit juice is viewed by parents as nutritious, but toddlers and young children should be encouraged to eat whole fruit instead.
“We know that excessive fruit juice can lead to excessive weight gain and tooth decay,” coauthor Steven A. Abrams, MD, of the University of Texas, Austin, said in a press release. “Pediatricians have a lot of information to share with families on how to provide the proper balance of fresh fruit within their child’s diet.”
The authors said they had no relevant financial conflicts.
according to a 2017 policy statement by the American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition and the Committee on Nutrition.
In addition, no more than 4 ounces of fruit juice per day should be given to toddlers aged 1-3 years, and no more than 4-6 ounces to children aged 4-6 years. For children aged 7-18 years, fruit juice intake should be limited to 8 ounces (Pediatrics. 2017 Jun;139[6]:e20170967).
In fact, the AAP recommends that human milk be the only nutrient for infants up to 6 months of age, or a prepared infant formula for mothers who cannot breastfeed or choose not to breastfeed their infants. In a study of 168 children aged either 2 years or 5 years, consumption of 12 fluid ounces or more per day of fruit juice was associated with short stature and with obesity (Pediatrics. 1997 Jan;99[1]:15-22).
If toddlers are given fruit juice, it should be in a cup rather that a bottle, sippy cup, or box of juice that they can carry around for long periods. Also, infants and toddlers should not be put to bed with a bottle of fruit juice, according to the statement. Prolonged exposure of the teeth to the sugars in juice can result in dental caries.
Fruit juice is sometime erroneously used instead of oral electrolyte solutions to rehydrate infants and young children with gastroenteritis or diarrhea, but the high carbohydrate content of fruit juice “may exceed the intestine’s ability to absorb carbohydrate, resulting in carbohydrate malabsorption. Carbohydrate malabsorption causes osmotic diarrhea, increasing the severity of the diarrhea already present,” according to the statement. Also, if fruit juice is used to replace fluid losses in infants, it may cause hyponatremia.
There are several medical conditions in which it is prudent to determine how much fruit juice is being consumed:
- Overnutrition or undernutrition.
- Chronic diarrhea, excessive flatulence, abdominal pain, and bloating.
- Dental caries.
- Poor or excessive weight gain.
Fruit juice is viewed by parents as nutritious, but toddlers and young children should be encouraged to eat whole fruit instead.
“We know that excessive fruit juice can lead to excessive weight gain and tooth decay,” coauthor Steven A. Abrams, MD, of the University of Texas, Austin, said in a press release. “Pediatricians have a lot of information to share with families on how to provide the proper balance of fresh fruit within their child’s diet.”
The authors said they had no relevant financial conflicts.
Making sense of MACRA: MIPS and Advanced APMs
Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.
Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.1,2
This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.2
The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.1
Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.
Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.
Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.
Here is what to know for now:
MIPS
All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.3 There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.4
Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.
The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.5 Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.
The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.
“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”
For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.4
“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.
The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.
However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”
In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.
In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.
However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”
In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”
This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.4
Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.
Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).5
The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.
“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”
Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.4
The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.4
According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.7
“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”
Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.
In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.2
Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).8
“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”
One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.
“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
Advanced APMs
Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.9 They are paid based on the parameters of their particular model.
Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.
In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)5
The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.4
At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.
Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.
Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.
“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.
For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.
The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.
“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”
The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.
“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”
Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.
For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”
References
1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.
2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.
3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.
4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.
5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.
6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.
7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.
8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.
9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.
Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.
Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.1,2
This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.2
The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.1
Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.
Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.
Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.
Here is what to know for now:
MIPS
All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.3 There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.4
Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.
The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.5 Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.
The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.
“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”
For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.4
“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.
The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.
However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”
In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.
In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.
However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”
In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”
This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.4
Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.
Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).5
The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.
“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”
Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.4
The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.4
According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.7
“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”
Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.
In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.2
Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).8
“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”
One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.
“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
Advanced APMs
Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.9 They are paid based on the parameters of their particular model.
Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.
In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)5
The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.4
At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.
Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.
Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.
“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.
For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.
The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.
“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”
The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.
“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”
Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.
For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”
References
1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.
2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.
3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.
4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.
5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.
6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.
7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.
8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.
9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.
Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.
Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.1,2
This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.2
The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.1
Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.
Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.
Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.
Here is what to know for now:
MIPS
All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.3 There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.4
Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.
The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.5 Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.
The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.
“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”
For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.4
“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.
The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.
However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”
In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.
In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.
However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”
In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”
This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.4
Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.
Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).5
The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.
“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”
Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.4
The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.4
According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.7
“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”
Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.
In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.2
Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).8
“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”
One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.
“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
Advanced APMs
Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.9 They are paid based on the parameters of their particular model.
Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.
In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)5
The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.4
At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.
Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.
Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.
“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.
For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.
The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.
“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”
The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.
“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”
Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.
For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”
References
1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.
2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.
3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.
4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.
5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.
6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.
7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.
8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.
9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.
VIDEO: Surgeon case volume linked to mitral valve repair outcomes
BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.
The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.
The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.
The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
AT THE AATS ANNUAL MEETING
HCV incidence in young women doubled 2006-2014
The incidence of hepatitis C virus infection in reproductive-age women has doubled between 2006 and 2014 while the number of acute cases increased more than threefold, according to data published in the Annals of Internal Medicine.
Researchers analyzed data from the National Notifiable Diseases Surveillance System (NNDSS) from 2006 to 2014 and the Quest Diagnostics Health Trends national database from 2011 to 2014, finding 425,322 women with confirmed HCV infection, 40.4% of whom were aged 15-44 years.
Around half of all acute infections were in non-Hispanic white women, and of the 2,069 women with available risk information, 63% acknowledged injection drug use (Ann Intern Med. 2017 May 8. doi: 10.7326/M16-2350).
The analysis also found 1,859 cases of hepatitis C infection in children aged 2-13 years. According to the Quest data, the proportion of children with current hepatitis C infection was 3.2-fold higher in children aged 2-3 years than in those aged 12-13 years.
Commenting on this age difference, Kathleen N. Ly, MPH, from the Centers for Disease Control and Prevention, and her coauthors noted that it may have been the result of decreased testing over time in children already known to have chronic hepatitis C infection, or could be caused by spontaneous remission of infection, which is more common in infants and children than in adults.
The rate of infection among pregnant women tested for hepatitis C virus between 2011 and 2014 was 0.73%, which the authors calculated would mean that overall, 29,000 women with hepatitis C virus infection gave birth during that period across the United States. Based on data from a recent systematic review and meta-analysis, which found a likely mother-to-child transmission rate of 5.8/100 live births, they estimated that 1,700 infants were born with hepatitis C infection during that period.
“In contrast, only about 200 childhood cases per year are reported to the NNDSS, which may suggest a need for wider screening for HCV in pregnant women and their infants, as is recommended for HIV and hepatitis B virus,” the authors wrote. “However, recommendations for screening in pregnant women and clearer testing guidelines for infants born to HCV-infected mothers do not exist at this time.”
The study was supported by the CDC. One author was an employee of Quest Diagnostics, but no other conflicts of interest were declared.
AGA Resource
The AGA HCV Clinical Service Line provides tools to help you become more efficient, understand quality standards and improve the process of care for patients. Learn more at http://www.gastro.org/patient-care/conditions-diseases/hepatitis-c.
Recognizing hepatitis C infection in pregnant women and neonates is possible, and clinical trials of antiviral therapy may show safety and efficacy in pregnant women and in children. Rather than silence, HCV infection calls out for public health action directed at all aspects of the epidemic, including consideration of screening pregnant women. At the very least, screening of pregnant women for HCV infection risk factors, as well as risk-based testing, requires more emphasis. Another issue in need of attention is the lack of authoritative, consensus-based recommendations for the identification, testing, and case management of newborns of infected mothers.
Much work lies ahead to eradicate HCV, starting with resources for public health surveillance to monitor incidence and prevalence and to fully characterize the infection in the population. Strategies to effectively prevent or cure infection in reproductive-age women and their sexual and needle-sharing partners are critical.
Alfred DeMaria Jr., MD, is from the Massachusetts Department of Public Health. These comments are taken from an accompanying editorial (Ann Intern Med. 2017 May 8. doi: 10.7326/M17-0927). No conflicts of interest were declared.
Recognizing hepatitis C infection in pregnant women and neonates is possible, and clinical trials of antiviral therapy may show safety and efficacy in pregnant women and in children. Rather than silence, HCV infection calls out for public health action directed at all aspects of the epidemic, including consideration of screening pregnant women. At the very least, screening of pregnant women for HCV infection risk factors, as well as risk-based testing, requires more emphasis. Another issue in need of attention is the lack of authoritative, consensus-based recommendations for the identification, testing, and case management of newborns of infected mothers.
Much work lies ahead to eradicate HCV, starting with resources for public health surveillance to monitor incidence and prevalence and to fully characterize the infection in the population. Strategies to effectively prevent or cure infection in reproductive-age women and their sexual and needle-sharing partners are critical.
Alfred DeMaria Jr., MD, is from the Massachusetts Department of Public Health. These comments are taken from an accompanying editorial (Ann Intern Med. 2017 May 8. doi: 10.7326/M17-0927). No conflicts of interest were declared.
Recognizing hepatitis C infection in pregnant women and neonates is possible, and clinical trials of antiviral therapy may show safety and efficacy in pregnant women and in children. Rather than silence, HCV infection calls out for public health action directed at all aspects of the epidemic, including consideration of screening pregnant women. At the very least, screening of pregnant women for HCV infection risk factors, as well as risk-based testing, requires more emphasis. Another issue in need of attention is the lack of authoritative, consensus-based recommendations for the identification, testing, and case management of newborns of infected mothers.
Much work lies ahead to eradicate HCV, starting with resources for public health surveillance to monitor incidence and prevalence and to fully characterize the infection in the population. Strategies to effectively prevent or cure infection in reproductive-age women and their sexual and needle-sharing partners are critical.
Alfred DeMaria Jr., MD, is from the Massachusetts Department of Public Health. These comments are taken from an accompanying editorial (Ann Intern Med. 2017 May 8. doi: 10.7326/M17-0927). No conflicts of interest were declared.
The incidence of hepatitis C virus infection in reproductive-age women has doubled between 2006 and 2014 while the number of acute cases increased more than threefold, according to data published in the Annals of Internal Medicine.
Researchers analyzed data from the National Notifiable Diseases Surveillance System (NNDSS) from 2006 to 2014 and the Quest Diagnostics Health Trends national database from 2011 to 2014, finding 425,322 women with confirmed HCV infection, 40.4% of whom were aged 15-44 years.
Around half of all acute infections were in non-Hispanic white women, and of the 2,069 women with available risk information, 63% acknowledged injection drug use (Ann Intern Med. 2017 May 8. doi: 10.7326/M16-2350).
The analysis also found 1,859 cases of hepatitis C infection in children aged 2-13 years. According to the Quest data, the proportion of children with current hepatitis C infection was 3.2-fold higher in children aged 2-3 years than in those aged 12-13 years.
Commenting on this age difference, Kathleen N. Ly, MPH, from the Centers for Disease Control and Prevention, and her coauthors noted that it may have been the result of decreased testing over time in children already known to have chronic hepatitis C infection, or could be caused by spontaneous remission of infection, which is more common in infants and children than in adults.
The rate of infection among pregnant women tested for hepatitis C virus between 2011 and 2014 was 0.73%, which the authors calculated would mean that overall, 29,000 women with hepatitis C virus infection gave birth during that period across the United States. Based on data from a recent systematic review and meta-analysis, which found a likely mother-to-child transmission rate of 5.8/100 live births, they estimated that 1,700 infants were born with hepatitis C infection during that period.
“In contrast, only about 200 childhood cases per year are reported to the NNDSS, which may suggest a need for wider screening for HCV in pregnant women and their infants, as is recommended for HIV and hepatitis B virus,” the authors wrote. “However, recommendations for screening in pregnant women and clearer testing guidelines for infants born to HCV-infected mothers do not exist at this time.”
The study was supported by the CDC. One author was an employee of Quest Diagnostics, but no other conflicts of interest were declared.
AGA Resource
The AGA HCV Clinical Service Line provides tools to help you become more efficient, understand quality standards and improve the process of care for patients. Learn more at http://www.gastro.org/patient-care/conditions-diseases/hepatitis-c.
The incidence of hepatitis C virus infection in reproductive-age women has doubled between 2006 and 2014 while the number of acute cases increased more than threefold, according to data published in the Annals of Internal Medicine.
Researchers analyzed data from the National Notifiable Diseases Surveillance System (NNDSS) from 2006 to 2014 and the Quest Diagnostics Health Trends national database from 2011 to 2014, finding 425,322 women with confirmed HCV infection, 40.4% of whom were aged 15-44 years.
Around half of all acute infections were in non-Hispanic white women, and of the 2,069 women with available risk information, 63% acknowledged injection drug use (Ann Intern Med. 2017 May 8. doi: 10.7326/M16-2350).
The analysis also found 1,859 cases of hepatitis C infection in children aged 2-13 years. According to the Quest data, the proportion of children with current hepatitis C infection was 3.2-fold higher in children aged 2-3 years than in those aged 12-13 years.
Commenting on this age difference, Kathleen N. Ly, MPH, from the Centers for Disease Control and Prevention, and her coauthors noted that it may have been the result of decreased testing over time in children already known to have chronic hepatitis C infection, or could be caused by spontaneous remission of infection, which is more common in infants and children than in adults.
The rate of infection among pregnant women tested for hepatitis C virus between 2011 and 2014 was 0.73%, which the authors calculated would mean that overall, 29,000 women with hepatitis C virus infection gave birth during that period across the United States. Based on data from a recent systematic review and meta-analysis, which found a likely mother-to-child transmission rate of 5.8/100 live births, they estimated that 1,700 infants were born with hepatitis C infection during that period.
“In contrast, only about 200 childhood cases per year are reported to the NNDSS, which may suggest a need for wider screening for HCV in pregnant women and their infants, as is recommended for HIV and hepatitis B virus,” the authors wrote. “However, recommendations for screening in pregnant women and clearer testing guidelines for infants born to HCV-infected mothers do not exist at this time.”
The study was supported by the CDC. One author was an employee of Quest Diagnostics, but no other conflicts of interest were declared.
AGA Resource
The AGA HCV Clinical Service Line provides tools to help you become more efficient, understand quality standards and improve the process of care for patients. Learn more at http://www.gastro.org/patient-care/conditions-diseases/hepatitis-c.
FROM ANNALS OF INTERNAL MEDICINE
Stage IV sarcoidosis differs in blacks and whites
WASHINGTON – , a finding with potentially important implications for prognosis and management.
Systematic assessment of 349 American patients diagnosed with sarcoidosis – 264 whites and 85 blacks – showed that black patients had nearly double the prevalence of advanced, end-stage, Scadding stage IV fibrosis in their lungs, with a 19% rate among whites and a 34% rate among blacks, confirming that blacks generally have worse sarcoidosis, Andy Levy, MD, said at an international conference of the American Thoracic Society.
Honeycomb scar is associated with more restrictive disease, characterized by reduced total lung capacity and reduced diffusing capacity of the lungs for carbon monoxide, features seen in these black stage IV patients, said Dr. Levy, a pulmonologist at National Jewish Health in Denver. Bronchovascular distortion, the more common scar pattern seen in the white patients, results in more obstructive symptoms, such as a reduced ratio of forced expiratory volume in 1 second divided by forced vital capacity, which Dr. Levy reported as a characteristic of the white GRADS patients.
Even though the pulmonary fibrosis was end-stage in all the black and white stage IV patients examined, “where the scar occurs may depend on genetics or environment, and may affect how the disease manifests. We don’t fully know what it means yet,” Dr. Levy said in an interview. “There is this difference in the sarcoidosis of some black patients compared with white patients that needs further investigation to figure out why the scar is different.”
The different distribution of lung fibrosis in blacks and whites “could have huge implications for prognosis and management,” said Laura Koth, MD, a pulmonologist and professor at the University of California, San Francisco, and lead investigator for the study reported by Dr. Levy.
The GRADS data collection also showed that a significantly higher percentage of black patients had most recently received prednisone treatment for their sarcoidosis, 45% compared with 29% in whites, Dr. Levy reported. Ideally most sarcoidosis patients would be on a steroid-sparing regimen, such as methotrexate. The excess prednisone treatment the black patients received confirmed prior reports of treatment disparities by race among American sarcoidosis patients, he said.
GRADS includes patients enrolled at seven U.S. research centers. The study’s primary goal is to try to identify “genomic signatures” that link with the clinical phenotypes identified through spirometry, bronchoscopy, CT scans, and physical examinations, Dr. Koth explained. The investigators plan to enroll more patients into the program to validate the findings, she said. “This is an early stage, but we have seen some signals we want to follow-up.”
GRADS is funded by the National Heart, Lung, and Blood Institute. Dr. Levy and Dr. Koth had no relevant financial disclosures.
[email protected]
On Twitter @mitchelzoler
WASHINGTON – , a finding with potentially important implications for prognosis and management.
Systematic assessment of 349 American patients diagnosed with sarcoidosis – 264 whites and 85 blacks – showed that black patients had nearly double the prevalence of advanced, end-stage, Scadding stage IV fibrosis in their lungs, with a 19% rate among whites and a 34% rate among blacks, confirming that blacks generally have worse sarcoidosis, Andy Levy, MD, said at an international conference of the American Thoracic Society.
Honeycomb scar is associated with more restrictive disease, characterized by reduced total lung capacity and reduced diffusing capacity of the lungs for carbon monoxide, features seen in these black stage IV patients, said Dr. Levy, a pulmonologist at National Jewish Health in Denver. Bronchovascular distortion, the more common scar pattern seen in the white patients, results in more obstructive symptoms, such as a reduced ratio of forced expiratory volume in 1 second divided by forced vital capacity, which Dr. Levy reported as a characteristic of the white GRADS patients.
Even though the pulmonary fibrosis was end-stage in all the black and white stage IV patients examined, “where the scar occurs may depend on genetics or environment, and may affect how the disease manifests. We don’t fully know what it means yet,” Dr. Levy said in an interview. “There is this difference in the sarcoidosis of some black patients compared with white patients that needs further investigation to figure out why the scar is different.”
The different distribution of lung fibrosis in blacks and whites “could have huge implications for prognosis and management,” said Laura Koth, MD, a pulmonologist and professor at the University of California, San Francisco, and lead investigator for the study reported by Dr. Levy.
The GRADS data collection also showed that a significantly higher percentage of black patients had most recently received prednisone treatment for their sarcoidosis, 45% compared with 29% in whites, Dr. Levy reported. Ideally most sarcoidosis patients would be on a steroid-sparing regimen, such as methotrexate. The excess prednisone treatment the black patients received confirmed prior reports of treatment disparities by race among American sarcoidosis patients, he said.
GRADS includes patients enrolled at seven U.S. research centers. The study’s primary goal is to try to identify “genomic signatures” that link with the clinical phenotypes identified through spirometry, bronchoscopy, CT scans, and physical examinations, Dr. Koth explained. The investigators plan to enroll more patients into the program to validate the findings, she said. “This is an early stage, but we have seen some signals we want to follow-up.”
GRADS is funded by the National Heart, Lung, and Blood Institute. Dr. Levy and Dr. Koth had no relevant financial disclosures.
[email protected]
On Twitter @mitchelzoler
WASHINGTON – , a finding with potentially important implications for prognosis and management.
Systematic assessment of 349 American patients diagnosed with sarcoidosis – 264 whites and 85 blacks – showed that black patients had nearly double the prevalence of advanced, end-stage, Scadding stage IV fibrosis in their lungs, with a 19% rate among whites and a 34% rate among blacks, confirming that blacks generally have worse sarcoidosis, Andy Levy, MD, said at an international conference of the American Thoracic Society.
Honeycomb scar is associated with more restrictive disease, characterized by reduced total lung capacity and reduced diffusing capacity of the lungs for carbon monoxide, features seen in these black stage IV patients, said Dr. Levy, a pulmonologist at National Jewish Health in Denver. Bronchovascular distortion, the more common scar pattern seen in the white patients, results in more obstructive symptoms, such as a reduced ratio of forced expiratory volume in 1 second divided by forced vital capacity, which Dr. Levy reported as a characteristic of the white GRADS patients.
Even though the pulmonary fibrosis was end-stage in all the black and white stage IV patients examined, “where the scar occurs may depend on genetics or environment, and may affect how the disease manifests. We don’t fully know what it means yet,” Dr. Levy said in an interview. “There is this difference in the sarcoidosis of some black patients compared with white patients that needs further investigation to figure out why the scar is different.”
The different distribution of lung fibrosis in blacks and whites “could have huge implications for prognosis and management,” said Laura Koth, MD, a pulmonologist and professor at the University of California, San Francisco, and lead investigator for the study reported by Dr. Levy.
The GRADS data collection also showed that a significantly higher percentage of black patients had most recently received prednisone treatment for their sarcoidosis, 45% compared with 29% in whites, Dr. Levy reported. Ideally most sarcoidosis patients would be on a steroid-sparing regimen, such as methotrexate. The excess prednisone treatment the black patients received confirmed prior reports of treatment disparities by race among American sarcoidosis patients, he said.
GRADS includes patients enrolled at seven U.S. research centers. The study’s primary goal is to try to identify “genomic signatures” that link with the clinical phenotypes identified through spirometry, bronchoscopy, CT scans, and physical examinations, Dr. Koth explained. The investigators plan to enroll more patients into the program to validate the findings, she said. “This is an early stage, but we have seen some signals we want to follow-up.”
GRADS is funded by the National Heart, Lung, and Blood Institute. Dr. Levy and Dr. Koth had no relevant financial disclosures.
[email protected]
On Twitter @mitchelzoler
AT ATS 2017
Key clinical point: A restrictive, “honeycomb” fibrotic scar was more common in black patients with stage IV sarcoidosis than in white stage IV patients, who more often had obstructive bronchovascular distortion.
Major finding: Honeycomb lung fibrosis occurred in 19% of black sarcoidosis patients and in 4% of white sarcoidosis patients.
Data source: GRADS, which enrolled 349 sarcoidosis patients at seven U.S. centers.
Disclosures: GRADS is funded by the National Heart, Lung, and Blood Institute. Dr. Levy and Dr. Koth had no relevant financial disclosures.
Hot Threads in ACS Communities
Here are the top discussion threads in ACS Communities this week. (All of these threads are from the General Surgery community except where indicated.) 
- Texas SB 1148 The MOC Bill
- Low back pain (Women Surgeons)
- Domestic volunteerism
- Hour limits for staff/attending surgeons?
- Health Care Reform
- A day on Capitol Hill
- Reactions to the “Replacement” of our Surgeon General?
- Any input on this article?
- Another tough case
- Rectal prolapse (Colon and Rectal Surgery)
To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to [email protected].
Here are the top discussion threads in ACS Communities this week. (All of these threads are from the General Surgery community except where indicated.)
- Texas SB 1148 The MOC Bill
- Low back pain (Women Surgeons)
- Domestic volunteerism
- Hour limits for staff/attending surgeons?
- Health Care Reform
- A day on Capitol Hill
- Reactions to the “Replacement” of our Surgeon General?
- Any input on this article?
- Another tough case
- Rectal prolapse (Colon and Rectal Surgery)
To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to [email protected].
Here are the top discussion threads in ACS Communities this week. (All of these threads are from the General Surgery community except where indicated.)
- Texas SB 1148 The MOC Bill
- Low back pain (Women Surgeons)
- Domestic volunteerism
- Hour limits for staff/attending surgeons?
- Health Care Reform
- A day on Capitol Hill
- Reactions to the “Replacement” of our Surgeon General?
- Any input on this article?
- Another tough case
- Rectal prolapse (Colon and Rectal Surgery)
To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to [email protected].
Nurse practitioner urges advocacy for HPV vaccination
"IT IS TIME FOR HPV VACCINATION TO BE CONSIDERED PART OF ROUTINE PREVENTIVE HEALTH CARE"
BARBARA S. LEVY, MD (MARCH 2017)
Nurse practitioner urges advocacy for HPV vaccination
I could not agree more with Dr. Levy's view on human papillomavirus (HPV) vaccination. I am a Doctor of Nursing Practice student and improving HPV vaccination rates in adolescents is the focus of my research project for the next year. Based on the current literature, the most significant factors for increasing vaccination rates are patient education and provider recommendation. As the article mentions, "special" attention should not be given to the HPV vaccine, because this raises questions with families presenting to the office for routine well-child care. There have been many missed opportunities for vaccination of our young people over the past 10 years. As a result, we will continue to see increases in HPV-related cancers. We have a vaccine that has the potential to significantly decrease these cases, but it is underutilized. The recent recommendation of a 2-dose series (before the age of 15) should make completing the series easier. I urge all providers to be better advocates for their patients and make appropriate changes to their current practice in order to reduce the significant burden this disease carries.
Tiffany Edwards, MSN, APRN, FNP-BC
Seaford, Delaware
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
"IT IS TIME FOR HPV VACCINATION TO BE CONSIDERED PART OF ROUTINE PREVENTIVE HEALTH CARE"
BARBARA S. LEVY, MD (MARCH 2017)
Nurse practitioner urges advocacy for HPV vaccination
I could not agree more with Dr. Levy's view on human papillomavirus (HPV) vaccination. I am a Doctor of Nursing Practice student and improving HPV vaccination rates in adolescents is the focus of my research project for the next year. Based on the current literature, the most significant factors for increasing vaccination rates are patient education and provider recommendation. As the article mentions, "special" attention should not be given to the HPV vaccine, because this raises questions with families presenting to the office for routine well-child care. There have been many missed opportunities for vaccination of our young people over the past 10 years. As a result, we will continue to see increases in HPV-related cancers. We have a vaccine that has the potential to significantly decrease these cases, but it is underutilized. The recent recommendation of a 2-dose series (before the age of 15) should make completing the series easier. I urge all providers to be better advocates for their patients and make appropriate changes to their current practice in order to reduce the significant burden this disease carries.
Tiffany Edwards, MSN, APRN, FNP-BC
Seaford, Delaware
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
"IT IS TIME FOR HPV VACCINATION TO BE CONSIDERED PART OF ROUTINE PREVENTIVE HEALTH CARE"
BARBARA S. LEVY, MD (MARCH 2017)
Nurse practitioner urges advocacy for HPV vaccination
I could not agree more with Dr. Levy's view on human papillomavirus (HPV) vaccination. I am a Doctor of Nursing Practice student and improving HPV vaccination rates in adolescents is the focus of my research project for the next year. Based on the current literature, the most significant factors for increasing vaccination rates are patient education and provider recommendation. As the article mentions, "special" attention should not be given to the HPV vaccine, because this raises questions with families presenting to the office for routine well-child care. There have been many missed opportunities for vaccination of our young people over the past 10 years. As a result, we will continue to see increases in HPV-related cancers. We have a vaccine that has the potential to significantly decrease these cases, but it is underutilized. The recent recommendation of a 2-dose series (before the age of 15) should make completing the series easier. I urge all providers to be better advocates for their patients and make appropriate changes to their current practice in order to reduce the significant burden this disease carries.
Tiffany Edwards, MSN, APRN, FNP-BC
Seaford, Delaware
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Leadership hacks: The drama triangle
There are plenty of leadership books, seminars, podcasts, and websites available for the aspiring physician leader. However, not all of them are pertinent to the health care environment. As chairman of a large academic department, I have sifted through some of these resources and have found a few that have been particularly helpful to me. One of the more useful is the drama triangle.
Here’s an example: Pat, the administrator, just sent Sam an email stating that, starting today, all computers will be automatically turned off at 5 p.m. and cannot be restarted until 8 a.m. the next day. The reasons are many but unimportant to Sam because they pale in comparison to the inconvenience this places on Sam’s ability to finish work in the evening. No one asked about this change or even gave advance warning.
Anger builds in Sam, especially toward Pat. Something has to be done about this! That something becomes a petition to Kelly, a supervisor/manager/director/chairman with authority. Sam recounts the surprise of the order, details the inefficiencies created, expresses indignation at not being consulted first, lists the personal failings of Pat, and demands an immediate resolution to the problem. Kelly wants to help Sam and approaches Pat to reverse the order. Kelly feels good about helping Sam, and Sam feels great about going to Kelly. Pat doesn’t feel good at all.
Sam started, and Kelly completed, the drama triangle.
Breaking a drama triangle requires uncomfortable work building trust and a more functional relationship between the three players. Ideally, the victim becomes challenged, not threatened. The rescuer becomes a coach, not an enabler. The persecutor raises the bar rather than creating obstacles. With roles redefined, trust is restored. There are many methods and techniques to develop psychological safety and interdependent trust, but the work is the critical first step toward improving the function of a team (Lencioni, P. (2002). The Five Dysfunctions of a Team. Jossey-Bass).
What could Kelly have done to stop a triangle from forming? Sam wanted help, and Kelly’s first instinct is to do just that. However, by completing the triangle with a visit to Pat, Kelly creates more tension between Pat and Sam. To help both Sam and Pat, Kelly has to resist the temptation to rescue Sam from Pat and instead leverage Sam’s trust to begin asking Sam questions that lead Sam toward resolution of Sam’s own problem.
Aware of drama triangles, Kelly asks Sam what the ideal situation would be. Sam replies that all the work would get done by the end of the day. Kelly then asks what the current situation is. According to Pat, the computers turn off at 5, but the work is not done by then. Then, Kelly asks Sam what could be done before 5 that would help get the work done. Sam considers the question and then begins to list some changes to work flow that could allow greater efficiency during the day. Sam also decides to meet with Pat to explain how the two of them can improve communication in the future. Through coaching, Kelly defuses Sam’s anger, avoids a drama triangle, and gets Sam to start considering previously unknown solutions. The model Kelly uses to begin the work of breaking the triangle is sometimes called structural, or dynamic, tension.
Drama triangles compromise trust. The workplace culture can either enable simmering tensions and resentments to persist or it can foster psychological safety that allows for open and honest debate whereby all are heard and validated when change inevitably occurs. Exploring structural tension can build a sense of team and restore trust. A more robust discussion of structural tension will have to wait until my next column. In the meantime, as yourselves, Where do you see drama triangles? What worked to break them? What failed?
For more reading: Emerald, D. (2010). The Power of Ted* (The Empowerment Dynamic). Bainbridge Island, WA: Polaris Publishing.
I invite you to reply to [email protected] to initiate a broader discussion of physician leadership. Responses will be posted to hematologynews.com. Dr. Kalaycio is editor in chief of Hematology News. Dr. Kalaycio chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].
There are plenty of leadership books, seminars, podcasts, and websites available for the aspiring physician leader. However, not all of them are pertinent to the health care environment. As chairman of a large academic department, I have sifted through some of these resources and have found a few that have been particularly helpful to me. One of the more useful is the drama triangle.
Here’s an example: Pat, the administrator, just sent Sam an email stating that, starting today, all computers will be automatically turned off at 5 p.m. and cannot be restarted until 8 a.m. the next day. The reasons are many but unimportant to Sam because they pale in comparison to the inconvenience this places on Sam’s ability to finish work in the evening. No one asked about this change or even gave advance warning.
Anger builds in Sam, especially toward Pat. Something has to be done about this! That something becomes a petition to Kelly, a supervisor/manager/director/chairman with authority. Sam recounts the surprise of the order, details the inefficiencies created, expresses indignation at not being consulted first, lists the personal failings of Pat, and demands an immediate resolution to the problem. Kelly wants to help Sam and approaches Pat to reverse the order. Kelly feels good about helping Sam, and Sam feels great about going to Kelly. Pat doesn’t feel good at all.
Sam started, and Kelly completed, the drama triangle.
Breaking a drama triangle requires uncomfortable work building trust and a more functional relationship between the three players. Ideally, the victim becomes challenged, not threatened. The rescuer becomes a coach, not an enabler. The persecutor raises the bar rather than creating obstacles. With roles redefined, trust is restored. There are many methods and techniques to develop psychological safety and interdependent trust, but the work is the critical first step toward improving the function of a team (Lencioni, P. (2002). The Five Dysfunctions of a Team. Jossey-Bass).
What could Kelly have done to stop a triangle from forming? Sam wanted help, and Kelly’s first instinct is to do just that. However, by completing the triangle with a visit to Pat, Kelly creates more tension between Pat and Sam. To help both Sam and Pat, Kelly has to resist the temptation to rescue Sam from Pat and instead leverage Sam’s trust to begin asking Sam questions that lead Sam toward resolution of Sam’s own problem.
Aware of drama triangles, Kelly asks Sam what the ideal situation would be. Sam replies that all the work would get done by the end of the day. Kelly then asks what the current situation is. According to Pat, the computers turn off at 5, but the work is not done by then. Then, Kelly asks Sam what could be done before 5 that would help get the work done. Sam considers the question and then begins to list some changes to work flow that could allow greater efficiency during the day. Sam also decides to meet with Pat to explain how the two of them can improve communication in the future. Through coaching, Kelly defuses Sam’s anger, avoids a drama triangle, and gets Sam to start considering previously unknown solutions. The model Kelly uses to begin the work of breaking the triangle is sometimes called structural, or dynamic, tension.
Drama triangles compromise trust. The workplace culture can either enable simmering tensions and resentments to persist or it can foster psychological safety that allows for open and honest debate whereby all are heard and validated when change inevitably occurs. Exploring structural tension can build a sense of team and restore trust. A more robust discussion of structural tension will have to wait until my next column. In the meantime, as yourselves, Where do you see drama triangles? What worked to break them? What failed?
For more reading: Emerald, D. (2010). The Power of Ted* (The Empowerment Dynamic). Bainbridge Island, WA: Polaris Publishing.
I invite you to reply to [email protected] to initiate a broader discussion of physician leadership. Responses will be posted to hematologynews.com. Dr. Kalaycio is editor in chief of Hematology News. Dr. Kalaycio chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].
There are plenty of leadership books, seminars, podcasts, and websites available for the aspiring physician leader. However, not all of them are pertinent to the health care environment. As chairman of a large academic department, I have sifted through some of these resources and have found a few that have been particularly helpful to me. One of the more useful is the drama triangle.
Here’s an example: Pat, the administrator, just sent Sam an email stating that, starting today, all computers will be automatically turned off at 5 p.m. and cannot be restarted until 8 a.m. the next day. The reasons are many but unimportant to Sam because they pale in comparison to the inconvenience this places on Sam’s ability to finish work in the evening. No one asked about this change or even gave advance warning.
Anger builds in Sam, especially toward Pat. Something has to be done about this! That something becomes a petition to Kelly, a supervisor/manager/director/chairman with authority. Sam recounts the surprise of the order, details the inefficiencies created, expresses indignation at not being consulted first, lists the personal failings of Pat, and demands an immediate resolution to the problem. Kelly wants to help Sam and approaches Pat to reverse the order. Kelly feels good about helping Sam, and Sam feels great about going to Kelly. Pat doesn’t feel good at all.
Sam started, and Kelly completed, the drama triangle.
Breaking a drama triangle requires uncomfortable work building trust and a more functional relationship between the three players. Ideally, the victim becomes challenged, not threatened. The rescuer becomes a coach, not an enabler. The persecutor raises the bar rather than creating obstacles. With roles redefined, trust is restored. There are many methods and techniques to develop psychological safety and interdependent trust, but the work is the critical first step toward improving the function of a team (Lencioni, P. (2002). The Five Dysfunctions of a Team. Jossey-Bass).
What could Kelly have done to stop a triangle from forming? Sam wanted help, and Kelly’s first instinct is to do just that. However, by completing the triangle with a visit to Pat, Kelly creates more tension between Pat and Sam. To help both Sam and Pat, Kelly has to resist the temptation to rescue Sam from Pat and instead leverage Sam’s trust to begin asking Sam questions that lead Sam toward resolution of Sam’s own problem.
Aware of drama triangles, Kelly asks Sam what the ideal situation would be. Sam replies that all the work would get done by the end of the day. Kelly then asks what the current situation is. According to Pat, the computers turn off at 5, but the work is not done by then. Then, Kelly asks Sam what could be done before 5 that would help get the work done. Sam considers the question and then begins to list some changes to work flow that could allow greater efficiency during the day. Sam also decides to meet with Pat to explain how the two of them can improve communication in the future. Through coaching, Kelly defuses Sam’s anger, avoids a drama triangle, and gets Sam to start considering previously unknown solutions. The model Kelly uses to begin the work of breaking the triangle is sometimes called structural, or dynamic, tension.
Drama triangles compromise trust. The workplace culture can either enable simmering tensions and resentments to persist or it can foster psychological safety that allows for open and honest debate whereby all are heard and validated when change inevitably occurs. Exploring structural tension can build a sense of team and restore trust. A more robust discussion of structural tension will have to wait until my next column. In the meantime, as yourselves, Where do you see drama triangles? What worked to break them? What failed?
For more reading: Emerald, D. (2010). The Power of Ted* (The Empowerment Dynamic). Bainbridge Island, WA: Polaris Publishing.
I invite you to reply to [email protected] to initiate a broader discussion of physician leadership. Responses will be posted to hematologynews.com. Dr. Kalaycio is editor in chief of Hematology News. Dr. Kalaycio chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].
Prepping the vagina before cesarean delivery
"SHOULD YOU ADOPT THE PRACTICE OF VAGINAL CLEANSING WITH POVIDONE-IODINE PRIOR TO CESAREAN DELIVERY?"
ROBERT L. BARBIERI, MD (EDITORIAL; JANUARY 2016)
"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"
KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)
Prepping the vagina before cesarean delivery
I enjoyed your review of the topic. I am interested in using vaginal preparation prior to cesarean in the settings of active-phase and second-stage arrest. This should be most valuable since we anticipate possible prolonged attempt at head delivery. There may be a need for head elevation as well. Of course, we have become enthusiastic about using reverse breech extraction in difficult cases since your article a few years ago. I have yet to do a Patwardhan maneuver. That seems to rely on rotating the spine anteriorly to get the second arm out. With the head impaction, there is limited range for neck rotation. With vaginal preparation, is there any concern about fetal exposure to iodine?
Kimberly Harney, MD
Stanford, California
Dr. Barbieri responds
Dr. Harney raises the important issue of the potential adverse effects of povidone-iodine surgical preparation when used on a pregnant woman with ruptured membranes. There is very little direct evidence of a toxic effect of povidone-iodine on the fetus, but studies on women report that there is a transient increase in circulating iodine and iodine excretion following a vaginal povidone-iodine preparation.1 The American College of Obstetricians and Gynecologists has suggested that chlorhexidine might be a superior vaginal disinfectant than povidone-iodine,2 but chlorhexidine is not approved by the US Food and Drug Administration for use in the vagina, and many surgical nursing directors favor the use of povidone-iodine in the vagina.3
"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"
KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)
Another way to prevent post-cesarean delivery infections
After 40 years in ObGyn practice (I am now retired), I find it interesting that experts have ignored a major potential source of infection--the operation team. Back in the day of Phisohex (hexachlorophene) use, we scrubbed our hands, arms, and fingers for a finite time--10 minutes--systematically and religiously. Our infection rates increased only when house staff rather than surgical assistants "helped" us. When scrubbing, I was always amazed that the house staff appeared at the sink long after I did and left before I had completed my presurgical ritual. (This was not true of non-MD assistants.) And my private practice postoperative infection rate reflected the difference. So perhaps the evidence is skewed away from this source of infection, which I submit may well be the major one!
Steve Melkin, MD
Phoenix, Arizona
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Velasco I, Naranjo S, Lopez-Pedrera C, Garriga MJ, Garcia-Fuentes E, Soriquer F. Use of povidine-iodine during the first trimester of pregnancy: a correct practice? BJOG. 2009;116(3):452-455.
- Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. Committee Opinion No. 571: solutions for surgical preparation of the vagina. Obstet Gynecol. 2013;122(3):718-720.
- Guideline for preoperative patient skin antisepsis. In: Guidelines for perioperative practice. Denver, CO: Association of Perioperative Registered Nurses, Inc; 2014.
"SHOULD YOU ADOPT THE PRACTICE OF VAGINAL CLEANSING WITH POVIDONE-IODINE PRIOR TO CESAREAN DELIVERY?"
ROBERT L. BARBIERI, MD (EDITORIAL; JANUARY 2016)
"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"
KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)
Prepping the vagina before cesarean delivery
I enjoyed your review of the topic. I am interested in using vaginal preparation prior to cesarean in the settings of active-phase and second-stage arrest. This should be most valuable since we anticipate possible prolonged attempt at head delivery. There may be a need for head elevation as well. Of course, we have become enthusiastic about using reverse breech extraction in difficult cases since your article a few years ago. I have yet to do a Patwardhan maneuver. That seems to rely on rotating the spine anteriorly to get the second arm out. With the head impaction, there is limited range for neck rotation. With vaginal preparation, is there any concern about fetal exposure to iodine?
Kimberly Harney, MD
Stanford, California
Dr. Barbieri responds
Dr. Harney raises the important issue of the potential adverse effects of povidone-iodine surgical preparation when used on a pregnant woman with ruptured membranes. There is very little direct evidence of a toxic effect of povidone-iodine on the fetus, but studies on women report that there is a transient increase in circulating iodine and iodine excretion following a vaginal povidone-iodine preparation.1 The American College of Obstetricians and Gynecologists has suggested that chlorhexidine might be a superior vaginal disinfectant than povidone-iodine,2 but chlorhexidine is not approved by the US Food and Drug Administration for use in the vagina, and many surgical nursing directors favor the use of povidone-iodine in the vagina.3
"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"
KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)
Another way to prevent post-cesarean delivery infections
After 40 years in ObGyn practice (I am now retired), I find it interesting that experts have ignored a major potential source of infection--the operation team. Back in the day of Phisohex (hexachlorophene) use, we scrubbed our hands, arms, and fingers for a finite time--10 minutes--systematically and religiously. Our infection rates increased only when house staff rather than surgical assistants "helped" us. When scrubbing, I was always amazed that the house staff appeared at the sink long after I did and left before I had completed my presurgical ritual. (This was not true of non-MD assistants.) And my private practice postoperative infection rate reflected the difference. So perhaps the evidence is skewed away from this source of infection, which I submit may well be the major one!
Steve Melkin, MD
Phoenix, Arizona
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
"SHOULD YOU ADOPT THE PRACTICE OF VAGINAL CLEANSING WITH POVIDONE-IODINE PRIOR TO CESAREAN DELIVERY?"
ROBERT L. BARBIERI, MD (EDITORIAL; JANUARY 2016)
"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"
KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)
Prepping the vagina before cesarean delivery
I enjoyed your review of the topic. I am interested in using vaginal preparation prior to cesarean in the settings of active-phase and second-stage arrest. This should be most valuable since we anticipate possible prolonged attempt at head delivery. There may be a need for head elevation as well. Of course, we have become enthusiastic about using reverse breech extraction in difficult cases since your article a few years ago. I have yet to do a Patwardhan maneuver. That seems to rely on rotating the spine anteriorly to get the second arm out. With the head impaction, there is limited range for neck rotation. With vaginal preparation, is there any concern about fetal exposure to iodine?
Kimberly Harney, MD
Stanford, California
Dr. Barbieri responds
Dr. Harney raises the important issue of the potential adverse effects of povidone-iodine surgical preparation when used on a pregnant woman with ruptured membranes. There is very little direct evidence of a toxic effect of povidone-iodine on the fetus, but studies on women report that there is a transient increase in circulating iodine and iodine excretion following a vaginal povidone-iodine preparation.1 The American College of Obstetricians and Gynecologists has suggested that chlorhexidine might be a superior vaginal disinfectant than povidone-iodine,2 but chlorhexidine is not approved by the US Food and Drug Administration for use in the vagina, and many surgical nursing directors favor the use of povidone-iodine in the vagina.3
"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"
KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)
Another way to prevent post-cesarean delivery infections
After 40 years in ObGyn practice (I am now retired), I find it interesting that experts have ignored a major potential source of infection--the operation team. Back in the day of Phisohex (hexachlorophene) use, we scrubbed our hands, arms, and fingers for a finite time--10 minutes--systematically and religiously. Our infection rates increased only when house staff rather than surgical assistants "helped" us. When scrubbing, I was always amazed that the house staff appeared at the sink long after I did and left before I had completed my presurgical ritual. (This was not true of non-MD assistants.) And my private practice postoperative infection rate reflected the difference. So perhaps the evidence is skewed away from this source of infection, which I submit may well be the major one!
Steve Melkin, MD
Phoenix, Arizona
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Velasco I, Naranjo S, Lopez-Pedrera C, Garriga MJ, Garcia-Fuentes E, Soriquer F. Use of povidine-iodine during the first trimester of pregnancy: a correct practice? BJOG. 2009;116(3):452-455.
- Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. Committee Opinion No. 571: solutions for surgical preparation of the vagina. Obstet Gynecol. 2013;122(3):718-720.
- Guideline for preoperative patient skin antisepsis. In: Guidelines for perioperative practice. Denver, CO: Association of Perioperative Registered Nurses, Inc; 2014.
- Velasco I, Naranjo S, Lopez-Pedrera C, Garriga MJ, Garcia-Fuentes E, Soriquer F. Use of povidine-iodine during the first trimester of pregnancy: a correct practice? BJOG. 2009;116(3):452-455.
- Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. Committee Opinion No. 571: solutions for surgical preparation of the vagina. Obstet Gynecol. 2013;122(3):718-720.
- Guideline for preoperative patient skin antisepsis. In: Guidelines for perioperative practice. Denver, CO: Association of Perioperative Registered Nurses, Inc; 2014.